Innovative Medical School Research Articles

Digital morphology network for effective teaching of cytology, histology and histopathology for medical and biology curriculum. VM3.0 Erasmus+ project.

Digital microscopy transformation, the basis for the virtual microscopy applications, is a challenge but also a requirement in modern Medical Education. This paper presents the scope, background, methods, and results of the project "Digital Transformation of Histology and Histopathology by Virtual Microscopy (VM) for an Innovative Medical School Curriculum", VM3.0, funded by the European Union under the Erasmus+ framework (ref.no.2022-1- RO01-KA220-HED-000089017). The project was initiated at Grigore T. Popa University of Medicine and Pharmacy, Iași, Romania, with the support of Euroed Foundation, Iași, and cooperation of University partners from Gdansk (Poland), Plovdiv (Bulgaria), Alicante (Spain), and Patras (Greece) aimed to implement digital histology and histopathology teaching in a common network. The backbone of the project was the development of a Digital Slide Platform based on the scans of histological slides collected from all the partners of the participating universities and the creation of a simple and fast digital/internet communication tool that could be used to improve histology and histopathology teaching of medical and natural sciences students. The construction of a Virtual Microscopy Library (VML) has been based on the acquisition of whole scans of high-quality histological slides stained by hematoxylin and eosin (H&E) and other classical staining methods and description of various organs' details in English as well as respective languages of the project's partners. The VML can be used for different approches, both for students' instruction in classes as well as for individual students' work and self-testing. Universities from other countries could use the modal structure of the developed VML system on the condition that more slides are provided and the implementation of national language(s) is implemented. The combined efforts of all university partners allowed to establish the dynamic low-cost virtual microscopy educational system. The VM system could help unify the standards of cytology, histology, and histopathology teaching in a quest for the digital transformation of the European educational system.

Ten-year evaluation of an immersive global health medical school course using a four-principle equity framework

IntroductionResponding to a growing need for health care professionals equipped with global expertise in local and international settings, an innovative global health medical school course was developed that combines rigorous didactics, mentorship, cross-cultural training, and international experiences to build students’ cultural humility and clinical skills.MethodsRecognizing that global health service trips and courses can unintentionally exacerbate inequities and power imbalances, this course was evaluated using the four principles of Melby et al.’s Guidelines for Implementing Short-term Experiences in Global Health. These principles include skill building in cross-cultural effectiveness and cultural humility, bidirectional participatory relationships, local capacity building, and long-term sustainability.ResultsThe course was developed with long-standing global partners and includes a capstone project that is intended to strengthen local capacity with benefits to the site and student. Student course evaluations, supervisors’ observations of students, and supervisor feedback forms indicate that this course achieves these principles. Furthermore, there is evidence that students developed cultural humility, acquired foundational science knowledge and relevant skills, and changed their medical practice.DiscussionThis approach could serve as a model for institutions seeking to enhance training in global health for medical students.

Learning How to Learn: An Innovative Medical School Orientation Activity.

In 2018, Creighton University School of Medicine initiated a multiyear strategy to redesign the pedagogic approach of its educational program, transitioning from large-group, lecture-based experiences to small-group, active learning experiences using case-based learning (CBL) as required prework for team-based learning (TBL). In July 2019, the authors introduced their first-year medical students to the pedagogic and empiric underpinnings of the new curriculum they would experience. Initially, and ironically, this introduction was presented as a 30-minute didactic lecture, and students' ability to assimilate this information in any meaningful way was challenged. In addition, students required several sessions of the CBL-TBL activities during the official curriculum before they were able to effectively function as a team of learners. The authors created a novel introduction to their educational program that was active, meaningful, and efficient. In 2022, the authors created a 2-hour, small-group CBL activity using a fictional narrative of a medical student encountering their curriculum. During development, the authors recognized that the narrative was conducive to introduction of affective responses to medical education stressors, such as imposter phenomenon and Stanford duck syndrome. The CBL activity was given 4 hours during the formal 2022 orientation; 230 students participated. The CBL activity occurred on the second day of orientation and the TBL activity on the third (final) day of orientation. The results of the TBL activity indicate that students acquired a fundamental understanding of the attributes of active learning, features of imposter syndrome, substance abuse associated with Stanford duck syndrome, and peer evaluation. This CBL-TBL activity will become a permanent part of orientation. The authors hope to evaluate the qualitative outcomes of this innovation on students' professional identity formation, institutional affiliation, and motivation. The authors will assess for any negative impact of this experience and the overall orientation.

