Charting a New Course for Future Physicians

Spring/Summer 2016

Students settle into their seats in the dimly lit auditorium, flipping open laptops and chatting with classmates about housing arrangements and course schedules. The roughly 200 second-year medical students, just back from winter break, had three hours of lectures that morning in the same room. Now after lunch, with filled bellies and blood circulating again, they prepare for another 90 minutes of class.

But something looks different. Not one but three white-coated professors confer near the podium. A classroom assistant stands nearby holding a pad of sticky-backed poster paper and a large bag of colored markers.

Family medicine professor Yumi Jarris introduces the topic and format for the afternoon: a cross-disciplinary team-taught interactive module on kidney disease and health disparities in Washington, D.C. After a quick 30-minute overview of the medical data and risk factors associated with different populations, the students are asked to break into small groups to research and respond to questions as a team, addressing the problems in the greater Washington community. One student from each team comes up to get markers and poster paper to document the group findings, and then share out with the entire class.

Clusters of 5-10 students spread out across the auditorium, in the aisles, up on the stage, and even out into the hallways, making use of wall and floor space to hang their posters and explore ideas together. The area buzzes with discussion and energy as students share their different perspectives and growing knowledge about the challenges of addressing health disparities. They consult laptops to review online data through links provided by the professors. They work on consensus-building and eventually put thoughts to paper, as the professors walk among groups, observing and answering questions.

As the students flow back into the auditorium and take their seats, the air in the room feels refreshed. One by one, each group shares one or two results from their discussions. All the posters are photographed and posted to a class portal online for students and professors to review later. Although the room is not easily modified for group work, the students make the most of it and enjoy the lively, engaging format and the chance to discuss solutions with their classmates.

“We have a lot of lecture hours, but I learn better by doing and talking to someone,” says Kristin Spitz (M’18). Over the past decade, faculty members have developed innovative approaches to teaching like this one, supported by CIRCLE grants (Curricular Innovation Research Creativity in Learning Environments) and other programs at the medical school. However, finding room to incorporate the best new ideas—and needed innovation—into the existing curriculum proved difficult, says Stephen Ray Mitchell, dean of medical education.

Now a new approach to medical education is on the horizon at Georgetown School of Medicine, represented in part by classes like this one. Faculty members are working to design an educational path with a more integrated curriculum, blending clinical experience with basic science teaching over the four years. The new curriculum will also emphasize student-centered, team-based, interactive learning, with less time in the formal lecture setting. 

Moving away from traditional lectures to a more inquiry-based, learner-centered teaching style can prove challenging for professors. 

“Things can go in any direction,” says Jeff Weinfeld, associate professor of family medicine and one of the population and health disparities course co-teachers. “It’s hard to be thoughtful and to prepare to teach this kind of class, but the more interactive setting generates a lot of positive, creative energy.”

Curriculum for the next century

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For the past 100 years, medical schools in the U.S. have trained generations of physicians in generally the same four-year format. The first two years are classically spent in the lecture halls and labs, covering basic science. The third and fourth years are in the clinical setting, as students work alongside practicing physicians, see patients, and learn more about the different specialties. This structure took shape based on sweeping medical education reforms recommended by the Carnegie Foundation’s famous Flexner Report of 1910. On the 100th anniversary of the historic overhaul, the Carnegie Foundation released a new examination of how best to train doctors for today’s evolving medical field, prompting schools across the country to revisit how they teach medicine.

Outside the school walls, the practice of medicine in the U.S. is undergoing major change. Delivery of care is shifting with the rise of new technologies, a growing emphasis on disease prevention and wellness rather than procedures, and more reliance on team-based care. In addition, rapidly advancing science and research are expanding medical knowledge, and the impact of global health continues to grow.

Society’s expectations of doctors are changing too, says Jessica Jones, associate professor of biochemistry and molecular and cellular biology. “We have a much more diverse group of people who are becoming doctors, and the people who receive health care today are a more diverse group,” she says. “We no longer have the Dr. Kildare, the lone doctor who steps in and solves everyone’s problems. More than ever, doctors are part of a team; they don’t work alone. Each one has a certain set of knowledge, and in order for that to be useful it has to be placed in the context of other people with different sets of knowledge, different professional skills.”

In response to the changing field  of medicine and the new Carnegie recommendations, medical schools including Georgetown School of Medicine are undertaking major curriculum reform. 

Curricular revision is nothing new at the school. In the Jesuit tradition, Georgetown has always placed a strong emphasis on teaching, and over the years has prioritized reflection and innovation in this arena.

“We have had early clinical entry to ambulatory mentored settings for a long time,” says Mitchell. “And in 2003, we moved from teaching basic sciences in departmental, disjointed lectures to modular content, integrating more logically from molecules and cells to an organ-based first year, with the second year integrated around disease. Even with this major change, 24 rigid months remained, and room for emerging innovation was lacking.”

