First, a search was conducted to identify the main medical schools on each continent using the following indexes: Academic Ranking of World Universities,6 QS World University Rankings,7 and the Center for World University Rankings.8 Second, a representative sample from each continent was selected according to quality level, including at least the top five medical schools on each continent with the highest average combined scores on these three rankings. Considering the number of medical schools by country, we also selected at least the first five medical schools with the highest average scores from countries with a greater number of medical schools.

Once this process was complete, the information available on the medical schools’ websites was used to explore their academic curricula with the aim of identifying any references to chronicity, chronic diseases, or chronic patients. References related to geriatric medicine, comorbidity, or aging were also searched for. Schools in which there were no references to these terms in their curricula were considered to offer no instruction on chronicity. If any of the related key terms was identified, attempts were made to confirm the existence of a program or subject dedicated to education on chronicity by reviewing the subject’s syllabus or by contacting department heads or other professionals when this information was not sufficient for evaluating the presence of chronicity. For this step, the person in charge was emailed at their listed email address and he or she was directly asked if he or she considered that chronicity was fully and correctly addressed in the curriculum.

Programs were recorded as having a “Reference to chronicity” when the existence of specific teaching programs or subjects on chronicity was confirmed. Programs were recorded as having a “Potentially related subject” when some link to chronicity was found, but there was a lack of specific education on chronicity (Tables 1 and 2).

The review included the five main medical schools from United Kingdom, Germany, Portugal, France, and Italy and the 15 main medical schools from the remaining European countries. All Spanish medical schools were included in the review. Fifteen main medical schools from the United States of America, five from Canada, 25 from Latin America, 25 from Asia, five from Oceania, and five from Africa were also included. In the end, 120 medical schools were included in the review in addition to the 43 Spanish medical schools. The complete list of the medical schools included is available in Tables 1 and 2.

A literature review was conducted on the PubMed, Scopus, SciELO, and Dialnet databases using keywords with the following searching strategy: (((chronicity[Title/Abstract]) OR (chronic disease[Title/Abstract])) AND ((teaching[Title/Abstract]) OR (medical education[Title/Abstract]) OR (medical school[Title/Abstract]) OR (undergraduate[Title/Abstract]))). The literature review was also expanded through related citations and by checking the reference section of the selected articles.

The main objective of this review was to identify publications on the teaching methods used in chronicity in medical studies. The inclusion criteria were articles with a description or evaluation of any teaching experience in the field of chronicity or articles with any proposals for new teaching methods in this field. Only articles which referred to undergraduate medical teaching were included; those which focused on postgraduate or specialized medical training were excluded. All duplicate articles or those referring to the same experience or project were excluded.

These criteria were applied through an initial reading of the title and abstract or through a deeper review of the article’s full content when necessary. The main key points extracted from the articles were: innovative proposal, use of technology, transmission of values and skills to students, existence of a completed project, and existence of a critical evaluation of results. The presence of these key points allowed for the articles to be considered high quality.

The information extracted from the selected articles was summarized as highlights regarding innovative aspects, specific target competences and skills, and type of self-assessment of outcomes.

Once all the available information was evaluated, a proposal was developed for innovative educational elements or programs related to chronicity that could be applied not only at our center (University of Santiago de Compostela Medical School), but also at any medical school interested in improving the teaching systems regarding chronicity.

The first notable difference regarding the various medical schools’ teaching programs is the educational curriculum itself, which may be organized in blocks of subjects, sets of competences, cross-curricular competences, or pre-defined itineraries with optional additional training.

A huge degree of variability can be observed not only when comparing schools in different countries, but also among medical schools in the same country, as shown in Tables 1 and 2. Nevertheless, one conclusion that can easily be drawn from a review of educational programs and curricula is that medical schools of greater importance and international recognition have changed the structure of their teaching into a competence-based curricula, with educational systems based on wide-ranging cross-curricular educational competences that are present throughout student’s entire medical education.9 Unfortunately, chronicity was not one of these cross-curricular competences in most cases and its presence in medical schools’ curricula is very unusual.

In the case of Spain, a subject that includes the concept of chronicity was only found in half of medical schools, with no mention made in the other half. No medical schools recognized chronicity as a cross-curricular competence. Our own institution, the University of Santiago de Compostela, is no exception: there is no mention of chronicity in the medical school educational program. Regarding the rest of Europe, as can be seen in Table 2, chronicity is not present as a global competence, though some medical schools in the United Kingdom, France, and Germany have recently made profound changes to their educational programs and have established competence-based programs.

