Monday, 9 a.m.. A small group of basic science researchers from the Champalimaud Foundation and other people working at the Foundation who are interested in bridging the gap between science and medicine is scheduled for a “medical class” via Zoom (due to pandemic restrictions) with Pedro Marvão, their tutor in a new course called Fundamentals of Medicine. In one week, they will have to “solve”, together, a clinical case. They will do this, week after week, with a series of other cases.
This type of medical learning, based on real clinical cases and termed problem-based learning or PBL, was invented in Canada in the 1960’s and later developed in the Netherlands during the 1970’s. During the following decades, it was integrated in the medical courses of a number of universities in Anglo-Saxon countries. Since 2009, it has been applied at the UAlg’s Medical School. “PBL offers certain advantages: better training in problem-solving, enhanced skills for searching information, higher retentive levels of acquired knowledge, and, from a more subjective perspective, a more stimulating and interesting learning process”, says Pedro Marvão, who has taught Physiology at the UAlg Faculty of Medicine, the University of Manchester and the Nova Medical School.
However, the Fundamentals of Medicine course at the Champalimaud Centre for the Unknown, which stemmed from a proposal by João Silveira Botelho, Vice-President of the Champalimaud Foundation, is the first pedagogical initiative in which PBL targets, rather than medical students, scientists without medical training, aiming to make them experience medical practice. “To the best of our knowledge, there currently exists no other similar experience, either at the national or at the international level,” notes Isabel Palmeirim, director of the UAlg Faculty of Medicine and Biomedical Sciences (FMCB-UAlg) and of the Fundamentals of Medicine course.
The aim of Fundamentals of Medicine, a graduate course born through a protocol co-signed by the Algarve Biomedical Center (ABC) – a consortium of which UAlg is an integral part – and the Champalimaud Foundation, is not to make physicians out of scientists. It is to allow scientists, who are used to a much more controlled and structured work environment, to understand the complexity of the real-world problems that physicians have to deal with, which require making decisions about patients in real time, in the bustle of a hospital or clinic.
Why is that important? There is a growing consensus that it is necessary to facilitate the transposition – or “translation”, as experts call it – of scientific results into clinical applications, and that requires establishing a profound dialogue between scientists and physicians. But for this dialogue to be truly meaningful, it is essential for scientists to understand that the situations physicians experience in their daily work have little to do with the atmosphere and daily life in a lab.
In the Life Sciences, researchers work in extremely controlled conditions. They want to unravel the universal biological mechanisms that govern the workings of living organisms and are committed to answer questions they deem interesting. The scientific method takes time: it entails formulating hypotheses to answer those questions and performing experiments on artificial systems – such as cells, tissues, organs or animals – to validate or exclude those hypotheses. Ideally, when the experimental results prove interesting and are positively evaluated by selected peers, they will give rise to papers in scientific journals – and the scientists will then study the next relevant question (very often resulting from the initial questions they asked), always by applying the same research rules to once again ensure the objectivity of their results.
A physician’s outlook is solving problems. Physicians are like detectives who have to discover, through observation and various diagnostic exams, what is going on in the body of a given patient, who presents a set of symptoms, who is in pain and suffers from various indispositions that may or not be related to one another. The process also includes listening to the subjective narrative of the patient. Armed with all this information, the physician then has to come up with an adequate treatment. And in emergency situations, she or he has to act very fast, basing decisions on scarce information, to save the patient’s life. A physician’s work thus consists of making decisions in an environment full of uncertainties and uncontrolled – or even unknown – parameters. Contrary to scientists, who try to minimise contamination risks and to isolate the object of their study from any spurious influence, physicians have to study the whole patient – a complex system subject to multiple interactions and influences, and always susceptible to all kinds of contaminations. Reality is definitely not a scientific experiment.
It is precisely with the reality of medical practice that the students enrolled in the Fundamentals of Medicine course are trying to cope. By analysing reports from real medical cases – with the data, sometimes contradictory, emerging gradually, just like in real life – they will, week after week, discuss these cases together, perform individual information searches, and then share and reflect on what they have learned through these searches in order to formulate diagnoses and define treatments like true clinical detectives.
“This is a medical postgraduate course delivered in an open-course mode, exclusively directed to people with a PhD in a scientific area and whose goal is to familiarise students with the terminology as well as the anatomical, physiological, pathological and pharmacological aspects of the various functional organic systems of the human body,” explains Isabel Palmeirim.
During this academic year (that is still ongoing), students will have analysed a total of 36 clinical cases, at the rate of one case per week, dedicating three consecutive sessions to each. At the end of each run of six cases, they will have a one-week break to study, followed by an evaluation of the acquired knowledge.
A new weekly cycle begins every Monday with a session lasting an hour and a half, during which the students are provided basic information about the case (one person with one set of symptoms). Under the tutor’s guidance, the students perform a preliminary analysis of the case and propose hypotheses about the cause of the problems and their possible resolution.
“The tutor’s function here is not to teach,” says Pedro Marvão. “He is the gatekeeper of the case’s information, supplying additional data only when the group has reached the adequate point to receive it. He also aids and guides the inquiry process (the ‘detective’ work) on the supplied information, which leads the members of the group to formulate the questions that will guide their autonomous study.”
The discussions naturally give rise to a set of doubts and questions that the students will have to solve and answer so as to be able to propose a provisional diagnosis by Thursday of the same week. For this autonomous and individual task, they can use whatever source of information they wish. During the second session (on Thursday), they will share with the others what they learned from their searches.
