New Ideas An Integrated Preclerkship Curriculum in Neuroscience, Psychiatry, and Neurology Thomas H. Glick, M.D., Elizabeth G. Armstrong, Ph.D. Margaret A. Waterman, Ph.D., Edward M. Hundert, M.D. Steven E. Hyman, M.D. The study's objective was to promote understanding of the integration of preclerkship learning in neuroscience, psychiatry, and neurology and to share the authors' experience with such a program. A dualism, which may have survived in the past for lack of robust evidence of mind-brain relationships, is now increasingly outmoded. Medical school education should reflect the increasing coherence to be found in these fields. The authors describe curricular and course innovations and revisions at Harvard Medical School that have been implemented in successive iterations over the past decade. These changes have depended upon multidisciplinary leadership, planning, and faculty participation, as weil as faculty development and closer coordination between classroom- and hospitalbased activity. A hybrid, problem-based block course in the second year integrates basic science with neurologie and psychiatrie topics that are aligned with practice of relevant clinical skills. The authors have achieved a high level of integration and coordination of these subjects at preclerkship levels in the domains of both knowledge and skills.The students, as weil as the faculty, strongly endorse an intellectually coherent and clinically relevant program of integrated preclerkship learning in neuroscience, psychiatry, and neurology. (Academic Psychiatry 1997; 21:212-218)

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modem approach to psychiatry and neurology requires changes in ways of thinking about the mind and brain that should be embedded in both the structure and the content of medical education (1). In this artide, we describe the integration and coordination of courses addressing neuroscience and behavior, as part of the "New Pathway" curricular reform effort at Harvard Medical School. These changes are not intended to slight the psychological aspects of psychiatry, but to express in a more coherent way a common task: to develop understanding of the mind and behavior as expressions of nervous system activity. Indeed, by postulating mechanisms by which individual and social experience ~i'

interact with the brain and can even affect gene expression (2), a greater appreciation for the role of the psyche in illness and health can be fostered. In addition, both systems-level and cellular-molecular-Ievel neurosciences are necessary to understand Dr. Glick is associate professor of neurology, Dr. Armstrong is director of medical education and assodate professor in pediatrics, Dr. Waterman currently is assistant professor of biology, Southeast Missouri State University; Dr. Hundert currently is senior associate dean for medical education, University of Rochester School of Medicine and Dentistry; and Dr. Hyman is currently director, National Institute of Mental Health. Address reprint requests to Dr. Glick, 1493 Cambridge Street, Cambridge, MA 02139. Copyright © 1997 Academic Psychilltry. \\111 \11

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elinieal disorders. This new approaeh eontrasts with a eommon tendency in teaehing biologie psychiatry to focus exeessively on synaptie pharmaeology, whieh makes it difficult for students to develop a broader view of how the brain works and how mental symptoms might arise. We use prec1erkship edueation to create an interest in and open-mindedness about both neurology and psyehiatry as elinieal disciplines, and in neuroscienee as a research enterprise. Although many medical sehools have made some efforts to join teaching (as weIl as research and service aspects) of neurology and psyehiatry, a review of the limited information in the Association 01 American Medical Colleges' Curriculum Directory eovering all V.S. and Canadian sehools (3) does not reveal any eomparable, eomprehensive integration of the prec1erkship program in neuroscienee, psychiatry, and neurology. Although others (4) have thoughtfully probed some of these edueational issues, a review of relevant journals, as weIl as multiple personal eommunications, has not yielded descriptions of such programs, thus eneouraging us to share our experienee. THE PRECLERKSHIP NEUROSCIENCE AND BEHAVIOR CURRICULUM

From its ineeption in 1985, the "New Pathway" curriculum in general medical education at Harvard Medieal School (5) has made integrated prec1erkship learning in psychiatry and neurology a key element of the seeond-year program for 160 students. The Human Nervous System and Behavior (HNSB) eourse has been designed and operated as an interdisciplinary eourse to stimulate learning of the basic principles that will prepare students weIl not only for derkships, but also for the progress and the anticipated ehallenges as we prepare to enter the 21st eentury. In the prior curriculum, not only were the various neural disciplines taught separately, but psychiatrie and neurologie dinical skills and psyehopathology were not aligned or eoordinated.

