Part 1: Dis-Integration?

Geographical Dis-Integration of Pre-Clinical Instruction

As early as1909, Abraham Flexner initiated the model for educating physicians that largely exists to this day in both medical and, with variations, veterinary education: 2 years of pre-clinical and 2 years of clinical training.1 In recent years, veterinary education has seen increasingly flexible approaches to pre-clinical instruction, some extending beyond a single institution. In fact, there are multiple examples of “2+2” programs where the first 2 years of instruction occurs at an institution other than that of the clinical instruction (3rd and 4th year). Pairs of pre-clinical and clinical institutions include:

1. University of Nebraska-LincolnIowa State University College of Veterinary Medicine.

2. University of Alaska-FairbanksColorado State University College of Veterinary Medicine & Biomedical Sciences.

3. Utah State UniversityWashington State University College of Veterinary Medicine

4. South Dakota State University University of Minnesota College of Veterinary Medicine.

In a different model of training, Montana State University sends students after one year to complete their degree at Washington State University College of Veterinary  Medicine.2

Is a Multi-institutional Core Pre-Clinical Curriculum Possible?

If a pair of schools can devise interdigitating instruction, why would it not be possible to develop a national “common core” of pre-clinical instruction? Dr. Peter Eyre, once a Dean at the Virginia/Maryland College of Veterinary Medicine, has proposed contraction of the pre-veterinary instruction to 2 years, and also discussed an approximately 2-year period of common core veterinary instruction, with both traditional pre-clinical topics as well as core species non-specific topics. In a previous blog post, his “engineering” model for a shorter pathway toward a veterinary education was discussed (https://vetmedacademy.org/prereqtocompetency).

However, the pairs of schools above focus on the pre-clinical, not on the pre-veterinary phase of the standard 4-year curriculum.  For the sake of this discussion, “core” content will be considered a widely accepted curricular subset of the following topics: anatomy, behavior, epidemiology, genetics, immunology, microbiology, nutrition, parasitology, pathology, pharmacology, physiology, and toxicology. Traditionally, these topics have been explicitly included within the first 2 years of a veterinary curriculum.

One of us (DCF) was a department head of a pre-clinical science department at the University of Illinois College of Veterinary Medicine during the development of an “integrated” curriculum over a decade ago.3 It became quickly apparent that pre-clinical contact time and, therefore, core content needed to be condensed based upon clinical relevance and/or shifted to the “clinical” phase of instruction. Of utmost importance was maintainence of concepts and skills most relevant for a student’s conceptual framework. However, there is a tendency for remnant disciplinary parochialism to result in maintenance or expansion of clinical topics rather than include thoughtful re-integration of relevant core concepts (see Part 2).

A risk to formalizing a clear dichotomy between pre-clinical and clinical phases of training, either by instructional site or methodology, is regarded as the burnishing of the reputation of pre-clinical sciences as a largely irrelevant training “hurdle” never to be re-visited. Also, a focus on only “delivering” pre-clinical content discourages attention to early student indoctrination to the mindset and regimentation of critical clinical thinking. Our partial response at the University of Illinois was to build this training into first-year “Clinical Correlations” case analysis experiences,4,5 but ideally, such an approach could be extended in escalating fashion into later years of the curriculum.

Trends in Physician Education
It is notable that physician education is currently undergoing gradual but significant change as well. Part of the ongoing transformation is a shortening of the preclinical education period from 24 months to 12 to 15 months and, therefore, potentially reducing the total time of medical school. Three-year medical school curricula have been recently proposed, driven by rising excessive educational debt and a predicted physician shortage,6 recently exacerbated by the COVID-19 crisis. The median debt/average career income ratio is 120% for family practice and 60-100% for specialty physicians.7  The debt issue is more acute for veterinary school graduates where the median income/debt percentage is at least twice as high (186% in 2017), and, for some graduates, it can be 400-500%.8  In an article entitled “The Inevitable Reimagining of Medical Education” earlier this year in the Journal of the American Medical Association, Dr. Emanuel of the University of Pennsylvania College of Medicine describes this trend to shorten medical school through truncating the pre-clinical phase.9 The 25-minute audio podcast accompanying this article is well worth the reader’s time. In the process, please consider whether veterinary education leads or lags behind this trend.

https://edhub.ama-assn.org/jn-learning/audio-player/18270291

As far as shortening or removing the last year of medical school, some argue that the 4th year “allows for student maturation, rounds out and enriches core medical education experiences with research and specialty electives, and provides ample time for choosing residency programs.” Shorter curricula have raised concern over “student burnout, faculty fatigue, the increasing complexity of medicine, quality issues, and diminished competitiveness for residencies.”6 Despite completion of similar content in less time, graduates of 3-year programs have demonstrated equivalent clinical academic performance. Furthermore, some have argued that the “physician’s tendency to be lifelong learners” should alleviate concerns over length of the program.6  In a world where scientific information is doubling every 70 days, instilling evidence-based medicine practices should be a feature of training rather than a vague “tendency” of those admitted to be enforced only by continuing medical education requirements.  In veterinary medicine, without the current requirement for internships and residencies to practice, the curricular burden of providing clinical experience is somewhat higher, as is its burden to develop a life-long self-correcting learner.  

