PLME SCIENCE CURRICULUM

Julianne Ip, MD

Associate Dean of Medicine (PLME and VIMS)

Clinical Associate Professor of Family Medicine

Alpert Medical School

Brown University

How will we go from college freshmen

To MD graduates of the Alpert Medical School of Brown University 2012

Overload of facts and information, fatigue, loss of compassion and passion for learning, and humanity

HHMI-AAMC report

• concerns about increasingly rapid rate at which new knowledge revises our understanding of sciences fundamental to medicine•Importance of educating future physicians to be “inquisitive”•To help them build a strong scientific FOUNDATION… but not overwhelm them with “facts”•To equip them with the knowledge, skills and habits to integrate new scientific discovery into their medical practice throughout their lives…

Brown’s Baccalaureate-MD program is poised to be a pilot for changes in pre-medical education. We set the admissions standards and competencies required for our curriculum.

The Warren Alpert Medical School of Brown University

Basically, assist and teach extremely bright, intelligent, motivated young men and women the skills and fuel their passion to be LIFE-LONG LEARNERS, to practice science-based medicine with greater synergy and efficiency along the continuum of their premedical and medical education.

PLME versus Standard Pre-Med

• Biology-2 semesters

• Inorganic Chemistry-2 semesters

• Organic Chemistry-2 semesters

• Physics-2 semesters

• Calculus-generally 1 semester minimum

• English-2 semesters

• MCATS

Biology-three semesters (most place out of intro level so have 2 semesters)

Inorganic Chemistry-one semester

Organic Chemistry-one semester

Physics-2 semesters

Calculus-one semester (most place out)

Humanities/Social Science ( 2 writing courses)

No MCATS

PLME COMPETENCIES PRE-MED Requirements

We start with our end product--our Brown MD graduate. What does it take?

•Our graduates must be ready to be outstanding residents and future physicians therefore they must be outstanding 3rd- and 4th- year med students• Our first- and second-year med students must be prepared for clinical clerkships, clinical electives and decisions about future professional career•Therefore, our PLMEs must be prepared for first- and second-year integrated basic medical sciences and the Doctoring course

Initial Proposal

• Two semester freshmen/sophomore course; integrate Chemistry, Physics, Math pertaining to biological and medical sciences

• Senior year one semester capstone course: interdisciplinary, integrative case-based promoting a holistic view of the human condition.

• Emphasis on:

- Self-directed learning

- Small group learning

- Incorporation of ethics, history of medicine, new

technology particularly as it pertains to the humanistic

aspects of patient care

PLME Science/Behavioral –Social Science and Humanities curriculum committee

• Associate Dean of Medical Education• Director of First and Second year Basic Science

Curriculum (eventually the second year assistant director took over)

• A Cogut Fellow in the Humanities (funded by the Medical School to oversee the writing and development of the curriculum)

• Associate Dean of the College (for sciences)• Associate Dean of Medicine (PLME)

Contributing Groups

• PLME Alumni Survey and Focus Group

• PLME advising deans

• Alpert Medical School students survey and focus group

• PLME survey and focus group

• Wayland Collegium• College funded think tank

group • Picks one topic/semester• Interdisciplinary: included

physics, math, biostats, chemistry (both inorganic and organic) and biology faculty

CHALLENGES

Alpert Medical School takes ownership. Uses the HHMI-Scientific Foundations as template.

White Paper

REINVENTING PREMED EDUCATION AT BROWN: AN INNOVATIVE REDESIGN OF THE PLME

UNDERGRADUATE CURRICULUM

Prepared by Philip Gruppuso, Juli Ip and Rina Bliss, April 2011

The Alpert Medical School is in the midst of a comprehensive curriculum redesign process. The purpose of this document is to articulate the principles, process and overall design aspects of a related process: a new undergraduate curriculum for the Program in Liberal Medical Education. Both processes are motivated by a call for a new approach to educating physicians, the principles and goals for which have been articulated by the AAMC and HHMI in a document entitled “Scientific Foundations for Future Physicians.”1 One of the goals for the project described in this report was to “provide greater flexibility in the premedical curriculum that would permit undergraduate institutions to develop more interdisciplinary and integrative science courses…by focusing on scientific competencies.”

