mistakes. That's what life is all about and medicine isn't exempt." Shumak says that undergraduate medical training, because of its nature, will always remain somewhat stressful, regardless of curriculum format. But he believes the bonding that will inevitably happen in small groups, and the resulting trust and support, will encourage students to be open about their feelings and anxieties. Also, he thinks closer personal relationships between faculty and students will be fostered by the small groups. "It's not that we actually see the new curriculum as the solution to stress, but as a means of providing better ways to cope with stress," says Shumak. "Once trust builds up between
people, it creates an atmosphere that is conducive to saying what's on your mind. The best way to alleviate stress is to put it on the table." Stuart McCluskey, a thirdyear medical student and 1992-93 president of the Medical Society, the organization representing undergraduate medical students at the U of T, says students are by and large enthusiastic about the new curriculum. Although he and other students already engaged in undergraduate training will not be directly affected by the revised system, he believes it is bound to have a spillover effect on the existing curriculum. McCluskey was one of many students involved in task force activities and curriculum renewal
committees. "One of the really good things about the new curriculum is that it will be student driven," he says. "The self-government of the Medical Society is now being reviewed to make it more responsive to representing the student body in terms of the changes to the curriculum and any problems or criticisms that may arise. "The students are starting to take responsibility now. Many of us realize that it was our complaints and input that played a large role in getting the whole process going. We want to ensure that the lines of communication between students and faculty remain open and that the curriculum can be revised or improved as the need arises."-
U of I not the only Ontario medical school heavily involved in curriculum renewal Olga Lechky T he face of undergraduate medical education is taking on a new look in all five of Ontario's medical schools. While the extent of changes at the University of Toronto is the most radical (see previous article), as it moves virtually overnight from a traditional lecture-based curriculum to an almost exclusively problem-based, independentlearning model, Queen's University in Kingston, the University of Western Ontario in London and the University of Ottawa have already or are about to introduce varying degrees of the same type of change. Even McMaster University in Hamilton is not resting on its Olga Lechky is a freelance writer living in North York, Ont. OCTOBER 15,1992
"We're changing the focus from inpatient hospital care and giving students a lot more exposure to community and ambulatory care." Dr. Jennifer Blake, McMaster University -
laurels as the North American innovator when it comes to studentcentred medical education. Several times it has revised and updated the problem-based curriculum
it introduced in 1969, revisions designed to keep it abreast of changing population and health care trends. While each school is making changes in its own time and in its own way, all five share the same goal: to train socially aware, sensitive physicians who are as at home in the realm of interpersonal relations as they are in the arena of scientific medicine. Features common to all the schools' curricula are a heavy emphasis on the integration of basic science and clinical medicine, early student exposure to patients, communication skills, psychosocial issues, medical ethics, medical literacy and health promotion. The last major curriculum renewal at McMaster started in 1982 with a shift from a "supplyside to a demand-side perspecCAN MED ASSOC J 1992; 147 (8)
1233
tive," says Dr. Jennifer Blake, chairperson of the undergraduate medical program. "In the past medical schools produced physicians based on new scientific and technological advances and hoped this would meet the needs of the population. What we started to do in 1982 was look seriously at what the needs of the population were and adapt our curriculum to better meet those needs. Our main focus right now is to integrate what we consider to be the three perspectives in medicine - population, behaviour and biology - into all the units and subunits the students rotate through." The McMaster curriculum now places more emphasis than ever on communication skills, psychosocial aspects of medicine, community issues, and disease prevention and health promotion. A unit on the life cycle, which focuses on health needs at various life stages in different populations, has recently been expanded to devote more time to the impact of substance abuse on patients, their families and society, elderly patients and occupational health. "Right now we've got a major thrust in communications issues and professional behaviour," says Blake. "We're also changing the focus from inpatient hospital care and giving students a lot more exposure to community and ambulatory care." Although almost entirely problem based, the curriculum at McMaster always has - and still does - include some lectures. However, the lectures do not deliver the course content; they are
designed to highlight
or
supple-
ment information being provided during tutorials and to present different points of view. A lecture on headaches, for example, offers
