Influence of a problem-based learning curriculum on the selection of pathology as a career: evidence from the Canadian match of 1993-2004

Since the introduction of problem-based learning (PBL) to North American medical education more than 30 years ago, there have been a number of analyses of its educational outcomes. Several authors have suggested that PBL may influence medical students' career choices. The balance of opinion in the pathology literature appears to assume that PBL curricula limit students' contact with pathologists and hypothesizes that PBL may impair recruitment into pathology residency programs. To evaluate this latter hypothesis, evidence from the 1993-2004 Canadian residency match was considered. During this period, 8 of 13 English-language medical schools in Canada changed from a non-PBL to a PBL curriculum; 1 had been using a PBL curriculum even before the 1993 start point and 4 remained using a non-PBL curriculum throughout the period under consideration. The proportion of medical school graduates ranking pathology first in their residency application match is compared between PBL and non-PBL medical schools. On average, 1.1% of non-PBL graduates and 1.2% of PBL graduates ranked a pathology residency program first. In general, there were proportionately slightly more pathology recruits from non-PBL schools at the beginning of the 1993-2004 period and slightly more pathology recruits from PBL schools toward the end of the period. In the absence of a nationally or internationally recognized standard for what constitutes a PBL school, this analysis must remain somewhat subjective. However, it does indicate that graduates from PBL schools are approximately as likely as those from non-PBL schools to rank pathology first in residency applications.     

Training U.S. medical students to care for the chronically ill.

PURPOSE: The growing prevalence of chronic illness has important implications for the training of all physicians. The authors assessed the degree to which undergraduate medical curricula explicitly address chronic care competencies selected through literature and expert review. METHOD: In 2001, trained student assistants interviewed directors of required medical school courses (internal medicine, pediatrics, family practice, and ambulatory care clerkships; longitudinal care; and other relevant courses) at 16 representative U.S. medical schools sampled by geography, curriculum reform activity, and primary care orientation of graduates. Course directors were asked whether chronic care competencies were addressed using specific curricular methods (written objectives, course materials, observational evaluations, written/oral examinations, other required course activities), and to rate the importance (1 = not important; 5 = essential) of each competency for their course and for the overall undergraduate curriculum. RESULTS: All 70 eligible course directors responded. Of 49 chronic care competencies, 29 (59%) received mean importance ratings for a course of >/=3, but only 14 (29%) were addressed using two or more specific curricular methods. Course directors gave highest importance ratings (mean > 3.9) to screening for abuse, awareness of patients' sociocultural perspectives, and protecting patients' confidentiality. They gave lowest importance ratings (mean 相似文献   

Charting the winds of change: evaluating innovative medical curricula

The increased interest, in North America and around the world, in problem-based and community-oriented medical curricula has sparked interest in the evaluation of these innovative programs. In January 1989, the Josiah Macy Jr. Foundation sponsored a conference to consider designs for evaluation studies and the potential distinctive outcomes of the innovative curricula that might be foci of these studies. After defining an "innovative curriculum," the participants identified seven characteristics of "important evaluation studies," particularly endorsing studies that compare curricula as whole entities. The participants then identified 26 areas where differences between graduates of innovative and traditional curricula might be expected, and five equally important areas where differences are not expected. Distinctive outcomes of innovative curricula were anticipated in areas such as interpersonal skills, continuing learning, and professional satisfaction. Overall, these recommendations are offered to stimulate creative evaluations of the growing number of innovative programs in medical education.     

Preparing the ground: contributions of the preclinical years to medical education for care near the end of life. Working Group on the Pre-clinical Years of the National Consensus Conference on Medical Education for Care Near the End of Life.

The preclinical years of medical education have rich potential for preparing medical students to provide optimal end-of-life care. Most of the opportunities and settings for this education already exist in the curricula of most medical schools, although they are underutilized for this purpose. In this report The Working Group on the Pre-clinical Years of the National Consensus Conference on Medical Education for Care Near the End of Life identifies the most promising settings and suggests how they might be used for maximum benefit in end-of-life education. Basic end-of-life care competencies are in five domains: (1) psychological, sociologic, cultural, and spiritual issues; (2) interviewing and communication skills; (3) management of common symptoms; (4) ethical issues; and (5) self-knowledge and self-reflection. A centralized group should oversee educational activities related to end-of-life care at each medical school. This group would identify and facilitate teaching opportunities in the preclinical curriculum: basic science courses; problem-based learning seminars; courses in interviewing, the doctor-patient relationship, and introduction to clinical medicine; courses in ethics, humanities, and the social-behavioral sciences; clinical preceptorships; and longitudinal experiences with patients. The group would also assess the potential impact of the "hidden curriculum."     

