Whitcomb, Michael E. MD
As I noted in last month's column, medical educators have confronted during the past decade a formidable array of challenges as they have striven to improve the quality of their medical education programs. Efforts to align the content and goals of these programs with evolving societal needs, practice patterns, and scientific developments have led to extraordinary changes in the ways that medical students and, to a lesser degree, residents are now being educated. Despite the successes that have been realized, there is much work yet to be done. A number of the papers in this month's journal provide insights into two of the important challenges that remain.
One of these challenges is the need to improve the teaching of five important topics: epidemiology, biostatistics, evidence-based medicine, the behavioral sciences, and humanism in medicine. These have generally not been well received by medical students and residents, who see them as less important than topics in the biological sciences and the clinical disciplines. The authors of some of this month's papers suggest that the key to overcoming this attitude is to present the course material in ways that make it clear to the learners that the topics are, in fact, highly relevant to clinical medicine. Indeed, several of the papers describe innovative approaches for accomplishing this.
The other challenge discussed in this issue—perhaps the most important one facing the medical education community—is how to improve the teaching of the core clinical disciplines. Three of this month's papers relate to this challenge. Two deal specifically with the teaching of psychiatry, and the third provides insight into residents' and faculty members' attitudes about bedside teaching in internal medicine. Although the papers present the issues of concern as they relate to the disciplines of psychiatry and internal medicine, the messages they convey are just as relevant for the teaching of the other core clinical disciplines.
To put this in context, let's reflect a bit on what the papers dealing with the teaching of psychiatry have to say. In their paper, Rubin and Zurumski provide an overview of the impact that scientific advances are having on the field of psychiatry, and thereby on the practice of clinical psychiatry. They go on to suggest, rightly, that the changes occurring in psychiatry should affect the ways that students and residents are educated in the discipline. They note, for example, the need to rethink the kinds of educational experiences now being provided medical students and residents who are training for careers in generalist specialties, to ensure that they are exposed to patients with the kinds of psychiatric disorders they are likely to see in their future practices. And in his brief report, Christensen describes an example of the kind of experience that needs to be developed for residents in family medicine. In keeping with the point made by Rubin and Zurumski, he notes that because of changes in the ways that patients with common psychiatric disorders are now being cared for, rotations on inpatient psychiatry units—the traditional approach used for teaching psychiatry in many institutions—are no longer adequate for residents training in family medicine. The important message of these two papers is that failure to change clinical rotations in psychiatry will almost certainly result in inadequate educational experiences for medical students, psychiatry residents, and residents in other disciplines.
It is particularly important for medical schools to respond to this concern. Psychiatry is one of the clinical disciplines that all students are required to study (the psychiatry clerkship), yet only a small percentage of medical school graduates will pursue careers as psychiatrists. Thus, medical schools must make every effort to give their students educational experiences in the clinical environments in which common psychiatric disorders are being managed. Experiences limited to psychiatric inpatient services, still commonplace in many schools, should no longer be considered adequate. Students should receive instruction in psychiatry during rotations in internal medicine, family medicine, and emergency medicine because it is during these rotations that they will encounter patients with common psychiatric disorders. If this is not done, students will leave medical school with an inadequate exposure to common psychiatric disorders and, therefore, will not have an adequate understanding of the roles of psychiatrists, other physicians, and other health professionals in the management of patients with those disorders.
So what does this have to do with the teaching of other core clinical disciplines? Quite simply, the general principle involved applies equally well to most, if not all, of those disciplines. Medical schools must examine critically the sites now being used for student experiences in each of the clinical disciplines to determine whether or not individual sites are providing clinical experiences that will allow students to achieve the learning objectives established for the clinical curricula in those disciplines. It seems quite likely that an objective review of current clerkship experiences would raise serious concerns about the appropriateness of many of the sites being used.
Finally, the paper by Ramani and colleagues reminds us that it is not simply the design of the educational experience and the nature of the site where the experience occurs that are important in determining the quality of the clinical education provided students and residents. In addition, these learners must be supervised and taught by faculty who have the willingness and skills to engage in patient-centered clinical teaching, whether at the bedside or in ambulatory care settings. To ensure that this occurs, medical schools and teaching hospitals need first to identify the barriers that are preventing that from happening and then take whatever actions are required to eliminate or minimize those barriers. The strategies that are adopted to address those barriers must make clear to the clinical faculty that patient-centered teaching is not only valued but expected. To help achieve this goal, the institutions must establish faculty development programs that will enhance the ability of faculty members to teach effectively in clinical environments and take advantage of the unique educational experiences provided by interactions with real patients.
Clearly, the papers in this month's journal show that the medical education community continues to face formidable challenges as it strives to meet its responsibility to improve the ways that doctors are educated. No doubt, most of the changes that are being introduced into the design and conduct of undergraduate and graduate medical education programs are contributing in a positive way to this effort. But when all is said and done, success will be achieved only when those responsible for the programs can guarantee that their students or residents are being assigned to clinical sites that foster the necessary learning experiences, that they encounter at those sites skilled clinicians who are willing and able to engage in patient-centered teaching, and that they are exposed during those encounters to all clinically important content, no matter which discipline is being taught. Achieving that goal will not be easy, but as the papers make clear, the effort is under way.
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