the viewpoints of a neurologist, a psychiatrist and a patient. A major change being planned at McMaster is the introduction of periodic examinations, OCTOBER 15,1992
something this maverick institution has always shied away from. The introduction of exams is in response to student demands for an objective test of knowledge. "The tests will be completed to reassure students that their knowledge base is growing and to allow them to identify their strengths and weaknesses," explains Blake. "We're introducing this with some trepidation because we don't want [the exams] to become the tail that wags the dog. We feel very strongly that the two things that make our system work are the problems that stimulate curiosity and the small groups that create the kind of atmosphere that motivates students to do their very best." There will also be a greater focus on. preparing students for the Medical Council of Canada licensing examination. Historically, students from the 3-year program at McMaster have scored lower than students from traditional 4-year programs. However, last year, for the first time, McMaster students scored above the national average. "We don't know what made the difference, but we hope the trend continues," says Blake. "We've never set much store by the LMCC [Licentiate of the Medical Council of Canada] because
we didn't believe it was a reliable measure of what it means to be a good physician. But now we realize it might have been unfair to the students to downplay it too much and that it is psychologically important for them to do well in it." While McMaster students' exam scores may have given ammunition to those sceptical of the merits of problem-based learning, there is evidence that the faculty of McMaster has succeeded in its goal of producing well-rounded and competent physicians, says Blake. For example, Mac graduates are sought after by residency programs because of their good clinical and communication skills. In practice, McMaster graduates tend to see fewer patients and to spend more time with the patients they do see. A recent study comparing McMaster graduates with those from the U of T suggested that the doctors produced by McMaster were more motivated to be continual learners and to keep up to date with advances in medical knowledge than their counterparts
from "traditional" medical schools. Interestingly, a higher proportion of McMaster graduates enter research and academic medicine than do their counterparts from traditional schools. This may be a reflection of their desire to use and pass on the love of learning they developed during their undergraduate years. "The best thing about problem-based learning is that the students really enjoy it and the faculty loves teaching it," says Blake. "I don't think that's anything to sneeze at if you're looking for some kind of indicator of success." In September 1989, the University of Western Ontario introduced a new curriculum for its 96 first-year medical students. Preferring to tread cautiously, faculty at Western retained what is essentially a traditional, lecture-based CAN MED ASSOCJ 1992; 147(8)
1235
curriculum while devoting 1 day per week to problem-based learning that is provided through small groups and independent study. "Our approach has been one of evolution rather than revolution," says Dr. Wayne Weston, director of health sciences educational development. "Our hope is that by changing the curriculum in smaller steps we'll have a better chance of being successful and demonstrate to the sceptics that students really do learn a lot on their own or in small groups. "What we're trying to do at Western is institutionalize change so that every year we'll introduce something new. We think PBL [problem-based learning] has some advantages, but it's not the only way to teach and not the best way to teach everything. I think there is a place for really good interactive lectures. There's also room for the case method, which we've already incorporated into one of our courses and plan to have more of in the future. Ideally, we would like to have a whole smorgasbord of different teaching methods depending on what it is we're trying to teach and to accommodate as much as possible different learning styles among the students." A disadvantage of introduc-
| N\
Weston: evolution, not rev,olution 1236
CAN MED ASSOC J 1992; 147 (8)
Maudsley: need some lectures
ing gradual change, says Weston, is the risk of giving a "mixed message" to the students. "For 4 days of the week students are exposed to a fair amount of passive learning in the lectures. Then in the middle of the week we expect them to figure out what they're supposed to be learning and to learn it. Sometimes the content they're learning through PBL is repeated in the lectures. As a result, the message we're giving is that we don't really trust them to learn on their own, and the students have complained about this. "So we're still ironing out the bugs, encouraging people who teach the lecture-based courses not to duplicate material being learned in tutorials. I'm optimistic that through faculty development, and as people get to understand better what we're doing, the curriculum will be better integrated." Queen's University also chose to stick to the middle ground when it introduced a new currcu lum in September 199 1. About one-third of the teaching is devoted to PBL. "In a small school like Queen's, we simply don't have enough faculty to do exclusively problem-based learning," explains Dr. Robert Maudsley, the vicedean of medicine.
