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13 November 2001

UCSF Reinvents Medical Education

Imagine a scene from the hit television series E.R. Doors fly open. Paramedics run alongside a man strapped to a gurney. Only this time, as the "motorcycle versus truck" is wheeled into the emergency room, the doctors and nurses each take turns looking into the camera and explaining what their roles are, what they are about to do and why.

Sure, it's a little slower than both the TV show and real life, but first-year student Becky Gladding, for one, says she was on the edge of her seat.

"Although I knew they were acting, it felt very real and exciting," says the 26-year-old student from Los Angeles. "We had been in medical school for two days and were now witnessing something that we might end up participating in a couple of years from now. It put our upcoming lectures and material into perspective and gave me a sense of excitement and interest I otherwise might not have had."

Those responsible for the most sweeping curricular reform in the history of the UCSF School of Medicine say they could not have hoped for better results. "There was applause at the end of the demonstration," says anatomy professor Pat Patterson who helped to plan the new Prologue course and observed its first class. "It's phenomenal--an energy you saw very rarely" under the old curriculum, he explains. "The students didn't want to stop asking questions. But, it was time to go."

Three years in the planning, the medical school launched the new curriculum with this year's entering class. Case reenactments are only just a part of this cutting-edge medical training program, which focuses on the integration of disciplines. In the past the links between courses like Physiology and Pharmacology were rarely clear and involved lots of rote memorization. Now, students take courses such as Cancer that include relevant lectures on everything from cell biology to psychology.

The idea is to train students to think across disciplines as they deal with a particular illness or part of the body, says David Irby, vice dean for education. "Now we start with clinical topics and issues and bring all appropriate discussions to bear on those problems," Irby explains.

In many ways, the differences between previous and future classes of students will not be in what is learned but how it is learned, Irby explains. Traditional curricula are organized for the convenience of faculty and centered around individual departments.

Students take separate courses in psychiatry, molecular biology, etc. But that model all too often leaves students asking: "Why do we have to know all this stuff?" The goal of the new curriculum is to make the objectives crystal clear and to prompt students to think about a patient on multiple levels, from molecular to cultural. "We believe that this will more adequately prepare them for clinical practice where that kind of integration occurs all the time," Irby says.

Nancy Adler, director of the Center for Health and Community and chair of the committee on curriculum and educational policy, says the investment of time and resources is bound to pay off. "We're breaking down intellectual barriers," Adler says.

"There's way too much knowledge to cram into people's minds. We're doing it in a much more innovative and fun way."

Medical Education Focuses on Culture and Behavior

One of the most notable aspects of the new curriculum introduced by UCSF's School of Medicine in September is its full integration of culture and behavior -- subjects that in the past had been covered in a couple of lectures in psychiatry and during a course on patient care.

Now students are taught about everything from culturally held beliefs on death to the effects of behavior on healing right along with lessons on anatomy and physiology.

The patient introduced on the first day of classes, for example, is a helmetless and inebriated motorcyclist who just found out he lost his job. The case reenactment offered students an insight into risk-taking behavior. Later in the case, the patient's wound doesn't heal, bringing up issues of adherence and the effects of stress on wound healing.

The challenge in creating these cases is raising issues of culture without stereotyping, says Nancy Adler, chair of the committee on curriculum and educational policy and director of the Center for Health and Community. The motorcyclist, for example, is white, but poor.

"Students will learn about the extra burdens of low social class," says Adler, professor and vice chair of psychiatry, whose research with colleagues has focused on understanding how socioeconomic factors affect the health of individuals and their communities. "We know that culture and behavioral factors play a huge role in health that wasn't represented in the old curriculum," she says. While researchers have long known that men and women of higher social and economic status have lived longer and healthier lives than those lower on the socioeconomic hierarchy, reasons as to why remain unclear. The health care system has struggled with solutions to these problems.

Taking into account a person's background and the basics of human nature are fundamental in providing proper medical care and now it is an integral part of medical school education. The newly revamped curriculum, the product of collaboration among faculty, students and administrators, integrates basic, social, behavioral and clinical sciences across all four years.

"I've presented the design of the new curriculum to a dozen different groups and, almost universally, people say this makes sense," says David Irby, vice dean for education who is in charge of the reform efforts.

