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Chapter 4
Current Educational Activities in
the Core Competencies
This chapter reviews current undergraduate and graduate educational activities for medicine,
nursing, pharmacy, and selected allied health professions with respect to the core competencies
outlined in Chapter 3: provide patient-centered care, employ evidence-based practice, work in
interdisciplinary teams, apply quality improvement, and utilize informatics. The focus is on what,
how, and when health professionals are taught these competencies in academic programs. There is
broad variation in this regard. Some of these competencies are intrinsic to the historical vision of
certain professions, while others are inadequately addressed in the educational programs of any of the
professions. The chapter concludes with a discussion of how educational institutions are moving
toward an outcome-based education approach to ensure that students can demonstrate such
competencies upon graduation, and a review of the issues surrounding this approach.
The committee obtained information published in the professional literature and supplemented
these published descriptions by soliciting input from educational institutions The committee notes
that there are few rigorous evaluations of educational interventions in the health professions. Indeed,
the lack of evidence-based education is an issue that the committee decided to address with a
recommendation and that a working group at the summit deemed important to address (see Appendix
C). Studies examining the effect of education in any quantifiable manner come largely from medical
education, which accounts for the predominance of references related to medical education in this
chapter. In discussing preparation in the five competencies, the professions are addressed in order of
the extent of available evidence: medicine, nursing, pharmacy, and allied health.
Provide Patient-Centered Care
In general, comprehensive attention to patient-centered care in medical education is lacking. The
75
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HEALTH PROFESSIONS EDUCATION
dominant biomedical model of practice,
whereby patients are viewed in terms of signs
and symptoms, remains a large barrier to
redressing this need (Mead and Bower, 20004.
Though efforts to teach patient-centered care,
however defined, are increasingly being
advocated and incorporated into the training of
physicians (Lewin et al., 2001), such efforts are
regarded as ad hoc and are often not ascribed
significant value, energy, and financial
resources (Flores et al., 2000; Malloch et al.,
20004. Shared and informed decision making
with patients needs greater emphasis in medical
education. One survey of medical students and
residents revealed that over 90 percent of
respondents believed physicians should have
greater input in decisions than patients; as
training and experience increased beyond
medical school, there was an increased tendency
toward a belief in physician-only decision
making (Beisecker et al., 19964.
Medical students also are not adequately
prepared for promoting prevention and healthy
lifestyles with patients. Although an expert
panel convened by the Association of Teachers
of Preventive Medicine proposed a curricular
requirement "of making preventive medicine an
integral part of the education, training, and
practice of physicians" (Collins et al.,
1991 :307), the integration of disease and illness
prevention and welIness into medical education
has largely not been achieved (Garr et al., 2000;
Heller et al., 2000; Institute of Medicine, 1988;
Pomrehn et al., 2000~. Indeed, given the
tradition in medicine of overwork, sleep
deprivation, and neglect of one's own welIness,
medical students and residents cannot even
serve as good examples for patients of healthy
lifestyles and welIness.
Medical education has recently placed more
emphasis on enhancing patient-clinician
communication, and such efforts have been
shown to increase patient satisfaction and
improve patient outcomes (Halpern et al., 2001;
Henbest and Stewart, 1990; Langewitz et al.,
1998; Lewin et al., 2001; Lipkin, 1996; Smith et
al., 1995; Swick et al., 1999~. However, there is
broad variation in the content and evaluation of
communication courses. The American
Association of Medical Colleges (AAMC) has
begun to address this lack of uniformity by
developing communication competencies
through its Medical School Objective Project
(American Association of Medical Colleges,
2000~.
Nurses have long been taught to focus on
the patient's needs, the family, or in some cases,
a clinically defined population group. On
balance, they are educated to use preventive and
health-promoting interventions, to counsel and
communicate with patients, to apply community
and behavioral interventions, and to be highly
sensitive to the needs of individuals (Allen,
2000; Milio, 2002; O'Neil and the Pew Health
Professions Commission, 19984. However, the
realities of the day-to-day practice environment
and systems design often constrain
opportunities to utilize this knowledge fully
(Peterson, 20014. Further, some worry that there
. . . ~~ .
are mayor clliterences among nursmg programs
with regard to educational preparedness in
competencies associated with population-
focused care, health protection, and promotion
and prevention (Institute of Medicine, 19954.
