North American Medical Schools Research Articles

Evolutionary Biology in the Medical School Curriculum

The principles of evolution are finding new applications in medicine, but little is known about the role of evolutionary biology in medical curricula. To determine which aspects of evolutionary biology are included in medical curricula and the factors that influence this, a questionnaire was sent to all deans at North American medical schools who are responsible for curricula. The questionnaire asked about content areas in the curriculum, their perceived importance, and the factors that influence the amount of coverage given to those areas. Forty-eight percent of the deans who responded considered evolutionary biology important knowledge for physicians. Only 32 percent of the respondents reported that their schools covered at least 8 of 16 core topics in evolutionary biology, and only 16 percent of the schools reported having any faculty with a PhD in evolutionary biology. Lack of time in the curriculum and lack of faculty expertise are the main perceived impediments to increased teaching of evolution. We conclude that the role of evolutionary biology as a basic medical science should be carefully considered by a distinguished group of biologists and medical educators. In the meanwhile, undergraduate educators need to recognize that, for now at least, most future physicians must learn evolutionary biology as undergraduates if they are to learn it at all.

Betrayal of Trust

Betrayal of Trust

Micro Inequities and Everyday Inequalities: "Race," Gender, Sexuality and Class in Medical School

Abstract: Medical students in the 1990s are heterogeneous in terms of gender, race, class and sexual orientation. Based on a survey of third-year students, student interviews, and faculty/administrator interviews at one Canadian medical school, this paper goes beyond the identification of blatant forms of discrimination to examine micro level interactional practices of inclusion and exclusion that cumulatively convey messages about who does and who does not belong in medical school. These micro inequities and everyday inequalities construct an institutional climate that may marginalize and alienate some students, reproducing hierarchies of inequality despite the institution's express commitment to formal equality. Resume: Les etudiants en medecine des annees 90 sont un groupe heterogene en ce qui concerne leur sexe, ethnicite, classe sociale et sexualite. Prenant comme point de depart un sondage d'etudiants en troisieme annee et des entrevues avec des etudiants, des membres du corps professoral et de l'administration a une ecole de medecine canadienne, cette etude va au-dela de l'identification des formes flagrantes de discrimination pour examiner a un niveau plus subtil les pratiques interactives d'inclusion et d'exclusion qui, prises dans leur ensemble, transmettent le message de qui devrait et qui ne devrait pas etre etudiant en medecine. Malgre l'engagement public de l'institution a une egalite formelle, ces micro-iniquites et injustices de tous les jours creent un climat institutionnel qui marginaliserait et alienerait certains etudiants en reproduisant des hierarchies d'inegalite. Elements in the students' background do not exert any decisive influence ... in medical school. Such background factors may have indirect influence in many ways, but the problems of the student role are so pressing ... that the perspectives developed are much more apt to reflect the pressures of the immediate school situation than of ideas associated with prior roles and experiences (Becker et al., 1961: 47). In this passage from Boys in White, a classic study of medical professional socialization, Howard Becker and his colleagues insist that social characteristics such as gender, race, (2) culture, social class, sexual orientation, and religion have little or no impact on medical student experiences. Social differences become background variables in the face of an overwhelming medical student culture. In their study, conducted in 1956-57, about 5% of the students in any class were women and 5% to 7% were non-white (1961: 60). (3) They really were boys in white -- in fact they were white boys in white. Over the next 40 years the profile of the typical North American medical school class changed considerably. By 1993, 42% of medical students in the United States were women (Bickel and Kopriva, 1993). In Canada, women's proportion of medical school classes increased from 9% in 1957-58 to 49% by 1997-98 (Association of Canadian Medical Colleges, 1998: 17). By 1991-92 African American, Native American, Mexican American, Puerto Rican, other Hispanic, and Asian or Pacific Islander students made up 27% of all medical students in the United States (Jonas et al., 1992: 1088; c.f. Foster, 1996). In Canada statistics on the race of medical students are not available. As well, medical students are somewhat older and better educated upon entry than they were in previous years (Gray and Reudy, 1998: 1047). Evidence also indicates there are more openly-identified gay/lesbian/bisexual medical students. There are currently gay and lesbian student caucuses in medical schools, a Canadian gay and lesbian medical student E-ma il list, a gay and lesbian committee of the American Medical Student Association (Oriel et al., 1996), and recent journal articles addressing the concerns of gays and lesbians in medicine (Cook et al., 1995; Druzin et al., 1998; Klamen et al., 1999; Oriel et al., 1996; Risdon et al., 2000; Rose, 1994; Wallick et al. …

