Implementation of an Integrated Pharmacology Curriculum in a Flipped, Small-Group, Case-Based, Pre-Clerkship Medical Curriculum Improved Student Performance.

University of Virginia School of Medicine.

Rush Medical College

Curriculum Management and Governance Structure Case Western Reserve University (CWRU) School of Medicine (SOM) has two collaborative and innovative educational tracks: University track and College track. ♦ University-based program (University track) was established in 1843 and Cleveland Clinic-based Cleveland Clinic Lerner College of Medicine (College track) was established in 2002. ♦ University track implemented a major curriculum revision in 2006, focusing on development of lifelong learners and incorporating themes of scholarship, clinical mastery, leadership, and civic professionalism. A dedicated four-month research requirement culminating in an MD thesis was incorporated into the four-year curriculum. A hybrid of active, student-centered PBL groups and teacher-centered large and medium group sessions form the backbone of learning venues. ♦ Five-year competency-based College track is designed to train graduates with excellent clinical skills, expertise in research, and a passion for scientific inquiry. Students complete a master's level thesis and graduate with an MD degree with Special Qualification in Biomedical Research. ♦ While course format, assessment approaches, and curricular topics beyond core content of University and College tracks differ, clinical rotations for both tracks were designed collaboratively and implemented jointly. Curriculum Management and Governance Structure ♦ SOM faculty Committee on Medical Education evaluates, reviews, and makes recommendations concerning overall goals and policies of medical education programs for University and College tracks. ♦ Curriculum Monitoring Council (University track) and Curriculum Steering Council (College track) have responsibility for (1) defining and allocating educational objectives, (2) approving teaching methods and instructional formats, (3) monitoring coordination and integration of curricular content, (4) selecting assessment methods to document student performance, (5) monitoring quality of teaching, (6) overseeing curricular and program outcomes. ♦ Basic science leadership groups for each track facilitate sharing of best educational practices among course leaders, design and implement programs to ensure basic science mastery, and facilitate smooth implementation of methods of student assessment. ♦ Joint Clinical Oversight Group (JCOG) monitors and evaluates clinical experiences at affiliated teaching hospitals of CWRU SOM. JCOG oversees curriculum design, program evaluation, educational quality, student assessment, and compliance with LCME and institutional requirements for the clinical curriculum. ♦ The Dean is chief academic officer responsible for both education tracks. ♦ The Dean delegates day-to-day responsibility for both tracks to the Vice Dean for Education and Academic Affairs. The Executive Dean for the College track reports to the Vice Dean for Education and Academic Affairs. The Executive Dean for the College track is also accountable to the Chief of Staff of the Cleveland Clinic with regard to Cleveland Clinic resources and support for the College track. Curriculum Support Offices ♦ Offices of Curricular Affairs for each track include an associate dean for curricular affairs, MD and PhD educational leaders, and administrative staff who provide support for their respective educational programs. These offices support curriculum development and implementation, ongoing quality improvement, student assessment, and program evaluation. They work collaboratively with respective offices of information technology to develop, improve, and maintain extensive electronic curricula, student assessment resources, and program evaluation methodologies. ♦ Each track has a director of undergraduate clinical education, support staff, and physician and nonphysician educators to support components of clinical curriculum for each track and collaborate on the joint clinical program. ♦ Both tracks have robust faculty development programs to support teaching and implemented initiatives to encourage educational scholarship. Financial Management of Educational Programs ♦ When the Dean committed to revision of the University track's curriculum in 2004, a new curriculum budget was established to support University track curriculum development, implementation, ongoing program maintenance, and improvement. ♦ CWRU School of Medicine has affiliation agreements with its major teaching hospitals. As a part of affiliation agreements with three teaching hospitals, faculty are expected to contribute 100 hours annually to medical school teaching activities. University track established a faculty-teaching database that provides ongoing reports about faculty teaching effort to department chairs. ♦ All College track faculty are salaried employees of a central Cleveland Clinic budget, allowing Department Chairs to allocate release time for teaching and service activities. Valuing Teaching ♦ Qualifications for faculty appointments include “a high level of teaching effectiveness,” with documentation of quality and quantity of teaching activities within teaching portfolios. ♦ Nontenure track faculty appointments are based on an area of excellence: teaching, clinical service, or research. ♦ In addition to schoolwide and departmental teaching awards, faculty are invited annually to submit applications for Scholarship in Teaching awards. Applications are peer-reviewed, and each year 20–30 faculty are recognized by the Dean at the Annual Education Retreat. ♦ Cleveland Clinic faculty are recognized for teaching as part of annual performance reviews, which are used to determine promotion and salary decisions. College track maintains a database of faculty leadership and teaching activities for all components of the curriculum; summary information is provided to faculty members and chairs as part of the reviews. Curriculum Renewal/Development Process University Track Curriculum Development ♦ Major curriculum transformation, Western Reserve2 (WR2), launched July 2006. ♦ Key Objectives for Curriculum Development Process Medical education will be experiential and emphasize skills for scholarship, critical thinking, and lifelong learning. Educational methods will stimulate an active interchange of ideas among students and faculty. Students will be immersed in a graduate school educational environment with flexibility and high expectations for independent study and self-directed learning. Learning will be fostered by weaving scientific foundations of medicine and health with clinical experiences throughout the curriculum. These scientific foundations include basic science, clinical science, population-based science, and social and behavioral sciences. Every student will have an in-depth mentored experience in research and scholarship. Recognizing obligations of physicians to society, central themes of public health, civic professionalism, and leadership will be longitudinally woven throughout the curriculum. Systems issues of patient safety, quality medical care, and health care delivery will be emphasized and integrated throughout the curriculum. Students will acquire a core set of competencies in knowledge, mastery of clinical skills, and attitudes that are prerequisite to graduate medical education. Learning Outcomes/Competencies ♦ WR2 Curriculum is based on nine core competencies with well-defined achievement levels for each that serve as educational objectives (medical knowledge, patient care, communication skills, professionalism, lifelong learning–personal development, research