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Best Medical Schools in the World

Updated: February 29, 2024

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Below is a list of best universities in the World ranked based on their research performance in Medicine. A graph of 1.07B citations received by 41.1M academic papers made by 6,680 universities in the World was used to calculate publications' ratings, which then were adjusted for release dates and added to final scores.

We don't distinguish between undergraduate and graduate programs nor do we adjust for current majors offered. You can find information about granted degrees on a university page but always double-check with the university website.

1. Harvard University

For Medicine

2. Johns Hopkins University

3. University College London

4. University of California - San Francisco

5. University of Toronto

6. University of Michigan - Ann Arbor

7. Stanford University

8. University of Washington - Seattle

9. University of Pennsylvania

10. Yale University

11. University of California - Los Angeles

12. Cornell University

13. Mayo Clinic College of Medicine and Science

14. University of Pittsburgh

15. Columbia University

16. University of Texas MD Anderson Cancer Center

17. University of Oxford

18. University of California-San Diego

19. University of North Carolina at Chapel Hill

20. University of Minnesota - Twin Cities

21. Karolinska Institute

22. Heidelberg University - Germany

23. Washington University in St Louis

24. Emory University

25. Baylor College of Medicine

26. University of Wisconsin - Madison

27. University of British Columbia

28. Northwestern University

29. University of Southern California

30. Boston University

31. University of Sydney

32. University of Chicago

33. University of Texas Southwestern Medical Center

34. University of Florida

35. New York University

36. University of Melbourne

37. McGill University

38. University of Cambridge

39. Ohio State University

40. Pierre and Marie Curie University

41. University of Tokyo

42. Imperial College London

43. University of Sao Paulo

44. University of Alabama at Birmingham

45. Charite - Medical University of Berlin

46. Icahn School of Medicine at Mount Sinai

47. Catholic University of Leuven

48. University of California - Davis

49. Case Western Reserve University

50. Lund University

51. King's College London

52. Duke University

53. University of Utah

54. Radboud University

55. University of Iowa

56. University of Munich

57. Osaka University

58. University of Colorado Denver/Anschutz Medical Campus

59. University of Copenhagen

60. University of Miami

61. Kyoto University

62. McMaster University

63. University of Queensland

64. University of Amsterdam

65. Indiana University - Purdue University - Indianapolis

66. University of Alberta

67. University of Maryland, Baltimore

68. University of California - Berkeley

69. Vanderbilt University

70. University of Manchester

71. University of Milan

72. University of Illinois at Chicago

73. Massachusetts Institute of Technology

74. Tel Aviv University

75. Monash University

76. Oregon Health & Science University

77. University of Arizona

78. Pennsylvania State University

79. University of Edinburgh

80. University of Virginia

81. Rutgers University - New Brunswick

82. University of Hong Kong

83. University of Calgary

84. University of New South Wales

85. Peking University

86. Peking Union Medical College

87. Sun Yat - Sen University

88. University of Helsinki

89. Tufts University

90. University of Illinois at Urbana - Champaign

91. University of Liverpool

92. University of Padua

93. University of California - Irvine

94. Sapienza University of Rome

95. Wayne State University

96. University of Hamburg

97. University of Birmingham

98. University of Zurich

99. Shanghai Jiao Tong University

100. Chinese University of Hong Kong

Medicine subfields in the World

The World Directory of Medical Schools has been developed through a partnership between the World Federation for Medical Education (WFME) and FAIMER ® , a division of Intealth.

The World Directory provides a comprehensive compilation of the information previously contained in the IMED and Avicenna directories.

Contact: World Federation for Medical Education 13A chemin du Levant 01210 Ferney-Voltaire France www.wfme.org

Contact: FAIMER 3624 Market Street Philadelphia, PA 19104-2685 USA www.faimer.org

Inquiries and other correspondence regarding the World Directory may be sent to [email protected] .

Page updated May 8, 2024.

The World Federation for Medical Education

Up until the 1970s the first World Conferences on Medical Education were organised by the World Medical Association. The WMA maintained a Standing Committee on Medical Education from 1950 to 1982. Acknowledging the decisive role of medical schools and faculties, as well as the by then well-established global medical students’ organisation, the International Federation of Medical Students Associations (IFMSA), the WMA joined forces with the World Health Organization, the regional organisations of medical schools and academic teachers and the IFMSA to found the World Federation for Medical Education (WFME) in 1972.

Since then, the WFME has been the common platform for agreeing on principles and standards for medical education over the full life cycle of professional activities. The WMA has endorsed the core documents on basic, post-graduate, and continuous professional education , as well as on Distributed and Distance Learning in Medical Education in 2021.

The WFME has developed a global recognition program for the accreditation of basic medical education and is co-editor of the World Directory of Medical Schools . The WMA closely cooperates with the WFME on educational matters.

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Best universities for medicine 2024

Find the best universities for medicine using times higher education ’s world university rankings 2024 data.

• Rankings for Students

Top 10 universities in the world for medicine 2024

Scroll down for the full list of best universities in the world for medicine and health sciences.

The study of medicine varies greatly around the world. In the US, medicine is studied in graduate school after the completion of an undergraduate degree that is not directly related to medicine.

Develop the skills top employers want while you study and get a digital certificate to boost your CV!

Elsewhere, such as in the UK, students can enrol for undergraduate clinical degrees.

Wherever you study, almost all clinical degrees span a good number of years – more than non-clinical courses.

So it’s best to ensure that you make a wise choice when you commit yourself to a lengthy course of study.

Best universities for arts and humanities Best universities for business and economics Best universities for computer science Best universities for engineering and technology Best universities for life sciences Best universities for physical sciences Best universities for social sciences Best universities for law degrees Best universities for education degrees Best universities for psychology degrees

Times Higher Education has published a ranking of the top 1,059 universities for clinical, pre-clinical and health studies , featuring colleges in more than 50 countries worldwide.

The ranking uses the same methodology as the THE World University Rankings, but with more weight on citations and slightly less on teaching and research metrics. The full methodology can be found  here .

Scroll down for a full list of degrees included in the clinical subject ranking of top universities, and a guide on what you can do with them.

Best universities in the United States for medicine degrees Best universities for medicine degrees in Canada Best universities in Australia for medicine degrees Best universities in the UK for medicine degrees

Top five universities for clinical studies and health sciences

5.  stanford university.

The graduate school at  Stanford University  provides master’s and PhD programmes to students who wish to further their medical training.

Six Nobel prizewinners, 31 members of the National Academy of Sciences and 42 members of the Institute of Medicine are among the current faculty at the school.

Researchers at Stanford Medicine are undertaking research across a number of different areas, including cancer, immunology, genetics and neuroscience.

The school also provides healthcare for adults and children, with a dedicated centre for children.

4.  Imperial College London

The medical programme at Imperial College London offers a range of teaching approaches, from traditional theoretical classes to innovative and hands-on experience. From the very first term, students have direct contact with patients, unlike at other universities in the UK.

The six-year undergraduate qualification in medicine also includes a bachelor of science, in addition to the MBBS.

Imperial’s courses are heavily scientific, with an emphasis not only on clinical practice but also on research techniques.

Entry requirements are high; most accepted students will have top grades in chemistry, biology and a third subject, and will achieve a high score in the BMAT exam. The application process also includes an interview.

Imperial is one of the most international institutions in the UK, but only a few overseas students are accepted on the medical programme each year.

What can you do with a medical degree? What can you do with a dentistry degree? What can you do with a nursing degree?

3.  University of Cambridge

Students can enrol in an undergraduate medicine degree at the University of Cambridge . Graduates also have several options to study medicine, either on an accelerated graduate programme or a condensed version of the pre-clinical and clinical courses.

Half the graduates of Cambridge’s medical degrees become general practitioners, and almost all will work in the NHS in the UK.

Entrance to the medicine degree requires excellent secondary qualifications and high scores on the BMAT test.

Cambridge students, particularly medical students, have a busy schedule, juggling studies, college social events and a variety of recreational activities.

2.  Harvard University

Founded in 1782, the medical school at Harvard University is the third-oldest medical school in the US.

Faculty of the school also teach in other science departments at Harvard, as well as working in clinical departments at some of the hospitals affiliated to the university.

There are four main teaching hospitals across the Boston area.

Harvard has introduced problem-based learning to the curriculum. There is also a specialised programme, accepting only 30 applicants each year, that focuses on biomedical research.

Medical students at Harvard belong to one of five societies named after alumni. Students work in small groups within each society, compete in sports competitions and attend social events.

1.  University of Oxford

Medicine at the University of Oxford is a traditional course, split into pre-clinical and clinical stages. About 150 students are admitted to the course each year, and another 30 to a graduate course that condenses medical studies into just four years.

In the first few years, students are taught theoretically with little patient contact. In the course’s later years, they move to the clinical phase, spending much more time at the John Radcliffe Hospital.

The university has two main libraries for medicine and clinical studies, one providing resources for the pre-clinical elements of the course and another focusing on healthcare.

In addition to its distinctive course, Oxford offers students the experience of college life, where social events and small tutorials take place.

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Click each institution to view its World University Rankings 2024  profile

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• Open access
• Published: 16 April 2019

Medical education today: all that glitters is not gold

• L. Maximilian Buja   ORCID: orcid.org/0000-0001-8386-7029 1  

BMC Medical Education volume  19 , Article number:  110 ( 2019 ) Cite this article

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The medical education system based on principles advocated by Flexner and Osler has produced generations of scientifically grounded and clinically skilled physicians whose collective experiences and contributions have served medicine and patients well. Yet sweeping changes launched around the turn of the millennium have constituted a revolution in medical education. In this article, a critique is presented of the new undergraduate medical education (UME) curricula in relationship to graduate medical education (GME) and clinical practice.

Medical education has changed and will continue to change in response to scientific advances and societal needs. However, enthusiasm for reform needs to be tempered by a more measured approach to avoid unintended consequences. Movement from novice to master in medicine cannot be rushed. An argument is made for a shoring up of biomedical science in revised curricula with the beneficiaries being nascent practitioners, developing physician-scientists --and the public.

Unless there is further modification, the new integrated curricula are at risk of produce graduates deficient in the characteristics that have set physicians apart from other healthcare professionals, namely high-level clinical expertise based on a deep grounding in biomedical science and understanding of the pathologic basis of disease. The challenges for education of the best possible physicians are great but the benefits to medicine and society are enormous.

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Introduction

The traditional medical education system widely adopted throughout most of the twentieth century has produced generations of scientifically grounded and clinically skilled physicians who have served medicine and society well. Yet sweeping changes launched around the turn of the millennium have constituted a revolution in undergraduate medical education (UME) and graduate medical education (GME) [ 1 , 2 , 3 ]. While continual assessment leading to measured adaptation is essential for the enduring value of a system, simultaneous and multifaceted change such as that occurring in the traditional medical education system qualifies as disruptive innovation [ 4 ]. The purpose of this article is to offer a critique and express a major concern by a physician-scientist, pathologist and medical educator that the contemporary medical education system is being subject to the downside of disruptive innovation with unintended and potentially detrimental long-term outcomes for academic medicine and clinical practice.

The past century in medical education

The education of a physician has developed to encompass pre-medical preparation, a course of study in a medical school which is typically a major component of an academic medical center (AHC), and medical specialty training in residency and fellowship programs, UME and GME, respectively [ 5 , 6 ]. This education provides the basis for a professional career enhanced by continuing medical education and life-long learning. Early in the twentieth century, medical education became guided by principles articulated by Abraham Flexner and William Osler. Flexner recommended that medical schools should be university based, have minimum admission requirements, implement a rigorous curriculum with applied laboratory and clinical science content, and have faculty actively engaged in research [ 5 , 7 ]. Osler championed bedside teaching, bringing medical students into direct contact with patients, and learning medicine from these direct experiences under the guidance of faculty clinicians [ 7 , 8 ]. The result was the establishment of two key components or pillars of medical education, namely, the basic or foundational sciences and the clinical sciences [ 2 ]. The two-pillar model of medical education provided the conceptual basis for a four-year UME curriculum comprising biomedical science courses in the pre-clinical years and clinical clerkships in the clinical years. Medical schools utilizing this construct produced scientifically grounded physicians capable of a high level of clinical practice as well as a subset who pursued highly successful careers as physician-scientists and academicians [ 9 ].

AHCs and healthcare system

A fundamental element in the achievement of medical schools in the twentieth century was the development of medical education as a public trust and social contract between the medical schools and society [ 5 ]. However, in-depth analysis of the history of medical education has shown that it is inextricably intertwined with healthcare delivery and broader societal norms [ 5 , 6 , 7 ]. UME and much of GME take place in academic health centers (AHC), which must function in the world of healthcare delivery [ 10 ], and are subject to the complexities of the associated health care system in which they operate, including the fragmented American healthcare system [ 11 , 12 , 13 , 14 ].

Calls for curriculum reform and restructuring

In this context, discontent among academics and professional organizations concerning the traditional medical education construct has accelerated in recent years [ 1 , 2 , 3 , 15 , 16 , 17 , 18 , 19 , 20 , 21 ]. Both the teaching methodology and the content of the established curriculum have come under severe criticism. Calls have been made repeatedly for the cultivation of a different type of physician more attuned to and equipped for practice in the current healthcare scene [ 15 , 16 , 17 , 18 , 19 , 20 ].

Reform movement and integrated curriculum

To promote more active learning and less passive learning, curriculum developers have introduced a variety of approaches, including small group sessions, problem-based learning, self-directed learning, team-based learning, and flipped classrooms as replacements for the traditional lecture format [ 21 ]. However, many in the reform movement consider that pedagogical reform, while necessary, must be joined by content reform to develop the requisite skill set in future practitioners of medicine [ 15 , 16 , 17 , 18 , 19 , 20 ]. As a result, there has been a movement in mass toward adoption of a radically redesigned curriculum as a third wave, post-Flexnerian approach to medical education [ 1 , 2 ]. A major goal of the curriculum reformers is to produce physicians who can deliver an individualized plan of care that reflects the physician’s mastery of basic physiology, awareness of the best current evidence, skillful patient communication, and shared decision-making [ 20 ].

The ideal of the post-Flexnerian third wave is a fully integrated curriculum in place of the traditional curriculum comprised of a distinct pre-clinical component with subject-based courses and a subsequent clinical component [ 22 ]. Initial implementation involves partial integration comprising horizontal integration defined as integration across disciplines but within a finite period of time and vertical integration representing integration across time with breakdown of the traditional barrier between basic and clinical sciences. A fully integrated curriculum is characterized by spiral integration encompassing both horizontal and vertical integration combining integration across time and across disciplines [ 22 ].

