Promoting fundamental clinical skills: a competency-based college approach at the University of Washington.

The focus on fundamental clinical skills in undergraduate medical education has declined over the last several decades. Dramatic growth in the number of faculty involved in teaching and increasing clinical and research commitments have contributed to depersonalization and declining individual attention to students. In contrast to the close teaching and mentoring relationship between faculty and students 50 years ago, today's medical students may interact with hundreds of faculty members without the benefit of a focused program of teaching and evaluating clinical skills to form the core of their four-year curriculum. Bedside teaching has also declined, which may negatively affect clinical skills development. In response to these and other concerns, the University of Washington School of Medicine has created an integrated developmental curriculum that emphasizes bedside teaching and role modeling, focuses on enhancing fundamental clinical skills and professionalism, and implements these goals via a new administrative structure, the College system, which consists of a core of clinical teachers who spend substantial time teaching and mentoring medical students. Each medical student is assigned a faculty mentor within a College for the duration of his or her medical school career. Mentors continuously teach and reflect with students on clinical skills development and professionalism and, during the second year, work intensively with them at the bedside. They also provide an ongoing personal faculty contact. Competency domains and benchmarks define skill areas in which deepening, progressive attention is focused throughout medical school. This educational model places primary focus on the student.     

Evolution of clinical ethics teaching at the University of Pittsburgh

The authors explain that several years of effort, by many faculty from a variety of disciplines, were required to expand medical ethics teaching at the University of Pittsburgh School of Medicine beyond the preclinical years. Since 1986, faculty associated with the school's Center for Medical Ethics have begun a comprehensive ethics teaching program for all four years and the residency period; they also are attempting to develop an ethics consultation service. The authors describe the program, its promise and plans, and the significant difficulties involved in establishing and maintaining it, not only problems of long-term funding but of the uninformed and negative attitudes of some students and faculty toward ethics teaching, especially in the clinical setting. Also discussed are the pros and cons of using cases in ethics teaching and the program's approaches to evaluation and to training clinical faculty in clinical ethics issues.     

Community-based clinical education at the University of Birmingham Medical School.

Throughout the United Kingdom, medical schools have begun to make significant changes in the content and delivery of their undergraduate curricula in response to a number of social and educational forces. In particular, many schools have begun to focus increasingly on community-based education. This and other changes mirror developments that have taken place in other countries and in the context of other health care systems, with such forerunners as Harvard, Maastricht, and McMaster having had a fundamental influence. In this article, the authors describe the forces for curricular change in the United Kingdom and the specific recommendations for change made by the General Medical Council. They then discuss in detail the new curriculum at the University of Birmingham medical school, focusing in particular on a community medicine module, where students spend ten days per academic year learning in general medical practices in and around the city of Birmingham.     

From concept to culture: the WWAMI program at the University of Washington School of Medicine.

Shortages of primary care physicians have historically affected rural areas more severely than urban and suburban areas. In 1970, the University of Washington School of Medicine (UWSOM) administrators and faculty initiated a four-state, community-based program to increase the number of generalist physicians throughout a predominantly rural and underserved region in the U.S. Northwest. The program developed regional medical education for three neighboring states that lacked their own medical schools, and encouraged physicians in training to practice in the region. Now serving five Northwest states (Washington, Wyoming, Alaska, Montana, and Idaho), the WWAMI program has solidified and expanded throughout its 30-year history. Factors important to success include widespread participation in and ownership of the program by the participating physicians, faculty, institutions, legislatures, and associations; partnership among constituents; educational equivalency among training sites; and development of an educational continuum with recruitment and/or training at multiple levels, including K--12, undergraduate, graduate training, residency, and practice. The program's positive influences on the UWSOM have included historically early attention to primary care and community-based clinical training and development of an ethic of closely monitored innovation. The use of new information technologies promises to further expand the ability to organize and offer medical education in the WWAMI region.     

