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

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Workshop focus Pre-clinical training

• Integration of basic, clinical and psychosocial
  sciences
• Autonomous, self-directed learning

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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

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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

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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

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

25
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.

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• DEBRIEFING

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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
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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
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
  (Pardees 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?

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• LUNCH BREAK
• 2 HOURS

34
Brainstorming

• What characterize a good preclinical problem?
• Lets 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
  (Pardees 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
  (Pardees 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
Practical exercise Problem write-up

• 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 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)

40
Practical exercise Problem write-up

• 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)

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)

49
Creation of structures
Education Committee
Program Committees
Preclinical years
Clinical years
Representatives of basic () and clinical (-)
disciplines
Heads of units
Representatives of clinical disciplines
Heads of clerkships
50
Elaboration of Module and Unit general content
Education Committee
Definition of the learning units and of their
sequence and grouping (module)
51
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)

52
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
Discipline-related biomedical concepts
Integration/Consensus
Unit general content Concepts and Problems
53
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)

54
Curriculum development / design

• What do you need to select and build problems for
  your Unit?

55
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)

56
Problem elaboration
Unit working group 10 to 15 members - basic
scientists and clinicians of different disciplines
Identification of unit content
7-8 problems (2 per week)
Biomedical concepts
Elaboration of problems and their learning
objectives
Verification and sequencing of problems
57
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)

58
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?

59
Unit vertical integration

• Between problems and other learning activities
• Lectures
• Practicals
• Clinical skills
• Community oriented skills

60
Unit horizontal integration

• Across transversal disciplines
• Anatomy
• Genetics
• Basics of radiology
• Fondamental pathology
• Fondamental pharmacology
• Across biomedical concepts and organ systems

61

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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
63
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)

64
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.

65
Instructional approach

• Problem-based small group tutorials
• Lectures
• Forums/ Discussions (live and electronically)
• Seminars
• Practical laboratory sessions
• Practice-based learning

66
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

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68
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

69
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