Medical Education

A major consequence of the introduction of new medical curricula is the individualization of medical schools. From the time of the Flexner report in 1910 until Case Western Reserve University introduced organ-based learning in 1952, all medical schools were essentially the same in following the traditional two-year basic science courses plus a two-year clinical science curriculum. They differed only in the size, facilities, and quality of their teaching staff. With the introduction by McMaster University of problem-based learning in 1975, the option for wide-ranging curricula variations became feasible and has, in fact, taken place.

The major nontraditional approach to medical education in the basic and clinical sciences involves incorporating fact-intensive courses into an integrated curriculum. In this approach the focus is on general principles that usually cut across traditional disciplines, resulting in blocks of time devoted to a particular organ system in the context of various relevant sciences. Frequently coupled with this educational format is a technique known as problem-based learning, in which small groups of medical students analyze clinical case histories with the participation of a faculty member. Each student selects an aspect of the case to research and at the next session each discusses what was uncovered, thereby generating a collaborative learning system. This system is currently in effect on a limited basis in about 60 medical schools, about half the medical programs in the United States. While fully assessing the effectiveness of this approach is premature, preliminary findings indicate that students educated under the nontraditional system had overall lower scores on Step 1 of the USMLE, but generally scored higher on Step 2. Students seem to like the new system, perhaps because it is less demanding. A full day of lectures along with tedious lab work has been eliminated in favor of only a few lecture hours daily with streamlined labs.

There are some stresses in small group learning situations, such as one-upmanship to impress teachers and classmates by students who enjoy demonstrating their substantial pool of knowledge. Another problem is that some students do not pull their weight in meeting their assignments, making it more difficult for others. In addition, this new approach requires readjustment away from the competitive isolated learning experience. Approaching a problem in a “holistic” manner, rather than memorizing a mass of facts as was done during the premed years, involves drastic change, but may prove very worthwhile in the end.

Alternative Medicine

Over the past few decades many alternative practitioners of healing have gradually gained some acceptance. In a recent survey it was found that about one-third of all Americans use some form of unconventional therapy, spending close to $14 billion annually on treatments.

U.S. medical schools have responded slowly to this change. Thus far, about half include information about alternative medicine in their curriculum. These include Georgetown, Harvard, Tufts, University of California in San Francisco, and the Universities of Arizona, Louisville, and Virginia. Among the reasons offered for doing so is that nontraditional medicine can benefit patients, especially those suffering from chronic pain. Physicians may sometimes find using a holistic approach more stimulating than merely treating diseases.

The momentum behind the drive for alternatives to conventional medicine may have its roots in the longstanding undercurrent of unorthodox practices existing in medicine. The assertive spirit of social movements in our society, where the call is to take hold of one's destiny, has probably also impacted on the practice of medicine.

Within the medical community, there is strong opposition by some to alternative medical approaches, with the argument that their claims are not subject to rigorous scientific testing. Thus, physicians who desire to include alternative therapies in their practice run the risk of ostracism. However, intense public interest in alternative medicine is gradually forcing a change. In mid-1992, the National Institutes of Health opened an office for the study of unconventional medical practices, which will provide research grants. Establishing good clinical trials to test unorthodox treatments is not easy. When definitive positive results emerge, the possibility of including some alternative medical practice into the mainstream of allopathic medicine will become more likely. (For definitions of alternative medical practices, see Appendix E.)

In view of the large number of individuals using alternative modalities, it is desirable that future physicians be aware of the nontraditional practitioners and be sympathetic to patients who have sought help outside of conventional medicine.

Elective Programs

Almost all schools now offer opportunities for students to pursue such activities as independent study, honors programs, and special research projects, either at home or elsewhere during the academic year or in the summer.

Elective time may be offered any year but, it is especially common in the fourth year. In most schools the students have the option of consulting a faculty advisor when selecting electives. The extent of elective time may vary from a number of weeks to the entire fourth academic year. The choice of electives will depend on a student's personal interests and talents. Clinical electives may include additional clerkships in primary care and in many specialties and subspecialties. Electives may, at the medical school's discretion, be taken at academic centers or nonacademic centers away from one's institution of matriculation. Thus, some choose to become involved in a research project, while others may select a preceptorship, practicing with a physician in a rural community. Some students even decide to go overseas for a period of service (see below). In addition to clinical electives, the option may exist for electives in the basic of behavioral sciences.

