Johns Hopkins Gazette | March 9, 2009
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The newspaper of The Johns Hopkins University March 9, 2009 | Vol. 38 No. 25
Sea Change for Medical Education

SoM's new curriculum was nearly six years in the making

By Greg Rienzi
The Gazette

This fall, the School of Medicine will fully implement its new Genes to Society curriculum, the first wholesale academic overhaul at the school in two decades.

The curriculum, nearly six years in the making, centers on advances in understanding of the human genome and will feature a slew of new courses and modified existing ones — and ultimately render some elements of medical training obsolete.

The changes, some of which have already been integrated into the academic schedule, are grounded in the Human Genome Project and the concepts of human variability, risk and the ability to alter disease presentation and outcomes. Genes to Society also incorporates a wealth of new knowledge in the social and behavioral sciences, as well as public health and policy content, with an aim toward improving societal health outcomes.

As a basic principle, students will now experience a more integrative, holistic approach to health from the first week of medical school.

"This is a very substantial change in our outlook and the delivery and continuity of care," said David Nichols, vice dean for education at the School of Medicine.

Other major modifications include a new career preparation course with a scholarly project, a longitudinal clerkship, translational science intersessions, transition courses at milestones in the curriculum and improved assessment and evaluation. For the longitudinal clerkship, students in their first and second year will follow patients over an extended period, not just on periods of hospitalization.

The balance of lecture and active learning strategies will change with the new curriculum, which will prominently feature the use of simulations.

While the school updates the curriculum every so often in order to meet accreditation standards, the curriculum has not been so dramatically altered since the tail end of the 1980s.

"In this instance, we did not look at accreditation," Nichols said. "We stood back and asked what medicine will look like in the future and what we need to do to prepare our students."

The ambitious effort dates back to 2003 and began with a simple question: How will medicine be practiced 10 years from now?

To start the process, the school's leadership formed a strategic-planning group comprising basic and clinical scientists, former patients and policy-makers.

The group worked for six months and came up with a general framework. Then came the next question: How will the school prepare its students to practice this new brand of medicine?

In spring 2004, the Dean's Office formed a Curriculum Reform Committee charged with developing the new training. The committee was chaired by Charles Wiener, vice chair of the Department of Medicine, and eventually included up to 30 faculty, staff and students.

"We wanted to start to work out the details of what this new curriculum would look like," Nichols said, "but not just a curriculum that would function, one that would keep us in a leadership position."

As a jumping-off point, Nichols presented key committee members with a copy of the book Genetic Medicine: A Logic of Disease by Barton Childs, a professor emeritus at the School of Medicine. In the book, published by The Johns Hopkins University Press in 1999, the author lays out a vision of medical education based on the impact of genetic advances.

For the next two years, the group convened on a regular basis and divided into working groups such as Faculty, Research, Basic Sciences and Clinical Clerkships.

Nichols said that the committee early on in the process realized that the endeavor was much broader in scope than it had anticipated.

"Changing how we prepare our students for professional careers is also linked to how faculty spend their time, our facilities, tenure, class and lab schedules, all the elements of what a medical school does," Nichols said.

To work through all the issues, the Curriculum Reform Committee met with department heads, hosted town hall meetings and periodically went on retreats, in addition to holding its regular meetings. Nichols said there were many "spirited debates" along the way, but eventually an outline for the new curriculum came into view.

To help implement the changes, an Integration Committee was formed in 2006 and continues to meet weekly.

The yearlong Genes to Society course will be the centerpiece of the new curriculum. The course, which will begin in the students' first year, will cover the major biological aspects of training. The students will seek to understand how various internal factors (genes, molecules, cells, organs) and external factors (family, community, environment) interact to explain the patient's condition, or phenotype. The curriculum will also place heavy emphasis on communication skills, teamwork in medical problem solving and lifelong learning.

Nichols said that the current educational model, generally speaking, classifies people as "sick" or "healthy," with nothing in between.

"More or less, doctors are mechanics who find out what is broken and try to fix it and return the person to health," Nichols said. "You look at a person with a specific problem and treat that problem. That is where we are now, and there is an attraction to this model. It's one that has served us well for a long time."

However, with advances in genomics, Nichols said, physicians have come to learn that a patient with a given diagnosis is not like every other patient with that diagnosis. There are important details, beginning with genotypes, that are unique to every person.

"Genetic medicine has already moved into the oncology area," Nichols said. "Over time, this level of understanding will migrate to every specialty. This is a huge departure from where we are now and a main reason for why we have to change the way we train people to become doctors."

Nichols said that the concepts of the new curriculum literally altered the physical landscape of the campus.

The newly opened Anne and Mike Armstrong Medical Education Building was specifically designed around the new curriculum. The building, located centrally on the campus between the Outpatient Center and the Denton A. Cooley Center, features a variety of learning settings, ranging from a 70-person learning studio and two large lecture halls with seating for 180 students each to flexible lab space and study areas for smaller groups.

Students can access the latest digital communications technology for tapping into network data and displaying digital images. Instead of using conventional microscopes, students have virtual microscopy tools composed of high-resolution monitors and displays that show multiple images housed on centralized servers. Large screens at the end of each dissection table in the anatomy labs provide students with digital reference tools.

In 2008, Johns Hopkins Medicine opened the Simulation Center, located in the Outpatient Center, immediately adjacent to the Armstrong Building. The new training facility allows medical students to learn and practice procedures, such as inserting a chest tube, on plastic manikins and robots before performing them on patients, ideally enhancing both the educational experience and patient safety.

The new curriculum will go live with the class of 2013, entering in September. Current students will remain on their present tracks and see less-sweeping changes to their training.

"You can't big bang something like this as we already have students in the pipeline," Nichols said. "So there will effectively be a three-year phase-in with students arriving in the fall being the inaugural class entirely under this new curriculum."


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