and scholarship, civic professionalism–health advocacy–leadership, problem-based learning and improvement, systems-based practice). Components of the Curriculum Development Process ♦ Preclerkship basic science portion of WR2 curriculum is 20 months in length with six systems-based course blocks that integrate normal and abnormal content throughout (Chart 1).CHART 1: University Track Basic Science Curriculum♦ Weekly in-class basic science teaching is limited to 16 hours a week, paired with high expectations for self-directed learning outside the classroom. ♦ A wide range of dual-degree opportunities are available for students to pursue. ♦ One week of each block is dedicated to experiences in the clinical setting. During Clinical Immersion Weeks, students have opportunities to see how basic science concepts learned in the classroom translate to and impact on patient care. ♦ First block of the curriculum, five weeks in length, is “Becoming a Doctor.” It introduces students to medical school education at the macrolevel with a focus on social and behavioral context of health and disease. ♦ Themes from the first block and additional content in Health Policy, Bioethics, Doctor–Patient relationship, and sociobehavioral medicine are continued in weekly 2-hour seminars. ♦ Case Inquiry Groups (IQ groups), based on McMaster's revised PBL format, serve as a core teaching method for six of the formal teaching hours (three 2-hour sessions per week). ♦ Anatomy, histopathology, and radiology are integrated into a longitudinal “Structure” block. ♦ Learning from multiple sources is emphasized (including a rich array of web-based resources); previous extensive written syllabus was eliminated. ♦ Weekly Foundations of Clinical Medicine Seminars (Doctoring Course) integrates with IQ cases when appropriate. ♦ Sixteen-week mentored research experience with MD thesis is required for all students. Components of the Assessment Process ♦ Goal of deep learning, synthesis, and information transfer expected in WR2 requires that assessment strategies align with curriculum objectives. ♦ CWRU SOM's longstanding pass-fail, criterion-referenced assessment system in the preclerkship curriculum was maintained. ♦ Weekly formative assessments include 20–30 multiple choice questions and 2 synthesis essay questions primarily based on content of the week; these are open book, and group work is encouraged. ♦ End of block basic science summative assessment is a 4- to 5-hour synthesis essay examination; each essay is vignette-based and incorporates multiple concepts and transfer of knowledge to new contexts. ♦ There is an end of block summative anatomy and histopathology examination with practical, short answer, and multiple choice portions. ♦ At the end of each block, students take a formative multiple choice test developed through the NBME customized assessment services. Each test has questions specific to current block of study as well as questions assessing material from previous blocks. This enables students to monitor their progress in studying for USMLE Step 1. ♦ At midpoint of each block, students engage in a personal quality improvement exercise by defining an area for improvement and developing a Professional Learning Plan of action. ♦ Students complete an end of year reflective portfolio to assess progress in nine core competencies. ♦ IQ group performance within areas of (1) contributions to group content and process, (2) skills of critical appraisal, and (3) professional behaviors are evaluated by IQ group faculty facilitators; students engage in peer assessment as well. ♦ Performance in preclerkship clinical curriculum is integrated into the overall assessment process and incorporates formative OSCEs, preceptor feedback, and student reflections. New Topics in the Curriculum Since 2000 ♦ Quality improvement and patient safety, longitudinal theme across four years ♦ Leadership and teamwork, evolving as longitudinal theme across four years ♦ Population health ♦ Increased emphasis on longitudinal development of communication skills, both preclerkship and clerkship components with opportunities for peer teaching in fourth year ♦ Health policy and health care economics Changes in Pedagogy ♦ Student-centered problem-based learning groups (Case Inquiry Groups) ♦ No formal syllabus; rich electronic curriculum guides students to multiple sources for study ♦ Increased emphasis on self-directed learning ♦ Decrease in formal classroom time ♦ Selective videotaping of educational activities; 16 hours of core classroom time not videotaped ♦ Weekly formative assessment and integrative summative assessment ♦ Summative essay examinations focus on synthesis and integration of concepts ♦ Portfolios used to assess nine core competencies ♦ Increased emphasis on clinical context of basic science concepts through IQ cases and clinical immersion activities ♦ Developmental introduction of clinical reasoning skills and case presentations through IQ groups ♦ Integration and extension of basic science curriculum into core clinical clerkships Program Evaluation ♦ Students complete online confidential surveys assessing their perceptions of course faculty, content and instructional methods, and learning resources. ♦ Curriculum committees, individual faculty instructors and course leaders, education leaders, and department chairs receive reports following each course or rotation. ♦ Curriculum effectiveness is assessed by tracking USMLE scores, residency program directors' perceptions, and graduation questionnaire responses. Scores on the Cognitive Behavior Survey, Attitudes toward Social Issues in Medicine, Learning Climate Inventory, Research and Scholarship Checklist, and Case Lifelong Learning Scale are also tracked. College Track Curriculum Development Components of Curriculum Development Process ♦ Affiliation agreement between Cleveland Clinic and CWRU in 2002 ensuring compliance with LCME strategies and appropriate oversight by CWRU. ♦ Mission to train physician investigators who will advance biomedical research and medical practice. ♦ Series of faculty retreats Identified outcomes for College track graduates: independent thinkers, self-directed learners, team players, strong clinical skills, broad-based research skills, scientific inquisitiveness. Developed curricular principles that guided curriculum development: provide a graduate school environment where students are responsible for their learning and seminars focus on application of knowledge; use active learning methods; research is major curriculum thread culminating in master's level thesis; students guided in personal and professional development of physicians and researchers by faculty dedicated to these activities; sufficient time and flexibility in curriculum to accommodate independent study and investigation; basic science, research, and clinical experience integrated into all years of the curriculum. ♦ All students participate in 9- to 10-week summer research experience in basic/translational research (year one) and clinical research (year two) in addition to two-year organ-based basic-science curriculum (Chart 2).CHART 2: College Track Basic Science Curriculum♦ Each week of the curriculum has a theme around which three 2-hour PBL sessions, 8 hours of seminars, and one hour of Advanced Research in Medicine seminars are organized. ♦ Foundations of Clinical Medicine seminars are held weekly. ♦ Thirteen Thread Leaders (representing sciences basic to medicine such as anatomy, physiology, ethics, epidemiology, and biostatistics) charged with responsibility to develop learning objectives for their discipline and work with organ-system course directors to determine best placement of these objectives in the curriculum. Curriculum