Journal of the New Zealand Medical Association, 03-April-2009, Vol 122 No 1292
The revised ‘Early Learning in Medicine’ curriculum at the University of Otago—focusing on students, patients, and community
David Perez, Joy R Rudland, Hamish Wilson, Gayle Roberton, David Gerrard, Antony Wheatley
The Medical School of the University of Otago was established in 1874, is proud of the reputation of its medical graduates, and is committed to evolutionary curriculum critique and development.
The learning for undergraduates is framed by a number of broad outcomes related to personal and professional practice as well as interactive skills (doctor and patient) and competence in medical disciplines (knowledge of medical and clinical sciences).1 The Faculty provides educational programmes and opportunities which allow students to meet these outcomes and in so doing will prepare graduates to meet the diverse health needs of New Zealanders.
There has been wide spread international reform in medical undergraduate education. This article describes recent changes in 2008 to the early years of undergraduate medical education at the University of Otago; Years 2 and 3 are now termed ‘Early Learning in Medicine’.
Otago has retained the best of the current course whilst being innovative in others areas. The revised course details are provided, then the educational rationale for changes are outlined. These include the importance of learning that is contextually relevant, student centred, horizontally integrated, and community based.
Students now start to acquire clinical skills in their first year and have more frequent patient contact, some in community settings. In addition to the existing Module programme where students engage with traditional subjects such as physiology and anatomy, the course now includes three new programmes; Integrated Cases, Clinical Skills, and Healthcare in the Community.
There have been a number of pressures for change, the first being changes in healthcare delivery in the past few decades. There are fewer patients accessible to students within the traditional tertiary teaching environment. Patients spend shorter time in hospital with an increasing role of community care coordinated by general practitioners with specialist follow-up as required. Furthermore, a strong primary health care system is central to improving the health of New Zealanders;2 this changing emphasis should be reflected in the education of future doctors.
Secondly, there has been an unprecedented increase in medical information that informs current clinical practice. Traditional programmes of undergraduate medical education struggle with the effective delivery of such volumes of material. The new student-centred approach to learning provides both a structure for the assimilation of new information and a context within which students can identify relevant, scientifically informed research.
Thirdly, students have also identified a need for change; suggestions being earlier clinical skills, more patient contact, and more clinical relevance to biomedical science.3 A typical comment on the old curriculum is as follows:
...Still too much emphasis on gaining knowledge (in the preclinical years) that has no relevance in the day-to-day practice of clinical medicine. It just serves to distance students from the reality of patient care and clutter our minds with unnecessary information. The course needs to be patient orientated from the beginning, and certainly needs to have a greater focus on the development of real, practical clinical skills.
The need for curricular change along these lines was mooted and planned for in the late 1990s through to 2004, but political and funding issues resulted in the proposed ‘New Pathway Curriculum’ being cancelled in 2004 shortly before implementation. However, following Australian Medical Council (AMC) recommendations at the same time and with improved funding from the Tertiary Education Commission, the Faculty of Medicine re-initiated reappraisal of curricular directions in 2005.
The introduction of a new course in 2007 for Health Science First Year (HSFY) was also a driver and temporal focus for a revised course. HSFY is the common undergraduate entry point to all health professional courses at Otago (medicine, dentistry, physiotherapy, pharmacy, and laboratory science). After HSFY, all students admitted to medicine in Year 2 begin the Early Learning in Medicine curriculum in Dunedin, then attend one of three campuses for the Advanced Learning in Medicine curriculum (Years 4–6) in Christchurch, Wellington, and Dunedin.
248 students started the revised Year 2 curriculum in 2008; this article describes the course changes in more detail, and then outlines the background educational rationale. We believe the revised curriculum will provide a stimulating educational platform for our undergraduates which will serve them well in the constantly evolving world of medical practice.
The previous curriculum (1997–2007) comprised three main programmes: the Module Programme (biomedical science and body systems): Systems Integration (SI; clinical case or scenario learning); and Patient, Doctor, and Society (PDS; population health, psychological/social dimensions of illness, doctor-patient issues). The Module Programme for the biomedical sciences has now been revised, SI and PDS are combined into the Integrated Case Programme, and two new modules have been established: Clinical Skills and Healthcare in the Community.
Table 1 provides an overview, then the main programmes are described in more detail.
