A 21st Century Curriculum for
21st Century Doctors

By Gina Shaw

When the class of 2013 arrives at P&S this fall, they will be met with a curriculum that looks remarkably different from the one that greeted the class of 2012 less than a year ago. Not since 1991 has P&S undertaken such a major transformation of the four-year curriculum.
     “Although it has evolved, the basic structure of our curriculum has not changed since then, while a great deal in medicine has,” says Ronald Drusin, M.D., vice dean for education. “There is a lot more information to be learned, and the use of online resources for teaching and learning has exploded. When we looked at the current curriculum, we realized that it needed more flexibility. Students who come to Columbia, many with specific interests that excite them, can’t have a real opportunity to explore those interests until after they finish their major clinical year, leaving them with little time to really define themselves as individuals.”
     The new curriculum offers that flexibility, through a fundamental reorganization that tosses out the old designations of first, second, third, and fourth years. Those categories are replaced by three major segments in the restructured curriculum: fundamentals, major clinical year, and electives and selectives.
     “It sounds like a great curriculum, very modern,” says Michael Chen’12, a student representative to the curriculum committee. “I know they don’t jump on every bandwagon, but I think this will put P&S in the vanguard of medical education.”

A Less Redundant Foundation
For decades, the first two years of a medical student’s life at P&S have emphasized the “preclinical,” involving biomedical science lectures, anatomy and pathology labs, and hours of digesting core concepts and facts. In recent years some clinical experience has been added to the first two years, but the basic math — 2 years of preclinical + 2 years of clinical = M.D. degree — has not changed.

“If we combine, in an organ systems approach, teaching both normal structure and function and the impact of disease, it’s a way of saving time.”

     But the equation is changing. The new curriculum reduces what was two years of preclinical instruction into 18 months, running from late August through January of the second year, including a summer vacation.
     “It’s a tradition in medical school, going back to Flexner, that the first two years are basic science and the last two are clinical, but that shouldn’t necessarily be true,” says Dr. Drusin.
     But can the fundamental preclinical sciences that have required two years to teach really be conveyed in just 18 months? Absolutely, says Dr. Drusin. “Our goal, in terms of the amount of material students have to carry around in their brains, has changed because of the sophistication of information systems. We’re trying to teach what we think our students in the 21st century should know and at the same time encourage them to be curious and provide them with the techniques for finding their own answers.”
     And much redundancy can be reduced (and class time maximized) by doing away with another long-held medical education dictum — that the first year of medical school involves teaching normal structure and function, while the second year teaches the impact of disease on normal structure and function. “If we combine, in an organ systems approach, teaching both normal structure and function and the impact of disease, it’s a way of saving time,” says Dr. Drusin.
     The new fundamentals curriculum will have three components:
1. “Molecular Mechanisms” for one semester, followed by two semesters of a new course called “The Body … in Health and in Disease”
2. “Foundations of Clinical Medicine I, II, and III”
3. One semester of anatomy, followed by two semesters of psychiatric medicine
     Students in the College of Dental Medicine will continue to join P&S students in preclinical courses, as part of Columbia’s long tradition of students in both schools studying these sciences together. Faculty from the dental school helped plan this segment of the curriculum.
     Paulette Bernd, Ph.D., professor of clinical pathology & cell biology, will direct a gross anatomy course that is shortened from its current 200 hours to 130. She will introduce an approach she used when directing the course at SUNY Downstate in Brooklyn, which she found very effective.
     Students will form groups of four, and two groups will be assigned to each cadaver, and they will alternate dissection. During each class session, one group will dissect one segment — say, the forearm — while the group that is not dissecting will do other anatomical activities that reflect the highly clinical nature of the course. “For instance, they will examine bones and correlate that with radiology, surface anatomy, and palpation, something that the new course will emphasize much more than we have in the past,” says Dr. Bernd.
     At the end of the afternoon session, one student from the non-dissecting group will go to the gross anatomy laboratory to learn the day’s dissection. The next day that student will teach the other members of their group. Then they will switch: The second group will dissect a different region, while the group that dissected the forearm will be in another space working on other anatomical studies. “Not every one will dissect every part of the body,” explains Dr. Bernd. “The aim is to put more responsibility on the teams of four students. I want them to function as a unit and teach each other. The day’s non-dissecting group will learn much that previously had been taught by lecture but in a far more active way.”
     The “non-dissecting” time also will include clinical cases, with students working in their four-person group to solve anatomical cases, such as carpal tunnel syndrome or damage to a part of the brachial plexus, from a case study.
     “Molecular Mechanisms” will use cell processes to examine normal and adaptive changes in health and disease, with an emphasis on hypothesis-driven learning and small groups. The course will be organized into four components: biomolecules and cells (cell biology), tissues (histology), tissues in their environment (embryology, pathology, and pharmacology), and genomic regulation (genetics).

