REVIEW
Trends in North American medical education
Karyn D. Baum1 and Sara Axtell2
1Department of Medicine, 2Ofﬁce of Educational Development and Research, University of Minnesota Medical
School, Minneapolis, MN, USA(Received for publication on September 6, 2004)(Revised for publication on September 6, 2004)(Accepted for publication on December 16, 2004)

Abstract. Medical education in the United States of America (USA), and worldwide, is increasingly
concentrating on the process and outcome of the educational experience. The ﬁrst efforts to substantially improve medical education in the USA resulted in the Flexner Report in the early 1900s. The
release of this report led to signiﬁcant advancements in the quality of curriculum content. However, inthe past few decades there has been increasing realization that delivery of content will not, by itself,
assure the development of excellent physicians. As a result, there has been an increasing emphasison the process, and, most recently, the outcome, of medical education. Process movements haveexamined the context and methods for teaching and learning. The problem-based learning movement
is perhaps the most widely-known example of process trends. The latest trends in USA medical education focus on the outcomes of the learning process. At the forefront of this movement is the American Council on Graduate Medical Education (ACGME), which accredits all USA post-graduate
training programs. Recently, the ACGME has deﬁned a set of six core clinical competencies that all
graduates must demonstrate. A second emerging trend is inter-professional education. Increasingly,
healthcare is provided by inter-professional healthcare team, and students must be competent to function effectively in this setting. Many academic health centers are developing joint curricula to address
this need. Medical education has evolved from a primary focus on content to an emphasis on process ofteaching and learning, and will increasingly concentrate on educational outcomes. (Keio J Med 54 (1):22–28, March 2005)
Key words: medical education, history of medicine, medical school, curriculum development, interprofessional education

making women’s dresses. Slowly however, by the midnineteenth century, those who practiced medicine began to do so full-time and as a primary occupation.1
Increasingly, Americans who had undergone an apprenticeship would also go to study more formally inEurope, and they were bringing back not only medical
knowledge but methods of education.
By the end of the 19th century, there were threemain routes to becoming a physician in America. The
ﬁrst was apprenticeship, the oldest training system
available. A physician who felt in need of an assistantcould ﬁnd one by offering an apprenticeship position toa ‘‘likely youth.’’ Training was variable in terms ofeducational worth. An apprentice had access to hismaster’s library, but there was little, if anything, in theway of formal lecturing involved in the training. An
apprentice ‘‘ran his master’s errands, washed the bot-History of Medical Education in the USA
The best way to understand where medical educationis headed is to begin with an examination of where itcame from. To that end, we would like to brieﬂy review
the history of medical education in the United States ofAmerica (USA), as a means of understanding the context in which medical education is evolving.
In the seventeenth and eighteenth centuries, physicians in the United States were surgeons as well as
apothecaries. Because there was little in the way ofoversight, anyone could practice ‘‘medicine’’ and appropriate the title of ‘‘doctor.’’ Clergy often functioned
in a physician’s role, as did both men and women oflower socioeconomic status. In order to make a living
wage, doctors not only practiced medicine but also engaged in other enterprises such as selling coffee andPresented at the 1353rd Meeting of the Keio Medical Society in Tokyo, June 12, 2004
Reprint requests to: Karyn Baum, MD, Assistant Professor, Department of Medicine, University of Minnesota, MMC 741, 420 Delaware St SE,
Minneapolis, MN 55455, USA, e-mail: kbaum@umn.edu
22Keio J Med 2005; 54 (1): 22–28

