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This thesis deals with two related questions. The first relates to a critical inquiry into the processes of curriculum creation and formation within a medical school which has undergone a significant curriculum revision. I explore the notion that such processes can be understood as a form of practice in which the relationship between content and process is held together by what is explored in the thesis as an indivisible, paradoxical tension. Exploring curriculum as a kind of process is a novel approach in a school steeped in the traditions of the natural sciences. The common metaphors for curriculum in this setting refer to blueprints, models, behavioural competencies and objective standards. These are all founded on the belief in an objective observer who can maintain some form of distance between themselves and the subject in question. Issues of method are, therefore, central to my explorations of how we might, instead, locate curriculum in social processes and acts of evaluation involving power relations, conflict and the continuous negotiation of how it is we work together. The paradox of process and content in this way of understanding is that participants in curricular practice are simultaneously forming and being formed by their participation. In this way of thinking, it makes no sense to say one can either “step back” to “reflect” on their participation or that there is a way to approach participation “objectively.” The other question I address in this thesis has to do with the emergence of excellence. By emergence, I refer to thinking in the complexity sciences which attempts to explain phenomena which have a coherence which cannot be planned for or known in advance. “Excellence” is a kind of idealization which has no meaning until it is taken up and “functionalized” within specific settings and situations. In the setting of participating in curriculum formation, excellence may be understood as one possible outcome of persisting engagement and continuous inquiry which itself influences the ongoing conversation of how excellence is recognized and understood. In other words, excellence emerges in social processes as a theme simultaneously shaping and being shaped by curricular practice. This research was initiated as a result of a mandate to establish a program which could demonstrate excellence in the area of relationships in health care. The magnitude of this mandate felt overwhelming at the time and raised a lot of anxiety. I found that the traditional thinking regarding participation in organizational change processes (which, within my setting, could be understood as “set your goal and work backwards”) did not satisfactorily account for the uncertainties and surprises of working with colleagues to create something new. The method of inquiry can be read as another example of a process / content paradox through which my findings regarding curriculum and excellence emerged. This method involved taking narratives from my experience as an educator and clinician and a participant in varied forms of curricular processes and inquiring into them further by both locating them within relevant discourses from sociology, medical education and organizational studies and also sharing them with peers in my doctoral program as well as colleagues from my local setting. This method led to an inquiry and series of findings which was substantively different from my starting point. This movement in thinking offers another demonstration of an emergent methodology in which original findings are “discovered” through the course of inquiry. These findings continue to affect my practice and my approach to inquiry within the setting of medical education. The original contributions to thinking in medical education occur in several ways. One is in the demonstration of a research method which takes my own original experience seriously and seeks to challenge taken for granted assumptions about a separation of process and content, instead exploring the implications of understanding these in a relation of paradox. By locating my work within social processes of engagement and recognition, I explore the possibility that excellence can also be understood as an emergent property of interaction which is under continuous negotiation which itself forms the basis for further recognition and exploration of “excellence.” The social processes which shape and are shaped by “excellence” are fundamental to the practice of curriculum itself. Both curricula and “excellence” emerge within the interactions of people with a stake in the desired outcomes as the product of continued involvement and consideration of ongoing experience. Finally, a process view of medical education is presented as a contribution to understanding the work of training physicians who are comfortable with the uncertainties and contingencies involved in the humane care of their patients.

