Introduction To Clinical Medicine Research Articles

Background: The way that students learn and the caliber of their learning results are both influenced by their judgments about their learning modes. The clinical portion of undergraduate medical courses is conducted in a setting intended more for clinical service than for instruction. When these two activities fight for resources, tension results. A projected rise in the number of medical students prompted us to evaluate the learning environment in order to make future plans. Objective was to evaluate students’ attitude towards different modalities of teaching in the medical curriculum of the faculty of physiology, SKIMS medical college, Bemina. Methods: 200 SKIMS medical college students between the ages of 19 and 25 participated in a questionnaire-based study starting in October 2022. The phrasing of the question is repeated below. Each teaching method- lectures, handouts, textbooks, media sites (video-recorded lectures), simulation, PBL (problem-based learning), TBL (team-based learning), and ICM (introduction to clinical medicine, physical examination) practicals- was the subject of five questions. Answers were on a 5-step Likert scale. Results: It was a descriptive type of research in nature. The data has been collected with the help of a structured questionnaire based on the Likert scale. Conclusions: The study’s overall conclusions demonstrated that there had been significant changes in attitudes regarding professional development, team experiences, and peer evaluation.

Background: Introduction to Clinical Medicine (ICM) is a relatively new and innovative approach for teaching medicine. ICM engages medical students in their understanding of the disease process from clinical feature to diagnosis, studying abnormalities of complaints, examination. The aim of this study was to find the undergraduate medical students’ perceptions and opinions towards Introduction towards Clinical Medicine. Methods: An analytical cross-sectional study was conducted among MBBS students using non-probability sampling technique from 22nd June 2022 to 15th October 2022. Ethical approval was taken from institutional review committee of College of Medical Sciences. Data was analyzed using descriptive and inferential statistical tools in SPSS-20. P-value <0.05 was considered as statistically significant. Results: This study was carried out among 220 medical students. The mean and standard deviation of age of students was found to be 22.50±1.89 years. The ratio of gender of students was almost equal. The positive level of perception was found to be 43.6% with 95% CI 37.04% to 50.15%. More than 99% student’s choice was to read clinical medicine. None of the variables was found to be statistically significant with the level of perception. Conclusions: Most of the students are strongly agree with the relevance and significance of this subject introducing in MBBS level. Very minimum percentage students had making future plan to read basic science subject while more than half of the students had future plan to choose ICM as a carrier subject.

Medical Education Program Highlights The Albert Einstein College of Medicine (Einstein) curriculum integrates basic, clinical, behavioral, and population health sciences to produce physicians and clinician–scientists that meet the modern, evolving needs of patients and society. Students can pursue electives in the first, second, and fourth years for deeper exploration into areas of interest. A capstone scholarly paper is a graduation requisite. Recent highlights: The Teaching Star Program enhances and supports faculty and nonfaculty instructors’ teaching and assessment skills. The program begins with mandatory teaching development seminars and resources for all instructors. Course/clerkship objectives and expected teaching and assessment roles are clarified. Students complete evaluations of instructors’ teaching skills after each course/clerkship, which are used as the objective basis for teaching awards and underpin a carefully documented process of improvement plans for any instructor with inadequate teaching skills. In 2019, Einstein’s Global Health Center and the City University of New York School of Public Health and Health Policy (CUNY SPH) joined together to create an MPH program specifically designed to fit into a gap year within the Einstein MD program. Composed of online and in-person courses, the program will include a summer when studentscan complete an Einstein global health fellowship that fulfills the CUNY SPH fieldwork requirement. Students will engage in public health research with an Einstein mentor concurrent with MPH coursework during the gap year. The peer tutor program is a free service available to all Einstein students, monitored by the Office of Academic Support and Counseling (OASC). Students have the opportunity to work individually or in small groups with upper-class students who have excelled in the curriculum and have excellent interpersonal and communication skills. Peer tutors are available for all basic science courses, USMLE examinations, and subject test preparation. Through this program, students learn more effective study strategies, reinforce course material, and work with others who are facing similar challenges, facilitating their successes. In alignment with Einstein’s mission of social justice, the curriculum has a robust community-based service learning (CBSL) program. This provides an opportunity for students to partner with members of the Bronx community and local organizations to make a lasting impact on health outcomes and social justice for the Bronx community. The CBSL program combines trainings, workshops, and seminars with experiential education for students to develop the skills to incorporate social medicine in their future practice. Curriculum Curriculum description See Supplemental Digital Appendix 1—Curriculum Map—at https://links.lww.com/ACADMED/A922. See Figure 1—Longitudinal curricular themes.Figure 1: Longitudinal curricular themes.Curriculum changes since 2010 In the last decade, the Einstein curriculum has significantly increased integration of foundational science content in the preclerkship years and substantially increased instruction by active learning throughout all 4 years. Einstein has extensively incorporated audience response systems; flipped classrooms; and self-directed, team-based, and case-based learning. Education centers in the former library stacks and a dining hall have created spaces for active learning modes of instruction. Leveraging the Educational Innovations Team, launched in 2019, we plan to continue basic and clinical sciences integration supported by modalities for prelearning