The contemporary education of American physicians is biphasic, including
the undergraduate and graduate (residency) educational periods. While
there is need for connection if not integration between these phases,
our present educational planning focuses only on the undergraduate curriculum.
The EC believes curriculum content should be guided by an understanding
of what a medical student should accomplish prior to beginning graduate
medical training. Two aspects of cognitive learning1
must comprise the content: knowledge (information) and cognitive skills
(the ability to obtain, manipulate, and integrate information effectively).
The content criteria for any given element of the curriculum should
encompass and explicitly address both of these cognitive domains. Although
there are many conditions that a physician might encounter, the curriculum
should focus on preparing medical students to recognize and understand
common conditions, while at the same time fostering the skills of self-directed
learning which will enable the student and later, the physician, to
analyze and address the unusual or novel situation. Taken together,
the information base and cognitive skills developed during undergraduate
medical education should broadly prepare the student for supervised
clinical practice, from understanding the molecular basis of disease
to an appreciation of the social context of medical care.
CONTENT COMPONENTS
Information
The information to be learned should provide a foundation for graduate
clinical education and subsequent independent medical practice. Since
the content of the undergraduate curriculum should reflect these goals,
the primary basis for selecting essential information to be transmitted
should be common clinical conditions. An epidemiologic approach to curricular
content would therefore entail identifying those conditions most common
in primary-care oriented practices, and tying the content of curricular
elements insofar as possible to the material germane to those conditions.
For instance, cancer, diabetes, hypertension, AIDS, depression and preventive
medicine would clearly be among the clinical concerns for which a thorough
understanding would be essential, from their molecular basis through
their behavioral and social implications. Irrespective of the organization
of the curriculum, both "basic science" and "clinical" elements of the
curriculum would thus be designed to introduce and reinforce learning
related to epidemiologically common and/or serious situations.
Cognitive Skills
Medicine, and medical practice are in a state of constant change. New
understandings of the mechanisms of disease, entirely new diseases,
and new approaches to therapy will inevitably emerge during the course
of one's medical career. Medical students should therefore be prepared
to teach themselves so that, as physicians, they can remain abreast
of and even anticipate change, and respond to it appropriately. While
memorization and recall are clearly important to recognition of clinical
conditions, of equal importance to clinical practice are problem-solving
skills: the ability to formulate questions, to find information to answer
those questions, to evaluate the source of the information and to integrate
relevant information in meaningful ways. The "cognitive skills" content
of the curriculum should therefore serve not only to reinforce effective
retention of facts, but also to teach and reinforce such problem-solving
abilities.
Behavioral Skills
The ability to communicate effectively with patients and their families
is critical to the practice of medicine. Students should be prepared
to respond appropriately to a wide range of patient behaviors, to be
able to obtain an accurate history and to be able to elicit and respect
the patient's values, concerns and preferences. Irrespective of their
choice of career, students will also need to develop the ability to
work with groups of colleagues and co-workers.
Technical Skills
A wide variety of psychomotor skills are essential to the clinician's
repertoire. At minimum, students should be able to perform a comprehensive
and accurate physical and mental status exam (cognizant of, and using
techniques which convey respect for the patient's privacy and dignity).
Other fundamental technical skills should reflect the demands of common
clinical situations, including those situations where the immediate
application of the skills could prevent severe disability or death (e.g.
CPR).
The remainder of this document will focus on curricular content from
a cognitive skills perspective only. Other documents will address behavioral
and technical skills.
CRITERIA FOR CURRICULAR CONTENT
The criteria below are intended to serve as benchmarks by which the
content of individual curricular elements should be assessed. (Similar
sets of criteria will be developed for such curricular concerns as behavioral
and technical skills.) With respect to content, each proposed course
or clinical rotation should be designed to meet the following criteria.
The design (and methods) of the educational program must be documented
to facilitate faculty and EC review as well as understanding by all
those involved in the educational enterprise.
Proposed Criteria for Individual Curricular Elements
1. Clinical Applicability: Curricular elements
should prepare students for medical practice. The content should be
"epidemiology-based": course content should reflect material related
to an agreed upon set of "common" and important clinical conditions.2
2. Emphasis on Mechanisms: Content should
focus on learning processes and reasoning, as well as mastery of important
information. Answers to "why" and "how" questions rather than "what"
questions should dominate both teaching and examinations. Relationships
should be stressed. (To invoke a straw man: one would not teach impact
of histamine on vessels, or of antigens on mast cells in isolation--the
discussion of antigen-initiated pathology would serve to relate these
elements and demonstrate the underlying immunologic, biochemical and
physiologic principles' relevance to clinical situations as well.)
3. Development of Clinical Reasoning: Each
"block" or "course" would reinforce cognitive skills essential to clinical
reasoning. In addition to placing material in a clinical context, course
design should require that students engage in independent learning activities
(question formulation, information gathering and problem solving).
4. Goal Validity: Content proposals would
be linked to explicit goals. Articulated goals (i.e. the purpose of
the educational experience) will serve as touchstones for subsequent
descriptions of content and will help ensure a coherent educational
plan. The goals should reflect criteria 1--3 above. Extensive lists
of individual objectives are not required. Rather, the goals should
provide a guide and serve as a "test" for the appropriateness of proposed
content.
5. Process Validity: Small interdisciplinary
groups, comprising representatives of appropriate clinical and basic
science disciplines, will work with departments and course directors
to plan and review curricular content. The EC will have ultimate responsibility
for evaluating proposed courses, and will do so in this interdisciplinary
mode.
6. Accountability and Reliability: Content
for any curricular element should be sufficiently explicit and detailed
that all students going through the course/experience would come away
with the same fundamental set of information and skills. (Obviously,
each may well also come away with some learning unique to his or her
interests or experience during the course/rotation.) Clinical curricula
would be subject to the same expectations of accountability and reliability.
1. Learning in Medicine must include the cognitive, on
which this discussion focuses. Behavioral and technical skill acquisition
will be treated separately.
