Transcript PLME Science-Humanities Curriculum

PLME SCIENCE
CURRICULUM
Julianne Ip, MD
Associate Dean of Medicine (PLME and VIMS)
Clinical Associate Professor of Family Medicine
Alpert Medical School
Brown University
How will we go from college freshmen
To MD graduates of the Alpert Medical School of Brown University 2012
Overload of facts and
information, fatigue,
loss of compassion and
passion for learning,
and humanity
HHMI-AAMC report
• concerns
about increasingly rapid rate at which new
knowledge revises our understanding of sciences
fundamental to medicine
•Importance of educating future physicians to be
“inquisitive”
•To help them build a strong scientific FOUNDATION…
but not overwhelm them with “facts”
•To equip them with the knowledge, skills and habits to
integrate new scientific discovery into their medical
practice throughout their lives…
Brown’s
Baccalaureate-MD
program is poised
to be a pilot for
changes in premedical education.
We set the
admissions
standards and
competencies
required for our
curriculum.
The Warren Alpert Medical School of Brown University
Basically, assist and teach extremely
bright, intelligent, motivated young men
and women the skills and fuel their
passion to be LIFE-LONG LEARNERS, to
practice science-based medicine with
greater synergy and efficiency along the
continuum of their premedical and
medical education.
PLME versus Standard Pre-Med
PLME COMPETENCIES
PRE-MED Requirements
Biology-three semesters (most place
out of intro level so have 2 semesters)
• Biology-2 semesters
Inorganic Chemistry-one semester
• Inorganic Chemistry-2 semesters
Organic Chemistry-one semester
• Organic Chemistry-2 semesters
Physics-2 semesters
• Physics-2 semesters
Calculus-one semester (most place
out)
• Calculus-generally 1 semester
Humanities/Social Science ( 2 writing
courses)
• English-2 semesters
No MCATS
• MCATS
minimum
We start with our end product--our Brown
MD graduate. What does it take?
•Our graduates must be ready to be
outstanding residents and future physicians
therefore they must be outstanding 3rd- and 4thyear med students
• Our first- and second-year med students
must be prepared for clinical clerkships, clinical
electives and decisions about future
professional career
•Therefore, our PLMEs must be prepared for
first- and second-year integrated basic medical
sciences and the Doctoring course
Initial Proposal
• Two semester freshmen/sophomore course; integrate
Chemistry, Physics, Math pertaining to biological and medical
sciences
• Senior year one semester capstone course: interdisciplinary,
integrative case-based promoting a holistic view of the human
condition.
• Emphasis on:
- Self-directed learning
- Small group learning
- Incorporation of ethics, history of medicine, new
technology particularly as it pertains to the humanistic
aspects of patient care
PLME Science/Behavioral –Social Science
and Humanities curriculum committee
• Associate Dean of Medical Education
• Director of First and Second year Basic Science
Curriculum (eventually the second year assistant director
took over)
• A Cogut Fellow in the Humanities (funded by the Medical
School to oversee the writing and development of the
curriculum)
• Associate Dean of the College (for sciences)
• Associate Dean of Medicine (PLME)
Contributing Groups
• PLME Alumni Survey
and Focus Group
• PLME advising deans
• Alpert Medical School
students survey and focus
group
• PLME survey and focus
group
• Wayland Collegium
• College funded think tank
group
• Picks one topic/semester
• Interdisciplinary: included
physics, math, biostats,
chemistry (both inorganic and
organic) and biology faculty
CHALLENGES
Alpert
Medical
School takes
ownership.
Uses the
HHMIScientific
Foundations
as template.
White Paper
REINVENTING PREMED EDUCATION AT BROWN:
AN INNOVATIVE REDESIGN OF THE PLME
UNDERGRADUATE CURRICULUM
Prepared by Philip Gruppuso, Juli Ip and Rina Bliss, April 2011
The Alpert Medical School is in the midst of a comprehensive curriculum redesign
process. The purpose of this document is to articulate the principles, process and
overall design aspects of a related process: a new undergraduate curriculum for the
Program in Liberal Medical Education. Both processes are motivated by a call for a new
approach to educating physicians, the principles and goals for which have been
articulated by the AAMC and HHMI in a document entitled “Scientific Foundations for
Future Physicians.”1 One of the goals for the project described in this report was to
“provide greater flexibility in the premedical curriculum that would permit
undergraduate institutions to develop more interdisciplinary and integrative science
courses…by focusing on scientific competencies.”
