Undergraduate curriculum reform at the Pontifical Catholic University Medical School: aims, methodology and advance status

The Medical School of the Pontifical Catholic University is devoted to a reform process aiming to adequate undergraduate training to scientific, technological, cultural and social changes in medical practice in Chile and to incorporate novel teaching methodology. One of the main modifications is the change of the resulting professional from "a general physician capable of resolving most medical problems of rural or urban populations" to "a physician with a solid general training but qualified for a subsequent specialization". This requires curricular flexibility to obtain different professional profiles. Other important changes are a reduction in curricular contents and their vertical and horizontal integration, modernization of teaching methodologies with the incorporation of computing techniques and problem oriented teaching and the incorporation of new subjects such as molecular biology, clinical genetics, health economics. To achieve these objectives, a semi-flexible curriculum was devised, the curricular mesh has been modified extensively, an outpatient and a nine months elective internship were added. Most modifications have been implemented, remaining changes in 4th and 5th years. These changes required a reorganisation of academic structure, the use of new selection, training and perfecting criteria for teachers, better salaries for outstanding professors and improvement of teaching infrastructure. This reform must be seen as a medium term integral change in the context of an integral academic development plan.     

Aims and objectives of medical training at the University of Valparaíso

The Medical School of the University of Valparaíso was founded thirty years ago aiming to produce a physician considering the health needs of the population and with a solid humanitarian training. The epidemiological, demographic and scientific changes of the last decades prompted the introduction of modifications in the curriculum such as using problem oriented active learning, incorporation of new subjects such as geriatrics, labour medicine and trauma and training in communication skills. The curricular mesh will be modified to allow an efficient vertical integration of educational contents, which will be delivered sequentially during the different years of the career. The internship, as a crucial part of the career, has incorporated outpatient clinical practice, has emphasized preventive medicine and has stimulated active learning through research projects and active reviews of specific issues. These changes will require cultural changes of professors and students and more resources that are difficult to obtain.     

The independent study program at the University of Wisconsin Medical School

A program for 30 additional medical students for the first two years of the University of Wisconsin Medical School curriculum has been developed, and two groups of students have advanced to the clinical years. Design included providing modules of course materials to students and utilizing faculty predominantly in the developmental and managerial role. Preliminary results are based on student and faculty opinion of the program in categories of faculty acceptance, faculty-student interaction, certifying examinations, student attitudes, material developed, and course objectives. The course has been accepted as a continuing part of the medical school curriculum and provides a more flexible track for some students. There has been no significant difference in performance on Part I of the examination of the National Board of Medical Examiners for the first two groups. The concepts of individualized medical education have strengthened the basic science and core curriculum of the medical school.     

How medical students can bring about curricular change

Traditionally, medical school committees have been charged with curricular improvement and modification, while medical students have had little or no involvement in reform efforts. However, medical students can sometimes be ahead of faculty in recognizing new topics that need to be covered, and their energy, commitment, and vision can be a very important impetus for curricular change. In 1995-96, as part of a general curricular restructuring effort, faculty at Dartmouth Medical School began to design and offer new electives in innovative topics, with the idea that electives might become part of the required curriculum if the material presented in them were deemed to be "core." Students were invited to organize their own electives if a topic in which they were interested was not being covered. The authors (two were second-year medical students and the third was their faculty sponsor) developed an elective in women's health. This paper describes the development and implementation of this elective, and the process by which the course was later made part of the required curriculum at Dartmouth. The success of the authors' efforts highlights the crucial role students can play in reforming medical curricula.     