In the last decade, pharmacists have
reformulated their vision of the profession,
shifting from an orientation primarily toward
the dispensing of drugs to a greater focus on
pharmaceutical care, an approach designed to
promote health; prevent disease; and assess,
monitor, initiate, and modify medication use to
ensure that drug therapy regimens are safe and
effective (American Pharmacuetical
Association, 20024. The result has been a
widespread curricular change in pharmacy
education during the last decade to better
prepare graduates for this new mission
(American Association of Colleges of Pharmacy
Commission to Implement Change in
Pharmaceutical Education, 1993; Center for the
Advancement of Pharmaceutical Education
tCAPE] Advisory Panel on Educational
Outcomes, 1998; Pharmacy Deans Task Force
on Professionalism, 2000~. In these reform
efforts, considerable emphasis has been placed
on a revision of curricula to include more
76
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CURRENT EDUCATIONAL ACTIVITIES
service learning opportunities and education of
students in new communication and health
promotion and disease prevention competencies
(Murawski et al., 19994. Though changes have
been substantial, a recent survey of pharmacy
faculty revealed that training in communication
skills is irregular and not well developed in
some schools (Beardsley, 20014.
Prevention and health promotion, as well as
shared decision making with patients, are
intrinsic to the vision of a number of allied
health professions, including dental hygienist,
registered dietician, physical therapist, and
occupational therapist, and the educational
preparation and curricula for these professions
reflect this fact. However, the Association of
Schools of Allied Health Professions and the
National Commission on Allied Health (Health
Resources and Services Administration, 1999),
citing allied health professionals' frequent
contact with patients and their relative lack of
preparation in this area, have suggested that
allied health curricula be strengthened further to
include communication and patient and family
education.
Being competent in providing patient-
centered care includes easing pain and
providing comfort to patients who need it.
These skills are particularly important in end-of-
life care. Yet review commissions have found
that pain management is not sufficiently
addressed in the education of all the health
professions to meet the needs of the American
people (Institute of Medicine, 2001; 2002b). In
one survey, the authors reviewed postgraduate
medical training programs on the care of
seriously ill and dying patients and found that
the majority included no training in pain
assessment and management (Weissman and
Block, 20024. And while nurses have been
central in the development of the international
hospice movement, specific educational
opportunities for nurses in pain management are
still rare (Institute of Medicine, 2002b). The
American Association of Colleges of Nursing
has concluded that "end-of-life education and
training is inconsistent at best and sometimes
completely neglected within nursing
curricula" (American Association of Colleges of
Nursing, 2002:1)
Understanding the patient's values and
experience outside of the hospital necessitates
cross-cultural awareness and competence.
However, there is little documentation of the
extent to which cross-cultural issues are covered
in the education of health professionals
(Institute of Medicine, 2002a). Summit
participants stressed the need to develop cultural
competency standards to promote better
understanding of and communication with
diverse populations, as well as increased
education in community settings in the form of
home visits and community-based partnerships
with schools. Participants emphasized the
importance of involving patients and their
families in all aspects of the educational
process, including having them rate student
performance in providing care, holding more
clinical discussions at bedside, videotaping
encounters between students and patients, and
using patient focus groups to provide feedback
on performance. Research supports the view
that these techniques greatly enhance patient
satisfaction and facilitate better student
performance with patients (Branch, 2000;
Branch et al.,2001; Chisholm and Wade, 1999;
Eyler et al., 2001; Gerteis et al., 1993; Maguire
et al., 1996; Novack et al., 1999; Self et al.,
19984. Box 4-1 presents some examples of
effective education in patient-centered care.
77
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HEALTH PROFESSIONS EDUCATION
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78
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CURRENT EDUCATIONAL ACTIVITIES
Work in Interdisciplinary Teams
The Quality Chasm report (Institute of
Medicine, 2001:83) envisions a future in which
clinicians "understand the advantage of high
levels of cooperation, coordination and
standardization to guarantee excellence,
continuity, and reliability. Cooperation in
patient care is more important than professional
prerogatives and roles. There is a focus on good
communication among members of a team,
using all the expertise and knowledge of team
members, and where appropriate, sensibly
extending roles to meet patients' needs." As
discussed in Chapter 3, this level of cooperation
and coordination across all the professions is
not yet a reality. There is generally a great lack
of understanding among the professions for
what each profession does, its level of training
and education, and its existing or potential
competencies. The absence of a common
language, differing philosophies, politics, and
turf battles across the professions remain the
norm.
This situation is exacerbated by the fact that
in the vast majority of educational settings,
health professionals are socialized in isolation.
hierarchy is fostered, and individual
responsibility and decision making are relied
upon almost exclusively (Hall and Weaver,
20014. Health professions education occurs
largely in an environment of separately housed
professional schools and separate clinical arenas
governed by powerful separate deans, directors,
and department chairs. Professional schools
also have their own separate faculty, school
calendars, and different points of entry into the
profession. Frequently, separate schedules
prevent the development of new courses and
innovative curriculum design (Holmes, 19994.