Comparing self-reported communication skills of medical students in traditional and integrated curricula: a nationwide study

OBJECTIVES: To investigate medical students' self-assessments of their communication skills through medical school related to background factors, curriculum design and perceived medical school stress. METHODS: Medical students at all year levels attending Norwegian universities in the spring of 2003 were mailed the Oslo Inventory of Self-reported Communication Skills (OSISCS) developed by the authors. Of the total number of students (N=3055), 60% responded. One school had a traditional curriculum, the other three ran integrated models. RESULTS: Students assessed their instrumental communication skills to increase linearly year by year, while the relational skills showed a curve-linear trajectory reaching the optimum level half-way into the curriculum. Students attending the traditional school reported lower levels of instrumental skills compared to the students from the integrated schools. In relational skills, a similar difference was maintained half-way into the curriculum, but disappeared towards the end. Perceived medical school stress correlated to the self-reported end point levels of the two types of communication skills. DISCUSSION: The trajectories of self-reported instrumental and relational skills indicate significant variations in facilitating mechanisms between curricula, cognitive processing and perceived medical school stress. CONCLUSIONS: Self-reported instrumental and relational communication skills develop differently in medical students over the years according to the type of curriculum. PRACTICE IMPLICATIONS: Curricula should be evaluated for improvement implementations.     

Preparing graduates for the first year of residency: are medical schools meeting the need?

PURPOSE: Changes in graduate medical education associated with full implementation of the Balanced Budget Act of 1997 have required medical schools to review and revise their curricula. As limited funding increases pressures to streamline training, residencies will potentially expect an entry level of skill and competence that is greater than that which schools are currently providing. To determine whether medical school curricular requirements correlate with residency needs, this multidisciplinary pilot study investigated expectations and prerequisites for postgraduate specialty training. METHOD: A questionnaire about 100 skills and competencies expected of new first-year residents was sent to 50 U.S. residency directors from surgery, internal medicine, family medicine, pediatrics, and obstetrics-gynecology programs. Each director was asked to state expectations of a first-year resident's competence in each skill at entry to residency and after three months of training. Skills deemed most appropriately acquired in residency were also identified. Competencies included diagnosis, management, triage, interpretation of data, informatics and technology, record keeping, interpersonal communications, and manual skills. RESULTS: A total of 39 residency directors responded, including seven surgery, nine medicine, seven family medicine, eight pediatrics, and eight obstetrics-gynecology. In addition to physical examination skills, 13 competencies achieved more than 70% agreement as being entry-level skills. There was wide variability as to the relative importance of the remaining skills, with residency directors expecting to devote significant resources and time in early training to ensure competence. CONCLUSIONS: Medical schools should consider the expectations of their students' future residency directors when developing new curricula. Assuring students' competencies through focused curricular change should save both time and resources during residency.     

Care at the end of life: a novel curriculum module implemented by medical students.

End-of-life (EOL) and palliative care education in medical school curricula stand at a crossroads. Consensus has emerged that these topics merit systematic instruction throughout medical school training, yet curricula all too often consist of sporadic lectures focused on bioethics instead of clinical skills. The medical student authors identified a deficit in their curriculum, and designed and implemented an EOL curriculum module for their colleagues. In early 2000 the authors surveyed senior medical students about their experiences with EOL and palliative education, identifying deficits in clinical training and recommendations for interventions. They then designed a case-based educational module to teach EOL communication skills to medical students commencing clinical training. Faculty with national and local experience with EOL and palliative care reviewed the curriculum. Twelve of these faculty were oriented to the curriculum and then taught it in pairs to groups of 12 to 16 medical students in 2000 and 2001. The curriculum develops skills, attitudes, and knowledge relevant for communicating bad news and establishing treatment options in the EOL setting by utilizing trigger videos, group discussion, role plays, and case discussions. Approximately 75% of the 86 eligible students attended the module in 2000 and 2001. Feedback has guided the curriculum's refinement by the medical student authors. In addition, a standardized patient exercise, introduced in 2001, allowed students to reinforce the skills learned during the module.     

