LMU students propose new structure for pre-clinical curriculum

In August, a group of fourth-year medical students from Ludwig Maximilians University (LMU) in Munich capped off their four-month clerkships at various Harvard teaching hospitals with a visit to HMI, where they presented their ideas for reforming the pre-clinical years of the LMU curriculum. Since 1997, students from LMU have come to Boston to complete core and elective clinical rotations and take a special course in medical education, which requires that they work on a curriculum design project. The task of this year’s group was to create a curriculum for the first two years in the new LMU curriculum, which are dedicated to basic science. Their proposal called for an organ-based curriculum in which students would benefit from continuous assessment.

Clockwise from front right: Fabian Toegel, Annie Horng, Angela Meier, Bianca Obermaier, Stefanie Geisenhof, Jan Ricken, Hendrik Poeck, Nikolaus Sarafoff, Nadine Lehnen, and Gil Westmeyer.

The students introduced their proposal by asserting that their new pre-clinical curriculum was based on an understanding of medicine as a unifying endeavor of science, technology, and humanity. Although they covered each of these aspects, their emphasis on this last idea and the mechanisms they developed to support it revealed a team focused on creating an environment where learning, teaching, and reflection, not merely the transfer of knowledge, could flourish. Respect, rewards, pride, and community—these words were as much a part of the students’ proposal as the organ-based course progression, the blend of different teaching methods, and the system of assessment. The students aimed to deliver a curriculum that, rather than overemphasizing factual knowledge, incorporated communication skills, ethics and professionalism, and an understanding of the socio-economic backgrounds of individual patients.

Getting it all in
One of the challenges of the basic science years is the ever expanding corpus of medical knowledge that must be covered in order to prepare students for the clinical years. The LMU group developed an “organomatrix” that structured the content of the first two years. In the first semester, all students would begin with a 16-week course in “The Dimensions of Life” and a course on the musculoskeletal system. This would provide a solid foundation for the second semester, when students would focus on the cardiovascular system and the respiratory system. In the second year, students would first go through courses on the gastrointestinal system and the genitourinary tract, and finish their basic science curriculum with a course in the brain, peripheral nervous system, and endocrinology. The coursework in this last semester would last for 12 weeks, with students using the final four weeks to prepare for the first required national examination.

Hendrik and Bianca observe their peers performing a history and physical examination on standardized patients.

The feedback loop
One of the students, Hendrik Poeck, talked about the need to introduce a “feedback culture” in Germany. Today such a culture of continuous assessment —of not only students, but of teachers and courses as well—does not exist, but the highly structured regimens of the basic science years depend on it. “We wanted to design a curriculum that places students in a steady state of assessment,” said Poeck, calling for an increase in the number of times students are evaluated, and for feedback from faculty to include positive remarks when the students have performed well, not just pejorative assessments.

Eager to see the curriculum address the “whole physician,” the students also emphasized “soft skills” that should be evaluated, like desire to learn, enthusiasm, and interaction with other students.

And the feedback will flow in the other direction as well, if the students have their way. Although the lecture will remain a crucial teaching method, the students want to implement a “feedback loop” that will indicate to teachers the effectiveness of their lectures, so that theoretically they can improve their presentations for future lectures or new audiences.

Changing the curriculum is about changing the university
An interesting element of the students’ work is their consideration of how redesigning the LMU medical curriculum can help to enhance the university as a whole. The students cited a need to nurture a positive image of LMU as a community of students and faculty where hard work is rewarded and recognized and respect is mutual. As one student said, “At Harvard Medical School, students are seen as a quality control,” with faculty continually updating their knowledge and revisiting their approaches to teaching in order to produce more capable graduates. The LMU students believe that continuous (and constructive) feedback, awards for teaching excellence, and more contact, both among the students, and between students and faculty, can help to shape an identity at LMU that all involved would be comfortable promoting to the next generation of students and faculty.

Toni Peters, PhD, director of curriculum development in the HMS Office for Educational Development, directed the student course in medical education. Speaking to the LMU students following their final curriculum presentation at HMI, she highlighted the students’ ideas for a two-day orientation and buddy system, both of which are designed to foster a sense of community among the students and help students to support one another as they progress. “Students can be as much of an impediment to curriculum reform efforts as faculty. But the orientation and buddy system give the students information about themselves that will show them how they are growing each week,” she said. “The processes you have designed are very supportive.”

Earlier, the students presented their ideas via teleconference to faculty at LMU, and their work drew praise from Prof. Bernd Sutor, the dean of students for the basic science years at LMU. Before the students arrived in Boston, Sutor had encouraged them to strive to develop an ideal curriculum, without worrying about what elements would prove unrealistic in the German system or impossible to implement for other reasons. Those decisions will come later, when the students return to Munich to collaborate with him, and they realize already that parts of their proposal will be difficult to implement. Their ambitious proposal challenges the status quo of both the content and culture of German medical education. But Peters urged the students to be prepared to push for those components of the curriculum that they felt were absolutely needed. She added that the students’ proposal was based on an evaluation of the state examinations. “To me, this proves that curricular plans can be innovative even when constrained by the demands external bodies make,” she said.

We will have to wait and see how the students’ efforts translate into curriculum changes at LMU. But today, as Peters pointed out, echoed by the students, they have overcome a significant barrier to change in that they have learned how to work well together—something that even experienced professionals do not take for granted. “They should be congratulated not for only for their product, but for their process, ” said Peters.

During a rare break in the action at Harvard Medical School, Gil and the rest of the LMU students take in a baseball game at the famous Fenway Park.

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