Sweeney G
Clin Invest Med. 1999 Feb;22(1):15-22.
There has been intense debate about medical curriculum reform since the early 1950s. The last 25 years have seen a steady shift ward problem-based learning curriculum design in schools of medicine and allied health sciences. This trend has been less challenging for clinical departments than for departments of basic science, where it has often evoked anxiety, antipathy, lack of cooperation, and general mistrust. This appears paradoxical, as problem-based learning (PBL) is promoted as an improved method of integrating scientific concepts, and the advances that drive much of modern medical practice are advances in the basic sciences. While proponents of PBL argue that the approach promotes better integration and use of scientific concepts, the evidence, such as it is, is against this. As well, other evidence suggests that clinicians do not use basic science concepts extensively in their practice. This then questions the utility of scientific knowledge in a medical curriculum. This article examines this notion of utility (the quality or state of being useful), to establish some ground rules for what does, and does not, possess utility, and to present strategies to develop specific objectives from general statements concerning utility. Understanding of biologic and pathologic processes becomes of central importance and arguably possesses utility. If it is both required and evaluated, such understanding necessitates mastery of basic science concepts. Previously, the presentation of the basic sciences in medical curricula has emphasized the acquisition of knowledge rather than its use. Such learning has been perceived to lack utility; strategies to enhance the value of studying basic science concepts are suggested. If the importance of objectives in the basic medical sciences is accepted, these objectives should be achieved early in training, maintained at exit from medical school, and revisited in continuing medical education. The process of change in medical education initiated by Abraham Flexner early in this century remains incomplete. One reason why curricular changes have proved frustrating to basic scientists is that much of clinical medicine remains unnecessarily unscientific. Until clinical medicine itself changes, the utility of science in the training of a physician will remain difficult to demonstrate.
自20世纪50年代初以来，关于医学课程改革一直存在激烈的争论。在过去的25年里，医学院校和相关健康科学专业的课程设计逐渐转向以问题为基础的学习模式。与基础科学部门相比，这种趋势对临床部门的挑战性较小，基础科学部门常常因此产生焦虑、反感、缺乏合作以及普遍的不信任。这似乎自相矛盾，因为基于问题的学习（PBL）被推崇为整合科学概念的一种改进方法，而推动现代医学实践发展的诸多进步正是基础科学的进步。虽然PBL的支持者认为这种方法能促进科学概念更好地整合与运用，但现有证据却并非如此。此外，其他证据表明临床医生在实践中并未广泛运用基础科学概念。这就对医学课程中科学知识的实用性提出了质疑。本文探讨实用性这一概念（有用的性质或状态），以确立关于什么具有实用性、什么不具有实用性的一些基本规则，并提出从关于实用性的一般性陈述中制定具体目标的策略。对生物和病理过程的理解变得至关重要，并且可以说具有实用性。如果这种理解既被要求又被评估，那么掌握基础科学概念就成为必要。以前，医学课程中基础科学的呈现强调知识的获取而非运用。这种学习被认为缺乏实用性；文中提出了提高学习基础科学概念价值的策略。如果认可基础医学科学中目标的重要性，这些目标应在培训早期实现，在医学院毕业时保持，并在继续医学教育中重新审视。亚伯拉罕·弗莱克斯纳在本世纪初发起的医学教育变革进程仍未完成。课程改革令基础科学家感到沮丧的一个原因是，许多临床医学仍然不必要地不科学。在临床医学自身发生改变之前，科学在医生培训中的实用性将仍然难以证明。