Shifting Foundations
Meanwhile, a number of the changes to the “Foundations of Clinical Medicine” course (which will merge the two courses previously called “Physical Diagnosis” and “Clinical Practice”) already have begun. “The changes really stem from us asking the question, ‘What are the foundational clinical skills students should have as they begin a career in clinical medicine?’” says Deepu Gowda, M.D., assistant clinical professor of medicine, who co-directs the course with Delphine Taylor, M.D., assistant professor of clinical medicine.

Asking open-ended questions and listening to patients are clinical skills that can be learned in the first few years, not innate abilities that you have or don’t have.

     Changes already made have involved a re-envisioning of “Physical Diagnosis,” which even in its name was lacking something, says Dr. Gowda. “The foundation of clinical skills involves the physical exam, but it’s much more than that: advanced history taking, development of clinical reasoning, learning how to navigate the medical literature and incorporate that into clinical thinking, and becoming familiar with laboratory information.”
     “Foundations” is designed to prepare students for what they will do on day one of their major clinical year: admit patients, do a workup, attend rounds, and present their case in a coherent oral presentation. “That’s a very advanced skill, and they won’t be masters on week one, but we want to unpack the basic skills that students will need to have to function effectively in their major clinical year.”
     One new format for teaching students those skills has already been put into place: the “on-call case.” As part of both the refashioned “Physical Diagnosis” and the developing “Foundations,” groups of four students are placed at various sites, including Allen Pavilion, Harlem Hospital, and St. Luke’s-Roosevelt. They meet weekly with a preceptor. The on-call cases were added to preceptor meetings this past year.
     “These are cases we’ve created that correspond to what they’ve already done in pathophysiology,” says Dr. Gowda. “For example, students had already done neurology, infectious disease, and cardiology, and one of the cases we used was a patient who came in with weight loss, fevers, and fatigue for several months and new neurological findings. It turned out that the patient had bacterial endocarditis that resulted in septic emboli to the brain and then a stroke.”
     One student familiar with the entire case leads the discussion. He tells his group, “You’re a third-year student, your intern pages you and says, ‘You have a 65-year-old man coming in with fatigue and fevers for four months. Go to the ER and see him and I’ll see you in a half hour.’” The students are given three minutes to spend on a differential and 15 minutes to take a history based on that differential, asking questions of their student leader.
     “They’re starting to develop hypothesis-based history taking,” explains Dr. Gowda. “Instead of just learning all the things they’re supposed to ask in a rote fashion, this approach asks students to connect history-taking with clinical reasoning skills. After their time for history is up, they’re asked if their differential has changed. Then they move on to a physical exam and are asked what maneuvers they’d like to do and why. Then they move on to labs and imaging and are asked to approach them in a systematic way. The reality is, once they enter their major clinical year, they’ll be asked to do this in their very first week.”
     Another new course, “The Body … in Health and in Disease,” will continue with an organ systems-based approach to integrating core biomedical information about embryology, histology, pathology, pathophysiology, genetics, and pharmacology. The course runs for a calendar year, starting for the first time in January 2010 and finishing in December, with a summer break.
     “This is an all-inclusive course focusing on each of the organ systems,” explains Thomas Garrett, M.D., professor of clinical medicine, director of the Glenda Garvey Teaching Academy, and course director. “We’re trying to eliminate unnecessary duplication and focus on subjects once rather than having them come up repeatedly. After ‘Molecular Mechanisms,’ a one-semester course in the first year where they learn the fundamentals of cellular biology up to the level of tissue, we view our course as the logical next step in helping students master the fundamental sciences of medicine.”
     About half of the course’s 20 weekly hours will be lectures, while the other half will incorporate a mix of small groups, case-based discussions, pathology labs, and demonstrations. “We also hope to coordinate our courses better. For example, when students are learning about one organ in our course, they will also be focusing on it in the ‘Foundations’ course,” says Dr. Garrett.
     A much closer longitudinal integration between courses in the fundamentals curriculum will be a big advantage, says Nat Langer’11, a student representative to the curriculum committee who has been working with faculty on clinical education in the preclinical years. “We’ll spend time talking about how you talk to the patients in the context of a history and physical exam, but also tying it into comprehensive pathophysiology, for example, learning the heart/lung exam at the same time you learn that pathophysiology. I think this new approach will help students realize that a lot of things, like asking open-ended questions and listening to patients, are clinical skills you can develop in your first couple of years, not just innate abilities that you either have or you don’t.”