In the United States of America, most medical schools had a competence-based educational program. Regarding chronicity, though its presence was not explicit, it was found in concepts related to quality of life, functional status, or the relationship between chronic diseases and social and work life. Some specific projects, like the Longitudinal Standardized Patient Case, have been implemented in some medical schools. This project focuses on the evaluation of chronic patients and the disease’s impact on daily life, in all cases with a high degree of satisfaction reported by the medical students.10–13 Other noteworthy strategies are those based on follow-up on the clinical progress of real chronic patients (Longitudinal Clinical Experience), rather than just simulated clinical cases. This strategy aims for students to become familiar with patients’ real lives and understand the disease’s impact on it.14

The search strategy retrieved 651 articles, of which 498 were excluded after reviewing the title and abstract because they did not meet the inclusion criteria. In a second round, another 112 articles were excluded due to absence of a detailed description of the teaching method or because they belonged to the field of postgraduate or specialized medical training. Of the remaining 41 articles, 21 were included in the review after reading and analyzing them in detail (Fig. 1).

Figure 1.

Flowchart.

(0.54MB).

Among the 21 articles analyzed, six which contained proposals for objectives or competences to be acquired through specific education on aspects related to chronicity are presented. The remaining 15 articles describe specific proposals for innovative teaching methods in the field of chronicity that have been carried out as pilot projects and, in most cases, have been subjected to a critical evaluation by students and/or teaching staff. The articles included in the review are detailed in Table 3.

In the first group of six articles, a paper from 1964 already discussed the challenge posed by chronic patients, the impact of disease on all areas of people’s lives, and the need to implement measures that go beyond mere medical treatment.15 In this sense, A. J. Cohen remarked in 1996 that existing educational deficits in this field led to an erroneous subsequent approach and poor resource management both when treating and preventing the development of chronic diseases.16

In 2004, Pham et al. published a survey of medical school department directors in the United States with the intention of proposing a common plan of action to improve medical training on chronicity. The results reflected a certain degree of agreement on the need for change, but enormous variability in the approach that each would propose.17

Other authors developed proposals based on students’ need to evaluate the functional repercussions of any chronic disease and the degree of disability it causes.18 Shi and Nambudiri advocated for extending medical training on chronicity to the entire educational period and all medical specialties, making chronicity one of the main cross-curricular competences in medicine.19

Recently, an expert panel comprising members from different universities in the United States of America have proposed six major objectives for improving medical teaching on chronicity that revolve around optimal data and resource management.4

The second group of 15 articles focused on proposals for specific educational projects on chronicity. One of the first works, published in 1996, was based on seminars and workshops and reported a high level of student satisfaction.20 Subsequently, other authors have made various proposals based on students learning directly by visiting patients’ family settings, such as the “Keeping Families Healthy” project,21 or a project which took place at Cornell University in which students conducted interviews with patients in their homes.22

The idea of bringing teaching on chronicity to the patient’s environment has been spreading in recent years through different projects based on the “Health Mentor” system, in which a student or group of students is assigned to a chronic patient and learn directly from his or her life experience with the disease.23,24

In general, the main structure of most projects could be summarized as follows:

• a)

  The student or group of students is assigned to a patient who acts as a Health Mentor.

• b)

  The student reflects throughout the experience by keeping a journal or completing questionnaires.

• c)

  The student conveys his or her experiences and the knowledge acquired to other students.

The third point has been explored in different teaching projects on chronicity and in most, it is accompanied by completing surveys before and after the project which evaluate changes in students’ perceptions about chronicity.25 Some long-term experiences, like the teaching project developed at Harvard University, have shown great results by improving the teaching process every year through the students’ evaluation and self-management of the educational process.26

Other authors have published experiences in which students filmed interviews in order to create a documentary that they later presented in public27 or even translated their experiences with the patients into a work of artistic expression through painting, music, or other media.28 Some projects based on the Longitudinal Standardized Patient Case system have explored the use of roleplay dynamics and simulation systems for educational experiences on chronicity.13,29 Finally, the project conducted by Liu et al. at Yale University, in which students were involved not only in patient evaluations, but also in the decision-making process, merits mention.30