Carver College of Medicine Curriculum for the Medical Doctorate Degree Overview
The Carver College of Medicine’s medical doctorate degree curriculum recently underwent an exciting major renewal. The goals of this renewal effort were to develop an innovative curriculum that improved the integration of basic sciences with clinical application and experience while increasing the students’ ability to individually tailor their educational experience. Innovation, Integration and Individualization constitute the three “I’s” of our new curriculum. Given the phenomenal pace of change in technologic progress and the explosion of scientific discovery of new knowledge, tomorrow’s physicians must now be educated in ways that will allow them to continuously adapt to the complex and continuously evolving environment of health care delivery. The goal of the new curriculum is to develop enduring attitudes, skills, and knowledge that will provide focus and direction for tomorrow’s physicians in a future that cannot be easily predicted.
Examples of the ‘Three I’s’ in the CCOM Curriculum:
- Innovation- Scientific content taught in context of the 6 fundamental mechanisms of health.
- Integration- Early clinical experiences integrated with scientific content to provide contextual learning. Our foundational science courses are each co-directed by a scientist and a clinician.
- Individualization- Increased time during the last three semesters for students to choose how they will tailor their educational experience.
Our exciting new curriculum consists of a triple helix model componsed of three strands that extend through all four years of medical school. The three strands are Mechanisms of Health and Disease, Medicine and Society, and Clinical and Professional Skills. The strands are interwoven in a helical spiral that assures not only integration of their material but also affords the deliberate revisiting of material in a manner that promotes progressively deeper understanding and mastery.
Other new features of the curriculum include longitudinal mentored clinical experiences starting in the first week of medical school as well as beginning clinical clerkships after just 3 semesters of preclinical instruction, rather than the previous four-semester format, which is a more common practice. By the end of the 5th semester students will have completed all of their core requirements leaving the remaining 3 semesters for students to tailor their educational experience along various pathways to prepare them for their selected specialty.
When a person becomes ill, there is a complex and dynamic interaction happening between the basic internal mechanisms that maintain health and those that produce disease. At the same time, there is an interaction between the person and their environment, as well as with their health care provider. The triple helix model of our curriculum reflects these core interactions and their interrelatedness. They are inter-twined and inter-related in the same manner as they are in real life. The ultimate goal for our graduates is to achieve a complete and comprehensive understanding of each of the three strands as well as their intimate interconnections in order to provide holistic health care for patients and populations.
Further Curricular Explanation
Students will learn the art and science of medicine through an integrated approach among the three strands, which is similar to how they will practice medicine in the future. Health is maintained by a complex state of continuously changing interactions within our bodies and with our environment. The Mechanisms of Health and Disease (MOHD) strand covers the 6 basic internal mechanisms that help maintain health. The 6 basic mechanisms include genetics, the immune system, metabolism, the delivery of oxygen and its use, structural and locomotive (skin, musculoskeletal) systems and neuropsychiatry. Significant disruptions or abnormalities of the homeostatic balance within and among these mechanisms results in disease states. These mechanisms are so inter-related it is difficult, or even impossible, to impact one system without impacting the others. The MOHD strand is delivered in the first 18 months through a series of separate courses, each of which is co-directed by a basic scientist and clinician. The MOHD strand continues throughout the entire curriculum – its content integrated within the clinical clerkships and pathways.
Beginning students are often startled to discover that the proximate causes of over half of human disease lies in our environment, including our behaviors, culture and society. Interactions with a changing environment result in dynamic responses within the 6 basic mechanisms in order to try and maintain a steady state of health. Failure to maintain homeostasis leads to disease. To emphasize the critical impact of the environmental component on both health and disease another major strand in our curriculum is called Medicine and Society (MAS). This strand also has separate courses in the first 18 months as well as content embedded within clinical clerkships.
The physician or health care provider plays a critical role through the effective utilization of their professional skills in helping to maintain the health of individuals and populations. These medical professional skills as well as expected professional behaviors will be taught in a third strand of the curriculum called Clinical and Professional Skills (CAPS). As with the previous mentioned strands, it too will have separate courses in the first 18 months and ongoing content integrated during the clinical clerkships. The goal of CAPS is to provide students with the knowledge, skills and attitudes required for professional development and clinical excellence including the sense of inquiry and lifelong habits of skill acquisition, self-assessment and reflective practice. CAPS incorporates the developmental process of learning by offering sequentially more challenging experiences across the four years, repeated practice opportunities, observation and feedback, and self-directed learning and reflection.