that advance active learning sessions. We will be expanding our population health curriculum to more robustly address structural determinants of health faced by communities in the Bronx and developing content to assure that students can harness big data to address their patients’ health care needs. Assessment Einstein established internally developed institutional objectives in 1997, which were refined in 2006. In 2011, an intensive institution-wide process enabled the shift to a competency-based education model. All graduates must demonstrate competency in 7 areas: healer, scientist, advocate, educator, colleague, role model, and lifelong learner. Our competencies are linked to the Physician Competency Reference Set. With this curricular evolution, we initiated a new revision process in mid-2019 with the Medical Education Council committees, to be completed in 2020. In 2018, Einstein implemented policies expanding our assessment system to formally promote assessment for learning. As of 2019, all preclerkship courses have a developmental assessment system (e.g., assessment timelines, mechanisms for formative assessments, assessments that build on previous content) to ensure that students can measure their progress in learning at multiple points during a course. Students can use feedback from no-stakes and low-stakes assessments to reinforce concepts, promote their planning for study, or take corrective steps before final course grades are assigned. Students who do not pass a specified number of assessments must meet for advising during the course with the course director and the OASC. Course directors also receive feedback about students’ understanding of material in real time. All students can electronically review their high-stakes multiple-choice question (MCQ) exams and discuss items and content with their instructors. Also in 2018, a quality improvement policy was introduced for all medium- and high-stakes MCQ exams created by Einstein faculty. Exams are electronically analyzed, and those questions with > 95% or < 40% of the class answering correctly, those in which more than one answer was accepted, or eliminated questions are flagged. As a measure of overall test reliability, the Kudar-Richardson Formula 20 (KR20) value for the assessment is also reported. Faculty with training in MCQ standards review the entire exam and mark additional MCQs that do not conform to NBME format guidelines, lack clarity, or are deemed not to be core content. The faculty reviewer prepares an annotated Excel sheet highlighting flagged items and composes a report of the analysis, listing specific questions to be answered by the instructor. The instructor submits a response and meets with the reviewer to discuss the report, with the goal of changing a minimum of 10%–20% of the MCQs on the assessment each year. See Supplemental Digital Appendix 2—Competencies, Program Objectives, and Assessment Methods—at https://links.lww.com/ACADMED/A922. Pedagogy We use the following instructional methods: Case-based learning Clinical experience: ambulatory Clinical experience: inpatient Discussion: large group (> 12) Discussion: small group (≤ 12) Laboratory Lecture Peer teaching Preceptorship Problem-based learning Role play/dramatization Self-directed learning/tutorial Simulation Standardized/simulated patients Team-based learning Video/podcast Virtual patient Workshop As noted, there has been a concerted effort to decrease use of lectures in the foundational sciences curriculum and convert them into interactive sessions using active learning pedagogy. In the clerkship phase, students routinely participate in both ambulatory and inpatient clinical experiences as well as preceptorship in the context of patient care. There is increased use of problem-based learning, peer teaching, role play, and simulations across clerkships. There are both formative and summative assessments through OSCEs using trained standardized patients across the 4-year curriculum. Clinical experiences Einstein students participate in clinical activities in all 4 years of the curriculum. In years 1 and 2, students participate in 1 half day per week preceptorships in ambulatory, emergency medicine, and inpatient services of the Montefiore Health System and Jacobi Hospital Health System, as well as other community-based practices affiliated with the school. Sites used in years 3 and 4 include inpatient and outpatient services of affiliated municipal, state, voluntary, and academic medical center hospitals and clinics located in the Bronx, Queens, Long Island, and Westchester and Rockland counties. Einstein students participate in the Clinical Experience Module (CEM) of the Introduction to Clinical Medicine (ICM) course during the preclerkship phase of the curriculum. Assignments to clinical sites are based on student preference and a lottery system, and students visit the same site, typically working with the same preceptor for a full year or even for both years 1 and 2, thus having a longitudinal mentoring experience with the provider as well as getting to know the site’s patient population and other health professions staff. In the third year, students spend 1 half day per month away from clerkships, to participate in the Patients, Doctors, and Communities course. This course provides a safe place for reflection and debriefing challenging experiences in the clerkship and serves as a curricular element to teach and assess advanced clinical skills and ethics. It also provides opportunity for students to assess their professional identity formation. As noted, students start the CEM of the ICM course in the fall of their first year, participating in near weekly experiences throughout the preclerkship curriculum. Additionally, as part of the communication module of ICM, students visit medical and psychiatric wards where they interact with patients under observation. Einstein students have required community-based rotations as part of the ICM course in years 1 and 2 as well as in components of the family medicine, obstetrics, internal medicine, pediatrics, surgery, psychiatry, neurology, and geriatrics clerkships. There is a required community-based project in the family medicine clerkship. Additionally, required fourth-year rotations in ambulatory medicine have community-based features. Myriad ambulatory opportunities are available to students through fourth-year electives both at the school and away, available through VSAS. Einstein has a formal Office for Community-Based Service Learning that oversees a diverse range of engagement, educational, research, and leadership opportunities for students. Since 1999, students have operated a free clinic serving uninsured adults in the Bronx. Current