A medical school curriculum for the 90s and beyond

McGill Journal of Education, Apr 2000 by McLeod, Peter

ABSTRACT. During the 20th century there have been many attempts to correct perceived problems with the education of medical students. None has been overly successful and many would say that medical education of the 80s and 90s is not vastly different from that of the 20s. The most recent trend is problem based learning (PBL), a format that has been adapted by many schools worldwide. McGill has examined and rejected PBL for our faculty. We have instead introduced a modified systems-based curriculum which emphasizes small group clinical case-based teaching with horizontal and vertical integration. Self-directed learning is emphasized. Adoption of the new curriculum has been met with enthusiasm among clinician educators, mixed reactions among basic scientists, and positive reports from students. It has spawned a faculty development bonanza.

RESUME. Beaucoup de tentatives ont ete faites, durant le XX siecle, pour corriger les lacunes qu'on croyait percevoir dans l'enseignement de la medecine. Aucune n'a ete vraiment fructueuse et beaucoup soutiennent que 1'enseignement de la medecine ne differait guere, durant les annees 80 et 90, de ce qu'il a ate durant les annees 20. La tendance la plus recente est l'apprentissage par probIemes (APPS, methode que beaucoup d'ecoles de medecine du monde ont adopte. McGill a examine et rejete cette approche. Nous lui aeons prefere une approche analytique modifiee qui privilegie l'enseignement en petits groupes fonde sur des cas, avec integration horizontale et verticale. Cette approche met egalement l'accent sur l'enseignement autodirige. Le nouveau programme d'etudes a suscite l'enthousiasme des professeurs cliniciens; les reactions ont ete mitiges chez les specialistes des sciences fondamentales et favorables chez les etudiants. Le nouveau programme a grandement favorise le developpement de la faculte.

The year 1999 sees McGill University celebrating the 150th anniversary of the birth of Sir William Osler, a renowned Canadian medical educator who revolutionized medical education at the turn of the century. He encouraged "active invasion of the hospitals" by medical students accustomed to stifling classroom lectures and irrelevant laboratory experiments. His patient-based teaching carried out at the bedside became so popular that department officials had to set up regular teaching sessions in the hospital amphitheater to accommodate, not only students, but also fellow clinicians eager to learn from the master. From this developed the institution known as "grand rounds," a teaching format used world wide even today. Osler's leadership and the landmark Flexner report (Flexner, 1910) early in the century set the stage for medical education in the 20th century. Over subsequent decades there has been much discussion and debate about how best to educate medical students. Multiple "landmark" commissions addressed the perceived problems of medical schools and sweeping changes have regularly been recommended. Alas, many educators feel that little has changed and that medical education in the 80s and maybe even in the 90s is, in many ways, taught the way it was in the 20s.

One major effort to deal with this disturbing reality originated at McMaster University in Hamilton, Ontario where a unique problem-based curriculum was instituted in the 60s. The curriculum followed the lead of cognitive science and used clinical problems as the context for learning. Typically students analyze a clinical problem such as diabetes as the central method of acquiring and applying information spanning the spectrum from molecular mechanisms to treatment with insulin. Small group learning is the forum and independent learning is the goal. The apparent McMaster success led to a flood of medical schools worldwide adopting problem,based learning (PBL). Among the adopters are numerous Canadian universities.

Educators at McGill University watched this "revolution" with interest but there was no widespread enthusiasm for PBL. Nevertheless some disquieting aspects of the McGill curriculum of the late 80s led the then dean, Dr. Richard Cruess, to establish a curriculum review committee (CIC) whose mandates were to evaluate our current practices, make new recommendations for change, and give consideration to whether we should adopt PBL. The 12 members of the committee met regularly over an 18-month period in the early 90s. We identified numerous problems. Departmentalization of the teaching seemed to favor learning of the science but not the art of medicine. Departmental control of instruction also meant that information and concepts were broken up into little bits with inadequate attention paid to the whole. Noted medical educator Stephen Abrahamson, in his humorous essay on diseases of the curriculum (Abrahamson, 1978), called this phenomenon "curriculosclerosis" or "hardening of the categories." A second problem identified by the CIC was fact overload. This problem has been recognized for decades but nothing is ever done about it. In 1925, Dr. Harvey Cushing published an article lamenting the fact that students try to learn too much and we try to teach them too much. A third major problem involved poor integration of learning modules both horizontally and vertically. Departmentalization favours turf protection and turf protection is not compatible with integration. Abrahamson called this "curriculoarthritis, a crippling disease which affects articulations between adjacent or related segments of the curriculum." Other CIC concerns included excessive passive learning and student ennui with respect to understanding the relevance of much of the basic science taught in the first two years of medical school.