A lack of appreciation of the actual or potential
contributions of each of the health professions is
reinforced by such settings, and more important,
students learn little about the high levels of
coordination and collaboration needed to
provide quality care for Americans. There is a
profound disconnect between current role-
oriented, isolated academic preparation and
practice environments that rely on teams or
wish to do so (Stumpf and Clark, 1999~.
One key to fostering interdisciplinary
practice is interdisciplinary education, whereby
a group of students from the health-related
occupations with different educational
backgrounds learn and interact together during
certain periods of their education in order to
collaborate in providing health-related services
(Holmes, 19994. Educating the professions
together affords students the opportunity to
develop the collaborative relationships essential
for cross-fertilization among disciplines in the
practice environment and supports respect
among the disciplines as well (Hayward et al.,
1996~.
There are many examples of successful
efforts to provide education in working in teams
and in developing team-related skills in a
variety of care settings (Hall and Weaver, 2001;
Headrick et al., 1996; Lavin et al., 2001;
McCallin, 2001; Zwarenstein, 19994. One
example involves an interdisciplinary team of
student nurses, physical therapists, occupational
therapists, and patient care assistants who
developed interventions around patient activity
and mobility, resulting in reduced incidence of
immobility- as s ociated complications (Markey
and Brown, 2002~. In another example, teams
of students in physical and occupational
therapy, speech and language therapy, and
exercise physiology worked over a semester to
provide wellness and prevention interventions
to the homeless and the chronically ill senior
population (Hamel, 2001~.
Although such successful examples exist
(Murray et al., 2000), interdisciplinary
education has yet to become the norm in health
professions education. This is true despite
efforts over the past 50 years on the part of
foundations, private organizations, and
government agencies, with enthusiasm waxing
and waning, often in relationship to funding
support. In 1995, fewer than 15 percent of U.S.
nursing and medical schools had any
interdisciplinary programs (Larson, 1995)
despite the calls for this approach for decades
from a variety of disciplines (American
Association of Colleges of Nursing, 1995;
79
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HEALTH PROFESSIONS EDUCATION
Health Resources and Services Administration,
1999; National League for Nursing
Interdisciplinary Health Education Panel, 1998;
Pharmacy Deans Task Force on
Professionalism, 20004. Although some
professions and programs have revised their
mission statements and written learning
objectives related to interdisciplinary teams, few
have set benchmarks and standards that all
students must attain before graduation
(Stephenson et al., 2002~.
One barrier is that differences persist
around the roles of team members and
interprofessional relationships and attitudes
among students (Hall and Weaver, 2001~. A
recent study of health professions students
revealed that medical residents were less
inclined overall toward interdisciplinary
teamwork, although residents in internal
medicine or family practice and students of
advanced practice nursing and masters-level
social work were positively inclined (Leipzig et
al., 20024. The researchers concluded that for
physicians, exposure to interdisciplinary
teamwork and team decision making needs to
occur earlier than residency training. Other
studies have echoed the notion that early
introduction to interdisciplinary education is
key to success (Horak et al., 19984.
Some of the reluctance on the part of
schools that educate health professionals to
embark on interdisciplinary education is related
to the limited research on the effect of such
education on interdisciplinary practice and
patient care (Zwarenstein, 1999~. Some fear
that professional identities, hierarchies, and
power relationships may be diluted if the focus
becomes interdisciplinary (Headrick et al.,
l998b). Many questions about when, whom,
and how to educate remain unanswered and are
open to future research (Hall and Weaver,
2001), though preliminary studies show that
problem-based learning is highly effective for
training students in teams (Brickell and Cole,
19964. Box 4-2 provides selected examples of
successful efforts in interdisciplinary education.
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CURRENT EDUCATIONAL ACTIVITIES
Employ Evidence-Based Practice
Given the constant changes in knowledge
and management of health care systems, a major
challenge for the educational process is to
prepare students for lifelong learning. As
explored in Chapter 2, the amount of knowledge
that health professionals must acquire has
grown immensely. Genomics, proteomics,
neuroscience, epidemiology, and emerging
infectious diseases, especially as they relate to
bioterrorism, are just some of the recent
additions to the expanding knowledge base
needed to use new diagnostic and therapeutic
agents for the 21St century.
Professionals in training cannot hope to
provide competent care to patients over their
career unless they have the ability to update
their knowledge and skills. The formal
curricula of health professional schools are
dated almost as soon as students graduate. The
traditional emphasis, especially in medicine, on
teaching a core of knowledge focused largely on
the basic mechanisms of disease and
pathophysiological principles, with the
expectation that students will memorize the
hundreds of facts presented to them, is outdated
in light of this ever-expanding knowledge base.
