Transcript Integrated medical curriculum

Integrated medical curriculum
Implications for program design,
implementation and instructional approach
Charles Bader, Anne Baroffio, Michel Magistris,
Mathieu Nendaz & Nu V. Vu
Workshop
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Purposes
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Organization
Why a curriculum reform in Geneva
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External complaints
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Internal complaints
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Physicians “unaware of economical related
issues; bad communicators”
Students, teachers (clinical vs.preclinical)
Teachers’ realization
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Not conformed to the legislation
Objectives of undergraduate training –
1980 Federal regulation
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General medical training; preparation for
postgraduate specialization
Oriented to the community health priorities
Develop an attitude towards long-life, selfdirected learning
Develop medical knowledge, technical skills,
and professionalism
The situation is gloom but …why
changing?
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The average Swiss physician is one of the best in the
world!
The situation is gloom but …why
changing?
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Why the change?
We need to progress
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Sure to do better?
It cannot be worse
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Worth the trouble?
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Preclinical or clinical?
Pedagogical expertise
Both
Program goals: Pre-clinical training
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Integration of basic, clinical and
psychosocial sciences
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Autonomous, self-directed learning
Program goals: Clinical training
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A comprehensive, general training
From problem analysis and synthesis to
problem-solving
Transversal disciplines
Clinical knowledge, problem-solving and
patient care
Integrate learning activities with ward
activities
Program Goals: Active skills
acquisition and practical experiences
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Active clinical skills acquisition
Ambulatory, primary care experiences
Community-based experiences
Clinical care experiences
Workshop focus: Pre-clinical training
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Integration of basic, clinical and
psychosocial sciences
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Autonomous, self-directed learning
Integrated Curriculum
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Why an integrated curriculum?
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What to integrate?
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How to integrate?
Why an integrated curriculum?
Feedback on:
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Unnecessary repetitions and overlaps of
topics
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Content gaps
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Content priorities and relevance
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Compartmentalized knowledge
Why integrate?
“When all the gain from good communication
has been achieved and all knowledge from
textbook and technical studies has been
mobilized, there is a final step that is no less
crucial than all the others. This is the wise
and scientific integration of all the varieties of
data into the biologic portrait of a single
human being.”
Dana Atchley - Cecil-Loeb Textbook of Medicine
Why integrate?
Cognitive psychology research on learning
process:
effective retrieval of relevant information and
clinical problem solving results from a wellorganized and well elaborated knowledge
structures
Integration is a cognitive process that can be
facilitated, but not guaranteed, by a well-designed
and well implemented curriculum
Bordage, G., Boshuizen, HPA, Patel VL, Schmidt, HG,.
Why integrate?
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Evidence of integration in the:
human systems and functions
new biology/ new knowledge: genetics,
molecular biology, neurosciences
Evidence of Integration
Genetics
Immunology
Neuroscience
Anatomy
Biochemistry
Microbiology
Pathology
Pharmacology
Physiology
What to integrate
Within basic sciences
 Between basic, clinical, biopsychosocial
sciences and humanities
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Within clinical sciences
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Cross-clerkships topics: ethics, clinical pathology,
diagnostic radiology, legal medicine
Basic Sciences Integration: What and how?
Systems
Organ
Molecular to cells, tissues, and systems
 From normal to abnormal biology
Integration of normal and abnormal biology
 Integration of different disciplines
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Biological
1st year program
MODULE A – 12 weeks + 1 week review + 1 week examination
Molecules to Cells
Cells to Organs
Case illustration
Case illustration
Review and exams
Person, Heath & Society
MODULE B – 14 weeks + 1 week review + 1 week examination
Organs to Systems
Integration
Statistics for clinicians
Statistics for clinicians
Person, Health & Society
Review and exams
First Year Program
Semester 1
Semester 2
Evaluation
Module A
Module A
Molecules to Cells
Cells to Structures
Molecular biology/ genetics /
microbiology
chemistry / biochemistry /
pharmacology
Embryology / mol. bio./
genetics
cell bio. / cytology
histology / pathology
anatomy / radiology
Evaluation
Module B
Module B
Structures to Fonctions
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Chemistry /
biochemistry/
physics / physiology /
molecular biology
Metabolism/
cell and systems
pathophysiology
Patient, Health, Society / Research
Clinical activities (clinical & research)
Ethics/ history
sociology
Informatics/
Psychosocial medecine research of bibliography
statistics /epidemiology
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2nd and 3rd year program
PAUSE
20 MINUTES
Practice case
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What is it like to be a student in an
integrated curriculum?
