Neurologic education for the future: a decade of curricular reform at Harvard Medical School.

The field of neurology is undergoing significant changes to which curricular reform is both responding and contributing. We reflect on a decade of experience at Harvard Medical School with integration of neuroscience, behaviour, pathophysiology and introductory clinical skills. As part of Harvard's "New Pathway" curriculum, this coordinated, pre-clerkship program embraces a "hybrid" form of problem-based learning. A variety of methods are employed synergistically to meet the two broad goals of preparing for competency in neurologic clerkships and for career-long learning in clinically relevant neuroscience. We articulate specific ways of elevating the level of intellectual inquiry, involving multi-disciplinary faculty more productively, and vertically integrating the learning experience through the years of medical school.

An integrated preclerkship curriculum in neuroscience, psychiatry, and neurology.

The study's objective was to promote understanding of the integration of preclerkship learning in neuroscience, psychiatry, and neurology and to share the authors' experience with such a program. A dualism, which may have survived in the past for lack of robust evidence of mind-brain relationships, is now increasingly outmoded. Medical school education should reflect the increasing coherence to be found in these fields. The authors describe curricular and course innovations and revisions at Harvard Medical School that have been implemented in successive iterations over the past decade. These changes have depended upon multidisciplinary leadership, planning, and faculty participation, as well as faculty development and closer coordination between classroom- and hospital-based activity. A hybrid, problem-based block course in the second year integrates basic science with neurologic and psychiatric topics that are aligned with practice of relevant clinical skills. The authors have achieved a high level of integration and coordination of these subjects at preclerkship levels in the domains of both knowledge and skills. The students, as well as the faculty, strongly endorse an intellectually coherent and clinically relevant program of integrated preclerkship learning in neuroscience, psychiatry, and neurology.

Context in medical education: the informal ethics curriculum.

As some formal bioethics instruction has become the norm in American medical schools, a trend has emerged toward increased attention to context in both bioethics education and bioethical decision-making. A focus on classical dilemmas and a textbook knowledge of principles is yielding its previous dominance to permit a more detailed examination of ethical behaviour in actual practice in medicine. After documenting and analysing this emerging trend in bioethics education and its parallel in bioethics theory and research, we turn to the context of medical education itself to look beyond formal bioethics instruction to the 'informal curriculum' that is so central to the moral development of medical students and residents. A qualitative research strategy is being used to study the informal curriculum through analysing tape-recorded informal conversations students and residents have with their friends and colleagues at work about issues bearing on their professional development. Data presented are documenting 'the unwritten code' for medical students on a surgical clerkship and the senior residents' informal ways of producing a 'practical ethics of conduct' that shapes understanding of what is good, skilful, and right on that surgical service. How conceptions of appropriate conduct are conveyed, rewarded and sanctioned also reveals how professional demeanour is taught, permitting discussion about what should be retained and what changed. The context in which ethical issues arise enhances understanding of ethical practice in medicine.

Accounting for context: future directions in bioethics theory and research.

Many physicians have found that the traditional approach to bioethics fails to account for important aspects of their moral experience in practice. New approaches to bioethics theory are challenging the traditional application of universal moral principles based in liberal moral theory. At the same time, a shift in both the goals and methods of bioethics education has accompanied its "coming of age" in the medical school curriculum. Taken together, these changes challenge both bioethics educators and theorists to come closer to the details and nuances of real clinical encounters. The emerging trend emphasizes the importance of context in bioethics education and in the moral theory and research undergirding it. This article introduces one research approach examining the practical life contexts of medical students' ethical experiences and learning. It calls for increased attention to research and theory in bioethics that more adequately accounts for the ways different contexts produce significant changes in meaning and understanding in medical encounters.

Characteristics of the informal curriculum and trainees' ethical choices.

