MEDICAL EDUCATION REFORM

Tutorial Format Will Grow With Students

Graham Ramsay David Cardozo and colleagues have developed a new tutorial system in which teaching formats change as the students acquire more knowledge and skill.

Tutorials are part of the DNA of Harvard medical education. But it is not unfair, according to David Cardozo, to say that they expect too much free association from students—self-propelled learning in a system lacking structure.

“Students would take a paper case of a clinical problem, read it out loud, and investigate different aspects of it,” said Cardozo, an HMS assistant professor of neurobiology. “The style of the tutorials was unchanged, from the very first case students saw in the first year to the last case they saw in the second year. But the students’ knowledge and skill set had evolved significantly during that time.” The static tutorials did not boost the intellectual challenge in recognition of those higher abilities.

The result? Student assessments reported boredom with tutorials. Moreover, too much was left to student taste in terms of study topics. Recognizing the problem, instructors tinkered with tutorials in recent years. Students and tutors both gave the new approaches an enthusiastic thumbs-up, leading to a group—Cardozo, Julian Seifter, Thomas Aretz, Michael Parker, and Benjamin White—that developed the more structured “developmental tutorials,” which are being vetted with course directors in advance of a hoped-for debut in the 2008–09 academic year.

The group proposes to replace or augment paper cases with videotapes of real patients. More importantly, tutorials will be integrated under thematic canopies. The tutorials for all courses will touch on the same themes, but grow increasingly challenging as students progress through the first and second years, in acknowledgment of the students’ advancing skills.

The first change will be more clearly defined learning goals. Students will get a blueprint at the start of their first year, explicitly laying out the themes, the steps to be taken in considering these themes, and the expectations along the way for student proficiency. One theme will be group dynamics and teamwork. Tutorials initially will emphasize being comfortable working with and speaking before a team. Then they will focus on ways to contribute effectively when a student is solely responsible for a particular aspect of the case. By the end, the students will learn how to lead a tutorial group.

Another theme will focus on researching medical literature. “You have to learn, first, how to find information in assigned textbook readings,” Cardozo said. “Then you move up to getting the information from review articles and conducting literature searches. Ultimately, students will get to the point of being able to compare information from primary research articles that show conflicting results.” Yet another theme will be “cross-cultural care,” in which students consider how social and economic differences among patients can lead to disparate disease occurrence, treatment, and compliance with treatment.

First-year tutorials, oriented around basic science, will give way in the second year to a focus on clinical decision-making. The idea is to build students’ confidence to the point that they will be asked to bring in their own cases for study from their Patient–Doctor coursework, said Cardozo.

All of these changes will require tutors to make multiyear commitments to running tutorials, another change from the old system.

—Rich Barlow

Toward Evidence-based Pedagogy

Graham Ramsay The HMS Center for Evaluation, under Edward Krupat, helps faculty members gather the data they need to refine the student curriculum.

“In the same way we talk about evidence-based medicine, we should be making evidence-based decisions about our students and courses,” said Edward Krupat, director of the HMS Center for Evaluation and an HMS associate professor of psychology in the Department of Psychiatry at Beth Israel Deaconess Medical Center. Like a car on a maintenance schedule, faculty take their courses and clerkships for regularly planned checkups to the center, which Krupat calls “the assessment/evaluation conscience of the Medical School.” The center warehouses voluminous data—from student and peer assessments to outside consultants’ critiques—for the faculty and administration to use. And it provides consultation to faculty seeking better methods of testing students. The center also oversees the Objective Structured Clinical Exam (OSCE) at the end of the second and third years, in which students practice their examination skills on actors posing as patients.

Among a spate of recent or impending projects, the center has worked with the faculty on a new evaluation form for clerkships to render student grading less subjective. “There really had not been very precise, objective criteria for distinguishing between a high honors grade and honors, for instance,” said Krupat. The new form bases grades on identification of specific competencies achieved.

Krupat’s center and the Academy Center for Teaching and Learning are planning a workshop this fall to hone faculty skills in writing more specific feedback on student clerkship evaluation. “To say that someone is ‘hard working’ doesn’t tell the student much about him- or herself.” The two centers also have developed a new program under which the dean for medical education recognizes outstanding tutors.

The Center for Evaluation has initiated peer reviews of basic science courses and is assembling a committee of senior faculty to look at the first-year Human Body course. It has done similar reviews of clerkships for years and currently has the neurology clerkship under its spotlight, compiling assessments by faculty, outside consultants, and students while conducting on-site meetings with students and clerkship directors.

To ensure that curriculum reform is not a faith-based initiative, the center will take its measuring tape to that as well. Krupat has begun surveying current second- and third-year students—those who began their medical education under the old curriculum—to learn how well that curriculum met their needs. And he will do the same for students in the first two years of the new curriculum. All those surveyed will be followed up until their graduation and perhaps beyond.

The center has begun measuring the clinical performance of students in the Principal Clinical Experience, the newly formatted approach to single-site clerkships. The oldest PCE—the pilot integrated clerkship at Cambridge Hospital—will be the subject of an article by Krupat and the Cambridge directors in Academic Medicine. Their conclusion? “Although the numbers were small, we found that the pilot students did at least as well, if not better, on Harvard and national board performance measures of knowledge and skills. Further, the students told us that they feel well prepared.”

Newer PCEs at the Harvard-affiliated teaching hospitals—involving specialty rotations even though students get a longitudinal experience at one hospital—are still being refined, but students report that they are much better prepared by staying in one institution, enjoying the continuity with faculty and feeling that they get a great deal of support, Krupat said.

As part of the second-year reforms, the center is helping course directors design a “week of integration” at the end of each semester, during which students will be tested to see if they have made connections among the content and concepts of the different courses that they have had—the whole point of integration.

—Rich Barlow

top