The Development of Professional Character in Medical Students

What is a professional? A professional commands a special body of knowledge and skills. A professional also is given specific rights not generally provided to the public, and has specific responsibilities or duties not generally expected of the public. What distinguishes a professional from an expert, then, is the contract negotiated between a specific group of experts and society.[1] In trade for specific rights--physicians, for example, have the right to ask private and personal questions, to prescribe narcotics, and to perform operations--professionals must accept responsibilities or duties not expected of society in general. These include confidentiality, compassion, integrity, interprofessional respect, public service, responsibility, and self-policing.[2] These are values that society expects its physicians to uphold as professionals, and values we intend to teach, promote, or at least not destroy in the course of medical education.[3] But there is good evidence that we in fact inhibit or impair the development of positive professional values in medical education. While the formal curriculum of medical school espouses professional values, the informal curriculum may teach something quite different. How Professional Values Are Taught formal curriculum of values is taught in medical school through both texts, including the medical school's statement of goals, and experiences. goals statement of the medical school at the University of Michigan, for example, reads: [The medical school's] goals will be attained when students have acquired ... [i]nterpersonal skills that facilitate effective and empathetic relationships with patients and effective collaborations with other health care professionals; the professional attributes of compassion, honesty and integrity; and social and professional responsibility in the context of a diverse and changing society ...[4] Formal curricular experiences include courses variably titled Introduction to the Patient, The Patient-Physician Relationship, or Doctoring, in which the principles of the doctor's behavior and relationship with patients are explored.[5] Other formal curricular experiences in medical school are similarly designed to instill some of the professional characteristics expected of doctors. Arnold P. Gold Foundation for example, has supported an exercise in North American medical schools in the last few years in which entering medical students are provided with a white coat and a lapel pin, signifying their preliminary initiation into the profession.[6] During this exercise, students are advised that the wearing of a white coat signifies the acceptance of a code of professional conduct, and that the public has very specific expectations of the wearer's behavior. Although many of these entering students will not have significant patient contact for at least two years, they are explicitly appraised of the standards to which they will be held. Although some institutions continue a few formal lectures and seminars into the third and fourth medical school years, professional values are heavily influenced by the socialization process that occurs during the clinical portion of medical education. While the values taught in the formal curriculum of the first and second years are highly consistent with the values outlined by the school and the profession, the values learned in the informal curriculum of the clinical years are highly variable.[7] Some values are enhanced, some are ignored, and some are overtly inhibited through demonstration or explanation, through parables, and through the negotiation of values conflicts. When asked how values are taught in clinical medical education, many individuals respond with role-modeling. As Melvin Konner noted in his first-hand account of medical school: physician's attitudes, mindset, moral stance, and the hour-by-hour decisions about how to use one's time--all these and many other matters, even including how and what and how much to feel, are observed by the student and imitated assiduously. …

What Postdocs Want--and How

POSTDOC ACTIVISMIn October 1998, postdocs from nine universities, research institutes, and national laboratories met in Palm Springs, California, at the annual conference of the Group on Graduate Research, Education, and Training, a subgroup of the Association of American Medical Colleges that includes faculty and deans from major North American medical schools. The meeting, informally dubbed the postdoc summit, produced a list of recommendations that postdocs are pushing for nationwide.

Teaching medical ethics: a review of the literature from North American medical schools with emphasis on education.

