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Redefining Osteopathic Undergraduate Medical Education for the 21 st Century: Transforming good educational programs into great ones Frank J Papa, DO,

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Presentation on theme: "Redefining Osteopathic Undergraduate Medical Education for the 21 st Century: Transforming good educational programs into great ones Frank J Papa, DO,"— Presentation transcript:

1 Redefining Osteopathic Undergraduate Medical Education for the 21 st Century: Transforming good educational programs into great ones Frank J Papa, DO, PhD

2 Redefining Undergraduate Medical Education 21 st century undergraduate medical education has yet to be defined 21 st century undergraduate medical education has yet to be defined The undergraduate curriculum will be very different from what currently exists The undergraduate curriculum will be very different from what currently exists What will the curriculum look like?What will the curriculum look like? How will educational technologies be used?How will educational technologies be used? Can osteopathic undergraduate programs lead in defining a 21 st century undergraduate curricula?Can osteopathic undergraduate programs lead in defining a 21 st century undergraduate curricula?

3 What will 21 st century medical education look like? To know where the future lies, it is essential to first understand how we got where we are To know where the future lies, it is essential to first understand how we got where we are Only a handful of curricular models have evolved over the past 200 years in North AmericaOnly a handful of curricular models have evolved over the past 200 years in North America Curricular models evolve for very specific reasons, i.e., to address deficienciesCurricular models evolve for very specific reasons, i.e., to address deficiencies

4 Where medical education has been Five curricular models have evolved/coexisted in North America Five curricular models have evolved/coexisted in North America ApprenticeshipApprenticeship DisciplineDiscipline Organ SystemOrgan System Problem-basedProblem-based Presentation (structured knowledge)Presentation (structured knowledge) Curricular Reform in North America, 1765 to the present: A Cognitive Science Perspective. Academic Medicine 1999;74:154-164 Curricular Reform in North America, 1765 to the present: A Cognitive Science Perspective. Academic Medicine 1999;74:154-164

5 Apprenticeship model 1765 – present 1765 – present A small group of clinicians create their own medical schools (training and practice unregulated)A small group of clinicians create their own medical schools (training and practice unregulated) Training primarily dependent upon efforts of individual cliniciansTraining primarily dependent upon efforts of individual clinicians Basis for contemporary clerkshipsBasis for contemporary clerkships

6 Apprenticeship model Problems: Problems: Quality of training programs seriously questionedQuality of training programs seriously questioned Instructors untrained in educational techniquesInstructors untrained in educational techniques Educational goals and objectives inadequately statedEducational goals and objectives inadequately stated Memorization-oriented performance assessmentsMemorization-oriented performance assessments Gross inconsistencies from school to schoolGross inconsistencies from school to school Sound familiar? (Contemporary apprenticeships [rotations/residencies] continue to share many similar problems)Sound familiar? (Contemporary apprenticeships [rotations/residencies] continue to share many similar problems)

7 Discipline model 1871 – present 1871 – present Medical schools should be based in major educational institutions (universities) and regulated (AMA / AOA)Medical schools should be based in major educational institutions (universities) and regulated (AMA / AOA) Formally trained individuals given faculty positionsFormally trained individuals given faculty positions Several experts in a given discipline brought together to form a departmentSeveral experts in a given discipline brought together to form a department Each department/discipline owned their own piece of the curriculumEach department/discipline owned their own piece of the curriculum Departments/disciplines taught their content independently of each otherDepartments/disciplines taught their content independently of each other

8 Discipline model Problems No curricular oversightNo curricular oversight No faculty based attempt to interdigitate content among basic sciences, nor across basic and clinical sciencesNo faculty based attempt to interdigitate content among basic sciences, nor across basic and clinical sciences Memorization-oriented performance assessmentsMemorization-oriented performance assessments Students (novices) expected to interdigitate the basic and clinical sciences content on their own (despite lack of patient care contact)Students (novices) expected to interdigitate the basic and clinical sciences content on their own (despite lack of patient care contact) Not to worry, the students are very smart - everything will come together for them during clerkships – thats what clerkships are for!Not to worry, the students are very smart - everything will come together for them during clerkships – thats what clerkships are for! Sound familiar? How many contemporary undergraduate programs are predicated upon this model?Sound familiar? How many contemporary undergraduate programs are predicated upon this model?

