Integrating Basic Sciences and Patient Care
in a Core Clerkship Curriculum:
Why do we care about integrating basic
science into the clinical years?
Frazier Stevenson, M.D.
Director of Education Devt. UC Davis SOM
President, IAMSE (Intl. Assn. of Medical Science
Educators)
Yale SOM Curriculum 1875
Year 2
•Dispensary
•Chemistry
•Practical Anatomy
•Embryology
•Physiological Chemistry
•Chemistry of Urine
•Chemical Laboratory
•Histology
•Pathology
•Theory and Practice
•Ophthalmology
•Obstetrics
•Surgery
Year 3
•Dispensary
•Surgery Clinic
•Eye Clinic
•Medical Clinic
•Hospital
•Toxicology
•Diseases of Women and Children
•Lectures on Insanity
Abraham Flexner
Flexner Report, 1908
• Admission to a medical school should require, at
minimum, a high school diploma and at least two years
of university study, primarily devoted to basic science.
• The length of medical education be four years, 2 years
of basic science and 2 years of clinical practice
• Proprietary medical schools should either close or be
incorporated into existing universities, because a standalone medical school would have to charge too much in
order to break even.
• Medical schools should appoint full-time clinical
professors--"true university teachers, barred from all
but charity practice, in the interest of teaching."
UCSF 1980
1
2
Anatomy
Biochemistry
Histology
Physiology
Genetics
Endocrinology
Human Behavior
Immunology
Pathology
Microbiology
Pharmacology
Human
Sexuality
Statistics
Psychiatry
3
Clerkships:
Surgery
Pediatrics
Internal Medicine OB-GYN
4
Electives
Basic Science
Selective
Senior Surgery
Anaesthesia
Neurology
Psychiatry
Intro to
Clinical
Medicine
Case Western 1955
1
2
3
4
Normal
Diseases
Neurologic
Musculoskeletal
Pulmonary
Hematology
Endocrine
Renal
Neurologic
Musculoskeletal
Pulmonary
Hematology
Endocrine
Renal
Clerkships Surgery
(12 months) Internal Medicine
Electives
Cardiac
Cardiac
Pediatrics
Neurology
OB-GYN
Psychiatry
UCSF CURRICULUM (February 2003)
YEAR 1
Prologue
Organs (heart, lungs, kidneys, GI)
Gross Anatomy
Cell Biology
Biochemistry
General Pathology
General
Pharmacology
Anatomy review
Physiology
Histo-Pathology
Pharmacology
Clinical
Interlude
Cancer
Brain, Mind, and
Behavior
Oncology
Hematology
Genetics
Biochemistry
Histo-Pathology
Pharmacology
Neurobiology
Neuroanatomy
Neurology
Psychiatry
Histo-Pathology
Pharmacology
Foundations of Patient Care
YEAR 2
Immunology, Infection, and
Inflammation
Microbiology
Immunology
Rheumatology
Histo-Pathology
Pharmacology
Metabolism and Nutrition
Life Cycle
Physiology
Gastroenterology
Nutrition
Endocrinology
Biochemistry
Histo-Pathology
Pharmacology
Genetics
Embryology
Repro Physiology
OB/GYN
Pediatrics
Geriatrics
Dev..Psychol.
Pharmacology
Integration
and
Review
Foundations of Patient Care
YEAR 3
Internal Medicine
Family Comm. Med
INTERSESSIONS
Obstetrics-Gynecology
Surgical Specialties
Surgery
Psychiatry
Pediatrics
Neurology
Anaesthesia
Student Perspective of Medical Biochemistry
Source: frommedskoll.com
8
% responding agree or
strongly agree
AAMC Graduation Questionnaire: Basic Science Education
“Basic science content was sufficiently integrated”
80
75
70
65
60
55
50
45
40
35
30
0.0
All
schools
UCD
2.5
1998
5.0
7.5
10.0
12.5
2008
How well did these basic science courses prepare
you for the clinical clerkships?
1998
2008
Anatomy
79
85
Biochemistry
42
53
Biostats/Epi
40
51
Genetics
45
60
Immunology
70
70
Histology
51
61
Microbiology
76
75
Neuroscience
68
74
Pathology
85
82
Pharmacology
80
66
Physiology
83
83
IAMSE 2009-- Flexner Revisited: Defining
the Role and Value of the Basic Sciences in
Medical Education
Goals:
1. Define and describe the sciences that constitute
the foundation of medicine
2. Identify the role and value of the sciences and
scientific thinking in medical education
3. Identify the best practices of when, where and how
the foundation sciences should be incorporated
into medical education
11
Questions to be Addressed:
1. What are the sciences that constitute the
foundation for medical practice of the future?
2. What is the value and role of the foundational
sciences in medical education?
3. When and how should these foundational
sciences be incorporated into the medical
education curriculum?
4. What sciences could/should be pre-requisite
components of the undergraduate medical
curriculum (i.e. be part of the pre-medical
requirements)?
5. What are examples of the best practices for
incorporation of the foundational sciences in
the medical education curriculum?
12
What are the sciences that constitute the
foundation for medical practice of the
future?
• All basic sciences taught currently will remain
important for the future.
• Normal structure and function are the basis for
understanding pathophysiology
• Depth/detail may vary considerably
– must be informed by clinical relevance
– a moving target requiring diligent monitoring and
assessment
13
How to assess clinical relevance?
• Key vocabulary
• Basis for understanding disease
– Common diseases  algorithms, practice guidelines
– Complex or unusual diseases  deeper learning and
understanding required
• Changing clinical practice creates a persistent
and dynamic relationship between basic and
clinical sciences
14
Designing a new basic science curriculum:
WHAT?
• ability to access basic science mechanisms to
solve clinical problems
• critical thinking skills, problem solving skills
• group interaction and communication skills
• ability to formulate research questions and
hypotheses
• ability to find and use information to answer
these questions
15
Designing a new basic science curriculum:
WHEN?
• When – all years
– A USMLE mandate
• Rather than a bolus of “ghettoized” information
once, distribute content across the continuum
• Revisit science cyclically (upward spiral)
• Use opportunities to build upon previous
learning
16
Designing a new basic science curriculum:
WHEN?
Clinical Sciences
Basic Sciences
Year 1



Year 4
Clinical Sciences
Basic Sciences
Year 1



Year 4
See Milbank Report
17
HOW?
18