William Stead, Vanderbilt University, noted at
the summit:
The root of the problem stems from
the design of our curricula...the
curriculum places a premium on
individual knowledge. And that
individual knowledge is
memorized, and it's applied with
individual flair. That works in
what [can be] referred to as medical
care, or for an acute problem where
we can actually fix it. It does not
work in a case where the rate of
development of knowledge exceeds
what you can learn and retain. If
you read two articles every night,
you're 500 years behind at the end
of the first year. That's if you
remember those two articles.
(Stead, 2002)
Many medical schools are making strides in
shifting away from rote memorization and
incorporating evidence-based practice as part of
the curriculum (Grad et al., 2001) In a 1999
AAMC survey, however, more than a quarter of
the graduates of the 88 percent of medical
schools teaching skills related to evidence-based
medicine reported feeling unprepared to
interpret clinical data, research, literature
reviews, and critiques (American Association of
Medical Colleges, 1 999a). A national survey of
internal medicine Association residency
programs found that 37 percent of those
81
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HEALTH PROFESSIONS EDUCATION
surveyed had a freestanding evidence-based
practice curriculum, but fewer than half offered
faculty development in this area or performed
an evaluation of the course (Green, 20004.
As discussed in Chapter 3, the collection of
evidence related to the contribution of nursing
to care has been thwarted in part by a failure to
gather relevant data at practice sites. This lack
of data has impacted the diffusion of evidence-
based practice into nursing curricula. Scattered
educational experiences exist (French, 1999),
but these are not the norm.
Most programs that grant doctor of
pharmacy degrees require coursework in
subjects related to skills needed for evidence-
based practice. These include courses in
statistics, drug information, literature
evaluation, and research methodology, the latter
being required least often. In a recent survey,
however, only 12.9 percent of schools required
an extensive project involving data collection,
analysis, and write-up (Murphy et al., 19994.
Like nursing, pharmacy is currently attempting
to identify and disseminate evidence related to
its profession (Etminan et al., 1998)
The teaching of evidence-based practice is
thwarted in part by a lack of easily replicable
teaching methods, and questions remain
regarding how such courses are translated into
practice (Norman and Shannon, 1998; Taylor et
al., 2000~. Work has been done on assessing the
skills associated with learning about evidence-
based practice and evaluating the ability of
students to apply evidence in managing
common clinical problems (Bradley and
Humphris, 1999~. Problem-based learning has
also been shown to facilitate the development of
critical appraisal skills, and collaboration
between researchers and practitioners within
and among disciplines has been found to
enhance the diffusion of innovations in
evidence-based practice (Lusardi et al., 2002;
Rosswurm and Larrabee, 19994. The success of
evidence-based instruction may also be related
to the point at which it is offered. One study
found that evidence-based instruction enhanced
knowledge of epidemiology in undergraduate
programs, but not necessarily at the residency
level (Norman and Shannon, 1998~. Box 4-3
presents selected examples of education in
evidence-based practice.
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CURRENT EDUCATIONAL ACTIVITIES
Apply Quality Improvement
Current evidence for educational activities
in quality improvement across the health
professions is sparse. There is little available
information on the extent to which students are
educated in such skill areas as error reduction,
process measurement and redesign, and
monitoring of patient data (Headrick et al.,
l99Sa; Henley, 2002; Mosher and Colton,
2001).
In medicine, scattered experiences in
educating students or residents in quality
improvement principles have been documented.
Researchers recently tested a new quality
improvement curriculum by comparing a group
of internal medicine students who took the
course with a control group who did not. The
intervention group scored significantly higher
scores on post-tests compared with the control
group (Ogrinc et al., 2002~. One course at the
University of Illinois College of Medicine at
Rockford had a quality improvement curriculum
in which students performed a series of chart
audits of diabetes and made improvement
recommendations to clinic directors (Henley,
20024. In another study, resident involvement
was deemed critical to the success of a quality
improvement intervention that significantly
decreased the use of unnecessary intravenous
catheters (Parent) et al., 1994~. Recent efforts
by AAMC have articulated the learning
objectives and educational strategies that should
be used to integrate quality improvement into
education (American Association of Medical
Colleges, 20014.
In nursing, content on quality improvement
is most commonly incorporated into lectures
within management courses and rarely included
in clinical courses. Moreover, most nursing
education programs have not required students
to implement quality improvement strategies in
clinical areas through experiential learning
strategies (Buerhaus and Norman, 2001~.