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The HNSB eourse indudes one lecture per day; eaeh week, two 2-hour laboratories for anatomy, pathology, and imaging; one live-patient elinieal demonstration; and three 2-hour problem-based tutorial sessions, with 8 students and 1 "expert" tutor per group. The problems are presently embedded in ease narratives with neuroimages where pertinent; video-based eases are in development. The tutorial faculty typically eomprises one-third neurobiologists, one-third aeademie psychiatrists, and one-third neurologists. Several senior psychiatrie residents have participated as tutors with great sueeess. The HNSB eourse (occupying a block of 10 weeks in the fall of the second year) runs eoncurrently and in dose eoordination with instruction in the physical neurologie and mental status exams and psychiatrie interviewing and psyehopathology. This model enables direct patient eontacts that stimulate interest in basic scienee and pathophysiology (6,7). Conversely, students carry evolving ideas, such as plasticity and adaptive neural meehanisms, into the eoordinated psyehiatry sessions. (A longitudinal "patient-doctor" eourse in the first year indudes psychosocial issues, general interviewing, and attention to the emotional and social aspects of disease and illness, but the eourse does not address mental status examination or psyehopathology.) COURSECONTENT In addition to structural integration within the HNSB eourse and eoordination of eoncurrent eourses, many of the tutorial eases that we have used embody both "neurologie" and "psyehiatric" aspects (Table 1). To relate the modes of learning and assessment, cases (similar to those used in tutorials) serve as the instruments of final student evaluation. In some instances, we have juxtaposed similar phenomenology because of different underlying mechanisms. For example, we pair a case of eomplex partial seizures with a ease of panie

T ABLE 1. Week

An integrated prederkship c:unicu1um for neuroscienee, psychiatry, and neurology Psychiatrie Interviewing and Psychopathology

Human Nervous System and Behavior Course Peripheral neurobiology ITutorial case: sciatic nerve compression during drug-indueed coma) Neuromuscular transmission; spinal eord ITutorial case: myasthenie syndrome) Cerebral anatomy and localization (Thtorial case: patient with weakness that is due to stroke vs. hysterical eonversion; issue of "denial" and "neg1ect") Monoaminergie systems and motor control ITutorial case: Parkinson's disease with psychomotor retardation, dementia) Substanee abuse, motivation, reward ITutorial case: Aleohol and cocaine abuse vs. depression) Central nervous system plasticity, critical periods in development; sensory processing ITutorial case: child with congenital cataract) Cortical and limbic organization, psyehosis ITutorial case: manie-depressive illness vs. schizophrenia) Chronie pain ITutorial case: phantom limb and pain) ParO)cysmal events; epilepsy, learning and memory (ThtoriaI case: complex partial seizures VS. panie attacks) Central nervous system infection; review ITutorial case: AIDS with focal deficits, depression, dementia)

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(Not started) Mental status exam (Neurology exam sessions eoncurrently) Focal neurobehavioral syndromes, eonfusion, delirium Depression Substanee abuse, stress PsycholOgie development Schizophrenia and/or manie-depressive illness Psychiatrie aspects of medical illness Anxiety, panie disorder

Psychiatrie issues in AIDS (Additional sessions, topics in ensuing weeks)

Note: AIDS = aequired immune deficiency syndrome.