At the same time, the tutor will provide additional information about the case (such as the results of complementary exams), eliciting new questions that will require the students to perform further searches until the following Monday. During this third and last session, also lasting an hour and a half, the final questions are analysed and solved and the case is closed. Also, the analysis of the next case begins.
To complete this autonomous, tutor-guided learning, students have to attend weekly interactive seminars on basic, clinical or scientific matters, as well as roundtable debates. “Since they are already well-prepared on these matters, they can profit much more from the interactions with the specialists involved,” says Isabel Palmeirim. “This year, nearly 40 specialists participated in this part of the course.”
Rita Marçal, for instance, a physician who teaches Anatomy at the UAlg Medical School, was invited to give the Anatomy seminar. “I found this initiative extremely interesting and immediately accepted the invitation”, she says. “During my clinical career, I have myself felt the huge distance existing between research and the clinic, in particular with respect to the type of language used by each. Moreover, I consider the Champalimaud Foundation as the perfect example of a private health institution where the proximity of the clinical and the research areas can be very productive and clearly benefit the patients we treat.”
Bruno Morgado, a physician at the same medical school, who was in charge of the Pharmacology seminars during the course, also finds this teaching experience very enriching. “Most of the classes I give, namely to undergraduate students, tend to be a unilateral sharing of knowledge. The teacher shares his knowledge, but receives little in return, which is completely understandable given that the dialogue involves people who are 18 to 20 years old and have little previous experience. But with the scientists of the Champalimaud Foundation, the sharing became bilateral as soon as the matter at hand marginally stumbled on an area of the students’ past or current research. Sometimes, the dialogue became so intense that the class ended up lasting two or three hours instead of the scheduled one hour!
We also asked the tutor and the students (this year, a total of seven) their opinions about the course. As could be expected, the students’ general motivation to attend the course was to understand the medical world they interact with at the Champalimaud Centre for the Unknown – which includes a Clinical Centre dedicated to oncological diseases and the basic science research facility Champalimaud Research, and is committed to promoting the translation of scientific results into the clinic.
The students point out that the course has helped them to understand how different the medical and the scientific approach actually are. “The medical goal is to ‘solve’ diseases, whereas the scientific goal is to understand the mechanisms of disease. Medicine has to provide answers, science has to ask questions,” explains Ana Catarina Certal, head of the Molecular and Transgenic Tools platform at Champalimaud Research. From the human perspective, “dealing with patients and their families in a diversity of situations is in fact crucial in a physician’s daily work, while in general, that concern doesn’t arise in the scientific approach (except when working with humans),” notes Daniel Nunes, a neuroscientist at Champalimaud Research’s Learning Lab.
Among the biggest challenges encountered by these student-scientists, as they tried to solve the clinical cases, were things such as learning when to stop asking questions and start making decisions based on scarce information they had. “For me, the main difficulties were to resist going into as much detail as we are used to as scientists and the need to be more practical,” says Rita Fior, group leader of the Cancer Development and Innate Immune Evasion Lab. The same is true for André Valente, researcher and advisor to the Champalimaud Foundation’s Board of Directors: “For me, the most challenging aspect of the course was undoubtedly, when faced with the huge amount of anatomical, pathophysiological and pharmacological data, to be able to select the relevant material and to know when to stop searching.”
In these matters, the tutor’s role is essential. “The tutor ensures, among other things, that the students analyse the contents they are provided with to the necessary depth, keeping them away from irrelevant minutia and overly general considerations”, says Pedro Marvão. “Scientists are the best students when it comes to applying the PBL method, because they are very accustomed to questioning and processing information. Their problem is, rather, knowing when to stop asking and move forward based on the available information. This is precisely the skill they have to learn and practice. There was no particular resistance on the part of the students to accept this attitude – and the level of the group discussions, as well as the quality of the material and sources they contributed to the discussions, were much higher than those I was used to. It was a very pleasant experience.”
As to the students, they consider that what they learned during the course was beneficial. “I hope to put this new knowledge to use in my work and my scientific questions,” says Rita Fior. “I hope to be able to guide my research so as to take more into account the gaps that still exist in medical practice, making my research more translational,” reflects Daniel Nunes. And Ana Catarina Certal is certain that her dialogue with physicians will become much more fruitful. “I am already applying what I learned every time I speak with clinicians in my daily work,” she says. “My perception of priorities, my understanding of medical problems is now very different and I am much better equipped to follow the clinical discourse. One of the things I think most important was for us to realise that there are many clinical limitations that have no reason to be, because science has already found solutions for them.”
The only concern all students mentioned was the workload required by the course, which makes it difficult to conciliate it with their professional work. This is why the organisers are already thinking of modifying the course’s format by setting its duration to 18 months instead of ten. And maybe even including a practical component, performed on human simulators, which, if implemented, will take place at the FMCB-UAlg.
Says Ana Catarina Certal: “the biggest challenge was certainly the lack of time to truly consolidate concepts. It takes a lot of willpower (and a high-quality course) to be able to manage this and our full-time professional activity.” But despite that, she adds, “the fact of being surprised by new knowledge every day, the fact that everything was so cool and interesting, enabled me to always find the energy to study, even when I was exhausted!”
By Ana Gerschenfeld, Health & Science Writer of the Champalimaud Foundation.