With the constant evolution of medical knowledge, how can schools ensure that they are providing the best training possible for tomorrow’s physicians?
The Keck School of Medicine continues to update and improve its curriculum and the educational opportunities offered to students. “One of the most important duties of the Keck School of Medicine is the education of its medical students,” said Henri Ford, M.D., vice dean for medical education at the Keck School.
“Active participation of the entire faculty in medical student education at various levels is essential in order for the Keck School to fulfill its core mission.”
In 2001, the school introduced a drastically restructured program for Years I-II that shifted emphasis from basic science courses and long hours of lecture to organ systems and small group learning. Almost eight years after the revised curriculum was introduced, students and faculty appear pleased, and the proof is in the pudding. Keck students consistently score well above the national mean on the United States Medical Licensing Examination (USMLE) Step I, a multi-part professional exam required to practice medicine in the U.S. In 2008, Keck students scored 10 points above the national mean, and not one student failed, compared to a 6.7 percent failure rate nationwide.
Now, new changes to Years III-IV are under consideration.
“Under the old curriculum, students were tested more narrowly and that limited their motivation or reinforcement to take on studies or topics outside the core, including ethics or humanities,” said Ron Ben-Ari, M.D., senior associate chair for educational affairs for the Department of Medicine, and chair of the Year III-IV Curriculum Revision Group. “The new curriculum has broadened the scope of their education. I know that the new curriculum is helping to strengthen our students particularly as evidenced by their outstanding USMLE scores.”
The Keck School of Medicine gained a reputation as an innovative leader in medical education in the early 1960s, when it introduced the now-widespread practice of using standardized patients for honing students’ diagnostic skills.
The curriculum was basically unchanged for almost three decades after its design in 1969, according to Allan Abbott, M.D., the Keck School of Medicine’s associate dean for curriculum. While faculty and administrators had a plan for updating the curriculum, they lacked a sense of urgency. “We just needed the motivation to make it a high priority at all levels of the school,” he said.
The work to change the program began in earnest in 1999, after a significant visit from the Liaison Committee on Medical Education made the school’s administration take a critical look. Committees comprising faculty, administrators, students and recent graduates began to review the components of the curriculum with a particular focus on the composition of courses in Years I and II. Early on, the committees agreed upon a set of guiding principles to help establish a framework for the new structure:
“The new curriculum will be designed to enhance the understanding and clinical relevance of the basic sciences and to improve students’ problem solving and independent study skills. The curriculum will be based upon the use of cases and will increasingly incorporate small group learning, directed self-study and newer instructional technologies.”
CURRICULUM WITH A DIFFERENCE The curriculum launched in 2001 offers vast differences from the previous program. First-year students now start their medical education in a section called “Core Principles,” which presents the tenets of the basic sciences while making the sciences clinically relevant. Students then proceed to the hematology and immunology, neuroscience, and musculoskeletal systems. The second year consists of the remainder of the systems, such as cardiovascular, renal and respiratory.
Students spend less time in lectures and more time working in small groups with other students and professors. No more than four hours per day are spent receiving didactic material. The curriculum introduced a new required course for first- and second-year students: “Professionalism and the Practice of Medicine.” The course provides opportunities for students to gain skill and demonstrate competence in the areas of communication, social and community context of health care, ethical judgment, self-awareness, professionalism and life-long learning.
“The small groups for anatomy, pathology, microanatomy and our other classes were crucial for talking through and learning the thinking process of a physician in approaching diagnosis and treatment,” said Julia Cormano, a fourth-year medical student at the Keck School. “Pure facts can come from books, but it is the medical thought process that leads to a high (USMLE) Step I score, and to becoming a good physician.”
Another big change was the switch to a pass/fail model, rather than grades. Many top-tier medical schools, including Harvard, Yale, Johns Hopkins, Duke and Stanford, use some form of a pass-fail system.
“In the old system, there was a tendency for students who were best at memorizing details to excel on the exams, and they were the ones at the top of the class,” Abbott said. “In a pass/fail system, everybody has a chance to be at the top of the class, as those tops are determined more by breadth of knowledge, depth of knowledge, and other things, like performance in ‘Introduction to Clinical Medicine’ and other courses we offer.”
Designers of the new curriculum had to tread a fine line to make sure that the changes still met requirements for accreditation, as well as preparing students for the USMLE. “The USMLE does not tell you how to design a curriculum; it tells you what your goals need to be,” Abbott said. “It’s like some organization tells you, ‘You need to design a car that needs to get you safely from Point A to Point B, driving on streets and capable of carrying three people.’ It’s up to you to design the car, and you have quite a bit of freedom within those requirements.”
EMBRACING CHANGE Major changes to the structure of the program obviously take some getting used to, on the part of both faculty and students. The shift to an organ-based approach meant that some of the teaching of the basic sciences had to be changed dramatically to incorporate clinical material.
“The reaction from the students was very positive,” said Donna Elliott, M.D., Ed.D., associate dean for student affairs for the Keck School. “In the first few years there were some issues that needed to be addressed, but overall it was very well received. Faculty tend to be a little more resistant to change, but with ongoing open dialogue, consensus was reached on most issues.”
Numerous meetings, retreats and discussions were held to address faculty and student concerns about material and methods. “We had substantial buy-in from faculty, and most of them understood that this was a sensible, modern and even groundbreaking approach to medical education,” Ben-Ari said. “They saw that we were responding to the needs of the students.”
High test scores are an empirical way to measure student achievement, but the curriculum’s increased emphasis on small group learning and presentation, as well as added material in ethics and humanities, have shown dividends in ways that are harder to measure. “The way that recent students conduct themselves in group settings is much more sophisticated, and they seem to develop more sophisticated skills in presentation, synthesizing information and sharing it with others,” said Ben-Ari. “And my impression is that these students have gone on to be even more effective physicians, team leaders and self-directed learners.”
Having let the previous curriculum sit virtually unchanged for so many years, the Keck School now has in place mechanisms to allow for regular review and improvement to the design and structure of the educational program. Administrators, faculty and students continue to make suggestions to better meet student needs.
“Fortunately both the Student Affairs office and the Dean’s office have been extremely receptive to student-motivated changes,” Cormano said. “A major example is that currently students feel we spend too much time on outpatient medicine in our third year – effectively nine weeks (internal medicine and family medicine combined). We lobbied the administration to allow us to spend more time on inpatient medicine – currently only three weeks. As of next year, the third-year class will do six weeks of inpatient internal medicine and six weeks of outpatient family medicine.”
Currently, committees are examining a significant number of projects to update and change the Years III and IV curriculum, but the overall structure of the clerkships are expected to remain in place. (See sidebar for specific changes proposed.)
The Keck School’s emphasis on turning out well-rounded and thoughtful graduates reflects an understanding by the faculty of the critical nature of the time students spend in medical school.
“When I was in medical school, I didn’t realize the dramatic effect it was having on me,” Abbott said. “I think oftentimes as we look back on our lives, we realize that some pivotal thing happened to us at some point and that’s when the course of our lives
changed. … Medical students are at a formative stage where big things happen.” |
