Should a 50-year-old woman at low risk for breast cancer get a mammogram? Does a new study on responses to asthma medication warrant a change in their patient’s treatment plan? What dosage of a drug studied only in adults is safe to give to a pediatric patient?
Scenarios of clinical uncertainty such as these are a regular part of the health professions, but rarely addressed in traditional education of health professionals, which leans toward the memorization and accumulation of facts.
UC San Francisco’s schools of dentistry, medicine and pharmacy either have implemented or are developing new curricula with the goal of equipping students with the tools and strategies to make wise, evidence-based decisions in real-world clinical situations – where answers are not always found in textbooks.
Medical School Launches Core Inquiry
All first-year students in the School of Medicine this year are starting the new Bridges curriculum, which tackles clinical uncertainty early and often with a three-phase Inquiry program that makes up nearly a quarter of the curriculum and spans all four years of medical school.
In the first phase of the Inquiry program, known as Core Inquiry, students meet weekly in small groups to discuss cases that involve complex clinical decision-making. Students are encouraged to ask questions, seek out new evidence from the scientific literature and challenge common assumptions.
“The objective of the Inquiry program is to bring students face to face with clinical uncertainty right from the beginning so that the inquiring mindset becomes second nature,” said Buck Strewler, MD, director of the Inquiry program.
The concept of uncertainty can be a difficult lesson for first-year medical students, said Strewler. “Everyone likes to say normal or not normal, cancerous or benign, heart attack or indigestion. That instinct drives the way medical students approach their education. Students want just the facts; they say, ‘Just tell me what I need to know for the test.’”
But students won’t see yes-or-no questions on exams in the Inquiry program, said Strewler. Instead, they will be evaluated on critical-thinking skills and an understanding of how probability and statistics apply to clinical problems.
Holding Knowledge Lightly
In a classic essay from 1957, sociologist Renée Fox, PhD, described the three types of uncertainty that plague medical trainees: First, the uncertainty of their own grasp of the necessary knowledge and skills; second, the uncertainty of the overall limits of medical knowledge as a discipline; and third, the uncertainty of distinguishing the one from the other.
Types of Medical Uncertainty
Sociologist Renée Fox, PhD, described the three types of uncertainty that plague medical trainees in a essay from 1957:
1. The uncertainty of their own grasp of the necessary knowledge and skills;
2. The uncertainty of the overall limits of medical knowledge as a discipline;
3. The uncertainty of distinguishing the one from the other.
The Inquiry program targets the second form of uncertainty – professional uncertainty – by teaching a more scientific way of thinking, said Catherine Lucey, MD, vice dean for education in the School of Medicine. She said input from physician-scientists at UCSF was essential in the redesign of the curriculum. “They are continuously aware of the observation that medical science has gotten us only so far,” she said.
The second phase of the Inquiry program, called Inquiry Immersion, allows medical students to hear directly from researchers working in a wide range of biomedical science. They can learn formal tools of scientific investigation from molecular biologists and epidemiologists, and take mini-courses on controversial topics in health care, such as the risk of e-cigarettes.
Robert Hiatt, MD, PhD, professor and chair of Epidemiology and Biostatistics, an expert on cancer prevention and screening, will teach some of the Inquiry program classes. Hiatt said uncertainty is the intellectual posture of “holding your knowledge lightly.”
“You use that knowledge as best as you can, but you’re willing to give it up if better ideas or new knowledge comes along,” he said.
As an example of the shifting knowledge base, he gave the use of hormone replacement therapy for women after menopause, which for a long time was thought to diminish the risk of heart disease. “That was received knowledge that was acted upon by doctors all around the world in terms of prescribing estrogens. Then the question was raised: Do we really know whether this is risky in terms of breast cancer and heart disease? A randomized trial was done, and that changed everything. It indicated there was increased risk of breast cancer and didn’t help heart disease that much,” he said.
Transforming the Pharmacy Curriculum
Starting with the class entering in 2018, the School of Pharmacy will fully implement a new doctor of pharmacy curriculum that emphasizes critical-thinking skills and an earlier introduction to uncertainty, according to Sharon Youmans, PharmD, MPH, vice dean of the School of Pharmacy.
“Our goal is to train our students as experts in the safe, effective use of medications – yes. But now is the time to also instill ingenuity, adaptability and critical thinking as a habit of mind," she said. "The new curriculum will do this purposefully – across the board. In many ways, mindset today is as important as skillset.”
The new curriculum will give students a framework to critically appraise existing knowledge, handle ambiguity and explore the unknown. Courses will incorporate the latest scientific developments and innovations in patient care – how microbes in the human gut can produce antibiotics, for example, or how genetic ancestry can affect a person’s response to a medication.
“Society expects clinicians to know everything,” said Youmans. “But the reality is there’s a lot we don’t know. We still don’t have a full understanding, for example, of the best medications to give an individual who has seizures or lung cancer. Why do some medications work for some people and not others?
“Our students need prolonged exposure to the changing frontier of health sciences discoveries – to the possibilities they might encounter as realities once they graduate,” said Youmans. “This exposure to the unknown is actually intended to make them comfortable with the unknown.”
Teaching Beyond Static Facts
The School of Dentistry is in the early stages of developing a new curriculum for 2019, and as a first step, the school revised its competency statements to include: “Demonstrates critical thinking and problem-solving, and applies foundational sciences and the best available evidence in decision-making.”
In the current milieu of information overload we can’t teach static facts and expect that to be a good education for our future trainees.
Associate Clinical Professor of Preventive and Restorative Dental Sciences
“Traditionally we have had a very passive teaching methodology,” said Sophia Saeed, DMD, associate clinical professor of Preventive and Restorative Dental Sciences and a member of the curriculum development committee. “But in the current milieu of information overload we can’t teach static facts and expect that to be a good education for our future trainees.”
The school, which is in the process of training its faculty in evidence-based dentistry, has tested out some inquiry exercises in the current curriculum, such as asking students to conduct literature research on a clinical question – for example, fluoridated toothpaste versus non-fluoridated toothpaste in cavity prevention.
Research to Advance Human Health
The new curricula aim to empower students to seek out new knowledge, which in the School of Medicine will culminate in hands-on research. Fourth-year medical students apply their inquiry skills to a 30-week research project of their own design in the Deep Explore portion of the program. Students can choose any area of scholarly inquiry, including lab work, clinical trials, public health, patient safety, systems improvements or education. They will work closely with a faculty mentor who specializes in their area of interest.
“The scholarly project reaffirms the belief that graduation from UCSF should mean that you have this set of skills to continue the advancement of human health,” said Lucey.
Some graduates may go on to research careers, but even for those who do not, the ability to question and augment existing medical knowledge is a critical skill. “Even as clinicians, you have to recognize when something new is appearing before you,” said Lucey. “At the very least, we expect them to do two things: fully consume the scientific literature in their fields and champion the need for continued research.”
The new wave of curricula changes addresses the big picture paradox that with an ever more sophisticated understanding of human health, comes the ever more sophisticated understanding of what's unknown. That is exactly how knowledge works, said Lucey. “The bigger the island of knowledge, the longer the shoreline of uncertainty,” she said.