Medical education

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In modern times, regulation of the medical profession includes legal licensure to practice medicine in most countries. Part of being able to qualify for such a license involves meeting certain achievement standards in medical education. Usually those standards are met by qualifying and receiving some sort of "medical degree" that is obtained in formal study in an accredited professional school. This is called undergraduate medical education. Those degrees, and the requirements for obtaining them, are different depending on region. In some countries, there is more than one type of medical degree, depending on the type and extent of medical education.

There is more to having a license to practice medicine than meeting an educational standard. Licensure also requires completion of some sort of clinical "apprenticeship", called internship and residency, as well as passing grades on one or more standardized tests.

In some countries, there are still additional requirements called graduate medical education in order to practice specialties within medicine.

Classification

Undergraduate medical education

Undergraduate medical education is the "period of medical education in a medical school. In the United States it follows the baccalaureate degree and precedes the granting of the M.D."[1]

Graduate medical education

Graduate medical education (GME) includes "educational programs for medical graduates entering a specialty. They include formal specialty training as well as academic work in the clinical and basic medical sciences, and may lead to board certification or an advanced medical degree."[2]

Internship and residency are "programs of training in medicine and medical specialties offered by hospitals for graduates of medicine to meet the requirements established by accrediting authorities."[3]

Fellowship training is focused on qualification for subspecialties.

GME may also combine with research, policy, or management graduate education, often leading to the additional academic qualification of Doctor of Philosophy, Master of Public Health or a clinical outcomes area, or a graduate degree in hospital or health policy management.

The Accreditation Council for Graduate Medical Education (ACGME) recommends the following core competencies for graduates:[4]

  1. Patient Care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health
  2. Medical Knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care
  3. Practice-Based Learning and Improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care
  4. Interpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other health professionals
  5. Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population
  6. Systems-Based Practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value

Continuing medical education

Continuing medical education (CME) is "educational programs designed to inform physicians of recent advances in their field."[5] In the United States, it is regulated by the Accreditation Council for Continuing Medical Education (http://accme.org/).

New method of CME is called point of care (CME) whose goal is to provide CME credit for information management that occurs during clinical care. Examples of this are UpToDate, PIER, and Essential Evidence Plus.

CME may be integrated into health care reform and health care quality assurance.[6]

Variations by geographic region

The Foundation for Advancement of International Medical Education and Research (FAIMER) [1] is dedicated to improving world health through education of the medical educators. They also maintain an open access International Medical Directory [2].

United States

In the United States, curricular objectives for medical education are guided by:

Canada

Most medical schools in Canada require at least three years of postsecondary education towards a bachelor's degree prior to admission although the majority of entrants hold at least a bachelor's degree, usually in the sciences. The most notable exception to this is at McGill University, where a subset of the entering class are accepted directly after completion of CEGEP.

Schools typically admit applicants based on their undergraduate record (GPA), tatement, MCAT score, non-academic (extracurricular) score, and interview.

Medical school in Canada is usually four years in length although McMaster University and the University of Calgary offer accelerated programs which run three years in total. Students in the first two years cover basic sciences such as anatomy, physiology, immunology and pharmacology and are given preliminary clinical exposure. Education is delivered through traditional lectures and small group learning, including problem-based learning. Years 3 and 4 are known as the clinical years or the clerkship, in which students learn in a hospital-based setting through clinical rotations in such fields as Internal Medicine, Emergency Medicine, Surgery and Pediatrics.

At the end of Year 4, students enter the Canadian Resident Matching Service (CaRMS) and are matched to a speciality and location depending on their particular preferences. Students typically graduate with the title Doctor of Medicine (MD).

Postgraduate training, or residency, varies in length from two years (such as in Family Medicine) to six years (such as in General Surgery). Most residency programs last about five years.

To receive full certification, physicians must be certified as a Licentiate of the Medical Council of Canada (LMCC) by completing the Medical Council of Canada Qualifying Exam (MCCQE) Part I at the end of Year 4 and the MCCQE Part II at the end of PGY-1. Furthermore, they must receive certification from an appropriate certifying body: The College of Family Physicians of Canada (CFPC) for family physicians and the Royal College of Physicians and Surgeons of Canada (RCPSC) for specialists.

Finally, physicians must register with the appropriate regulating body to be eligible to practise in a particular province. For example, physicians wishing to practise in British Columbia must register with the College of Physicians and Surgeons of British Columbia (CPSBC).

Auxiliary medical education

If one is interested in the medical field, but does not wish to become a doctor, other alternative careers include:

These fields do not require attending medical school. The premedical courses are usually combined with another field that provides support to the medical industry.

Issues in medical education

Quantity versus quality of clinical experiences

Student performance may not associate with the volume of patients seen.[7][8][9][10] The quality of clinical supervision may be more important.[7] This may also be true in dental education.[11]

Teaching at the bedside

Issues in bedside teaching have been reviewed.[12]

Teaching compassion

Medical students may loose compassion while in medical school.[13]

Teaching procedural skills

Procedures should first be demonstrated by the teacher[14][15][16] (perhaps twice - once fast and then slowly[14]), then the learner tries the procedure slowly stating what they are doing and with coaching[14][15][16], and lastly then the learner tries the procedure without coaching[14].