tles, mixed the drugs, spread the plasters, and ﬁnally, as
the stipulated term drew towards its close, actually took
part in the daily practice of his preceptor.’’2
The second training method available to students
was the proprietary, or for-proﬁt, school system. These
schools, which were owned and run by practicing
physicians, could be opened by any physician interested
in doing so. They were often, but not necessarily,
loosely afﬁliated with larger institutions who allowed
these small schools the right to award degrees in theirname. Students paid tuition to the school and in return
received a series of lectures from the local physicians.
Teaching in these schools was faculty-centered, andthere was little in the way of admission criteria beyond
the ability to pay the fees.2
Because faculty were seeing patients when notteaching, and derived most of their livelihood from that
activity, content was delivered in lecture format, themost efﬁcient teaching method available.3 The standard
curriculum consisted of seven courses including anatomy, medical jurisprudence, surgery, and obstetrics.4
The lectures in the second term were identical tothose in the ﬁrst. The ‘‘school’’ itself usually consistedof a lecture room, a small library, and a space for anatomy. There was little oversight for these schools, andmany state medical boards refused to accept theirgraduates.5
The ﬁnal, and least common, path to becoming adoctor was through the University system. This system
was originally designed to supplement the apprenticesystem,2 where teaching was variable and inconsistent.
The ﬁrst of these schools, University of Pennsylvania,
opened in 1765, followed by King’s College (now Columbia) in 1767 and Harvard in 1782.4 These schools
eventually mixed both lecture and clinical experiences;
Johns Hopkins was the ﬁrst school to open its own
hospital for clinical teaching in 1893. Once again admission criteria were quite variable. Initially, medical
education was quite short: 16 weeks of lectures repeated during the next term.6 By the early 1900s thelength of training had stretched to the 4-year curriculum currently in place.3 Tuition at Johns Hopkins
Medical School was $200 in 1907.7
By the turn of the 20th century, several breakthroughs had occurred in science and medicine. The
Flexner Report argued that, ‘‘the fundamental science
upon which medicine depends [had] been greatly
extended.’’2 Medicine was developing a scientiﬁc basis,and there was an ever-expanding set of diagnostic
and treatment options available to physicians and theirpatients. Koch’s Postulates, a set of procedures to isolate and identify the causative microbial agent in disease, had been developed by Robert Koch at the end of
the nineteenth century; medicine was ﬁnally able toidentify the causes of common illnesses.

23

At the same time, there was a growing concern that
there was an overproduction of poorly qualiﬁed physicians. In addition, regular physicians were struggling togain and consolidate respect and authority in the 19th
century. National organizations such as the American
Medical Association (AMA) developed a strong interest in improving and, to some extent standardizing,
medical education as a means of addressing both ofthese concerns. By institutionalizing and licensing medical education and practice, authority and respect could
be reliably transmitted from one group of physicians to
the next.1 As Paul Starr noted in his treatise on the riseof the American medical system, ‘‘from apprenticeship,a young man might get a certiﬁcate of proﬁciency, butfrom a school of medicine he could get a warrant ofauthority.1’’
Much of the newly-won authority of medicine rested
upon its alliance with the scientiﬁc model, which wasrespected by the American population. The AMA wasalso seeking to eliminate schools that had not adopted
this new rigorous paradigm for medical education
through the standardization of the educational process.
In 1904 the AMA created the Council on Medical Education (CME) to promote this restructuring.8
In 1908, the CME planned to undertake a surveyof medical education in the United States to promotechange and the acceptance of its ‘‘ideal’’ four year
medical curriculum. The CME requested that the
newly-formed Carnegie Foundation for the Advancement of Teaching lead the survey. Carnegie president
Henry Pritchett chose Abraham Flexner, a noted educational theorist, to head the survey, possibly because
he felt that any given physician might be perceived asbiased. This partnership represents the ﬁrst major collaboration between educators and physicians in thecause of medical education. Dr. Flexner visited all 155
American and Canadian medical schools over an 18
month period, rating them on ﬁve factors: entrance
requirements, size and training of the faculty, size ofendowment and tuition, quality of laboratories, andavailability of a teaching hospital.8,9 In 1910, he produced his 363-page report, Medical Education in the
United States and Canada. He provided overall recommendations for changes in medical education as well as
individual ‘‘report cards’’ for each school. So enduringis this report that it is still available on-line via the
Carnegie Foundation website.10
The Flexner Report, as it came to be known, led tosome pivotal changes in the American medical system.
First, between seven and twenty-two percent of all
medical schools closed or merged at least partially as aresult of the report.9 By 1927 there were only 71 USA
medical colleges,11 and we still have only 126 today
despite the interval population increase. Secondly, proprietary medical schools and the apprentice system dis-

