Clinical skills are usually learned by pre-clinical students in a manner divorced from their basic science foundations. The value of previously learned basic sciences thus fails to be re-enforced. A clinical skills course was developed for an experimental curriculum of medical students in their first year. It was organized and taught by a team of basic and clinical scientists and emphasized the basic pathophysiological principles underlying clinical skills. Sessions were supported by related basic science audiovisual resources and a series of clinical problems with questions obliging the student to reason through basic-science mechanisms. Over the span of the course, students' interest shifted dramatically from a focus on proficiency in motor skills to an understanding of basic pathophysiological mechanisms underlying observed phenomena. Compared to conventional curriculum students, those in the experimental curriculum failed to show a diminution in perceived value of basic sciences in their future career and, on cumulative, cognitive examinations, scored equally in basic science, but significantly higher in clinical science subjects. A clinical skills course integrating both teachers and concepts from basic, as well as clinical sciences can improve student attitudes toward basic sciences.
Over the past ten years the University of New Mexico School of Medicine has conducted an educational experiment featuring learner-centered, problem-based, community-oriented learning. The experiment was introduced into an established institution by means of an innovative educational track running parallel to the more conventional curriculum. Students in the innovative track, compared with those in the conventional tract, tended to score lower on the National Board of Medical Examiners (NBME) Part I examination (basic sciences) and higher on NBME Part II (clinical sciences), received higher clinical grades on clinical clerkships, and experienced less distress. They were more likely than conventional-track students to retain their initial interest in or switch their preference to careers in family medicine. The parallel-track strategy for introducing curriculum reform succeeded in fostering institutional acceptance of continuing educational innovation. Generic steps in overcoming institutional barriers to change are identified.
Academic health care centers increasingly are exploring innovative ways to increase the supply of generalist physicians. The authors review successful innovations at representative academic health centers in the areas of recruitment and admissions, undergraduate medical education, residency training, and practice support. Lessons learned focus on those areas that have demonstrated improvements in the number and quality of physicians trained in family practice, general pediatrics, and general internal medicine. Successful recruitment of generalism-oriented applicants requires identification and tracking of rural, minority, and other special groups of students at the high school and college levels. Academic health care centers that provide early, sustained, community-based, ambulatory experiences for medical students and residents encourage trainees to maintain and choose generalist careers. Finally, academic health care centers that link with community providers and with state government encourage the retention of generalist physicians through continuing education and teaching networks.
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