Moving the Medical Curriculum Forward

 

 

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Stephen Ray Mitchell, MD, likes to talk about immovable objects when describing the process of turning college students into clinicians.

It’s not the eager, would-be doctors who don’t budge, it’s what – and how - they are taught, says Mitchell, who, as dean for medical education at Georgetown University’s School of Medicine, knows of what he speaks.

“Medicine in recent years has been anything but static, yet the curriculum at nearly every medical school has been almost etched in concrete,” he says.

So, for the past four years, Mitchell has wielded a pick ax of sorts to chip away at the School of Medicine’s curricula and hammer in some new objectives. At first it was just Mitchell and his small task force who began breaking down and rebuilding the existing curricula, but soon enough, many School of Medicine faculty got into the swing, and the impact of Mitchell’s work is now being felt throughout the Georgetown University Medical Center.

"I commend the faculty and educational leadership for their sustained effort that has resulted in a next-generation curriculum,” says Howard J. Federoff, MD, PhD, Executive Vice President for Health Sciences and Executive Dean of the School of Medicine. “The first duty of the medical school is to train future physicians to practice evidence-based, ethically grounded, patient-oriented medicine, and I think we are succeeding in this high priority goal.”

Many medical schools are going through this process, Mitchell says, because they realize that the standardized national tests that med students soon will take emphasize a more integrated form of teaching. And they are doing it because it is, simply, time to change.

The School of Medicine’s work in creating a new, and much more fluid curriculum is in place for the first, third, and fourth years of medical school. The new second-year curricula will debut in August.

Changes in the first two years were the most comprehensive because they prepare students for the intensive clinical care experienced in the final two years, says Shyrl Sistrunk, MD, a specialist in geriatrics and internal medicine who is associate dean for curriculum and assessment at the school. Broadly speaking, year one is devoted to studying what’s right with the healthy body and year two is focused on what can go wrong in disease, she says. But within that framework, the curriculum now integrates different components of medical education into a body system.

“It is a shift in paradigm,” Mitchell says. “We needed to focus on a curriculum that does more than deliver massive content to be memorized, regurgitated on exams, and then forgotten.”

Now, the curriculum is evidence-based, he says. “During all four years, we are giving the students the tools to analyze evidence, to think through it critically.

“The questions in medicine don’t change much, but the answers change profoundly,” Mitchell says. “We are working to give our students the tools to understand 21st century medicine.”

An Interdisciplinary Approach

The new curriculum is no longer grouped by disciplines – biochemistry one semester, anatomy in another – but more logically by biological systems, which means that a single course can include teachings about molecules and cells, metabolism, and signal transduction, as well as anatomy.

For example, in “cardiopulmonary,” one of the 10 specialized modules in the first year, “students are living the heart,” Sistrunk says.

“They are understanding the microanatomy and electrophysiology of heart cells, the hemodynamics of the organ, the gross anatomy of what it truly looks like and functions, and clinical applications to pull it all together.” In the past they might have seen the heart in an anatomy class, and learned about heart cells in another.

These changes involved altering some longstanding medical school traditions, such as the one that calls for students to dissect cadavers their very first week of medical school. “Now they do it in November, because the dissection is done in concert with studying each organ system,” Mitchell says. The students are much more calm and focused when they take gross anatomy four months after starting medical school, he adds.

Even though these modules were only launched last August, medical school administrators have already found, through testing of the 199 first-year students, that this approach improves retention and understanding of the complex subject matter.

The traditional second year consisted of year-long courses, such as pathology and pharmacology. Now, every module in the second year curricula will focus on disease states and will stress evidence-based medicine as a way to solve and treat these medical issues. The courses will incorporate clinical presentations and physical diagnoses, infectious disease, pathology, pharmacology, and the basic sciences and will wrap up with presentation of patient cases and discussions about treatment ethics. “So, starting this August, students will, for example, now see and study abnormal hearts, will talk with patients diagnosed with congestive heart failure, will search the literature for ways to treat that patient, will spend time in the pathology lab,” Sistrunk says.

“We want students to start thinking like physicians early on so in their third year, they will be able to apply concepts more easily,” she says. “They need to be able to take the information they are learning and apply it to their time in the clinic.”

The third and fourth years for School of Medicine students have always been heavy in clinical work, compared to other medical schools, but they now include more flexibility, Sistrunk says.

In the third year, students now have two-week “selectives” in which they are able to preview certain disciplines that, in the past, they wouldn’t have had access to until their fourth year. During two weeks, the students can rotate with physicians and the medical team. “It’s a way to preview a possible career choice,” she says.

In the senior year, students now have two required acting internships. “They take the role of an intern, with first call responsibility,” Sistrunk says. “That offers them some pretty heavy clinical responsibilities.

“Medicine is not a spectator sport for our students,” she says. “In the fourth year, they have a lot of responsibility in patient care, and they do very well.”

The process of changing medical school curricula has been a communal one. Medical schools share their best ideas for change with others, and then each institution “weaves its own threads,” Mitchell says. “Our curriculum continues to put an emphasis on advocacy, community services, and clinical practice.”

By Renee Twombly, GUMC Communications
Story also appeared in the February 23, 2009, issue of Blue & Gray