Emory Medicine, Spring 1995


Humanizing Medical Education

"One of the most important accomplishments of the curriculum change has been to bring faculty and students closer together," says Dr. Jonas Shulman.

A new pathophysiology course designed by Dr. Joel Felner (center) helps prepare second-year students for clinical training. Here, Dr. Felner works with M-4s Myra Phipps and Chris Sward on "Harvey," a cardiology patient simulator Dr. Felner also helped develop.

by Karon Schindler

Lisa Cooper's first interview with a patient is one she is unlikely to forget. With her first-year medical school classmates looking on, she gamely began asking the probing, highly personal, and sometimes embarrassing questions involved in taking a patient history. When the patient informed her calmly that he had AIDS, she started crying, and he responded, in a reversal of the usual doctor-patient role, by trying to console her.

Lisa, now a seasoned M-2, was participating in Emory's new patient-doctor course, introduced to the curriculum last year as part of an effort to get students involved with patients from the very beginning of their academic careers. "Students love the patient interview part of this course," says Dr. Jonas Shulman, associate dean for medical education and student affairs. "It's a humbling experience, but it's good for them. If you don't learn how to connect with patients, nothing else really matters."

In addition to patient interviews, the patient-doctor course encompasses the content of what was formerly called "analytic medicine," which covered biostatistics and epidemiology, and "community health," which covered public health issues.

Besides the patient-doctor course, another recent addition to the first- and second-year curriculum is medical problem solving, a course in which students in groups of eight are given a case description and then work as a team to come up with a diagnosis and to grasp some of the underlying mechanisms of the disease in question. Under the guidance of two faculty mentors (preferably, one from basic science and one from clinical medicine), students discuss the case in a small seminar setting, determine learning issues to be explored, and use independent study time between sessions to do background research. Students in these problem-based seminars address not only clinical and scientific issues but ethical, legal, financial, and other considerations deemed relevant to the individual case, thereby gaining some understanding of the interrelationships of the vast amount of different subject materials they are expected to learn.

Also recently added to Emory's medical curriculum was pathophysiology, a course for second-year students intended to help bridge the gap between basic science and clinical medicine. "We try to integrate the content of pathophysiology with the pathology and clinical methods courses also taught in the second year," says course designer Joel Felner, associate dean for clinical education. "While pathology teaches about lesions of the mitral valve, we explain how such lesions affect the entire cardiovascular system. While the clinical methods course teaches how to take blood pressure readings, we discuss the reasons why blood pressure might be abnormal."

These new courses and other recent curriculum changes at Emory - including a substantial reduction of student time spent in lecture - reflect those being made across the country, as medical schools strive to make their education more humane and less dependent on rote memorization of a litany of facts divorced from their clinical application.

Reassessing traditional approaches

*The Flexner report - a critique of the quality of medical education in this country, charging a failure to provide the scientific background that physicians would need to provide care in the 20th century.

"You get out of problem-based learning what you put in," says Amy Zepp, who is now in her third year of medical school. "You learn differently," she adds, "when studying what you find interesting, as opposed to what someone tells you to study."

Until recently, the basic format in medical education had changed little since publication of the Flexner report* in 1910," says Dr. Shulman. "Most schools have continued to have a fairly rigid division between the first two years of training, which cover the basic sciences, and the final two years, in which students are totally immersed in clinical care."

"We wanted to break down this dichotomy and give our students a taste of clinical medicine their first week here," he says. "At the same time, we also wanted to help them appreciate that basic science is a crucial ally in diagnosis and treatment and not just something they need to get through to pass Part I of the board exam."

There are other reasons to reassess the way medicine traditionally has been taught, says Dr. Shulman. Medical students today need some background in a growing array of complex subjects - decision analysis, ethics, socioeconomics, behavioral patterns, computers, and medical liability, to name a few. These are unlikely to fit neatly into a lecture format, and the typical curriculum has no spare hours left for additional lectures anyway. Educators are finding they need more ways to discuss these issues within a meaningful context, such as that afforded by small-group sessions with a problem-based learning format.