Steering Council monitors implementation. ♦ Each student is assigned to a family medicine or internal medicine longitudinal preceptor during years one to two; students develop clinical skills with preceptors in every other week half-day sessions in year one and weekly sessions in year two; additional experiences include pediatrics, geriatrics, and acute care. ♦ Formal curriculum hours limited to 21 hours weekly; curriculum changes are time neutral to maintain flexibility for students. ♦ Opportunities available to earn master's degrees (Public Health, Engineering, Biomedical Investigation in Clinical Research, Nutrition, Pathology, or Biochemistry). ♦ Cleveland Clinic provides full tuition scholarships to all College track medical students to avoid significant financial debt at graduation and thereby facilitate entry into research careers. Learning Outcomes/Competencies ♦ The curriculum is based on nine competencies; seven reflecting ACGME competencies (medical knowledge, clinical skills, clinical reasoning, communication, professionalism, health care systems, reflective practice) as well as research and personal development. ♦ Each competency has three to five specific standards for students to achieve by the end of years one, two, and five. Components of the Assessment Process ♦ Goal of the College track assessment process is to help students become reflective practitioners of medicine complemented by a critical approach to self-assessment and self-improvement. ♦ Faculty developed assessment principles that require frequent, formative assessments to enhance student learning and engage students in ongoing cycles of self-assessment, supported by mentoring from physician advisors. ♦ Assessments align with the College track's nine competencies and developmentally appropriate standards; there are no grades or class rankings. ♦ Assessments are collected from multiple sources (faculty, peers, self) and multiple methods (OSCEs, faculty observations, MCQs) and contexts to provide students with frequent narrative formative feedback across the curriculum to identify strengths and areas needing improvement and document students' achievement of competency standards. ♦ In basic science courses, weekly CAPPS (concept appraisal essays) require students to integrate and apply knowledge to solve problems related to course material. ♦ All assessments collected in an ePortfolio for students and their advisors to reflect on and monitor progress longitudinally. ♦ Students use their assessment data to construct both formative and summative portfolios that document achievement of competency standards. ♦ Students' formative portfolios are reviewed with their advisors to develop learning plans; summative portfolios are reviewed by a Medical Student Promotion and Review Committee for promotion decisions. New Topics in the Curriculum Since 2006 ♦ Clinical reasoning in year two. ♦ Integrated program in medical humanities. ♦ Bioinformatics taught as a component of the Genetics Thread progressively over first two years. Changes in Pedagogy ♦ Course directors have increased use of small group sessions (eight students per group) whenever possible to improve teacher–student and student–student interactions and increase student learning. ♦ Emphasis on faculty development to assist faculty in developing skills in small group, interactive teaching, and providing useful formative feedback. Program Evaluation ♦ College track uses a systematic approach based on principles (collect only essential information, and so on) to determine fulfillment of institutional goals, identify curricular strengths and areas requiring improvement, and contribute to educational research. ♦ Student feedback is collected for all courses and track-specific innovations (portfolio-based assessment, research thesis, and so on) using multiple methods (debriefing meetings, web-based questionnaires, performance assessments, focus groups). ♦ Office of Curricular Affairs for College track summarizes evaluation evidence for each course into formal reports for course directors and related committees to identify curricular strengths and limitations. ♦ Course directors reflect on this information and prepare written reports for presentation to respective curriculum committees and approval by College track's curricular governance committee. ♦ Office of Curricular Affairs uses external, track-specific data (AAMC Matriculation and Graduation Questionnaires, USMLE reports) for bench-marking purposes. ♦ Since College track's inception, assessment and program evaluation data maintained in IRB-approved data registry to ensure ethical practices for program evaluation and educational research. Clinical Experiences ♦ Clinical instruction and rotations for both tracks designed collaboratively and shared from third year onward. ♦ Four affiliated teaching hospitals: University Hospitals/Case Medical Center, Cleveland Clinic, MetroHealth Medical Center, Veterans Affairs Medical Center. ♦ Clinical rotations begin March of second year. ♦ Required clinical rotations: 40 weeks of basic core rotations, 8 weeks of advanced core rotations, and two subinternships Three basic cores, each completed at one site Basic Core 1 (medicine and surgery, 16 weeks) Basic Core 2 (pediatrics, OB–Gyn, family medicine, 16 weeks) Basic Core 3 (neuroscience and psychiatry, 8 weeks) Two advanced cores Aging and Society (4 weeks) Undifferentiated and Emergent Care (4 weeks) ♦ Robust electronic Clinical Assessment System (CAS) combines patient logs with real time formative feedback and summative assessment in competency-based format. ♦ Track-specific curriculum one afternoon a week at students' home base University track: IQ+ program to integrate reflection, basic science content, and advanced clinical skills into clerkships College track: programs in advanced research skills and medical ethics and humanities ♦ Challenges Achieving uniformity in student assessment across broad base of faculty Students' desire for more formative assessments from faculty; challenging to encourage busy faculty to provide more frequent written narratives Supporting clinicians' time for teaching Moving faculty and students to consider new models for clinical education Highlights of University Track ♦ High expectations for active, student-centered learning ♦ Case Inquiry Groups: new PBL variant with shorter, more focused cases ♦ Clinical immersion weeks embedded within basic science blocks ♦ Integrative essays to assess basic science knowledge ♦ Sixteen-week research and scholarship requirement with MD thesis ♦ Integration of SNAPPS case presentations across four-year curriculum to enhance expression and strengthening of clinical reasoning ♦ Portfolio assessment of competencies ♦ Integration of basic science into core clerkships through weekly IQ+ program Highlights of College Track ♦ Small class size promotes collaborative learning environments, interactive teaching methods, collegial relationships with faculty ♦ Five-year integrated research curriculum and required master's level thesis ♦ Reliance on formative assessments to document student achievement of competencies; no grades, no class ranking ♦ Portfolio approach for competency-based assessment system ♦ Institutional commitment to faculty development for teaching and assessment roles and full tuition scholarships for all College track students ♦ Comprehensive program evaluation activities Highlights of Shared Clinical Curriculum ♦ Clinical Assessment System featuring continuous formative assessment ♦ Clerkship groupings in 8- to 16-week integrated blocks ♦ Advanced cores introduce new, innovative curricular content ♦ Dedicated curriculum time during clerkships for program- specific educational goals

