Coordinating Pathology Education in an Integrated Curriculum

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Coordinating Pathology Education in an Integrated
Curriculum

• Carolyn L. Cambor, M.D. University of
  Pennsylvania
• GRIPE Meeting January 2007

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Introduction

• Curriculum revision
• Educational focus for the past decade
• Out with the old
• Discipline based courses
• In with the new
• Integrated courses
• Need for change?
• Did the change change anything?
• Value in sharing experiences

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Objectives

• What is integration?
• Horizontal vertical integration
• How many of us have integrated curricula?
• General Pathology at Penn
• Organ Pathology at Penn
• Benefits drawbacks to integration
• Considerations for those embarking on integration

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What is integration?

• Variable definitions
• Coordinating content
• A lecture or a lab or the whole curriculum
• Content takes priority over maintaining
  disciplines
• Planned repetition
• Avoidance of redundancy
• Packaging
• Sometimes everything in one place and
• Someone knows where everything is and makes
  necessary connections

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Horizontal and Vertical Integration

• Horizontal integration
• Concurrent courses
• Preclinical
• Anatomy, histology, physiology, pathology,
  pathophysiology
• Vertical integration
• Temporally separated courses
• Clinical information in pre-clinical courses
• Basic science information in clinical rotations
• Basic science information in basic science
  courses

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Pathology Integration at Penn

• Education Officer (EO)
• Oversight of all Pathology education
• Has the big picture
• Helps identify areas of coordination within and
  between courses
• Liaison to the Curriculum office
• Year-round contact for student questions
• Subspecialty Course directors
• Work with EO

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Curriculum 2000 Overview

• Pre-clinical Curriculum
• Module 1 August Year 1 December Year 1
• Traditional discipline based courses
• Anatomy
• Biochemistry
• Embryology (through organogenesis)
• Basic Genetics
• Basic Immunology
• Basic Microbiology (bacteria, viruses)
• Basic Histology
• Epithelia, muscle, connective tissue, blood, BM,
  Lymph node, thymus, spleen

No General Pathology!!
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C2000 Overview

• Pre-clinical Curriculum
• Module 2
• January Year 1 December Year 2
• 10 teaching months
• Organ Blocks
• Integrated courses
• Normal anatomy, histology, physiology
• Pathophysiology, pathology
• Selected aspects of pharmacology

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C2000 Overview

• Clinical Curriculum
• Module 4
• January Year 2 December Year 3
• 12 months required rotations
• Module 5
• January Year 3 Graduation
• Subinternship
• Selectives
• Electives
• Frontiers in Medicine
• Scholarly Pursuit

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C2000 Overview

• Throughout the 4 years
• Module 3 Module 6
• Physical diagnosis
• Ethics
• Health care systems
• Epidemiology
• Evidence based medicine

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Integrating Pathology in C2000

• General Pathology
• Not included in Module 1 courses
• Biggest challenge
• Most interesting challenge
• Organ Pathology
• More straightforward

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Integrating General Pathology

• Define components
• 5 basic pathologic processes
• Cell injury cell death
• Inflammation
• Tissue renewal repair
• Hemodynamic disorders (emphasis on thrombosis)
• Neoplasia

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Integrating General Pathology

• Other aspects of GP covered elsewhere
• Genetic disorders
• Diseases of Immunity
• Infectious diseases
• Environmental Nutritional diseases
• Diseases of Infancy Childhood

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Integrating General Pathology - Part 1

• Put components where they fit best
• Cell injury, inflammation, repair
• Integrate with Microbiology Immunology
• Module 1
• Hemodynamic disorders
• Integrate with Cardiology block
• End of Module 2
• Neoplasia
• Create new 2 week transition block before Mod2
• Orphan subjects neoplasia, clinical immunology

Complete failure!!
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How did we know we failed?

• Students didnt know basic pathologic processes
• Clinical faculty feedback
• Problems with knowledge foundation
• Problems with DDx

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Why did it fail?

• Achieved physical integration with other courses
• Lost conceptual integration with other basic
  pathologic processes
• Lost the big picture for General Pathology
• Essential for understanding disease
• Essential for generating DDx

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Integrating General Pathology Part 2

• General Pathology must be integrated as a unit
• Include other courses that fit
• Expand the 2 week transition block before Module
  2
• Develop a new course
• Mechanisms of Disease and Therapeutic
  Interventions (MDTI)
• Fundamentals needed to study disease
• 5 weeks 105 hours
• 65 h lecture 40 hr small groups

