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

Purposes

Organization

Why a curriculum reform in Geneva External complaints

Physicians “unaware of economical related issues; bad communicators”

Internal complaints Students, teachers (clinical vs.preclinical)

Teachers’ realization Not conformed to the legislation

Objectives of undergraduate training – 1980 Federal regulation General medical training; preparation for

postgraduate specialization Oriented to the community health priorities Develop an attitude towards long-life, self-

directed learning Develop medical knowledge, technical skills,

and professionalism

The situation is gloom but …why changing?

The average Swiss physician is one of the best in the world!

The situation is gloom but …why changing?

Why the change? We need to progress

Sure to do better? It cannot be worse

Worth the trouble? Pedagogical expertise

Preclinical or clinical? Both

Program goals: Pre-clinical training

Integration of basic, clinical and psychosocial sciences

Autonomous, self-directed learning

Program goals: Clinical training

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

Active clinical skills acquisition Ambulatory, primary care experiences Community-based experiences Clinical care experiences

Workshop focus: Pre-clinical training

Integration of basic, clinical and psychosocial sciences

Autonomous, self-directed learning

Integrated Curriculum

Why an integrated curriculum?

What to integrate?

How to integrate?

Why an integrated curriculum?Feedback on:

Unnecessary repetitions and overlaps of topics

Content gaps

Content priorities and relevance

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 well-organized and well elaborated knowledge structuresIntegration 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?

Evidence of integration in the:

human systems and functions

new biology/ new knowledge: genetics, molecular biology, neurosciences

Evidence of Integration

GeneticsAnatomyBiochemistryMicrobiology

Immunology PathologyPharmacologyPhysiology

Neuroscience

What to integrate

Within basic sciences Between basic, clinical, biopsychosocial

sciences and humanities

Within clinical sciences Cross-clerkships topics: ethics, clinical

pathology, diagnostic radiology, legal medicine

Basic Sciences Integration: What and how?

Systems

Organ Biological

Molecular to cells, tissues, and systems From normal to abnormal biology

Integration of normal and abnormal biology Integration of different disciplines

1st year program

Molecules to CellsCase illustration

Cells to OrgansCase illustration

MODULE A – 12 weeks + 1 week review + 1 week examination

Review and exams

MODULE B – 14 weeks + 1 week review + 1 week examination

Person, Heath & Society

Organs to SystemsStatistics for clinicians

IntegrationStatistics for clinicians

Review and exams

Person, Health & Society

First Year Program

Module A Module A Module B Module B

Molecules to Cells Cells to Structures

Molecular biology/ genetics / microbiology

chemistry / biochemistry / pharmacology

Embryology / mol. bio./ genetics

cell bio. / cytologyhistology / pathologyanatomy / radiology

Summative

Formative

Chemistry / biochemistry/

physics / physiology /molecular biology

Metabolism/cell and systems pathophysiology

Summative

Formative

Clinical activities (clinical & research)Ethics/ history

sociologyPsychosocial medecine

Informatics/research of bibliographystatistics /epidemiology

Patient, Health, Society / Research

EvaluationSemester 2Semester 1

Evaluation

Structures to Fonctions

2nd and 3rd year programModule 1 Module 2

Intro Cell growth & Nutrition et Reproduction Syn- Circu- Elimina. & Respiration Syn-

aging Digestion Vac thesis R EV vac Vac Homeost. thesis R EV

CCPS

Module 3 Module 4

Locomotion Perception, Defense & Community

R EV Vac Immunity Vac R EV Vac based

Experience

Vac = vacation EV = evaluation R = exam review

CCPS CCPS CCPS CCPS

Practice Skills (CCPS) CCPS

Vacation / Military service

lation

Clinical & Community

Vac

Emotion,

Beha viorInfections Viral Model


PAUSE

20 MINUTES

Practice case

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-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

A practical exerciseAn 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 minutesRead the problemIdentify possible explanations/ answers to the questionRepresent 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 Phenomena (a set of physiological observations,

clinical findings, …) to be explained Attempts to explain with existing knowledge Combined knowledge Identification of unknown of unsure issues or concepts

Integration across Disciplines Organ systems Previous knowledge

Curriculum design

Selection of problems in an integrated curriculum

A way to derive an integrated curriculum/ content in the preclinical years

Natural departure point for the integration of basic medical sciences content Organ/ physiological system

Identify the organ/ physiological systems to be covered in the program

2nd and 3rd year programModule 1 Module 2



CCPS

Module 3 Module 4



Experience


CCPS CCPS CCPS CCPS



lation


Vac

Emotion,



Basic sciences integrationWhat 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 examplesMr 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

What characterize a good preclinical problem?

