Network is a verb. The experience of the network of community-oriented educational institutions for health sciences.

The process of networking has great potential for facilitating and accelerating global health development. This article presents some of the experiences of the Network of Community-Oriented Educational Institutions for Health Sciences. Three components are identified, each of which is illustrated by a specific Network activity: (1) tasks and projects, (2) information and communications technology, (3) people and institutions--the human factor. Some important lessons have been learned. Because people are the key to successful networking, there is a need to strengthen the research about how networks function. Encouraging progress is being made toward more effective global collaboration.

The McMaster M.D. program: a case study of renewal in medical education.

This paper presents four aspects of health professions education at McMaster University: (1) a review of the key elements of the history and distinctive approach of the Doctor of Medicine (M.D.) program; (2) a description of the process and substance of curriculum change over the past decade, focusing on a major revision of the M.D. program that began in 1983; (3) a summary of the findings of follow-up studies of McMaster M.D. program graduates; and (4) an analysis of the current context within which the Faculty of Health Sciences (of which the M.D. program is a part) is operating and a description of strategies for renewal that are being implemented. The evidence and experience to date support the assertion that satisfactory--and in some ways special--physicians can be prepared using the "McMaster approach" to medical education, but that continuous review and periodic major revisions of the educational program are both necessary and possible; they must occur in concert with developments in other sectors of Faculty of Health Sciences activities.

Educating future physicians for Ontario.

In 1987, Ontario's physicians conducted a strike, ultimately not successful, over the issue of "extra billing." The fact that the Ontario public did not support this action reflected a major gap between the profession's view of itself and the public's view of the profession. In 1990, the province's five medical schools launched a collaborative project to determine more specifically what the people of Ontario expect of their physicians, and how the programs that prepare future physicians should be changed in response. The authors report on the first five years of that ongoing project. Consumer groups were asked to state their views concerning the current roles of physicians, future trends that would affect these roles, changes in roles they wished to see, and suggestions for changes in medical education. Methods used included focus groups, key informant interviews, an extensive literature review, and surveys, including a survey of health professionals. Concurrently, inter-university working groups prepared tools and strategies for strengthening faculty development, assessing student performance, and preparing future leadership for Ontario's medical education system. Eight specific physician roles were identified: medical expert, communicator, collaborator, health advocate, learner, manager ("gatekeeper"), scholar, and "physician as person." Educational strategies to help medical students learn to assume these eight roles were then incorporated into the curricula of the five participating medical schools. The authors conclude that the project shows that it is feasible to learn specifically what society expects of its physicians, to integrate this knowledge into the process of medical education reform, and to implement major curriculum changes through a collaborative, multi-institutional consortium within a single geopolitical jurisdiction.

Educating future physicians for Ontario: phase II.

In 1990, a collaborative project was launched to determine what the people of Ontario expect of their physicians and how the programs that prepare future physicians should be changed in response. The project, called Educating Future Physicians for Ontario (EFPO), brought together the five Ontario medical schools, the Council of Ontario Faculties of Medicine (COFM); a nonprofit, charitable organization, Associated Medical Services (AMS); and the Ontario Ministry of Health. The first phase ran for five years and was described in the November 1998 issue of Academic Medicine. After an external review, the project was continued for a second phase (EFPO II) for four more years until December 1998; that second phase is the topic of this article. EFPO II (1) focused more on residents' education; (2) emphasized four of the EFPO I-created physician roles in project activities; (3) maintained the province-wide, inter-institutional medical education framework of phase I, but fostered greater involvement of the seven sites (five medical schools and two regional health centers) in project activities; (4) stressed five project components (e.g., needs assessment and community partnerships) and worked for collaboration among components at all sites; (5) enhanced the original EFPO I Fellowship Program by adding residents and community fellows to the existing fellowships and by initiating leadership development activities, all of which bode well for the future leadership of medical education in Ontario. Students and residents played a vital role in EPFO II. Most of EFPO II's objectives were met, but the overall view of external reviewers was that the project was less successful than EFPO I. For example, the impact on clinical education, especially residency education, was less than anticipated. On the other hand, the project helped encourage the wide adoption of the eight physician roles that originated in EFPO I and advanced faculty development and assessment activities based on these roles. A third phase of EFPO concerning continuing medical education was planned, but support was not available. However, one of the funders will continue to support the successful fellowship and leadership program and the provincial education network for the next three years. Overall, the two phases of EFPO substantially modified medical education in Ontario to make it more responsive to evolving social needs.

