To describe current educational imperatives and trends for curricular changes in the clinical education of medical students and to delineate the nature and extent of participation in these curricular trends by departments of pediatrics.
Site visits to 26 representative US medical schools and a review of detailed information from 12 additional schools. Evaluation of the core curriculum was developed by the Council on Medical Student Education in Pediatrics within the context of the major curricular trends observed.
The major observed curricular trends emphasized community-based ambulatory experiences, continuity of care, integration, and population-based experiences. Supporting educational principles included student-directed learning and performance-based assessments. The 3 major curricular changes were early clinical experiences (longitudinal preceptorships), community-oriented/ population-based experiences, and multispecialty clerkships. The focus of the Council on Medical Student Education in Pediatrics objectives was the year 3 clerkship, and substantive participation by pediatric faculty in the overall curriculum was primarily related to the pediatric clerkship.
Revising the clerkship-based Council on Medical Student Education in Pediatrics guidelines according to the new educational trends will extend clinical curricular opportunities for pediatrics beyond the traditional boundaries of the clerkship. The discipline of pediatrics will, as a consequence, be able to achieve enhanced partnership in the planning, conduct, and evaluation of a clinical curriculum for medical students that is relevant to child health issues and that extends across all 4 years.
DURING THE past few decades, many observers of medical education have asked medical school deans and faculties to increase the amount of time provided in the curriculum for the clinical education of students in ambulatory care settings. The call for more ambulatory care experience has been based primarily on the premise that ambulatory care settings provide clinical experience that is particularly relevant to the future practice activities of most students, regardless of ultimate specialty choice. In recent years, the effect of managed care on the provision of medical services has made the inpatient environment less conducive to the education of medical students and made the development of ambulatory care–based educational experiences an imperative.
Several national initiatives developed in the early 1990s in response to the aforementioned needs for curricular change. These included the Robert Wood Johnson Curriculum Initiative and Robert Wood Johnson Generalist Initiative, the Kellogg Community Partners Project, Health Professions Schools in Service to the Nation (Pew Charitable Trusts), and the Interdisciplinary Generalist Curriculum (Bureau of Health Professions, Health Resources and Service Administration). The 3 essential elements of the Interdisciplinary Generalist Curriculum project were generalist mentorship, interdisciplinary faculty collaboration, and generalist curricular innovation, especially as related to early and community-based ambulatory experiences.
In late 1996, the Association of American Medical Colleges embarked on a project to determine how medical schools both with and without external funding for curricular innovation had responded to this imperative. To this end, the Association of American Medical Colleges staff conducted site visits to 26 medical schools that had implemented new ambulatory care–based experiences for students and collected from 12 additional schools materials describing clinical experiences they had implemented. The 2 central purposes of our study were to describe the 3 major types of ambulatory care–based clinical experiences implemented by medical schools in recent years and to delineate the implications of these developments for the discipline of pediatrics. As related to medical schools in general and to pediatric departments in particular, we identify the major challenges confronted in implementing these experiences, provide insight into the degree that these challenges are being successfully met, and provide information that will be helpful in efforts to design and conduct educationally sound ambulatory care–based clinical experiences. In particular, these data should be useful to pediatric educational leaders considering comprehensive integration of pediatric health–related curricular content across all 4 years.
The traditional "basics first" approach where theory is presented before practice is less efficient than when (students) first have some relevant practical experience . . . which enables them to process effectively the abstract information, facts, and principles. Paradoxically, the presentation of information after the establishment of the learning context is the complete opposite of how most medical education is structured . . . Practice should precede, or be closely interrelated with, theory. We learn theory best through its practical application.1(p197)
The database for this project sponsored by the Association of American Medical Colleges was derived from site visits to 26 medical schools (Table 1) that implemented new ambulatory care–based experiences and from materials collected from 12 additional schools describing their experiences. To identify these 38 schools, a 1-page questionnaire was sent to each US and Canadian medical school. One hundred twelve schools provided information. Association of American Medical Colleges staff also contacted representatives from 5 national curriculum reform grant programs (4 funded by private foundations and 1 funded by the federal government) to gain their views on which of the awardee schools had implemented particularly innovative ambulatory care–based educational experiences. The schools included in the visits were located in every region of the United States and included both public and private schools, community-based schools, research-intense schools, and schools with and without external grant funding for curricular innovation.
The 1-day site visits were conducted between October 20, 1996, and March 10, 1997. Each site visit included meetings with the dean and/or the associate dean(s) of education, chairs of curriculum-related committees, and chairs (or designees) of the 3 primary care departments. The curriculum leaders interviewed were primarily from the primary care and basic science departments, but also included faculty from other clinical departments. In most instances, students were also interviewed. Each school was characterized for changes in the clinical curriculum and the environment in which these changes occurred. The specific roles and contributions of pediatric, family medicine (FM), and internal medicine (IM) departments were evaluated. The second phase of this project was an analysis of the guidelines for student education in pediatrics developed by the Council on Medical Student Education in Pediatrics (COMSEP)2 from the perspective of recent trends in clinical education of medical students.
