Academic Medicine

The Technological Innovations in Medical Education (TIME) Project has created an interactive videodisc patient-simulation model that provides faculty with a new method for patient-centered teaching in the medical school classroom. The TIME model is designed to be controlled by a professor in the classroom setting, and incorporates voice recognition technology and video dramatization to create a believable patient encounter. Under the auspices of the Lister Hill National Center for Biomedical Communications, National Library of Medicine, where the Project originated in 1983, three medical schools participated in a field test of this "high-tech" model. Six faculty members made ten classroom presentations of two TIME simulations to 306 second-year medical students. The principal finding was that, in a group setting, a large majority of the students at all three schools became individually committed to the care and management of the simulated patient. They acted as if the patient's problems were real and left the session feeling as though they had interacted with an actual person. Therefore, in terms of simulating a real patient, the TIME patient-simulation model was validated, providing the basis for the development of new patient-centered methods to teach and test medical students in the classroom setting. The Project has been at the Georgetown University School of Medicine, where the model is being introduced into the existing curriculum, since 1988. It is currently being used as a part of the final examination for second-year students and in discussion-group settings for fourth-year students in the internal medicine clerkship. A field test is also under way using the TIME model to assess the clinical performance of third-year students.

This chapter provides an overview of the decisions, activities, events, and issues that influenced the process of change at the eight schools that participated in The Robert Wood Johnson Foundation's "Preparing Physicians for the Future: Program in Medical Education." The author focuses in particular on three stages of the change process: planning and creating the climate for change, making the change, and reinforcing the new model. She describes the different strategies the schools used to work through these stages (in some cases, several iterations of these stages) and the common lessons participants learned about how to successfully implement curricular reforms.

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'I am in a car park in Leeds when I tell my husband I don't want to be married to him any more...' London GP Katie Carr always thought she was a good person. With her husband David making a living as 'The Angriest Man in Holloway', she figured she could put up with anything. Until, that is, David meets DJ Goodnews and becomes a good person too. A far-too-good person who starts committing crimes of charity like taking in the homeless and giving their kids' toys away. Suddenly Katie's feeling very bad about herself, and thinking that if charity begins at home, then maybe its time to move...Penguin Street Art: Hawksmoor by Peter Ackroyd / Armadillo by William Boyd/ And The Ass Saw the Angel by Nick Cave / What a Carve Up by Jonathan Coe/ Americana by Don DeLillo/ Then We Came to the End by Joshua Ferris/ The Reluctant Fundamentalist by Mohsin Hamid/ The Believers by Zoe Heller/ How to Be Good by Nick Hornby/ Lights out for the Territory by Iain Sinclair.

To compare knowledge acquisition as measured by test scores for students in nontraditional clinical clerkships to scores for students in traditional urban hospital-based clerkships. Interdisciplinary and continuity-of-care clerkships in rural areas are the focus of the study. All the students' Medical College Admission Test (MCAT) scores, National Board of Medical Examiners (NBME) subject exam scores, and United States Medical Licensing Examination (USMLE) Step 1 and Step 2 scores over a six-year period, 1998-99 to 2003-04, were compared for third-year students in nontraditional and traditional clerkships at the University of North Dakota School of Medicine and Health Sciences. Cohorts were 29 students in our Rural Opportunities in Medical Education (ROME) program and 296 students in traditional third-year clerkships. NBME subject exam scores were those in pediatrics, internal medicine, surgery, and obstetrics and gynecology. The exam used for family medicine is not standardized to national standards, but controlled within the Department of Family Medicine. MCAT and USMLE Step 1 scores were used as a means of controlling for prior academic achievement and ability. There were no significant differences (p > or = .05) in MCAT scores, Step 1 scores, subject exam scores, or Step 2 scores between the two groups. In contrast, students from ROME scored higher (p < or = .05) on the internal medicine clinical preceptor assessments than did students from the traditional track. These findings suggest that students in remote, rural, longitudinal, integrated learning environments can attain fund-of-knowledge scores comparable to the scores of students in traditional clerkships, and may, as in this study, receive higher ratings for clinical proficiency.