Curriculum Management and Governance Structure ♦ Curriculum Committees The MD curriculum is managed by a central Medicine Program Curriculum Committee (MPCC) that involves faculty representing the preclinical and clinical sciences in addition to students and administration representatives. The MPCC is divided into two subcommittees: (1) the Preclinical Sciences Curriculum Committee (PCSCC) representing the faculty in preclinical courses in the first and second years, and (2) the Clinical Sciences Curriculum Committee (CSCC), which includes representative faculty from the clinical clerkships in the third and fourth years. ♦ Responsibilities The MPCC has the primary responsibility to assess how well the MD program is achieving its goals and objectives and determining the effects of curricular changes. The purpose is to improve the MD curriculum. The committee focuses on how well individual courses are organized and taught; how well the curriculum fits together into an integrated and logical whole, how adequate the resources are for teaching, and how satisfied all parties are with the quality of the educational program. The committee assesses the effectiveness of the curriculum using learning outcomes measures to determine how well medicine students are achieving the knowledge, skills, and attitudes/values expected in the program's goals. The committee also defines core competencies for promotion and graduation, develops objective student clinical performance evaluation instruments, develops a uniform course and program evaluation systems, and identifies needs and priorities for faculty development. The two subcommittees will report to the chair of the MPCC, and their main role will be revision of the components of the curriculum. ♦ Institutional Oversight The MPCC is responsible for the central oversight and the management of the entire MD curriculum. The MPCC ensures that the MD curriculum is coherent and coordinated and that the revisions and recommendations submitted by the subcommittees are congruent with the program's educational objectives and reflect the mission and goals of the Institution. The MPCC brings a broader perspective to the four years of the MD curriculum. The departments implement the decisions of the MD curriculum committees. The Associate Dean for Academic Affairs (ADAA) provides support to the curriculum committees and monitors the implementation of curricular changes. (Figure 1 illustrates the structure of the curriculum committees.)FIGURE 1:: Curriculum Management and Governance Structure Office of Education ♦ The Ponce School of Medicine (PSM) has an office of education under the ADAA and is directed by the Assistant Dean for Education (ADE). It is staffed by full-time staff: the ADE and an executive secretary. The ADE has a doctoral degree in education (EdD) and specialization in curriculum and instruction. The role of the office of education is to monitor the compliance of medical education program with the standards of the Liaison Committee on Medical Education (LCME). advise curriculum committee members about curricular management and curricular changes of the MD Program. assist the faculty to improve their teaching methods and skills and designing innovative teaching strategies. instruct the faculty in educational measurement, research, and evaluation. design instruments to evaluate faculty performance in teaching, scholarly activity, and service. assist in the evaluation of educational effectiveness of the MD program. assist the Clinical Practice Examination Committee in the technical development of student performance assessment. conduct validity and reliability assessment of new evaluation methodologies. Financial Management of Educational Programs ♦ A budget to support the educational program is developed by the School's administration with the insight of department chairs and associate and assistant deans. The annual budget is approved by the board of trustees. The education budget is allocated to support administration, research, instructional activities, student services, and health services. ♦ The sources of revenue include student tuition and fees, federal and private grants, service activities revenues, fundraising and development, tuition from summer courses, and others. ♦ The PSM has taken the following steps to address the current financial downturn in order to be able to support the educational programs: Temporary 10% reduction of personnel working hours representing significant annual savings. This plan was designed not to affect academic and educational activities. Reevaluation of mortgage loan. After negotiations with the bank officers, a moratorium of the payment of the principle on the outstanding mortgage loans was obtained. The approval of the continuation of federal research grants and the approval of new ones have led to an increase in indirect cost revenues. The efforts to obtain external funding from research, service, and educational grants have been intensified. Valuing Teaching ♦ Faculty Development Program PSM has implemented an active Faculty Development Program (FDP) to identify and improve skills in teaching and evaluation of student achievements, with innovative and effective student-centered learning strategies. The needs assessment for this program is obtained from the faculty, program directors, departmental chairs, and current educational trends. Other implemented strategies include the following: Newly appointed course/clerkship directors are required to attend their corresponding academic society's new course/clerkship director's workshop. Faculty is encouraged to keep current in their specialty area, providing evidence of CME and/or participation certificates of professional development activities. Faculty members are sponsored by PSM to attend national and regional academic society meetings. PSM sponsors workshops presenting innovations in medical education, education technology, and other topics based on faculty development needs. Mentoring is available to new faculty members. Evidence of professional growth and development is highly valued in annual evaluations and in faculty promotion. ♦ Criteria for Faculty Promotion Three tracks have been identified to characterize the academic endeavors and professional developments of the PSM faculty. These are the Clinician-Teacher, the Investigator-Teacher, and the Investigator tracks, each containing specific criteria set forth to guide the general expectations of the faculty and to frame their appointment and promotion procedures. ♦ Clinician-Teacher Track: designed for faculty members with local and/or national recognition by peers and patients as an excellent clinician with active and ongoing achievements in clinical research, documented community service involvement, and evidence of excellence in teaching, as described in the Faculty Regulations Manual. ♦ Investigator-Teacher Track: for faculty members with evidence of excellence in investigation with sustained external funding of competitive peer-reviewed research projects; continued publications in peer-reviewed journals; authorship or editorship of textbooks, chapters, monographs, or journals; membership