Nineteen (73%) of the 26 medical schools visited had a total of 21 extramural curriculum grants: 11 from the Robert Wood Johnson Foundation, 7 from the Interdisciplinary Generalist Curriculum project, 2 from the Kellogg Foundation, and 1 from Pew Charitable Trusts. The 3 major curricular innovations identified3 were longitudinal preceptorships (LPs), community-oriented/population-based experiences (CO/PBs), and multispecialty clerkships (MSCs).
Longitudinal preceptorships encompassed a variety of early clinical educational experiences in year 1 and/or year 2 that typically occurred in a community-based practice setting. The minimum criteria for an LP included a frequency of 2 scheduled sessions per month for 1 continuous year. The objectives usually included the following: (1) earlier clinical exposure; (2) exposure to primary care physicians; (3) enhanced understanding of continuity, physician-patient relationship, and the broader context in which patient care occurs; (4) opportunity to practice basic clinical skills; (5) increased awareness of community resources; and (6) enhanced clinical correlations with basic sciences. Continuity between the student, preceptor, and site was generally achieved.
The office experiences required an accompanying small group program with sufficient frequency and content to introduce patient care, communication skills, and professionalization; integrate basic science content; and debrief students' office experiences. Additional topics included aspects of the illness context, ethics, and other medical-society interface issues. The small group format was generally a mix of discussion and problem-based instruction. The extent of integration of the LP with these small group sessions was sometimes extensive and included specific tasks, such as finding an example of a basic science topic or professionalization issue in the preceptorship experience or requiring the student to perform a patient-oriented task that would be helpful to the preceptor's overall provision of health care.
The preceptor pools for the office-based clinical experience were almost always primary care physicians, and about 90% were community based. Pediatricians accounted overall for 20% to 25% of the LP preceptors. About 40% of the preceptors were from FM and the balance were from IM.
Community-oriented/ population-based experiences
Community-oriented/population-based experiences encompassed an epidemiologically based approach to primary care that emphasized a community or population rather than individual patients. The objectives were to introduce to students the types of relevant, community-based resources available to the clinician and the concepts related to the epidemiological and public health status of the aggregate groups of patients from which individual patients were derived.
A few of the required CO/PB experiences were structured as a single block experience over several weeks. Students were matched with a specific community site and/or population for a brief but full-time assignment. A project was often assigned and required a description of the demographics of a specific community or population, followed by an analysis and prioritization of health concerns. In the other schools with a CO/PB experience, it was extended over a longer period and had the potential to be more integrated with other clinical and classroom learning experiences. In a few instances, schools developed an extended CO/PB experience that was integrated with a well-developed LP and/or MSC.
Multispecialty clerkships represented a dramatic change from traditional, departmentally administered individual clerkships. There were varying degrees of enhanced exposure to generalist teaching and clinical experiences and an increased emphasis on community-based and sometimes rural settings.4-6 Integration within the primary care disciplines was invariably strengthened, and enhanced integration with other clinical disciplines and between clinical and basic science disciplines was evident. Enhanced opportunities for continuity-of-care experiences were common. The MSCs generally represented an effort to complement, modify, or replace the traditional clerkships in the 3 generalist disciplines.
The individual assignments to FM, IM, or pediatrics ranged from traditional block assignments occurring sequentially to concurrent assignments involving 2 or all 3 generalist disciplines and were organized to maximize the opportunities for continuity care experiences in an ambulatory setting. The MSCs were equally divided between offering the individual specialties as separate blocks in series and as parallel assignments, the latter permitting continuity-based exposure to each discipline at least every other week and generally every week. All were community based, included integrated core clinical teaching that occurred at regular intervals during the MSC. Most provided time at the end for integrated, performance-based student assessments.