This revised design also includes added content addressing broader issues constituting “Health Systems Science” as a third pillar of medical education co-equal with basic and clinical medical sciences [ 23 , 24 , 25 , 26 ]. Topics include population health, health policy, healthcare delivery systems, and interdisciplinary care. A correlate is the replacement of the biomedical model of health and disease with a broader biopsychosocial model of health, disease and the patient-physician relationship [ 23 , 27 ].

A related development is the implementation of the new MCAT that aims to balance testing in the natural sciences with testing in the social and behavioral sciences and assessing critical analysis and reasoning skills. The redesign is based on the premise that tomorrow’s physicians need broader skills and knowledge than in the past [ 28 ]. Medical education reform also includes heavy emphasis on professionalism and professional identity development [ 29 ]. The reforms also are aimed at achieving a more coherent continuum of medical education [ 30 ]. My institution, McGovern Medical School of The University of Texas Health Science Center at Houston, embarked on the path of curriculum restructuring in 2013 and has instituted such a redesigned curriculum beginning in 2016 [ 31 ].

Influence of oversight bodies

Advances in medical care and technology have been driving forces behind these curriculum changes. In the United States, a major impetus for such curriculum changes has come from the Liaison Committee for Medical Education (LCME), and its sponsoring institutions, the American Association of Medical Colleges (AAMC) and the American Medical Association (AMA), and the Accreditation Council for Graduate Medical Education (ACGME) (more accurately, thought leaders in these organizations) [ 32 ]. Regulatory bodies in other countries have had similar roles [ 22 ]. Curriculum reformers have used the imperative of actual and perceived expectations of the LCME as a driver of curriculum revision.

Characteristics of Today’s medical students

A major consideration in any discussion of education is the profile of the students. Analysis of today’s students is that they score higher on assertiveness, self-liking, narcissistic traits, high expectations, and some measures of stress, anxiety and poor mental health, and also lower on self-reliance [ 33 , 34 , 35 ]. These generational characteristics are rooted in shifts in culture and reflect changes in society. These character traits are clearly established by the time students enter medical school.

Notable individual exceptions reinforce the average characteristics of today’s students which have definite positive aspects, such as the focus on the individual, but also some negative consequences [ 33 , 34 , 35 ]. Motivation can become dysfunctional so that high levels of dedication to a previously enjoyed activity can result in burnout. Burnout is alarmingly high among today’s medical students and residents [ 36 , 37 ]. Burnout is a psychosocial syndrome that is associated with motivational, performance and psychological difficulties. Perfectionism, defined as a combination of high standards and high self-criticism, is also on the rise [ 38 , 39 ]. The two may compound each other.

The characteristics of today’s medical students including their strengths and vulnerabilities, present special challenges for faculty engaged in their education [ 40 , 41 , 42 , 43 ]. Notably, while these students have high I.Q.s, they typically show little desire to read long texts [ 33 ]. The implication for educational design (pedagogy) is that these students likely benefit from a structured but also more interactive learning experience and that instruction may need to be delivered in shorter segments and perhaps incorporate more material in media such as videos and an interactive format. But, even when the classroom hour is used for so-called active learning approaches, such as the flipped classroom, attendance is still often poor. There has been a proliferation of commercial products, including First Aid, Firecracker, Osmosis and Pathoma, that attract students with shortcut approaches, including flashcards and videos, for passing standardized tests [ 44 ]. These products cater to the study habits of many of today’s students. Many of today’s medical students are opting for elective perusal online of previously recorded lectures and the use of various previously mentioned study aids while minimizing direct classroom interaction with professors [ 45 ].

General critique

While apparently accepting the practices of today’s medical students as a fait accompli , a key tenant of the reform movement is that the traditional subject-based and lecture-based curriculum has failed to accomplish the desired outcome of producing physicians for the twenty-first century [ 20 ]. Content reformers favor a repeal of major parts of the traditional UME curriculum to make room for the lessons that are aimed at allowing students to develop skills in modern clinical reasoning and decision-making. Major goals of integration are to break down barriers between the basic and clinical sciences and to promote retention of knowledge and acquisition of skills through repetitive and progressive development of concepts and their applications [ 22 ].

Reformers recognize that implementation of the new curriculum requires trade-offs and hard choices. They have clearly articulated that topics such as clinical decision-making, comparative effectiveness and other Health Systems Science topics must take priority over the depth of basic science content presented in traditional courses [ 20 ]. The argument is made that major revamping of basic science in the curriculum is acceptable because of perceived major overlap and repetition among traditional basic science courses. There also is the often unstated but implied view that traditional basic science courses burden medical students with excessive and unnecessary detail. While strong emphasis is placed on integrating basic science courses and providing clinical experiences early in the curriculum, the extension of basic science content into the clinical years has been identified as a major challenge and a major shortcoming of integrated curricula [ 22 , 46 ].

The first two years of the UME curriculum is the only time in the entire professional career of a physician when the fundamentals of biomedical science and the clinical skills of history taking and physical examination intersect coherently, and are formally taught and learned. A background in factual knowledge and relationships among facts is crucial for critical thinking and evidence-based decision-making in medicine [ 46 , 47 , 48 , 49 ]. Studies have shown that factual knowledge of medical science is essential for the development of clinical skill [ 46 , 47 , 48 , 49 , 50 ]. Clinical knowledge is gained from the integration of conceptual knowledge (facts, “what” information), strategic knowledge (“how” information) and conditional knowledge (“why” information) [ 49 ]. There is no short cut here; a certain amount of memorization and with some repetition is required. It is counterproductive to dilute the learning experience of the core material in the pre-clinical years by substituting other topics that are best learned after a foundation is laid and its strength tested through the crucible of clinical practice.

Competency-based education: time-based versus competency-based medical education and accelerated medical education

Momentum has continued to grow for demonstration of a set of competencies rather than cognitive knowledge alone as the primary outcome of UME as well as GME. The movement toward outcomes and competency-based education in UME was presaged by a focus on innovation in GME, which led to the introduction by the Accreditation Council for Graduate Medical Education (ACGME) of the six competencies as key elements in residency training programs [ 51 , 52 ]. Change in the world of GME was compounded by the introduction of the duty hour requirements at about the same time [ 53 ]. The ACGME has moved further along the path of competency-based training with the introduction of milestones as a focus of the new accreditation system (NAS) [ 54 , 55 ]. Competencies also have been linked to Entrustable Professional Activities [ 56 ].

Some are taking the competency construct further by promoting time variable criteria for the granting of the medical degree as well as certification in medical specialties following a period of graduate training [ 57 , 58 , 59 , 60 , 61 , 62 ]. Others are promoting an accelerated three-year UME program [ 63 ].

All would agree that the goal of medical education is to produce competent physicians. However, the educational approach embodied in competence-based curricula for highly skilled professions including medicine versus lower level occupations has been found to be philosophically questionable, methodologically complex and highly controversial [ 64 , 65 ]. The logistics of implementing such programs are daunting and represent another major draw on faculty time to provide evaluation of the ascertainment of the set of competencies and entrustable professional activities (EPAs) of the learners [ 56 , 66 ]. A more feasible approach would be to maintain fixed time programs but allow accelerated advancement coupled with opportunities for dual degrees, pursuit of research, and other projects [ 67 ].

Arguments in favor of reduction of UME to a 3 year program include increased production of physicians to meet the shortage and reduction of student debt. The current interest in some quarters for a 3 year program represents the third time in the last century this idea has been promoted [ 64 ]. This third wave will have to face many of the same issues that affected the previous two attempts.

Impact of student evaluation systems

How students function in an educational program is inextricably linked to how they are evaluated. Recurrent movements to abolish grades, exams and honor societies to mitigate undue competiveness, stress and general malaise is the present educational zeitgeist [ 68 , 69 , 70 , 71 , 72 ]. For many years, the standard system of student evaluation was based on numerical grades in every course and led to a cumulative numerical score and class ranking. As a component of disruptive innovation, some medical schools have completely abolished grades and implemented pass-fail systems. However, most medical schools, including some who have tried the purely pass-fail approach, have arrived at a system of Honors, High Pass, Pass, Marginal Pass and Fail -- essentially the A through F system used in K-12 education [ 73 ].

This has led to the rise of the exaggerated importance of United States Medical Licensing Exam (USMLE) scores, particularly, USMLE Step 1 scores, as the major or sole objective evaluation of cognitive achievement of medical students. Proponents argue that the new curricula are successful because students are performing at least as well on USMLE Step 1 as they did in the old curricula, and that they do as well in pass-fail systems as in systems with grades [ 68 , 69 , 70 , 71 , 72 ]. However, these advocates, in essence, are contributing to the perpetuation of the undue importance of USMLE Step 1.

An undue emphasis on a single high stakes summative evaluation creates a dilemma for medical educators and students [ 73 ]. An excessive focus develops on preparing students for the USMLE Step 1 examination and “teaching to the test” [ 20 , 74 ]. This milieu is counterproductive to in depth assimilation of subject matter in the biomedical sciences. Unintended consequences in multiple domains include conflict with holistic undergraduate medical education admission practices, student well-being, and medical curricula.

Medical students have become increasingly aware of the “USMLE issue.” In an Invited Commentary, medical students from various institutions across the country have reflected on their shared experiences and have postulated that the emphasis on USMLE Step 1 for residency selection has fundamentally altered the preclinical learning environment, creating a “Step 1 climate” [ 44 ]. They have commented on how the Step 1 climate negatively impacts education, diversity, and student well-being, and they have urged a national conversation on the elimination of reporting Step 1 numeric scores. Educators also have articulated similar recommendations regarding making the USMLE results reporting as pass/fail [ 75 , 76 ]. But concern has also been voiced that pass/fail can be a disincentive to motivation for broad knowledge acquisition. Also, the development of an alternate, more holistic standardized metric by which to compare students’ applications for residency positions has been proposed but is currently not operative [ 74 ].

The movement away from meaningful grades for medical school courses also has led to an increasingly elaborate subjective evaluation in “dean’s letters” [ 77 , 78 ]. The AAMC has introduced the Medical Student Performance Evaluation (MSPE) as a refinement of the “dean’s letter.” Approaches to evaluation of student performance generally involve formative and summative exams in the pre-clinical years, and subject exams coupled with faculty assessment of performance, in the clinical clerkships. Then, these evaluations (honors, high pass, pass, etc.) are integrated into lengthy MSPEs or dean’s letters that provide commentary and largely subjective impressions. In spite of the AAMC guidelines of comparative information about applicants be included, dean’s letters or MSPEs often continue to lack specificity regarding student performance [ 77 , 78 ]. Major emphasis continues to rest on USMLE scores for the granting of interviews and ranking of applicants by residency program selection committees [ 74 ].

A second influential criterion relied upon in resident candidate ranking and selection is election to the Alpha Omega Alpha (AOA) Honor Society from the top one-sixth of the class. Election into AOA has long been a motivator for student performance. A relationship between AOA membership and selection into highly competitive residencies is well known [ 79 ]. AOA is receiving criticism that membership is not reflecting the balance of diversity of the student body [ 80 , 81 ]. But, I hold that AOA must maintain a focus on excellence [ 82 ].

The grade abolition movement misses the reality of competition in human affairs. I think that the dilemmas about the “USMLE issue” can be diffused by a return to providing meaningful grades for medical school courses and an overall summative evaluation for the four years of medical school. (My definition of meaningful grades encompasses either numerical or letter grade equivalents which reflect actual performance relative to other students and objective norms.) Students must compete and excel to gain admittance into medical school. This shouldn’t be any different when students are training to be physicians. Safeguards can be put in place to deal with excess competition [ 33 ]. Nevertheless, competition within bounds promotes excellence. I strongly concur with the view that medicine is based on being a meritocracy and needs to remain a meritocracy [ 82 , 83 ].

Impact on medical educators

Over the years, medical educators, including basic biomedical science educators and clinician educators, have had to adapt to changes in curriculum [ 84 , 85 , 86 ]. Many medical educators have experienced significant challenges in the implementation of the new curriculum [ 87 ]. Competing demands on faculty time are causing stress and burnout among faculty as well as learners. A curriculum heavily geared to small group teaching places further considerable demand on faculty time. A significant inverse relationship has been found between faculty members’ readiness to change teaching approaches and their severity of burnout [ 87 ].

The educational mission itself can be enhanced by the recognition of foundational principles for teaching and education [ 88 ]. At Johns Hopkins University School of Medicine, a formal review process has led to the articulation of 10 foundational principles or characteristics of a medical educator [ 88 ]. Each principle addresses an important theme in the educational mission. These principles include specific recognition of the importance of being a role model and the responsibility to develop the next generation of physicians (Table  1 ).

Ethics, professionalism and inter-professionalism in the curriculum

A major goal of the new curriculum is the development of holistic, ethical physicians with clear communication skills imbued with empathy and compassion for patients [ 29 ]. These goals are not new but are imbedded in the ideals of the medical profession which are intrinsic to its code of ethics [ 89 ]. There is a longstanding consensus that professionalism and professional identity formation need to be key elements of medical education [ 29 ]. However, a unifying theoretical or practical model to integrate the teaching of professionalism into the medical curriculum has not emerged [ 90 , 91 ]. Nevertheless, role modeling and personal reflections -- ideally guided by faculty -- rather than blocks of time devoted to didactic exercises -- are widely held to be the most effective techniques for developing professionalism [ 90 , 91 ]. Inter-professional education, another major contemporary thrust, also is best addressed after a foundation in the biomedical sciences is developed [ 92 ].

Regarding the issue of classroom attendance, medical student and teaching faculty attitudes have been found to differ regarding the importance of classroom attendance and its relationship to professionalism, findings that were at least partially explained by differing expectations of the purpose of the preclinical classroom experience [ 45 ]. Students tended to view class-going primarily as a tool for learning factual material, whereas many faculty viewed it as serving important functions in the professional socialization process [ 45 ]. Rather than dealing with practical solutions to enhancing the value of lectures, other formats are promoted which place inordinate demands on faculty time. This scenario is off-kilter. It sends the wrong messages to students regarding personal responsibility and professionalism. A practical approach to dealing with differing expectations and to effectively instill professionalism is to provide students, residents and staff with a written list of expected behaviors coupled with teaching and role modeling, assessment and remediation [ 93 ].