"With a class size of 75 and a small compact campus, the students and faculty get to know one another and naturally have more interaction than in a mammoth place like the University of Toronto. For us, it's much more efficient to deliver certain types of information by having a faculty member lecture to the students for an hour." Medical training at Queen's now comprises two basically parallel arms. Using a body-systems approach, students learn- basic science and cjlinical and communication skills in small groups and lectures. Concurrently they are exposed throughout the entire 4-year course to "horizontal themes" that focus on social issues as they relate to medicine, medical ethics, medicine and the law, the history of medicine and medical literacy. This year, second-year students will be challenged to use the data-collecting skills they acquired in the medical literacy program in their first year. Queen's is introducing a critical-inquiry elective that will require all students to produce a piece of scholarly work that must be done satisfactorily in order to continue in the program. "We want students to demonstrate that they can pose an intelligent question, then search the literature carefully to see what's already known about it, to formulate a plan and answer the question," explains Maudsley. "The project can be done in the laboratory or it can be something much broader, like some public health issue. The purpose is not to create young Nobel laureates, but to impress upon students that critical inquiry is fundamental to being a good physician." This September, the University of Ottawa accepted 84 students into a brand new curriculum. About 50% of it is problem based, and all lectures and laboratory work is directly linked to the problem under study. "What we're hoping to do with our hyLE 15 OCTOBRE 1992
brid type of curriculum is blend the good parts of a traditional curriculum with a problem-based curriculum," says Dr. Jeff Turnbull, the assistant dean of medical education. "Our lectures are all designed to highlight, complement, to give principles and concepts related to the problem. It's not an independent-lecture series." Each week will begin with a problem from the body system being studied. The problems all encompass basic science, clinical skills and communication skills and all have a strong focus on the psychosocial dimension. Interwoven into the problems will also be Turnbull: hybrid curriculum an emphasis on medical ethics and health promotion. Community health care delivery is a promi- health care delivery project nent feature of Ottawa's new cur- throughout their 4 years of trainriculum, with students participat- ing. "An added complication we ing in an ongoing community
(mISopFoSLOI) 200 mCg CYTOTEC BRIEF PRESCRIBING INFORMATION Therapetc Classfficatlon Cytoprotete Agent
INDICATION: CYTOTEC (misoprostol) is indicated in the treatment and prevention of NSAID-induced gastric ulcers (defined as 0.3 cm in diameter) and in the treatment of duodenal ulcers. CONTRAINDICATIONS: Known sensitivity to prostaglandins, prostaglandin analogues, or excipients (micro-crystalline and hydroxypropyl methylcellulose, sodium starch and hydrogenated castor oil). Contraindicated in pregnancy. Women should be advised not tobecome pregnant while taking CYTOTEC. If pregnancy is suspected, use of the product should be discontinued and the pregnancy followed very closely (weekly) for the next four weeks. WARNINGS: Women of childbearing potential should employ adequate contraception (i.e. oral or intrauterine devices) while receiving CYTOTEC. (See CONTRAINDICATIONS.) Nursing Mothers: It is unlikely that CYTOTEC is excreted in human milk since it is rapidly metabolized throughout the body. However, it is not known if the active metabolite (misoprostol acid) is excreted in human milk. Therefore, CYTOTEC should not be administered to nursing mothers because the potential excretion of misoprostol acid could cause significant diarrhea in nursing infants. PedIatIc Use: Safety and effectiveness in patients below the age of 18 have not been established. PRECAUTIONS: Selecton of Patients: Before treatment is undertaken, a positive diagnosis of duodenal ulcer or NSAID-induced gastric ulcer should be made. In addition, the general health of the patient should be considered. Misoprostol is rapidly metabolized by most body tissues to inactive metabolites. Nevertheless, caution should be exercised when patients have impairment of renal or hepatic function. Experience to date with such patients is limited. Diarrhea: Rare instances of profound diarrhea leading to severe dehydration have been reported. Patients with an underlying condition such as irritable bowel disease, or