Medical education research at the University of Washington School of Medicine: lessons from the past and potential for the future.

Faculty in the Department of Medical Education and Biomedical Informatics at the University of Washington School of Medicine received over $1.2 million in direct grant and contract support in 2003. In this case study, the authors provide some of the history and background of the evolution of the department's structure and its role in providing leadership in medical education research at the university, as well as regionally, nationally, and internationally. The authors offer their observations and reflections on what has helped and hindered the department's success, and end with some predictions on medical education research in the future. The University of Washington's five-state regional WWAMI educational program, establishing a single medical school for the states of Washington, Wyoming, Alaska, Montana, and Idaho, has been an important environmental influence on the direction of the department's educational and research activities. External support has helped the department to create the Northwest Consortium for Clinical Performance Assessment, the Center for Medical Education Research, the Teaching Scholars Program, and a Biomedical and Health Informatics graduate and fellowship training program, as well as a number of international programs.     

Bringing the human genome and the revolution in bioinformatics to the medical school classroom: a case report from Washington University School of Medicine.

The human genome project is revolutionizing medical research and the practice of clinical medicine. To understand and participate in this revolution, physicians must be fluent in human genomics and bioinformatics. At Washington University School of Medicine (WUSM), the authors designed a module for teaching these skills to first-year students. The module uses clinical cases as a platform for accessing information stored in GenBank, Online Mendelian Inheritance in Man (OMIM), and PubMed databases at the National Center for Biotechnology Information (NCBI). This module, which is also designed to reinforce problem-solving skills, has been integrated into WUSM's first-year medical genetics course.     

General pathology teaching at the University of Washington

I have provided a brief overview of our experience teaching undergraduate general pathology at the University of Washington School of Medicine. Our course is part of a pathology curriculum that is somewhat unusual in light of the amount of time we devote to general, as opposed to organ system pathology. We think this makes sense in relation to the way medical teaching and practice are changing. Resources and curriculum time needed to teach an extensive, morphology-based organ system pathology curriculum are no longer available. In addition, experimental biology and medicine are beginning to improve the way human diseases are diagnosed and treated. Many of these advances are the result of new information on disease aetiology and pathogenesis. Students and practitioners of medicine need an understanding of disease processes that will allow them to rapidly assimilate and rationally apply this new information. The particular strengths of our course, as we view them, are an opportunity to discuss the small number of processes that underlie most human disease in some depth, and thus to emphasize general pathology as a conceptual and practical foundation for the practice of medicine; our laboratory sessions, which in a sense illustrate and summarize the course; and early placement of the course in the curriculum, which allows us to capitalize on concurrent basic science courses and a high level of interest among students in applying basic science knowledge to understanding human disease. Problems we face include the need for more 'active' learning exercises in the lecture and laboratory format we are bound to; the need, given the scope of general pathology, to present more 'take home messages' and fewer systematic reviews of evidence than we would like; the limited clinical knowledge of first year students, which restricts the scope of our laboratory and disease example presentations; and an inability to consistently challenge the abilities of the best students in each class. Organizing and teaching the course described above has been in large part satisfying and stimulating. I hope this overview has provided useful ideas for others teaching or contemplating courses in general pathology.     

Improvement of oncology education at the University of Washington School of Medicine, 1984-1988

In 1984, performance on the National Board of Medical Examiners (NBME) examination by medical students from the University of Washington School of Medicine was significantly lower in clinical oncology, pathology, surgery, and oncology-related subjects than was their performance in other subjects (p = .002) and inversely proportional to the degree of oncology-relatedness of the material examined. Moreover, their performance on oncology-related questions was significantly lower than the national average (p less than .001). The curriculum committee thus initiated a review of the oncology content in the curriculum of the school of medicine and implemented a two-year plan in 1984-1986 to improve the perceived deficiencies. During the year the two-year intervention was completed, reevaluation demonstrated evidence that substantial improvement had occurred in oncology performance by the students, relative to their performance in non-oncology subjects (p less than .05) and to the national average. Performance on the non-oncology items was unchanged. The authors conclude that oncology education and performance of the students was significantly improved within two years, after instituting the short-term plan to enhance cancer education in the medical school, the improvement in oncology did not occur at the expense of a reduction in performance in non-oncology subjects, and the improved performance in oncology by the students enhanced their overall performance on the NBME examination.     

