Undergraduate medical education.

Pressures from students and teachers, from professional bodies, and from changes in the way health care is delivered are all forcing a rethink of how medical students should be taught. These pressures may be more intense in London but are not confined to it. The recommendation the Tomlinson report advocates that has been generally welcomed is for more investment in primary care in London. General practitioners have much to teach medical schools about effective ways of learning, but incentives for teaching students in general practice are currently low, organising such teaching is difficult and needs resources, and resistance within traditional medical school hierarchies needs to be overcome. Likewise, students value learning within local communities, but the effort demanded of public health departments and community organisations is great at a time when they are under greater pressure than ever before. The arguments over research that favour concentration in four multifaculty schools are less clear cut for undergraduate education, where personal support for students is important. An immediate concern is that the effort demanded for reorganising along the lines suggested by Tomlinson will not leave medical schools much energy for innovating.     

An American's view of Canadian medical education.

Undergraduate medical education in Canada and the United States is remarkably similar, except for the fact that Canadian medical schools are supported by their provincial governments. However, the systems diverge sharply at the postgraduate level. In Canada, the number and specialty mix of residents are negotiated by medical schools in response to educational and social needs; in the United States, these factors are largely determined by hospital service needs. The Canadian systems of accreditation, certification and payment for medical education after graduation are much simpler than those of the United States, and the accreditation and certification systems are more objective. In addition, the US system promotes subspecialization and a costly specialty imbalance, whereas Canada''s system has achieved an appropriate balance of specialists and generalists. In general, Canadian medical education appears to be simpler, more accountable and more socially responsive.     

CMA membership survey: opinions on issues facing the medical profession

A sample survey of Canadian Medical Association (CMA) members, conducted in early summer 1985 and designed to provide information to help guide the association''s activities and policies, shows that most Canadian physicians support involvement in political activities both by CMA and by indivudual physicians. A majority wishes to maintain the concept of extra/balance billing, to pursue the position that the health care system is underfunded and favours medicare premiums and hospital user fees as the preferred methods for increasing revenue.Most respondents believe that the number of doctors in Canada is about right but would prefer any reduction to be achieved by cutting medical school admissions or reducing postgraduate training positions open to graduates of foreign medical schools.Most of those members who know of CMA policies on a number of health care issues agree with them and also find them useful, but a significant proportion are not aware of their content.There is support for compulsory payment of dues by all licensed physicians to both their provincial medical association and CMA. A majority would like more information on pharmaceutical products and additional membership surveys.     

Demand-side medical education: educating future physicians for Ontario.

Initiated by Associated Medical Services (AMS), Educating Future Physicians for Ontario is a 5-year collaborative project whose overall goal is to make medical education in Ontario more responsive to that province''s evolving health needs. It is supported by AMS, the five universities with medical schools or academic health sciences centres and the Ontario Ministry of Health. The project''s five objectives are to (a) define the health needs and expectations of the public as they relate to the training of physicians, (b) prepare the educators of future physicians, (c) assess medical students'' competencies, (d) support related curricular innovations and (e) develop ongoing leadership in medical education. There are several distinctive features: a focus on "demand-side" considerations in the design of curricula, collaboration within a geopolitical jurisdiction (Ontario), implementation rather than recommendation, a systematic project-evaluation plan and agreement as to defined project outcomes, in particular the development of institutional mechanisms of curriculum renewal as health needs and expectations evolve.     

Buffeted by harsh economic winds,medical schools turn a wary eye to the future

All parts of Canada''s health care system are facing fiscal pressures these days, but they are particularly great at Canada''s medical schools. However, Dr. David Hawkins of the Association of Canadian Medical Colleges is optimistic that all 16 of Canada''s medical schools will remain open, mainly because of the huge impact they have on health care in their local communities. “We don''t just turn out students — we raise the standard of health care in a whole community,” he says.     

The academic medical centre: an idea whose time has come.

Interdependence of faculties of medicine or health sciences and teaching hospitals is central to the academic medical centre''s three "products": education, research and clinical service. Whether a voluntary association, partnership, joint venture or single entity, the strength of the association of member institutions must lie in mutual dependency. With the potential of reducing costs and increasing effectiveness through administrative efficiency and rationalization, especially of planning and setting priorities, the academic medical centre can outstrip its individual member institutions in contributing to the solution of Canada''s present and future challenges in health care.     

Guidelines for medical practice: 1. The reasons why.