Impact on pathology

Pathology is uniquely both a medical science and a clinical discipline [ 94 , 95 , 96 , 97 , 98 , 99 ]. In the analogy of the tree of medicine, the trunk is general pathology, which draws from all the basic biomedical sciences to elucidate general principles of regulation and dysregulation of homeostasis, and divides into the many branches of special pathology (organ system pathology); each one of these branches supports a specialized field of clinical medicine [ 95 ]. Thus, the place of pathology in the curriculum is seminally important in linking the basic biomedical sciences to clinical medicine and providing an understanding of the pathobiological basis of disease. The Association of Pathology Chairs has put forward a position paper on pathology competencies for medical education [ 99 ]. Since a solid understanding of pathology is core to the practice of medicine in any specialty, the position paper posits that all medical students must learn the basic mechanisms of disease, their manifestations in major organ systems, and how to apply that knowledge to clinical practice for diagnosis and management of patients. However, the place given to the pathobiological basis of disease in the new curriculum models is diminished.

Although a traditional curriculum includes a formal pathology course, pathology has been disadvantaged by the fact that students generally have little exposure to pathology or pathologists in the professionally formative clerkship years [ 100 , 101 , 102 ]. However, a distinction needs to be made between student perceptions of pathology as a career and pathology as a critically important medical science. The task of grounding medical students in principles of pathology, including pathogenesis and pathophysiology of disease, has been made considerably more difficult by the design of the new integrated, modular curriculum. The resultant discontinuance of pathology courses and their replacement by elements of pathology scattered episodically in the pre-clinical years likely has resulted in the dilution of core scientific principles and has contributed to a reduced understanding and interest in pathology [ 100 , 101 , 102 ].

Initiatives to increase the exposure and understanding of pathology and the autopsy are necessarily going to be tailored to the local environment operative at each institution [ 100 , 101 , 102 , 103 , 104 , 105 ]. While these approaches cannot fully substitute for the coherent presentation of the pathobiological basis of disease in a pathology course, it is imperative that pathology educators make this effort.

Nevertheless, exposure of medical students to the autopsy is a casualty of the current environment [ 106 , 107 , 108 , 109 ]. As a consequence, it is disconcerting but hardly surprising that physicians now in residency training and clinical practice have little understanding or appreciation for the autopsy, and, therefore, have little motivation for or experience with discussion of the autopsy with next of kin of the deceased. This state of affairs is contributing to the decline of the autopsy, which remains a uniquely important procedure for quality assurance in medicine [ 108 , 109 ].

Another correlate of the current undergraduate medical educational environment is that pathology now has the lowest percentage of residency positions filled by U.S. seniors in the National Residency Matching Program [ 110 , 111 ]. Furthermore, pathology residency programs have joined other medical specialties in conducting “boot camps” for incoming trainees [ 112 , 113 , 114 ]. The boot camps are aimed at providing the basics of a necessary foundation in pathology-specific medical science and in introducing basic skills and processes required for practice of anatomic pathology and laboratory medicine [ 112 ]. The assessment of pathology educators is that the new LCME-driven curriculum is producing a medical graduate who may think differently, but certainly lacks subject-specific knowledge for a variety of medical specialties. A putatively superior curriculum should not present a need for remedial learning for its graduates. Hopefully, boot camps for pathology trainees will be more effective than appears to be the case for bootcamps for trainees in surgical specialties [ 114 ].

Impact on physician-scientists

Physician-scientists of various stripes have a unique and important role in translating basic science discoveries into advances in clinical medicine [ 115 , 116 ]. Their numbers are small and their development is under threat. In some institutions, tailored curricula are being implemented to promote the development of clinician scientists [ 117 , 118 ]. Nevertheless, there is a legitimate concern that the diminished position of basic science in the new curriculum is detrimental to the future maturation of physician-scientists [ 119 ].

Early predictors of career achievement in academic medicine have been identified as: 1) membership in AOA, 2) rank in the top third of the graduating class, and 3) research experience in medical school [ 9 ]. These three factors were of crucial importance in launching my career as was the seminal importance of a faculty mentor [ 120 , 121 ]. The new curricula need to ensure that such opportunities are available for motivated medical students.

Complexities and proposed solutions

Reformers contend that changes in the healthcare system and in medical practice in the clinic and hospital have outpaced those in the classroom, resulting in a declining relevance of the traditional curriculum and a growing urgency for a paradigm shift in medical education. Three barriers to the implementation of evidence-based curriculum reform have been identified [ 20 ]. First, curriculum revision must take place within a certain time frame, making it a zero-sum game. Second, transitioning from a few basic scientists lecturing entire classes from the podium to numerous small groups often tutored by clinical faculty dramatically increases the teaching demands on all faculty and especially faculty clinicians. Third, an inevitable tension is created between a holistic educational approach and the imperative to prepare students for USMLE Step 1.

Regarding the first point, reformers contend that reduction and revamping of the basic science content is warranted and can be achieved by elimination of perceived redundancy in the old curriculum. But the reality is that biomedical science, both in terms of curriculum time and emphasis, has been diminished in the new curricula [ 102 , 118 , 119 ]. Further negative pressure on the basic sciences is coming from the initiative to incorporate Health Systems Science into the curriculum with associated need to develop faculty with skills in teaching this material [ 23 , 24 , 25 , 26 , 27 ].

Pertinent to the second point, there are special challenges for faculty in educating the current generation of medical students in the Information Age [ 33 , 40 , 41 , 42 ]. Certainly faculty educators need to recognize the characteristics of today’s students and take this into consideration in implementation of the curriculum. However, rather than taking a laissez faire approach, faculty educators need to set expectations regarding standards of performance [ 93 ]. In medical education, it is vital that faculty and staff temper overconfidence and excessive risk-taking [ 33 ]. Pedagogical approaches can be modified to meet the learning pattern of today’s medical students, for example, by blending lecture and non-lecture formats [ 43 ]. Nevertheless, standards for content and learning should remain the same; educators cannot compromise on the material that must be learned [ 33 ]. Also, medical students need to be taught and experience functioning and decision making in the face of inevitable uncertainties in life and medical practice [ 122 , 123 ].

Regarding the third point, neo-curriculum advocates contend that solutions to the dilemma of the usurpation of the curriculum by the USMLE lie outside the control of undergraduate medical educators [ 20 ]. These advocates say that solutions require creativity and action from residency selection committees and the USMLE’s sponsors, the Federation of State Medical Boards and the National Board of Medical Examiners, because of the implementation of the new UME curriculum. But those in control of the UME curriculum can ensure that meaningful objective summative assessments of students in both pre-clinical and clinical courses are included in dean’s letters so that the USMLE is not the sole or primary objective assessment presented to residency selection committees.

In spite of the complexities, I contend that rebalancing the position of medical science in the medical educational curriculum has paramount importance [ 46 , 47 , 48 , 49 , 50 , 102 , 119 ]. This is to be achieved by providing the necessary amount of unencumbered space freed of major competing priorities. Different schools may use different approaches. Nevertheless, I favor restoration of subject-based courses, including a pathology course. Appropriate coordination of subject matter among the courses is essential, but this does not require the modular integration approach. Optimal ways of integrating topics in Health Systems Science during the multiyear curriculum need to be developed such as not to unduly compete with education in the core medical sciences.

Trends in American healthcare, academic medical centers and academic medicine

Contemporaneous with restructuring of medical education, medical practice has undergone a fundamental transformation, dominated by a fixation on increasing efficiency in the delivery of care with quality of care a secondary consideration [ 124 , 125 ]. The standard for the medical product has become good enough rather than excellent.

Regarding academic medicine, from 1985 to 2008, the percentage of active doctors engaged in teaching, research or administration decreased from 9 to 5.5%, and the number of teachers and mentors per US medical graduate declined from 0.11 to 0.07 [ 124 , 125 ]. During the decade prior to 2004, biomedical research funding from all sources in America increased at an annual rate of 6.3%, and the United States funded more than half of all biomedical research conducted throughout the world. Since 2004, the growth rate for research funding has decreased to 0.8%, and the U.S.’ share of the world’s research investment has decreased to 44%. From 1996 to 2014, the percent of Nobel laureates in medicine or physiology who were at US institutions at the time of the award decreased from 80 to 45% [ 124 , 125 ].

These very disturbing trends underscore some of the final words of the noted astrophysicist, Stephen Hawking, who warned that education and science around the world are “in danger now more than ever before” [ 126 ].

As eloquently stated by Brigham and Johns, the essence of excellence in medicine is more than doing what we know to do well, but must include a commitment to discovering what will make the better possible, and a dedication to perpetuating the best of the profession [ 125 ]. I content that countering the very disturbing trends just described is going to require a major multifaceted effort including a renewed commitment to advocacy for education and science and the rigorous education of new scientifically grounded physicians and physician-scientists who can carry the torch forward.

The essence of a physician

As articulated over 100 years ago, the characteristics of the ideal physician extend to personal life, professional life and public life [ 127 ]. There is a broad consensus that the good doctor manifests a combination of humanistic and scientific attributes and capabilities [ 128 , 129 ]. Seven key roles of the ideal doctor have been identified as communicator, collaborator, manager, health advocate, scholar, professional, and the integrating role of medical expert. Importantly all the roles overlap equally to create the ‘Medical Expert’ [ 130 , 131 ]. Movement from novice to master in medicine (medical expert) cannot be rushed. Time, experience –and yes, repetition -- is necessary for maturation. This maturation needs to be built on a solid foundation in biomedical science and the pathobiology of disease. The time and place to inculcate the core of this foundation is the first two years of the UME. There are many years for learning and perfecting clinical skills and evidence-based medicine. This will not happen effectively without a sound foundation in biomedical science. A byproduct of a restoration of a strong medical science curriculum will be a boost to the development of future generations of physician-scientists. Conversely, the combination of educational deficiencies coupled with lifestyle preferences carries the risk of diminishing the status of future physicians [ 33 ].

Enthusiasm for reform needs to be tempered by a more cautious and realistic approach. Unless there is modulation, the new curriculum is at risk of producing graduates deficient in the characteristic which have set physicians apart from other healthcare professionals, namely superior clinical expertise based on a deep grounding in biomedical science and understanding of the pathobiology of disease. Physicians need to remain the preeminent medical experts who strongly rely on understanding of basic mechanisms, particularly in dealing with difficult cases [ 47 , 48 , 49 ].

The overarching goal of medical education is the imparting of the highest principles, knowledge and skills in the nascent physician -- not bending medical education to follow prevalent but counterproductive personal and cultural trends. Our society requires physicians who will not just fit into the current dysfunctional American healthcare system but rather work to change it [ 11 , 12 , 13 , 14 ].

Medicine is a field that attracts people who want to have an impact, and this desire can be harnessed to improve medical education. The character traits of today’s medical students can potentially be harnessed to good ends, such as helping others through medicine. Good medical education resembles evolution in that it advances by ensuring the advancement of the fittest, including the fittest of the current generation of medical students just as the fittest of previous generations have succeeded in the past [ 33 , 82 , 83 ]. The challenges for education of the best possible physicians are great but the benefits for medicine and society are enormous.

Into the future, medical education Quo Vadis?

Abbreviations

American Association of Medical Colleges

Accreditation Council for Graduate Medical Education

Academic health center

American Medical Association

Alpha omega alpha honor medical society

Entrustable professional activity

• Graduate medical education

Liaison Committee for Medical Education

Medical college aptitude test

Medical Student Performance Evaluation

New accreditation system

• Undergraduate medical education

United States Medical Licensing Examination

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Medical education: past, present and future

Geoff norman.

Department of Clinical Epidemiology and Biostatistics, MDCL 3519, McMaster University, 1200 Main St. W., Hamilton, ON L8N3Z5 Canada

This article reviews changes in undergraduate and postgraduate medical education since the Flexner report of 1910. I argue that many of the changes in the twentieth century could be viewed as ‘post-Flexnerian’, and related to the integration of biomedical science in the preclinical medical curriculum. I then go on to argue that recent changes in the health care systems worldwide will force a critical re-examination of our approach to clinical education—a ‘post-Oslerian’ era. I suggest that one approach would be to decouple clinical education from clinical care, to some degree, and supplement with curricula designed around careful sequencing of simulated cases.

This is perhaps a good time in my own career, which is now winding down after 40 years, as well as an important time for the journal, to take a look back and a peek into the future. Winston Churchill said, ‘The farther backward you can look, the farther forward you are likely to see’. Keeping this in mind, I intend to take a sweeping look back over 100 years, although I am not so foolish as to cast my vision forward more than into the very immediate future. If this may be viewed as timidity on my part, I recommend a book I recently read, called ‘Future Babble,’ [ 1 ] which discusses human inadequacy at predicting the future, from geology (earthquakes) to economics (recessions) that contrasts with our unshakeable belief that we’re very good at it.

I will not be writing about the scholarly discipline of medical education that I have been fortunate to be a part of for 40 years (although it is more correctly a field of study populated by many disciplines); rather I will discuss the process of educating physicians, how it has changed in the past century, and how it must change in the near future. In doing so, I walk among giants, and view myself as no more than a chronicler of events.

In reviewing individuals who have had a major influence on medical education in the twentieth century, two names stand above all others: Abraham Flexner and William Osler. Perhaps this is a North American bias, and in the longer history, many Europeans have contributed. But my thesis, for better or worse, revolves around the influence of these two personalities.

Flexner (1886–1959) was an American educator who was commissioned by the Carnegie Foundation to write a review of American medical education. His recommendations had the effect of closing down many freestanding medical schools and incorporating medical schools within existing universities, where students might acquire the skills of academic inquiry and the language of biomedical science. In the longer term, this might be seen as a significant initiative toward ensuring that medicine was firmly rooted in biological science (Fig.  1 ).

Abraham Flexner (1886–1959)

Osler (1849–1919) was a Canadian physician. Born in Bond Head, Ontario, he grew up in Dundas, now a suburb of Hamilton. His family home is about 3 km. west of McMaster University. He received an MD from McGill University, he went on to academic positions at McGill, Johns Hopkins, Pennsylvania, and Oxford. He is renowned for his approach to bedside teaching, and his insistence that students learn from their patients. One of his many quotes is, ‘He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.’ He was the ‘inventor’ of both the medical residency and the clinical clerkship (Fig.  2 ).

William Osler (1849–1919)

This article is not a historical review of the contributions of these two outstanding individuals; it would be pretentious for me to presume that I have the skills to write such an essay. Rather, my thesis is that the past century was strongly influenced by Flexner’s report, both directly and indirectly, and less so by Osler. But conversely, as I examine current trends, I suggest that medical education must take seriously Osler’s admonitions to learn from patients, and failure to do so will inevitably compromise the skills of tomorrow’s doctors.

