Preparation for clinical practice: a survey of medical students’ and graduates’ perceptions of the effectiveness of their medical school curriculum

Abstract

This paper describes the perceptions of students and graduates of the Hebrew University—Hadassah medical school in Israel regarding the effectiveness of their medical education in preparing them for work in the clinical setting. The six-year curriculum consists of three years of mainly lecture-based Basic Science courses, and three years of clinical education, consisting of clinical clerkship rotations of various lengths. An anonymous questionnaire containing 114 items was distributed to 294 students (in their clinical years) and 500 graduates of the faculty. A total of 371 respondents completed the questionnaire (response rate 49%). Overall 60% of the respondents were generally satisfied with the medical training they received. However, respondents indicated many deficiencies in the curriculum, and in their competences. More than half of the respondents felt that Basic Science courses lacked clinical relevance. Almost 40% of the respondents reported that students were not taught sufficient clinical skills in preparations for clinical practice. At least 50% of the respondents reported that they had not received adequate exposure to 26 out of the 36 important clinical activities and skills during clerkships. Only 33% of the respondents agreed that the fundamental knowledge, skills, attitudes and values that medical students should possess at the time of graduation were made explicitly clear to them. Perspectives of students and graduates were compared. In many questions significantly more graduates tended to rate their learning experience better than students. This study illuminates many aspects of the curriculum the faculty needs to address in order to prepare physicians effectively and efficiently for clinical work. It also stresses the need to integrate better preclinical and clinical studies, and to change to active learning methods. This study demonstrates the necessity of gathering information from students and graduates to evaluate their medical education experience.

Introduction

The world of medical care has changed dramatically over the past three decades (Greenlick, 1995). Scientific discoveries have had a significant impact on the philosophy of health, and dramatically changed the doctor–patient relationship. These discoveries have led to a rapid increase in the volume of medical knowledge and diagnostic and therapeutic tools that medical trainees and practicing physicians have to deal with in order to provide quality care to their patients (Tosteson, 1990). These changes have also required medical educators to seek out approaches to training that will enable medical graduates to effectively enter the rapidly changing healthcare environment in which they will have to function (Muller, 1984).

Early in the twentieth century reports began to be published identifying the shortcomings of medical schools to prepare their graduates effectively for practice (Flexner, 1925). During the past two decades systems of medical education have been criticized for failing to achieve their goals, and the quality of medical education has been debated extensively (Fraser, 1991). Most recently a report issued by the Association of American Medical Colleges made reference to a recurring theme that has been manifest in many reports published during the past decade on medical education, namely the lack of effectiveness of medical schools in preparing their graduates for practice. The report emphasized the need for new ways to train doctors (Ad Hoc Committee of Deans, 2004).

To address these criticisms many projects have been implemented; some have identified specific objectives and recommendations for medical schools (Greenlick, 1995). Others have stressed that medical schools should emphasize the acquisition of skills, values and attitudes by students as much as the acquisition of knowledge (Rabinowitz et al., 2001; Informatics Panel and Population Health Perspective Panel, 1999; Medical School Objectives Writing Group, 1999; General Medical Council, 2003).

An interesting development in medical education during the past decade has been the application of the principles of evidence-based medicine (EBM) to medical education in the form of best-evidence medical education (BEME). BEME requires the presentation of evidence of whether or not medical education is of good quality (Wolf et al., 2001). Evaluation of the quality of medical education not only requires reliable and valid studies of outcomes, but also studies that identify the trainee's perception of the effectiveness of the training programs he/she is involved in (Vroeijenstijn, 1995). These evaluations should include all interested parties, namely students, graduates and faculty (Hamilton, 1995). In the United States and Canada and some European countries medical faculties are required to conduct self-evaluations periodically as a part of an externally based accreditation process. Nevertheless, there is little information about how students and graduates of medical schools evaluate the medical education they have received (McLaughlin et al., 1992). A few works have been published in the United States (Finocchio et al., 1995), Canada (Woodward & Ferrier, 1983), England (Clack, 1994; Hesketh et al., 2003; Lempp et al., 2005), Finland (Hyppölä et al., 2000) and Denmark (Moercke & Eika, 2002).