in editorial boards, study sections, and/or advisory groups; leadership and membership in major scientific societies; and evidence of excellence in teaching, as described in the Faculty Regulations Manual. Investigator Track: these faculty members must show evidence of excellence in investigation (as described above) with national and/or international recognition. Curriculum Renewal Process ♦ The curriculum renewal process was initiated during the first semester of academic year 2003–04 and was included as a strategic goal in the 2004–09 PSM Strategic Plan. ♦ Goal The goal of the curricular renewal process is to develop a coherent, integrated, and high-quality MD curriculum, to educate a new generation of physicians for the 21st century who are able to effectively, ethically, and responsibly respond to the needs of their patients and of society as a whole. Educational principles that guide the curricular renewal process of the PSM are as follows: The major purpose is to improve the quality of the MD curriculum and of the teaching and learning processes. The revision of the MD curriculum must be viewed as a continuous process. The MD curriculum is dynamic and constantly changing. Medical education must be viewed as a continuum. Medical students are actors in the learning process. Learning is active and must be student centered. Faculty is responsible for curriculum management through the established curriculum committees. The incorporation of new content must be based on the information needs of the students. Students and faculty participation in the curriculum revision process is key for the successful implementation of the MD curriculum. The process of medical education must evolve to satisfy the changing needs of society and the health care environment. ♦ Specific objectives of curricular renewal are to: improve the quality of the teaching and learning processes and the student learning outcomes. foster independent and self-directed learning and the development of the skills of problem solving, clinical reasoning, and critical thinking. continue the preparation of students for taking and approving the medical licensing examinations. train students for advancing to the next level of training: graduate medical education. develop the skills of life-long learning. update basic and clinical sciences content to include new knowledge and current technological advances. include the competencies, skills, attitudes, and knowledge responsive to the changes that are transforming the practice of medicine in Puerto Rico and in the world. provide a relevant, integrated, and challenging curriculum to MD students. adapt learning to new trends of health care and patients needs. provide feedback to the curricular renewal process through the use of interrelated methods such as planning, implementation, and assessment in order to ensure follow-up and continuity of the process. Learning Outcomes/Competencies ♦ MD Program Educational Objectives During the 2008 LCME Self-Study, the Educational Program Committee recommended to revisit the educational objectives of the MD program in light of the six ACGME competencies: Medical Knowledge, Patient Care, Interpersonal and Communication Skills, Practice-Based Learning and Improvement, Systems-Based Practice, and Professionalism. The medical curriculum committees have already generated the statement of the competencies with the accompanied specific educational objectives. The competencies and revised educational objectives will be presented to the Curriculum Policy Committee and the Academic Senate. Once approved, they will be available for publication. New Topics in the Curriculum Since 2000 ♦ Patient safety Basic Psychiatry (second-year course) discusses patient safety during the sessions of ethics in psychiatry, psychiatric emergencies, and forensic psychiatry. Formal and informal discussions concerning patient safety are held for third-year pediatrics students. Prevention of patient errors is continuously addressed during the surgery and Ob-Gyn clerkships. Pediatric residents involve medical students in record revision for evaluating record's legibility, dose calculations, and the use of abbreviations as contributors of medical errors in Pediatrics. The family medicine residency offers formal conferences to residents and medical students in patient safety using the guidelines of the Joint Commission, the measures of QUIPRO, and hospital protocols. The Introduction to Clinical Practice (ICP) summer course teaches universal precautions and risk management to second-year students. ♦ Team-based learning The team-based learning approach is used for case discussions during the Introduction to Clinical Skills course and in the Pediatric Clerkship. Groups of students prepare and deliver seminars on the latest advances of surgical topics in surgery after review of the medical literature. PBL cases, small-group activities, and clinical correlations are used as the context to help students to learn in cooperative teams and develop communication skills. ♦ Surgical techniques Students are trained in operating room techniques and suturing and wound healing during the ICP course. Students participate in major and minor gynecology surgeries, cesarean sections, and pap smears in the Ob-Gyn clerkship. Students observe hand and reconstructive surgery, neurosurgery, and pediatrics surgery techniques during the third-year Surgery clerkship. ♦ Evidence-based medicine (EBM) Students conduct literature searches and collect external evidence during the ICP course. They review assigned web-based EBM cases in Pediatrics to find answers to problems posed on case study information. The concept of EBM is discussed during required clinical clerkships to help medical students base clinical practice on valid evidence. ♦ End-of-life care The topic is discussed in the clinical clerkships of Family Medicine, Internal Medicine, Pediatrics, and Surgery and in the medical ethics, behavioral science, and family and community medicine courses. A family medicine preceptor introduces the topic of death and dying in the ICP course. ♦ Geriatrics The Family Medicine and Internal Medicine Departments integrate the topic of geriatrics across the four years of medical school. Students are exposed to geriatric patients and have the opportunity to conduct geriatric assessments in the Community Medicine course. Psychiatry and Family Medicine clerkships introduce sessions of elder neglect during the clinical clerkships. ♦ Domestic violence and abuse The diagnosis, prevention, reporting, and treatment of domestic violence and abuse are discussed in the Internal Medicine, Family Medicine, Psychiatry, Pediatrics, and Ob-Gyn clerkships and in the Behavioral Science and Basic Psychiatry courses. ♦ Health Service Management Senior medical students participate in a one-week required course in which they discuss issues related to health care service models, medical licensing, rules and regulations that affect the medical practice, prevention of fraud and abuse, quality service at the ambulatory setting, the billing cycle, electronic medical records, office personnel issues, and cost-effective medical care. Course