Academic
and
health
care
problems
arisen
by
hypothetical-deductive reasoning-based curricula
Abstract
The aim of this study was to identify problems arisen by conventional curricula,
the guidelines for development of an appropriate educational model for 21st
century, and the advantages and disadvantages of the last two curricular models
of North America.
The medical education literature published from 1995 through 2002 of four
reputable journals in medical education were searched (Academic Medicine,
Teaching and Learning in Medicine, Medical Education, and Medical Teacher).
First the possibly best articles were identified. During the second screening
process 76 of 180 articles were found to be highly relevant to our questions. A
review of the chosen articles revealed a concept map which starts from
currently
applied
hypothetical-deductive-reasoning-based(HDR-based)
curricula in many medical schools all around the world.
Current issues in health care system are possibly attributable to current HDRbased curricular models including PBL. Advantages of reiterative PBL theory
can not be denied, but it appears that its limited application should be mainly
seen in some academic classes to develop some generic transferable skills
simultaneously with other teaching methods. Therefore vast application of HDR
in clinical settings is not recommended according to our study. However the
relationships demonstrated between factors and outcomes mentioned in the
concept map above can be used to run some new studies to test some
hypotheses.
1
Keywords: Curriculum, Health care system, Integration, Hypotheticaldeductive reasoning, Community-oriented Medical Education
Short running title: Curricular models and health care issues
Introduction
There is an obvious gap between medical education and professional
expectations (outcomes) encountered by recent medical graduates
1,2,3.
One of
the most important reasons of this discrepancy is the conventional curricula,
which rely on hypothetical-deductive reasoning model (HDR or backward
reasoning or disease-centered medical education)4,5 .
From the historical point of view this educational philosophy returns to Dr.
Abraham Flexner's ideas who believed that in order to perform successful
problem solving like basic scientists, one should emulate closely the
hypothetico-deductive (scientific reasoning) applied by basic scientists in
clinical setting and medical education too 6. Actually this idea was established
in Flexner’s era by his influence and strength and because of the halo effect
around him many concurrent educators have followed his idea. Therefore this
belief has been remaining so far even in modern problem-based learning (PBL)
curricula 6.
Generally, the patients who come to various clinical setting, do not mention the
name of their disease, but they talk about their complaints (or clinical
presentation for example chest pain, cough, dysuria etc.) and some associated
symptoms. Actually the current educational direction is from the disease to
manifestations (ie. from unknown territory to known variables in real clinical
setting). Authorities including those suggesting PBL curricula, believe that
there is a serious need for a hypothesis generated beforehand in order to enable
2
one to set an inquiry strategy. Although this type of problem-solving is used by
basic scientists, yet it may be not completely appropriate for problem solving
under the constraints of clinical setting (eg. constraints of time, knowledge and
skills),
5,7
especially considering that in clinical practice a deliberate trial-and-
error approach on a human subject is unethical.
In the backward clinical problem solving model (the background of the jumps
of PBL theory) proposed by Barrows and Pickell 4, the hypothesis generation is
located before the inquiry. If we remind the nature of traditional education in
medical schools, in which the teaching process starts from disease (diseasecentered learning) we notice that the same direction is subtly included in both
problem-solving model and PBL jumps. But it is astonishing because despite
the challenge of PBL theory to start from the case presentations (problem) as its
name implies, in the interim of its process it somehow returns again to diseasecentered education. Simply put, it tries to match the clinical problem solving
with the traditional disease-centered education inspired from hypotheticaldeductive philosophy of Flexner that does not coincide with many real case
instances . But if it is to develop a successful education in medical school, one
should do the best to simulate precisely the events which happens in experts
mind in real clinical setting not vice versa. So it is reasonable to match medical
education with direction of real clinical problem solving starting from clinical
presentation and going forward as the experts perform using key predictors to
discriminate major categories, subcategories, disease classes and differentials in
most instances.
3
On the other hand some recent articles put a question mark on whether PBL
curricula are more effective than conventional curricula on knowledge base and
clinical performance 8,9.
