A medical school curriculum for the 90s and beyond

McGill Journal of Education, Apr 2000 by McLeod, Peter

Having outlined our concerns with the then current curriculum, we looked closely at, but rejected, problem-based learning as a solution to our problems. We liked the small group teaching aspect but were concerned that an entire PBL curriculum would be too resource-intensive for our faculty. We were also concerned with the assumption that problem solving is a generalizable process that can be used to deal successfully with all clinical problems. These concerns combined with the absence of convincing evidence of superiority of graduates of PBL schools led us to borrow in only a minor way from PBL.

What evolved from the CIC deliberation is an exciting modified "systems-- based" approach to learning which is a hybrid of an organ-based model, a problem-based model, and a clinical presentation model. In the systems-- based curriculum, student learning is fostered by concentrating the instruction on body systems. For example, the kidney will be the focus of study for a period of several weeks. Its development, function, and diseases will be discussed by experts representing the basic and clinical sciences. Horizontal integration of teaching is assured by simultaneous involvement of basic scientists such as biochemists, physiologist, and pathologists. Experienced clinicians will be part of the faculty mix to emphasize vertical integration of learning from the basics to the practice setting. All of the learning is focused on a clinical case in the relevant system. In this new curriculum the first 18 months of medical school were radically changed while the subsequent two and a half years of patient-based learning were reorganized but remained basically unchanged. The 18-month basis of medicine course in years 1 and 2 is characterized by clinical case-based instruction, small group expert tutors working as instructors, some lectures and considerable nonscheduled time for self-directed learning. Provision has also been made for students to Team computer and information-management skills. This new curriculum has been in place for five years and it is time to ask, "What impact has it had?"

It is probably fair to say that most clinician-teachers are pleased with the changes. They would say that students seem to be better problem solvers, less concerned with acquiring encyclopedic knowledge. Some of us feel that those in the early years are happier with what they are learning and this may reflect the practice of embedding the basic science instruction in clinical cases. As Flexner said in 1910, "There is no cement like interest, no stimulus like the hint of a practical consideration." Basic science instructors are somewhat less enamored of the new curriculum. Many feel that basic science concepts are being glossed over in favour of the "romance" of clinical cases. Others express concerns about the difficulty teaching with clinical cases and some are finding it difficult to adopt the Socratic approach to teaching that is recommended for small groups.

One surprising outcome of the new curriculum is a remarkably heightened awareness of the importance of faculty development. Serendipitously, at the time the new curriculum was being considered, a new position, that of associate dean for faculty development, was created. Shortly thereafter a four- member faculty development advisory committee came into being and in 1994 the faculty development office opened. There is little doubt that faculty members' apprehensions about their instructional role in the era of the new curriculum stimulated many to demand workshops and individual instruction in topics such as small group teaching and interactive lecturing. During the past four years we have held more than 50 workshops and over 1300 different faculty members have attended for a total of 2027 "visits" with representation from both the basic and clinical sciences. Among the 13 or so different types of workshops presented are topics such as effective lecturing and AN aids, effective clinical teaching, information technology and teaching in the ambulatory setting.