Where should we train doctors in the future?

Less in hospitals, more in general practices From the early nineteenth century until the late twentieth century it has seemed natural, indeed obvious, that medical students should receive their clinical education in teaching hospitals where medical skill and patients with serious illness were concentrated. This system is now under educational and financial threat. Professional and demographic changes and the action ofmarket forces require a review ofthe fundamental assumptions of basic medical education. Educationally, the threats can be divided into those that are already with us and those that are as yet only grim prospects. Dwindling local populations combined with the concentration of tertiary care facilities in teaching centres have seriously unbalanced an already highly unrepresentative case mix. The gradual loss of general physicians and surgeons from the staffs of teaching hospitals means that the teaching that students receive has become both more specialised' and more subject to chance. Specialists' interests bias the cases referred to them, which inevitably biases the teaching given to students attached to their firms. Luck usually plays a larger part in what students learn than does curricular planning. Other educational threats come from the near certainty that time and enthusiasm for teaching will be squeezed both by the service consequences ofAchieving a Balance2 and the absolute necessity for academic departments to boost their income from grants and their output of research. Finally, at a practical level, every pressure for shorter hospital stays and more intensive investigation, day care surgery, and community care reduces the opportunity for students to study illness by the patient's hospital bed. At the same time the financial outlook is very uncertain. The future of the service increment for teaching and research still worries deans. The Department of Health's call for action to unravel the longstanding "knock for knock" arrangements between universities and health authorities may have become temporarily less insistent, but in the NHS of the 1990s managers are not going to be content to allow specialists to devote time to teaching without this time being somehow quantified and paid for. Even less can be expected if teaching hospitals opt for independent trust status. What is the alternative to simply gritting our teeth and making the most of whatever resources are available? It is crucial to remember that we are considering basic medical education-that which all medical graduates should experience before choosing and training for a specialty. Although it cannot be deep, …