Successful accomplishment of educational goals with clinical experience at public primary care facilities.

GOAL: To compare the spectrum of clinical encounters experienced by medical students at the primary level of care in six urban public health units, and to determine the extent to which these educational experiences were sufficient to meet learning objectives proposed for a teaching module. METHOD: During the 4th year of a new six- year curriculum, 113 students cared for adults, the elderly, women and children. They were supervised by faculty and trained supervisors during three 4-hours periods a week, every other week, from January to October at six primary health units. RESULTS: There were 7198 clinical encounters (2493 for adults, 2440 for women, and 2302 for children), during a total of 37 periods, averaging 1.8 cases/student per period. The top five primary diagnoses, similar at all primary health units, included: for adults--hypertension, diabetes, upper respiratory diseases, anxiety/depression, and obesity; for children--first-year follow up, upper respiratory diseases, dermatological, and infectious diseases; for women--antenatal care, vaginal discharge, cervical cancer screening, climacteric symptoms/menstrual disorders, and family planning. CONCLUSIONS: Students were exposed to and cared for the most common conditions observed at the primary level of care, with a sufficient homogeneous clinical spectrum among six primary health units, meeting essential learning objectives related to ambulatory care.

Scholarship in teaching: an imperative for the 21st century.

At some medical schools broader definitions of scholarship have emerged along with corresponding changes in their academic reward systems. Such situations are not common, however. The definition of scholarship generally applied by medical schools is unnecessarily narrow and excludes areas of legitimate academic activity and productivity that are vital to the fulfillment of the school's educational mission. The authors maintain that creative teaching with effectiveness that is rigorously substantiated, educational leadership with results that are demonstrable and broadly felt, and educational methods that advance learners' knowledge are consistent with the traditional definition of scholarship. Faculty whose educational activities fulfill the criteria above are scholars and must be recognized by promotion. The authors specifically address scholarship in education, focusing on teaching and other learning-related activities rather than on educational research, which may be assessed and rewarded using the same forms of evidence as basic science or clinical research. They build on Boyer's work, which provides a vocabulary for discussing the assumptions and values that underlie the roles of faculty as academicians. Next, they apply Glassick et al.'s criteria for judging scholarly work to faculty members' educational activities to establish a basis for recognition and reward consistent with those given for other forms of scholarship. Finally, the authors outline the organizational infrastructure needed to support scholars in education.

A story of change.

In this introduction to Issues and Strategies for Reform in Medical Education: Lessons from Eight Medical Schools, the authors describe the overall objective of the supplement, which is to present the qualitative reflections of 12 faculty members at eight medical schools who worked to reform their schools' curricula as part of The Robert Wood Johnson Foundation's "Preparing Physicians for the Future: A Program in Medical Education." They outline the issues addressed in the reform efforts at all of the eight schools, including health promotion/disease prevention and ambulatory care, the editors' choice of a "vignette-based" format for the chapters, and the content of the three appendices that end the supplement. They conclude with a brief description of the lessons learned by all participants in the collaborative effort of producing this supplement on curriculum change.

Student assessment.

This chapter looks at changes in assessing medical students implemented by the eight schools participating in The Robert Wood Foundation's "Preparing Physicians for the Future: Program in Medical Education." The eight schools took a variety of approaches, some working incrementally, others making large, cross-departmental changes. Each school's support for or constraints to change influenced its approach in assessment. The authors describe the ways in which students were assessed within their courses and clerkships. They look at specific forms of assessment, such as self-assessment, feedback, and standardized-patient assessment. For most of the schools, changes in student assessment were controlled by course or clerkship directors and managed by faculty. Often, changes in assessment came after changes in curriculum. Changes were easier to make in the first two years of medical school than in the clinical years. The authors also discuss the integration of assessment within the curriculum, comprehensive performance-based assessments, and situations where change in assessment did not occur. They discuss the politics of change, and offer a summary of the eight schools' assessment experiences and the lessons learned.

Reflections on relevance, resistance, and reform in medical education.

This chapter reflects upon the collective experiences of the eight schools participating in the Robert Wood Johnson Foundation's "Preparing Physicians for the Future: A Program in Medical Education," highlighting the lessons learned over the five years of the program. The authors set the context and give a short history of the program. They discuss the ways in which the processes of change occurred at the eight schools, commenting on issues of leadership, governance, communication, faculty development, integration, instructional methods, student assessment, and program evaluation (all of which received lengthier treatment in earlier chapters). The authors conclude that changes in all of these areas are necessary for successful reform of medical education.

A survey of graduates in practice from the University of New Mexico's conventional and community-oriented, problem-based tracks.

