Compared to half a century ago, medical students are now learning different skills to adapt to the ever-changing landscape of healthcare.

“Today’s students are learning about healthcare costs and how to work in teams. They are moving away from hospital settings and training in community centres and even in patients’ homes,” explains Dr George E. Thibault of Josiah Macy Jr. Foundation.

They are also learning in small groups, with mentors instead of teachers with all-knowing authorities. However, Dr Thibault points out that one thing remains the same: the length of education and training is still pre-determined.

“That needs to change,” he says.

He suggests a new model of education where “students advance when they master required competencies, not because they’ve passed an exam after a set period of time.” This would allow students to increase their competency at their own pace without the pressure of finishing medical school ‘on time’.

“A competency-based, time-variable approach gives faculty members the opportunity to tailor education to the needs of the students and lets students use more or less time in different educational experiences as they achieve predetermined competencies,” elaborates Dr Thibault.

Expectations kick in – raised pressure for medical students

Dr Thibault is not alone in this.

A 2010 study that assessed the expectations of clinical skills preparation for clerkships (the practice of medicine by final year medical students in the US) found that the pre-clinical faculty and medical students had higher expectations than clerkship faculty.

As part of the result, researchers stated that “clarification of skills expectations may also alleviate student anxiety about clerkships and enhance their learning.”

They also highlighted the complex and multifaceted struggles students face as they start clerkships and called for improved communication between students and teachers early in clerkships.

This can also be seen in The Education in Paediatrics Across the Continuum (EPAC) programme at the UCSF, Minnesota, Colorado, and Utah medical schools, which tested a competency-based approach for medical students to move into residencies in paediatrics in a time-variable way.

Students reported easier transitions when residency programme directors were involved in student education and evaluation much earlier in the programme.

The researchers in the 2010 study, therefore, suggested developing common expectations for clinical-skills preparation between students and faculty as a method to reduce student anxiety, ease the transition, and maximising efficient skill improvement.

Students reported easier transitions when residency programme directors were involved in student education and evaluation much earlier in the EPAC programme.
Students reported easier transitions when residency programme directors were involved in student education and evaluation much earlier in the EPAC programme.

Time is what they need to be a ‘good’ doctor

Another study done in 2014 argued that while importance of professional behaviour has been emphasised in medical school curricula, the lack of consensus on what constitutes professionalism poses a challenge to medical educators. They end up resorting to a negative model of assessment based on the identification of offensive behaviour.

The paper studied 49 medical students who took part in 13 focus groups and observed the differences between students’ understandings of the ‘good’ and ‘professional’ doctor.

Students report feeling more connected to the concept of the ‘good’ doctor, and perceived professionalism as an external and imposed construct. The research also identified that students tended to forgo professionalism in favour of becoming a ‘good’ doctor.

It was concluded that the teaching of professionalism should incorporate more formal reflection on the complexities of medical practice. This would allow students and educators to openly explore and articulate any perceived tensions between what is formally taught and what is being observed in clinical practice.

This will require more than just a standardised test with time limitations, as Dr Thibault suggested.

Evolve medical education to fit current practices

The Josiah Macy Jr. Foundation that Dr Thibault leads has recently gathered leaders in the education and accreditation of health professionals to craft a competency-based education path.

The group suggested first and foremost, the systematic redesign of the current teaching system – including curricula, learning environments and faculty development. This would be followed by the creation of a continuum of education, training and practice to allow medical students to transition between phases of learning seamlessly.

They have also called for an establishment of a robust programme of assessment that links a set of competencies to each stage of a healthcare professional’s education, training and career. This would be tracked by leveraging new and existing technology that supports more complex administrative processes – such as tracking students’ accomplishments and facilitate instructional needs.

Finally, they suggested the development of a rigorous evaluation model to measure the effectiveness of the programmes based on outcomes that are important to society. This includes improved patient care and improved practitioner performance and satisfaction.

“A transformation to a competency-based, time-variable education programme will take time and won’t be easy. But it’s time to stop tinkering at the edges. We and our patients don’t have another 50 years to wait,” concludes Dr Thibault. MIMS

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