Context in medical education: the informal ethics curriculum

As some formal bioethics instruction has become the norm in American medical schools, a trend has emerged toward increased attention to context in both bioethics education and bioethical decision-making. A focus on classical dilemmas and a textbook knowledge of principles is yielding its previous dominance to permit a more detailed examination of ethical behaviour in actual practice in medicine. After documenting and analysing this emerging trend in bioethics education and its parallel in bioethics theory and research, we turn to the context of medical education itself to look beyond formal bioethics instruction to the ' informal curriculum ' that is so central to the moral development of medical students and residents.
A qualitative research strategy is being used to study the informal curriculum through analysing tape-recorded informal conversations students and residents have with their friends and colleagues at work about issues bearing on their professional development. Data presented are documenting 'the unwritten code' for medical students on a surgical clerkship and the senior residents' informal ways of producing a ' practical ethics of conduct ' that shapes understanding of what is good, skilful, and right on that surgical service. How conceptions of appropriate conduct are conveyed, rewarded and sanctioned also reveals how professional demeanour is taught, permitting discussion about what should be retained and what changed. The context in which ethical issues arise enhances understanding of ethical practice in medicine.     

Postgraduate education in medical ethics in Japan

The objective of this paper was to investigate what kind of postgraduate education in medical ethics medical residents in Japan receive and what they want for ethical education and guidelines. Sixteen teaching hospitals that provide a general internal medicine residency programme in Japan were used (145 medical residents working at the departments of general internal medicine). A total of 114 residents participated in our survey, yielding a response rate of 79%. Of these, 28% received education in medical ethics more than once a month; 24% were offered it only when ethical problems were involved in actual patient care; and 18% answered that opportunities were very rare and sporadic. A full 30% had received no education in medical ethics at all. Many residents (71%) learned medical ethics from individual supervising doctors. A majority of the residents had been taught about informed consent (79%) and doctor–patient relationships (54%); 46% had learned about the appropriateness of truth telling and of ethical decisions regarding withholding and withdrawing a life-sustaining treatment, respectively. A total of 85 residents (75%) wanted to have more comprehensive education in medical ethics, 13% could not decide, and 12% did not want it. Many (66%) thought that both doctors and ethical philosophers should jointly teach medical ethics in postgraduate residency programmes. The results suggest that many residents desire more comprehensive and interdisciplinary education in medical ethics and educators in Japan should aim to develop education programmes to meet these desires.     

Status of nutrition education in medical schools

BACKGROUND: Numerous entreaties have been made over the past 2 decades to improve the nutrition knowledge and skills of medical students and physicians. However, most graduating medical students continue to rate their nutrition preparation as inadequate. OBJECTIVE: The objective was to determine the amount and type of nutrition instruction at US medical schools, especially including the instruction that occurs outside designated nutrition courses. DESIGN: A 12-item survey asked nutrition educators to characterize nutrition instruction at their medical schools (required, optional, or not offered) and to quantify nutrition contact hours occurring both inside and outside designated nutrition courses. During 2004, we surveyed all 126 US medical schools accredited at that time. RESULTS: A total of 106 surveys were returned for a response rate of 84%. Ninety-nine of the 106 schools responding required some form of nutrition education; however, only 32 schools (30%) required a separate nutrition course. On average, students received 23.9 contact hours of nutrition instruction during medical school (range: 2-70 h). Only 40 schools required the minimum 25 h recommended by the National Academy of Sciences. Most instructors (88%) expressed the need for additional nutrition instruction at their institutions. CONCLUSION: With the move to a more integrated curriculum and problem-based learning at many medical schools, a substantial portion of the total nutrition instruction is occurring outside courses specifically dedicated to nutrition. The amount of nutrition education in medical schools remains inadequate.     

Attitudes of medical students to medical ethics in their curriculum

One hundred and one students at different levels of their medical education were surveyed as to their views about inclusion of medical ethics in their curriculum. The results showed that 88% of the students feel that medical ethics has a place in their curriculum, and 84% rated medical ethics to be of High to Critical Importance to good medical care. They tended to read infrequently about medical ethics, which they would like integrated at all levels of the curriculum, particularly the clinical years. The more senior students were less sensitive to ethical issues. The students mentioned only dramatic issues in their accounts of encounters with cases involving ethical issues. It is felt that a wide gap is left in the education of these students if medical ethics is not included in a positive way in their curriculum.     