Medical education in Japan.

There are 79 medical schools in Japan--42 national, 8 prefectural (i.e., founded by a local government), and 29 private--representing approximately one school for every 1.6 million people. Undergraduate medical education is six years long, typically consisting of four years of preclinical education and then two years of clinical education. High school graduates are eligible to enter medical school. In 36 schools, college graduates are offered admission, but they account for fewer than 10% of the available positions. There were 46,800 medical students in 2006; 32.8% were women.Since 1990, Japanese medical education has undergone significant changes, with some medical schools implementing integrated curricula, problem-based learning tutorials, and clinical clerkships. A model core curriculum was proposed by the government in 2001 that outlined a core structure for undergraduate medical education, with 1,218 specific behavioral objectives. A nationwide common achievement test was instituted in 2005; students must pass this test to qualify for preclinical medical education. It is similar to the United States Medical Licensing Examination step 1, although the Japanese test is not a licensing examination.The National Examination for Physicians is a 500-item examination that is administered once a year. In 2006, 8,602 applicants took the examination, and 7,742 of them (90.0%) passed. A new law requires postgraduate training for two years after graduation. Residents are paid reasonably, and the work hours are limited to 40 hours a week. In 2004, a matching system was started; the match rate was 95.6% (46.2% for the university hospitals and 49.4% for other teaching hospitals).Sustained and meaningful change in Japanese medical education is continuing.     

How can the postgraduate training program in pathology departments in India be improved?

There exists a wide variation in the competence of the postgraduate residents trained in pathology in different institutions across India. This results in strong disparities in the clinical diagnostic skills, teaching skills, research capabilities and the managerial skills of the graduates. The end users of this training, namely the community, clinicians and health care institutions would benefit from a more uniform and better trained pathologist. The article reviews the reasons for the variation in the quality of the training programs. The main deficiencies include, lack of well-defined criteria for recruitment of residents, training facilities, faculty resources, curriculum with well-defined learning objectives and competencies, hands-on experiences in diagnostic and research activities, diagnostic specimens and medical autopsies, exposure to molecular pathology, pathology informatics, electron microscopy, research experiences, communication skills, professional behavior and bioethics, business practices in pathology and quality assurance. There is also a lack of defined career tracks in various disciplines in laboratory medicine, standard protocols for evaluation and regional and national oversight of the programs. The steps for rectification should include defining the competencies and learning objectives, development of the curriculum including teaching methods, facilities and evaluation strategies, communication skills, professional behavior skills, teaching skills, legal aspects of practicing pathology and the various career pathways to subspecialties in pathology. The training should include defined exposure to molecular pathology, electron microscopy, quality control and assurance, laboratory accreditation, business aspects of pathology practice, review of literature, evidence-based medicine, medical autopsy and medical informatics. Efforts should be made to share human and laboratory resources between regional cooperation. The oversight and accreditation policies should be evolved and well-documented. Web-based platforms need to be developed for easy interaction among residents, faculty and administrators on a national level.     

Natural and traditional medicine in Cuba: lessons for U.S. medical education.

The Institute of Medicine's (IOM's) Academy of Science has recommended that medical schools incorporate information on CAM (complementary and alternative medicine) into required medical school curricula so that graduates will be able to competently advise their patients in the use of CAM. The report states a need to study models of systems that integrate CAM and allopathic medicine. The authors present Cuba's health care system as one such model and describe how CAM (or natural and traditional medicine) is integrated into all levels of clinical care and medical education in Cuba. The authors examine the Cuban medical school curriculum in which students, residents, and practicing physicians are oriented in the two paradigms of CAM and allopathic medicine. Only health professionals are permitted to practice CAM in Cuba; therefore, Cuba's medical education curriculum incorporates not only teaching about CAM, but it also teaches basic CAM approaches and clinical skills. Both the theory and practice of CAM are integrated into courses throughout the six-year curriculum. Similarities and differences between the U.S. and Cuban approaches to CAM are examined, including issues of access and cost, and levels of acceptance by the medical profession and by the public at large in both countries. The authors conclude that there is potentially much to learn from the Cuban experience to inform U.S. medical educators and institutions in their endeavors to comply with the IOM recommendations and to incorporate CAM into medical school curricula.     

