Graduation Ceremony 5
Academic Oration
Thursday 25 November 2010 at 1630hrs
JESUITS’ CHURCH – VALLETTA
Looking to the Future: Educating for Professionalism
Dr Bridget Ellul
Head, Department of Pathology,
Faculty of Medicine and Surgery
Rector, graduands and parents, academic members of the Faculty of Medicine and
Surgery and the Faculty of Science, distinguished guests, welcome to this Graduation
ceremony. I thank Senate for the privilege and honour of inviting me to deliver this
oration. As I look at the list of graduands, I realise I am addressing mainly the new
doctors, whom I know well, whom I have tutored, advised and guided along the years of
the course. I also see before me the postgraduate students, from my own department,
from our Faculty and the Faculty of Science. I congratulate all of you. This is your
ceremony, a time to celebrate, to be satisfied with your achievement. The long hours of
study have surely paid off. For this, a debt is no doubt owed to parents, relatives and
friends who have invested time and money to ease your struggles to success. It is also a
time to look to the future, this is just the beginning of your professional life.
I searched for a common thread for this ceremony’s oration and the solution lay in my
speciality. Pathology as a discipline in the medical course is after all the bridge between
the basic sciences and the clinical years - this is what I tell the students in their first
introductory pathology lecture, to be followed by: the practice of Medicine is based on
Pathology. I was therefore extremely heartened to read Professor Sir John Bell’s
Harveian Oration delivered at the Royal College of Physicians, London, this October. His
lecture, ‘Redefining disease’, emphasised that it is the ‘scientific basis of disease’, which
allows us to establish cause and pathogenesis, so as to arrive to management and
treatment of patients. He eloquently traced significant achievements in the basic sciences,
including pathology disciplines, which have paved the way to our current advanced, but
still limited, knowledge of molecular medicine.1 Such an approach will ‘provide
enormous opportunities for the development of therapies targeted at appropriately defined
patient populations with specifically characterised diseases, creating an era of more
personalised medicine.’ Excellence in medicine thrives on high quality research in basic
sciences. Moreover, for the medical graduates, it is this marriage of basic science with
clinical medicine that really turns the doctor into a professional, as I shall illustrate in this
address.
Educating for professionalism
The Royal College of Physicians, RCP, defines professionalism as: ‘A set of values,
behaviours and relationships that underpins the trust the public has in doctors.’2 In a joint
collaboration with the King’s Fund, a charity committed to improving health services, the
RCP carried out a series of consultations with UK doctors. They agreed that
professionalism offers ‘a strong value-based framework within which doctors can shape
the improvement of health care and exercise a constructive influence on health policy in
the public interest’. 3
Intending to plan for the future, subsequent research concentrated on medical students;
they represented over 70% of the health carers and health policy workers consulted. The
resulting publication, ‘The 21st century doctor: Understanding the doctors of tomorrow’4
is a thought provoking read for all who have at heart good medical practice and medical
education. I will just mention two of the topics covered: educating for professionalism
and the role of the doctor in the future.
A very strong statement was made in the same report with regard to how students can
learn to become professionals: ‘Positive role models remain one of the most powerful
ways of demonstrating excellence in medical professionalism. Ways need to be sought
within busy modern practice to preserve this.’ Questions were raised as to whether short
term attachments to medical firms are sufficient to allow learning ‘by example’.
Although this referred to learning professionalism, no doubt it applies as well, if not more
so, to learning clinical skills.
It is also fitting that the Malta Medical Council has just now issued guidelines to ‘guide
medical and dental students on the kinds of professional behaviour expected of them in
order to be fit to practice’.5
The role of the doctor in the future
With regard to the second topic, the report cited above lists changes in patients’
expectations, changes in the roles and responsibilities of doctors, for example the
requirement to take on managerial roles, and the technological developments in medicine.
Emphasis is placed on the task of the medical profession to guarantee that it ‘continues to
produce doctors soundly educated and trained in scientific principles’ ‘because this is
perhaps the best way to ensure adaptability as the role of the doctor evolves in the future’.
So the report puts the onus on the medical profession in general, and on academics in
particular, to provide the best medical curriculum with the resources available. Moreover
there is also a duty to be aware of the burden of being role models – it is well worth us,
the Faculty, reflecting on this responsibility, as individuals, as well as, on a collective
basis. However this is after all what a profession embodies, the responsibility of training
future successors, as the Hippocratic oath expressively states: ‘to give a share both of
rules and of lectures, and of all the rest of learning, to my sons and to the [sons] of him
who has taught me and to the pupils who have sworn by a medical convention’. It is
worth remembering that Greek physicians took on apprentices to train.