The aim of this study was to identify problems arisen by conventional curricula,
the outline for development of an appropriate educational model for 21st
century, and the advantages and disadvantages of the first four curricular
models of North America. i.e. Apprenticeship-based, Discipline-based, OrganSystem-based, and Problem-based learning curricula.
Method
The medical education literature published from 1995 through 2002 was
thoroughly searched to identify the problems arisen by conventional curricula,
the guidelines for development of an appropriate educational model for 21st
century, and the advantages and disadvantages of the last two curricular models
of North America i.e. Problem-Based Learning (PBL) and Clinical Presentation
Curriculum
6
(CPC). Four reputable journals in medical education were
searched: Academic Medicine, Teaching and Learning in Medicine, Medical
Education, and Medical Teacher. First the possibly best articles were identified.
Then during the second screening process, the abstracts of the primarily
selected papers were studied and 180 articles were chosen. During studying
those articles we realized that 76 articles were highly relevant to our questions.
A summary of each article was written including information about article
objectives, findings, and conclusion. Although the process may not locate all
the relevant articles yet studying the finally chosen 76 ones, it was realized that
those would answer our questions appropriately.
4
Based on our past experience with these journals, we thought that the careful
search would have located the most relevant papers and although electronic
searches might yield to many relevant and irrelevant citations quickly, yet
studying the articles carefully, we made sure that many quality and relevant
articles, peer reviewed by reputable evaluators of those famous journals, were
chosen.
A review of the chosen articles using the mentioned questions yield to
compiling and analyzing many current issues in medical education and in this
article we discuss those problems by using a concept map in a cause-effect way.
The concept map starts from currently applied HDR-based curricula in many
medical schools all around the world.
Overview of research results
It is necessary to point out that in hypothetical-deductive reasoning (backward
reasoning), the problem-solving model is based on generating one/a few
hypothesis(es) in each cycle then verifying that by the end of the cycle. This
process of ruling out hypothesis(es) is reminiscent of trial-and-error to achieve
the definite diagnosis.
However using such a process for clinical practice and teaching clinical
reasoning, possibly yield to the following issues in academic and health care
system (Figure 1):
1- Nowadays clinical professors deal with a magnitude of non-educational
responsibilities
2
(Therapeutic,
Research,
and
occasionally
Administrative ones). On the other hand in continuing cyclical process,
5
the first cycle's hypothesis generated by students may not be the
patients' definite diagnosis and the students or junior physicians usually
repeat the cycle again and again to reach the correct diagnosis. So
application of this kind of problem solving in clinical setting is timeconsuming
10,11
and inconsistent with workload of clinical professors in
this era (Arrow 1) 3,12,13,14,15.
2- The first problem causes the burden of education to be placed on
residents and students' free flowing clinical contact. Under these
circumstances "Residents see interns as extra pairs of hands but not
probationers, who still need training and supervision at a significant
point in their career" (Arrow 2).
2,12,16,17,18,19.
As a side effect, this kind
of education is usually stressful for students
12,20
because residents
usually don't have the necessary educational and clinical expertise to
educate students. (Arrow 18)
3- The first two problems cause shortage
16,21
of novice physicians'
knowledge and skills for clinical practice even in PBL curriculum
(Arrow 3 ).18,22,23,24,25
4- The cognitive, attitude
26
and psychomotor skills' shortage cause the
beginner physicians to make diagnostic and therapeutic errors (Arrow
4).12,27 Also part of those errors return to the nature of continuing
cyclical process itself. Leblanc, Norman, Bordage, and Friedman 6,12,28,29
found that the hypothesis generated in first cycle may cause the data
gathered in inquiry step to be misinterpreted because the physician
would like to see patient's manifestations according to his/her generated
hypothesis manifestations (Fabricating false findings28,29 to support their
6
own hypothesis). This may add some misinterpreted data at the end of
each cycle to patient information, so further divert next cycles'
hypotheses from the precise diagnosis (Arrow 8) 29.
