Avoiding the chopping block in curricular reform: reimagining physiology laboratories in the era of integrated medical curricula.

FOR THE PAST 100 yr or so, the Flexner 2 2 model of medical education has been the dominant paradigm for undergraduate medical curricula (4). The recognition of disadvantages with this approach has prompted a growing movement of curricular reform, beginning with a focus on pedagogical format and, more recently, resulting in the transition to integrated curricula designed to foster a stronger connection between the basic and clinical sciences (1). While curricular reform has taken many forms, several thematic trends have underwritten this progress, including early meaningful exposure to the community of practice in health care environments, a shift from a structured, discipline-based curricula to one that integrates basic with clinical science, and, in some cases, reduction in the traditional 2-yr period of preclerkship instruction (3). In 2011, the basic science and clinical faculty at the F. Edward Hebert School of Medicine at the Uniformed Services University of the Health Sciences (USUHS) engaged in a collaborative curricular reform effort. This resulted in the implementation of an integrated, organ-based curriculum that emphasized early clinical engagement (10). In addition to changing the overall philosophy of the curricular design, a key component of reform was a reduction in the preclerkship phase from the traditional 2 yr to approximately 18 mo. Subsequent experience with this integrated curriculum has demonstrated many benefits, including a seemingly stable trend of historically peak performance on high-stakes certifying examination, as well as improved clinical performance in the clerkship phase of the curriculum. A balanced view of this reform effort will illustrate several potential unintended consequences. One common concern is the effect that this reform effort has had on active, experientialbased learning activities (6). In particular, a significant reduction in laboratory-based experiences was observed. Before integration, there were ~392 h of laboratory instruction in the disciplines of physiology, anatomy, histology, pathology, and pharmacology. This has been reduced to ~340 h in the new integrated curriculum. Reduced time for laboratory instruction has occurred across all disciplines. However, physiology laboratories were almost completely abolished, and this is not a phenomenon unique to our curriculum or university (8, 11, 12). It is difficult to measure the effect of discontinuing the physiology laboratory exercises on learning. In comparisons of dissection-based vs. prosection-based or computerized anatomy instruction, it is unclear whether there is any tangible difference in test performance associated with a specific modality (9, 14). Similar results are observed when comparing live animal laboratory exercises with video or computer simulations (2). Although these are important observations, physiology laboratories at our institution were not replaced, but abolished. At USUHS, it was generally perceived by faculty that students viewed physiology material as an esoteric concept reserved for bench scientists with little appreciation for the real world clinical implications and applications of physiological concepts and measurements. In addition to this, the advent of e-learning technology, lecture capture software, and other technological innovations has widened the divide between learners and teachers (5). Significant declines in lecture attendance rates and the growing use of third-party educational tools and social media underscores this cultural shift in the way medical students in the modern era learn (7). Why is the use of physiology laboratories in medical education declining? The reduction or elimination of “wet lab” physiology experiments in medical education is becoming the norm rather than the exception (3, 8, 9, 11, 13). Naftalin (8) posits several possible reasons for the decline in physiology teaching, including the increased utilization of problem-based learning exercises and reorganization of traditional physiology department organizational structures. At USUHS, there has been no single rationale for the discontinuation of physiology laboratories, but really an amalgam of reasons that gradually led to the removal of these active-learning exercises from the curriculum. Time constraints and faculty availability were major factors leading to laboratory discontinuation (13). Some of the exercises that were conducted required a time block of 4 h. In an increasingly streamlined curriculum, 4 h is a substantial amount of time to devote to a single exercise, particularly when a fair bit of the time is spent waiting to collect or process samples. In addition, some activities required a minimum of 7–10 faculty members to oversee the exercise and assist small groups of ~20–30 students. With increased demands outside of the education arena, obtaining this time commitment from faculty proved burdensome. Moreover, there has been an overall decline in the percentage of faculty with training, *All authors contributed equally to this work. Address for reprint requests and other correspondence: B. Neubauer, Uniformed Services University of the Health Sciences, MED-EDP, Building 53, Room 53, 4301 Jones Bridge Rd., Bethesda, MD 20814 (e-mail: brian. [email protected]). Adv Physiol Educ 41: 279–285, 2017; doi:10.1152/advan.00194.2016.