Transforming the Curriculum: Improving Medical Education

When James Shropshire, MD '89, was a medical student at the University of Wisconsin School of Medicine and Public Health (SMPH) 20 years ago, he and his classmates spent their first two years deeply immersed in the basic sciences.

In the first year alone, the students' lives were filled with a dizzying schedule that included hours of sitting in physiological chemistry lectures, standing at gross anatomy dissection tanks and peering into microscopes at histology slides.

To his disappointment, Shropshire found that very little of the vast amount of information he was expected to memorize in those first two years related directly to clinical practice.

"There seemed to be so many missed opportunities to bring patient experiences into the curriculum," says Shropshire, a family medicine physician at UW Health's small Monona Clinic. "There was very little developing of doctoring skills. It felt very impersonal."

Such was the educational tradition at almost all American medical schools for decades, until the situation gradually began to change.

Now, as one of the course directors in the school's four-semester Patient, Doctor and Society (PDS) course and a contributor to the changing curriculum, Shropshire is pleased to see that members of the SMPH Class of 2012 are learning medicine in quite a different way. The students are benefiting from instruction that meshes disciplines, incorporates prevention and public health and promotes self-directed learning more than ever before. Not only has the content changed, but so has the manner in which parts of it are delivered.

School leaders made the changes following an enormous amount of deliberation involving faculty members, staff and students. After more than a year of examining how to improve years one and two, the SMPH can now showcase a revised first-year curriculum that is more coordinated, relevant and stimulating, according to Christine Seibert, MD, who was charged specifically with enhancing the curriculum when she was named SMPH associate dean for medical education one year ago.

"This has been a tremendous collaborative effort by so many people who really thought outside the box to create something new," says Seibert.

Seibert and her colleagues, who are now working on curriculum changes for years two, three and four, rolled out the first phase of the enhancements this fall after giving attendees at Medical Education Day a preview last spring.

Connecting the Dots

The new curriculum attempts to integrate content, ideas and themes more synergistically, with less regard for traditional discipline boundaries than in the past. Historically, courses were taught fairly independently, with not much sharing of material, teaching methods or innovations among course directors.

"We believe that ‘connecting the dots' between courses in a more coordinated way, in a web-like fashion, is a more effective way to teach," says Seibert. "That's what we've tried to do."

The rationale behind this move toward integrating disciplines stems, in large part, from the emerging healthcare culture, says Seibert, which features collaboration, engagement and interdisciplinary teams. The realities of clinical experience also come into play.

"When patients come to us, they have issues that are not confined to ‘an anatomy problem' or even a ‘respiratory problem,'" Seibert says. "Patients are integrated."

Seibert believes that it's best to begin teaching students to think across disciplines as early as possible.

"If you want students to perform in an integrated manner as doctors, you should probably be teaching classes that way from the beginning, instead of having students connect the dots later on when they see patients," she says.

What's more, Seibert says, since the national board examinations are moving away from questions focusing on one discipline, the integrated coursework will better prepare students for that important step.

During fall semester 2008, SMPH Med 1s currently are taking three biomedical courses: Molecular and Medical Genetics, Medical Cell Biology and Immunology, and Comprehensive Human Biochemistry, the first two of which are interdisciplinary and new. To ensure that a close degree of coordination exists between these classes, instructors are asked to communicate course plans and outlines with each other on a regular basis.

An expanded Principles of Population Medicine and Epidemiology is now also offered in the first, instead of the second, semester. This is meant to ensure that students start thinking about public and community health from the beginning of their medical education. First semester also features a revised PDS 1, which introduces students to ethics and physician-patient communication, including cultural awareness in medical practice.

Throughout all of this, the educators have made a concerted effort to apply material learned in classes to clinical situations through relevant patient cases.

"We think this is a great first semester that really aligns content nicely and is very patient centered," Seibert says.

The medical educators have also made integration a priority during the second semester of the first year, when, in a significant departure from the past, anatomy and physiology are now taught.

Material presented in anatomy and physiology classes now meshes more clearly in an organ-system approach to structure and function. Using the heart as an example, the structure of valves and chambers will be discussed in tandem with lessons on functions such as ejection fractions and the volume-pressure relationship. Then when students focus on the physical exam in PDS 2, they will listen to a patient's heart and become familiar with other tests used to determine cardiac pathophysiology.

"Marrying structure and function in this way will be a powerful learning experience," says Seibert, stressing that integrating material from various disciplines and including clinical cases will be the standard and not the exception from now on.

Neurobiology and Anatomy of Health and Neck rounds out the new second semester class schedule. With completely restructured content, this has become an interdisciplinary course that integrates neuroscience with gross anatomy, histology and physiology of the head and neck.