Ranking clinical problems and ocular diseases in ophthalmology: an innovative approach to curriculum design.

The MD program of the Faculty of Health Sciences, McMaster University, Hamilton, Ont., has used a problem-based, self-directed, small-group learning approach to medical education since 1969. Substantial curriculum revision was begun in 1983 as part of a process of institutional renewal. A faculty survey of all academic clinicians in the Division of Ophthalmology, Department of Surgery, was carried out in 1984 to determine which problems and diseases the teaching faculty thought had the highest priority for student learning. The results have been used by educational planners in revising the curriculum. They have also served to clarify faculty members' expectations of students within an ophthalmology rotation.

A method of evaluating residency training programs.

A method for conducting residency program reviews is presented, based on experience with four reviews at McMaster University. The key elements are the stance of the review group as fact finders rather than judges, direct communication with the program director at the beginning and end of the review, and the relatively unbiased perspective which individuals can bring who are 'internal' to the university but external to the program being reviewed.

A randomized trial of librarian educational participation in clinical settings.

In order to evaluate the librarian's educational role in patient care settings, an information service was provided for health professionals, patients, and families by two part-time clinical librarians. Eight clinical areas were randomly selected from a pool of settings which met predetermined entry criteria. Four of these settings were randomly allocated to the experimental maneuver (that is, the clinical librarian service), and four were control settings. Results showed that the clinical librarians were accepted by health professionals and that services to all groups were viewed as successful. Significant differences in information-seeking patterns were found between study and control groups of health professionals. In particular, the study group was more likely to use the library for direct patient care and rated the librarian and library resources more highly as sources of information. This time-limited and education-oriented model would be useful for settings in which a full-time librarian program is not feasible.

Solving problems: how does the family physician do it?

Objective evidence exists for a model of clinical problem solving by family physicians. Previous studies have examined the activities of family physicians, but there have been no data indicating the mental process behind these activities. This study, exploring the thought processes of family physicians engaged in clinical problem solving, has lead to the model described in this paper. Its educational and clinical implications are considered.

Giant-cell arteritis of the uterus and adnexa.

The case history and pathological findings in an excisional biopsy are described of a sixth example of giant-cell arteritis affecting the female internal genitalia. Histologically, giant-cell arteritis in this location tends to focus on the outer layers of the blood vessel, and it is thought that this is due to the "senile" elastosis of the adventitia which occurs so commonly in blood vessels in this situation.

Clinical problem-solving by medical students: a cross-sectional and longitudinal analysis.

The evolution of clinical reasoning in medical students was studied. A cross-sectional sample consisted of randomly-selected medical students from three classes. Additionally, twenty-two students were observed at yearly intervals from the preclerkship period to the first post-graduate year. Subjects were observed in a clinical examination of a simulated patient, and their thought processes were abstracted from a 'stimulated recall' of the videotaped encounter. The data were transcribed and coded for computer analysis, yielding several variables characterizing the clinical reasoning process, and four measures of outcome of the encounter. Analysis of variance of differences between students at various educational levels and a doctor criterion group indicated that the majority of the process variables were unrelated to educational level. By contrast, diagnostic and management outcomes were positively related to education. The single process variable which was related to both educational level and outcome was an 'hypothesis aggregate score', a measure of the content of the student's diagnostic hypotheses. The results of the study indicate that the problem-solving or clinical reasoning process remains relatively constant from medical school entry to practice. This observation has important implications for clinical teaching and evaluation.

The clinical reasoning of randomly selected physicians in general medical practice.

Most formal studies of the clinical reasoning process have been carried out on physicians in the sub-specialties and do not permit generalizations about the nature of the process in the average practising physician. Eighteen family physicians and 19 general internists were randomly selected and assigned to 1 of 4 standardized simulated patient problems in a natural practice setting. Sixty-two physician-patient encounters were studied by direct observation, videotape recall, and subsequent analysis of encounter transcripts by the physician. Physicians consistently developed multiple diagnostic hypotheses early in the patient encounter to guide their inquiry in a manner that would allow them to choose the appropriate hypothesis. Their approach was primarily problem-oriented and was not based on a routine inquiry intended to gather a comprehensive body of data as a basis for making subsequent diagnostic decisions. Little variation occurred between different patient problems. The accuracy and promptness of hypothesis generation were seen to play a significant role in the accuracy of diagnostic formulations. The process must be understood by those concerned with teaching and evaluating clinical competence.

