DISSECTION AND EVOLUTION OF A PATHOLOGY PATHOPHYSIOLOGY COURSE

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DISSECTION AND EVOLUTION OF A PATHOLOGY -
PATHOPHYSIOLOGY COURSE

• Byron E. Crawford, MD
• Associate Professor of Pathology
• Department of Pathology and Laboratory Medicine
• Tulane University School of Medicine
• New Orleans, Louisiana

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The strongest and most intelligent species are
not the ones who survive. Ones that adapt
survive.Charles Darwin
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If I have two managers who always agree, I dont
need both of them.
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HISTORY

• Pathology - Pre-1998
• Pathology and Pathophysiology - 1998-2001
• Mechanisms of Disease - Pathology and
• Pathophysiology - 2002
• 300 lb. Gorilla

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GOALS

• 1) To develop an understanding of the causes and
  mechanisms of disease and the associated
  alterations of structure and function of cells,
  tissues, and organ-systems.
• 2) To develop skills of observation,
  interpretation, and integration needed to analyze
  human disease. When provided with the clinical
  history, the anatomical lesions, and the
  laboratory data of a patient, to determine the
  differential diagnosis, the most likely diagnosis
  and explain the pathogenesis of the disease.

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DISTRIBUTION OF COURSE HOURS
1995/1996 2001/2002 2003/20041 Pathology Patholo
gy- MOD Pathology Pathophysiology and
Pathophysiology Lectures 91 154 128 Tutorials 28
25 25 Small groups (PBL) 0 63 63 Case
Studies 9 (88)2 (88)2 Laboratory 40 1 1 Patient
Contact 0 0 0 Computer Based 12 16 18 Self
Study 0 14 40 Review, Misc 0 21 21 Exams 12
17 17__ TOTAL 180 hrs. 310 hrs. 313
hrs. 1 Proposed distribution of course hours 2
Included in lectures, tutorials and small group
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MAJOR COURSE CHANGES

• Perceived Problems or Issues
• Definitive Problems
• Owl Club Recommendations
• Faculty Recommendations (In and Out)
• Recommendations from Curriculum Committee
• NBME Shelf Exams
• Other - Out of Date

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OUTSIDE IN-PUT

• GRIPE
• IAMSE
• OERD
• T-2 Curriculum Advisory Committee
• Curriculum Committee

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MAJOR CHANGES

• Dropped Laboratory - 1996
• Case Studies - 1997
• Integration - Coordination - 1998
• Coordination - Clinical Diagnosis - 2001
• Dropped Microscopic Slides - 2002
• Reduction in Contact time - 2003

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TEACHING INCENTIVES

• Personal Rewarding Experience
• Educational Grants
• OWL Club Teaching Awards
• AOA Teaching Awards
• OERD and Deans Office Award
• Department of Pathology and Laboratory -
• Excellence in Teaching Award
• Promotions

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EDUCATIONAL GRANTS

• Development of CD-ROM
• GI-Liver
• Neuropathology
• Renal Pathology
• Pulmonary Pathology
• Hematopathology
• Reproductive Pathology

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Faculty CREATED Problems

• Tell students, you do not need to know this
• Tell students, do not use Robbins - it is
  wrong, bad terms
• Pathology - Clinician disagreements
• Pimping students
• Teaching research
• Excessive teaching of treatment

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STUDENT OPINIONS REGARDING EFFECTIVENESS OF
DIFFERENT TEACHING METHODS (2002 OWL CLUB STUDY)
Occurred Occurred Occurred Regularly Sometimes R
arely Lectures 41 31 10 Tutorials 60 24 16
PBLs 64 29 17 Slide Reviews 68 17 15 Tu
lane Computer-based 58 20 22 Other
Computer-based 16 10 74 Student
Independent 93 3 4 Self Study Student group
study 29 28 43 Faculty handouts 80 13 7 Ro
bbins 73 14 13
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TUTORING

• Offered to 5-10 of students
• Criteria
• Group vs Private
• Free vs Pay
• Selecting Tutors
• Successful vs Un-successful

