learner-centered strategies in clerkship education

Commentarm

Over the past two years, the Clerkship Directors in Internal Medicine {CDIM) has had the opportunity to use this fomLm to discuss issues of interest to internists participating in medical student education. CDIM has tried to foczLs on educational topics of current debate and practical interest to internists. Given the uncertainty in much of medical education, the articles have been more descriptive than prescriptive in tone.

The association has tried to create a logicalflow in the commentaries. They began by discussing areas of con$ict and compatibility between clerkship goals and the national go& of creating primary care physicians. That article was followed by one describing methods used to evaluate how well stuoknls achieve our clerhxhip goals. The next two contributions dealt with new clerhxhip structures that are arising as education responds to clinical practice changes. Thefirst addressed ambulatory educational issues, while the most recent commentury described cl&ships where students’ clinical education is conducted in col- laboration between internal medicine and other disciplines.

This issue’s commentary shifts to the way medical students learn, rather than where they learn. In&-r& medicine is being challenged to prepare students to become life-long learners, and stuoknt-centered strategies are means to that end. An upcoming commentary wiU continue this theme and discuss 1.h.e application of evidence-based medicine in medical education. Of particular interest to both chairs of okpart- merits of internal medicine and internal medicine clerhxhip directors will be a commentary addressing the effect of seroing as a clerkship director on academic careers.

Learner-centered Strategies in Clerkship Education

T he need to engage medical students as active learners has been a consistent theme in modern

medical education.’ Recently, a number of schools have sought to address this need through major re- visions of the preclinical curriculum, including de- creased use of lecture formats, the introduction of problem-based learning, and more emphasis on early exposure to clinical perspectives and skills. How- ever, reform efforts have focused far less attention on clinical clerkships, the major learning environ- ments for third- and fourth-year medical studentszB If anything, the typical inpatient clerkship is less patient-based and less conducive to students’ active learning than in years past.4,5

In Physicians for the Twenty-First Century, pub- lished in 1984, the Association of American Medical Colleges was quite explicit about the role of active learning in clinical medicine, noting that “the basic clinical clerkship is the optimal setting for this type of learning, but the reality . . . often falls far short of the ideal.“6 Newer concepts and strategies for adult education7v8 can greatly enhance students’ clinical medical education. A brief historical perspective will provide the foundation for our discussion. A summary of the terms and principles of “learner-centered learning,” an active-learning construct we fmd most applicable in this context, will follow. We will

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then offer suggestions for enhancing the learning environment in internal medicine and primary care clerkships, building on other recent assessments of the goals and structure of these core educational experiences for studentsg,”

THE CLINICAL CLERKSHIP: A PROGRESSIVE IDEA A CENTURY AGO

The medical education reforms of the late twen- tieth century are, in principle, quite similar to those of 100 years ago. The reformers of medical education at Johns Hopkins University spoke of “self-education under guidance,” and the curriculum featured, for example, a gross anatomy course taught entirely in the laboratory. I1 The most enduring innovation of the Hopkins reforms, the modern clinical clerkship, was clearly designed as an active learning experience. In the “natural method of teaching,” wrote Sir William Osler, “the student begins with the patient, continues with the patient, and ends his studies with the patient, using books and lectures as tools, as means to an end.“”

Though the philosophy of clinical education remains much the same, the reality has changed. Consider the following description of the clinical evaluation of patients during an internal medicine clerkship, written nearly a decade ago:

0002-9343/96/$1!5.00 669 PII sooo2-9343001~00-2

. . . implicit in the situation is a decision on the part of the student: “Should I learn from this patient by trying to understand him myself, for- mulate a hypothesis, and then seek illumination from others, or should I obtain as quickly as possible facts about the patient and his illness from experts?” Prom many of their teachers and from the hospital records, students receive the an- swers to large numbers of questions they did not generate.

The pressures contributing to this passive mode of learning have progressively worsened. Decreasing lengths of stay for hospitalized patients and increasing patient volume demands in the office create a hectic environment, overflowing with information and offering little time for reflection and critical thinking. In addition, students are spending less time with patients and more time assisting in the admin- istrative aspects of care as well as in organized educational activities often far removed from the bed- side.5 Despite the essentially experiential nature of the clinical clerkship, opportunities for promoting active learning and ensuring the development of life- long learning skills are seldom fully realized.

