what would william osler think of clinical education in japan today
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What would William Osler think of Clinical Education in Japan today? Why this topic? Osler - Canada connection Osler - McGill connection Osler – Kaga connection Purpose To educate To motivate To inspire To change My ‘sources’ Curriculum descriptions and curriculum reports Reading

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why this topic
Why this topic?
  • Osler - Canada connection
  • Osler - McGill connection
  • Osler – Kaga connection
purpose
Purpose
  • To educate
  • To motivate
  • To inspire
  • To change
my sources
My ‘sources’
  • Curriculum descriptions and curriculum reports
  • Reading
    • Medical Education literature *
    • “The Quotable Osler” **
    • K Kaga proposals re curriculum change
  • Discussions
    • Students
    • Faculty
    • Japanese medical educators
  • Observation of & participation in clinical education

*Kozu. Acad. Med. 81(12):1069-75, Dec 2006; Teo. Med. Educ. 41:302-8, Mar 2007

**Eds Silverman, Murray, Bryan. ACP. 2003

slide5
1. Curriculum

2. Bedside

learning

3. Postgraduate

education

4. Life-long

learning

Osler the person

Strengths

Challenges

Selected points,

not an organized overview!

Osler’s thoughts

Clinical education in Japan

clinical education not clinical teaching
Clinical Education, not Clinical Teaching
  • Teaching and the teachers
  • Learning and the learners
  • The clinical context
  • The curriculum
clinical education
Clinical Education
  • Curriculum
  • Bedside learning
  • Postgraduate education
  • Life-long learning
the curriculum
Discipline-based – affects learning of clinical medicine

Late clinical exposure

Clerkships short duration, many subspecialty areas

Emphasis on memory & recall, vs understanding and development of problem-solving skills

PBL (4/5)

Core curriculum (4/5)

Integrated lectures

OSCE as part of CAT

Free quarter

Exposure to community hospital-type patients (4/5)

The curriculum
osler was not convinced that clinical work should begin at the onset of medical school
Osler: Was not convinced that clinical work should begin at the onset of medical school

“I do not think that, with our present congested curriculum, it is an advantage to begin clinical work at once. It may be good for the student morally, but I am sure it is bad for him intellectually, and he gleans a heterogeneous collection of isolated half-understood experiences, instead of an orderly sequence in which the acquired knowledge of laboratories is brought to bear on the problems of disease.”

insisted students go to bedside and participate in hands on care
Insisted students go to bedside and participate in hands-on care

“take the student from the lecture room, take him from the amphitheatre – put him in the outpatient department – put him in the wards.”

osler recognized that a combination of concurrent book learning and clinical learning was effective
Osler: recognized that a combination of concurrent ‘book learning’ and clinical learning was effective

“To study the phenomena of disease without books is to sail an uncharted sea. Whilst to study books without patients is not to go to sea at all.”

"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”

“Divide your attention equally between books and men”

osler emphasized methods thinking skills rather than the acquisition and regurgitation of facts
Osler: Emphasized ‘methods’ (thinking skills) rather than the acquisition and regurgitation of facts

“The student needs more time for quiet study, fewer classes, fewer lectures, and above all examinations should be lifted from his soul.”

“We try to teach the student too much. Give him good methods and a proper point of view, and all other things will be added as experience grows.”

the curriculum13
Discipline-based – affects learning of clinical medicine

Late clinical exposure

Clerkships short duration, many subspecialty areas

Emphasis on memory & recall, vs understanding and development of problem-solving skills

PBL (4/5)

Core curriculum (4/5)

Integrated lectures

OSCE as part of CAT

Free quarter

Exposure to community hospital-type patients (4/5)

The curriculum
clinical education14
Clinical Education
  • Curriculum
  • Bedside learning
  • Postgraduate education
  • Life-long learning
bedside education
Students observe – little ‘hands-on’, passive

“Patients do not want to see students”

Competing demands on teachers - decreased time with rounding team

Clinical skills labs

Popular professors teach critical thinking & clinical reasoning

Bedside education
osler pioneer of bedside teaching recognized its importance for learning
Osler: Pioneer of bedside teaching – recognized its importance for learning

“Medicine is learned at the bedside and not in the classroom … Live in the ward.”

slide17
Emphasized the importance of taking a good history, doing a thorough exam, spending time with the patient

“…It is a safe rule to have no teaching without the patient for a text, and the best teaching is that taught by the patient himself”

osler knew active experiential was effective learning
Osler knew active experiential was effective learning

“Observe, record, tabulate, communicate. Use your five senses. Learn to see, learn to hear, learn to feel, learn to smell, and know by practice alone that you can become an expert. Medicine is learned by the bedside and not in the classroom. Let not your conceptions of disease come from words heard in the lecture room or read from the book. See, then reason and compare and control. But see first.”

osler recognized the patient s contribution to learning
Osler recognized the patient’s contribution to learning

The patient was made to feel that he was helping in the education of medical students, and that the student was his doctor… Dr Osler always created a friendly atmosphere … The student was seeing in Dr Osler a demonstration of the best sort of physician-patient relationship and was gaining invaluable preparation for his own independent clinical work”

