Medical Education - The Traditional Curriculum
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THE TRADITIONAL CURRICULUM
The First Year
This introductory phase is devoted to the study of normal human biology, which includes anatomy, biochemistry, and physiology. The scope and emphasis within each of these areas are gradually being altered as new experimental approaches result in fresh data. Thus, for example, while the time allotted to gross anatomy is being diminished, the time spent on histology (microscopic anatomy) is being increased, and more emphasis is being placed on ultrastructural and histochemical findings. Most schools incorporate clinical demonstrations within basic science lectures so as to relate subject matter to actual medical problems. Many schools offer some introductory lectures in the behavioral sciences and genetics during the first year.
The first year is about 35 weeks long, with about 35 hours of required class work per week. Half or more of the class time is spent in lectures; the rest is spent in the laboratory.
The Second Year
The second year is the bridge between the preclinical sciences and the clinical subjects that occupy the bulk of the final two years of study. This year establishes the scientific basis for understanding abnormal states of human biology. The standard courses taken during the sophomore year are pathology, microbiology, pharmacology, physical diagnosis, clinical laboratory procedures, and introductions to certain specialty fields such as public health and psychiatry.
Pathology is probably the keystone course of the sophomore year. It provides an introduction to the essential nature of disease and, in particular, the structural and functional changes that cause or are caused by disease. During the second semester, the more common diseases of each organ system and each organ are studied. The teaching process in pathology involves formal lectures, clinical pathological conferences, and laboratory exercises in pathological histology.
Microbiology provides an introduction to disease processes. It involves a study of the microorganisms that invade the body. The basis of mechanisms of infection and immunity is analyzed. One of the most effective means of combating disease is through drugs. Pharmacology concerns itself with the chemistry of the natural and synthetic drugs and their action in the healthy and diseased human body. The full impact of this subject comes to the forefront during the lengthy laboratory exercises in which experimental animals are frequently used to measure the effects of drugs.
The groundwork provided by the aforementioned courses, together with those completed during the first year, provide a great deal of fundamental information about the human body in illness and in health. The next step is to become familiar with the practical techniques required to determine the nature of a patient's illness. An introduction to this procedure is provided by the course in physical diagnosis. This phase of preclinical study gives one a strong psychological lift. The student learns the art of taking a medical history and examining a sick patient. The sophomore year ends with a framework for the clinical years well established.
The Third Year
While the junior year is highlighted by considerable exposure to clinical experience, the formal educational process continues during this period with lectures, conferences, and seminars in medicine, surgery, pediatrics, obstetrics, and gynecology, as well as other specialties and subspecialties. The educational process is usually closely integrated with presentation of relevant patient cases. The emphasis in this early clinical training period is on the diagnosis of disease. The principles of treatment noted will be emphasized later.
Juniors are assigned various patients for a “workup,” obtaining a history and physical examination. To carry out the former, the junior medical student learns to interrogate the patient so as to elicit and organize the chronological story of his or her present illness, obtain information as to the general state of his or her past and present health, secure vital data concerning the patient's family history, occupation, and social life. Supplementing this is a physical examination using manual manipulative and instrumental aids (stethoscope and ophthalmoscope). All the information is then integrated to provide preliminary diagnosis. The student then decides whether laboratory tests, X-rays, or special studies are needed. A faculty member reviews the entire “workup” and makes adjustments or confirms the order for diagnostic tests. This preliminary stage of clinical training, like all initial educational experiences, is of special importance. It helps develop a critical approach that tends to avoid the hazards that result from insufficient gathering of information, careless observation, or improper evaluation of the obtained data.
The initial diagnostic training is provided as part of service in the outpatient clinics and in the hospital wards. Later in the year, having attained proficiency in working up new patients, the student serves as a full-time clinical clerk in various clinical departments and in their outpatient clinics. As an apprenticing diagnostician, he or she is introduced to a variety of specialties. The aim of these experiences is not only to introduce the student to possible areas of specialization, but to teach the techniques of detecting all kinds of illness, regardless of specialization. Generally, the student will spend one quarter on medicine, another on surgery, a third on obstetrics-gynecology and pediatrics, and a fourth on electives.
As a clerk in medicine the student will rotate among various outpatient clinics and become familiar with groups of diseases that are classified as cardiovascular, allergic, infectious, rheumatic, neurological, gastrointestinal, and dermatological. Teaching clinics in these subspecialties are conducted by members of the medical school's faculty.
