Education and Tra.ining

D. Ingram, J. Murphy Education and Training

Centre for Health Informatics and Multiprofessional Education (CHIME), Integrating Informatics into the University College London Medical School, Undergraduate Curriculum: London, United Kingdom A Report on a Pilot Project

Abstract: Previous case reports in this series on Education and Training have looked at specialist courses for postgraduate students seeking an in-depth know ledge ofinformatics and a career in the field. By contrast, this review describes a project designed to pilot a series of learning opportunities for undergraduate medical students. Although some UK medical colleges have opted to introduce informatics into the curriculum as a discipline in its own right, the Informatics Department at St Bartholomew's Hospital Medical College chose a different approach. When a new curriculum was introduced at St Bartholomew's and at The London Hospital Medical College, the Head ofthe Informatics Department saw this as an ideal opportunity to explore ways of integrating informatics into the curriculum. The initiatives described in this paper were made possible as a result of an award from the UK government Department of Employment. Money from an Enterprise in Higher Education grant funded a range of programmes, one of which was designed to introduce students to selected aspects of informatics and to demonstrate what is feasible in the undergraduate curriculum. The work carried out over a period of three and a half years was intended to provide the basis for the next phase of curriculum development. However, in the wake of the restructuring which has taken place in London medical colleges, the Informatics Department at what was St Bartholomew's has relocated to University College London Medical School, and is now called The Centre for Health Informatics and Multiprofessional Education (CHIME). University College is designing a new medical curriculum and CHIME is drawing on the experience gained through the Enterprise Project to find the best way to integrate informatics into this curriculum. Keywords: Medical Informatics, Medical Education, Undergraduate Medical Curriculum

The Challenges Facing graduates are not adequately prepared tients for teaching purposes. Conse­ Medical Education in the for the challenges they face once they quently, most schools are looking to 1990s have qualified. A particular concern is find ways to move students out of that teacher-centred methods of edu­ hospitals and into community settings In the UK,· as in most developed cation do not equip professionals to be [4]. A third critique of medical educa­ societies, there is growing concern life-long learners [3]. A second worry tion relates to the teaching of clinical about the way in which we train phy­ relates to where we train doctors. His­ skills; there is a worry that medical sicians. Traditional methods of medi­ torically, medical schools have been education has lost sight oftheir impor­ cal education, it is charged, do not affiliated to hospitals which have pro­ tance. To remedy this, medical schools encourage students to develop prob­ vided the source material (i.e., pa­ are introducing more structured meth­ lem-solving strategies or critical ap­ tients) for clinical teaching. Today, as ods of teaching and assessing clinical praisal skills. Didactic teaching meth­ length ofhospital stay gets ever shorter skills and many are building clinical ods perpetuate a reliance on experts and as more and more patients are skills laboratories [ 5]. It is against this and a rather passive approach to learn­ treated in day-care clinics or in the general background that medical ing [1,2]. The net result is that our community, there is a shortage of pa- informatics educators must decide how

