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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
Vacation / Military service
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
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
Vacation / Military service
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, 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? 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, 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?”
TITLE TRIGGERMATERIALS
QUESTIONS
Practical exercise – Problem write-upSystem (organ or biological)
Relevant/ important biomedical concepts
Interactions/ interrelations between concepts
Physiological or clinical manifestations or events
Contexts: Situations or Problems
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)
Relevant/ important biomedical concepts
Interactions/ interrelations between concepts
Physiological or clinical manifestations or events
Contexts: Situations or Problems
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
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
Vacation / Military service
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
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]
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)
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
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)
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
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)
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