24

Baum KD and Axtell S: Trends in North American medical education

appeared within two decades of the report. Thirdly, theGerman model of blending bioscience with clinicalwork and the ‘‘scientiﬁc’’ reasoning process became
ﬁrmly established as the dominant curricular model.6,12
Finally, there was an attempt to have medical educators
gain the status of full-time university faculty, with mostof their time (until recently) being spent on teaching
and research rather than clinical care. This conversion
from primarily clinicians to primarily faculty was not
fully implemented until mid-century. The post-Flexner
era also saw a dramatic rise in oversight of medical education and practice. In 1912, the National Confederation of State Medical Examining and Licensing Boards(established in 1891) and the American Confederationof Reciprocating Examining and Licensing Boards(established in 1902) merged to form the Federation ofState Medical Boards.13 For the ﬁrst time, there wasnational coordination of certiﬁcation methods for individual physicians. By 1927 an early system for accreditation of post-graduate residency programs throughspecialty boards had begun, which some decades later
became the Accreditation Council for Graduate Medical Education. Finally, in 1942 the American Medical
Association and the Association of American Medical
Colleges, which had until then evaluated medical
schools separately, jointly formed the Liaison Committee on Medical Education as a single body to certify thequality of North American medical schools.14 Now,each level of medical education and practice, frommedical school to post-graduate training to individual
licensing for practice, is overseen by its own national
body.
Since the Flexner Revolution, there have been two
major curriculum movements in United States medical
education: the organ-based reform and problem-basedlearning. The ﬁrst curricular reform, the organ-based
movement, developed in the 1950s as a response to thegrowing amount of biomedical knowledge as well as thedisorganization inherent in a discipline-run curriculum.6
Topics were taught within the organ-system framework,and active learning techniques were encouraged. For
example, the second year of medical school might consist of blocks of time, within which all material on one
organ system is presented together. One such block
would be cardiology; during the block the anatomy,
pharmacology, pathophysiology, and in some cases evenclinical exam skills would be taught.
This reform developed as an attempt to reduce theshear amount of information that educators were attempting to transmit to their students and to better integrate the information remaining. In this ‘‘integrated’’
educational system, curricular content was overseen byinterdepartmental topic committees rather than individual departments. As a result of this movement, curriculum control became more centralized within the

medical school rather than controlled separately byeach department. There was improved coordination at
the topic level but a separation of education from thedaily routines and functions of a department.
The next major reform in medical education was theﬁrst one to focus on the process of medical education
rather than the content itself. This reform, problembased learning (PBL), is based upon several education
theories. PBL was ﬁrst introduced at McMaster University in Ontario, Canada in the late 1960s, largely
through the efforts of Dr. Howard Barrows. PBL takes
place in small, student-driven groups, maximizing active
learning and problem-solving skills, using speciallyconstructed patient cases designed to have learners utilize knowledge in context. PBL was originally developed utilizing several cognitive learning theories, and is
the ﬁrst major curricular reform to focus on how students learn rather than what information is presented.
Most North American medical schools have used or areusing PBL as a part of their curriculum. There is anever-growing body of literature on the efﬁcacy of PBL;
as of July 2004, there were 1642 papers in Medline on
PBL.
Current Structure of Medical Education in the
United States
All medical students in the United States complete
an undergraduate degree program (typically four years
in length) prior to entering medical school. Students
can earn any degree in any ﬁeld they wish, as long as
they take certain courses required by most medical
schools for entrance. These courses include biochemistry, organic chemistry, and biology. Medical students
are, on average, 23.7 years old when they begin training.15 There are nearly equal numbers of male and female medical students.16 The majority of students are
Caucasian, with Asian and African Americans being
the most common race and ethnic minorities represented.16
To this day, Dr. Flexner’s recommendations casta long shadow over medical training in the UnitedStates. The basic curricular structure remains that of
the four-year curriculum ﬁrst proposed by the Council
on Medical Education and championed by Dr. Flexner.
The ﬁrst two years, the ‘‘pre-clinical’’ experience, arestill predominantly lecture-based and content-heavy inmost medical schools. Students study topics including
anatomy, pharmacology, physiology, pathology, microbiology, medical ethics, and histology in addition tolearning to perform a history and physical examination. The last two years are spent on clinical rotations,
fulﬁlling the place of apprenticeships (along with postgraduate training). Students take a combination ofrequired and elective rotations. Required rotations