challenges to our clinical education include the consolidation of health care systems, which has led to closing or restructuring services offered by historical affiliates. Additionally, the current financial model at our clinical affiliates is based on the relative value unit, which can have a negative impact on the time and interest faculty members have in providing clinical education. The founding of new medical schools in close proximity has also created clinical capacity stress. It is difficult to maintain a fair, reliable system to assess all of our learners’ competencies across multiple clinical sites with different types of faculty working. We are working to develop sufficient resources to provide reliable and high-quality clerkship OSCEs. Curricular Governance See Figure 2—Curricular governance.Figure 2: Curricular governance.Education Staff Einstein’s Office of Medical Education (OME) is responsible for ensuring delivery of the curriculum. In addition to deans for biomedical and clinical sciences, staff in OME support our electronic curriculum by assisting faculty in uploading resources to our learning management system (LMS) and administering exams. The Educational Innovations team of instructional designers assists course and clerkship directors in creating teaching and assessment initiatives that incorporate evidence-based best practices in educational technology and active learning. We also provide support for the educational technologies used at Einstein, including the LMS, a lecture capture system, and an audience response system. We require students to evaluate courses and clerkships, lecturers, and small-group facilitators using an online evaluation tool. We have implemented several programs to monitor the activity of the curriculum and continually drive process improvement. The primary role of the OME is to expertly deliver and robustly assess Einstein’s curriculum to produce physicians who will excel in diverse future activities. Within OME, the Office of Diversity runs a state-funded program for grade 7–12 students that provides preparative opportunities for advancement in science and medicine, which is followed by an extension program for college students. We also run a diversity summer research program for college sophomores and juniors. The Office of Student Affairs is a close partner with OME in actualizing the primary role of medical education staff and faculty. See Figure 3—Educational staff organizational chart.Figure 3: Educational staff organizational chart.Faculty Development and Support in Education The Office of Faculty Development (OFD) offers a comprehensive program of workshops, workshop series, and full-day seminars that promote research seminars and clinical faculty in enhancing their educational and professional skills. The OFD also sponsors major annual events such as Davidoff Education Day, which includes a keynote lecture from a national leader in medical education; the Assessment Summit, which trains course and clerkship leaders in best practices in assessing learners; and the Summer Intensive for New Medical Educators focused, on faculty new to teaching within 5 years. Teaching is a key component of the promotion process as it is considered a “major leg” in determining promotion. A teaching portfolio is required for faculty in the educator tracks and is strongly encouraged for all faculty undergoing consideration for promotion. Among the various components, the portfolio requires student evaluations provided by OME. To be considered for promotion or tenure, all faculty must document their teaching contributions.

Medical Education Program Highlights The Keck School of Medicine (KSOM) medical education curriculum is integrated and system based with substantial emphasis on the early and progressive development of clinical skills; the clinical relevance of basic science; direct experience with patients or simulations representing a set of common and/or important diseases and conditions; gaining skills in hypothesis-driven research; well-being; professional identity formation; and the roles of the humanities, ethics, art, and law in medicine. The following courses and programs are highlights within the KSOM curriculum and illustrate how we address select areas of emphasis listed above: Clinical skills development: The Introduction to Clinical Medicine (ICM) course is over 50 years old and ensures that students develop clinical skills early in medical school. It is a longitudinal course during years 1–2 with a faculty-to-student ratio of 1:6. Students systematically acquire clinical skills and competency in interviewing, history taking, and physical examination through workshops with standardized patients and hone their skills through encounters with actual patients every other week beginning the first few weeks of medical school. ICM also introduces students to clinical problem solving and documentation in the medical record. Mentoring and professional identity formation: The Professionalism and the Practice of Medicine (PPM) course pairs 2 faculty mentors with a group of 24 students in years 1–2 to gain skills and competence in communication, the social and community contexts of health care, ethical judgment, self-awareness and reflection, self-care and personal growth, professionalism, cultural competence, and lifelong learning. Mentoring is extended into year 3 with the Track Mentor Program (a faculty member meets regularly with students on each clerkship track) to continue student professional identity formation and to support a positive learning environment. Student well-being: The KSOM hired a director of medical student wellness and has integrated 34 hours of required well-being curriculum throughout years 1–3 and additional optional activities to facilitate student wellness. The content is not tested/graded and focuses on the lived experience of the medical students, the link between physician well-being and quality/patient safety outcomes, incorporation of student self-reflection, and promotion of appropriate self-disclosure/role modeling by instructors. Humanities, ethics, art, and law curriculum: This 4-year curricular thread is integrated into courses including ICM, required clerkships, and year 3 intersessions. In years 1 and 2, the focus is on collaborative discourse to help students learn to identify, analyze, and resolve clinical ethical problems. Years 3 and 4 include ethics education by clinical role models. Curriculum Curriculum description The KSOM is currently a 4-year curriculum. Years 1–2 are delivered as integrated systems and longitudinal courses (ICM, PPM, and the Scholarly Project course). USMLE Step 1 is taken at the end of year 2. Years 3–4 are designed as a