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Integrated medical curriculum Implications for program design, implementation and instructional approach Charles Bader, Anne Baroffio, Michel Magistris,

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Presentation on theme: "Integrated medical curriculum Implications for program design, implementation and instructional approach Charles Bader, Anne Baroffio, Michel Magistris,"— Presentation transcript:

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

20 First Year Program

21 2 nd 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 2 nd and 3rd year program

31 Basic sciences integration What 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 (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?

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 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?” TITLE TRIGGER MATERIALS 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 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) Some proposed steps

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

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

51 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) Some proposed steps

52 Elaboration of Module and Unit general content Preclinical Program Committee Representatives of basic (+) and clinical (-) disciplinesHeads of units Unit-related biomedical and clinical concepts Integration/Consensus Discipline-related biomedical concepts Unit general content [Concepts and Problems]

53 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) Final review and approval by Program committee (Plenary session - Preclinical program committee) Some proposed steps

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 7-8 problems (2 per week) Elaboration of problems and their learning objectives Verification and sequencing of problems Identification of unit content Biomedical concepts

57 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) Final review and approval by Program committee (Plenary session - Preclinical program committee) Some proposed steps

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 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) Final review and approval by Program committee (Plenary session - Preclinical program committee) Some proposed steps

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

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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