Bridging the Gap Between the Scientific and Societal Aspects of Medical Education

INTRODUCTION

How can we encourage our students to more clearly see the connection between the scientific foundations of medicine and the practice of their profession in the real world? Modern medical school curricula increasingly emphasize societal aspects of disease; public health issues related to screening for and control of diseases; ethical practice of medicine; relationship to allied health professionals; issues related to the availability of healthcare resources and infrastructure; and considerations of cost vs. benefit of diagnostic and therapeutic procedures and interventions. However, students do not necessarily see such issues in the context of scientific medicine. Compartmentalization of learning may lead to an inadequate view of medical practice as being either scientific or social in its intent.

Provided that learning about societal issues in medical practice is integrated with learning about the science of medicine, assessment that is similarly integrated may help to reinforce the linkage of the medical sciences with societal, public health, ethical, resource and cost-benefit considerations. Such “constructive alignment” between objectives, teaching methods and assessment helps to drive deep learning.¹ In this paper, we describe our successful implementation of such integrated project assessment in pathology and our plans to use it more extensively in the new medicine program at the University of New South Wales (UNSW).

Program Description
The existing UNSW Medicine program is a six-year post-high school entry program, with approximately 210 students enrolled each year. Teaching is largely discipline-based and pathology is taught in the third and fourth years. In third year practical classes, the Department of Pathology has long emphasized appropriate use of diagnostic investigations and the costs associated with their use. To concentrate the minds of students on this issue during their fourth year, which primarily involves clinical training, an innovative project assessment was introduced in 1996. This requires students to discuss the pathologic basis of disease through the study of an individual case and, specifically, to demonstrate an understanding of the role of pathology services in a hospital inpatient setting. Students submit a project report, which is limited to 2,500 words. They are encouraged to discuss the suitability of the case they have chosen as well as the approach to presentation with a pathology tutor. The medical record number of the patient they have selected must be registered with the clinical school administration. As a consequence, projects are unique and self-renewing from one year to the next.

MATERIALS AND METHODS

Marking of the project is based on the extent to which it satisfies each of five objectives, about which students are advised at the beginning of the year as follows:

1. A clear demonstration of the pathologic processes underlying the clinical features of the case.
2. A detailed discussion of three investigative procedures performed, which must include:
   • An imaging procedure that provided information about pathological changes at a macroscopic level.
   • A cell or tissue sampling procedure that provided information at a microscopic level.
   • Any other investigation that provided additional relevant information about the disease process e.g. in terms of biochemical, microbiologic, hematologic or immunologic abnormalities. This need not necessarily have yielded an abnormal finding.

   The discussion should include a brief explanation of the investigative procedures, and a commentary upon the ways in which the results obtained were interpreted.

3. A cost-benefit analysis of pathology tests performed on the individual during the period of admission to hospital, which examines whether and in what way the results of such tests influenced the management of the patient.
4. Appropriate and demonstrable use of the current medical literature to support the project report.
5. Clear expression and evidence of critical evaluation.

For each objective, a score of zero may be awarded if the report failed to adequately address the objective; one if it satisfactorily addressed the objective; and two if it addressed the objective well. There is no provision for half marks. The student manual includes multiple examples of projects that scored ten out of ten. Clear guidelines are given to graders, who are primarily hospital-based diagnostic pathologists. Each marker grades five-ten projects each year.

Several characteristics of the design of this assessment may help students to see the connections between basic science and real world practice. Notably, the project requires interaction with clinicians involved in the case, so that students are empowered to ask why senior medical staff made the decisions that they did. The task is based on a real patient they have clerked, so is experiential in nature, and it allows considerable autonomy and ownership – with the accompanying responsibility – because students have to think about and select a case that is best going to demonstrate the issues. In addition, there is ample time for reflection as they have over 6 months in which to complete the project. The assessment thus requires student engagement and evidence of learning that achieves at least the fourth (relational) level of Biggs’ SOLO taxonomy.²

RESULTS

Students invest considerable effort in writing their reports, at least in part because the project is worth 20% of the barrier assessment in pathology at the end of the fourth year of the program. The submissions are frequently reflective essays of high quality. Cost-benefit issues are usually particularly well addressed, with often stern criticism of the overuse of blood counts, clinical chemistry and imaging procedures.