continuum and include the core required clerkships (family medicine, internal medicine, internal medicine subinternship, neurology, obstetrics–gynecology, pediatrics, surgery, and surgery subspecialty) and individualized selective and elective rotations, enabling senior students to pursue independent learning plans in pursuit of their specific career goals. See Supplemental Digital Appendix 1—Curriculum Description—at https://links.lww.com/ACADMED/A831. Curriculum changes since 2010 Changes made to the curriculum since 2010 are highlighted below: Learning by cadaveric dissection was better integrated with system content. A Transition to Clinical Practice course was established to precede start of core clerkships in year 3. Two single-week intersession courses during year 3 were added for students to pause, reflect, and consolidate clinical/educational experiences of year 3. The requirement of a scholarly project was implemented through the Scholarly Project course to engage all students in hypothesis-driven research. The longitudinal year 3 Track Mentor Program to continue to promote professional identity formation and a positive learning environment was established. A number of year 4 electives were made flexible by self-directed asynchronous learning, distance learning, and/or flexible clinical shifts to enable students to participate in residency interviews while achieving the objectives of the electives. Assessment The KSOM medical education program objectives are adapted from the ACGME domains of competence to meet the needs of the KSOM curriculum. See Supplemental Digital Appendix 2—Program Objectives and Assessment Methods—at https://links.lww.com/ACADMED/A831. Changes in student assessment implemented since 2010 are highlighted below: An end-of-year 2 cumulative exam was discontinued because it did not provide additional student performance information. An end-of-year 1 cumulative exam was changed from summative to formative. A clinical assessment tool based on observable behaviors was implemented in all required clerkships. Narrative assessments by research mentors and some small-group facilitators were added. OSCEs in required clerkships were supplanted by twice yearly multistation mini-clinical performance examinations with OSCEs reflective of each student’s prior clerkship experiences. Pedagogy The KSOM uses a variety of pedagogical approaches within courses and across all 4 years to achieve medical education program objectives. See Table 1—Pedagogy.Table 1: PedagogyChanges in pedagogy implemented since 2010 are highlighted below: The use of audience response systems in lectures has been promoted and increased. Approximately 50% of the 6-week hematology and clinical immunology system and 100% of the obstetrics–gynecology clerkship curriculum were converted to flipped classroom teaching models. The internal medicine subinternship curriculum was converted to a predominantly workshop-based learning approach. A year 4 elective, Teaching and Leading in Residency, made up of web-based meetings and distance learning was created. Clinical experiences LAC+USC Medical Center is one of the largest public health care hospital and ambulatory networks in the country and serves as the primary inpatient and ambulatory teaching site for KSOM students. Other health care settings include Keck Hospital and the Norris Comprehensive Cancer Center (USC-owned private healthcare facilities), community-based clinics, private physician offices, and Children’s Hospital Los Angeles. The principal challenge in designing and implementing clinical experiences is in identifying new clinical sites for required clerkships, especially in psychiatry and obstetrics–gynecology. Required longitudinal experiences ICM is delivered in years 1–2 and enables students to achieve competency in basic clinical skills through workshops and encounters with real patients. Students learn from real patients and are exposed to patient care activities in the ICM course in the first few weeks of medical school and every other week in years 1–2. PPM is delivered in years 1–2 as a mentoring and professional identity formation program. The Track Mentor Program in year 3 promotes the continued development of professional identity formation and a positive learning environment. Required and elective community-based rotations The family medicine clerkship provides all students with individualized opportunities to experience community-based practices and to understand the role of a primary care physician. A variety of elective community-based experiences are also offered in general internal medicine, neurology, and integrative medicine. Curricular Governance See Figure 1—Medical Education Curriculum Committee governance.Figure 1: Medical Education Curriculum Committee governance.The KSOM provides stipends for the roles of system chairs and clerkship directors and funding for salaries of medical student educators (MSEs). Departments may provide additional funds for MSEs and they support all other faculty time and activities. Departments that oversee required clerkships fund clerkship coordinator positions. Each department receives funding allocations from the Office of the Dean to assist with faculty and staff compensation, which are based on department undergraduate education effort. Education Staff The Office of Curriculum is responsible for overseeing and ensuring the development, implementation, and delivery of the 4-year MD curriculum. The Office of Curriculum provides direct support to faculty course directors, instructors, and medical students. It oversees the scheduling and coordination of courses and faculty and the development and distribution of supporting materials. The Office of Curriculum organizes and administers the Medical Education Curriculum Committee and its subcommittees to ensure continuous quality improvement efforts in all aspects of the MD curriculum. The Evaluation, Assessment, and Reporting unit within the Department of Medical Education manages the entire evaluation process of all core learning and teaching events throughout the 4-year MD program. It oversees the development of tools (examinations, questionnaires, focus groups, etc.) and produces relevant reports for assessment of outcomes and continuous quality improvement activities. The role of primary medical education staff and administrative faculty in the Office of Medical Education is to support all aspects of the MD program. The office is responsible for multiple areas outside of educational programming relevant to medical students, that is, admissions, student affairs, diversity, and inclusion, and the undergraduate minor in health care studies. The Office of Curriculum is responsible for overseeing