Transforming Medical Education

Transforming Medical Education The New Curriculum at Case Western Reserve School of Medicine Daniel R. Wolpaw, M.D. Professor of Medicine Case Western Reserve University School of Medicine Cleveland, Ohio

Objectives: Transforming Medical Education at CWRU Compare and contrast changes in medical education at CWRU over the last century Outline the guiding educational principles of the new curriculum Describe the new 4 year MD curriculum at CWRU

Western Reserve Before 1953 Department Chairs owned the curriculum Separate courses in basic science disciplines Minimal patient or clinical contact before clerkships

The Education Revolution of 1953 Department Chairs removed from ownership of the curriculum Organ system organization Early clinical exposure Family Clinic Dramatic reduction in classroom time - increased student responsibility for learning Thesis requirement

Living with the Revolution: 1953 to 2006 Scholarship (thesis) requirement removed - 1960 s Periodic review without significant change in structure Falling behind in innovation and early patient contact Clerkships unchanged other than increased ambulatory exposure Model LCME review 2001

The 2004 Curriculum: Year 1 - Normal

The 2004 Curriculum: Year 2 - Abnormal

The 2004 Curriculum: Year 3 Core Clerkships 7 Separate rotations: Internal Medicine 12 weeks Surgery 8 weeks Family Medicine 4 weeks Pediatrics 8 weeks OB-Gyn 7 weeks Neurology 4 weeks Psychiatry 6 weeks

The 2004 Curriculum: Year 4 Electives Student choice of 4 week experiences Acting Internships, Specialty Consult Services, Research Residency interviewing

Why Change Now? The New Environment Increasing demands on Faculty time demands of funding and clinical care Technology: Expanding electronic resources Video-streaming and Pod-casting Resident work hours

Why Change Now? The Information Environment The electronic environment has changed the role of content in learning by fiat. It has rendered the teaching-as-transfer-ofinformation model pretty much obsolete. From Weimer, Learner-Centered Teaching,, 2002

Why Change Now? The Information Environment Today s learners must be able to access information, find resources, organize them, and, perhaps most important, evaluate the ocean of information that now exists in that electronic sea. From Weimer, Learner-Centered Teaching,, 2002

Why Change? A New Vision Dean Horwitz (2003): Four pillars: 1. Scholarship 2. Clinical Mastery 3. Civic Professionalism 4. Leadership Graduate School environment student responsibility for learning Beginning with learning objectives

The New Curriculum: Learning-Centered Principles Medical education will be experiential and instill the skills for critical thinking and lifelong learning Educational methods will be chosen that stimulate an active interchange of ideas between students and faculty

The New Curriculum: Learning-Centered Principles Students and faculty will be mutually respectful partners in learning Students will be immersed in a graduate school educational environment characterized by flexibility and high expectations for independent study and self-directed learning

Focusing on the Learner: Constructivist Theory Learners must actively construct their own knowledge and meaning rather than passively receive information from teachers and textbooks.

A New Paradigm Old Paradigm Teacher Centered Faculty give information Teaching Time Summative assessments New Paradigm Learner Centered Students seek information Learning Time Formative, reflective assessment

Year I Year II Year III Year IV Foundations of Medicine and Health (20 months, including vacation) Core Clinical Rotations (48 weeks, flexible scheduling) Research and Scholarship (4-month block plus electives, flexible scheduling) Advanced Clinical and Scientific Studies (10 months, flexible scheduling) Medical Education at CWRU: Integration, Scholarship, and Flexibility

The Foundations of Medicine and Health Putting organ systems together Longitudinal themes Beginning with learning objectives Case Inquiry Groups PBL Self-directed learning + extensive resources Clinical immersions Formative assessment

A Week at Case School of Medicine and Health: Aligning the Schedule with Educational Objectives Monday Tuesday Wednesday Thursday Friday 8-10 AM Learning Groups Science of Clinical Practice Learning Groups Self-directed Learning Learning Groups 10-12 PM Interactive Sessions Anatomy/ Histopath/ Radiology Interactive sessions/ Research & Scholarship (1 hr) Self-directed Learning Interactive Sessions 12-1 PM 1-5 PM Clinical skills Self-directed Learning Self-directed Learning Self-directed Learning Self-directed Learning

Surface vs. Deep Learning Surface learning: Memorization of facts, focus on the discrete elements of the reading, poor differentiation between evidence and information, absence of reflection, tasks seen as an external imposition Marton and Saljo, 1976

Surface vs. Deep Learning Deep learning: Learners focus on meaning, relate new information to prior knowledge + experience, work to organize + structure content, view the work of learning as important Marton and Saljo, 1976

Assessment Methods: Weekly monitoring: Pre-Clerkship Small group performance facilitator + peers Synthesis Essay Questions (SEQ s) Multiple Choice Questions

Assessment Methods: End of Block: Pre-Clerkship Summative SEQ s 3-6 National Board of Medical Examiners (NBME) Cumulative Exams Every 3-4 months: NBME Professionalism assessment Portfolio Reviews

Impact of Assessment Candid, formative feedback Productive reflection Perspective across the full range of competencies Retention of learning Preparation for Board exams

Research in the New Curriculum Mentored experience in research and scholarship Minimum of 4 months protected time Each student will identify a question, develop an approach and proposal, engage the project, and interpret findings Product: Thesis in the format of a journal manuscript

Research and Scholarship July Aug Sep Oct Nov Dec Jan Feb Mar Apr May June Year 1 Year 2 Vacation or research Research or clinical rotations Vacation or research Year 3 Year 4 Research or clinical rotations Research or clinical rotations Foundations of Research and Scholarship (1-2 h/week) Elective research opportunities

Opportunities in Biomedical Research Basic research Translational research Clinical research Populationbased research

Teaching Clinical Skills before the Clerkships: Clinical Mastery 8/06-12/06 1/07-12/08 Jan 08 Introduction to clinical skills RAMP (Rotating Apprenticeships in Medical Practice) Science of Clinical Practice Web Resources Advanced Clinical Skills Clinical Preceptorships Health Policy, Leadership Civic Professionalism, Ethics

The Clinical Curriculum: Key Concepts Meaningful collaboration between Departments Well-thought out learning objectives Uniform, criterion-based assessment across hospital sites Developmental model Basic Science Correlation

Clinical Curriculum: Required Activities Basic Core I 16 weeks: Internal Medicine, Surgery, Family Medicine Basic Core II 16 weeks: Pediatrics, OB- Gyn, Psychiatry, Neurology Thesis Block (Research) 16 weeks Advanced Core rotations total of 16 weeks (taken as 4 separate rotations)

TYPICAL OPTIONS FOR CORE CLINICAL ROTATIONS AND RESEARCH March 08 July 09 Research 16 weeks (March-July) Basic Core 1 or 2 16 weeks Basic Core 1 or 2 16 weeks Advance Core 16 weeks Flexible scheduling Basic Core 1 or 2 16 weeks Research 16 weeks (July- November) Basic Core 1 or 2 16 weeks Advance Core 16 weeks Flexible scheduling Basic Core 1 or 2 16 weeks Basic Core 1or 2 16 weeks Research 16 weeks (November- March) Advance Core 16 weeks Flexible scheduling

Clinical Curriculum: Friday Afternoon Learning Basic science correlation three sessions/month (2 hours each) Advanced Clinical Skills Evidence-Based Medicine Advanced Science of Clinical Practice

Advanced Clinical and Scientific Studies Two Acting Internships each 4 week intensive inpatient or ER rotation Areas of Concentration: 12 weeks of linked experiences integrating basic science and clinical experiences and intended to result in an area of expertise Further clinical and research electives

Clinical Assessment Clinical Activity Scores Basic and Advanced Core rotations Patient logs and episode-specific feedback Cumulative Clinical Activity reports NBME Progress testing NBME Professionalism tool Year 4 OSCE

Clinical Assessment: A Developmental Model Basic Cores Advanced Cores NBME Progress Test Clinical Activity Score Basic Science Correlation OSCE