This goal is one that could and should be applied to the PLME. The original goals of the PLME, which have been achieved to a significant degree in the years since its founding in 1985, have been to “graduate doctors, scholars and leaders in medicine who have been exposed to a wide, sensitizing view of the human condition and who are committed to bettering human health.” The intent of the program was to achieve this through a liberal undergraduate education.

Changes at the Alpert Medical School (AMS) have placed some constraints on the means of achieving the goals of the PLME. Once a truly integrated 8-year program that afforded its students significant flexibility during the medical years, the redesigned, integrated (non-course based) AMS curriculum has significantly diminished PLME students’ curriculum flexibility. In addition, an increased level of scientific rigor in the first two years of the AMS curriculum has placed greater demands on the scientific preparedness of PLME undergraduate students. This has resulted in pressure on PLME students to emphasize a liberal education to a lesser degree than had been the case.

1 http://www.aamc.org/newsroom/pressrel/2009/090604.htm

PLME 1000 Senior Seminar inScientific Medicine

• This course is an interdisciplinary and integrative science course that will supplement the preparation of both PLME and premedical students for the study of medicine in the 21st century.

• The course will use a case-based approach to relevant and contemporary subjects in medicine and health care, such as biological systems and their interactions, mechanisms of intra- and intercellular communication, drug therapy optimization, and humanistic aspects of patient care.

• This course is intended for seniors interested in attending medical school, but will preferentially enroll students in the PLME. This is an S/NC course.

AssessmentsQuizzes 10%You will be a given a brief, five question quiz prior to the beginning of lecture each week. The quizzes will be based on your reading assignment for the week. Participation (class and small group) 10%This class and the learning you will be doing are structured around small group problem-based learning and class discussion. We are looking for thoughtful contributions that refer directly to the readings and lectures at hand.

Reflective Narratives 20%You will be asked to write three reflective narratives during the course. These narratives should be one page in length, single spaced and be in response to topics presented in the course. Prompts for these narratives will be given in class. The due dates of the narratives are:•October 15th

•November 5th

•December 3rd

Midterm Exam 25%The midterm examination will mainly be comprised of single best answer, multiple choice questions but may also contain other questions types (true/false, fill in the blank and essay type questions). Questions on the midterm examination will be drawn from lecture, small group discussions, large group discussions and the readings.

Final Exam *same as midterm 35%

Teaching Assistants:• There are six teaching assistants for

this course. Each student will be assigned one of these teaching assistants for small group work.

• TA’s are second-year medical students with an interest in medical education; generally are participating in the Teaching Academy and Scholarly Concentration in Medical Education

FIRST THREE WEEKS OF

COURSE WE START WITH SEX…Objectives:

Describe the molecular biology of androgen insensitivity.  

Compare and contrast the phenotypic variation seen in androgen insensitivity.  

Describe the medical management of differences of sex development.

Construct an argument for the postponement of surgical management of differences of sex development using ethical principles.

 

Readings: Jääskeläinen J. Molecular biology of androgen insensitivity.  Molecular and Cellular Endocrinology.  In press. Wiesemann C, Ude-Koeller, Sinnecker GHG, Thyen U. Ethical principles and recommendations for the medical management of differences of sex development (DSD)/intersex in children and adolescents. Eur J Pediatr (2010) 169: 671–679. Dreger, A; Chase, C; Souza, A; Gruppuso, P. Frader J: Changing the Nomenclature/Taxomony for Intersex; A Scientific and Clinical Rationale. J Ped Endocrinology and Metabolism 19 729-733 (2005) Phornphutkul, C; Fausto-Sterling, A; Gruppsuo, P: Experience and Reason Pediatrics Vol 106 No1 135-137 2000Hines, M. Sex-related variation in human behavior and the brain Trends in Cognitive Science Vol 14 no. 10 448-456

 Monday, September 10th: Session #1Quiz on Readings (Ip; 10 minutes)Lecture on Androgen insensitivity (Gruppuso, 70 minutes)

Wednesday, September 12th: Session #2 Case-based vignettes on diagnosis and treatment of androgen insensitivity (Forcier, 40 minutes)Discussion of the ethics of medical management of sex differentiation (Small Groups, 40 minutes)

Complete Androgen Insensitivity(Testicular Feminization Syndrome)

X-linked recessive disorder, expressed in 46,XY individuals only Mutation in the Androgen Receptor gene Manifests as a disorder of sexual differentiation

• Breast development and female habitus at puberty; primary amenorrhea; scant or absent pubic and axillary hair

• Genitalia: female with blind vaginal pouch• Wolffian derivatives: usually absent• Mullerian derivatives: absent or vestigial

Gonads: testes

Mutation in AR gene affecting androgen binding to AR or AR binding to DNA.

