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Education of Medical Students: Present Innovations, Future Issues

      In this editorial, we will review some of the problems that make this a particularly challenging time to educate medical students. Such aspects as the shrinking pool of applicants, the changing profile of the applicants, and the effect of economics on medical education will be considered. Recent innovations in medical education such as problem-based learning, use of computers in teaching, and the teaching and assessment of clinical skills will be examined critically.

      Problem-Based Learning.

      Although problem-based learning produced an initial flurry of excitement, no objective data support the contention that the end product of this type of learning is a “better” physician.
      • Schmidt HG
      • Dauphinee WD
      • Patel VL
      Comparing the effects of problem-based and conventional curricula in an international sample.
      In its purest form, problem-based learning implies that all requisite medical knowledge can be acquired as a result of researching and understanding patient problems. This clinically based “need to know” will cause better retention of basic science and clinical information because it will be hinged on a patient problem. This approach, however, has several fundamental problems. The first deficiency is that, without meticulous planning, students may complete their medical training and have large gaps in their knowledge base. The second difficulty is that problem-based learning is a faculty-intensive approach to training. Group leaders must undergo training, meet with students on an ongoing basis or until the case is solved, and be retrained in the complexities of each new problem. This concentrated use of faculty members makes problem-based learning expensive.
      As we look toward the future, we should identify alternative approaches that would facilitate achievement of the major goals of problem-based learning in a more cost-effective, less labor-intensive fashion. One suggestion is the rebirth of clinical correlations. Although they were widely used 10 to 15 years ago, their application seems to have declined with the advent of problem-based learning. This trend may have been attributable to a failure to develop master teachers who could effectively conduct clinical correlation exercises with a large group of students. The students might first be presented with background reading or a lecture in a basic science area to provide them with the requisite knowledge. This introductory material could be followed by a case presentation, and the students would be requested to ask a faculty member for information from the patient's history and physical examination. For each piece of information requested, the faculty person would inquire why it was necessary and how it would help solve the patient's problem. A master teacher could engage 50 to 100 students with this process and provide great economy in faculty time. Such a clinical correlation encourages students to think in a logical and clinical fashion and to use basic science information to solve clinical problems. The role model has certainly been established with the case study method used in business and law schools.
      • Christensen CR
      • Hansen AJ
      An alternative approach is to use problem-based learning episodically throughout a traditional curriculum. For each session, the group of students might be presented with a case that would anticipate upcoming course material while also incorporating information from recently completed courses. The case could have multiple parts, and groups of students could identify learning issues for each segment. Objectives could be developed and provided by the group leader to ensure coverage of key issues and uniformity in the learning process. Clinical demonstrations and interaction with patients (actual or simulated) could be included as ancillary learning activities. The case might culminate with the presentation of an actual patient who mirrors many of the issues discussed during the case. For the past 3 years, this model has been used successfully at the University of Massachusetts and has received enthusiastic support from students and faculty. It is one strategy for introducing some problem-based learning into a traditional curriculum.

      Use of Computers in Teaching and Learning.

      Computers have been widely touted as essential tools for the teaching and evaluation of medical knowledge and skills. Without an adequate definition of the term “computer literacy,” medical educators have considered it critical for the next generation of physicians. Undoubtedly, knowledge of word processing, spread sheets, and data bases for information retrieval has greatly simplified our existence. Except in isolated instances, however, little evidence has shown computers to be effective in teaching and testing. Computer graphics generated in live time are a magnificent way to illustrate pressure-flow relationships. Ideas that require three-dimensional axes for presentation can best be demonstrated on a computer screen rather than on a two-dimensional sheet of paper. Computers are useful for drill exercises with a large bank of questions in which students are allowed to progress at their own pace and ability level. Computers also provide a strategy to allow more answer options to be presented than can be easily managed with a paper and pencil exercise. The interaction of computers and videodisks is a striking technique that allows the visualization of some extraordinary clinical material.
      We suspect that computer-assisted instruction and evaluation will probably be important in the future, but the currently available software does not support widespread use at this time. Programs are expensive to produce, and few high-quality programs exist. Although computers are a useful tool for medical education, they should not be presumed to be capable of teaching and evaluating all aspects of medicine. Their use should be reserved for competency areas in which they have demonstrated benefit for efficiency and effectiveness. We are eagerly awaiting the development of new software programs that can be integrated into our curriculum.

      Teaching and Assessment of Clinical Skills.