Measuring physicians' performances by using simulated patients.

The authors in this paper discuss a new approach to the assessment of physicians' performances in practice using undetected standardized (simulated) patients. Case-specific performance criteria were established for seven standardized patients by eight family physicians and two specialists. The patients were then introduced into the practices of the family physicians and of a second cohort of seven family physicians. No differences were found between the criteria-setting and the noncriteria-setting physicians; but large differences were found among the criteria, the physicians' performances as indicated by the patient, and the data recorded by the physicians on the patient chart. Depending on the method used to score the performance and the recorded data, about 30 to 45 percent of the procedures were not performed, and 50 to 70 percent of the criteria were not recorded. The implications of the study for assessment of physician performance are discussed.

Measuring the outcome of clinical problem-solving.

The authors describe a new technique for measuring the outcomes of a clinical encounter using objective criteria derived from the performance of a criterion group.

The impact of continuing education on the quality of patient care.

We randomly allocated family physicians meeting explicit entry criteria to experimental and control groups to determine whether CME affects the quality of patient care. The experimental group received educational packages, the control group did not. These educational packages were closely matched with explicit criteria used in the indicator condition-our method of measuring the quality of care. The indicator conditions were divided into elective, mandatory and hidden categories. We compared over 4,500 patient encounters, before and after the educational maneuver, with explicit clinical criteria in the indicator condition. These episodes of care were then classified according to quality of care. Though knowledge increased from the educational packages, overall quality of care improved very little. If the topics were elective, quality of care improved equally in both the experimental and control groups. When the topics were mandatory, quality of care provided by the experimental group improved (P < 0.05). Topics covered by the hidden indicator conditions showed no spillover effect.

A controlled trial of teaching critical appraisal of the clinical literature to medical students.

We carried out a controlled trial of teaching the critical appraisal of clinical literature among final-year clinical clerks. Tutors at two of four teaching hospitals were offered a short course in the critical appraisal of clinical articles that describe diagnostic tests and treatments and were assisted in identifying and appraising specialty-specific articles that described those diagnostic tests and treatments that clinical clerks were sure to encounter during their clerkship tutorials. Tutors and clerks at the other two hospitals received no special intervention and served as controls. Experimental and control clinical clerks completed pretests and posttests of their ability to take and defend a stand on whether to apply specific diagnostic tests and treatments in specific clinical situations. Experimental clerks demonstrated both statistically and "clinically" significant increases in their critical appraisal skills, improving 37% on the diagnostic test exercise and 8% on the treatment exercise; control students' scores deteriorated for both.

Demand-side medical education: educating future physicians for Ontario.

Initiated by Associated Medical Services (AMS), Educating Future Physicians for Ontario is a 5-year collaborative project whose overall goal is to make medical education in Ontario more responsive to that province's evolving health needs. It is supported by AMS, the five universities with medical schools or academic health sciences centres and the Ontario Ministry of Health. The project's five objectives are to (a) define the health needs and expectations of the public as they relate to the training of physicians, (b) prepare the educators of future physicians, (c) assess medical students' competencies, (d) support related curricular innovations and (e) develop ongoing leadership in medical education. There are several distinctive features: a focus on "demand-side" considerations in the design of curricula, collaboration within a geopolitical jurisdiction (Ontario), implementation rather than recommendation, a systematic project-evaluation plan and agreement as to defined project outcomes, in particular the development of institutional mechanisms of curriculum renewal as health needs and expectations evolve.

Setting educational priorities for learning the concepts of population health.

Following the World Health Organization's policy of 'Health for All by the Year 2000', doctors are increasingly being seen as health care providers to populations of patients, in addition to their more traditional role as doctors to individuals in a one-to-one encounter. In order for doctors to take on this expanded role, they must learn the knowledge and skills appropriate to population health. In this paper, we propose a method of educational priority-setting which allows educational planners to identify those diseases and adverse health conditions most appropriate for studying the concepts of population health. Using the Measurement Iterative Loop of Tugwell and colleagues as a framework, a table of Priority Illness Conditions was developed and compared with a previous priority list developed from a survey of clinical teachers at the McMaster University Medical School. Discussion of the implications for this approach in setting educational priorities at undergraduate, postgraduate and continuing medical education levels is presented, along with a review of possible shortcomings and caveats in using this approach.