Faculty members hear many voices calling for the “integration of basic and clinical science material” throughout the four years of the typical undergraduate medical curriculum. While such voices can be traced to documents such as the GPEP and the ACME-TRI report, it remains confusing for individual faculty members to know what can be done to “make it happen at my own school”. In fact, one quickly comes to suspect that there are no easy solutions to this problem, as exemplified by the wide variety of proposals put forward during a recent two-day symposium on this topic (Northeast Section of the GEA, Spring 1992). Solutions will vary from school to school, and from discipline to discipline. Perhaps our experience at Dartmouth in attempting to integrate instruction in basic and clinical pharmacology might prove useful for other faculty members.
Dartmouth Medical School has a “traditional” four-year curriculum, including a required course in basic pharmacology given in the fall of the second year. This course has gradually been reduced to its current allocation of about 84 hours of instruction. In 1984, we introduced a required course in clinical pharmacology, given in the early spring of the fourth year. My efforts to “integrate” instruction in basic and clinical pharmacology have focused on three issues: introducing simple clinical material into the basic pharmacology course to enhance learning; rationally coordinating material that appears in both courses; and grounding the clinical pharmacology course firmly in the basic sciences of pharmacology and pathophysiology.
Our first challenge was to make the standard second-year lecture course less dry, and more interesting to second-year students craving some “clinical relevance”. We wrote several brief clinical problems foreach of our major lecture topics (1). These clinical problems or cases were sufficiently simple so that second year students could understand the medical portion of each case. For example, clinical scenarios dealing with headache, cystitis, or chest pain were developed, all subjects that students have had direct or indirect experience with in their own health problems or those of their close relatives. In order to “solve” each clinical problem, the students must recall the material they learned in basic pharmacology leactures or reading, and apply or extend that material to the clinical scenario. Principles of drug action and drug use are stressed, not dosing or other aspects that become important during the third year. These clinical problems have been liked by the students because they help to make the basic science material more “interesting” and more “clinical relevant”. We have not formally evaluated their use to try to document improved learning or performance, although these problems have been used in different years as required exercises for the whole class, or elective exercises for a portion of the class. One interesting difficulty we have encountered with this approach is the fact that some of my colleagues in basic pharmacology feel that providing such cases “dilutes the rigor” of a traditional basic science lecture course. In addition, while some basic science faculty felt comfortable leading small-group discussion of the this material, others did not, fearing that even this elementary clinical material was beyond the “comfort zone” of a basic scientist. Helping faculty with the material (using the answers in the books itself, plus an introductory orientation session ) relieved the anxiety of some faculty members, but others remained uncomfortable with the material.
Our second goal was to coordinate our instruction in the pharmacology material offered in the second? and fourth-year courses. This provided quite easy to achieve, since I serve on the course planning committee for the second-year course, and I am the course director for the fourth-year course. This curricular flexibility has allowed us to “cover” material in different ways. Some material (e.g.. Receptor theory) is formally “covered” only in the second year; some material (e.g. effects of renal dysfunction on drug pharmacokinetics and pharmacodynamics) is “covered” only during the fourth year; Despite this benefit of having pharmacology instruction offered twice during the medical school (84 hours in year two, and 66 hours in year four), some basic science faculty continue to believe that “real instruction” in pharmacology occurs only in the second year, and they don’t perceive the instruction that occurs in the fourth year as part of an integrated curriculum of basic and clinical pharmacology.
Finally, we have developed a fourth-year course in the principles of clinical pharmacology, and their application for form the basis of rational therapeutics. We have described this course in some details (2), and have based in on “core” material in the form of necessary facts, skills, and attitudes that we would like all our student to learn. EW have done a fair amount of work to try to understand the impact of this course, which was first introduced in 1984. Our data have revealed that our students find the course extremely valuable as senor students, and in retrospect as interns; and their performance on post-test questions increased dramatically compared to their performance on similar pre-test material; than their performance on clinical pharmacology-related questions on National Board Exams (Part II) has increased dramatically since the course was begun (and is now better than their performance on other subject areas on those exams); and that students feel their knowledge in this area is usually better than the knowledge of their fellow interns (2). Based on these observations, we proposed that other schools might want to consider adding required senior courses in clinical pharmacology, to complement their required second-year courses in basic pharmacology (3).
Most recently, four national scientific societies sharing an interest in pharmacology instruction have formulated a consensus on a core curriculum for clinical pharmacology instruction, and how this could supplement teaching in basic pharmacology (4). This consensus developed by representatives from four independent societies was heartening to all of us, and made an even stronger case for faculty at individual schools to work towards implementing such courses (5). Most recently, with new texts available to help faculty members develop new courses, implementing such courses in clinical pharmacology, based firmly on underlying principles of basic pharmacology, should be even less traumatic for committed faculty (6).
In summary, the issue of trying to integrate material from basic and clinical sciences is a difficult one, and will like require different approaches for different subjects at different schools. We have had considerable success with a model at Dartmouth for instruction in pharmacology that involves introducing clinically relevant material into the basic course during the second year, basing a fourth-year “clinical” course on the basic sciences of pharmacology and pathophysiology, and working hard to coordinate the teaching in both courses. Implementation of this plan has met some resistance from both basic science faculty and clinicians. I believe, however, that such a model should be extrapolatable to many other basic sciences such as immunology, microbiology, or biochemistry, for example (7). In a ?traditional’ curriculum, introducing elementary clinical material into the first two years does appear to make basic science material more interesting for the student, and returning to basic science topics during the fourth year helps to reinforce the scientific underpinnings of the clinical disciplines. If such models are to be useful, however, both students and faculty will have to work on rejecting the concept that the first two years of medical school are barely related to the last two years. students and faculty will need to embrace the philosophy that basic sciences and clinical disciplines are truly so deeply intertwined and interdependent that each can be learned better if integrated with the other in a appropriate fashion.
1. Nierenberg, D.W. and Smith, R.P.: Clinical Problems in Basic Pharmacology. St. Louis, CV Mosby Company, 1989.
2. Nierenberg, D.W. and Stukel, T.A.: The effects of a required fourth-year clinical pharmacology a course on student attitudes and subsequent performance. Clin. Pharmacol. Ther. 1986; 40: 488-93
3. Nierenberg, D.W.: Commentary: clinical pharmacology instruction for all medical students. Clin. Pharmacol. Ther. 1986; 40: 483-7.
4. Nierenberg, D.W., and the Council for Medical Student Education in Clinical Pharmacology and Therapeutics. A core curriculum for medical students in clinical pharmacology and therapeutics. Clin. Pharmacol. Ther. 1990; 48: 606-610.
5. Nierenberg, D.W.: Consensus for a core curriculum in clinical pharmacology for medical students. Clin. Pharmacol. Ther. 1990; 48: 603-5.
6. Melmon, K.L., Morrelli, H.F., Hoffman, B.B., Nierenberg, D.W.: Clinical Pharmacology: Basic Principles in Therapeutics, 3rd Ed. New York, McGraw-Hill, Inc., 1992.
7. Nierenberg, D.W.: Teaching clinical pharmacology: a process of lifelong learning. J Clin. Pharmacol. 1993, in press.