Breaking the procedure into steps that the students learn separately before performing as a whole may assist in teaching.[16]

Regarding which procedures should be learned, there is lack of consensus.[17][18][19]

Rote memorization

Much of undergraduate medical education is rote memorization.[20] The amount of reading, if earnestly read, may be excessive.[21] Rote memorization, and evaluation on it, may lead to interpersonal dynamics, among students and faculty, which are not necessarily in the best interest of patient care. [22]

Lectures

Perhaps due to the role of rote memorization, one medical school noted that only 17% of students reported routinely attending lectures.[23] Other schools have reported similarly.[24][25][26] Approximately 16% of atendees may nap during lecture.[27][28]

The incremental value of lectures over textbooks at improving grades may not be strong.[29]

Factors associated with successful lectures are:[30]

  • engaging the audience
  • lecture clarity
  • using a case-based format

In addition, active learning[31] and the use of audience response systems may help.[32][33] Interactive sessions may add to strictly didactic sessions.[34]

Conflict of interest

Conflict of interests may influence lectures[35][36] and student attitudes to industry.

The issue is even more acute with graduate medical education and informal education for practititioners, delivered by product and service providers. It is not a black-and-white situation, since someone may have a financial interest because they developed a product and know the most about it.

Grading

Pass-fail grading may reduce stress, increase group cohesion and increase quality. [37]

Duty hours

See also Medical error

A survey of 200 residents who trained both before and after duty hours reform reported improved quality of life. However, "Residents reported that whereas fatigue-related errors decreased slightly, errors related to reduced continuity of care significantly increased." [38] Resident believe excessive work hours is a common cause of medical error.[39][40][41]

Restricting duty hours may[42][43][44] or may not[45] improve performance. However, restrictions may be costly.[46]

References

  1. Anonymous (2015), Undergraduate medical education (English). Medical Subject Headings. U.S. National Library of Medicine.
  2. Anonymous (2015), Graduate medical education (English). Medical Subject Headings. U.S. National Library of Medicine.
  3. Anonymous (2015), Internship and residency (English). Medical Subject Headings. U.S. National Library of Medicine.
  4. ( September 28, 1999) ACGME Outcome Project
  5. Anonymous (2015), Continuing medical education (English). Medical Subject Headings. U.S. National Library of Medicine.
  6. Bellande, Bruce J. PhD; Winicur, Zev M. PhD; Cox, Kathleen M. [Commentary: Urgently Needed: A Safe Place for Self-Assessment on the Path to Maintaining Competence and Improving Performance http://journals.lww.com/academicmedicine/Fulltext/2010/01000/Commentary__Urgently_Needed__A_Safe_Place_for.11.aspx]. Academic Medicine: January 2010 - Volume 85 - Issue 1 - pp 16-18 DOI:10.1097/ACM.0b013e3181c41b6f
  7. 7.0 7.1 Wimmers PF, Schmidt HG, Splinter TA (2006). "Influence of clerkship experiences on clinical competence.". Med Educ 40 (5): 450-8. DOI:10.1111/j.1365-2929.2006.02447.x. PMID 16635125. Research Blogging.
  8. Poisson SN, Gelb DJ, Oh MF, Gruppen LD (2009). "Experience may not be the best teacher: patient logs do not correlate with clerkship performance.". Neurology 72 (8): 699-704. DOI:10.1212/01.wnl.0000343000.20272.32. PMID 19237698. Research Blogging.
  9. Huang GC, Almeida JM, Roberts DH (2012). "Reaching the limits of mandated self-reporting: clinical logbooks do not predict clerkship performance.". Med Teach 34 (3): e185-8. DOI:10.3109/0142159X.2012.642826. PMID 22364475. Research Blogging.
  10. Peeraer G, Muijtjens AM, De Winter BY, Remmen R, Hendrickx K, Bossaert L et al. (2008). "Unintentional failure to assess for experience in senior undergraduate OSCE scoring.". Med Educ 42 (7): 669-75. DOI:10.1111/j.1365-2923.2008.03043.x. PMID 18588647. Research Blogging.
  11. Spector M, Holmes DC, Doering JV (2008). "Correlation of quantity of dental students' clinical experiences with faculty evaluation of overall clinical competence: a twenty-two-year retrospective investigation.". J Dent Educ 72 (12): 1465-71. PMID 19056625[e]
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  16. 16.0 16.1 16.2 Grantcharov TP, Reznick RK (2008). "Teaching procedural skills.". BMJ 336 (7653): 1129-31. DOI:10.1136/bmj.39517.686956.47. PMID 18483056. Research Blogging.
  17. Wigton RS, Blank LL, Nicolas JA, Tape TG (1989). "Procedural skills training in internal medicine residencies. A survey of program directors.". Ann Intern Med 111 (11): 932-8. PMID 2817641.
  18. Wigton RS, Nicolas JA, Blank LL (1989). "Procedural skills of the general internist. A survey of 2500 physicians.". Ann Intern Med 111 (12): 1023-34. PMID 2596769.
  19. Norris TE, Cullison SW, Fihn SD (1997). "Teaching procedural skills.". J Gen Intern Med 12 Suppl 2: S64-70. PMID 9127246. PMC PMC1497230. Review in: J Fam Pract. 1995 Feb;40(2):153-60 Review in: J Fam Pract. 1994 Oct;39(4):341-7 Review in: J Fam Pract. 1994 Feb;38(2):132-7 Review in: J Fam Pract. 1993 May;36(5):515-20 Review in: J Fam Pract. 1992 Feb;34(2):186-94, 197-200
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  22. Deborah Bowman; Daniel Sokol (2009), "Secrets and Lies", Stud BMJ 9 (2): 50-51
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See also