One charge of the second Carnegie commission is to create a competence curriculum that allows individualization of the career path for each student, says Mitchell, something Georgetown has been exploring for two decades. “Over the last 20 years, at least five groups of our faculty have proposed individual tracks, or journeys, built around a student’s individual passions, talents, and career targets,” he explains. “We have had students pursuing the Health Justice Scholar track, leading to creation of the HOYA Clinic. Students take the Population Health Scholar track to better understand health disparities and advocate for the underserved. Future teachers may choose the Medical Education track.” Student-directed options continue to expand.

Time for fostering intellectual curiosity

Central to all the change rests Georgetown’s grounding principle of cura personalis, care of the whole person. “Always we must create mindful, reflective, resilient physicians who are sensitive, empathetic, and compassionate scientists as well,” says Mitchell.

With this in mind, in the fall of 2014 the school established five Learning Societies in which every student is enrolled all four years in order to create mentor-rich environments for crowd-sourced learning of mindfulness, resiliency, professional authenticity, and leadership. Each Society is composed of four academic families. One academic family has 10 students and a faculty member, and forms the curricular unit for teaching a more active medical science curriculum going forward, explains Mitchell.

These incremental innovations led faculty to pull back for a big-picture perspective on all four years of the student experience. In the summer of 2015, 80 faculty, alumni, and students gathered for a pivotal two-day retreat to envision a curriculum for the new century and consider how it would ideally take shape.

“Inspired by an outstanding alumni class who had gathered for their 50-year reunion, we brainstormed about their enduring qualities that we value—qualities we want and must continue to develop in our Georgetown graduates,” recalls Mitchell. “We began to consider reductions in those pre-clinical 24 months to 18 months, with room to develop individual student journeys along individual tracks, including ‘deep dives’ back into medical science after clinical experience, offering long-term clinical exposure occurring earlier, followed by continued clinical responsi-bility under mentored supervision.”

Although details of the new curriculum are still being finalized, the overall shift is designed to give students more time to foster intellectual curiosity, says Jones, who serves as chair of the Curriculum Reform Steering Committee. “That’s why we are shrinking the preclinical period and creating more time for customization during the clerkship period.

“By allowing students to direct more of their own learning, we hope they develop a new way of thinking so that they can continue to find what they need to know after they finish medical school,” Jones explains. “Undoubtedly 10 years after they’ve graduated, 50 percent of what we thought was true we will no longer think is true. Unfortunately there is no list of facts that you can memorize to become a doctor. You have to learn to continue to learn.”

And so the faculty team designing Georgetown’s new curriculum is asking: How can we do better? Overall the curriculum will be more learner-centered, with the two major changes being an integrated curriculum with more early clinical experience, and more interactive and team-based learning.

The Journey Begins: Proposed Longitudinal Curriculum Model
The Journey Begins: Proposed Longitudinal Curriculum Model

Meshing clinical experience and basic science

By the fall of 2017, the new curriculum will begin to phase in. The medical school class of 2021 will have had 18 months of preclinical basic science education rather than the traditional two years currently in place. By entering their clerkships in the spring of their second year, students will have an earlier opportunity to enter their clinical rotations in all basic specialties. The new curriculum allows them to work with cohorts with similar interests as they pursue their individual paths.

During their two and half years of clinical training, students will come back for one- or two-week intersessions, immersing in basic science “deep dives” for a short time. The expectation is that the material will be even more meaningful when students can connect it to clinical experience they have already had. By weaving clinical experience in earlier and basic science back in later, the curriculum becomes more integrated overall.

Kristin Spitz is glad to see the shift to earlier clinically based learning. “When we have the opportunity to hear from patients in person, either in clinical settings or on patient panels in the classroom, I remember more, and all the medical knowledge becomes relevant.”

“The experiential learning is really helpful,” agrees Sam Fox (M’18), recalling the opportunity to meet patients during his ambulatory care sessions. The outpatient experiences for students take place during the second semester of the first year and continue into the first semester of the second year. “My first year I had very few clinical skills, but those opportunities were so useful. I remember all of those cases, and I know they will stick with me over the long term.”

“When I was in medical school, we didn’t see or touch a patient until our third year,” recalls Edward Healton, executive vice president for health sciences at the medical center. “Of course that was back in the stone ages,” he laughs.

Healton points to Georgetown University Medical Center’s expanding partnership with MedStar to broaden medical student opportunities for clinical training, including additional selectives and a new six-month primary care clerkship opportunity at MedStar Franklin Square Hospital in Baltimore. The pilot program will launch a new longitudinal integrated clerkship, which pairs each student with a primary care mentor who oversees the curriculum. A cohort of third-year medical students will spend half a year working with the same family physician every week, following patients into the hospital and doing their medicine, pediatrics, family medicine, and obstetrics training in a more longitudinal model, caring for a panel of patients over a longer period of time. 

This new approach allows students to learn more about evolving chronic conditions, putting the patient at the center. Students experience mentorship in the delivery of long-term primary care and observe the development of a physician-patient relationship. The students will begin with 10 patients and add more over the duration of their clerkship, including one who is pregnant and expected to deliver during that timeframe.

During the last two and half years in the new curricular format, students will also be able to experience more clinical “selectives” for better career exposure, and “bootcamps” before clerkships and before graduation, in preparation for residency training.

