How can medical schools and teaching hospitals ensure that their students and residents are learning enough about the health care issues they will face as physicians in today's world? This has become a bigger challenge in recent years because our country's demographics and the public's expectations of medicine are rapidly changing. To respond effectively, undergraduate and graduate medical education curricula must now include content related to population health, nutrition, cultural competence, geriatrics, quality of care, and end-of-life care, among others.
Two major problems must be confronted successfully if this important challenge is to be met. First, the curricula of medical education programs are already filled with content related to traditional topics, so it is extremely difficult to add new content relevant to more contemporary issues, regardless of how important those issues may be. Second, the issues noted above—as well as others—do not fall exclusively within the domain of any particular discipline. As a result, it isn't clear who should teach the relevant content.
Medical school and residency programs have struggled to determine the best ways to introduce the required content into their existing curricula. Given the experience to date, it seems clear that a variety of educational strategies may be employed, provided that they are well done. Since it is extremely difficult to quickly conduct the kind of educational research needed to identify the best way to present any given topic, it makes sense for those responsible for the design and conduct of medical education programs to first ensure that the topics are covered, and to use whatever approaches seem most likely to work.
As noted above, end-of-life care is one of the topics that must be covered. Although a number of articles addressing various approaches for presenting this topic have been published in previous issues of this journal, the topic is so important that it deserves continued attention. To that end, three Research Reports and one Article appearing in this month's journal provide additional insight into how content about end-of-life care might be introduced into the curricula of medical education programs.
To begin, Sullivan and her colleagues report the results of their research to determine what a select group of associate deans for medical education think about incorporating content relevant to end-of-life care into their schools’ curricula. While the deans acknowledged the importance of adding the content, they cautioned against doing so by creating a distinct course or clerkship. Instead, they endorsed unanimously the idea of integrating the content into existing courses and clerkships.
The remaining three pieces are directly relevant to that recommendation: Each discusses a different approach for integrating end-of-life-care content into an existing curriculum. Porter-Williamson et al. describe a four-day hospice rotation that is incorporated into the ambulatory block of the internal medicine clerkship for third-year students at their medical school. Fineberg and her colleagues describe workshops designed to orient third- and fourth-year medical students to the importance of interdisciplinary collaboration in providing palliative care. And Liao et al. explain an innovative longitudinal hospice rotation for internal medicine residents. It is important to note that each of these reports details a different strategy for incorporating relevant content into existing learning experiences, and that each of the strategies was designed to achieve a specific purpose.
Taken as a whole, these four reports make an important point about how best to meet the challenge of integrating content about contemporary issues of medicine into medical education curricula. Since multiple aspects of each issue need to be presented, it makes sense to select the educational strategies that best present the specific aspects. A combination of strategies such as those illustrated in the papers appearing this month—a short course, a focused set of workshops, a longitudinal experience, augmented by other strategies as needed—will almost certainly be more effective in promoting students’ and residents’ learning than will any single approach.
But, of course, the success of this multipronged strategy depends on determining in advance the aspects of the issue that need to appear in the curriculum—in other words, what is the relevant content? Two years ago, Wood and her colleagues1 described how a curriculum evaluation tool they developed could be used to determine how well various aspects of palliative care were represented in the curricula of the medical schools in New York. The results of their study showed that in all of the schools important aspects of the topic that should have appeared in their curricula were missing. Their article emphasized the importance of using a rigorous evaluation process to document that a topic was truly being represented adequately in the curriculum.
But in making that point, they also emphasized that it is important to determine in advance all of the aspects of an issue that should be covered. Having done that, it is then possible to select specific educational strategies that seem best able to present those aspects effectively.
The reports appearing this month provide examples of some of the different strategies that might be used to cover various aspects of end-of-life care. Another group of articles that describe a variety of ways that a particular topic was integrated into existing curricula is found in the supplement to last month's issue of Academic Medicine. Authors from 40 different U.S. medical schools explain how their institutions successfully wove information about geriatrics medicine into their curricula in ways that, in most cases, have ensured that the new material will remain a vital part of those curricula.
To help educators meet the challenge described above, the journal will continue to publish reports of the various ways schools have used to integrate important contemporary issues of health care into medical students’ and residents’ education.
Michael E. Whitcomb, MD
1. Wood EB, Meekin SA, Fins JJ, Fleischman AR. Enhancing palliative care education in medical school curricula: implementation of the Palliative Education Assessment Tool. Acad Med. 2002;77:285–91.