ANNUAL FEATURE: IN PROGRESS: REPORTS OF NEW APPROACHES IN MEDICAL EDUCATION: CURRICULUM: Hot Topics
Objective: Case-based tutorials have been at the core of the New Pathway curriculum at Harvard Medical School since 1985. Conducted over the course of a student's first two years, these tutorials have been constant in their format and approach, i.e., approximately one case concerning one patient per week. We developed a case format toward the end of the second year that (1) recognized student development over the preceding year and a half, (2) provided a more deliberate transition to the upcoming clinical years, and (3) actively engaged students as their attention was increasingly drawn to studying for the United States Medical Licensure Examination Step 1. At the same time, in the new model we preserved a focus on mechanisms of disease rather than clinical differential diagnosis.
Description: In the spring of 1999, a course on renal and endocrine pathophysiology developed and used tutorial cases asking students to follow four patients a week. The tutorial group of eight students was asked to function as a “medical team,” with two students assigned to each patient. Students followed the progress of their patients, presented them each day to the other students, and took alternating cross-cover call on another patient for the next meeting. The on-call teams were given information about developments for all patients and presented these findings in tutorial, leading a discussion in pathophysiologic terms. This added a sense of responsibility for understanding the patient and orally communicating with peers, important in the clinical years but often underemphasized in the basic science tutorial. If students decided they needed more time to understand a case, they could keep the tutorial “patient” in the “hospital” longer. If not, the patient could be “discharged.” Faculty meetings before and during the course provided introduction and support for the new format. The tutor—attending physician functioned as a facilitator of discussion and helped with time management, a necessary feature on clinical rounds.
Discussion: Both faculty and students were impressed with the tutors' greater engagement. A student survey achieved a 91% return rate; the data are being evaluated. Students responded enthusiastically to the verisimilitude of the experience, reporting increased motivation and responsibility and an appreciation of teamwork; they also noted the benefit of concurrent cases allowing constructive comparison and the improved preparation for the clinical years. Emotional engagement was intense, including anticipation, frustration, anxiety, and empathy, a rehearsal for ward experiences. Challenges included determining the optimal number and complexity of cases and maintaining the focus on science rather than clinical management. The format has been retained, with its third iteration in the spring of 2001. We have been considering the appropriate number of patients per session and ways to strengthen the pathophysiologic focus. Faculty development will continue to play an important role. Overall we are grateful for an approach that strengthens students' dedication to tutorial cases late in the second year, while also better preparing them for clinical work.
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