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Rebuilding Medical Education


By Carole Bartoo
August 2012

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This fall Vanderbilt University School of Medicine will transition to an innovative, four-year curriculum that has been characterized as its most comprehensive education revision in decades.

Called Curriculum 2.0, it is a switch from a highly regarded, but traditional, one-size-fits-all curriculum to a complex, integrated, collaborative and flexible course schedule that includes less traditional lecture and more clinical and case-based experience.

Kim Lomis, M.D., associate professor of Surgery and associate dean for Undergraduate Medical Education, is leading a team of faculty and students in launching the new curriculum. She says when she shows the colorful chart of the fully implemented coursework to faculty, she still gets a few glassy-eye looks.

“We are still working to educate the faculty on the structure and flow, but when implementation is complete, the real difference will be that clinical, scientific and humanities learning will take place in the workplace throughout all four years,” she said.

She fully recognizes the School of Medicine is doing this before a large audience of parents, alumni and colleagues who will be watching board scores and residency placements closely for any sign of strain.

Leadership across the School of Medicine, the Medical Center and the University recognizes the change as necessary and a step toward an exciting and evolving model of medicine.

“Today, the delivery of health care is vastly different than it was even a decade ago. The rate of scientific discovery and the accumulation of knowledge is accelerating so rapidly that in order for our students to continue to be tomorrow’s leaders, we feel this curriculum change is necessary. What our faculty and administrators have created together with the students may very well set a new standard for teaching and learning for other medical schools to follow,” said Jeff Balser, M.D., Ph.D., vice chancellor for Health Affairs and dean of the School of Medicine.

Bonnie Miller, M.D., senior associate dean for Health Sciences, has been a driving force behind the curriculum change since 2006.

"The traditional curriculum was no longer consistent with how people use science to provide up-to-date medical care. It was time for us to incorporate new research and concepts about how people learn and how they apply what they learn.  ­Bonnie Miller, M.D. Photo by Daniel Dubois.

"The traditional curriculum was no longer consistent with how people use science to provide up-to-date medical care. It was time for us to incorporate new research and concepts about how people learn and how they apply what they learn.  ­Bonnie Miller, M.D. Photo by Daniel Dubois.

“We needed a curriculum that is agile and better equipped to meet the needs of our students. The traditional curriculum was no longer consistent with how people use science to provide up-to-date medical care. It was time for us to incorporate new research and concepts about how people learn and how they apply what they learn,” Miller said.

Lomis and Miller are quick to point out that the new curriculum is not driven by a shortfall in instruction at Vanderbilt, but rather by the need for a fundamental change in how medicine is practiced.

“The driver is the acknowledgement that leading physicians need a new skill set. We will focus less on what they learn and more on how they learn. With the pace of scientific change and discovery, we needed to stretch learning out,” Lomis said. Thus, lifelong learning is key to the revised curriculum. William Stead, M.D., associate vice chancellor for Health Affairs and chief strategy and information officer at VUMC, has been heavily involved in developing methods to teach incorporation of ever-changing and progressing scientific information.

“He calls it a 40-year curriculum rather than a four-year curriculum,” Lomis said.

Another element is instruction in teamwork: students will work together on more team and group projects, faculty will teach collaboratively, and the School of Medicine will share learning experiences with other health disciplines like nursing, pharmacy and social work.

“In my dad’s era, it was the individual physician’s knowledge that largely determined the outcome for patients, but now a collaborative approach is needed,” Lomis said. “We work in teams every day in clinical practice and participate in team research across disciplines across campus.

“Everyone is thinking differently about medicine, and this is ultimately good for patients.”

Input from Students
Since the design committees began working on Curriculum 2.0 several years ago, students have been involved, approaching it the same way they approach most things. They see it as an opportunity to take their own education apart and see how it ticks, and then put it back together again – differently, and better. They are natural leaders and agents of change.

“The traditional system is set up now to generate the same results it has produced in the past, but if we keep creating physicians in the same manner, the health care system might never successfully change,” said Billy Sullivan, a fourth-year medical student who joined the curriculum committee his first year, and will serve as co-chair next year.

Another major trend is blending facts with critical thinking or problem-solving skills. This is in contrast to the traditional system of teaching and testing with the goal of transmitting great volumes of factual knowledge and engendering a skillful ability to recall them.

“The concept of a great leader in medicine used to conjure an image of the cowboy physician, like a Doc Martin, who had all the answers on his own,” Sullivan said, adding that is not what he aspires to now. He says he can expect his patients to arrive for appointments with Internet printouts and an expectation that he will listen to them.