PURPOSE: To survey graduates in practice from the first four classes of the University of New Mexico School of Medicine's (UNMSOM's) parallel curricular tracks, and compare data about the graduates' practice patterns, learning behaviors, and satisfaction with the profession of medicine. METHOD: Between 1979 and 1993, the UNMSOM had two tracks for the first two years of medical school: a conventional track and the Primary Care Curriculum (PCC), a community-oriented, problem-based track. In 1990, a survey was conducted of the 140 graduates from the first four classes (1983-1986) who had completed their postgraduate training: 40 from the PCC and 100 from the conventional track. Statistical methods included two-way analyses of variance, logistic regression, and chi-square, adjusted by Bonferroni methods. Comparisons between tracks are reported after adjustments were made for specialty effects. RESULTS: Thirty-three graduates (83%) from the PCC and 87 (87%) from the conventional tracks responded. The PCC graduates were much more likely to work in medically underserved areas, practice in publicly funded health care settings, and care for non-paying patients. The PCC graduates more often identified patient problems and curiosity as providing motivation for their learning. They more frequently studied clinical medicine and community health topics and spent time in community activities. The PCC graduates felt better prepared for practice by their undergraduate medical education. There was no difference between the graduates of the two tracks in the sizes of the populations in which they practiced, in the criteria they used for deciding on referrals to other physicians, in the ranges of community resource utilization, or in the degrees of satisfaction within their chosen professions. Large percentages of graduates from both tracks (67% conventional and 79% PCC) considered themselves to be practicing either primary care or a combination of primary care and non-primary care. In addition, 38% of all the graduates practiced in the state of New Mexico. More PCC graduates chose careers in family practice; however, no significant difference was found in a comparison between the proportions of PCC and conventional-track graduates who chose primary care careers. CONCLUSION: Track differences favorable to the PCC were evident in relation to the two major goals established by the program: to attract graduates to careers in primary care in rural and underserved areas and to provide graduates with self-directed, lifelong learning skills. Some expected track effects were not found.

Performances on the NBME I, II, and III by medical students in the problem-based learning and conventional tracks at the University of New Mexico.

BACKGROUND: Problem-based learning curricula are growing in popularity, and questions have been raised about the appropriateness of standardized examinations, such as the National Board of Medical Examiners (NBME) Parts I, II, and III examinations, for assessing students in these new curricula. METHOD: Data on students' performances on the NBME I were analyzed for 508 graduates of the conventional track and 167 graduates of the problem-based Primary Care Curriculum (PCC) track at the University of New Mexico School of Medicine from the classes of 1983-1992; on NBME II, for 447 and 144 graduates, respectively (classes of 1983-1991); and on NBME III, for 313 and 100 graduates, respectively (classes of 1983-1989). The analyses also included data on the students' total Medical College Admission Test (MCAT) scores, undergraduate science grade-point averages (SGPAs), and admission subgroups within tracks. The statistical methods included analysis of covariance, Student's t-test, and the Fisher exact test. RESULTS: The students who had requested the PCC track but had been randomized into the conventional track had the highest mean scores on all the study variables (for 34 students, 521 on the NBME I, and for 19 students, 551 on the NMBE III). The high-risk students who had requested but had not been accepted into the PCC track seemed to benefit from the highly structured conventional track with regard to their NMBE I performances (467 for 18 students). The PCC students--both those who had been randomized into the PCC and those who had been selected into the PCC--had significantly lower mean scores on the NBME I (455 for 85 students and 463 for 82 students compared with 505 for the 439 students who chose the conventional track), but significantly higher mean scores on the NBME III (521 for 38 students and 522 for 62 students compared with 483 for the seven high-risk students and 487 for the 276 students who chose the conventional track). For both tracks, strong relationships were found among the scores on the three NBME examinations. For the PCC students, significantly weaker relationships were found between mean SGPAs and mean scores on the NBME I, II, and III. For both tracks, MCAT scores, especially in the lowest and highest ranges, were most predictive of performances on the NBME I and II. CONCLUSION: In the short run, the more teacher-centered and structured conventional curriculum better prepared the students for the NBME I, while in the long run, the more student-centered problem-based curriculum better prepared the students for the NBME III:

Rethinking critical issues in performance assessment.

The recent interest of medical schools and licensure organizations in establishing performance assessment methods in medical education presents new challenges to medical educators. The problems encountered in establishing the reliability and validity properties of performance assessment necessitate rethinking the accepted definitions of reliability and validity. The authors examine the relationship between Classical Test Theory and job performance. They discuss several critical issues: the meanings of reliability and validity in performance assessment and the balance between them (including simple versus complex behaviors), stability of performance, specific versus generic abilities, and the role of experts in clinical performance assessment. The authors call for a critical appraisal of applying Classical Test Theory to the assessment of job-related behaviors.

Residency performance of graduates from a problem-based and a conventional curriculum.

Performance of 130 graduates in residency from a community-oriented, problem-based medical curriculum, and from a parallel, conventional track, were compared on eight dimensions: knowledge, communication with patients, independent learning ability, teamwork, patient education, critical thinking ability, attention to health care costs, and self-assessment. Ratings were obtained from three evaluators: a doctor-supervisor, a nurse and the resident him/herself. The study was undertaken to identify differences between graduates from the two curricular tracks. Differences were observed in the areas of health care costs (supervisors) and communication with patients (residents), and a trend was observed in patient education (supervisors) and knowledge (nurses), The outcomes of the study are discussed in light of the literature on residency performance, and in terms of the educational experiences that characterize the two medical curricula.

