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Integrated medical curriculum

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Title: 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.
  • 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.

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
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?

33
  • 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

62
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

67
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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
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