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