Clinical Changes
The major clinical year also will undergo some significant changes. The overarching goal, says Kathy Nickerson, M.D., associate professor of clinical medicine and vice chair in the Department of Medicine, is “to design one coherent year instead of separate ‘clerkship silos,’ and, to a much greater extent, share expertise among clerkship directors with regard to optimizing clinical experiences, faculty development, and evaluation practices. In the current curriculum, each clerkship stands alone and there is no place for interaction or overlap.”

Intersessions: “It’s a time to take a step back from the clerkships to process the experiences they’ve had and consolidate what they’ve learned”

     One strategy to change that situation is to pair clerkships in ways that promote interaction and continuity. For example, pediatrics and obstetrics/gynecology will share the same 12-week block. “Our hope is to find creative ways for students to learn a continuity of experience from prenatal care to newborn and to incorporate interdisciplinary topics such as genetics,” says Dr. Nickerson. “It will be the same with psychiatry and neurology, where both have contrasting approaches to brain disease, but also fascinating convergence in areas such as brain imaging. This presents exciting opportunities to teach students in new ways.”
     To further promote continuity among clerkships, a team of clerkship directors will develop a common set of tools and a common groundwork for students, such as a patient interviewing guide named “P&S Questions,” being developed by a group of faculty brought together by Rita Charon, M.D., Ph.D., professor of clinical medicine and director of the Program in Narrative Medicine, as part of a $1.35 million NIH grant aimed at strengthening the behavioral and social sciences in medical education.
     “We want to set up an ongoing process, so that everyone is familiar with the logistics of one another’s clerkships as well as the content areas,” says Dr. Nickerson. “That way, if there are gaps we can work to fill them either in the clerkships or the intersessions.”
     Intersessions? Those are another distinguishing feature of the new major clinical year. Following each paired clerkship, students will come together for classroom-based, small group teaching. “It’s a time to take a step back from the clerkships to process the experiences they’ve had and consolidate what they’ve learned, exploring aspects of medicine and health care that run through the different clerkships, like the patient-physician relationship and accessing and using the medical literature,” explains Michael Devlin, M.D., associate professor of clinical psychiatry and coordinator of the intersession development work group. “The third year is when you’re getting all this experience, and sometimes it can be hard to step back and build that theoretical framework. That’s what intersessions are for.”
     What has been known simply as the fourth year will now be called “Electives and Selectives” and has been expanded to 14 months. This period will include eight months of clinical electives (including a one-month course called “Back to the Classroom” that re-emphasizes basic science), a four-week senior medicine clerkship, and a four-month scholarly project in one of six areas of academic concentration: basic research, clinical and translational research, population research or community service, international health research or service, humanism and professionalism (including narrative medicine), or medical education.

