Improving Medical Education: A Narrative Review

With the advancement in basic and clinical sciences, medical education is also constantly evolving. The Accreditation Council for Graduate Medical Education (ACGME) has endorsed six core competencies to improve teaching and learning. This narrative review was conducted after searching the article databases (PubMed, PubMed Central, Embase, and Scopus) about the core competencies such as medical knowledge (problem-based learning), interpersonal communication, patient care, professionalism, practice-based learning and improvement, and system-based care endorsed by ACGME. We included randomized and quasi-experimental trials, cohorts, and case-control studies in this narrative review. In a problem-based learning modality, a real-life scenario is allocated to a group of students. Studies have shown that it is more effectively demonstrated by a better post-test score, improved concentration, and application of knowledge. Interpersonal communication skills promote collaboration with interdisciplinary teams, work quality, and patient adherence to treatment. Professionalism is a human attribute that creates a pleasant work environment and is an essential trait that improves patients' adherence to treatment. In system-based care, patients are benefitted through a well-structured plan of care. Finally, in practice-based learning, medical trainees learn to systematically evaluate the pattern of care and practice the best modality to improve the overall patient care and physician satisfaction. These core competencies need to be incorporated into all levels of medical training.

medical professionalism, which fellow health professionals have used to gauge their professionalism in medical education [7]. However, different institutions have different ways of assessing it.
Although several evidence-based care treatment plans are developed for diverse medical conditions, they cannot be executed without well-functioning multidisciplinary teams. A system-based care strategy involves planning, cooperation, and a structured management plan based on evidence that benefits patient care [8].
In practice-based learning and improvement, the trainees in medicine are expected to systematically investigate and evaluate their care to their patients and the practice patterns of their workplaces to identify the areas of improvement. They incorporate the best practices and implement the changes with the goal of improvement. They participate in educating patients, families, students, and other healthcare professionals [9].
All these sectors have a crucial effect on the upliftment of medical education.

Review Methods
We searched different databases such as PubMed, PubMed Central, Embase, and Scopus. Studies regarding problem-based learning, interpersonal communication, patient care, professionalism, practice-based learning and improvement, and system-based care were used for this review. Here, we have the narrative review to comply with the above terms.

Problem-Based Learning
Nine studies included in our problem-based learning review revealed its tremendous benefits. Most studies assessed this by conducting pre-and post-PBL sessions and pre-and post-traditional lecture-based sessions. Studies showed an increase in post-test scores after PBL sessions in comparison to team-based learning (TBL) [4,10]. This is further supported by the meta-analysis findings of Qin et al. and Galvao et al. [11,12].
In contrast, a study done in Harvard Medical School demonstrated no significant difference among the students whose mean prior exam scores were above the median in either group [7]. Apart from the scores, PBL improved attention, application of knowledge, better use of time, and available resources compared to conventional forms of learning [1,4,5,11,12]. Likewise, 97% of the students strongly agreed that PBL sessions should be part of the normal curriculum [11]. Due to the effect of the current pandemic, web-based learning has also become popular among medical students. Virtual learning was found to be as effective as face-to-face interaction learning [13].
Among nine studies on problem-based learning, four were from the USA, three from Europe, and one each from Africa and India. Five studies were from the medical profession, one each from nursing, dental, and physician assistant. Six studies enrolled undergraduate level, two including residents, and one enrolling postgraduate level. Three studies were randomized controlled trials (RCTs), two each cohort, a pre-and post-test single-group study, one each quasi-experimental trial, and a case-control study. A summary of some of the studies on problem-based learning is mentioned in Table

Interpersonal Communication
We included two studies under this heading. The first study was conducted in Switzerland to assess the triggers for conflict in a team and its impact on teamwork. Team members perceived that observed tensions were directly related to lower quality work based on multilevel regression analysis (except among anesthetists) with or without adjusting for hospital and surgery duration. Moreover, the quality of teamwork was rated high by all surgical team members [21]. The second study in Singapore showed increased selfconfidence among the healthcare workers when they underwent a simulation-based interprofessional educational program for caring for a deteriorating patient [22]. Subsequently, a meta-analysis by Zolnierek et al. revealed marked improvement in patient adherence after the physician communication training. Furthermore, it was clearly stated that non-adherence was common among the patients attended by physicians who communicate poorly [23]. All these findings highlight the importance of interpersonal communication.

