In 2010, a comprehensive study, following in the footsteps of the Flexner report, called for additional reform in medical education, especially the application of prior knowledge and experience through the concept of integrating basic, clinical, and social sciences in what has also been called a “spiral curriculum.”1 Significant efforts have successfully integrated medical knowledge horizontally such that material is taught on the basis of organ systems, rather than as separate disciplines. In an additional step of integration, medical schools, including Boston University School of Medicine (BUSM), are working to improve vertical integration of the basic sciences and clinical disciplines. In a review of U.S. and Canadian medical curricula, Spencer and colleagues2 found that only 19% of U.S. and 24% of Canadian medical schools required any course that integrated basic science instruction into the final, clinical years of undergraduate medical education. As evidenced by the small number of schools that require basic science content in the fourth year of medical school, integrating basic science concepts into clinical medicine is more difficult than integrating clinical applications into basic science material.
Irby and colleagues1 discuss several trends in medical education that have inspired curricular innovations. Noteworthy among them are the need to model a team-based approach to patient care and the increased use of case-based learning strategies. Research shows that a team-based approach improves knowledge retention, the connections between different subjects, interpersonal skills, psychosocial understanding, attitudes towards patients, and teamwork skills. However, disseminating and implementing educational reform requires careful planning, the development of appropriate learning objectives, and the creation of a clear assessment plan.3 Medical school faculty who face the competing draws of research, clinical duties, and education in a constantly evolving academic environment may perceive implementing such reform as daunting.
We identified an opportunity for curricular integration with the launch of an organ-based redesign of the medical school year (MS) 2 curriculum at BUSM. Here, we describe a novel approach to sustainably integrate basic science and clinical content over three years of medical school in a “spiral learning model.” To the best of our knowledge, we are the first to involve medical students in every stage of the design of this integrative curricular innovation.
BUSM instituted major curricular changes in 2008–2009, which involved integrating the MS 2 curricular content into an organ-system-based course called Disease and Therapy (DRx). During the planning and design of this integrated curriculum, teaching faculty in the Department of Pathology and Laboratory Medicine, the Department of Anatomy and Neurobiology, and the Department of Radiology closely collaborated to develop vertically integrated curricular content through what we called the Cadaver Biopsy Project (CBP). Supplemental Digital Figure 1, available at https://links.lww.com/ACADMED/A169, represents the general framework of the curriculum at BUSM after implementation of these changes.
The objectives of the CBP are (1) to bring a patient-oriented approach to the study of the various disciplines during the first, second, and third years of medical school at BUSM (the cadaver is the students’ first patient); (2) to recognize the relevance of basic science concepts in clinical and therapeutic algorithms; (3) to promote small-group learning and collaboration; (4) to emphasize case-based learning; and (5) to encourage medical students to actively participate in medical education reform.
To achieve these goals, we developed the project in three phases over a period of three years. Phase 1 of the CBP began in the fall semester of 2009 with MS 1 students identifying specific pathologic conditions through the dissection of their cadavers during gross anatomy lab sessions. A team of faculty and residents from the pathology department performed cadaver rounds during which they discussed clinical perspectives, gross pathology, and differential diagnoses of pathologic conditions observed in the cadavers. The MS 1 students performed dissections (see Supplemental Digital Figure 2a, https://links.lww.com/ACADMED/A170) while faculty (L.J.) and senior (MS 3 and MD-PhD) students (including L.V.) took biopsies of any abnormal tissue. Pathology residents further dissected the specimens obtained at these sessions, and faculty (L.J.) selected any additional appropriate areas for evaluation. Histology laboratory staff prepared microscopic sections through hematoxylin and eosin staining, and representative images from these specimens were available for further review by the MS 1 medical students.
In the histology course during the spring semester of MS 1 (2010), students attended a review session of the biopsies taken from their own cadavers. During this session, the students who dissected specific cadavers during gross anatomy discussed their findings, and then the pathologist (L.J.) presented the specific pathology and a final diagnosis. At this point in the semester, the MS 1 students had sufficient knowledge of normal histology and were able to understand the significance of abnormal microscopic pathology in the context of their own cadaver dissections (see Supplemental Digital Figures 2b and 2c, https://links.lww.com/ACADMED/A170). The faculty member (L.J.) specifically told the students that they would revisit this content over the next two years.
