Year 3- 4 Taskforce Report
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Transcript of Year 3- 4 Taskforce Report
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