rant: it's all about the tone....

i cannot speak for all medical schools (there were certainly things in the 101 list that do *not* apply to my program), but it seems that there's a general tone of animosity directed at the students, particularly by the science ph.d. professors. anatomists, in particular, seem to despise medical students. they think we're stupid (<--heard at many an anatomy lecture last year: "if you don't understand this, you're so dumb you should get up, leave, and go fill out a subway application")*. one of my study buddies had a conversation with a physician she shadowed before beginning medical school and he issued this caveat: "watch out for the ph.d.s. they're bitter because they didn't get in to med school." ouch. ordinarily i'd have thought this physician's hypothesis was off, but after what i've observed, i'm not so sure anymore.... at the very least, they hate teaching--that much is clear. since mwms is an odd place that runs on a pbl program, the school has made some very bassackwards curricular decisions. they're still trying to figure out the best way to "teach" and test our knowledge. while our anatomy class was a 10 week marathon of lectures, we're now deep into the pbl portion of our program. so far, the way we've been tested is in the form of "learning issues." basically, after our group finishes a case, we're supposed to pick learning issues, relevant to the case, on which we want to be tested. the powers that be try to act like these should be discrete packets of knowledge for the case at hand, but since that's impossible (the books, after all, aren't designed around our cases!), what ends up happening is that we pick chapters from our various books. so, for any given exam, there might be 40 or so learning issues, all derived from different chapters. all the groups choose their own issues and go at their own pace, with some direction given by the faculty facilitator. for the last pbl exam that the class of 2010 took, the majority of the pbl cases were based on neuroanatomy. by the time they were finished with the 8 cases for that block, most groups had picked nearly the entire neuroanatomy textbook. *gulp* it's simply not possible (in my opinion) to learn all of neuroanatomy on one's own by reading the textbook, particularly in 6 weeks when that's not the only class/book/bit of material one has to learn during that time. there are only 6 hours of pbl class per week, so discussing all the material in group is not really an option, either. basically, we're left to sink or swim on our own. many groups, as a result, have attempted to make the learning issues more manageable. in other words, while the group as a whole reads broadly during the case, learning issues are picked with what the group feels it needs to be tested on in particular. the thought is that if the group is specific about learning issues, there won't end up being 50+ learning issues on an exam. basically, pbl groups are trying to choose wisely so as to survive these horrid exams. as list 101 indicates, though, everyone in medical school is smart. there's nobody there who didn't have to do some amount of more-than-ordinary work to get accepted. everyone is self-motivated, if not exceptionally so. but are we treated as if that's a given? heck no. we're treated like incorrigible schoolchildren. lest you think i jest, consider the following email (only modified by changing names to protect privacy) sent by the professor in charge of compiling all the learning issues for the exams. i swear to you, it's all about the tone.

Dear class of 2010:

After compiling the exam topics sheet from the 1st 2 cases, I have noticed that most groups are choosing only a few topics from each case. These cases contain many more basic science topics than are being chosen at this time. For example, why are most groups avoiding gross anatomy? If you are deciding to avoid gross anatomy because you “already had that,” you are making a huge mistake. What you already had was a “survey” course, not a full anatomy course. As stated by I and Dr. Head Anatomist several times during anatomy, you MUST choose anatomy exam topics in PBL to learn this science well enough. You were also told by Dr. Head of PBL and I that in PBL you must review topics several times to fully understand them. Why are you not reviewing anatomy? Aren’t you discussing gross anatomy during the cases? If not, you should be!

Please be reminded that you are in medical college where you need to learn all the basic sciences in a PBL curriculum. In this curriculum, it is assumed that you take the responsibility of learning seriously and become adult learners where you are responsible for your own education. Most of you are achieving that goal, but others need to be reminded from time to time that this freedom in your education comes at a price. If you continue to minimalize exam topics as a strategy to score better on PBL exams, this strategy WILL backfire: you will not learn enough basic science information to score well on PBL exams, the COMLEX exam, or to be a knowledgeable physician.