Status of gross anatomy in the U.S. and Canada: Dilemma for the 21st century

As a component of a recent academic review, the Department of Anatomy and Neurosciences faculty at the University of Texas Medical Branch in Galveston, Texas, developed a questionnaire designed to compare the curricula, direction, and challenges of their department with the approximately 140 anatomy departments in the U. S. and Canada. The response was overwhelming in that over 80% of the schools returned a completed questionnaire. One of the areas of interest revealed by this survey was a growing concern over significant changes in both medical school curricula and the future of anatomy departments. Most departments still used traditional lectures to present course material and the majority of the scheduled contact hours were in the dissection laboratory; however, other teaching formats, such as case studies and small group discussions, accounted for significantly more of the teaching effort. Nearly 20% of the schools were making major modifications in their teaching methods. The general trend was to include more integrated, problem-based learning and computer-assisted teaching while reducing overall content, didactic lectures, and rote memorization. The role and need for traditionally trained gross anatomists in medical education appeared to be diminishing as curricular reform moved toward more student-directed, faculty-facilitated programs. Concurrently, the recruitment and career development of gross anatomy faculty appeared to be influenced more by funding status than by academic training or teaching experience, as most departmental chairman were willing to hire non-anatomists and “train” them to assume an often reduced teaching load in gross anatomy courses. In addition, fewer graduate students were being trained in classical gross anatomy, a trend that better suited the emerging student-directed medical school curricula. The reduction in classically trained anatomists also appeared to reflect the widespread practice whereby anatomy faculty were rewarded far more for research than for teaching. Although the continued inclusion of gross anatomy in medical education appeared to be assured, its traditional mode of presentation and academic prominence will likely change by the turn of the century. © 1994 Wiley-Liss, Inc.     

Implementing a problem-based learning curriculum in an Argentinean medical school: implications for developing countries.

The authors review the difficulties that Argentina's medical schools, particularly the public ones, are likely to face when implementing a problem-based learning (PBL) curriculum, describe the barriers that were faced by their medical school as it implemented PBL, and point out the implications for medical education in developing countries with conditions and education programs similar to those in Argentina. Specifically, they (1) outline the basic requirements for successful implementation of a PBL curriculum, (2) describe the training contradiction in Argentina between a complex and heterogeneous health care system that forces specialization and medical schools' attempts to train generalists, and (3) review the effects on curriculum change of the size and the training levels of the student population and the availability of human and financial resources. This information indicates the context in which the Rosario University School of Medicine designed a new PBL curriculum and implemented it in 2002. The authors close by suggesting that schools in developing countries that are in circumstances similar to that of Rosario should consider whether a PBL curriculum is even appropriate for them, and should realize the difficulties (discussed in the article) they will have to overcome. Also, uncertainties about the efficacy of PBL create a case for exploring alternatives to PBL, including hybrid curricula. Considering the available research on curricular innovations such as PBL and the particular situations of their countries may help schools anywhere avoid wrong decisions about what curricula to implement.     

Contribution of academic departments of general practice to undergraduate teaching, and their plans for curriculum development.