Christian HA Arch Intern Med 1949

osler teaching on the wards is a pleasure not an obligation
Osler: teaching on the wards is a pleasure not an obligation

“The best life of the teacher is in supervising the personal daily contact of the patient with the student on the wards.”

osler thought that outstanding teachers with practical experience should be department chairs
Osler thought that outstanding teachers with practical experience should be department Chairs

University departments should be “in the charge of men who have, first, enthusiasm, that deep love of a subject, that desire to teach and extend it…; secondly, a full personal knowledge of the branch taught, not second hand from books but from living experience …”

bedside education22
Students observe – little ‘hands-on’, passive

“Patients do not want to see students”

Competing demands on teachers - decreased time with rounding team

Clinical skills labs

‘Popular teachers’ try to teach critical thinking & clinical reasoning

Bedside education
clinical education23
Clinical Education
  • Curriculum
  • Bedside learning
  • Postgraduate education
  • Life-long learning
postgraduate education pgy1 2
Emphasis on technical aspects

Little exposure to outpatients

Didactic education varies: (conferences, grand rounds, half-days, M&M rounds)

‘Core competencies’ not formally taught

Entry level low clinical skills

2 year internship emphasis on hands-on skills

Learning ‘hierarchy: interns taught by residents …

Emphasis on primary care:

GIM, general surgery & EM

Objectives:

doctor patient relationship;

collaborative skills;

social, organizational & ethical aspects;

case presentation;

medical problem solving

Postgraduate education - PGY1-2
osler created first residency programs
Osler: Created first residency programs
  • Live in the hospital

“Postgraduate study has always been a feature of our profession”

  • Hierarchical & Pyramidal

“No man can teach successfully who is not at the same time a student”

osler recognized the value of experience as a learning method
Osler: Recognized the value of experience as a learning method

“The important thing is to make the lesson of each case tell on your education. The value of experience is not in seeing much, but in seeing wisely.”

osler promoted the importance of learning general medicine
Osler: Promoted the importance of learning general medicine

“The art is getting longer and longer, the brain [of the learner] has its limits…the time is too short for a man already burdened to the breaking point, to study any specialty from the standpoint of the specialist.”

slide28
Osler: Emphasis on learning to care for whole patient, and role modeling the doctor patient relationship

the learner “should learn how to study disease and how to treat it, or rather, as I prefer to teach, how to treat patients.”

“Every patient you see is a lesson in much more than the malady which he suffers.”

“Our study is man, as the subject of accidents or disease.”

clinical education29
Clinical Education
  • Curriculum
  • Bedside learning
  • Postgraduate education
  • Life-long learning
life long learning
Reflection rarely taught

Skills of LLL not role modeled or explicitly discussed

Journal clubs and EBM discussion uncommon

Emphasis in internship in ‘learning from cases’

Life-long learning
osler recognized the information explosion and the need to keep up to date
Osler: Recognized the ‘information explosion’ and the need to keep up to date

“Medicine is a “progressive science, day by day receiving fresh acquisitions, opening up new fields for investigation, and it will be your duty … to keep pace with this progress.”

osler was a life long learner
Osler was a life-long learner

“It is a good many years since I sat on the benches, but I am happy to say that I am still a medical student, and still feel I have much to learn”

osler believed that ongoing education essential for the life of a practitioner
Osler: Believed that ongoing education essential for the life of a practitioner

“The hardest conviction to get into the mind of the beginner is that the education upon which he is engaged is not a college course, not a medical course, but a life course, for which the work of a few years under teachers is but a preparation”

osler originated the first journal club
Osler: Originated the first journal club

“A physician who does not read books and journals … who does not read one or two of the best weeklies and monthlies, soon sinks to the level of a cross-counter prescriber”.

“For the general practitioner a well-used library is one of the few correctives of premature senility…”

osler as a role model
Osler as a role model
  • ‘Humanitarian and teacher’:

taught medicine as a humanity and an art,

as well as a science

  • Renaissance man
  • Personal qualities
art and science of medicine
Art and Science of Medicine

“The practice of medicine is an art, based on science.”

“The practice of medicine is an art, not a trade; a calling, not a business: a calling in which your heart will be exercised equally with your head”

renaissance man
Renaissance man

“Before going to sleep, read for half an hour, and in the morning have a book open on your dressing table. You will be surprised to find how much can be accomplished in the course of a year.”

“The young doctor should look about early for an avocation, a pastime that will take him away from patients, pills and potions …anything will do so long as he straddles a hobby and rides it hard.”

personal qualities
Compassionate

Caring

Sense of humour

Humble

Respectful

Tolerant

Love of fellow man

Warm

Personal qualities
kaga recommendations for medical education reform
Kaga recommendations for medical education reform
  • Standardized clinical curriculum
  • Integrate basic science & clinical medicine: “facts of disease should relate to clinical presentation & reasoning”
  • Small group tutorials with case discussion for clinical links
  • Long core clerkships: more time learning clinical practice
  • Exposure to outpatients – continuity
  • Importance of bedside learning
  • Humanist – ‘listen to the patient’s story’

1969

last words
Last words

“Medicine is a most difficult art to acquire. All the college can do is teach the student principles, based on facts in science, and give him good methods of work. These simply start him in the right direction…”

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