Let’s look again at “Mr. Karr” problem

Mr. Karr



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? 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

Title « Trigger material »

A story: a description of phenomena or events Instruction

Questions asked of the students provide an explanation; indicate which actions to undertake

Mr. Karr



Mr Karr asks: “Hey doc, what is a myocardial infarct and why do you

need to take my blood for analysis?”

TITLE TRIGGERMATERIALS

QUESTIONS

Practical exercise – Problem write-upSystem (organ or biological)





Practical exercise Limit to 2-3 interconnected

concepts from different biomedical disciplines

Elaboration and selection of concepts and selection of the problem/ scenario (30 minutes)

Elaboration of the problem (30 minutes)

Practical exercise – Problem write-upSystem (organ or biological)





Practical exercise

Write up your problem on the provided transparency

Presentation of elaborated problem by each group (5 mn presentation, 10 mn discussions)

PROBLEM DEVELOPMENT

SMALL GROUP EXERCISE

Review of problems

Guess what are my learning objectives?

DEBRIEFING

What constitute a good preclinical problem? 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? 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 Geneva: (± 12 hours)

Curriculum development / design

Selection and organization

of modules, units, problems

within an integrated curriculum

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)

Some proposed steps

Creation of structures

Education Committee

Program Committees

Representatives of basic (+)and clinical (-) disciplines

Heads of units

Representatives of clinical disciplines

Heads of clerkships

Preclinical years Clinical years

Elaboration of Module and Unit general content

Education Committee

Definition of the learning units and of their sequence and grouping (module)

Module 1 Module 2



CCPS

Module 3 Module 4



Experience


CCPS CCPS CCPS CCPS



lation


Vac

Emotion,




Elaboration of unit general content(Plenary session- Preclinical program committee)





Some proposed steps

Elaboration of Module and Unit general content

Preclinical Program Committee

Representatives of basic (+)and clinical (-) disciplines Heads of units

Unit-related biomedical and clinical concepts

Integration/Consensus

Discipline-related biomedical concepts

Unit general content[Concepts and Problems]


Elaboration of units general content(Plenary session- Preclinical program committee)





Some proposed steps

Curriculum development / design

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)

Problem elaborationUnit working group

10 to 15 members - basic scientists and clinicians of different disciplines

7-8 problems (2 per week)

Elaboration of problems and their learning objectives

Verification and sequencing of problems

Identification of unit content

Biomedical concepts







Some proposed steps

Verification of the unit content Do problems cover the defined content of the unit?

Does the problem text fit learning objectives?

Are references adequate for learning objectives?

Is the time for self-directed learning sufficient?

Is the sequence of problems adequate?

Do problems and learning objectives integrate longitudinally across Units?

Unit vertical integration Between problems and other learning

activities Lectures Practicals Clinical skills Community oriented skills

Unit horizontal integration Across transversal disciplines

Anatomy Genetics Basics of radiology Fondamental pathology Fondamental pharmacology

Across biomedical concepts and organ systems

Basic sciences horizontal integration

SystemsOrgan system 1 Organ system 2 Organ system 3(Prob. 1,2,3,…) (Prob. 1,2,3,…) (Prob. 1,2,3,...)

Inter-relationships between biomedical concepts, phenomena or events across organs systems

HORIZONTAL INTEGRATION

Module – Unit contentPreliminary 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

Vertical integration/ coordination Integration/ coordination with

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

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)

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

Overcoming departmental barriers Start with natural and existing domains of integration

Program evaluation – Overall organization

All unit teaching activities are evaluated by the students

Evaluation of tutors/teachers by students 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 Centralized collection, analysis and reports Evaluation of teaching activities

Closing the program evaluation loop – discussion of results at the program committees and propositions for improvements if applicable

Results distribution lists and access Teaching activities evaluation Teachers/tutors’ evaluation Procedures adopted for repeated low ratings

integrated medical curriculum

Documents

clinical problem

clinical pathology

teachers clinical vs

technical skills

general training

learning process

problem analysis

curriculum reform