Year 3-4 taskforce report
March 24, 2010
Faculty Members: Jennifer Cox, Shelly Holmstrom, Laura Haubner, Drew Keister (LVHN), Barbara Lubrano, Dawn Schocken, Jamie Shutter, Frazier Stevenson, Kira Zwygert
Student Members: Alicia Billington, John Emerson, Byron Moran, Nishit Patel
OEA staff: Tanisha Battle, Patti Parisian
Process
1. Reviewed history of current requirements2. Reviewed national, grad questionnaire, and course
data3. Received written or verbal input from required
clerkship directors4. Rec’d written and verbal input from MS3 and MS4
students5. Rec’d Written or verbal input from chairs (IM,
Psych, Peds, Anat-Path, Pharm/Phys, Mol Bio, Neurology)
6. Formed recommendations to Curriculum Committee
LCME standards
ED-13. Clinical instruction must cover all organ systems, and include the important aspects of preventive, acute, chronic, continuing, rehabilitative, and end-of-life care.
ED-14. Clinical experience in primary care must be included as part of the curriculum.
ED-15. The curriculum should include clinical experiences in family medicine, internal medicine, obstetrics and gynecology, pediatrics, psychiatry, and surgery. – Schools that do not require clinical experience in one or
another of these disciplines must ensure that their students possess the knowledge and clinical abilities to enter any field of graduate medical education.
ED-16. Students' clinical experiences must utilize both outpatient and inpatient settings.
Health Professions Education: A Bridge to Quality (2003)
• Students must learn to provide patient-centered care in inter-disciplinary teams.
• Refocus the clinical experiences• Patient centered• Student centered• Not department-centered!
• Use multiple venues• Emergently ill• Acutely ill• Chronically ill• Healthy
The AAMC Project on the Clinical Education of Medical Students
Improve integration of learning exercises related to contemporary issues in medicine– End of life care– Breaking bad news– Nutrition, health promotion– Ethics and professionalism– Genetics
• Competency based curriculum and assessment
• Integration of basic and clinical science
The Clinical Education of Medical Students: Report on the Millennium Conferences I and II (2003)
Improve coherence in the design of year 4• Courses should have objectives and thoughtfully produced
curricula, not just “tag along”• Innovative advanced experiences need to be created that:
– build on the scientific and clinical foundations begun in the earlier years of medical school;
– integrate interdisciplinary topics, especially orphan topics; and
– provide guided elective experiences of particular value for the individual student based on his/her future goals and career plans.
• Quality faculty guidance is key, so students do not take multiple, and essentially repetitive, “audition electives” in the same discipline.
Macy Foundation Report 2009
Adopt pedagogy to:– Underscore relevance of basic science to
clinical situations– Emphasize inter-professional team-
based care– Use community and hospital based
experiences– Use simulation– Use E-learning to model lifelong learning
Macy Foundation Report 2009
Ensure student familiarity with:– Health care quality and safety– Public health and prevention– Non-biologic determinants of illness– Health implications of cultural diversity– Organization of health care system– Governmental health policy
Carnegie Foundation Report 2009
• Build learner identity formation– Professionalism, values, community, role
models, mentoring
• Enhance individualization of learning– Build on learners’ prior experience and
expertise– Increase curricular/educational flexibility
Rationales for Change, 2003
Ongoing challengesUnplanned redundancy between clerkshipsSense that students were unable to care for undifferentiated patientsPoor communication between departments/ clerkshipsLack of mid-clerkship feedback for studentsAssessment of students only involved written examinations; lack of assessment of clinical skills in many clerkships
USF 3rd/4th Year Curriculum Prior to 2003-4 Changes
Third Year: Six 8-week rotations
Internal Medicine, Psychiatry, Surgery, Family Medicine, Pediatrics, OB/Gyn
Fourth Year: Two required rotations
Neurology (4 weeks)Critical Care (8 weeks)
IOM Vision for Education
“All health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics.”
IOM’s Committee on Health Professions Education
2004 Curriculum Changes
Problem How addressed
Undifferentiated patients
Require ER clerkship; Acute care in Primary Care clerkship
Unplanned redundancy
Content discussed and divided up prior to construction of clerkships
Lack of communication
Interdisciplinary course structure should improve communication
Mid-clerkship feedback
All clerkships provide and document feedback
Overreliance on objective tests
All clerkships utilize multiple forms of assessment (CPX, e.g.) as appropriate
Year 3—Revised 2007
Year 4: Original Plan
Year 4: Revised 2007
Outcomes:Graduation Questionnaire (GQ)-- Overall Clerkship Quality
Clerkship Rating 2005 2009 All Schools
Emergency Medicine 2.9 3.2 3.3
Family Medicine 3.2 3.4 3.2
Internal Medicine 3.6 3.5 3.5
OB/GYN 3.1 3.1 3.0
Neurology 2.2 3.1 3.0
Pediatrics 3.4 3.3 3.3
Psychiatry 3.3 3.4 3.2
Surgery 2.9 3.5 3.2
GQ: % “inadequate” education
2005 2009 All Schools
Long term health care 22 14 20
Continuity of Care 16 9 18MD-MD communication skills 22 14 15
Complement. Alt Medicine 20 47 34
Sexuality 15 26 22
Domestic Violence 20 11 20
Law and medicine 23 57 48
Rehabilitative Medicine 62 28 37
Public health 42 31 30
Occupational med 43 41 42
Environmental Health 55 39 40
Healthcare disparities 22 12 16
Health Policy 66 45 42
GQ: Year 4 (1-5 scale, 5 best)
2005 2009 All Schools
Adequate elective time 3.6 4 3.8Yr 4 helpful in preparing for residency 3.8 4.1 4.0
Additional requirements should be added 2.2 2.1 2.2
Rec'd appropriate guidance in elective selection 4.2 4.1 3.4
General results from feedback
Positives: year 3
• The integrated clerkships are, in general, delivering excellent learning experiences
• Consistent clerkship student evals in 3.7-3.9 range on GQ
• USMLE 2CK scores steady (overall and disciplines), whether or not shelf exams are given in discipline
General results from feedbackChallenges: year 3
• There is variable integration within these “integrated” clerkships
• Clerkships with multiple USMLE shelf exams, esp. in close proximity, reduce student clinical time and diminish clinical experience.
