The Evolution of “A Modified Systems – Application Based Approach.”
Two years ago, Kansas City University of Medicine and Biosciences (KCU) adopted a new curriculum model with the goal of best preparing medical students for a lifetime of future learning and patient care. In developing the model, KCU identified the necessary skills and competencies of highly proficient physicians and established the following eight principles:
Medical schools have a social contract to train future physicians at the highest level possible to care for their patients. In fewer than four years of medical school, student doctors will care for a patient who is someone’s “mother, father, son, daughter or child.” As physicians, we owe our patients the best we can give.
Physicians work through a formulated differential diagnosis, thus problem-solving and critical thinking are key elements of the educational model.
Graduates of medical schools must be skilled in self-taught learning so they can continually update their skills for the 40 to 50 years of their practice life.
The role of medical informatics, especially access to medical information and guidelines at the bedside or “point of service,“ must be developed in medical school graduates for their future practice life.
In terms of the basic biological sciences, future medicine will become increasingly personalized with the growth of immunology, genomics, and proteomics.
The practice of medicine must incorporate humanistic and ethical domains. Faculty must include these precepts as part of the medical student training process.
The educational pedagogy utilized in teaching must incorporate how modern medical students best learn. The learning patterns of millennials are very different from those of students who matriculated prior to 1990.
Core competencies (now part of entrustable professional activities) must be incorporated.
With the addition of these eight principals, modern medical curricula were reviewed to ascertain which models or hybrids might best serve the KCU pedagogy. Concepts within the following modern curricula models were considered. Best practices from each model were then incorporated into the development of the KCU educational model.
The Classic Discipline-Based Medical School Curriculum
Modern medical education began when Johns Hopkins developed the standard four-year medical school curriculum in the early 1900s. It consisted of two years of pre-clinical basic science study and two years of clinical study. Some remnants of this model remain today. Essentially, students take a variety of basic science classes during the pre-clinical years, with some occasional clinical medicine incorporated as well. Courses are lecture-based in their delivery. Most of the basic science courses are taught throughout the two pre-clinical years. In anatomy, a student may be studying the brachial plexus, and in the physiology class the next hour, studying the renin – angiotensin system. The third hour may consist of a lecture on obstetrics. In other words, this approach includes a lot of different courses on variable topics over time with many exams. Considerations of the discipline-based model include:
Many highly qualified physicians were trained with this model.
It is not very student – subject centric. A number of class disciplines occur at the same time.
The four-year curriculum from this model presents optimal time for medical student education.
Students often have difficulty understanding why they are training in the basic sciences, given no real clinical correlation in the classic model.
Lectures incorporated by this model are less efficient in terms of learning. Since a lecture is passive knowledge acquisition rather than active learning, it does not train a student in critical thinking / problem-solving. An active learning process would provide better learning and problem-solving.
The Systems-Based Curriculum
In the late 1950s, Case Western Reserve Medical School developed what is now the most commonly used curriculum model in the U.S. Case realized that contextually, student learning could be enhanced if some disciplines were closely correlated at the time of delivery. For example, students can better grasp the complexities of physiology and anatomy if they are taught concurrently or in close proximity to each other. Think of learning the physiology of absorption and microanatomy of the GI tract together. It makes for better understanding. Thus, students in the pre-clinical years learn each organ system, moving from one organ to the next over a two-year time span. While studying a particular organ system, a student is tasked to learn all the basic science and clinical science of that system. The systems-based model is more student-centric and provides good-quality education. There are some important areas of concern:
In a school with full cadaveric dissection, it’s hard to keep a cadaver in good condition for two years. Some schools have gotten around this by front-loading anatomy as an early course (a problem if you are a systems education theorist, as it defeats that purpose); or they have moved away from dissection to plastinated or computer-based anatomical instruction.
The sequencing may prevent good correlative learning. Many diseases are multi-system / multiorgan. Diabetes is an easy prototype. If a clinical lecturer discusses diabetic renal disease, and a student hasn’t yet studied the renal system, learning is more superficial and mostly rote memorization, rather than deeper understanding.