In Phase 2 (fall of 2010 and spring of 2011), during the DRx course, which horizontally integrated the MS 2 curriculum by organ system (see Supplemental Digital Figure 1b, https://links.lww.com/ACADMED/A169), the students revisited the gross anatomy and histology content (through the biopsies taken from their cadavers) in proctored cases, self-study cases, and/or gross lab demonstrations (see Supplemental Digital Figures 2d and 2e, https://links.lww.com/ACADMED/A170). A few new radiology concepts were introduced during these sessions—specifically, content that students would review during the radiology rotation of MS 3. For example, students identified organs in radiological studies and correlated interventional images in an appropriate context (e.g., lung tumor [see Supplemental Figure 2f, https://links.lww.com/ACADMED/A170] or coronary artery stenosis).
During Phase 3 (fall 2011 and spring 2012), MS 3 students revisited basic science material that they had learned in the first two years of medical school in their mandatory third-year radiology clinical clerkship. This phase of the project incorporated the same cadaver biopsy material and DRx content that students had previously encountered in their first and second years of medical school. Faculty provided the diagnosis up front because the case study for the seminar was not intended to be yet another “unknown diagnosis” workup. The case study was broken into four sections; each section included short-answer questions that addressed, respectively, (1) gross pathology and anatomy; (2) histology and microscopic pathology; (3) laboratory and imaging studies; and (4) clinical medicine, treatment, and follow-up. Some questions required direct answers (e.g., “Define ischemia and hypoxia”), and some required indirect answers (e.g., “What is the relevance of microsatellite instability testing in a 45-year-old patient diagnosed with colon cancer?”).
Students were divided into four groups, and each group was assigned one of the four sets of questions. A faculty member (L.J.) encouraged the students to review information from their first two years of medical school and provided specific links to this material (see Supplemental Digital Figures 3a and 3b, https://links.lww.com/ACADMED/A171). Faculty also asked students to review current data from certain key online references (e.g., the National Comprehensive Cancer Network). Groups addressed the questions in a 15- to 20-minute presentation to the class. The short-answer format allowed the students freedom to individualize their presentations and made the final discussion more interactive. Basic science faculty (L.J. and C.O’H.) and a designated radiology faculty member (radiology resident or fellow) proctored the seminar and shared further expertise on the topics covered. The faculty modeled a team-based approach to addressing the index case (e.g., what is the most cost-effective imaging modality to assess a patient with suspected acute appendicitis?).
The students received a pass/fail grade for the seminar that was incorporated into their final radiology grade. At the end of the seminar, faculty posted the answers for the discussion questions online for review. Faculty have created an electronic library of the cases discussed thus far so that medical students can use them to learn more about a variety of different disease processes. Some of the discussion questions have incorporated social science content, epidemiology, and emerging heath care models into the patient care decision algorithms.
Medical students were involved throughout the design and implementation of the CBP. Senior students, selected from those who applied, contributed to all three phases; that is, they played a part in the cadaver biopsy rounds in Phase 1 (L.V.) and the gross pathology demonstrations in Phase 2 (A.G.), and they developed case studies for Phase 3 (L.V., A.G., A.E., H.J.C.). For Phase 3, they chose a disease process to research, met with basic science and clinical science faculty, reviewed lecture material presented during MS 1 and 2, and then developed questions and “expected answers” for the case study. The students dedicated 24 to 48 hours of time to the development of each case. These senior medical students received mentoring throughout the project through face-to-face meetings (once every month during the development phase) with a faculty member in charge of the project (L.J., D.V., C.O’H., K.S.). They also received feedback from other students and faculty members through an online collaborative Web site that provided access to all course developers.