Efforts to reform medical education have emphasized the need to formalize instruction in medical ethics. However, the discipline of medical ethics education is still searching for an acceptable identity among North American medical schools; in these schools, no real consensus exists on its definition. Medical educators are grappling with not only what to teach (content) in this regard, but also with how to teach (process) ethics to the physicians of tomorrow. A literature review focused on medical ethics education among North American medical schools reveals that instruction in ethics is considered to be vitally important for medical students. Agreement by medical educators on a possible "core curriculum" in ethics should be explored. To develop such a curriculum, "deliberative curriculum inquiry" by means of a targeted Delphi technique may be a useful methodology. However, the literature reveals that medical curricular change is notoriously slow. General implications for medical ethics education as a discipline are discussed.

Medical studentsʼ evaluations of curriculum innovations at ten North American medical schools

The authors recount medical educators' calls in the 1980s to reform general professional medical education by supplementing the standard lecture-lab biomedical curriculum with new biopsychosocial pedagogy and emphases. They then report selected medical students' evaluations of corresponding curriculum reform efforts that were in place by 1990 at eight U.S. and two Canadian medical schools known for being innovators. From interviews conducted in 1992-93 with a group of three to nine medical students at each school, the authors report two findings. First, the students' positive evaluations converged: at all ten schools they invariably appreciated curriculum reform efforts of any sort that encouraged individuation, connection, and diversity. Second, the students' negative evaluations diverged: specifically, those enrolled at the smaller schools with more distinctly teaching-service missions, schools where innovation was more wholesale, even extending across the entire curriculum, objected to curricula that provide too much in the way of new pedagogy and emphases and too little standard instruction; conversely, those enrolled at the larger schools with more comprehensive teaching-research-service missions, schools where innovation must be more piecemeal, often course by course, objected to curricula that provided too little in the way of new pedagogy and emphases and too much standard instruction. Suggesting that the smaller schools studied may be over-supplementing--and the larger schools under-supplementing--standard biomedical with new biopsychosocial pedagogy and emphases, the authors make two recommendations: first, that medical educators at schools of every size and sort contemplating curriculum reform of any scope recognize that medical students invariably appreciate educational opportunities for individuation, connection, and diversity; second, that the same educators, but especially those at the smaller teaching-service medical schools considering more wholesale innovation, recognize that medical students must soon compete for residencies and posts in a rapidly changing health care environment and thus want effective instruction per se, whether it be delivered by a lecturer or a tutor, in class or in tutorial, on a ward or in a clinic. That would be the meaning, they conclude, of student-centered learning, however it were tailored.

Twelve tips for a successful clerkship

There have been many formal calls for change in medical education during this century, from Flexner's report in 1910 to the Association of American Medical Colleges' 1992 paper entitled “Assessing Change in Medical Education—The Road to Implementation” (Swanson, 1992). Most of these calls have fallen on deaf ears. However, recently many North American medical schools, primarily as a result of external forces, have introduced changes in the way they educate their students. Some of the more common changes have been to: decrease time devoted to lectures while increasing time in small group conferences; teach cognitive skills and self-directed learning skills; present medical education in a more humane environment; and introduce clinical experiences, especially in generalist settings, earlier in the curriculum.The goal of this article is to discuss suggestions for change by outlining 12 tips for a successful clinical clerkship for medical students. These suggestions are primarily intended for clerkship directors, but anyone involved with the administration and organization of a clinical clerkship should find these tips helpful.

Survey of Clinical Pharmacology Training in North American Medical Schools

Clinical Pharmacology & Therapeutics (1996) 59, 212–212; doi: 10.1038/sj.clpt.1996.346

INTERNATIONAL HEALTH MEDICAL EDUCATION CONSORTIUM: Its History, Philosophy, and Role in Medical Education and Health Development

The International Health Medical Education Consortium (IHMEC) is the first national organization created to link faculty in North American medical schools that teach international health. This article presents IHMEC's role in international medical education, including their mission, structure, and future agendas.

An Emerging Consensus in Behavioral Science Course Content

The results of a survey of North American medical schools (N = 65) about the content of their behavioral science courses are presented. Child psychological development and psychodynamic theory are the most frequently taught subjects in the schools (for 94% and 88% of the programs, respectively). Greater agreement on topics is found than in earlier surveys. The historical reasons for disagreement on content and objectives are explored and proposals for reform are offered.

