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ACE-ing the curriculum

A look back at the first year of the new ACE curriculum

Medical students practicing on a medical dummy

In the 2017-2018 academic year, the University of Kansas School of Medicine launched the most sweeping redesign of the school’s curriculum in 20 years. Four years in the making, the overhaul was a response to the explosion of new medical knowledge and rapid changes in the technology and delivery of health care over the last two decades. It also mirrored a national trend as medical schools across the country re-evaluate how they train physicians to practice medicine in this brave new world of health care.

The new ACE (Active, Competency-based, and Excellence-driven) curriculum is designed to produce physicians who are lifelong learners and can adapt to the ever-evolving science and practice of medicine; who understand the health care system and how it affects patient care; who are comfortable working in interdisciplinary teams and using new health care technology; who consider the health of populations as well as individuals; and who are skilled in research, patient safety and continuous quality improvement.

The curriculum also reflects the ways today’s students learn. In your grandfather’s medical school, professors lectured while students took notes, but that model no longer suits a world in which students can look up information electronically in mere seconds. The foundation of the ACE curriculum is active learning: interactive and often group activities related to the material. The new Health Education Building at the University of Kansas Medical Center, with its open study spaces and simulation facilities, facilitates these hands-on, collaborative ways of learning.

In May 2018, the first class of medical students following the ACE curriculum completed their first year. We spoke to a panel of three KU School of Medicine faculty and two students explained more about how the new curriculum works and reflected on how things are going so far.

Giulia Bonaminio, Ph.D., is the associate dean for medical education and a research professor in the Department of Family Medicine.

Brice Dean just finished his first year as a student at the KU School of Medicine—Wichita.

Tomas Griebling, M.D., MPH, is the senior associate dean for medical education and the John P. Wolf 33 Masonic Distinguished Professor of Urology.

Joseph Fontes, Ph.D., a professor in the Department of Biochemistry and Molecular Biology, is the director for the Molecular and Cellular Medicine block of the ACE Curriculum.

Ann Herrick just finished her first year as a student at the KU School of Medicine and serves as the student communication liaison for the ACE curriculum, gathering and providing student feedback to faculty and the Office of Medical Education.

What are the biggest changes from the prior (Legacy) curriculum?

Tomas Griebling: In the Legacy curriculum, instruction was delivered using a combination of lectures, labs and PBL (problem-based learning) small group sessions. Students in the ACE curriculum spend a maximum of only five hours in lectures per week. They spend most of their time working in small groups, what we call learning communities.

Students also now learn in flipped classrooms, so instead of learning content by listening to a lecture in the classroom, they learn it ahead of class by reading or by watching a podcast and then use time in the classroom to apply that what they learned to solve a problem posed by the instructor. There is also much more direct faculty involvement with the students. Each student has a faculty coach who works with them on their progress and professional development.

Giulia Bonaminio: Another change is the integration of basic science and clinical skills. With previous curricula, students spent the first two years learning foundational science, such as anatomy and physiology, and then next two years learning clinical skills, such as performing medical procedures. The ACE curriculum does away with that division between the preclinical and clinical years, and students start learning clinical skills the first year. Starting in their third year, students begin their clerkships, working in clinics as “apprentice doctors.”

Material is now organized around a “block structure.” Blocks are based largely around organ systems; Respiration and Circulation is one block, and Muscles and Movement is another. Students learn the basic science and clinical skills related to that block at the same time.

Could you give us some more details on the block structure?

Joseph Fontes: Except for the first block, Introduction to Doctoring, and the last block, the Medicine Capstone, all blocks are nine weeks long, broken up into two-week units with an exam at the end of each. The ninth week is used for assessment, remediation and enrichment activities.

Typically each week begins with an experienced clinician presenting a “big case.” For example, the big case might be rheumatoid arthritis. The clinician lays out the critical clinical and foundational science knowledge necessary for assessing and managing a patient with this condition.

In subsequent activities, such in learning clinical skills in the simulation lab or solving problems with their learning community, students might learn about the basics of the immune system and autoimmunity, the social and behavioral aspects of a chronic condition like rheumatoid arthritis, and the genetics and epidemiology of autoimmune disease. The big case puts a human face on all the molecules, statistics and mechanisms and allows students to reflect upon the human aspects of the biomedical, social and behavioral sciences they’re learning in activities as lectures throughout that week.

The block organization make the material more accessible, but they are not strict silos. For example, in the Brain, Mind and Behavior block, students might encounter a patient who presents with the symptoms of a stroke or kidney disease that must be taken into account. They then apply principles from everything they have learned before, in multiple settings.

