SMEC Curricular retreat- part 1 Sunday 5/3/09
S.M.E.C. Mulholland: John Ableson, Pattie Frost, Evan Lapinski, Maureen Dale, John Hemler, Emily Binns, Nosheen Reza, Jason Woods, Laura Page, Nicole White, Andrew Pfeffer, Tom Hardka
Dual Degree Students: Adam Meuller, Jon Overdevest
Students from curricular forum: None in attendance
Moderator: Brad Bradenham (S.M.E.C./ Mulholland)
Agenda: Brad presented in broad strokes what the “Next generation” curriculum will look like- planned to effect for the class of 2014. This took roughly 20 minutes. At that point the meeting shifted focus to six issues that the S.M.E.C. had previously identified as issues where student input could be beneficial.
1. Autonomic pharmacology in the new curriculum: have an “autonomics thread”
1) We almost unanimously agreed that student would greatly benefit from keeping autonomic pharmacology early on in the curriculum (which is where it is currently placed). The main issue was how to prepare students to understand autonomic pharmacology. Currently, students have a full course of systems physiology before we are taught autonomics. This is ideal as autonomics interact with almost every system in the body; however, we came to the conclusion that it wasn’t entirely necessary. If anatomy, physiology and pharmacology worked together to create an ” automonics thread” taught in the foundations/S1: Molecular and cellular medicine section of the curriculum, we believe that would be enough. We don’t need an entire systems physiology course to understand autonomics. We just need to basics up front. Autonomic pharmacology will be revisited again and again throughout the curriculum and as it does, our understanding of those drugs and their physiology will only improve. However, initially, as with many subjects, a comprehensive understanding may not be what is called for. So, with anatomy professors teaching us the organization of the autonomic nervous system and physiology/ pharmacology teaching us what we need to know to have a basic understanding of what autonomic drugs are all about, we believe the result could be great for future students.
2. Immunology and Microbiology:
1) Immunology has found a home within the foundations/ S1: Molecular and Cellular Medicine section of the new curriculum.
2) Microbiology/ virology/ mycology/ parasites/ antibiotics = a different story. This will likely be one of the more difficult issues to handle in the new curriculum. There are two schools of thought; however we ultimately agreed that the middle way was the best way.
i. School of thought #1: “understanding micro for the sake of micro- ie: our current approach.” Brad used the following example from his wards experience. When thinking about an infection, what pops up in his head is an organizational scheme of gram positive bugs and gram negative bugs. You’ve got the spore forming gram positives, the enteric gram negatives etc…they are all grouped together by what they have in common on a microbiological level. For a student with minimal to no clinical experience, we all agreed that this was really the only way we can conceptualize infection. The only way we can understand infection in any organized fashion is to have some sort of organizational scheme that makes sense to us for where we are in our education (ie: we haven’t seen any sick people yet…all we’ve seen are charts of bugs grouped by common microbiologic characteristics- ie: gram positive/ gram negatives/. Growing in clusters
ii. School of thought #2: Understanding bugs from a clinical perspective: Many more experienced clinicians see infection from a purely clinical standpoint. Eg: when someone has infectious endocarditis, the have a list in their head of bugs that they have grouped together as likely culprits of that infection. This is a differential that has been assembled in their own heads from years of clinical experience. They have likely had a several patients that they can remember that had each bug growing on that heart valve. However, students don’t have that context to draw from. We haven’t seen any patients yet. While at one point this is where we all want to be and is how we all want to be able to think about infection, for our educational levels, it is not an appropriate expectation for us to be able to think this way. To make it clear, this is what would be asked of students if the microbiology course was spread apart all of the systems. We fear that we would never truly grasp the concepts that bring various bugs together and those characteristics that we use to differentiate one bug from the other. These would be links that we couldn’t make as we wouldn’t be learning about the bugs side by side- allowing us to compare them with one another.
iii. The middle road- “a little bit of both”. Multiple ways to do it….In curriculum speak- having both an infectious disease system and an infectious disease thread/ content director.
1. We thought that having an infectious disease system early on in the new curriculum where for 3-4 weeks, a very “nuts and bolts” approach to micro was presented to students. It would not be necessary to give students the full picture at this point. You could leave that to the systems. Pertinent infections to each system would be revisited in amore clinical context in each system. We could be briefly reminded of the “nuts and bolts” micro and the majority for the time in the systems could be spent talking about more clinical aspects surrounding infectious agents pertinent to that system.