9 Organ Systems model 1951 – present 1951 – present Basic science departments required to interdigitate content within systems (i.e., anat, physio, hist, biochem will present content relevant to each system during a given organ system block)Basic science departments required to interdigitate content within systems (i.e., anat, physio, hist, biochem will present content relevant to each system during a given organ system block) Formation of a rudimentary, centralized curricular oversight committeeFormation of a rudimentary, centralized curricular oversight committee

10 Organ Systems model Problems Problems Clinical sciences still presented separately from basic sciences (no faculty-based attempt to interdigitate basic and clinical sciences)Clinical sciences still presented separately from basic sciences (no faculty-based attempt to interdigitate basic and clinical sciences) Memorization-oriented performance assessmentsMemorization-oriented performance assessments Students (novices) expected to interdigitate the basic and clinical sciences content on their own (despite lack of patient care contact and training in knowledge base construction {interdigitation} techniques [metacognitive skills])Students (novices) expected to interdigitate the basic and clinical sciences content on their own (despite lack of patient care contact and training in knowledge base construction {interdigitation} techniques [metacognitive skills]) Not to worry, the students are very smart - everything will come together for them during clerkships – thats what clerkships are forNot to worry, the students are very smart - everything will come together for them during clerkships – thats what clerkships are for Sound familiar? How many contemporary undergraduate programs are predicated upon this model?Sound familiar? How many contemporary undergraduate programs are predicated upon this model?

11 Problem-based model 1971 – present 1971 – present Introduce x number of patient cases (problems) into either discipline or systems-based curriculumIntroduce x number of patient cases (problems) into either discipline or systems-based curriculum Cases will provide students opportunities to develop long sought after general problem solving skills (GPSS)Cases will provide students opportunities to develop long sought after general problem solving skills (GPSS) GPSS will enable students to interdigitate basic and clinical sciences contentGPSS will enable students to interdigitate basic and clinical sciences content Centralization of curricular oversight more firmly establishedCentralization of curricular oversight more firmly established

12 Problem-based model Problems Problems Research makes clear that general problem solving skills have little to do with the development of medical expertiseResearch makes clear that general problem solving skills have little to do with the development of medical expertise Despite 30 years of wide spread adoption, no evidence students interdigitate basic and clinical sciences content (construct useful knowledge bases) any better than in discipline or systems curriculaDespite 30 years of wide spread adoption, no evidence students interdigitate basic and clinical sciences content (construct useful knowledge bases) any better than in discipline or systems curricula PBL sessions incredibly faculty and resource intensivePBL sessions incredibly faculty and resource intensive Clinically relevant performance assessments introduced but memorization-oriented assessment still dominantClinically relevant performance assessments introduced but memorization-oriented assessment still dominant Not to worry, the students are very smart - everything will come together for them during clerkships – thats what clerkships are forNot to worry, the students are very smart - everything will come together for them during clerkships – thats what clerkships are for Sound familiar? How many contemporary undergraduate programs are predicated upon this model?Sound familiar? How many contemporary undergraduate programs are predicated upon this model?

13 Presentation model (Structured Knowledge curriculum) 1991 – present 1991 – present Twenty years of research demonstrates that expertise is predicated upon the organization of the medical knowledge base (competence/expertise has little to do with GPSS)Twenty years of research demonstrates that expertise is predicated upon the organization of the medical knowledge base (competence/expertise has little to do with GPSS) Knowledge bases of experts are organized around a single problem; experts construct problem-specific knowledge bases for those problems most relevant to their particular fieldKnowledge bases of experts are organized around a single problem; experts construct problem-specific knowledge bases for those problems most relevant to their particular field Faculty should take responsibility for creating interdigitated, problem-specific knowledge basesFaculty should take responsibility for creating interdigitated, problem-specific knowledge bases Curriculum: Impart Approximately 120 interdigitated problem-specific knowledge basesCurriculum: Impart Approximately 120 interdigitated problem-specific knowledge bases Knowledge base integration (deep learning – primary objective of higher education) depends upon multiple opportunities to apply interdigitated knowledge basesKnowledge base integration (deep learning – primary objective of higher education) depends upon multiple opportunities to apply interdigitated knowledge bases Curriculum should provide students with a sufficient number of clinically relevant opportunities to apply their evolving, problem-specific knowledge basesCurriculum should provide students with a sufficient number of clinically relevant opportunities to apply their evolving, problem-specific knowledge bases Curricular design centralizedCurricular design centralized

14 Presentation model (structured knowledge curriculum) Problems Problems Development of 120 problem-specific knowledge bases is faculty/resource intensiveDevelopment of 120 problem-specific knowledge bases is faculty/resource intensive Faculty lack training, and technological support, in the construction of interdigitated problem-specific knowledge basesFaculty lack training, and technological support, in the construction of interdigitated problem-specific knowledge bases Resistance to reducing number of passive lectures and replacing them with knowledge base application opportunitiesResistance to reducing number of passive lectures and replacing them with knowledge base application opportunities Difficulty in developing number of training and testing cases needed to provide sufficient application opportunitiesDifficulty in developing number of training and testing cases needed to provide sufficient application opportunities