Revision ♦ The following changes have occurred in the MD curriculum since 2000 as a result of curricular revision: incorporation of the Skills Development course for second-year students. This course protects time at the end of the second year for independent study to prepare to take and pass the USMLE 1. integration of first-year general pathology with the second-year systemic pathology into the Pathology course for second-year students. redistribution of the number of weeks for the clinical clerkships: from 10 to eight weeks in Internal Medicine, Pediatrics, and Surgery; from five to eight weeks in Ob-Gyn; and from five to four weeks in Family Medicine and Psychiatry. introduction of the Community Medicine course for first-year students. substitution of the subinternship course in the fourth year for a primary-care selective course. introduction of a neurophysiology block in the neuroscience course during the first year. renaming the Introduction to Clinical Medicine (ICM) course as Introduction to Clinical Skills (ICS) and the Pathophysiology course as Fundamental Pathophysiology for Clinical Medicine. integration of standardized patient activities into the ICS course. integration of Geriatrics into the medicine curriculum. use of clinical correlations in the neuroanatomy block. increase time for laboratory activities and clinical correlations in the Anatomy course. approval of a model of 10 clinical rotations/20 days each for the third-year clinical clerkships. comprehensive revision of the Physiology and Microbiology courses based on the national learning objectives. redistribution of basic science courses to assign the last block of the first year to Medical Ethics I and the first block of the second year to Medical Ethics II. integration of Biochemistry and Genetics into Medical Biochemistry for first-year students. decrease of lecture contact hours to increase the time for small-group activities and independent study. adjusting lecture time from 1 hour and 20 minutes to 1 hour in the mornings. The afternoons are used for small-group discussions and laboratory activities, ending formal instructional activities by 3:00 pm. substitution of the two-week surgical specialties course in the fourth-year curriculum for an additional (third) week in Clinical Radiology and incorporation of a one-week required course in Introduction to Health Services Management effective in 2008–09. Changes in Pedagogy ♦ The following pedagogy changes and innovations have been implemented in the MD curriculum since 2000: an FDP was established to coordinate faculty development activities for improving teaching skills. emphasis on Problem-Based Learning (PBL) appointment of a new director. conduct of workshops to train faculty on PBL. incorporation of biomedical senior students as teacher/tutor in PBL. use of computer-assisted instruction modules in Anatomy. increase of interactive, student-centered activities. development of NBME-style examinations to help students prepare for taking the USMLEs. use of interactive cases online (CLIPP Cases). incorporation of diagnostic tools such as Kaplan and the NBME Comprehensive Basic Science Examination. adoption of the Moodle distance learning platform with the corresponding training for users. Changes in Assessment ♦ The following changes in student assessment have been implemented since 2000: incorporated NBME Shelf Examinations in the Neuroscience and the Fundamental Pathophysiology for Clinical Medicine courses. administered the Comprehensive Basic Sciences Examination at the end of the second year as a diagnostic tool for measuring student readiness to take the USMLE Step 1. initiated annual curriculum evaluations of courses and clerkships by medical students. implemented a revised policy for decreasing the weight of the subject examination from 30% to 20% when computing the final grade of the clinical clerkships. assigned to the OSCE a weight of 10% when computing the final grade of the third-year clerkships. assigned a grade of Pass/Fail to the Ethics course. designed the clinical performance evaluation form for clinical clerkships based on the ACGME competencies. incorporated the use of patient diagnosis and procedures logs in all clerkships. introduced changes on the Clinical Performance Examination (CPX) to better prepare students for taking the USMLE 2 CS: taught communication skills in English using standardized patients (formerly done in Spanish). included an activity to evaluate the quality of documentation on the medical record. recruited an assessment specialist to provide support to the academic programs. developed a policy for the reposition of the clinical shelves. Carried out continuous evaluation of the effectiveness of medicine courses using the following criteria: student satisfaction with individual courses. student satisfaction with the quality of teaching. results with the shelf and comparative analysis with national norms of achievement. results of the USMLEs. analysis of student recommendations submitted during annual curriculum evaluations. incorporation of the electronic platform E-value available through the Internet for the evaluation of students, faculty, and courses for clinical years. development of a pilot project for those students who fail the USMLE 1 on the first attempt but who have a high probability to pass on the second attempt to let them register in the third clinical year and complete the required clerkship during the summer. use of the Moodle platform for grade reporting and test administration. Clinical Experiences ♦ Inpatient and ambulatory teaching sites Hospital Episcopal San Lucas Damas Hospital La Concepcion Hospital Tito Mattei Hospital San Cristobal Hospital Ponce School of Medicine Health Services Clinics at Ponce and Mayaguez La Playa Diagnostic and Treatment Center ♦ Challenges for Clinical Education The Health Reform in Puerto Rico and its effect in the availability of clinical sites The need for new residency programs and additional resident slots Availability of resources for clinical research Medical liability coverage for clinical teachers and high costs of liability insurance Highlights of the Program/School Strong interpersonal collaboration across all educational programs of the schools: Medicine, Biomedical Sciences, Public Health, and Clinical Psychology. The standardized patients unit performs comprehensive integration of standardized patient-based formative and summative assessments across all years of the curriculum. Wide variety of service learning opportunities that foster student involvement in the community and the profession. Offers a decelerated five-year medical curriculum Development of a successful Clinical Research Center for clinical trials. Continuity of the RCMI and MBRS research grants Has affiliation with the Moffitt Cancer Center in Tampa, Florida for collaborative activities in cancer research. PSM has been granted a $19.2 million award from the Department of Health and Human Services to establish a Regional Extension Center (REC) for the adoption and implementation of Health Information Technology (HIT) in Puerto Rico and the Virgin Islands beginning in 2010.

