A Simple Model for Improving Pathology Curricula

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A Simple Model for Improving Pathology Curricula

• Regina Kreisle, MD, PhD
• Lafayette Center for Medical Education
• at Purdue University, Lafayette, Indiana
• Indiana University School of Medicine

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Searching for Solutions

• What is the best curricular format to teach
  Pathology?
• How can Pathology gain more control over
  curricular issues?
• What should be taught?
• What role should the laboratory play?
• How do we recruit students as future Pathologists?

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Major Concerns

• Pathology is being squeezed out of the curriculum
  by other priorities
• Pathology is losing control over the teaching of
  Pathology as a discipline
• Our opportunities to recruit students into
  Pathology are diminishing
• Teaching resources are becoming more scarce
• Income concerns place clinical/research effort
  over teaching

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A Traditional Approach to Pathology Education

• Many hours of lecture, often based on kodachrome
  slides
• Many more hours in the laboratory
• Gross specimens
• Histopathology using glass slides
• Autopsy and other discipline-specific experiences
• Emphasis on the scientific basis of disease
  processes

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A Traditional Approach to Pathology Education

• A discipline-based approach to the understanding
  of disease processes that taught as much about
  being a Pathologist as it did about the subject
  of Pathology

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Historical Perspective

• Traditional approach born as a result of a
  revolution in medical education
• Placed an understanding of the scientific basis
  of disease first and foremost in the study of
  medicine
• Pathology was perfectly suited to be the
  centerpiece of this style of curricular approach
• Basic philosophy and approach unchanged for 80
  years

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Pre-Clinical
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Pathology at the Center of the Flexner Model

• Emphasized a basic science understanding of
  disease
• Utilized scientific method in investigating
  disease processes
• Bridged basic and clinical sciences
• The Pathologist as a medical academician

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Problems with the Traditional Flexner Model

• Aimed at introducing laboratory science to
  medical students
• Artificially separated basic science and clinical
  science
• (over) Emphasized mastery of an extensive
  knowledge base
• Time-intensive students had little time for
  study or self-directed learning

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Core Principles of the Flexner Model

• A scientific understanding of disease aids in
  clinical practice
• Teaching medical science as scientific
  investigation results in good problem-solving and
  lifelong learning skills
• Experiencing disease processes through laboratory
  experiences enhances an understanding of disease
• Showcased Pathology as a discipline/specialty

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Challenges to traditional undergraduate pathology
curricula

• Exponential expansion in scientific knowledge
• Decrease in the number of lecture hours
• Decrease in the number of laboratory hours
• Decrease in the availability of teaching
  materials
• Increase in demand for self-directed learning
  modalities

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Challenges to traditional undergraduate pathology
curricula, contd.

• horizontal integration of clinical and basic
  science courses
• vertical integration of courses
• Increased emphasis on skills and attitudes in
  addition to knowledge (competency-based
  curriculum)
• Competition between clinical practice (and/or
  research) and teaching efforts

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New Directions in Medical Education

• Increase in self-directed and active learning
• Increased integration of basic sciences and
  clinical science
• Focus on skills, behaviors, and attitudes
  required to be a doctor, not just basic science
  knowledge

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New Curricular Initiatives

• PBL (problem-based learning)
• Integrated (not discipline-based) curricula
• Competency-based curricula

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PBL (problem-based learning)

• Students acquire knowledge by generating
  case-based learning issues
• Student-directed learning with minimal faculty
  direction
• Emphasis on problem-solving and lifelong learning
  skills rather than detailed facts
• Integration of clinical science and basic medical
  science

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PBL (problem-based learning)

• Strengths
• Problem-solving skills
• Self-directed learning
• Life-long learning skills
• Self-confidence
• Team-work and communication skills

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PBL (problem-based learning)

• Problems
• ?mastery of fund of knowledge
• Decreased detail/breadth of knowledge
• Little faculty guidance, role-modeling
• Pathology lost as a discipline/medical specialty
• Little student exposure to pathology
  specimens/slides
• Faculty-intensive more faculty needed to cover
  multiple small groups
• Requires new facilities, resources

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PBL (problem-based learning)

• Attempts to improve PBL
• Development of clear and broad learning
  objectives (in addition to student-identified
  learning issues)
• Supplemental lectures/labs on key subjects