Overseas Study

In the pre-World War II decades, it was common for U.S. physicians to travel overseas, usually to Europe, for specialty training. With the dramatic advances in U.S. medical education, this is no longer necessary. During the 1980s, however, it was noted that there was an increase in the number of U.S. medical students taking clinical electives abroad, especially in developing countries. It is thought that currently more than 15% of medical students participate in international health projects.

Overseas study is essentially a student-motivated undertaking. Finding an appropriate place abroad that has adequate funding can be quite difficult. The initiative to secure a position rests with students, although they may find a sympathetic faculty member to assist them.

The desire to have a unique life adventure while also serving as a goodwill ambassador is one of the motivating factors for overseas work-study endeavors. A more pragmatic motive is the desire by some students to determine which area of international health they should pursue. However, most of those who feel compelled to undertake such a project do so in order to contribute to improving health care resources of underserved people.

Medical students considering an overseas stint should be prepared to be flexible so far as living conditions are concerned, both in terms of accommodations and diet. Also, they should not consider their project a sight-seeing trip and they need to take time to learn about the culture of the elective country. They must be aware that there are negative aspects to service abroad. Some residency program directors view such an activity as time off from medicine. Frustrated by the inability to improve conditions in underdeveloped areas, some individuals may fail in their efforts to study and help overseas health care providers.

Obtaining permission from a medical school to study abroad should, in most cases, not prove difficult, since more than 90% of the schools allow third- or fourth-year students to do so for up to two months. However, only about 25% of the schools provide training in international health. This is regrettable, since preparation is the key to a successful overseas stay and typical university-based clinical training is inadequate for preparing students for service in underdeveloped areas. The University of Arizona Health Sciences Center in Tucson, Arizona, offers a free summer international health course that is held in high regard.

Medical Assistance Program International, Brunswick, Georgia, funded by the Reader's Digest International Fellowships, provides funding for 50 senior medical students to serve in overseas missions. It is one of the few programs offering overseas study support.

The following additional advice can be useful in trying to secure an overseas elective:

1. Seek an established program to ensure that it will be well organized.
2. Start the search for an elective country early; overseas correspondence is time consuming.
3. Get to know people in your elective country, since this can provide for meaningful future relationships.
4. Be prepared to deal with communication problems, loneliness, and frustration.
5. Consider yourself a collaborator for health improvement, rather than a savior.
6. Travel lightly, but be sure to take pure chlorine for water purification and a non-leaking water bottle in which to store it.
7. Respect the ways of the people you are visiting; in all likelihood, they will then reciprocate.
8. Before departing, read Cross-cultural Medicine: What to Know Before You Go (AMSA International Health Task Force) and Where There Is No Doctor: A Village Health Care Handbook (Chesperian Foundation, Palo Alto, California).

For an in-depth discussion of foreign medical study, see Chapter 13.

Community Service Activities

In the 1950s medicine emphasized the patient as an individual, rather than as part of a larger group. In the 1960s patients were introduced to students early in the educational process and medical ethics became a part of the curriculum. Currently, new concerns have emerged, such as the impact of technology on the terminally ill and the spiraling cost of and accessibility to health care.

In recent years there has been a growing awareness among health care professionals of the needs of the disadvantaged, which include nearly 40 million uninsured Americans. This has resulted in students volunteering their services, and some of these activities are gaining medical school recognition.

Service programs that students have initiated and led involve a very wide range of activities such as work in soup kitchens for the homeless, helping to build low-income housing, serving as health educators in local grade schools, or assisting in medical clinics. Increasing numbers of medical school administrators are beginning to view such activities as an integral component of medical education, rather than merely an extracurricular activity. Medical schools are starting to support such programs both financially and by granting academic credit for community service. Some schools are engaged in formally integrating community service into their curricula. Schools such as Dartmouth, University of California (Davis), and the University of Miami have large numbers of their first-year students participating in community service projects. Thousands of fourth-year students are involved in service as community health educators or as volunteers in clinics for under-served populations.

Community service is also reflected in the activities of medical students (and physicians) at the hundreds of free clinics located in urban and rural areas across the country. Medical students can thus gain hands-on experience under supervision in primary care. Both this and nonmedical-oriented service projects offer students an opportunity for a brief respite from the rigors of formal lectures, labs, and exams. It also serves as a reminder about the humanitarian goals of medicine as a caring profession.

Legislation that is part of the National Community Service Trust Act supports the award of grants to schools to facilitate service learning. The extent of funding for this and similar programs remains uncertain in an era of budget tightening.