and administering curricular aspects of the MD program or the MD component of dual-degree options. See Figure 2—Medical education leadership.Figure 2: Medical education leadership.The Department of Medical Education is composed primarily of PhD/EdD educator faculty members and part-time or voluntary faculty instructors in required longitudinal courses. The department is composed of multiple units, including clinical skills education and evaluation, evaluation and assessment, educational technologies, faculty development, academic support, and instructional design. The department has offered a Masters of Academic Medicine program since 2009 and graduated 103 individuals to date, including many KSOM faculty. The department also sponsors an annual Innovations in Medical Education conference. Faculty Development and Support in Education The Faculty Development Unit in the Department of Medical Education provides direct support for Keck faculty and residents who wish to improve teaching skills and educational scholarship. The unit provides a wide range of services and offerings including customizable faculty development sessions on assessment and feedback, curriculum design, instructional design and strategies, program evaluation, and educational scholarship and research. Interactive workshops are targeted to specific teaching needs including, but not limited to, creating a positive learning environment, identifying learners in difficulty, assessing learners, providing effective feedback, small-group teaching, and teaching in the clinical setting. Small-group or 1-on-1 consultation sessions addressing the specific needs of individual faculty or small groups (disciplines, systems, clerkships, etc.) are available upon request. The department also oversees residents-as-teachers training by directly delivering content or by coordinating with departmental training programs. The KSOM has established 7 promotion tracks that reflect the different profiles of activities and contributions of faculty. Each track includes expectations for contributions in scholarship, education, and service and, in the case of the clinician–educator and practitioner series, clinical practice. The amount of time devoted to individual areas and expectations in each area differ among the promotion series. Aggregate evaluation reports from students and residents of teaching/education activities are included in the promotion dossiers. Letters from mentees are also solicited and, in the case of the clinician–educator series, evaluation of teaching effectiveness by residency and/or fellowship directors may be requested. Teaching evaluation data are provided annually to each department chair at the time of faculty merit review. Initiatives in Progress The KSOM curriculum will transition to a renewed 4-year physician–citizen–scholar curriculum effective 2021 with the class of 2025. The renewed curriculum will be delivered in 3 phases: preclerkship (18 months), clerkship (12 months), advanced clinical experiences (18 months). Planned features of the renewed physician–citizen–scholar curriculum are: Four hours of active case-based learning each week of the preclerkship phase. Enhanced clinical skills and clinical reasoning development in the preclerkship phase. Emphasis on active learning strategies throughout the curriculum, early clinical immersion, and a learning environment that fosters the well-being and professional development of students. Engagement of students with surrounding communities. Enhanced offerings in humanities, ethics, art, and law. Provision of a certificate in Social Justice in Medicine. A new longitudinal coaching program to guide professional identity formation. Integration of health systems science instruction and related clinical experiences throughout the preclerkship and clerkship phases. Immersive clinical training in the clerkship phase through a series of core clerkships organized into two 26-week blocks of grouped clinical rotations: 1 block of internal medicine/family medicine/psychiatry/neurology and 1 block of surgery/anesthesia/obstetrics–gynecology/pediatrics. The blocks will be enhanced by “just in time” training and by longitudinal cross-cutting themes covering geriatric medicine, chronic disease prevention and management, and mental health during the internal medicine/family medicine/psychiatry/neurology block; and health systems science, social justice, and quality and patient safety during the surgery/anesthesia/obstetrics–gynecology/pediatrics block. Individualized training in the advanced clinical experiences phase to enable the determination and pursuit of one’s areas of interest and ultimate career goals. An end-of-year 4 Transition to Residency course. Step 1 will be taken after the clerkship phase.

This study was designed to make bare the importance of a proficiency driven curriculum, the need to foster self -directed and self- motivated learners hence the study investigated the factors influencing the acquisition of clinical skills and skills proficiency in preclerkship clinical education using video modelling among medical students in MacArthur Clinical Skills Laboratory (MCSL). It adopted the ex-post facto design. The population of the study was three hundred and eight(308) 4 th and 5 th year medical students who took the course Introduction to Clinical Medicine (ICM). Four research questions and four hypotheses guided the study. The instrument titled clinical skills acquisition through video modelling questionnaire (CSATVMQ) was developed and used to collect data. The reliability of the instruments was established using the Cronbach Alpha method of internal consistency. The reliability coefficients of the sub scales of CSATVMQ were 0.57, 0.84, 0.86, 0.95, respectively for self- directed learning, clinical skills acquisition, frequency of visitation and proficiency. Simple percentage was employed for analyzing the research questions while the hypotheses were tested using the chi-square. The findings established that the utilization of video modelling technique for the promotion of clinical skills acquisition and proficiency was not dependent on gender, academic level and age of medical students, also further test with lambda ( λ) indicated no relationship with a λ value of 0.0 between the dependent and independent variables studied. The researcher therefore recommend that College of Health Sciences, University of Port Harcourt should allocate more time in their Faculty lecture timetable to provide students with adequate practice hours and feedback sessions while enforcing it as a compulsory teaching and learning technique to enhance proficiency and self –evaluation of learnt skills during preclerkship clinical training.