S S

-P-P

P-P-

SRC

7-dehydrocholesterol

cholesterol

cortisol progesterone

aldosterone

androstenedione estrone

testosterone estradiol

Steroid Hormone Biosynthesis

Gonads

Target tissues 5a-dihydrotestosterone

By age 4 Gender identity is stable, for many/most Recognize that gender is constant

At 3 years old— Can label themselves as girl or boy

Between ages 1 and 2— Children become conscious of physical differences between sexes

Awareness of Gender Identity

What is sex? What is gender? Who defines them?Are they binaries?How much does culture play a role in gender? Does it at all? Are there differences across countries/regions?Does sex determine gender? How much does nature play a role in gender? How about nurture? Greenspan seems to suggest at the end of the reading that androgens may play a role in gender identification—do you agree?Where do individuals with DSD fall? How much does gender define you? Is it a large part of your identity? Do you feel you fall into the gender binary? How do we understand individuals that don’t quite fit into the gender binary (ie tomboys)? Is there a stigma associated with not conforming to your culturally expected gender? Does it differ for males and females? (ie is it worse to be a feminine guy or a masculine girl? Does this influence how you think of DSD individuals or what you would recommend to them?

Small group discussion…TA Guru

WEEK 2-EVIDENCED-BASED MEDICINE; BIOSTATISTICS LEARNING THE TERMS

Biostatistics: group problem solving

  (Outcome +)+Breast Cancer

(Outcome -)- Breast Cancer

(Exposure +)+Tamoxifen

A=25 

B=225 (Exposure –)- Tamoxifen

C=200 

D=550

•In a population of 1000 women, 250 are on tamoxifen to prevent breast cancer. 25 of the women on tamoxifen develop breast cancer. • Of the 750 women not on tamoxifen, 200 develop breast cancer. •What is the number needed to treat with tamoxifen to prevent one case of breast cancer?

Risk of developing breast cancer on Tamoxifen: 25/250Risk of developing breast cancer not on Tamoxifen: 200/750Absolute risk reduction = 25/250 – 200/750NNT = 1/ARR = 5.88 (round up to 6)

Review current guidelines for breast cancer screening, including screening of high risk patients with MRI

Highlight controversy surrounding screening mammography

Overview of the management of malignant breast diseases

Identify who and how to screen for familial breast and gynecologic cancers

Breast Cancer Screening and Overview of Breast Cancer: Goals

Sensitivity: 77%-95%Specificity: 94%-97%

Seven statistical models showed screening mammography reduces the rate of death from breast cancer by 7 to 23 percent, with a median of 15 percent.

Meta-analysis of 8 randomized trialsReduction of rate of death for women > 40 y

Reduction of mortality by 15 to 20% for ages 40 to 49 yrReduction of mortality by 16 to 35% for ages 50 to 69 yr

NB: Results reported for women ‘invited to screen’. Advocates suggest women ‘actually screened’ probably benefit even more.

Mammography, when to start?

Standard Mammography views;Cranio-caudal and Midline Oblique

Screening Guidelines• In USA, most recommend screening at 40 years• Between 40-49 years:

• ACS: annually• ACR: annually• ACOG: every 1-2 years • NCI: every 1-2 years• USP-STF (2009): not recommended• Canadian Task Force on Preventive Health Care: not

recommended• Annual screening > 50 years:

• Most organizations• USP-STF (2009): every 1-2 years

A new patient, a 28 year old single female comes to your office for a first time physical. She is otherwise healthy and has no risk factors for any illness including a negative family history for cancer, cardiovascular disease, hypertension or any other major illness. She asks you about her chances of developing breast cancer over her lifetime. You tell her that:

A:Every patient is different so you cannot answerB:One in eight women will develop breast cancerC:One in every one hundred women has breast cancer

D:Given she has no risk factors she will not develop breast cancer

Sample Midterm Multiple Choice QuestionChoose single best answer; bubble into scantron sheet

You are a primary care physician who is part of the new system of "capitation" on your group practice mandated by the changes after the election of 2012 in the "New" Affordable Health Plan. This capitation is similar to the United Kingdom system of having a set amount of funds to care for all your patients; so no matter what tests, procedures or exams you perform on your panel of patients, this is ALL the funds you will have. You receive $1,000,000 for the care of your 2500 patient panel, all ages.• One of your patients is a 27 year man who gets convicted of first degree murder and is

incarcerated for life (no parole).  He needs a liver transplant. This transplant will cost $350,000 of your funds which will leave far less to care for the rest of your patients. Do you put the patient on the transplant list? Why or why not?