Flexner and the lessons of the past

Medicine is both an art and a science; such a thesis has been advanced many times. But the twentieth century saw the balance between science and art shift toward the former. Clearly Flexner is not solely responsible; scientific developments such as Koch’s discovery of penicillin arose in the nineteenth century. But Flexner forged a link between medical science and medical education. I am not conversant with the early changes in American medical education that resulted, nor is it particularly relevant. But the intimate link between medical research and education in the university environment resulted in large changes in education that followed rapidly from the rapid advances in medical practice such as antibiotics and vaccinations around the Second World War. Immediately after the war, the American government invested heavily in the National Institutes of Health, which provided huge funding for medical research and created numerous positions in university medical schools for basic scientists. The consequence for education was predictable—an expansion of the preclinical curriculum to ‘cover’ the many medical advances, and control of the curriculum in the hands of the basic scientists. While these changes are not a direct consequence of the Flexner report, undoubtedly Flexner would be pleased. Osler, however, may be concerned. I cannot comment on the extent to which European medical education saw similar changes; however, the extent of American hegemony and the near-universal admiration of science and technology immediately after the war make such changes very likely.

The impact on the curriculum was predictable. There was so much science to be learned that it was not unusual for students to have 40–50 scheduled lecture hours per week. Teachers were primarily research scientists, so spent little time linking concepts to clinical medicine. Basic science facts were taught in isolation and tested frequently, all without any clinical correlates. Moreover, the sciences of education and psychology were willing partners in this enterprise. Both were dominated by the behaviourist tradition, in which the student, like the rat, is a passive and motivation-free recipient of stimuli. Curricula devolved to books of objectives, decomposing all aspects of competence into long lists of behavioural elements.

Not surprisingly, some pushback occurred: in the 1950s Case Western Reserve began an Organ System curriculum in which all courses were organized around organ systems such as ‘Cardiovascular’ so that students would be learning the anatomy of the heart at the same time they were learning the physiology of the cardiovascular system. This at least forced some curriculum integration. Perhaps a more profound change was Problem Based Learning (PBL), beginning at McMaster University in the late 1960s [ 2 ]. Indeed, PBL incorporated many of the values of the 1960s—independent, self-directed learning, individual objectives, self-assessment, small-group tutorials, minimal lectures, and no examinations. The adoption of PBL by Maastricht came first, around 1973, then many more schools followed. This led to a proliferation of studies comparing outcomes of both curricula, and to a number of systematic reviews [ 3 , 4 ]. By and large, outcomes are similar despite large differences in process. One recent systematic review shows that PBL students in the Netherlands have better retention and higher scores on objective tests [ 5 ]. On the other hand, a large study of 10 years of North American graduates showed a minimal effect of PBL [ 6 ].

The PBL debate appears to have calmed down in the first decade of the twenty-first century, and it seems that there is acceptance that whatever its deficiencies or benefits, outcomes of PBL schools are similar.

In terms of my present thesis, it should be recognized that all of these changes arise in the preclinical years, thus represent a continuation of the Flexnerian legacy, integrating biomedical science into medical education. Comparable interventions in the clinical years—clerkship and residency—have not occurred. There has been some examination of community-based and integrated clerkships, and again, the evidence appears to support the null hypothesis. There has been very little emphasis on the nature of the specific experiences required to achieve competence in a clinical discipline. Instead, clerkship and residency experiences remain guided and circumscribed by the nature of the patient care demands. Admittedly, there has been some attempt to facilitate acquisition of clinical skills (e.g. intubation, laparoscopy, suturing) using simulation, but these are often inadequately integrated with the rest of the curriculum.

Osler and clinical education in the future

There is some cause for concern that the current approach to clinical education, dictated primarily by patient care demands within the health care system, is gradually eroding the quality of clinical education. Academic clinicians frequently raise the issue of restriction of resident working hours and its impact on learning. Interestingly, the acceptable maximum differs substantially between North America and Europe—48 h in the EU, and 88 h in the US. But this is only the most visible part of the problem. In my view, far more critical is the change in the nature of the clinical experience. The general medicine ward where Osler conveyed his skills at the bedside no longer exists. There are fewer and sicker patients admitted to hospital, for shorter time periods. They are older and have more multi-system disease. Data from the National Health Service (UK) comparing 2010 to 2000, a 10 year period, show:

7.8 to 5.6 days 2000–2010

Elderly, chronic disease, multi-system

66% increase of admissions for patients over 75

• Reduced number of admissions overall
• More patients handled on an outpatient basis

More homogeneous, more procedure-orientation

As the supply side (patients) shrinks, the demand side (learners) increases as medical schools have responded to physician shortages by substantially increasing enrolment, and as other health professional programmes such as physician assistant programmes are initiated. One response to these pressures is to seek out additional clinical sites outside the academic environment, in rural or other community sites. While this may increase access of learners, it creates additional problems in the increased use of non-academic clinicians, and the difficulty of accessing educational materials from remote sites (leading to more research on distance education and web-based learning).

There is no way for educators to have any impact on clinical environments. These changes are a consequence of many more converging forces than can possibly be influenced by educators. We may continue to pursue educational goals in the clinical settings, and should work, as much as possible, to adapt the clinical environment to optimise learning. But as we come to understand expertise, we also come to appreciate the increasing gap between optimal strategies to achieve expertise and the real environments in which our learners function.

I propose a radical solution. In addition to providing experience in the clinical environment, a significant amount of clinical learning, both undergraduate and postgraduate, should occur in carefully engineered simulated settings. Such a proposal is not at all infeasible; as a consequence of the digital revolution of the past decade, we have a proliferation of highly sophisticated simulations for learning everything from basic perceptual skills such as cardiac auscultation to highly complex skills such as ‘weaning’ cardiac patients from bypass. But, to a large degree, these simulations reside under green sheets in clinical skills centres and are rarely part of integrated curricula.

Second, although the cost and fidelity of these simulations is highly variable, literally from €10 to €100,000, there is a growing literature that suggests that low fidelity and low cost simulators can provide a learning experience that closely approximates gains from high fidelity simulations [ 7 ]. In addition, although simulators remain inferior to actual clinical experience, there is ample evidence that skills acquired in simulator settings can be applied (transferred) to the real setting [ 8 ]. Thus, the evidence to date is that a simulated clinical curriculum is both feasible at relatively modest cost (since expensive high fidelity simulations are rarely necessary) and educationally valid.

Finally, it may be the case that learning in a simulated setting, all other things being equal, may not be as effective as learning in an equivalent real setting with real patients. But all other things are not equal. My intent in advocating this approach derives from the recognition, as described above, that the real setting is far from optimal and is likely, in future, to grow worse, not better.

Simulation and the optimal clinical curriculum

Although historically, elite performance in many domains was viewed as primarily a consequence of native talent, more recent evidence has challenged this view. Ericsson has shown in a variety of domains that it takes 10,000 h of deliberate practice to become an expert [ 9 ]. However, it is critical to take note of the adjective deliberate . Simply seeing a sequence of problems, without reflection or carefully engineered difficulty, is not deliberate practice. Instead, to profit from practice, the individual must deliberately move to the edge of his domain of competence, and systematically practise and receive feedback at this level of difficulty.

A second critical observation with respect to medical expertise is that these experiences are not a matter of practising. Rather, the experiences comprise a second corpus of knowledge that resides in a different area of the brain from the formal knowledge of the preclinical curriculum [ 10 ]. A recent paper [ 11 ] shows that learners’ perception of medical expertise is that it derives from a large number of case experiences that enable the expert to tailor his approach to the individual patient. This view of expertise is, I think, completely consistent with Osler’s view. One becomes an expert clinician first and foremost by learning from, and building on, patient experience.

The emphasis, then, is not on devising clinical skills teaching around specific simulators for specific skills, the usual focus of simulations. Rather, I suggest we create an environment where students can work up a series of cases that adequately represents the speciality domain. I am not particularly worried about the characteristics of the individual simulation; there is ample evidence from systematic reviews that various formats lead to equivalent learning [ 12 – 14 ]. Rather I am interested in assembling a large number of cases that ultimately exemplify all the diagnostic, management and motor skills required for expertise in the domain. There have been some attempts along these lines already. The UMedic paediatric problems, 28 in number, are used by about 80% of North American medical schools to ensure that all clinical clerks ‘see’ all the important clinical problems in paediatrics. The ‘clinical presentations’ curriculum at Calgary [ 15 ] has created a total of 129 clinical presentations that are claimed to encompass all important medical problems.

However, expertise does not arise from an extensive and systematic workup of a single case; as I discussed earlier, our current understanding of expertise is that it derives from both a formal systematic knowledge base and extensive experience with many variants of cases. It might be argued that we run a real risk of distorting diagnostic reasoning by introducing students to a large series of simulated cases which have been deliberately sampled for educational relevance, not prevalence. Perhaps, but most health care settings, particularly in-patient, deal with an unrepresentative sample of cases, as pointed out by White many years ago [ 16 ]. In any case, while students must learn that most headaches are tension headaches, not brain tumours, the base rate is only one piece of evidence in arriving at a diagnostic conclusion for a patient with a headache. A simulated environment may well provide a far more optimal situation than the current real world for sharpening diagnostic skills.

But is that all there is? In constructing our simulated health sciences centre, is it simply a matter of having lots and lots of cases available, sampled according to some blueprint, in a variety of formats? If that was all there was, then we would have difficulty in providing sufficient clinical experience within the 48 h/week allocated. Moreover, evidence from aviation suggests that even the best simulation has an efficiency of about 0.5 compared with real experiences (2 h in simulator = 1 h of the real thing). We must do something to increase the efficiency of clinical learning.

The key is to recognize the importance of sequencing. A real clinical setting is a very inefficient place to learn diagnosis. Common things are common, and it is very difficult to arrange experiences so that students learn to differentiate between common benign conditions and the rarer, confusable, ‘don’t miss’ diagnoses. Moreover, the sequence of presentations is determined by the waiting room, not the curriculum, so that two cases of chest pain with confusable diagnoses, an ideal learning situation, may arise weeks or months apart, or never.

Intuitively, an ideal situation for learning diagnosis would be to see a series of cases side by side where two factors are engineered—different presentations of the same diagnosis or condition and similar presentations of different diagnoses. In this manner, the clinician would learn those features or aspects of the case that discriminate among different conditions. Acquisition of perceptual and motor skills could also be enhanced by practice on multiple cases from typical to atypical. Fortunately, cognitive psychology provides evidence for specific approaches that can increase efficiency of learning. Mixed practice, wherein examples from confusable cases are practised and diagnosed together, has shown increases in efficiency of the order of 50% over blocked practice [ 17 ], where one sees examples of one condition, then examples of the next, and so on. Distributed practice, where learning is deliberately spread out over several sessions, can result in learning gains compared with massed practice, where all learning occurs in one session [ 18 ].

Conclusions

As the twenty-first century unfolds, the clinical education of medical students is under constant erosion as a consequence of demographic changes in the population they serve and economic and organizational changes in the health care system designed to respond to these pressures. The consequence is that students cannot expect the same kind of extensive and comprehensive experience with patients that may have been accepted as ordinary a century ago. To cope with these changes will require extensive and imaginative changes in medical education. The solution I have suggested involves decoupling clinical education from clinical service, then carefully engineering education to optimize these experiences.

• In the twentieth century, innovations in medical education were primarily confined to the preclinical curriculum.
• Health care systems worldwide are under increasing pressures that together result in less than optimal educational experiences.
• Medical education in the twenty-first century must come to grips with these changes.
• One possible solution is to implement a parallel curriculum designed around careful sequences of clinical cases using emerging digital technologies.

Conflict of interest

The author reports no conflict of interest.

Open Access

This article is distributed under the terms of the Creative Commons Attribution License which permits any use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.

Geoff Norman’s

experience with Medical Education in the Netherlands is multiple: (co-) author of several review articles, keynote speaker at a symposium in Egmond aan Zee, spent two sabbaticals at Maastricht University and Erasmus MC Rotterdam, visited medical education operations at Amsterdam, Rotterdam, Nijmegen, Groningen, and Leiden.

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• Published: 20 May 2021

Global trends in medical education accreditation

• Deborah Bedoll   ORCID: orcid.org/0000-0003-2442-6228 1 ,
• Marta van Zanten   ORCID: orcid.org/0000-0002-7433-6418 1 &
• Danette McKinley   ORCID: orcid.org/0000-0002-8709-0365 1  

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Accreditation systems in medical education aim to assure various stakeholders that graduates are ready to further their training or begin practice. The purpose of this paper is to explore the current state of medical education accreditation around the world and describe the incidence and variability of these accreditation agencies worldwide. This paper explores trends in agency age, organization, and scope according to both World Bank region and income group.

To find information on accreditation agencies, we searched multiple online accreditation and quality assurance databases as well as the University of Michigan Online Library and the Google search engine. All included agencies were recorded on a spreadsheet along with date of formation or first accreditation activity, name changes, scope, level of government independence, accessibility and type of accreditation standards, and status of WFME recognition. Comparisons by country region and income classification were made based on the World Bank’s lists for fiscal year 2021.

As of August 2020, there were 3,323 operating medical schools located in 186 countries or territories listed in the World Directory of Medical Schools. Ninety-two (49%) of these countries currently have access to undergraduate accreditation that uses medical-specific standards. Sixty-four percent ( n  = 38) of high-income countries have medical-specific accreditation available to their medical schools, compared to only 20% ( n  = 6) of low-income countries. The majority of World Bank regions experienced the greatest increase in medical education accreditation agency establishment since the year 2000.

Conclusions

Most smaller countries in Europe, South America, and the Pacific only have access to general undergraduate accreditation, and many countries in Africa have no accreditation available. In countries where medical education accreditation exists, the scope and organization of the agencies varies considerably. Regional cooperation and international agencies seem to be a growing trend. The data described in our study can serve as an important resource for further investigations on the effectiveness of accreditation activities worldwide. Our research also highlights regions and countries that may need focused accreditation development support.

Peer Review reports

There are currently over 3000 medical schools providing education and training to aspiring physicians around the world. The medical education curriculums, experiences offered, available resources, length of study, etc., vary widely depending on regional, political and other contextual factors. This variability in educational models, combined with the rapid increases in the number of medical schools worldwide [ 1 ] and increasing international mobility for education and employment [ 2 ] necessitate oversight of quality assurance, such as formal accreditation systems, to ensure medical educational institutions function appropriately [ 3 ]. For the purpose of this paper, we use the definition of accreditation as described by van Zanten et al. [ 4 ], “a process by which a designated authority reviews and evaluates an educational institution using a set of clearly defined criteria and procedures”.