“It’s a curriculum that fosters the team-based approach that is an essential element of medicine today, while at the same time allowing students to explore their individual goals in medicine.”

     “Students will finish their major clinical year early enough so that they can look at their career trajectories,” says Dr. Drusin. “Electives can begin as early as January or February of the third year, well before students have to make decisions about what kind of residency to apply to. This gives them enough time in the curriculum to do something meaningful to them in their scholarly project: Develop an issue, explore, do research or service in an area, and present the work they’ve done publicly.”
     A formal mechanism will be established to help students get started with their scholarly projects, including training for an in-depth project, committees to review proposals, or connections to meet faculty members who are potential mentors. “We want students to choose a part of medicine that excites them and immerse themselves in it,” says Dr. Drusin.
     The new curriculum continues to evolve. Through an intense process of retreats and working groups involving both students and faculty, P&S has developed a new framework for school-wide learning objectives. “We hope this new framework will guide instructional design decisions, serve as an evaluation standard, and inspire students to take ownership of their learning,” says Boyd Richards, Ph.D., director of the Center for Education Research and Evaluation, which has been involved in development of the curriculum. “For example, there are active discussions under way about implementing a ‘learning chart’ or type of portfolio that will enable students to present to faculty evidence they have accumulated over time that they have achieved the knowledge, skills, and attitudes expected of P&S graduates.”
     As with all transitions, the move from the old to the new comes with some bumps in the road. One challenge will be the “collision” between the class of 2013 and the class of 2012. Since the preclinical period for the class of 2013 is shortened from two years to 18 months, the two classes will necessarily overlap clerkships.
     “We do have two semesters where the class of 2012 and the index class of 2013 may overlap and be doing similar things, which will put stress on both the faculty and clinical facilities,” acknowledges Dr. Drusin. Students in the class of 2012 are concerned but pleased that they were allowed to provide input. “We polled our class and had everyone express their concerns and wrote up a document with all the questions about how to make sure the quality of education and evaluation is the same,” says Monica Sethi’12, another student curriculum representative. The committee has “been very responsible and accommodating and very aware of the issues. In general, I think this change is going to be great. It’s where medical education is going.”
     Overall, says Dr. Drusin, the new curriculum takes better advantage of the latest knowledge about how adults learn. The Center for Education Research and Evaluation, led by Dr. Richards, and the Columbia Center for New Media Teaching and Learning, led by John Zimmerman, provided input to P&S faculty and students as they developed the new curriculum. “Using up-to-date technology and teaching techniques, we’re encouraging our students to be curious, find answers, and critically evaluate the information they find. It’s a curriculum that fosters the team-based approach that is an essential element of medicine today, while at the same time allowing students to explore their individual goals in medicine.”

Mixing the New with the Traditional

A P&S medical education is more than a grid of courses, schedule of rotations, or list of electives. Hallmarks of the P&S experience that will not change:

Dual degree programs (MD/DDS, MD/MBA, MD/MPH, and MD/PhD)

Research opportunities, including the Doris Duke Clinical Research Fellowship Program, Howard Hughes research training fellowships, the Sarnoff Fellowship for Biomedical Research, and research fellowships with faculty mentors

Fellowship in urban medicine and immigrant health on the Lower East Side

Preceptorships, similar to apprentice programs of long ago

Extramural program, including opportunities abroad through formal exchange agreements with universities in nearly 20 countries

Support services, including the advisory deans program, P&S Club, Center for Student Wellness, Student Success Network, AI:MS, and peer support network

Ceremonies for incoming students (white coat) and students moving into their major clinical year (transition)

Unique academic offerings, such as narrative medicine, the Clown Care program that pairs students with clowns to learn about nonverbal communication, and arts in medicine








 

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