A miraculous rescue
An 8-year old boy, Maurice, has been lying under water
for more than 15 minutes. Fortunately a passer-by
succeeds in bringing him out of the water. Mouth-tomouth resuscitation is applied immediately. Everyone is
astonished to notice that the boy is still alive. At the
moment Maurice is on the intensive care ward of the local
hospital and is out of danger of life. According to his
medical attendant, he is expected to recover completely.
Explain why it is possible for the boy to survive after lying
under water for more than 15 minutes
A practical exercise
An 8-year old boy, Maurice, has
been lying under water for more
than 15 minutes. Fortunately a
passer-by succeeds in bringing him
out of the water. Mouth-to-mouth
resuscitation is applied
immediately. Everyone is
astonished to notice that the boy is
still alive. At the moment Maurice
is on the intensive care ward of the
local hospital and is out of danger
of life. According to his medical
attendant, he is expected to recover
completely.
Explain why it is possible for the
boy to survive after lying under
water for more than 15 minutes
Small group process:
20 minutes
Read the problem
Identify possible explanations/
answers to the question
Represent the explanations in
terms of schemas/ concept trees
on a transparency
20 minutes (2 mn. presentation + 3
mn. verification)
Presentation of group
explanations to other groups.
DEBRIEFING
Debriefing
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Phenomena (a set of physiological observations,
clinical findings, …) to be explained
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Attempts to explain with existing knowledge
Combined knowledge
Identification of unknown of unsure issues or concepts
Integration across
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Disciplines
Organ systems
Previous knowledge
Curriculum design
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Selection of problems in an integrated
curriculum
A way to derive an integrated curriculum/
content in the preclinical years
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Natural departure point for the integration of
basic medical sciences content
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Organ/ physiological system
Identify the organ/ physiological systems to
be covered in the program
2nd and 3rd year program
Basic sciences integration
What and how?
System (organ or biological)
Relevant/ important biomedical concepts
Interactions/ interrelations between concepts
Physiological or clinical manifestations or events
Contexts: Situations or Problems
Problems – some examples
Mr Karr
Mr Karr, a taxi-driver, had this morning a
violent dispute with another car-driver. Some
minutes later, he feels an intense constrictive
pain in the chest irradiating to the left shoulder
and the left arm. As the pain is still present
some 30 minutes later, one of his colleagues
calls the emergency centre of the city for an
ambulance.
When he arrives at the emergency centre of the
hospital, the patient is agitated, sweating,
nauseous, and stills complaints of chest pain.
His blood pressure is 170/100 mm Hg and the
pulse is 84/min regular. The auscultation of the
heart and the chest are normal. The EKG
shows typical signs of acute myocardial infarct
(Pardee’s waves). A blood test is performed to
measure the level of his cardiac enzymes and
the appropriate treatment is quickly started.
Mr Karr asks: “Hey doc, what is a myocardial
infarct and why do you need to take my blood
for analysis?”
Mr Cab
Mr Cab, a taxi-driver, had this morning a
violent dispute with another car-driver.
Some minutes later, he feels an intense
pain in the chest and drives to the
emergency service of your hospital.
How would you proceed with this patient?
LUNCH BREAK
2 HOURS
Brainstorming
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What characterize a good preclinical
problem?
Let’s look again at “Mr. Karr” problem
Mr. Karr
Mr Karr, a taxi-driver, had this morning a violent dispute with another
car-driver. Some minutes later, he feels an intense constrictive pain in the
chest irradiating to the left shoulder and the left arm. As the pain is still
present some 30 minutes later, one of his colleagues calls the emergency
centre of the city for an ambulance.
When he arrives at the emergency centre of the hospital, the patient is
agitated, sweating, nauseous, and stills complaints of chest pain. His blood
pressure is 170/100 mm Hg and the pulse is 84/min regular. The
auscultation of the heart and the chest are normal. The EKG shows typical
signs of acute myocardial infarct (Pardee’s waves). A blood test is
performed to measure the level of his cardiac enzymes and the appropriate
treatment is quickly started.
Mr Karr asks: “Hey doc, what is a myocardial infarct and why do you
need to take my blood for analysis?”
What constitute a good preclinical
problem?