Patient Care
Three studies in our review showed improved patient satisfaction and care after a collaborative and multimodal approach in their management [5,25,26].
A study in the United States of America that focused on improving the quality of diabetes care in community centers was intervened by collaboration with community organizations, a self-management tool to track the patient's progress, group cluster visits, and diabetes flow sheet. Of the respondents, 95% strongly believed that the collaboration was successful, and >80% wished to continue the interventions [25]. Similarly, a study in Sweden using a multi-modality approach to pain management for musculoskeletal pain found a significant improvement in patients' post-intervention status, which was sustained at the 12 months. However, the longer duration of the program was not found to be beneficial compared to shorter-duration programs [5]. A systematic review done by Hush et al. also exhibited that patient satisfaction is determined by interpersonal attributes and patient care approach. However, patient satisfaction was inconsistent with the treatment outcome [27].

Professionalism
A total of five studies qualified for the study under the heading of "professionalism" and are summarized in Table 4 [28 -31]. Most health professionals are well aware of professionalism and its impact on medical education and clinical practice [31]. In a study in Japan, emergency medicine (EM) residents scored higher than EM physicians when questioned about confidentiality and sexual harassment [32]. Another study showed that clinical groups of students scored higher than preclinical students in a quiz about professionalism. However, the finding was not statistically significant [29]. In a study done in Australia, 95% of respondents stated that personal and professional development (PPD) helped them learn about professional development. Interviewing patients in the community and writing from the patient's perspective helped students understand the biopsychosocial aspect of medicine and guided appropriate behavior in clinical practice [6]. Health professionals who are well informed about work habits and work ethics will foster patient adherence and create a healthy working environment.

No.
Year

System-Based Care
Multiple studies have shown that system-based care aligns with the quality of patient care and decreases the risks associated with the clinical practice [8,33]. In addition, inter-specialty collaboration to manage hard and soft tissue injuries with a systematic approach has also boosted the confidence and reinforced their surgical skills [34]. For example, a study undertaken in the United States implementing the Six Building Blocks Program for managing patients taking opioids for chronic pain analyzed its effect on the work-life of primary care providers and staff. As a result, the involved staff reported improved work-life balance, confidence and comfort in clinical areas, ease in managing cases with chronic pain, increased comfort in work processes and their role, and increased collaboration after implementing the program [33]. Thus, system-based care has a two-way advantage where the patient gets better care along with physician satisfaction. Table 5 summarizes the study findings.

No.
Year Country Outcome

Practice-Based Learning and Improvement
Practice-based learning and improvement (PBLI) connect continuous learning to good patient care. It is an experiential continuum that reveals trainees their own learning needs and the needs of their practices. The trainees then develop and implement plans for their self-improvement and the improvement of their practices. Small and sustained changes in individual clinicians and practice patterns can result in the improvement of healthcare systems [35]. For example, a study by Ogrinc et al. in 2004 revealed that four weeks of PBLI elective by internal medicine residents improved quality Improvement Knowledge Application Tool scores compared to the control group [36]. Other studies by Varkey et al. in 2009 describe that the application of PBLI and systems-based practice in the curriculum in Mayo Clinic resulted in a 13% increase in perceived ability to measure competency in systolic blood pressure (SBP), no change in their perceived ability to measure competence in PBLI, a 15% increase in their ability to provide written documentation of competence in PBLI and a 35% increase in their ability to provide written documentation of competence in SBP between 2005 and 2007. In addition, 70% of the residents participated in quality improvement (QI) projects during the time [37]. Therefore, it is crucial to develop and implement a curriculum in PBLI by every teaching medical institution.

Conclusions
Improvement of medical education involves integrating problem-based learning, robust interpersonal communication, patient care, professionalism, and practice-based learning and improvement and improving system-based care. Incorporating and implementing these core competencies in medical curricula is essential in all levels of medical training, including undergraduate level, residency, and fellowship training.

Conflicts of interest:
In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.