Diagnostic value of a miracidium in urinary sediment

The Medical School of the Ljubljana University has a long lasting tradition in teaching the history of medicine. Since 1934, all students of medicine and dentistry in Slovenia have attended the courses in history of medicine which were and still are mandatory. The first years of lectures on the history of medicine at the Ljubljana University Medical School coincided with the struggle for the establishment and recognition of a full medical curriculum in Slovenia. Dr Ivan Pintar (1888-1963), the first lecturer of the history of medicine (1934-1963), was a man of great ethical and national values and an ardent advocate for the promotion of Slovene contribution to medical culture in Slovenia, former Yugoslavia, and Europe. Pintar's concept of history of medicine included general historical, sociological, ethical, cultural, psychological, biotechnical, and other aspects. During 30 years of his endeavors, he did a pioneer work in the research on the history of medicine in Slovenia. For many years he was the editor of the Medical Chamber Bulletin, chairman of the Slovene Medical Society, and the founder of the Section for the History of Medicine in 1951. He wrote the first Slovene textbook on the history of medicine and published many articles on prominent physicians from Slovenia. He paved the way for the new generation of medical historians in Slovenia. Owing to him, contemporary Slovene physicians and dentists are aware of the importance of professional tradition. They know how to use the past experiences for new achievements.     

Medical education at Universidad de los Andes, Santiago, Chile

Universidad de los Andes School of Medicine started in 1991 with a new medical curriculum aimed at providing a medical education for its students, that is, it attempts to give, together with technical proficiency in medical matters, formation of character and a strong ethical attitude. The curriculum lasts for seven years: five of basic, pre-clinical and clinical theoretical and practical courses, followed by two years of internships in Internal Medicine, Surgery, Obstetrics and Pediatrics, plus a four month period of an elective internship. The courses have an integrated design, in which each matter is presented from multiple perspectives, e.g. in Internal Medicine together with the clinical aspects of disease, the pathophysiology and the pharmacology of the drugs used are presented. Also the Pathology of each disease is given in coordination in the Pathology course. General educational matters such as Anthropology, Psychology, Origin of Living Beings, Theology and Medical Ethics are interspersed in the curriculum. An important feature is the personal counselling system, in which each student may choose an academic counsellor and discuss with him (her) the subjects of his choosing. Clinical practice is given in a system that includes five hospitals and five private clinics that range from general medical practice to Psychiatry or Ophthalmology.     

Concomitant rotavirus serotypes 1 and 4 infections in a diarrhoeic child from Belém, Brazil

With the discussion of the quality of medical education in Germany the importance of evaluating the curriculum has grown. A working group of representatives of the German scientific societies for general medicine and the so-called "psychosocial" disciplines in medical education had adapted a questionnaire from Harvard Medical School and tested this version for the first time in summer 1995. 56 teachers and 1250 students took part in this pilot study. The instrument proved to be sufficiently valid to evaluate the quality of different types of teaching lessons. The disciplines (Medical Sociology, Medical Psychology, Social Medicine, General Medicine, Psychotherapy/Psychosomatics) were valued equally with concern to their relevance for medical education. They got significantly better values for quality of teaching and teaching engagement of the professors. It is recommended to notice these results in the actual debate on the reform of the medical curriculum and to include other disciplines in further evaluative investigations.     

Teaching disability and rehabilitation to medical students. Steering Group on Medical Education and Disability

A survey of UK medical schools was undertaken to determine the teaching that was being offered on disability and rehabilitation. In general, teaching on this topic appeared fragmented and inadequate but a number of interesting innovations were identified. These included: a drama workshop run by a group whose members mainly have learning disabilities at St George's Medical School, student-directed learning at the University of Dundee and structured teaching programmes at the Universities of Leeds and Edinburgh. The General Medical Council Education Committee's 1991 discussion document on the undergraduate curriculum specifically mentions disability as an important topic. A number of schools mentioned that they were in the process of revising their curriculum as a consequence. Recommendations arising from the findings of the survey include integration of disability and rehabilitation into clinical teaching, focus of teaching on those types of disability which are common in the community, greater emphasis on functional assessment in teaching the physical examination, and the wider use of standard assessment instruments, for example for activities of daily living, cognitive impairment and locomotor disability. There is a need for improved communication between medical schools to facilitate the spread of educational activities on this topic.     

