Uncovering the Hidden Medical Curriculum through a Pedagogy of Discomfort

What lies beneath the formal or overt curriculum may impair students' professional growth and development, including their ability to foster genuine relationships with patients and others, and may contribute to the inadvertent, often negative attitudes, beliefs, and behaviors expressed by medical students and witnessed by educators within and external to the classroom environment. To understand the impact a hidden medical curriculum has on both students and educators, I look at one particular model often used in medical education – the physician–patient relationship. I show how this therapeutic relationship ought to be understood through a pedagogy of discomfort, a model developed by Megan Boler (Feeling Power; Emotions and Education, 1999), as a way to uncover the hidden curriculum as it engages students in a collective, critical discourse through which their sense of self in relation to others becomes the groundwork for their professional and moral development. Understanding the physician–patient relationship through a pedagogy of discomfort also teachers students how to critically think about the different values and beliefs held by physicians and patients and how to begin to recognize themselves as physicians in relation to their patients and others.     

某医学院本科生性心理现状分析

目的 了解医学生性心理现状,为建立高校性心理健康教育模式提供依据.方法 采用自编问卷对某医学院399名本科医学生进行问卷调查.结果 男、女生是否喜欢自身性别的报告率差异有统计学意义(P<0.01),男生更愿意接受自身性别;大多数学生都希望与异性交往,且男生的需求更强烈;男、女生在释放性心理压力的途径与方法上差异有统计学意义(P<0.05);多数学生认为大学期间恋爱动机是排遣寂寞.结论 医学生性发展与性知识不协调,性需求和性满足之间存在冲突和矛盾.应科学引导学生树立正确的恋爱观,重视在校园内开展性知识教育和性文化建设.     

'Science', 'critical thinking' and 'competence' for tomorrow's doctors. A review of terms and concepts

CONTEXT: The recommendations of the General Medical Council in Tomorrow's Doctors renewed efforts to define core knowledge in undergraduate medical education. They also encouraged better use of the medical knowledge base in nurturing clinical judgement, critical thinking, and reflective practice. What then does the medical world understand by 'science', 'critical thinking' and 'competence', given the need to address both growth and uncertainty in the knowledge base and to practise evidence-based healthcare? AIM AND OBJECTIVES: This review aims to outline the role of these key concepts in preparing undergraduate medical students for professional practice. Specifically, it explores: the fallibility of the 'scientific' foundations of medical practice; the role of understanding and thinking in undergraduate medical education; the need for a broad interpretation of competence and its relationship to transferability, and the nature of clinical judgement. COMMENT: Tensions are seen to lie in the varying interpretations of clinical decision making as art or science; the varying characterizations of the nature of skilled performance in the novice, the competent and the expert practitioner, and the varying reactions to the acceptability and usefulness of 'meta-' concepts in capturing the essence of professional practice. Habitual self-conscious monitoring of mental processes may be the key to the flexible transfer and application of knowledge and skills across the contexts, characterized by uncertainty and incomplete evidence, for which doctors must be prepared.     

Modelling medicine

Context Aristotle's writing on poiesis and techne in general, and his frequent references to medicine in particular, suggest that medicine is instrumental, contingent and procedural. These 3 basic characteristics give rise to three questions: What do doctors do? What affects what they do? How do they do it? Similar questions can be applied to other professions. Objectives This paper sets out a 3‐dimensional model of medicine which addresses these 3 questions. The model can be used to explore general issues in the field such as the nature of general practice, the scope of evidence‐based medicine and the relationship between medicine and cognate professions. It may help to clarify decisions about the scope, sequence and integration of the medical curriculum and it offers a framework for the concrete analysis of clinical situations and decisions. Methods The article is based on conceptual analysis rather than empirical investigation although there are some examples of practical applications of the model. Conclusions Although the headings in the model must be treated as tentative, it offers one way of viewing medicine as a whole. It also offers potential scope for development and use in both initial and continuing medical education. Further work is needed to develop and refine the model for medical education and practice.     