2. Have a “nuts and bolts micro” course taught within the foundations/ S1: Molecular and Cellular medicine course- as described above. Again, as above, we could have some clinical micro addressed within each system as it is pertinent. However, what differentiates this “middle way” approach from the above approach is that we could include an infectious disease section as the last section of the curriculum. After having been exposed to all the systems, a soon to be 3rd year student could be spending their last weeks in second year thinking about truly global infectious processes that involve every system. By the way, this would not be much different from how POM2 is currently set up with infectious disease at the end.
3. Core Clerkships:
Somewhere along the line, we have lost what defines a core clerkship. It is a complicated issue- what is a core clerkship. We preliminarily concluded that the definition varies widely depending on who you talk to; however, perhaps what is core for one student may not be “core” for another. For a student interested in neurosurgery, having a two week neurosurgery experience during the third year is very much a core part of their education; however, for a student interested in pediatrics nephrology, this may not be the case. In essence, what makes up the “core” clerkship experience could differ slightly from person to person.
1) 4 weeks of surgery selectives in the third year. While this seemed a bit arbitrary, students have largely responded well to this for the following reasons. For those interested in competitive subspecialties, it is a big advantage to be able to gain exposure to their field of interest earlier as opposed to later. First and second year student voiced concern about making a poor impression on a surgical subspecialty clerkship early on in their medical training and preemptively “closing the door” on their future carre before they even got a chance at it. Fourth year students in attendance responded with the following. Basically, as a third year student- expectations are going to lower- after all surgical subspecialties made the sacrifice when they moved into the third year- they decided that they would be willing to take brand new third year students. Secondly, if you’re interested in something, you’ll be doing a few fourth year rotations in that field. This will be when your performance will determine your future/ ability to get letters of recommendation. Basically, these two weeks of selective just function as a taste of a field…nothing more. Some students voiced discontent that they only had surgical selectives to chose from as opposed to psychiatry selectives or OPB/ Gyn selectives or medicine selectives. In a perfect world, that would of course be preferable; however, given how competitive some of the surgical subspecialties have become, in fairness to our colleagues that are interested in those fields, perhaps it is more important to make sure they get the early exposure they need to ensure they’re making the right decision for themselves.
2) Should we trim down AIM/Family Med? What’s its overlap with geriatrics?
This has been a topic thrown around by students for years. Is redundancy/ overlap between family medicine/ AIM worthwhile/ necessary. It provides such a unique learning experience, but do we really need 8 weeks of it in the core clerkships…? Again…the important question: What should be considered “core”. Very difficult to answer at this time. The group did discuss the concept of moving AIM in it’s current state into the “new 6th core clerkship block, accompanying critical care/ geriatrics. This would allow the internal medicine clerkship to dramatically increase student exposure to the inpatient setting. Additionally, a dismantling of AIM, in its current form, was discussed in favor of having 2 weeks of AIM in the core internal medicine clerkship and 2 weeks paired with geriatrics in the “ new sixth block”. Such an arrangement was generally viewed as not only appealing, but more favorable than the current setup. Some of those present cited examples of having inadequate mentoring/ poor experiences on their AIM/ family medicine type rotations and by splitting up the experience…one would only be made to suffer through 2 weeks of a mediocre learning experience as opposed to a full four weeks. After all…a full 4 weeks of a mediocre learning experience during the core clerkships is a lot to swallow for students.
3) What about a Primary Care block or Outpatient Block ‡ this could include AIM, family, outpatient ob/ GYN, pediatrics/ psychiatry. Very feasible with our current setup of selectives…simply emphasize primary care more. Again, this would involve dismantling AIM in it’s current for in favor of a more flexible form. In this structure, it was duiscussed that AIM would essentially remain the same except for the fact that it would be offered in 2 week increments and students could have a lot more flexibility in scheduling these incremements (students may be able to choose between having their “AIM selective” in one of several locations) . In addition, it was noted that geriatrics will be an AIMish experience, emphasizing skilled nursing facility care/ palliative care etc…however, it will still predominantly be an adult internal medicine type experience. So, instead of 8 weeks of outpatient medicine, we currently have 10 weeks of it. The question was raised: are we bordering on excess? It was agreed that geriatric medicine should be a focus in our curriculum, as should primary care as both are in high demand in our current socio-medical environment…however, as student, perhaps a little more give and take is appropriate. While we were largely ok with it, it did not go unnoticed that an additional month of graduation requirements were pushed upon us. Again, would a little more give and take be out of the question?
4) Proposal: “new sixth block” be purely selectives ( four 2 week experiences, or one 4 week, and two 2 week experiences), including perhaps include a month of elective for select student interested in things that would afford such an opportunity eg: pathology, radiology, anesthesiology, dermatology etc.