Children raised in fatherless families from infancy: family relationships and the socioemotional development of children of lesbian and single heterosexual mothers

The Medical School of the University of Chile is enforcing deep transformations in its curricular setting, to cope with the physician model of the next century. It is following the universal trends that look for new objectives, methodologies, scenarios and resources in medical teaching. These goals should be accomplished very soon, allowing the School to be in the lead of curricular transformations. These changes have overflowed the limits of curricular renovation and a process of institutional reorganisation is aiming to increase its efficacy and yield. The bases of this reorganisation are the search for excellency, the renovation of academic staff with the incorporation of better trained professionals, the integration of basic and clinical disciplines in coherent programmatic proposals and the configuration of structures to organise and articulate medical knowledge. Optimisation of education has also extra-institutional implications with the establishment of accreditation systems for professionals and educational institutions. These systems are mandatory world wide and guarantee the capability of educational institutions and their products. The School of Medicine is committed in this achievement along with the Association of Medical Schools and The Superior Education Council.     

Education programs in US medical schools, 1995-1996

We present herein data on US medical education programs and describe how medical schools are adapting to a changing health care environment. The data mainly derive from the 1995-1996 Liaison Committee on Medical Education Medical School Questionnaire, which had a 100% response rate. The data indicate that in the 1995-1996 academic year there were 91 451 full-time faculty members in basic science and clinical departments, a 1.6% increase from 1994-1995. In clinical departments, major increases occurred in emergency medicine (a 10.6% increase in full-time faculty) and family medicine (a 13.5% increase). Applicants for the class entering in 1995 numbered 46 591, an increase of 2.7% from 1994; however, the number of first-time applicants decreased slightly (0.6%). Of the 17 357 applicants accepted, 2179 (12.6%) were members of underrepresented minority groups. Health system changes are affecting medical school clinical affiliations. During the past 2 years, 42 schools saw a merger, acquisition, or closure involving medical school-owned or medical school-affiliated hospitals used for core clinical clerkships. At 15 sites, this change affected the distribution of students across clinical sites. In 1995-1996, 40 medical schools or their universities owned a health maintenance organization or other managed care organization, 93 schools contracted with a managed care organization to provide primary care services, and 96 schools contracted with managed care to provide specialty services. During the past year, 57 schools acquired primary care physician practices, and 70 started primary care clinics in the community.     

Unrelated donor bone marrow transplantation for Fanconi anemia

This paper describes the approach taken at the University of Queensland to broaden the scope of curriculum design to involve rural general practitioners, medical students and rural health care consumers. A form of nominal group process in serial telephone teleconferences was used, with a group of rural general practitioners, to develop and pilot curriculum content, learning strategies and assessment methods. Medical students assisted in the evaluation of the curriculum and representatives of rural organisations were consulted about the value of hosting medical students in rural communities. The three groups made significant contributions to the project. The results will be trialed for the entire year 6 cohort (240 students) in 1995 and will form the basis of the planned rural practice term in the new graduate course.     

History of the public health policy in Chad 1900-1995

Public health policy in Chad began after colonization in 1899 and remained under the control of French Army Medical Corps for a long time. Military doctors shared their time between treating service personnel and indigenous people entitled Medical Assistance and making rounds in their sector. Since independence public health in the country has been based on a two-pronged association including fixed facilities (hospitals and dispensaries) and mobile services such as the Endemic Disease Unit whose most notable success was control of sleeping sickness in the southern part of the country. Over the years Chad has built up a national medical staff comprising 150 physicians. A medical school was opened in N'Djamena in 1990 and paramedical personnel are now trained at the National School for Public Health. War and lack of funds interrupted mobile services and there is presently a recrudescence of sleeping sickness. Since 1990 the World Health Organization has imposed its views and primary care is now available for all. However, it is now too early to judge the efficacity of this program in Chad.     