University of Missouri School of Medicine in Columbia

Louisiana State University School of Medicine--New Orleans.

Measuring progress in entrepreneurship education

BackgroundBeyond the adoption of the principles of horizontal and vertical integration, significant planning and implementation of curriculum reform is needed. This study aimed to assess the effect of the interdisciplinary integrated Cardiovascular System (CVS) module on both student satisfaction and performance and comparing them to those of the temporally coordinated CVS module that was implemented in the previous year at the faculty of Medicine of the King Abdulaziz University, Saudi Arabia.MethodsThis interventional study used mixed method research design to assess student and faculty satisfaction with the level of integration within the CVS module. A team from the medical education department was assembled in 2010/2011 to design a plan to improve the CVS module integration level. After delivering the developed module, both student and faculty satisfaction as well as students performance were assessed and compared to those of the previous year to provide an idea about module effectiveness.ResultsMany challenges faced the medical education team during design and implementation of the developed CVS module e.g. resistance of faculty members to change, increasing the percentage of students directed learning hours from the total contact hour allotted to the module and shifting to integrated item writing in students assessment, spite of that the module achieved a significant increase in both teaching faculty and student satisfaction as well as in the module scores.ConclusionThe fully integrated CVS has yielded encouraging results that individual teachers or other medical schools who attempt to reformulate their curriculum may find valuable.

Simulated patient cases using DecisionSim™ improves student performance and satisfaction in pharmacotherapeutics education

The online Executive MPH (EMPH) Program at Emory University offers three majors, and prior to 2015, all integrated learning experiences (ILE) required theses. In 2015, the Program adjusted the ILE requirement based on each major’s intended career outcomes: Applied Epidemiology (Epidemiology: research thesis); Applied Public Health Informatics (Informatics: program-focused capstone courses instead of thesis); Prevention Science (Prevention: choice of research or program-focused thesis or program-focused capstone courses). Our goal was to describe major-specific curricular changes of the ILE requirement aimed to reduce time-to-graduation. We compared three cohort years before (2012–2014) and after (2015–2017) the 2015 curricular change using registrar data of time-to-graduation (339 students) and students’ self-reported satisfaction with their thesis experience (152 students). Informatics and Prevention majors had significantly more students (34%–35%) graduate on time in the 2015–2017, compared to the 2012–2015, cohorts. There was no significant difference by cohorts in perceived student thesis satisfaction in Informatics and Prevention majors and a decrease in satisfaction in Epidemiology majors. Before 2015, the main theme reported as a detractor to thesis satisfaction was lack of Program thesis support. After 2015, this detractor theme was not mentioned and instead a motivator theme was continuous thesis support. After 2015, the main detractor theme was difficulty with time management. Consistent motivator themes across 2012–2015 included thesis committee support and students’ self-fulfillment due to their thesis learning experience. The curricular strategies described can inform other online and residential programs that have a thesis requirement for the ILE.