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SOPHOMORE PATHOLOGY COURSE NEUROPATHOLOGY
BLOCK January 6, 2003, 1100 a.m. 1200
noon Dr. Frank Bastian TOPIC Brain Edema,
Herniation Hydrocephalous, and Trauma Objectives,
the student should be able to 1). Discuss the
pathogenesis of cerebral edema and the
differences between vasogenic and cytotoxic
edema. Be able to identify the gross and
microscopic features of cerebral
edema. 2). Discuss the pathogenesis of elevated
intracranial pressure and identify the different
brain herniation syndromes (tonsillar, uncal and
subfalcine herniation). Discuss the gross
morphology of these types of herniation. 3). Orga
nize and be able to discuss the mechanisms of
development of hydrocephalous and the differences
between communicating and noncommunicating
hydrocephalous. Define the term hydrocephalous
ex vacuo and discuss its effect on brain
parenchyma. 4). Discuss the pathogenesis and
gross morphology of an epidural hematoma, acute
subdural hematoma and chronic subdural hematoma.
Compare the etiologies and clinical presentation
of each. 5). Discuss the differences between a
coup and contrecoup contusion and define
concussion, contusion, and laceration. Define
the terms diffuse axonal injury and persistent
vegetative state. 6). Discuss the different
neurologic syndromes, which can develop post CNS
trauma. Vocabulary and Related Terms Define and
be able to use in context Cerebral edem
Subdural hematoma Vasogenic and cytotoxic
edema Lucid interval Tonsillar herniation, uncal
(transtentorial) Bridging veins herniation
and subfalcine herniation Concussion/contusion/la
ceration Durets Hemorrhage Coup and contrecoup
contusion Communicating hydrocephalous
Displaced skull fracture Non-communicating
hydrocephalous Post traumatic hydrocephalous Hydr
ocephalous ex vacuo Post traumatic
dementia Epidural hematoma Recommend
Reading Robbins Pathologic Basis of Disease
Cotran, Kumar, Collins Objective 1 pp.
1297-1298 Objective 2 pp.
1298 Objective 3 pp. 1298-1299 Objective
4 pp. 1304-1305 Objective 5 pp.
1302-1304 Objective 6 pp. 1305-1306 Basic
Pathology, Kumar, Cotran, Robbins Brain
Edema, herniation and hydrocephalous - p.
715-717 Trauma - p. 721-723
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OBJECTIVES

• Group Research in Pathology Education
• (GRIPE)
• USMLE, STEP 1 Content Outline
• Robbins Pathologic Basis of Disease

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LIASON COMMITTEE ON MEDICAL EDUCATION(LCME)STAND
ARDS FOR ACCREDITATION

• Educational objectives state what students are
  expected to learn, not what is to be taught

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USMLE, Step 1 ContentOBJECTIVES

• Skin appendage tumors
• Chlorine gas inhalation
• Hemochromatosis of heart
• Autoimmune hypogonadism

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STUDENT COMMENTSON OBJECTIVES
- extremely helpful and were a great way to
direct my studying . It made Robbins
approachable. - too detailed and very
overwhelming - too broad - objectives do not
always correspond to lecture material -
pathophysiology really didnt have good
objectives - the gang in pathophys should take
a cue from path (and gross anatomy) and make
learning objectives more specific. - the
vocabulary list was very helpful
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EXAM DEVELOPMENT

• Writing Questions - ART
• Creators
• Type - Clinical vignette, K-type, all of
  the following are true except matching
• Images
• Question Bank - Tulane (1200)
• GRIPE - Regular questions, Clinical cases
• Fine Tuning Questions - Question Statistics

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ASSESSING COURSE SUCCESS

• Exam Grades
• NBME - Shelf Exam Scores
• USMLE, Step 1 Exam Scores
• T-3 and T-4 Clinical Faculty Input
• Peer Review
• T-3 and T-4 Student Surveys

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RECOMMENDATIONSCLINICIANS IN T-3 AND T4 CLINICAL
BLOCKS

• Utilize Case Presentations
• Acid-base electrolytes regarding surgery patients
• Increase student exposure to radiologic images in
  relationship to Mechanisms of Diseases
• Only neurologists should teach neurology
• Increase practical clinical pharmacology

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STUDENT PERCEPTION
Did the course at least adequately prepare you
for the MAJORITY of your CLINICAL
ROTATIONS? Class of 2003 - 91.1 (N56) Class
of 2004 - 89.0 (N37) Combined class of 2003
2004 - 90.3 (N93) Did the course adequately
prepare you for ALL topics in your CLINICAL
ROTATIONS? Class of 2003 - 23.2 (N-56) Class
of 2004 - 32.4 (N-37) Combined class of 2003
2004 - 26.8 (N93)
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STUDENT PERCEPTION
Did the course at least adequately prepare you
for the MAJORITY of topics on USMLE, STEP
1? Class of 2003 - 98.2 (N56) Class of 2004
- 89.2 (N37) Combined class of 2003 2004 -
94.6 (N93) Did the course adequately prepare
you for ALL topics on USMLE, STEP 1? Class of
2003 - 34 (N-56) Class of 2004 -
54 (N-37) Combined class of 2003 2004 -
41.9 (N93)
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STUDENT PERCEPTION
STUDENT BLOCK ACKNOWLEDGEMENTS /-
INDEX Cardiovascular 68 58 Hematology 52 40 P
ulmonary 43 35 Renal 48 16
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STUDENT PERCEPTION
STUDENT BLOCK ACKNOWLEDGEMENTS /-
INDEX Neoplasia 34 13 GI-Liver 49 11 Endocrin
e 23 6 Neurology 25 3
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STUDENT PERCEPTION
STUDENT BLOCK ACKNOWLEDGEMENTS /-
INDEX Reproductive 23 -2 Inflammation-Immunology
21 -3 Infectious Diseases 19 -5 Environmental 1
8 -7 Clinical Laboratory Medicine 35 -35 Radiolo
gy 50 -47
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SOPHOMORE PATHOLOGY COURSE - TULANE UNIVERSITY
SCHOOL OF MEDICINECLINICAL PATHOLOGY
QUESTIONS1999 - 2000