Vertical Integration and Reinforcement of BasicScience Concepts in an Engaging Clinically Oriented Physiology Pharmacology Session (COPPS).

Medical educators are finding it challenging to ensure strong basic sciences knowledge is built in the allocated time assigned in the innovative medical school curriculum. In this article, we introduce a novel method to vertically integrate basic sciences knowledge during clinical training.

An innovative medical school curriculum to enhance exposure to genetics and genomics: Updates and outcomes

PurposeIn 2011, we introduced an innovative parallel curriculum at Baylor College of Medicine, formerly called the Genetics Track Curriculum and now called the Genetics and Genomics Pathway, aimed at providing an opportunity for an enriched educational experience throughout medical school. In this report, we describe our 10-year experience with the program and highlight growth in enrollment as well as academic achievements of graduating students. MethodsWe reviewed the data of students enrolled in this pathway, including retention, satisfaction, student-driven curriculum changes, scholarly outcomes, and career outcomes. ResultsFrom September 2011 to June 2021, 121 students were enrolled in the Genetics and Genomics Pathway program. In total, 64 students (64/121 = 53%) left the program before graduating (the majority, after their first year). Of the 57 remaining students, 29 graduated (29/57, approximately 51%), and 4 of the 29 students (4/29 = 14%) matched into a genetics training program. ConclusionThis novel program serves as a mechanism for garnering increased interest and competence in medical genetics. The longitudinal nature of the program fosters enthusiasm for genetics and provides ample opportunity to develop valuable research skills. Given the ongoing shortage of providers in this field, such programs are vital to increase the size of the workforce and broaden the knowledge of providers in diverse fields.

A Comparative Study Between Nineveh and Tikrit Medical School Teachers Perceptions regarding the Effectiveness of OSCE in Clinical Examination

Assessment students competence is of much importance especially when evaluation the expected learningout come of medical education and because of increasing students number enrolled in medical colleges , thislead to enhance the chance of malpractice that compromise patient conditions , therefore it is challenging todevelop and implement such an objective assessment method in clinical examination. Objective of the study:The study aim is to compare the traditional and innovative medical school teachers perceptions regardingthe effectiveness of OSCE in clinical examination . A descriptive cross sectional study has been conductedin both (Nineveh and Tikrit medical college from the period of 15th February till 20 th April / 2014.The study was included 95 medical teachers from both traditional and innovative schools .( 55 teachersfrom the traditional school and 40 from innovative school). A special questionnaire form was prepared bythe researcher through direct interviewing with the study sample. The results show that 63.1% of medicalteachers are male , 49.5% aged between 40-49 years ,65.3 % from basic specialty sciences , 51.6% havinga period more than 10 years in teaching, 70.9% of traditional school teachers agree that OSCE evaluate thepractical objectives in comparison to 67.5% of innovative school teachers agree with that OSCE evaluateknowledge, understanding , practical , and intellectual objectives. The study concluded that more than halfof traditional medical teachers agree with the affectivity of OSCE in assessing large number of studentswithout bias while medical teachers from innovative school agree with the objectivity of OSCE in clinicalevaluation.

Hands-on Cooking in Medical Schools: Diffusion of a Prevention Education Innovation.

Educating physicians early and often on how to have conversations with patients about diet to prevent and treat chronic disease is imperative, yet under realized. Some innovative medical schools have begun implementing hands-on cooking (HOC) programs to fill this gap, but how these programs are promoted is unknown. This study assessed the prevalence and innovation characteristics of HOC programs offered to medical students in the USA. Content analysis of webpages was conducted using a Diffusion of Innovation (e.g., relative advantage, compatibility, complexity, trialability, and observability) framework. Themes of relative advantage included increasing students' confidence, improvements in medical and interprofessional education, and translating into a benefit to patients through improved care. Compatibility codes showed only a quarter of webpages referred to the program as "evidence-based." Complexity codes showed most (86%) webpages clearly described the course. About half the webpages described the program as an elective, suggesting trialability of this innovation. Many (43%) of the programs referenced use of a standardized "culinary medicine" curriculum, contributing to the observability of this innovation. Within the sample of schools, 35% provided HOC programs for their students. These findings suggest HOC programs have a strong foothold in healthcare education and provide a framework from which future studies might examine what effects innovative, successful HOC programs have on curriculum development, student experience, and, ultimately, patient outcomes.

