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Portfolio used in education can be defined as a collection of documentation of performed learning activities, feedback, and progress. Currently, the documentation is electronic, hence the term e-portfolio is used. The portfolio must have a clear purpose and be aligned with the learning outcomes of the program. To be successfully implemented a portfolio must be an integral part of the education with defined tasks for both the students and the teachers. Students and teacher support in how to use the portfolio is essential especially in the beginning of the program. Learning analytics enables teachers to identify and develop support for students at risk of not achieving the outcomes.

The first national evaluation of undergraduate medical education in Finland was carried out by the Finnish Education Evaluation Centre (FINEEC) in 2016–2018. The evaluation covered all five universities that offer the Licentiate Degree in Medicine programme: Universities of Eastern Finland, Helsinki, Oulu, Tampere and Turku. The evaluation is based on the principles of enhancement-led evaluation, emphasising active participation and trust. Both the process and its results are intended to help education providers to identify the strengths, good practices and areas in need of development in undergraduate medical education. The evaluation aimed at producing an overall picture on the current state, strengths and challenges of undergraduate medical education, and developing recommendations that reflect the changing competence requirements in doctors’ work and their future operating environment. The evaluation team identified the following areas as strengths that apply to all five Medical Schools:* Undergraduate medical education programmes are regularly reviewed and developed; various drivers for changes have been identified and processes of quality management exist, and the Schools seem committed to improve their education continuously.* Each School has many good practices of education planning and implementation that others can share.* National collaboration is increasing, and joint analyses of core learning contents have started.* Student engagement is particularly strong; the students are involved in the development of education in all five Schools at all levels of studies through feedback and representatives.* All Schools provide decentralised clinical placements outside the university hospital and early patient contact, often in primary care. There is good collaboration with teaching units outside the university, especially in primary health care featuring enthusiastic teachers as role models.The core recommendations to support the development of undergraduate medical education are:* Defining the “Finnish Doctor”. To engage effectively with the forthcoming health and social care (SOTE) reforms, there must be a consensus on the skills, attitudes and role of a newly graduating doctor. Currently there is no national consensus about what is a “Finnish Doctor” – how they are educated and what they should master at graduation. The structure of medical curriculum varies between universities. Medical Schools need to take more of a leadership role in defining the “Finnish Doctor” and involve a range of stakeholders (patients, students, other health professions, employers) to develop a shared vision and agree on key curricular outcomes.* Curriculum mapping and alignment. Curriculum mapping – displaying the key elements of curriculum and the relationship between them – can make curriculum planning more effective, the scope and sequence of student learning explicit, and the result more transparent to all stakeholders. Medical Schools could then continue collaboration to align the curricula so that shared national programme outcomes can be taught, learnt and assessed with certainty.* Development of key skills. A doctor’s key task is diagnostic work with patients. Particularly important for learning, then, is assessment of clinical skills and reasoning in patient encounters with constructive feedback. Readiness to apply new technologies with a critical attitude, teamworking skills, and abilities to manage difficult situations constructively are also core competencies to be facilitated throughout undergraduate learning.* Learning environment. Increased medical student intake has coincided with organizational and budget changes, affecting student and staff well-being. Larger groups especially in the clinics increase teacher workload and decrease opportunity for hands-on experience and personal feedback. Medical Schools’ approaches to preventing, identifying and managing problems in student and staff well-being should be developed.* Valuing teacher skills. Medical School teachers balance between demands from teaching, clinic, research, and family. Finnish Medical Schools should explore ways of appreciating teaching and consider creating tenure tracks in medical teaching. Centres for medical education could support systematic provision of pedagogical training for all who teach medical students.Achieving changes required by the rapidly changing operating environment can be done while protecting the unique flavours of the five Medical Schools. The Faculties can collaborate to ensure that graduates are trained in the skills they need as fledgling practitioners, in further speciality training, when taking on roles in research, management, education or health policy, and for lifelong learning. Ultimately the changes will improve the quality of graduates, increase patient safety, and result in better medical care in Finland.