Accreditation systems in medical education aim to assure various stakeholders, including students, educators in postgraduate educational programs, employers, and patients, that graduates are ready to further their training or begin practice. Oversight of the educational content and pedagogical methods is necessary to ensure that the learning needs of the students are met and endeavor to ultimately impact the quality of medical care provided to patients. While there should also be significant consequences for educational institutions that do not meet the standards, an important aim of the accreditation process should be encouraging ongoing institutional improvement and fostering the dissemination of best practices, both regionally and globally.

The development and sustainability of educational quality assurance systems is supported by various international organizations worldwide. The World Health Assembly in its Global Strategy on Human Resources for Health: Workforce 2030, encouraged all countries to have accreditation for medical and other health training programs by 2020 [ 5 ]. The World Medical Association also supports quality assurance mechanisms to promote trust in the health workforce [ 6 ]. The World Federation for Medical Education (WFME) Recognition Programme aims to provide an independent, transparent and rigorous method of ensuring that accreditation of medical schools worldwide is at an internationally accepted and high standard [ 7 ]. As part of the Recognition Programme, WFME evaluates compliance of accrediting agencies with pre-defined criteria [ 8 ].

Since 2005, the Foundation for Advancement of International Medical Education and Research (FAIMER®) has been gathering and publishing data on accreditation activities worldwide. Their Directory of Organizations that Recognize/Accredit medical schools (DORA) lists organizations that recognize, authorize, or certify medical schools and/or medical education programs and related data [ 9 ]. Summary data from DORA of accreditation activities around the world showed that while over half of all countries with medical schools indicate that there is a national process of accrediting medical education programs, there was considerable variation in scope of authority and level of enforcement [ 4 ]. For example, accreditation is managed and implemented by various organizations/agencies around the world, including professional bodies or associations, such as associations of medical schools, statutory bodies such as Medical Councils, or by national accreditation authorities that conduct quality assurance reviews of all higher education, including health professions education [ 10 ]. While the creation of a separate medical education accreditation system, in addition to an accreditation system already in place to review an entire university (including the medical school) could be viewed as redundant, authorities that compared health-care discipline specific accreditation systems with general higher education accreditation processes have argued for the importance of specific quality assurance focused on health professions such as medicine [ 11 , 12 ].

The purpose of this paper is to explore the current state of medical education accreditation around the world and describe the incidence and variability of these accreditation agencies worldwide. By tracking the founding years of accreditation organizations and comparing our data against that found in 2008 [ 4 ], we show the growth and change of such academic accreditors over time, as well as updating the data available for future research. This descriptive study explores trends in agency organization and scope according to both World Bank region and income group, and highlights regions that may need focused accreditation development support.

Search strategy

To find information on accreditation agencies in each country and to identify trends in organization and scope, in August 2020 we searched DORA [ 9 ], the International Network for Quality Assurance Agencies in Higher Education (INQAAHE) [ 13 ], a worldwide association of organizations that are active in quality assurance in higher education, and the Database of External Quality Assurance Results (DEQAR) [ 14 ], a database of reports and decisions on higher education institutions and programs from agencies registered in the European Quality Assurance Register (EQAR). We supplemented our search with the Google search engine and the University of Michigan Online Library, using the terms “medical education accreditation ‘[Country]’” and “medical education quality assurance ‘[Country]’” to find further information about agency histories and relationships or additional accreditation agencies that were not listed in the above databases. Figure  1 below shows a visual representation of our search strategy.

A visual representation of our search strategy. Countries and agencies that did not meet the criteria listed as questions below were not included in the analysis

As of August 2020, there were 3,323 operating medical schools located in 186 countries or territories listed in the World Directory of Medical Schools ( World Directory ) [ 15 ]. Countries and territories that did not have at least one operational medical school listed on the World Directory by August 1, 2020, were not included in the analysis. A complete list of accreditation agencies included in this analysis can be found in Appendix 1 .

Each identified accreditation agency was screened to identify its operational status. Agencies that were non-operational were excluded from the analysis. To be included, an accreditation agency must have the term “accreditation” or “quality assurance” as an activity, apply this activity to undergraduate programs or schools that include basic medical education programs, and have demonstrably begun or completed at least one accreditation. Agencies performing consultative visits only were not included.

All included agencies were recorded on a spreadsheet along with their date of formation or first accreditation activity. If date of first medical school/program accreditation was 5 years or more later than date of formation, the later accreditation date was used. Where it could be shown that an agency had undergone name changes, the date of first accreditation of their parent agency was used. Information recorded for each agency included national or international scope, whether accreditation standards were accessible, if the agency is currently WFME recognized or had applied for WFME recognition as of September 1, 2020, and supplemental links and details. In addition, to provide contextual background information, the level of independence from the national government was investigated. Government relationship was recorded as “public” if the agency was originally formed and still managed as a government agency, “independent” if the agency was formed by the government but managed autonomously, and “private” if the agency was not formed by an act of government.

To be included in this review, agency standards documents were available in English language, or in a document that could be translated into English using Google Translate ( https://translate.google.com/ ). To be recorded as offering medical-specific accreditation in this review, an agency’s standards were available online or provided through email. If an agency could be verified as providing some type of accreditation, but their standards could not be located or successfully translated, the agency was recorded as having general accreditation standards.

To classify agencies as having medical-specific or general accreditation standards, we referred to the WFME Standards for Basic Medical Education, 2015 [ 12 ]. These standards comprise basic curricular standards including biomedical sciences (B 2.3), medical ethics (B 2.4.3), medical research methods (B 2.2.2), evidence-based medicine (B 2.2.3), and patient contact (B 2.5.2), must ensure adequate clinical training facilities (B 6.2.2), and must specify the amount of time spent in training in major clinical disciplines (B 2.5.4). We selected these seven requirements as being unique to the health professions, and representative of health-professions-specific standards. For the purpose of this review, the terms “health-professions” and “medical” are used interchangeably. Agency standards were reviewed and classified as medical-specific if they included two or more requirements that focused on content comparable to the above standards. Agencies with standards that included one or no requirements related to the seven Basic Medical Education standards above were classified as offering general accreditation. Agencies with standards that did not stipulate medical education requirements beyond the inclusion of a health-professions expert in the accreditation team were recorded as having general accreditation standards.

We used counts and percentages to describe the number of agencies by accreditation type, location, founding date, and level of government independence. Country region and income classifications were based on the World Bank’s lists for fiscal year 2021 [ 16 ]. Comparisons by country region and income classification were made. We compared these results to the findings of van Zanten et al. [ 4 ] to identify trends.

Table 1 presents information on the level of accreditation that is available for undergraduate medical programs or schools in countries with at least one known medical school ( n  = 186) by World Bank region. Ninety-two (49%) of these countries currently have access to undergraduate accreditation that uses medical-specific standards. This accreditation is provided by 71 accreditation agencies, of which 23 (32%) are currently recognized by WFME.

There is wide variability in the availability of medical-focused accreditation across the regions, ranging from 31% ( n  = 13 countries) in Sub-Saharan Africa to 100% ( n  = 2 countries) in North America. Of all types of accreditation agencies for which we were able to determine their government relationship ( n  = 189 agencies), about half ( n  = 94) of the organizations are public, 35% ( n  = 67) are independent, and 15% ( n  = 28) are private. Of the medical-education-specific accreditation agencies, 42% ( n  = 30) are public, 37% ( n  = 26) are independent, and 21% ( n  = 15) are private.

Table 2 presents information on the level of accreditation available for undergraduate medical programs or schools in countries with medical schools ( n  = 186 countries) by World Bank economic group. Sixty-four percent ( n  = 38) of high-income countries have medical-specific accreditation available to their medical schools, compared to only 20% ( n  = 6) of low-income countries. More than half of low-income countries did not have undergraduate accreditation systems that we could discern.

To examine scope and tenure of the agencies, we examined trends by region. Findings are summarized in Fig.  2 , which contrasts the number of medical education accreditation agencies created in each time period and highlights the recent acceleration of agency creation. Four of the nine regions experienced the greatest increase in medical education accreditation agency establishment since the year 2000; however, East Asia and the Pacific saw the greatest growth in the years 1980–1999, while both South Asia and North America developed most of their agencies pre-1980. The Latin America region has the greatest number of medical education accreditation agencies, followed by the Europe & Central Asia region.

Medical education accreditation agencies by World Bank Region

Figure  3 shows the age of undergraduate medical education accreditors on a global map. Medical education accreditation is now available in most larger countries, although it exists in only about half of countries with medical schools. Areas that are still under-represented in this type of accreditation include western Africa, southern and eastern Europe, northern South America, and Scandinavia.

Countries with undergraduate medical education accreditation agencies

Figure  4 shows the type of undergraduate accreditation agency in each country on a global map. Most smaller countries in Europe, South America, and the Pacific only have access to general accreditation, and many countries in Africa do not have medical accreditation available. Detailed information on the agencies scope and trends over time are reported in the next section of the paper.

Countries with accreditation agencies that review undergraduate medical programs or schools

Sub-Saharan Africa

Of the 42 countries in the World Bank’s Sub-Saharan Africa region that have medical schools listed in the World Directory, 20 (48%) have known accreditation authorities. Although this is the lowest percentage of countries with academic accreditation of all World Bank regions, this number has increased almost 300% since van Zanten’s 2008 review [ 4 ], in which only seven countries had accreditation authorities. The 20 countries are served by a total of 28 different organizations, half of which ( n  = 14) provide medical-education accreditation, while the other half offer general accreditation. Most of these organizations ( n  = 19, 68%) are government-run, although four (14%) are independent entities, and five (18%) are private organizations.

The Sub-Saharan Africa region includes one of the oldest medical-education accreditors in the world, the National Universities Commission of Nigeria. This public, national agency was established in 1962 as an advisory agency and was upgraded to a statutory body in 1974. This agency has not yet applied for WFME recognition, and in fact the Sudan Medical Council (SMC) is the only WFME-recognized accreditor in this region. This leaves a large region of the world underserved by WFME-recognized medical education accreditors.

Twelve countries gained access to medical education accreditation in this region since the year 2000. However, there are seven countries in this region that only have access to general academic accreditation agencies, and 22 countries without any known form of undergraduate medical school accreditation.

Middle East and North Africa

There are 20 countries with medical schools listed in the World Directory in the World Bank’s Middle East and North Africa region. We found 18 of these countries to offer some type of undergraduate accreditation, and of those, 12 utilized medical education standards. This is a 163% increase from the 11 countries with undergraduate accreditation noted by van Zanten et al. in 2008 [ 4 ].

The 18 countries with undergraduate accreditation are served by 27 separate agencies, of which 14 use medical guidelines and 13 offer only general accreditation. Many of the countries in this region have more than one accreditation agency, most notably Kuwait and Jordan, which are each served by three separate organizations. Most accreditation agencies are either run by the country’s government ( n  = 13) or are independent but government-based organizations ( n  = 12), however there are two private agencies operating in this space. One of those, The Association for Evaluation and Accreditation of Medical Education Programs (TEPDAD), is an international accreditation agency that utilizes medical guidelines and offers accreditation to three different countries in this region and four more countries in other regions of the world.

Seven countries in this region are served by an agency already recognized by WFME, and another two agencies have applications under review.

Europe and Central Asia

This region includes 48 countries with currently operating medical schools listed in the World Directory , which is the largest number of countries of all World Bank regions. Similarly, this region has the highest number of accreditation organizations, with 71 agencies providing some type of undergraduate academic accreditation. Half of these agencies ( n  = 36) are independent agencies, with government organizations and private agencies each representing about a quarter of the total ( n  = 17 and n  = 13, respectively). Accreditation coverage in this region has grown by 150% since the 2008 van Zanten et al. paper [ 4 ], and is now found in every country.

Although this region has a high number of high-income nations (58%), only 18 of these countries (38%) have medical-specific accreditation available. The remaining 62% use only general undergraduate accreditation standards.

Eleven countries in this region are covered by WFME-recognized accreditation organizations, with one additional agency’s application (in Germany) currently under review. Although Poland was the first country in this region to develop medical-specific accreditation standards, in 1997, their agency has not yet applied for WFME recognition.

Eastern Asia and Pacific

This region includes 23 countries with medical schools listed in the World Directory . Of those, 21 countries have known undergraduate accreditation authorities, and more than half of those ( n  = 12) have medical-education accreditation available within their borders. Accreditation coverage in this region has increased by 233% since 2008 [ 4 ].

This region is served by 40 different undergraduate accreditation agencies, which are about equally divided between Public, Independent, and Private organizations ( n  = 11, 13, and 10, respectively), although we were unable to determine the organizational structure of six agencies. There are two countries in this region, Micronesia and North Korea, for which we were unable to find evidence of active accreditation organizations.

In this region, we see medical education accreditation forming as early as 1957, by the Philippine Accrediting Association of Schools, Colleges and Universities (PAASCU). This organization is a private, international agency, and their application for recognition by WFME is currently under review. Eight countries in this region are currently served by a WFME-recognized agency.

Latin America and the Caribbean

There are 37 countries with active medical schools listed in the World Directory that are included in the World Bank’s Latin America and Caribbean region. Undergraduate accreditation systems are in place in 34 of these countries, which is a 142% increase from the number found in 2008 [ 4 ]. Of these countries, 70% ( n  = 26) have medical-education accreditation available.

The 34 countries with medical or general accreditation are serviced by 58 agencies, of which 26 are private organizations. Twenty more organizations are publicly run and funded, and we found seven independent agencies. In this region, most of the agencies ( n  = 37, 63%) use medical education-specific standards for their accreditation. Twenty countries are covered by a WFME-recognized organization, and one agency’s application for WFME recognition is currently under review, granting this region the highest rate of WFME recognition in the world.

The World Bank lists Puerto Rico as a country in the Latin American region, and this is the only nation with medical education accreditation that was formed pre-1980, through the US-based Liaison Committee on Medical Education (LCME). Three more countries (Mexico, Colombia, and Sint Maarten) gained access to medical education accreditation between 1980 and 1999. The remaining 22 countries in this region with medical education-specific accreditation have developed it in the last 20 years, making this area the 2nd largest growth region for medical education accreditation in the last two decades.

North America

This region, with only two countries (Canada and the United States), has had medical-specific accreditation agencies in both countries since 1979. The LCME, founded in 1942, is the accrediting authority for allopathic medical education programs leading to a Doctor of Medicine (MD) degree in the US. This agency is a private organization and recognized by WFME, as is the Committee on Accreditation of Canadian Medical Schools. Also operating in this region is the Commission on Osteopathic College Accreditation (COCA), which began accreditation activities in 1952, but is not yet recognized by WFME.