In Medical Gross Anatomy students learn to identify the various components comprising the human body and how their structures and locations relate to their functions. This includes complete dissection of the human body. The course provides students with much of the the new language they will need to communicate accurately and specifically with patients and other healthcare providers.
The Foundations course incorporates genetics, embryology, molecular biology, biochemistry, cell biology and histology. Students will learn the molecular events required for cellular life and describe how cells grow and interact to form the basic tissues of the human body. This course provides the necessary framework to begin to explore the six Mechanisms of Health and Disease.
The Mechanisms of Health and Disease (MOHD) curricular strand is comprised of six multi-system mechanisms. MOHD 1 and 3 cover the mechanisms of Oxygenation, Metabolism, and Genetics/Development. MOHD 2 and 4 cover the mechanisms of Immunology/Inflammation, Locomotion/Integument, and Neuropsychiatry.
- Oxygenation is the story of how molecular oxygen is acquired from the atmosphere, crosses membranes, binds to hemoglobin and is pumped through the cardiovascular system to individual tissues and cells. It also includes the generation and disposal of carbon dioxide as well as other gases. Ischemia is the result of inadequate delivery of oxygen with resultant damage to or dysfunction of tissue.
- Metabolism is the story of appetite, food consumption, digestion within and absorption from the gastro-intestinal tract and its microbiome, and transport to the liver and other tissues. It is also the story of how metabolic products, medications and other substances are detoxified and excreted via the liver, GI tract and kidney. At the cellular level this story includes how the body generates energy-rich phosphate compounds in a tissue specific fashion to fuel the energy-requiring processes the body uses to maintain homeostasis, grow, reproduce, and move. Hormonal modulation of these homeostatic processes is an important aspect of this mechanism. Disorders of these processes can result in disruption of internal homeostasis.
- Genetics/Development is the story of development from conception through embryonic development and birth through childhood to adulthood and aging. At the cellular level it encompasses how individual cells reproduce into fully differentiated multicellular tissues. Hormonal modulation of these processes is an important aspect of this mechanism. Disorders of growth or division of cells are the basis for congenital disorders and cancers.
- Immunology/Inflammation is the story of how the body differentiates self from non-self, and how it maintains homeostasis in the face of non-self. Included are the role of the microbiome, in which self and non-self live symbiotically and influence immune maturation as well as the disordered recognition of self. Disruptions within this mechanism are the basis for infectious diseases as well as a number of rheumatologic conditions.
- Locomotion/Integument is the story of the erect body and its coordinated movement. Included is the integument and its roles in demarcating self from the external environment, thermostasis and immunology. Disorders of this mechanism result in impaired mobility and protection from the external environment.
- Neuropsychiatry is the story of the complex neural networks that enable rapid reception and transmission of sensory information; its interpretation, processing and integration; and equally rapid transduction into an appropriate response. Included are the higher functions central to what it means to be human (cognition, memory, emotion) and problems encountered in living. This includes interactions within families and larger social groups. At the cellular level this mechanism includes ion channels, neural and neuromuscular junctions, and neurotransmitters.
The Keystone course sits at the transition between classroom instruction in the mechanisms of health and disease and clinical practice. In this course the foundational information from the mechanisms of health and disease sequence will be approached from the perspective of what is commonly encountered in the clinics. Students can expect to sharpen their skills with respect to application of that information to make diagnostic and management decisions of common important clinical problems.
Medicine and Society (MAS) consists of three consecutive, integrated courses in which students learn about disease prevention, health promotion services, public health, epidemiology, health services organizations and delivery, and community dimensions of medical practice.
- MAS I: Students will be introduced to social determinants of health, investigate the influence and impact of culture and the community on healthcare, learn about community resources, and apply health and risk assessment to individual patients and themselves.
- MAS II: Students will focus on public health and epidemiology, with particular attention to screening, global health, and environmental hazards.
- MAS III: Students will learn about health services organization and delivery, with a particular emphasis on community dimensions of medical practice and patient safety.
- MAS in the CLERKSHIPS: During the clerkships, students will learn to apply the foundational concepts from the first three semesters within the context of their own patients. We plan to work with the clerkships to develop content and assignments that will encourage students to revisit these concepts in more depth.
Clinical and Professional Skills (CAPS) is one of three longitudinal strands used to deliver the integrated undergraduate medical education curriculum at Carver College of Medicine. The goal of CAPS is to provide students with the knowledge, skills and attitudes required for professional development and clinical excellence including the sense of inquiry and lifelong habits of skill acquisition, self-assessment and reflective practice. CAPS incorporates the developmental process of learning by offering sequentially more challenging experiences across the four years, repeated practice opportunities, observation and feedback, and self-directed learning and reflection. Students will learn the art and science of medicine through an integrated approach with other strands and in a way that is similar to how they will practice medicine in the future.