“All of these experiences will allow students to more thoughtfully select the area of specialty for their residencies after medical school,” says Healton.

More interactive, competency-based, team learning

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Today’s medical student experiences a different classroom from that of just five or ten years ago. For example, the massive packet of shrink-wrapped course hand-outs has been replaced with a mostly paperless, digital experience. In a broader context, advances in education technology like lecture capture add convenience and adaptability according to a student’s learning style. Often the classroom experience is flipped, with students watching the lecture before class meets, offering time for a more interactive experience with the professor. Students use laptops to connect to flat screens at the front of the room, ready to discuss the content interactively, ask questions, solve problems, and engage with fellow students to deepen learning.

Other advancements in the interactive learning model include increased opportunities for students to experience simulations. A new MedStar mobile van offers simulations on the go, wherever students rotate. Students see more standardized patients, as actors play an increasing role in teaching communication and diagnostic skills in both clinical and basic science principles.

In response to the changing classroom experience, educators are looking at the campus facility for creative use of existing teaching spaces. The new Proctor Harvey amphitheater might host basic science instructors and clinicians teaching side by side, says Mitchell. Work is currently underway in Dahlgren Memorial Library to reconfigure space for dedicated modular classrooms designed to better support the small group, team-based learning with academic families.

“The faculty have done a remarkable job planning for the new curriculum,” he says. “They own it, they are fired up, they have a timeline, and they are rolling it out. Now their pedagogy committee is asking: How do we teach this?Maybe it’s going to be 40-40-20. So 40 percent may still be lectures—they’re efficient. But 40 percent may be small groups where you collide with the material, you’ve done your homework, and you come prepared. Maybe 20 percent we take out of the curriculum and you’re going to learn that on your own.”

Mitchell notes that the concept of competence recently inspired the Student Medical Education Committee to complete evidence-based research on the impact of a graduated versus pass/fail grading scale for the basic science years. The students shared that of the 81 other schools in the nation who have done so, most have documented a drop in anxiety and depression scales, and an increase in resilience in students, without a decline on National Board scores. After careful consideration, the administration adopted the student-led proposal.

Alumni work to improve academic medicine

Derek Allison (M’14) explored medical education research while studying medicine at Georgetown.

In addition to the students and faculty, nearly a dozen Georgetown School of Medicine alumni participated in the curriculum reform planning retreat last year. Many alumni have an interest in academic medicine and go on to become professors and curricular innovators at other schools after graduating. One such individual is Marcia Glass (M’03), associate professor of hospital medicine at the University of California San Francisco. She notes several changes in how students experience medical school today, and adapts her teaching in response.

“A big change is how much work medical students are doing abroad,” she says. “Often they have very little preparation. They arrive in a country they’ve never been to and try to deliver good medical care, but they face many ethical issues on the job.” To address the need, she and her colleagues have designed curriculum that uses simulations with cultural and ethical challenges. 

Glass sees an increasing use of simulations for teaching, including at Tulane where she did her residency. Sometimes realistic mannequins are part of the experience, but in other scenarios such as the ethics training at UCSF, professional actors are hired. And the results for students can be dramatic.

“The first time we conducted the ethics simulation, I was surprised by how into it the students got,” recalls Glass. “It was intense. Some students were in tears. And they asked for a debriefing, which we now have after all our sessions.” In the end she hopes to help students become more aware of their own limitations, she says, so that they are prepared to learn during their global health experiences as much as they are there to help.

Simulation experiences, inquiry-based learning, integrated clinical and basic science content, and team-based learning are some of the approaches to teaching medicine that are attracting more attention today as schools across the country implement curriculum renewal. What really works and how do we know?

Derek Allison (M’14) hopes to help figure that out. A pathology resident at Johns Hopkins, he joined the new Medical Education Research Scholar Track in his second year of medical school at Georgetown. The program introduces students to current topics in medical education, he explains, and helps them become informed producers and consumers of medical education literature. In the program, students collaborate with faculty mentors to formulate a scholarly question and research project during their final two years in medical school.

Allison sees a need for education reform, as medical science becomes more complex, but choosing the best path forward for teaching medicine is also complex.

“Education reform requires innovation with new applications and techniques that incorporate new technology and novel learning opportunities,” he says. “This kind of curriculum development, however, needs to be evidence-based.”

His interest in academic medicine drew him to the specialty track. “I decided to participate in the program to learn about the practices already in place, how to ask the right questions about education reform and, more importantly, how to solve them.”

“With the increasing complexity of medical science and technology, medical schools, research programs, and teaching hospitals must change,” Allison says. But to do it well, he adds, more people need to be active producers and consumers of medical education scholarship.

What it’s all for

Dean Mitchell views Georgetown’s carefully considered, faculty-driven curriculum reform from a wide lens, but also reflects on what is its simple, central purpose.  “In the end, it’s about one  patient and one physician—how we bring better science to that relationship, and how we nurture the mindfulness and compassion in that relationship.” 

By Jane Varner Malhotra