The current trend in medical education is to introduce clinical teaching early in the medical school curriculum to help students understand the relevance of the basic sciences to clinical practice. The Introduction to Clinical Medicine (ICM) Program for students in the first two years at the Albert Einstein College of Medicine (AECOM) is comprised of three, required, integrated courses providing skills training in both medical interviewing and physical examination, training in diagnostic reasoning skills, and opportunities to discuss broad themes in medicine and the doctor-patient relationship. Competency evaluation of students’ clinical skills is an essential part of the ICM Program. Innovative strategies for weaving themes related to cultural competency have been incorporated into the ICM program to address the wide spectrum of cultural issues affecting medical care and the doctor/patient relationship, including diversity, spirituality, complementary and alternative medical practices, and end-of-life care. A total of 300 medical school faculty members teach in the various ICM courses. Much effort goes into keeping the faculty current, happy, and rewarded for their dedication and hard work in teaching the students. The ICM Program continues to strive for excellence as we prepare AECOM students to face the demands of medical practice in the twenty-first century

At the University of Texas Houston Medical School, a rotational dissection system was introduced to improve coordination between the Gross Anatomy and the Introduction to Clinical Medicine (ICM) courses. Six students were assigned to each cadaver and divided into two teams. For each laboratory, one team was assigned to dissect and the other to attend ICM or study independently. For the next laboratory, the assignments were reversed. At the start of the session, the team that had dissected previously spent 30 minutes teaching the other team. In 2012, the students were given three traditional practical examinations with 50 questions drawn equally from each laboratory. Students also completed three mid-course evaluations. There were no significant differences in overall performance between the two teams. Nevertheless, we wanted to determine how well individual students identified structures they had dissected compared with those they had not. For dissected structures, the mean percent correct was 80.0 ± 13.0 (mean ± standard deviation), and for undissected structures, it was 78.3 ± 14.1. The difference was small, but statistically significant (P = 0.0007). Although this result validated the concerns expressed by some students, it did not appear that a change in the system was justified. Students were generally enthusiastic about the opportunity to learn clinical skills in the first semester of medical school, and 91-96% of the students agreed that learning anatomy at the same time helped them understand the physical examination exercises in ICM.

At UT-Houston, we use a rotational dissection system to improve coordination between Gross Anatomy and Introduction to Clinical Medicine (ICM), in which first-year medical students learn physical examination skills focused on the region they are dissecting. Six students are assigned to each cadaver and divided into two teams. For each laboratory, one team is assigned to dissect and the other to attend ICM and study independently. For the next laboratory, the assignments are reversed, and the team that dissected spends 30 minutes teaching the other team. The students are given three traditional practical examinations with questions drawn equally from each laboratory and three course evaluations. In 2012, there were no significant differences in overall performance between the two teams. To determine whether the students did better at identifying structures they had dissected than those they had not, we used a mixed effect model with repeated measures, with each student serving as his or her own control. Results from all three exams were combined and expressed as % correct ± SD. For dissected structures, the mean was 80.0 ± 13.0, and for undissected structures, it was 78.3 ± 14. The difference was small, but statistically significant (p = 0.0007). This validated the concerns expressed by some students, but 91-96% of the students agreed that learning Gross Anatomy helped them understand the physical exam exercises in ICM.

Curriculum of introduction to clinical medicine（ICM） in the University of Ottawa＇s Faculty of Medicine was analyzed. Characteristics of ICM course in the University of Ottawa＇s Faculty of Medicine were： early setting, rich in content, long duration and focusing on clinical. ICM course between Guangxi Medical University and University of Ottawa＇s Faculty of Medicine were compared. Taking advantages of ICM course in the University of Ottawa＇s Faculty of Medicine was conductive to better understanding the importance , teaching objectives and means of ICM course . The teaching quality evaluation system of ICM course would be built in the future. Key words: University of Ottawa＇s Faculty of Medicine; Guangxi Medical University; In-troduction to clinical medicine

Little is known about the acceptance of different teaching/learning modalities by students and faculty in the preclinical semesters of medical school. We report the results of an anonymous survey at Ross University School of Medicine, where most of the currently popular instructional methods are used. Study subjects included 327 students and 30 faculty members. 5 questions each were asked about lectures, handouts, textbooks, mediasite (video-recorded lectures), simulation, PBL (problem based learning), TBL (team-based learning), and ICM (introduction to clinical medicine, physical examination) practicals, scored on a 5-step Likert scale. Response rates were approximately 80% for students and more than 50% for faculty. Students gave the highest scores to mediasite followed by simulation, handouts, and ICM practicals. Lowest student scores were for PBL followed by TBL and textbooks. Faculty gave highest scores for lectures, followed by ICM practicals and textbooks. They gave the lowest scores for TBL followed by mediasite and PBL. Differences between students and faculty were statistically significant for lectures (P<.001), mediasite (P=.001), textbooks (P=.002), and PBL (P=.043).