Keio J Med 2005; 54 (1): 22–28(‘‘clerkships’’) include medicine, pediatrics, surgery,and obstetrics and gynecology.
Current Trends in Undergraduate Medical Education
At the turn of the century, concern over the trainingof unqualiﬁed physicians and poor educational oversight led to the Flexner report and a signiﬁcant standardization of medical content delivered nation-wide.
However, in education, content is only part of thelearning story. Educational theory and research notesthat the methods used to teach information may havejust as much to do with retention as the content itself.
As a result of this insight, there are several major trends
in medical education which focus on the process ofeducation rather than the content itself.
Process Movements in North American Medical
Education
Several recent trends in North American medical
education have focused on the process of teaching
and learning. These curricular reforms have focused on
how we structure our curricula, where we teach ourstudents, and on what basis we make decisions about
our education programs.
In response to questions about how best to structure
the medical curriculum, medical educators have focused
their answers on curriculum integration. One such trend,
course integration, is essentially an extension of theorgan-based curriculum movement. Course integration
involves teaching about the same topic from multiple
disciplinary perspectives, for example, teaching anatomy of the shoulder alongside radiography and physicalexam of the shoulder. A course integration strategy has
been used to teach a range of content areas, such associal and behavioral sciences17 and musculoskeletal
pathophysiology.18 Typically, course integration brings
basic science content into a clinical or social context.
We know from learning theory that learners are better
able to apply newly acquired skills and knowledge if thecontext for learning is similar to the conditions underwhich they must eventually perform. Integrated course
segments provide students the opportunity to learn
together the knowledge and skills that they will apply
together.
While course integration focuses on horizontal integration of the curriculum, or the integration of concurrent curriculum components, a second trend focuses onvertical integration. Vertical integration can be deﬁned
as coordination and sequencing of content areas longitudinally across a curriculum. Often, vertical integration
efforts focus on areas that do not fall along traditional
disciplinary lines.19 For example, a vertical curriculum
thread on quality improvement might include the fol-25

lowing components: basic concepts of quality improvement presented in a lecture format in year one of medical school; application of those concepts while students
work on a quality improvement project in year three;
and the learner leading a quality improvement team asa resident. This structure allows for repeated exposures
to the content, with increasing complexity. Reportsof vertical integration projects have focused on suchcontent areas as cultural competence20 and end-of-lifecare.21
The second education process issue relates to where
our students should be educated. An increasing amountof patient care occurs in an outpatient setting. For example, so estimates indicate the as much as 60% of
surgeries are now taking place in the ambulatory setting.22,23 In response to this trend, the education of
medical students is also shifting to outpatient clinics.
Current reports indicate that the percentage of timespent in ambulatory settings in required clerkships
varies by specialty. For example, 93% of time in family
practice clerkships, 25% of time in internal medicine
clerkships, 35% of time in OB/Gyn clerkships, 42% of
pediatric clerkships, and 33% of time surgery clerkships
is spent in ambulatory settings.24 This represents a
gradual increase from a decade ago, when 90% of timein family practice clerkships, 35% in pediatric clerkships, 25% in OB-Gyn clerkships, 20% in internal
medicine clerkships, and only 13% in surgery clerkships
was spent in an ambulatory setting.25 Some studies
have documented that student learning and student
perceptions of the quality of the learning experience iscomparable for hospital-based and outpatient clerkships experiences.26 However, logistical concerns aboutproviding consistent experiences across sites remain.
The ﬁnal process issue focuses on how we makedecisions about our educational programs. A reportfrom 1990 suggested that our curricular decisions may
not always be based in existing evidence of educational
effectiveness.27 Since that time, there has been an
increased emphasis both on the scholarship of teaching28 and on best evidence medical education.29,30 The
movement toward evidence-based clinical care has
increased the interest of medical teachers in the use ofevidence to make educational decisions. In order toencourage the use of evidence in education decisionmaking, it will be necessary to develop training programs for faculty and systems of incentives that encourage the use of evidence.31 Indeed, a number ofcertiﬁcate and degree programs currently exist to credential medical school faculty in education.32,33
In addition to support for faculty, an increase in thequality of the evidence available will be necessary if weare to effectively employ an evidenced-based approachto our curriculum decisions. One recent review ofreports of the effectiveness of continuing medical edu-

