Innovation in the Classroom

With the December 2023 publication of what they have dubbed the Patient Presentation Problem-Based Learning Curriculum (PPPC), faculty at the Hackensack Meridian School of Medicine, in Nutley, New Jersey, are aiming to revolutionize medical training and provide students with an innovative curriculum that takes the focus away from the textbook and integrates basic and clinical sciences to hone the decision-making skills they will need in their careers.1

“We’re a new medical school—our first class matriculated in 2018—so we had the incredible opportunity to build a medical school from a blank slate in a mission-driven fashion,” said Miriam Hoffman, MD. “PPPC is a great example of how the vision and the mission informed the what as well as the how. One of our guiding principles was that everything our students learn should be grounded in the community and clinical context.”

Research by Hoffman and coauthors published in Medical Teacher explained that the PPPC is based on the Master Adaptive Learner model, which aims to develop students into self-regulated and lifelong learners who are equipped to practice medicine in a fast-paced environment. The paper laid out the 9 guiding principles of PPPC: A weekly clinical case serves as the scaffolding of the curriculum; the case should allow students to apply basic science to clinical medicine; structured and unstructured discussion time concerning the case should take place; the case should be presented with a discussion to practice clinical reasoning; at the end of the week the group gathers to review the knowledge gained during the week; formal and informal feedback on specific skills is provided; students will utilize outside resources to answer clinical questions; PPPC is primarily student-driven, allowing students to hone in on their individual needs; and the case should allow students to connect all determinants of health to patient care and outcomes.2

In an interview with Oncology Fellows, Hoffman, vice dean for academic affairs at Hackensack Meridian School of Medicine, outlined additional details of the novel curriculum, describing what separates PPPC from traditional medical teaching methods as well as the impact she hopes it will have on students during both their training and time as practicing physicians.

Oncology Fellows: How was PPPC developed, and what makes it unique among medical school curricula?

Hoffman: We have a guiding principle of everything you learn in the preclerkship curriculum is grounded in its clinical context. That’s very different from 2 years of lecture on basic sciences before you ever see your first patient. Our students are in the clinical setting; they’re [using] clinical skills from week 1 of this 16-month preclerkship curriculum.

We have an entirely integrated curriculum; it’s not like [the students] have pharmacology on Monday, anatomy on Tuesday, public health on Wednesday, [etc]. Rather, they’re in 1 course that integrates all the content from the biomedical, behavioral, social, and health system sciences. That’s all integrated and framed in a clinical setting. With everything they’re learning, they’re tying it all together and doing cognitive integration.

Many schools are struggling because they record their lectures, and they don’t require students to be in class. Students are not coming to class and they’re watching [the recordings] at home. I can teach that medical student [that they] need to learn about this receptor, because when sodium does this and chlorine does this, the gradient goes up, etc, [but] it’s abstract, it’s random, and it’s hard to learn. But if I’m teaching [them] about that very same receptor, and you’re mapping [it out in] a concept map, [then you realize] that’s why this 58-year-old has chest pain. Now I’ve grounded what you’ve learned in something relevant. You understand why you’re learning it, you understand how it connects to all the other stuff you’re learning, and you understand how to take what you’re learning and apply it to a patient case.

[The PPPC] provides deeper, more meaningful, and long-lasting learning of that content than if I just put you in a lecture hall and lecture at you about this. You’re really using this information, applying it, and synthesizing it—that’s what we call higher-order cognitive goals, as opposed to just dumping it in your brain and dumping it out on a test. It’s more effortful and it takes more work. Students don’t always love it right away, but it gives them meaningful learning of the content, and they’re building those domain-general critical skills that they need to be lifelong learners and to be effective physicians.

What unmet needs for both students and faculty could PPPC fill, and what could its impact be on the landscape of medical education?

There has been a debate in the problem-based– learning literature of whether the focus [should] be more on the content or should it be more about the domain-general skills. What [PPPC] shows is a way to do that in an uber-integrated way. We’re completely integrating and achieving those 2 goals [through the PPPC]. That is a gap that this [curriculum] is demonstrating.

In terms of the [overall] landscape, our students have done amazingly well. Our goal is [to ensure] that you are a lifelong learner, that you can find information and apply it critically, but learning for that higher goal helps you do well on a standardized test [as well]. That’s why our students have knocked it out of the park on all 3 steps of the boards. Short-term recall doesn’t get you far. The goal is to get them to work smarter, which is effortful.

There’s evidence in the educational literature that with active learning students will [initially] say that they’re “not learning anything.” But when you look at medium- and long-term learning, they learn more from it, so there’s an inverse relationship there. You have to be OK with that because it takes a bit for students to learn how to engage in the process, and you have to support them in that. You have to really be explicit when you’re having students engage in this because it’s very different from how most of them spent their undergraduate college learning experiences.

What does the future hold for PPPC as far as improvements and potential expansion to other medical schools?

To execute this kind of curriculum, you really need to train your faculty. One of the things that’s critically important is that there’s collaboration between clinical faculty and basic science faculty in the building of the cases, in facilitating that Monday session, and so forth. We’ve invested a lot of time in developing all those faculty, and some of our greatest skeptics from the early years have become our greatest champions, and I appreciate them sticking with it.

Something we’re focusing on now and we’ll continue to focus on more is some of the overlap between what our students are doing in PPPC, what they’re doing with their small-group faculty, what they’re talking about with their advisers, and what they’re talking about with their clinical skills faculty, so that we’re really reinforcing it. It’s not like information mastery is only applicable in PPPC; it’s applicable everywhere else. The more that there’s an explicit integration, the more synergy [there will be].

We’re also continuing to build how we assess these skills because you can’t simply assess this with a multiple-choice test. We’re doing more assessment in our simulation center; we do a lot of simulation center training and assessment. [Also], at the end of every course, our students have what’s called an observed structured clinical exam, where they have standardized patients [played by actors] or simulators, which are very fancy manikins that have heart sounds, can speak, and have clinical findings. Additionally, 4 times throughout our curriculum we have a high stakes multi-station observed structured clinical exam. We simulate the clinical setting in a variety of ways. Continuing to build that and assessing more basic science content in the simulation center is an area of growth.

Another area that we will be studying more is [further defining] what the outcomes are that we’re hoping to achieve. How are [the students] demonstrating them? How do we assess that? That’s a research question.

We also just finished the first phase of a research project looking at what are called metacognitive moments, meaning moments when a student encounters [a] moment in a scenario where they don’t know what to do, where they’ve reached their limit. What do they do at that point? Do they think systematically, do they try to think about what additional information they need and how they should find it? How does emotion play into those cognitive processes? That’s an area that a group of us are actively looking at now as well.

References

1. SOM faculty publish study describing novel curriculum. News release. Hackensack Meridian School of Medicine. December 21, 2023. Accessed March 29, 2024. bit.ly/43LgYrp
2. Tripp T, Martinez O, Dreker M, Duffy C, Hoffman M. Expanding the scope of problem-based-learning at Hackensack Meridian School of Medicine; integrating domain-general skills with domain-specific content. Med Teach. Published online December 17, 2023. doi:10.1080/0142159X.2023.2289850