Quality of education has been a concern since the early twentieth century and is of particular concern in medical education, as graduates of medical schools provide patient care. Medical education accreditation, first developed 60 years ago, has seen significant growth around the world in the last 20 years. While in 1980 there were only eight such accreditors, by the time of this review there were 71. High-income countries began this trend, with 11 high-income countries served by medical education accreditors before 1980. Growth has been fastest in middle-income countries, which have seen 36 countries begin using medical education accreditation in the last 20 years, but slowest in low-income countries where only six countries currently use medical education accreditation standards. Although low-income countries account for 17% ( n  = 30) of the countries in this study, they had only 6% ( n  = 7) of the medical education accreditation agencies worldwide.

These data show us that the use of medical education accreditation and standards, although increasing, is not universal. Although most countries have some type of undergraduate accreditation systems in place, the majority of these do not use standards that are specific to medical education. The Sub-Saharan African region, in particular, has a low incidence of medical education accreditation.

In countries where medical education accreditation exists, the scope and organization of the agencies varies considerably. Some international agencies were found to provide accreditation services in more than 10 countries, while others only served one or two additional countries. Latin America has a high number of private accreditation agencies, while the Middle East and North African region has only two each, and South Asia has none. In Sub-Saharan Africa, public accreditation agencies outnumber private and independent agencies by 4:1, in contrast to Europe and Central Asia where independent agencies are twice as common as either public or private organizations. This global variability in legislative formats is likely due to cultural and historical differences and is not associated with the quality or rigor of the accreditor.

Regional cooperation and international agencies seem to be a growing trend. These transnational initiatives support physician migration, mutual degree recognition, and the sharing of academic resources as technology becomes increasingly accessible. The development and recent growth of WFME recognition also indicates the spread of globalization in this area.

Our data demonstrate that medical education quality assurance systems have been increasing and improving worldwide, which should lead to evidence of more highly skilled physicians and in turn, better patient heath. For example, program data at one medical school in Saudi Arabia were analyzed following accreditation, and the authors conclude that there were significant improvements to the administration, curriculum, and educational processes [ 17 ]. In Canada, accreditation encourages medical education programs to establish processes likely to be associated with improved quality [ 18 ]. In the US, quantitative analyses have demonstrated that for certain populations of international medical graduates, graduating from an accredited medical school is associated with better performance on the United States Medical Licensing Exam (USMLE) [ 19 , 20 ]. Recently, a study demonstrated that Canadian accreditation review cycles appear correlated with educational processes that are associated with better student outcomes on a national licensing examination [ 21 ]. To the extent that performance on licensing examinations is predictive of improved patient health, these studies provide evidence of a relationship between accreditation and the proficiency of graduates of accredited schools.

While this study provides an overview to medical school accreditation practices internationally, it is not without limitations. This project encountered challenges throughout the data collection and review process, such as a reliance on accreditors’ websites that may not have been updated recently or exist at all, limited access to accreditation process data for many agencies, and a pandemic that may have distracted some agencies from responding to our queries. Complex relationships and international agreements, especially those within the Central and South American region, made confirming accreditation activity for some countries difficult to discern. It is likely that agencies are operational in some countries that we did not find documentation of online. Despite our best efforts to obtain accurate data, track agencies through multiple name changes and organizational structures, and classify organizations appropriately, some agencies may have start dates considerably earlier or later than recorded, or be miscategorized, due to confusing terminology and multiple interpretations of terms such as “accreditation”, “independent”, or “autonomous”.

According to a recent review of published research on accreditation in basic medical education, accreditation agencies from high-income countries were featured most often, and most studies had at least one author from the United States or Canada [ 22 ]. As the number of accreditation agencies and their specific focus on medical education quality assurance continues to increase globally, more investigations from all regions in the world providing evidence of effectiveness are warranted. In addition, while for this study we combined medical and health profession program accreditation data, future research is needed to determine if these systems are organized and implemented the same way, within and across countries, and the impact of separation by health profession on the effectiveness of quality assurance systems.

These data show us that the use of medical education accreditation and standards, although increasing, is not universal. Although most countries have some type of undergraduate accreditation systems in place, many of these do not use standards that are specific to medical education. Most accreditation systems have only developed in the last 20 years. The summary and trend data described in our study can serve as an important resource for further investigations on the effectiveness of accreditation activities worldwide, especially in areas not frequently highlighted in the literature. Descriptive data, such as type and scope of accreditation agencies and country classification statistics, can serve as a basis for frameworks for identifying and disseminating best practices. Our research also highlights regions and countries that may need focused accreditation development support.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Commission on Osteopathic College Accreditation

Directory of Organizations that Recognize/Accredit medical schools

Database of External Quality Assurance Results

European Quality Assurance Register

Foundation for Advancement of International Medical Education and Research

International Network for Quality Assurance Agencies in Higher Education

Liaison Committee on Medical Education

Philippine Accrediting Association of Schools, Colleges and Universities

Sudan Medical Council

The Association for Evaluation and Accreditation of Medical Education Programs

United States Medical Licensing Exam

World Directory of Medical Schools

World Federation for Medical Education

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Bedoll, D., van Zanten, M. & McKinley, D. Global trends in medical education accreditation. Hum Resour Health 19 , 70 (2021). https://doi.org/10.1186/s12960-021-00588-x

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2 Division of Life Science, Hong Kong University of Science and Technology, , Clear Water Bay, Kowloon, HKSAR, , China

3 Gies College of Business, University of Illinois Urbana-Champaign, , Urbana-Champaign, IL, , United States

4 School of Education, South China Normal University, , Guangzhou, , China

*these authors contributed equally

Corresponding Author:

Yuechun Wang, PhD

Background: Over the last decade, there has been growing interest in inverted classroom teaching (ICT) and its various forms within the education sector. Physiology is a core course that bridges basic and clinical medicine, and ICT in physiology has been sporadically practiced to different extents globally. However, students’ and teachers’ responses and feedback to ICT in physiology are diverse, and the effectiveness of a modified ICT model integrated into regular teaching practice in physiology courses is difficult to assess objectively and quantitatively.

Objective: This study aimed to explore the current status and development direction of ICT in physiology in basic medical education using bibliometric visual analysis of the related literature.

Methods: A bibliometric analysis of the ICT-related literature in physiology published between 2000 and 2023 was performed using CiteSpace, a bibliometric visualization tool, based on the Web of Science database. Moreover, an in-depth review was performed to summarize the application of ICT in physiology courses worldwide, along with identification of research hot spots and development trends.

Results: A total of 42 studies were included for this bibliometric analysis, with the year 2013 marking the commencement of the field. University staff and doctors working at affiliated hospitals represent the core authors of this field, with several research teams forming cooperative relationships and developing research networks. The development of ICT in physiology could be divided into several stages: the introduction stage (2013‐2014), extensive practice stage (2015‐2019), and modification and growth stage (2020‐2023). Gopalan C is the author with the highest citation count of 5 cited publications and has published 14 relevant papers since 2016, with a significant surge from 2019 to 2022. Author collaboration is generally limited in this field, and most academic work has been conducted in independent teams, with minimal cross-team communication. Authors from the United States published the highest number of papers related to ICT in physiology (18 in total, accounting for over 43% of the total papers), and their intermediary centrality was 0.24, indicating strong connections both within the country and internationally. Chinese authors ranked second, publishing 8 papers in the field, although their intermediary centrality was only 0.02, suggesting limited international influence and lower overall research quality. The topics of ICT in physiology research have been multifaceted, covering active learning, autonomous learning, student performance, teaching effect, blended teaching, and others.

Conclusions: This bibliometric analysis and literature review provides a comprehensive overview of the history, development process, and future direction of the field of ICT in physiology. These findings can help to strengthen academic exchange and cooperation internationally, while promoting the diversification and effectiveness of ICT in physiology through building academic communities to jointly train emerging medical talents.

Introduction

In recent decades, student-centered active learning strategies have been implemented in numerous educational institutions worldwide as an alternative to traditional passive learning strategies such as didactic lecturing [ 1 ]. As a novel teaching mode, inverted classroom teaching (ICT), first proposed by Lage et al [ 2 ] in 2020, is now widely used to enhance the engagement of students in the active learning process. ICT, also known as “flipped classroom teaching,” promotes student participation, engagement, and identification of necessary resources and needs to meet learning objectives by repurposing classroom time for student-centered learning activities [ 3 , 4 ]. The teaching materials are made available for self-study outside of the classroom, while ICT also emphasizes active learning by assigning preclass tasks to students with clear learning objectives. ICT represents a significant advancement in modern classroom design, and its potential for promoting student-centered learning is particularly noteworthy.

Medical institutions were among the first to shift away from traditional didactic methods toward student-centered learning, which has been shown to motivate and empower students to be life-long learners, foster self-growth, and encourage receiving and applying up-to-date information and techniques in various medical fields [ 5 , 6 ]. Since it was first proposed as a teaching model [ 2 ], ICT has been used in almost all fields of education, especially in basic medicine and clinical medicine, and has become a focus of educational research. A recent bibliometric analysis on ICT revealed its ability to reallocate the teaching content taught in traditional classrooms outside the classroom for students to study on their own before the class. The resulting saved classroom time is then used for various student-centered learning activities such as problem-based and inquiry-based learning [ 4 , 7 , 8 ]. With the COVID-19 pandemic wreaking havoc around the globe, ICT has been increasingly incorporated into online teaching and is regarded as a promising and flexible approach for securing high-quality teaching via different forms of teaching media [ 9 ]. Despite the overwhelming benefits and compelling cases, researchers have also reported negative examples and disadvantages of using active-learning strategies, such as students lacking learning motivation [ 10 , 11 ], increased workload for both faculty and students [ 12 ], longer preparation time [ 12 ], and reluctance to discuss the teaching content with peers [ 13 ]. Moreover, a systematic theoretical and practical system of ICT in medical education has not yet been established.

Physiology is a bridging course between basic and clinical medicine, which is a core course for students in medicine and related subjects. Physiology is typically scheduled in the first semester of the second year of medical school. This course is often considered challenging for students in the early stages of their medical education owing to its highly conceptual nature, the significant cognitive effort required to acquire academic information, and the combined laboratory experiments associated with theoretical knowledge [ 9 , 14 , 15 ]. To a certain extent, the history and development of inverted teaching in physiology may serve as a window to probe into the general picture of the use of ICT in basic medical education. However, there is still a vast knowledge gap in the development and application of ICT in physiology courses; for example, it remains unclear how ICT in physiology evolved from the information era to the digital and artificial intelligence era. With the development of CiteSpace, a powerful visualization and analysis software, it has now become feasible to depict and visualize science knowledge graphs [ 16 ], including the outline and timeline of ICT in physiology, which can help to address these knowledge gaps in a more quantitative manner than possible with traditional qualitative methods such as a scoping review.

Therefore, in this study, we performed a visual analysis of the ICT in physiology literature from the Web of Science (WoS) database with CiteSpace. The aim was to explore the temporal evolution context and spatial distribution networks of ICT in physiology; investigate the cooperation network among authors, institutions, and countries publishing research in this field using co-occurrence analysis; and uncover hot research topics and development trends through cocitation analysis of references, authors, and journals, along with keyword co-occurrence and clustering analyses.

Search Strategy

We selected the WoS Core Collection as the data source for this study. To capture a broad range of potentially eligible articles, we used the following search terms with Boolean operators: (“flipped classroom” OR “flipped classroom teaching” OR “flipped study” OR “flipped learning” OR “flipped teaching” OR “flipped instruction” OR “inverted teaching” OR “inverted learning” OR “inverted study” or “inverted classroom” OR “inverted instruction”) in all fields AND (“Physiology”) in all fields. The time span was set from January 2000 to April 2023, and the data were collected on December 11, 2023. Only journal articles indexed in the WoS Core Collection were used to gather data. This database was selected because it is the longest-established citation tracking database, which includes quality indices such as Journal Citation Reports [ 17 ], provides a well-recognized subject classification for research journals, and permits the easy download of a considerable number of stored references [ 18 ].

Study Selection Criteria

The search was performed in English to obtain the largest number of documents in the WoS data set on the use of ICT in physiology education. The following inclusion criteria were applied: (1) document type=articles, (2) language=English, (3) years of publication=2000-2023 (November). The exclusion criteria were (1) studies in a field not related to medicine or pedagogy; (2) not published in English; (3) categorized as books, chapters, theses, protocols, study outlines, government publications, posters, editorial materials, duplicates, or nonpeer-reviewed articles; and (4) published outside of the time frame of 2000-2023.

Upon applying the above search strategy, 632 indices were retrieved in the WoS data set and 295 records were screened after removing 237 studies using automation tools from the database. Before further screening and retrieval of the full texts of the references, all 294 indices with detailed citation records and bibliometric information were exported in both record and reference formats, saved as plain-text files, and stored in the .txt format. The stored records were then input into the CiteSpace software for visualization, as indicated by the user manual [ 19 ], which generated clustered plots of bibliometric references and differentiated various topics. The relevant articles pertaining to inverted classroom pedagogy were identified by examining the visualized clusters and topics, and irrelevant literature was excluded by adhering to the guidelines in the CiteSpace manual. In brief, in the cluster plots, irrelevant topics are presented in isolated clusters without citation networks; hence, these dots, representing the irrelevant literature, were removed from the eligible references after reviewing the titles and abstracts.

The full text of the included articles was downloaded and reviewed by two authors independently (YW and ZH), and a consensus was reached through discussion between the two reviewers in the case of any disagreements. In total, 253 studies were excluded after title and abstract screening and a total of 42 articles were included for the final analysis. The flowchart of study selection is provided in Multimedia Appendix 1 and the details of the excluded studies with reasons for exclusion are provided in Multimedia Appendix 2 .

Data Analysis Process

CiteSpace 6.1.R6 software was used to visually analyze the literature related to ICT in physiology published up to November 2023. CiteSpace is a knowledge visualization software developed by Chaomei Chen at Drexel University and is now a widely used knowledge mapping tool in various fields of education and teaching [ 20 ]. CiteSpace can measure and visualize literature collections in broad fields of the natural and social sciences using cocitations of references, authors, and journals; the co-occurrence of authors, keywords, institutes, and countries; and cluster analysis to create a scientific knowledge network map, explore the critical path of the evolution of the discipline, and analyze the hot spot research topics and frontier trends clearly and scientifically.