Please let me remind you that the PBL exam will be comprised of 185 questions. If you choose too few exam topics, your exam will have 8 or more questions from each topic. As you might not be aware, deriving 6, 7, 8, or more questions from a topic requires that I examine you on very minute details: the kind of details in which you may need to memorize charts or graphs to answer. If you choose enough topics, say 4, 5, or 6 from each case, then I can attempt to make your exam from big picture topics that are most important clinically. Although not always reached, this is my goal.

In closing, let me make it perfectly clear that choosing very few exam topics from cases in not a good strategy: neither for the PBL exam, nor for your medical education.

Another Frustrated Anatomist, Ph.D.

*no offense to anyone working for subway; i guess the anatomists just have issues with those employees, too, even though they eat lunch there almost every day.....

going awol: my exceptionally difficult decision

when i last posted, i'd just experienced a day from hell in which my body revolted and the medical system pretty much tortured me. the time since then has been turbulent, to say the least. and what i'm about to describe may well surprise you.

first, my ct scan came back relatively normal. normal enough, that is, to rule out any kind of pathological process for my pain. the antispasmodics worked nicely to reduce spasms, but my gut remained tender and sore for several days. on the up side, my mom returned to town and proceeded to feed me--so i'm finally off my diet of applesauce, rice, toast and bananas. believe me, this is a good thing.

the whole experience of the pain, the er, etc, however, left me feeling quite anxious. most of you already know that i have a tendency to be an anxious person (again, i was the cautious one of the kids; my brother was the one always running toward fire instead of away from it, like me). but i have good reason for my anxieties regarding my healthcare. to bring the point home without offering too much information, i'll turn 30 this summer, and in this decade of my 20s, i'll have lost 3 different internal body parts, been put through chemical menopause, have endured four surgeries (three abdominal, one routine loss of wisdom teeth), spent more money than i've earned trying to pay for all the procedures and doctors' visits, and, at one point, counted up that I'd been put through more than 24 pelvic &/or rectal exams in a period of 18 months. No, i'm not making this up. and i don't have munchausen's, either. i've merely had a string of really, really, really bad luck. speaking of which, does anyone know where i can get a body transplant? or a refund? or at least some *good* luck? i feel like i could be despair.com's poster child.

so...anyway...let's just say that the recent medical events have pushed some major buttons in me and that now i'm at the point of feeling rather depressed by all of it. it didn't help that i was under tremendous stress in school. in fact, tremendous may be putting it lightly. since i failed a course in the fall (i'm blushing; this still embarrasses the heck out of me), mwms put me on "probation." i'm not the only one out of 163 that's now on the dean's hit list; in fact, 3 didn't even get a chance to return for this semester--but it still really stings to be in this position. not to mention that it makes me doubt myself even more. it's a tough spot to be in, considering that this is precisely the point when i need confidence the most. but the worst thing was the pressure of knowing that if i failed another class, i'd lose my seat in medical school. for good. and i've worked way too long and way too hard to get here to let that happen.

the_godfather has been working hard to coach me through this process and I really don't think i'd have gotten this far without him. in fact, i'm convinced i wouldn't have. but what he showed me last week was probably the most powerful thing of all. i've been doubting myself so much that i keep getting paralyzed. i freeze on tests and i've generally been feeling, well, stupid. in pbl last week, however, something major shifted.

throughout the week, i ended up in positions where i was leading the group. this was particularly profound last friday, when i was given the role of scribe (the person who writes case information on the board and directs the flow of the group discussion). that day, i realized that my intensive liberal arts training, in spite lacking science training, prepared me for clinical cases in an amazing way. i know how to ask questions. i know how to lead group discussion. i know how to teach. and, somehow, through all of this, i've developed instinct--this sense that i know how to approach a case in a logical, yet thorough, manner. and i remember the human side of it all, too, which is not always an easy feat when your patient is on paper and your whole group is intent on "solving the case" rather than thinking of it as a real live situation that we'll face someday soon. i was stunned by what i was able to do in pbl on friday. during wrap-up, all my group-mates commented on it. since beginning of medical school last august, it was the first time i've felt confident in my abilities. and let me tell you: it felt really, really good.

