A medical school curriculum should integrate the teaching of basic sciences and clinical care, allow room for individual exploration, develop lifelong learners, and nurture professional identity, said David M. Irby, Ph.D., in his keynote lecture for the School of Medicine’s Medical Education Day on May 21. Irby, professor of medicine at University of California, San Francisco (UCSF), punctuated these four guidelines with anecdotes from a 40-year career spent researching how medical students learn—and how they can learn better.
The third annual daylong event is sponsored by the school’s Teaching and Learning Center (TLC), which was created to foster excellence in medical education. The center assists in educator development, assessment, learning technologies, and curriculum design. The annual Medical Education Day provides faculty, fellows, residents, students, and staff an opportunity to learn about a specific topic during a keynote lecture, and then attend hands-on breakout workshops that cover particular curriculum concerns. Janet P. Hafler, Ed.D., TLC director and professor of pediatrics, said she invited Irby to speak this year because of his knowledge, scholarship, and research in medical education. In 2010, Irby co-authored a report by the Carnegie Foundation for the Advancement of Teaching, called Educating Physicians: A Call for Reform of Medical School and Residency. Irby and his colleagues visited 14 U.S. medical schools and spent three years preparing the report. His talk at Med Ed Day came as the School of Medicine is poised to launch a new curriculum. Now that he was here on Yale’s campus, what did Irby think?
“Your school is doing magnificent work,” Irby said, referring to Yale’s classic emphasis on student initiative, close faculty mentoring and individual research projects, and the new curriculum. Starting in the fall, basic science and clinical core concepts will be integrated throughout the four years of medical school. This approach helps students master the underlying anatomy, molecular biology, or biochemistry concepts and apply them clinically, Irby said.
Irby’s second recommendation is that medical school curriculum be comprised of core material that all must master, and elective opportunities for individualized in-depth learning opportunities. The core portion provides a common ground, which can be measured by such milestones as performing a physical exam. The remaining learning allows students to pursue a dual MPH, Ph.D., or MBA degree, or engage in research or service in their final year, Irby said.
A medical school curriculum should also spur students to develop an insatiable desire to learn the latest medical advances and cultivate a professional demeanor as a physician. These third and fourth recommendations of the 2010 report are difficult to capture on paper, Irby said, but this elusiveness does not detract from their importance. Doctors sometimes remain stuck in the era in which they went to medical school; when he gives talks, Irby said, he can often guess a physician’s graduation year based on the questions asked. The concept of physician-as-a-lifelong-learner should be molded during medical school, Irby said. Equally important is learning how to conduct oneself as a physician. Medical school curriculum should teach professionalism, and grade students on it, he said. Faculty, residents, and students could evaluate each other on a rubric with checkboxes for respect, diplomacy, and communication skills. And if upper-class medical students serve as good role models for newer students, the battle is halfway won. “Students will pick up on the informal curriculum [from other students, residents, and faculty members] and remember that better than what you formally teach them,” Irby said.
Given that technology and health policy change quickly, a comprehensive review of medical school curricula every 10 years is ideal, Irby said. But, he added, major curriculum changes take years to complete successfully. “Faculty are anxious about doing something they have never done before,” Irby said. Despite this anxiety, “curriculum change is absolutely the right thing to do.” Skeptics or critics of a major overhaul should revisit an economic theory called the “J curve effect,” he said. The concept is that businesses, or, in this case, medical schools, rarely go from a current state to an improved or desired state in a steady, upwards movement. Progress is measured in a line that looks like the letter “J”—a sharp decline before the positive upswing kicks in.
In another parting bit of advice, Irby argued that students must be active participants in curriculum design and implementation, not passive observers. Several years ago, UCSF School of Medicine implemented a new rule that required students to receive instruction in a format called small group learning (SGL). Faculty struggled to figure out how to fit the same material into half the lecture time. Rather than encourage discussions and interactive learning during SGL, some faculty used the time to finish their lectures. “The result was that SGL was the students’ and faculty’s worst experience within the curriculum,” Irby said. Why, then, did the medical school stick with the concept? “We stuck with it because we remembered the J-Curve, because SGL was the right thing to do based on the learning sciences literature and because we knew that our students and faculty members could make it better over time, which they did. Now it is the highest rated component of our integrated curriculum,”
Teaching Physical Diagnosis
Following the lecture, the audience broke up for small group sessions, including one led by Stephen Holt, M.D., HS ’08, assistant professor of medicine, “Strategies for Teaching Physical Diagnosis at the Bedside.” In a room on the fourth floor of the Jane Ellen Hope Building, Holt stood at his patient’s bedside with an intern and a medical student. The patient, a 38-year-old male with a strange tingling sensation in his right hand, was about to help Holt demonstrate a physical exam technique called Hoffman’s maneuver. The test helps diagnose potential disorders involving the upper motor neurons.
Kneeling by the patient, Holt gently flicked the tip of the patient’s middle finger, showing the proper technique to his learners—and the patient’s fingers curl inward, contracting, revealing the underlying disorder. “Oh, it’s present!” exclaimed Holt. “Well, now we have to do a brain MRI.” Laughter fills the room.