116 Yearbook of Medical Informatics 1996 Education and Traitl'ilJg and where informatics fits into the Informatics. The Department initially the coordinating partner in the Good curriculum. comprised six full-time staff. It had an European Health Record Project which established track record in the design developed the GEHR architecture and The General Medical Council and development of computer-based object model as a formalism to capture Review of Undergraduate Medical learning resources. These included the the generic content and context of the Education Mac Series, in use throughout the world clinical record and make it available in In 1993, the UK General Medical to model the human cardiovascular ethical and legal clinical practice [ 11]. Council (GMC) Education Commit­ and respiratory systems and human The work shaped evolving ideas of tee published a set of recommenda­ drug kinetics, as well as a range of how informatics could best be inte­ tions aimed at improving basic medi­ interactive videodiscs used in cancer grated within clinical curricula of the cal education [6]. Although the GMC education and in anatomy teaching. It medical school [12-15]. document did not use the phrase 'medi­ played a leading role in establishing cal informatics', several of its recom­ the computer networks and services mendations have implications for shared between the college and hospi­ A Window of Opportunity informatics teaching in the context of tal and an information systems com­ for Developing Medical undergraduate education. The most mittee chaired by Professor Ingram Informatics Within the New significant thread running through the had oversight of all administrative and Curriculum review is that educators must reduce academic computing services. the amount of factual overload which One of the unique features of the In the late 1980s, the UK govern­ results in uncritical memorising offacts Department was that it was located in ment funded the Enterprise in Higher and neglect of critical appraisal. These a division of the medical college which Education initiative (EHE) to support criticisms have stimulated an interest included general practice and primary institutions seeking to promote changes in a range of new approaches, such as care, clinical skills and medical educa­ in teaching and learning styles. EHE problem-based learning and evidence­ tion. Consequently, the informatics was also intended to encourage educa­ based medicine. Medical informatics staff worked closely with clinicians, tion establishments to form partner­ has a twofold role to play in enabling health service researchers and medi­ ships with industry, commerce and the medical schools to meet these chal­ cal educationalists, as well as basic voluntary and public sector. The lenges. On the one hand, curriculum medical scientists, computer scientists programme was managed not by the managers look to informatics groups and medical physicists. This meant Department of Education but by the to provide useful electronic tools and that the Department was well placed to Department of Employment and the resources for education, such as stan­ make a major contribution to the new goal was to enable graduates to gain dard software packages, specially de­ curriculum which was launched in enterprising skills which have tended signed courseware, bibliographic da­ 1990. Equally important, the Dean of to be neglected by traditional univer­ tabases, email and Internet links. Easy the medical college was very support­ sity education. access to high quality information is ive of plans to include informatics in Educational institutions throughout essential to the new types of curricula. the new programme, as part of a new the country were invited to submit The second role for informatics is to initiative in teaching clinical skills to proposals which specified their aims stimulate the faculty to think about the medical and nursing students. and objectives for achieving change nature of medical information and to The department took the lead in over a5-yearperiod. StBartholomew' s make students aware of their role in developing the first UK clinical skills Medical College and The London the information cycle [7]. teaching laboratory, jointly with the Hospital Medical College, success­ local college of nursing and pioneered fullybidforEHEmoney;£0.8million common approaches between the pro­ was allocated to the project [16]. The The Medical Informatics fessions in teaching and assessing clini­ Enterprise Project was set up shortly Department at cal skills [8]. A main focus of this after the first intake of students were St Bartholomew's work was the development of IT and enrolled on the new curriculum. Hospital Medical College informatics skills in the context of general clinical skills [9]. Electronic The new medical curriculum at The Medical Informatics Depart­ health care records were seen to be Barts and The London ment was established in 1988, under central to many aspects of new devel­ Students beginning their medical the leadership of Professor Ingram, opments in clinical education [10]. and dental studies at Bart's and The the first UK Professor of Medical Between 1992-95, the department was London in the autumn of 1990, en-

