A NEW Curriculum for a five-state region

This story is dedicated to Kellie Engle, director of curriculum, and the hundreds of faculty, students and staff throughout the WWAMI region whose hard work, commitment and talent make outstanding education possible.

Before she started medical school, Washington native Arita Thatte was working in finance on the East Coast. “It was super-abstract,” she says. “I was typing numbers into a computer.”

Thatte is finding medical school anything but abstract. She is among the first cohort of students at the UW School of Medicine to experience a new curriculum, begun in fall 2015. Among other innovations, the curriculum brings students into contact with real patients immediately, which helps students connect their classroom learning with real-life experience.

“When you’re studying,” explains Thatte, “you’re thinking about how it’s relevant to your future practice as a clinician.”

Although patients provide valuable insights for medical students, they sometimes provide even more. For instance, Thatte knows she has a lot to learn, and she’s sometimes a little reticent in front of the patients. One of them, a woman in her eighties, noticed.

The patient’s advice? “She told me not to be so timid,” Thatte remembers. “That was really encouraging.”

A little history

For more than 100 years, American medical-school curricula have followed a structure developed by Abraham Flexner, an educator hired by the Carnegie Foundation in the early 1900s to examine the state of medical schools nationwide. He found medical education wanting and issued a series of recommendations. Today’s traditional medical-school format — two years of classroom-based learning, then two years of hands-on training with patients in clinics and hospitals — is an outcome of the Flexner report.

In other words: learn about something before you practice it. But does this teaching method hold up after 100 years of rapid technological and societal change? Not completely.

“If you apply information that you’ve learned to a real problem, you will retain that information better,” says Suzanne Allen, M.D., MPH, the UW School of Medicine’s vice dean for academic, rural and regional affairs.

And that is the core of the new UW School of Medicine curriculum: taking down the fence between the classroom and the clinic; integrating what students learn in the classroom with what they learn, see and do in clinical settings. Instead of waiting until third-year clerkships to interact with patients, as is traditional in many medical schools, students in the new curriculum see patients their first year. In fact, students see patients their first week.

Learning and doing is a good combination. “I love that we have the opportunity to practice our clinical skills alongside our academic work,” says first-year medical student Aera Shin. Shin is based in Seattle, one of several campus sites. “It provides a way to solidify the material we learn in class through real-life application.”

First-year student Aera Shin and her preceptor, Lise Alexander, M.D. ’03, examine patient Sheryl Blumberg (center). Alexander, who practices at Pacific Medical Center in Federal Way, Wash., is one of many physicians who volunteer to teach students in the new curriculum.
Photo: Clare McLean

The WWAMI factor

The UW School of Medicine is unusual in that it addresses the needs of multiple states, and its educational program links classes, clerkships, teachers and students throughout the five-state region of Washington, Wyoming, Alaska, Montana and Idaho — otherwise known as WWAMI. The region includes six classroom teaching sites at six outstanding universities, hundreds of medical training sites and thousands of people.

Viewed one way, a major, five-state curriculum renewal — with a goal to update and standardize classes throughout the region — could be an enormous challenge.

“We heard it over and over,” says Michael Ryan, M.D., Res. ’89, Chief Res. ’90, associate dean for curriculum. “People told us we couldn’t do this curriculum in the region.” Ryan and his collaborators, including Suzanne Allen and Marjorie Wenrich, MPH, chief of staff for UW Medicine, disagreed.

“We used WWAMI as the reason to do curriculum renewal,” says Ryan. “It’s why we’re successful — because we have so much talent throughout the five-state region. Why not use everyone’s brainpower and energy to build the world’s best curriculum?”

The seed for curriculum renewal was planted during the School’s last national accreditation — a yearlong process of self-study accompanied by a site visit. The accreditation went well, and the School received the maximum accreditation term. At the same time, many medical schools nationwide were starting to respond to rapid advances in medical knowledge, technology and a new understanding regarding the value of active, integrated, lifelong learning.

“Medicine is changing rapidly, and we need to be prepared to change with it,” says Paul G. Ramsey, M.D., CEO, UW Medicine, and dean of the UW School of Medicine. After the accreditation was completed, he brought key leaders together to consider employing continuous curriculum improvement and assessment, rather than the usual pattern of examining a curriculum every 15 or 20 years.