A large barrier to education in this
competency is the shortage of practitioners
knowledgeable in practices of quality
improvement who can understand and
implement quality improvement innovations in
their clinical settings. With regard to safety in
particular, surveys have shown that there is a
shortage of teachers and researchers who have a
profound understanding of how safety is
maintained and can pass on those insights and
associated innovations (Croskerry et al., 2000;
Institute of Medicine, 20004. Moreover, the
shift from traditional classroom-based lectures
to project-oriented learning that is required for
quality improvement activities is a source of
tension for some educators (Schillinger et al.
2000~. Evaluation of quality improvement
activities also remains an issue, with student
satisfaction scores or other less rigorous
83
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HEALTH PROFESSIONS EDUCATION
measures being the norm (Baker et al., 1998;
Gordon et al., 1996; Headrick et al., 1998a;
Weeks et al., 20004. A recent study by Ogrinc
et al. (2002) made some progress on this front
by developing a more reliable method for
evaluating a quality improvement course for
medical residents.
Quality improvement is usually discussed in
terms of teams improving processes or systems,
but there is another aspect of quality
improvement that is more narrowly focused on
the individual clinician continuous self-
assessment. There is as yet no clear
understanding of how health professionals are
or should be educated to reflect on their own
performance strengths and weaknesses in order
to identify learning needs, conduct a review of
their performance, and reinforce new skills or
behaviors so they can improve their
performance. Education that addresses the
various dimensions of ensuring continuing
competency past the initial preparation for
practice therefore requires attention.
Box 4-4 describes selected examples of
educational programs that have addressed
quality improvement.
84
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CURRENT EDUCATIONAL ACTIVITIES
Utilize Informatics
Without a basic education in informatics,
health professionals are limited in their ability
to make effective use of communication and
information technology in their practice. Yet
without appropriate input from health
professionals skilled in informatics, it may be
impossible to implement a clinical computing
infrastructure that meets the needs of clinicians
and patients. Educating health professionals in
informatics should enable many important
capabilities, including appropriate interaction
with clinical information systems for making
decisions and mitigating error, use of the
Internet to inform themselves and their patients,
and facility in using e-mail to communicate and
coordinate with their team members and
patients.
Though many studies focus on the use of
computers in the delivery of educational
content, very few studies document how
students or professionals in practice are
educated to use information technology in
support of patient care. Many institutions are
now offering degrees (masters and doctorate),
fellowships, certificates, and short courses in
this area, some through remote learning; the
website of the American Medical Informatics
Association (2002) lists over 50 such programs.
However, these are usually special degrees and
optional courses not required of the professions.
According to findings from a 1999 AAMC
medical school graduation questionnaire, about
86 percent of respondents felt comfortable using
the Web to locate and acquire information, and
nearly three-quarters felt confident about using
a computer-based clinical record-keeping
program for both finding and recording patient-
specific information (American Association of
Medical Colleges, l999b). During 2000-2001,
46 percent of medical schools required their
students to own or rent personal computers
(Barzansky and Etzel, 20014. AAMC, through
the Medical School Objectives Project, recently
identified core informatics competencies in
medicine (American Association of Medical
Colleges, l999b).
Probably as a result of resource constraints
in the settings in which they are educated,
nursing and allied health professionals have
embraced informatics on a more limited scale as
compared with their medical counterparts
(Gassert, 1998; Hovenga, 2000; McDaniel et al.,
1998~. Community colleges, where the majority
of registered nurses are trained, do not provide
access to information technology to the same
extent as academic medical centers. A 1998
survey of accredited diploma, associates,
bachelors, and masters nursing programs
revealed that a majority of schools lacked a
coordinated plan for technology implementation
and were underfinanced for technology and
related personnel; fewer than one-third of the
schools addressed nursing informatics in the
curriculum (Carty and Rosenfeld, 19984.
Issues around competencies associated with
the use of informatics and whether they are
discipline-specific or broad-based hinder
progress on widespread education in this area
(Masys et al., 20004. One recent effort to
address discipline-specific competencies has
been the International Medical Informatics
Association recommendations regarding courses
by profession, by type of specialization in
health, and by stage of career progression (e.g.,
bachelors, masters). These recommendations
address educational programs in medicine,
nursing, health care management, dentistry,
pharmacology, public health, health record
administration, and informatics/computer
science, as well as dedicated health informatics
programs (American Medical Informatics
Association, 20024. Another example is the
multitiered set of technology competencies
specifically designed for occupational therapy
practitioners authored by the American
Occupational Therapy Association Technology
Special Interest Section (Hammer and Angelo,
1996~.
