The publication in 1993 by the General Medical Council of Tomorrow's Doctors—Recommendations on Undergraduate Medical Education provided the first real opportunity for many medical schools to advance the introduction of the history of medicine into the undergraduate medical curriculum. While the University of Birmingham Medical School, was not one of the first to introduce the subject, it has been at the forefront of the introduction of the history of medicine into the undergraduate medical curriculum since 1997, and can now boast a number of special study modules in the subject and the second largest intercalated BMedSc (History of Medicine) degree programme in the country. This article tells the story of why and how we introduced history into the curriculum and how important it is that tomorrow's doctors know something of the history of the profession they are about to enter.
- Medical education
- medical humanities
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The history of medicine has been around as an academic subject on the periphery of medical education for a long time. Until the last decade, however, with one or two clear exceptions, it was not taught in any structured way. What little history there was introduced many unsuspecting students to a world outside the growing biomedical constraints of the undergraduate curriculum.
In December 1993, the education committee of the General Medical Council (GMC) recommended, in its report Tomorrow's Doctors: Recommendations on Undergraduate Medical Education, a comprehensive overhaul of the undergraduate medical curriculum, with a new emphasis on evidence based medicine and self-directed learning.1 This was a major step towards attempting to abandon the old and rigidly defined and distinct preclinical and clinical components of medical education. The report referred to the importance of future medical students, and by definition future practitioners, having “approaches to learning that are based on curiosity and the exploration of knowledge rather than on its passive acquisition that will be retained throughout professional life”.1 The report gave those concerned with the expansion and integration of the history of medicine into the curriculum an opportunity to offer a new but wholly relevant learning opportunity to the majority of medical students. It was now beginning to be accepted that studying the history of medicine could develop a number of the necessary “attributes of the independent practitioner”. It was even coming to be accepted that a basic knowledge of the history of their profession was something that all medical practitioners should acquire as a matter of course. Studying the history of medicine was now being seen as offering a considerable number of benefits to medical students, broadening their educational horizons and developing their critical and analytical approaches to medical knowledge and practice beyond the rigidly biomedical and statistical preoccupation of modern medicine. It could even encourage them to see medical history as a possible research activity with potential advantages.2 Hopefully, no longer would a clinician undertaking serious work in medical history be seen as committing professional suicide.
THE BIRMINGHAM EXPERIENCE
Special study modules
The history of medicine was introduced into the new undergraduate medical curriculum in the University of Birmingham Medical School during the 1996–97 session. As the result of lobbying, it was first offered to second year MB/ChB students as one of a group of new integrated health science special study modules (SSMs) for the first time in the spring of 1997.
Each second year student is expected to take an SSM from one of two major categories—integrated health sciences or biomedical sciences. In the third year they have to choose an SSM from a list of subjects in the other category. The history of medicine SSM, consists of a series of introductory lectures, which include basic historical skills, historiography, and research methods, a brief survey of medical history from prehistory to recent times, and a mixture of traditional classroom didactic lecture-based teaching and “learning by doing.” In the second part of the module, based on self-directed learning, the students conduct their own independent study, many using primary source material, on a subject of their choice, with a half-hour supervisory session per week. The result is a 4,000 word essay. The SSMs, which last for three months, are formally assessed and have to be passed before a student can proceed into the next year. The third year SSM is taught over four weeks, but during a time when this is the students, sole activity. It follows very much the same pattern, although the emphasis in this module, entitled “Plagues and People”, is on historical epidemiology.
The second year history of medicine SSM started in a modest way with six students studying a diversity of subjects from ancient Egyptian and Greek medicine, to 20th century gastroenterology. In subsequent sessions, the class size has grown dramatically and in the 2000–2001 session it attracted thirty-seven students. The first intake of the third year SSM in the 1997–98 session saw sixteen students enrol for the module. It now attracts around thirty students per year.
Of the nearly two hundred students who have so far taken one of the history of medicine modules, the average mark has been equivalent to upper second class honours, with over twenty firsts. The structure and content of the SSMs in general were singled out for special praise by the Quality Assurance Agency/General Medical Council inspection of the medical school.
The intercalated BMedSc (History of Medicine) degree
The 1998–99 session saw the introduction of the intercalated BMedSc (History of Medicine) degree—a major step in the expansion of history of medicine teaching at the university. It is an integral part of a series of similar degree programmes, which include subjects such as ethics, public health and epidemiology, and occupational medicine, which are also open to undergraduate students from the School of Dentistry. It provides medical students between their second and third, third and fourth, or even fourth and fifth years, with the opportunity to acquire research skills and knowledge in what are termed, at the University of Birmingham, the integrated health sciences (called medical humanities elsewhere). The students undertake a series of core courses, designed to give specialist training in quantitative, qualitative, and historical research methods, critical analysis, and historiography, as well as two other major modules, which in the 2001–2002 session include “The History of Occupational Medicine and Health” and “Ancient Disease and Medicine”. During the second semester the students devote their energies to their chosen research topic, culminating in a 15,000 word dissertation. Whenever possible they are encouraged to undertake fieldwork and in recent years students have travelled as far as Poland, India, Greece, and the USA to work in libraries and archives.