Medical education and economics

The time available to medical students for learning is scarce in relation to the knowledge they are asked to absorb. New material should not therefore be added to medical curricula without careful consideration of the benefits of the extra knowledge compared to the costs of obtaining this knowledge. In this paper a justification for integrating economic principles into medical education is presented. It would benefit society by encouraging the practice of efficient medicine, and benefit students by giving them the ability to absorb the growing economic content of the medical literature and by encouraging an appreciation of why economic factors will influence their clinical decision-making. These benefits would accrue at little cost because only a limited number of economic concepts need to be absorbed by medical students. The critical concepts are outlined and some of the obstacles to students applying this knowledge in practice are considered. The paper concludes by suggesting that the impact of teaching economics to medical students should be evaluated, but this will require further research into ways of evaluating the outcome of medical education programmes in general.     

Transnational Medical Aid and the Wrongdoing of Others

One of the ways in which transnational medical agencies (TMAs)such as Medicins Sans Frontieres aim to increase the accessof the global poor to health services is by supplying medicalaid to people who need it in developing countries. The moralimperative supporting such work is clear enough, but a varietyof factors can make such work difficult. One of those factorsis the wrongdoing of other agents and agencies. For as a resultof such wrongdoing, the attempt to supply medical aid can sometimeslead to significant negative effects. What should TMAs do insuch situations? On one view, TMAs should take account of anynegative effects arising from the wrongdoing of others in justthe same way in which they take account of negative effectsarising more directly from their own actions, or from naturalforces. To many people, this view seems wrong. In this paper,I articulate and discuss several different reasons why one mightthink this. In doing so, I hope to contribute to a debate aboutthe more general question of how TMAs should respond to thewrongdoing of others.     

Medical students' professional identity: self-reflection during the preclinical years

Critical thinking, readiness for self-reflection and professional development have recently been emphasized as important goals of medical education. However, little is known about the developmental processes through which a medical student elaborates his or her personal experiences during the training, and about the way he or she gradually develops a professional identity. How does the student identify the opportunities and alternatives offered by the profession and finally commit to the professional values and goals he or she finds personally important? In order to grasp the essential characteristics of the personal development process in depth, qualitative, process-oriented and individually tailored methods are warranted. In this paper, the quality of professional self-reflection and identity formation during the preclinical training are described on the basis of two qualitative materials – learning logs and identity status interviews. Four types of learning log reports on the early patient contact course could be identified: `committed reflection', `emotional exploration', `objective reporting' and `diffuse reporting'. At the end of the preclinical training, the identity status of several students could still be characterized as diffuse or giving rise to only very tentative professional considerations.     

Medical school entrance and career plans of Malaysian medical students

This study investigates the reasons for entry to medicine and the career perspectives of phase III medical students of the Universiti Sains Malaysia (USM). The majority of the students were Malays from low socio-economic backgrounds who entered medical school after completing a 2–year matriculation course. An interest in medicine and helping people were the two main stated reasons for entry to medical school. A group of students wishing to work in private practice was identified. In comparison to the rest of the study body, students in the group were: not well prepared to enter medical school; dissatisfied with the course; and subject to family influences. A desire for monetary gain motivated their choice of medicine as a career. Overall, 13% of the students wished to change career because they were dissatisfied with their experience of medicine as undergraduates.
The study did not find a significant difference in career intentions between female and male medical students. However, women were less likely to seek entrance into private practice or pursue formal postgraduate education. The choice of surgery as a career was confined to men. About 90% of the students had already decided on their future specialty. Four well-established specialties were their most popular choices. The gender of the students had no significant influences of the decision to continue into postgraduate education. The proportion of female students who wished to marry doctors was significantly higher than for male students.     