BACKGROUND. In 1991, the General Medical Council suggested the development of a new undergraduate curriculum, on a 'core plus electives' basis. The combination of National Health Service reforms and the rising profile of academic departments of general practice had led to a consideration of general practice as an alternative teaching environment. These departments now face escalating expectations from their medical schools of their ability to provide additional community based teaching. AIM. The aim of this study was to investigate the present contribution of academic departments of general practice to undergraduate teaching and their plans for curriculum development, including the introduction of community-based clinical skills teaching. METHOD. A questionnaire was circulated in June 1993 to all academic departments of general practice in the United Kingdom and Eire. RESULTS. Twenty seven out of 28 questionnaires were returned. Twenty two departments provided pre-clinical teaching and all provided a clinical practice attachment. Eight medical schools were organizing community-based clinical skills teaching, and in two this formed the basis for a community-based medical attachment. Eight planned to reduce the factual content of their curricula and introduce problem-based learning while nine were contemplating a 'core plus electives' option. Fourteen medical schools had primary care input in teaching basic clinical skills and an additional seven planned to introduce this. Problems encountered by the general practitioner tutors in teaching clinical skills included insufficient time and resources and poor self-esteem; they identified a need for good central and peripheral organization. CONCLUSION. Compared with a 1988 study, academic departments of general practice are increasingly involved in teaching both general practice and general medical skills at undergraduate level. Curriculum change is occurring rapidly, with an increasing trend towards community teaching; the implications for both academic departments and general practitioner tutors are discussed.     

Development of a palliative education assessment tool for medical student education.

Studies assessing palliative care education in U.S. medical schools reveal that little attention is paid to this topic. Although core competencies have been defined, few schools have implemented effective means to incorporate formal palliative care education into undergraduate curricula. To promote reform, each school needs to conduct a thorough assessment to identify palliative care content throughout the four-year curriculum. The authors developed an innovative assessment instrument to facilitate curricular mapping of palliative care education. The Palliative Education Assessment Tool (PEAT) comprises seven palliative care domains: palliative medicine, pain, neuropsychologic symptoms, other symptoms, ethics and the law, patient/family/nonclinical caregiver perspectives on end-of-life care, and clinical communication skills. Each domain details specific curricular objectives of knowledge, skills, and attitudes. Designed as a flexible self-assessment tool, PEAT helps determine the existence of palliative care education, which usually is found in various formats throughout a medical school's curriculum and thus sometimes "hidden." PEAT enables educators to describe a specific, multidimensional aspect of the curriculum and use the information for strategic planning, educational reform, and evaluation. The curricular reform implications of such an instrument are broader than palliative care assessment. A modified version of PEAT can be used to assess systematically other topics that are taught in various formats in the curriculum and to develop collaborative approaches to fulfilling the educational objectives of those topics.     

Problem-based learning: an assessment of its feasibility and cost

As our knowledge of human biology becomes more complex and the medical school applicant pool declines, there is ample reason to consider an alternative to the conventional medical curriculum. Many authorities feel that a format incorporating problem-based learning (PBL) would be more appropriate and effective. The problem-based medical curriculum is one in which facts and principles are learned in the context of a clinical problem. Problem-based medical education began as a revision of the McMaster University medical curriculum in 1969 and was instituted in the United States as a problem-based experimental track at the University of New Mexico School of Medicine in 1979. The first completely integrated, totally problem-based, McMaster-type, medical curriculum in the United States began operation in 1982 with the establishment of Mercer University School of Medicine. Many years of experience at these three institutions have shown that the problem-based curriculum works well. Several medical schools throughout the world are either practicing PBL or investigating the feasibility of adopting it. A comparison of the costs (in faculty time) of problem-based and conventional pathology programs suggests that the PBL curriculum is quite feasible for schools with a class size of 60 or less and may be so for many schools and programs with classes of less than 100.     

Competencies in nutrition that U.S. medical students should acquire

The nutrition education that most medical students receive is inadequate in quantity and quality, according to the National Research Council, which conducted a study of nutrition education in one-third of the medical schools in the United States. This finding stimulated the creation of the present study, which identified basic competencies in the field of nutrition that medical students should acquire and obtained the opinions of 484 medical school faculty members concerning both the importance of these competencies and where in the medical school curriculum students should acquire them. Of 39 competencies, the faculty members judged that 33 should be included in medical school curricula. Those rated most important were competencies in the use of enteral and parenteral feeding techniques in patient therapy, the improvement of fluid and electrolyte imbalances, and knowledge of the role of nutrition in the identification and management of selected disease states. There was significant agreement in ratings and curriculum placements by preclinical and clinical faculty members.     

Assessing residents' competencies at baseline: identifying the gaps.

