Loma Linda University School of Medicine.

Abstract

Medical Education Program Highlights Loma Linda University School of Medicine has educated medical students for over 100 years. Our unique mission focuses on training students to deliver culturally appropriate wholistic care to individuals, families, and communities. This mission is embedded throughout our educational program. Our admissions process emphasizes selection of students who are mission aligned and committed to service. Our program includes patient care, small-group, and classroom experiences that provide students with the knowledge and skills to care for patients’ physical, psychological, social, and spiritual needs. In addition to the 6 ACGME competencies, we have added a seventh, whole person care, to assess mission achievement. A second strength is our longitudinal, integrated clinical skills curriculum. A centralized clinical skills education center (CSEC) provides consistent reinforcement of clinical skills throughout medical school. First-year students practice history, physical examination, and differential diagnosis skills in small-group laboratory sessions. Second-year students progress to integrated basic science OSCEs, where they obtain a history, examine a standardized patient, review related basic science, present, and discuss the patient in faculty-led small groups. Workshops focus on oral presentations and note writing. First- and second-year students participate in continuity clinic and 5 weeks of inpatient experiences, complementing CSEC learning. Third-year students rotate through traditional clerkships, returning to the CSEC for OSCEs and a formative junior clinical skills assessment, including peer, standardized patient, and faculty feedback. A clinical skills enhancement track supports students identified as needing additional support. Fourth-year students return to the CSEC for a subinternship OSCE focusing on assessing clinical reasoning, handoff skills, and cross-coverage questions from a nurse. The simulation center also enhances students’ clinical skills and interprofessional experiences, culminating in assessment of several Entrustable Professional Activities (EPAs). An ultrasound curriculum is integrated throughout medical school. We deliberately created systems to promote development of students’ professional identity, resilience, and wellness. The Christian Physician Formation longitudinal course is taught by clinicians mentoring small groups of students across all 4 years. The course teaches content through small-group discussion, including learning skills, professionalism, resilience, bias, social determinants of health, whole person care, and lifestyle medicine. It allows for mentoring students by faculty, enhances community among students, and creates opportunities for students from different classes to share experiences. For example, junior and senior students meet with sophomore students preparing for the USMLE Step 1 examination to share strategies and provide encouragement. Students’ commitment to service is demonstrated by their development of and participation in local and international service projects. Students provide weekly tutoring and mentorship for disadvantaged elementary through high school students, mentor and educate pregnant and parenting teens at local high schools, provide volunteer care in local free clinics and shelters for the homeless, and provide free music and swimming lessons to children from disadvantaged backgrounds. Many students participate in global health projects and international electives in numerous countries. Curriculum Curriculum description See Supplemental Digital Appendix 1—Organ Systems Block Curriculum—at https://links.lww.com/ACADMED/A854. Curriculum changes since 2010 The school has been undertaking curricular redesign over the past 3 years, with full implementation of the new curriculum planned for the entering class in July 2020. Specific goals for the new curriculum include: Emphasizing topics relating to our unique mission and heritage Increasing learning integration horizontally and vertically Supporting the development of professional identity, resilience, and wellness Transitioning pedagogy to include more active learning Using technology to support today’s learners Allocating resources to support innovation Aspects of the new curriculum implemented over the past 3 years include increased use of active-learning pedagogies; planned resilience activities; and development of communities to provide mentorship, create community, and support wellness. New aspects of our curriculum include: Organ system blocks, integrating traditional basic science disciplines into one individual course. Content taught previously has been reviewed, prioritized, and integrated. Faculty have implemented evidence-based learning strategies such as planned repetition within the curriculum. Increased use of active-learning pedagogies. Our problem-based learning (PBL) curriculum has been redesigned as patient inquiry (PIQ). Each block will include 2 to 6 cases, designed to teach and reinforce content and develop lifelong and self-directed learning skills. Other active pedagogies include team-based learning (TBL), case-based learning (CBL), and flipped classrooms. Integration of basic and clinical sciences through the use of student-developed integrated illness scripts. These scripts focus on the basic science behind patients’ symptoms, create a framework for review before boards, and integrate basic science into the third-year clerkships. Creation of integrated examination questions that cross disciplines and are mapped to learning objectives and Bloom’s taxonomy. Weekly quizzes will be based on integrated learning objectives. These will count toward the course grade and also serve as formative assessment for learning. Two longitudinal courses will continue throughout medical school. The Christian Physician Formation course will be taught by clinical faculty paired with small groups of students for mentoring and nurturing community. Content will include professional identity formation, resilience, social determinants of health, community engagement, lifestyle medicine, and lifelong learning. The Clinical Skills longitudinal course is centered in the CSEC and provides consistent teaching by core faculty. Threads including traditional basic science disciplines, social determinants, social advocacy, service learning, academic medicine, pain and palliative care, patient safety and quality improvement, spiritual and whole person care, lifestyle medicine, interprofessional education, and telemedicine are woven throughout the curriculum. Thread directors ensure content is appropriate and updated regularly. Intersession weeks in the first and third years allow students to gain resilience and technical skills, explore topics of personal interest, and grow in their professional identity and sense of community. Class size has not increased since 2010. Assessment See Supplemental Digital Appendix 2—Program Objectives and Assessment Methods—at https://links.lww.com/ACADMED/A854. Initial development of program objectives was based on the AAMC’s Medical School Objectives Project and CanMEDs. With the transition to competency assessment, the Curriculum Committee chose ACGME domains of competence, adding our mission-related whole person care competency. Competency-based assessments were implemented with the class of 2018. The competency subdomains