• Discipline-based shelf exams do not reflect interdisciplinary clerkships and may detract from clerkship integration
• Travel logistics are sometimes difficult to match with interdepartmental clerkships
2004 Changes: Outcomes
Problem How addressed Outcome
Undifferentiated patients
Require ER clerkship; Acute care in Primary Care clerkship
Unplanned redundancy
Content discussed and divided up prior to construction of clerkships
Lack of communication
Interdisciplinary course structure should improve communication
variable
Mid-clerkship feedback
All clerkships provide and document feedback
better
Overreliance on objective tests
All clerkships utilize multiple forms of assessment (CPX, e.g.) as appropriate
better
Themes for improvement 2010: year 3
How can we:• Enhance interdisciplinary learning?• Improve assessment?• Improve clerkship logistical barriers?• Return to mechanistic “basic” science?• Improve curriculum for LCME focus
areas:– CAM– Law and medicine– Public health– Occupational, environmental health– Public health policy
Recommendations: Assessment
• Students assessment should focus on material actually covered in the clerkship
• Make use of NBME custom exams when available
• Assessment should not detract from the clinical experience (exam fatigue)• CPX and other CACL exams should reflect actual clerkship objectives and, if possible, simulate USMLE 2CS conditions and grading.
Recommendations: Basic Science
1. An organized plan to reinforce pathophysiology in years 3-4 should be developed
2. Current anatomy elective is highly popular and is a model
3. Basic science should be tailored to student needs and career goals, esp in year 4
4. Clinical faculty need development to ensure mechanistic teaching is integrated into clinical education
Recommendations: LCME focus topics
1. Work with the Doctoring faculty to develop year 3 objectives and specific pedagogy to deliver these
2. Models:a. Within clerkships? Has been difficult to
accomplishb. Create a separate year 3 Doctoring
longitudinal parallel curriculum?c. Current model of assigning topics as
lectures to Intro to Clerkships not effective
Feedback: Year 4 Requirements
• Current requirements well run but variably received, often not perceived relevant to career needs
– Critical Care, Skin/Bones, Interdisc. Oncology
• Year 4 requirements are challenging to administer—interviews, externships, specialty interest, USMLE exams, etc.
Feedback, year 4 AI (acting internship) selectives
• Required acting internships are of variable intensity and are not evaluated centrally
• Goal was for an intense patient care experience for all students—not always delivered
• Assessment of these courses has not occurred
Year 4 AAMC/CurrMIT data
• Avg months of year 4 requirements: 2.0
• Avg months of year 4 selectives: 0.8
• USF months yr 4 requirements: 3• USF months yr 4 selectives: 1
Themes for USF in 2010: year 4
• Are current requirements appropriate?
• How can we build mentored learner individualization within an appropriate core curriculum?
Principles of a better year 4
Recommended Goals for Students• Individuation of learning• Mentorship by expert faculty who are oriented
appropriately• All students select electives with clear purpose:
• to prepare for specific residency programs• to cap longitudinal experience (Scholarly
Concentrations, LVHN SELECT program)• to correct gaps in knowledge or skill• to broaden experience in a clearly targeted
way
Possible Year 4 Tracks
• Students all do a “mini major”• 3-4 months of targeted requirements
– All include a clinically intense AI– All include targeted basic science– Developed by each department based on entry
skills needed for interns in their discipline
• Acknowledged in MSPE (Deans Letter)
Possible Flavors:1. Career-directed (i.e. ENT, Psychiatry)2. Scholarly Concentration capstone
Suggested Plan for 2011-12
• Taskforce to develop plan for selective tracks, working with departments
• OEA develops plans for robust evaluation of all year 4 courses, esp. AIs
• AIs all need to meet time and intensity guidelines
• Current year 4 required courses to be re-evaluated in context of time requirements for new curricular tracks
Specific year 4 feedback: Interdisciplinary Oncology
• Well run, with selective options for students
• Several well done core activities, i.e. Giving Bad News
• Difficult to administer, limited sites, difficult to tailor to student desires for all 120 students
• Oncology is required by no other medical schools
• Current course directors are supportive of elective status for course
Interdisciplinary Oncology
Recommendation: (for June, 2010)
• Convert to elective status
• Offer enough sections in 2010-11 to accommodate all students who want it
• Add 2 week Oncology selective option for Med-Peds in 2011-12
• Incorporate interactive Bad News session into Med-Peds seminar series
Interdisciplinary Oncology
Rationale for recommendations
• Well done course, but not truly core to all students
• Very challenging administratively; highly intricate scheduling and tailoring to student needs would be more feasible as elective course
• No other school has similar specialty requirements for all students