those in whom dehydration were it to occur, would be dangerous, should be monitored carefully if CYTOTEC is prescribed. ADVERSE REACTIONS: Gastrointestinal: In subjects receiving CYTOTEC (misoprostol) 400 or 800 mcg daily in clinical trials, the most frequent gastrointestinal adverse events were diarrhea, abdominal pain and flatulence. The average incidences of these events were 11.4%, 6.8% and 2.9%, respectively. In clinical trials using a dosage regimen of 400 mcg bid, the incidence of diarrhea was 12.6%. The events were usually transient and mild to moderate in severity. Diarrhea, when it occurred, usually developed early in the course of therapy, was self-limiting and required discontinuation of CYTOTEC in less than 2% of the patients. The incidence of diarrhea can be
OCT^OBER 15, 1992
have in moving to a new curriculum is that we'll be doing it in two languages," explains Turnbull. "We'll do French at first only in the small groups. The lectures will still be given in English." Ontario's medical schools have not made changes to their curricula in isolation. Since 1989, the deans and faculty representatives from the five schools have collaborated in a project known as Educating Future Physicians of Ontario (EFPO). A 5-year project funded by the Ministry of Health, Associated Medical Services and Ontario's five medical schools, EFPO is examining issues that are fundamental in designing and implementing new undergraduate medical curricula, such as defining societal health care needs and expectations, faculty development and student evaluation.u
minimized by adjusting the dose of CYTOTEC, by administering after food and by avoiding coadministration of CYTOTEC with magnesium-containing antacids. GyncobgIcal: Women who received CYTOTEC during clinical trials reported the following gynecological disorders: spotting (0.7%), cramps (0.6%), hypermenorrhea (0.5%), menstral disorder (0.3%) and dysmenorrhea (0.1%). Elderly: There were no significant difference in the safety profile of CYTOTEC in approximately 500 ulcer patients who were 65 years of age or older compared with younger patients. Incidence greater than 1%: In clinical trials, the following adverse reactions were reported by more than 1% of the subjects receiving CYTOTEC and may be casually related to the drug: nausea (3.2%), headache (2.4%), dyspepsia (2%), vomiting (1.3%) and constipation (1.1%). However, there were no clinically significant differences between the incidences of these events for CYTOTEC and placebo. DOSAGE AND ADMINISTRATION: Treatm and Prevmet of NSAID-hdcd GastIc Ukcrs: The recommended adult oral dosage of CYTOTEC for the prevention and treatment of NSAID-induced gastric ulcer is 400 to 800 mcg a day in divided doses. NSAIDs should be taken according to the schedule prescribed by the physician. When appropriate CYTOTEC and NSAIDs are to be taken simultaneously. CYTOTEC should be taken after food. Dedenal Ulcer The recommended adult oral dosage of CYTOTEC (misoprostol) for duodenal ulcer is 800mcg per day for 4 weeks in two or four equall divided doses (i.e. 200 mcg qid or 400 mcg bid). The last dose should be taken at bedtime. Antacids (aluminumbased) may be used as needed for rellef of pain. Treatment should be continued for a total of 4 weeks unless healing in less time has been documented by endoscopic examination. In the small number of patients who may not have fully healed after 4 weeks, therapy with CYTOTEC may be continued for a further 4 weeks.
AVAILABILITY:
CYTOTEC 200 mcg tablets are white to off-white - scored, hexagonal with SEARLE 1461 engraved on one side. CYTOTEC 100 mcg tablets are white to off-white, round tablets with SEARLE engraved on one side and CYTOTEC on the other. Store below 300C (1860F). Pharmacist Dispense with Patient Insert.
Only Cytotec Protects. REFERENCES: 1. Adapted from Langman, MJS. Peptic Ulcer Complications and the use of Non-Aspirin, Non-Steroidal, Anti-inflammatory Drugs. Adverse Drug Reaction Bulletin 1986;120:488451. 2. Cytotec Product Monograph May 1991. 3. Graham DY, Agrawal NM, Roth SH et al. Prevention of NSAID-induced gastric ulcer with misoprostol. Lancet 1988;2:1277-1280. 4. Elliot SL, Yeomans ND, Buchanan RRC, et al. Long term epidemiology of gastropathy associated with nonsteroidal antiinflammatory drugs (NSAID) PW, et al. Toward an (abstr). Clin Exp Rheumatol 1990; (suppI 4) 8:58. 5. Fries JF, Miller SR, Spitz use. epidemiology of gastropathy associated with nonsteroidal antiinflammatory drug Gastroenterlogy for Risk C. serious gastrointestinal 1989;96:647-655. 6. Gabriel S, Jaakkimainen L, Bombardier complications related to use of nonsteroidal antiinflammatory drugs A meta-analsis. Annals of Intemal Medicine. 1991;115:787-796.