Meeting the course objectives
Overall, we were successful in achieving the five goals that we had set at the beginning of the CBP, which emphasized vertical integration of histology, physiology, pathology, molecular genetics, and clinical medicine information through the first three years of medical school. We designed the CBP to be centered on the patient by using the cadaver as the students’ first patient in Phase 1. We integrated basic sciences into clinical diagnosis, and we encouraged small-group learning in Phase 3. Case-based learning was emphasized throughout the CBP. Finally, medical students were actively involved in the design and implementation of the intervention.
Including senior students in course design
This last objective is especially notable in view of limited resources (time and otherwise) for faculty review of curricular content in courses other than the ones that they teach. We identified medical students as a unique resource able to fill this role because they have recently been active participants in the actual curriculum. While the medical students who developed the cases in Phase 3 of the CBP added a special perspective to the project, they also gained the experience of enacting curriculum reform and developing innovations in education. Further, their involvement with clinical and basic science faculty contributed to the team-based model.
Students’ satisfaction and institutional support
In addition to accomplishing all five of the objectives we set out to meet, the students (according to surveys and informal feedback) enjoyed the CBP. One student remarked, “I wish the donor body pathology session had been even longer.” Students acknowledged the effort to integrate the curriculum. One student commented, “[G]reat idea of incorporating past DRx material,” and another student wrote, “I appreciate the review of basic science material … an essential component of 3rd year.” Faculty and senior administrators of the office of academic affairs (D.V.) were also supportive of the project and offered creative ideas toward assessment and improvement.
During the design and implementation of the CBP, we also learned important lessons regarding curriculum development. First, identifying key stakeholders (in our case, medical students, course managers, and administrative team managers) is vital. A project of such integrative nature requires the dedication and commitment of key faculty members who own the project and take on leadership roles. Support from department chairpersons and key administrative personnel from the medical school is essential. Second, the project required identifying course content that can be integrated smoothly, course managers who are willing to try the innovation, and clinical rotations that allow students time to prepare the presentations in Phase 3. We found that clearly and explicitly defining the specific methods used, the goals, and the objectives of the project for not only the students but also other team members was important for buy-in. Finally, when engaging senior medical students in the design of the project, meeting regularly to discuss progress, providing access to course content, and encouraging them to meet with clinical and basic science faculty to discuss the accuracy and clinical relevance of the content of their cases proved important. Ultimately, we found that a project that integrates basic science and clinical medicine throughout the basic and clinical years of medical school can be implemented as long as the vision, commitment, resources, and interest are present.
Developing appropriate and measurable outcomes is always a challenge in medical education initiatives such as this one. Going forward, BUSM faculty and leaders need to be able to acquire sufficient and meaningful data to consistently and effectively gauge the project. The use of qualitative surveys will lead to the accumulation of data useful for ongoing course improvement. A few such attempts are reported in the literature.4,5 Student evaluations of the CBP have been strongly positive overall. However, documenting the impact of this curricular innovation in correlating with United States Medical Licensing Exam scores and other long-term competency-based outcome measures will need further consideration.
Acknowledgments: The authors thank Todd Hoagland, PhD, Ann Zumwalt, PhD, Douglas Hughes, MD, Elizabeth Rivera, Paul Romesser, MD, Anunita Garg, MD, Bjorn Watsjold, MD, Sandra Hsu MD, and Jimmy Wang, MD, for their invaluable contributions for the success of this project.
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2. Spencer AL, Brosenitsch T, Levine AS, Kanter SL. Back to the basic sciences: An innovative approach to teaching senior medical students how best to integrate basic science and clinical medicine. Acad Med. 2008;83:662–669
3. Kanter SL. Toward better descriptions of innovations. Acad Med. 2008;83:703–704
4. de Jong Z, van Nies JA, Peters SW, Vink S, Dekker FW, Scherpbier A. Interactive seminars or small group tutorials in preclinical medical education: Results of a randomized controlled trial. BMC Med Educ. 2010;10:79
5. Scicluna HA, Grimm MC, O’Sullivan AJ, et al. Clinical capabilities of graduates of an outcomes-based integrated medical program. BMC Med Educ. 2012;12:12–23