Sequencing is especially a problem in teaching pharmacology. Suppose that ACE inhibitors and beta-blockers are introduced in the renal system as part of the treatment of hypertension. If a student has not studied the physiology of the heart / cardiology system yet, he / she will not comprehend the concepts of pre-load or after-load as they might apply.
This model still does not address the needs of critical thinking or active learning by moving away from a lecture-based (passive knowledge acquisition) system.
Problem-Based Learning
Physicians solve problems. That’s what we do. A patient comes to us with a “chief complaint,” a problem. We develop a differential diagnosis and then a treatment plan. The introduction of problem-based learning (PBL) by McMaster University Medical School in Canada in the late 1960s was a major conceptual breakthrough in physician education. Medical schools adopting PBL ideas began to concentrate more on active learning and problem-solving. Classic PBL utilizes small groups (usually 10 – 12 students) and a facilitator. All participate in solving the problems presented by the case, an active learning process. True PBL has students design their own learning objectives (usually not a component of most schools that claim they are using PBL), and students engage in case- based education. Most PBL curricula move from organ system to organ system (just like the Systems-Based Curricula), and it takes two years to complete the entire list of all organ systems. Considerations of PBL for possible adaptation to the KCU model were:
It is a very expensive model to use. A class of 150 students would require 12 or more facilitators. It also requires a great number of “break-out” rooms, in which small groups can meet.
It is subject to the vagaries of the group dynamic. Some groups work well together, others don’t.
In most cases, the model still follows the same two-year systems schedule, thus the problems remain with “fractionated learning” in multi-organ disease and with understanding pharmacology (essentially applied physiology) in the absence of a broad grasp of the physiology of all systems at the time of learning.
A major strength is the emphasis on solving problems through clinical cases. The model helps develop critical thinking skills through an active learning and problem- solving process, if the cases are designed correctly.
The KCU Curriculum Model
Based upon a review of the strengths and weaknesses of the previously described models, the new KCU curriculum model evolved. It is a “Modified Systems – Application Based” curriculum model. A condensed description follows.
Year I
Cellular Mechanisms is the first introductory course that is taught. With students coming from myriad undergraduate and graduate school backgrounds, this course serves as a review of undergraduate cell science, biochemistry and fundamental genetics. It helps to get the first-year student body on a uniform platform that faculty can build upon.
A primer in immunology follows. This short course is front-loaded based upon student feedback and previous exam performance.
Following these two introductory courses, students move through all the systems in Year I, with concentration upon cadaveric anatomy, physiology, clinical biochemistry, immunology and genetics. The previously mentioned problem of cadaveric preservation over two years is solved, since the full cadaveric dissection begins in mid-September and ends in May. Also, the correlative learning of organ- based physiology and anatomy is preserved with this model — a goal of the systems-based learning process.
From the end of May and through the end of June, students are introduced to Mechanisms of Disease. Basically, this is an introductory pathology course that centers upon pathology and microbiology fundamentals. It incorporates both “pathogenetics” and “immune-genetics.”
Primary Care Clinical Medicine (PCM) is a course on the fundamentals of patient history-taking, communication skills and physical examination, which occurs throughout the entire first year of medical school. At the end of the first academic year, students have demonstrated their ability to perform a full history and physical examination, as well as master basic clinical skills. High-fidelity simulators, standardized patients and early patient encounters are all utilized in student training.
Medical Informatics, is a course taught by our librarians and faculty. This course encompasses the entire first year. During the first six weeks of medical school, student doctors are trained in both accessing and evaluating the medical literature and important database resources. After the introductory six weeks, students are assigned to small groups throughout the year. Each group is required to present “Grand Rounds” to all classes and campus faculty, based upon a case report given to them from New England Journal of Medicine. The standard for their presentation is that of a PGY-1 resident or higher. Students must teach themselves the requisite material for their case (the material they present isn’t part of their coursework until Year II and beyond), and the presentation must include an update on the basic science, research, practice guidelines, ethics and patient education materials for the case topic. During the presentation, members of the immediate audience, or those observing the presentation on the Internet (Grand Rounds are broadcast live on YouTube at “KCU Grand Rounds “), may submit questions for the panel to answer. This course helps students in becoming lifelong learners.