friday afternoon, after a long discussion with some of my classmates, i went for my weekly meeting with the_godfather. before i reached his office, though, i ran into biochem_enthusiast, my facilitator from the first 10 weeks of these past two semesters. he is also an exceptional teacher and a very interesting person, even if he does sometimes get hyper-obsessed with those pesky little molecules that do everything in our bodies. ;-) he was concerned about me and, for the second time, questioned as to whether i should take a leave of absence. hmm...

i went to see the_godfather next. 28 days out from a big pbl exam that would basically cover all of neuroanatomy (on which we have not been lectured; we've merely read the book and taught ourselves), i was starting to hit the peak of my panic. and that's when everything began to unravel. the_godfather pointed out that i was performing well in pbl--so well, in fact, that i'm often two steps ahead of my colleagues. he also noted that this is not showing in my exams because i'm freezing. i mentioned that i'd tried taking some anti-anxiety medication, but that it had been sedating (and therefore not very helpful for exam-taking purposes), but he stopped me. "this is not a physiological problem," he said. "this is a mental problem." and, in hearing him say that, i knew he was absolutely right. he was also quite accurate in pointing out that i've had a rough year. i threw out my back right at the beginning of the year, which subsequently threw off my studies at a crucial time, and then, right about the moment i was recovering from that, my grandmother died, as did one of my favorite high school teachers with whom i was close. combine that with undiagnosed gallstones and the pain they cause and, well, you get where i'm going: first semester was a nightmare. [a note on this: i wrote a lot during that time, but i haven't published it here yet. i haven't decided whether i'll go back and add these to the blog or not, but i thought i should explain why some of this is just being mentioned for the first time.]

when you add into the mix that this semester has involved illness, surgery, recovery, and more illness, it's clear that i haven't had the opportunity to adequately learn the material, let alone show that i've learned it. so, to make a long story shorter, i finally made the decision to take a leave of absence from medical school.

*gulp*

after working so hard for so many years to get here, it's hard to believe that i've made the decision to step away from medical school. in fact, it feels completely surreal. but here i am, one day after the official clearance from dean_honey (who, upon hearing my decision, said "honey, you're making the right decision. you should've done this months ago. i'm glad you've gotten over your stubbornness."), and i feel like i've been shot out of a cannon or something. it's...overwhelming.

so what does this all mean? well, other than another $50K in student loans (i must be crazy to be doing this), it means that i get to repeat the first year of medical school. so now i'll be in the class of 2011 instead of 2010. this feels *very* strange to me.

on the upside, though, i now have four months to get my health under control (<--maybe that's not the best phrase to use...maybe i should say more balanced...because i clearly have no control over this crap whatsoever). i also will have a chance to fill in some of the gaps in my education (since i wasn't a science major in college, i still have some areas of science that are unfamiliar to me, in spite of all those post bacc classes i took). if i can find someone willing to hire an overqualified slave (will work for food!), i may be able to earn a little money, too. that would certainly feel good.

in the meantime, though, i'm reminded of one of my favorite episodes of the west wing. (yes, i'm a wingnut. i loved that show. i'm not usually addicted to tv, but i never missed that one.) in it, cj is exercising on a treadmill and her pager goes off. so she's trying to check her pager and talk to the guy next to her. that's when she trips--splat--and gets thrown off the treadmill. that's *exactly* what this feels like.

*splat*

problem-based learning - a detailed description

Description

The Problem-Based Learning (PBL) emphasizes student-centered, self-directed learning. Groups of eight students meet with a faculty facilitator two to three times per week. Faculty members do not "teach" in the traditional sense. Instead, they serve as facilitators.

A series of cases focus on learning the basic sciences required to understand patient problems. Students then work independently and in small groups on learning issues before the next meeting, at which time the new information is discussed and refined in the context of the case.


The Problem-Based Learning Pathway is ideal for students who:

* Are self-directed;
* Are comfortable with flexibility in their learning goals;
* Learn best through reading and small group discussion; and
* Want a strong clinical context for their learning.