Lääketieteen peruskoulutus on arvioitu Suomessa ensi kertaa. Kansainvälisen arviointiryhmän tärkein ehdotus on, että suomalaisen lääkärin ydinosaaminen pitää määritellä selvästi. Opintojen rakenteen, oppimismenetelmien ja arvioinnin tulisi johtaa linjakkaasti tämän osaamisen hyvään hallintaan.

Definition of the CanMEDS roles. Definition of the CanMEDS roles which together build up the professional competence of a physician. (DOCX 16 kb)

Questionnaire for medical students. The CASS questionnaire the students were asked to respond every third week. (DOC 83 kb)

Globus, a non-painful sensation of a lump in the throat, is a common symptom; however, little is known about the etiology, and the causes have remained controversial. Dysphagia is a multifaceted symptom. Identifying the stage of the swallowing process at which the problem occurs directs us to possible further investigations in dysphagia diagnostics. The aim of this thesis was to investigate the etiology of globus, to clarify globus and dysphagia diagnostics, and to describe the natural course of these symptoms. In the first study, we examined the esophageal background of globus with transnasal esophagoscopy, high-resolution manometry, and 24-hour multichannel intraluminal impedance and pH monitoring. We had 30 globus patients and, as controls, 24 patients who were referred to the Department of Abdominal Surgery for evaluation of operative treatment because of difficult reflux symptoms. The study indicated that globus patients without reflux symptoms did not have acid or non-acid gastroesophageal reflux disease, the upper esophageal sphincter pressure was not elevated, and esophageal motor disorders diagnosed were mainly minor, a finding evident in healthy subjects, as well. However, globus patients had supragastric belching more often than controls with reflux. In the second study, we observed that globus patients felt symptom relief in the Reflux Symptom Index and Deglutition Handicap Index after a four-month follow-up without any treatment. None of the videolaryngoscopies revealed a laryngopharyngeal reflux using the Reflux Finding Score. A speech and language pathologist examined globus patients after four months and found six patients with simultaneous functional voice problems, possibly associated with persistent globus. In the third and fourth study, we searched from the hospital database all globus (n=76) and dysphagia (n=303) patients, respectively, who were referred to our clinic in 2009. From the medical records, we surveyed patients symptoms, investigations, findings, and treatment. From the Finnish Cancer Registry (FCR) database, we recorded all of these patients cancer diagnoses at the end of 2012. In the third study, the questionnaire concerning the globus patients present symptoms indicated that three and six years after their initial visit half of the globus patients were asymptomatic or had fewer symptoms, whereas the rest suffered persistent symptoms. Videofluorography and neck ultrasound showed no benefit in globus diagnostics. The FCR data revealed no malignancies associated with globus during the follow-up to the end of 2012. In the fourth study, dysphagia patients received a questionnaire about their current symptoms three years after their visit to our clinic. It showed that almost half of the dysphagia patients were asymptomatic or had milder symptoms, implying that spontaneous recovery may occur. Based on the case records, most dysphagia diagnoses remained unspecific dysphagia (55%) despite performing many investigations. All patients with a malignant disease either already had a positive finding at the ear, nose, and throat examination or suffered from alarming signs leading to gastroscopy, which revealed the diagnosis. The FCR data indicated no additional malignant cases during the three-year follow-up. Our study clarifies the