Transcript Year 3-4 taskforce report - University of South Florida

Year 3- 4
Taskforce Report
March 24, 2010
Office of Educational Affairs
USF 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
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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 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
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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
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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:
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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
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 evidencebased practice, quality
improvement
approaches, and
informatics.”
IOM’s Committee on Health
Professions Education
2004 Curriculum Changes
Problem
Undifferentiated
patients
How addressed
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
Long term health care
Continuity of Care
MD-MD com m unication s kills
Com plem ent. Alt Medicine
Sexuality
Dom es tic Violence
Law and m edicine
Rehabilitative Medicine
Public health
Occupational m ed
Environm ental Health
Healthcare dis parities
Health Policy
2005
2009
All Schools
22
16
22
20
15
20
23
62
42
43
55
22
66
14
9
14
47
26
11
57
28
31
41
39
12
45
20
18
15
34
22
20
48
37
30
42
40
16
42
GQ: Year 4 (1-5 scale, 5 best)
2005
2009
All
Schools
3.6
4
3.8
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
Adequate elective time
Yr 4 helpful in preparing for
residency
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: Outcomes
Problem
How addressed
Outcome
Undifferentiated
patients
Require ER clerkship; Acute care in
Primary Care clerkship
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Unplanned
redundancy
Content discussed and divided up prior to
construction of clerkships
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Lack of
communication
Interdisciplinary course structure should
improve communication
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
variable
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:
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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:
 Avgerage months of year 4 selectives:
2.0
0.8
 USF months year 4 requirements:
 USF months year 4 selectives:
3
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:
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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 reevaluated 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 MedPeds 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