Curriculum Management and Governance Structure ♦ Education Policy Committee (EPC): The EPC advises the Dean and evaluates all matters related to medical education including general oversight of the curriculum and focuses on policies related to administering medical education. ♦ The EPC membership includes representatives from every clinical and basic science department, chairpersons of the Year I-II and Year III-IV Curriculum Committees, as well as student representatives. Educational deans and medical education faculty participate in an ex officio capacity. ♦ Curriculum Committees: The curriculum committees that report to the EPC are comprised of System Chairs and Discipline Coordinators (Year I-II Curriculum Committee) and Clerkship Directors, Medical Student Educators (MSE), and Basic Science representatives (Year III-IV Curriculum Committee). Students, educational deans, and medical education faculty participate in all meetings. Office of Education ♦ There are multiple offices that support the medical student education program: The Curriculum Office, the Student Affairs Office, the Office of Diversity, and the Division of Medical Education. ♦ The Division of Medical Education was organized in 1963. The Division is staffed by ten doctorate-level professionals with degrees in education and six full-time staff members. ♦ The Division of Medical Education was established to support and encourage the improvement of medical education by providing faculty development; consulting on the design, implementation, and revision of educational programs; and conducting research into effective means of delivering medical education. The division has an active standardized patient program that provides patients for teaching and evaluation at USC. The program conducts clinical performance examinations for all USC students matriculating into the fourth year of medical school as well as Objective Structured Clinical Examinations (OSCE) for students in Introduction to Clinical Medicine (ICM) and the clerkships. The program participates as a member of the California Consortium for the Assessment of Clinical Competence, which was created by a grant from the Josiah Macy Jr. Foundation. Medical Education maintains a unit with expertise in psychometrics, research design, and statistical analysis. The unit is active in institutional research (i.e., admission history and graduation rates) and other educational research projects. The division offers a masters degree program for faculty in health professions, two faculty development fellowships in Teaching/Learning and Educational Leadership, and an Educational Scholars program for USC faculty. The division also supports a Learning Resource Specialist who counsels students experiencing academic difficulties. Financial Management of Educational Program ♦ The KSOM has a mix of revenues to support its varied activities. This mix negates any volatility of its revenues and allows for a consistent revenue stream. ♦ Additionally, USC is a large private university and as such remains unaffected by the decreased support from the State of California that has negatively impacted other California medical schools. ♦ In 2008, the Dean appointed a new position, Vice Dean for Education, providing centralized financial management. ♦ In FY 2009, a new budget methodology was enacted that allocated budgets to departments based on medical student teaching effort. The budget allocation to the respective department was provided based on a formula that evaluated teaching effort provided by faculty that were based within their department. Valuing Teaching ♦ The Medical Educators' Collegium is constituted as an honor society of faculty, fellows, residents, and students committed to promoting and supporting educational excellence at the Keck School of Medicine. Its faculty members are individuals with established records of excellence as educators. ♦ The promotion and tenure process includes a Clinical Educator designation for clinician faculty whose primary activities include teaching and educational scholarship. Promotion of tenure track faculty requires demonstrable excellence in teaching of medical students and trainees. Curriculum Renewal Process ♦ Full curriculum integration was advanced through redesign of the Keck curriculum, initiated in 2001, in which each section and system of the curriculum builds upon previously acquired knowledge and skills. Disciplines that had been taught and graded separately in the old curriculum were integrated within the new curriculum. ♦ Ongoing integration and coordination is managed through systematic curriculum review by the Curriculum Committees and periodic meetings of the EPC with the Curriculum Committees. ♦ A phased-in revision of the year III-IV curriculum has occurred over the past nine years. The years I-II and III-IV Curriculum Committees perform regular review of their respective curricula. If results of curricular review suggest that educational delivery of a particular unit may not be optimal, this information is brought to the attention of the appropriate Curriculum Committee and/or EPC for further discussion. ♦ If necessary, a subcommittee may be appointed to conduct a needs assessment and report back to the EPC. In this way, curricular planning operates as an extension of curricular evaluation. Learning Outcomes/Competencies Competencies for KSOM graduates have been established and linked to the School's Educational Objectives, as indicated in Table 1.TABLE 1: Competencies for GraduatesTABLE 1: (Continued)New Topics in the Curriculum Since 2000 ♦ Patient Safety and Quality Improvement are taught in an integrated manner across all four years of the curriculum. Students are introduced to core concepts in year I and II ICM, receive instructions during year III Orientation, which is reinforced during each of