During this second semester, the students continue to meet for a weekly two-hour “work-in-progress” seminar, where they have the opportunity to present interim and final research findings, to share experiences, and to practise informal and formal presentation skills. The degree is awarded on the basis of a combination of carried forward marks from the second year of the MB/ChB course, assessed essays, and an examination on research methods undertaken during the intercalated degree course and the student's dissertation, with the single largest allocation of marks being awarded to the dissertations.
In the first year, two students took the History of Medicine degree. One wrote her dissertation on the life and work of Dr Louisa Atkins, one of the very first women medical practitioners in this country and the first in Birmingham. The other wrote his dissertation on the place of electroconvulsive therapy in history and in English literature, itself an example of the potential for collaboration between the medical humanities. Both were awarded Norah Shuster Prizes by the Royal Society of Medicine, a pattern that has continued in later years. The degree has now become very popular and is attracting students from other medical schools. In the 2001–2002 session, the number of students has risen to thirteen.
The teaching of the history of medicine at the university continues to expand to meet demand and a growing interest and enthusiasm. It is now possible for students who are taking their third year module in public health and epidemiology to undertake a research project with an historical dimension. It is also possible for students to be supervised for historical projects associated with elective studies taken at the end of the fourth year; much of the project work is taken abroad. Talks are underway with the School of Dentistry on teaching the history of dentistry to dental students, and a module in the history of primary care and general practice is now offered to the postgraduate MSc (Primary Care) degree programme.
One of the attractions of all these modules and degree programmes is that they help students to begin to realise that there are other intellectual dimensions to the university and student life, outside the narrow confines of modern biomedicine, local teaching hospitals, and general practitioners' surgeries. However, the objectives of developing their literary, communication, computer, and research skills, as trainee medical practitioners, are also being fulfilled.
The University of Birmingham has a large and rapidly growing medical school, having received in recent years the largest single allocation of additional student places to an existing medical school. This will continue to open up further opportunities for the history of medicine. What is significant through all this, however, is that this development in the place of the history of medicine has occurred without resources from external funding bodies and has led to the creation of the Centre for the History of Medicine. The centre now has a staff of five and has a mandate to develop high quality research as well as high quality teaching.
One thing we can be sure about is that history really matters. As Michael Biddiss, Professor of History at the University of Reading, has reminded us, whilst the knowledge that historians acquire has to be valued above all for its own sake, we can also appreciate its ability to assist us, as individuals, to develop a better judgment of our own context in time. If properly used, such knowledge possesses a transferability of application to other areas. Historical study, by virtue of its range, findings, and methods can contribute both to individual self knowledge and to wider social comprehension, and furthermore can claim to be regarded as a vital ingredient in any project of medical education, as much as in preparing for any other profession that aspires to transcend mere training.3
There is always room for development and expansion. Although the attitudes of many clinicians towards history are certainly becoming more positive, the pace of its total integration into the undergraduate medical curriculum remains a little slower than we had originally hoped. In fact, some medical schools have yet to embrace the new curriculum, let alone the teaching of the history of medicine, even when there are qualified teachers willing and able to do so. It is now possible, however, to create and expand intercalated degree programmes, given the recent decision that six years of medical (and dental) education will be fully funded by local education authorities. This can provide opportunities for a much deeper understanding of the history of medicine to gain ground at an early stage of student careers, bringing with it great benefits in the enlargement of the mind and a much greater openness to experience in the future.
I return to where I started—why teach the history of medicine? The case has been made and the skills that a medical practitioner can acquire by studying it are obvious. However, we must never lose sight of our second objective, that is to provide tomorrow's doctors, in any way we can, with some knowledge of the profession into which they are about to enter. We must get away from what Sir David Weatherall has described as “... the blissful ignorance of the history of our field which has characterised most British medical graduates (and their teachers) over the past 30 years”.4
We must always remember, however, that we are training tomorrow's doctors, not historians. If we are successful in fostering critical thinking, we shall also instil scepticism about the content and durability of everything else taught on the curriculum. We must also demonstrate that history is a research discipline, built on questions, rigorous methods, and a wide variety of sources, not unlike those in biomedical science. These standpoints reinforce the new attitudinal objectives for all in medicine towards lifelong learning, adaptation to change, and the expansion of research horizons far beyond the petrie dish towards the wider world of conceptual and social structures.5