Although the use of problem-based learning (PBL) is widespread in U.S. medical schools, its true prevalence is unknown. This study examined the prevalence of PBL in preclinical curricula. In 2003, a Web-based questionnaire was sent to education deans or directors of medical education at the 123 Liaison Committee on Medical Education-accredited medical schools in the United States. The respondents indicated whether or not they were using PBL and what percentage of faculty-student contact hours in the preclinical years used PBL. All 123 schools responded. Of them, 70% used PBL in the preclinical years. Of schools using PBL, 45% used it for less than 10% of their formal teaching, while 6% used it for more than half of their formal teaching. Of the 30% of schools not using PBL, 22% had used it in the past, and 2% had plans to incorporate it in the future. Use of PBL is widespread in the preclinical curricula of U.S. medical schools. That use is limited, however, since fewer than 6% of programs use it for more than 50% of their instruction.

The personal health care of medical students is an important but neglected issue in medical education. Preliminary work suggests that medical student-patients experience special barriers to health care services and report problematic care-seeking practices that merit further inquiry. A self-report questionnaire was piloted, revised, and distributed to students at nine medical schools in 1996-97. The survey included questions regarding access to health services, care-seeking practices, and demographic information. A total of 1,027 students participated (52% response rate). Ninety percent reported needing care for various health concerns. Fifty-seven percent did not seek care at times, in part due to training demands, and 48% had encountered difficulties in obtaining care. A majority had received treatment at their training institutions, and students commonly pursued informal or "curbside" care from medical colleagues. Almost all participants (96%) were insured. Differences in responses were associated with level of training, gender, and medical school. Medical schools shoulder the responsibility not only of educating but also of providing health services for their students. Students encounter barriers to care and engage in problematic care-seeking practices. Greater attention to issues surrounding medical student health may benefit students and their future patients.

Skills needed by physicians to address and prevent our communities' leading causes of premature death--injuries, cancer, cardiovascular disease, homicide, and suicide--are not in the typical roster of medical school learning experiences. And traditional, urban, hospital-based venues of medical education scarcely model for students appealing careers in the community. These twin problems are especially severe in rural America. Yet rural training sites are ideal locations for students to confront the array of social, political, and economic forces underlying ill health in our society. If learning in medical schools is to be suitable for rural practice, students must receive early and sustained exposure to rural communities and to rural physician role models. To facilitate this educational redirection, medical schools must (1) sensitize their existing faculty and residents to community health needs via in-service training on community health topics, (2) encourage faculty and residents to provide service and education outreach to rural communities, and (3) promote rural health research. Finally, to prevent the marginalization of rural health concerns within the academic agenda, efforts should be made to develop university-community partnerships in which model rural training practices and a "field" teaching faculty are established and nourished by the medical center.

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.

The authors attempted to determine male and female medical students' exposures to and perceptions of gender discrimination and sexual harassment (GD/SH) in selected academic and nonacademic contexts. An anonymous, self-report questionnaire was administered in the spring of 1997 to senior medical students at 14 U.S. medical schools. Data were collected about students' exposures to GD/SH during undergraduate medical education and outside the medical training environment. Students' perceptions of GD/SH in various medical specialties and practice settings were also measured. Of the 1,911 questionnaires administered, 1,314 were completed (response rate, 69%). Both men and women reported exposures to GD/SH. More women than men reported all types of exposures to GD/SH across all academic and nonacademic contexts. Differences between men and women in the frequencies of exposures were greatest outside the medical training environment (t = 15.67, df = 1171, p <or=.001). Within academic medical training contexts, the differences by sex were most evident in core clerkships (t = 11.17, df = 1176, p <or=.001). Women students perceived the prevalence of GD/SH to be significantly (p <or=.001) higher in a number of medical specialties than did men. However, both groups believed these behaviors to be most common in general surgery and obstetrics-gynecology. Women perceived significantly more GD/SH in academic medical centers and community hospitals. Both groups perceived these behaviors to be significantly more prevalent in academic medical centers than in community hospitals, and more prevalent in community hospitals than in outpatient office settings. This study suggests that mistreatment in the form of GD/SH is prevalent in undergraduate medical education, particularly within core clerkships. Interventions focused on particular specialties and training periods may be helpful.

The National Board of Medical Examiners (NBME) has been developing new tests to be administered using computers. As these tests near readiness for use, logistical issues of test administration have become important. In 1989-1990, in order to plan for the implementation of computer-based testing in NBME examinations of the future, the authors, under the auspices of the NBME, conducted a telephone survey of knowledgeable individuals at the 143 LCME-accredited medical schools in the United States and Canada to gauge the numbers and types of microcomputers and workstations available for students' use at these schools. The findings, based on the responses of all the schools surveyed, are reported.