This goal is one that could and should be applied to the PLME. The original goals of the
PLME, which have been achieved to a significant degree in the years since its founding
in 1985, have been to “graduate doctors, scholars and leaders in medicine who have
been exposed to a wide, sensitizing view of the human condition and who are
committed to bettering human health.” The intent of the program was to achieve this
through a liberal undergraduate education.
Changes at the Alpert Medical School (AMS) have placed some constraints on the
means of achieving the goals of the PLME. Once a truly integrated 8-year program that
afforded its students significant flexibility during the medical years, the redesigned,
integrated (non-course based) AMS curriculum has significantly diminished PLME
students’ curriculum flexibility. In addition, an increased level of scientific rigor in the
first two years of the AMS curriculum has placed greater demands on the scientific
preparedness of PLME undergraduate students. This has resulted in pressure on PLME
students to emphasize a liberal education to a lesser degree than had been the case.
1
http://www.aamc.org/newsroom/pressrel/2009/090604.htm
PLME 1000 Senior Seminar in
Scientific Medicine
• This course is an interdisciplinary and integrative science
course that will supplement the preparation of both PLME and
premedical students for the study of medicine in the 21st
century.
• The course will use a case-based approach to relevant and
contemporary subjects in medicine and health care, such as
biological systems and their interactions, mechanisms of intraand intercellular communication, drug therapy optimization, and
humanistic aspects of patient care.
• This course is intended for seniors interested in attending
medical school, but will preferentially enroll students in the
PLME. This is an S/NC course.
Assessments
Quizzes
10%
You will be a given a brief, five question quiz prior to the beginning of lecture each week. The
quizzes will be based on your reading assignment for the week.
Participation (class and small group) 10%
This class and the learning you will be doing are structured around small group problem-based
learning and class discussion. We are looking for thoughtful contributions that refer directly to
the readings and lectures at hand.
Reflective Narratives
20%
You will be asked to write three reflective narratives during the course. These narratives
should be one page in length, single spaced and be in response to topics presented in the
course. Prompts for these narratives will be given in class. The due dates of the narratives
are:
•October 15th
•November 5th
•December 3rd
Midterm Exam
25%
The midterm examination will mainly be comprised of single best answer, multiple choice
questions but may also contain other questions types (true/false, fill in the blank and essay
type questions). Questions on the midterm examination will be drawn from lecture, small
group discussions, large group discussions and the readings.
Final Exam *same as midterm
35%
Teaching Assistants:
• There are six teaching assistants for
this course. Each student will be
assigned one of these teaching
assistants for small group work.
• TA’s are second-year medical
students with an interest in medical
education; generally are
participating in the Teaching
Academy and Scholarly
Concentration in Medical Education
FIRST THREE WEEKS
OF COURSE WE START WITH SEX…
Objectives:
Describe the molecular biology of androgen insensitivity.
Compare and contrast the phenotypic variation seen in
androgen insensitivity.
Describe the medical management of differences of sex
development.
Construct an argument for the postponement of surgical
management of differences of sex development using ethical
principles.
Readings:
Jääskeläinen J. Molecular biology of androgen
insensitivity. Molecular and Cellular Endocrinology. In press.
Wiesemann C, Ude-Koeller, Sinnecker GHG, Thyen U. Ethical
principles and recommendations for the medical management of
differences of sex development (DSD)/intersex in children and
adolescents. Eur J Pediatr (2010) 169: 671–679.
Dreger, A; Chase, C; Souza, A; Gruppuso, P. Frader J: Changing
the Nomenclature/Taxomony for Intersex; A Scientific and Clinical
Rationale. J Ped Endocrinology and Metabolism 19 729-733 (2005)
Phornphutkul, C; Fausto-Sterling, A; Gruppsuo, P: Experience and
Reason Pediatrics Vol 106 No1 135-137 2000
Hines, M. Sex-related variation in human behavior and the brain
Trends in Cognitive Science Vol 14 no. 10 448-456
Monday, September 10th:
Session #1
Quiz on Readings (Ip; 10 minutes)
Lecture on Androgen insensitivity
(Gruppuso, 70 minutes)
Wednesday, September 12th:
Session #2
Case-based vignettes on diagnosis and
treatment of androgen insensitivity (Forcier,
40 minutes)
Discussion of the ethics of medical
management of sex differentiation (Small
Groups, 40 minutes)
Complete Androgen Insensitivity
(Testicular Feminization Syndrome)
SRC
S
PP-
S
-P
-P
Mutation in AR gene affecting
androgen binding to AR or AR
binding to DNA.