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16 What will 21 st century medical education look like? To know where the future lies it is essential to first understand how we got where we are To know where the future lies it is essential to first understand how we got where we are Curricular models evolve for very specific reasons, i.e., to replace deficiencies in training and/or assessment with new approachesCurricular models evolve for very specific reasons, i.e., to replace deficiencies in training and/or assessment with new approaches The Structured Knowledge curricular model represents the state of the art in terms of our understanding of the development of clinical expertiseThe Structured Knowledge curricular model represents the state of the art in terms of our understanding of the development of clinical expertise 21 st century undergraduate medical training programs will most likely adopt, and improve upon, many aspects of the structured knowledge curricular model21 st century undergraduate medical training programs will most likely adopt, and improve upon, many aspects of the structured knowledge curricular model

17 What will 21 st century medical education look like? Prerequisites to the implementation of a 21 st century, Structured Knowledge curriculum Prerequisites to the implementation of a 21 st century, Structured Knowledge curriculum Development of faculty training programs and technological tools in support of faculty efforts to construct interdigitated problem-specific knowledge basesDevelopment of faculty training programs and technological tools in support of faculty efforts to construct interdigitated problem-specific knowledge bases Development of faculty training programs and technological tools in support of faculty efforts to construct the number of training and testing cases needed to provide sufficient clinically relevant application opportunitiesDevelopment of faculty training programs and technological tools in support of faculty efforts to construct the number of training and testing cases needed to provide sufficient clinically relevant application opportunities Development of x number of problem-specific knowledge bases for dissemination during undergraduate trainingDevelopment of x number of problem-specific knowledge bases for dissemination during undergraduate training Address faculty/administrative fears: Demonstrate that the replacement of passive lectures with new approaches will not result in performance degradationAddress faculty/administrative fears: Demonstrate that the replacement of passive lectures with new approaches will not result in performance degradation New performance outcomes measures needed, outcomes demonstrating that the structured knowledge curriculum accelerates the development of clinically relevant skills and expertiseNew performance outcomes measures needed, outcomes demonstrating that the structured knowledge curriculum accelerates the development of clinically relevant skills and expertise

18 What will 21 st century medical education look like? Characteristics of a Structured Knowledge curriculum Characteristics of a Structured Knowledge curriculum Amount of basic sciences content imparted in isolation will be dramatically reduced: passive lectures will be few and far betweenAmount of basic sciences content imparted in isolation will be dramatically reduced: passive lectures will be few and far between Majority of undergraduate curriculum will consist of 100 – 150 problem-specific modulesMajority of undergraduate curriculum will consist of 100 – 150 problem-specific modules Each module will consist of 2 – 5 contiguous days of problem-specific basic and clinical sciences contentEach module will consist of 2 – 5 contiguous days of problem-specific basic and clinical sciences content Students will acquire content contained in each problem-specific module primarily via self study from a WEB-based toolStudents will acquire content contained in each problem-specific module primarily via self study from a WEB-based tool Classroom time within each module will be limited and primarily devoted to interactive sessions wherein faculty pose clinical case scenarios as the basis for student engagementClassroom time within each module will be limited and primarily devoted to interactive sessions wherein faculty pose clinical case scenarios as the basis for student engagement Intelligent tutors will serve as primary tool for supporting students in the development of problem-specific, diagnostic knowledge basesIntelligent tutors will serve as primary tool for supporting students in the development of problem-specific, diagnostic knowledge bases Problem-specific performance measures will assess competenceProblem-specific performance measures will assess competence Students will continue to use and update their problem-specific WEB-based knowledge bases during clinical rotations, residencies and practiceStudents will continue to use and update their problem-specific WEB-based knowledge bases during clinical rotations, residencies and practice

19 A three day Dyspnea module Module addresses 6-10 differentials for dyspnea Self study via WEB-based explanatory knowledge base (EKB) tool EKB tool presents an interdigitated knowledge base consisting of basic and clinical sciences relevant to the disease differentials for the problem Interactive large classroom session involving pathologist, internal medicine/primary care practitioner and relevant basic science faculty Self study continues via WEB based EKB tool Diagnostic skills developed through self study via an intelligent DDX tutor Interactive large classroom session involving pathologist, internal medicine/primary care practitioner and relevant basic science faculty Dyspnea-specific clinical skills sessions offered Self study continues via WEB based EKB and DDX tool 2 – 3 hour interactive, large classroom problem-specific performance session involving presentation of multiple case presentations and immediate feedback of DDX and explanatory knowledge base performance Dyspnea written examination