Until recently, no accreditation process was required of medical schools in Israel. This has changed, and recently the four medical schools in Israel were reviewed by the Council for Higher Education, the body responsible for authorizing all programs of higher education in the country. At this time, the self-study process required of medical schools of their programs of study does not require a formal evaluation of either outcomes or perceptions of the trainees of the effectiveness of the curricula they are exposed to. This research represents the first attempt at a comprehensive self-evaluation of the effectiveness of components of the curriculum, conducted at the Hebrew University—Hadassah Faculty of Medicine in Jerusalem. This paper describes the results obtained from a survey of medical students involved in the clinical years of study, interns and residents who have graduated from the medical school during the past five years. The primary goal of the survey was to determine the degree to which respondents felt that the curriculum prepared them for clinical practice.

The Hebrew University Faculty of Medicine was the first medical school to be established in Israel, in 1946. The six-year curriculum is a traditional one, with the first three (preclinical) years being devoted almost entirely to the basic sciences, with minimal patient contact. On completion of the first three years students receive a BSc degree. Years 4, 5 and 6 (clinical years) are devoted to traditional clinical clerkships. Students may also enroll in an MSc or PhD program during their undergraduate training. Approximately 100 students are admitted per year. One of the major goals of the faculty is to train medical students who will engage in research after graduation. After completion of the clinical clerkship and the fulfillment of the MD thesis requirement, students are required to do a one-year rotating internship in order to receive their MD degree and licence to practice medicine, and they are then eligible to apply for residency training.

Table

Practice points
•It is important for students and graduates to be part of the self-evaluation of medical faculties.
•It is important to conduct formal student and graduate evaluation of the curriculum every few years.
•It is important for faculties to implement the results of their self-evaluation study in their curriculum.

Methods

A self-administered questionnaire was developed based on the graduation questionnaire distributed in the United States by the Association of American Medical Colleges (AAMC, 2001), and on the recommendations of the projects referred to above. The questionnaire was pilot tested prior to administration. The questionnaire contained 114 items consisting of Likert-scale-type questions used for items measuring satisfaction, in addition to demographic and career choice items. For the data analysis, ratings of ‘agree’ and ‘strongly agree’ were combined, as were ratings of ‘disagree’ and ‘strongly disagree’. ‘Partially agree’ was omitted.

Participants were requested to evaluate the adequacy of their undergraduate medical education experience focusing on four aspects: (1) effectiveness of the preclinical years (first to third years) in general, and more specifically the contribution of the basic sciences in preparation for the clinical clerkships, and in the case of graduates preparation for medical practice; (2) effectiveness of the clinical years (fourth to sixth years) in providing the knowledge and skills required to function in the clinical setting; (3) overall satisfaction and preparedness for clinical practice; and (4) the degree to which respondents felt prepared to carry out research.

During June 2002 questionnaires were distributed to 294 students in their fourth, fifth and sixth years of study. In April 2002 questionnaires were mailed to 500 graduates, comprising 100 interns and 400 residents who completed their undergraduate training between the years 1997 and 2000. Anonymity of respondents was respected. A second mailing to non-respondents of the mailed questionnaire was carried out. In order to increase response rate a covering letter from the Dean of the Faculty of Medicine supporting the study was sent with the questionnaire. In order to refresh the memory of graduates, an outline of the preclinical curriculum accompanied the questionnaire.

Statistical analysis consisted of frequency distributions for each variable. A chi-squared test was used to identify statistically significant differences between groups (p < 0.05).

Results

A total of 794 questionnaires were distributed; the overall response rate was 49% (371). Thirty-eight questionnaires (7%) were returned for lack of a current address. A total of 218 (74%) of the 294 students and 153 (30.6%) of the 500 graduates completed the questionnaire.

Characteristics of survey population

Among the respondents 52% were male and 48% were female; 59% were students—of which 20% were fourth-year, 18% fifth-year, and 21% sixth-year students. In total 41% of the respondents were graduates—of whom 15% were interns and 26% residents. Some 66% of the graduates worked in large hospitals (over 900 beds) and 44% worked in small hospitals (less than 900 beds). Altogether, 12% of the respondents were enrolled in or had completed a joint degree (MD/Master's or MD/PhD). Significantly more males did a joint degree than females (17% vs. 6%, p = 0.001).