26

Baum KD and Axtell S: Trends in North American medical education

cation indicated that relatively few studies (18.9%)
looked at the learner’s application of the skills andknowledge taught, and even fewer (1.6%) measuredchanges in patient outcomes as a result of educational
interventions.34

to deﬁne the crucial knowledge, skills, attitudes, andbehaviors that all graduates must be able to demonstrate at completion of their training.36,42,43 Training
programs must then develop and implement valid,reliable, and practical evaluation tools in order to certify competency for each of those skills.36,43 These
requirements are not as easy as it might seem on thesurface. For example, how to you show a trainee isprofessional? What tests can a school use to ascertain
the decision-making skills of its students? Additionally,
despite best intentions, it is nearly impossible to remove
personal opinion from the evaluation process, making
reliability in measurement difﬁcult to achieve. Finally,
demands on faculty time are likely increase as a resultof more oversight and assessment of clinical competence.43
Despite the challenges of deﬁning the criticalskills and developing evaluation tools, CBE is likely
to receive more attention in the coming years for several reasons. The most obvious, of course, is that postgraduate training programs are now mandated to focus
on outcomes rather than curriculum delivery in order tomaintain accreditation. Secondly, there is a public andprofessional push for the medical profession to assure
the competency of its graduates.44 Finally, it aligns theeducational process with the desired outcomes, andshould lead to a more active learning experience for the
trainees.

Outcome Movements in North American Medical
Education
Most recently educators and the public have begun
to focus on the outcome that we would all most desire:assuring the development of competent, qualiﬁed
physicians. In other words, the outcome of education ismore important than the content or even the process,similar to physicians being more concerned with thepatient outcomes than the actual treatment modality.
The recent concern over educational outcomes has led
to two major trends in medical education: competencybased education and interprofessional education.
Competency-based education
Traditionally, medical education, especially postgraduate education, has focused upon deﬁning a periodof time over which training takes place and the content
delivered during that period.35 At the conclusionof training, the trainee was considered ‘‘trained’’ andable to practice medicine. Competency-based education(CBE), however, ‘‘implies a training process that results
in proven competency’’36 in certain skills and behaviors
required to practice that profession. Each trainee would
have to demonstrate the acquisition and application therequired knowledge, skills, and behavior in order tocomplete training (or move to the next step in the curriculum).
Surgery programs likely have the most experience
with this type of education,36–39 but more and moreprograms are experimenting with CBE as a means ofassuring that their graduates are able to practice highquality medicine. At the forefront of this movement,
the Accreditation Council on Graduate Medical Education (ACGME) has recently deﬁned a set of six coreclinical competencies which it will use to accredit all
post-graduate training programs.40 All programs will
have to demonstrate that their graduates have acquired
certain skills, such as professionalism and patient care(as opposed to demonstrating that the program teaches
these skills), in order to be accredited. It is a signiﬁcant
shift in the accreditation process: the programs muchdemonstrate what their trainees have learned rather
than what they have taught. The American Associationof Medical Colleges also support a shift to competencybased education and aligning those competencies withthose of the ACGME.41
Implementing CBE requires that educators be able

Interprofessional education
Over the years, the face of healthcare has changed.
Patients are living longer with complicated and chronic
medical conditions such as diabetes and congestive
heart failure. Increasingly, healthcare is practiced inteams of professionals, each working together for thecommon goal of good patient care for those with these
conditions. There has been a growing realization that
all healthcare professionals need to function well in ateam, and have a clear understanding of their respectiveroles. They must be able to communicate clearly andprofessionally.
However, health professions students are trained
separately for years, and then asked to function well as
an integrated team. They have little to no understanding of each others’ training, roles, strengths, and limitations. Students are rarely given training in team orleadership skills or conﬂict resolution. One method
postulated to help develop team skills and an understanding of respective strengths is to train together.
Interprofessional education (IPE) is an educational
process through which students are provided with formal opportunities for shared or team learning.45
This curricular movement, interprofessional education (IPE), is by no means entirely new. There wereKeio J Med 2005; 54 (1): 22–28