Developing consortia for clinical practice examinations: The Macy project

A series of workshops demonstrating a model for assessing the clinical performance of medical students with standardized patients (SPs) was conducted between 1989 and 1991, with deans or senior faculty from more than 90 North American medical schools in attendance. Although 80% of these schools subsequently expressed interest in implementing similar programs, the cost in faculty time and resources was an issue of concern. To facilitate the best use of the limited resources available, and with the financial assistance of the Josiah Macy Jr. Foundation, six consortia of schools were established for this purpose: North Carolina, Gulf Coast, Northwest, Southern California, Metropolitan New York, and Upstate New York. Although all consortia share similarities, each has its own vision, purpose, and operational methods. This article describes the consortia generically and in their individual variations.

The depiction of medical education in medical school catalogs.

Medical educators bear responsibility for the informational materials that their institutions use to communicate with potential applicants. These documents, because they are often the first official correspondence that prospective students receive, may be influential in shaping students' expectations. In March 1990 all North American medical schools that awarded MD or DO degrees were requested to send their catalogs and courses of study to the authors. In response came 175 documents, with nearly all the schools represented at least once. The photographs and other visual images in these documents were then analyzed from the perspective of a hypothetical applicant who perused what his or her initial request for information had produced. Nearly 3,400 images were analyzed and categorized according to content and stylistic approach. Two basic stylistic approaches were found: stylized and documentary. Few documents used exclusively one or the other approach, as the approaches represent poles along a continuum. The stylized approach portrays medical education as a product to be sold, whereas the documentary approach candidly tells the story of medical education. The authors conclude that the documentary approach is a more morally responsible way for schools to communicate with individuals who are in the beginning stages of building their mental images of medical education and medical care.

The medical school curriculum committee revisited.

Numerous study commissions have contended that departmental territoriality and lack of coordinated planning are stagnating contemporary medical education. As a cure, these commissions have recommended the creation of centralized academic management units empowered to oversee revitalization of the curriculum through a series of reforms, including better definition of graduation competencies, community-based training, interdisciplinary courses, problem-based learning, and modernization of evaluation strategies. To determine the extent to which these recommendations were being adopted, in 1990 the authors sent a questionnaire on curriculum committee functions, current innovation efforts, and future priorities to academic administrators and members of medical school curriculum committees at 143 North American medical schools. Responses were received from administrators (primarily associate deans for academic affairs) at 118 schools and committee members (primarily faculty) at 111 schools. Recommendations for enhancing curriculum committee effectiveness were also elicited. The authors conclude that centralization of curricular management has occurred at very few institutions, and that the commonly mentioned reforms are being adopted at a modest pace. The results are analyzed in light of theories of the institutional change process and strategies for introducing educational innovations into established institutions.

Functional and dysfunctional characteristics of the prevailing model of clinical evaluation systems in North American medical schools.

To ensure that graduates are ready to move on to residency, medical schools need systems to monitor students' progress through clinical experiences. Clinical rotations occur in geographically separated settings in a variety of disciplines that use evaluators of varying levels of experience. That this complexity lends itself to error has been documented by the Association of American Medical Colleges' ongoing Clinical Evaluation Project, begun in 1979. This paper draws from that work and a 1987-1988 survey of 77% of the U.S. and Canadian deans for student affairs. This information is subjected to an analysis that emphasizes both common and unique characteristics of evaluation systems that are based on the four-stage model employed by most medical schools. Seventeen symptoms that can be signs of system errors are identified. It is recommended that schools having these symptoms review their clinical evaluation systems to ensure effective and efficient monitoring of clinical students.

The process of change in medical education in Switzerland

Centuries of tradition have instilled in Swiss medical doctors a healthy skepticism for innovations in professional practice. This same attitude seems to apply to medical education, with Swiss medical associations and interest groups taking various initiatives in observing and reporting international changes. Recently, a small delegation of Swiss doctors representing practitioners—and professors from the medical schools in Geneva and Berne— visited selected North American medical schools that have adopted problem‐based curricula. That visit led to insights being discussed at a national conference in Berne in 1989. The conference was well represented—with faculty and students from all five Swiss medical schools, invited health professionals, politicians, and administrators. The main challenge confronting any likely major curriculum reform in Switzerland will be whether faculty can accept the kind of educational principles now being implemented at the University of Berne and those recommended at the 1988 Wo...