There are of course other changes in the roles of doctors, notably related to the doctorpatient relationship. True this must still be based on trust but respect for patients today
must be anchored on respecting autonomy. As the UK General Medical Council stated in
its Policy statement in 2007: ‘They must establish and maintain effective relationships
with patients, respect patients’ autonomy’. Patients have the right to information, so as to
be able to make informed decisions about their healthcare, which increasingly today is
based on a multidisciplinary approach. The professional has to engage in effective
teamwork, to ensure the optimum management of patients. The Maltese subsidiary
legislation, Ethics of the Medical Profession, re-iterates that the profession ‘occupies a
position of trust in society. A doctor’s calling is to serve humanity under all conditions.
Members of the profession have built up a tradition of placing the needs of the patient
above all else’.6
The role of the Faculty / Curricular reform
The Faculty has naturally been concerned about safe, professional future doctors and is
now in the process of a major curricular reform, which according to its mission statement,
must incorporate factual knowledge, skills and professional attitudes in every part of the
curriculum. We have just seen the end of the first year of the new MD course, now
restructured to include both vertical and horizontal integration, with the introduction of
the European Credit Transfer System. The latter has been in response to the Bologna
process and in an attempt to harmonise the medical course with other university courses.
The Bologna model has not been universally accepted in Europe, for medical courses,
with certain member states claiming that they already fulfil the main obligations of
quality, mobility and employability.
Medical students appear to be more in accord. At the students’ 8th International FollowUp Workshop on the Bologna Process in Medical Education, in 2009, they report that
‘the quality of medical education can benefit from the Bologna Process’. They do
appreciate the difficulties in adoption of a three cycle based system but recommend that
‘progress regarding the other action lines in the Bologna Process’ should proceed while
they agreed to work towards European harmonization, at least by signatory countries. 7
There is of course already European agreement, through the Doctors’ Directive on the
basic medical training requirements, which is to conform to ‘at least 6 years of study or
5500 hours of theoretical and practical training provided by, or under the supervision of,
a university.’8 This legal requirement alone already makes curricular reform difficult to
fit into the framework of a modular system, without imagination and creativity. Well the
challenge is still with us, as the Curriculum Committee forges ahead to finalise the
transformation of the three traditionally predominant clinical years.
Another change in the Curriculum has been the introduction of structured programmes in
behaviour sciences, including communication skills and in ethics. Medical ethics
underlies how healthcare professionals behave or act, or rather how they ought to behave
or act, in matters related to medical practice, and biological sciences, based on decisions
taken in line with moral values and principles. Medical ethics has been spread over the 5
year course, a curriculum which needs to be extended into the postgraduate Foundation
training, part of life long learning, to be honed by the daily clinical experiences. We have
seen a rise in interest in postgraduate degrees in bioethics but are yet to see ethical review
committees in the health department involving clinicians in solving ethical dilemmas.
On the plus side the new Curriculum has been a stimulating development and has been
well received by medical students. They students have responded by taking on more
responsibility for self directed learning and are turning up well prepared for teaching
sessions. Have we started the ball rolling to reverse the student culture from an extension
of secondary school mentality to self learning? This spurs us on to continue improving
the course. It has encouraged us, the department of pathology to revise our input, and to
integrate in multidisciplinary study units as from first year, mirroring our established
practice in the clinical years. Of course the organizational aspects of timetabling and
avoiding clashes have been a real nightmare. This to some extent can be relieved by
better resources.
Now is the time to restate the need for a Medical Education unit to be set up within the
Faculty, with trained academics with dedicated time.9 Also, what has become obvious is
the dedication of the committed lecturers who have given much effort to see the project a
success. It is perhaps unfortunate that I cannot be uniform in praise but one has to accept
that a few have absolutely no interest at all in, or are afraid of, change. For others, it is
not the lack of willingness, and nor of ability, but it is the priorities of part-time
academics who have clinical commitments that at times disrupt our planned schedules.
This is nothing new, but in the past, one could re-allocate missed teaching sessions easily
– now this depends on matching the student group to the tutor at a mutually convenient
time in addition to the fact that one has to find the right sized lecture room.
The last two years of entry into medical school have seen an explosion in the numbers of
students, out of all proportion to resources. This raises the issue of ensuring consistent
and reliable high quality education and most pertinent, the acquisition of clinical skills
may be jeopardised. The Faculty has already looked at this issue and published reports in
the past to stress we cannot continue to guarantee adequate exposure to clinical medicine
should entry numbers keep increasing. We have probably reached saturation point and
our testing field will be the coming year.
Dare I ask, is it time to limit entry to medical school by introducing an assessment
process for all, not just for applicants with overseas qualifications. Should this be
expanded to all applicants? We have the availability of well organized, tried and tested
tools, such as UKCAT, the UK Clinical Aptitude Test, but this comes at a cost. In a
recent publication, the UKCAT was found to be ‘a reasonable proxy for A levels in the
selection process’.10 Other methods used include models, such as the Personal Qualities
Assessment, PQA, based on psychometric tests to measure cognitive skills and to assess
personality and interpersonal skills.11
Scientific aspects
I return to our science graduates. I am pleased that here with us today we also have
postgraduate and doctoral students, who have been involved in a variety of scientific
projects. I congratulate those whose research already shows the promise of international
impact.
