Practice of Clinical Medicine
The medical school has debuted a new curriculum that will get medical students into the clinical arena earlier. Made possible by the opening of the McGlothlin Medical Education Center, the curriculum has been tailored to the way adult students learn.
Traditional medical school curricula uses a large-group lecture format to teach the "normal" during the first year and disease states during the second. The new curriculum on the MCV Campus integrates the first two years of medical school, trimming the preclinical stage to 18 months, which will allow students to enter into their clerkships in their second year.
The Class of 1984's Susan DiGiovanni, M.D., is a professor of internal medicine and the assistant dean for preclinical medical education. She's been at the center of planning the curriculum's overhaul. She says that a new course, Practice of Clinical Medicine, is a key feature of our new approach.
"It began this year with a weeklong boot camp for the incoming students who started learning the essentials of obtaining a history and physical examination on day one," says DiGiovanni. Faculty and fourth-year students taught them how to measure blood pressure, pulse, respiratory rate and pulse oximetry. They also led them through a massive role play exercise on how to obtain a History of Present Illness and gave them the basics of an abbreviated head-to-toe physical examination.
By the end of the week, students were face-to-face with a standardized patient in their first comprehensive encounter.
A team effort: The medical school's new curriculum is known as the C3 Curriculum. It's centered on student needs, is clinically relevant and competency based. It's such a transformation that it was only possible through a team effort. More than 200 faculty and students have been involved in the process, led by Ike Wood, M.D., along with Cheryl Al-Mateen, M.D.; John Bigbee, Ph.D.; Lelia Brinegar, M.Ed.; Ellen Brock, M.D.; Joel Browning; Craig Cheifetz, M.D.; Stephen Cohen, M.D.; Linda Costanzo, Ph.D.; Steven Crossman, M.D.; Robert Diegelmann, Ph.D.; Susan Digiovanni, M.D.; Alan Dow, M.D.; Jeffrey Dupree, Ph.D.; Douglas Franzen, M.D.; Frank Fulco, M.D.; Margaret Grimes, M.D.; Phillip Hylemon, Ph.D.; Richard Krieg, Ph.D.; Laurel Lyckholm, M.D.; Virginia Pallante, M.S.; Evan Reiter, M.D.; Jeanne Schlesinger, M.A.; and JK Stringer.
"I will admit, at first it seemed like we were being thrown into the lion's den, but honestly there is no better way to learn," said first-year student Samay Sappal. "We are getting so much practice and experience in clinical settings that much of the class is already becoming comfortable with interviewing and examining a patient. The fact that we were able to start right away within the first week put our class way ahead of the curve of other medical students in gaining clinical skills early."
His classmate Baaba Blankson agrees. "By the end of that week, I could talk about exams with my second-year friends in other schools and they were surprised. The standardized patient at the end of the first week was icing on the cake. None of my friends had that experience."
She says that the PCM course and its standardized patient encounters correlate with what she learns in lectures, frequently providing a real-world application whenever she's wondered why what they are learning in class is important or how it can manifest clinically.
The new PCM course alternates weekly small group sessions with standardized patient scenarios. By the time they enter their clinical clerkships, they will have had dozens of encounters with standardized and real patients. DiGiovanni hopes that will translate to a difference in their level of confidence, clinical and presentation skills and in their encounter notes.
Baaba does, too. In fact, she says that "I wanted a school that will help me perform well on my USMLEs. I actually researched the basis for the curriculum and shared the information with a learning specialist. She revealed to me that the curriculum is organized to help me become a life-long learner: taking the initiative in my learning and letting me take responsibility for my education."
Front and center in the new course are the so-called Foundation Cases, specially conceived to integrate key basic science principles into the clinical scenarios. Students have already encountered a baby with sickle cell anemia and an undiagnosed case of pancreatitis-caused hyperlipidemia.
To arrive at their diagnosis, small groups of students interview a standardized patient in one of 16 exam rooms in the Center for Human Simulation and Patient Safety housed in the McGlothlin Center. Then the team moves downstairs to the learning studios to work through the case using a new computer program developed by our in-house IT team.
"An exceptional group of computer programmers makes our sometimes outlandish requests a reality," says DiGiovanni. "We're the envy of other medical schools."
With textbooks and internet resources, students use the program to "order" physical examinations for the patient along with laboratory tests. Each exam and test carries a cost, measured in time and money. The students submit those orders along with their differential diagnosis based on the history and must justify what they chose to order.
In a second round of teamwork, the students review the results, order more tests and refine their differential. By the end of the third round, they are expected to make a diagnosis.
"So far, 90 percent of the teams have come to the correct diagnosis," DiGiovanni says. They also get a score based on their use of time and money. "So if they got to the correct diagnosis but it took two months to get all results back and it cost $100,000, they didn't do as well as the group that took three days and spent $250!"
Baaba says that her team looks at the cost report after each case. "My group mates and I have started taking that into consideration when ordering tests. We research each test to see if there is a cheaper option or to find out if there is a preliminary test we can order before we go ahead with the expensive tests."
DiGiovanni says that the course is proving to be a great way to maintain the enthusiasm that students have when they enter medical school. "The students love the system, which is built to train them to think like physicians."
According to Samay, "It allows us to have a taste of what it is like to go through the process as a physician and gives us the flexibility of trial and error so that we can learn from our mistakes and improve as diagnosticians."
An expert wraps up each case, tying the pathophysiology of the disease to the basic science the students are learning in the classroom.
Spanning all four years of medical school, the Practice of Clinical Medicine course will give students experience in obtaining a variety of histories including sexual or substance abuse as well as specialized examinations. In scenarios with standardized patients, the students will also learn how to deal with difficult situations like delivering bad news, dealing with an angry patient or overcoming cultural barriers in health care.
"This is better than I thought medical school was going to be, honestly," Samay said. "I was expecting to sit in lecture and lab until my brain melted, but the new curriculum forces us to be more active in our education. We are required to study the material before lecture so that we can apply the knowledge to activities in lecture that help us to gain a deeper understanding. Everything we learn seems to connect so well in this system and it honestly makes learning a lot easier and a lot more enjoyable."
The accrediting organization for U.S. medical schools will require that we demonstrate the efficacy of the new curriculum. We will use traditional benchmarks such as scores on the United State Medical Licensing Examination and ratings on the national Graduation Questionnaire. In addition, we will also measure student performance against eight outcomes that faculty and students prioritized when they first met in 2008 to begin the process of transforming the curriculum.
Eight outcomes serve as a compass for the new curriculum. Being able to:
- identify, analyze, synthesize and assess the credibility of relevant information
- be lifelong learners with intellectual curiosity
- integrate the scientific foundations of medicine with the clinical practice of medicine
- self-assess learning needs (reflective practice)
- function in systems and teach each other (teams)
- demonstrate competency as outcomes
- be active learners
- demonstrate emotional intelligence, deal with the whole patient and love the profession