The learning communities seem to be integral to the curriculum.

Ann Herrick: The small group experience is not new to the ACE curriculum, but we work in our small groups much more than in the previous curriculum. We meet in our small groups three times a week, once for a PBL session, and twice for Case-Based Collaborative Learning (CBCL) sessions. PBL learning is not new to the curriculum, but CBCL is entirely new.

In PBL sessions, we meet with the same facilitator every week. All we know walking into PBL is that the case will be categorically similar to a topic presented in lectures and flipped classrooms during that week. So the case requires more investigation during small group time. These cases reflect and prepare us for what we will experience seeing patients in the wards.

During CBCL, we work through cases that are specific to the pre-learning we are assigned for that CBCL session. For example, if the focus of the CBCL is hepatitis, the individual cases will present with the different signs and symptoms of each type of hepatitis, and we must determine the type of hepatitis presented and discuss various aspects of each specific virus. These CBCL sessions let us dive deeper into the many subsets of a large-category disease in a case-based format, which makes it the perfect learning design for many medical conditions.

How do flipped classroom change the way you prepare for class?

Brice Dean: In the past, I’ve had the typical school experience of taking notes while the teacher lectures ad nauseam. Flipped classrooms are more engaging and can be fun depending on the professor. We answer questions as we learn the material or work through a case. I love to answer the questions. It helps build my confidence on the material and also learn what I need to study more. When preparing for flipped classrooms, I usually spend a little extra time digesting the material before class to make sure I'm prepared.

Joseph Fontes: Flipped classrooms require different kind of preparation than for lectures, trying to anticipate questions and challenges students will face in solving problems. It’s also much more about leading students to the correct answer rather than telling them the correct answer.

One facet of the new curriculum is interprofessional learning—training with nursing students and other health care professionals. How does that seem to be working so far?

Ann Herrick: Working with students from all schools is great because we can teach each other the different knowledge that we have acquired about one medical condition. It also gives us a greater appreciation for the roles that each medical personnel play in caring for the patient. The medical student on these teams is not always the person leading each clinical scenario, because often it will be the nurses who are first on the scene or who know the patient’s condition the best. Students have the chance to practice all roles—the leader, the executer, the patient interviewer, and the transcriber—because each role requires a different skillset that will be required of each of us at some point.

Brice Dean: Our class participated in a medical interprofessional day at Wichita State University. Groups of students from schools of medicine, dental hygiene, nursing, physician assistant, speech pathology, and more all gathered. The experience was enlightening in the sense that we were able to learn a little bit more about other professions in the medical field. The message of the entire event was that medicine is a team game. The experience was also beneficial in breaking down social barriers and getting to know people on personal levels.

What do you see as some of the curriculum’s big successes so far?

Joseph Fontes: The coach-student relationships that have developed are unlike anything we had in the Legacy curriculum. Not only has it been beneficial to students who are performing well, it has also allowed us to identify students who are struggling in specific areas much earlier.

Giulia Bonaminio: We have faculty who in the past didn’t teach medical students until the third year, and now they are working with the learning communities in the first year. One of them told me that the students are so good and so engaged that they are like graduate students in the first year. These students are already thinking through things clinically and problem-solving.

Ann Herrick: There are so many great things that the ACE curriculum has introduced. It involves so many more faculty members than the previous curriculum, and we work closely with different faculty members several times per week, specifically in our CBCL and PBL sessions. Each faculty member offers us something new to learn.

Tomas Griebling: What has surprised me the most is how quickly both students and faculty have embraced this new educational methodology and approach to our work. Initial results of national standardized testing have shown our students are doing very well, and are achieving comparable outcomes to their predecessors. In some areas, their results have been higher.

How do you think the ACE curriculum could be improved?

Anne Herrick: The largest area for improvement has to do with the incongruity of the pre-work, in-class material, and practice questions for flipped classrooms and CBCLs. These are the areas that are the most dynamic, and it can be very difficult for the pre-learning material to align perfectly with the in-class application and then for both sessions to be well-reflected in the questions on the material.

Additionally, the majority of the questions that we receive, for both practice and on summative exams, are entirely new. So it makes sense that some questions are flawed or don’t always reflect what we have actually been taught.

Tomas Griebling: We are already making some adjustments for next year including the timing of remediation activities for students who need additional time or focus in some areas. The new system will allow them to participate in the Scholarship and Enrichment activities for career exploration and development. We are also making some changes in preceptor visit programs, in which students are assigned to a preceptor whom they shadow and practice clinical skills, to enhance both student and faculty experiences in these early clinical activities.

KU School of Medicine

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