PBackground
The tasks of postgraduate medical education
The task for postgraduate medical education
(PME) is to educate newly graduated doctors
with a predominantly theoretical background,
into competent, professional, empathic and
safe medical specialists. PME mainly takes
place in clinical settings, where health care is
provided in order to treat patients. This means
that PME takes place in a clinical environment
influenced by many agendas, such as the need
for productivity, high professional standards,
collective agreements, political- and patient
safety agendas (2).
The development of medical expertise is a
continuum. It starts on the first day at the
medical school and should not end before
retirement (3). To improve the facilitation of
medical expertise, the future PME efforts
should encompass the entire continuum from
university graduation to retirement. The PME
continuum can be divided into distinct stages
(4). In most countries it consists of a basic
postgraduate training programme, followed by
years of specialist training, and continues after
specialist graduation as continuous
professional development (CPD) (4). Fig 1.1.
shows the timeline of the author's medical
education on order to illustrated the different
stages of PME.
Figure 1a. This figure shows the timeline of the authors
medical education. The phases of PME are as following;
the period between 2-3 is basic postgraduate training,
between 3-4 it is specialist training and between 4-5 it is
CPD training.
PME has undergone significant changes over
the years and several countries have launched
postgraduate medical reforms in recent years
(5-8). Progressive institutions and
organisations such as the Association for
Medical Education in Europe (AMEE) (9) and
others have undoubtedly had a substantial
positive influence on PME. However, both in
relation to content and how PME is provided,
there still seems to be room for improvement
(6, 10). The next section will try to explore
how this maybe can be achieved by presenting
already known knowledge from a growing
research in expertise development. A better
understanding of how and when expertise
develops can be assumed to be helpful to PME
planning (11, 12).
The education researchers'
perspective on expertise development
The history of research in expertise
development
Researchers and philosophers have probably
tried to explore how humans develop expertise,
as long as mankind has reflected (13, 14). The
American philosopher and educationalist J.
Dewey described at the start of the 20th
century theories addressing the generic
development of expertise. (14). He fostered,
inspired by Kierkegaard (15) and Hegel (16),
an understanding of learning through
experience and reflection (14). The interest in
expertise development has been followed up by
philosophers and researchers such as D. Sh''n
(17), the Dreyfus brothers (18) and many
others as described by Gustavsson (16).
Research in expertise development includes an
interest in the development of medical
expertise. For more than 40 years researchers
have published papers addressing medical
expertise development (11). Expertise is
usually understood as the ability to perform
complex tasks in a swift easy and error free
manner within a specified field (19) and
researchers have tried to understand why
variance in this medical expertise develops
among doctors in their various professional
medical fields (3).
8
The distinction between science and practice
in medical education
Pre-graduate medical education has in the
majority of medical schools up to the new
millennium, primarily been based on a
dichotomy between basic science and clinical
performance (20). This distinction has been
based on long lasting ideas introduced by
Flexner in 1910 (21), and it has to some extent
been maintained in the PME illustrated e.g. in
the distinction between diseases and illness in
curricula and clinical training (20). This
artificial division of medical education has
clear advantages. It has secured a medical
profession built on science and evidence based
knowledge (21). But the division has also
caused problems for PME. These problems
have probably be known since 1910 but I
found no papers from before 1967 publishing
arguments for greater integration of clinical
skills and basic knowledge (22). See textbox
0.1. The introduction of problem based
learning (PBL) by McMaster University in
Canada in the late 1960s started a development
in medical schools all over the world to support
the integration of knowledge and skills in
medical education (23).
Today no-one would argue against the
integration of basic science and clinical skills
in PME. A doctor must of course be trained in;
'to know', but he must also be trained in; 'to
know how', 'to know when', 'to know why',
'to know where' and 'to know how his/hers
performance works' (17, 24). This can only be
successfully trained for if knowledge, skills
and performance are integrated in postgraduate
medical education (22, 23).
Textbox 0.1. Quotation by A
Feinstein. (1967)
'Although a clinician can be both healer and a
scientist, he cannot be an effective therapist if
he merely joins these roles in tandem by
oscillating between them, add science to
bedside art. A clinician's objective in therapy
is not just a conjunction, but a true synthesis of
art and science, fusing the parts into a whole
that unifies his work and makes his to roles
one: a scientific healer.
As a healer, the clinician's purpose is to treat
the sick person, not merely the manifestation
of disease'
Alvan Feistein. (22)
Medical expertise development alongside
increased clinical experience
It has long been known that increased clinical
experience affects both the way doctors think
and how they make clinical decisions (25). A
majority of clinical decisions taken by
experienced clinicians, are not taken on the
basis of thorough analysis, but based on a
deductive or even a non-analytical approach
(12, 26, 27). Psychology based education
research literature on medical expertise
development has tried to explain these
findings. This literature has followed two
different paths in the search for a deeper
understanding. One path argues for a 'process
oriented' understanding of medical expertise
development, the other path for a 'structural'
understanding (28). The process oriented
understanding focuses on the required amount
of and quality of, clinical learning experiences,
while the structural understanding focuses on
the underlying structure of knowledge used in
clinical decision making(28).aste your text in here…