Review of ethics curricula in undergraduate medical education

Medical ethics education, it has been said, has 'come of age' in recent years in terms of its formal inclusion in undergraduate medical curricula. This review article examines the background to its inclusion in undergraduate curricula and goes on to examine the consensus that has arisen on the design of ethics curricula, using Harden's curriculum and S.P.I.C.E.S models as templates. While there is consensus on content for undergraduate medical ethics education, there is still significant debate on learning and teaching methods. Despite the broad agreement on the need to apply adult education principles to ethics teaching, there would appear to be some tension between balancing the need for experiential learning and achieving the 'core curriculum'. There are also as yet unresolved difficulties with regards to resources for delivery, academic expertise, curriculum integration and consolidation of learning. Assessment methods also remain contentious. Although there is consensus that the ultimate goal of medical ethics, and indeed of medical education as a whole, is to create 'good doctors', the influence of the 'hidden curriculum' on students' development is only beginning to be recognized, and strategies to counteract its effects are in their infancy. The need for proper evaluation studies is recognized. It is suggested that the areas of debate appearing in the literature could be used as a starting point for evaluation studies, which would form the empirical basis of future curriculum development.     

Thinking the post-colonial in medical education

Context  Western medicine and medical techniques are being exported to all corners of the world at an increasing rate. In a parallel wave of globalisation, Western medical education is also making inroads into medical schools, hospitals and clinics across the world. Despite this rapidly expanding field of activity, there is no body of literature discussing the relationship between post-colonial theory and medical education.
Discussion  Although the potential benefits of international partnerships and collaborations in education are incontrovertible, many medical educators are sometimes too unreflecting about what they are doing when they advocate the export of Western curricula, educational approaches and teaching technologies. The Western medical curriculum is steeped in a particular set of cultural attitudes that are rarely questioned. We argue that, from a critical theoretical perspective, the unconsidered enterprise of globalising the medical curriculum risks coming to represent a 'new wave' of imperialism. Using examples from Japan, India and Southeast Asia, we show how medical schools in non-Western countries struggle with the ingrained cultural assumptions of some curricular innovations such as the objective structured clinical examination, problem-based learning and the teaching of clinical skills.
Conclusions  We need to develop greater understanding of the relationship between post-colonial studies and medical education if we are to prevent a new wave of imperialism through the unreflecting dissemination of conceptual frameworks and practices which assume that 'metropolitan West is best'.     

A process evaluation of medical ethics education in the first year of a new medical curriculum

BACKGROUND: Despite the recent increase in activity in the field of medical ethics education, few evaluative studies have been carried out. Most studies have taken place in North America, in curricula where teaching is discipline-based, and have concentrated on outcome rather than on the curricular processes adopted. AIM: To evaluate the process of medical ethics education in the first year of a new learner-centred, problem-based, integrated medical curriculum. METHOD: A qualitative, multi-method approach was adopted using open questionnaires, focus groups and tutor evaluation rating scales. The study involved all 238 students in the first year of the new medical curriculum, and the 30 clinical tutors who facilitated ethics learning. A stratified sampling technique was used to choose focus group participants. RESULTS: Small group teaching proved highly acceptable to both students and tutors. Tutors' teaching skills were central to its effectiveness. Tutors played an important role in promoting students' appreciation of the relevance of medical ethics to clinical practice, and in establishing a climate where constructive criticism of colleagues' actions is acceptable. Course integration, including the provision for students of clinical experiences on which to reflect, was an important aid to learning. Students and tutors were noted to be driving the ethics curriculum towards having a contextual rather than theoretical base. CONCLUSION: This evaluation identified those aspects of the medical ethics course which contributed to its effectiveness and those which detracted from it. This information will be used to inform future development.     

Trends of medical education in Japan†

Summary. This article introduces recent trends in medical education in Japan, from undergraduate education through continuing education, and explains changes in the number of medical schools and in the content of the curriculum. Some obstacles to the implementation of changes, particularly in undergraduate medical education, are discussed. Now that Japan has become relatively developed in the quantity of its health manpower and also socioeconomically, a change must be directed towards qualitative reorganization and rearrangement in medical education in line with the objectives posed for the new century. The establishment of something new is difficult; to change something old and established, however, is much more difficult. In Japan, while some new designs in the curriculum are found in almost all the new schools, any fundamental change in the established curriculum in the old schools can be found only rarely, and attempts at changing the established curriculum frequently encountered resistance in the old schools.     

Caring,competence and professional identities in medical education

This paper considers the multiple discourses that influence medical education with a focus on the discourses of competence and caring. Discourses of competence are largely constituted through, and related to, biomedical and clinical issues whereas discourses of caring generally focus on social concerns. These discourses are not necessarily equal partners in the enterprise of medical education. Discourses of competence tend to be privileged while those discourses of caring are often marginalised. Medical students learn to be physicians, and develop professional identities, in the context of these competing discourses. This paper documents a qualitative study designed to explore how professional identities are developed in the context of competing discourses. The study included a Foucauldian discourse analysis of medical education curriculum documents (67 problem-based learning cases in total), 26 h of observation of a small group learning experience (a problem-based learning tutorial), and in-depth, open-ended interviews with five medical students and nine medical educators at a Canadian medical school. The paper describes how professional identities are developed in relation to discourses of competence, noting that students displayed what they considered to be desirable professional identities of confidence, capability and suitability. Also explored are the professional identities demonstrated in relation to discourses of caring, including those of benevolence and humbleness. Despite current conceptualisations, medical education is ripe with potential. The data indicate Foucauldian “spaces of freedom”—sites at which the complexity of the practice of medicine and the interwoven natures of the discourses of competence and caring might be taken into account as a means of challenging taken for granted cultural norms and broadening the medical gaze.     