Another general observation about the traditional curriculum is that its competitive environment and rigorous demands can hamper students' interpersonal and communication skills and dampen their original enthusiasm for their chosen profession. "We're trying to abuse students less," says Dr. Shulman, "and we want to make sure we're sending the message that we place a premium on people skills. We also want our students to graduate even more excited about medicine than they were when they entered medical school."

A commitment of time and resources

Second-year student Dan Budnitz says he has gotten the impression that the medical school administration cares about student input and feedback. He would like to see more components of clinical methods, a second-year course covering history-taking and diagnosis, offered to first-year students, as a bridge to clinical care.

Sondralyn Fackler, now in her third year, says problem-based learning "helped me realize how ignorant we were. It also helped us understand that medicine is a team effort."

The kind of curriculum changes recently implemented at Emory do not happen overnight. They require planning, hard work, patience, and determination. They also require faculty time, facility space, and funding.

This process of change began back in 1991, when Dean Houpt appointed a committee, which gradually compiled a list of goals and suggestions based on input from surveys and retreats attended by both faculty and selected students. "We wanted to be conservative in our approach," says Dr. Shulman. "We knew we already had a good program. We just wanted to see if we could make it better."

Committee members determined that the first two years of medical school at Emory provided too little active learning. They said clinical faculty should play a bigger role in the design and teaching of basic science courses. They recommended that students have two problem-based learning seminars per week, that lecture hours be limited to no more than two hours per day, and that two afternoons per week be available for independent study. They also concluded that these changes would require a considerable investment in time and money and would therefore need whole-hearted support from the medical school administration.

Introducing problem-based learning seminars was a particularly resource-intensive endeavor. Seminar rooms had to be carved out of former classrooms, cases had to be written, faculty leaders had to be selected and trained. The consensus among faculty and students so far, however, seems to be that the effort was well worthwhile. "Preparing for and conducting these seminars has forced basic science and clinical faculty into the same room with each other," says Dr. Shulman. "They've gained new respect for each other and a better understanding of what they're each trying to do. "Another bonus," he adds, "is that students have a lot more interaction with faculty than in the past."

By the same token, faculty also have more interaction with students, says biochemistry professor Ray Shapira. "You can't really meet 100-plus students in a lecture," he says, "but in the small group sessions, you can get to know them." He thinks these seminars require "a lot more work" than lectures but that they're also "a lot more enjoyable."

Dr. Shulman says that the medical curriculum at Emory is still being fine-tuned, but he admits that he's pleased with the progress thus far. The reduction of lecture hours seems to have had no ill effect on students' grasp of the basic sciences. Indeed, scores on Part I of the board exams have been exceptionally high for the past two years, with a 99% pass rate on the first try. In addition, says Dr. Shulman, "I think the students are happier."

One Notch Beyond Socrates

William Waters III, '58M

According to Wenliang Chen, now in his second year, information in problem-based learning "sticks tighter" than in other courses. He also described the patient interview part of the school's new patient-doctor course as the "highlight of the whole semester."

Second-year student Heather Slay, who plans to go into primary care, says when learning basic science in a problem-based context, "You know it matters because you're seeing it applied."

Second-year student Tawana Walker says problem-based learning last year was "intimidating because we knew nothing." Now she thinks it's wonderful. "You see what's clinically relevant, and you understand why you need to know the normal range for glucose levels, for example."

To be honest, I had my doubts about the whole thing. Throw a full-size clinical problem at a group of first-year medical students. Then sit there with your mouth shut - you, the teacher - like a mummy. Expect them to slog through without getting mired down. Unlikely, very unlikely.

True, the students had told those of us on the curriculum committee that they were tired of endless didactic lectures. Tired of one teacher staring into 110 pairs of glazed eyes. Fatigued by the transcript that the student-stenographer of the month would supply. They even requested authorized typed summaries of the lectures. Then they wouldn't have to come at all. Stay home and study. Or do something important - play Frisbee, catch an old flick on TV, maybe stack some z's. They weren't that happy. They were, horror of all horrors, beginning to get bored. Bored? With medicine? That most absorbing of all disciplines?