Treating a diverse population Teaching physicians to treat an increasingly diverse population is especially tricky. Recently, cultural competency -- the idea that encyclopedic knowledge of the belief systems of each culture will result in the best of care -- has begun to be replaced by the idea of cultural humility.

In theory, cultural humility means not assuming that everyone shares your cultural perspective, Adler explains. In practice, it means not pigeon-holing people, she says.

Bringing in the science behind issues of culture and behavior is what will make this aspect of training work, predicts Linda Mitteness, a professor of anthropology, history and social medicine.

"It's important to recognize that teaching physicians to use cultural concepts and giving them knowledge and skills to work with a culturally diverse population benefits minority patients as well as the broader field of medicine," she says.

As part of the curriculum reform, the school has created the Culture and Behavior Resource Library, which is available to anyone interested in learning more about how culture and behavior influence health outcomes.

The research shows that physicians can improve the quality of the care they give by making fewer assumptions about their patients and learning good communication skills. "Doctors need to be able to find out what each person needs."

This kind of training is not only an education for the students, but for the faculty, as well, Mitteness says. "We're trying to force ourselves to think about how we have to work across levels of analysis with any particular case," she explains.

"It's not the way any of us were trained, but it duplicates medical practice more accurately."

Leading the Medical Education Revolution

Overhauling a deeply entrenched system like medical education is no easy task. But that's exactly what faculty, students and staff of UCSF's School of Medicine have been working toward for three years.

This fall, they introduced sweeping reforms characterized by an integrative, case-based approach. "We believe that this will more adequately prepare students for clinical practice, where integration occurs all the time," says David Irby, vice dean for education and lead architect of the curriculum reform.

In addition to focusing on the patient, the new plan also focuses on the student, Irby says. "What we want is to motivate and inspire students to develop in-depth learning habits and persist at learning longer so that they develop better skills for life-long learning," he explains.

More small groups and labs have been added and classroom hours have been cut from 30 to 24 per week. The idea is for students to have more time for independent and collaborative learning and that they will be less likely to become frustrated and depressed - as has been common in the past.

In addition to integrating the curriculum and making it more user friendly, the school has also:

· Launched MedRocket, a Web-based resource that provides a new way for students to interact with faculty, access additional course-related information and opportunities for further study and self-testing.

· Introduced the Academy of Medical Educators, a school-wide organization dedicated to fostering teaching excellence and supporting faculty members through career development.

· Appointed new Advisory Colleges to promote relationships between students and faculty members who provide mentoring and career advising.

The impetus for these changes had been building on campus for some time, but gained momentum when an accreditation team cited the medical school for a lack of oversight of the curriculum. Although the campus consistently ranks among the top-ten medical schools in the country, the citation was a wake-up call to faculty, who became intent on creating a curriculum centered on integration and based upon the best research on learning.

Making changes of this magnitude requires an amazing amount of energy and dedication from literally hundreds of people, says Helen Loeser, associate dean for curricular affairs and a professor of pediatrics. Loeser and others looked to schools across the country for guidance, hoping to learn from both successes and failures.

"The changes we made were not made in isolation," she says. Individually, most of the changes made are not novel ones. But, Loeser adds, "we've put together our own particular recipe."

These insightful changes would not have been possible without the input and hard work by current and former medical students, Loeser says. "Having students involved has made a huge difference in anchoring the change in the reality of how students experience their education," says Loeser, who worked closely with these students.

Many students served as Medical Education Fellows while taking time away from their studies. The experience was well worth it, says medical student Jo Feldman. "I've been able to come up with ideas and create things and work with the incredible people on our faculty," Feldman says.

Feldman, who holds degrees in environmental education, has alternated between third-year rotations and being a fellow. In the end, she will have put in a total of 13 months into shaping and implementing the new curriculum. "How we teach has always been important to me," she says. "It just felt like the right thing to do."

Feldman admits she envies the education new students are receiving. "A lot of us do feel jealous," she says. But, Feldman also believes the new system will undoubtedly present challenges she didn't have to deal with. "Some things will take a few years to work out," she says.

Writing truly integrated test questions, for example, takes time, thought and collaboration. "We're not going to know how things really work until we try them."

Adds Irby, "Throughout the process of curriculum reform, the faculty have initiated many exciting innovations. The number and range of these educational innovations is impressive and places UCSF in a leadership position nationally and internationally."

Source: Camille Mojica Rey

This article appeared originally as a three-part series in Newsbreak.

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