Abstract: Technostress can be seen as a relevant factor that may affect student satisfaction and student performance. However, a lack of research has been carried out to analyse the simultaneous effect of the four technostress dimensions, namely techno-overload, techno-complexity, techno-insecurity, and techno-uncertainty on student satisfaction and performance expectancy. Performance expectancy is appropriate to use as an endogenous construct since this research was carried out during open and distance learning (ODL) implementation and before the final examination. Hence, this study aims to investigate the association between the four technostress dimensions towards student satisfaction. This research also seeks to examine the relationship between student satisfaction and performance expectancy among undergraduates. A total of 500 self-administered questionnaires were distributed but 458 valid questionnaires were found. All of the respondents were at the diploma level from UiTM Pahang Branch Campus. An online survey questionnaire was used since all respondents were in their hometowns due to the Malaysian government's Movement Control Order (MCO). In this study, SEM-AMOS was conducted to evaluate the measurement model and to test the hypotheses. This study found that techno-complexity displays a more significant contribution to student satisfaction and performance expectancy than techno-uncertainty. However, the results explicitly imply that the influence of techno-overload and techno-insecurity on students' satisfaction and performance expectancy is not significant. 
 Keywords: Performance expectancy; student satisfaction; technostress; university students

The Dean is the chief academic officer of the medical school. Management of the educational programs is a shared responsibility of the academic departments and the Office of Education reporting to the Vice Dean. The faculty organization solicits and provides input to the Committee on Committees, which selects members for the nine standing committees that are approved by the Faculty Council (Figure 1). The Committee on Academic Programs and Policies (CAP2), a standing committee of Faculty Council, is charged with the design, evaluation, revision, approval, and oversight of the curriculum and overall educational program. CAP2 also makes recommendations to the Dean and to the Faculty Council regarding implementation of various programs. CAP2 represented by faculty, students, and administrators (ex officio) is a surrogate for the faculty at large. Members on the CAP2 are not representational of the various departments. The Dean or his designee, the Vice Dean, in concert with the CAP2 provides the strategic leadership in managing the educational programs and developing policies and procedures. The Vice Dean works closely with the academic departmental chairs, course and clerkship directors, and faculty to implement innovations in education, assessment, and evaluation as they pertain to undergraduate medical education. Two subcommittees report to the CAP2—the Preclinical and Clinical advisory subcommittees, which consist of course and clerkship directors, respectively. Subcommittees assist in achieving horizontal and vertical integration of the curriculum. A major curriculum revision was rolled out in 2004-05 (see Curriculum Renewal Process). Interdepartmental and interdisciplinary courses are managed jointly by departments and the Office of Education (OE). Office of Education

Improved performance and student satisfaction after implementation of a problem-based preclinical obstetrics and gynecology curriculum

This study investigated student interaction, satisfaction, and performance in accelerated online learning environments with the use of an online learning course-management system. The interactions assessed in this study included learner–learner interaction, learner–instructor interaction, and learner–content interaction. The participants were African American students from a university in the southeastern United States. Quantitative approaches including correlation and regression analyses were performed to examine the contribution of interaction predictors to student satisfaction as well as the relationship between student satisfaction and student performance. In addition, Internet self-efficacy and its impact on interaction was investigated. The results showed that learner–content interaction was the only significant predictor of student satisfaction whereas interaction among students or with the instructor did not significantly predict student satisfaction. Internet self-efficacy was positively correlated with three types of interaction. Student satisfaction was found to be related to student performance.

Texas Tech University Health Sciences Center School of Medicine converted its legacy two-pass preclinical curriculum to a one-pass organ system-based format and changed the grading system from categorical to pass/fail (>70%). Our objective was to assess first-year medical student (MS1) performance and satisfaction in the first iteration of Organ Systems-2:Renal and Respiratory ( RNR), an 8-week block taught at the end of Year I. RNR integrates the physiology, pathophysiology, infectious diseases, and pharmacology of the renal system (Weeks 1-4) and respiratory system (Weeks 5-8), using reorganized and updated material from legacy Year-I blocks ( General Principles & Infectious Diseases and Structure & Function of Major Organ Systems) and Year-II blocks ( Immunity & Multisystem Disorders and Systems Disorders). Instruction was delivered via didactic lectures, team-based activities, case-based reviews, dry labs, cognitive integration of clinical reasoning (CICR) sessions, and simulations. Formative weekly quizzes and practice exams were assigned before each exam. Learning in the renal physiology, renal pathophysiology, and respiratory physiology units was assessed by instructor-generated exams at the end of Weeks 2, 4 and 6, respectively, and a final customized, comprehensive NBME exam at the end of Week 8. Aggregate performance on instructor-generated renal and respiratory exam questions was compared to that on similar questions from legacy curriculum exams. Aggregate performance on the NBME exam was compared to USMLE Step 1 exam difficulty, as the legacy curriculum did not include a dedicated renal/respiratory NBME exam. Aggregate performance on instructor-generated renal physiology and pathophysiology and respiratory physiology questions was comparable to that in the legacy curriculum. Average performance on the renal portion of the NBME exam was 0.76 vs. Step 1 exam difficulty of 0.78; average performance on the respiratory portion of the exam was 0.77 vs. Step 1 exam difficulty of 0.78. Per end of block survey and student focus group feedback, overall student satisfaction with RNR was 73%. Thus, the first iteration of the integrated organ systems-based renal and respiratory systems course in Year I yielded a MS1 performance on the NBME that was comparable to USMLE Step 1 source difficulty, and student satisfaction was positive overall. More detailed analysis of exam performance is needed. Further modifications of RNR will include additional simulations and flipped-classroom sessions. This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.