But those laughing weren’t callous observers to a man’s neurological disorder—far from it. They were attendees at a workshop during Medical Education Day, learning best practices for teaching at their patients’ bedsides. The patient in question, sitting in a red plastic chair rather than a hospital bed, was Adrian Wyllie, a postdoctoral associate in internal medicine.
The workshop, led by Holt, Trishul Siddharthan, M.D., instructor in medicine, and Sarita Soares, M.D., assistant professor of medicine, focused on the diagnostic potential of the physical exam and strategies for teaching learners—medical students, interns, and residents—how to perform it effectively. Holt also underscored the critical need for educators to be comfortable with the exam. “Physical diagnosis is not antiquated,” he says. Skills learned for the physical exam are valuable throughout a clinician’s career, in addition to being less expensive than radiology tests.
Before Holt’s demonstration, attendees discussed the challenges and expectations inherent in bedside teaching. Educators have to juggle their learners, patients, and lesson content in a brief but sometimes daunting interaction. The conversation emphasized sensitivity to the patient’s needs, open-ended questions for the learners, clear expectations, and humility for clinicians themselves as necessary components.
Once they got a taste of the teaching simulation—and determined that Wyllie did not, in fact, need a brain scan—participants divided into three groups for their own mock bedside sessions. The facilitators gave each member a role to play: one was the seasoned clinical educator, three played various levels of learners, one pretended to be the patient, and the remaining members acted as observers to provide feedback for the “educator.”
The first scenario involved a female patient with a history of multiple sclerosis. The educators had to instruct their learners to examine the patient’s deep tendon reflexes using a reflex hammer. Each learner also exhibited difficult personality traits, ranging from dismissiveness to over eagerness. Before the exercise began, Holt took the educators aside for an overview of the procedure—just in case they needed to sharpen their own skills. “It’s not my area of expertise,” laughed one woman as she practiced with the reflex hammer.
In their groups, the acting educators tackled the challenge in different ways. Some gave their learners a brief lecture before meeting the patient, while others dove headfirst into teaching at the bedside. Once the scenario finished, participants rotated roles and began anew, this time examining a male patient with neck and shoulder discomfort. Educators demonstrated a physical test called Spurling’s Maneuver, used to assess disorders involving the nerve root; groans and grimaces filled the room as the “patients” exhibited a pained response.
Workshop participants eventually reconvened to discuss what they’d learned. Many noted the need to interpret the exam technique and avoid medical jargon in front of the patient. The value of having a specific instructional plan also seemed to hit home with some. “That was as good as it got all year,” commented one “educator” on her teaching after going through each scenario with the provided objectives. Holt pointed out that they didn’t need to be experts to feel comfortable; they just needed to choose and review the procedure beforehand. At the workshop’s conclusion, he directed participants to Evidence-based Physical Diagnosis by Steven McGee.
Clinical Reasoning Skills
Female patient with infertility concerns, treated for chlamydia five years prior, showing signs of a pelvic mass during a limited pelvic exam, with a current diabetic male partner. With so much information, how should a second-year medical student glean the most useful pieces from her history? And how should the student be taught to do so in the first place?
To start answering these questions, participants in the “Developing Clinical Reasoning Skills for Use in Small Group Sessions” workshop—ranging from rising senior pediatric residents to instructors in the OBGYN department—practiced breaking down the thought process themselves. Imagining themselves as second-year medical students at Yale, they discussed the case study and played detective, brainstorming potential causes for the couple’s infertility and laying out a plan to collect more data.
The workshop, led by France Galerneau, M.D., associate professor of obstetrics, gynecology, and reproductive sciences, and Janet Hafler, Ed.D., professor of pediatrics and director of the Teaching and Learning Center, focused on strategies for teaching clinical reasoning in small groups. Clinical reasoning, the process of gathering information about a patient, evaluating the potential for different diagnoses, and generating an adaptive treatment plan, can be difficult for experienced clinicians to teach novice learners. For the experts, it’s second nature, but students may have trouble recognizing the same patterns and organizing the information. However, clinical reasoning “is a skill that can be learned and acquired,” says Galerneau, if properly slowed down.
After the brainstorming session, the workshop attendees broke into groups and assigned a probability score to each item on a short list of possible diagnoses. Spirited discussions ringed the room as they debated each potential cause of infertility. “There’s no right or wrong,” Galerneau reminded them as she prepared the second round of information. Theoretically, once the initial diagnoses were in, the participants would order tests to assess the patients’ conditions.
Galerneau displayed a few figures on her PowerPoint, showing an abnormal ultrasound on the female patient, a normal radiology test examining her fallopian tubes, and a table indicating that the male patient had difficulty producing sperm. The attendees returned to their groups and revised their diagnoses based on this new information, eventually deciding that the male patient presented the most likely cause of the couple’s infertility.
Now armed with a full understanding of the steps in clinical reasoning, the participants moved on to discuss strategies for teaching the process to students. Based on their own experiences in the workshop, they concluded that small groups work well to foster discussion and collaborative learning. They also asked the facilitators questions that every teacher struggles with: how to encourage quiet students to participate, how to praise a student without creating a toxic or competitive atmosphere, and how to keep groups on-track. The workshop highlighted the need for conferences like Medical Education Day, giving faculty and instructors the tools to help their students succeed.