A number of issues help explain the current
barriers to integrating informatics into health
professions curriculum: the lack of a clear
understanding of informatics as a discipline,
limited support for informatics education among
administrators and faculty, the overcrowded
85
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HEALTH PROFESSIONS EDUCATION
nature of existing curricula, inadequate time for
faculty to develop associated skills (Jerant,
1999), and the lack of quick and easy access to
local informatics experts (Cartwr~ght et al.,
20024. The difficulty in conceptualizing
informatics education is often exacerbated by a
"tendency to conflate education in informatics
with the use of computers to deliver
education" (Buckeridge and Goel, 2002:4~.
Interacting with computing resources in the
educational process is not the same as applying
informatics to patient care. Box 4-5 describes
some examples of successful efforts to provide
education on the use of informatics.
.......................................................................................................................................... ........................ ......... ............. ~ ...... .. .... .
. ~.
T1e -c --u-ca :--o-n-a- ~ ~-e-~--ces~ e-n-a-r :-me-n ~ -ewe --or ~ --n--l-~-rs--l- am Alec --l-ca-
. . . . . ~
-l--n- ;-ro-c -u-ce-c ~~ a m-u-- -l-c ~'SClp --l--n-a-~ l--n-To~-a I'CS"""'CU'~!'C'U' --u-m~ l-e-c --u-a-l-n-g~ a m-e-n--u~ ~~ ~-rl-n-g-s~ ln-a-l~ can
.................................................................
be- d t d---t t th- i ~ kill do do h-- do l
.............................................................................................................................................................................................................................
~~""~ ""ad 2-2-a-""n--""^e' """"''Q"' ''' """""s""""a
- v v ~ ~ l v p vVl~Q"a ~n~orma~lcs solely are Unpeg a-~-~-
.................................................................................................................................................................................................................................................
86
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CURRENT EDUCATIONAL ACTIVITIES
A Vision of the Future Health
Professions Student
The five competencies described in this
chapter define the environment that leaders in
health professions education, such as those who
attended the Health Professions Education
Summit, must address. These competencies can
enable both students and practicing
professionals to better meet the needs of
patients. Box 4-6 presents a scenario depicting
an educational experience as it could be if these
competencies were incorporated into the
curriculum of the health professions.
B- - I D i i. i
h h i i
......................................................................................................................................................................................................................................................
.-.-.i-.n-te-rn-al~ m -at i a- so all the i- - t ~ h- - -it -1~
:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::
............................................................... ........ ...........................................................................................................................................................................
E-- ~ revea- -e-c ~ 1a ~ 1e as e -pe-rl-e--n-c-l-ng~ an a-cu ;e~ meccas --la- ~ l-en arc -l-o-n~ a-e-c ~-e~ was
......... """"""""""""" '"""""" ''''''''1''"""""'''' """i" '''' e"""""'''e' '''''1''' '"""""" ''"""""""'' '''""""""" ''"''""""""
.
""' Is"""""'''' ;' Is""""' ''IS '-'I' ''''""""'''l'S'I' IS""""'' ;o~ a co-m-m-u--n--lw~ Tea --in Tac-l--l--llv~ l--n-To-rm-al-l-o-n~ ano-ul--
I. ~ ~ ~
---we- l lea e-as-l--l-v a-- - es Iol ~ it- " ""T' 't" " e"""U'Se"""~""a'n'~""'OT"""~
............. ........ .................. ~ ........ ....................... ............ ..... ~
:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::
................................. . j m j j j .......................
,...................................................................................................................
87
OCR for page 88
HEALTH PROFESSIONS EDUCATION
M ................................................................................. ........... ................................................................... .......................................
.................................. . -o-n-l-ca~ a-n-< -bustling per o-rm~ a p a-~-l-ca- ~ exam--l-n-at-l-o-n~ wilt- n~ g-u--l-< -a-n-ce~ -~-m~ t n-e-l-r~ acu- By . --l-s
........ .......... ......... . .... .......................... ...... ..... .......
~v- -la- ~ s-lg-n-s~ are spa- it- -Ed a-e-c ---is cal ~-ererl-zall-on~ wo-u--n-c ~ s-l-le~ less sea- --l--ng~ we- ~ a- -. Young- A
....... ........ ............ ............................................ .... ...... , ...... .............
.............................................................................................................................