5- The continuing cyclical process usually causes novice physicians to
request
long
lists
of
investigations,
clinical
questions,
and
examinations1,30,31,32. Because in each cycle some new data would be
necessary to verify that cycle's hypothesis (Arrow 6).
6- Verifying hypotheses one by one (one or a few in each cycle) causes a
long-lasting clinical inference 30 (Arrow 9).
7- The last issue in turn causes elongation of clinical practice time for
ambulatory (rotation between different offices and clinics) and inward
patients (bed occupancy time) (Arrow 10). This elongation is further
enhanced by novice physicians’ diagnostic and therapeutic errors
(Arrow 12) 32.
8- Elongation of clinical practice time (Arrow 11) and long list of
investigations lead to raise countries' health care system expenses
31
(Arrow 7).
9- Diagnostic and therapeutic errors (incompetent care), which is well felt
by interns and recent graduates themselves cause them to lose their selfesteem13,33,34,35 to involve with patients (Arrow 17). Especially
remembering their stressful period of hard studying in medical school,
cause them to dissatisfy with traditional and conventional curricula ie.
discipline-based and organ-system-based ones (Arrow 16) 24,33.
7
10- As an emotional reaction to the last two issues, medical students' may
fall into occupational depression
36
or sometimes attrition from their
field of study 37 (Arrows 19).
11- Patients feel novice physicians' incompetence so dissatisfy with quality
of care and resist such physicians and feel strongly to have their
professors presence. Therefore novice physicians will lose the
opportunity to gain required skills independently 38 (Arrow 20).
12- The last item assist in making patients uncooperative with novice
doctors in the diagnostic and therapeutic processes (Arrow 21).
13- Cumulative effects of some mentioned factors possibly lead to raise
mortality and morbidity in HDR-based health care systems (decreased
community health). 12,29,34,35,36 (Arrows 13, 14, 22).
14- Also the increased morbidity participates in the enhancement of the
health care system expenses due to extra treatments needed for ensued
morbidities (Arrow 15).
Without any doubt some of the mentioned arrows are bi-directional and
some correlations may not be demonstrated here, yet to simplify the
discussion those are not expressed here.
Discussion
It appears that many current issues in health care system are possibly
attributable to current HDR-based curricular models including PBL. Because
such models encourage generalized application of HDR for problem-solving,
while according to stage theory for evolution of knowledge structure and
clinical reasoning, clinical experts apply HDR in a few occasions in which they
8
encounter atypical cases with ambiguous findings 39. Thus vast application of
HDR in clinical settings is not recommended according to our study. However
the relationships demonstrated between factors and outcomes mentioned in the
concept map above can be used to run some new studies to test some
hypotheses.
It is also clear that some factors above are out of the control of medical
education, and health care system itself also plays roles in the mentioned
outcomes. However, it also appears from the concept map that vast application
of HDR-based curricula in real clinical settings are the main source of many
current problems of health care system.
Under these circumstances our question is whether a medical education system,
which relies on just HDR-based problem-solving, is able to integrate with
health care system and to address the problems of that system satisfactorily?
If we want to address many problems of health system (community needs) and
deal with the idea of integration between medical education and health system
to bridge the gap between medical education and professional expectations
(outcomes), we should take a serious endeavor to develop inductive or forwardreasoning-based curricula.
Without any doubt, we can not deny advantages brought up by reiterative PBL
theory e.g. critical thinking skill, but it appears that its limited application
should be mainly seen in some academic classes to develop some generic
transferable skills simultaneously with other teaching methods like lecture and
scheme-driven PBL 39 to assure that the main cognitive skill of a physician
(differential diagnosis) will not be sacrificed for attaining generic skills. But in
real clinical practice and clinical education its application should be considered
9
very conservatively e.g. just on the theoretical preclinical encounters for
educational goals. What seems to be advisable to apply in clinical setting either
for practice or for education, is possibly the forward-reasoning-based modules
developed in Clinical Presentation Curriculum (CPC). Because with fast and
frugal inductive models for clinical inference, we possibly remove the source of
many issues in health care delivery system (HDR-based practice) (Fig. 1)
10
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