disorder that indudes dissociative speIls. For students to confront symptoms that eould be either "psychiatrie" or "neurologie" carries eonsiderable heuristie value, but more important is the intellectual modeling that engenders the question: "Can we hypothesize some commonality of physiologie mechanism in the final expression of dissociative speIls?" Might psychic "sears," for example, alter limbic structure and function in a way that produces focal, paroxysmal, synchronized. limbic hyperaetivity-5omething very dose to our current eoneept of seizure pathogenesis? Similarly, parkinsonism and depression often share features of psyehomotor retardation that '[;

suggest elements of neurobiologie eonvergence, but how does experience interact with monoaminergie insufficiency? A life crisis may precipitate a depressive episode, or, eonversely, a crisis like yelling ''FIRE!'' may trigger the well-known paradoxical reaction in the akinetie parkinsonian patient. From the simplest, deterministie monoaminergic neurotransmission, we enlarge the view to indude eo-transmission (as by peptides), more diffuse neuromodulation, and then modifieation of eonnectivities. This expanded and more subtle neurobiologie view has led us to increase our attention to the subject of neural plasticity as a forus of psychiatrie and neurologie \\111 \11

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connection. An understanding of critical periods in brain development, as in the visual system, potentially adds new dimensions to consideration of critica1 periods in psychologic development. We command neither adequate knowledge, as yet, nor sufficient teaching time to explore deeply the mutual ramifications of plasticity in psychiatry and neurology. However, topics like competition for synaptic connections and neuronal survival during development, long-term potentiation and learning, and programmed cell death will help the clinicians, as weIl as scientists, of the next generation to think more constructively about nature and nurture. We acknowledge the difficulty of choosing content. Our choices have changed over time, and others will choose differently according to their goals and insights. Yet we should continue to reflect on the fundamental principles of psychiatry and cognitive and behavioral science (as weIl as straightforward neural science) that should be addressed in the preclerkship curriculum. Although some topics, such as neuropsychopharmacology, clearly demand attention (8), we also present problems of motivation, reward, stress, and aggression in relationship to brain structure and function, on the one hand, and to clinical and sodal cha1lenges, such as substance abuse, on the other. Other topics, including many important aspects of development, have frustrated our attempts at meaningful integration within the HNSB course because of currently inadequate connections to neuroscience or our failure to generate robust learning models. Thus, we stress the interactions between psychologica1 and neurobiologica1 levels of explanation, but we currently lack adequate theories or data to make compelling educationallinkages in all areas. Faculty development efforts are multipronged, addressing issues of both process and content. We promote content-oriented aspects of professional growth through

weekly faculty meetings that take up perplexing subjects such as schizophrenia. Tutors become messengers of new outlooks in their home departments of psychiatry, neurology, and neuroscience. Clinically, many faculty members have found their own daily .work enriched, and this value is passed along to others. Just as the student's mind is stretched by thinking about dissodative speIls in a new light, the teaching neurologist consults in a fresh way on a psychiatric patient with episodic loss of contro!. The consultation becomes less a routine exercise in ruling out complex partial seizures, and more achallenge to think about novel explanatory models. Similarly, a psychiatric consultation on a patient with atypica1 hallucinations may be informed by a new perspective. EVALUATION The best opportunity for evaluating the integrated neuroscience and behavior course (HNSB) in comparison with the prior, more traditional, discipline-based offerings occurred during the 2-year pilot phase of the New Pathway curricular reform, when the "old" co-existed with the "new." As exhaustively studied by Moore et al. (9), some statistically significant differences were discerned between the two groups of students, those who volunteered for the New Pathway pilot projects, but were not selected by lottery, and those who were selected. In the National Board of Medica1 Examiners Part I exam, the New Pathway students scored significantly higher on the behavioral science subtest. Also, by using multiple measures, teaching of interpersonal skills was more effective in the new curriculum. However, several interventions in the curriculum may have contributed to these differences. For example, only the New Pathway students were introduced to general interviewing skills and a variety of psychosocial issues in their first-year patient-doctor course. Thus, we cannot attribute the observed advantages