Yearbook of Medical Informatics 1996 117 Education and Training rolled on a five-year course, divided ing informatics education and clinical to assess their learning needs. Our into three phases and leading to an MB skills, side-by-side, greatly facilitated fmdings about our own student group BS degree, This new curriculum had the making of this case. confirmed the findings of various stud­ the following features: ies reported in the literature [ 17, 18]. - a reduction in the amount of factual The Student Body A number of other Phase I activities content, The annual intake at Bart's and The introduced students to the concepts, - a shift from didactic teaching to London is about 220 students. Ap­ methods and tools of informatics. All self-directed learning, proximately half the intake are women. students were scheduled to attend a - clearly defined core objectives, In the UK, medicine is not a graduate session at the start of the course to - the introduction of projects and op- entry profession. Most entrants are 18- introduce them to Medline. Students tions (called special study modules), 19 years of age and begin their studies were required to use computers for - a greater emphasis on the behavioural as soon as they have completed their data capture and analysis in their bi­ sciences and medical ethics, and final school examination. The most ometry course, and in laboratory - new assessment methods. common choice of A-level subjects practicals. Several modules made use for medical students are chemistry (re­ of computer-assisted learning The Enterprise project provided re­ quired), physics, mathematics and bi­ programmes and tutors were encour­ sources to launch the new curriculum ology. Very few students have had any aged to start developing question banks and also made it possible to introduce formal exposure to computing and for use with a computerised assess­ several new themes to the course. A surveys indicate that the level of com­ ment package. Although the Faculty number of new posts were funded, puter literacy amongst medical stu­ of Basic Medical Sciences did not including a Senior Lectureship in dents is no different from that of en­ have a learning resource centre with Medical Informatics. trants to other faculties. (About 30% computers for self-directed study, we claimtohaveusedacomputer, but this found that groups of students started to figure conceals great differences. One look to the computer as a way of en­ Informatics Initiatives or two of these students may be com­ hancing their presentational skills. petent programmers, but the majority They started to use their word process­ Informatics initiatives were devel­ will have used a wordprocessing pack­ ing skills to make overheads, to pro­ opedfor all three phases of the medical age and played computer games.) In duce handouts, leaflets, and posters. curriculum and were evaluated in a the UK, it is extremely rare for stu­ Again, the need for these skills was variety of ways (e.g. through ques­ dents to have keyboard skills [17,18]. very much driven by the dictates of the tionnaires, student focus groups and curriculum. The Community Module, feedback forms completed by tutors). Phase I (Basic Medical Sciences) which introduced students to our di­ Throughout the project we worked to During the first 5 terms, the empha­ verse local communities and their develop links with curriculum work­ sis was on basic computer literacy. health care needs, required students to ing groups, service units, and clinical Workshops were scheduled to intro­ communicate the results of their work tutors. Our mission, as we saw it, was duce students to the facilities available in very imaginative ways [19]. to win allies by demonstrating that in the faculty and to teach them how to informatics has a role to play in the word process their assignments. These Phase II (Introduction to Clinical undergraduate curriculum. Where ap­ workshops were scheduled so as to Skills) propriate, we helped to set up new support students when they were writ­ We identified a number of opportu­ structures to support and manage the ing up their first major piece of nities in this part of the course for informatics activities. What we wanted course work. This initiative was evalu­ introducing informatics, for demon­ to achieve was a greater awareness ated annually by the Student Enter­ strating systems, and building on the amongst the faculty that informatics prise Officer, the Informatics Co­ foundations laid in Phase I. There were needs to be a core theme in the course ordinator and a working group in the two key areas where informatics was (in much the same way as communica­ Faculty of Basic Medical Sciences. included: in the Projects and in the tion skills and clinical skills are) and We found that students were very keen Clinical Skills Course (which included that all tutors have a role to play in to be provided a structured introduc­ a communication skills workbook as­ getting students to "buy-in" to the in­ tion to the computing resources. At­ signment). formation culture. The high level sup­ tendance was very high (above 90% of The workbook assignment required port of the Dean, Professor Lesley the student body). We also carried out students to learn how to elicit informa­ Reed, and her initiatives in develop- a survey of our incoming student body tion from patients which could be used