Table 1: Summary of major structural changes
The Integrated Case Programme is the backbone of the Early Learning in Medicine curriculum; there are 27 cases over Years 2 and 3 with widely varying student tasks. Contextual and integrated learning are combined within small group work (10 students per group). The use of clinical cases facilitates the attainment of basic science principles whilst demonstrating and enhancing clinical relevance.4
Students work on a clinical case or health scenario for a two week period. This is often initiated by a volunteer patient with a particular condition talking to the whole class about their personal health experiences of arthritis, angina, HIV, and so on. The clinical scenario is reviewed in the initial two hour tutorial, then students complete tasks to further their understanding of the health issue, drawing on previous medical science and clinical learning.
Students then have tasks to complete in their independent study time. The second week tutorial allows them to share their independent learning and to apply their accumulated learning from the scenario to more advanced tasks.
In Year 3, independent learning will become more self-directed, whereby the students also identify what they need to learn. This will be a further step in the students’ learning evolution.
Important central concepts such as the ‘patient-as-person’ as the central focus of medical care5 are reinforced with clinical scenarios that include the management of the patient’s problems as well as the doctor’s diagnoses. In the case involving polyarthritis, for example, students listen to a woman’s experiences of coming to terms with her diagnosis and her acceptance of future limitations to her sporting career.
In the first case tutorial they address the scientific issues of a systemic inflammatory disease, and later discuss the psychology and pharmacology of pain management. Alongside in the clinical skills course, students are practising basic history taking and examination relevant to the musculoskeletal system; they also meet with volunteer patients to learn about the illness experience of arthritis within the Healthcare in the Community programme.
The clinical skills programme is a major addition to the Early Learning in Medicine curriculum. Every week students spend 2 hours learning basic clinical skills in the new purpose-built Hunter Centre. Clinical skills are learned using peers5 as well as volunteer and simulated patients (actors). The intention is to prepare students for their transition to the clinical environment; by the end of Year 3 they will able to take a medical history, carry out a complete physical examination, carry out bedside procedures, and formulate a basic patient management plan.
Communication skills are included in the clinical skills programme, building on the previous course run by the Department of Psychological Medicine. Consistent with the majority of medical schools in the UK,7 the new course is based on the Calgary Cambridge model of medical interviewing which combines both content and process within each consultation, leading to improved awareness of consulting skills and responses to communication problems.8
Community-based learning and awareness were an important part of the previous programme (Early Community Contact) with two dedicated immersion weeks in Years 2 and 3, some within a Māori setting.9 However, this model lacked continuity of exposure or links back to the rest of the course.
The new Healthcare in the Community module develops community contact further and widens its scope; students are allocated at least 2 hours per week over 2 years. The immersion week in a community setting is retained with the focus being on rapid participatory appraisal of community health needs in small towns throughout New Zealand.10
The Faculty of Medicine has promoted the development of a volunteer patient base termed ‘The Friends of the Medical School’. Up to 900 volunteer patients, carers, and volunteers with a disability are being recruited within the Dunedin area for students to interview and sometimes perform limited clinical examinations.
Students in this programme are expected to function as ‘student-doctors’; they work independently to interview patients, carers, community agencies, people with disabilities, and other health professionals, and work as care-givers themselves in community hospitals and rest homes.11 These activities increase the relevance of their otherwise theoretical learning; such interactions and experiences of health professional work can foster an early appreciation of professional responsibilities and challenges.12–14
The previous programme was structured almost exclusively on various body systems. However, several modules were often present in any week of learning which gave students the impression of a congested and fragmented course. The revised module programme now contains body system modules configured as sequential blocks of learning for 4–6 weeks. In addition, there are several vertically integrated modules throughout Years 2/3. These include pathology, infection and immunity, blood, professional development, Hauora Māori, and others. Learning within these modules is supported by, and linked to, the associated clinical cases during that period of time to achieve greater horizontal integration within modules.
The lecture is still an important aspect of teaching,15 used to clarify difficult concepts, introduce material not contained in the literature, and/or direct the students in their independent and small group work. Didactic spoon feeding has been reduced, raising the expectation of the students to be prepared, thinking adults. Laboratory based work remains a key practical element of the module course. Years 2/3 build on some of the independent learning skills acquired in the revised HSFY course.
It is often stated that assessment drives learning; it is perhaps the most important aspect of the educational process.16 The assessment programme has been reconsidered in light of the changes to the course. In the past, Years 2/3 paper-based examinations were driven by clinical scenarios with the application of basic sciences, and this is retained. Students also sit regular multiple choice tests related to current topics, write essays about their learning in community settings, and are tested on their acquisition of clinical skills through Objective Structured Clinical Examinations (OSCEs).
The expectations and experiences of the new students and their tutors and the challenges in delivering this revised course will be evaluated regularly using focus groups, discussion with student educational representatives, and web based survey tools. Initial feedback (May 2008) has been positive.
