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In 1900 the United States had more medical schools than the rest of the world combined. Many of them were commercial institutions devoted to making profits rather than to educating men to perform competently within the medical profession. The profit incentive precipitated low educational standards and made American medical practice decidedly inferior to medical practice almost anywhere else in the civilized world. By 1900 medical education had become pernicious, threatening the health of the nation and the future of the American medical profession. This thesis discusses the efforts to reform medical education practices.

Undergraduate medical curricula are required to change and evolve in order to reflect the evolving and changing needs of contemporary medical practice. Making substantial changes to the form and delivery of medical education is challenging. While there is a growing body of research that focuses on curriculum change, relatively little attention is given to the notion of curriculum reform as a process rather than an outcome. In addition, the buildings and learning spaces where curriculum reform and undergraduate medical education are enacted contribute to people's experiences of these spaces. However, this aspect of context is currently neglected in the medical education literature. This thesis investigates the influences, vision, intentions and unintended consequences associated with an undergraduate medical curriculum reform and how the learning place and space of the medical school (where a curriculum is translated) is understood and experienced by key stakeholders (e.g., building designers, teaching faculty and students). Ontologically and epistemologically grounded within the social constructivist paradigm, the overall thesis aim was achieved through four overlapping empirical studies. Using a qualitative exploratory case study approach, data were gathered from document analysis, interviews and focus groups, and enriched by different theoretical concepts. Findings demonstrated that both (re)designing a medical curriculum and the learning space and place where reform is enacted and where teaching and learning occur is extremely complex, multifactorial and shaped and impacted by a myriad of influences and external and internal drivers for change; influenced by numerous voices and differing opinions and perspectives, different values systems, local traditions, history, geographical location and overall context. Finally, as a contribution to scholarship, the collective findings in this thesis advances our understanding of the complexities and unintended consequences associated with curriculum reform and the space and place of learning.

Duchenne Muscular Dystrophy (DMD), characterized by the lack of dystrophin, results from a mutation in the Xp21 gene which encodes for the protein dystrophin that links the extracellular matrix to the actin cytoskeleton in skeletal, cardiac and smooth muscle. Slow colonic transit and chronic constipation are common in DMD patients due to the weakening of the abdominal wall muscles and gut smooth muscle. However, the cause of this hypocontractility in DMD patients and the expression of contractile proteins in smooth muscle are unknown. Expression of contractile proteins is regulated by the signaling pathways activated by excitatory (e.g., acetylcholine, ACh) and inhibitory transmitters (e.g., nitric oxide). Hydrogen sulfide (H2S) is well-known for its anti-oxidant effects; however, its utility to restore DMD-induced effects is unknown. Aim: To investigate the expression of contractile proteins and smooth muscle function in the colon of wild type mice and models of DMD (mdx and mdx/mTR mice) and the effect of H2S on these in mdx mice. Methods: Contraction of colonic segments was measured in the longitudinal orientation from 3-month old control and mdx mice, and 9-month old control and mdx/mTR mice, (mdx/mTR exhibit increased disease severity). The effect of SG1002, an orally active slow releasing H2S agent, was tested in mdx/mTR mice (40 mg/kg body weight in chow/every 3 days starting from 3 weeks to 9 months). Expression of contractile proteins was measured by qRT-PCR and western blot. Results: Expression of smoothelin, caldesmon, calponin and tropomyosin was decreased in colonic smooth muscle of mdx mice compared to control. This decrease was associated with a decrease in ACh-induced contraction in colonic segments (21 ± 3 mN/100 mg tissue in control and 3 ± 1 mN/100 mg tissue in mdx mice). To identify the specific involvement of smooth muscle dysfunction in the decrease in contraction, colonic muscle cells were isolated and contraction in response to ACh was measured by scanning micrometry and expressed as the percent decrease in cell length from control cell length. ACh-induced contraction was also inhibited in muscle cells isolated from mdx mice compared to control (43±5% in control and 27±3% in mdx mice). ACh-induced contraction was decreased in colonic segments from mdx/mTR mice (12 ± 2 mN/100 mg tissue in control versus 4 ± 1 mN/100 mg tissue in mdx/mTR) and the decrease was partly reversed by SG1002 treatment (9 ± 1 mN/100 mg tissue). mRNA expression of thin filament associated proteins was also decreased in colonic smooth muscle from mdx/mTR mice and the decrease was reversed by SG1002. These results suggest that H2S restores contractile protein mRNA expression and contraction in mdx/mTR mice. Conclusion: The data indicate that the lack of dystrophin in mdx mice adversely affects colonic smooth muscle contractility through the down regulation of contractile protein mRNA expression. Treatment of mdx/mTR mice with H2S restores contractile phenotype. Thus, H2S treatment would be an area of study in therapeutic control of DMD-induced gastrointestinal motility disorders.

