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| Journal of the New Zealand Medical Association,
03-April-2009, Vol 122 No 1292
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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 revised ‘Early Learning in Medicine’ curriculumThe 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 programmeThe 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.
Clinical skillsThe 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
Healthcare in the communityCommunity-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 module programmeThe 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.
Assessment and evaluationIt 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.
Trends in medical educationRecent 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.
Student-centred and active learningTo 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 introduction of clinical skills and patient contact‘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
Community-based learningLearning 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
Contextually relevant and integrated learningThe 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
Challenges to implementing changes in years 2 and 3The 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.
ConclusionsIt 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: joy.rudland@stonebow.otago.ac.nz
References:
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