Medical schools in the United States serve to train the next generation of physicians, admitting students who will continue to advance each school’s mission. Admission committees are tasked with identifying those candidates who will be successful academically and who promote the objectives of the school with respect to mission. The Quillen College of Medicine at East Tennessee State University in northeast Tennessee seeks to attract and retain physicians with an interest in rural and primary care medicine. A total of 630 students were included in this study representing classes from 2001 to 2011. This study examined admissions data including MCAT scores, undergraduate GPAs, admission interview scores, and admission committee rating scores along with USMLE Step 1 scores to determine if there is any correlation of these variables with graduates selecting a primary care career or a rural practice location. With respect to data available at admission, only MCAT scores were shown to have a significant correlation to specialty choice. None of the admission data significantly correlated with practice location. USMLE Step 1 scores had a weak negative relationship with specialty choice and a negligible relationship with practice location. This study provides the admission committee information that these variables are insufficient by themselves to predict whether a medical student applicant will select a primary care specialty or practice in a rural location. Other data, perhaps even subjective data, would need to be analyzed to predict how well the admissions committee is addressing the college’s mission with its selection of medical students.

From 1900 to 1944, public health was a pillar of the French colonial project in French West Africa. African medical workers became the backbone of the Native Medical Service, which sought to “grow the race” (faire du noir) and popularize French cultural ideals while improving the general health of the African population and combating epidemic diseases. Through successive yellow fever and plague epidemics, the Medical Service honed a set of health measures that it utilized in epidemic outbreaks. These health measures remained largely unchanged throughout the period. The political environment and the reactions of African residents, especially residents of the Four Communes, to these anti-epidemic measures did change though. Intermittent popular resistance to health measures, along with persistent personnel shortages, budget constraints, the sparsely settled population, and the vast land area of West Africa conspired to make the goals of the Native Medical Service difficult to achieve. An examination of the internal profile (personnel numbers, job descriptions, evaluations, organization and organizational changes, and policies) of the Native Medical Service from 1900 - 1944 demonstrates some of the aspects of how the ideology of French colonialism was at odds with itself and with colonial realities. The Native Medical Service was an arm of the colonial government in areas where it was weak, such as spreading French civilization and appreciation for French culture. Despite being used to compensate for some of the government’s shortcomings, the Native Medical Service experienced disjunctions between its goals and the means to achieve them that hindered its effectiveness. The ideological core of French colonialism was built around the Civilizing Mission, development (la mise en valeur), and the myth of the indissolubility of Greater France. The widespread French belief in African inferiority and that the benefits of French imperial rule to the subject peoples outweighed the drawbacks both worked against the success of French goals in West Africa to spread their civilization, foster economic and human development, and form a lasting addition to France Outre-Mer. / text

BACKGROUND: In recent years, medical and physician assistant (PA) education has moved towards a competency based model. This model encourages teaching students to “know how” to use what they learn in practice rather than simply gain a large knowledge base. This allows students to garner a deeper understanding of the material. Active learning strategies such as flipped classroom and interactive learning, have gained great support in recent years. These models have helped further the ability of universities to move towards these competency based education models. At the core of these newer teaching and learning modalities are the instructors themselves. They play a vital role in not only what a student learns, but how well they learn it. LITERATURE REVIEW: A literature review highlights both the importance of hiring quality instructors as well as the importance of their ability to fulfill these new teaching models. There have been numerous studies on how effective teaching influences a student’s performance in the classroom. To date, there has not been any research on how to increase the probability of hiring an effective instructor from day one. PROPOSED PROJECT: The objective of this study is to develop a tool that would help employers screen for potentially less qualified candidates. The proposed tool is a questionnaire that would be filled out by potential employees and would raise a red flag if a potentially concerning answer choice was selected. The validity of this questionnaire will be tested by comparing current physician assistant didactic and clinical instructors’ scores on the questionnaire, to their respective student evaluations. CONCLUSION: It is predicted that a “red flag” score on/this questionnaire will correlate with poor instructor scores on student evaluations. Successful validation and deployment of this tool would allow students to be instructed by the best possible instructors, bettering their education.