::::::::::: :::::::::::::::::::::::::A::::' ::::::::::::::::::::::::::::::::j: ::::::::::::::::::::::::::::::::::
.-.-ove-~e-l~-nl~ ~e-r~ a-l-sc-u-s-s-i-o-n~ am-o-nn~ l-n-e-m-se-l-ves~ an-a l-n-e-l-r~ Tacu-llV One slucenls
:: :....:::: :....:::: :.. :.: :....:: :~::::: :...:::::::: :::::: ::::::: ::.:..:.:.:.:: ::::::: :.:.:.:.:::::::.:.:.:. ::.:.:.::.:.:.:.::.:.:-:-:::-:-:-:- ::: ::-:-:-:- :::: ::::::: -:-:-:
:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::-:::::::::::::::::::::::
..an.~ m--l-l- -Neal Al sT- a-~-l-o-a ~ al-l-n-o-- -a--n~ -no- lie- Q-l~ of n-l-s~ ca-~-l-ac~ en- miss nest a-ec'e-aseo~ s-l- Iced
:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::~:::::::::::::::::::::::::::::::::::::::::::::::::::::::
. . .n .l s . . .a.~-m--l s-s-l-o.n~ I n ~ l a t I a I a a e ~ ~ l ~ Il t
.....
T
t J a ~ ~
~ a ~:::::~Tl::a:a :~a :T:O':':':':':~^ a a '1:'l:~':':':':': a~ a -a ~-a -t-~i :':':':':'i':l'—:T:':':':'T~:8 ':':':':'I~:fl-i ~ :8 -I l t7 a -~ a -~-
::::::a:~::::::a::::::::: ::::::::::::::::::i:::J::::::a::::::::::::: :::::::::a::::::::::: ::::::::::::::i:::::::::::::::::::::a:::
.... ~ I.a.~.eles.--- i l.g n -cn-ol-es e-a ol~ a-
~ m-~ca-r a--l-a-a~ l-ma' cl-l-o-n~ a-' ases LoUac~ ~ a-n~ ls~ we~-a~ a-a ove~ ~-l-$~ o-pl-1-m-a-a~ we-1-g--a al a a-e~ a-a--s-o~ ~-as~
7
a a ~ a
co-n-cern-s~ aa 0 al lne COSI OT nis mealcal caa ~ as~ e-l-l~ a-s~ n-l-s~ an-l--l--l-~ lo~ ~-nl-l--n--u-e~ wCa Kln a~ l~ n-e~
's't''''O'e'''n'ts""'0" ' '1" "'~'' """""'1"''M' -'' 't' ~ I -tn t"""'' O'0
..... ....
M J
~ o-n-l-ca~ ms-ea-mn-es~ a-pep o-prl-ate~ ~--l-ag-~-ost-l=~ a-n-~ In-~- a-p- """tO'a"""'M'a'"""""'~" "1' '---
........................................................................................................ . . ...
~ ~ a ~ ~ ~ ~ a
---~--l-s-e-a-se~ ~--l-a-~- tQS nign cnoleste'ol~ a-n-~ re-n-a-l~ ~--l-seas-~ ~-n-~ a ecr- --l-ts~ as-s-ls-ta-n-ce~ t' O'a a""""tn'B"'
... .. ..
..a..e.sign an e e~lse p~g m TQr l~r lz lo assisl ln ls cove~ an
i i i a a i
,,,,w,,,o.a K~ a-n-~ Trom~ ln-e~ a--l-a-Dell-c~ le-a-m~ to~ a-ov-l-se~ o a~ co-nlrol~ oT~ n-l-s~ a--l-s-e-ase~ a-n-a~ l-ls~ com--~-l--lcall-o-n-s~
M a.a l.a ~ l--n-
..................................................................... ........................................................
~ a ~ e
-
-
- - a~ a ~ a a a ~
a J i ~ a
~p-a S.e.nt la eir t eatmenl pl..a.n tO a la ~ al~ a-e~ e -pea pSes lnteresl ln {ne p
some suggestions aDoUl wa s~ ~ l-nteg--a te~ t-n-e~ cn-a-n-g-es~
88
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CURRENT EDUCATIONAL ACTIVITIES
Outcome-Based Education
Identification of general competencies
represents an articulation of what health
professionals should know and be able to do. In
the previous chapter, the committee defined five
competencies that it deems critical for all
clinicians to possess, with the understanding
that the way in which these competencies are
integrated into educational programs will be
discipline-specific. In this chapter, the
committee has explored the extent to which
such competencies are addressed in educational
curricula.
