Community-oriented medical education

To determine whether moving clinical medical education out of the tertiary hospital into a community setting compromises academic standards. Cohort study. Flinders University four year graduate entry medical course. In their third year, students are able to choose to study at the tertiary teaching hospital in Adelaide, in rural general practices, or at Royal Darwin Hospital, a regional secondary referral hospital. All 371 medical students who did their year 3 study from 1998-2002. Mean student examination score (%) at the end of year 3. The unadjusted mean year 3 scores at each location differed significantly (P < 0.001); the mean score was 65.2 (SE = 0.43) for Adelaide students, 68.2 (0.83) for Darwin students, and 69.3 (0.97) for students on the rural programme. Mean year 2 scores were similar for each location. Post hoc tests of means adjusted for sex, age, year 2 score, and cohort year showed that the rural and Darwin groups had a significantly improved score in year 3 compared with the Adelaide group (adjusted mean difference = 3.08, 95% confidence interval 1.25 to 4.90, P < 0.001 for rural group; 1.91, 0.47 to 3.36, P = 0.001 for Darwin group). These findings show that the concern that student academic performance in the tertiary hospital would be better than that of students in the regional hospital and community settings is not justified. This challenges the orthodoxy of a tertiary hospital education being the gold standard for undergraduate medical students.

The impact of the University of Tromsø Medical School on the distribution of doctors in rural areas in northern Norway was evaluated by a postal questionnaire. The survey covered 11 graduation years (417 doctors), and the response rate was 84.2%. The establishment of a new medical school in northern Norway has clearly had beneficial effects: a total of 56.1% of the graduates stay in these remote areas. Of those who also spent their youth in northern Norway the proportion is 82.0%, compared to graduates who lived in the southern parts of the country while growing up (37.7%). The results clearly demonstrate that one of the main goals for the Medical School at the University in Tromsø, to educate doctors who prefer to work in these rural areas, has been accomplished.

With Health for All as a social goal and a reference point, medical schools must create new alliances within the health sector and with other sectors bearing on health. The future role and responsibility of the medical school should reflect the likely essential features of the future health system and the aptitudes that medical practitioners will have to possess. Medical schools should be encouraged not only to shape their educational programs accordingly, but also to devote energy and resources to the considerable task of creating opportunities for this new practitioner. Quality in medical education results from a coordinated effort to ensure relevance and efficiency in the education of future doctors and to ensure these doctors' optimal fit in society. Implicit in the notion of quality is a special consideration for social accountability. A medical school shows social accountability through its commitment to addressing issues, or helping solve problems, identified jointly with society as priorities for both the present and the longer term, in the expectation that the medical school's action will benefit in part the local community and in part the country as a whole or the international community. Indicators of quality in medical education, as well as measurement tools, must be developed and tested in various sociocultural contexts. A taxonomy to assess the social accountability of medical schools is proposed.