Tendency of Medical Curriculum ReformsYeu-Jhy Chang, MDStroke SectionDepartment of NeurologyChang Gung Memorial Hospital, Linkou

OutlineWhy do we change? Have we fulfilled the expectation of the society?The past and present curricular modelsClinical Presentation CurriculumHow about the future at CGU? In Taiwan?

OutlineWhy do we change? Have we fulfilled the expectation of the society?The past and present curricular modelsClinical Presentation CurriculumHow about the future at CGU? In Taiwan?

Why It Should Be Changed?If it is not broken, dont change it!

Programme for International Student Assessment (PISA)Finland ranked No. 1 in the PISAs 2006 survey in the area of science, followed by Hong Kong and Canada.In Finland, all school teachers receive their training at universities and are certified after obtain a Masters degree.The number of applicants for teaching greatly outnumbers the teaching spots available.Teachers are well paid and hold high status within the work force.

PISA 2006

MathematicsScienceReading1.Taiwan 1Finland 1South Korea2.Finland 2Hong Kong 2Finland 23.Hong Kong 3CanadaHong Kong 34.South KoreaTaiwan 4Canada5.NetherlandsEstoniaNew Zealand6.SwitzerlandJapanIreland7.CanadaNew ZealandAustralia8.MacauAustraliaLiechtenstein9.LiechtensteinNetherlandsPoland10.JapanLiechtensteinSweden11.New ZealandSouth KoreaNetherlands12.BelgiumSloveniaBelgium13.AustraliaGermanyMacau14.EstoniaUnited KingdomSwitzerland15.DenmarkCzech RepublicJapan16.Czech RepublicSwitzerlandTaiwan 1617.IcelandMacauUnited Kingdom18.AustriaAustriaGermany19.SloveniaBelgiumDenmark20.GermanyIrelandSlovenia

PISA 2003

Finish TeachersTeaching qualifications are prescribed by law and vary for different kinds of teachersThese national requirements guarantee that the standard of teacher education remains high.All teaching have clearly defined objectives.The curriculum emphasizes doing (problem solving).Learning activities reflect a balance between left and right brain activities.

Curricular Problems in the Past and Present (1)Redundancies, duplications, and irrelevant informationLack of integration among basic, clinical, humanities, and biopsychosocial sciencesToo much emphasis on memorization and recallDifficult to meaningfully sequence content

Curricular Problems in the Past and Present (2)Knowledge gapsInformation overloadReduced learning by teaching out of contextToo much lecturing (Passive learning)Excessive class time

Medical Curricula of 11 Medical Schools in Taiwan

8

8

Solutions for Resolving Curricular ProblemsRe-categorization: create a new blueprintCreate new courses: with new names, that help integrate basic, clinical, and behavioral sciencesIdentify the needs: based on students and faculties

*KnowledgeComprehensionApplicationAnalysisSynthesisEvaluationEvidence and dataCollectionAnalysisSynthesisEvaluationPerformanceDiagnosisTreatmentJudgment & data managementValue, Cost-BenefitExperience, Intuition, BiasBy: Paul PL ChangReasoningEvidenceThe Outcome

The Social ContractR. Cruess & S. Cruess. Perspectives in Biology and Medicine 2008;51(4):57998.

EXPECTATIONS: THE PUBLIC AND THE MEDICAL PROFESSIONR. Cruess & S. Cruess. Perspectives in Biology and Medicine 2008;51(4):57998.

Patients/publics expectations of medicineMedicines expectations of patients/publicFulfill role of healerAssured competence of physiciansTimely access to competent careAltruistic serviceMorality, integrity, honestyTrustworthiness (codes of ethics)Accountability/transparencyRespect for patient autonomySource of objective advicePromotion of the public goodTrust sufficient to meet patients needsAutonomy sufficient to exercise judgmentRole in public policy in healthShared responsibility for healthBalanced lifestyleRewards: nonfinancial (respect, status), financial

Roles and Attributes of a PhysicianR. Cruess & S. Cruess (The Healer)

Roles and Attributes of a PhysicianR. Cruess & S. Cruess (The Healer)(The Professional)

Relationship-Center EducationStudent-Center vs. Teacher-Center EducationDean vs. TeachersInter-disciplineInter-colleague

Outcome-Based EducationKnowledgeSkillCompetencePerformanceCapability (The power or ability to generate an outcome)