Various external special interest groups are promoting attempts to better measure and control the performance of the medical profession, primarily to restrain costs. We can neither afford to ignore the rising costs nor reject efforts by provincial licensing authorities to improve supervision of the quality of care. Furthermore, there is increasing public interest in the outcome of medical treatment and a suspicion that some care may be unnecessary or inappropriate. Much of what physicians do is not based on impeccable or complete scientific evidence, and we have not established a method whereby science can consistently be translated into practice. Optimal practice patterns must be defined to improve the quality of care and to maximize the efficiency with which scarce resources are used. Careful scientific evaluation of data is particularly necessary with the arrival of new drugs and technology. Sensible, flexible guidelines produced by appropriate panels will help promote improved practice. Rigid standards must be avoided to allow for individual consideration and scientific innovation. The recognized difficulties of influencing clinical practice by precept or education and the problems imposed by rapidly changing scientific knowledge are two hurdles to be overcome. Licensing bodies must identify and enforce minimal standards, but optimal practice patterns are better devised by a broader segment of the profession. Intervention by third-party payers, as is prevalent in the United States, intrudes upon physician autonomy and reduces access to care. Physicians must support the development of guidelines for optimal medical practice based on the best existing data and focused on improving the quality of care.     

Medical education and society.

As health care changes under the pressures of restraint and constraint our vision of the future of medical education should be based on the medical school''s responsibility to the community. The medical school is "an academy in the community": as an academy, it fosters the highest standards in education and research; as an institution in the community, it seeks to improve public health and alleviate suffering. The author argues that to better achieve these goals medical schools need to become more responsible and responsive to the population they serve. Medical schools have been slow to accept fully the social contract by which, in return for their service to society, they enjoy special rights and benefits. This contract requires that medical educators listen to the public, talk honestly and constructively with government representatives and assess the needs and expectations of the community.     

Bioethics for clinicians: 9. Involving children in medical decisions

Medical decisions involving children raise particular ethical issues for physicians and other members of the health care team. Although parents and physicians have traditionally made most medical decisions on behalf of children, the developing autonomy of children is increasingly being recognized in medical decision-making. This poses a challenge for physicians, who must work with the child''s family and with other health care practitioners to determine the child''s role in decision-making. A family-centred approach respects the complex nature of parent-child relationships, the dependence and vulnerability of the child and the child''s developing capacity for decision-making.     

Protecting and securing networked medical devices

Designing, building, and maintaining a secure environment for medical devices is a critical component in health care technology management. This article will address several avenues to harden a health care information network to provide a secure enclave for medical devices.     

Translation is not enough. Interpreting in a medical setting.

Unique obstacles must be overcome when providing medical care to patients who have an incomplete command of the English language. Serious barriers to effective communication may arise at the exact point where our health care system must succeed or fail. Miscommunication, differences in attitudes about health care, and various other misunderstandings interfere with or frustrate good health care for these patients and their families. Such difficulties are best overcome by the use of a professional interpreter who can ensure good communication between patients and health care professionals. My daily experiences as a professional medical interpreter and translator in Spanish provide insights into the complexities of bilingual and bicultural communication in the hospital setting. Although the examples given relate to Hispanic patients, the lessons learned can be extended to other foreign language patients as well.     

Delivery of postgraduate medical education--who pays?

As the cost of academic postgraduate medical education increases the DHSS may sometimes need to fund established academic posts or sessions within universities, and it must recognise the need for salaried sessional commitments by clinical tutors and encourage universities to integrate them more effectively into regional medical schools. Such activities will otherwise increasingly impose on undergraduate departments teaching demands that are neither practicable nor proper.     

What Is So Special About a Family Physician?

Around a core of common, acute and chronic, recurrent health problems, a family physician must marshall the traditional episodic management for both inpatient and outpatient illness. He must also be especially adept at recently emerging routines of prevention and early detection. He provides individual and familial psychologic support and counselling, for both its therapeutic and preventive values. In addition, he must relate the individual care of his patient and the patient''s family to the community as a whole. In doing this he will use not only his own skills but those of lay health volunteers, trained allied health care professionals and skilled subspecialists in the limited medical disciplines.The proper preparation of family physicians for this complicated role has far-reaching implications for change in both medical education and medical practice.     

Consumer demand for caesarean sections in Brazil: informed decision making,patient choice,or social inequality? A population based birth cohort study linking ethnographic and epidemiological methods

ObjectivesTo investigate why some women prefer caesarean sections and how decisions to medicalise birthing are influenced by patients, doctors, and the sociomedical environment.DesignPopulation based birth cohort study, using ethnographic and epidemiological methods.SettingEpidemiological study: women living in the urban area of Pelotas, Brazil who gave birth in hospital during the study. Ethnographic study: subsample of 80 women selected at random from the birth cohort. Nineteen medical staff were interviewed.Participants5304 women who gave birth in any of the city''s hospitals in 1993.ResultsIn both samples women from families with higher incomes and higher levels of education had caesarean sections more often than other women. Many lower to middle class women sought caesarean sections to avoid what they considered poor quality care and medical neglect, resulting from social prejudice. These women used medicalised prenatal and birthing health care to increase their chance of acquiring a caesarean section, particularly if they had social power in the home. Both social power and women''s behaviour towards seeking medicalised health care remained significantly associated with type of birth after controlling for family income and maternal education.ConclusionsFear of substandard care is behind many poor women''s preferences for a caesarean section. Variables pertaining to women''s role in the process of redefining and negotiating medical risks were much stronger correlates of caesarean section rates than income or education. The unequal distribution of medical technology has altered concepts of good and normal birthing. Arguments supporting interventionist birthing for all on the basis of equal access to health care must be reviewed.