A Comparative Study between Traditional and Innovative Medical School Students Perceptions and attitude Regarding the Effectiveness of Patient Safety in Medical Education

Patient safety is a new discipline in a health care that determine the medical errors which leads to adverse events and it is a fundamental principle of health care. The simplest definition of patient safety is the prevention of errors and adverse effects to patients associated with health care . The study aimed is to compare between traditional and innovative medical school students perceptions and attitude regarding the effectiveness of patient safety in medical education Introduction: Health care services have improved considerably in the light of medical advances; however, these advancements were considered as major threats to health care industry [1]. For example, in 1999 the US Institute of Medicine (IOM) estimated 44000–99000 deaths every year as a result of preventable medical errors [2]. Other studies have indicated adverse events as an international concer Method : A cross- sectional study was carried out in both medical schools ( Mosel & Tikrit ) after receiving administrative agreement and a verbal consent was taken from each participant before establishing the study. Results : Medical students from both collages and two stages were selected randomly (Third & fourth ) and (180) students were participated in the study . A special questionnaire form has been designed by the investigator included five main dimensions prepared for that purpose. The results show that medical students from third and fourth stage from traditional school go with the needed for adequate reliable reporting system for patient safety registration (47.7% and 47.3%) Fourth stage from traditional and innovative school agree with the effective strategy to deal with the medical errors carefully as an preventive measure (60.0%, 85.7%) respectively . Conclusions: Engagement of formal curriculum on patient safety in medical education is necessary . Recommendations : Better policies investment for patient safety improvement with introduction of large scale studies to assess the nursing care impact on patient safety .

Longitudinal Continuity Learning Experiences and Primary Care Career Interest: Outcomes from an Innovative Medical School Curriculum.

Medical students in the USA have negative perceptions of primary care careers, which are exacerbated by the hidden curriculum and medical school culture. Longitudinal integrated clerkships (LICs) have shown promise in ameliorating this situation by promoting student/preceptor continuity relationships and helping students maintain empathy. The aim of this study is to describe the Student Continuity of Practice Experience (SCOPE) program and demonstrate program outcomes using evaluation data from residency match results, course evaluations, and student grades. University of Texas Medical Branch, an academic health center in Galveston, Texas. Undergraduate medical students. Learners participate in a longitudinal curriculum designed to enhance their skills as primary care physicians. They regularly attend continuity clinic, establishing a panel of patients by their third year. Students receive frequent feedback from a faculty mentor on assignments and clinical performance. SCOPE students have high primary care residency match rates and experience patient continuity rates comparable to an intern. Their interest in primary care increases between years one and three, a departure from typical medical student trends. SCOPE appears to promote and maintain primary care career interest in participants and has transferability to other institutions.

An innovative medical school curriculum to address human papillomavirus vaccine hesitancy

BackgroundVaccination rates against Human Papillomavirus (HPV) in the US remain alarmingly low. Physicians can significantly influence a parent’s decision to vaccinate their children. However, medical education often lacks training on specific strategies for communicating with vaccine hesitant parents. MethodsWe created an innovative curriculum designed to teach medical students how to address HPV vaccine hesitancy. The curriculum consisted of (1) a presentation on the epidemiology, biology, and disease morbidity associated with HPV, (2) a video that teaches specific communication strategies and (3) role-playing simulations. This curriculum was delivered to medical students at two separate sites. Medical students were surveyed before and after completing the educational curriculum. The surveys assessed student comfort talking to HPV vaccine hesitant parents and their likelihood to recommend the HPV vaccine. ResultsPre- and post-intervention surveys were completed by 101 of the 132 participants (77% response rate). After the intervention, student awareness of the benefits of the HPV vaccine increased by a mean of 0.82 points (Likert scale 1–5, p < 0.01) and student comfort talking to vaccine hesitant parents increased by a mean of 1.37 points (p < 0.01). Prior to the intervention, students more strongly recommended the HPV vaccine to females compared to males, but this gender disparity was eliminated after the intervention (p < 0.01). Personal vaccination status was independately associated with a higher likelihood of recommending the HPV vaccine both before and after the intervention. ConclusionOur innovative curriculum improved medical student comfort level discussing HPV vaccination with hesitant parents and increased the perceived likelihood of recommending HPV vaccination. The intervention is easy to implement, scalable, and requires minimal resources. Educating future providers on this important topic has the potential to improve vaccination rates nationwide and thus should be considered for all medical students.