Implications for pediatrics
Since 1991, pediatric clerkships have become more consistent in the presence and the quality of detailed clerkship objectives.2,7 The COMSEP core curriculum aided individual schools in developing clerkship objectives and a curriculum appropriate to the available time and clinical resources. Pediatric education leaders (n=16) in 62% of the 26 schools visited, however, expressed their perception that medical students were still underexposed to pediatric patients, teachers, and role models; these concerns were based on the relatively limited participation of pediatric clinical faculty in the 3 major curricular innovations and related small group activities. Pediatric curriculum leaders also identified continuing difficulties in incorporating child health perspectives in the year-1 and -2 innovations as related to both clinical skills and performance-based assessments. The pediatric representatives from the Interdisciplinary Generalist Curriculum project (funded by the Division of Medicine, Bureau of Health Professions, Health Resources and Service Administration) further confirmed this long-standing perception, especially for years 1 and 2.8-11
As a consequence of the observed trends in the clinical education of students, there was an overall greater extent of communication between pediatric faculty and their generalist colleagues in FM and IM than had existed previously. In addition, there was an increased extent of vertical integration between pediatrics and the basic science departments, reflected in part by joint preparation and conduct of problem-based learning. Following 2 to 3 years of experience with the LP programs funded by the Interdisciplinary Generalist Curriculum, a notably greater extent of pediatric participation in years 1 and 2 and of overall visibility within the curriculum was consistently reported.8-17
Extensive use of standardized patients for both formative and summative purposes was common in schools with the most comprehensive curricular innovations.18 A few of the schools visited had some experience using standardized adolescents or standardized parents, and an older child was occasionally included in an objective structured clinical examination. Pediatric faculty and pediatric-related issues were otherwise unrepresented in performance-based student assessment strategies.
There were several characteristics or logistical limitations that were unique to the discipline of pediatrics and child-related health care and that restricted the extent to which some successful curricular strategies could include pediatrics. An invariable dilemma in enhanced continuity of care was how to balance the goal of an optimal continuity-of-care experience against the need to avoid an unbalanced exposure to adults or, conversely, to children. Some students initially assigned to a pediatric office were concerned about the lack of adult patient experiences, some students assigned to an IM office wanted to have comparable experiences with pediatric health, and some students assigned to FM also wanted exposure to pediatric faculty (or vice versa). In several schools, one third or more of the students were assigned to a different preceptor in year 2 than in year 1 to be responsive to such concerns.
Children's hospitals have advantages for patients, parents, and caregivers, but geographic separation of many children's hospitals from the rest of the medical school created another logistical limitation. Related both to geographic separation and to the unique behavioral and physical characteristics of pediatric subjects, infants and children were underrepresented in the standard physical diagnosis and clinical skills courses.
A final logistical limitation was the reduced number of pediatricians practicing in smaller communities, especially in rural sites. As a result, the availability of pediatricians to serve as preceptors for an MSC or LP was notably limited when students were assigned to rural or semirural practices.
The LP and CO/PB experiences and the MSC illustrated several major trends in the clinical education of medical students (Table 2). The 3 generalist disciplines were the focus for most changes, and enhanced integration was a major theme. Integration efforts occurred at several levels: among the generalists in the 3 primary care departments, between the generalists and the other 3 core clinical disciplines, and between the core clinical and basic science disciplines. Early clinical experiences were generally community based and were combined with integrated small group teaching. Extensive faculty development and the introduction of more meaningful, performance-based assessment strategies18 were common areas of emphasis.
Continuity-of-care experiences also seemed to be a major benefit of the observed curricular trends. The ability to form comfortable and effective student-teacher relationships facilitated integrated learning of the knowledge, skills, values, and attitudes required of all future clinicians. Nevertheless, preceptor assignments were typically limited to 1 year due to a perceived higher priority for diversity and equality of specialty exposure than for continuity.
The national initiatives in support of curricular innovation were a consequence of the imperatives for change, but also served as a catalyst for more timely and comprehensive change. Building on the successful development of early clinical experiences and related curricular innovations, the Division of Medicine (Bureau of Health Professions, Health Resources and Services Administration) has just implemented a new 5-year funding initiative (Undergraduate Medical Education for the 21st Century) that will concentrate on the knowledge, skills, values, and attitudes necessary for practice in the environments where health care is increasingly being managed. These curricular innovations must be implemented by the third year of medical school and should preferably be continued into graduate medical education.
The core curriculum developed by COMSEP had well-defined objectives based on the concept of a generalist core of pediatric knowledge and clinical skills, attitudes, and values that should be possessed by all medical school graduates. Although COMSEP relied on the structure of the traditional clerkship as its point of reference, the educational environment has now changed, and many new opportunities and priorities can be considered that were not apparent when the guidelines were written (Table 3). Most notably, the pediatric curriculum no longer needs to be confined or limited to a clerkship block in year 3. The introduction of LPs and other early clinical experiences has blurred the traditional separation between the preclinical and the clinical years, and there are substantive components of pediatric knowledge and clinical skills, attitudes, and values that can now be effectively integrated across the 4 years. Although not unique to pediatrics, these opportunities may be of greater relevance to pediatrics due to its typically lesser involvement in years 1 and 2 than FM or IM.
As part of the multispecialty integration focus of the new curricular trends, pediatric faculty now have a unique opportunity to review the overall generalist objectives of the curriculum from a collaborative perspective, to identify the essential pediatric objectives for each of the 4 years, and to develop strategies for eliminating duplication. For overlapping topics (eg, diabetes mellitus), opportunities can be pursued to develop pediatric health–related curricular offerings that are integrated rather than compartmentalized within individual, departmentally administered clerkships.