Searle Canada Inc.
400 Iroquois Shore Road Oakville, Ontario L6H 1M5 Product Monograph Available on Request.
CAN MED ASSOC J 1992; 147 (8)
IPAABI January, 1992 1237
people, it creates an atmosphere that is conducive to saying what's on your mind. The best way to alleviate stress is to put it on the table." Stuart McCluskey, a thirdyear medical student and 1992-93 president of the Medical Society, the organization representing undergraduate medical students at the U of T, says students are by and large enthusiastic about the new curriculum. Although he and other students already engaged in undergraduate training will not be directly affected by the revised system, he believes it is bound to have a spillover effect on the existing curriculum. McCluskey was one of many students involved in task force activities and curriculum renewal
committees. "One of the really good things about the new curriculum is that it will be student driven," he says. "The self-government of the Medical Society is now being reviewed to make it more responsive to representing the student body in terms of the changes to the curriculum and any problems or criticisms that may arise. "The students are starting to take responsibility now. Many of us realize that it was our complaints and input that played a large role in getting the whole process going. We want to ensure that the lines of communication between students and faculty remain open and that the curriculum can be revised or improved as the need arises."-
U of I not the only Ontario medical school heavily involved in curriculum renewal Olga Lechky T he face of undergraduate medical education is taking on a new look in all five of Ontario's medical schools. While the extent of changes at the University of Toronto is the most radical (see previous article), as it moves virtually overnight from a traditional lecture-based curriculum to an almost exclusively problem-based, independentlearning model, Queen's University in Kingston, the University of Western Ontario in London and the University of Ottawa have already or are about to introduce varying degrees of the same type of change. Even McMaster University in Hamilton is not resting on its Olga Lechky is a freelance writer living in North York, Ont. OCTOBER 15,1992
"We're changing the focus from inpatient hospital care and giving students a lot more exposure to community and ambulatory care." Dr. Jennifer Blake, McMaster University -
laurels as the North American innovator when it comes to studentcentred medical education. Several times it has revised and updated the problem-based curriculum
it introduced in 1969, revisions designed to keep it abreast of changing population and health care trends. While each school is making changes in its own time and in its own way, all five share the same goal: to train socially aware, sensitive physicians who are as at home in the realm of interpersonal relations as they are in the arena of scientific medicine. Features common to all the schools' curricula are a heavy emphasis on the integration of basic science and clinical medicine, early student exposure to patients, communication skills, psychosocial issues, medical ethics, medical literacy and health promotion. The last major curriculum renewal at McMaster started in 1982 with a shift from a "supplyside to a demand-side perspecCAN MED ASSOC J 1992; 147 (8)
1233
tive," says Dr. Jennifer Blake, chairperson of the undergraduate medical program. "In the past medical schools produced physicians based on new scientific and technological advances and hoped this would meet the needs of the population. What we started to do in 1982 was look seriously at what the needs of the population were and adapt our curriculum to better meet those needs. Our main focus right now is to integrate what we consider to be the three perspectives in medicine - population, behaviour and biology - into all the units and subunits the students rotate through." The McMaster curriculum now places more emphasis than ever on communication skills, psychosocial aspects of medicine, community issues, and disease prevention and health promotion. A unit on the life cycle, which focuses on health needs at various life stages in different populations, has recently been expanded to devote more time to the impact of substance abuse on patients, their families and society, elderly patients and occupational health. "Right now we've got a major thrust in communications issues and professional behaviour," says Blake. "We're also changing the focus from inpatient hospital care and giving students a lot more exposure to community and ambulatory care." Although almost entirely problem based, the curriculum at McMaster always has - and still does - include some lectures. However, the lectures do not deliver the course content; they are
designed to highlight
or
supple-
ment information being provided during tutorials and to present different points of view. A lecture on headaches, for example, offers
the viewpoints of a neurologist, a psychiatrist and a patient. A major change being planned at McMaster is the introduction of periodic examinations, OCTOBER 15,1992
