How hard is this? Not too hard.
Here are some ways to integrate science into the clinical courses (and vice versa)
Hi all: I’m recycling a recent post, having drastically reduced it. I hope to write more about examples of integration and integrators from our curriculum in the future.
You may think you don’t use basic science knowledge anymore. Think about this case:
An adult patient comes into the outpatient office of
a doctor complaining of facial pain and nasal
obstruction for 2 days duration. Instantly, from these
2 signs, knowledge about acute facial pain pops into
the clinician’s mind, with sinusitis being especially
salient because of its frequency of occurrence in this
age group. This specific knowledge then orients the
questions asked and physical examinations administered.
A few minutes later, a new patient comes in
with vertigo signs. Instantly, knowledge about sinusitis
and facial pain is dismissed from active memory,
and knowledge of vertigo takes over. (Charlin, 2007).
Many physicians, encountering these patient presentations would react exactly as the physician above did. We call the virtually unconscious use of basic science in this scenario “encapsulation.” (Schmidt, 2007) Alternatively, a physician mobilizes organized knowledge in an “illness script.” (Charlin et al 2007, Schmidt, 2007) It’s not that you as a physician don’t use basic science–it’s just that experience, and practice has blended it seamlessly into your thinking.
But how can we get our students there? Of course, practice makes perfect and experience tells. However, the practice needs to be guided and scaffolded by good teaching and learning. Here are some good teaching and learning interventions:
In pre-clerkship or clerkship, some key principles:
- Be explicit about the science that grounds the clinical case or knowledge. Insert science slides into your lecture/seminar slides that speak to basic science concepts at work.
- Use various media (words,pictures,practical experiences, lab results, microscope slides, etc.) to link science concepts to the clinical picture.
- Link to assessment. Critically, the assessment of integrated learring should reflect students’ sophisticated understanding of how the basic science relates to clinical understanding–not their ability to recall facts. (Mandin, 2000).
In clerkship: Practical ideas:
Provide opportunities for students to explore, research and strengthen their knowledge base of basic science issues relevant to commonly encountered clinical problems. Context is critical…for example, Laplace’s law describes fluid flow in the lungs which you can relate to asthma.
- Try: Case of the week? Case of the day? In rounds, or in a seminar, or in Case of the Week such as Internal Medicine undertakes, consider questions for students to investigate: What are the basic science issues that underlie this case? What is the pathophysiology at work here? (See Questions and Cues below.)
- Complement the mini-scholar CEX with a “Mini-science CEX”: ask students to use the same case as for their mini-Scholar CEX and inquire into the underlying science principles. Provide a worksheet or table for them to fill in that allows them to capture what you’re looking for. (See Questions and Cues, below.)
- Use some of the online modules developed for pre-clerkship as refreshers for clerkship. Students do this already. Why not make it a part of the learning?
Need some help finding the modules? Ask an Educational Developer –we’re working with students to update the list.
Work with one of the scientists in terms 1 or 2 and build one that will be useful from years 1-4.
- Bedside teaching: Ask a question about the underlying science of the case, in order to activate that learning.
- Questions and Cues that activate learning:
- What organ system(s) draws your attention here?
- How does this system normally work?
- What normally happens?
- What’s likely to have interrupted the process here?
- What does that look like? What changes does that precipitate?
- What are the basic processes used in reaching this state?
- What changes occur when someone reaches this state?
- What influences: the quality, location, duration, precipitation, course of symptoms
- What could be misleading you (confounding)?
- What are limitations to your knowledge of this?
- Use this blank schema/organizer to illustrate what is going wrong…(you’ll have to fill this one in!)
Basic Science Questions for Clerkship and Pre-Clerkship:
I found some examples of questions in Bierer et al’s work, Methods to assess students’ acquisition, application and integration of basic science knowledge in an innovative competency-based curriculum in Medical Teacher. Their examples come from a first year course (!) that integrates science and clinical teaching. Please read about what they do in the article, but here are some of the questions:
o What percentage of filtered sodium is being excreted? Reabsorbed?
o Is the patient in sodium balance?
o What does this information tell you about the kidney’s role in sodium homeostasis?
I like these Self-Assessment Questions too:
1. The renal clearance of inulin and creatinine are different. What explains this?
A. Creatinine is not freely filtered through the glomerulus, whereas inulin is.
B. Creatinine is only filtered while inulin is both filtered and secreted.
C. Creatinine is both filtered and secreted while inulin is only filtered. *
D. Creatinine is metabolized in the urine while inulin is not.
2. Which of the following events is most likely to result in lower extremity edema?
A. Low capillary hydrostatic pressure
B. High plasma oncotic pressure
C. Low plasma oncotic pressure *
D. High tissue oncotic pressure
3. The majority of glomeruli are found within which region of the kidney?
B. Cortex *
- Develop a weekly or monthly, undifferentiated case, where possible, “Case of the Week”, either in pre-clerkship or clerkship, to look at 20 main opportunities or “boluses” or “nodes”. In clerkship these can be sent electronically, similar to “NEJM” Case, to create an online curriculum. Focus can be given to special populations. Course Directors would need to get together to do this to include the Course Directors from year 1. Year Directors can provide a focus.
- Build online resources that may be used in different ways by different faculty in the future into clerkship. E.g. Sodium/Acid Base. Consult the foundational science faculty for assistance, as they have a huge database of images for use.
- OR consult the library for existing modules that may be used similarly. There are several videos, and other media, such as Anatomy TV which may be used.
- Modify the Clinico-Pathologic Conference Approach used in the NEJM cases (examples at http://oac.med.jhmi.edu/cpc/links.cfm) where a case is presented to a clinician, who then demonstrates the process of reasoning that leads to his or her diagnosis. A pathologist then presents an anatomic diagnosis, based on the study of tissue removed at surgery or obtained in autopsy. Students work on the diagnosis, and discussion ensues.
- Who could be involved in preclerkship or clerkship? See how these faculty and concepts are located around a single node or bolus?
We have some places in pre-clerkship that are waiting for some basic science; and some great places that are waiting for some clinical applications.
- In FSGL, we have the opportunity to integrate pathology, anatomy, imaging, etc. into cases.
- In Expanded Clinical Skills, there exist spaces for this integration.
- Problem solving exercises in SGL require foundational science for solutions and diagnoses. See above re. cases for some examples.
- CAUTION: Don’t overload. Use these examples of integration judiciously. Perhaps imaging is all that Dr. Davidson will use in a case of a limping child. Or perhaps Dr. Murray will use knowledge of histology and pathology or drug therapies in a case of a female patient presenting with shortness of breath that could be a case of myocardial infarction.
- Looking for some places and people with which to integrate?
- In term 1, we teach Normal Human Structure (anatomy/histology), Normal Human Function (Physiology) and Critical Appraisal, Research and Learning (Epidemiology, stats, methods of study).
- In term 2 we teach Therapeutics (pharmacology) and Mechanisms of Disease (immunology, infection, pathology). We teach about neoplasia, etc. in Blood and Coagulation. Genetics is taught in Genetics and Pediatrics in Term 2.
- In the C courses, many concepts are bundled together, often by faculty who taught in pre-clerkship.
I hope I’ve given you some insight into the how and the where of integration. In later blog articles I hope to feature the “who”.
Let me know your thoughts on integration of science into clinical courses.