Preclinical years

Participants rated the degree to which they agreed with seven aspects related to the preclinical years (first to third years), and the results are summarized in Figure 1. Overall, 79% of the respondents agreed that the preclinical years should include clinical experiences; however, 74% indicated that they had not been exposed to enough clinical simulations (e.g. patient models and case discussions), and 65% reported not having received enough illustrations of clinical relevance in the preclinical years. While significantly fewer graduates felt that there had been a lack of clinical simulations and demonstration of clinical relevance in the preclinical curricula, 40% of the graduates nevertheless rated the preclinical curriculum as not providing opportunities of clinical relevance. In addition approximately half of all respondents (56%, including 50% of the graduates) reported that the Basic Science course lacked clinical relevance.

Figure 1. Items evaluating the preclinical years: respondents’ ratings of ‘agree’ and ‘disagree’ (†) for the following statements. Key to statement number 1. Basic science courses provided relevant preparation for clerkships* 2. Basic science courses had too many frontal lectures 3. Clinical experiences should be part of the preclinical years¶ 4. Basic science courses included enough simulations (79% vs. 66%, p = 0.012)§ 5. Basic science courses had sufficient illustrations (76% vs. 50%, p = 0.000)§ 6. Basic science courses emphasized clinical relevance adequately (67% vs. 41%, p = 0.000)§ 7. Basic science courses developed or sharpened problem-solving skills (60% vs. 40%, p = 0.001)§ Notes: †Ratings of ‘agree’ are ‘agree’ and ‘strongly agree’ combined, and ratings of ‘disagree’ are ‘disagree’ and ‘strongly disagree’ combined. ‘Partially agree’ omitted. Unless otherwise stated this applies for all graphs. *Significantly more graduates agreed with this statement than students (52% vs. 27%, p = 0.000). ¶Significantly more respondents with an MD degree agreed with this statement than respondents with a joint degree (81% vs. 65%, p = 0.005). §Significantly more students disagreed with these statements than graduates; percentages are shown in parentheses next to the statements.

The proportion of class time that was spent in case-based learning experiences during the preclinical years was rated as problematic: 96% of the respondents indicated that not enough time was devoted to case based-learning. No difference was found between students and graduates.

Figure 2 summarizes the evaluation of the relevance of the specific Basic Science course in preparation for clinical work. Courses are ordered by the degree to which respondents felt they contributed to preparation for work in the clinical setting. Between 60% and 77% of the respondents indicated that the following courses—physics, chemistry, community medicine, and medical law—had little if any relevance to their work in the clinical setting. In addition, approximately 40% reported that courses in computers and statistics had little relevance, and around 30% reported that courses of patho-psychology and embryology contributed minimally to their work in the clinical setting.

Figure 2. Evaluation of basic science courses for preparation for work in the clinical setting: respondents’ ratings of ‘good’ or ‘poor’ (†) when asked how well instruction in the following basic sciences courses prepared them for clinical clerkships (as a student) or clinical work (as a physician). Key to curriculum item  1. Anatomy  2. Physiology  3. Pharmacology  4. Pathology*  5. Microbiology  6. Neuroscience§  7. Histology  8. Metabolism  9. Immunology 10. Genetics 11. Developmental science 12. Biology¶ 13. Biochemistry¶ 14. Embryology 15. Pathopsychology 16. Statistics¶ 17. Computers¶ 18. Medical law 19. Community medicine# 20. General & organic chemistry¶ 21. Physics¶ Notes: †Ratings of ‘good’ are ‘good’ and ‘very good’ combined, ratings of ‘poor’ are ‘poor’ and ‘very poor’ combined, ratings of ‘fair’ omitted. *Significantly more graduates thought that teaching of pathology prepared them well for work in the clinical setting than did students (85% vs. 72%, p = 0.014). §Significantly more students thought that teaching of neuroscience prepared them for work in the clinical setting than did graduates (73% vs. 54%, p = 0.001). ¶Significantly more respondents with a joint degree thought that teaching the above courses prepared them for work in the clinical setting than respondents with an MD degree (p < 0.046). # Significantly more graduates working in a small hospital thought that community medicine course prepared them for clinical practice than graduates working in a large hospital (40% vs. 14%, p = 0.003).