Development of a teaching program in clinical medical ethics at the University of Chicago

The University of Chicago Pritzker School of Medicine has developed and evaluated an extensive teaching program in clinical ethics coordinated primarily through the Center for Clinical Medical Ethics. The program provides medical students with a foundation in medical ethics during the four years of medical school and augments the clinical ethics knowledge and teaching skills of the housestaff and clinical faculty at the University of Chicago. Together, medical student teaching and clinical faculty development have made clinical ethics an integral part of medical education at the University of Chicago. Through these efforts, the teaching program aims to incorporate clinical ethics considerations into medical decisions and in this way contribute to improving patient care. (A detailed overview of all clinical ethics instruction at the school is provided.)     

Clinical education of ethicists: the role of a clinical ethics fellowship

Background  

Although clinical ethicists are becoming more prevalent in healthcare settings, their required training and education have not been clearly delineated. Most agree that training and education are important, but their nature and delivery remain topics of debate. One option is through completion of a clinical ethics fellowship.     

Promoting academic excellence through leadership development at the University of Washington: the Teaching Scholars Program.

The University of Washington Teaching Scholars Program (TSP) was established in 1995 to prepare faculty for local and national leadership and promote academic excellence by fostering a community of educational leaders to innovate, enliven, and enrich the environment for teaching and learning at the University of Washington (UW). Faculty in the Department of Medical Education and Biomedical Informatics designed and continue to implement the program. Qualified individuals from the UW Health Sciences Professional Schools and foreign scholars who are studying at the UW are eligible to apply for acceptance into the program. To date, 109 faculty and fellows have participated in the program, the majority of whom have been physicians. The program is committed to interprofessional education and seeks to diversify its participants. The curriculum is developed collaboratively with each cohort and comprises topics central to medical education and an emergent set of topics related to the specific interests and teaching responsibilities of the participating scholars. Core sessions cover the history of health professions education, learning theories, educational research methods, assessment, curriculum development, instructional methods, professionalism, and leadership. To graduate, scholars must complete a scholarly project in curriculum development, faculty development, or educational research; demonstrate progress towards construction of a teaching portfolio; and participate regularly and actively in program sessions. The TSP has developed and nurtured an active cadre of supportive colleagues who are transforming educational practice, elevating the status of teaching, and increasing the recognition of teachers. Graduates fill key teaching and leadership positions at the UW and in national and international professional organizations.     

Interprofessional education in ethics at an academic health sciences center.

The authors relate their experiences with interprofessional teaching of ethics at the University of Colorado Health Sciences Center, describing the history, planning, content, and structure of a required ethics course and discussing its role in the institution's plan to create more interprofessional education opportunities. The authors describe both the benefits of teaching ethics on an interprofessional basis and the challenges they encountered in launching the course. Challenges included responding to diverse and divergent faculty and student reactions, controlling a curriculum across schools, and learning how to think about education in interprofessional rather than profession-specific ways. Included in the discussion are the results obtained with various evaluation tools designed and assessed by the Office of Education on the campus, to which students and faculty responded the first time the course was offered.     

Insights from outstanding rural internal medicine residency rotations at the University of Washington.