In those instances in which logistical limitations preclude full achievement of pediatric educational objectives, the challenge for COMSEP will be to identify alternative strategies whenever possible. The relative lack of pediatricians in rural locations, for example, needs to be addressed in regard to strategies for curricular alternatives. To the extent that there are essential clinical experiences related to pediatric health objectives that cannot be accomplished at nonrural sites, the present spirit of collaboration between primary care disciplines may permit the creation of multispecialty curricular offerings contributing to the COMSEP objectives while concurrently enhancing the overall generalist objectives.
Community-oriented/population-based experiences were not a specific focus in the COMSEP guidelines, and pediatric faculty were not prominently involved in any of the observed CO/PB experiences. Most of the CO/PB experiences were adult related, and most of the faculty were FM or, to a lesser degree, general IM. Community-oriented/population-based experiences therefore represent another window of opportunity for multispecialty collaboration between pediatrics, FM, and IM. There are substantial opportunities for collaborative programs in CO/PB that could be beneficial to the health status of children, to the integration of COMSEP objectives with the various curricular trends, and to the overall enhancement of the generalist core of the curriculum. Substantive questions to be addressed may include the extent that CO/PB experiences can be and should be pediatrics related and the extent that such components should be taught by pediatricians. Although additional practice models and role models for CO/PB activities may need to be developed in pediatric departments, doing so will be beneficial both clinically and educationally.
The extensive development of performance-based assessment strategies has been part of the transformations at many schools.3,18 As a result, there is both an opportunity and a need to explore the extent that standardized parents, adolescents, and older children can be included and to explore ways that remaining pediatric-related assessment needs can be achieved in alternative ways. Especially as related to skills, attitudes, and values pertaining to infants and young children, it may be necessary to also consider the rich array of computer-based instruction alternatives becoming progressively available. Recent developments in computer-based instruction may be of particular importance as part of an expanded strategy for performance-based assessments of pediatric health issues. Integrated case studies using computer-based techniques have been effectively used for pediatric health–related assessments in several schools, and virtual pediatric patients have been evaluated to a limited extent.
Failure to eliminate the pediatric gap in assessment strategies would likely have a 2-fold affect on the COMSEP curriculum objectives. In addition to the continuing inability to assess student performance for a significant portion of the age spectrum, the persistence of pediatric underrepresentation in the overall assessment process would perpetuate the perception that skills, attitudes, and values referable to children are not as important as those referable to adults. As confirmed in the site visits, assessment strategies did drive the curriculum to some extent; students tended to focus their learning and their examination preparation on what was being tested, creating a hidden curriculum that shaped what students learned independent of what they were being taught.19
Current curricular trends have substantially expanded the opportunities for pediatric departments to achieve full partnership and provide an optimal environment for students to acquire a sound general medical education, preparing them for any specialty and for lifelong learning in an evolving health care system.20 For the next steps, curriculum leaders in pediatrics can consider each of the following approaches: (1) full partnership with FM and IM in the planning and conduct of LP, CO/PB, MSC, and other integrated ambulatory experiences; (2) active participation as a precepter, small group facilitator, and mentor or role model for case-based educational experiences and small group activities related to acquisition of necessary skills, attitudes, and values for the early clinical experiences; (3) partnership with basic science and other clinical departments to ensure that clinical correlations and case-based opportunities provide balanced and representative exposure to pediatric diseases, maintenance of health, and prevention of illness concepts that are pertinent to adult-onset manifestations of illness; (4) emphasis on developmental and maturational aspects of wellness and of illness, even when age-related or logistical limitations preclude access to a comprehensive age range of infants and children; and (5) full representation of core principles of pediatric health in the curriculum and in performance-based assessments, including biologic and psychosocial development, parental and family support systems, risk behaviors, and environmental risks in children as antecedents of adult-onset morbidity and mortality, social and emotional development and behavior, and relationships between parenting, family dynamics, and maintenance of pediatric health and prevention of adult illnesses. Comprehensive incorporation of the principles of developmental biology, preventive pediatric health care, growth and development, maladaptive environments, and the pediatric origins of major medical and psychological morbidities across all 4 years of medical school is more readily attainable in the context of these new curricular trends.
Box Section Ref ID
Purpose: This section is intended to share information concerning educational efforts in the broad field of pediatrics. We welcome studies on the following topics: undergraduate and graduate education in medicine and allied health occupations; continuing education of health professionals; education of patients and families; and health education for the general public, the community, and organizations that contribute to the promotion and improvement of the health of children and adolescents.
Accepted for publication August 4, 1998.
Presented in part at Pediatric Academic Societies Annual Meeting, New Orleans, La, May 3, 1998.
Reprints: Carl E. Hunt, MD, Medical College of Ohio, Medical College Hospital, 3000 Arlington Ave, Toledo, OH 43614-2598.
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