Clinical years

Respondents evaluated 11 items relating to their education experience during the clinical clerkships years (fourth to sixth years). As can be seen in Figure 3, the majority of the respondents were satisfied with the number and diversity of patients they were exposed to. Although most respondents (70%) reported that faculty members demonstrated use of current EBM in patient care, only 47% reported that students were expected to demonstrate use of EBM. This deficiency was more notable for graduates who worked in small hospitals.

Figure 3. Evaluation of clinical clerkships: percentage of respondents answering ‘agree’ or ‘disagree’ on 11 items concerning the quality of their educational experience during clinical clerkships. Key to statement numbers  1. The number of patient experiences in clerkships was appropriate*  2. The diversity of patient experiences in clerkships was appropriate*  3. Attending faculty demonstrated use of current EBM in patient care  4. Students were expected to demonstrate the use of EBM in patient care#  5. Attending faculty were involved adequately in teaching and evaluating during clerkship¶  6. Residents played an appropriate role in teaching and evaluation during clerkships  7. Students were given an appropriate role in patient care during clerkships*  8. There was sufficient use of simulations during clerkships  9. Students were given timely feedback on performance in clerkships 10. Bio-ethical issues were discussed during clerkships 11. Students were taught sufficient clinical skills in preparation for clinical practice as physicians Notes: *Significant difference between graduates and students, students tended to be more dissatisfied (p < 0.005). ¶Significantly more respondents with joint degrees agreed with this statement than respondents with MD degrees (63% vs. 55%, p = 0.049). #Significantly more graduates working at a large hospital agreed with this statement than graduates working at a small hospital (61% vs. 38%, p = 0.029).

Role of the residents

With regard to the role of residents in teaching and evaluation, 25% of the respondents felt that this had been problematic; 87% of these respondents felt that residents had not contributed enough to their learning.

Responsibility of students for patient care

A total of 35% of the respondents felt that this issue had been problematic; 99% of these respondents felt that their responsibility for patient care was too limited.

Clinical skills

Some 39% of the respondents reported that students were not taught sufficient clinical skills in preparation for clinical practice as physicians; significantly fewer graduates tended to rate this issue as being a problem (p = 0.000).

Allocation of time to specific clerkships activities

Respondents rated the amount of time that was devoted to 36 activities during the clerkships. Figure 4 summarizes in decreasing order of inadequacy the percentage of respondents who felt that exposure to these activities was inadequate (ratings of ‘absent’ and ‘inadequate’ were combined). As can be seen in Figure 4 exposure to numerous activities was rated by respondents as being inadequate: ‘carrying out invasive diagnostic procedures’ (91%), ‘complementary and alternative medicine’ (88%), ‘family/domestic violence’ (87%), ‘clinical pharmacology’ (83.5%), ‘cultural differences and health-related behaviors’ (83%), ‘care of ambulatory patients in the community’ (81%), ‘teamwork with other health professionals’ (80%), ‘occupational medicine’ (80%), ‘drug and alcohol abuse’ (79%), ‘pain management’ (77%), ‘long term healthcare’ (76%), ‘public health and community medicine’ (74%), ‘palliative care’ (72.5%), ‘health promotion and disease prevention’ (72%), ‘students’ involvement in clinical decision-making’ (69%), ‘communication skills’ (67%). In all, 65% of the respondents rated the following activities as being deficient: ‘diagnosis and management of medical emergencies’, ‘primary care’, ‘care of ambulatory patients in the hospital’, ‘patient follow-up’, ‘psycho-social aspects of diseases’, and ‘behavioral sciences’. More than 50% of the respondents reported inadequacy in teaching ‘physician–patient relationship’, ‘medical genetics and genetics counseling’, ‘clinical epidemiology and biostatistics’ and ‘screening for disease’. Only three activities were rated as being adequate by the majority of respondents: ‘diagnosis of disease’, ‘differential diagnosis’ and ‘care of hospitalized patients’. Students rated 11 out of the 36 activities as being more problematic than did graduates (p < 0.040): ‘clinical pharmacology’ and ‘occupational medicine’ (85% vs. 75%); ‘involvement in clinical decision-making’, ‘diagnosis and management of medical emergencies’, ‘primary care’ and ‘behavioral sciences’ (75% vs. 58%); ‘interpretation of laboratory results’ (50% vs. 40%); ‘physical examination’ and ‘patient interviewing skills’ (40% vs. 20%); and ‘diagnosis of disease’ and ‘differential diagnosis’ (27% vs. 10%). It is interesting to note that three activities (‘long-term healthcare’, ‘palliative care’, and ‘care of ambulatory patients in the hospital’) were rated by graduates as being more problematic compared with students (p < 0.050).