Adaptation of medical care to the changing disease spectrum of adolescents

The spectrum of diseases affecting today's children and adolescents has changed. Today's urgent health problems are no longer acute and infectious disorders but much rather psychosomatic and chronic disorders. However, the present health delivery system has not adapted its structure to this changed spectrum of disease. This paper reports on a study carried out by the project "Health Risks and Structures of Medical and Mental Health Care." The project belongs to the North Rhine-Westphalian Consortium for Public Health, and the study was carried out in cooperation with the Special Research Unit 227: "Prevention and Intervention in Childhood and Adolescence." Results show that a small proportion of adolescents actually consult general practitioners. Inadequate cooperation between medical and mental health care services as well as insufficient links between these services and the life world of adolescents have led to a situation in which the use of professional assistance meets with barriers. As a result, adolescents continue to avoid visiting a physician even when they have already become ill. For this reason, there is an increasingly strong need to consider how to change the structures of medical and mental health care. Proposals are developed that meet the needs of adolescents and are oriented toward the requirements arising from the changing spectrum of disease.     

The future supply of physicians

Many health services researchers point to a growing surplus of physicians by the end of the century. The author discusses in detail a variety of policy positions, from the Flexner Report onward, that have affected the present and projected supplies of U.S. physicians. These include the American Medical Association's decades of efforts to control the numbers and types of U.S. medical students; effects of Medicare and Medicaid; changes in immigration and naturalization laws that increased the number of international medical graduates (IMGs); the medical community's non-response to the 1981 GMENAC Report's forecasts on physician oversupply; growth in the numbers of specialists; the fall and subsequent rise in the numbers of applicants to medical schools; the changing composition of the physician workforce; the refusal of the medical profession to consider a shorter training period for physicians; and other events from the past that can inform today's policymakers. The author then evaluates four policy recommendations that have evolved to deal with the problem of physician oversupply, and concludes that (1) reliance on the market to contain physician supply is unwarranted; (2) there is little prospect that Congress will soon reduce the inflow of IMGs, and even if it did, such action would have a marginal effect; (3) there is no prospect that 20-25% of U.S. medical schools will be closed by 2005, since the forces militating against such action are overwhelming; and (4) it remains to be seen whether the new health care environment will have more than a marginal effect in altering the current ratio of primary care to specialist physicians in the years ahead. In fact, if future outlays for health care increase as predicted, there should be sufficient funds for physician supply to continue to grow and for specialists to continue to make good incomes.     

Hemidesmosomes show abnormal association with the keratin filament network in junctional forms of epidermolysis bullosa

Leadership in improving the education of doctors, while impressive, is not happening fast enough. While there are many obstacles, there is no time to waste in restructuring medical education to repair its present deficiencies, for otherwise outside forces could overwhelm today's education leaders with imperatives to make improvements on their own terms. The first step in addressing present shortcomings is to establish measurable objectives for the education of doctors that are aligned with the legitimate expectations of society and the enduring precepts of the medical profession. To provide guidance in establishing these objectives, the AAMC launched the Medical School Objectives Project (MSOP) two years ago. This project is now close to completing its initial phase, which is to define the knowledge, skills, attitudes, and values every medical student must demonstrate before graduating. Phase Two will be concerned with implementation (e.g., establishing assessment methods; improving faculty development; etc.). As for aligning the outcomes of medical education with the precepts of the profession, nothing is more important: if doctors do not have high standards of professionalism--altruism, respect, compassion, honesty, integrity, and others--medicine's very survival is threatened. Medical educators must insist that their graduates demonstrate these attributes, through more careful admission criteria, more attention to medical professionalism in the curriculum and in the evaluation of students, more community service for students, and improved role modeling by faculty. Leadership for the changes that are needed will not come from a once-in-a-lifetime leader of heroic proportions but from everyone within academic medicine leading the profession to its promising future through quality education.     