considerable attempts made in the 1970s to advance thisidea of training students from multiple professions together, but the movement stalled in the early 1980s.46
In recent years educators in many settings have beentackling this complicated but intriguing educational
technique as a means of assuring the desired outcome:health professions graduates that function well as ateam. Interprofessional education can take place in theclassroom or clinical setting. Examples include joint
rotations in a geriatric clinic47 and joint ethics courses
for students from multiple health professions.48
Indeed, several national and governmentalorganizations have championed IPE as a means ofcreating more efﬁcient, safe, and satisfying healthcare
systems.49–51 Academic medical centers across North
America and in Europe are reconsidering the most effective IPE methods. Programs are being piloted atmany institutions, and several Academic Health Centers have developed Centers for Interprofessional Education.52–54
One determinate of whether this IPE movement
will be longer lasting than that of a generation ago
will be demonstration of convincing quality outcomes.
While there has been evaluation of many IPE programs,47,55–57 it has typically been at the level of theindividual students rather than at the programmatic or
patient levels; most student evaluation centers aroundattitudes and satisfaction with the learning experience.
A recent review on the subject of IPE was unable toﬁnd a single paper meeting the inclusion criteria ofassessing patient satisfaction or outcomes.58 Anothersystematic review did support a positive change in theknowledge, skills, and attitudes of health professions
students, but was unable to demonstrate change inactual practice behavior.59 Clearly, as with competencybased education, a shift to a concern with outcomes will
necessitate an increased level of sophistication withregards to curricular evaluation.
Conclusion
Medical education in the United States and Canada
has evolved dramatically over the centuries. What was
originally a haphazard educational process dependent
upon the good will of the educator has become a complicated system full of standards and oversight. The
curricular movements of this century have shifted theeducators’ focus from medical content to the process ofeducation itself. Most recently, attention has turned
to assuring the outcomes of the training process. The
increasing focus on process and outcomes will demandthat the medical system further deﬁne what it means to
be a competent physician and develop valid, reliable,and practical evaluation methods for students and programs. Educators are fortunate to be teaching during a

27time of such promise and change, and must rise to thechallenge of helping to train the next generation ofhealers.

References
1. Starr P: The Social Transformation of American Medicine, NY,
Basic Books, 1982
2. Flexner A: Medical education in the United States and Canada.
From the Carnegie Foundation for the Advancement of Teaching, Bulletin Number Four, 1910. Bull World Health Organ 2002;
80: 594–602
3. Ludmerer KM: Time and medical education. Ann Intern Med
2000; 132: 25–28
4. Rutkow IM: Medical education in early 19th century America.
Arch Surg 1999; 134: 453
5. Rae A: Osler vindicated: the ghost of Flexner laid to rest. CMAJ
2001; 164: 1860–1861
6. Papa FJ, Harasym PH: Medical curriculum reform in North
America, 1765 to the present: a cognitive science perspective.
Acad Med 1999; 74: 154–164
7. Naradzay JF: Into the deep well: the evolution of medical school
loan debt. JAMA 1998; 280: 1881, 1883
8. Beck AH: STUDENTJAMA. The Flexner report and the standardization of American medical education. JAMA 2004; 291:
2139–2140
9. Hiatt MD, Stockton CG: The impact of the Flexner Report on
the fate of medical schools in North America after 1909. Journalof American Physicians and Surgeons 2003; 8: 37–40
10. Carnegie Foundation. Medical education in the United States
and Canada. Available at: www.carnegiefoundation.org/elibrary/docs/ﬂexner_report.pdf (accessed June 24, 2004)
11. National Resident Matching Program. Save the match. Available
at: www.savethematch.org (accessed June 20, 2004)
12. Debas HT: Medical education and practice: end of century
reﬂections. Arch Surg 2000; 135: 1096–1100
13. Federation of State Medical Boards. Federation Facts. Available
at: www.fsmb.org (accessed June 29, 2004)
14. Liaison Committee on Medical Education. Liaison Committee
on Medical Education History and Organization. Available at:www.lcme.org/studentrole.htm (accessed June 29, 2004)
15. American Association of Medical Colleges. Matriculant age
at anticipated matriculation, 1992–2001. Available at: http://
www.aamc.org/data/facts/archive/famg122001a.htm(accessed
August 17, 2004)
16. American Association of Medical Colleges. Matriculants by raceand ethnicity within gender, 2002 and 2003. Available at: http://
www.aamc.org/data/facts/2003/20022003detmat.htm(accessed
August 18, 2004)
17. Satterﬁeld JM, Mitteness LS, Tervalon M, Adler N: Integrating
the social and behavioral sciences in an undergraduate medical
curriculum: the UCSF essential core. Acad Med 2004; 79: 6–
15
18. Saleh K, Messner R, Axtell S, Harris I, Mahowald ML: Development and evaluation of an integrated musculoskeletal disease
course for medical students. J Bone Joint Surg Am 2004; 86-A:
1653–1658
19. Nierenberg DW: The use of ‘‘vertical integration groups’’ to help
deﬁne and update course/clerkship content. Acad Med 1998; 73:
1068–1071
20. Turner J, Wagner D, Schnuth R: Weaving a Theme Across the
Curriculum: Health Care for the Economically Disadvantaged,
Omaha, NB, USA, 2004