Problem-Based Learning Curriculum Program Description and Objectives

In the Problem-Based Learning Pathway, the passive delivery of information is completely eliminated. Students are placed in small groups of eight students each, and each group is assigned one faculty member whose function it is to facilitate discussion in the group. Because the faculty members who serve as group facilitators are not necessarily authorities on the material being discussed, the students learn to not rely upon him/her to teach. A series of cases serve as a basis for learning the basic science required to understand the clinical scenario. The object is not to diagnose the case, but to identify what are called learning issues, topics for further independent and/or group study. Students then work independently and in small groups on their learning issues before the next meeting, at which time the new information is discussed and refined in the context of the case. If necessary, further learning issues are then identified and studied.

This program provides an environment in which the learning of the basic sciences will be approached with considerably more enthusiasm than under the lecture system. With a problem-based approach to the basic sciences it is also hoped that the students will feel more comfortable and confident in dealing with uncertainties, and with the challenge of solving clinical problems. If so, then the students should be better prepared to enter into their clinical clerkships, which commence with the third year of medical school.

With this approach, the memorization of isolated facts, taken out of context, is de-emphasized. Those skills which are of value in helping students develop into self-directed, independent learners are used repeatedly throughout the students' education. It is the process of learning rather than the factual information itself which is stressed. The small group setting also fosters the development of a sense of community among students, who learn to work together in a problem-solving capacity. They learn both trust and responsibility as active members of the group. They become comfortable both receiving and giving criticism, with having their position questioned without taking it personally, and questioning without fear of threatening others. The small group process also provides valuable practice in sharpening students' clinical reasoning skills, which have been suggested to constitute the scientific method of clinical medicine.


The main objective of the course is to foster the educational and personal development of medical students who will:

* Take personal responsibility for learning, both during and following medical training;
* Command a relevant knowledge base characterized by depth, breadth and flexibility;
* Be skilled in the critical evaluation and acquisition of new knowledge, with a commitment to life-long learning;
* Be proficient at clinical reasoning;
* Have good interpersonal skills and enjoy working with other students.
* Be better prepared for entry into clinical clerkships.



The mechanism of achieving this objective will be an approach which will:

Shift the emphasis of the program from teaching to learning, by requiring students to be active, independent and self-directed learners and problem solvers, rather than passive recipients of information;

Emphasize the development of attitudes and skills which stress the acquisition of new knowledge rather than the memorization of existing knowledge, by limiting the amount of factual information that students are expected to memorize;

Provide a small group environment, within which the students can work cooperatively to solve common problems in an analytical way, with faculty who are facilitators of the discussion rather than teachers.


The Tutorial Process in Problem-Based Learning

The heart of a Problem-Based Learning Pathway is the tutorial group (8 students plus one faculty facilitator). Each member of the group has responsibilities which are important if the process is to succeed (See Roles of Participants). Members must feel free to challenge one another in a constructive manner and feel comfortable with being challenged, but without feeling personally threatened or insulted. In the early stages of group dynamics, this is difficult because members are uncomfortable with this behavior, but with familiarity, it becomes an enjoyable exercise which serves to help the group and its members focus on those areas where their knowledge must be extended.

The PBL cases are based on actual patients. The Progressive Disclosure Model is used. Initially, only the name, age, gender and chief complaint are made available. Following discussion, the group will request additional information, such as the results of a history and physical. Additional discussion follows and the students begin to form an initial differential diagnosis. After this discussion, the group will request new data, such as the results of an EKG or an MRI, and again, discussion follows. During the process, the students raise "learning issues", topics that they need to know more about. Following completion of a case, the students submit their final learning issues to the PBL office. The final learning issues serve as the basis for examination questions.

The facilitator will monitor the direction of the group, and redirect them by asking appropriate questions for discussion if they digress too far, but this is done only if absolutely necessary. The students are given the latitude to pursue unproductive directions, and decide for themselves that a particular learning issue was not germane to understanding the patient's problems.


The Group Tutorial Process

Initially, a case requires several tutorial sessions to complete. The group tutorial process may be divided into three phases. In the first phase, one student reads the case while another serves as a "scribe" and writes information on a blackboard. The blackboard are divided into three areas, for facts, general ideas and learning issues. Facts are listed as they are read. The students then begin to discuss the facts, to decide as a group which facts are important and which are irrelevant, and to probe for scientific explanations and correlative information relating to the clinical picture presented. This is accomplished first using existing knowledge of the group members.

