Redefining Osteopathic Undergraduate Medical Education for the 21 st Century: Transforming good educational programs into great ones Frank J Papa, DO,

Redefining Osteopathic Undergraduate Redefining Osteopathic Undergraduate Medical Education for the 21Medical Education for the 21stst Century: Century:

Transforming good educational programs Transforming good educational programs into great onesinto great ones

Frank J Papa, DO, PhDFrank J Papa, DO, PhD

Redefining Undergraduate Redefining Undergraduate Medical EducationMedical Education

2121stst century undergraduate medical century undergraduate medical education has yet to be definededucation has yet to be defined

The undergraduate curriculum will be very The undergraduate curriculum will be very different from what currently existsdifferent from what currently exists

• What will the curriculum look like?What will the curriculum look like?• How will educational technologies be used?How will educational technologies be used?• Can osteopathic undergraduate programs lead Can osteopathic undergraduate programs lead

in defining a 21in defining a 21stst century undergraduate century undergraduate curricula?curricula?

What will 21What will 21stst century medical century medical education look like?education look like?

To know where the future lies, it is To know where the future lies, it is essential to first understand how we got essential to first understand how we got where we arewhere we are

• Only a handful of curricular models have Only a handful of curricular models have evolved over the past 200 years in North evolved over the past 200 years in North AmericaAmerica

• Curricular models evolve for very specific Curricular models evolve for very specific reasons, i.e., to address deficienciesreasons, i.e., to address deficiencies

Where medical education has beenWhere medical education has been

Five curricular models have Five curricular models have evolved/coexisted in North Americaevolved/coexisted in North America

• ApprenticeshipApprenticeship• DisciplineDiscipline• Organ SystemOrgan System• Problem-basedProblem-based• Presentation (structured knowledge)Presentation (structured knowledge)

Curricular Reform in North America, 1765 to the Curricular Reform in North America, 1765 to the present: A Cognitive Science Perspective. Academic present: A Cognitive Science Perspective. Academic Medicine 1999;74:154-164Medicine 1999;74:154-164

Apprenticeship modelApprenticeship model

1765 – present1765 – present

• A small group of clinicians create their own A small group of clinicians create their own medical schools (training and practice medical schools (training and practice unregulated)unregulated)

• Training primarily dependent upon efforts of Training primarily dependent upon efforts of individual cliniciansindividual clinicians

• Basis for contemporary clerkships Basis for contemporary clerkships

Apprenticeship modelApprenticeship model Problems:Problems:

• Quality of training programs seriously questionedQuality of training programs seriously questioned

• Instructors untrained in educational techniquesInstructors untrained in educational techniques

• Educational goals and objectives inadequately statedEducational goals and objectives inadequately stated

• Memorization-oriented performance assessmentsMemorization-oriented performance assessments

• Gross inconsistencies from school to schoolGross inconsistencies from school to school

• Sound familiar? (Contemporary apprenticeships Sound familiar? (Contemporary apprenticeships [rotations/residencies] continue to share many similar [rotations/residencies] continue to share many similar problems)problems)

Discipline modelDiscipline model


• Medical schools should be based in major educational Medical schools should be based in major educational institutions (universities) and regulated (AMA / AOA)institutions (universities) and regulated (AMA / AOA)

• Formally trained individuals given faculty positionsFormally trained individuals given faculty positions

• Several experts in a given discipline brought together to Several experts in a given discipline brought together to form a departmentform a department

• Each department/discipline owned their own piece of the Each department/discipline owned their own piece of the curriculumcurriculum

• Departments/disciplines taught their content Departments/disciplines taught their content independently of each otherindependently of each other

Discipline modelDiscipline modelProblemsProblems

• No curricular oversightNo curricular oversight

• No faculty based attempt to interdigitate content among basic No faculty based attempt to interdigitate content among basic sciences, nor across basic and clinical sciencessciences, nor across basic and clinical sciences


• Students (novices) expected to interdigitate the basic and clinical Students (novices) expected to interdigitate the basic and clinical sciences content on their own (despite lack of patient care contact)sciences content on their own (despite lack of patient care contact)

• Not to worry, the students are very smart - everything will come Not to worry, the students are very smart - everything will come together for them during clerkships – that’s what clerkships are for!together for them during clerkships – that’s what clerkships are for!