Becoming a Family Physician – Exploring the Experiences of Residents During the First Six Months of Postgraduate Training describes the early training experience of residents from their perspective as they begin a postgraduate program in Family Medicine. A case study approach using focus groups and individual interviews was used to gain insight into the resident-participant’s experiences of the first six months of training. Resident-participants were asked to describe their concerns, changes that occurred and the influences they attributed to those changes as a way to explore their early training experiences from their perspective. This study found resident-trainees do not begin a Family Medicine postgraduate training program knowing what it means to be a Family Physician, but must learn what it means to fulfill this role. From the participants’ perspective, this process involves adjusting to significant shifts in responsibility in the areas of Knowledge, Practice Management and Relationships that occur when they make the transition from being medical students in undergraduate training to doctors responsible for the outcome of care during postgraduate training. As the participants began postgraduate training they were eager to accept the responsibility of being the doctor, but were uncertain they had the necessary medical experience and expertise for someone calling themselves the doctor. The experience of practice, which included developing relationships with different patients over time (continuity of care) was particularly influential in helping the participants gain confidence in fulfilling the role of doctor and learning that the role of Family Physician is complex, multifaceted and not limited to their initial concept of doctoring. As the participants adjusted to their new responsibilities, they gained confidence in their new role as doctor, which subsequently led to a more comprehensive understanding of what it meant to be a Family Physician. This study was able to contribute to what little is know about the transition into a postgraduate Family Medicine program by illuminating from the resident-participant’s perspective how the transition is experienced. In doing so, medical educators have a better understanding of the early training experience of resident-trainees and how these experiences contribute to consolidating their new professional identity.

Becoming a Family Physician – Exploring the Experiences of Residents During the First Six Months of Postgraduate Training describes the early training experience of residents from their perspective as they begin a postgraduate program in Family Medicine. A case study approach using focus groups and individual interviews was used to gain insight into the resident-participant’s experiences of the first six months of training. Resident-participants were asked to describe their concerns, changes that occurred and the influences they attributed to those changes as a way to explore their early training experiences from their perspective. This study found resident-trainees do not begin a Family Medicine postgraduate training program knowing what it means to be a Family Physician, but must learn what it means to fulfill this role. From the participants’ perspective, this process involves adjusting to significant shifts in responsibility in the areas of Knowledge, Practice Management and Relationships that occur when they make the transition from being medical students in undergraduate training to doctors responsible for the outcome of care during postgraduate training. As the participants began postgraduate training they were eager to accept the responsibility of being the doctor, but were uncertain they had the necessary medical experience and expertise for someone calling themselves the doctor. The experience of practice, which included developing relationships with different patients over time (continuity of care) was particularly influential in helping the participants gain confidence in fulfilling the role of doctor and learning that the role of Family Physician is complex, multifaceted and not limited to their initial concept of doctoring. As the participants adjusted to their new responsibilities, they gained confidence in their new role as doctor, which subsequently led to a more comprehensive understanding of what it meant to be a Family Physician. This study was able to contribute to what little is know about the transition into a postgraduate Family Medicine program by illuminating from the resident-participant’s perspective how the transition is experienced. In doing so, medical educators have a better understanding of the early training experience of resident-trainees and how these experiences contribute to consolidating their new professional identity.

Medical students enter medical school with varied backgrounds and learning expectations. Tensions arise between medical students’ expectations and expectations of the teachers and program, which impacts motivation. In self-determination theory people are motivated by satisfaction of three psychological needs: autonomy, competence, and relatedness, which enhance self-determination, but when hindered decrease motivation and well-being. The purpose of this study was to explore medical students' perspectives of their self-determination during medical school by exploring medical students’ perspectives of autonomy-supportiveness, competence-supportiveness, and relatedness with their teachers in their medical education program, and the impact on their learning. I used mixed methods design with two phases. In Phase I, medical students from a single institution completed three surveys all derived from self-determination theory, which investigated causality orientation, autonomy-supportiveness of teachers, and motivation to engage in learning. In Phase II, two World Café events were held at two sites. Medical students’ discussed their perspectives of autonomy, competence, and relatedness in their medical education. I used deductive content analysis to organize the findings into themes. In Phase I, 178 students responded (57% female). Survey scores were compared by gender, year in program, years of university before medical school, and distributed program site. The results indicated that medical students were autonomously oriented. Females were more autonomy-oriented than males, and engaged in learning for more autonomous reasons. Students in the distributed site perceived their teachers to be less autonomy supportive. In Phase II, 64 students attended two World Café events. Themes were categorized according to psychological need. The students identified several teacher actions and curricular structures that supported and hindered their self-determination. The themes across distributed sites were consistent; however, students in the distributed site perceived lower autonomy and less relatedness with their teachers. This study used qualitative methods to explore students’ perspectives of self-determination, which is unique to the self-determination literature. Educators often emphasize teaching methods to maximize cognitive and motivational outcomes. However, medical students emphasized specific teacher actions and curricular supports as most important for establishing the motivational context for learning. This research will help medical teachers to intentionally create appropriate motivational contexts for learners.