28
21. Grauel RR, Eger R, Finley RC, Hawtin C, Keay T, O’Brien W
3rd, Pickens N, Schnapper N, Timmel D, O’Mara A, Ross DD:
Educational program in palliative and hospice care at the University of Maryland School of Medicine. J Cancer Educ 1996; 11:
144–147
22. Healthcare Review. Moving out: How outpatient surgey ischanging healthcare. Available at: http://www.ﬁndarticles.com/p/
articles/mi_m0HSV/is_5_16/ai_102979182 (accessed August 22,
2004)
23. Vila H Jr, Soto R, Cantor AB, Mackey D: Comparative outcomes analysis of procedures performed in physician ofﬁces andambulatory surgery centers. Arch Surg 2003; 138: 991–995
24. Barzansky B, Etzel SI: Educational programs in US medical
schools, 2002–2003. JAMA 2003; 290: 1190–1196
25. Jonas HS, Etzel SI, Barzansky B: Educational programs in US
medical schools, 1993–1994. JAMA 1994; 272: 694–701
26. Satran L, Harris IB, Allen S, Anderson DC, Poland GA, Miller
WL: Hospital-based versus community-based clinical education:comparing performances and course evaluations by students intheir second-year pediatrics rotation. Acad Med 1993; 68: 380–
382
27. Nelson MS, Clayton BL, Moreno R: How medical school faculty
regard educational research and make pedagogical decisions.
Acad Med 1990; 65: 122–126
28. Fincher RM, Simpson DE, Mennin SP, Rosenfeld GC, Rothman
A, McGrew MC, Hansen PA, Mazmanian PE, Turnbull JM:
Scholarship in teaching: an imperative for the 21st century. Acad
Med 2000; 75: 887–894
29. Harden RM, Grant J, Buckley G, Hart IR: Best Evidence Medical Education. Adv Health Sci Educ Theory Pract 2000; 5: 71–
90
30. Mennin SP, Cole-McGrew M: Scholarship in teaching and best
evidence medical education: synergy for teaching and learning.
Medical Teacher 2000; 22: 468–471
31. Van Der Vleuten CPM, Dolmans D, Scherpbier A: The need forevidence in education. Medical Teacher 2000; 22: 246–50
32. University of Illinois at Chicago. Online Masters of Education. Available at: http://ness2.uic.edu/UI-Service/programs/
UIUC667.html (accessed August 22, 2004)
33. University of Southern California Division of Medical Education. USC Masters of Science in Education Programs. Available
at: http://mededonline.hsc.usc.edu/program.html (accessed August 23, 2004)
34. Belﬁeld C, Thomas H, Bullock A, Eynon R, Wall D: Measuring
effectiveness for best evidence medical education: a discussion.
Med Teach 2001; 23: 164–170
35. Leung WC: Competency based medical training: review. BMJ
2002; 325: 693–696
36. Long DM: Competency-based residency training: the next advance in graduate medical education. Acad Med 2000; 75: 1178–
1183
37. Martin M, Vashisht B, Frezza E, Ferone T, Lopez B, Pahuja M,
Spence RK: Competency-based instruction in critical invasive
skills improves both resident performance and patient safety.
Surgery 1998; 124: 313–317
38. Ilott I, Bunch G: Competencies of basic surgical trainees. Ann R
Coll Surg Engl 1998; 80: 14–16
39. Scott DJ, Valentine RJ, Bergen PC, Rege RV, Laycock R, Tesfay ST, Jones DB: Evaluating surgical competency with theAmerican Board of Surgery In-Training Examination, skill testing, and intraoperative assessment. Surgery 2000; 128: 613–622
40. Accreditation Council for Graduate Medical Education.

