At the newly established Duke-NUS Medical School in Singapore, deans and faculty have a rare opportunity to take a step back from the traditional medical school curriculum and start down a different path in training medical students. For instance, they have begun to question the importance of memorization for medical training. With rapid advances in medical technology and so much good information available on line, the faculty believe students need to develop a different skill set.

“As Vice Dean of Education Dr. Robert Kamei has pointed out, the best doctor is no longer the doctor with the best memory,” says
Dr. Doyle Graham who teaches Duke-NUS first-year medical students.

“Our emphasis in teaching has shifted to learning and problem solving,” Dr. Graham explains. “As a faculty, we’re asking ourselves how we can promote creativity and critical thinking and how course material will actually be used down the line in the students’ professional lives.”

  
“This class is the most powerful learning situation I’ve ever been in”, says Dr. Graham (left). “It’s the highlight of my teacher career.” Dr. Puthucheary (right) co-teaches the course and is a consultant at the KK Women’s & Children’s Hospital.

Team Based Learning takes root

At Duke-NUS, lecture based courses have been replaced by a learning methodology that involves teamwork, called TeamLEAD - representing the core values of Learn, Engage, and Develop. With TeamLEAD, the students spend their class time divided into teams that work together to solve actual (and sometimes fictional) medical cases. It is a competitive, high energy and very animated process. To succeed, students must apply their book knowledge to diagnose and treat the patients in the faculty-written case studies.

“For me, establishing a new kind of training for medical students is a dream come true,” says Dr. Kamei. “And the case studies allow the students to not only access their medical and scientific knowledge, but to apply it to real-life situations. The studies are very clear: the more you apply something you’ve learned the more likely you are to retain it.”

 
 

Accountability for pre-class learning

Interestingly, the burden is placed on the students to learn the content of the class material ahead of time and on their own. They download lectures from Duke Medical School in Durham, North Carolina and receive a long syllabus with textbook chapters and timely medical articles to read for each subject such as immunology or pharmacology.

“We’re really standing on the shoulders of the Duke faculty,” Dr. Graham says. “They offer us superb lectures. Our only variation is to try to present more Southeast Asian diseases than they do at Duke.”

For typical medical school courses, students reportedly often come to class unprepared, hoping to absorb information from the lecture with plans to catch up on the reading before exams. At Duke-NUS, the students are held more accountable for their pre-class preparation. A typical TeamLEAD session begins with an Individual Readiness Assessment that tests the student’s understanding of the key concepts and most important information on any given topic.
The applications push the students beyond memorizing core principles and facts, as they must understand how the information can be applied to a medical situation.
 

Faculty members can easily extol the benefits of the pre-class preparation. For one, they say instructors do not have to waste time covering material the students can master on their own; instead they can give students a better sense of the clinical application of their studies.

Also, based on the students’ multiple choice test results (which immediately and electronically are reported), the instructors can focus on areas where the students have struggled most.

Dr. John Rush, Vice Dean for Clinical Sciences, also points out that with Team Based Learning, students are asked to quickly retrieve and apply what they have learned. “This approach fosters deeper learning,” he says, “and with medical information growing so quickly, our teaching cannot be simply content driven.”

 

This team is relying on their studies of pharmacology to diagnose and treat a fictional patient who has overdosed.
 

The making of a team

After the students have taken the Individual Readiness Assessment and learned their scores (they typically score 70% to 75%), class time truly begins with the Group Readiness Test. The students gather into teams of 6 or 7 and retake the closed-book exam but this time in a small group. They are given a fixed amount of time, usually 30 - 45 minutes, and report their answers again through the multiple-choice format.

The group test-taking also simulates another aspect of medicine: medical professionals usually work as a team to treat patients. With the group working together, the test scores soar to 95% on average.

“Being on a team is fun,” says first-year medical student Valerie Tan. “And it augments my learning process. It’s surprising how much you can gain from opinions other than your own.”
 

The instructor steps into the spotlight only when the teams simultaneously report their answers. The instructor helps the teams verbalize their answers, directs discussion and facilitates debate.

“There is nothing like the power of the moment,” says Dr. Graham, “watching the students’ faces and energy after having struggled as an individual, and then working with other students, their colleagues really, as they are forced to reach consensus and present their decision to the rest of the class.”

After a break, the students reconvene for a 3 hour “application session”, devoted to a number of clinically oriented questions. Relying on their understanding of the material they just were tested on, the teams must come to consensus for each question. After 1 ½ hours, the faculty rejoins the class and the students report their answers. The faculty, accompanied by guest medical and research experts facilitate debate between teams about the merits of differing answers and stimulate the students to think like doctors, constructing differential diagnoses and treatment plans that become increasingly sophisticated as the course progresses.

A shift in emphasis

Dr. Graham describes how the burden of the faculty shifts from writing lectures to coming up with patient cases that spawn open, spirited debate. “We’re always faced with the big decision,” he says, “how to present the content as a case, often rewriting questions, refining them after each session and continuously making judgments about which material is important.

As for the students, the emphasis changes from self-advancement to problem solving as a team. To ensure the success of the team (and to receive a good grade), students are accountable to their teammates for their individual preparation as well as their performance on the team.

Students are divided into teams simply based on their educational backgrounds. The teams are self-managed and evolve over the year-long series of basic science courses - with some of the more confident and assertive students eventually drawing out the quieter ones who may know the path to the right answer. Usually the more talkative students also become better listeners. The desire for the team to be successful motivates students and pushes them to reflect on their own style in the group.

  
For the Body and Disease course, the faculty form their own team of course directors, content experts and administrators. Pictured here (from left to right) are: Dr. Tan Soo Yong, Pathology; Dr Hwang Nian Chih, Pharmacology; Dr. Puthucheary, TeamLEAD facilitator; Dr. Ponampalan, Emergency Room Physician and Content Expert for this exercise, Dr. Graham, Course Director.
Faculty members find that over time, students usually adapt to each other to form a cohesive team, and then, with the aid of good case studies, the learning objective in the class becomes the same objective in the health care profession - to diagnose and treat patients in a setting that necessitates trust.

“Medical school has been practically taught the same way for the past 100 years,” says Dr. Rush. “At Duke-NUS, we’re starting to feel that we’re teaching the right skill set: problem-solving as a team, putting your hands on the right information quickly, and asking the right questions."