• Sound familiar? How many contemporary undergraduate programs are Sound familiar? How many contemporary undergraduate programs are predicated upon this model?predicated upon this model?

Organ Systems modelOrgan Systems model


• Basic science departments required to Basic science departments required to interdigitate content within ‘systems’ interdigitate content within ‘systems’ (i.e., anat, physio, hist, biochem will (i.e., anat, physio, hist, biochem will present content relevant to each system present content relevant to each system during a given ‘organ system’ block) during a given ‘organ system’ block)

• Formation of a rudimentary, centralized Formation of a rudimentary, centralized curricular oversight committeecurricular oversight committee

Organ Systems modelOrgan Systems model ProblemsProblems

• Clinical sciences still presented separately from basic sciences (no Clinical sciences still presented separately from basic sciences (no faculty-based attempt to interdigitate basic and clinical sciences)faculty-based attempt to interdigitate basic and clinical sciences)


• Students (novices) expected to interdigitate the basic and clinical Students (novices) expected to interdigitate the basic and clinical sciences content on their own (despite lack of patient care contact and sciences content on their own (despite lack of patient care contact and training in knowledge base construction {interdigitation} techniques training in knowledge base construction {interdigitation} techniques [metacognitive skills])[metacognitive skills])

• Not to worry, the students are very smart - everything will come Not to worry, the students are very smart - everything will come together for them during clerkships – that’s what clerkships are fortogether for them during clerkships – that’s what clerkships are for


Problem-based modelProblem-based model 1971 – present1971 – present

• Introduce ‘x’ number of patient cases (problems) into Introduce ‘x’ number of patient cases (problems) into either discipline or systems-based curriculumeither discipline or systems-based curriculum

• Cases will provide students opportunities to develop Cases will provide students opportunities to develop long sought after ‘general problem solving skills (GPSS)’long sought after ‘general problem solving skills (GPSS)’

• GPSS will enable students to interdigitate basic and GPSS will enable students to interdigitate basic and clinical sciences contentclinical sciences content

• Centralization of curricular oversight more firmly Centralization of curricular oversight more firmly establishedestablished

Problem-based modelProblem-based model ProblemsProblems

• Research makes clear that general problem solving skills have little to Research makes clear that general problem solving skills have little to do with the development of medical expertisedo with the development of medical expertise

• Despite 30 years of wide spread adoption, no evidence students Despite 30 years of wide spread adoption, no evidence students interdigitate basic and clinical sciences content (construct useful interdigitate basic and clinical sciences content (construct useful knowledge bases) any better than in discipline or systems curriculaknowledge bases) any better than in discipline or systems curricula

• PBL sessions incredibly faculty and resource intensivePBL sessions incredibly faculty and resource intensive

• Clinically relevant performance assessments introduced but Clinically relevant performance assessments introduced but memorization-oriented assessment still dominantmemorization-oriented assessment still dominant

• Not to worry, the students are very smart - everything will come Not to worry, the students are very smart - everything will come together for them during clerkships – that’s what clerkships are fortogether for them during clerkships – that’s what clerkships are for


Presentation modelPresentation model(Structured Knowledge curriculum)(Structured Knowledge curriculum)


• Twenty years of research demonstrates that expertise is predicated upon the Twenty years of research demonstrates that expertise is predicated upon the ‘organization of the medical knowledge base’ (competence/expertise has little to do ‘organization of the medical knowledge base’ (competence/expertise has little to do with GPSS)with GPSS)

• Knowledge bases of experts are organized around a single problem; experts construct Knowledge bases of experts are organized around a single problem; experts construct problem-specific knowledge bases for those problems most relevant to their particular problem-specific knowledge bases for those problems most relevant to their particular fieldfield

• Faculty should take responsibility for creating interdigitated, problem-specific Faculty should take responsibility for creating interdigitated, problem-specific knowledge basesknowledge bases

• Curriculum: Impart Approximately 120 interdigitated problem-specific knowledge Curriculum: Impart Approximately 120 interdigitated problem-specific knowledge basesbases

• Knowledge base integration (deep learning – primary objective of higher education) Knowledge base integration (deep learning – primary objective of higher education) depends upon multiple opportunities to apply interdigitated knowledge basesdepends upon multiple opportunities to apply interdigitated knowledge bases

• Curriculum should provide students with a sufficient number of clinically relevant Curriculum should provide students with a sufficient number of clinically relevant opportunities to apply their evolving, problem-specific knowledge basesopportunities to apply their evolving, problem-specific knowledge bases