are mapped to EPAs, ensuring students are prepared to transition to residency. Competencies were revised and approved in 2019 to match our curricular change, using the same domains. Our competencies are mapped to the Physician Competence Reference Set via the AAMC Curriculum Inventory Report and uploaded annually. Evaluations and assessments were revised during our transition to competency-based program outcomes. We created new assessments to better demonstrate student growth, which are completed by each clerkship in our curriculum management system, with data downloaded to a dashboard for Competency Review Committee. Grading is criterion-referenced for all 4 years to allow for individual student assessment. We have created an electronic database for our skills log, which is uploaded to student iPads at the start of the third year. Once a skill is completed and assessed using this application, it uploads to our in-house database. Clinical students receive formative (midyear) and summative feedback from the Competency Review Committee. Preclinical students receive formative and summative feedback at the end of the academic year. When a noncognitive concern (area of strength, praise, or growth) is recognized, faculty send an electronic form to the associate dean for curriculum evaluation and learner assessment. We completed a review of all learner assessments in 2019 and have centralized the download to a single system, allowing for deeper evaluation and tracking of student growth. Pedagogy A variety of approaches are used to achieve program objectives. During the basic science years, students participate in TBL, CBL, small- and large-group discussion, PBL, self-directed learning, and are provided video/podcasts. Students complete 5 weeks of inpatient medicine and multiple outpatient clinic encounters. Lectures are limited to 8–10 hours per week and engage students through think-pair-share, interactive questions, and large-group discussions. PBL is used to teach content and lifelong learning skills. Students experience laboratory sessions in multiple disciplines, peer teaching, and use standardized patients and simulation. In the clinical phase, clerkship didactics also include CBL, small- and large-group discussions, standardized patients and simulation, and lectures. We are implementing PIQ as a form of modified PBL. Previously, PBL was used to teach students effective literature search strategies to answer questions; it will now be used to teach actual content. Through patient cases, students will develop their own learning objectives, independently answer questions, and report on what they learned. During PIQ cases, students write integrated illness scripts as a team, deepening understanding of basic science mechanisms behind the symptoms. Flipped-classroom modalities are increasingly used to replace lecture, including TBL, CBL, and peer teaching. In 2020, standardized TBL activities will increase to approximately 2 sessions per week. CBL activities will also occur directly after the weekly integrated quiz to reinforce learning. Lectures are increasingly employing active-learning techniques, inserting cases, think-pair-share activities, and polling questions to reinforce concepts. Clinical experiences Clinical sites for required educational experiences include: Tertiary care medical center Veterans Administration hospital 2 county hospitals Psychiatric hospital Inner-city hospital Rotations at affiliated sites in Ohio and Florida Students also rotate through outpatient sites including a federally qualified health center (FQHC) clinic (San Bernardino, California) and multiple hospital-based and private clinic sites. Students participate in a longitudinal continuity clinic during their sophomore year. Students are assigned to inpatient services on the first day of school to observe medical care delivery and instill early professionalism. Students are asked to note health care provider communications, listen to a patient’s story, and interview a health care professional from another field, then debrief in small groups. Students may be assigned to community-based outpatient rotations as part of family medicine and pediatric clerkships. We identify clinical preceptors and sites where students see a variety of patients and can meet learning objectives and required patient experiences. Students may also rotate at university, VA, county, or FQHC clinics and have elective rotations options at community-based sites. Challenges in designing and implementing clinical experiences include: Ensuring that patient experiences are of adequate volume and variety to meet clerkship learning objectives and required patient experiences Ensuring that faculty and residents know the learning objectives, required patient experiences, and supervision and evaluation standards Evaluating the impact of other learners at the site Ensuring that students at each site meet equivalency standards in educational experience and outcomes Planning for future needs, based upon projected impact of additional medical schools’ student rotations Curricular Governance Courses and clerkships have education committees that work with course/clerkship directors to recommend content and required experiences (based upon faculty expertise and input from national organizations) to the Curriculum Committee. That committee makes final decisions on content and required experiences. Responsibility and expenses for clerkship administrative support is shared between the school and clinical departments. Departments are provided funds to help with educational expenses. Funds are available for clinical clerkships to apply for annual innovation grants, encouraging continual develop of educational advances. The associate and assistant deans are provided the administrative support and technology necessary to implement and evaluate the curriculum as it is planned and overseen by the Curriculum Committee. See Figure 1—Curriculum management chart.Figure 1: Curriculum management chart.The Office of Medical Education is responsible for implementation and evaluation of the curriculum as designed by the Curriculum Committee. Associate deans for graduate medical education and continuing medical education work with this office and are members of the Curriculum Committee. The Office of Medical Student Education works with the Office of Student Affairs in designing programs to promote student success. The Office of Medical Education is responsible for creating the MSPE for each graduating student. In the Department of Medical Education, leaders in education hold secondary appointments. Faculty who teach, but are not part of a traditional basic science or clinical department, may hold primary appointments in this department. See Figure 2—Organizational chart.Figure 2: Organizational chart.Faculty Development and Support in Education Faculty are provided professional development focused on education monthly through the dean’s office, in addition to multiple departmental faculty educational offerings. The dean’s office also offers faculty development at distant clinical sites. An annual faculty development course for junior faculty is offered. Basic and clinical science educator tracks are available for faculty promotion pathways and include educator portfolios. Promotion requires significant teaching with outstanding evaluations, education-related CME, or training and a publication record related to medical education.