Report I
Learning Objectives for Medical Student Education
Medical Schools Objectives Project January, 1998
Copyright 1998 by the Association of American Medical Colleges. All
Rights Reserved AAMC/1998
The AAMC should stimulate changes in medical education to create a
better alignment of educational content and goals with evolving societal needs,
practice patterns, and scientific developments.
Taking Charge of the Future (AAMC Strategic Plan)
In recent years, many observers of medicine have expressed concerns
that new doctors are not as well prepared as they should be to meet society's
expec-tations of them. This view is held also by some within the medical
profession and, more specifically, the medical education community. To address
these concerns, medical educators must understand how changes in society's views
of health and disease and changes in the organization, financing, and delivery
of health care shape expectations of physicians. They must then use this
understanding to inform the design, content, and conduct of medical education
programs. In January 1996 the association of American Medical Colleges (AAMC)
embarked on a major new initiative - the Medical School Objectives Project
(MSOP) - to assist medical schools in their efforts to respond to these
concerns. The goal for the first phase of the project was to develop a consensus
within the medical education community on the attributes that medical students
should possess at the time of graduation, and to set forth learning objectives
for the medical school curriculum derived from those attributes.
Background
Establishing learning objectives to guide the design. Content, and
conduct of an educational program is an important principle supported by
educational theory and practice. Since publication of tile Final Report of tile
Commission on Medical Education (the Rappeleye Commission) in 1932, the AAMMC
has periodically called on medical schools to develop learning objectives for
their curricula. Indeed, in tile early 1950s title & association itself
developed a set of objectives to assist medical schools in changing their
curricula in response to the changes in medical practice occurring after World
War II. Over the next two decades, however, the purpose of medical student
education changed; medical school was no longer intended primarily to pre-pare
physicians for the independent practice of medicine. As a result, the objectives
developed in the early 1950s became outdated and new objectives were needed. In
1981, the AAMC created a panel on the General Professional Education of the
Physician and College Preparation for Medicine (GPEP Panel) to develop
strategies for improving the general professional education of the physician.
The Association hoped that the GPEP Panel would lead not only to agreement on
the knowledge and skills that all physicians should possess to practice medicine
in the 21st century, but also would promote debate on the personal qualities,
values, and attitudes that those pursuing careers in medicine should possess. In
its final report in 1984, the panel asserted that all physicians regardless of
specialty should possess a common foundation of knowledge, skills, attitudes,
and values, and recommended that each medical school faculty specify the
attributes appropriate for students graduating from its school and adopt
learning objectives for the curriculum consistent with those attributes. In
keeping with this recommendation, in 1985 the Liaison Committee on Medical
Education (LCME) added to the accreditation standards for the medical student
education program a requirement that "a medical school must define its
objectives and make them known to faculty and students." In the early 1990s
the AAMC sought to learn how schools had responded to the recommendations of the
GPEP Panel and other blue ribbon panels that had been established in the 1980s
to review the state of medical education. This initiative - Assessing Change in
Medical Education: The Road to Implementation (ACME-TRI) - revealed that few
medical schools had delineated a coherent and comprehensive set of learning
objectives for the medical student education program. To remedy this situation,
the ACME-TRI recommended that the AAMC establish a task force to develop a set
of goals and objectives that could guide individual schools in estab-lishing
objectives for their own programs. The MSOP fulfills this recommendation. This
report marks the conclusion of the initial phase of the MSOP. Subsequent reports
will be issued during the second, or implementation, phase of the project. In
issuing this report, the Association reaffirms its longstanding commitment to
the principle that the faculty of each medical school, working with the school's
dean, is responsible for determining the learning objectives and specifying the
curriculum for the school's educational program. The Association believes that
the objectives set forth in this report can guide medical schools in developing
their own objectives that reflect an understanding of the implications for
medical practice and medical education of "evolving societal needs,
practice patterns, and scientific developments." We hope that medical
schools, during the second phase of the project, will develop their own learning
objectives and use them to review and, if necessary, reform their curricula to
ensure that their students have opportunities to achieve those objectives.