Medical Schools and Immunization Policies: Missed Opportunities for Disease Prevention

To describe current immunization requirements and policies in North American medical schools both at matriculation and before students begin clinical clerkships. Survey of all allopathic medical schools in the United States and Canada. One hundred and fifteen medical schools. Twenty-eight percent of medical schools had no immunization requirements for matriculating medical students. Thirty-one percent of the schools had no rubella immunity requirement, 40% had no measles immunity requirement, and 44% had no polio immunity requirement for matriculating students. For students beginning clinical clerkships, 18%, 35%, and 40% of schools did not require rubella, measles, and polio immunity, respectively. Only 19% and 4% of schools required hepatitis B and influenza immunizations, respectively, at any time during training. Between 20% and 30% of schools accepted student self-report as evidence of rubella and measles immunity. Despite expert guidelines, current medical school immunization policies for matriculating medical students are inadequate. Methods to assess, monitor compliance with, and facilitate student immunization are needed. Medical schools should review their immunization policies to comply with published guidelines.

A survey of medical school teachers to identify basic biomedical concepts medical students should understand

Insights from the cognitive sciences indicate a continuing need for physicians to understand conceptual knowledge from the basic sciences, despite recent concerns regarding the increasing amount of information in medicine and the growing emphasis on performance skills. A 1987 survey of selected basic science and clinical teachers in North American medical schools was undertaken to identify basic biomedical concepts that are important in the practice of medicine and to specify how difficult these are for students to learn, apply, or both. Responses from faculty (nominated by their deans to answer the survey) from 82% of the medical schools indicated considerable agreement between the basic science teachers and clinical teachers on the relative importance of a set of biomedical concepts, and showed relatively minor levels of disagreement on how difficult these concepts are. The judgments of these teachers could prove extremely useful in (1) determining concepts that--because of their importance--should receive special attention in curriculum efforts, and (2) determining concepts that--because of their difficulty--need "special handling."

Diversity across medical schools: Programs, enrollment, and fees for continuing medical education

It is understood that the delivery of medical school-based continuing medical education (CME) is organizationally diverse. One hundred and twenty (120) North American medical schools were surveyed in 1986 and 1988. Data on the number and types of programs offered, enrollments, and fees for fiscal years 1984–85 and 1986–87 were analyzed. The number and types of CME programs, enrollments, and fees increased over the two-year period, with smaller CME units experiencing the greatest growth. As shifts occur in the funding of health care and of medical education, medical school-based CME providers are challenged to maintain largely self-supporting units, protect the integrity of program content from the influence of health care marketing, and deliver more continuing education to the workplace and homes of physicians. As resource allocation and cost effectiveness assume increasing importance, more emphasis is likely to be placed on documenting the cost effectiveness of various types of programs and of the CME units that produce them.

Noncognitive criteria for assessing students in North American medical schools.

In 1986 the authors mailed a one-page questionnaire to 135 North American medical schools requesting information about written expectations for students that contain noncognitive criteria. Eighty-eight questionnaires (65.2%) were returned, and 48 schools (54.5%) indicated they possessed written noncognitive criteria. Those schools having noncognitive criteria were asked to submit the criteria for review and were questioned about their reasons for establishing such criteria. Those schools not having noncognitive criteria were asked whether they perceived a need for such criteria and had plans for developing them. The study showed an increasing trend to create criteria that assist in administrative actions when problems arise. In the 31 sets of noncognitive criteria submitted for the study, the rank order of specific expectations was, from most to least frequently mentioned: honesty, professional behavior, dedication to learning, appearance, respect for law, respect for others, confidentiality, aid to others, substance abuse, and financial responsibility. The authors make recommendations for schools wishing to create noncognitive criteria and explain why they feel such criteria should receive the recognition and importance given to cognitive criteria.