Settings for learning: the community beyond

The primary objective of medical education to medical students should not be the recruitment of specialists or to provide instructions about highly sophisticated clinic medicine. Our responsibility towards them is rather to enable them to learn about medical practice in its most prevalent context, which is the community medical practice, and to contribute to their general medical education and the health welfare of their community. The health needed by the nation cannot possibly be provided by specialists. It is a task for all doctors. If we agree that the ultimate goal of medical education is to secure health and proper care (whether primary, secondary or tertiary) for the population, medical curricula and learning settings should be open for any modifications that ensure a proper approach to our patients' practicalities, resources and needs. A major modification involved in that process would be for the educational setting to move from the hospital into the community and doctors to acquire the skills and conviction of working as part of a health team, in which they are not necessarily the leaders. The main social target of the World Health Organization and its member states, and in fact the main goal of humanity, is 'Health for All by the year 2000' through primary health care (HFA/PHC). Health systems of countries will have to be reoriented, so that they are based on the PHC approach. Health personnel are needed to service those health systems which are relevant to the needs of HFA/PHC, and hence whose education should be relevant to this major goal. This does not mean that by the year 2000 doctors and nurses will provide medical care for everybody or that sickness and disability will be eradicated. It does mean, however, that health begins at home, in schools and in factories, and that health care services should be available in those places and should respond to the needs expressed in those places. It is there, where people live and work, that health is made or broken. It does mean that essential health should be accessible to all individuals and families in an acceptable and affordable way, and with their full involvement. Health personnel should be trained according to the plans of integrated health services and health manpower development (HSMD), with a view of placing at the disposal of the system the right kind of manpower, in the right numbers, at the right time, in the right place (WHO 1979, 1985, 1987). Graduates of programmes based on problem-based, community-oriented tracks as opposed to the traditional track should certainly be able to: respond to the health needs and expressed demands of the community, work with the community, stimulate healthy lifestyles and self-care, educate the community as well as their co-workers, solve and stimulate the resolve of both individual and community health problems, orient their own as well as community efforts to health promotion, prevent disease, unnecessary suffering, disability and death, work in and with health teams, if necessary provide leadership to such teams, continue learning lifelong so as to keep competence up to date, and improve this competence as much as possible (Fülöp 1990). A limited literature is available comparing innovative and conventional medical curricula, where the innovative one is based on problem-solving learning with a community-oriented track geared towards community needs (Schmidt 1983). This approach showed that the outcome is better, if directed towards the health needs of the community.