In October 1995, the Association of American Medical Colleges held its first Conference on Students' and Residents' Ethical and Professional Development. In a plenary session and break-out sessions, the 150 participants, representing a wide variety of medical and professional specialties and roles, discussed the factors and programs that affect medical trainees' development of ethical and professional standards of behavior. The main challenge of addressing students' professional development is the enormous range of influences on that development, many of which, such as the declines in civic responsibility and good manners throughout the United States, fall outside the scope of academic medicine. Nonetheless, many influences fall within reach of medical educators. In a pre-conference survey, participants ranked eight issues related to graduating ethical physicians. The respondents ranked highest the inadequacy of the understanding of how best to influence students' ethical development, followed by faculty use of dehumanizing coping mechanisms, and the "business" of medicine's taking precedence over academic goals. The plenary speakers discussed the "informal curriculum" and the "hidden curriculum" and the need for medical faculty to take seriously the great influence they have on students' and residents' moral and professional development as they become physicians. Whether consciously or not, medical education programs are producing physicians who do not meet the ethical standards the profession has traditionally expected its members to meet. In three series of break-out sessions, the participants analyzed the nature of the ethical dilemmas that medical students and residents face from virtually the first day of their training, the use of role playing in promoting ethical development, and ways to improve policies and overcome barriers to change.

Boundaries in psychotherapy: model guidelines.

THE maintenance of boundaries in psychotherapy is now one of the most critical areas of ethical inquiry for psychiatrists and other mental health professionals. Sexual contact between therapists and patients-the most egregious example of boundary violation-has received a good deal of attention (Gabbard 1994), and a firm consensus regarding its inappropriateness has developed (American Psychiatric Association 1992b; American Psychological Association 1992). But public concern over nonsexual boundary violations is growing, as witnessed by highly publicized cases in the media (Kagan 1988; Karel 1993), rulings by licensure bodies (In the Matter of Aronoff 1992), and lawsuits (Jorgenson and Sutherland 1993). Evidence from all of these sources suggests that the task of defining appropriate boundaries in psychotherapy is complex and confusing for therapists, regulators, and the public alike.

Thoughts and feelings and things: a new psychiatric epistemology.

Epistemology--the study of knowledge--is a philosophical discipline with close ties to psychiatry. When epistemologists address specific questions about how knowledge is actually realized by human beings, their philosophy must be informed by empirical studies of the sort psychiatrists now take up in a variety of forms. As this paper describes, psychiatrists can likewise improve their understanding of human psychology through a deeper appreciation of philosophical analysis in epistemology. The aim of this article is to introduce a unifying framework within which the experience from different approaches to psychiatry--(1) the conceptual schemas of cognitive psychiatry, (2) the mental structures of psychoanalytic psychiatry, (3) the categorical forms of existential psychiatry, and (4) the neural pathways of biological psychiatry--can all be applied productively to the central question of epistemology. By establishing a broad understanding of the problem of knowledge, this new view of epistemology is developed within the idiom of each psychiatric approach. In addressing themselves to a unitary problem, these diverse psychiatric approaches are themselves revealed, not as competing points of view, but as complementary views of a single subject. The result is a new epistemology that can not only bring the insights of psychiatry to philosophy, but can also contribute to the care of patients when psychiatrists bring this broader view to their clinical work.

A controlled study of phenomenology and family history in outpatients with bulimia nervosa.

We administered structured diagnostic interviews and family history evaluations to 69 outpatient women meeting the new DSM-III-R criteria for bulimia nervosa. This group was compared with 50 women with DSM-III bulimia, 24 women with major depression, and 28 nonpsychiatric control women, all recruited during previous studies. On both phenomenologic and family history assessments, the women with DSM-III-R bulimia nervosa closely resembled the women with DSM-III bulimia, and both groups differed significantly from controls in their prevalence of personal and familial major mood disorders. These data support a relationship between bulimia nervosa and major mood disorders, consistent with that suggested by studies of bulimia assessed by earlier diagnostic criteria.

A model for ethical problem solving in medicine, with practical applications.

Despite the dramatic increase over recent years in the research and teaching of medical ethics, there exists no theoretical framework within which to conceptualize ethical problems in medicine, to say nothing of solutions to these problems. The model proposed here attempts to fill this void by developing a conceptual understanding of the nature of moral dilemmas that can be applied to both theoretical and practical problems in medicine. Practical applications are demonstrated in three areas: personal ethical problem solving, hospital ethics committees, and the teaching of medical ethics. Suggestions are offered for the extension of these and other applications of the model, a model proposed as a foundation to be built upon through further research and daily experiences in a world of conflicting values.