“We realize there is too much information, and it is changing too fast to know it all. I admire physicians who are able to hear a patient’s question and sit before them and say with confidence, ‘I don’t know, but I will find out,’” Sullivan said.

Sullivan took a one-year break from his medical training to complete a Masters of Education in Learning and Instruction. He says even in K-12 education circles there is a trend away from solely focusing on the acquisition of factual knowledge.

“It used to be the more knowledge, the better. Instead, today, it’s teaching the transfer of problem-solving skills to new situations,” he said.

A Different Kind of Intelligence
Lomis says that’s a great example of why the new curriculum is needed.

“Scientists struggle in today’s model with getting practitioners to appreciate what is new, what discoveries have been made, and how they can apply it to their practice,” Lomis said. “The fact is the pace of changing information will never slow down. This is further evidence that a different kind of intelligence is needed in today’s health care system.”

Lomis uses a colorful stair-step chart to illustrate the dimensions of learning. At the lowest step are the facts students memorize. Then as learners they mature and build up to learning concepts and procedures. Finally, they begin to apply, analyze and evaluate.

At the very top of the steps is what is called “metacognition,” the place where students can truly be creative.

Traditionally, the latter two steps began mostly after graduation from medical school. Lomis says Curriculum 2.0 begins incorporating higher levels of learning right from the start so that by graduation students are primed to become creative physicians, well-positioned to discover and lead.

“We need to spend a lot less time at the fact-remembering stage because, frankly, computers and even our phones can retrieve better than our brains,” Lomis said.

"We need to train our students, residents and fellows to know they are part of a system and they can shape it. So this is an important question: In four years of medical school, how do we create doctors who will change medicine? - Kim Lomis, M.D. Photo by Daniel Dubois.

"We need to train our students, residents and fellows to know they are part of a system and they can shape it. So this is an important question: In four years of medical school, how do we create doctors who will change medicine? - Kim Lomis, M.D. Photo by Daniel Dubois.

With Curriculum 2.0, the hard work and dedication to becoming knowledgeable about medicine comes through case-based or problem-based learning, followed by early clinical experience that allows students to begin taking ownership of the problems they will see in practice.

Required research projects in the third or fourth year will further enhance critical thinking skills while allowing students to build mentoring relationships with Vanderbilt investigators.

Lomis and Miller say as Curriculum 2.0 progresses, it will become more flexible so that the students can shape it. By the third and fourth years, they will have their own highly personalized education plans designed for their own learning needs.

“Part of why we have done so well so far is because students are of such high caliber. We tell them, ‘This is us trying to get out of your way.’ Let’s free these bright young people to shape their education, then they will be ready for continuous quality improvement in practice,” Lomis said.

Meanwhile, critics might ask why one of the top medical programs in the nation would tinker with a very successful curriculum. After all, Step 1 U.S. Medical Licensing Exam scores at Vanderbilt are well above the national average, contributing to the success the medical students enjoy in matching to the best residency programs.

Lomis promises great care is being taken to ensure that quality measures do not suffer, but she says there is plenty of proof the old model stopped working long ago. When physician job satisfaction declined in the 1990s, the Robert Wood Johnson Foundation researched the reasons. Doctors cited increased fragmentation, the emergence of managed care, dilution of physician decision-making authority and society’s increased skepticism toward professionals. Lomis says that view was in large part due to the type of practice physicians were trained to engage in, one which no longer fits the changing health care model.

“Challenges were attributed to the system, and doctors saw it as imposed on them,” Lomis said. “We need to train our students, residents and fellows to know they are part of a system and they can shape it. So this is an important question: In four years of medical school, how do we create doctors who will change medicine?”

We might have the answers soon. Since 2010, graduating VUSM students have been exposed to elements of the new curriculum. Former Curriculum Committee co-chair Conrad Myler, M.D., says he wishes Curriculum 2.0 had been fully in place for his training. He and Sullivan say they will continue working with Lomis and other students and faculty to see that the rollout of Curriculum 2.0 goes smoothly.

“I want people to know that students coming into the Vanderbilt University School of Medicine are already very smart and have proven themselves worthy acquirers of factual information,” Sullivan said. “But top-of-the-line physicians are never satisfied with status quo, they want to have a role in making things better. Those are the kinds of students we have here and the kinds of physicians we will be.”
 

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