• Topic_________________________________N___________
  ________________Class Average
• Laboratory
• Statistics 5 81
• Inflammation 3 65
• Urinalysis 8 87
• E B Virus 2 75
• C S F Analysis 4 89
• Culture Specimens 2 68
• Proteins 2 75
• PCR 1 37
• Tumor Markers 4 86
• Lipids 3 87
• Cardiac Profiles 1 99
• Water, lytes, acid base 15 72
• Hematology 28 86
• Coagulation 7 87
• Transfusion Medicine 3 72
• Endocrinology 8 79
• GI Liver __3__ 56

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PATHOLOGY AND PATHOPHYSIOLOGYSHELF EXAM

• Year Percentile Class Average
• 1997-19981 66 76.4
• 1998-19991,2 65 75.4
• 1999-20002 65 74.5
• 2000-20012 69 77
• 2001-20022,3 80 80
• 2002-2003 80 80
• 1 - Director - Sanda Clejan, Ph.D
• 2 - Director - Eric Simon, MD and Byron Crawford,
  MD
• 3 - First year course coordinated/integrated with
  physical diagnosis.

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2002 - SHELF EXAM

• T-2 Average National Average Difference
• Cardiovascular 81.6 72.3 9.3
• Pulmonary 74.8 70.8 4.0
• Renal 81.8 72.3 9.5
• Hematology 70 60.3 9.7
• GI Liver 77.6 70.5 7.1
• Genetics 84.7 75.1 9.6
• Neurology 88.9 87.1 1.8
• Infectious Diseases 87.2 66.4 20.8
• Endocrine 77.3 76.5 0.8
• Reproductive 68 61.8 6.2
• Environmental 79.8 69.2 10.6
• Miscellaneous 82.9 72.9 10.5
• Inflammatory 82.7 77.8 4.9

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NBME SHELF EXAMS
- Course Coordinated with Physical Diagnosis
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STDEXAM CLASS AVERAGE

• 27 27 CLASS AVERAGE
• 2002 97.6 76 87.3
• 2003 93.6 70 84
• 2001/2002 2002/2003
• Average - All questions 81.5 79.1
• Average - without
• self taught question 84.2 78.5