Figure 4. Deficiencies in the curriculum during clinical clerkships: percentage of respondents reporting that the amount of time devoted to different curricular activities was inadequate. Key to curriculum activity  1. Carrying out invasive diagnostic procedures (CVP etc.)  2. Complementary and alternative medicine  3. Family/domestic violence  4. Clinical pharmacology*  5. Cultural differences and health-related behaviors  6. Care of ambulatory patients in the community  7. Teamwork with other health professionals  8. Occupational medicine*  9. Drug and alcohol abuse 10. Pain management# 11. Long-term healthcare§ 12. Public health and community medicine 13. Palliative care§ 14. Health promotion and disease prevention 15. Students’ involvement in clinical decision-making* 16. Communication skills 17. Diagnosis and management of medical emergencies*¶ 18. Primary care* 19. Care of ambulatory patients in the hospital§ 20. Patient follow-up 21. Psychosocial aspects of diseases 22. Behavioral sciences* 23. Physician–patient relationship 24. Medical genetics and genetic counseling 25. Clinical epidemiology and biostatistics 26. Screening for disease 27. Interpretation of laboratory results*# 28. Evidence-based medicine 29. Geriatrics 30. Medical law 31. Patient interviewing skills* 32. Physical examination* 33. Management of disease 34. Diagnosis of disease* 35. Differential diagnosis* 36. Care of hospitalized patients Notes: *Significantly more students than graduates reported ‘inadequate’ in these curriculum items (p < 0.040). §Significantly more graduates than students reported ‘inadequate’ in these curriculum items (p < 0.050). ¶Significantly more respondents with MD degree reported ‘inadequate’ than respondents with joint degree (for item 2: 89% vs. 83%, p = 0.013; for item 17: 69% vs. 48%, p = 0.010). #Significantly more graduates working at a large hospital reported ‘inadequate’ in these curriculum items than graduates working at a small hospital (for item 10: 89% vs. 70% p = 0.006; for item 27: 43% vs. 26%, p = 0.004).

Overall assessment and preparedness

Respondents were asked to evaluate their skills in carrying out a literature search using medical databases, their self-learning skills and their overall satisfaction with their medical education. In the first case, 80% of the respondents felt competent to carry out a literature search; graduates reported being more skilled than students (92% vs. 71%, p = 0.000). In the second, 56% of the respondents were satisfied with their self-learning capabilities; again, graduates rated this more positively than students (75%, vs. 41%, p = 0.000). In the third, 60% of the respondents were generally satisfied with their medical education; graduates were significantly more satisfied than students (78% vs. 45% p = 0.000).

In addition, respondents were asked whether or not the fundamental knowledge, skills, attitudes and values that medical students should possess at the time of graduation were made explicitly clear to them. Only 33% of the respondents agreed with this statement. Graduates were significantly more satisfied than students (49% vs. 22%, p = 0.000).

At each stage in their training respondents were asked whether they felt prepared for the next stage in their training. Results are summarized in Figure 5. Only 15% of the students indicated that they felt ready for internship, and there was no significant difference between students by clinical year of study. Most interns tended to feel prepared for residency training, as did residents for practice.