Short periods of time (several weeks each) are usually allotted to otolaryngology (diseases of the ear and throat) and ophthalmology. The student learns the basic diagnostic techniques in these specialties and has an opportunity to study the medical and surgical treatments used in these areas.
The clerkship in surgery enables the student to apply their newly acquired diagnostical training. The student gains insight into the process of determining when an operation is required as well as the need for pre- and post-surgical care. If assigned to the emergency room, he or she may have an opportunity to perform, under supervision, minor surgery such as treatment for infections of fingers, draining of abscesses, or suturing of lacerations. Many institutions offer as an elective a course in operative surgery where animals are treated as patients. Participation by the third-year student in such a program provides him or her with an opportunity for training as a surgeon, first assistant, scrub nurse, and anesthetist.
The student develops a foundation in the physiology of the human female in the first year and in pathology of diseases of the female urogenital system in the second year; he or she is now prepared for clinical work in gynecological diseases, and during the third year, the student participates in conferences, ward rounds, lectures, surgery, and outpatient clinics. It is quite common for the student to deliver about a half dozen babies. These deliveries are naturally performed under the close supervision of a resident in obstetrics. Aside from the training in childbirth, the student learns about the medical and emotional problems of prenatal care. In the outpatient obstetric clinic the student has the opportunity to examine and counsel women in pregnancy. This provides an especially favorable opportunity to develop skills in doctor-patient relationships.
The clerkship in pediatrics is devoted to the study of children and their diseases. The life span covered is from shortly after birth to adolescence. The student is taught to recognize the need not only for diagnosis of the pediatric diseases but to anticipate them and thus better help to ensure that the child will develop into a healthy adult. The preparation for the pediatric clerkship is frequently initiated in the latter part of the second year with lectures and some clinical experience in the fundamentals, such as heart sounds, X-rays, and EEGs of infants and children. Work in the clinics and wards becomes more intensive in the third year when the student is exposed to varied medical and surgical problems of children's diseases. The fourth year provides additional opportunity for pediatric training along with greater responsibility.
During the third year, the student-instructor relationship becomes more personalized and an exchange of views begins to take place; the student assumes the status of a junior colleague. The junior medical student's responsibilities are carefully demarcated and essentially restricted to taking medical history and carrying out a physical examination. The acute illnesses students see in the wards and the explicit problems they handle in the clinics are often “classical,” and therefore students are free from the necessity of coping with diagnostic and therapeutic uncertainties that fall outside their limited area of knowledge.
The Fourth Year
In the fourth year, the student's activities are frequently divided into four quarters. One is devoted to surgery (including general, orthopedic, and urological), another to medicine, a third to pediatrics, psychiatry, neurology, and radiology, and a fourth to elective study. There is usually considerable latitude in the arrangement of the order in which the program may be carried out.
In the surgical clerkship, seniors may frequently be assigned their own cases. They will, under careful supervision, be responsible for the patient workup, help arrange for laboratory tests, and contribute to discussions involving the diagnosis. Students will participate in preparing the patient for surgery, and, in the operating room, can expect to serve as third or fourth surgical assistant. They may be assigned to keep watch over the patient in the recovery room and be responsible for routine postoperative check-ups until the patient is discharged. The aim of the limited surgical experience for the senior student is not to secure specialized training, but to gain diagnostic experience so as to have a balanced insight into the usefulness of surgical intervention in the process of healing the sick. The exposure in surgery will be very broad, ranging from tonsillectomies to cardiac surgery.
In the block of surgical time devoted to orthopedics, the senior is exposed to the diagnosis and treatment of diseases of the joints and vertebral column, as well as fractures and deformities of the bones of the body. In urology some surgical and medical experience is gained by coming into contact with patients suffering from diseases of the kidney, bladder, prostate gland, and reproductive organs.
The quarter devoted to clinical clerkship in medicine is rather similar to that in surgery; naturally, the nature of the patient's illness and the method of treatment differ. Nevertheless, for the fourth-year student, there are workups to be made, tests to be ordered, and diagnoses to be reached. Several times a week students and their supervisors will go on rounds and students will participate in the discussions about the patients' conditions, treatments, and prognoses. During the clerkship period, seniors will be on call 24 hours a day and must be ready to assist in emergencies and to comfort patients through periods of stress. Naturally, throughout this period, the house staff—the residents—will bear the direct responsibilities for prescribing treatment and directing emergency care. But senior medical students nevertheless gain firsthand insight into the responsibilities that must be assumed by them during postgraduate training.
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