A PRIMER ON LEARNER-CENTERED LEARNING

How do modern adult educational principles differ from the “self-education under guidance” espoused by the Hopkins reformers? The models introduced in the late nineteenth century did not go beyond the realization that learning by doing was a stimulating and effective approach; they placed the burden of learning on the student but rarely offered concrete principles for learning or for teaching. According to Kenneth Ludmerer, MD, of Washington University School of Medicine, the concept of “self-education under guidance” suffered from too much self-education and too little guidance.” Concepts and strategies of adult education have evolved a great deal in the latter half of this century, however, and we shall now highlight a few of these concepts in the context of clinical medical education.

The term “learner-centered learning” is derived from principles of adult learning as articulated by Malcolm Knowles, PhD (formerly of North Carolina State University), and others. This theory assumes that a mature learner seeks to move from de- pendence toward increasing self-directedness. The learner has an increasing reservoir of experiences that not only become a rich resource for further learning but also provide real-life challenges that drive the “need to know.” Such a person seeks not only knowledge but the competence to address tasks

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and solve problems. Dr. Knowles thought these fea- tures distinct from the assumptions that guide the teaching of children (pedagogy) and used the term “andragogy” (Greek an&-u = adult) to emphasize this distinction.7

The literature of learner-centered learning also provides a distinct philosophy of teaching, based on a very different concept of the teacher-learner relationship. It remains a common misperception that “self-directed learning” replaces the passive student with a passive teacher. A learner-centered environment requires much more; the teacher must move beyond the role of one who imparts knowledge (though this remains an important function) to a facilitator of learning. In this capacity, the teacher serves not only as a resource but also challenges the learners’ interpretation of their experience, often even causing them to reexamine basic assumptions and values.7p8

The role of facilitator depends on certain attitu- dinal qualities the teacher must contribute to this relationship. Carl Rogers, PhD, identified these at- tributes as integrity, respect, and co:mpassion.‘3 Teaching with integrity means being genuine, trust- worthy, and honest with the student and1 with one’s self; the teacher must have the courage to share his/ her observations with the student and address responses effectively. Respect involves kindness and caring for the welfare of the learner, recognition of individual autonomy, and acceptance of differences-in Dr. Rogers’ phrase, “unconditional posi- tive regard.” Compassion requires an attempt to see the world as the student does (empathy) as well as a willingness to take action to help the learner recognize and deal with important issues. Often this will involve a willingness to share individual emotional responses to shared experiences.

CAN MEDICAL STUDENTS FUNCTION AS ADULT LEARNERS?

Most of the young adults in our medical schools have been very focused on their premedical and medical education, often postponing dealing with issues of interpersonal intimacy, indepen.dence, and other aspects of personal grow&i4 Their accultura- tion in the medical profession requires the adoption of a very complex, multidimensional role, one that immerses the student in a world of illness and suf- fering and requires the assimilation of tremendous amounts of information. Considerable structure and guidance are required for this transformation and perhaps are most acutely needed as students first enter the clerkship learning environment. Most clerkships, however, expect the routines and priori- ties of the housestaff or office preceptor to provide

this structure and do not explicitly attend to the individual learning needs of medical students.

Attention to learner-centered learning principles can help provide the guidance these students need. The facilitative teacher can encourage reflection on professional roles and interpersonal skills and guide students’ goal definition by helping them identify what they need to know. With such guidance, medical students are capable of managing their own learning to a much greater extent than usually takes place in clinical clerkships.

LEARNER-CENTERED ENHANCEMENTS OF THE CLERKSHIP ENVIRONMENT

We will now explore several ways in which learner-centered learning concepts can be incorporated into specific strategies to enhance internal medicine clerkships.

Students and teachers should explicitly agree on clerkship goals and objectives, and there should be opportunity for inclusion of students’ personal learning objectives. Setting expecta- tions is a crucial component of any educational ac- tivity. A statement of goals and objectives created by course administrators is a necessary but insufficient means to this end. It is important for students to know what is expected of them, for teachers to be aware of the student’s current level of skill and experience, and to have an understanding of what the student expects of the rotation.