• Curricular design centralizedCurricular design centralized

Presentation modelPresentation model(structured knowledge curriculum)(structured knowledge curriculum)

ProblemsProblems

• Development of 120 problem-specific knowledge bases is Development of 120 problem-specific knowledge bases is faculty/resource intensivefaculty/resource intensive

• Faculty lack training, and technological support, in the Faculty lack training, and technological support, in the construction of interdigitated problem-specific knowledge construction of interdigitated problem-specific knowledge basesbases

• Resistance to reducing number of passive lectures and Resistance to reducing number of passive lectures and replacing them with knowledge base application opportunitiesreplacing them with knowledge base application opportunities

• Difficulty in developing number of training and testing cases Difficulty in developing number of training and testing cases needed to provide sufficient application opportunitiesneeded to provide sufficient application opportunities


To know where the future lies it is essential to To know where the future lies it is essential to first understand how we got where we arefirst understand how we got where we are

• Curricular models evolve for very specific reasons, i.e., Curricular models evolve for very specific reasons, i.e., to replace deficiencies in training and/or assessment to replace deficiencies in training and/or assessment with new approacheswith new approaches

• The ‘Structured Knowledge’ curricular model represents The ‘Structured Knowledge’ curricular model represents the state of the art in terms of our understanding of the the state of the art in terms of our understanding of the development of clinical expertise development of clinical expertise

• 2121stst century undergraduate medical training programs century undergraduate medical training programs will most likely adopt , and improve upon, many aspects will most likely adopt , and improve upon, many aspects of the structured knowledge curricular modelof the structured knowledge curricular model


Prerequisites to the implementation of a 21Prerequisites to the implementation of a 21stst century, ‘Structured century, ‘Structured Knowledge’ curriculum Knowledge’ curriculum

• Development of faculty training programs and technological tools in support of Development of faculty training programs and technological tools in support of faculty efforts to construct interdigitated problem-specific knowledge basesfaculty efforts to construct interdigitated problem-specific knowledge bases

• Development of faculty training programs and technological tools in support of Development of faculty training programs and technological tools in support of faculty efforts to construct the number of training and testing cases needed to faculty efforts to construct the number of training and testing cases needed to provide sufficient clinically relevant application opportunitiesprovide sufficient clinically relevant application opportunities

• Development of ‘x’ number of problem-specific knowledge bases for Development of ‘x’ number of problem-specific knowledge bases for dissemination during undergraduate trainingdissemination during undergraduate training

• Address faculty/administrative fears: Demonstrate that the replacement of Address faculty/administrative fears: Demonstrate that the replacement of passive lectures with new approaches will not result in performance degradation passive lectures with new approaches will not result in performance degradation

• New performance outcomes measures needed, outcomes demonstrating that the New performance outcomes measures needed, outcomes demonstrating that the structured knowledge curriculum accelerates the development of clinically structured knowledge curriculum accelerates the development of clinically relevant skills and expertiserelevant skills and expertise


Characteristics of a Structured Knowledge curriculumCharacteristics of a Structured Knowledge curriculum

• Amount of basic sciences content imparted in isolation will be dramatically reduced: Amount of basic sciences content imparted in isolation will be dramatically reduced: passive lectures will be few and far betweenpassive lectures will be few and far between

• Majority of undergraduate curriculum will consist of 100 – 150 problem-specific ‘modules’ Majority of undergraduate curriculum will consist of 100 – 150 problem-specific ‘modules’

• Each module will consist of 2 – 5 contiguous days of problem-specific basic and clinical Each module will consist of 2 – 5 contiguous days of problem-specific basic and clinical sciences contentsciences content

• Students will acquire content contained in each problem-specific module primarily via Students will acquire content contained in each problem-specific module primarily via self study from a WEB-based tool self study from a WEB-based tool

• Classroom time within each module will be limited and primarily devoted to ‘interactive Classroom time within each module will be limited and primarily devoted to ‘interactive sessions’ wherein faculty pose clinical case scenarios as the basis for student sessions’ wherein faculty pose clinical case scenarios as the basis for student engagementengagement

• Intelligent tutors will serve as primary tool for supporting students in the development of Intelligent tutors will serve as primary tool for supporting students in the development of problem-specific, diagnostic knowledge basesproblem-specific, diagnostic knowledge bases