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MDTI
General Pathology
Hematology - Oncology
Pharmacology
Rheumatology
Transfusion Medicine
Oversight by MDTI Course Director
(Pathologist) Separate section leaders
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MDTI
General Pathology
Hematology- Oncology
Pharmacology
Rheumatology
Platelet Coagulation Disorders
RBC Disorders
WBC Disorders
Oncology
Tx Med
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MDTI
General Pathology
Hematology
Pharmacology
Rheumatology
General Principles
Specific Examples of Therapeutic Interventions
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MDTI
General Pathology
Hematology- Oncology
Pharmacology
Rheumatology
5 Basic Mechanisms of Disease
Cell injury cell death
Inflammation
Wound repair
Circulatory disorders
Neoplasia
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MDTI
General Pathology
Pharmacology
Rheumatology
Hematology- Oncology
Systemic Autoimmune Diseases
Arthritides
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Weeks 1 2
Hematology Platelets Coagulation Disorders
Antiplatelet
CPC HIT Autopsy Hematology
Anticoagulation Rx
Pathology
Basic Pharmacology
Anti-inflammatory Rx
Circulatory disorders - thrombosis
Wound repair
Cell injury
Inflammation
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Weeks 3 4
Neoplasia
Basics of Clinical Oncology
Anti-neoplastic Agents
Transfusion Medicine
RBC Disorders
WBC Malignancies
Hematopoiesis
Rheumatology
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Weeks 3 4
Neoplasia
Basics of Clinical Oncology
Anti-neoplastic Rx
Transfusion Medicine
RBC Disorders
WBC Malignancies
Hematopoiesis
Rheumatology
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Week 5
CPC Pathology
Rheumatology
Rheumatology
Rx in Rheumatologic Diseases
Immunosuppressives
Exam
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Week 5
Anemias
CPC RA, OA Gout Path
Rheumatology
Rheumatology
Immunology (Module 1), cell injury, inflammation,
thrombosis, repair
Rx in Rheumatologic Diseases
Immunosuppressives
Exam
Anti-inflammatories
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Horizontal vertical integration of GP

• Horizontal
• Vertical
• Between Module 1 2
• Histology
• Anatomy (eg dual blood supply thrombosis)
• Immunology
• Microbiology
• Within Module 2
• Emphasize basic processes in Organ blocks
• Between Module 2 clinical years
• To follow

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MDTI Success or Failure?
Success!!
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MDTI Measures of success

• Student faculty evaluations
• Student comprehension
• Student preparation for rest of Module 2
• Student preparation for clinical rotations
• Contribution from additional DDx course

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MDTI Why does it work?

• Successful horizontal integration
• Organization
• Coordination
• Content fits together
• Connections identified for faculty to make
• Connections identified for students
• Communication
• Between CD and students
• Between CD and Section Leaders
• Between Section Leaders
• Between all faculty students
• Faculty leadership
• Commitment, time, enthusiasm

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Integrating Organ Pathology

• Distributed throughout Module 2
• Multidisciplinary organ blocks
• Normal to abnormal
• Selected therapeutics

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Methods to Integrate Organ Pathology

• Co-Directors for each block
• Medicine, Pathology
• Oversight and coordination of content
• Variable levels of Pathology involvement
• Personality, commitment, enthusiasm VIP
• Lectures small groups
• Medicine alone include Pathology
• Pathology alone include clinical
• Medicine Pathology together

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Integration in Organ Pathology

• Horizontal integration
• Anatomy, histology, physiology, pathophysiology,
  pathology
• More straightforward than General Pathology
• Vertical integration
• Within Module 2 connections made to MDTI
• Within Clinical years to follow

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Organ Pathology Success or failure?
More variable Overall, a success!
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Integrating Organ Pathology

• Successes
• In large part, depend on block leaders
• Better coordination of content
• Decreased level of content
• Increased emphasis on basic concepts
• Focused emphasis on selected specific details
• Joint sessions
• Stable USMLE scores
• Good feedback from clinical faculty

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Integrating Organ Pathology

• Problems
• Variable success depending on block leaders
• Joint sessions dont always work well
• Decreased time to cover content
• Decreased level of content
• Time, time, time

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Vertical Integration

• More challenging than horizontal
• Within parts of Module 2 - easier
• Between Module 2 clinical years - harder
• Back to the classroom New opportunity??
• Pathology electives
• Frontiers in Medicine 2 pathology courses
• Effective use of clinical testing
• Aging
• Scholarly pursuit
• Research opportunities

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Overall benefits of integration

• Fresh look at the curriculum
• Critical appraisal of content and delivery
• Eliminate unnecessary material
• Teach students information management
• Establishes oversight of content
• What, where, who, how
• Improves communication cooperation between
  departments
• New and innovative ways to deliver content
• Better learning? or just different?

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Drawbacks to integration

• Loss of course identity
• How important is this?
• Loss of discipline identity
• Particularly important for Pathology
• Reduction in contact time
• New courses introduced simultaneously
• Reduction of content level
• Hard to maintain intellectual rigor w/ fewer
  hours
• Need to cooperate and coordinate with other
  faculty

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Tips on integration

• Hold your ground for the time contact you
  really need, but have a give and take attitude
• Critically assess your content
• Be flexible but dont give in or give up if it
  really matters to you
• Be creative in finding solutions
• Communicate, communicate, communicate
• With your teaching faculty residents
• With teaching teams from other departments
• Especially before joint sessions
• Make a game plan establish expectations
• Stick to it
• No reason to be clueless

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More tips

• Keep a highly visible profile in the curriculum
  office and with the students
• Identify an overall Pathology Coordinator /
  Liaison
• Continuity
• Pathology block leaders need to be visible
  involved
• Attend student feedback sessions
• Create opportunities in Pathology outside of
  class
• Autopsy call
• A day in pathology
• (or a few hours, half day anything you can
  get!)
• Notify of relevant Grand Rounds
• More communication

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• The end