something this maverick institution has always shied away from. The introduction of exams is in response to student demands for an objective test of knowledge. "The tests will be completed to reassure students that their knowledge base is growing and to allow them to identify their strengths and weaknesses," explains Blake. "We're introducing this with some trepidation because we don't want [the exams] to become the tail that wags the dog. We feel very strongly that the two things that make our system work are the problems that stimulate curiosity and the small groups that create the kind of atmosphere that motivates students to do their very best." There will also be a greater focus on. preparing students for the Medical Council of Canada licensing examination. Historically, students from the 3-year program at McMaster have scored lower than students from traditional 4-year programs. However, last year, for the first time, McMaster students scored above the national average. "We don't know what made the difference, but we hope the trend continues," says Blake. "We've never set much store by the LMCC [Licentiate of the Medical Council of Canada] because
we didn't believe it was a reliable measure of what it means to be a good physician. But now we realize it might have been unfair to the students to downplay it too much and that it is psychologically important for them to do well in it." While McMaster students' exam scores may have given ammunition to those sceptical of the merits of problem-based learning, there is evidence that the faculty of McMaster has succeeded in its goal of producing well-rounded and competent physicians, says Blake. For example, Mac graduates are sought after by residency programs because of their good clinical and communication skills. In practice, McMaster graduates tend to see fewer patients and to spend more time with the patients they do see. A recent study comparing McMaster graduates with those from the U of T suggested that the doctors produced by McMaster were more motivated to be continual learners and to keep up to date with advances in medical knowledge than their counterparts
from "traditional" medical schools. Interestingly, a higher proportion of McMaster graduates enter research and academic medicine than do their counterparts from traditional schools. This may be a reflection of their desire to use and pass on the love of learning they developed during their undergraduate years. "The best thing about problem-based learning is that the students really enjoy it and the faculty loves teaching it," says Blake. "I don't think that's anything to sneeze at if you're looking for some kind of indicator of success." In September 1989, the University of Western Ontario introduced a new curriculum for its 96 first-year medical students. Preferring to tread cautiously, faculty at Western retained what is essentially a traditional, lecture-based CAN MED ASSOCJ 1992; 147(8)
1235
curriculum while devoting 1 day per week to problem-based learning that is provided through small groups and independent study. "Our approach has been one of evolution rather than revolution," says Dr. Wayne Weston, director of health sciences educational development. "Our hope is that by changing the curriculum in smaller steps we'll have a better chance of being successful and demonstrate to the sceptics that students really do learn a lot on their own or in small groups. "What we're trying to do at Western is institutionalize change so that every year we'll introduce something new. We think PBL [problem-based learning] has some advantages, but it's not the only way to teach and not the best way to teach everything. I think there is a place for really good interactive lectures. There's also room for the case method, which we've already incorporated into one of our courses and plan to have more of in the future. Ideally, we would like to have a whole smorgasbord of different teaching methods depending on what it is we're trying to teach and to accommodate as much as possible different learning styles among the students." A disadvantage of introduc-
| N\
Weston: evolution, not rev,olution 1236
CAN MED ASSOC J 1992; 147 (8)
Maudsley: need some lectures
ing gradual change, says Weston, is the risk of giving a "mixed message" to the students. "For 4 days of the week students are exposed to a fair amount of passive learning in the lectures. Then in the middle of the week we expect them to figure out what they're supposed to be learning and to learn it. Sometimes the content they're learning through PBL is repeated in the lectures. As a result, the message we're giving is that we don't really trust them to learn on their own, and the students have complained about this. "So we're still ironing out the bugs, encouraging people who teach the lecture-based courses not to duplicate material being learned in tutorials. I'm optimistic that through faculty development, and as people get to understand better what we're doing, the curriculum will be better integrated." Queen's University also chose to stick to the middle ground when it introduced a new currcu lum in September 199 1. About one-third of the teaching is devoted to PBL. "In a small school like Queen's, we simply don't have enough faculty to do exclusively problem-based learning," explains Dr. Robert Maudsley, the vicedean of medicine.