Effectively Training the Hospice and Palliative Medicine Physician Workforce for Improved End-of-Life Health Care in the United States

The widening gap between the demand for palliative care services and the supply of trained palliative care professionals has resulted in considerable end-of-life distress for patients. Without formal training in palliative medicine and end-of-life symptom management, physicians in the United States are less equipped to competently address seriously ill and dying patients' medical, emotional, and spiritual needs. Recent attempts within graduate medical education training deliberately seek to prepare a critical mass of physicians as the new hospice and palliative medicine workforce in the United States. In addition, healthcare reform proposals may re-define the National Health Service Corps (NHSC) post-graduate training over the next five years and the Hospice Medicare Benefit altogether. Healthcare policy options include steady changes at multiple levels of medical training -namely, medical school curriculum mandates, requiring all graduate physician residency training to foster patient-centered communication skills and discussions about advanced directives, and instituting palliative medicine proficiency Continuing Medical Education (CME) requirements for all states' medical licensing boards. Attracting qualified physicians to serve patients at the end of life, innovative medical school loan repayment programs and scholarships will also foster excellence in the field of hospice and palliative medicine. Correcting our current paucity of formal training in palliative medicine better utilizes hospice and restores patients' dignity at the end of life.

Enhancing exposure to genetics and genomics through an innovative medical school curriculum

Enhancing exposure to genetics and genomics through an innovative medical school curriculum

Beyond knowledge, toward linguistic competency: an experiential curriculum.

Training is essential for future health care providers to effectively communicate with limited English proficient (LEP) patients during interpreted encounters. Our aim is to describe an innovative skill-based medical school linguistic competency curriculum and its impact on knowledge and skills. At Stanford University School of Medicine, we incorporated a linguistic competency curriculum into a 2-year Practice of Medicine preclinical doctoring course and pediatrics clerkship over three cohorts. First year students participated in extensive interpreter-related training including: a knowledge-based online module, interactive role-play exercises, and didactic skill-building sessions. Students in the pediatrics clerkship participated in interpreted training exercises with facilitated feedback. Knowledge and skills were evaluated in the first and fourth years. First year students' knowledge scores increased (pre-test = 0.62, post-test = 0.89, P < 0.001), and they demonstrated good skill attainment during an end-year performance assessment. One cohort of students participated in the entire curriculum and maintained performance into the fourth year. Our curriculum increased knowledge and led to skill attainment, each of which showed good durability for a cohort of students evaluated 3 years later. With a growing LEP population, these skills are essential to foster in future health care providers to effectively communicate with LEP patients and reduce health disparities.

Development of a synergistic case‐based microanatomy curriculum

This paper discusses the development of an interactive approach to teaching and assessing a microanatomy curriculum in an innovative medical school program. As an alternative to lectures and labs, students are engaged in interactive seminars focused on discussion of clinical and research-based cases matched with normal histology and pathology slides. A virtual microscopic system is used rather than the traditional glass slide and light microscope. Evaluation of student performance consists of self-assessment board style questions, concept appraisal problems, and utilization of a portfolio system where the assessment pieces are continuously integrated as part of written formative and summative assessments.