The identification of competencies is not an
isolated activity identifying competencies is
just the first of many steps in ensuring that
students are prepared to deliver quality health
care. Once competencies have been established,
the knowledge, skills, and attitudes
underpinning each competency need to be
clearly articulated in writing and related
measures developed. Assessment tools must
then be matched to each competency to evaluate
outcomes the results providing evidence that
goals and objectives have been accomplished
(Carraccio et al., 2002; Calhoun, 2002~. This
articulation of what students should be able to
do and of education based on related objectives
is often referred to as competency-based or
outcome-basec1 educations
Epstein and Hundert (2002) note that the
outcomes of assessment serve many needs for
learners, academic institutions, and the public,
including the following:
· Learner fosters learning, inspires
confidence, and enhances the ability to self-
monitor.
· Curriculum drives change, certifies
achievement of curricular goals, and creates
coherence.
· Academic institutions drives self-
assessment, expresses values, serves to
develop faculty, and provides data for
educational research.
· Public certifies competence of graduates,
and offers comparative data on the quality of
educational programs.
Hendricson and Cohen (2001) outline three
questions that educational institutions must
answer to develop competency-based health
89
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HEALTH PROFESSIONS EDUCATION
professions education:
· What knowledge, skills, and professional/
personal values should the student possess at
the time of graduation so he or she will be
ready for the next level of training (e.g., a
postgraduate year one) or be prepared to
serve as an independently functioning entry-
level general practitioner?
· What learning experiences will enable
students to acquire these competencies?
· What proof, or evidence, is needed to
establish for faculty that a student has
attained competency?
Hendricson and Cohen describe a
competency-based curriculum as ideally having
three features: (1) top-down planning based on
analysis of the health care needs of patients, (2)
a readiness-based model in which students
advance through the curriculum at different
rates based on their individual capabilities, and
(3) a horizontal curriculum structure in which
students progress through competency modules
hierarchically sequenced by level of difficulty.
Scattered clinical education institutions
have restructured their curricula and student
learning methods using a competency-based
approach (DeWald and McCann, 19994.
However, little attention has been devoted to
defining the standards for such competencies;
determining how to attain them; or evaluating
competence, particularly with respect to
professionalism and humanism. Each of these
areas remains a large challenge (Carraccio et al.,
2002~.
A major impediment to moving towards
competency-based education is making
additions to existing overcrowded curricula.
Some institutions have integrated competencies
as "themes" into existing coursework rather
than instituting new courses. Examples of
themes that are woven into the entire education
experience include evidence-based practice,
ethics, and AIDS (Dartmouth Medical School,
1998; Harvard Medical School, 20004. At the
same time, the environment for health
professions education is changing with respect
to the use of computers and new educational
approaches, such as problem based learning
which in combination may allow the same
amount of content to be conveyed more
efficiently and effectively. One 3-year study of
a new curriculum that integrated computer-
based activities and problem-based learning
found that students could identify and retrieve
information more rapidly and were more self-
reliant in solving problems, therefore making
fewer time demands of faculty and tutors. This
new curriculum also resulted in reducing
laboratory time from the national norm of 141
hours to 93 hours (Levine et al.. 19991.
Educational reformers posit that by
supporting students in directing their own
learning and providing the tools they need to
access, analyze, and apply information,
education will be transformed. Distance
learning technology, standardized patients, and
clinical skilIs-testing techniques also hold the
potential for revolutionizing health professions
education, offering students the opportunity to
customize their learning and to progress at their
own pace and at geographic locations that meet
their educational needs. Of course, such an
approach would need to be closely monitored
bY faculty and validated through testing.
Colleen Conway-Welch, Vanderbilt
University, commented at the summit on the
need to focus more on students:
Wouldn't it be interesting if we
also thought that the student was
the center of the educational
system? And perhaps, if the focus
moved to the patient and the
student, that might reinforce this
whole idea that they are both highly
valued. And the students then may
start asking some of the tougher
questions because they themselves
feel that they have been valued in
the process and can transfer some
of those [earnings over to the
patient. Perhaps we could
accelerate this change (Conway-
Welch, 2002~.
90
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CURRENT EDUCATIONAL ACTIVITIES
Conclusion
The committee concludes with the
following observations on the current state of
educational preparation in the five
competencies:
.
.
The extent to which health
professionals are prepared to achieve
the five competencies necessary for
optimum patient-centered care
requires more standardization
across and within the professions.
The core set of competencies needs to
be integrated more thoroughly into a
cohesive educational experience and
to be offered using interactive
methods.
· Evaluation of the effects of health
professions education requires
increased attention. Few
investigators study whether
curricula, courses, or teaching
methods are having the desired
impact on learners and their practice
or on the delivery of health care to
the American public. When
evaluations are done, they often do
not have the types of designs
necessary to provide an adequate
understanding of those effects.
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Representative terms from entire chapter:
quality improvement