The Goals and Objectives of Medical Student Education
The goal of medical education is to produce physicians who are prepared
to serve the fundamental purposes of medicine. To this end, physicians must
possess the attributes that are necessary to meet their individual and
collective responsibilities to society. If medical education is to serve the
goal of medicine, medical educators must develop learning objectives for medical
education programs that reflect an understanding of those attributes. To gain
insight into society's expectations of physicians reports issued by the Hastings
Center and by a group of medical educators in Canada were reviewed carefully,
and individual interviews were conducted with a group of scholars* of
con-temporary medicine in the United States. The Hastings Center report
summarized the consensus views on society's expectations reached by the
representatives of 14 countries that participated in the project. In the
Canadian project, many citizen groups participated directly in the process that
led to the definition of that society's expectations of physicians. Finally,
each of the scholars who were interviewed contributed important perspectives on
this issue based on their understanding of contemporary U.S. medicine. These
activities revealed that society's expectations of medicine have changed over
time to reflect contemporary values. For more that a quarter of a century the
medical profession .and the society at large have perceived the goal of medicine
to be largely the cure of disease; to a great extent. all other aspects of
medicine have been subordinated to this purpose. This view has had a major
impact on the way doctors have been educated and on the culture of the
institutions respon-sible for their education. Our society now recognizes the
need for a broader view and wants doctors who can and will attend equally well
to all aspects of health care. During the initial phase of the MSOP, a consensus
was reached among leaders of the medical education community on the attributes
that physicians need to meet society's expectations of them in the practice of
medicine. Those attributes are set forth below. Each attribute is followed by a
set of learning objectives that reflect consensus on the contribution that the
medical school experience should make toward achievement of those attributes.
The learning objectives are purpose-fully broad in scope and general in nature
since they are intended to provide a frame of reference for guiding medical
schools in developing their own objectives.
Physicians must be altruistic. Physicians must be compassionate and
empathetic in caring for patients, and must be trustworthy and truthful in all
of their professional dealings. The)' must bring to the study and practice of
medicine those character traits, attitudes, and values that underpin ethical and
beneficent medical care. They must understand the history of medicine, the
nature of medicine's social compact, the ethical precepts of the medical
profession, and their obligations under law. At all times they must act with
integrity, honesty, respect for patients' privacy, and respect for the dignity
of patients as persons. In all of their interactions with patients they must
seek to understand the meaning of the patients' stories in the context of the
patients' beliefs, and family and cultural values. They must avoid being
judgmental when the patients' beliefs and values conflict with their own. They
must continue to care for dying patients even when disease-specific therapy is
no longer available or desired.
For its part the medical school must ensure that before graduation a student
will have demonstrated, to the satisfaction of the faculty, the following:
· Knowledge of the theories and principles that govern ethical
decision making, and of the major ethical dilemmas in medicine, particularly
those that arise at the beginning and end of life and those that arise from the
rapid expansion of knowledge of genetics
· Compassionate treatment of patients, and respect for their privacy
and dignity
· Honesty and integrity in all interactions with patients' families,
colleagues, and others with whom physicians must interact in their professional
lives
· An understanding of, and respect for, the roles of other health
care profes-sionals, and of the need to collaborate with others in caring for
individual patients and in promoting the health of defined populations
· A commitment to advocate at all times the interests of one's
patients over one's own interests
· An understanding of the threats to medical professionalism posed by
the conflicts of interest inherent in various financial and organizational
arrangements for the practice of medicine.
· The capacity to recognize and accept limitations in one's knowledge
and clinical skills, and a commitment to continuously improve one's knowledge
and ability
Physicians must be knowledgeable. Physicians must understand the
scientific basis of medicine and be able to apply that understanding to the
practice of medicine. They must have sufficient knowledge of the structure and
function of the body (as an intact organism) and its major organ systems and of
the molecular, cellular, and biochemical mechanisms that maintain the body's
homeostasis in order to comprehend disease and to incor-porate wisely modern
diagnostic and therapeutic modalities in their practice. They must engage in
lifelong learning to remain current in their understanding of the scientific
basis of medicine.
