Year 3- 4 Taskforce Report

March 24, 2010Office of Educational AffairsUSF College of Medicine

Year 3-4 Taskforce Report

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

Reviewed history of current requirements Reviewed national graduate questionnaire, and course data Received written or verbal input from required clerkship

directors Received written and verbal input from MSIII and MSIV

students Received written or verbal input from chairs (Internal

Medicine, Psychiatry, Pediatrics, Anatomy-Pathology, Pharmacology/Physiology, Molecular Biology, and Neurology)

Formed recommendations to Curriculum Committee

LCME standardsED-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 challenges: Unplanned redundancy between clerkships Sense that students were unable to care for

undifferentiated patients Poor communication between departments/

clerkships Lack of mid-clerkship feedback for students Assessment of students only involved written

examinations; lack of assessment of clinical skills in many clerkships

USF 3rd/4th Year Curriculum Prior to 2003-04

ChangesThird Year: Six 8-week rotations

Internal Medicine, Psychiatry, Surgery, Family Medicine, Pediatrics, OB/Gyn

Fourth Year: Two required rotationsNeurology (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 ChangesProblem 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: Original Plan

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 SchoolsLong term health care 22 14 20Continuity of Care 16 9 18MD-MD communication skills 22 14 15Complement. Alt Medicine 20 47 34Sexuality 15 26 22Domestic Violence 20 11 20Law and medicine 23 57 48Rehabilitative Medicine 62 28 37Public health 42 31 30Occupational med 43 41 42Environmental Health 55 39 40Healthcare disparities 22 12 16Health Policy 66 45 42

GQ: Year 4 (1-5 scale, 5 best)

2005 2009All

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 feedback

Challenges: Year 3 There is variable integration within these

“integrated” clerkships Clerkships with multiple USMLE shelf exams,

especially 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: OutcomesProblem 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 in 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

An organized plan to reinforce pathophysiology in Years 3-4 should be developed

Current anatomy elective is highly popular and is a model

Basic science should be tailored to student needs and career goals, especially in Year 4

Clinical faculty need development to ensure mechanistic teaching is integrated into clinical education

Recommendations: LCME focus topics

Work with the Doctoring faculty to develop Year 3 objectives and specific pedagogy to deliver these objectives

Models: Within clerkships? Has been difficult to accomplish Create a separate Year 3 Doctoring longitudinal

parallel curriculum? Current model of assigning topics as lectures to

Introduction to Clerkships not effective

Feedback: Year 4 Requirements

Current requirements well run but variably received, often not perceived relevant to career needs Critical Care Medicine, Skin & Bones and

Interdisciplinary Oncology Year 4 requirements are challenging to administer

—interviews, externships, specialty interest, USMLE exams, etc.

Feedback: Year 4 AI (Acting/SUB 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

Avgerage months of year 4 requirements: 2.0 Avgerage months of year 4 selectives: 0.8

USF months year 4 requirements: 3 USF months year 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:

Career-directed (i.e. ENT, Psychiatry) Scholarly Concentration capstone

Suggested Plan for 2011-12

Taskforce to develop plan for selective tracks, working with departments

Office of Educational Affairs develops plans for robust evaluation of all Year 4 courses, especially Acting Internships (AI’s)

AI’s 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: (effective 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