Should Pre-Clinical Training Be Reduced to its Basic Science Content?

Emanuel projects an interesting future for physician education. Having experienced medical students eschewing pre-clinical lecture attendance only to watch the recordings at 2x speed, he proposes that the core subjects could be taught by capturing the lectures of a handful of award-winning instructors and delivering them using a MOOC (Massive Open Online Course) platform. He asks:

Why should professors give the same lecture on the cranial nerves or pharmacokinetics  that they gave last year and the year before for a limited number of students?

He also notes that the pandemic has reinforced the idea that a student could proceed through such a digital curriculum in any geographical location. Consistent with duration recommendations for video discussed in a prior blog post (https://vetmedacademy.org/videolength), he concludes that short micro-content (6-12 minute) videos should be the central focus of such instruction, and predicts that medical schools will purchase such content for their curriculum or that students will seek such content regardless.  He also proposes, without going into detail, that student “competence” will be confirmable by standardized tests. Presumably, such tests would mostly focus on content recollection as opposed to more complex professional skills.

It is worth noting that Emanuel’s article was published in March, 2020, when most schools were moving rapidly to sole online instruction for pre-clinical subjects. Although perhaps over-simplifying the idea that content delivered is content learned, he does put his finger on the idea that content usually presented in lectures would better be presented as digital micro-content.  However, following the emergency experimentation that has occurred during the pandemic, higher education has learned (or re-learned?) that student engagement and motivation needs to be carefully cultivated when teaching online.  The creativity of the awardees of the COVID Educational Creations contest conducted by VetMedAcademy and Merck Veterinary Manual is testament that lecture capture isn’t sufficient.

Indeed, success in an online instructional format requires different techniques to engage students. Our opinion is that a MOOC platform is not ideal for core medical education, but concur that digital educational resources, optimized for clinical relevance and the encouragement of critical thinking, could be a viable model for pre-clinical training.   Although the core content of the first 18-24 months of most veterinary curricula is fairly standard, what varies is the degree to which clinical context is provided. In our experience, pre-clinical instructors who are not veterinarians (an increasing trend) often feel that it is not their role nor within their expertise to convey clinical concepts.  We would argue that critical thinking is a daily pursuit of any faculty member, regardless of medical training, and that, with some expectation and guidance, any pre-clinical instructor incorporate their content while modeling problem-solving at an appropriate level for their students. Certainly, students have a dim view of non-clinician instructor getting “over their skis” when discussing clinical material, but the key to success is careful framing of a case discussion to the appropriate pre-clinical concepts. Seeking to help such faculty, VetMedAcademy seeks to “curate” effective short-form digital content that emphasizes clinical problem-solving through accompanying case analysis exercises.  The goal is not to replace the local instructor but to free faculty to focus on methods for maximizing student engagement and motivation.

Effects of the Pandemic on Medical Education

A recent opinion piece in the Journal of the American Medical Association by Lucey and Johnston entitled “The Transformational Effects of COVID-19 on Medical Education” suggests that the pandemic has accelerated consideration of new strategies for physician education.10  Not surprisingly, U.S. medical schools are considering collaborating on more epidemiology, population medicine, and social/behavioral sciences to the curriculum. However, more central to pre-clinical training, they suggest that medical schools…

1. Use a combination of synchronous and asynchronous learning of foundational content across the curriculum to enable learners to accommodate individual learning plans…”
2. Develop new models of continuing medical education to streamline adoption of new and emerging science and standards of care across the institution and into clinical practice by using online learning materials developed for undergraduate and graduate medical education.
3. Design and implement new models of faculty development to optimize online teaching strategies and new models of peer review of teaching strategies.

So, workforce and economic trends have the tendency to push the pre-clinical “core” content temporally and even geographically away from the clinical training experience, and, also, and even to reduce that training to a digital commodity. In the next part, we will look more carefully at the risk of dis-integration of this content, the methodology to re-integrate it into clinical experiences or exercises based upon careful mapping of Day 1 skills, and how existing licensing examinations influence the tendency for schools to reimagine medical education.

Submitted by:

Duncan C. Ferguson, VMD, PhD, DACVIM, DACVCP, Emeritus Professor of Clinical Pharmacology, College of Veterinary Medicine, University of Illinois at Urbana-Champaign
Bill Cope, PhD, Professor of Education Policy, Organization and Leadership, College of Education, University of Illinois at Urbana-Champaign
Mary Kalantzis, PhD, Professor of Education Policy, Organization and Leadership, College of Education, University of Illinois at Urbana-Champaign

Feature Image: “Disintegration”: Photo by Dennis Wilkinson of the so-named LEGO art by Nathan Sawaya.

References: Provided at the end of Part 2