| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
APS REFRESHER COURSE REPORT
Departments of Physiology and Family and Community Medicine, Dalton Cardiovascular Research Center, School of Medicine, University of Missouri-Columbia, Columbia, Missouri 65211
Abstract
At the University of Missouri-Columbia, the medical school employs a problem-based learning curriculum that began in 1993. Since the curriculum was changed, student performance on step 1 of the United States Medical Licensing Examination has significantly increased from slightly below the national average to almost one-half a standard deviation above the national mean. In the first and second years, classes for students are organized in classes or blocks that are 8 wk long, followed by 1 wk for evaluation. Initially, basic science endocrinology was taught in the fourth block of the first year with immunology and molecular biology. Student and faculty evaluations of the curriculum indicated that endocrinology did not integrate well with the rest of the material taught in that block. To address these issues, basic science endocrinology was moved into another block with neurosciences. We integrate endocrinology with neurosciences by using the hypothalamus and its role in neuroendocrinology as a springboard for endocrinology. This is accomplished by using clinical cases with clear neuroscience and endocrinology aspects such as Cushing’s disease and multiple endocrine neoplastic syndrome type 1.
Key words: active learning; student-centered learning; neuroendocrinology; case studies
Problem-based learning (PBL) has become part of the curriculum in many medical schools in North America (1, 4, 5). In 1993, the University of Missouri-Columbia introduced an integrated basic science curriculum with no discipline- or department-based courses. Lecture was reduced 
60% from the previous traditional curriculum, and the primary learning strategy was small group case-based discussions facilitated by a faculty tutor. Changes were also made in the preclinical skills and clinical training parts of the curriculum. A significant improvement in student performance on step 1 and step 2 of the United States Medical Licensing Examination has been associated with the curricular changes (2, 3). On the step 1 exam, the class averages have steadily increased since we switched to a PBL curriculum, from slightly below the national mean score to almost a one-half standard deviation above the national mean score (Fig. 1A) (2). Furthermore, in the last two classes to take the exam, >30% of the students scored higher than the 90th percentile (Fig. 1B) (2). In addition, clinical faculty rated the students who completed the new curriculum as having greater knowledge of pathophysiology and disease processes as well as superior clinical reasoning and problem-solving skills compared with students trained in the traditional discipline-based curriculum (3).
|
CURRICULUM OVERVIEW
Before 1993, the School of Medicine at the University of Missouri-Columbia used a traditional discipline-based curriculum with courses that relied heavily on lectures and laboratories. In fact, in 1987, after an accreditation site visit from the Liaison Committee on Medical Education, the report commented that the curriculum was "a perfectly preserved 1960s curriculum" (2). After that visit, the dean formed a faculty committee to review and recommend changes to modernize the curriculum.
After the committee reviewed innovations in medical education, it made six specific recommendations for the new curriculum: 1) the first 2 yr should include PBL, 2) clinical training should begin in the first year, 3) students should be tested for their problem-solving abilities as well as their information base, 4) primary care should be emphasized, 5) basic science should be reviewed in the third and fourth years, and 6) the new curriculum should be managed jointly by the dean’s office and the faculty. In 1993, the School of Medicine at the University of Missouri-Columbia started a hybrid PBL curriculum that is similar to the clinical presentation model described by Papa and Harasym (6) but incorporates all of the recommendations of the faculty committee.
In the first and second years of the medical student curriculum, each year is constructed around four 9-wk blocks with a week off between blocks. Each block has 8 wk for learning, 1 wk for evaluation, and a 1-wk break. Each block has two major components, Basic Science/PBL and Introduction to Patient Care (IPC). The blocks are organized around a core set of learning objectives generated by the basic science faculty, the block-planning committees, and the curriculum board of the School of Medicine.
These block objectives are covered by a combination of case-based, student-directed learning and traditional lecture and laboratory experiences. In the first year, Basic Science/PBL consists of three PBL sessions per week, and all student groups work on the same case for the week. The lectures and laboratories are designed to either complement the cases or cover learning objectives that are not part of the cases.
During the first year, the students spend 8–10 h/wk in PBL and not more than 10 h/wk in lectures and laboratories. IPC is scheduled in the afternoon and includes small group sessions with clinical tutors. Among other things, the students learn how to take interviews and histories (block 1 IPC), perform a basic physical exam (block 2 IPC), understand clinical epidemiology (block 3 IPC), and critically read the literature (block 4 IPC).
At the end of each block, the students take an examination (week 9). The examination has two main components for Basic Science/PBL, problem-solving tests and a multiple-choice exam. The problem-solving tests are given to the students a page or two at a time with several questions that must be answered for each section. Students must evaluate the information in each case to come up with a differential diagnosis and order clinical tests or treatments based on their differential. The basic sciences rationale for symptoms, hypotheses, tests, and procedures must be provided by the student. The other component of the Basic Science/PBL exam is the knowledge-based exam, which is a more traditional multiple-choice test. The content of the exam is based on the learning objectives for the block covered in lectures and labs and the PBL cases and the learning objectives from all of the PBL cases. The curriculum is jointly managed by the dean’s office and the faculty curriculum board. The dean’s office appoints the directors for Basic Science/PBL and IPC and the directors for each block. The block directors each form a planning committee that is made up of faculty from different clinical and basic science departments that contribute to teaching in the respective block. The faculty share governance of the curriculum through the curriculum board, which oversees the creation and coverage of learning objectives for each block. Members of the curriculum board are elected by the medical school faculty.