• Problem-specific performance measures will assess competenceProblem-specific performance measures will assess competence

• Students will continue to use and update their problem-specific WEB-based knowledge Students will continue to use and update their problem-specific WEB-based knowledge bases during clinical rotations, residencies and practicebases during clinical rotations, residencies and practice

A three day ‘Dyspnea’ moduleA three day ‘Dyspnea’ moduleModule addresses 6-10 Module addresses 6-10 differentials for dyspneadifferentials for dyspnea

Self study via WEB-based Self study via WEB-based ‘explanatory knowledge ‘explanatory knowledge base (EKB)’ toolbase (EKB)’ tool

EKB tool presents an EKB tool presents an interdigitated knowledge interdigitated knowledge base consisting of basic and base consisting of basic and clinical sciences relevant to clinical sciences relevant to the disease differentials for the disease differentials for the problemthe problem

Interactive large classroom Interactive large classroom session involving session involving pathologist, internal pathologist, internal medicine/primary care medicine/primary care practitioner and relevant practitioner and relevant basic science facultybasic science faculty

Self study continues via Self study continues via WEB based EKB toolWEB based EKB tool

Diagnostic skills developed Diagnostic skills developed through self study via an through self study via an intelligent DDX tutorintelligent DDX tutor

Interactive large classroom Interactive large classroom session involving session involving pathologist, internal pathologist, internal medicine/primary care medicine/primary care practitioner and relevant practitioner and relevant basic science facultybasic science faculty

Dyspnea-specific clinical Dyspnea-specific clinical skills sessions offeredskills sessions offered

Self study continues via Self study continues via WEB based EKB and DDX WEB based EKB and DDX tooltool

2 – 3 hour interactive, large 2 – 3 hour interactive, large classroom ‘problem-specific’ classroom ‘problem-specific’ performance session performance session involving presentation of involving presentation of multiple case presentations multiple case presentations and immediate feedback of and immediate feedback of DDX and explanatory DDX and explanatory knowledge base knowledge base performanceperformance

Dyspnea written Dyspnea written examinationexamination

A five week Respiratory Block in a A five week Respiratory Block in a Structured Knowledge CurriculumStructured Knowledge Curriculum

Review of Resp Review of Resp system physio, anat, system physio, anat, hist, biochemhist, biochem

Pathology of Pathology of Respiratory system: Respiratory system: Guided self study Guided self study through Robbins through Robbins chapter on Resp dischapter on Resp dis



Path examPath exam

Internal Med, peds and Internal Med, peds and Surg assignmentsSurg assignments

Guided self studyGuided self study

Internal Med, peds and Internal Med, peds and Surg reading Surg reading assignmentsassignments

Guided self study and Guided self study and interactive sessionsinteractive sessions





Med/Peds/Surg examMed/Peds/Surg exam Dyspnea moduleDyspnea module

Dyspnea moduleDyspnea module Dyspnea moduleDyspnea module Hemoptysis moduleHemoptysis module Hemoptysis moduleHemoptysis module Cough moduleCough module

Cough moduleCough module Cough moduleCough module Epistaxis moduleEpistaxis module Ear pain moduleEar pain module Ear pain moduleEar pain module

Sinusitis moduleSinusitis module Sore throat moduleSore throat module Sore throat moduleSore throat module OSCE/final examOSCE/final exam OSCE/final examOSCE/final exam

Structured Knowledge CurriculumStructured Knowledge Curriculum

BEGINBEGIN

YEARYEAR

ONEONE

Intro to Intro to interdig-interdig-itated itated systems-systems-based,based,

basic basic sciencessciences

NeuroNeuro

RespResp

CardioCardio

GIGI

GUGU

ReproRepro

MSMS

EndoEndo

HemeHeme

Neuro Neuro systemsystem

IntroIntro

ProblemProblem

Modules:Modules:

WeaknessWeakness

DizzinessDizziness

Vis lossVis loss

Hearing lossHearing loss

Focal deficitFocal deficit

DepressionDepression

Sub abuseSub abuse

Decres LOCDecres LOC

etcetc

RespResp

System System IntroIntro

ProblemProblem

Modules:Modules:

DyspneaDyspnea

CoughCough

HemoptHemopt

EpistaxisEpistaxis

Ear painEar pain

SinusitisSinusitis

Sore throaSore throa

etcetc

CardCard


ProblemProblem

Modules:Modules:

Chest painChest pain

HTNHTN

HypotenHypoten

SyncopeSyncope

PalpitationPalpitation

ArrythmiasArrythmias

etcetc

GIGI

SystemSystem

IntroIntro

Problem Problem modules: modules:

Abd painAbd pain

DiarrheaDiarrhea

MelenaMelena

HematemHematem

Wt lossWt loss

etcetc

BEGINBEGIN

YEARYEAR

TWOTWO

GU GU system system IntroIntro

ProblemProblem

Modules: Modules:

DysuriaDysuria

HematurHematur

Flank pnFlank pn

etcetc

ReproRepro

SystemSystem

IntroIntro

ProblemProblem

Modules:Modules:

Vag bleedVag bleed

Pelvic painPelvic pain

Pelvic massPelvic mass

ImpotentImpotent

AmmenorAmmenor

Testic painTestic pain

Testic mass Testic mass

MSMS


ProblemProblem

modules:modules:

Lum painLum pain

Neck painNeck pain

Shldr painShldr pain

Wrist painWrist pain

etcetc

ENDOENDO


Problem Problem modules:modules:

FatigueFatigue

Poly ureaPoly urea

ObesityObesity

etcetc

HemeHeme

SystemSystem

IntroIntro

Problem Problem modules:modules:

AnemiaAnemia

LeukocytosLeukocytos

LeukopenLeukopen

ThrombocyThrombocy

etcetc

Moving from good to greatMoving from good to great Few DO or MD schools could realistically implement a structured knowledge Few DO or MD schools could realistically implement a structured knowledge

curriculum on their owncurriculum on their own

However, with shared responsibilities DO schools could all have a structured However, with shared responsibilities DO schools could all have a structured knowledge curriculum by 2010knowledge curriculum by 2010

How? Each school takes responsibility for developing one module a yearHow? Each school takes responsibility for developing one module a year

Institutional investment (per school): commitment of resources to develop a module Institutional investment (per school): commitment of resources to develop a module a year, and placement in their curriculum for field testinga year, and placement in their curriculum for field testing

20 schools – 20 modules each year – approximately 140 by 201020 schools – 20 modules each year – approximately 140 by 2010

Incrementally small reductions in number of passive lectures in each school’s current Incrementally small reductions in number of passive lectures in each school’s current curriculum and their replacement with a growing number of problem-specific curriculum and their replacement with a growing number of problem-specific modulesmodules

Content of modules shared over WEB and accessible to all schoolsContent of modules shared over WEB and accessible to all schools

Each school free to modify their modules and use only those modules they desireEach school free to modify their modules and use only those modules they desire

Moving from good to greatMoving from good to great Benefits: Benefits:

• Individual institutional resource investment leveraged 20 – 1Individual institutional resource investment leveraged 20 – 1

• Address curricular reform fear factor: continual assessment of student Address curricular reform fear factor: continual assessment of student and faculty receptivity to modules, and faculty receptivity to modules,

• Gradual development of a standardized DO curriculumGradual development of a standardized DO curriculum

• Students able to individually modify/update their own WEB-based Students able to individually modify/update their own WEB-based modules as their education continuesmodules as their education continues

• Graduates have access to most updated, problem-specific knowledge Graduates have access to most updated, problem-specific knowledge bases most relevant to practicebases most relevant to practice

• Development of problem-specific performance measures and Development of problem-specific performance measures and standardsstandards

Moving from good to greatMoving from good to great

Benefits:Benefits:

• Profession positioned to create new problem-specific outcomes Profession positioned to create new problem-specific outcomes measures-based licensure process and demonstrates its superiority measures-based licensure process and demonstrates its superiority over current licensure processover current licensure process

• Profession publishes ongoing results of findingsProfession publishes ongoing results of findings

• Profession gains international recognition for development of first 21Profession gains international recognition for development of first 21stst century curricular modelcentury curricular model

• Profession recognized as leader in medical educationProfession recognized as leader in medical education

• Graduates access to desirable residencies accelerates as residency Graduates access to desirable residencies accelerates as residency programs recognize superior capabilitiesprograms recognize superior capabilities

• Profession redefines itself as it enters 21Profession redefines itself as it enters 21stst century century

Documents

Redefining Osteopathic Undergraduate Medical Education for the 21 st Century: Transforming good educational programs into great ones Frank J Papa, DO,