A Roundtable of Innovative Leaders in Medical Education

In 2008, the Global Health Education Consortium (GHEC) created the Training for Health Equity Network (THEnet), bringing together schools in different parts of the world that share a core mission: to recruit students from, and produce physicians for, underserved communities. In determining the competencies such physicians will need, these schools also share an approach to medical education that looks beyond the traditional curriculum and seeks the involvement of communities and other stakeholders. Their input helps define the knowledge, skills, and attitudes around which new curriculum is built, and helps guide the selection of educational methodologies, taking into account context and resource constraints. The nascent THEnet now has a nucleus of eight member schools, each dedicated to fulfilling a strong social accountability mandate. The network is designed to assist them by providing a collaborative platform conducive to experimentation; dialogue; and creation and sharing of tools, experiences and evidence. It will also support systematic outcome evaluations, innovation, and joint research to strengthen the knowledge base on successful strategies for increasing the number and quality of doctors in neglected communities. By bringing these schools together, developing synergy among them and publishing their results, THEnet hopes to more broadly promote the transformation of medical education and medical practice into more socially accountable endeavors that improve health system equity and performance. Leaders from six of these innovative medical schools spoke with the Guest Editors of this issue of MEDICC Review, a conversation we bring you below. They are: Dr Juan Carrizo, Rector of the Latin American Medical School (ELAM), Cuba; Dr Fortunato L. Cristobal, founding Dean of the School of Medicine at Ateneo de Zamboanga University (AZU), the Philippines; Dr Pedro D�az, member of the National Academic Coordinating Committee of the National Training Program for Comprehensive Community Physicians (NTPCCP), Venezuela; Dr Richard Murray, Dean and Head of the School of Medicine and Dentistry, James Cook University (JCU), Australia; Dr Roger Strasser, founding Dean of Northern Ontario School of Medicine (NOSM), Canada; and Dr Paul Worley, Dean of Flinders University School of Medicine (FUSM), Australia. Erratum Neusy, AJ, Palsdottir, B. A Roundtable of Innovative Leaders in Medical Education. MEDICC Review. 2008;10(4):20-24. The correct website for the Ateneo de Zamboanga University School of Medicine in the Philippines is: http://som.adzu.edu.ph.

Educational Environment in Traditional and Innovative Medical Schools: A Study in Four Undergraduate Medical Schools

The undergraduate curricula of medical schools in King Abdul Aziz University, Saudi Arabia, Umm Al-Qura University, Saudi Arabia and Sana'a University, Republic of Yemen are traditional, like most of the medical schools in the Middle East region. The curriculum in Dundee University Medical School, UK, claims to follow the prescriptions of the UK General Medical Council to be outcome based with three interlocking phases and students encouraged to take responsibility for their own learning. The aim of this study is to measure the educational environment, using the 50-item Dundee Ready Education Environment Measure (DREEM), in each medical school and to compare the educational environment as perceived by the responding students of the traditional medical schools in developing countries with that of the "modernised" medical school in Dundee University, UK. The DREEM was administered to 1072 medical students in the four different universities. Using SPSS, data were expressed as means of scores. Comparisons between schools, years of study and gender were made using non-parametric tests. For all three traditional medical schools, the mean scores of the inventory were lower compared with Dundee Medical School. Students from traditional schools rated their learning and teaching environment significantly lower than their counterparts in Dundee Medical School. Similarly, they rated their academic self-perceptions, social-self perceptions and their atmosphere more poorly than the Dundee students. The DREEM provides useful diagnostic information about medical schools, whether it is in developing or western developed countries.

Evaluation of an innovative approach to community-based medical undergraduate education in Nigeria.

Although innovative, community-oriented and PHC-focused medical education programmes have been in operation in some medical schools in Nigeria for over a decade, they are yet to be comprehensively evaluated. This study therefore aimed at evaluating some impacts of the programmes on medical education in the country. The study was conducted in three innovative medical schools in South-Western Nigeria. Two traditional medical schools were selected as control. Questionnaires were used for the collection of data from random samples of 44 final year medical students in the innovative medical schools (SIMS) and 40 final year medical students in the traditional medical schools (STMS). Forty (40) medical graduates of the innovative medical schools (GIMS) and 33 graduates of the traditional medical schools (GTMS) also participated in the study. In addition, in-depth interviews of key stakeholders of the programmes and focus group discussions of selected members of the communities were conducted. Findings revealed that the graduates of the innovative schools were better exposed to PHC education than those in the traditional schools. Their perceptions of the objectives of, and functions during, the PHC education were significantly different. Methods of learning during the programmes appear to be more experiential and inductive. Attitudes of members of rural communities were also favourable to the programmes. The innovative programmes appear to have impacted positively on medical education in the country. A major deficiency of the programmes is inadequacy of human and material resources for their effective functioning.