Among the first premises of learner-centered education is that individual students may have very different educational needs. This is especially true in the third year of medical school, when students are in the midst of a remarkably steep learning curve. As a result, even small differences in the rate of skill or knowledge acquisition among students at this stage will create an extremely broad range of learning needs.16 In addition, students assimilate and organize the complex knowledge base of medicine in diverse ways, some more appropriate than others. Georges Bordage, MD, PhD -Professor of Medical Education of the University of Illinois at Chicago College of Medicine- has described common patterns of knowledge organization (“reduced,” “dispersed,” “elaborated”) in an effort to provide a useful tool for clinical teachersI

To promote a better understanding of the students’ needs and interests relevant to an ambulatory care clerkship, Linda Lesky, MD - Assistant Profes- sor of Medicine at Harvard Medical School - and Warren Her&man, MD - Director of the Third-Year Medical Clerkship and Associate Clinical Professor of Medicine at Boston University School of Medicine - have employed a student self-assessment ques-

tionnaire.15 They recommend students receive this questionnaire before they begin the rotaltion and complete it in preparation for their first meeting with the preceptor. The students’ responses to questions regarding previous learning experiences, a self-assessment of strengths and weaknesses, and goals for the clerkship serve as a starting point for the initial student-preceptor meeting and illustrate the role of self-assessment in life-long learning.

Several clerkship educators have utilized formal learning agreements. In addition to documenting students’ specific learning goals, a learning agreement specifies how and when the requisite experiences will be sought as well as how both learner and teacher will know the objectives have been accom- plished.7 The students’ goals can then be negotiated openly, integrated with the goals and objectives defined by the faculty, and form a part of the istudents’ formal evaluation.

Such learning agreements have been incorporated into fourth-year elective clerkships at the University of Oklahoma Health Sciences Center at Tulsa and were also introduced into the third-year clerkship.17 Students in the third year were less successful in uti- lizing the learning agreements. Their limited experiences and knowledge often led them to name internal medicine disease topics or the comprjehensive physical examination as a “goal,” rather th1a.n identifying focused objectives. By the fourth year, however, students were able to reflect on thei:r experiences and productively identify areas of interest or need.

Learning agreements may prove more successful in ambulatory clerkship settings. The family medicine clerkship at the University of Oklahoma College of Medicine la and the multidisciplinary primary care clerkship at Northwestern Univer- sity Medical School lg have used the Ilearning agreement as a means of providing additional structure to a clerkship environment that involves decentralized, diverse clinical sites and in which the individual student-preceptor relationship is a major focus for learning. At Northwestern, the successful completion of the learning agreement is a defined portion of students’ performance evaluation. Formal learning agreements, then, may prove most useful in clerkships in which the students’ days are less structured by competing ele- ments of the curriculum and with more advanced students who can better articulate their personal learning needs.

Mutual problem-solving and feedback should be a major element of the student-teacher relationship. Once agreement about learning goals is established, the major mechanism for students’ con-

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tinued learning and growth is open, ongoing com- munication about progress toward those goals. While Jack Ende, MD - Associate Professor of Med- icine at the University of Pennsylvania School of Medicine - has provided a clear introduction to the principles of giving feedback in clinical settings,” it remains difficult in practice. All too often, opportunities for formative feedback are casualties of the busy clinical environment, and what remains is merely a brief, summative, one-way delivery of information at the end of the learning relationship. The learner-centered learning approach, on the other hand, views feedback as an opportunity for mutual fact-finding, problem-solving, and negotiation.15 Fac- ulty must learn the skills required for formative assessment of student performance and apply them in unscheduled, specific discussion of daily performance and in frequent scheduled feedback sessions.

In a learner-centered environment, students often provide a remarkably accurate view of their own performance and can be asked to identify their strengths and weaknesses and assess their progress toward their initial goals. By involving the student in identifying problems and generating solutions, we are more likely to empower them to take proactive steps that will lead to meaningful improvement.

The development of learner-centered attri- butes and skills in teachers is an important primary goal for faculty development. Each of the previous suggestions for incorporating learner-centered principles into the clerkship depends on the understanding and acceptance of these principles by individual faculty and developing appropriate skills in the facilitative role. Learner-centered learning has many parallels with patient-centered medicine;” faculty development to promote a more learner-centered approach to clinical education can proceed from the interest most physicians have in understanding the world of their patients and helping them deal with their emotional responses to illness. By explicit extension of these principles to the care of their students, those who hold the values of integrity, respect, and compassion can serve as effective role models and create a stimulating environment for learning. The American Academy on Physician and Patient offers learner-centered faculty development courses, promoting the teaching of patient-centered medical interviewing and medical care. These courses have fostered significant change in the perspectives of faculty who have participated.22

The clerkship environment must support students’ learning needs. Even the best at- tempts at constructing appropriate institutional or personal learning goals will be insufficient if students are not provided learning experiences ap-

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propriate for pursuit of these goals. Dr. Ende and Frank Davidoff, MD -Editor-in-Chief, Annals of Internal Medicine - have written on the importance of experiences achievable within the learning environment and how these experiences often actually define the curricul~m.~~ This is a major impetus be- hind the tremendous interest in providing appropriate ambulatory and primary care experiences in internal medicine clerkships.g,‘O The same principle applies to the structure of inpatient medical services; students working on a general medical service are more likely to attain a broad range of learning goals than those confined, for example, to a service dealing mostly with cardiology problems.