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PBL (problem-based learning)

• What we have learned
• Students are smart and capable of learning
  anything they feel is important to learn
• Direct transfer of knowledge from professors to
  students is not required
• Students enjoy the clinical applications they
  put more effort into things they like
• They appear to be able to function in the
  clinical setting without having learned every
  detail about every subject (because they know how
  to continue learning)

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PBL (problem-based learning)

• Does it work?
• Difficult to measure using knowledge-based
  assessment tools such as Board examinations
• PBL and traditional students bring different
  skills and knowledge base to the clinics the
  differences disappear by graduation
• No study to date shows superiority or inferiority
• No studies available on effect of PBL on
  specialty choices such as Pathology

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Integrated Curricula

• Vertical integration of different disciplines in
  a single course organized by organ system
• May involve all aspects normal and abnormal
• May focus only on disease-based disciplines
  medicine, pathology, pharmacology
• Teaching often dominated by a single discipline
  (i.e., medicine)

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Integrated Curricula

• Strengths
• Students learn different aspects of the disease
  process at one time
• Minimizes redundancy in didactic presentations
• Students integrate different approaches to a
  disease process

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Integrated Curricula

• Problems
• Minimal time given Pathology often focuses
  solely on morphologic features of disease
• Pathogenesis covered (if at all) by other
  disciplines
• Pathology lost as a discipline/medical specialty
• Courses usually focus on specific disease
  entities rather than survey of pathologic
  processes affecting an organ system

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Integrated Curricula

• Does it work?
• Too soon to tell regarding student proficiency
• Students appear to like the integrative aspects
• Eliminate benefits of planned redundancy
• Accountability for the curriculum by specific
  disciplines is removed
• Often requires more centralized educational
  services (not departmental)

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Competency Based Curricula

• Most recent challenge in Medical School Curricula
• Can be combined with any of the commonly used
  formats Traditional, PBL, Integrated
• Aspects will likely be required by all
  undergraduate medical programs in the near future
  (currently required of all residency programs)

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Competency Based Curricula

• Departs from Flexner approach
• Begins with an assessment of the desired
  qualities (knowledge, skills, attitudes,
  behaviors) that should be possessed by all
  medical school graduates
• Requires that assessments and evaluations of
  these qualities be incorporated at all levels of
  undergraduate medical education

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Competency-based approach asks

• What do you want your end product to be?
• What are the knowledge, attributes, skills,
  attitudes, and behaviors that all students should
  demonstrate when they graduate from medical
  school?

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MSOP

• Physicians must be altruistic, altruistic and
  truthful.
• Physicians must be knowledgeable about the
  scientific basis of medicine.
• Physicians must be skillful in communicating with
  and caring for patients.
• Physicians must be dutiful in working with other
  to promote the health of individual patients and
  the broader community.

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Brown University/Indiana UniversityThe Nine
Competencies

• I. Effective Communication
• II. Basic Clinical Skills
• III. Basic Science Knowledge
• IV. Lifelong Learning
• V. Self-Awareness and Self Care
• VI. Social and Community Context of Health Care
• VII. Moral Reasoning and Ethical Judgment
• VIII. Problem-Solving
• IX. Professionalism and Role Recognition

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Competency-Based Education

• Implies that skills, attitudes, and behaviors are
  as important as knowledge base
• Incorporates formal assessments of desired
  competencies
• Competencies are woven throughout curriculum
  (even in basic sciences)

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So what are the Core Medical Competencies that
can be addressed in the Undergraduate Medical
Curriculum (especially by Pathology)?
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Think about

• Knowledge base
• Skills/applications
• Communication
• Problem-solving
• Data interpretation
• Life-long learning
• Attitudes
• Professionalism
• Ethics

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Core Competencies Core Values

• Knowledge of disease-associated structural
  changes
• Knowledge of pathophysiology
• Clinical problem solving
• Interpretation of laboratory data
• Interpretation of gross and histopathology
• Appropriate use of descriptive terminology
• Knowledge of the role of the pathologist
• Communication with other members of the health
  care team
• Ability to access relevant information sources
• Ability to incorporate new knowledge as it
  becomes available
• Etc.