ENDOCRINOLOGY
In the discipline-based curriculum, endocrinology was taught primarily as a section of the medical physiology course, with additional lectures in the pharmacology and biochemistry courses. In the new curriculum, the basic science aspects of endocrinology were first covered in the fourth block of year one (Table 1). This coverage included 2–3 wk of lectures and 2–3 PBL cases in block 4. During the second year,the pathophysiology of endocrinology was covered in block 7. Again, 2 or 3 wk of didactic and PBL cases were devoted to endocrinology in block 7. Whereas endocrinology integrated very well with the other material taught in block 7, student and faculty evaluations indicated that endocrinology did not fit very well with microbiology and immunology, taught in block 4.
|
|
The first step in the process was a redistribution of learning objectives (APPENDIX A) among the blocks. The most obvious change was moving the objectives relating to endocrinology and reproduction from block 4 to block 3. Other adjustments of the learning objectives were required due to the change in the order of the blocks and to make room for the new material in block 3. For example, learning objectives on the differences in skeletal, cardiac, and smooth muscle were moved into blocks 1 and 2 so that they were still covered before the integrative work on the cardiovascular system. Objectives related to ion channels and membrane potential formally presented in the context of neurophysiology were distributed more evenly throughout the first three blocks. Learning objectives on the pharmacology and physiology of the autonomic nervous system were moved into the new second block where the major organ systems are covered. The next step involved adjusting PBL cases, lectures, and laboratories to cover the learning objectives. This was accomplished by the block directors and their organizing committees and reviewed by the curriculum board.
NEUROENDOCRINOLOGY LINKING ENDOCRINOLOGY WITH NEUROSCIENCE
Initially, the neuroscience block was designed to cover one major area of neuroscience each week. The neuroanatomy laboratories took place during the first 6 wk of the block to set the stage for problem-solving sessions with additional clinical neurology cases (APPENDIX B). Each week was built around a PBL case that was selected to generate independent learning in a particular area of neuroscience, and lecture topics were chosen to complement the learning objectives associated with each case and to cover block learning objectives that are not addressed by PBL.
To accommodate endocrinology, we reduced the number of anatomy laboratories so that they could be covered in the first 4 wk of the block (APPENDIX C). The content of the first 4 wk was similar to what we used before. The first week covers elementary issues in neuroscience such as embryology, histology, and nerve conduction. The PBL case for this week involves either a peripheral neuropathy (saxitoxin poisoning) or, more recently, development issues (fetal alcohol syndrome). In the second week, we cover neuropharmacology and synaptic transmission and introduce reflexes. The case for this week is usually myasthenia gravis, which focuses on neuromuscular junction and cholinergic neurotransmission. In the third and fourth weeks, we covered somatosensory system, motor pathway, and cranial nerve systems with a spinal cord injury case and a Parkinson’s disease case. By the end of the fourth week, the students have covered the basic efferent and somatosensory system. They have also completed their neuroanatomy laboratories. At this point, they are ready to move on to higher order and integrative functions of the central nervous system.
At the beginning of the fifth week, we begin the shift over to endocrinology. In the didactic part of the block, this starts with a lecture on hypothalamic function and neuroendocrinology. The PBL case for this week is related to the hypothalamic-pituitary-ovary axis, using an in vitro fertilization or a pregnancy case. The lectures for this week cover human reproduction and the histology of the male and female reproductive systems. In week 6, we cover other systems regulated by the anterior pituitary with PBL cases involving Cushing’s disease, multiple endocrine neoplastic syndrome type 1, or hyperthyroidism. Lectures in this week cover aspects of endocrinology not covered by the cases, and at the end of the week return to neuroscience.
The block finishes with lectures on special sensory systems, problem-solving sessions, and special lectures on, for example, the neuropharmacology of drug addiction. The PBL cases for the last 2 wk tend to be more complicated, such as reflex sympathetic dystrophy and stroke caused by occlusion of the middle cerebral artery.
Thus, by using the hypothalamus and its role in endocrine function as the springboard and PBL cases with obvious neuroscience and endocrine components, we have been able to present basic endocrinology to first-year medical students in a context where neuroendocrinology is integrated with end organ function. Since making these changes, the students’ positive ratings of block 3 have increased. As seen in Fig. 1, student performance on step 1 has continued to improve; the changes in our curriculum were not associated with a decrease in student performance.
In the traditional curriculum, integration of knowledge and skills must take place in the minds of the learners. In the integrated PBL curriculum, the integration must first take place in the minds of the faculty. The traditional departmental and discipline "silos" have been replaced by faculty planning groups. It is our hope that this curriculum guides students to conceptualize rather than memorize and to learn as physicians practice, by solving problems.
APPENDIX A
Examples of Block 3 Learning Objectives
|
|
Address for reprint requests and other correspondence: J. Thomas Cunningham, Dalton Cardiovascular Research Center, Research Park, Columbia, MO 65211 (E-mail: cunninghamjt{at}missouri.edu).
REFERENCES
This article has been cited by other articles:
|
|
 |
|
  S. A. Azer A multimedia CD-ROM tool to improve student understanding of bile salts and bilirubin metabolism: evaluation of its use in a medical hybrid PBL course Advan Physiol Educ, March 1, 2005; 29(1): 40 - 50. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| Visit Other APS Journals Online |