esophageal background of globus, but also offers some new insights into possible causes. The study updates globus and dysphagia diagnostics and presents the natural course of these symptoms. According to our study, many swallowing difficulties are mild and no specific cause can be identified. Our results emphasize the importance of a careful clinical evaluation to find possible malignancies and to determine whether further investigations in dysphagia diagnostics are necessary. Palantunne ja nielemisvaikeus ovat yleisiä, perusterveydenhuollossa vastaantulevia, potilaita huolestuttavia oireita, jotka johtavat usein erikoissairaanhoidon konsultointiin. Vaikka palantunne on yleinen vaiva, sen aiheuttajista tiedetään vain vähän. Nielemisvaikeus taas on useita erikoisaloja koskettava oire, ja siitä kärsivää potilasta tutkittaessa onkin tärkeää selvittää, mihin nielemisen vaiheeseen ongelma liittyy. Väitöskirjassa tutkittiin palantunteen ruokatorviperäisiä syitä nenän kautta tehtävällä ruokatorven tähystyksellä (transnasal esophagoscopy), tarkkuusmanometrialla (high-resolution manometry) sekä impedanssin ja pH:n pitkäaikaisrekisteröinnillä (24-hour multichannel intraluminal impedance and pH monitoring). Tutkimuksessa oli 30 HYKS:n korvaklinikkaan lähetettyä palantunnepotilasta, ja kontrolliryhmänä 24 hankalasta refluksista kärsivää, HYKS:n vatsaelinkirurgian klinikkaan lähetettyä potilasta. Niillä palantunnepotilailla, jotka eivät kärsineet närästyksestä, ei todettu hapanta tai ei-hapanta refluksitautia ja ruokatorven yläsulkijan paine oli normaali. Myös todetut ruokatorven liikehäiriöt olivat pääosin lieviä, joiden kaltaisia voidaan löytää myös terveillä henkilöillä. Kuitenkin palantunnepotilailla oli ruokatorviröyhtäilyä yleisemmin kuin refluksista kärsivillä kontrolleilla. Palantunnepotilaiden neljän kuukauden seuranta osoitti, että oireet voivat lievittyä jo lyhyessä ajassa ilman hoitoa. Puheterapeutti löysi kuudelta potilaalta ääneen liittyviä ongelmia, jotka voivat olla myötävaikuttava tekijä palantunteen jatkumiselle. Väitöskirjatyössä kerättiin lisäksi kaikkien vuonna 2009 HYKS:n korvaklinikkaan lähetettyjen palantunne- ja nielemisvaikeuspotilaiden tiedot (oireet, tutkimukset, löydökset, hoito). Videofluorografia ja kaulan ultraääni eivät olleet hyödyllisiä palantunnepotilaiden diagnostiikassa. Palantunnepotilaille lähetetyt kyselyt kolme ja kuusi vuotta ensikäynnistä osoittivat, että puolet potilaista oli oireettomia tai heidän oireensa olivat lievittyneet, kun taas loput kärsivät edelleen palantunteesta. Syöpärekisterin tiedot vahvistivat, ettei kenenkään palantunnepotilaan oire ollut kehittynyt syöväksi kolmen vuoden seurannassa. Yli puolessa tapauksista nielemisvaikeuspotilaan diagnoosi jäi epäselväksi, vaikka potilaita tutkittiin melko paljon. Potilaille lähetetty kysely kolme vuotta ensikäynnin jälkeen kuitenkin osoitti, että puolet vastanneista oli oireettomia tai heidän oireensa olivat lievittyneet. Kaikilla potilailla, joilla nielemisvaikeuden syy oli syöpä, löydös oli ollut nähtävissä jo korva-, nenä- ja kurkkualueen tutkimuksessa tai potilaan hälyttävien oireiden vuoksi tehdyssä gastroskopiassa. Syöpärekisterin mukaan kenellekään muulle nielemisvaikeuspotilaalle ei kehittynyt tähän oireeseen liittyvää syöpää kolmen vuoden seurannassa. Tutkimuksemme osoittaa, että usein palantunteen taustalla epäilty refluksitauti ei ole syy, ellei potilas kärsi närästyksestä. Vaikka palantunne saattaa lievittyä jo lyhyessä seurannassa, osalla potilaista vaiva on pitkäkestoinen. Monet nielemisvaikeudet taas ovat lieviä, eikä oireelle löydy erityistä syytä. Tuloksemme painottavat potilaan esitietojen ja huolellisen kliinisen tutkimuksen tärkeyttä sekä palantunteen että nielemisvaikeuden diagnostiikassa. Jatkotutkimusten tarve harkitaan erityisesti sen perusteella, onko potilaalla huolestuttavia oireita tai löydöksiä.