Mentioning race at the beginning of clinical case presentations: a survey of US medical schools

Objectives  Medical students and doctors in the USA frequently mention the patient's race at the beginning of oral or written clinical case presentations. However, this practice is controversial. We aimed to determine whether US medical schools explicitly teach students to mention race at the beginning of case presentations, and to collect additional information on the schools' perspectives on this practice.
Methods  An Internet-based questionnaire was submitted to directors of courses on history taking and physical examination at all US medical schools.
Results  The response rate was 85%. Students are taught to mention race routinely at 11% of schools and selectively at 63% of schools; this practice is discouraged at 9% of schools and not addressed at 18% of schools. Most respondents noted that resident doctors at their institutions routinely mention race at the beginning of case presentations. Even at schools in which mentioning race is discouraged or not addressed, students tend to include race during their clinical rotations. Respondents were divided on whether a standardised approach to inclusion of race should exist at US schools.
Conclusions  Teaching about inclusion or exclusion of race in the opening statement of clinical case presentations varies across US medical schools. This variation presents an opportunity for medical educators to discuss tensions between stereotyping and cultural competence in medical education.     

Expected benefits of streamlining undergraduate medical education by early commitment to specific medical specialties

Undergraduate medical education is too long; it does not meet the needs for physicians’ workforce; and its content is inconsistent with the job characteristics of some of its graduates. In this paper we attempt to respond to these problems by streamlining medical education along the following three reforms. First, high school graduates would be eligible for undergraduate medical education programs of 4 years duration. Second, medical school applicants would be required to commit themselves to a medical specialty and choose one of four undergraduate paths: (1) “Interventions/consultations” path that would prepare its graduates for residencies in secondary and tertiary specialties, such as cardiology and surgery, (2) “continuous patient care” path for primary care specialties, such as family medicine and psychiatry, (3) “diagnostic laboratory medicine and biomedical research” path that would prepare for either laboratory-based careers, such as pathology, biochemistry and bacteriology, or research in e.g., immunology and molecular genetics, and (4) “epidemiology and public health” path that would include population-based research, preventive medicine and health care administration. Third, the content of each of these paths would focus on relevant learning outcomes, and medical school graduates would be eligible for residency training only in specialties included in their path. Hopefully, an early commitment to a medical specialty will reduce the duration of medical education, improve the regulation of physicians’ workforce and adapt the curricular content to the future job requirements from medical school graduates.     

Preparing doctors for tomorrow: information management as a theme in undergraduate medical education

The evolving nature of medical knowledge and technology requires that the practitioners of tomorrow be able to develop practice management and computer skills in order to enhance quality patient care, ongoing education, and research. The paper describes how the discipline of medical informatics can be integrated into an undergraduate medical curriculum, not as a course or series of courses but as a repeated theme throughout the 3-year system-based curriculum. Recommendations specific to integrating medical informatics into an undergraduate curriculum are outlined with respect to: (1) content; (2) content organization; (3) management; and (4) evaluation. Six areas of information and computer management applications are discussed. These are computer-assisted learning, retrieving and organizing information from computerised databases, the application of medical informatics tools to the critical appraisal of literature and associated statistical software packages, hospital- and office-based information systems, and electronic communications. Medical education has a history of resistance to change. Reference to guidelines and experiences of others who have negotiated information management and medical informatics changes into medical school environments can therefore be helpful. It is in this context that this paper is presented.     

Computer-Assisted Instruction in Clinical Education: a Roadmap to Increasing CAI Implementation

This reflection is based on the premise that clinical education can be improved by more widespread use of computer-assisted instruction (CAI) and that a roadmap will enable more medical educators to begin using CAI. The rationale for CAI use includes many of its inherent features such as incorporation of multimedia and interactivity yet the use of CAI remains limited, apparently because educators are not convinced about the role for CAI. Barriers to CAI use are discussed including misinterpretation of the literature for CAI effectiveness; a disconnect between CAI developers and the educators who make decisions about CAI use; and the paucity of knowledge regarding how to integrate CAI effectively into clinical education. Specific roles for CAI in undergraduate and graduate medical education can include improving uniformity of instruction, providing documentation of exposure or competence, improving the learners’ educational experience or outcomes, and assessment that is matched to learning. Funding for CAI remains an important barrier but the authors believe that this will be overcome when use of CAI becomes more widespread.     