For its part the medical school must ensure that before graduation a
student will have demonstrated, to the satisfaction of the faculty, the
following:
· Knowledge of the normal structure and function of the body (as an
intact organism) and of each of its major organ systems
Knowledge of the molecular, biochemical and cellular mechanisms that are
important in maintaining the body's homeostasis
Knowledge of the various causes (genetic, developmental, metabolic, toxic,
microbiologic, autoimmune, neoplastic, degenerative, and traumatic) of maladies
and the ways in which they operate on the body (pathogenesis)
Knowledge of the altered structure and function (pathology and
pathophysiology) of the body and its major organ systems that are seen in
various diseases and conditions
An understanding of the power of the scientific method in establishing the
causation of disease and efficacy of traditional and non-traditional therapies
An understanding of the need to engage in lifelong learning to stay
abreast of relevant scientific advances, especially in the disciplines of
genetics and molecular biology
Physicians must be skillful.
Physicians must be highly skilled in providing care to individual
patients. They must be able to obtain from their patients an accurate medical
history that contains all relevant information; to perform in a highly skilled
manner a complete and a limited, organ system specific, physical examination; to
perform skillfully those diagnostic procedures warranted by their patients'
conditions and for which they have been trained; to obtain, interpret properly,
and manage information from laboratory and radiology), studies that relate to
the patients' conditions; and seek consultation from other physicians and other
health professionals when indi-cated. They must understand the etiology; the
pathogenesis; and the clinical, labo-ratory, roentgenologic, and pathologic
manifestations of the diseases or conditions they are likely to confront in the
practice of their specialty. They also must under-stand the scientific basis and
evidence of effectiveness for each of the therapeutic options that are available
for patients at different times in the course of the patients' conditions, and
be prepared to discuss those options with patients in an honest and objective
fashion. Physicians must be able to communicate with patients and patients'
families about all of their concerns regarding the patients' health and well
being. They must be sufficiently knowledgeable about both traditional and
non-traditional modes of care to provide intelligent guidance to their patients.
For its part the medical school must ensure that before graduation a
student will have demonstrated, to the satisfaction of the faculty, the
following:
· The ability to obtain an accurate medical history that covers all
essential aspects of the history, including issues related to age, gender, and
socio-economic status
· The ability to perform both a complete and an organ system specific
examination, including a mental status examination
· The ability to perform routine technical procedures including at a
minimum venipuncture, inserting an intravenous catheter, arterial puncture,
thoracentesis, lumbar puncture, inserting a nasogastric tube, inserting a foley
catheter, and suturing lacerations
· The ability to interpret the results of commonly used diagnostic
procedures · Knowledge of the most frequent clinical, laboratory,
roentgenologic, and pathologic manifestations of common maladies · The
ability to reason deductively in solving clinical problems
· The ability to construct appropriate management strategies (both
diagnostic and therapeutic) for patients with common conditions, both acute and
chronic, including medical, psychiatric, and surgical conditions, and those
requiring short- and long-term rehabilitation
· The ability to recognize patients with immediately life threatening
cardiac, pulmonary, or neurological conditions regardless of etiology, and to
institute appropriate initial therapy
· The ability to recognize and outline an initial course of
management for patients with serious conditions requiring critical care · Knowledge
about relieving pain and ameliorating the suffering of patients
· The ability to communicate effectively, both orally and in writing,
with patients, patients' families, colleagues, and others with whom physicians
must exchange information in carrying out their responsibilities.
Physicians must be dutiful. Physicians must feel obliged to
collaborate with other health professionals and to use systematic approaches for
promoting, maintaining. and improving the health of individuals and populations.