5) 6th block = 4 two week blocks distributed out across all specialties
i. Or, make these requirements for 4th year…timing is important…couldn’t we just call the new 2 week geriatrics and critical care experiences “selectives” that could be done during third year, but are required to be done during fourth year, just like our current selectives?
4. Individualized Medical School experience:
1) Thesis? We are a professional school, not a graduate school. The word/ idea of a thesis was received extremely poorly by the group as a whole- nearly unanimously people hated it. However, the idea of an “ experience” was very appealing to everyone at the meeting. If students were given access to a database that had lists/ descriptions of all/ any medically/ community related projects o at UVA and were told to go out and try a few, the group unanimously agreed it would be a success. Emphasis would be on having an experience…if the experience inspired you to take on a project of your own, get published, present something…great…but there would be no formal pressure to do so. What would be required is a forum to very informally talk about your experience/ what you learned from your experience. (eg: 5 minute presentation to a SIM/ POM small group).
i. A comprehensive list of possible experiences/ projects students could pursue would have to include: medical research opportunities (clinical and basic science), community service programs/ specific projects, global health projects, interdisciplinary projects (business school, law school, education school, school of arts and sciences, school of public health, school of engineering, school of architecture).
Other issues/ specific questions we had regarding this topic:
– we discussed the current Preceptor program in POM1, and its evolution- Brad discussed what it used to be….a weeklong one on one experience in the community with a doc during Spring break of first year.
– Everyone has their own Experience spread across for 4 years
– Advisor/mentorship office ‡ mirror the MSSRP format- but again… across al 4 years…
1) We need to be competitive as a school ‡ need prep for the Boards, but no teacher in their right mind wants to teach to a test…one word for those familiar with Va. Public schools: SOLs…
2) Objective truth: The way you learn is driven by the way you are evaluated
3) One big exam at the end of the pre- clinical years vs current structure-we’re a bit skiddish over the idea of one big test ant the end of the preclinical years….once of those is plenty…boards suffices…
4) Breaking down notes ‡ path/pharm/anatomy; will it be tested each way- subject based testing? System- based testing. What are going to do?
Big organizational question….are we gong to get a few big packets of notes at the beginning of the course entitled: molecular and cellular medicine, repiratory, cardiovascualr… – or- are we gong to get the same big packets of notes we get currently – organized by disciplines….- or…are we going to get something else entirely?
Bottom line….we do want you to give us something…don’t do away with handouts….that’s just mean…at least we think it’s mean. Just think about how you want us to learn the info/ in what context you want us to learn it…and present the info in a manner best suited to learning what you want us to learn.
5) Important to get broken down feedback from each exam- if we do have “systems based testing”- we would eed a breakdown of what disciplines we’re testing wel in, poorly in, withn a given system.
Having thought about this a priori will be useful when constructing tests…we need to be able to identify our weaknesses in this type of learning environment…it can be difficult at times for us to do it on our own in a reliable fashion.
6) Do we test by thread, or by block…big question…
7) CRITICAL: we cannot increase the frequency at which we have tests…this was unanimously agreed upon. UVA has got it right! Having significant blocks of testing roughly every 10 weeks during the preclinical years is perfect. Testing less frequently is possible, but should be done cautiously….testing more frequently would significantly decrease the quality of life of students here at UVA. In our current structure, the group unanimously agreed that UVA’s testing structure is well thought out- we are not perpetually going into a block of testing/ coming out of a block of testing. The group viewed this as critical to the learning process. When you’re being taught new material as your going into a testing block, a student is only but so engaged in the new material being taught if it isn’t going to be on the upcoming test. Similarly, immediately following a test, students are generally less engaged and need to take a little mental break before buckling down again.
6. Oncology and Pediatrics:
1) There are several highly clinical topics that students feel are grossly underrepresented in the pre- clinical years. These are two of the big ones… (OB/ GYN also falls into this category in many ways…although it does not lend itself to the following recommendations as readily as peds or oncology as it does not span the systems as widely.)
i. Present in every system ‡ needs more attention that currently receives in POM2
ii. Throw it into the systems with an increased emphasis, maybe a few devoted days
iii. Could they each be a thread
iv. *** In hindsight, the author of these minutes feels that Surgery could also be included in this list…not just general surgery, but all surgical disciplines receive a cursory if not nonexistent treatment in the preclinical years. This will likely change in the new curriculum with many clinicians from surgical subspecialties.
*** a structure for better integrating basic sciences into the third year needs to be developed. If this group does not have any ideas for such a structure, the S.M.E.C. as an independent organization will address it in a timely fashion.