Recent international educational research has indicated a number of trends in undergraduate medical education.17 While some of these approaches have already been implemented within the Otago curriculum there are still areas requiring evolutionary improvement. Four key areas will be described briefly.
To enhance cognitive gains learning should be an ‘active’ rather than passive process;18,19 student-centred learning allows the learner to take more responsibility for learning rather than being directed by a teacher. It also mirrors more closely the need for the independent work required in clinical settings. These goals can be achieved through enhanced small group work, prescribed independent learning, and ultimately self-directed study modules. Independent work encourages students to learn to seek answers to set tasks and/or problems whilst self-directed learning requires students to start asking themselves what they need to learn.
Small group learning is a method that is student-centred and active.20 Benefits include: greater cognitive gains; deeper understanding of material; development of interpersonal and team working skills; problem solving; and awareness of differing views and attitudes.21
By its nature, independent learning is both active and learner centred. While medical knowledge is always expanding and changing, the ability to extract relevant information and to understand and apply it is a generic skill that is more valuable in the long term than the ability to recall facts for a moment in time.
‘Early patient contact’ refers to students interviewing and examining patients in their first 2 years of training; there has been a significant shift in perception in the last few decades that this idea is both feasible and desirable.22 Early exposure to patients and clinical practice may encourage a more intrinsic motivation to learn, compared to extrinsic motivation fuelled only by external examinations.23 Early patient contact facilitates more appropriate attitudes towards future practice, and improves the undergraduate educational experience24 (Box 1).
Box 1. Summary of educational benefits of early patient contact
Early clinical experience ‘fostered self awareness and empathic attitudes towards ill people, boosted students’ confidence, motivated them, gave them satisfaction, and helped them develop a professional identity. By helping develop interpersonal skills, it made entering clerkships a less stressful experience. Early experience helped students learn about professional roles and responsibilities, healthcare systems, and health needs of a population. It made biomedical, behavioural, and social sciences more relevant and easier to learn. It motivated and rewarded teachers and patients and enriched curricula. In some countries, junior students provided preventive health care directly to underserved populations.’24
The traditional pre-clinical/clinical divide has caused anxiety for students. Students move from a theoretical-, lecture-, and laboratory-based environment to the complex clinical setting; many suffer anxiety based on the abrupt changes to their learning environment.25
Earlier acquisition of clinical skills and cognisance of the complexity of the clinical environment may ease this transition; students also need to have a legitimate service role to feel more valued within the clinical environment. Furthermore, the combination of early acquisition of clinical skills and community learning can facilitate a better appreciation of the role of the health professional and professional behaviour.12,13,22,24
Learning about community-based healthcare is important; the majority of healthcare interactions now occur within community settings, which is also where the majority of graduates will practice. The opportunity for students to listen and talk with elderly patients in the community may be synergistic with later training.23
The Australian experience of undergraduate learning in rural settings has also been informative; outcomes include better synergy between the university and local health services, student perception of being more valued by supervising doctors and their patients, and ‘opportunities for students to learn how professional expectations can mesh with their own personal values.’12
The psychology literature supports the relationship between learning material in context and the ability to recall information in an aligned contextual setting.26 In other words, students can achieve greater recall of basic sciences if this is linked with a particular patient at the time (contextual anchoring). The concern leveled by clinicians regarding lack of basic science acquisition may have more to do with retention and recall of learning rather than with lack of teaching.
Grundy described two main types of integration in medical education: horizontal and vertical.27 Horizontal integration is the linking of various disciplines despite teaching at different periods of time (e.g. anatomy to physiology to surface anatomy), while vertical integration refers to linkages across different years of a course or programme.28
The changes proposed for the first 2 years of the MBChB curriculum have not been without their challenges; some of these are listed below.
Teaching versus research—Within the University setting there is emphasis on research, driven more recently by performance-based research funding. Anecdotal data suggests that university staff are feeling increasingly pressured to increase their research outputs. A symbiotic relationship needs to be re-established to avoid education being perceived as an extra burden on clinicians and researchers.
The Faculty of Medicine has responded by implementing new appointments that focus predominantly on education. These include programme conveners to design and develop each of the new programmes, teaching fellows, and administrative support. This has had a positive effect by reducing the burden on existing staff to put time aside for curriculum design.
Departmental structure—Traditionally, many undergraduate medical curricula have been structured around disease-centred teaching based on departmental interests. Students are exposed to widely differing approaches in clinical practice; integration of learning between various clinical rotations has been problematic.
Given current clinical pressures, releasing clinicians for Year 2/3 teaching has been difficult. The Faculty of Medicine has responded by consolidating more funding within Faculty for the revised course, particularly funding of tutors. This will represent a partial move away from departmental bulk-funding. Furthermore, it is hoped that better vertical integration will be achieved by involving Year 4–6 clinicians in the planning of cases with the Year 2/3 biomedical scientists.