Priorities for nutrition content in a medical school curriculum: a national consensus of medical educators

The ASCN Committee on Medical/Dental School and Residency Nutrition Education conducted a series of activities to establish guidelines for nutrition core content in a medical school curriculum. These activities included mail surveys of medical-nutrition educators and a representative group of medical school curriculum administrators and a national consensus workshop of nutrition educators. Results indicated close agreement between the nutrition educators and curriculum administrators (r = 0.89, p less than 0.0001) on the importance ratings of 41 nutrition topics and on the number of hours of nutrition course work that medical schools should provide (44 vs 37 h, respectively, p = 0.14). There was consensus among the nutrition educators that 26 topics should be given priority ratings as essential for inclusion in medical course work. Further prioritization of these topics resulted in a listing of core content topics and subtopics to serve as a guide to administrators and educators for planning nutrition course work in a medical school curriculum.     

Attitudes of medical students to the teaching of medical ethics

Summary. The teaching of ethics to medical students has recently become a topic of much importance to all concerned with medical education. However, those most involved, the students themselves, have been consulted very little. This paper reports the views of a sample of medical students at Oxford University on what ethics teaching they receive, of how much value they consider it to be and what form of teaching they would like to see included in their curriculum.     

The problem with outcomes-based curricula in medical education: insights from educational theory

BACKGROUND: Educators across the world are charged with the responsibility of producing core learning outcomes for medical curricula. However, much educational theory exists which deliberates the value of learning outcomes in education. AIMS: This paper aims to discuss the problems surrounding outcomes-based curricula in medical education, using insights from educational theory. DISCUSSION: The paper begins with a discussion of the traditions, values and ideologies of medical curricula. It continues by analysing the issue of control within the curriculum and argues that curriculum designers and teachers control product-orientated curricula, leading to student disempowerment. The paper debates outcomes-based curricula from an ideological perspective and argues that learning outcomes cannot specify exactly what is to be achieved as a result of learning. CONCLUSIONS: The paper argues that medical schools should adopt a model for co-operative control of the curriculum, thus empowering learners. The paper also suggests that medical educators should determine the value of precise learning outcomes before blindly adopting an outcomes-based model.     

On whose shoulders we stand: lessons from Exemplar medical educators

The hiring of educators in medical schools (faculty who study the educational process and prepare others to become educators) has been one of the most successful educational innovations ever. Starting in 1954, through a collaboration between the Schools of Medicine and Education at the University of Buffalo, the innovation has spread to over half of the medical schools in the United States and to medical schools in several other countries. Practically every medical school and specialty now hires educators to conduct faculty development, evaluate learners, and develop or revise curricula. This article focuses on lessons learned by six-first-generation educators hired in medical education. These individuals made unique contributions that improved the process of educating and evaluating future physicians. Among their most important contributions have been the use of standardized patients, faculty development to improve instruction, and the use of clinical decision making theory. In addition, these professional educators created a home and career path for other professionals and nurtured protégés to continue the work they started. Ten lessons are reported from structured interviews using a standardized protocol. These lessons will hopefully inform current and future medical educators to help them sustain the effective collaboration between medical schools and educators.     

The need for medical ethics education in family medicine training

Professional and accreditation organizations have endorsed medical ethics as a fundamental component of education for family medicine trainees. Yet various obstacles combine to work against the continuation of formal medical ethics education beyond medical school and into residency training. This article reviews the current consensus on the scope and objectives of medical ethics education in the context of family medicine training. The need for, and outcomes of, medical ethics teaching are analyzed on the basis of the available evidence. Recent trends in medical education that potentially influence graduate medical ethics training are also discussed (specifically ethics training in medical schools and the priority given to training in professionalism). This review shows a strong evidence-based need to provide medical ethics education for family physicians in training, a need that is apparent on many levels. The current reliance on medical school ethics education and emphasis on professionalism does not answer this need. A well-constructed course in medical ethics for family medicine trainees can teach an array of competencies stipulated by professional and accreditation agencies as important in the practice of family medicine. Educators must strive to overcome barriers and provide formal medical ethics programs to better prepare family physicians for modern professional roles.     

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.     

Introducing complementary medicine into the medical curriculum.

We surveyed the deans of British medical schools to determine the provision of complementary medicine in the undergraduate curriculum. We also sampled medical students at one British medical school to determine their knowledge of, and views on instruction in, complementary medicine. There is little education in complementary medicine at British medical schools, but it is an area of active curriculum development. Students' levels of knowledge vary widely between different therapies. Most medical students would like to learn about acupuncture, hypnosis, homoeopathy and osteopathy. We conclude that complementary medicine should be included in the medical undergraduate curriculum. This could be done without a great increase in teaching of facts, and could serve as a vehicle to introduce broader issues, as recommended by the General Medical Council.