Contribution The main contribution offered by my research is an increased understanding of medical students’ perceptions of empathy and the factors that influence this. By using an innovative method in medical education research, the study contributes to research methodology. Background Empathy is accepted as a fundamental part of the patient-doctor relationship and essential for effective clinical care. Current societal opinions are that some healthcare professionals lack empathy and that medical students become less empathetic during their training, although the reasons for this are not understood. If this perceived decline is to be addressed, medical educators need to understand students’ perspectives of the factors that influence their empathy. Aims of the research The study sought to gain a deeper understanding of the development of medical students’ empathy and the factors influencing this during their undergraduate training. It is hoped that this understanding may lead to improvements in medical education and patient care. Methods Ethical approval for the study was granted by the University. A phenomenological approach was adopted, which involved listening to the students’ views and experiences of their course. Serial, semi-structured, indepth, interviews were conducted with sixteen medical students. Each year the student completed an hour-long interview over three years. One group of eight students were followed during the preclinical years of the course (years 1-3) and the other group, during the clinical years (years 4-6). The interviews were audio-recorded, transcribed, coded using qualitative data analysis software (N Vivo), and analysed using an interpretative phenomenological approach. Findings The students in the preclinical years described empathy as a personal attribute, emphasising its emotional dimension. In the clinical years, students viewed empathy differently: as a complex relational process with the patient, which varied in depth and quality according to the clinical context. They described the tensions between connecting with and detachment from a patient. Students indicated influences which enhanced their empathy, including patient contact and positive role models. They also identified barriers to empathy, including: the medical school culture, a biomedical bias in the curriculum, a lack of patient contact, negative role models and teaching of professionalism as distancing from patients. The preclinical group of students reported gaining in self-confidence during their course. The clinical group described how their empathy with patients had increased but they detected a conflict between empathy and efficiency. Conclusions The use of an innovative longitudinal, phenomenological approach in medical education research generated new understanding of a complex interpersonal view of empathy and highlighted aspects of a ‘hidden curriculum’. The students maintained that their contact with patients was the most useful way of developing empathy. They expressed a desire to connect emotionally with patients but were uncertain how to balance this connection with professional detachment. They described a marked biomedical emphasis in their course and perceived that teaching on professionalism encouraged a distancing from patients. In contrast to the widely-reported opinion that there has been a decline in medical students’ empathy, this study suggested that students perceived that their empathy increased during their training. However, some students had learned distancing behaviours to hide their empathetic feelings. In the light of this research, it is hoped that medical educators will develop ways of supporting students to deal appropriately with their own emotions and those of patients.

Made available in DSpace on 2014-06-11T19:33:27Z (GMT). No. of bitstreams: 0 Previous issue date: 2002Bitstream added on 2014-06-13T19:04:14Z : No. of bitstreams: 1 cyrino_eg_dr_botfm.pdf: 1051308 bytes, checksum: 43dc82ef9643c7314b55af43fb4c9550 (MD5) / Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) / Um movimento amplo vem se estruturando para responder à formação de um médico crítico, criativo, com responsabilidade, ético e mais humano e que participe ativamente na construção do Sistema Único de Saúde. Em 1998, docentes dos Departamentos de Pediatria e de Saúde Pública iniciaram a construção de novos cursos a serem ministrados ao terceiro ano de graduação médica. O objetivo desta investigação foi descrever os casos de inovação dos cursos de Semiologia Pediátrica e de Saúde Coletiva III para o desenvolvimento da proposta de reforma curricular da instituição. Foram escolhidos dois casos singulares: Saúde Coletiva III, com a participação de cinco disciplinas: Administração, Ciências Sociais, Epidemiologia, Ética e Nutrição em Saúde Publica, oferecido em 1999 e Semiologia Pediátrica ministrado em 2000. Para descrição e avaliação dos casos, utilizaram-se de métodos quantitativos e qualitativos. O de Saúde