Figure 5. Percentage of respondents reporting ‘agree’ or ‘disagree’ in respect of the following statements regarding overall assessment, preparedness and research. Key to statement numbers  1. I’m confident that I have the appropriate skills and knowledge to carry out reasonably sophisticated searches of medical   information databases*  2. Overall I’m satisfied with the self-learning skills I’ve acquired during my medical education*  3. Overall I’m satisfied with the quality of my medical education*  4. The fundamental knowledge, skills, attitudes and values that medical students should possess at the time of graduation were   made explicitly clear to students at my medical school*  5. Students only—I’m confident that I have acquired the clinical skills required to begin an internship program  6. Interns only—I’m confident that I have acquired the clinical skills required to begin a residency program  7. Residents only—I’m confident that I have acquired the clinical skills required to work as a physician  8. I’m confident that I have the appropriate skills and knowledge to conduct research*¶  9. I’m confident that I have the appropriate skills and knowledge to use a statistical software package (e.g. SPSS etc.)* Notes: *Significantly more graduates agreed with this statement than students, p = 0.000. ¶Significantly more respondents with a joint degree agreed with this statement than respondents with an MD degree (57% vs. 20%, p = 0.000).

Research

Respondents evaluated how extensively they thought they would be involved in research during their medical career, and whether they felt adequately prepared to conduct research and use statistical software. Almost all, 99%, of the respondents reported that they wanted to be involved in research to some degree. Of these respondents 23% indicated that they wanted to be significantly involved in research (several years set aside for full-time research or 25% or more of continuous career devoted to research); 49% want to be somewhat involved (one year or less set aside for research or less than 25% of continuous career); and 27% want to be involved in a limited way (occasional cooperation with clinical trials in their practice). Respondents with a joint degree tended to want to be more involved in research than respondents with an MD degree (64% vs. 18%, p = 0.000). Although most respondents reported their intention to be involved in research to some degree, only 24% felt able to conduct research. There was a significant difference between graduates and students (35% vs. 17%, p = 0.000), nevertheless, one out of three graduates felt unable to conduct research. Significantly more respondents with a joint degree felt competent to conduct research than respondents with an MD degree (57% vs. 20%, p = 0.000). A total of 83% of the respondents felt that they lacked the ability to use statistical software appropriately, 75% amongst the graduate group.

Discussion

This evaluation of the undergraduate curriculum by students in their clinical years and graduates of the Faculty of the Hebrew University—Hadassah Medical School has provided faculty with important information. However, the data must be regarded with some degree of caution. The survey has a number of limitations, primarily the relatively low response rate from graduates, and the fact that some of the graduates were evaluating their preclinical educational experiences, which they had completed close to four years previously. The time gap may have influenced their ratings.

Preclinical years

Respondents in this survey consistently evaluated the preclinical phase of their training as providing too few opportunities of clinical relevance. Interestingly, significantly more graduates tended to feel that the Basic Science curriculum had provided relevant preparation for the clerkship than did medical students. This finding raises an interesting question for faculty, namely, which group should be given greater credence? Given the fact that graduates in retrospect felt that the Basic Science curriculum had in fact prepared them reasonably well for the clinical clerkships, it could be argued that students’ concerns were temporal and need not be a cause for significant and costly changes. There are two possible explanations that could be offered for this phenomenon: the issue of recall bias, and the possibility that with entry into the internship and/or residency, graduates feel more confident about the level of knowledge and the skills they acquired during their training.

Respondents identified a number of courses given in the preclinical years that they perceived to have little if any relevance for their work in the clinical setting. Of major concern is the fact that amongst these courses were the courses in Community Medicine and Medical Law. The fact that courses such as Physics, Chemistry and Statistics were perceived as having little clinical relevance is to be expected in a curriculum that is not based on a pre-med requirement. Faculty, nevertheless, need to reconsider what is being taught in these courses, and how they are being taught. These courses need to be modified so that they will enhance the ability of students to understand how the content of these courses will have relevance for their work in the clinical setting. Providing for greater clinical relevance in a traditional lecture–teacher based curriculum presents major challenges to curriculum planners. Medical educators have, for the past three decades, consistently emphasized the need for medical school curricula to move from teacher-centered, lecture-based curricula, to programs that are learner-centered (Ludmerer, 2004).