More Public Health Throughout

Since the school has made incorporating public health into all of its missions a key goal, Seibert and her colleagues have made finding ways to integrate it into each year of the four-year curriculum a top priority.

"The integration of our core biomedical curriculum laid the foundation for including prevention and public health content," she says. "But making room for it posed a challenge. You can't simply add public health material on top of anatomy and physiology. Furthermore, not all faculty members have a grasp of how public health figures in their disciplines."

The curriculum architecture committee recommended a creative way to incorporate the material: a format change that entails separating five-week blocks of intense instruction with what has been named "assessment and integration weeks."

The weeks begin with exam reviews and then exams. In the integrative activities at the end of the week, students explore how health policies and programs, cost and access issues and other factors go hand-in-hand with basic science and clinical medicine in preventing and treating disease.

Building on what they have learned and anticipating what they will learn, students discover important overarching themes in medicine that might be missed in any single class.

Basic scientists, clinical scientists and public health experts have created the integrative activities with the help of Seibert's staff.

During the first integrating week at the beginning of October, for example, students tackled the causes and consequences of preterm birth. They looked at not only the treatment of these vulnerable infants but at the range of biological, social and economic factors that are involved in addressing the growing problem.

Seibert expects that the integrating week exercises will have great value for faculty members as well as students.

"Just working together on a case gets people really energized," she says, "and will help them learn the public health implications of what they do."

Beginning in fall semester 2009, the new second-year curriculum will also inject assessment and integration weeks into an organ-block structure across both semesters. In the past, longitudinal pathophysiology, pharmacology and pathology courses relating to various organ systems extended the whole year. Smaller multiweek sessions dealing with nutrition and neoplasia were strategically added in.

Now the year will have multi-disciplinary organ blocks devoted to cardiovascular, respiratory, renal, hematology, gastrointestinal, endocrine, dermatology and muscloskeletal topics, with relevant pathophysiology, pharmacology, nutrition, neoplasia and pathology integrated into each block.

"The new organ-block courses are being designed by teams of individuals representing many different disciplines," notes Seibert.

Three additional courses, a reconfigured Infection and Immunity and PDS 3 and 4, will run longitudinally for the duration of the year. And before launching into all the organ blocks, the curriculum will begin with a course called Foundations, which will present some of the basic principles students will use for the rest of the year.

Promoting Active Learning

As all medical educators know, the ongoing explosion of biomedical knowledge requires them to change the way they teach. Precious little space is available for additional material. With its need to make room for expanded new public health content, the SMPH has been further motivated to streamline its curriculum. And this has forced instructors to be most efficient about the content of their courses.

"We've asked instructors in the first two years of the curriculum to concentrate on providing students the basic concepts and underlying principles that every doctor needs to know. Then the students will learn how to apply this conceptual framework through paper cases and, eventually, their clinical work," Seibert says.

The school is also making progress on moving away from didactic toward active learning, although portions of the curriculum are still almost entirely lecture-based. Seibert points to the "problem-based exercises" (PBEs) that for years have been offered in Biomolecular Chemistry as one method of getting students used to learning in a more active way.

"We want to give students many more of these kinds of active-learning opportunities so that they become self-directed, lifelong learners as soon as possible," she says.

For the PBEs, small groups of students gather around a computer, which presents them with a case to solve, such as a patient arriving at the emergency room with chest pain. The students must decide what they are looking for. Is it heart damage? If so, they are prompted to think about what happens biochemically with heart damage and what kinds of blood tests they would order to evaluate this.

"These exercises take students through what they just learned, and translate that to clinical applications," Seibert says. "It helps them understand why they have to learn about things like troponin, myoglobin and creatine kinase."

The three main curriculum changes the school has made recently-integrating disciplines, incorporating public health and promoting active learning-are interrelated, says Seibert.

"We couldn't have successfully added public health without integrating other parts of the curriculum first," she says. "Public health encourages students to apply concepts broadly, and application is active learning."

In her presentation at Medical Education Day, Seibert referred often to the transformation of the curriculum. But she stresses that the job is never-ending because, like the ever-evolving patient care, medical education is a dynamic process.

"We should never feel transformed," she says. "We must have a constant quality improvement process, always asking: How can we make our curriculum better? How can we be a leader in medical education?"

Along with asking questions, Seibert suggests making a promise.

"We need to promise our students that we will give them the best medical education we possibly can," she says.

Shropshire, who says that until recently he never dreamed he'd be involved in helping improve medical education at his alma mater, thinks the school is on the right track.

"The new curriculum is about creating a learning environment that produces wholeness in doctors, which includes competency in the basic sciences, in making clinical and community applications, being professional and acquiring people skills," he says. "It's a different and a much better way to teach students how to be good doctors."

This article appears in the fall 2008 issue of Quarterly.