Cross-cultural communication in medicine: questions for educators

Most research into medical communication has had a western setting. It has been undertaken by western researchers and been influential in shaping communication skills curricula. However we know much less about what communication is effective under other circumstances. This article highlights gaps in our knowledge from research in this field, and poses attendant questions for debate by medical educators. We consider the following key aspects of debate on cross‐cultural work. (i) To what extent can our understanding of general principles in other cultures be summarized and presented for teaching in a way which does not descend into caricature? Alternatively, can features of other cultures be presented in ways which do not descend into particularity? (ii) Can such paradigms as ‘patient‐centredness’ be transferred from culture to culture? Should they be presented across cultures as features of ‘good’ consultations? (iii) What use can be made of the role of interpreters for teaching purposes? What importance does it have to the educator that a doctor may not be a native speaker of the majority language of the culture in which s/he is operating? (iv) Although the language of illness, and particularly metaphors associated with illness, are studied in other cultures, the way in which illness is metaphorized in British English is seldom discussed. What can educators learn and teach from a study of such matters? (v) What are the implications for communication skills teachers of the need to present materials within a culturally diverse environment?     

Medical students’ attitudes and wishes towards extending an educational general practice app to be suitable for practice: A cross-sectional survey from Leipzig,Germany

Background: In medical education and practice, smartphone apps are increasingly becoming popular. In general practice, apps could play an important future role in supporting medical education and practice.

Objectives: To explore medical students’ perceptions regarding the potential of a general practice app for training and subsequent work as a physician.

Methods: Cross-sectional survey among Leipzig fourth-year medical students who were provided with an app prototype for a mandatory general practice course.

Results: Response rate was 99.3% (n?=?305/307); 59.0% were female and mean age was 24.5 years. Students certified that the app had a higher potential than textbooks in both education (57.4% vs. 18.0%) and practice (47.1% vs. 22.8%). Students’ most desired possible app extensions when anticipating its use for subsequent work as a physician were looking up information for diagnostics, therapy and prediction (85.1%), access to electronic patient files (48.1%), communication and networking (44.3%), organization of medical training (42.9%) and online monitoring of patients (38.1%). Students experienced with medical smartphone apps were more interested in app extensions. Consideration to use the app to support the opening of their own practice was significantly associated with higher interest in accessing electronic patient files, networking with colleagues and telemedicine.

Conclusion: Fourth year medical students from Leipzig see a high potential in smartphone apps for education and practice and are interested in further using the technology after undergraduate education.     

实习生医疗安全管理的探讨

临床实习生医疗安全是教学医院管理中的重点和难点.探讨加强实习生医疗安全管理的途径与方法,完善实习生医疗安全管理机制,将医疗安全教育贯穿于临床课程教学之中,抓好进入实习前的培训,注重临床能力的培养,与医德医风教育相结合,发挥临床老师的带教作用,提高医患沟通技巧,重视医疗文件的规范书写,克服实习后期倦怠心理,强化临床实习生自我医疗安全管理意识,是教学医院实现医疗安全管理的有效策略.     

Teaching bioethics to medical students: the Newcastle experience

Summary. Over the past two decades in the USA, bioethics has become an accepted component of medical education, whereas in Australia, 10 years or even less would encompass the history of most existing programmes. Given the legendary conservatism of medical schools in Australia and the intractability of the medical curriculum, this is still a remarkable achievement. But does the teaching of bioethics change the thinking and/or decision-making behaviour of medical students or practitioners exposed to such courses? Those involved know only too well how difficult such courses are to design and evaluate since the connection between ethics education and practice is not known and may never be demonstrated to the satisfaction of critics. Critics not only seek answers to the questions of whether the teaching of bioethics makes a difference, which is a fair question, but they also seek answers to the question of whether bioethics should be taught in medical schools. Can bioethics be taught? Whose bioethics is being taught? What does the trained bio-ethicist contribute? Some of these questions arise from misunderstanding and some reflect the still too dominant view in medical schools which divides disciplines into those which provide ‘practical skills’, and those which contribute only theoretical and therefore peripheral knowledge. The authors will address these questions in the light of their experience at Newcastle, Australia, where the Faculty of Medicine has been teaching bioethics for over a decade.     

医学生和非医学生吸烟KAP比较

目的：探讨医学教育对大学生有关吸烟的知识、信念、行为的影响。方法：在两所大学随机抽取1、2年级在校大学生4355名，采用自填式结构问卷调查大学生的一般特征和吸烟相关的知识、信念、行为及吸烟者的吸烟原因等。并对知识、信念项目评分，比较不同组别大学生的平均得分有无差别。结果：医学生的吸烟相关知识、信念都显著高于非医学生，但两组吸烟率比较差异无统计学意义。结论：医学教育对大学生的吸烟相关知识具有一定的影响，需采取综合措施，做好大学生控烟工作。     

八年制临床医学生创新能力培养

知识的创新及创造性应用已成为医学发展和进步的不竭动力,培养创新性人才是高等医学教育的重要课题。我国八年制医学教育是参照国际高水平医学教育的标准和要求,新推行的一种长学制医学教育体制。本文结合近年来的八年制医学高等教育改革与实践,阐述了培养八年制医学生创新能力方面的做法和经验,探索医学生创新能力培养的有效途径。     

Conditions for successful reflective use of portfolios in undergraduate medical education

Aim Portfolios are often used as an instrument with which to stimulate students to reflect on their experiences. Research has shown that working with portfolios does not automatically stimulate reflection. In this study we addressed the question: What are the conditions for successful reflective use of portfolios in undergraduate medical education? Methodology/research design We designed a portfolio that was aimed at stimulating reflection in early undergraduate medical education, using experiences described in the medical education literature and elsewhere. Conditions for reflective portfolio use were identified through interviews with 13 teachers (mentors), who were experienced in mentoring students in the process of developing their portfolios. The interviews were analysed according to the principles of grounded theory. Results The conditions for successful reflective use of portfolios that emerged from the interviews fell into 4 categories: coaching; portfolio structure and guidelines; relevant experiences and materials, and summative assessment. According to the mentors, working with a portfolio designed to meet these conditions will stimulate students' reflective abilities. Conclusion This study shows that portfolios are a potentially valuable method of assessing and developing students' reflective skills in undergraduate medical training, provided certain conditions for effective portfolios are recognised and met. Portfolios have a strong potential for enhancing learning and assessment but they are very vulnerable and may easily lead to disappointment. Before implementing portfolios in education, one should first consider whether the necessary conditions can be fulfilled, including an appropriate portfolio structure, an appropriate assessment procedure, the provision of enough new experiences and materials, and sufficient teacher capacity for adequate coaching and assessment.     

Physician views on practicing professionalism in the corporate age

Arnold Relman argues that medical education does not prepare students and residents to practice their profession in today's corporate health care system. Corporate health care administrators agree: Physicians enter the workforce unskilled in contract negotiation, evidence-based medicine, navigating bureaucratic systems, and so forth. What about practicing physicians? Do they agree as well? According to this study, they do. Feeling like decentered double agents and unprepared, physicians find themselves professionally lost, struggling to balance issues of cost and care and expressing lots of negativity toward the cultures of medicine and managed care. However, physicians are resilient. A group of physicians, who may be called proactive, are meeting the professional demands of corporate health care by becoming sophisticated about its bureaucratic organization and the ways in which their professional and personal commitments fit within the system. Following the lead of proactive physicians, the authors support Relman's thesis and education for both students and physicians requires a major overhaul.     

Medical students’ views of power in doctor–patient interactions: the value of teacher–learner relationships

Medical Education 2010: 44 : 187–196 Context This paper aims to contribute to the important, and relatively underexplored, area of medical education research that seeks to illuminate the value and meaning of relationships in the undergraduate education of doctors. Here I present new empirical material in which I ground my reflections on some ways in which teacher–learner relationships can help address medical students’ often uncritical views of professional practice. The views I illustrate are of particular significance as they contrast sharply with the participative models of practice promoted by current policy, professional and educational discourses. Methods My reflections stem from the analysis of data I generated for a larger, broadly ethnographic study exploring students’ approaches to their future role as practitioners in one UK medical school. I draw upon this larger body of data and focus here on two examples in particular of the more general uncritical readings of medical professionalism I encountered at Sundown Medical School (an invented name), namely: students’ often reductive views of medical power, and their simplistic formulations of patient education. Discussion I argue for the need to foster richer and more critical understandings of professional power and knowledge among students and educators, and suggest here that teacher–learner interactions could have an important role in fostering such richer understandings. I argue that teacher–learner relationships can model some of the dynamics of the practitioner–patient interaction and thus provide useful opportunities for closer and more critical analysis of power, education and knowledge in the medical school classroom as well as in the consultation room. Conclusions I suggest that effective integration of participative and critical pedagogical strategies in medical curricula and more structured involvement of patients in the role of teachers may represent valuable strategies for the development of learning relationships that better promote reflexive and collaborative forms of professionalism.     