Clinical years

Overall, the respondents to this survey appeared to be more satisfied with their clinical years of training than they were with the preclinical phase. Issues relating to the amount of patient exposure, the care of hospitalized patients and learning that occurs as a result of this exposure, such as the ability to diagnose and develop differential diagnoses, was seen by a majority of the respondents as being good. However, respondents identified a significant number of deficiencies. Twenty-six out of the 36 activities listed were evaluated by 50% or more of the respondents as having received inadequate exposure. Most notable was the lack of ability to acquire technical skills, such as invasive diagnostic procedures, and limited opportunity for acquisition of knowledge relating to alternative medicine, family and domestic violence, drug and alcohol abuse, clinical pharmacology, pain management, and the treatment and management of ambulatory patients. The evaluation identified a significant need for faculty to review the manner in which issues relating to the behavioral sciences, culture and the psychosocial issues relating to health and illness need to be taught.

Although significantly fewer graduates reported major inadequacies in the clinical clerkships than did students, graduates tended to be similar to the students in identifying activities that had received inadequate exposure. The identification by graduates, specifically, of inadequate exposure to long-term care, palliative care and the care of ambulatory patients is important, and ways have to be found to address these issues in traditional clerkships.

Overall assessment and research

Although 60% of the respondents indicated that overall they were satisfied with their medical education, only 33% agreed that the fundamental knowledge, skills, attitudes and values that medical students should possess at the time of graduation were made explicitly clear to them as students. Graduates tended to be more satisfied than students; nevertheless, more than 50% of the graduates felt that their medical school training had not equipped them with the competences they needed for work in the clinical setting, a finding that is a cause for concern. The fact that graduates felt better prepared for their next stage in training than students emphasizes the importance of internship and residency in the medical education process, and the importance of clinical exposure in general as part of this process.

One of the major goals of the faculty is to train medical students who will engage in research after graduation. Therefore, research capabilities and potential involvement in research were of special interest: 99% of the respondents reported their intention to be involved in research to some degree during their career. Only 20% of the respondents indicated that they felt they had acquired the necessary knowledge and skills required to carry out independent research. Not surprisingly respondents with joint degrees (MD/PhD or MD/MSc) felt more competent to conduct research, but they are the minority of students (approximately 10%). These data suggest that in spite of its declared goal the faculty does not prepare students for a physician-researcher career. In addition, it would appear that this goal significantly limits the integration of clinically relevant material during the preclinical phase of training. Since educating researchers necessitates a wider knowledge of basic sciences there is less available time during preclinical years to teach clinically relevant courses.

The Hebrew University—Hadassah medical school has recently embarked on a process of curriculum renewal. Significant attention is being given to the findings of this study, and its findings relating in particular to the preclinical phase of training. The findings of this study will also be made available to the Council for Higher Education for the next accreditation visit, which is due to occur shortly.

The information reported in this paper represents only a small proportion of the information collected. The data presented in this study are relevant for all medical schools, but especially for those that continue to base their teaching on traditionally oriented curricula, and emphasizes the need in such medical schools, yet again, for change. In addition to the need for reliable and valid assessment techniques to monitor the performance of medical students, periodic surveys of both medical students and graduates regarding their perceptions of, and preparation for, their next stage in training reveal persistent curricular weaknesses, recognize successful adaptations and validate traditional strengths.

Acknowledgements

The authors gratefully acknowledge the students and graduates of the Hebrew University—Hadassah Medical Faculty for their participation in this research. The authors are grateful to Tali Bdolach-Avraham for statistical guidance.

Additional information

Notes on contributors

Lilach Eyal

LILACH EYAL is a graduate of the Hebrew University—Hadassah Faculty of Medicine, and will be entering a residency program. The research is part of an MD thesis required for completion of the MD degree at the Hebrew University Faculty of Medicine.

Robert Cohen

ROBERT COHEN is Professor and Chairman of the Center for Medical Education at the Hebrew University—Hadassah Faculty of Medicine, Jerusalem, Israel.