20 A five week Respiratory Block in a Structured Knowledge Curriculum Review of Resp system physio, anat, hist, biochem Pathology of Respiratory system: Guided self study through Robbins chapter on Resp dis Path exam Internal Med, peds and Surg assignments Guided self study Internal Med, peds and Surg reading assignments Guided self study and interactive sessions Internal Med, peds and Surg reading assignments Guided self study and interactive sessions Internal Med, peds and Surg reading assignments Guided self study and interactive sessions Med/Peds/Surg exam Dyspnea module Dyspnea module Dyspnea module Hemoptysis module Cough module Epistaxis module Ear pain module Sinusitis module Sore throat module OSCE/final exam

21 Structured Knowledge Curriculum BEGINYEARONE Intro to interdig- itated systems- based, basic sciences NeuroRespCardioGIGUReproMSEndoHeme Neuro system IntroProblemModules:WeaknessDizziness Vis loss Hearing loss Focal deficit Depression Sub abuse Decres LOC etcResp System Intro ProblemModules:DyspneaCoughHemoptEpistaxis Ear pain Sinusitis Sore throa etcCard System Intro ProblemModules: Chest pain HTNHypotenSyncopePalpitationArrythmiasetcGISystemIntro Problem modules: Abd pain DiarrheaMelenaHematem Wt loss etc BEGINYEARTWO GU system Intro ProblemModules:DysuriaHematur Flank pn etcReproSystemIntroProblemModules: Vag bleed Pelvic pain Pelvic mass ImpotentAmmenor Testic pain Testic mass MS System Intro Problemmodules: Lum pain Neck pain Shldr pain Wrist pain etcENDO System Intro Problem modules: Fatigue Poly urea ObesityetcHemeSystemIntro Problem modules: AnemiaLeukocytosLeukopenThrombocyetc

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23 Moving from good to great Few DO or MD schools could realistically implement a structured knowledge curriculum on their own Few DO or MD schools could realistically implement a structured knowledge curriculum on their own However, with shared responsibilities DO schools could all have a structured knowledge curriculum by 2010 However, with shared responsibilities DO schools could all have a structured knowledge curriculum by 2010 How? Each school takes responsibility for developing one module a year How? Each school takes responsibility for developing one module a year Institutional investment (per school): commitment of resources to develop a module a year, and placement in their curriculum for field testing Institutional investment (per school): commitment of resources to develop a module a year, and placement in their curriculum for field testing 20 schools – 20 modules each year – approximately 140 by 2010 20 schools – 20 modules each year – approximately 140 by 2010 Incrementally small reductions in number of passive lectures in each schools current curriculum and their replacement with a growing number of problem-specific modules Incrementally small reductions in number of passive lectures in each schools current curriculum and their replacement with a growing number of problem-specific modules Content of modules shared over WEB and accessible to all schools Content of modules shared over WEB and accessible to all schools Each school free to modify their modules and use only those modules they desire Each school free to modify their modules and use only those modules they desire

24 Moving from good to great Benefits: Benefits: Individual institutional resource investment leveraged 20 – 1Individual institutional resource investment leveraged 20 – 1 Address curricular reform fear factor: continual assessment of student and faculty receptivity to modules,Address curricular reform fear factor: continual assessment of student and faculty receptivity to modules, Gradual development of a standardized DO curriculumGradual development of a standardized DO curriculum Students able to individually modify/update their own WEB-based modules as their education continuesStudents able to individually modify/update their own WEB-based modules as their education continues Graduates have access to most updated, problem-specific knowledge bases most relevant to practiceGraduates have access to most updated, problem-specific knowledge bases most relevant to practice Development of problem-specific performance measures and standardsDevelopment of problem-specific performance measures and standards

25 Moving from good to great Benefits: Benefits: Profession positioned to create new problem-specific outcomes measures-based licensure process and demonstrates its superiority over current licensure processProfession positioned to create new problem-specific outcomes measures-based licensure process and demonstrates its superiority over current licensure process Profession publishes ongoing results of findingsProfession publishes ongoing results of findings Profession gains international recognition for development of first 21 st century curricular modelProfession gains international recognition for development of first 21 st century curricular model Profession recognized as leader in medical educationProfession recognized as leader in medical education Graduates access to desirable residencies accelerates as residency programs recognize superior capabilitiesGraduates access to desirable residencies accelerates as residency programs recognize superior capabilities Profession redefines itself as it enters 21 st centuryProfession redefines itself as it enters 21 st century


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