Moreover, many educators fmd it diificult to address topics often underemphasized in medical school curricula simply because they do not “be- long” to any single discipline. A comprehensive curriculum in clinical nutrition, geriatrics, or medical ethics requires either extraordinary coordination and cooperation between departmental clerkships or the creation of a discrete experience for students outside the usual clerkship structure.3,2” At the Uni- versity of California, Los Angeles, School of Medi- cine, third-year students spend one da;y every two weeks in a multidisciplinary course entirely separate from the traditional clerkship structure. Half this time is spent in, a continuity practice experience. The other half is taught in small group se:ssions, with eight students and two faculty managing a simulated generalist “practice” consisting of paper cases, stan- dardized patients, and other structureId exercises. Opportunities to learn about content areas underemphasized in the clerkships are built into the cases managed by the students in these sessic)ns.3

The use of patient simulation exercises should be considered as adjuncts to direct patient care. The frequent mismatch between students’ learning needs and the opportunities afforded by the educational environment can also be addressed through exercises that substitute for encounters with real patients. Computer-assisted in- struction (CAT), 25 mechanical devices such as the Harvey cardiology simulator, 26 and patient-instruc- tors all have the general purpose of providing structured learning experiences with known content.

In assessing the usefulness of a variety of CAI tools at Stanford University School of Medicine, Judith Ber- man, PhD, et al25 found that students fe:lt CAI better enabled them to integrate basic medical information with their patient-based experiences. These students appreciated the freedom to “manage” patients without real-life pressures of time and potential risk to their patients, and they saw the CAI exercises as synergistic with their patient experiences.

In 1989, the Department of Surgery at the Univer- sity of Kentucky College of Medicine began using a small group format similar to the problem-based learning sessions often used in preclinical education.27 These case-based sessions are now an integral part of a combined medical-surgical clerkship at Kentucky and ensure adequate emphasis on essen- tial areas that may or may not arise in the course of students’ work with patients.

From the learner-centered education perspective, these examples have a great deal to offer. Students can explore topics important to their needs and can do so at their own pace, in a safe environment, with adequate opportunity for reflection on the processes of problem-solving. Ironically, tools such as problem-based learning were developed in part to provide more relevance to preclinical education, in which learning had traditionally been isolated from the clinical context. Once introduced into the clinical realm, students should be encouraged to learn from patients to the greatest extent possible, with these alternative teaching methods serving as a useful and efficient adjunct to patient care activities. They should not become the primary focus of teaching or evaluation and must not unduly inhibit students’ opportunities to participate in patient care.

Students’ encounters with patients can be guided toward specific learning goals. Osler’s statement that clinical education begins and ends with the patient I2 remains an appropriate principle. In practice, students often tend to replicate the work habits and management-oriented approach of the housestaff rather than addressing their more funda- mental goals of enhancing basic clinical skills. This can be remedied by providing students specific tasks to address with patients during the clerkship. For example, one portion of the comprehensive four- year curriculum in nutrition at the University of Pennsylvania School of Medicine asks students to broaden the scope of selected patient evaluations on the medicine, pediatrics, and surgery clerkships to include a comprehensive nutritional assessment.28 With the help of a guide to nutritional history as well as the signs and symptoms of nutritional problems - and the guidance of a preceptor experienced in clinical nutrition - students incorporate their learning about clinical nutrition directly into their daily work on the clinical service. Similar approaches could certainly be applied to other aspects of clinical assessment.

Emphasis on the critical application of medical literature to problems in patient care can enhance students’ skills in life-long learning. Reading about patients’ medical problems has long been a major tool for learning in internal medicine

clerkships. Recent advances in information access through electronic links allow even greater emphasis on the use of empiric evidence from the medical literature to support clinical decisions2’ Instead of learning to evaluate medical literature critically only in a “journal club” setting, students now have the opportunity to practice these skills in the context of direct patient care. 3o Such an approach can become an important component of learner-centered experiences in which students may become empowered to challenge authoritative statements thoughtfully and to utilize their knowledge more con6dently and critically.

