Evolution of a Systems-Based Curriculum in Medical Neuroscience and Behavior

By: Dr. Ian Paul with notes by Dr. Eddie Perkins

In 2016, the School of Medicine embarked on a major effort to develop an integrated, systems-based curriculum focused on neuroscience and behavior, and spanning the first three years of medical training.  This work involved three preclinical and four clinical departments with a number of participating faculty.  In addition, the project set out to reimagine how all of this material was taught with a focus on evidence-based teaching approaches grounded in adult learning theory.

Prior to 1950, medical training in the U.S. used a 2-2 model with two years of preclinical training followed by two of clinical practice.  Preclinical courses were taught in disciplinary siloes reflecting specific biomedical sciences such as physiology, pharmacology, and anatomy.  Students were expected to integrate that information during their clinical years, largely on their own and there was very little intentional teaching or review of foundational material.  This approach made it difficult for students to clearly relate their preclinical training to clinical practice.

In 1950, Case Western Reserve University School of Medicine introduced a new model of training based on individual organ systems such as the cardiovascular system or the musculoskeletal system.  Since then, this approach has been widely adopted by medical schools around the country and some form of integrated organ systems-based training is used at almost all schools.  After considerable discussion, the UMMC School of Medicine decided to pilot this approach focusing first on nervous system function and dysfunction in 2017.

Medical Neuroscience and Behavior I was the first attempt at developing a systems-based course and integrated medical neurobiology, neurophysiology, and normal human behavior.  Introduced in 2016 under the direction first of Dr. Ryan Darling and later in 2017, Dr. Eddie Perkins in collaboration with Dr. Riddhiben Patel. The course content is delivered as a series of “Blocks” that represent different neuroscience topics. These include didactics lectures, both basic science and clinical correlations, laboratory sessions and laboratory demonstrations. In addition, students, are given a series of clinical cases (Case Base learning sessions – CBLs), one case for each block that correlate with the Block topic. The cases are presented to students in two parts (CBL1 and CBL 2) over the duration of the block. CBL 1 is the history and physical and CBL 2 is diagnostic (laboratory results and radiographic studies). During the CBL sessions students are assigned to groups and are required to complete and submit a rubric worksheet for each CBL sessions. Students are assisted during the CBL sessions with case facilitators.  At the completion of the block the clinical faculty provides the students with a “clinical case wrap-up” and a “clinical experience”. The wrap-up is a faculty member presenting the case and answering questions from the students. The experience is usually cases presented in either a PowerPoint format, the use of real or standardized patients or videos or a combination there of. These are all related to the case or the block topic.

Medical Neuroscience and Behavior 2, directed by Dr. Ian Paul in collaboration with Dr. Tarif Bakdash, was introduced in 2018 replacing the M2 psychiatry course and integrated psychopathology, neuropathology, CNS pharmacology, and neurosurgical treatments.  In addition, the course utilized active learning principles previously used in M2 psychiatry.  Specifically students finish each block of material by examining or interviewing standardized patients presenting some of the disorders from that block.  Students are coached through the process by clinical faculty or residents and are assigned to prepare a clinical write-up on the patient for evaluation by the coach.  This takes place in a small group setting where the Student Doctors examining the standardized patients are joined by about a dozen peers.  After the examination the coach facilitates a discussion of the case with the small group.

In AY2019-2020, MNB2 became the first course in the School of Medicine to be taught entirely as a “flipped classroom.”  In this approach, students learn foundational information about a topic online at their own pace.  Class time is reserved for highly interactive learning aimed at helping students integrate concepts from the various disciplines contributing foundational material.  First the entire class engages in guided case reviews presented by clinician experts.  Cases are broken into elements separated by questions for the class using polling software.  This both actively engages the students in the clinical thought process and also allows the clinician leading the class to identify and clarify concepts that the class as a whole is having difficulty understanding.  Following the guided case review session, students proceed to their small groups to examine standardized patients which allows students to solidify the integration of knowledge in realistic clinical scenarios.

Medical Neuroscience and Behavior 3 is a clerkship integrating clinical experience in psychiatry, neurology, and neurosurgery that was introduced this summer replacing the previous clerkships in psychiatry and neurology.  At the beginning of each of the clerkship rotations, Dr. Perkins provides a brief review of the neurobiology content from Medical Neuroscience and Behavior I that was taught in the M1 year. In the clerkship, students rotate through inpatient and outpatient units in psychiatry and neurology, spend time in either the neurosurgery intensive care unit or the neurosurgery service.  In addition, all students have and have an elective psychiatry week in adult consult-liaison psychiatry and emergency service, addiction psychiatry, the Center for Advancement of Youth, or the child and adolescence consult-liaison psychiatry and emergency service.  Along with clinical experience, students have 25 hours of focused didactics where they learn specialized techniques such as motivational interviewing or clinical skills such as the methods for diagnosis and treatment of increased intracranial pressure.  This time also includes weekly discussions of research students have done regarding cases and topics of particularly interest to them.

The development of this sequence of systems-oriented, interconnected coursework grounded in adult learning theory has convinced the School of Medicine that revision of the entire curriculum along these lines is both possible and advantageous to students.  A task force to develop such a curriculum has been formed, led by Dr. David Norris.   Dr. Perkins and Dr. Paul have been tapped to use their knowledge and experience with this process in medical neuroscience and behavior to guide and help develop and implement the new curriculum.