      What is the best way to teach students clinical skills? How do they learn to take medical histories, perform physical examinations, and talk to patients? Neither the current hospital nor ambulatory environment provides an opportunity for students to learn to talk to patients about sensitive issues such as sexual concerns, to tell a patient about the recurrence of a malignant lesion, to request an autopsy from the next of kin, or to deal with an abusing parent. Ideally, these skills should be practiced repeatedly before students are required to use them with actual patients.
      Over the years, we have developed a systematic approach to teaching students basic clinical skills and evaluating their competence. We have also been able to ensure that students will be exposed to common clinical problems and will learn how to diagnose and treat them capably. We believe that this model will become even more useful in the future as the practice of medicine continues to evolve.
      During a course on physical diagnosis, our first-year medical students practice their basic skills on each other before being exposed to actual patients. A detailed behavioral checklist is used as both a teaching and an evaluation instrument. To learn basic interviewing skills, small groups of first-year students work with a faculty facilitator in role-play exercises and interactions with simulated patients. During the course of a semester, each second-year student is required to see a minimum of 10 patients, for each of whom a complete history must be recorded and a physical examination must be performed. The student must then prepare a detailed write-up on each patient and present the case to a preceptor, who is either a full-time or a voluntary faculty member. For some degree of quality control, each student performs a complete physical examination, obtains an adult history, and obtains a pediatric history on a “standardized patient.” Standardized patients are nonphysicians who are trained to function in the roles of patient, teacher, and evaluator.
      • Stillman PL
      • Burpeau-Di Gregorio MY
      • Nicholson GI
      • Sabers DL
      • Stillman AE
      Six years of experience using patient instructors to teach interviewing skills.
      To present an objective and individualized critique of each student's performance, the standardized patients use detailed behavioral checklists and evaluation instruments with preset mastery criteria. Each student also interacts with a female standardized patient to learn how to perform breast and pelvic examinations and a male standardized patient to learn how a genitourinary examination should be done in a male patient.
      Third-year medical students also have contact with several standardized patients. During the internal medicine clerkship, they practice a complete physical examination on a standardized patient and are required to perform at an established level of competence. Each student also interacts with several patients who have common ambulatory problems. For most students, this is the first opportunity to elicit a brief but relevant history and to perform a physical examination on an actual patient, inasmuch as an outpatient experience is not a part of the medicine clerkship. As part of the obstetrics-gynecology clerkship, students perform a pelvic and breast examination on a standardized patient. During the pediatric clerkship, they interact with a standardized patient who first acts as a pediatric parent and then evaluates the student's history-taking skills. This experience is followed by an oral examination with a faculty member, who evaluates the case presentation, knowledge base, and problem-solving skills with use of the history from the standardized patient just seen.
      For the past 4 years, fourth-year students have participated in a day-long multiple-station clinical assessment exercise with standardized patients who have common ambulatory problems. This project has been conducted in conjunction with several medical schools in New England.
      • Stillman PL
      • Swanson DB
      Ensuring the clinical competence of medical school graduates through standardized patients.
      • Stillman PL
      • Regan MB
      • Swanson DB
      • Fourth-Year Performance Assessment Task Force Group
      A diagnostic fourth-year performance assessment.
      After each encounter, the standardized patient documents and evaluates the student's performance. At the end of the day-long exercise, the students discuss the cases with a faculty member and receive written feedback on their performance as well as a comparison of their scores with those of the other students who saw the same patients. If students who have weak clinical skills are identified, their respective schools provide special remediation programs.
      With increasing pressure on faculty to generate research and patient-care revenues, we anticipate that in the future more medical schools will use standardized patients as an integral part of their teaching and evaluation programs. Standardized patients are a logical strategy for helping students practice basic history-taking and physical examination skills and for guaranteeing that each student is exposed to patients with certain common clinical problems. We also expect that a multiple-station clinical assessment examination will become part of the licensure process for all graduates.

      Some Major Issues in Medical Education.

      The decline in applicants to medical school is striking. In 1976, more than 42,000 candidates applied to American medical schools. By 1988, the number had declined to 26,721. The reasons for the decline are multifactorial but can be attributed in large measure to the cost, to the time it takes to become certified (11 to 15 years after secondary school), and to the increased dissatisfaction of many practitioners who feel beleaguered by the high malpractice insurance premiums, increased governmental regulations, and declining reimbursement from third-party payers.
      In 1988, the average indebtedness of 82% of American medical school graduates was $38,489. More than 24% of these students had debts in excess of $50,000.
      The applicant pool is also changing. Increased numbers of applications are now received from women, older students, and minorities. It is expected that all three categories of students will be less willing than traditional students to assume a high debt burden.
      It is difficult to see how quality can be sustained in all medical schools when there are now only 1.7 applicants for each position. The question of decreasing class size may well become a key issue in medical education if the number of applicants does not stabilize.