Geographical constraints—The Dunedin area hosts a large medical school with up to 250 entrants per year. This requires creative solutions if Year 2/3 students are to interview and examine a wide variety of volunteer patients. This is partially achieved through volunteers from the ‘Friends of the Medical School’. Furthermore there are ongoing challenges in the coordination of the Years 4–6 programmes, being spread across three widely separated centres. Faculty is responding to these geographical challenges by promoting inter-school meetings and communal inter-school learning opportunities for Years 4 and 5.
Resistance to change—Compared to the ‘green field’ approach in developing brand new medical schools,29 it is more difficult to achieve curricular change within established institutions. Such change is inherently slow;30 staff are not always aware of research identifying educational innovation and/or progress, and generally it is easier to continue with the status quo than revise the overall structure and/or individual courses. While, anecdotally, the graduates from Otago are commended and sought after in other countries, it does not mean that better methods of education cannot be found.
The Faculty of Medicine has initiated a programme of regular review of the undergraduate programmes to ensure there is periodic updating and improvement of the curriculum. The focus is evolution rather than revolution; this should help avoid the disruption associated with major curricular change.
Attention to change management—Similarly, there has been much written about the management of innovations.31,32 Otago has been no different to many other medical schools where more attention is focused on planning than on managing the desired changes. For the University of Otago, this problem is further compounded by having three different campuses delivering advanced learning in medicine, increasing the problems of communication and coherence.
Leadership is essential within change management.33 The Faculty of Medicine has offered strong and supportive leadership from the top down. The changes in the curriculum have been deliberately incremental fulfilling many of the criteria espoused for change.34 Key coordinators of the Early Learning in Medicine programmes have made attempts to include staff in proposed changes through road shows, conferences, and written resources.
Staff expertise and training—The movement to an expanded cased-based programme, clinical skills teaching, and learning in community settings has brought new challenges in terms of staff training. Staff development is an essential requirement for these programmes in which most tutors facilitate learning rather than teach didactically. Training is now ongoing and comprehensive, while ‘teaching fellows’ have been employed to take tutorial groups and assist other academic staff.
It is hoped that the changes will ensure that the broad outcomes of the Faculty of Medicine are met and that it maintains its central role in the New Zealand healthcare system through the provision of excellent undergraduate education in medicine and the biomedical sciences.1
It is anticipated that the graduates from Otago will continue to serve the community with its changing health care needs and demographics and will be responsive to individual patients with varying personal needs.
Changes are intended do develop the individual student ensuring the ability of the graduate to continue as a growing independent practitioner for the whole of their career.
The educational model adopted by Otago is a hybrid system acknowledging diverse learning styles of the students and different learning modalities. The lecture, small groups, practical sessions, and patient-based sessions all contribute to the varying learning demands of the course and styles of the learners.
Irrespective of the challenges, it is anticipated that these evolutionary changes for the Early Learning in Medicine curriculum will build upon the strong features of the previous course and produce a student who is able to function effectively in the clinical environment at an earlier stage. It is also hoped that the new programmes of Clinical Skills, Integrated Cases, and Healthcare in the Community will enhance the graduates’ ability to function effectively as first year house officers and beyond.
There will be an inevitable impact of this revised early course on the current format of Years 4 to 6, and changes are now being considered. There have been, and will be, many challenges in implementing the revised Early Learning in Medicine curriculum, but there are two factors that we hope will ensure success. These are the students and staff who continue to be a source of inspiration: the students in their desire and ability to learn; and the staff’s dedication and desire to teach.
Despite the challenges and difficulties of curricular change, the opportunity to enhance the learning environment for our undergraduates and instil lifetime learning skills in our graduates is both exciting and compelling.
Competing interests: None known.
Author information: David Perez, Programme Director, Early Learning in Medicine Course; Joy R Rudland, Director of Educational Support and Development; Hamish Wilson, Healthcare in the Community Convenor, Gayle Roberton, Integrated Case Convenor; David Gerrard, Clinical Skills Convener; Antony Wheatley, Module Convener; Faculty of Medicine, University of Otago, Dunedin
Acknowledgements: We thank members of staff in the Faculty of Medicine and the undergraduate students who have invested time and energy into the development and initiation of this new programme.
Correspondence: J R Rudland, Director of Educational Support and Development, Faculty of Medicine, University of Otago, PO Box 913, Dunedin, New Zealand. Fax: +64 (0)3 4795459; email: email@example.com
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