A new way of educating tomorrow's doctors
Visionary curriculum changes at the School of Medicine are the most wide-reaching in the program’s 157-year history.
The School of Medicine’s impressive new home is the biggest physical change that Queen’s Faculty of Health Sciences has seen since the opening of the nearby Cancer Research Institute in 2001. But the new structure itself is merely a venue for a new curriculum that, once it’s fully implemented, will have Queen’s medical students learning their profession in dramatically different ways than their predecessors did even a decade ago.
For years, like their peers practically everywhere else, Queen’s medical students learned by sitting in a lecture hall and listening to a physician-professor expound upon whatever subject he or she was expert in. The students took careful notes and absorbed a brain-popping amount of information about human anatomy, physiology, diseases, symptoms, and treatment options. For much of third and fourth year, placements in clinics, emergency rooms and hospital wards put a real-world face to what the fledgling physicians learned in lecture halls and anatomy labs.
But times have changed. New knowledge about how students learn, increased use of computer technology in the classroom, and fresh ideas about the physician’s role have all led to new approaches to medical education that flip many of the old teaching methods on their head. Thus, after some four years of careful study and planning by faculty, staff, and students, Queen’s School of Medicine is rolling out a new curriculum that blends modern, proven medical-education techniques with the School’s longstanding values and academic strengths.
“We’re trying to provide a foundational education for someone who will go into residency training, because our graduates still have to do at least another four years of training before they’re qualified to practise,” explains Dr. Anthony Sanfilippo, the School’s Associate Dean of Undergraduate Medical Education.
Sanfilippo has made curriculum change a mandate of his term. “We also wanted to reflect the idea that this is foundational because our graduates have to know how to learn throughout their careers. They won’t learn everything about medicine in four years of medical school,” he says.
There are many differences between the old and the new curriculum. One of the biggest is that the new curriculum is “competency-based” – that is, the entire four-year program is aimed at producing not just graduates who are intimately familiar with science and disease, but rather who are fully rounded practitioners who can demonstrate competency in 15 different areas including basic science and the clinical components of medicine; professionalism; communication with patients, family members and others; scholarship and lifelong learning; managing a practice; collaboration and teamwork with nurses, colleagues and other healthcare professionals; and advocating for patients, community and society. While each subject has its own individual course, the themes are also interwoven throughout all courses of study, including several new ones designed specifically with the competency framework in mind, that students will take during their four years of medical-school instruction.
Another difference in the new curriculum is that there will be less focus on teaching the pathologies of different diseases and more on clinical presentations – the various ways that a patient might describe his or her malady to a physician. It’s been determined that there are about 125 fundamental presentations (such as cough, different types of pain, fatigue, pregnancy, burns, shock, allergic reactions, etc.) that an astute doctor can use to zero in on what might be ailing the patient.
“The traditional way of teaching medicine is for a specialist like me to teach about the diseases that I see, like heart attacks and such,” says Sanfilippo, who specializes in coronary medicine. “But what we’re recognizing in our education is that we need to teach the students not about the disease, but about how the patient presents with the disease. For example, a patient who presents with shortness of breath might have one of 100 different conditions, so instead of trying to teach the student about a hundred different conditions, we’re going to teach them to start with the shortness of breath and get down to one of the diagnoses.”
The new curriculum also incorporates a number of new courses that emphasize areas of practice that Queen’s values highly. One is called “Approaches in Family Medicine,” and students take it in their very first term. There is a new course in pediatrics, whose subject matter was previously dispersed among other several courses. There is a new course in professionalism, and another called “Critical Appraisal, Research and Learning” –“CARL” for short – in which students learn how to assess new issues and information that arise in the profession (such as, for example, Liberation Therapy, the controversial treatment for Multiple Sclerosis that recently made international headlines).
A further difference in the new curriculum involves the way medical students will receive it. Traditionally, lectures comprised about 90 per cent of courses. Lectures remain an efficient way to transmit information to large numbers of people, but they will account for no more than half of teaching time. It will now be far more common for students to work in small groups to solve problems amongst themselves, with guidance from a teacher, instead of merely sitting and listening to the instructor talk. It’s one manifestation of an educational concept called “active learning”.
“We know that people learn best when they engage actively in what they’re doing, so active learning means you’re reading, thinking, writing, talking, problem solving, you’re getting feedback, you’re really engaging with the material,” says Dr. Lindsay Davidson, Msc’90, MEd’09, a pediatric surgeon who teaches a first-year course on the musculoskeletal system. “It’s the same with my nine-year-old as it is with a medical student.”
