October 5, 2009

Integrated Medical School Curricula

by Julie Waldfogel, Pharm.D. - PGY2 Pain and Palliative Care Pharmacy Resident, Johns Hopkins Hospital

I recently passed a stand with the Johns Hopkins Hospital in-house newspaper and on the front cover was an article about the School of Medicine’s complete restructuring of their curriculum. I found the story intriguing and grounded in many of the fundamental principles of learning we’ve been discussing in this course.

The restructure curriculum is called Genes to Society – a curriculum that integrates basic science with clinical practice throughout the entire 4 year program of study. With this new model, first year medical students see patients within the first 6 months and 4th year students combine their clinical training with bench work in the lab. Students also get the chance to work at the Simulation Center, practicing procedures and assessment techniques before using them on real patients.

When viewed as an educational model, Genes to Society incorporates the major educational theories: Behaviorism, Constructivism and Social Learning. Behaviorism is a theory that learners follow a pattern dictated by the teacher. This is most visible in the traditional class structure of lectures and exams and is still present in the new John’s Hopkins curriculum. Constructivism relies more heavily on the learner for independent study and self-motivation and is seen through the school’s focus on clinical practice. Students will be seeing patients almost immediately and this environment is more conducive for self-directed learning. And the use of Social Learning is seen through the application of the Simulation Center. Social Learning is based on the theory that students learn best through example. By being able to observe a procedure and then practice it themselves, students get the benefit of modeling a behavior before applying it . By combining all three educational theories into their curriculum, the Johns Hopkins School of Medicine is building a program that engages multiple types of learners at once.

But the Johns Hopkins University is not the only program moving away from the traditional medical educational model. For example, McMaster University in Canada has developed the COMPASS curriculum. This model focuses on problem based learning (PBL). Students are divided into small groups, each with their own mentor. These small groups are given a series of problems from which they develop their own learning objectives and negotiate how to approach their learning tasks. Students in this curriculum are also exposed early in their training to clinical practice and patients. From the description of this curriculum, it’s easy to see that the major paradigm shift at McMaster is away from Behaviorism and towards a curriculum that focuses primarily on Constructivism and Social Learning as the major educational models.

But medical schools are not the only ones that can learn from these changes. Pharmacy is another health profession that could benefit from incorporating multiple educational theories into its teaching model. While I was in pharmacy school, the majority of my learning was in lecture-based format. In part due to the relatively rigid format and partly due to the nature of multiple choice exams with a single correct answer, I saw many choices as black and white. Medication decisions were clear-cut because they were based on guidelines and evidence-based medicine. However, as I’ve progressed through my residency training, many of the certainties that I once learned as a student have taken on shades of grey; because medicine is patient specific. And every day, as new information arises about the genetic basis for disease, the practice of medicine becomes even more personalized.

It’s this shift in the medical approach that has necessitated a change in medical education. With Genes to Society, it’s the cohesiveness of the curriculum that makes the model so appealing and so applicable to today’s medical practice. It integrates biological, societal and environmental components to help medical students evaluate the entire patient and provide the best care possible.

Of particular interest to me is the rejection of the concept of “normal” biology. In the classic medical educational model, students are taught to think of the body like a machine. A patient’s body is “broken” by a disease and it’s up to healthcare professionals to “fix” it. But many health professionals lack training regarding the emotional, spiritual, societal and ethnic issues that can also impact a person’s health. With their new curriculum, the Johns Hopkins University Medical School is saying “…no one is ‘normal’. Everyone is on some kind of continuum, and we need to understand why they’re presenting the way they do at any given moment in time.” The result is, hopefully, a more balanced clinician who can see each patient as an individual and has experience in addressing all aspects of health.

Whether this new curriculum helps produce better practitioners remains to be seen. But I’m relieved that the effort is being made to move us forward and into a new era of medical education.

[Editor's Commentary: From its founding in the late nineteenth century, the Johns Hopkins Hospital and the Johns Hopkins School of Medicine have been leaders in medical education. It was the first teaching hospital (as we understand them today) where the hospital, the medical school, and its faculty were fully integrated. It was not uncommon at the turn of the twentieth century for medical schools to be diploma mills in rented facilities with little or no clinical training prior to graduation. It wasn't until the publication of the Flexner report in 1910 that modern medical education took shape - and the model he espoused was largely based on the Johns Hopkins model of integration between didactic and clinical education. In the century that has since passed, other medical schools have adopted equally bold and innovative curricula. Problem based learning was pioneered at McMaster University in the 1970's and the concept was taken even further in the Compass Curriculum adopted a few years ago. But are these innovations in medical education really all the revolutionary? Not really - Maria Montessori developed curricula for pre-school and elementary education in which children were free to explore and learn in a carefully constructed environment. In this method, students directed their own learning through their interactions with the environment and with teachers as guides. Its seems medical (pharmacy and nursing) curricula are moving closer and closer to Montessori's vision. One wonders whether we need a didactic component in our curricula at all. S.H.]

No comments: