Fall 2012
Training physicians for the 21st century

synapse: University of Nevada, Reno School of Medicine

doctors sitting and discussing

Block 1 co-directors Tom Hunt, M.D. and Cynthia Mastick, Ph.D., discuss the new curriculum with first-year student Josh Catapano. Photo by David Calvert.

Two years in the classroom learning basic science principles followed by two years in a clinical setting applying those principles. That was the way the University of Nevada School of Medicine taught medical students for several decades.

By Anne McMillin, APR

Now, following a three-year process, the school has embarked on a journey of curricular transformation to bring itself into a "new" way of teaching students, beginning with the first two years of undergraduate medical education. However, taking a closer look, and borrowing a phrase from the song, "everything old is new again," as the school returns to its origins of teaching a block curriculum based on body organ systems.

"This was a massive undertaking that was important to do for ourselves," said Dean Thomas L. Schwenk, M.D., at a town hall meeting last spring to explain the transformation process.

"The quality improvement of education is ongoing and medicine is always changing, so we must be ahead of it."

"Over the last several years, the trend in medical education has moved from discipline-based teaching to contextually-based systems to students," said Timothy Baker, M.D. '04, associate dean of medical education.

"The saying goes that there will be ‘no content without context'-that from the outset, we must relate everything we teach back to the patient and what our students will be doing in the future as physicians."

So, instead of teaching histology, physiology, anatomy and the basic sciences in a vacuum during the first two years of medical school and then asking students to recall the information in their clinical years, the new curriculum teaches each of the basic sciences in the setting of a patient's organ system.

"Clinical integration is key to making the basic science concepts stick in the minds of adult learners," Baker said. For example, the science involved in how blood vessels work is better learned when linked to a patient with hypertension.

"We are making the jump from science to disease and gaining a deeper understanding of basic science because adult students are able to relate it clinically to a patient," Baker said.

Finding a new model

In 2009, the School of Medicine, encouraged by the Liaison Committee on Medical Education, began the four-phase curricular transformation process for the first two years of medical education, by looking at institutional objectives, guiding principles and curricular goals to make general decisions on which model to use. During the first phase of the transformation, the Office of Medical Education, at that time under the leadership of Gwen Shonkwiler, Ph.D., began the transformation process through group meetings with instrumental faculty. Goals and guiding principles were established in this phase through a process with faculty and administrators working in tandem.

The faculty voted to follow a block teaching model, with each body organ system being a ‘block,' and emphasizing integrated teaching between basic science and physician faculty members and a focus on small group team-based learning.

Phase 2 of the transformation involved setting up task forces of basic science and clinical faculty for the distribution of educational content and resources across Years 1 and 2 of medical education and establishing broad block learning objectives.

Phase 3 identified individual blocks and began to see them take shape as faculty teams were assembled to form block objectives, including weekly learning objectives, weekly schedule development, discussion of evaluation strategies and assignment of faculty to teaching activities.

In Phase 4, planning co-leaders (one basic science and one clinical faculty member) worked with their faculty teams writing a syllabus to recruit teaching faculty to implement the weekly presentations, case studies and activities.

Illustrating science with clinical cases

The integration of the basic and clinical sciences help reinforce the importance of basic science concepts and provide students with the strong foundation needed to practice both the art and science of medicine, according to Greg Highison, Ph.D., professor of physiology and cell biology and Block 2 co-director.

"Students appreciated the basic sciences prior to the curriculum change, but it will now be easier for them to connect basic science to patients earlier on," he said.

"The new curriculum puts basic and clinical science on an equal playing field and provides the strong translational foundation to go from bench to bedside. It keeps basic science hand-in-hand with clinical care in all four years of undergraduate medical education.

In order to link basic science principles and concepts to diseases seen in presenting patients, the concept of case-based learning is deeply integrated in the new curriculum. Substantial physician input was solicited from clinical departments across the medical school to develop relevant cases that illustrate basic science concepts.

"This is an off-shoot of the Clinical Problem Solving course, but brings basic science into the process of caring for the patient, because we know we will better understand how the Krebs cycle works if we apply it to patients in a clinical setting," said Dr. Tom Hunt, Block 1 co-director.

A faculty facilitator, such as Hunt, guides students through a web-based patient case of the week, or clinical vignette, designed to emphasize basic principles taught that week. The case is introduced at the beginning of the week with progressive disclosure of patient information throughout the week.

Students work among themselves in small groups to answer online questions about the case each day. The facilitator assesses students' work daily and leads a classroom wrap-up of the patient case at the end of the week.

Hunt described a typical learning week in Year 1, with more emphasis on normal body functions than Year 2, which focuses more heavily on abnormal functions.

"The clinical faculty member takes the first hour of class to discuss the history and physical exam of a patient case in a lecture format. This is followed by lab work and then students convene in a small group activity where they must work together to arrive at a diagnosis. At the end of the week, students return to the classroom for a wrap-up with the clinical faculty member," he said.

Since the shift is toward self-directed learning for students working in small groups, the course material had to be overhauled from the much more formal and traditional format of a professor standing in front of a board with slides illustrating his or her lecture points.

"We had to cut down the number of lecture hours and cut up the existing lectures which were based on disciplines, like anatomy, biochemistry and histology, and reapportion them throughout the year among the block systems being taught," Hunt said.

"We are getting away from PowerPoint lectures in favor of small groups with individual and group grades. The old lectures are being integrated into the new system," he said.

Team-based learning

The concept of medical students learning in small groups came out of the business community, according to Shonkwiler.
"Part of the rationale for making this curricular transformation is recognizing that there have been changes in what we know about how students learn best. Our students are highly motivated and very intelligent," she said.

"We realized that we can't teach all they need to know about medicine, so we must structure and guide their learning and assess their ability to apply their knowledge. Self-directed learning is teaching them to be lifelong learners and to know how to discover what they don't know as well as how and where to find the answers."

Making the grade

Following the national movement, undergraduate medical education is moving toward competency-based assessments.

"We are moving away from traditional grading of A-B-C-D to a less differentiated system of honors, high pass, pass and fail," said Shonkwiler, adding that students are still motivated by being able to distinguish themselves among their classmates as under the old grading system.

"This mirrors how we grade our third- and fourth-year clerkships and electives and provides grading consistency across all four years of medical school."

In addition to assessing knowledge and skill competencies, the element of professionalism is garnering a larger focus in the new curriculum.

Students will be graded periodically on their professionalism by peers who work with them in small groups and professionalism assessments.

Faculty benefits

Perhaps one of the pleasantly surprising positive outcomes of the curricular transformation process is the new collaboration that has grown up between clinical and basic science faculty.

"This is a really exciting time in our medical school because we are seeing basic scientists and clinicians working together for the best possible learning outcomes from our medical students," Hunt said.

Jennifer Hagen, M.D.'93, associate dean for faculty development, who served as case development team chair, agrees.
"Faculty working together across disciplines and departments was one of the largest benefits of this process."

Her sentiment is echoed by Robbyn Tolles, curriculum assessment and development coordinator: "The first fantastic thing to come from all this effort has been the communication and willing collaboration of our faculty. Although they worked at the same school, many never knew each other and now they are working together."

Tolles further believes that this new teaching model will help the School of Medicine keep what its students and alumni have always said is one of its greatest strengths.

"We have always been strong in behavior teaching and developing the physician-patient relationship and we kept that as part of the curricular transformation because we've always been good at this aspect."

Looking ahead

The curricular transformation process for Years 3 and 4 is already well underway following a similar model that guided the first two years. Since the last two years focus heavily on the clinical experiences, there will be a progression in those years to include continuity of patient care, patient safety and health concerns that face physicians treating Nevadans.

Each year's curriculum is dynamic and will be constantly reassessed and adjusted according to best practices and to meet the needs of both faculty and students.

The new curriculum for first-year students rolled out this fall and will be followed by the Year 2 rollout for the 2013-14 academic year. Students in the Class of 2016 will be the first to graduate having gone through medical school under the new medical education curriculum.