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ENVIRONMENTALEXAM CLASS AVERAGE
27 27 CLASS AVERAGE 2002 93.9 80.4 88.3 2003
92 65.6 79.7 2001/2002 2002/2003 Average -
All questions 81.5 79.1 Average - without
self taught question 84.2 78.5
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COST ANALYSIS - PROFESSIONAL
PATHOLOGY PATHOPHYSIOLOGY 77.43 / hr.
79.98 / hr. ___________ Lectures (459 hrs.)
35,540.37 Lectures (234 hrs.)
18,715.32 Tutorials (405 hrs.)
31,359.151 PBLs (1,044 hrs.)
83,499.122 Review Sessions, Misc. (95.5 hrs.)
7,394.57 Professional Benefits25,553.61 Exams
(21 hrs.) 1,626.05 Total Pathophysiology Comput
er Based Learning (65 hrs.) 5,032.95 Profession
al Cost 127,768.05 Small Groups (27 hrs.)
2,090.61 Director (960 hrs.)
74,332.80 Professional Benefits
39,345.38 TOTAL PATHOLOGY PROFESSIONAL COST
196,721.88
Total Pathology Professional Cost 196,721.88 To
tal Pathophysiology Professional
Cost____________127,768.05 Total Professional
Cost 324,489.93
Social Security, Retirement, Insurance
1 May include resident teaching 2 May include
resident and student teaching
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COST ANALYSIS - STAFF, MISC. FEES
Pathology Course Secretary (1,373
hrs.) 16,473.60 Pathophysiology Course
Secretary (669 hrs.) 8,038.80 Faculty
Secretaries (154 hrs.) 1,848.00 Contracted
computer programmers salaries (280
hrs.) 4,480.00 Photography Services, supplies,
equipment (40 hrs.) 1,836.00 Tutoring
Services Group (36 hrs.) 576.00 Individual
(48 hrs.) 768.00 Exams 1,260.00 NBME Shelf
Exam 3,750.00 Syllabus 4,275.00 Handouts 9,2
40.00 CD-ROMS 648.00 G.R.I.P.E.
2,150.00 I.A.M.S.E. 550.00 Building Cost
14,149.63 TOTAL - STAFF, MISC. FEES
70,043.03
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BUILDING COST
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TOTAL COST
Total Pathology Professional Cost 196,721.88 Tot
al Pathophysiology Professional
Cost 127.768.05 Total Staff, Misc.
Fees 70,043.03
TOTAL 394,532.96
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ACKNOWLEDGEMENTS
All faculty members and residents Dr. John
Krause Evelina Gaspard Previous Course
Directors Other Departments Dr. Sanda
Clejan Dr. Kevin Krane Dr. Norberto Schor Dr.
Craig Clarkson Dr. Will Robichaux Dr. Jeff
Weise Dr. Mary Beth Beasley Dr. Robert
Garry Dr. Eric Simon Dr. John Clements Dr.
Cindy Morris Dr. Mike Schurr Dr. Kent
Buchanan Dr. Bruce Bowdish Dr. Sheila
Chauvin Dr. Cathy Lazarus Dr. Paul
Rodenhauser Dr. Hans Andersen Ms. Delia
Anderson Mr. Tripp Frisch
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FACULTY - RESIDENT COURSE PARTICIPANTS
FRANK BASTIAN, M.D. MARY BETH BEASLEY, M.D. EDWIN
BECKMAN, M.D. ARNOLD BRODY, Ph.D. ALAN BURSHELL,
M.D. SANDRA CLEJAN, Ph.D. BYRON E. CRAWFORD,
M.D. PHILIP J. DAROCA, JR., M.D. ODILE DAVID,
M.D. NINA R. DHURANDHAR, M.D. JANE DRY, M.D. K.
BARTON FARRIS, M.D. CARLOS GARCIA, M.D. JAVED
GILL, M.D. SALIMA HAQUE, M.D. JAMES HARKIN,
M.D. JAMES HYLAND, M.D. ZEYNEL KARCIOGLU,
M.D. JOHN R. KRAUSE, M.D. STEVE KRAUS,
M.D. WILLIAM H. LUER, M.D. CINDY MORRIS,
Ph.D. GILBERT MORRIS, Ph.D.
KRZYSZTOF MOROZ, M.D. TIM PETERSON, M.D. HARRY
PIGMAN, M.D. WILLIAM H. ROBICHAUX, M.D. GLENN
RUDNER, M.D.. JANET L. SCHMID, M.D. JOHN
SCHARFENBERG, M.D. SUZANNE MELEG-SMITH, M.D. ALUN
WANG, M.D. MIGUEL LABOY, M.D. WEIQANG ZHAO,
M.D. BRIGITTE DEMOSS, M.D. RICHARD DEMOSS,
M.D. REHANA JAVED, M.D. RACHNA JETLY,
M.D. VIRGANEYCE LYONS-BOURDEAUX, M.D. LIAN QIAN,
M.D. LUIS REMUS, M.D. ARLENE ROSENBERG,
M.D. VECIHI BATUMAN, M.D. BARBARA BECKMAN,
Ph.D. ROBERT BULAT, M.D. JAMES CORRIGAN, M.D.
VIVIAN FONSECA, M.D. KAREN FRIDAY, M.D. MITCHELL
FRIEDMAN, M.D. RAMONA GRANDA-AYALA, M.D. L. LEE
HAMM, M.D. ROBERT HAMMER, M.D. DAVID JANSEN,
M.D. ROBERT N. JONES, M.D. VIRENDRA JOSHI,
M.D. MARC KAHN, M.D. MICHAEL KIERNAN, M.D. KEVIN
L. KOVITZ, M.D. N. KEVIN KRANE, M.D. JOE LASKEY,
M.D. ELMA LEDOUX, M.D. ROBERTA LOTTINGER,
M.D. ALAN MILLER, M.D. ROY ORLANDO, M.D. MERRI
LOU PENDERGRASS, M.D. FRED REGENSTEIN, M.D. ERIC
SIMON, M.D. LEON WEISBERG, M.D. ELLEN ZAKRIS, M.D.
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ACKNOWLEDGEMENTS
Course Secretaries Computer/Imaging Doreen
Barrett Bea Delucca Kathleen Guidry Donald
Olivares Staff Support Deans Office Corlis
Trepagnier Becky Levy Williams Marie
Brown Anne Alpers Brendon Doyle Odette Marquez
TMC Barbara Salmon Ruth Moses
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ACKNOWLEDGEMENT
Doreen Barrett
Larry Baudoin, Rob Holland, and John B. Stockwell