Opportunity for personal reflection on learning should be provided within the cllerlcship structure. Donald Schon, PhD, of the Massachu- setts Institute of Technology, describes blow successful practitioners and teachers in the professions encourage “reflection in action.“= Along with regu- lar use of feedback strategies as described above, other structured exercises can encourage students to develop the capacity for reflection. When he was at Harvard Medical School, William T. Branch, MD, - currently at Emory University School of Medicine - provided students an opportunity to write about “critical incidents” during their third-year medicine clerkship to enable them to recognize and process meaningful experiences.31 Others have noted the value of having such exercises facilitated by some- one closer to their own developmental stage, such as fourth-year students helping third-year :students understand their experiences. At the University of Pennsylvania School of Medicine, for example, a required ethics conference became much more valu- able to third-year students - and the content of discussions clearly changed to issues of direct relevance to them - when fourth-year students replaced faculty as facilitators.32

SOME CAVEATS At least two reasons for skepticism about the util-

ity of learner-centered learning in medical education are evident. First, these principles, as with much educational theory, are not empirically derived but serve rather as “practice injunctions” created by educators experienced in adult learning.8 However, observations of exemplary mentors and clinical teachers do support the notion that facilitative approaches can be effective teaching strategies in medical education.%pN Second, learner-centered educational strategies demand substantial faculty time and en- ergy, and the perspective and skills of a facilitative teacher are not acquired overnight. This level of faculty commitment and faculty development may be difficult to achieve in an age when specific funding

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TABLE I Developing a Learner-centered Clerkship Environment

Explicitly discuss and negotiate clerkship goals and objectives Include students’ personal learning goals Ensure ongoing, bidirectional feedback Develop teachers’ skills as facilitators Ensure a clerkship environment congruent with learning goals Use patient simulation exercises as adjuncts to direct patient

care Guide students’ encounters with patients toward specific,

learning goals Emphasize the critical application of medical literature in

students’ daily work Provide opportunities for personal reflection on learning

for medical education activities is more elusive than ever.

Rapid changes in medical care delivery and, con- sequently, the medical education environment demand a reexamination of traditional structures and goals for the clinical clerkship. A major redefinition of clerkship goals and objectives and an increased emphasis on ambulatory sites for much of clinical education are underway. ‘JO Learner-centered educational methods, such as those described above and summarized in Table I, can help guide the development of these new clerkships, maintaining the experiential learning that has characterized clerkship education while providing mechanisms to focus and guide students toward specific, meaningful learning goals. We hope that wider use of these curricular strategies will introduce students and faculty to some aspects of learner-centered learning and will support the emergence of more comprehensive new models for education in the clinical clerkship.

Raymond II. Curry, MD Warren Y. Hershman, MD, MPH Ronald B. Saizow, MD

Dr. Curry is Director of Undergraduate Education, Department of Medicine, and Assistant Professor of Medicine and Medical Education at Northwest- ern University Medical School, (312) 908-7252, [email protected]. Dr. Hershman is Director of the Third- Year Medicine Clerkship and Associate Clin- ical Professor of Medicine at Boston University School of Medicine, (617) 638-8030, hershman@ uh-genmed.bu.edu. Dr. Saixow is Director of Stu- dent Programs and Associate Professor, Depart- ment of Internal Medicine, University of Oklahoma College of Medicine at Tulsa, (918) 838-4808, [email protected].

REFERENCES 1. Christakis NA. The similarity and frequency of proposals to reform US med-

ical education. JAMA. 1995;274:706-711. 2. Educating medical students: assessing change in medical education: the road to implementation (ACME-TRI report). Acad Med 1993; June

(Suppl):68. 3. Slavin SJ, Wilkes MS, Usatine R. Doctoring Ill: innovations in education in the clinical years. Acad Med. 1995;70:1091-1095. 4. Mellinkoff SM. The medical clerkship. N Engl J Med. 1987;317:1089- 1091.