Problem-Based Learning in the Clinical Laboratory Science Curriculum

Introduction The clinical laboratory is changing at an unprecedented rate. The introduction of new technologies and increased automation along with a reduction in personnel has placed unparalleled demands on laboratory professionals. Increasingly, clinical laboratory practitioners must exhibit broad-based problem-solving skills, independence, flexibility, and a willingness to work collaboratively with other health care professionals. Educational programs in the clinical laboratory sciences (CLS) face the challenge of preparing graduates with these skills. A curricular approach gaining respect in allied health education is problem-based learning (PBL), which evolved from innovative medical school curricula introduced almost 30 years ago. PBL takes into account how students learn, fostering the development of critical reasoning skills within the context of their professional discipline, as well as the motivation for lifelong learning necessary for adaptation to a changing environment.1 At State University of New York (SUNY) Upstate Medical University (Syracuse, NY), a new course called Clinical Correlations was recently incorporated into the 2+2 bachelor of science curriculum in medical technology. The course uses a PBL format in which students apply critical reasoning, communication, and collaborative skills in a small-group, learner-centered environment. The philosophy underlying PBL is that individuals best develop knowledge and skills by actively solving problems and building conceptual frameworks rather than through the passive memorization of facts. Students explore carefully designed problems that integrate content from across the laboratory disciplines under the guidance of a facilitator who challenges them to an in-depth examination of the case objectives. Since implementation of this problem-based course, our students demonstrate an increased ability to evaluate information from multiple perspectives, are more comfortable critically questioning their own decisions and conclusions, and show a greater level of responsibility for their own learning.

Can selection assessments predict students' achievements in the premedical year?: a study at Arabian Gulf University.

In a problem-based learning (PBL) program, students are encouraged to develop self-motivation, self-confidence, communication skills and problem-solving skills. Measuring these attributes when selecting students into medical schools is a formidable task. Admission to medical school typically depends upon students' academic achievement in their prior education. In the past 3 years the College of Medicine and Medical Science (CMMS) at the Arabian Gulf University, which has a PBL curriculum, adopted an admission policy that utilizes final high school scores, a written admission examination in English and science, as well as a structured interview. To determine the extent to which the admissions measures predict academic achievement in the first year of studies at CMMS. Prediction study of prospectively collected data. Final cumulative score for all subjects at the end of the first year was the main dependent variable analyzed. All students admitted to the college during the academic year 1998-1999. The written admission science examination scores had the highest correlation (r =0.663, p< 0.05) with the Year 1 final cumulative score. Although the admission interview focused on non-cognitive student attributes, which may or may not affect the students' academic performance, its score had a statistically significant, if low, correlation with the Year 1 final cumulative score (r =0.275, p< 0.012). Approximately 59% of the total variability of the Year 1 final cumulative scores could be explained by the admission examination scores in science and English and the high school scores. Procedures for selecting students who are most likely to succeed academically in the initial year at an innovative medical school deserve further study and probably should include both academic performance and non-academic attributes.

Medical faculty as humanistic physicians and teachers: the perceptions of students at innovative and traditional medical schools.

The training of caring physicians represents an important goal of medical education. Little is known however, on whether medical faculty constitute good role models for teaching humanistic skills to medical students. In this study, we examined to what extent medical students at innovative and traditional schools perceived their teachers as humanistic physicians and teachers. We also explored whether pre-clinical and clinical students shared the same perceptions. A mail survey was conducted in Canada of all second-year students and senior clerks at one innovative medical school (problem-based learning (PBL), patient-centred, community-oriented) and three traditional medical schools. Students were asked to what extent they agreed or disagreed that the majority of their teachers behaved as humanistic physicians and teachers; 10 statements were used. Overall, 65% of the 1039 students returned the questionnaire. Over 25% of second-year students and 40% of senior clerks did not agree that their teachers behaved as humanistic caregivers with patients or were good role models in teaching the doctor-patient relationship. More than half of second-year students and senior clerks did not agree that their teachers valued human contact with them or were supportive of students who had difficulties. There were few differences in the way medical students at innovative and traditional schools perceived their teachers' humanistic qualities. At the pre-clinical level however, there were more students from the innovative school than from the traditional schools (around 60% vs. 40%, P < 0.005) who agreed that their teachers valued human contact with them and were supportive of students. Our results indicate that the PBL curriculum fosters better teacher-student relationships during the pre-clinical years. They also suggest that an unacceptably large number of medical students are taught by physicians who seem to lack compassion and caring in their interactions with patients. This study questions the adequacy of medical faculty as role models for the acquisition of caring competence by medical students.