In this study, we analyzed the overall national and regional distributions and cooperation of the authors of ICT in physiology research papers through the constructed network cooperation map, and then determined the knowledge base and the core authors of ICT in physiology research through analysis of the literature and author cocitation networks. We further identified the “star” journals publishing research in this field through a cocitation analysis of the source journals. Finally, the hot spot keywords were determined through keyword co-occurrence and clustering analysis based on the frequency and centrality of the keywords, which were used to further explore the hot topics of worldwide research on ICT in physiology. Overall, the methodology used in this study involved cooperative network analysis and cocitation analysis.

Cooperative network analysis was used to identify core authors, leading research institutions, and national/regional cooperation in ICT in physiology research. The nodes in the graph are represented by circles, with larger circles indicating a greater number of items represented, such as papers, authors, institutions, references, and countries. In CiteSpace, intermediary or between centrality is used as a critical indicator of node importance, which is characterized by the shortest number of paths passing through a node. Nodes with a centrality value above 0.1 are considered to be important. In this study, the circle size represents the cited frequency of an article, with purple circles indicating high centrality; thus, larger and deeper-purple circles suggest greater importance of the study in ICT in physiology research.

Cocitation analysis was used to identify relationships between cited articles, authors, and journals in the field of ICT in physiology research. For example, if two articles (or authors or journals) A and B are cited simultaneously by a third article, then a cocitation relationship exists between them. Frequent citation of articles (or authors or journals) together suggests that their research topics, including concepts, theories, or methods, are likely related. Cocitation analysis ranks key papers according to their citation frequency and explains the correlation between their contents and directions through the centrality value. This analysis can also infer literature clusters from various papers that are published during the same period, indicating hot spots in the field. The frequency and relevance of citations represent hot spots in scientific research over time, and these core documents form the knowledge base for the hot spots. In turn, the knowledge base clarifies the cutting-edge nature of the research, as frequently cited papers constitute the corresponding knowledge base [ 21 ].

Publication Trends in ICT in Physiology

The year 2013 marks the commencement of the field, in which Tune et al [ 22 ] were the first to publish a research paper related to ICT in physiology. The research volume then increased yearly, reaching its peak in 2022. According to the number of publications, different stages of ICT in physiology development can be defined. Before 2017, there were only a small number of papers related to ICT in physiology, marking 2013‐2017 as the gradual upward stage. In 2018, there was a slight decrease in the number of published papers on the topic, which may be due to the conflicts between conventional teaching and incorporating ICT into physiology teaching, indicating the need for more modification and reflection in practice. Hence, 2018‐2019 can be considered as the adaptation period. The second gradual upward period appeared during the COVID-19 outbreak in 2021 and then peaked in 2022, indicating a boom period for this field of study.

Authors’ Cooperative Network

An author’s contribution to the area of ICT in physiology can be identified by their significant publications and cooperative connections with other authors, which facilitates understanding the progress in ICT in physiology [ 23 ]. Author collaboration appears to be generally limited, and most academic work in this field is conducted in independent teams with minimal cross-team communication.

As shown in Figure 1A , the research author cooperation map highlights various research partnership teams, particularly those surrounding the authors Gopalan C, Gillam-Krakauer M, and multiple researchers with cooperative connections. Gopalan C has the highest citation count with 5 publications, followed by authors Carbajal MM, Falck AJ, Johnston LC, Feng D, Luo Z, French H, Dadiz R, Vasquez MM, and Gray MM who collaborated on three records with a citation count of 3 each, as depicted in Multimedia Appendix 3 .

Since 2016, Gopalan C has published 14 relevant papers, with a significant surge from 2019 to 2022, as illustrated in Figure 1A . Gopalan C, Bingen H, Tveit B, Steindal S, and Krumsvik R have jointly published three papers centered on nursing education [ 24 - 26 ], indicating a stable partnership among these authors who conducted a series of studies on ICT in nursing education. Additionally, some other authors, including Feng D and Luo Z from Central South University in China, have coauthored two papers [ 27 , 28 ].

National/Regional and Institutional Cooperative Networks

Overall, the extent of collaboration between nations and research institutions is relatively weak, with very low centrality, and the research power of countries is uneven. As seen in Figure 1 and Multimedia Appendix 4 , US-based authors published the highest number of inverted teaching in phyisology–related papers (18 in total, accounting for over 43% of the total papers). Moreover, their intermediary centrality is 0.24, indicating that they have strong connections and are highly engaged in international cooperation. Chinese authors ranked second, publishing 8 papers; however, their intermediary centrality is only 0.02, suggesting that their papers have limited international influence and lower overall quality, providing little influential power in the field of ICT in physiology. Australia ranked third, with a centrality of 0.01 covered by 3 papers on ICT in physiology.

As shown in Figure 1B and Multimedia Appendix 5 , universities and affiliated hospitals are the primary institutions that have published ICT in physiology–related papers. Southern Illinois University Edwardsville and Duke University in the United States have published the most papers in this field since 2018 and have significantly contributed to ICT in physiology research. Other institutions, including the University of Washington, University of Texas, Vanderbilt University, Central South University, University of Rochester, University of Pennsylvania, Yale University, University of Washington, and Baylor College of Medicine, contributed 3 research papers each. As seen from the year color bar on the left bottom corner of Figure 1B , most nodes are labeled in orange, indicating that most institutions published these articles in 2021 and 2022. Specifically, most of the studies performed in the United States are labeled in green and yellow, corresponding to earlier years, indicating the pioneering role of universities in the United States for ICT in physiology research; in particular, authors from Southern Illinois University published an ICT in physiology paper in 2017, which is earlier than most institutions contributing to this field.

Cocitation Analysis of References

The highly cited literature on ICT in physiology is summarized in Table 1 , which shows the top 15 most influential articles in this field of research ranked by citation frequency and mediation centrality published between 2013 and 2020. The top-ranked item by citation counts is by Chen et al [ 21 ], which was published in 2017 with a citation count of 8 and a centrality of 0.26, followed by the paper published by McLaughlin et al [ 29 ] in 2014, also with a citation count of 8.

Cocitation Analysis

As shown in Multimedia Appendix 6 and Multimedia Appendix 7 , Gopalan C was found to be the most cited author with a count of 5 and a centrality of 0.02.

Multimedia Appendix 8 summarizes the top 10 journals that published ICT in physiology papers. Advances in Physiology Education was the first journal to publish ICT in physiology research papers and has maintained the highest frequency of citations from 2013 to 2022 (also see Multimedia Appendix 6 ). Additionally, journals such as Computers & Education and The Internet and Higher Education have also provided considerable attention to this topic, implying that modern educational technologies such as information science and the internet play a crucial role in facilitating the inverted classroom mode.

Research Hot Spots Suggested by Keyword Co-Occurrence Analysis

Figure 2 presents the coexistence diagram of ICT in physiology keywords, with each node representing a keyword and the font size indicating the node’s size; that is, a larger font indicates that the keyword appears more frequently. The cluster labels obtained from the keyword cluster analysis can indirectly reflect the leading research topics, while the timeline map of the keyword clusters can demonstrate the leading research topics by time. Table 2 lists the top keyword clusters in ICT in physiology research according to the number of occurrences and centrality of each keyword, demonstrating that the top keywords are “flipped classroom,” “active learning,” “student performance,” “performance,” and “medical education.” Figure 2A shows that from 2013 to 2022, research on ICT in physiology focused on medical education, performance, engagement, active learning, online teaching, and other aspects. According to the intermediary centrality, “flipped classroom” (0.69) is the most influential keyword, followed by “medical education” (0.2) and “education” (0.14).

The keyword co-occurrence analysis showed that in addition to the retrieved topic term “flipped classroom,” “medical education” ranked the highest in terms of word frequency and ranked the third highest according to mediator centrality, reflecting that active learning is a hot topic in ICT in physiology research. The keywords ”education,” “performance,” and “engagement” followed closely behind, with the centrality being 0.14, 0.14, and 0.26, respectively ( Table 2 ). This indicates that researchers in the field of ICT in physiology have been paying relatively more attention to performance aspects, which could reflect the effectiveness and satisfaction of ICT in physiology. The keywords “engagement” and “perceptions” also had high co-occurrence numbers and mediator centrality.

Research Hot Spots and Frontier Topics Suggested by Keyword Cluster Analysis

Based on other keywords in the same cluster and the popular words obtained by the latent semantic analysis/indexing algorithm, it was found that many popular words in each cluster reflected the current hot spots of ICT in physiology and had good consistency with the hot spot topics obtained by the co-occurrence analysis of keywords (see Multimedia Appendix 9 ), such as active learning, self-directed learning, student characteristics, learning preferences, learning styles, modified team-based learning, learning environment, flipped design, student engagement, and undergraduate medical education, among others.

Principal Findings

In this study, we used CiteSpace software to visually analyze the literature related to the use of ICT in physiology published between 2000 and 2023 retrieved from the WoS database. The results of this bibliometric analysis showed that the core authors publishing in the field of ICT in physiology include staff from universities and affiliated hospitals. Some research teams have also formed cooperative relationships. Research in ICT in physiology mainly focuses on active learning, autonomous learning, student performance, teaching effectiveness, blended teaching, personalized flipped teaching, and other related topics.

Overall, studies on the ICT model in the context of physiology remain scarce, with limited collaboration among authors and a consequent lack of a cohesive research network. Regional growth in this field is uneven and international disparities are evident. Despite the many established benefits of ICT, it is not widely used in various nations and regions. This may be attributable to the fact that the development of the ICT model is still in its infancy, and a mature theoretical structure is needed and must be tested over a wide range of professional specialties. In this sense, relevant researchers must increase interaction and collaboration, investigate systematic teaching techniques appropriate for various disciplines, and perform practical testing and assessment of the model. In the future, research power can be integrated to form a cohesive unit through cooperation among research institutions to promote further breakthroughs in ICT research in the context of physiology.

Development of ICT in Physiology

The ICT model has undergone three stages of development, including the introduction stage (2013‐2014), extensive practice stage (2015‐2019), and modification and growth stage (2020‐2022).

Several studies have confirmed that an active-learning strategy is associated with improved student performance, a reduced failure rate, and better learning achievements in basic and clinical medical education [ 37 , 41 ]. Shaffer [ 42 ] reported that anatomy course objectives were achieved at a much higher rate after incorporating an active teaching style compared to the achievement rate following traditional teaching. Furthermore, in the clinical discipline, Qutub [ 43 ] reported the considerable effectiveness of ICT as an active learning style in a hematology course, enabling students to obtain desirable knowledge and improve their academic performance; moreover, students recognized that ICT as an active learning style was more beneficial than the traditional teaching approach. In 2016, Betihavas et al [ 1 ] performed a systematic review of 9 studies on the use of ICT in nursing education and reported that nursing students achieved similar or higher academic outcomes with ICT than with a conventional teaching strategy; however, the students indicated a mixed sense of satisfaction.

Other researchers in medical education and health science programs have reported similar results. For example, in an analysis of 274 papers, Barranquero-Herbosa et al [ 44 ] found that ICT in nursing education improves performance and is well-received by both students and instructors. O’Connor et al [ 45 ] concluded that reversing the flow of classroom teaching improves academic performance, develops self-directed learning skills, and consolidates acquired knowledge through active learning strategies. Sultan [ 46 ] found that flipping the classroom gives students more time for active learning, peer collaboration, and applying and analyzing theoretical knowledge. Moreover, McLean et al [ 47 ] showed that ICT could improve students’ preparation, attendance, and participation in the course Medical Sciences 4200, an elective nonthesis-based course that covers content related to physiology, biochemistry, and immunology.

With COVID-19 wreaking havoc worldwide in early 2020, the strict and rapid public health measures put forward led to the suspension of face-to-face education and the transfer of the classroom to online meetings, which also corresponds to the application of blended learning as a pedagogical approach based on a combination of online and face-to-face education processes [ 48 ]. This necessary shift during the pandemic greatly facilitated the implementation of ICT in various subjects and expanded the use of other types of education tools. For instance, Bawazeer et al [ 49 ] reported the use of polls in virtual sessions on physiology, pharmacology, and pathology courses to assess students’ engagement, understanding, performance, and attendance, and found improvements in understanding and permormance. Feng et al [ 28 ] reported that incorporating the inverted classroom and a team-based learning strategy in the online setting can enhance the learning outcomes for students in a clinical immunology laboratory course. Although the pandemic and the availability of novel technologies have made blended learning a “new normal” in medical education, the successful adaptation of blended learning requires sufficient teacher training as well as the adoption of appropriate technologies by educational institutions [ 50 ].

The Role of ICT in Medical Education

In 2018, Chung et al [ 51 ] performed a systematic review on the use of ICT in nursing education, which showed that the basic flipped classroom mode has been frequently used in nursing education; nevertheless, the effects of ICT on learning behavior in physiology courses were not clearly investigated and only a few studies included in the review reported the use of after-class activities to engage students in facilitating the applications of the knowledge learned. Moreover, Lin and Hwang [ 52 ] reviewed studies on ICT papers published up to 2017 based on the technology-enhanced learning model, and noted that little attention was paid to the assessment of learners’ higher-order thinking skills and their degree of preparation or cognitive load. Similar findings have also been reported in relation to the application of ICT in subjects other than medicine, including mathematics [ 53 ].

Nevertheless, there is no doubt that ICT can efficiently engage students in learning sessions, even during the pandemic [ 54 ]. Research investigating students’ perceptions and performance revealed that students have high levels of acceptance for a virtual flipped teaching approach, which was already evident prior to the COVID-19 pandemic [ 9 , 55 - 57 ].

Lack of a Cohesive Research Network in ICT in Physiology Research

Acknowledging the importance of international cooperation and the role of different countries contributing to research on ICT in physiology may facilitate communication and collaboration among countries. With the highest number of published papers, authors from the United States have been the primary contributors to research on the applications of ICT in physiology courses since 2013.

The positive effects of ICT largely depend on an effective classroom design [ 58 ]. Designing an effective inverted classroom, guiding students to engage in inverted classroom learning, and personalizing the ICT to enhance teaching effectiveness and student learning outcomes have increasingly become the main topics of ICT research. These are common challenges encountered by teachers and students in ICT. Since a layered teaching approach adapted to the learning, teaching, and classroom conditions can maximize the expected benefits, various ICT approaches have been developed to date, such as partially inverted classrooms [ 59 ], Small Private Online Courses–based inverted classrooms [ 60 ], and lecture-based inverted classrooms [ 61 ].