- CAPS I: While enrolled in CAPS I, students will be introduced to concepts of clinical reasoning, communication, physical examination and evidence-based clinical practice as well as the principles of biomedical ethics. The Longitudinal Clinical Mentor (LCM) Program allows early clinical interactions and helps place classroom experiences into the context of patient care. Students will also interact with students from other health sciences colleges as a way to begin to explore the inter-professional approach to caring for patients.
- CAPS II: During CAPS II concepts of clinical reasoning from the previous course will be reinforced and additional elements of clinical reasoning will be introduced and practiced during interactions with standardized patients as well as during LCM clinical visits. The variety of experiences will also help students gain a deeper appreciation for issues pertaining to biomedical ethics. As part of inter-professional education students will focus on the strengths as well as barriers to providing comprehensive interdisciplinary patient care.
- CAPS III: CAPS III will help students learn more advanced clinical reasoning skills through focused patient encounters and interactions with special patient populations. An emphasis will be placed on the students’ ability to integrate and use concepts from the other curricular strands required for cost-conscious, patient-centered, interdisciplinary care.
- CAPS in the CLERKSHIPS: Students will continue to develop tangible clinical reasoning skills in a variety of interdisciplinary healthcare settings and will assume graduated responsibility while caring for patients and their families. Skills learned will also help students assume responsibility for their professional development and prepare for transitioning to graduate medical education.
The second major component of the medical curriculum consists of over two years of supervised hands-on clinical training at the bedside on in-patient units, in outpatient clinics and in communities throughout the state. As a complement to the preclinical semesters, the clinical years involve a series of clerkships taken by students in a sequence that is progressively determined by the individual student according to hers or his career aspirations. Clinical training begins in January of the second year and extends until graduation.
Students must complete 1 week of skills training prior to the start of the clinical clerkships (Transition to Clerkships) followed by 42 weeks of Core clerkships. Students then enter various Pathways (see below) in which they complete a minimum of 20 weeks of selectives and 18 weeks of electives.
The primary goals of clinical training are to provide students with:
- a breadth of clinical exposure across numerous clinical disciplines;
- advanced exposure in the discipline(s) of the student’s choice;
- acquisition and mastery of a fund of general medical knowledge that builds on the principles introduced during the first 18 months;
- and competency in a broad array of clinical skills. These clinical skills range from patient and interprofessional interactions, exemplified by history-taking and performance of the physical examination, through attitudes — compassion, interest, independence, ethics — to the manual dexterity inherent in sterile technique, phlebotomy, suturing and other procedures uniquely associated with the medical profession.
Students must complete clerkships in multiple clinical disciplines as one means of ensuring both breadth and depth of clinical exposure. The Ambulatory Practice Module and Community-based rotations are designed to increase the students experience with practicing physicians, the array of experiences encountered in the community, the evaluation of patients in this setting, the use of community resources and their coordination to provide a team approach to patient health care, and the use and mastery of the problem focused history and physical examination. This will provide students the opportunity to observe patients in their own environment so as to appreciate better its potential impact on disease causation and prevention, as well as patient compliance. The inpatient setting encountered in the clerkships in Internal Medicine, Neurology, Pediatrics, Surgery, Obstetrics and Gynecology, as well as other clinical disciplines will provide students an opportunity to master an array of clinical skills including the comprehensive integration of the history and physical examination with diagnostic procedures, therapy, and an expanding knowledge base within the specific areas. Many of these clerkships involve ambulatory care experiences in the outpatient clinics or as part of the College’s and Hospital’s outreach programs, in addition to the experience on the wards.
- Preceptorship in Family Medicine
- Outpatient Internal Medicine
- Community Based Primary Care
- Inpatient Internal Medicine
- Clinical Neurology
- Clinical Obstetrics & Gynecology
- Clinical Pediatrics
- Clinical Psychiatry
- Clinical Surgery
After completing the Core clerkships, students must successfully complete Step 1 of the United States Medical Licensing Examination (USMLE) before they may be promoted to the Pathways component of the curriculum. Students take Step 2 of the USMLE during the fall of their M4 year.
The PATHWAYS component of the curriculum will include a menu of recommended selectives and electives for students choosing a specific pathway. These recommendations will be based on the student’s chosen future career in order to help individualize medical education and tailor it to fit the student’s needs during the next phase of their training and throughout their career. At present, three broad pathways are envisioned Generalist, Interventionalist, and Undifferentiated.