Year 3- 4 Taskforce Report

1. Year 3- 4 Taskforce Report March 24, 2010 Office of Educational Affairs USF College of Medicine

2. Year 3-4 Taskforce Report • Faculty Members: • Jennifer Cox, Shelly Holmstrom, Laura Haubner, Drew Keister (LVHN), Barbara Lubrano, Dawn Schocken, Jamie Shutter, Frazier Stevenson, KiraZwygert • Student Members: • Alicia Billington, John Emerson, Byron Moran, Nishit Patel • OEA staff: • Tanisha Battle, Patti Parisian

3. 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

4. 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.

5. 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

6. 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

7. 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.

8. 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

9. 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

10. 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

11. 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

12. 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)

13. 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

14. 2004 Curriculum Changes

15. Year 3: Original Plan

16. Year 3: Revised 2007

17. Year 4: Original Plan

18. Year 4: Revised 2007

19. Outcomes: Graduation Questionnaire (GQ)-Overall Clerkship Quality

20. GQ: % “inadequate” education

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

22. 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

23. 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

24. 2004 Changes: Outcomes

25. 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

26. 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.

27. 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

28. 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

29. 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.

30. 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

31. Year 4 AAMC/CurrMIT data • Avgeragemonths of year 4 requirements: 2.0 • Avgeragemonths of year 4 selectives: 0.8 • USF months year 4 requirements: 3 • USF months year 4 selectives: 1

32. Themes for USF in 2010: Year 4 • Are current requirements appropriate? • How can we build mentored learner individualization within an appropriate core curriculum?

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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