Davidson knows whereof she speaks: she wrote a Master’s thesis about small-group learning, using data drawn from her own classroom experiences and students, and she has used the approach since 2005, making her one of the School of Medicine’s pioneers in the method. Through her work on the medical school’s Curriculum Committee and at Queen’s Centre for Teaching and Learning, she’s also helping to spread the small-group gospel throughout the medical faculty and the University at large.
One trend that has spurred the rise of this type of learning is the increased use of technology, says Davidson. Most students bring laptops to class, and if they don’t understand something the instructor says, they simply search online for more information.
“Teachers aren’t needed as experts who deliver information, because the information is all around us,” says Davidson. “Instead, teachers are the people with experience that students need to help them interpret the information. That’s the paradigm shift.”
Typically the student groups work together to come up with a diagnosis for a theoretical patient. The teacher provides the group, or team, with background reading and a scenario, and over the next few weeks the teacher challenges the team to figure out what, as practising physicians, they would do next. What sort of examination would be necessary? What tests would need to be ordered? How would they rule out potential diagnoses? How would they deal with the child’s frantic parents? What specialists would they consult?
The teamwork and case-based learning needn’t always take place around a table. Thanks to an online learning-management system developed at Queen’s and dubbed “MEdTech,” team members can also “meet” virtually in online discussion forums to work thorough cases and provide feedback on each other’s ideas. Similarly, the teacher can use MEdTech to check in with students and teams and post assignments, quizzes, required readings and so on.
Of course, not all off-campus learning takes place online. A key component of medical school is the clerkship, or clinical placement, where the student spends a few weeks in an actual medical setting and works with practising physicians and other heath-care professionals. Queen’s outgoing curriculum included 18-month placements; the new curriculum increases it to 24 months, or the final two years of the program.
The longer duration is only one aspect of the revised placements. These placements used to occur at the end of term, and after the rotations were done and exams written, the student was finished with medical school. From now on, placements will work more like those in teacher’s college – students go on a placement for a few weeks, then return to classes for more advanced instruction.
“We recognized that there will be teaching that will have more relevance and students will be better able to assimilate after they’ve had some actual clinical experience under their belt,” says Sanfilippo.
People are developing or revising courses, matching the learning to the curricular objectives, implementing new learning and assessment strategies with their team, and they’re doing it with very little extra time.
The curriculum is being overhauled for several reasons. Prime among them is the fact that bodies that accredit Canadian and American medical schools and conduct student examinations – including the Liaison Committee on Medical Education and the Medical Council of Canada (MCC) – expect institutions to reflect the most up-to-date thinking and practices in what and how they teach. The MCC, for instance, is a strong proponent of the clinical presentations concept, and Queen’s new curriculum borrows heavily from that model. Similarly, the Association of Faculties of Medicine of Canada promotes the competency-based model as one of several changes that medical schools in this country should adopt in order to produce graduates with skills that meet contemporary societal needs.
So, while the medical school's former curriculum had strengths – particularly in the area of clinical skills training, for which the Queen’s is known nationally and which remains embedded in the new framework – other areas had to be revamped to better meet accreditation standards.
Overseeing that labyrinthine process is a Curriculum Committee head by Sanfilippo, and various sub-committees that report to the parent committee. There is plenty of activity at the classroom level, because medical courses differ from other university courses in that they typically have not one, but several instructors. The person with overall responsibility for the course, who serves as its “face” for students and is often its principal instructor, is called the Course Director. As is the case with most of the teaching faculty at the medical school, they are also practising physicians.
Some faculty, such as Davidson, Dr. Susan Moffatt, Meds’78, a respirologist and intensive care physician, and Dr. Michelle Gibson, a geriatrician, are curriculum leaders who are familiar with the new methods and comfortably employ them to great effect in their classes. The three also serve as Term Directors to whom the Course Directors report so that all teaching strategies, learning objectives and assessments can be aligned. As well, the Office of Health Sciences Education has recruited Sheila Pinchin, an educational developer who is assisting the medical school with the big transition and who often sits in on classes to provide support to professors who are themselves trying to learn the new methods.
“People are developing or revising courses, matching the learning to the curricular objectives, implementing new learning and assessment strategies with their team, and they’re doing it with very little extra time,” says Pinchin. “It’s a huge commitment, but hardly anyone complains. I’m really impressed at how faculty across the board are stepping up to the plate.”
And what about the students, for whom all this is being done? According to second-year medical student Sabra Gibbens, who during her time at Queen’s has experienced both the lecture-based format and the shift towards small-group learning, the new curriculum holds promise. Still, some kinks remain to be worked out. “Some teachers are better at it than others, and there are some subjects that lend themselves better to it than others,” she says. “But that’s the sort of stuff that gets sorted out over time. Overall, I think the new curriculum and the teamwork approach is going to be very beneficial. It really reflects how things work in the real world.”