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solely to the integrated neuroscience and behavior course, or to curricular coordination that was at the time still incomplete. Since generalizing the curricular changes, we have no longer had any true control group, nor can we benefit from historical controls, since the curriculum and local and national tests have all been changing. One section of the medical undergraduate student body (Health Sciences and Technology, a joint HarvardMassachusetts Institute of Technology program) takes a less integrated and less behaviorally oriented neuroscience course (that is not aligned with psychiatric interviewing), and these students do not take the patient-doctor course described earlier. We have not, however, been able to draw meaningful comparisons with respect to the second-year curriculum because of powerful selection bias and the dissimilar first-year experiences. Selection bias also vitiates comparison of performance in the second-year psychopathology course and the psychiatry and neurology derkships. An objective structured. clinical examination (OSCE) has been instituted for the Harvard Medical School dass at the end of the second-year physical diagnosis course and will be followed by a more comprehensive OSCE early in the fourth year. The experience thus far with the OSCE "Depression Station" or "Cranial Nerve Station" has not yielded data of use to curricular evaluation, but such approaches may ultimately enable measurement of absolute, if not comparative, outcomes. Subjective assessment of student attitudes is highly relevant. Since physicians' career development depends on continued learning, students should carry away from their formal education a positive attitude. Such an attitude influences retention of information and dedication to future upgrading of understanding and competence. As a starting point, we would emphasize the overwhelming assertion by students in the end-of-course written evaluation ~II,

instrument, year after year, that the integrated HNSB course not only ranks as one of the two best "science" courses, but it has greatly increased their interest in the relevant subject matter. Forusing on the specific coordination of aligned courses, with questionnaire response rates ranging from 40% to 85%, the students almost unanimously (97%-99%) have endorsed the concurrent course plan. As a consequence of learning relevant clinical skills and sitting with patients, students state that they bring to their problem-based neuroscience and behavior course an increased degree of interest and a more realistic sense of patients' illnesses. Conversely, learning about the nervous system informs and enriches the direct clinical activities. Aseparate and more detailed survey of student opinion, seeking to elicit any negative ramifications, indicated that students have not been confused by diversity of subject matter or additional conceptual levels. Moreover, despite anxiety over the formidable knowledge base of neuroscience and the need to succeed on the U.S. Medical Licensure Exam Step I, over 85% of responding students confirmed that the HNSB course should not forus only on the "hard" science. DISCUSSION Although a neuroscience platform for integrated learning might appear capable of supporting only a reductionistic approach, we intend to convey the mutual connections: We are as interested in the ways that thought, emotion, behavior, and environment can alter brain structure and function as the ways by which neural activity mediates the expression of human attributes (10,11). The one rule that we apply to both "psychiatric" and "neurologic" subjects is that there should be a reasonably coherent and evidence-based body of knowledge to make a topic accessible and memorable. Disease-oriented diagnosis and practical therapeutics should be largely the province \ ()I L \11

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oE the required psychiatric and neurologic derkships, as well as postgraduate training. Many members oE this Eaculty teach not only the HNSB course, but they also teach (in the same or different years) the psychiatric interviewing and clinical skills courses; in the neurology and psychiatry derkships; and in neurology, psychiatry, and general medicine residency programs. Such faculty "bridging" promises to connect individual courses and derkships; it may diminish the disparities between an evolving prederkship "culture" and the traditional ways oE derkship and residency training. Both the student stream and faculty bridges help to achieve an integration of neurologic and psychiatric education that a curricular framework alone cannot fulfill. Curricular change need not be a zerosum game, in which there are winners and losers. Topics that might have taken time from psychiatry coursework now find space in a "neuroscience" course--the HNSB course. More important, the second-year psychiatric interviewing and introductory psychopathology course has retained its prior contact hours, but students perceive these as more meaningful because of their dose coordination with learning neuroscience and neurologic skills. Conversely, although conventional neuropathology and physiology command fewer hours, we view the opportunity to shift attention partially to newer subjects, such as neural plasticity and use-dependent synaptic function, as representing progress. In fact, curricular reorganization has stimulated a rethinking oE educational goals, such that we have substantially revised our ideas about what the "undifferentiated" future physician should understand about behavior and the human nervous system. Problems with implementation oE our integrated curriculum stemmed largely from three sources: first, scientists who were concemed that basic science learning, in general, would be eroded by clinica1 infatuation in the first two years; second, some