The idea resonated with Allen, Ryan and other leaders, who initiated a curriculum renewal process focused on continuous improvement. Starting in 2010 — 100 years after the Flexner report — they met with people throughout the region, listening to and speaking with students, teachers and staff about curriculum successes and potential improvements. Paramount throughout their deliberations was the UW School of Medicine’s goal: educating doctors from the region for the region.

“I couldn’t be more pleased with the results,” says Ramsey. “Having the region come together to embrace a new idea so readily — one designed to produce even better, more adaptable doctors — is a new high in our WWAMI collaboration.”

Marcella Pascualy, M.D., Res. ’88, and R. Lane Brown, Ph.D., participate at a planning meeting for the new curriculum in January 2015.
Photo: Robert Steiner, Ph.D., Res. (obstetrics and gynecology)

"Having the region come together is a new high in our WWAMI collaboration."

- Paul G. Ramsey, M.D.

The flip to lifelong learning

Although the fast pace of 21st-century medical research and technology is a wonderful development, it presents some educational challenges. How can medical students learn all there is to know about medicine?

“There’s no way for a modern medical student to know everything,” says Tanya Leinicke, M.D., associate director for the Foundations of Clinical Medicine and College faculty at Alaska WWAMI. “What they really need to learn is how to learn and how to integrate information.”

In other words: don’t teach students hundreds of facts. Instead, teach them how to learn and reflect, how to be critical, how to prepare. And how to be nimble, thorough and careful.

This concept has led to two primary changes in the WWAMI learning environment. First, students are being ushered into a “flipped” classroom: fewer lectures, more preparatory work outside of class, and considerable in-class, case-based discussions.

“When they come to class, they’re being asked to do what they’re going to do as physicians for the rest of their careers — be on their toes and prepared to analyze,” says Ryan. “And, when needed, to look up information and consult others about things they don’t know.”

The second change is a massive, thoughtful integration of classes and topics. The first two years of medical school used to contain more than 30 basic science classes. Now there are seven, covered in 18 months. The students aren’t learning less; rather, their classes have become broader and more interdisciplinary.

As Ryan says, “We wanted our curriculum to match what actually happens. Diseases don’t follow a course description, and patients rarely show up with a single problem.”

This different way of teaching surprised some first-year students, like Thatte, located at the UW School of Medicine Spokane site. She had been a little wary of the first two years of medical school; friends and family had compared the educational process of becoming a doctor to memorizing all the bar codes at the supermarket.

“Our experience has been the polar opposite,” she says. “It’s been much more conceptual. They want us to know things in a way that’s useful and not just about memorization.”

"They want us to know things in a way that’s useful and not just about memorization."

- Arita Thatte

The long view

The new curriculum started in fall 2015 with the entering class, and while its two main tenets — early exposure to patients and flipped, revitalized classes — may sound fairly straightforward, it has involved an enormous amount of work and collaboration. Across five states, under deadline, at in-person retreats, via Zoom and Skype, and through an untold number of emails and weekly phone conferences. At any given point in time, 25 to 30 people from throughout the region would be talking together — debating approaches, discussing how to train new teachers and analyzing what to change.

You could call it messy and complex. The participants called it collaborative and inclusive.

“There’s a difference between a curriculum being handed to you and a curriculum being developed in conjunction with you, your needs, your site and your available resources,” says Janelle Clauser, M.D., director of the Foundations of Clinical Medicine course in Spokane. “It’s been a super-fun challenge to work on curriculum and change things to make them better.”

The challenges — and rewards — continue. Ryan and the large five-state team are about eight months in, approaching the halfway mark in the 18 months of their students’ “foundation” phase. Many classes and upcoming portions of the curriculum still require work and planning. Administrators and teachers are taking feedback from students and faculty and incorporating it into the curriculum in real time. It’s very much a work in progress. In fact, some of the planners compare it to flying an airplane while it’s being built. That sounds just about right to Ryan.

“This project has been a real gift: partners across five states and teams building together,” says Ryan. “And with everyone’s help, our plane is airborne. Sometimes the flight’s a little bumpy, but we’re definitely flying in the right direction.”