The development of a course in basic physical examination skills

Basic clinical skills of most medical school undergraduates continue unobserved and deficiencies have been detected in a significant number of physicians during residency. Nevertheless, our health care system is calling for competent graduates with solid basic clinical skills and a larger representation of qualified generalists in the increasingly important managed care environment. The need for a better introduction to Clinical Skills course was identified by students and clinical faculty at Ponce School of Medicine. In response to these concerns a new curriculum was developed with clear objectives, effective instructional strategies, and performance-based evaluation, with adult learning principles as its framework. The musculoskeletal examination unit of the curriculum was pilot tested and the course evaluation strategies revealed satisfaction with objectives, instructional and evaluation strategies, as well as improved confidence, and sense of usefulness for the learned skills. A curriculum in basic clinical skills that incorporates adult learning principles with solid instructional strategies can increase the confidence and skills of the learners and should lead to improved outcomes.     

The physician assistant in South Carolina

This article provides an overview of the physician assistant profession in general and in South Carolina. Information on the educational program at the Medical University of South Carolina and the results of a study of the satisfaction and contribution of the physician assistant as perceived by a sample of South Carolina supervising physicians is included. The study demonstrates that the physician assistant makes an important contribution to health care in South Carolina.     

Student and faculty collaboration in a clinic for the medically underserved

BACKGROUND AND OBJECTIVES: Growing numbers of uninsured and underinsured individuals in the United States have resulted in increased needs for health care for medically underserved populations. Educational strategies are needed that provide opportunities for students to develop the attitudes, knowledge, and skills necessary for providing quality health care for underserved patients. METHODS: Medical students, residents, and faculty of the University of Wisconsin-Madison Medical School worked together to establish extracurricular opportunities for first- and second-year students to participate in medical clinics serving the poor and homeless. The process for the development and operation of a volunteer clinic is described. RESULTS: In the last 2 years, 163 medical students, 27 residents, and 21 faculty have provided care to more than 1,000 patients. Patients, students, residents, and faculty reported high satisfaction with the experience. CONCLUSIONS: Medical students, residents, and faculty working in collaboration can provide increased access to care for the medically underserved. Engaging in community-oriented primary health care early in their medical education provided positive learning opportunities for medical students, especially those interested in generalist careers.     

Education and training of medical informatics in the medical curriculum

The teaching of medical informatics is of importance for students in medicine and health care, realizing that they will be the health professionals of the future. Training in medical informatics is also of value for practicing clinicians who are overwhelmed by the avalanche of systems that are available on the market. Some examples of operational systems are presented here to indicate that health care has changed dramatically over the last decades. This paper intends to contribute to the drafting of IMIA guidelines for teaching medical informatics by (1) reporting on the experience at the Faculty of Medicine and Health Sciences of the Erasmus University Rotterdam as part of the curriculum, (2) reporting on the implementation of guidelines for teaching medical informatics in The Netherlands since these guidelines were drafted in 1986, and (3) by introducing the teaching material contained in the new Handbook of Medical Informatics and on its Web site.     

Professional development of medical students: problems and promises

Observers and critics of the medical profession, both within and without, urge that more attention be paid to the moral sensibilities, the characters, of medical students. Passing on particular moral values and actions to physicians has always been an essential core of medical training, and this call for renewal is not new in modern medicine. Some of the structures and characteristics of modern medical education, however, often work directly against the professionalism that the education espouses. For example, medical students are socialized into a hierarchy that has broad implications for relations among health care professionals, other health care workers, and patients, and academic medicine has not promoted and taught critical reflection about the values and consequences of this hierarchy. Further, behind the formal curriculum lies the "hidden curriculum" of values that are unconsciously or half-consciously passed on from the faculty and older trainees. Two resources for thinking anew about professional development for medical students are feminist standpoint theory and critical multicultural theory, each of which raises important and fundamental questions about defining the role of medicine in society and the role of the physician in medicine. The author discusses these two theories and their implications for medical education, showing how they can be used to move discussions of professional development into analysis of the widespread social consequences of how a society organizes its health care and into critical reflection on the nature of medical knowledge.