"With a class size of 75 and a small compact campus, the students and faculty get to know one another and naturally have more interaction than in a mammoth place like the University of Toronto. For us, it's much more efficient to deliver certain types of information by having a faculty member lecture to the students for an hour." Medical training at Queen's now comprises two basically parallel arms. Using a body-systems approach, students learn- basic science and cjlinical and communication skills in small groups and lectures. Concurrently they are exposed throughout the entire 4-year course to "horizontal themes" that focus on social issues as they relate to medicine, medical ethics, medicine and the law, the history of medicine and medical literacy. This year, second-year students will be challenged to use the data-collecting skills they acquired in the medical literacy program in their first year. Queen's is introducing a critical-inquiry elective that will require all students to produce a piece of scholarly work that must be done satisfactorily in order to continue in the program. "We want students to demonstrate that they can pose an intelligent question, then search the literature carefully to see what's already known about it, to formulate a plan and answer the question," explains Maudsley. "The project can be done in the laboratory or it can be something much broader, like some public health issue. The purpose is not to create young Nobel laureates, but to impress upon students that critical inquiry is fundamental to being a good physician." This September, the University of Ottawa accepted 84 students into a brand new curriculum. About 50% of it is problem based, and all lectures and laboratory work is directly linked to the problem under study. "What we're hoping to do with our hyLE 15 OCTOBRE 1992
brid type of curriculum is blend the good parts of a traditional curriculum with a problem-based curriculum," says Dr. Jeff Turnbull, the assistant dean of medical education. "Our lectures are all designed to highlight, complement, to give principles and concepts related to the problem. It's not an independent-lecture series." Each week will begin with a problem from the body system being studied. The problems all encompass basic science, clinical skills and communication skills and all have a strong focus on the psychosocial dimension. Interwoven into the problems will also be Turnbull: hybrid curriculum an emphasis on medical ethics and health promotion. Community health care delivery is a promi- health care delivery project nent feature of Ottawa's new cur- throughout their 4 years of trainriculum, with students participat- ing. "An added complication we ing in an ongoing community
(mISopFoSLOI) 200 mCg CYTOTEC BRIEF PRESCRIBING INFORMATION Therapetc Classfficatlon Cytoprotete Agent
INDICATION: CYTOTEC (misoprostol) is indicated in the treatment and prevention of NSAID-induced gastric ulcers (defined as 0.3 cm in diameter) and in the treatment of duodenal ulcers. CONTRAINDICATIONS: Known sensitivity to prostaglandins, prostaglandin analogues, or excipients (micro-crystalline and hydroxypropyl methylcellulose, sodium starch and hydrogenated castor oil). Contraindicated in pregnancy. Women should be advised not tobecome pregnant while taking CYTOTEC. If pregnancy is suspected, use of the product should be discontinued and the pregnancy followed very closely (weekly) for the next four weeks. WARNINGS: Women of childbearing potential should employ adequate contraception (i.e. oral or intrauterine devices) while receiving CYTOTEC. (See CONTRAINDICATIONS.) Nursing Mothers: It is unlikely that CYTOTEC is excreted in human milk since it is rapidly metabolized throughout the body. However, it is not known if the active metabolite (misoprostol acid) is excreted in human milk. Therefore, CYTOTEC should not be administered to nursing mothers because the potential excretion of misoprostol acid could cause significant diarrhea in nursing infants. PedIatIc Use: Safety and effectiveness in patients below the age of 18 have not been established. PRECAUTIONS: Selecton of Patients: Before treatment is undertaken, a positive diagnosis of duodenal ulcer or NSAID-induced gastric ulcer should be made. In addition, the general health of the patient should be considered. Misoprostol is rapidly metabolized by most body tissues to inactive metabolites. Nevertheless, caution should be exercised when patients have impairment of renal or hepatic function. Experience to date with such patients is limited. Diarrhea: Rare instances of profound diarrhea leading to severe dehydration have been reported. Patients with an underlying condition such as irritable bowel disease, or those in whom dehydration were it to occur, would be dangerous, should be monitored carefully if CYTOTEC is prescribed. ADVERSE REACTIONS: Gastrointestinal: In subjects receiving CYTOTEC (misoprostol) 400 or 800 mcg daily in clinical trials, the most frequent gastrointestinal adverse events were diarrhea, abdominal pain and flatulence. The average incidences of these events were 11.4%, 6.8% and 2.9%, respectively. In clinical trials using a dosage regimen of 400 mcg bid, the incidence of diarrhea was 12.6%. The events were usually transient and mild to moderate in severity. Diarrhea, when it occurred, usually developed early in the course of therapy, was self-limiting and required discontinuation of CYTOTEC in less than 2% of the patients. The incidence of diarrhea can be