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Working Towards Balance
Knowledge Base
Undergraduate Pathology Education
Learning Skills
Clinical Integration
Role Modeling
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Knowledge

• Develop a set of clear learning objectives for
  your discipline
• Focus on teaching the pathogenesis of disease
• Use morphology and clinical pathology to
  illustrate the pathogenesis

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Clinical Integration the role is important
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Negative Messages

• Medicine doesnt cover it, so it must not be very
  important to being a clinician
• Pathology as a discipline is only interested in
  tissues, not the patient
• Since I am interested in the patient and dont
  want to limit myself to reading slides, I dont
  want to be a Pathologist
• Pathology is irrelevant and a waste of time

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Pathogenesis-Centered Pathology Education
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Positive Messages

• Pathology contributes my understanding of all
  aspects of the patients experience of the
  disease
• Pathology plays a critical role in diagnosis and
  clinical decision making
• The Pathologist is obviously a respected member
  of the health care team
• I want to be a Pathologist

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Developing Competencies

• Exercises to develop problem-solving skills
• Use information gathered through pathology
  resources (laboratory, histopathology, autopsies,
  etc.)
• Encourage the testing of hypotheses and
  development of differential diagnoses
• Encourage the development of lifelong learning
  skills by focusing on our continually evolving
  understanding of pathogenesis
• Develop vocabulary and communication skills

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Role-modeling

• Demonstrate enthusiasm for scientific inquiry and
  lifelong learning
• Demonstrate clinical problem solving using
  pathology as a means of collecting information
  and testing hypotheses
• Demonstrate how all aspects of clinical medicine
  derive from a thorough understanding of the
  pathogenesis of the disease

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Role-modeling, contd.

• Demonstrate how pathologists contribute to the
  health care team
• Encourage discipline-specific activities and
  experience (i.e., autopsy, clinical electives)
• Make sure students are introduced to pathologists
  early in their careers

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The Bottom Line

• No single curriculum or format is superior to all
  others
• All four key components can play a role in any
  format
• All four key components should be present in the
  curriculum, regardless of the format

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Improving Traditional Discipline-based Curricula

• Define specific objectives for the course
• Use laboratories to illustrate key concepts (not
  teach diagnostic pathology)
• Add active learning components (small group, case
  discussions, etc.) to develop skills and
  attitudes
• Use faculty that can serve as good role-models

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Working Towards Balance
Knowledge Base
Undergraduate Pathology Education
Learning Skills
Clinical Integration
Role Modeling
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Improving PBL Curricula

• Use Pathology faculty as tutors
• Develop specific pathology objectives to
  supplement the students learning objectives
• Make available resources to help the students
  with their learning objectives (image libraries,
  gross tissues, online resources, etc.)

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PBL, contd.

• Provide supportive learning opportunities
  (selective lectures, lab experiences)
• Encourage the use of information derived from
  pathology services in the development of cases
• Encourage the students to use the pathology
  faculty as primary resources for their learning
  issues

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Improving Integrated Curricula

• Provide specific discipline-based learning
  objectives for your contribution to the course
• Focus the pathology contributions on
  pathogenesis, not just morphology
• The course should be organized so that
  Pathologists are seen as valued members of the
  health care team, not a purveyor of irrelevant
  details

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Integrated Curricula, contd.

• Play a role in the administration of the course
• Participate in the central administration of the
  curriculum as a stake-holder be willing to offer
  more to the education of medical students than
  histopathology slides and gross specimens

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Improving Competency-based Curricular

• Embrace the competencies that best fit the
  practice of Pathology
• Develop specific course objectives for both
  knowledge base and skills/attitudes
• Include course components to develop and assess
  skills and attitudes as well as knowledge

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Competency-based Curricular, contd.

• Demonstrate to students that pathologists value
  all aspects of the students education
• Make sure faculty are good role-models for all of
  the values embodied by the competencies

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Working Towards Balance
Knowledge Base
Undergraduate Pathology Education
Learning Skills
Clinical Integration
Role Modeling
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Finding Your Way

• Develop discipline-based learning resources
• Employ enthusiastic and caring faculty for direct
  contact with students
• Develop a core of Pathology faculty to advocate
  for undergraduate pathology education at
  departmental and university levels