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Eaculty members who Eeared that neurobiologists would not respect psychiatrie legitimacy; and third, those who would have to accept more concentrated teaching schedules to achieve course alignments. While some of the first two groups oE concems linger, participants and wellinformed observers have appeared satisfied with the mutual respect and the balances that have been struck. Logistical barriers have been overcome by the dedication and high level of educational proEessionalism oE Eaculty members in the contributing departments. CONCLUSIONS Medical students should experience in curricular design, course content, and faculty participation a coherent and respectful introduction to the challenges posed by disorders oE behavior, thought, and emotion as expressions of altered nervous system activity. We try to avoid labeling neurologic and psychiatrie problems as such, but we encourage our students to view them as mutually relevant disorders in which the nervous system is the final common processor. We have attempted to maximize the p0tential for synergy; we have not only attempted to define a preclerkship content pertinent to neurology and psychiatry, but also have matched problem-based learning with patient-based encounters and skills. Students indicate to us that they value the aoordination of neuroscience, psychiatry, and neurology and the relevant clinical skills as an introduction to their learning about the mind, brain, and disorders in the neurobehavioral realm. We believe that an educational approach of this type meets broadly shared goals and represents a feasible model for wider implementation or adaptation.

This work was presented at the American Academy 01 Neurology, Scientific Session, May 3-5, 1994, in Washington, v.c.

The authors thank the following tor their contributions to curricular and course planning, implementation, and coordination: Drs. Edwin

Furshpan, Peter Reich, Cynthia Kettyle, Alfred Margolies, Lewis Sudarsky, and Thomas Walshe, and Ms. Janet Kirby.

References 1. Slavney PR: The mind-brain problem, episte-

mology, and psychiatrie education. Academie Psychiatry 1993; 17:59-66 2. Coyle JT: The neuroscience perspective and the changing role of the psychiatrist: the challenge for psychiatrie educators. Aeademie Psychiatry 1995; 19:202-212 3. Bennett C (ed): Association of American Medical Colleges (AAMC): AAMC Curriculum Directory 1995-1996, 24th ed. Washington, OC, AAMC, 1995 4. ManIey MRS. The emerging consensus in behavioral science course content. Academie Psychiatry 1994; 18:30-37 5. Tosteson OC, Adelstein SJ, Carver ST: New Pathways to General Medical Edueation. Cambridge, MA, Harvard University Press, 1994

6. Briggs-Style C, Maxwell JA, Moore GT: The effects of early patient eontact: the student's perspective. Acad Med 1990; 65(suppl):S33-S34 7. Duban S, Kaufman A: Clinical skills: enhancing basic science learning, in Implementing ProblemBased Medieal Edueation, edited by Kaufman A. New York, Springer, 1985, pp. 89-105 8. Cummings JL, Hegarty A: Neurology, psychiatry, and neuropsychiatry. Neurology 1994; 44:209-213 9. Moore GT, Block SO, Briggs Style C, et al: The influenee of the New Pathway Curriculum on Harvard medical students. Aead Med 1994; 69:983-989 10. Brenneis CB: The skewing of psychiatry. Academie Psychiatry 1994; 18:71~ 11. Eisenberg L: The social construction of the human brain. Am J Psychiatry 1995; 152:1~1575

An integrated preclerkship curriculum in neuroscience, psychiatry, and neurology.

The study's objective was to promote understanding of the integration of preclerkship learning in neuroscience, psychiatry, and neurology and to share...
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