I have already alluded to pathology as a bridge between science and clinical medicine.
Pathology has offered a masters for a number of years but conscious of the diversity of
disciplines it encompasses, based on pure and applied science, we have recently changed
the degree name from Masters in Pathology to Masters in Biomedical Sciences, reflecting
the mixture of specialties covered by our programme. This degree is now offered to
undergraduates from science faculties, some of whom are with us here today. We hope to
attract more science undergraduates to our programme.
The challenge in science is the ever expanding technology. Therefore we must invest in
new technologies; this is essential if we are to partner with foreign research groups. We
therefore welcome the European Regional Development Fund, ERDF, funding obtained
by Faculty, through which several departments have benefited in terms of laboratory
space and equipment, intended to be used for collaborative research projects within the
Faculty. Science has to be of relevance to the local community and the economy. The
Faculty has identified thematic areas of research interest. I am pleased to see research
posts being advertised as well as more funds becoming available for postgraduate and
doctoral students, and more medical specialists taking up the academic challenge.
We must foster the interaction between medicine and the basic sciences. And particularly
we should believe in the research capacity of medical graduates. The problem is how to
define research quality in medical academic output?12 Research should certainly be of
approved scientific standard and ideally now it should not only be relevant to clinical
practice, but also be of global health significance. However just relying on impact factors,
as accepted in basic science, may be doing medical research an injustice. In healthcare,
research may have a ‘benefit score’ despite not being in a journal publication and an
‘impact on policy or practice through dissemination by means other than journal
publication.’13 Medical practitioners also collaborate strongly with hospital colleagues
and there is often such perfect integration that it is difficult to pinpoint demarcation of
duties and funding but this is generally poorly understood by other academics. There
should be an attempt to forge proper links with non university collaborators and to
allocate resources proportionately to outputs.
Conclusion
The authors of the 2005 Millbank Memorial publication,14 define academic medicine as
the ‘capacity’ of the health sector to ‘think, study, research, discover, evaluate, innovate,
teach, learn, and improve.’ The university has traditionally undertaken the education of
our future doctors and scientists in healthcare but the postgraduate education of our
doctors and the service work are irrevocably linked to the success of a professional
career. Co-operation between the stakeholders is imperative to uphold the standards of
the Maltese medical profession.
I want to end by once more congratulating all our graduands from medicine and science
and to the medical graduates I want to add how proud I am to have been part of your
success. Take time to look back on the magical student years. This invitation has taken
me back 30 years to my graduation as a medical doctor. I still treasure the time and
money I invested in my professional development. I urge you to do the same. Again I
say, this is just the beginning, so step forward with heads held high to face the future. I
wish all of you the best of success in all your endeavours.
___________________________
1
Bell J. Redefining disease. Harveian Oration. London: Royal College of Physicians.
(2010).
2
Doctors in Society: Medical professionalism in a changing world. Report of a Working
Party of the Royal College of Physicians of London. London: Royal College of
Physicians. (2005a).
3
Levenson R., Dewar S., Shepherd S. Understanding Doctors: Harnessing
professionalism. London: The King’s Fund. (2008).
4
Levenson R., Atkinson S., Shepherd S. The 21st century doctor: Understanding the
doctors of tomorrow. The King’s Fund. (2010).
5
Guidelines for Medical and Dental Students: Professional Values and Fitness to
Practice. Medical Council Malta. (2010)
6
Ethics of the Medical Profession. SL 464.17, Schedule A 1(a).
7
IFMSA Policy Statement. The Bologna Process in Medical Education beyond 2010.
Report of the 8th International Follow-Up Workshop on the Bologna Process in Medical
Education. (2009).
8
Directive 2005/36/EC of the European Parliament and of the Council of 7 September
2005 on the recognition of professional qualifications, Article 24(2).
9
Faculty of Medicine & Surgery Curriculum Committee. Working Document (2008).
10
James D., Yates J., Nicholson S. Comparison of A level and UKCAT performance in
students applying to UK medical and dental schools in 2006: cohort study, British
Medical Journal, 340:c478 (2010).
11
Bore M., Munro D., Powis D. A comprehensive model for the selection of medical
students. Med Teacher, 31:1066-72 (2009).
12
Watts G. Beyond the impact factor. British Medical Journal, 338:b553 (2009).
13
Buxton M., Hanney S., Packwood T., Roberts S., Youll P. Assessing benefits from
Department of Health and National Health Service research and development. Public
Money and Management, 20:29-34 (2000).
14
Underwood T.J. and (ICRAM) International Campaign to Revitalise Academic
Medicine. The future of academic medicine - five scenarios to 2025, New York, USA,
Milbank Memorial Fund (2005).