Design and Implementation of Core Knowledge Objectives for Medical Microbiology and Immunology

INTRODUCTION

In 1986 the Association of Medical Schools Microbiology and Immunology Chairs (AMSMIC) hosted an inaugural educational conference at the Ocean Creek Conference Center in Myrtle Beach, South Carolina. The meeting brought together a wide range of plenary sessions and provided a number of afternoon workshops, covering specific topics on General and Molecular Microbiology, Immunology, Pathogenic Bacteriology, Virology, Parasitology and Mycology. The purpose of these sessions was to provide a format to discuss teaching modalities in medical education. The meetings have continued on a biennial basis since the inaugural session, with the concept of similar workshops facilitated by a variety of speakers and the objective to share experiences in teaching and implementing educational outcomes in medical microbiology and immunology. Additional evening workshops were also conducted on “Optimal Course Content.” In 1991 Cantor and coworkers, in a survey of 1369 medical educators, observed a strong endorsement of the need for “fundamental changes” or “thorough reform” in medical education.¹ In the mid to late 1990’s a major shift in the modes of medical student education was underway. The distinct levels of cognition, organized into a taxonomy of general objectives by Bloom, provided a basis for higher education.² Other avenues of concern, modifications and changes in the medical curriculum have occurred more recently.^3-6 As modification of the medical curriculum occurred, the “Myrtle Beach” meetings focused on curriculum change, innovative techniques and evaluation formats in medical education. At the 1998 meeting the former course categories were condensed to Pathogenesis/Infectious Disease and Immunology/Host Defenses. Since that time the meetings have, in addition to curriculum discussions, centered on bioterrorism, computerization techniques and up-to-date innovations. The fields of medical microbiology and immunology are rapidly evolving with new research and the appearance of unrecognized pathogens and discovery of new immunological diseases. There is a need therefore to provide a regularly updated resource for core knowledge objectives to aid in the development and improvement of existing discipline-based and integrated medical school curriculums. At the 2006 meeting the curriculum sessions were divided into three distinct areas: (1) Fundamental [Basic] Microbiology, (2) Host Defenses [Immunology] and (3) Pathogenesis [Infectious Disease]. Following the meeting a wiki website was created7 and made available for the membership to establish core knowledge objectives in these areas. This paper describes the outcome and current status of the medical microbiology and immunology core knowledge objectives project. However, the project is a continuum and the objectives are continuously open for modification at the wiki website and at biennial AMSMIC meetings.

MATERIALS AND METHODS

Beginning in 1998, three groups of faculty at the Myrtle Beach meeting were charged to provide a computerized listing of core knowledge objectives for the disciplines medical microbiology and immunology, including the broad areas of virology, medical parasitology and mycology. In May 2006, at the 11th Educational Strategies Meeting in Myrtle Beach, the learning objectives were further refined to three main academic areas, namely Fundamental Microbiology, Host Defenses and Pathogenesis. Each section subcommittee, directed by faculty facilitators, was responsible for compiling and documenting core knowledge objectives and a wiki website was created following the meeting to facilitate revision of the proposed objectives. The website carried the following general instructions:

“After you have logged in, click on your name next to the logoff link and change your password. Please remember to click “Update Password” link to change your password. You may then enter and exit the website.

Thank you for your efforts and assistance in designing the knowledge objectives for Medical Microbiology & Immunology.”

In addition, instructions for each academic area, including Fundamental [Basic] Microbiology, Host Defenses [Immunology] and Pathogenesis [Infectious Diseases], are available at:
http://mmi.creighton.edu/CoreObjectives/Default.aspx?tabid=53, http://mmi.creighton.edu/CoreObjectives/Default.aspx?tabid=54,
and http://mmi.creighton.edu/CoreObjectives/Default.aspx?tabid=55, respectively.

RESULTS

To date 117 responses have been obtained, representing 56 different medical schools in the United States, Canada, Dominica and Grenada. Individual responses totaled 1,847, resulting in 63, 15 and 55 revisions for the sections on Fundamental [Basic] Microbiology, Host Defenses [Immunology] and Pathogenesis [Infectious Diseases], respectively. For the section on Fundamental Microbiology, the working group ranked each item based on importance in the curriculum using a scale of ‘3’ for knowledge that was essential for inclusion in the curriculum, ‘2’ for important knowledge that should be included in the curriculum if time is available, and ‘1’ for information that was deemed trivial and therefore not required in the curriculum. This version of the core knowledge objectives is shown in Table 1 (see Appendix), with an average of the individual rankings. In addition, Table 1 represents the four major divisions of microbiology, including Basic Bacteriology, Basic Mycology, Basic Parasitology and Basic Virology. The division within Basic Bacteriology is divided into 9 subdivisions that represent (A) Structure and Function of Bacteria, (B) Nutrition and Growth, (C) Microbiological Techniques, (D) Physiology and Metabolism of Bacteria, (E) Microbial Genetics, (F) Antibiotic Susceptibility Testing, (G) Antibiotics, (H) Physical and Chemical Agents for Control of Microbial Growth and (I) Host-Parasite/Pathogen Relationships. The second division entails Basic Mycology and includes subdivisions on (A) Principles, (B) Fungal Classification and (C) Antifungal Agents. The third division entails Basic Parasitology and includes subdivisions on (A) Principles and (B) Classification. The fourth and last division entails Basic Virology and includes subdivisions on (A) Principles of Structure and Function, (B) Virus Multiplication and Infectivity and (C) Antiviral Agents.