What is already known on this topic

Women''s preferences for caesarean sections are understood to result from lack of knowledge and psychological aptitude to handle vaginal delivery and its consequencesEfforts to reduce the demand for caesarean sections have focused on providing consumers with correct information on the relative risks associated with vaginal and operative deliveries

What this study adds

In Brazil, many women prefer caesarean sections because they consider it good quality careRich women are more likely to have caesarean sections, supporting the notion that medical intervention represents superior carePoor women may implement a series of medicalised practices that justifies the need for greater medical intervention during birthInterventions for reducing caesarean sections by educating physicians and patients about risk factors associated with birthing procedures are not sufficient     

Medical education in an era of health-care reform

Medical educators are facing a challenge today that is quite analogous to that addressed by Abraham Flexner, namely how to transform a legacy system of education that is no longer preparing future physicians adequately to meet contemporary expectations and responsibilities. In facing up this challenge, however, today's educators not only must equip students to deal effectively with the rapidly changing paradigms in health care and medical practice, they also must adapt their curricula and pedagogical methods to the demanding new paradigms of medical education. Their success in addressing these dual imperatives will determine whether the educational transformations currently underway will have as momentous an effect on the public's health as did those stimulated by Flexner a century ago.     

Medical simulation: the new tool for training and skill assessment

Medical simulation is a new method to facilitate skill training and assessment. Simulation has achieved a high degree of sophistication in aviation and other fields. However, the complexity of health care, the numerous stakeholders, and the lack of central control of medical education have been barriers to the development and broad implementation of medical simulation. Acceptance by the medical community is growing, with the publication of scientific validation studies, the development of economic models and funding, and the integration of simulation into existing curricula and training programs. The major forces for implementing simulation will most likely come from the medical device industry and from institutions with mandates to improve the quality of health care and enhance patient safety. Certification boards are expected to increase their utilization of simulation technology to objectively assess proficiency of skills relevant to physicians and the health care system. Medical simulation has made the transition from an experimental technology to the clinical world, and the next five to 10 years may be viewed as the golden age of medical simulation.     

Status of nutrition education in Canadian dental and medical schools.

To investigate the present status of nutrition education for dentists and physicians in Canada, we conducted a survey of the nutrition education programs in 10 Canadian dental and 16 medical schools in the academic year 1982-83. Seven of the dental schools and seven of the medical schools had a separate course in nutrition. The average duration of these courses was 22 hours for the dental schools and 26 hours for the medical schools. Nutrition education was integrated with another discipline in 4 of the dental schools and 11 of the medical schools. The average duration of this type of instruction was 14 hours for the dental schools and 18 hours for the medical schools. Six of the dental schools and eight of the medical schools employed a nutritionist/dietitian to provide instruction in nutrition. We recommend that courses in basic and applied clinical nutrition be incorporated throughout the curricula of Canadian dental and medical schools, and that personnel trained in clinical nutrition be employed to provide instruction in this area.     

Continuing medical education: a personal view.

Over many generations doctors have kept up to date in ways which reflect their own learning styles. The current fashion for formalised and policed continuing medical education may prove ineffective unless it is recognised that individual needs must be taken into account. Attendance at formal courses based on lectures and papers may not suit a large proportion of those who attend to acquire the necessary points to satisfy their royal college. The ability to show that health care teams are up to date should come from effective clinical audit, which should also identify local educational needs.     

Sex Education in the Schools— The Doctor's Role

Physicians may be asked to act as consultants in the development of sex education programs in the schools or to contribute as professional experts. As most medical libraries contain very little material on this subject, the doctor must turn to public libraries, which have books ranging from useless to excellent. These must be examined critically. In his role of healer, the doctor may minimize his roles of teacher and community model, and thereby lose many opportunities to communicate with members of other professions and thus extend health education beyond the limits of his practice.     

Human genetics teaching in U.S. medical schools.

Information about instruction in genetics was obtained fron 103 of the 107 U.S. four-year medical schools. Seventy-two percent of the schools provide a compulsory course in genetics, but there was great variation in duration, content, departmental responsibility for giving the course, and in the disciplines of those doing the teaching. The variability in the number of hours devoted to teaching genetics was reflected in the competence of the students in giving correct answers to questions on genetics posed by the National Board of Medical Examiners. Electives and continuing education courses on genetics are given by two-thirds and one-half of the schools, respectively; but the subject receives very little attention in departments of preventive, community, or family medicine or in schools of allied health sciences. These findings suggest that genetics has not yet found a natural and comfortable context in the curricula of U.S. medical schools.