      Effect of Economic Realities on Medical Education.

      During the past decade, faculties of American medical schools have had increasing amounts of pressure to generate research and clinical revenues. Despite a doubling of full-time faculty from 1972 to 1986, it is increasingly difficult to provide “protected” time for teaching. Although good teaching receives administrative lip service, only rarely are such activities rewarded. Thus, faculty members are primarily committed to those activities that generate their salaries. Such a trend is even apparent in the recruitment of the chairperson of a clinical department, who is often chosen for the capacity to ensure continued and expanding grant support rather than a commitment to medical education.
      • Weller TH
      As it was and as it is: a half-century of progress.
      Other economic factors that have an influence on medical education are evident in the hospital. Patients must be admitted and dismissed in the shortest possible time to ensure maximal reimbursements to the hospital through the prospective-payment mechanisms. Therefore, the student may not even have a chance to interview and examine the patient, much less follow the natural history of the disease. The quaint tradition of ordering laboratory tests out of curiosity has long since disappeared, an appropriate evolution because these tests often became a poor substitute for the development of basic clinical skills.

      The Ordering of Academic Priorities.

      The current conventional wisdom is that the “triple threat” of medical academia is a rarity. Few faculty members can compete for federal research grants, generate substantial clinical dollars, and mesmerize students and residents with the skills of a master teacher. Most wise clinical chairpersons divide their faculty into clinicians and researchers. Both groups are expected to teach, and ideally, each group should spend at least a portion of time in the other group's major activity. Apart from these two revenue-generating groups, a third group, the scholarly teachers, need to be supported because they are rarely subsidized completely by scarce institutional funds. These individuals are the master teachers—;few in number but indispensable to the teaching mission of every medical school. The sequestration of funds for “protected” teaching time is essential. When a chairperson of a clinical department is recruited, it is vital that the candidate selected understands the need for the division of professional priorities in the modern clinical department. It is also important that the researcher participate in some clinical activities and that the clinician engage in some scholarly activities. Unless this cross-participation happens, walls will separate the laboratory from the bedside, to the detriment of teaching, research, and clinical care.
      Because our current hospital population consists of sicker patients with shorter durations of stay, it might not be prudent to allow students to learn and practice basic skills on these patients. A patient with multisystem disease or one who is admitted to the hospital for a diagnostic procedure may be an inappropriate candidate for a beginning student. Some educators suggest that students should be trained in an ambulatory patient setting,
      where the opportunity would exist to see patients with common problems such as hypertension, angina, minor gastrointestinal upsets, headaches, and backaches. These complaints would be typical of those encountered in practice. Teaching in the ambulatory setting, however, has other inherent problems because physicians and clinical facilities are under pressure to process patients as rapidly as possible. Therefore, this setting is not ideal for a beginning student who requires a considerable expenditure of time for history-taking and physical examinations. Also, many private patients may not readily accept the arrangement of being seen by a beginning student. In addition, when multiple physician preceptors in different specialties interact with students and are assigned the responsibility of teaching basic skills, the result may be a loss of quality control and uniformity in these learning experiences. The teaching might be “uneven” because each student may be exposed to the unique patient base of the preceptor.

      Can We Decrease the Cost of Medical Education?

      Recently, Ebert and Ginzberg
      • Ebert RH
      • Ginzberg E
      The reform of medical education.
      proposed, rather bravely, that medical school begin after 3 years of undergraduate school and that medical school be lengthened to 6 years in order to graduate generalists ready for licensure. They thought that a continuum of 4 clinical years, beginning with the third year of medical school, should be sufficient time to train physicians in the primary-care specialties. This plan would decrease the total training period for certification by 2 years. Students at Oxford and Cambridge planning to enter medicine complete the equivalent of the first 1½ years of medical school before they receive their bachelor of arts degree in physiology. In addition, during much of the fourth year of medical school, elective courses “outside the framework of a cohesive educational plan” are studied. Commenting on the proposal from Ebert and Ginzberg, Bondurant
      • Bondurant S
      Perspectives: a medical school dean.
      made the following statement: “… I do not believe that most young men and women would be so qualified in knowledge, experience, judgment, and perspective for medical practice after the best six-year curriculum that I can conceive. I wish that the experiment that is judiciously recommended were not doomed to success.” This statement reflects the ambiguity in the thinking of many medical educators when a foreshortening of the time for training of physicians is contemplated.
      The future of American medicine can be as exciting as its past, but it will take bold initiatives and realistic assessments of our current situation to preserve the considerable achievements of the past.

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