At this point, the students must challenge any information presented for accuracy and understanding. As they arise, ideas are listed which are eventually formulated into hypotheses to be tested. With each hypothesis, one or more learning issues (topics about which there is insufficient knowledge to understand the clinical picture or to pursue without additional research) are presented, as well as which resources the students should utilize in order to obtain the appropriate information.

During this process, the students must take particular care to not become preoccupied with making a diagnosis, but to adhere to their primary goal: that of understanding the basic mechanisms, not the diseases, responsible for the clinical symptoms and signs. The final activity of each session is for the group to evaluate its effort. The program objectives may be re-read at this time and recommendations made as to how to improve the group's performance.

During the second phase, the students engage in independent and small group study, addressing the learning issues adopted in the group session. Appropriate resources for acquiring this knowledge include textbooks, journals, microscope slides, X-rays and tomographic scans, audio-visual materials, and designated resource faculty, who may upon request provide information on a topic.

During the third phase, one student will present the patient using a format in which the known subjective and objective information is summarized and assessed, and a plan for continued management is proposed. This will initiate continued discussion, not only of the new knowledge and its use in evaluating their hypotheses, but also for the seeking of more information about the patient. In light of the new information they approach the case fresh, listing new ideas, formulating new hypotheses and learning issues, as new case information is provided and added to that which they already have. This is followed by another group self-evaluation, another period of independent study and another meeting. This process may be repeated several times during a single case, as additional learning issues are added until the group is satisfied that it has gained sufficient knowledge of basic scientific concepts to understand the basic mechanisms underlying the clinical picture presented in the case. At this time, a final self-evaluation occurs, and the group evaluates its activities and summarizes what it has learned.


Role of Participants

The facilitator is responsible for providing the case information at the appropriate times during the discussion. He/She also assures that each member of the group participates by prompting, if necessary, the more timid members. In addition, the facilitator monitors how accurately the group is addressing the desired objectives.

The facilitator will also evaluate the efforts of the group members in terms of the willingness to contribute and willingness to complete their independent study to the extent that they are able to contribute to the group effort.

The students have the responsibility to participate actively in the discussions of the group. They must be willing to both give and accept constructive criticism, be willing to admit to knowledge deficiencies where they exist and to conscientiously complete their independent study assignments so as to contribute effectively to the group effort. Students also have the responsibility to honestly evaluate the activities of each other, themselves, the facilitator and the group as a whole. Only in this way is improvement possible.


Content Examinations

Each exam includes board-type multiple choice questions, and may include practical questions about laboratory material such as interpretation of slides. The questions will be generated by the faculty and will be based upon the learning issues identified since the last examination. The exam process will be used to identify the students' strengths and weaknesses as well as contribute to their overall evaluation.


Faculty Evaluation of Student Performance

Students will be evaluated by each facilitator. In general, students performance in the small group will be evaluated in each of the following categories:

* Group participation and contributions;
* Preparation and learning skills;
* Interpersonal skills and professional behavior;
* Contributions to group progress.



General Overview

The core of the program is the series of problem-based learning cases which occupies much of the time in years 1 and 2. While Anatomical courses are taken, groups meet only once per week, thereafter groups meet three times per week for the remainder of the first year, and twice per week for the entire second year, up to approximately one month prior to the national administration of the NBOME COMLEX Level 1.


Other Coursework

Students in Problem-Based Learning Pathway will participate in all other components of the lecture-based curriculum during the first and second years. These include the following:

* Human Clinical Gross Anatomy
* Medical Ethics
* Osteopathic Manipulative Medicine I - IV
* Healthcare Management
* Clinical Examination I - IV
* Public Health and Preventative Medicine
* Geriatric Medicine
* Basic Life Support / Advanced Cardiac Life Support
* Medical Jurisprudence
* Behavioral Medicine
* Human Sexuality

Within Anatomy Course:

* Histology
* Embryology