118 Yearbook of Medical Informatics 1996 Education and Training for a variety of purposes: problem prise funds were used to appoint a students. The purpose of these mod­ identification, diagnosis, treatment Projects Co-ordinator whose role it ules is to allow students to: planning and patient education. The was to find persons and organisations - study a subject of their choice in course was taught alongside sociol­ willing to offer projects each year [22]. depth, and ogy, psychology and medical ethics. The Senior Lecturer in Informatics, - develop skills of independent study Students were assigned a patient to worked with the Projects Co-ordinator and self-directed learning. interview and for assessmentthey sub­ and staff in the Computer Services mitted a structured case study report of Department to design a modular work­ Final-year clinical students select their experience of interacting with shop programme covering a variety of three special study modules, each last­ the patient, together with a tape of the informatics topics such as advanced ing for 4 weeks. All tutors are free to interview [20]. In the course of work­ Medline searching; the design of data · propose a special study module. ing on their communication skills, stu­ collection instruments; data analysis Whether a module runs is dependent dents gained experience in clinical data using computer packages such as on student choice. (The same module capture and in data recording. The . SPSS; spreadsheets and databases. is generally offered twice each aca­ clinical skills focus of this part of the These sessions were advertised and demic year.) The Informatics Depart­ course made this a natural time to students were asked to attend relevant ment designed and supervised a mod­ introduce students to the hospital's sessions. Over the course of several ule in medical informatics. At the start patient information system. We were years, a variety of documents, hand­ of the module students are asked to able to provide hands-on experience books and online notes were prepared draw up a learning contract and a without breaching confidentiality be­ to support these sessions. In the evalu­ programme of activities is negotiated. cause we had a 'training system' which ation of student projects, when asked Thekeyactivitiesduringthefourweek did not contain real patient data. In the to cite what skills they had learned in block have included attending a series course of giving students the chance to the course of their projects, more than of lectures and seminars, attending a search the system and to input data, 30% mentioned IT and information major international conference on generic issues to do with data capture, handling. Medical Informatics, carrying out a data quality, and data protection were TheProjectcomponent ofthe course structured programme of reading, raised. provided a second 'hook' for working on IT skills, and carrying out The Medical Informatics Depart­ informatics initiatives in that each year a series of visits and interviews to ment at St Bartholomew's has been we offered at least one informatics informatics research sites. We were actively engaged in developing a wide project to students. During the period very fortunate that ten different agen­ range of computer-based learning re­ covered by this report, the following cies and research teams were prepared sources for the past fifteen years. The projects were run: to support the module by demonstrat­ programmes produced range from - General Practice computer systems, ing their systems, outlining their re­ simulations in the Mac series, to inter­ Electronic Learning Resources, search and giving their views on the active videos, image databases and, Patient Records and Medical Edu­ "grand challenges in medical CD-ROM and Internet-based tutorials cation [23], informatics". At the end of the month, (The Tropical Medicine Resource for Records of Achievement, and students are required to produce a re­ the Wellcome Trust) [21]. Tutors as­ Legal and Ethical Issues relating to port reviewing what they have learned, sociated with the clinical skills part of Health Records [24]. together with their analysis of one the course were given instruction in topic which they have researched in­ how to use these packages. Computers All of these projects had direct links depth. Feedback both from the first were made ava~lable in the newly­ with the major research foci of the student to take the module and from built clinical skills lab and in an adja­ Informatics Department, viz electronic the various external groups who had cent location so that students could patient records, GP systems, and elec­ participated in the exercise suggest access these resources for revision and tronic learning resources to support that this is a successful method of self-directed study. medical education. engaging final year clinical students in The other component of the cur­ the field of informatics. riculum which was linked to Phase III (The Clinical Component) informatics teaching was the Phase ll In keeping with the recommenda­ Intercalated Degree Students: the Project. The new curriculum required tions of the GMC, our medical schools BMedSci Course all students to carry out a small scale introduced what are called Special As well as working with students in project and to submit a report. Enter- Study Modules for final-year clinical the five year programme, our brief