*KASH makes cash. K Knowledge A Attitude S Skills H Habit = + x +

*KASHO makes much more cash. K Knowledge A Attitude S Skills H Habit O Organization culture (Decided by the Leaders will) (Learning) = (Emotion) + (Motivation)

* Paul PL Chang

KnowledgeCompetencePerformanceTypes of studentsYesYesYesPerformingYesYesNo ()Lazy, irresponsibleYesNoNoLack of practice & abilityNoNoNoSimply unable, idiot

*5%Within 2 weeks:&Immediate useAuditory

Visual

Kinestheticafter24 hoursActive Passive

Role ModelingThe process whereby faculty members exhibit knowledge, attitudes, and skills, demonstrate and articulate expert thought processes, and manifest positive (negative) professional behaviors and characteristics.After Irby: J Med Ed, 1986

Role modelingAre you eating properly and getting plenty of exercise?We do not only teach by what we say, but by who we are and what we do?

OutlineWhy do we change? Have we fulfilled the expectation of the society?The past and present curricular modelsClinical Presentation CurriculumHow about the future at CGU? In Taiwan?

Curricular Models of North AmericaApprenticeship-based (Discipline-based (Body System-based (Problem-based (Clinical Presentation-based (

106

80

20

20

Characteristics of five curricular models North American medical education, 1765 to the present

CharacteristicApprenticeship- based (1765~)Discipline- based (1871~)System- based (1951~)Problem- based (1971~)Clinical Presentation -based (1991~)Organization of course content (Skills, knowledge, attitudes)Around subjects (patients)Around disciplineAround organ systemsAround clinical casesAround 120 clinical presentationsControllers of contentFaculty/MentorDisciplinesTopic committeeCurriculum committeeCurriculum committeeRelationship of clinical to basic sciencesSeparated; emphasis on clinical workSeparated; emphasis on basic sciencesInterdigitated 50-50 within context of organ systemsIntegrated within context of clinical cases (emphasis on clinical)Integrated 50-50 within context of problem-specific schemataOrganization of concept formationAround individual coursesAround individual disciplineAround organ systems; definition of normal and abnormal; patients; signs and symptomsAround clinical problems as defined by learner, small groups, and tutorsAround presentation-specific, expert-derived schemataTeaching methodsLectures & observation of mentor LecturesPrimarily lecture, some small groupsEmphasis on small groups50-50 lectures and small groupsTiming of patient/case exposureDelayed & clinical observationDelayed until clerkshipsEarly but limitedEarly, simple exemplary casesEarly, multiple exemplary casesCognitive skills emphasizedMemorizingProblem solving (HD)Problem solving (Hypothetico-deductive, HD)Problem solving (HD)Problem solving (Scheme-Inductive)

MethodsCognitiveAffectivePsychomotorStudent centeredSelf-directedTeamworkLecture+++++discussion+++++++PBL++++++++++++++++Role play++++++++++++Video+++++++Hand-on+++++++++++Simulation+++++++++++++Brain storm+++++++++Case+++++++++++

Comparison of Problem-based learning (PBL) and Clinical presentation curriculum (CPC)

PBLCPCProcessDiscovered (Little guidance)Guided (More guidance)ReasoningHypothetico-deductiveScheme-inductiveLearning efficiencyInefficientEfficientPossible errorsNo correctionRefinedUtilityTheoretical usePractice useFaculty training & loadingLessMore (3-4 hrs/wk)IntegrationLowerHigher

OutlineWhy do we change? Have we fulfilled the expectation of the society?The past and present curricular modelsClinical Presentation CurriculumHow about the future at CGU? In Taiwan?

Cloudy Picture 1

Cloudy Picture 2

Broad Clear Picture

A Piece of Picture (1)

A Piece of Picture (2)

A Piece of Picture (3)

Broad Picture vs. A Piece of Picture112233

Case presentationDemonstrationLecture, DemonstrationPBL, Bedside/ambulatory teachingClinical Presentation Curriculum

M3 910 1112123456(Morphology)(Function)Human & Disease (1,5)Principle of Medicine (2)MSK (1,5)Dr. in the societyMedical skill programLanguage and culture (Mandarin)Practice of PBLInterpersonal skill programStudent Selected Module (SSM) IM4 910 1112123456CV (3)Respiratory (1,5)Immune/ Infection (1,5)Renal (2)Endocrine (2)Medical skill programSSM IIResearch methods and evidence-based medicineM5 910 1112123456Blood/Oncology(1,5)Reproductive (2,5)GI(2)Mind and Neurology (2,5)Human development (1,5)Medical skill programSSM IIM6 Clinical rotation: + SSM III 2elective program