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Consist of a description of phenomena which are in
need of an explanation (real situation, real
observation, phenomena)
Be formulated in concrete terms
Be concise – not too long
Not contain too many distractions
Should direct learning into a limited number of issues
Address issues that lend themselves for hypothesizing
based on prior knowledge
Structure of a simple written problem
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Title
« Trigger material »
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A story: a description of phenomena or events
Instruction
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Questions asked of the students
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provide an explanation;
indicate which actions to undertake
Mr. Karr
TITLE
TRIGGER
MATERIALS
Mr Karr, a taxi-driver, had this morning a violent dispute with another
car-driver. Some minutes later, he feels an intense constrictive pain in the
chest irradiating to the left shoulder and the left arm. As the pain is still
present some 30 minutes later, one of his colleagues calls the emergency
centre of the city for an ambulance.
When he arrives at the emergency centre of the hospital, the patient is
agitated, sweating, nauseous, and stills complaints of chest pain. His blood
pressure is 170/100 mm Hg and the pulse is 84/min regular. The
auscultation of the heart and the chest are normal. The EKG shows typical
signs of acute myocardial infarct (Pardee’s waves). A blood test is
performed to measure the level of his cardiac enzymes and the appropriate
treatment is quickly started.
Mr Karr asks: “Hey doc, what is a myocardial infarct and why do you
need to take my blood for analysis?”
QUESTIONS
Practical exercise – Problem write-up
System (organ or biological)
Relevant/ important biomedical
concepts
Interactions/ interrelations
between concepts
Practical exercise
 Limit to 2-3 interconnected
concepts from different
biomedical disciplines
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Elaboration and selection of
concepts and selection of the
problem/ scenario (30 minutes)
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Elaboration of the problem
(30 minutes)
Physiological or clinical
manifestations or events
Contexts: Situations or
Problems
Practical exercise – Problem write-up
System (organ or biological)
Relevant/ important biomedical
concepts
Practical exercise
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Write up your problem on
the provided transparency
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Presentation of elaborated
problem by each group (5 mn
presentation, 10 mn
discussions)
Interactions/ interrelations
between concepts
Physiological or clinical
manifestations or events
Contexts: Situations or
Problems
PROBLEM DEVELOPMENT
SMALL GROUP EXERCISE
Review of problems
Guess what are my learning objectives?
DEBRIEFING
What constitute a good preclinical
problem?
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Consist of a description of phenomena which are in
need of an explanation (real situation, real
observation, phenomena)
Be formulated in concrete terms
Be concise – not too long
Not contain too many distractions
Should direct learning into a limited number of issues
Address issues that lend themselves for hypothesizing
based on prior knowledge
± 12 hours of reading (Geneva)
Reference
What constitute a good preclinical
problem?
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Consist of a description of phenomena which are in need of
an explanation (real situation, real observation, phenomena)
Be formulated in concrete terms
Be concise – not too long
Not contain too many distractions
Should direct learning into a limited number of issues
Address issues that lend themselves for hypothesizing based
on prior knowledge
Should not take more than about 16 hours of independent
study to acquire a fair understanding
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Geneva: (± 12 hours)
Curriculum development / design
Selection and organization
of modules, units, problems
within an integrated curriculum
Some proposed steps
Definition of themes and sequences of instructional units, and modules
(Plenary session - Education committee)
Elaboration of unit general content
(Plenary session- Preclinical program committee)
Elaboration of unit preliminary content
(Small group session - unit working group)
Review of unit, module and program content
(Plenary session - Preclinical program committee)
Elaboration of unit final content
(small group session- unit working group)
Final review and approval by Program committee
(Plenary session - Preclinical program committee)
Creation of structures
Education Committee
Program Committees
Preclinical years
Representatives of basic (+)
and clinical (-) disciplines
Clinical years
Heads of
units
Heads of
clerkships
Representatives of clinical
disciplines
Elaboration of Module and Unit
general content
Education Committee
Definition of the learning units and of their sequence and grouping (module)
Some proposed steps
Definition of themes and sequences of instructional units, and modules
(Plenary session - Education committee)
Elaboration of unit general content
(Plenary session- Preclinical program committee)
Elaboration of unit preliminary content
(Small group session - unit working group)
Review of unit, module and program content
(Plenary session - Preclinical program committee)
Elaboration of unit final content
(small group session- unit working group)
Final review and approval by Program committee
(Plenary session - Preclinical program committee)
Elaboration of Module and Unit
general content
Preclinical Program Committee
Representatives of basic (+)
and clinical (-) disciplines
Discipline-related
biomedical concepts
Heads of units
Unit-related biomedical
and clinical concepts
Integration/Consensus
Unit general content
[Concepts and Problems]
Some proposed steps
Definition of themes and sequences of instructional units, and modules
(Plenary session - Education committee)
Elaboration of units general content
(Plenary session- Preclinical program committee)
Elaboration of unit preliminary content
(Small group session - unit working group)
Review of unit, module and program content
(Plenary session - Preclinical program committee)
Elaboration of unit final content
(small group session- unit working group)
Final review and approval by Program committee
(Plenary session - Preclinical program committee)
Curriculum development / design
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What do you need to select and build
problems for your Unit?