Yearbook of Medical Informatics 1996 119 E4'UVation and Training also extended to students taking what Staffdevelopment Activities cepts of informatics can support the is called an intercalated degree. UK Staff development was a focus for curriculum. What we are advocating is medical students are allowed to take a the entire Enterprise Team. On the a pragmatic approach which seeks to year's leave from their normal informatics side, regular workshops demonstrate how informatics can i) programme to study for a BSc degree. were organised in response to requests support students in their learning role; The majority of students exercising from the deans, heads of department ii) prepare students for their future this choice opt for a degree in one of and tutors. During the period covered clinical role; and iii) support faculty in the basic medical sciences (eg by this report, most tutors were preoc­ their teaching role. anatomy, physiology, endocrinology, cupied with writing learning objec­ New developments in medical edu­ immunology) but students are free to tives, preparing new courses and think­ cation, and changes in our national choose other subjects such as epide­ ing about teaching methods. What health service, are creating a climate miology or psychology. At the same most tutors wanted us to provide was whiCh is receptive to suggestions from time that the new undergraduate medi­ help in learning about computer-based the informatics community [26]. There cal curriculum was launched, St learning resources [26,27]. We ran is growing evidence that problem­ Bartholomew's Hospital Medical Col­ two different types of workshops: one based learning, evidence-based medi­ lege created anew intercalated course, type was organised with commercial cine and community-based medical leading to a BMedSci degree. This courseware producers and allowed education will require both investment course was different from most exist­ tutors to see some of the latest multi­ in technological infrastructure and a ing courses because instead of admit­ media products; other sessions were coherent educational philosophy for ting students at the end of their designed to address broader issues of introducing students to electronic tools preclinical course, it recruited students how to implement these resources into and information sources. The audit of who had completed the first two years the curriculum. In addition, staff in the clinical practice, the demonstration of of their clinical studies. medical informatics group provided clinical competence and the use of The core module of this course oc­ consultancy to tutors thinking of pro­ guidelines and decision support in cupied the whole of the first term of ducing their own materials. One dis­ pursuit of the highest quality of clini­ study and was led by the Informatics appointment was that very few tutors cal care and clinical outcome have all Department. Students attended a se­ spontaneously raised queries about been identified as national priorities ries ofiTworkshops and 3, three-hour where, how or whether informatics [28]. To facilitate these objectives, the sessions designed to demonstrate the was relevant to what they were teach­ National Health Service's Informa­ relevance of informatics to clinicians. ing. These broader issues were just tion Management and Technology The course was topic-based and stu­ starting to come to the fore as some strategy places patient-centred infor­ dents were required to answer a ques­ tutors became interested in teaching mation systems high on the agenda. tion on the examination. The topics evidence-based approaches to This in tum provides a focus for the chosen for the 'case studies' (health healthcare. research and development work of care records, clinical decision mak­ informatics. ing, mathematical modelling and simu­ What follows from this analysis is lation, and telemedicine and telecare) the need for centres of informatics to reflected the interest and expertise of Discussion work closely with medical education the Medical Informatics Department. departments, medical libraries, teach­ A particularly effective practical as­ The starting point for this project ing hospitals and clinical tutors, so as signment linked bioanalysis of samples was our belief that information han­ to develop a coherent approach both to from an insulin clearance experiment, dling skills are an integral part of clini­ information provision and to teaching. spreadsheet analysis ofkinetic param­ cal practice. Our goal was to explore Informatics specialists have a major eters and simulation of results using how to integrate informatics into the role to play in medical education. They the Mupharm human drug kinetic pro­ undergraduate curriculum so as to lay can help to develop the information gram developed in the Department the foundations for future professional strategy for the medical school; they [25]. The informatics component of development. Looking back at what can encourage the faculty to teach the BMedSci course has provided the we achieved, we remain convinced students good practice in relation to template for a very successful core that the best way to introduce under­ clinical data; ·they can provide learn­ module and elective at St George's . graduate students to informatics is not ing opportunities for students in the Hospital Medical School (part of their by developing specialist courses, but form of attachments and projects; they MSc in Health Sciences). by showing how the tools and con- can assist in developing learning re-

120 Yearbook of Medical Informatics 1996 Education and Training sources; and they can advise on the M. Educational Requirements of GEHR vey: BJHC Ltd, 1994:812. infrastructure needed to support new Architecture & Systems, GEHR Project 24. Ingram D, Southgate L, Heard S, Doyle L, A2014.DeliverableNo9,StBartholomew's Kalra D, et al. GEHR Requirements for ways of learning and of practising Hospital Medical College, 1993. Ethical and Legal Acceptability. The Good medicine using information technol­ 13. Murphy J, Griffith, S, Ingram D. How can European Health Record Project, Deliver­ ogy. electronic healthcare records benefit clini­ able No.8. AIM Office, Brussels, 1993. cal students? In: Richards B, et al, eds. 25. Saunders L, Ingram D, Jackson SJ. Human Drug Kinetics. Oxford: University Press, Acknowledgement: This work was Current Perspectives in Healthcare Com­ puting. Surrey: BJHC Ltd, 1995:162-72. 1989. supported by an Enterprise in Higher 14. Murphy J. 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