Baum KD and Axtell S: Trends in North American medical education

41.

42.

43.

44.

45.
46.
47.

48.

49.

50.

51.

52.

53.

54.

55.

56.

57.

58.
59.

ACGME Outcomes Project. Available at: http://www.acgme.org/
outcome/project/proHome.asp (accessed July 30, 2004)
Cullen L, Fraser D, Symonds I: Strategies for interprofessional
education: the Interprofessional Team Objective Structured
Clinical Examination for midwifery and medical students. Nurse
Educ Today 2003; 23: 427–433
Carraccio C, Englander R, Wolfsthal S, Martin C, Ferentz K:
Educating the pediatrician of the 21st century: deﬁning andimplementing a competency-based system. Pediatrics 2004; 113:
252–258
Goroll AH, Sirio C, Duffy FD, LeBlond RF, Alguire P, Blackwell TA, Rodak WE, Nasca T: Residency Review Committee forInternal Medicine: A new model for accreditation of residency
programs in internal medicine. Ann Intern Med 2004; 140: 902–
909
Carraccio C, Wolfsthal SD, Englander R, Ferentz K, Martin C:
Shifting paradigms: from Flexner to competencies. Acad Med
2002; 77: 361–367
Parsell G, Bligh J: Interprofessional learning. Postgrad Med J
1998; 74: 89–95
Hall P, Weaver L: Interdisciplinary education and teamwork: along and winding road. Med Educ 2001; 35: 867–875
Rosher RB, Robinson SB, Boesdorfer D, Lee K: Interdisciplinary education in a community-based geriatric evaluation clinic.
Teach Learn Med 2001; 13: 247–252
Kent H: Medical, health-science students bring different perspectives to interdisciplinary ethics course. CMAJ 1997; 156:
1317–1318
Headrick LA, Knapp M, Neuhauser D, Gelmon S, Norman L,
Quinn D, Baker R: Working from upstream to improve healthcare: the IHI interdisciplinary professional education collaborative. Jt Comm J Qual Improv 1996; 22: 149–164
Anonymous: Interdisciplinary education and practice. American
Association of Colleges of Nursing. J Prof Nurs 1996; 12: 119–
123
Greiner AC, Knebel E, eds, Committee on the Health Professions Education Summit. Health Professions Education: A
bridge to Quality, Washington, DC, National Academies Press;
2003
Saint Louis University. Center for interprofessional education
and research. Available at: http://www.slu.edu/centers/interpro/(accessed August 28, 2004)
University of Washington. Center for health sciences interprofessional education. Available at: http://interprofessional.
washington.edu/ (accessed August 28, 2004)
University of Minnesota. Interprofessional education andresource center. Available at: http://www.ahc.umn.edu/ahc_
content/education/ierc/ (accessed August 29, 2004)
Carpenter J: Interprofessional education for medical and nursing
students: evaluation of a programme. Med Educ 1995; 29: 265–
272
Greene RJ, Cavell GF, Jackson SH: Interprofessional clinicaleducation of medical and pharmacy students. Med Educ 1996;
30: 129–133
Laatsch LJ, Milson LM, Zimmer SE: Use of interdisciplinary
education to foster familiarization among health professionals. J
Allied Health 1986; 15: 33–42
Mattick K, Bligh J: Interprofessional learning involving medical
students or doctors. Med Educ 2003; 37: 1008–1011
Cooper H, Carlisle C, Gibbs T, Watkins C: Developing an evidence base for interdisciplinary learning: a systematic review. J
Adv Nurs 2001; 35: 228–237