Elaboration of a unit content
System (Unit theme)
Concepts
Problems
Relationships between problems
 Sequence of problems
(Cells, tissues, organs; normal/abnormal; concept difficulty or
level of integration)
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Problem elaboration
Unit working group
10 to 15 members - basic scientists and clinicians of different disciplines
Identification of unit content
Biomedical concepts
7-8 problems (2 per week)
Elaboration of problems and their learning objectives
Verification and sequencing of problems
Some proposed steps
Definition of themes and sequences of instructional units, and modules
(Plenary session - Education committee)
Elaboration of units general content
(Plenary session- Preclinical program committee)
Elaboration of unit preliminary content
(Small group session - unit working group)
Review of unit, module and program content
(Plenary session - Preclinical program committee)
Elaboration of unit final content
(small group session- unit working group)
Final review and approval by Program committee
(Plenary session - Preclinical program committee)
Verification of the unit content
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Do problems cover the defined content of the unit?
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Does the problem text fit learning objectives?
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Are references adequate for learning objectives?
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Is the time for self-directed learning sufficient?
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Is the sequence of problems adequate?
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Do problems and learning objectives integrate
longitudinally across Units?
Unit vertical integration
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Between problems and other learning
activities
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Lectures
Practicals
Clinical skills
Community oriented skills
Unit horizontal integration
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Across transversal disciplines
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Anatomy
Genetics
Basics of radiology
Fondamental pathology
Fondamental pharmacology
Across biomedical concepts and organ
systems
Basic sciences horizontal integration
Organ system 1
(Prob. 1,2,3,…)
Systems
Organ system 2
(Prob. 1,2,3,…)
Organ system 3
(Prob. 1,2,3,...)
Inter-relationships between biomedical concepts,
phenomena or events across organs systems
HORIZONTAL INTEGRATION
Module – Unit content
Preliminary content of Units
Identification of missing or redundant concepts
Redistribution of missing or redundant concepts into Units
Relevant and appropriate sequence of concepts and problems
Module preliminary content
Some proposed steps
Definition of themes and sequences of instructional units, and modules
(Plenary session - Education committee)
Elaboration of units general content
(Plenary session- Preclinical program committee)
Elaboration of unit preliminary content
(Small group session - unit working group)
Review of unit, module and program content
(Plenary session - Preclinical program committee)
Elaboration of unit final content
(small group session- unit working group)
Final review and approval by Program committee
(Plenary session - Preclinical program committee)
Vertical integration/ coordination
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Integration/ coordination with
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Pathology
Pharmacology
Introduction to clinical skills
Basics of radiology and diagnostic tests
Topics in « medical humanities »
Community related medical and public health
problems and issues.
Instructional approach
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Problem-based small group tutorials
Lectures
Forums/ Discussions (live and electronically)
Seminars
Practical laboratory sessions
Practice-based learning
Important considerations in implementing an
integrated curriculum (Maastricht & Geneva)
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Preparation and adaptation of students
Tutor role – Faculty development
Covering of essential subject matter (core curriculum)
Reorganization and streamlining – not reduction of content
Assessment of students
Reliance of adequate learning resources
Organizational infrastructure of education
Upfront investment vs maintenance costs
Costs vs. expected outcomes (investment
Sensitivity to student numbers
PBL as a “philosophy of education”
Adaptation to your Faculty culture and environment
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Overcoming departmental barriers
Start with natural and existing domains of integration
Program evaluation – Overall organization
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All unit teaching activities are evaluated by the
students
Evaluation of tutors/teachers by students
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More comprehensive in preclinical than clinical years
System to maximize return rates (average 70 to
90%)
Standardized questionnaire with individual
variations
Op-scan readable questionnaires
Program evaluation – Overall
organization
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Centralized collection, analysis and reports
Evaluation of teaching activities
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Closing the program evaluation loop – discussion of
results at the program committees and propositions for
improvements if applicable
Results distribution lists and access
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Teaching activities evaluation
Teachers/tutors’ evaluation
Procedures adopted for repeated low ratings