The course Osteopathic Principles and Practice is taught throughout the first year as a regular part of the curriculum. Basic landmarks are correlated to anatomic study as part of the osteopathic manipulation training.
A yearlong medical ethics course provides case-based and lecture materials in both the realm of applied medical bioethics and medical jurisprudence.
Year II
In dealing with the previously mentioned sequencing issues of systems-based learning, KCU bypasses the related problems by repeating all of the systems again in Year II. A quick one- or two-hour review of the basic sciences is followed by the pathology of any particular organ system. After the pathology section, the clinical portions of the system are presented along with the pertinent pharmacology. Students now understand the multi-system diseases and pharmacology better, since they have the requisite framework of anatomy, biochemistry and physiology. Thus, the sequencing problem is ameliorated.
The PCM course in Year II concentrates on clinical skills, differential diagnosis and, now, clinical order-writing and treatment plans. Students are given clinical cases in small groups. The groups are required to establish a differential diagnosis based upon the case scenario and write admitting orders or treatment plans. They present their work to the entire class and all clinical faculty. Students must defend their decision-making and explain / justify the orders presented. Clinical skills are further enhanced with simulators and standardized patients, as well as with patient encounters.
As mentioned earlier, the introduction of PBL by McMaster University was a significant breakthrough. The concept of critically thinking about and resolving problems is paramount to what a physician does. During the latter part of Year I and during Year II, a transition occurs in our classroom presentations. Rather than using lecture-based material, students are given very precise reading assignments for knowledge acquisition during time off. While in the classroom, faculty present case vignette problems. This is done with the entire class in an interactive manner. Students are called upon in the classroom, and iClickers are utilized as part of the vignette presentations. This form of teaching helps establish PBL critical thinking and the ability to form a differential diagnosis without the huge faculty demands for facilitators and breakout space.
Osteopathic Principles and Practice, as well as Medical Ethics, continue as part of Year II as well.
Years III and IV
Years III and IV follow the basic clinical format of most medical schools. On another note, however, honors rotation tracks have been developed in pediatrics, internal medicine, surgery, orthopedics, and obstetrics/gynecology. These tracks are designed for students who excel and are certain about the residency path they wish to pursue. Each track takes twelve students per year. Enhanced rotation opportunities provide extra course work, and didactics are available for these honors students.
Other Honors Programs
KCU also has honors programs in Global Medicine and Military Medicine. These special tracks occur over three-and-a-half years of school and add 20 to 25 contact hours per semester. The Global Medicine track is for students who see career paths in that venue, and the Military Medicine track is for students on Health Profession Scholarship Programs who have a future career in the military. Elements of the tracks include international experience and a research component for the global students; the Military Track includes extra training in trauma surgery in the field with military physicians.
Does This Modified Systems – Application Based Curriculum Model Work?
Medical schools (both osteopathic and allopathic) that have incorporated parts of this curriculum model have demonstrated higher performance on their national board scores.
In the courses where case vignettes and modified PBL-style teaching have occurred, student performance has been higher. Clinical faculty have reported increased student outcomes with differential diagnosis and interactions with standardized patients. In the summer of 2016, the first cohort of KCU students who have trained using this curriculum will sit for their national boards. It is anticipated that this curriculum model will demonstrate even higher performance.
Biography
Bruce Dubin, DO, FACOI, FCLM, JD, MSMA member since 2015, is Executive Vice President for Academic Affairs, and Provost and Dean Kansas City University of Medicine and Biosciences College of Osteopathic Medicine.
Contact: BDubin@kcumb.edu
