[The following notes were generated by Sandra Haudek, PhD.]
The Winter 2022 IAMSE Webinar Seminar Series, titled “How Science Educators Still Matter. Leveraging The Basic Sciences for Student Success” opened on Thursday January 6, 2022 with its first presentation, titled “New Horizons: Restructuring the basic and clinical sciences beyond USMLE”. This seminar was presented by Dr. Nadia Ismail, Senior Associated Dean of Curriculum, Dr. David Rowley, Assistant Dean of Foundational Sciences, and Dr. Munder Zagaar, Associate Professor of Foundational Sciences, at Baylor College of Medicine, School of Medicine, Houston, Texas. They discussed their experiences with shortening the foundational sciences curriculum, curricular challenges and opportunities, and how they are addressing the incorporation of the foundational sciences using a spiral integration and focused exposure to basic science concepts.
Dr. Ismail began with discussing curricula trends by presenting AAMC data (Curriculum Reports) showing curricula changes in US medical schools since 2017: ~20% completed curricular changes, ~65% planned or are in process of implementation, and 15% have no plans for changes. AAMC further reports that the majority of curricula changes target the pre-clerkship (also referred to as “foundational sciences”) phase typically by shortening its length. Other efforts of curricula changes target the enhancement of clerkship coordination and use of simulation, and more emphasis on interprofessional education, competency based education, team-based learning, self-directed learning formats, and online instruction.
Dr. Ismail then emphasized that in the context of USMLE Step 1 exam changes, the goal of curricula change is not to cut foundation sciences content but to better integrate basic science content throughout the whole curriculum, emphasizing on foundational thinking in clinical relevance and providing application or action opportunities for foundational sciences. Citing an issue of the Journal of IAMSE (before it was renamed to Medical Science Educator) from 2010, Dr. Ismail reviewed the value and role of foundational sciences in medical school education. She discussed that foundational sciences serve as basis of critical thinking and clinical problem solving, they enable learners to understand normal homeostasis, its disruption and management, and they require a fund of knowledge to base hypothetical possibilities and take action. Dr. Ismail finished her part of the presentation with highlighting that the majority of medical practice is routine with cases based on pattern recognition, but expert physicians rely on the understanding of basic sciences for difficult cases and require a strong foundational science background in order to write and deviate from guidelines.
Dr. Rowley continued with discussing curricular challenges at Baylor College of Medicine. He stated that the first step to meaningful integration of foundational sciences is accountability. Baylor College of Medicine has a history of experimenting with curricular changes. In the 1970, they explored an optional 3-year program with a truncated basic science curriculum, yet ultimately settled on an 18-month foundational science phase in a 4-year overall medical school curriculum. One major challenge was the departmental accountability for curricular content as courses were directed by experts in different departments resulting in “siloed management”, e.g., biochemistry in the Department of Biochemistry, pharmacology in the Department of Pharmacology. In the late 1990, Baylor College of Medicine started to centralize oversight and thus accountability to curriculum deans and the curriculum committee, which was a first and necessary step to address meaningful integration. As an example, a long foundational course emerged covering a human biology approach in which different disciplines were integrated in one course. However, over time it became apparent that content accountability was still managed more in a siloed manner and thus a curricular shift took place, from the intended curriculum to an implemented curriculum. A key question emerged: How do we best get back to the purposeful design and implementation of an intentionally curriculum that appropriately integrates basic sciences and foundational principles in clinical medicine?
Dr. Rowley stated that, in 2018, Baylor College of Medicine embarked on an intentional curriculum renewal. Decisions were made to strategically incorporate foundational sciences throughout the 4 years by starting with the bulk of foundational content including their clinical relevance during the first 12 months followed by deliberate threading of foundational material into the clinical curriculum. To do so, they used the method of Understanding by Design. According to this backwards design framework, the team started with developing desired outcomes, then assessments, followed by generating course goals, followed by session objections. The goal of this curriculum renewal process is to align fully the intended curriculum with the implemented curriculum.
Dr. Zagaar continued with discussing cultural reset of expectations and biases that can often hinder the curriculum viability and explained how a shared framework was helpful in keeping everyone focused and on target. He explained the three major components of the Understanding by Design framework that are well suited for a competency-based (or outcome-focused) medical education program: 1) Start with the end in mind, 2) Assess for understanding, and 3) Design learning experiences to teach. This process, starting with outcomes and working backwards to develop appropriate assessment tools before curricular content, is the opposite of the typical forward design method in which content is determined first. A clear understanding at the beginning of the destination assures that the steps taken are always in the right direction and encourages deeper understanding of transferrable concepts or skills (enduring knowledge) as opposed to just covering facts.
Dr. Zagaar then explained how Baylor College of Medicine used the principles of the Understanding by Design framework to guide their curriculum renewal process while maintaining a shared focus. First, the team had to establish essential understandings that are basic to the practice of medicine, including foundational sciences, clinical skills, metacognitive awareness, and inquiry. Second, they had to clarify acceptable evidence of learning that embraces individual student challenges; specifically they pivoted from a traditional approach to assessment towards a multifaceted assessment that included qualitative and quantitative formative assessment with build-in remediation that encourages students to progress from competence towards excellence. Third, they developed an integration mechanism for tracking alignment of curriculum by using curricular threads that helped them moving away from siloed structures towards a system accountability for learners, faculty, and curricular administrates.
Dr. Zagaar then illustrated their integrated framework as a staircase representing foundational sciences structured across the curriculum incorporating metacognition, clinical reasoning, and inquiry. Transitioning into medical school starts with basic understanding and board exposures to the principals of health and disease. From there, the foundational sciences are introduced from molecular to psychosocial levels, anchored with metacognitive and clinical context and delivered using different learning methods like self-directed learning (“Why?”). Thereafter the students will progress to an integrated system based framework of applied sciences in which foundational knowledge will be applied to clinical actions (“How?”). Build-in remediation is meant to capture all students by providing support, time, and opportunities to progress towards the desired outcomes. In the last phase, foundational science knowledge and thinking skills continue to be reinforced by purposeful repetition through integrated teaching sessions and mentored experiences to apply foundational science towards the discovery of new knowledge and dissemination.
Using another diagram Dr. Zagaar demonstrated the mechanisms of their curricular threads. The foundational science and clinical sciences were shown as two opposing triangles, with an overlapping diamond through which the three main curricular thread families are intertwined: foundational sciences, metacognitive skills, and clinical preparation skills. These threads ensure flexible movement from understanding to reasoning to taking action, and provide an accountability system for outcomes, assessments, and instructional content. Such threading of instruction and assessment encourages foundational thinking. The connect can be delivered in individual steps: Hybrid case-based clinical scenarios, hybrid clinical encounters, simulation-based learning, clinical teaching integrative sessions, applied foundational science electives, and an inquiry project that deliberately tie in foundational sciences into clinical decision making. Dr. Zagaar then gives a specific example of how a pharmacology skillset could be achieved using this framework.
In conclusion, Dr. Zagaar listed the three take home points: 1) Changes to USMLE are an opportunity to innovate, 2) Foundational sciences are essential for clinical-reasoning and decision-making, and 3) The Understanding by Design framework is well suited for competency-based medical education.
The presentation lasted about 30 minutes. During the ensuing 30 min, an engaging discussion followed addressing a record number of >60 questions from the audience, including change management, faculty development, specific challenges, who and how many individuals were/are involved in the process, how were content domains identified, etc. Dr. Ismail, Dr. Rowley, and Dr. Zagaar answered live and responded via the Q&A Chat function.