PURPOSE: Entering residents have variable medical school experiences and differing knowledge and skill levels. To structure curricula, enhance patient safety, and begin to meet accreditation requirements, baseline assessment of individual resident's knowledge and skills is needed. To this end, in 2001 the University of Michigan Health System created the Postgraduate Orientation Assessment (POA), an eight-station, objective structured clinical examination for incoming residents. METHOD: The POA, administered at orientation, included items addressing critical laboratory values, cross-cultural communication, evidence-based medicine, radio-graphic image interpretation, informed consent, pain assessment and management, aseptic technique, and system compliance such as fire safety. The POA assessed many of the skills needed by interns in their initial months of training when supervision by senior physicians might not be present. RESULTS: In 2002, 132 interns from 14 different specialties and 59 different schools participated in the POA. The mean score was 74.8% (SD = 5.8). When scores were controlled for U.S. Medical Licensing Examination scores, there were no significant differences in performance across specialties. There were differences between University of Michigan Medical School graduates and those from other institutions (p <.001). Eighty-one percent of the residents would recommend the POA. CONCLUSIONS: The POA provides a feasible format to measure initial knowledge and skills and identify learning needs. Orientation is an effective time to identify important gaps in learning between medical school and residency. This is the first step in a continuing evaluation of the Accreditation Council for Graduate Medical Education's general competencies.     

Are we serious about teaching professionalism in medicine?

Medical professionalism is an increasingly common topic of discussion in the medical education literature. Much of the recent literature on this subject addresses areas of weakness in the educational curricula of medical schools and residency programs. But students are living a world in which professional behavior is being redefined, often in ways that run contrary to the medical education curriculum. This article outlines three fundamental challenges that powerfully affect the ability to promote professionalism in students and young physicians. To overcome these challenges, the author suggests four steps that can be taken in the medical education community. First, medical schools should address cost and access to care as first-order intellectual problems and should encourage research programs in these areas. Second, schools should develop programs to humanize science and restore scientific integrity beyond the requirements of compliance programs. Next, medical school leaders should celebrate those who best embody moral leadership in the profession. Finally, the medical education community should acknowledge that the availability of affordable health care to the public depends on the practice choices of medical school graduates and should accept greater responsibility for this outcome.     

Competency-based goals for sleep and chronobiology in undergraduate medical education

STUDY OBJECTIVES: Sleep and circadian rhythms are biologic processes operative in health and disease, but as yet there is no articulated curriculum for undergraduate medical education. DESIGN: A multidisciplinary expert-opinion approach was utilized to assess and define education objectives and the potential for implementation. SETTING: N/A. PATIENTS OR PARTICIPANTS: National Institutes of Health Sleep Academic Awardees. INTERVENTIONS: N/A. RESULTS: Four competencies with examples of instruction objectives were identified relating to sleep processes and sleep need, the impact of sleep and sleep disorders on human illness, the sleep history, and the application of sleep physiology and pathophysiology to patent care. Various strategies and tools are currently available for implementation and assessment of learning objectives for these knowledge and skills. CONCLUSION: The core competencies can be designed to improve physician knowledge and skills in recognizing and intervening in sleep problems and disorders. Learning objectives can be immediately incorporated into most medical school curricula. At the same time, these competencies serve as an important bridge across multiple medical content areas and disciplines and between undergraduate and postgraduate training.     

The association between students' research involvement in medical school and their postgraduate medical activities

The authors examined the impact of students' research involvement during medical school on their postresidency medical activities. The three medical schools involved--The Pennsylvania State University College of Medicine (PSU), The University of Connecticut School of Medicine (UCONN), and The University of Massachusetts Medical School (UMASS)--have nearly indistinguishable applicant, matriculant, and curriculum profiles. However, at PSU a research project is a curriculum requirement for students who did not do medical research prior to entering medical school. Questionnaires were sent to all graduates from the classes of 1980, 1981, and 1982. A total of 567 graduates completed the questionnaires, an overall response rate of approximately 76%. Medical school research experience was reported by 83% (183) of the PSU graduates, 34% (52) of the UCONN graduates, and 28% (54) of the UMASS graduates. When compared on a school-by-school basis, the graduates from the three schools did not differ with respect to residency specialty training, fellowship training, academic appointments, career practice choices, or postgraduate research involvement. However, when all the graduates studied were examined as a single group, medical school research experience was found to be strongly associated with postgraduate research involvement.