5. Cook RL, Noecker RJ, Suits GW. Time allocation of students in basic clinical clerkships in a traditional curriculum. Acad Med. 1992;67:279-281. 6. Physicians for the Twenty-First Century: Report of the Project Panel on the

General Professional Education of the Physician and College Preparation for Medicine. J Med Educ. 1984;59(parI 2). 7. Knowles MS. Modern Practice of Adult Education: From Pedagogy to An drogogy. Englewood Cliffs, NJ: Cambridge Adult Education, Prentice Hail Re

gents, 1980. 8. Brookfield SD. Understanding and Facilitating Adultlearnng. San Francisco: Jossey-Bass, 1991. 9. Stagnaro-Green A, Packman C, Baker E, Elnicki DM. Ambulatory education: expanding undergraduate experience in medical education. Am J Med.

1995;99:111-115. 10. Goroll AH, Morrison G. Core Medicine Clerkship Curriculum Guide: A Co- operative Project of the Society of General Internal Medicine and the Clerkship

Directors in Internal Medicine. Contract No. 240-93-0029, Division of Medicine, Bureau of Health Professions, Health Resources and Services Administration, March 1995.

11. Ludmerer KM. Learning to Heal. New York: Basic Books, 1985. 12. Osler, W. The Hospital asa College. In: Aequanimitas wiih Other Addresses to Medical Students, Nurses, and Practitioners of Medicine. Philadelphia: Blak-

iston, 1932. 13. Rogers C. Freedom to Learn for the 80’s. Columbus, OH: Charles E. Merrill Publishing Company, 1983. 14. Pfeiffer RJ. Early adult development in the medical student. Mayo Clin Proc. 1983;58:127-134. 15. Lesky LL, Hershman WY. Practical approaches to a major educational

challenge: training students in the ambulatory setting. Arch Intern Med. 1995;155:897-904. 16. Bordage G. Elaborated knowledge: a key to successful (diagnostic thinking. Acad Med. 1994;69:883-885. 17. Saizow RB, Duffy FD, Gribbon KH. Learnercentered learning in internal medicine clerkships. Medical Encounter. 1992;8:9-11. 18. Schwiebert LP, Crandall SJS, Brown DS. Incorporating goal setting into a third-year family medicine clerkship: a pilot project. Teaching and learning in

Medicine. 1991;3:239-244. 19. Curry RH, McDermott MM, Stille FC, Martin GJ. Use of learning con- tracts in an office-based primary care clerkship. J Invest Med. 1995; 43:448A. 20. Ende J. Feedback in clinical medical education. JAMA. 1983;250:777- 781. 21. McWhinney IR. Are we on the brink of a major transformation of clinical method? Can Med Assoc J. 1986;135:873-878.

22. Gordon GH, Levinson W. Attitudes toward learnercentered learning at a faculty development course. Teaching and Learning in Medicine. 1990;2:106-

109. 23. Ende J, Davidoff F. What is a curriculum? Ann Intern Med. 1992;116:1055- 1057. 24. Branch Wl, Pels RJ, Harper G et al. A new educational approach for sup porting the professional development of third-year medical students. .J Gen In

tern Med. 1995;10:691-694. 25. Berman J, Bergen MR, Skeff KM. Feasibility of incorporating alternative

teaching methods into clinical clerkships. Teaching and Learning in Medicine. 1990;2:98-103. 26. Waugh RA, Mayer JW, Ewy GA et al. Multimedia computer-assisted instruc-

tion in cardiology. Arch Intern Med. 1995;155:197-203.

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27. Schwarz RW, Middleton J, Nash PP et al. The history of developing a stu-

dent-centered, problem-based surgery clerkship. Teaching and Learning in Me& icine. 1991;3:38-44. 28. Morrison G, Hark L, eds. Medical Nutrition and Disease. Cambridge, MA:

Blackwell Science, 1996. 29. Evidencebased working group. Evidence-based medicine: a new approach to teaching the practice of medicine. JAMA. 1992;268:2420-2425.

30. Ghali WA, Hershman WY. Academic journal clubs in the contextof evidencebased medicine: we need to do better. Submitted for publication.

31. Branch W, Pels RJ, Lawrence RS, Ivky R. Becoming a doctor: CriticaRncident

reports from third-year me&al students. N Engl J Med. 1993;1130-1132. 32. Christakis DA, Feudtner C. Ethics in a short white coat: The ethical dilemmas that medical students confront. AcadMed. 1993;68:249-254.

33. lrby DM. Three exemplary models of case-based teaching. Acad Med. 1994;69:947-953. 34. Schon D. Educating the Reflective Practitioner: Toward a New Design for Teaching and Learning in the Professions. San Francisco: Jossey-Bass, 1986.

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