Current Hot Spots of ICT in Physiology Research

There are currently three main topics generally discussed in the field of ICT: preparation before class, classroom activities, and consolidation after class [ 23 ]. The current hot spots of research in ICT for physiology worldwide focus on active learning, inverted classroom design, student perception and engagement, teaching effectiveness, and teaching evaluation, among others, while the scope of the research includes students, teachers, school teaching management, and national educational guidelines and policies. Moreover, our results are consistent with previous bibliometric studies related to the research on ICT in other fields [ 62 ]. For instance, a recent review by Cheng et al [ 62 ] on the top 100 highly cited ICT papers similarly showed that researchers in this field have largely focused on students’ learning achievements and learning behaviors rather than directly comparing the benefits of inverted and traditional learning. Similarly, Meral et al [ 63 ] reported that motivation, perception, and academic achievement/performance were the most common topics in the ICT studies published between 2010 and 2019.

Regarding the research hot spots suggested by the analysis of keywords, we identified the following main areas of focus of research on ICT in physiology at present: (1) ICT theories, including active learning and independent learning; (2) ICT strategies, including inverted design, student characteristics, learning style, learning preference, learning environment, educational technology, and student participation; and (3) ICT evaluations, including academic performance, student performance, and student satisfaction. Specific to disciplines and programs, the field of research on ICT in physiology covers clinical medicine, stomatology, nursing, pharmacy, and veterinary medicine, among others. With respect to the courses, ICT approaches can be applied to general physiology, gastrointestinal and renal physiology, exercise physiology, physiology lab courses, and introductory biology. The applicable levels of education include graduate, undergraduate, professional training, and adult continuing education.

Study Strengths and Limitations

This study has both strengths and limitations. To our knowledge, this is the first study to map the current ICT studies in physiology specifically rather than considering the whole field of ICT. Moreover, the visualization of the quantitative results provides a convenient and comprehensible understanding of the current publication status of studies, research hot spots, and development trends in the field of ICT for physiology.

Although all attempts were made to include relevant nouns and terms in the literature retrieval process, some relevant papers may have nevertheless been missed. Additionally, the search only incorporated “physiology” as the keyword for the teaching subject, which may have led to evidence selection bias in which research that covers all medical courses rather than physiology alone may have been missed and could not be incorporated into the study for analysis. In addition, the search was limited to the WoS database, which may have excluded some important non-English publications. Moreover, each subject has unique characteristics in the application of an inverted teaching model, and the results and conclusions reached based on the analysis of this study may not necessarily be generalized to other subjects; thus, these results should be interpreted with caution.

This study analyzes literature on ICT in physiology, identifying core authors, research topics, and development stages. To date, research in this field has focused on active and autonomous learning, student performance, the teaching effect, blended teaching, and personalized flipping teaching models. The development of ICT is linked to modern information technology, the COVID-19 pandemic, educational teaching concepts, and related teaching reform policies. Based on these findings, further academic exchanges and cooperation in applications of ICT in physiology are encouraged, which can highlight the potential of this teaching model to train the next generation of excellent medical talents.

Acknowledgments

This study has been supported by the educational science programs for research projects: Higher Education Special Project in Guangdong Province (2021GXJK259), Medical Teaching and Education Management Reform Research Project in Jinan University (2021YXJG005), Annual Experimental Teaching Curriculum Reform Special Project (SYJG202202), and "Four New" Experimental Teaching Curriculum Reform Project at Jinan University (SYJG202301).

Authors' Contributions

YW and JB conceptualized the study. ZH, BZ, and HF contributed to the methodology. ZH and BZ contributed to data visualization. JB and YW supervised the study. ZH, BT, HF, JB, and YW wrote the initial draft of the manuscript. ZH, BZ, HF, YW, and JB contributed to manuscript review and editing. All authors have read and agreed to the published version of the manuscript.

Conflicts of Interest

None declared.

Flowchart of literature selection.

Excluded studies with reasons.

The top 12 authors who published relevant papers on inverted teaching in physiology.

Distribution of countries publishing papers related to inverted teaching in physiology.

The top 12 institutions publishing papers related to inverted teaching in physiology.

(A) The cited reference analysis map of inverted teaching in physiology: N=235, E=684. Node size (N) corresponds to the frequency of publications from each reference. The connecting lines (E) represent collaborative connections between authors, with thicker lines indicating more frequent collaboration. (B) Analysis of cocited journals (N=236, E=996). Node size (N) corresponds to the frequency of publications from each journal. The connecting lines (E) represent citation connections between references, with thicker lines indicating more frequent cocitations.

The most influential authors of inverted teaching in physiology research.

Primary journals that publish research papers in the field of inverted classroom teaching in physiology.

Information of the main clusters of keywords in research related to inverted teaching in physiology.

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Abbreviations

Edited by Philipp Kanzow, Taiane de Azevedo Cardoso; submitted 02.09.23; peer-reviewed by Ionela Maniu, Qingwei Chen, Vedran Katavic; final revised version received 02.04.24; accepted 02.04.24; published 25.06.24.

© Zonglin He, Botao Zhou, Haixiao Feng, Jian Bai, Yuechun Wang. Originally published in JMIR Medical Education (https://mededu.jmir.org), 25.6.2024.

This is an open-access article distributed under the terms of the Creative Commons Attribution License ( https://creativecommons.org/licenses/by/4.0/ ), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Medical Education, is properly cited. The complete bibliographic information, a link to the original publication on https://mededu.jmir.org/ , as well as this copyright and license information must be included.

Maharashtra Govt to Offer Free Medical, Engineering Courses For Female Students

Curated By : Sukanya Nandy

Last Updated: June 28, 2024, 16:57 IST

New Delhi, India

The scheme is expected to benefit over 20 lakh female students in the state (Representative image)

The Maharashtra government will waive off academic fees for women studying engineering and medical courses, whose family income is below Rs 8 lakh

The Maharashtra government has decided to waive off academic fees for women willing to study medical and engineering courses across colleges in the state. However, it is applicable for those whose family annual income is less than Rs 8 lakh. The scheme is expected to benefit over 20 lakh female students in the state.

In February, Maharashtra’s higher and technical education minister Chandrakant Patil announced that there has been a 50 per cent academic fee waiver in the same category which is now extended to 100 per cent. Patil added that universities should strive towards ensuring that more girls are taking admission to higher education courses across various fields and urged VCs to run special campaigns in support of the same, highlighting the importance of varsities declaring results on time.

Meanwhile, about 200 candidates and parents had filed objections with the Maharashtra CET cell, Mumbai office regarding question papers and answer keys of MHT CET 2024. Following this, Dilip Sardesai, commissioner of MHT CET said that students and their parents must not believe in rumours , since all objections raised were addressed and fully resolved. He also said that “the objection that the candidates did not get the marks they scored as per the answer sheets made available to them is also incorrect.”

Sardesai said there was no negative marking for incorrect answers the results were declared using the percentile method, and no candidate got grace marks, he pointed out at a press conference. “If the candidate or their parents had any objection regarding the questions or answers, the CET cell provided them with an online facility for registering their objections. These objections were verified by the respective subject experts and, accordingly, the answer sheets were modified. The report of the modified answer sheets was published on the CET cell website,” Sardesai said.

— with PTI inputs

Stay ahead with all the exam results updates on News18 Website .

• maharashtra

Harvard-educated Gabby Thomas balances training for Paris while working at a Texas health clinic

A typical day for U.S. track and field athlete Gabby Thomas is a full 24 hours. During the day, she trains three to six hours in anticipation of the 2024 Paris Olympics.

But at night, she works at an Austin, Texas, volunteer health care clinic for people without insurance.

How does one of the fastest athletes in her sport find the time to do it all? She attributes that work ethic to her mother. When Thomas and her twin brother were young, their mom waitressed and took classes to become a professor. 

“She showed me in real time growing up what it’s like to go after your dreams and to achieve them, and to become successful,” Thomas, 27, told NBC News. “I watched her just achieve all of that by herself and while raising us.”

Stream every moment and every medal of the 2024 Paris Olympics on Peacock, starting with the Opening Ceremony July 26 at 12 p.m. ET.

Thomas’ interest in health care began at Harvard University, where she studied neurobiology. She took a class about the disparities in the American health care system and its impact on people of color. After graduating from Harvard, she earned a master’s at the University of Texas in public health, which she uses today.

“I get to go the clinic and volunteer and make a difference in people’s lives,” she told Olympics.com. “So I feel so fulfilled, and I feel so passionate about everything I do. And (that all) really just comes from gratitude.”

Although Thomas competed in high school, it wasn’t until Harvard that she started winning accolades in track. That’s where she broke the NCAA indoor collegiate record in the women’s 200-meter.

“I was pushing myself in the classroom, in my extracurriculars and on the track, and it forced me to just get better at everything I was doing,” she said to NBC News.

Thomas credits that drive to her success in the Tokyo Games , where she won bronze in the women’s 200-meter and silver in the women’s 4x100 meter relay. She also believes having additional interests outside of track plays a role in her athletic success.

“The way I became successful in track and field was basically running track part time,” she said. “And I think for me that’s really important for my mental health, just having other things in my life that helped fulfill, you know, my goals and make me feel fulfilled.”

Now looking ahead to the Paris Games, Thomas is competing in the track and field trials. On Thursday night, she posted a time of 22.11 seconds in her heat, advancing to the semifinal scheduled for Friday, and she hopes to make the finals the next night.

More Olympics from NBC News

• Sport climber going to Paris describes seeing the rapid growth of the event
• French swimmer's cold call email to Michael Phelps' coach could end in homegrown Olympic glory
• Break dancer Sunny Choi is focusing on mental health as much as physical in prepping for the Olympics
• Twin sisters are Paris-bound for badminton after taking a break for college and accounting careers

Although Thomas has ambitions to win more medals at the Paris Games, she also has another meaningful goal in mind: running a hospital or a nonprofit to expand access to health care.

“I hope that I’m doing the same thing I’m doing now, which is letting my passions drive me,” she said.

In the meantime, she’s hoping her story serves as inspiration for the younger generation of athletes.

“This is a message to all the younger girls who are watching, especially the young women of colour,” she told Olympics.com. “Just know that the world might try to put you down, but the sky is the limit for you. You can achieve anything that you want to do — so just keep going."

Greg Hyatt is a 2024 NBC News campaign embed.

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Dom world class teams: applications closed for 2024.

Click Here to download Application for the McGill DOM World Class Teams Process

This World Class Team process relates to a key objective from the DOM’s strategic plan-to become the most research-intensive DOM in Canada. The McGill DOM strives for excellence and we recognize that promoting growth in areas where we lead the world, or can lead the world, is/will be a key driver of reaching our strategic aspirations.

DOM World Class Teams are multi-disciplinary teams of scientists working in a specific “area” of focus, led by McGill DOM members. We are embarking on a process to identify our top 3 established world class teams and our top 3 emerging world class teams across the McGill DOM ecosystem. Established world class teams include multiple scientists collaborating and generating world leading outputs in an area. Emerging world class include multiple scientists collaborating in an area with clear and attainable plans to become world leaders.

Once we identify our world class teams, they will be given priority in areas under the DOM’s direct control such as fellowship support (salary and operating)​, recruitment (including future tenure slots, CAS Research start-up packages), etc. Successful teams will also benefit from DOMs advocacy for support from McGill, our affiliated institutions, and their affiliated Foundations.

To identify our teams, we will hold an open and transparent competition with written submissions and oral presentations by self-identified groups working in an “area” led by McGill DOM members. The submissions will articulate the structure (who), function (how), funding (with what), recent and upcoming outputs and the world comparable of their “world class team” in “area X” (i.e. identify/describe top 3 competitors in “area X”.). A 15-min presentation or “elevator pitch” to our DOM World Class Teams panel will be required as part of the process. The DOM World Class Teams panel will include the McGill FMHS Dean (or delegate), our affiliated Research Institute (RI) CSOs/CEOs (or delegates) and 3 external reviewers (senior, mid and early career).

The Department will open a call for applications every 4 years.

Application Deadline : January 15, 2024

Criteria for Application

• Team must be led by a primary McGill DOM Faculty member and include a core of at least 2 other McGill DOM Faculty members. Important cross-McGill collaborations and external collaborations are a strength but the team must be led by a primary McGill DOM member.
• Priority will be given to teams whose projects align with the McGill DOM strategic plan, McGill, affiliated hospital and affiliated RI priorities.
• A team’s research can be in any area and in any form including bench to bedside to policy work and can include medical education and quality initiatives. However, it must be focused, “centres of excellence” in a medical specialty will not be considered (e.g. World-Class team in Hematology would not be considered but a World Class Team in Multiple Myeloma would be considered).

Submission/Presentation

Successful applications will be selected based on a written submission to our panel and a 15min “elevator pitch” presentation to panel at an open forum.

Written submission formatting

A 3- page application (with appended CCVs of core team members), following the format below:

Name area (i.e. World Class Teams in “X”)

Choose “Emerging” or “Established” category .

Who ? Team Composition (1/2 page with attached CCVs)​:

• Identify “team” scientists (name, career path, percentage funded protected time, percentage time commitment to team “area”, 5-year external peer reviewed funding in “area”, career publications in “area”, reputational index ranking of members in “area” (Expertscape and Research.com).​ Note that teams of <3 scientists are unlikely to be selected.
• Appended the CCVs of the core scientists in the team (i.e. scientists that devote at least 25% of their total activity to research in the “area”)
• Identify key collaborators (internal/external scientists) and identify their roles

How? ​ (3/4 page)​

• Team structure- describe how the team currently interacts/collaborates​
• Current common team resources (common managerial support, common administrative support, common research staff support, shared lab/office space used for “area X”)​.
• Current team activities (seminars/rounds, grant pre-review, research in progress meetings, other activities that advance team’s agenda)​

Team Track Record (1/2 page)​:

• Publications in top “area” journals (describe why journal is top journal in “Area X” and top 60 medical journals in last 10 years​ (see DOM website for top 60 medical Journals list )
• Top 5 cited first/senior author papers for each team member​

Expected future output (3/4 page)​

• Description of team’s research program, planned activities and expected outputs from these activities​.

World Comparable Programs (1/2 page)​

• List and describe the top 3 research programs in “area” in the world (e.g. why are they top 3?, what is the structure, function, composition of team and top outputs of the top 3). Tell us ​why you are (established team) or will be (emerging team) in top 5 over the next 5-10 years?​

Application Review

Applications will be reviewed by the DOM World Class Teams Panel for both the written application and the 15-minute presentation.

Applicants should complete the attached form . Use single spacing, 12-point font and 1-inch margins. The proposal must then be submitted electronically to the office of the Chair of Medicine, by filling up the form below or emailing it to  dom.adminassistant [at] mcgill.ca .  

Application Form for the DOM World Class Teams Process Closed

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