Clinical training at Oxford: old skills, new tricks and a hard act for me to follow. Reflections from the new DCS
Dr Catherine Swales, Director of Clinical Studies
It’s not easy taking over a success story. There’s something much more comfortable about leaping in to the rescue – to a school that has unhappy students, miserable faculty, poor outcomes and multiple high-level recommendations from the GMC. Within that context, what could possibly go wrong? To put my succession into the Oxford context however, when I was appointed one of my closest friends in the Division commented: “You’ll be fine, just don’t crash it!”...
But there is a risk of being at cruising altitude – and complacency, even a hint of unassailable arrogance, is our worst enemy. If we’re not careful, coasting at the dizzying heights, the ground will come up to meet us. It’s not just a risk of actual loss, but also of projected loss – we need to be thinking not only what does the School need now and in the next few years, but actually what does British Medicine need in the next 15 or 20 years, and how can we produce happy fulfilled graduates who meet those requirements? Our landscape is changing rapidly: academically, politically (how long did you think I’d wait before mentioning Brexit?) and financially. Add in a healthy, and appropriate, blob of patient and public perception and we’re in uncertain terrain indeed. But there’s the joy. The challenge of meeting these interdigitating pressures, with students first and foremost and absolutely at the heart of it, that’s the best bit of all.
From a student perspective, a crucial element is a sense of belonging. Meaningful experiential learning matters. When they feel part of the team, of the firm, that they have something to contribute whilst they learn, the ‘doing as well as the knowing’ becomes second nature – and then that patient is never forgotten, a drug interaction is always remembered, a style is adopted, and professional character built and cemented. Sadly, this form of cognitive apprenticeship is under threat from a number of factors (some of which are beyond the control of the Medical School or supervising consultants), not least the way patient care is delivered. Teams are more fluid than previously, patients are in hospital for less time, and their presentations are more complex, with the rise of multimorbidity and frailty. This is the point at which virtual learning environments and simulation training can step in – and we’re funding and developing these initiatives, which will improve student learning hugely. But as innovative and exciting as these things are, there remains no substitute for spending time on the ward and in clinic, speaking to patients (‘expert’ or otherwise), and not retreating to the library and text. Oxford Medicine wouldn’t be the same without an Osler quote – and he made the point that “…he who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all…”. The line may be gendered, but the message is timeless. There is something to be learned from each conversation or examination or review of ever and our students must recognise that too in order to benefit most; they need to be taught how to learn again in this new world. And we in turn need to learn how to examine afresh – arguably our assessment methods are currently too snapshot, and fail to adequately address broader skills, including professionalism. The postgraduate arena has recognised the value of ongoing work-based assessments, reflective learning and portfolios and we must too – and will.
So, aside from skilled, thoughtful, kind and resilient clinicians, what else might British Medicine need? A cadre of clinical academics for certain – and Oxford has always been good at not only setting people on that path, but also keeping them there (OUCAGS has an unrivalled rate of progression into independent investigators for example). But there will also be a need for clinician pharmacologists, and for bioengineers. With changing times, we need to speak to the pluripotency of our students and offer them research or alternative opportunities at several stages through their training. Intercalated DPhils already exist, and a handful take up this opportunity each year – but dedicated funding for these placements, plus research internships, an MB DPhil program with Industry experience, even formal training in Leadership and Business Management Skills are all on the cards (even if not on the immediate horizon – I’m learning quickly how slowly things can move).
I’ve already quoted Osler, but I’d like to end with Pooh Bear, who once said: “When you see someone putting on Big boots, you can be pretty sure that an Adventure is going to happen...”. And we all have very exciting times ahead, and I have very big boots to fill. This piece would not be complete without my thanks, and those of countless students, to “The Tims” – my predecessors Tim Littlewood and Tim Lancaster, for developing and sustaining both a School and graduates who made us very proud, and their patients feel very cared for. Our heartfelt admiration and gratitude to you both. In your own ways you both taught me for several years, and whilst there may be changes ahead, I fervently hope that this apple doesn’t fall too far from such wise and kind trees.
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