Introduction to the Mechanisms of Disease Module

Welcome to the Mechanisms of Disease Module. This course is co-taught by the Departments of Medicine, Pathology and Pharmacology, and in many ways represents your transition from basic science to the clinical practice of medicine. Our overall goal is to convey to you an understanding of how normal human biology goes awry in disease, and how biological insight can lead to pharmacological and/or surgical intervention.

The course is structured according to individual organ systems, and each organ system block is co-taught by the three departments. Thus, you will have a cardiovascular block, a gastrointestinal block, etc. Within the block each department will teach those diseases and/or aspects that we each know best; every possible attempt will be made to avoid redundancy except to the extent that we may take the opportunity to reinforce important and overlapping issues. For example, where the medicine department might teach the pathophysiology of heart failure, the pathology department may cover the histologic aspects of the same disease, and pharmacology department will focus on drug interventions. To the fullest extent possible, the Physician, Patient and Society Course, as well as the Physical Diagnosis course, will make every effort to coordinate their schedules to align with the organ blocks as well, though this is still a work in progress.

Each contributing department organizes their teaching slightly differently. In all cases the core experience of the course is the lectures. However, the pathophysiology lectures are typically followed by small group meetings (designated “seminars”) which emphasize the clinical manifestations of the diseases under study, and the pathology lectures will be accompanied, in most instances, by case-based laboratory-style exercises (designated “conferences”). The pharmacology unit is mostly taught in a hybrid format of a large group lecture that is more fluid than a typical lecture, with questions during the presentation encouraged. Attendance at both the lectures and all of the small group meetings is both expected and required: the contents of the different formats will be related, but non-identical, and material will be covered in the small group formats that is not covered in the lectures. The small group sessions, in order to be successful, require the full participation of the entire group: both you and your colleagues suffer if you do not come prepared to share your thoughts, questions and concerns. Please be sure to go only to your assigned sections.

We would like to emphasize that in this course one of our collective goals is to help you develop your capacity not merely to know, but also to think about the processes and management of diseases. These thought processes are not easily learned from lectures alone; whereas the lectures provide you with a core of information, the small groups help you to understand how to integrate and apply that information. Past students who have elected to bypass their lectures and especially their small group sessions have frequently admitted that they were less prepared for exams, and (more importantly!) for the wards as a result.

Readings will vary somewhat according to the needs of each organ block. In general, most readings for pathophysiology lectures will come from Harrison’s Principles of Internal Medicine, and we expect that you will purchase or have access to this text (the third-year medical clerkship will also require it). For pathology, the readings will be from Robbin’s Pathologic Basis of Disease. For pharmacology, the suggested text is Basic and Clinical Pharmacology, Ninth Edition. Other readings may be provided by the individual section directors (and placed in your syllabus and/or online); these may either be supplemental or required, and we will make every effort to make clear which are the required readings.

Be aware that the material in the course is copious, and that you need to both learn and understand it. It will be much easier for you to keep up than to attempt to cram at the last minute!

A word about exams. For the purposes of exams, we will be grouping the organ systems in pairs or groups. So for example, cardiology and pulmonary will be tested together, GI and renal, etc. (For scheduling reasons, we will actually test cardiology and pulmonary separately, in two “half-exams”, but the grade will not be final until the two are combined.) Each exam will test pharmacology, pathology and pathophysiology together—sometimes multiple questions from each discipline will be asked in response to a single clinical scenario. Indeed, while some straightforward fact questions will be asked, most questions will be based on clinical scenarios. The material on the exam may come from your lectures, your small group sessions, or your readings.

Many of you are likely to find the exams—or at least the first exam—challenging. To that we say—great! Like the course itself, our exams will be one of your first opportunities to integrate clinical knowledge with clinical judgment in a clinical situation. It’s exactly like learning a language, and learning a language is always a bit of a stretch at first. Also, we will try to ask questions that require not just knowledge, but thought and insight in order to answer correctly. Even if you have studied thoroughly, you may very well have the feeling that you are guessing as you try to answer the questions. This feeling is not all that different than the one clinicians sometimes have when they need to make a clinical decision that is less than clear cut. You will also notice almost immediately that the exams are rather long. The typical exam will have somewhere between 100 and 150 questions, and you will have four hours to complete it. The length of the exam is neither an accident nor an act of sadism on the part of the course directors—it’s actually done for your benefit. First, the large number of questions permits us to come as close as reasonably possible to an accurate assessment of your knowledge and reasoning, as we reduce the possibility of accidentally testing you only on what you do—or do not—know (i.e., we try to correct sampling error). Also, both the format and the length of the exams are intended to begin to rehearse you in the format of the national boards, so when it’s time to take the boards, you’ll be ready. In fact, the time allotted is probably more than you will need, and more than you will be permitted on the boards. We will not penalize you for using the whole time, but you should realize that if you are using more than 3 hours to complete the exam you may need to improve your efficiency by the time the boards come around.