OCT^OBER 15, 1992
have in moving to a new curriculum is that we'll be doing it in two languages," explains Turnbull. "We'll do French at first only in the small groups. The lectures will still be given in English." Ontario's medical schools have not made changes to their curricula in isolation. Since 1989, the deans and faculty representatives from the five schools have collaborated in a project known as Educating Future Physicians of Ontario (EFPO). A 5-year project funded by the Ministry of Health, Associated Medical Services and Ontario's five medical schools, EFPO is examining issues that are fundamental in designing and implementing new undergraduate medical curricula, such as defining societal health care needs and expectations, faculty development and student evaluation.u
minimized by adjusting the dose of CYTOTEC, by administering after food and by avoiding coadministration of CYTOTEC with magnesium-containing antacids. GyncobgIcal: Women who received CYTOTEC during clinical trials reported the following gynecological disorders: spotting (0.7%), cramps (0.6%), hypermenorrhea (0.5%), menstral disorder (0.3%) and dysmenorrhea (0.1%). Elderly: There were no significant difference in the safety profile of CYTOTEC in approximately 500 ulcer patients who were 65 years of age or older compared with younger patients. Incidence greater than 1%: In clinical trials, the following adverse reactions were reported by more than 1% of the subjects receiving CYTOTEC and may be casually related to the drug: nausea (3.2%), headache (2.4%), dyspepsia (2%), vomiting (1.3%) and constipation (1.1%). However, there were no clinically significant differences between the incidences of these events for CYTOTEC and placebo. DOSAGE AND ADMINISTRATION: Treatm and Prevmet of NSAID-hdcd GastIc Ukcrs: The recommended adult oral dosage of CYTOTEC for the prevention and treatment of NSAID-induced gastric ulcer is 400 to 800 mcg a day in divided doses. NSAIDs should be taken according to the schedule prescribed by the physician. When appropriate CYTOTEC and NSAIDs are to be taken simultaneously. CYTOTEC should be taken after food. Dedenal Ulcer The recommended adult oral dosage of CYTOTEC (misoprostol) for duodenal ulcer is 800mcg per day for 4 weeks in two or four equall divided doses (i.e. 200 mcg qid or 400 mcg bid). The last dose should be taken at bedtime. Antacids (aluminumbased) may be used as needed for rellef of pain. Treatment should be continued for a total of 4 weeks unless healing in less time has been documented by endoscopic examination. In the small number of patients who may not have fully healed after 4 weeks, therapy with CYTOTEC may be continued for a further 4 weeks.
AVAILABILITY:
CYTOTEC 200 mcg tablets are white to off-white - scored, hexagonal with SEARLE 1461 engraved on one side. CYTOTEC 100 mcg tablets are white to off-white, round tablets with SEARLE engraved on one side and CYTOTEC on the other. Store below 300C (1860F). Pharmacist Dispense with Patient Insert.
Only Cytotec Protects. REFERENCES: 1. Adapted from Langman, MJS. Peptic Ulcer Complications and the use of Non-Aspirin, Non-Steroidal, Anti-inflammatory Drugs. Adverse Drug Reaction Bulletin 1986;120:488451. 2. Cytotec Product Monograph May 1991. 3. Graham DY, Agrawal NM, Roth SH et al. Prevention of NSAID-induced gastric ulcer with misoprostol. Lancet 1988;2:1277-1280. 4. Elliot SL, Yeomans ND, Buchanan RRC, et al. Long term epidemiology of gastropathy associated with nonsteroidal antiinflammatory drugs (NSAID) PW, et al. Toward an (abstr). Clin Exp Rheumatol 1990; (suppI 4) 8:58. 5. Fries JF, Miller SR, Spitz use. epidemiology of gastropathy associated with nonsteroidal antiinflammatory drug Gastroenterlogy for Risk C. serious gastrointestinal 1989;96:647-655. 6. Gabriel S, Jaakkimainen L, Bombardier complications related to use of nonsteroidal antiinflammatory drugs A meta-analsis. Annals of Intemal Medicine. 1991;115:787-796.
Searle Canada Inc.
400 Iroquois Shore Road Oakville, Ontario L6H 1M5 Product Monograph Available on Request.
CAN MED ASSOC J 1992; 147 (8)
IPAABI January, 1992 1237