They must be knowledgeable about the risk factors for disease and injury, must
understand how to utilize disease and injury prevention practices in the care of
individual patients. must promote healthy behaviors through counseling
individual patients and their families and public edu-cation and action, must
actively support traditional public health practices in their communities, and
must be advocates for improving access to care for everyone, especially those
who are members of traditional)' undeserved populations. They must understand
the economic, psychological, occupational, social, and cultural factors that
contribute to the development and/or perpetuation of conditions that impair
health. In caring for individual patients, they must apply the principles of
evidence-based medicine and cost effectiveness in making decisions about the
utilization of limited medical resources. They must be committed to working
collaboratively with other physicians; other health care professionals including
administrators of hospitals, health care organizations, and systems of care);
and individuals repre-senting a wide variety of community agencies. As members
of a team addressing individual or population-based health care issues, they
must be willing both to provide leadership when appropriate and to defer to the
leadership of others when indicated. They must acknowledge and respect the roles
of other health professionals in providing needed services to individual
patients, populations, or communities.
For its part the medical school must ensure that before graduation a student
will have demonstrated, to the satisfaction of the faculty, the following:
· Knowledge of the important non-biological determinants of poor
health and of the economic, psychological, social, and cultural factors that
contribute to the development and/or continuation of maladies
· Knowledge of the epidemiology of common maladies within a defined
population, and the systematic approaches useful in reducing the incidence and
prevalence of those maladies
· The ability to identify factors that place individuals at risk for
disease or injury, to select appropriate tests for detecting patients at risk
for specific diseases or in the early stage of disease, and to determine
strategies for responding appropriately
The ability to retrieve (from electronic databases and other resources),
manage, and utilize biomedical information for solving problems and making
decisions that are relevant to the care of individuals and populations
Knowledge of various approaches to the organization, financing, and
delivery of health care
· A commitment to provide care to patients
who are unable to pay and to advocate for access to health care for members of
traditionally undeserved populations
Conclusion Improving the quality of medical education through
curriculum renewal is a continuous process. Medicine must always be responsive
to "evolving societal needs, practice patterns, and scientific
developments." As circumstances change, medical educators must understand
the meaning that these changes have for medical practice and medical education,
and must renew the medical student education program accordingly. The statement
of necessary attributes presented in this report and the learning objectives
derived from them provide medical school deans and faculties with a frame of
reference for reviewing their school's curriculum. The Association is confident
that if the design, content, and conduct of a school's curriculum are guided ,by
the set of learning objectives presented in this report, the school's graduates
will be well prepared to assume the limited patient care responsibilities
expected of new resident physicians and also will have begun to achieve the
attributes that fully trained physicians should possess to practice contemporary
medicine. The Association recognizes that medical schools are having to respond
to unprecedented changes in the ways that medical care is organized, financed,
and delivered. Over time these changes could undermine the integrity, financial
stability, and traditional roles of these institutions and, thereby, impede the
efforts of deans and faculties to improve their education programs. We hope,
therefore, that medical schools will respond to the intent of this report with
some sense of urgency. Schools should consider establishing a formal process for
developing their own objectives and for using those objectives to guide a review
of their curricula. If curriculum changes are indicated, schools should consider
whether their administrative structures and budgeting policies will support
substantive curriculum renewal and, if necessary, make changes designed to serve
that purpose. The Association also recognizes that the learning objectives of an
educational program are most valuable when the desired outcomes can be measured.
That is, can one actually determine whether a student has achieved the
objectives? At present, universally agreed upon outcome measures do not exist
for all of the objectives set forth in this report. Although greater attention
is now being paid to developing and implementing appropriate assessment methods,
the paucity of suitable out-come measures presents a major challenge to the
medical education community. Of particular importance, desired outcomes related
to attitudes and values are difficult to measure. The Association hopes that the
MSOP report will stimulate faculties to undertake efforts to develop assessment
methods for each of the objectives set forth in this report. The AAMC will
assist deans and faculties in this effort.
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