B. Schrewe is a 2017 Pierre Elliott Trudeau Foundation Scholar and clinical assistant professor, Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada. R.H. Ellaway is professor, Department of Community Health Sciences, and director, Office of Health and Medical Education Scholarship (OHMES), Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada. C. Watling is professor, Departments of Clinical Neurological Sciences and Oncology, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada. J. Bates is professor, Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
Acad Med. 2018 Nov;93(11):1645-1651. doi: 10.1097/ACM.0000000000002345.
Changes in the health care landscape over the last 25 years have led to an expansion of training sites beyond the traditional academic health sciences center. The resulting contextual diversity in contemporary medical education affords new opportunities to consider the influence of contextual variation on learning. The authors describe how different contextual patterns in clinical learning environments-patients, clinical and educational practices, physical geography, health care systems, and culture-form a contextual learning matrix. Learners' participation in this contextual matrix shapes what and how they learn, and who they might become as physicians.Although competent performance is critically dependent on context, this dependence may not be actively considered or shaped by medical educators. Moreover, learners' inability to recognize the educational affordances of different contexts may mean that they miss critical learning opportunities, which in turn may affect patient care, particularly in the unavoidable times of transition that characterize a professional career. Learners therefore need support in recognizing the variability of learning opportunities afforded by different training contexts. The authors set out the concept of the contextual curriculum in medical education as that which is learned both intentionally and unintentionally from the settings in which learning takes place. Further, the authors consider strategies for medical educators through which the contextual curriculum can be made apparent and tangible to learners as they navigate a professional trajectory where their environments are not fixed but fluid and where change is a constant.
过去 25 年来，医疗保健领域的变化促使培训场所从传统的学术医疗科学中心扩展到其他地方。当代医学教育中由此产生的背景多样性为考虑背景变化对学习的影响提供了新的机会。作者描述了临床学习环境中的不同背景模式（患者、临床和教育实践、自然地理、医疗保健系统和文化）如何形成一个背景学习矩阵。学习者在这个背景矩阵中的参与塑造了他们学习的内容和方式，以及他们可能成为什么样的医生。尽管熟练的表现严重依赖于背景，但医学教育者可能没有积极考虑或塑造这种依赖性。此外，学习者无法认识到不同背景下的教育优势，这可能意味着他们错过了关键的学习机会，进而可能影响患者的护理，尤其是在职业生涯中不可避免的过渡时期。因此，学习者需要支持来识别不同培训环境提供的学习机会的可变性。作者提出了医学教育中背景课程的概念，即从学习发生的环境中有意和无意地学习到的内容。此外，作者还考虑了医学教育者的策略，通过这些策略，学习者在职业发展过程中可以看到并理解背景课程，因为他们的环境不是固定的，而是流动的，变化是常态。