Charting the winds of change: evaluating innovative medical curricula.

The increased interest, in North America and around the world, in problem-based and community-oriented medical curricula has sparked interest in the evaluation of these innovative programs. In January 1989, the Josiah Macy Jr. Foundation sponsored a conference to consider designs for evaluation studies and the potential distinctive outcomes of the innovative curricula that might be foci of these studies. After defining an "innovative curriculum," the participants identified seven characteristics of "important evaluation studies," particularly endorsing studies that compare curricula as whole entities. The participants then identified 26 areas where differences between graduates of innovative and traditional curricula might be expected, and five equally important areas where differences are not expected. Distinctive outcomes of innovative curricula were anticipated in areas such as interpersonal skills, continuing learning, and professional satisfaction. Overall, these recommendations are offered to stimulate creative evaluations of the growing number of innovative programs in medical education.

The change process and medical education.

Successful innovators in medical education accurately diagnose institutional barriers to innovation and employ effective strategies for overcoming these barriers. These institutional barriers and successful strategies are described with illustrative vignettes. They are generic to medical schools all over the world.

The cost of problem-based vs traditional medical education.

It is generally accepted that teachers' salaries are a major factor in the cost of medical education. Little is known about the effects of curriculum on teaching time. A comparison of teaching time devoted to each of two different medical education curricula is presented. In a traditional teacher-centered, subject-oriented curriculum, 61% of the total teaching effort expended by twenty-two teachers took place in the absence of students, i.e. in preparation for student contact. Only 39% of the effort devoted by these teachers to medical education took place in the presence of students. In a problem-based, student-centered curriculum which focuses upon small-group tutorial learning and early extended primary care experience in a rural community setting, 72% of the total teaching effort devoted to medical education was spent with students and only 28% was spent in preparation for student contact. Overall, there were no differences in the total amount of teaching time required by each of the two curricular approaches to medical education. There were, however, major differences in how teachers spent their teaching time.

Medical students' attitudes toward basic sciences: influence of a primary care curriculum.

The emerging popularity of family medicine and primary care among medical students with an attendant pressure for clinical relevance in pre-clinical coursework and early clinical exposure has raised questions in the minds of many academicians about the students' perceived value of basic sciences in such an educational environment. A comparison was made of attitudes toward the basic sciences between students in two, concurrent, pre-clinical medical school curricula at the University of New Mexico School of Medicine. The conventional curriculum offers a teacher-centered, 2-year curriculum of basic sciences taught predominantly by basic scientists in a lecture format. The experimental curriculum entitled the Primary Care Curriculum (PCC), offers a student-centered, 2-year curriculum in which pertinent basic and clinical science learning is derive primarily from common, primary care, patient problems, discussed in small group tutorials. There are no formal lectures. Half the tutors are primary care clinicians, half basic scientists. Attitude scales were administered in two successive classes of students in both curricula at the beginning of the first and second terms of the first year. Increased cynicism toward the curriculum and its relevance to future practice was observed among conventional, but not among PCC students. This findings lends supports to the hypothesis that modification in educational methods in general and relevant, primary care experience in particular can favourably influence students' attitudes toward basic sciences.

Interaction of beta-endorphin, naloxone and dopamine: effects on melanocyte-stimulating hormone secretion of amphibian pituitaries in vitro.

Neurointermediate lobes from amphibians (Rana pipiens) were incubated in Medium 199 containing dopamine, beta-endorphin or dopamine plus beta-endorphin. Dopamine inhibited melanocyte-stimulating hormone (MSH) secretion as measured by bioassay in hypophysectomized frogs, an effect which was transiently reversed by beta-endorphin. The effects of endorphin were in turn partially suppressed by the opiate antagonist, naloxone hydrochloride. Cells treated with all three agents exhibited expanded rough endoplasmic reticulum and decreased secretory granule content, indicative of peptide release and new synthesis. Beta-Endorphin alone did not stimulate MSH secretion above control levels, and at one time period was seen to reduce MSH secretion. The findings indicate a complex interaction between beta-endorphin and dopamine directly upon MSH secretion at the level of the neurointermediate lobe.

Naloxone prevents dark-background adaptation in amphibians.

Pituitary intermediate lobe melanocyte-stimulating hormone (MSH) is responsible for normal skin darkening in amphibians. Light-background adapted frogs (Rana pipiens) injected with naloxone and placed on black backgrounds maintain melanophore indices and pituitary cytology characteristic of light-background adaptation. In vitro and in vivo experiments showed that naloxone hydrochloride did not have a direct effect on skin melanophores or on the neurointermediate lobe. These data suggest that naloxone acts at the level of the central nervous system to inhibit the mechanism(s) responsible for release of MSH when light-background adapted frogs are placed on a dark background. Release of MSH, known to be tonically inhibited by the hypothalamus, may be modulated by opiate receptor-dependent mechanisms.