A second section on Host Defenses Core Knowledge Objectives is represented in Table 2 (see Appendix). The rankings, far right-hand column, are similar to Table 1, with a value of ‘3’ for essential knowledge, ‘2’ for important knowledge and ‘1’ for information that was found to be trivial and not an absolute requirement for the curriculum. As indicated, Table 2 is composed of three major divisions, including Division I: Basic Concepts in Immunology, Division II: The Immune System and Disease and Division III: Applied Immunology. Division I on Basic Concepts in Immunology consists of 9 sections that represent (A) General Principles, (B) Development of Cells and Function of Organs, (C) Innate Immunity, (D) Antigens and Antibodies, (E) Antigen Receptor Diversity, (F) MHC, Antigen Processing and Presentation, (G) B and T Lymphocyte Activation, (H) Regulation of the Immune Response and (I) Cell Mediated Immunity. Division II on The Immune System and Disease consists of 6 sections that represent (A) Hypersensitivities, Allergy and Asthma, (B) Autoimmunity, (C) Transplantation Immunology, (D) Immunodeficiencies – Congenital and Acquired, (E) Tumor Immunology and (F) Immunity to Microbes and Vaccines. The final division, Division III: Applied Immunology, is subdivided into 2 sections that represent (A) Immunotherapeutics and (B) Immunodiagnostics.
The final major division on core knowledge objectives for medical microbiology and immunology, Pathogenesis, is represented in Table 3 (see Appendix). The right-hand column represents values of ‘3’ for information that is essential knowledge to be included, ‘2’ for information that is important knowledge to be included if there is time in the curriculum and ‘1’ for information that is trivial knowledge not required in a curriculum on Pathogenesis/Infectious Diseases. In addition, Table 3 includes two major divisions, Essential Concepts in Infectious Pathogenesis and Systems-Based Diseases. The division on Essential Concepts in Infectious Pathogenesis is subdivided into 4 subdivisions that represent (A) Encounter with Pathogen, (B) Invasion and Dissemination, (C) Outcomes of Infection, (D) Treatment and Prevention. The second major division on Systems-Based Diseases consists of eleven subdivisions that represent (A) Upper Respiratory Tract Infections, (B) Lower Respiratory Tract Infections, (C) Cardiac Infections, (D) Gastrointestinal Infections, (E) Genitourinary Infections, (F) Genital Tract, (G) Musculoskeletal Infections, (H) Infections of the Nervous System, (I) Degenerative Brain Diseases, (J) Zoonotic Diseases and (K) Opportunistic Infections.

DISCUSSION

Over the past two decades the professional curriculum for medicine and other allied health professions has continued to change.^8-11 In the specialty of medicine the Liaison Committee for Medical Education (LCME), which accredits complete and independent M.D.-granting programs, is recognized as the reliable authority by the nation’s medical schools and the U.S. Department of Education for this purpose.¹² In effect, all U.S. and Canadian medical schools operate under the auspices of the LCME accreditation program. Since the LCME inception in 1942, numerous changes have altered and shaped the medical curriculum. In recent years, periodic review and amendment of the standards for the institutional setting, educational program for the M.D. degree, medical students, faculty and educational resources have all played a significant role in modification of the modern day medical school. In addition, new and progressive methods of teaching and changes in the curriculum over the past century have led to a variety of approaches.¹³ In general, didactic lectures and paper examinations have been replaced in favor of problem-based learning¹⁴, team-based learning¹⁵, e-based small group, simulation-based learning^16-18 and a shift to the use of computerized¹⁹ and block testing modalities²⁰, respectively. For medical microbiology and immunology, a single or dual course presentation under direction of the respective faculty remains preferable to provide an appropriate foundation in the period required for basic science. To the contrary, several medical schools have been able to integrate “some” or “a large portion” of medical microbiology and immunology into other coursework. The purpose of developing core knowledge objectives was to provide, not regarding either stand-alone or integrated coursework, guidelines for those minimal concepts and principles that are essential for the integration of medical microbiology and immunology into the practice of medicine. These guidelines provide a yardstick with which all institutions can measure the mastery of basic principles as well as to evaluate understanding and competency of their students, regardless of the curriculum used. The continuum of core knowledge objectives will be facilitated by future meetings and underscored by faculty participation at the wiki website.

ACKNOWLEDGMENTS

The authors wish to acknowledge and recognize the resources, collaborative efforts and support of AMSMIC [http://www.amsmic.org/index.htm], members of the Education Committee (Drs. Jerry W. Simecka, Agnes A. Day, Richard V. Goering, John M. Quarles, C. Jeffery Smith, Keith E. Weaver), program support (Paul Montgomery, Paul V. Phibbs) and meeting conferees for valuable assistance and guidance.

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