PURPOSE: Despite being well suited to provide the breadth of care needed in rural areas, few general internists become rural physicians. Little formal rural residency training is available and no formal curricula exist. For over 25 years the University of Washington School of Medicine has provided elective WWAMI (Washington, Wyoming, Alaska, Montana, Idaho) rural residency rotations to expose residents to the rewards and challenges of rural practice. This study identified the characteristics of outstanding rural residency rotations. METHOD: The key preceptors at three outstanding rural residency sites were interviewed about their experiences, teaching strategies, and opinions about curriculum. Their responses were categorized. Seven university-based residents and eight training at WWAMI sites recorded and rated the value of over 1,500 learning encounters. RESULTS: The preceptors agreed that outstanding rotations were led by enthusiastic preceptors who served as role models for excellence. These preceptors provided residents with meaningful responsibilities and emphasized independent decision making based on the history and physical examination. They stressed supervised independence and self-directed learning with frequent structured feedback for residents. The residents rated the learning value of patient encounters in rural locations significantly higher than that of those in university clinics. CONCLUSIONS: Exceptional rural residency experiences involve excellent role models who provide meaningful responsibility and emphasize core skills using a learner-centered approach. Rural training experiences should be supported, and the suggestions of outstanding preceptors should be used to develop and disseminate a curriculum that will better prepare residents for rural practice.     

Bringing interdisciplinary and multicultural team building to health care education: the downstate team-building initiative.

PURPOSE: To evaluate the impact of the Downstate Team-Building Initiative (DTBI), a model multicultural and interdisciplinary health care team-building program for health professions students. METHOD: A total of 65 students representing seven health disciplines participated in DTBI's first three years (one cohort per year since implementation). During the 18-session curriculum, students self-evaluated their group's progress through Tuckman's four team-development stages (FORMING, STORMING, NORMING, PERFORMING) on an 11-point scale. Students completed matched pre- and postintervention program evaluations assessing five variables: interdisciplinary understanding, interdisciplinary attitudes, teamwork skills, multicultural skills, and team atmosphere. After participation, students completed narrative follow-up questionnaires investigating impact one and two years after program completion. RESULTS: Each year's team development curve followed a similar logarithmic trajectory. Cohort 1 remained in team development stage 3 (NORMING) while Cohorts 2 and 3 advanced into the final stage-PERFORMING. A total of 34 matched pre- and postintervention evaluations showed significant change in all major variables: Team atmosphere and group teamwork skills improved most (48% and 44%, respectively). Interdisciplinary understanding improved 42%. Individual multicultural skills (defined by ability to address racism, homophobia, and sexism) started at the highest baseline and improved the least (13%). Group multicultural skills improved 36%. Of 23 responses to the follow-up surveys, 22 (96%) stated DTBI was a meaningful educational experience applicable to their current clinical surroundings. CONCLUSIONS: DTBI successfully united students across health discipline, ethnicity, socioeconomic class, gender, and sexual orientation into functioning teams. The model represents an effective approach to teaching health care team building and demonstrates benefits in both preclinical and clinical years of training.     

Bringing good teaching cases "to life": a simulator-based medical education service.

Realistic medical simulation has expanded worldwide over the last decade. Such technology is playing an increasing role in medical education not merely because simulator sessions are enjoyable, but because they can provide an enhanced environment for experiential learning and reflective thought. High-fidelity patient simulators allow students of all levels to "practice" medicine without risk, providing a natural framework for the integration of basic and clinical science in a safe environment. Often described as "flight simulation for doctors," the rationale, utility, and range of medical simulations have been described elsewhere, yet the challenges of integrating this technology into the medical school curriculum have received little attention. The authors report how Harvard Medical School established an on-campus simulator program for students in 2001, building on the work of the Center for Medical Simulation in Boston. As an overarching structure for the process, faculty and residents developed a simulator-based "medical education service"-like any other medical teaching service, but designed exclusively to help students learn on the simulator alongside a clinician-mentor, on demand. Initial evaluations among both preclinical and clinical students suggest that simulation is highly accepted and increasingly demanded. For some learners, simulation may allow complex information to be understood and retained more efficiently than can occur with traditional methods. Moreover, the process outlined here suggests that simulation can be integrated into existing curricula of almost any medical school or teaching hospital in an efficient and cost-effective manner.