Coletiva III foi organizado sob três núcleos temáticos: Problemas em Saúde Publica; Nutrição em Saúde Publica; Planejamento em Saúde. O modelo de ensino centrou-se na problematização de situações concretas vivenciadas na prática da Saúde Publica, trabalhando-se em centros de saúde, serviços e organizações de saúde da região de Botucatu. O de Semiologia Pediátrica privilegiou a atenção integral à saúde da criança. O modelo de ensino centrou-se na aprendizagem baseada em problemas e no aprendizado prático da semiologia pediátrica em diferentes cenários, enfatizando-se o ensino em ambulatório. Nos dois casos privilegiou-se o trabalho em pequenos grupos, com a orientação docente. A avaliação foi uma preocupação constante, apresentando aspectos diferentes para os dois cursos. Os cursos estudados inovaram pelo esforço de Departamentos que tiveram autonomia e independência para formulá-los... / Many projects and changes have been under way to add to the formation of a critical, creative, responsible, ethical and caring doctor who would be strongly participative in the consolidation of SUS (Unified Health System). In 1998, faculty members of the Pediatrics and Public Health Departments of Botucatu Medical School started planning new courses for the third year of Medical School. This work describes the innovations in the courses of Pediatric Semiology and Collective Health III aiming the curricular reform in the institution. Two particular cases were chosen: Collective Health III with five disciplines: Administration, Social Sciences, Epidemiology, Ethics and Nutrition in Public Health taught in 1999 and Pediatric Semiology in 2000. Quantitative and qualitative methods were used to describe and evaluate the cases. Collective Health covered tree themes: Problems in Public Health, Nutrition in Public Health and Planning in Health. The teaching model was centered on the inquiry of real situations routinely experienced in Health Centers and other Health Services in Botucatu and surrounding areas. Pediatric Semiology focused on full assistance to children. The teaching model adopted was Problem Based Learning and practical teaching of Pediatric Semiology in different scenarios, mainly in the outpatient department. Group work under professor guidance was encouraged in both cases. Constant evaluation was strongly valued presenting different aspects in these two courses. The innovation came as a result of the effort made by the departments who had autonomy to carry it out. The main goal was to realize and utilize the strategies that could offer a student-centered approach which would allow for more independence to build and increase his knowledge. As to Pediatrics, the model adopted was Comprehensive Medicine focused on child assistance... (Complete abstract, click electronic access below)

Orientador: Agueda Beatriz Pires Rizzato / Resumo: Um movimento amplo vem se estruturando para responder à formação de um médico crítico, criativo, com responsabilidade, ético e mais humano e que participe ativamente na construção do Sistema Único de Saúde. Em 1998, docentes dos Departamentos de Pediatria e de Saúde Pública iniciaram a construção de novos cursos a serem ministrados ao terceiro ano de graduação médica. O objetivo desta investigação foi descrever os casos de inovação dos cursos de Semiologia Pediátrica e de Saúde Coletiva III para o desenvolvimento da proposta de reforma curricular da instituição. Foram escolhidos dois casos singulares: Saúde Coletiva III, com a participação de cinco disciplinas: Administração, Ciências Sociais, Epidemiologia, Ética e Nutrição em Saúde Publica, oferecido em 1999 e Semiologia Pediátrica ministrado em 2000. Para descrição e avaliação dos casos, utilizaram-se de métodos quantitativos e qualitativos. O de Saúde Coletiva III foi organizado sob três núcleos temáticos: Problemas em Saúde Publica; Nutrição em Saúde Publica; Planejamento em Saúde. O modelo de ensino centrou-se na problematização de situações concretas vivenciadas na prática da Saúde Publica, trabalhando-se em centros de saúde, serviços e organizações de saúde da região de Botucatu. O de Semiologia Pediátrica privilegiou a atenção integral à saúde da criança. O modelo de ensino centrou-se na aprendizagem baseada em problemas e no aprendizado prático da semiologia pediátrica em diferentes cenários, enfatizando-se o ensino em ambulatório. Nos dois casos privilegiou-se o trabalho em pequenos grupos, com a orientação docente. A avaliação foi uma preocupação constante, apresentando aspectos diferentes para os dois cursos. Os cursos estudados inovaram pelo esforço de Departamentos que tiveram autonomia e independência para formulá-los... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Many projects and changes have been under way to add to the formation of a critical, creative, responsible, ethical and caring doctor who would be strongly participative in the consolidation of SUS (Unified Health System). In 1998, faculty members of the Pediatrics and Public Health Departments of Botucatu Medical School started planning new courses for the third year of Medical School. This work describes the innovations in the courses of Pediatric Semiology and Collective Health III aiming the curricular reform in the institution. Two particular cases were chosen: Collective Health III with five disciplines: Administration, Social Sciences, Epidemiology, Ethics and Nutrition in Public Health taught in 1999 and Pediatric Semiology in 2000. Quantitative and qualitative methods were used to describe and evaluate the cases. Collective Health covered tree themes: Problems in Public Health, Nutrition in Public Health and Planning in Health. The teaching model was centered on the inquiry of real situations routinely experienced in Health Centers and other Health Services in Botucatu and surrounding areas. Pediatric Semiology focused on full assistance to children. The teaching model adopted was Problem Based Learning and practical teaching of Pediatric Semiology in different scenarios, mainly in the outpatient department. Group work under professor guidance was encouraged in both cases. Constant evaluation was strongly valued presenting different aspects in these two courses. The innovation came as a result of the effort made by the departments who had autonomy to carry it out. The main goal was to realize and utilize the strategies that could offer a student-centered approach which would allow for more independence to build and increase his knowledge. As to Pediatrics, the model adopted was Comprehensive Medicine focused on child assistance... (Complete abstract, click electronic access below) / Doutor

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Cultural competence in health care provision has been broadly identified as the need for providers to acknowledge, address, or incorporate an understanding of the cultural and social context of patients' lives into the process of treating and managing patient's illnesses. However, how cultural competence can be incorporated has been the subject of debates in biomedicine and anthropology, and has often been met with difficulties in physician practice. These challenges arise from differing perspectives about how cultural competence is understood and institutional neglect of culturally relevant education. While the need for cultural competence integration into health care practitioner training during medical school education has been discussed for over six decades, effective incorporation of cultural competence into medical curriculum remains a multifaceted topic of interdisciplinary debate and a challenging task. The purpose of this project is to evaluate cultural competence integration in Southeastern medical school curriculum. Theoretically, this research utilizes critical medical anthropology as developed by anthropologists Arthur Kleinman, Janelle Taylor and Nancy Sheper-Hughes as a theoretical lens through which cultural competency implementation in Southeastern medical school curricula can be examined curricula Southeastern. This research also fills an interdisciplinary gap in both anthropological and medical scholarly knowledge bases. Methodologically, multiple project parameters have been explored utilizing qualitative data collection methods of cultural competence background and evaluation. This research combines primary data collection and secondary data analysis. Primary data collection involved interviewing individuals from Florida medical institutions concerning their experience and personal views of the benefit of cultural competence integration. The analysis of secondary data explored the integration of cultural competence into medical school curricula. These analyses include an examination of the content, format, and language of Southeastern medical school curricula, demographic trends as related to cultural competence in health care, federal grant allocation as related to cultural competence in health care, and institutional perspectives on incorporating social science concepts in medical education. This thesis makes three distinct but interrelated claims: (1) I argue that based on the provided descriptions of medical institution curriculum guides, there is a substantial discrepancy between the cultural competency incorporation claims made by the schools and what is actually integrated into their curriculum; (2) I argue that cultural competence integration must be delivered vertically across disciplines and horizontally across the entire four year span of medical education, and (3) Available ethnographic guides are presented with too narrow of a focus to apply to all medical school curricula. Understanding the shortcomings of medical school curricula in incorporating cultural competence training is significant because it draws attention to the need to develop more effective and systematic ways to train future health care providers to address the needs of an increasingly diverse patient population.