So we looked at the problem-based learning thing. Harvard was doing it, telling us it seems to work fine; anyway, the students like it. Case Western Reserve had been into it for years. Wake Forest said, sure, it's neat, but you have to get through the resistance of the faculty and sometimes deal with anxiety problems on the part of the most obsessive-compulsive students. The biggest problem, they said, is to get the professors to shut up and let the boys and girls do the work. There are other problems too - when you intrude seriously on the structured core curriculum, some serious holes in the knowledge base may show up later. But the kids come out OK on the National Boards; they seem to end up as first-rate residents. We think maybe it's going to be all right, they said.

Anyway, here we were - John and I (the moderators) and ten students, each of them with a walloping four months of first-year medical school under their belts: a little anatomy, a smattering of biochem, a taste of physiology. And here was this full-scale, no-kidding clinical case problem in seven stanzas. You see, they had received, in carefully rationed increments, scanty descriptions of the complex events in the distressing saga of Mr. Jankowski.

It seems that Mr. Jankowski had come into the emergency room in coma. I can't divulge here what was wrong with him because this case may turn up again in another class. Suffice it to say that his condition was complicated.

But all they were told at first was that Mr. J. was lying there, breathing heavily, not responding.

No way, I said to myself, no way. We'll be buried under a mass of fairy tales in 15 minutes. And John and I - why, we aren't even supposed to bail them out.

"I'll be the secretary," says Charles. He goes to the board and writes four column headings: "Data Known, Hypotheses, Data Needed, Learning Issues."

"He's unresponsive, and a lot of things can cause that," says Lee. He has on a Stanford jersey. He looks quizzically around the table at his contemporaries. "But this could be neurologic."

"Or metabolic," offers Sandy. Her hair, shoulder-length, explains her nickname.

"Is there any sign of trauma?" wonders Tom. Tom shows telltale signs of the soccer field. "That can cause stupor - you know, concussion, contusion, hematoma. Maybe we should do a CT scan."

"Maybe we should do a physical examination before we spend $800," Lee says. "Or just check his blood sugar or even give him some dextrose intravenously," suggests Kay.

"What about sedative antagonists - he may have OD'd on something," Cleve says.

In two minutes, this group of hopeless plebes - equipped with no books, no background, no experience, no prompting from their mentors, and thus far no training - had synthesized a sophisticated approach to a truly complex medical problem. In the two sessions on the same case which followed - after an opportunity to turn to the books and their imagination - they blew it away. John and I were, well, awed.

Long ago, I had discovered that Socrates was onto something. When teaching, don't give answers; ask questions. Listening is 90% of the process. You can convey the same ideas, say the same words, use the same inflections, keep the same gestures - and the results will vary 1:10 depending on the condition of the listening apparatus. The finest grass seed, broadcast widely over a parched plain, will expire without further biologic ceremony. Water the ground first, till it, make sure all the critical minerals and nitrogen are present, and the cheapest brand of fescue will germinate lasciviously.

So, I understood, with learning. Give a monotonous lecture, crammed with facts, and count the faraway looks. Read the didactic textbook aloud, and EEGs of the medical students' heads would show a sleeping pattern.

No. First get yourself - or any other "student" - aching with that peculiar craving called curiosity. Feed it, tickle it, nudge it, titillate it. Bring it to a boil. Make the answer difficult to come by. Don't tell them. Send them to the library. Don't help them find it. Let them struggle for a day or two. When the delicious answer surfaces, they will not forget. More important, they have sipped of the exotic liquid which will later become addictive. They will search for the Pierian spring, hoping by then for a Niagara.

There were no glazed eyes in their group. This was "Crossfire." This was excitement. This was fun. This, now, was another step, another notch beyond Socrates: Let the students supply the questions too. They do the plowing, apply the fertilizer, sow the seeds. And, of course, reap the harvest.

It helps, of course, that Emory picks its students from 8,700 candidates. Their natural curiosity is easy to stultify, but as this exercise demonstrated, it can be stimulated too. The problem-based method seems to be doing just that.

But I continue with my own troubles, as they had warned me: I'm still trying to keep my mouth shut.


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Web version by Jaime Henriquez.