Integrated medical curriculum

1. Integrated medical curriculum Implications for program design, implementation and instructional approach Charles Bader, Anne Baroffio, Michel Magistris, Mathieu Nendaz & Nu V. Vu

2. Workshop • Purposes • Organization

3. 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

4. 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

5. The situation is gloom but …why changing? • The average Swiss physician is one of the best in the world!

6. 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

7. Program goals: Pre-clinical training • Integration of basic, clinical and psychosocial sciences • Autonomous, self-directed learning

8. 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

9. Program Goals: Active skills acquisition and practical experiences • Active clinical skills acquisition • Ambulatory, primary care experiences • Community-based experiences • Clinical care experiences

10. Workshop focus: Pre-clinical training • Integration of basic, clinical and psychosocial sciences • Autonomous, self-directed learning

11. Integrated Curriculum • Why an integrated curriculum? • What to integrate? • How to integrate?

12. Why an integrated curriculum? Feedback on: • Unnecessary repetitions and overlaps of topics • Content gaps • Content priorities and relevance • Compartmentalized knowledge

13. 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

14. 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 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,.

15. Why integrate? • Evidence of integration in the: • human systems and functions • new biology/ new knowledge: genetics, molecular biology, neurosciences

16. Evidence of Integration Genetics Anatomy Biochemistry Microbiology Immunology Pathology Pharmacology Physiology Neuroscience

17. 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

18. 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

19. 1st year program MODULE A – 12 weeks + 1 week review + 1 week examination Molecules to Cells Case illustration Cells to Organs Case illustration Review and exams Person, Heath & Society MODULE B – 14 weeks + 1 week review + 1 week examination Organs to Systems Statistics for clinicians Integration Statistics for clinicians Review and exams Person, Health & Society

20. First Year Program

21. 2nd and 3rd year program

22. PAUSE 20 MINUTES

23. Practice case • What is it like to be a student in an integrated curriculum?

24. 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. • Explainwhy it is possible for the boy to survive after lying under water for more than 15 minutes

25. 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. Explainwhy 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. A practical exercise

26. DEBRIEFING

27. 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

28. Curriculum design • Selection of problems in an integrated curriculum

29. 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

30. 2nd and 3rd year program

31. 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

32. 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? Problems – some examples

33. LUNCH BREAK 2 HOURS

34. Brainstorming • What characterize a good preclinical problem? • Let’s look again at “Mr. Karr” problem

35. 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?”

36. 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

37. 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

38. 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

39. System (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 interconnectedconcepts from different biomedical disciplines Elaboration and selectionof concepts and selection of theproblem/ scenario (30 minutes) Elaborationof the problem (30 minutes) Practical exercise – Problem write-up

40. System (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) Practical exercise – Problem write-up

41. PROBLEM DEVELOPMENT SMALL GROUP EXERCISE

42. Review of problems Guess what are my learning objectives?

43. DEBRIEFING

44. 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)

45. Reference

46. 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)

47. Curriculum development / design Selection and organization of modules, units, problems within an integrated curriculum

48. 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)

49. Creation of structures Education Committee Program Committees Preclinical years Clinical years Representatives of basic (+) and clinical (-) disciplines Heads of units Heads of clerkships Representatives of clinical disciplines

50. Elaboration of Module and Unit general content Education Committee Definition of the learning units and of their sequence and grouping (module)