 X-linked recessive disorder, expressed in 46,XY individuals only
 Mutation in the Androgen Receptor gene
 Manifests as a disorder of sexual differentiation
• Breast development and female habitus at puberty; primary
amenorrhea; scant or absent pubic and axillary hair
• Genitalia: female with blind vaginal pouch
• Wolffian derivatives: usually absent
• Mullerian derivatives: absent or vestigial
 Gonads: testes
Steroid Hormone Biosynthesis
7-dehydrocholesterol
cholesterol
cortisol
progesterone
aldosterone
Gonads
androstenedione
testosterone
Target tissues
estrone
estradiol
5a-dihydrotestosterone
Awareness of Gender
Identity
Between ages 1 and 2—
Children become conscious of physical differences
between sexes
At 3 years old—
Can label themselves as girl or boy
By age 4
Gender identity is stable, for many/most
Recognize that gender is constant
Small group discussion…TA Guru
What is sex? What is gender? Who defines them?
Are they binaries?
How much does culture play a role in gender? Does it at all? Are there
differences across countries/regions?
Does sex determine gender? How much does nature play a role in gender?
How about nurture? Greenspan seems to suggest at the end of the reading
that androgens may play a role in gender identification—do you agree?
Where do individuals with DSD fall?
How much does gender define you? Is it a large part of your identity? Do
you feel you fall into the gender binary? How do we understand individuals
that don’t quite fit into the gender binary (ie tomboys)? Is there a stigma
associated with not conforming to your culturally expected gender? Does it
differ for males and females? (ie is it worse to be a feminine guy or a
masculine girl? Does this influence how you think of DSD individuals or
what you would recommend to them?
WEEK 2-EVIDENCED-BASED
MEDICINE; BIOSTATISTICS
LEARNING THE TERMS
Biostatistics: group problem solving
•In a population of 1000 women, 250 are on tamoxifen to prevent breast cancer. 25 of the
women on tamoxifen develop breast cancer.
• Of the 750 women not on tamoxifen, 200 develop breast cancer.
•What is the number needed to treat with tamoxifen to prevent one case of breast cancer?
(Exposure +)
+Tamoxifen
(Outcome +)
+Breast Cancer
A=25
(Outcome -)
- Breast Cancer
B=225
(Exposure –)
- Tamoxifen
C=200
D=550
Risk of developing breast cancer on Tamoxifen: 25/250
Risk of developing breast cancer not on Tamoxifen: 200/750
Absolute risk reduction = 25/250 – 200/750
NNT = 1/ARR = 5.88 (round up to 6)
Breast Cancer Screening and
Overview of Breast Cancer: Goals
Review current guidelines for breast
cancer screening, including screening of
high risk patients with MRI
Highlight controversy surrounding
screening mammography
Overview of the management of malignant
breast diseases
Identify who and how to screen for familial
breast and gynecologic cancers
Mammography, when to start?
Sensitivity: 77%-95%
Specificity: 94%-97%
Seven statistical models showed screening mammography
reduces the rate of death from breast cancer by 7 to 23
percent, with a median of 15 percent.
Meta-analysis of 8 randomized trials
Reduction of rate of death for women > 40 y
Reduction of mortality by 15 to 20% for ages 40 to 49 yr
Reduction of mortality by 16 to 35% for ages 50 to 69 yr
NB: Results reported for women ‘invited to screen’.
Advocates suggest women ‘actually screened’ probably
benefit even more.
Standard Mammography views;
Cranio-caudal and Midline Oblique
Screening Guidelines
• In USA, most recommend screening at 40 years
• Between 40-49 years:
• ACS: annually
• ACR: annually
• ACOG: every 1-2 years
• NCI: every 1-2 years
• USP-STF (2009): not recommended
• Canadian Task Force on Preventive Health Care: not
recommended
• Annual screening > 50 years:
• Most organizations
• USP-STF (2009): every 1-2 years
Sample Midterm Multiple Choice Question
Choose single best answer; bubble into scantron sheet
A new patient, a 28 year old single female comes to your office for a first
time physical. She is otherwise healthy and has no risk factors for any
illness including a negative family history for cancer, cardiovascular
disease, hypertension or any other major illness. She asks you about her
chances of developing breast cancer over her lifetime. You tell her that:
A:Every patient is different so you cannot answer
B:One in eight women will develop breast cancer
C:One in every one hundred women has breast cancer
D:Given she has no risk factors she will not develop
breast cancer
Narrative Reflection Prompts
You are a primary care physician who is part of the new system of "capitation" on your group
practice mandated by the changes after the election of 2012 in the "New" Affordable Health Plan.