• What if you have an active 80 year old who is still functioning at full capacity; he volunteers at the local school tutoring science and works out by running 1 mile per day. He has a wife who is healthy and 3 healthy children and 4 grandchildren who he often takes care of on a regular basis.  He needs a liver transplant. This will cost $350,000 of your funds as well.  Do you put him on the transplant list? Why or why not?

• What if you had to CHOOSE between the two patients (given your limited funding)...how might you make this decision? If you HAD to choose one person, which would you choose and why?

Narrative Reflection Prompts

Chronic Renal Disease Renal Transplantation

Autism and Vaccines

Prostate Cancer

Clinical Arts and Humanities

Health Care Financing: US and International

Pharmacology and Toxicology

Next Steps

Goals for the Redesigned PLME Year 1 Courses• Focus on the scientific competencies as detailed in the AAMC-HHMI

report. • Develop interdisciplinary science courses that more effectively engage

students interested in a career in medicine.• Integrate the sciences and non-science disciplines. An example is the

incorporation of ethics or history of science into any discussion of new technologies.  Another example is an emphasis on the humanistic aspects of patient care whenever discussing application of new knowledge or technology.

• Incorporate an inquiry-based approach into premed education.• Enhance the ability of all PLME’s to succeed in medical school, but

especially members of underrepresented groups. Members of underrepresented groups typically fare worse in the courses listed above. The integrated courses will include periodic exams and regularly scheduled tutorials for students who need help.

Overall Strategy: Central topic, a young boy with hereditary fructose intolerance, a disorder of fructose metabolism that results from a mutation in the gene that encodes the enzyme, Aldolase B. The proposed strategy is to use this case study as a means to address basic concepts in quantitative reasoning, physics and chemistry through an emphasis on enzyme catalysis.

PLME Freshman CourseSample Teaching Module

Case Presentation: Danny, a 3 year old boy was brought in for evaluation of failure to thrive (poor growth and weight gain).  His medical history included a profound aversion for sweet foods. In fact, it was described that he would retch when offered candy, other sweets, fruit juice, or fruit. Once, after drinking fruit juice, he vomited and had a near loss of consciousness for a short period of time. Based on this history, a it was suspected that Danny had hereditary fructose intolerance. This is a disorder that is inherited because it is due to a mutation in an enzyme. The enzyme, aldolase B, is involved in the metabolism of the dietary sugar, fructose.

To confirm the diagnosis, Danny was admitted to the hospital and given an oral fructose load. During the test, he became sleepy and had a low blood sugar. Laboratory tests confirmed the diagnosis.

What is fructose? (Discuss the major nutrients - carbohydrate, protein and fat - and the major dietary carbohydrates - glucose, fructose, sucrose, galactose and lactose)What is an enzyme? (Discuss the concept of catalysis)What is a mutation? (Review the central paradigm: DNA to RNA to protein)

Background Biology

Links to Important Principles in Chemistry and Physics:Chemistry Principles involved (pending review)Organic Molecule Structure (connectivity, shape, conformation - e.g., why are glucose and galactose different molecules? Can they interconvert? What about fructose and glucose?)Metabolism = chemical reactions of nutrientsKinetics - why are the adverse effects short lived as opposed to permanent?

Working with the Inorganic and Organic Chemists particularly as the material relates to biochemistry…how much do the students “need?” Chemistry as “gatekeepers” to medical school?

Physics principles involved (pending review)Coulomb’s lawElectric fields and potentialsElectric dipolesDielectrics and solubilityTorque Newton’s LawsEnergy Conservation

Working with the General Physics professors on these cases. How much is “enough?” Their opinion or ours?

Work in Progress…Questions???Thank you