Integrating Basic Sciences and Patient Care in a Core Clerkship Curriculum:

1. Integrating Basic Sciences and Patient Care in a Core Clerkship Curriculum: Transforming Medical Education Through Simulation and Technology Lynn M. Crespo, Ph.D. Assistant Dean Undergraduate Medical Education

2. Challenges Last Century Medical School Curriculum: • Emphasizes knowledge and skill • Lacks emphasis on critical thinking, judgment, decision-making or teamwork • Silos basic science and clinical knowledge - not integrated • Relies on lecture-based teaching methods • Not appealing to “digital natives”

3. Addressing the Challenges • Use simulation and technology as a tool • Change model from “see one, do one, teach one” to… • “See many, practice many, then…do one”

4. Evolution of Medical Education Lecture Advantages Efficient Limitations Low fidelity No skills training Clerkship & Internship Advantages Real patients Limitations Limited opportunities for practice Negative role modeling Standardized Patients Advantages Safe, controlled environment Limitations Limited opportunities for practice Expensive Mannequin Advantages Procedural skills Limitations Poor communication skills training Expensive Virtual Patient Repetitive practice Standardized Exposure to many populations Safe practice environment

5. Background • Simulation-based instruction has been shown to enhance learning & skill acquisition • Few Medical Schools are using simulation to its full potential

6. State of the Practice in Medical Simulation • Mostly mannequin based • Sophisticated systems that respond to trainee actions • Used primarily for team training and advanced skill development • Limited use of electronic simulations (exception = laparoscopic surgery) • Deficit of simulation/modeling to enhance acquisition of basic knowledge, attitudes or behavior

7. Opportunity • Introduce a simulation-based curriculum “out of the gate” starting Day 1 • Possibilities: • Enhance paper-based problem/case presentation with simulated environments • Improve mental model development using 3-D graphics and visualization techniques • Augment standardized patient exercises • Provide virtual environment for practice of communication and empathy • Virtual patients that can be followed through time

8. Simulation-Specific Plans Create an “Immersive Experience” • live and simulated patients • real-world situations in a protected environment • experiential learning • context in which future learning can be situated

9. Virtual Patients • Extensive use of avatars/computerized cases • Integrated context in which cases are scripted and presented • Augments and enhances in-class and clinical learning

10. Virtual Patient Case Characteristics • Interactive case management environment • Critical thinking and diagnostic skills • Collect information, order tests, and make diagnoses • Justify decisions based on science • Track and measure performance • Immediate feedback • Analyze decision making processes

11. E-Log Books • Basic Science Development of Specified Cases • EXAMPLE • Medicine – Cardiology • CHF: Based on patient case entered, discuss: • Physiological basis for symptoms • Explanation of tests ordered • Mechanism of therapeutic benefit for treatment ordered

12. Capstone Cases • Introduced in Year 1 • Followed throughout basic science years • Transfer of knowledge to real patients in Clerkship Years

13. Capstone Case Example • TY is a 32 year old woman who presents to her physician for new onset leg edema. She has been a type 2 diabetic since age 17, on insulin since age 22. Her mother and two of her sisters also have type 2 diabetes, and are obese. Her glucoses have been poorly controlled, and she neglects to check her glucose levels. She has gained 30 pounds over the last year, now weighing 250 pounds (she is 5”1” tall). She complains of vague chest pains on walking up stairs. Her physician finds that she has significant leg edema, numbness in her toes, an elevated serum glucose concentration (200 mg/dL), and heavy (4+) proteinuria on urinalysis.

14. Mapping of Capstone Case • Biochemistry – Metabolic pathways for glucose metabolism. • Genetics – Pedigree, modes of inheritance • Physiology – Effects of insulin, glucagon • Pathology – Complications of diabetes • Pharmacology – Treatment, adverse effects

15. Years 3 and 4 • OB/Gyn – Complications of pregnancy • Medicine – Cardiovascular complications • Neuro – CVA, retinopathy • Pediatrics – Type 1 vs Type 2; increasing childhood obesity • Family medicine – Diagnosis, prevention, lifestyle modification • Surgery – Risks, complications in diabetic

16. Summary • Virtual patients provide opportunity to revisit basic science concepts, track critical thinking, apply knowledge to real scenarios • Electronic log-books require basic science work-up of real cases • Capstone cases provide virtual longitudinal experience of patient across disciplines and specialties

20. Questions??? Discussion THANK YOU!