From your point of view as students, the real issue should not be whether the exams are hard or long, but whether they are fair. We make every effort to grade the exams fairly. Here’s how we do it: after the exam is completed by the students, it undergoes a rough scoring. We use that first scoring in order to evaluate the questions. If we find a question that many people got wrong, we will send it back to the authors to make sure we got the answer right, and to the unit leader, to make sure that the answer we think is right is the one that was taught in lecture. If either of these is not the case, we throw out the question. Also, we review the statistical performance of the question against the performance of the exam. If a question that many people got wrong performs poorly (i.e., if it doesn’t seem to correlate with overall performance on the test), we presume there’s something wrong with the question and throw it out. Since we do not permit you to ask questions during the exam, we do ask that you write down any questions or comments you may have about specific items; we will review these closely as well, and again, consider deleting any question that is genuinely defective. Then, we rescore the test, without the “bad” questions. We then set two possible passing scores. The first is a straight 65%. The second is a curved score—passing at or above two standard deviations above the mean. For the final passing grade we will take whichever of these is more favorable to the class (i.e., whichever is lower). This process takes a while, unfortunately, though we try hard to get your scores back within one week.

In order to advance to the third year, it is necessary to pass all of your courses, including ours. For the purpose of grading, we consider each organ block exam as testing a separate course, so you have to pass all of them. Since each exam/course in the Mechanisms of Disease Module is entirely pass/fail, the overwhelming majority of you will pass on the first try. What if you fail? All is not lost. You will be given the opportunity to take a remediation exam later in the term; if you pass this exam your failing grade will be expunged. (Except in very special circumstances, you must take your make-up on the make-up date scheduled by the Dean’s office.) If you do not pass this test, you will have additional opportunities to remediate; however, the failing grade will now be retained on your transcript, with an indication that the exam was subsequently remediated. Our goal, in the end, is only to make sure that you have adequate command of the material to move on to the third year. One exception to the above rules may pertain: if you have had problems with other modules during the course of the year, you may need to speak with the Dean about your eligibility for make-up. Also, please note that we give each test at a single sitting. We permit you to miss an exam only for an extraordinary reason, and then only with the Dean’s prior permission.

In the past, students have always wondered how our courses affect eligibility for AOA. Here’s how it works: we provide the AOA committee, when requested, a list of the students who performed at the top of the class for each of the exams taken (the AOA committee determines the requested cutoff). That’s our entire participation. Since the courses (i.e., different modules) are otherwise Pass/Fail, we will provide to the Registrar only your pass or fail grade. Except for our report to AOA, your actual exam scores will not be reported to the Registrar or anyone else, and will not be saved by us past the end of the semester (we maintain them until then in case any issues come up).

For MD/PhD students: since you must receive letter grades that count towards your eligibility for your program, you are graded differently from your classmates. Based on the whole-class performance, a curve will be generated for letter grades and your exam will be graded according to its place in the curve. If you fail, and take a retest, even if you pass both your passing grade and your original grade will be forwarded to the MD/PhD program director. Please speak to your MD/PhD program director if you want to know the significance of these grades.

This year, we will be testing out a new learning tool that we hope you will find useful. For at least the cardiac and pulmonary units, we will be offering you an on-line diagnostic self-assessment program (Our goal is to provide this program for all of the units, and we will do our best to do so). We are requesting that all students participate. You will have the opportunity to answer a series of questions (roughly 50) in a time-limited format, and will then be given an assessment of your apparent areas of strength and/or weakness. You will then be able to review the questions again, with explanations. It is important that we emphasize that the questions on the self-assessment do not specifically reflect the exam, and are not a surrogate for studying (even if you do well!). Moreover, this project is very much a work in progress; bear with us as we try to make it work. We will very much want your feedback as we go forward.

Don’t forget: more than studying for exams, you’re finally studying to be a doctor. That’s your real job now; and if you do it well, the exams will come out fine.

Good luck, and HAVE FUN!!!!

PATHOPHYSIOLOGIC BASIS OF MEDICINE CIRCULATORY SYSTEM SEMINARS
November 27 - December 15, 2006

Each of the six lectures to be delivered in the two weeks devoted to Cardiology is associated with a case history contained in this syllabus. The lectures will be given to the entire class on Monday through Thursday, November 28 - December 1, and Monday and Wednesday, December 5 and 7. The corresponding seminars will be held on Tuesday though Friday, November 29 - December 2, and Wednesday and Friday, December 7 and 9 from 12:30pm to 2pm. The class has been divided into twelve groups, corresponding to the Host Defense groups (A1,A2,B1...F2). Each group will meet with the same Faculty member at each seminar. The case associated with a lecture will be given at the following seminar. Office hours, an oppotunity to ask Dr. Tunick questions prior to the exam, will be held on Thursday, December 15 at 1-2pm.

The seminars associated with each lecture are designed to enhance your understanding of the topic by providing an opportunity to discuss an exemplary case in depth with an expert in cardiovascular medicine. It is the expectation of the Department of Medicine that you will have prepared for the seminar by reading sufficient materials from those suggested with each case so that you can engage in lively discussion with your colleagues and Section Leader. To help you prepare for the seminar, we have written a series of questions to guide your preparation. You need not read voluminously. Many of the questions can be answered with knowledge gained from the lecture and do not have a single correct answer. It is intended that you prepare enough to make the seminar a discussion of pathophysiology and medicine rather than merely another lecture and we encourage you to study in groups. We think you will find the cases interesting and enjoyable and we look forward to helping you begin the transition to the clinical years.

If you have any questions, please call the Cardiology office at 263-6554 and speak to Ms. Grace Ramirez-Maldonado. The Medicine Section Director is Dr. Paul A. Tunick, Paul.Tunick@med.nyu.edu, Tisch Echo Lab, HW 229.