Sample of Mackay Project4. Medical skill program4.1 Culture, Health, Wellness4.2 Communication4.3 Bioethics4.4 End of life4.5 Medical skills: History taking, collecting data, diagnosis, treatment & follow-up4.6 Physical examination4.7 Well physicians ()

Renal Electrolyte System1. Urinary Retention, Obstruction, Abnormal image findings2. Dysuria, Frequency3. Scrotal Mass (Testicular pain)4. Hematuria4.1 Hematuria, Extrarenal4.2 Hematuria, Intrarenal, Extraglomerular4.3 Hematuria, Glomerular5. Proteinuria6. Generalized Edema7. Renal Failure, Acute/Chronic8. Polyuria9. Hypertension9.1 Pregnancy Associated Hypertension9.2 Malignant Hypertension9.3 Hypertension in the elderly9.4 Hypertension in the Pediatric Age Group10. Abnormal Serum Sodium Concentration10.1 Hyponatremia10.2 Hypernatremia

Sample SchemeUrinary FrequencyPolyuriaFrequency/DysuriaWater diureticOsmotic diureticExternalInternalIrritable bladderExcessive lossExcessive intakeDiabetes insipidusPrimary polyuriaInfectious vulvovaginitisUrethritisUrinary tract infectionProstatitisCystitisPyelonephritisGonococcalC. TrachomatisTrichomonasAcute urethral syndromeE. ColiKlebsiellaEnterococciProteusPseudomonasSeratia

OutlineWhy do we change? Have we fulfilled the expectation of the society?The past and present curricular modelsClinical Presentation CurriculumHow about the future at CGU? In Taiwan?

Teaching Qualifications (1)Many countries (e.g. Japan) are trying to mimic the Finish education system.To maximize performance, the coach/teacher/tutor must be highly trained and dedicated.In medicine, many teachers teach the way they were taught (i.e., they have no formal training)There is a need to elevate the qualification, training and reward of teachers in medical education some are even poor role models.

Teacher Qualifications (2)Maximum performance in students is dependent on faculty qualifications.Faculty not only create the learning environment, guide the student learning, but are important role models.There is a greater need for faculty development in basic scientists and physicians working within medical schoolsAll teachers should be certified as master teachers

Time on Task (1)High performance & outstanding achievement is directly related to time on task.Outstanding performers are highly focused, spend more time on task, use deliberate practice, have highly qualified mentors/teachers/tutors/coaches, are passionate and desire to be their very best.Success/outstanding performance can be enhanced and encouraged in all students.

Time on Task (2)Students will learn whatever they spend their time onThe most important tasks of a physician are diagnostic competence, patient management, and working as a member of a health team.Unfortunately, there is a tendency to fill students heads with knowledge knowledge itself is useless. What students do with their knowledge in helping patients with their health problems is far more important.There is a greater need to prepare students to think and behave like experts most medical schools expect students to evolve into experts through experience and little guidance.

Clinical ReasoningStrategiesGuessingHypothetical deductive (hypothesis to data backward reasoning)Scheme inductive (signs and symptoms to disease forward reasoning)Pattern recognitionThe clinical reasoning strategy used is dependent on the knowledge structureScheme inductive reasoning only occurs when students knowledge structure is highly organized.

SPICES: Dundee University

ItemsSPICESOrientationStudent-Centered vs. Teacher-CenteredContentProblem-Based vs. Information-GatheringOrganizationIntegrated vs. Discipline-BasedClinical trainingCommunity-Based vs. Hospital-BasedFlexibilityElective vs. UniformEnvironmentSystematic vs. Apprenticeship

Curricular EvaluationCurricular mapContent arrangementCriteria for graduationImplementation

Year 3Year 4Years 5 & 6Teaching hours/weekElective courses (%)Teaching methods: Lecture (%) PBL & small group (%) Others (%)

*(The true teacher)(how to do self-learning)(how to think)(how to think logically)(how to communicate)J. Willis Hurst Conclusion

Taipei 101 represents a blending of traditional and modern ideas.Curriculum improvement is never ending

Acknowledgement:Most of the content and concept of this speech were come or modified from the handout of the International Medical Education Conference by Henry Mandin, MD, Peter H. Harasym, PhD, and Tsuen-Chiuan Tsai, MD, PhD, on 2009/6/6~7 at Taipei Medical University and Fu Jen Catholic University.Thank You for Your Attention!