Why? What? and How? IT provision for medical students in general practice

OBJECTIVES: The aim of this paper is to discuss the increasing use of computers in undergraduate medical education and explore the why, what and how of providing IT facilities to undergraduate medical students when they are on placement in general practice. Adequate computing facilities are usually available within hospitals and medical schools, however, major changes are taking place in undergraduate education resulting in more teaching being undertaken in the community. Students will therefore need access to comparable facilities whilst in primary care settings in order for their training not to be compromised. SETTING: This paper describes one initiative addressing this need: the University Linked Practices (ULP) project in the Department of General Practice and Primary Care at St. Bartholomew's and the Royal London School of Medicine and Dentistry. DESIGN: We discuss the ways in which computers are currently being used in medical education and discuss some of the merits and drawbacks that are associated with this increasing drive to computerization.     

Computer education: attitudes and opinions of first-year medical students

Summary: students' attitudes towards medical informatics were evaluated with self-administered questionnaires, answered by 140 (77%) first-year medical and dental students. Fourteen per cent classified their computer literacy as negligible and 49% as deficient. Ninety-six per cent had used a computer before and 59% used one regularly. Nineteen per cent had computer education in secondary school and a further 16% attended courses given by a computer company. Only 16% read regularly about informatics. These results are similar to those observed in more industrialized countries, except that high-school education is more deficient. To 93% of these students, computer literacy is important for doctors, and to 85% computers may be very useful in many areas of health care. In the opinion of 66% of students, the computer-based patient record will be available within the next 3 to 10 years. Women showed lesser computer literacy (77% computer illiteracy to 39% in men), but there were no relevant differences in attitudes, behaviour and beliefs towards medical informatics between gender, for the same level of computer literacy. Computer education in the undergraduate curriculum was demanded by 92%, and 75% of these preferred an elective course. Weekly hours suggested for lectures should be 1 (54%) or 2 (42%), and for hands-on practice 2 (54%) or 4 (31%) hours. The curriculum should include medical applications (83% of students), information science theory and technology (44%), micro-informatics (44%), bibliographic database search (27%), programming languages (23%) and statistical packages (23%). Gender, computer literacy or course did not correlate significantly with students' opinions about the contents of undergraduate education.     

Medical students' perceptions of their learning about the doctor-patient relationship: a qualitative study

Objective To describe and discuss Year 5 medical students' perceptions of their own learning about the doctor?patient relationship. Methods We carried out a qualitative study of semi‐structured interviews with 16 Year 5 medical students using 3‐way analysis at the School of Medicine, Federal University of São Paulo, São Paulo, Brazil. Results For experiences at the pre‐clinical stage, the subcategories were: positive aspects of the medical psychology course; great distance between theory and reality, and strong desire for clinical practice. For experiences at the clinical stage, the subcategories were: demand for opportunities to discuss the doctor?patient relationship; teachers as either role models or anti‐models; clinical situations favourable for developing empathic relationships, and clinical situations unfavourable for developing empathic relationships. For views about future experiences, the subcategories were: apprehension about ethical behaviour; anxiety about handling patients' psychosocial characteristics, and fear of professional ethics cases or legal action. Discussion To compensate for the lack of practical activities during the pre‐clinical stage, students search for extracurricular activities that often overload them. Because teachers function as professional role models, their attitudes towards patients have great importance. Students fear not being able to maintain their empathic capacity in the future because of work‐related issues. Knowledge of the psychological aspects of the doctor?patient relationship helps students to comprehend their experiences. Gradual contact between student and medical practice from the beginning of the course is advised. It should be followed by interdisciplinary discussions that deal with the technical aspects of cases and the doctor?patient relationship.