This capitation is similar to the United Kingdom system of having a set amount of funds to care
for all your patients; so no matter what tests, procedures or exams you perform on your panel of
patients, this is ALL the funds you will have. You receive $1,000,000 for the care of your 2500
patient panel, all ages.
• One of your patients is a 27 year man who gets convicted of first degree murder and is
incarcerated for life (no parole). He needs a liver transplant. This transplant will cost
$350,000 of your funds which will leave far less to care for the rest of your patients. Do you
put the patient on the transplant list? Why or why not?
• What if you have an active 80 year old who is still functioning at full capacity; he volunteers at
the local school tutoring science and works out by running 1 mile per day. He has a wife who
is healthy and 3 healthy children and 4 grandchildren who he often takes care of on a regular
basis. He needs a liver transplant. This will cost $350,000 of your funds as well. Do you put
him on the transplant list? Why or why not?
• What if you had to CHOOSE between the two patients (given your limited funding)...how
might you make this decision? If you HAD to choose one person, which would you choose
and why?
Chronic Renal Disease
Renal Transplantation
Autism and Vaccines
Pharmacology and Toxicology
Prostate Cancer
Clinical Arts and Humanities
Health Care Financing: US and International
Next Steps
Goals for the Redesigned PLME Year 1 Courses
• Focus on the scientific competencies as detailed in the AAMC-HHMI
report.
• Develop interdisciplinary science courses that more effectively
engage students interested in a career in medicine.
• Integrate the sciences and non-science disciplines. An example is
the incorporation of ethics or history of science into any discussion of
new technologies. Another example is an emphasis on the
humanistic aspects of patient care whenever discussing application of
new knowledge or technology.
• Incorporate an inquiry-based approach into premed education.
• Enhance the ability of all PLME’s to succeed in medical school, but
especially members of underrepresented groups. Members of
underrepresented groups typically fare worse in the courses listed
above. The integrated courses will include periodic exams and
regularly scheduled tutorials for students who need help.
PLME Freshman Course
Sample Teaching Module
Overall Strategy: Central topic, a young boy
with hereditary fructose intolerance, a
disorder of fructose metabolism that results
from a mutation in the gene that encodes the
enzyme, Aldolase B. The proposed strategy
is to use this case study as a means to
address basic concepts in quantitative
reasoning, physics and chemistry through an
emphasis on enzyme catalysis.
Case Presentation: Danny, a 3 year old boy was brought in for
evaluation of failure to thrive (poor growth and weight gain). His
medical history included a profound aversion for sweet foods. In
fact, it was described that he would retch when offered candy,
other sweets, fruit juice, or fruit. Once, after drinking fruit juice, he
vomited and had a near loss of consciousness for a short period
of time. Based on this history, a it was suspected that Danny had
hereditary fructose intolerance. This is a disorder that is
inherited because it is due to a mutation in an enzyme. The
enzyme, aldolase B, is involved in the metabolism of the dietary
sugar, fructose.
To confirm the diagnosis, Danny was admitted to the hospital and
given an oral fructose load. During the test, he became sleepy
and had a low blood sugar. Laboratory tests confirmed the
diagnosis.
Background Biology
What is fructose? (Discuss the major
nutrients - carbohydrate, protein and fat and the major dietary carbohydrates glucose, fructose, sucrose, galactose and
lactose)
What is an enzyme? (Discuss the concept
of catalysis)
What is a mutation? (Review the central
paradigm: DNA to RNA to protein)
Working with the Inorganic and Organic Chemists
particularly as the material relates to
biochemistry…how much do the students “need?”
Chemistry as “gatekeepers” to medical school?
Links to Important Principles in
Chemistry and Physics:
Chemistry Principles involved (pending
review)
Organic Molecule Structure (connectivity,
shape, conformation - e.g., why are
glucose and galactose different molecules?
Can they interconvert? What about
fructose and glucose?)
Metabolism = chemical reactions of
nutrients
Kinetics - why are the adverse effects short
lived as opposed to permanent?
Working with the General Physics professors on
these cases. How much is “enough?” Their opinion
or ours?
Physics principles involved (pending
review)
Coulomb’s law
Electric fields and potentials
Electric dipoles
Dielectrics and solubility
Torque
Newton’s Laws
Energy Conservation
Work in Progress…Questions???
Thank you