Using the criterion-referenced approach to marking, in the years 1996-2002 over 60% of students (69.8 ± 3.7, mean ± S.D.) scored eight or more out of ten for the project (range five-ten, median score eight, lower quartile seven, upper quartile nine). In end-of-year evaluations from 2000-2002, students rated the project highly as a learning exercise, with a median rating of five (lower quartile four, upper quartile six) on a scale from one (least favourable) to seven (most favourable).

As summarized in Table 1, students responding to a questionnaire indicated that undertaking the project significantly altered their perceptions of the role of the pathology laboratory, their understanding and interpretation of diagnostic tests, as well as their appreciation of the cost vs. benefit of investigations. They also believed that the exposure to critical analysis of investigations was likely to alter their test-ordering behaviour as practicing doctors. Many students offered additional comments indicating that they felt the project ought to be given a greater mark weighting.

CONCLUSIONS

Encouraged by the results to date, we now plan to extend the use of project-based correlative assessments in the new medicine program which commences at UNSW in 2004. Teaching in the new program will not be discipline-based, but will be scenario-based to encourage students to link a variety of biomedical sciences with relevant considerations of professional practice, healthcare policy and societal issues surrounding health and disease. Students will submit four project reports during Phase 2 of the new program (extending from early third year to approximately the middle of fourth year) of which at least one must be an individual report and at least one a group/team project. At least one project must focus on a population health or a community medicine issue and at least two must be based on individual patients clerked during the year and identified by medical record numbers. The project will be marked as above for the extent to which it addresses each of the following five (suitably modified) objectives:

1. a summary of the clinical problem or population health issue on which the project is focused.
2. a detailed discussion of one perspective from List A in Table 2.
3. a detailed discussion of one perspective from List B in Table 2 V each project submitted by an individual student must address a different perspective from each of these lists.
4. appropriate and demonstrable use of the current medical literature to support the project report.
5. clear expression and evidence of critical evaluation.

Students will be advised that their reports should demonstrate integration and correlation of prior and current learning. They will be required to satisfactorily complete all projects in order to progress to Phase 3.

A key question is how to evaluate outcomes beyond the immediate assessment. How can we know whether these integrative assessments really change how our students think about disciplinary inter-relationships beyond the biomedical sciences? In implementing this approach in pathology, focusing on the rational use of investigations, we were cognisant of the multiple interacting factors that impact upon attempts to change medical practitioners’ test-ordering behaviour.³ Trying to achieve behavioural change through a set of project assessments may be optimistic. However, as has long been recognized, “From our students’ point of view, the assessment always defines the actual curriculum”.⁴ Thus a carefully developed assessment tool such as the one described in this paper should certainly convey a powerful message and is a theoretically sound way of trying to bridge the gap between the scientific and societal aspects of medical education. Evaluation of whether undertaking such assessments contributes to a long-term change in clinical behaviour will require follow-up of graduates from our new program.

REFERENCES

1. Biggs, J. What the student does: teaching for enhanced learning. Higher Education Research and Development 1999; 18: 57-75.
2. Biggs, J. Formulating and clarifying curriculum objectives. Teaching for Quality Learning at University. Buckingham, Society for Research into Higher Education & Open University Press, 1999.
3. Winkens, R. and Dinant, G.J. Evidence base of clinical diagnosis: Rational, cost effective use of investigations in clinical practice. British Medical Journal 2002; 324:783-785.
4. Ramsden, P. Learning to Teach in Higher Education. London, Routledge, 1992.