the core clerkships, and they participate in a day-long seminar on Patient Safety (including performing a root cause analysis) during year IV. ♦ Simulations have been a part of the curriculum at USC since standardized patients were introduced in the 1970s. KSOM currently uses the SimMan/Ventriloscope/eye model in the ICM program and in the Medicine core clerkships. Students visit the Procedural Skills Center during all four years, and prior to beginning year III, they take a required one-day course in IV catheter insertion, ABGs, Foley catheter and nasogastric tube placement, suturing, incision, and drainage procedures, and so on. These skills are reinforced during all core clerkships, both in the Center and on the wards. Changes in Pedagogy ♦ Professionalism and the Practice of Medicine (PPM): This Year I-II course was implemented with the curricular revision in 2001 and was designed to address KSOM's core program goals in the domains of professionalism, ethics, cultural competence, and health care policy/finance. Students meet once per week in cohorts of 24 students with two faculty mentors. PPM stresses group process and reflective work, and students are evaluated on participation and presentation skills (Elliott DD, May W, Schaff PB, Nyquist JG, Tria J, Reilly JM, Lattore P. Shaping professionalism in preclinical medical students: Professionalism and the practice of medicine. Med Teacher. 2009; 31:7, e295–e302). ♦ Integrated Cases Section (ICS): This seven-week course takes place at the end of Year II. ICS includes studies of cases that integrate basic science knowledge with the diagnosis and management of complex clinical cases where multiple organ systems are involved. ICS emphasizes problem solving in the diagnosis and management of cases. Under the guidance of faculty facilitators, students learn clinical reasoning related to managing undifferentiated clinical problems such as fever, fatigue, and headache. The cases on the end-of-Year II OSCE are designed to evaluate students' mastery of the educational objectives of ICS. ♦ Student Practice Profile (SPP): The SPP integrates 200 case studies within all portions of the curriculum, providing a structure for curriculum organization and clinical relevance across the four-year curriculum. In Years I and II, SPP cases are integrated into the systems, providing a framework for establishing clinical relevance and correlations with the basic sciences. Clinical and didactic experience with SPP cases is completed in Years III and IV; required clerkships identify SPP cases and patient encounters needed to meet clerkship objectives, and adjustments have been made across clerkships to assure that all SPP cases are experienced, and the clerkship required cases are balanced and coordinated (Abbott A, Sullivan M, Nyquist J, Taylor C. The development of a ‘Medical Student Practice Profile’ core curriculum at the University of Southern California. Teaching Learning Med. In Press. 2010). Changes in Assessment ♦ Peer assessment of professionalism was implemented in the PPM course in 2001. ♦ Professionalism of students, residents, and faculty is also being assessed as part of the NBME Assessment of Professional Behaviors (APB) pilot project during 2009–11. ♦ Computerized testing was implemented in years I and II beginning in 2009. ♦ NBME subject examinations are now used in all core clerkships. ♦ All clerkships (with the exception of Pediatrics) now use OSCEs as part of the evaluation of students. ♦ Each clerkship also incorporates assessment of students' mastery of the SPP that represents the overarching structure (as well as the must-see cases) of the KSOM curriculum. Clinical Experiences ♦ KSOM's primary clinical teaching site, the new LAC + USC Medical Center, opened in November 2008 and provides students with a state-of-the-art learning environment and a wealth of patients and opportunities for clinical experiences. In anticipation of the new hospital having fewer beds than the old, KSOM recently added additional affiliated clinical sites. This includes two sites (Kaiser and California Hospital) for the Obstetrics-Gynecology clerkship to ensure that students have adequate labor and delivery experiences, as well as Santa Barbara Cottage Hospital where students can rotate through OB-GYN, Pediatrics, Internal Medicine, and Psychiatry. In April 2009, the University acquired ownership of USC University Hospital and Norris Cancer Hospital, thereby assuring a more seamless clinical education at these two hospitals. ♦ All clinical sites are reviewed by the Year III-IV Curriculum Committee for the appropriateness of clinical exposure, equivalence of opportunities across sites and excellence of faculty at sites other than KSOM's core teaching sites (LAC + USC, CHLA, USCUH, and Norris). For example, the Psychiatry clerkship sites (many of which were added as the clerkship sought to identify sufficient opportunities for clinical education) were reviewed, and of the multiple sites utilized in 2007–08, five were deemed to offer an inadequate educational experience during a review in 2008–09. Modifications were made, and for academic year 2009–10, students rotated through seven Psychiatry sites. ♦ Sites for clinical education are listed in Table 2.TABLE 2: Clinical Sites* Highlights of the Program/School ♦ Medical Student Educators (MSEs): Because medical school faculty members face increased clinical and academic demands, leaving less time for teaching, curriculum development, and assessment of learners, KSOM has hired a dedicated medical student educator (MSE) for each required clerkship. ♦ The medical student educator (usually an advanced practice nurse or physician assistant) assists the clerkship director with clinical teaching, curriculum development, student and program evaluation, and administrative functions. The program has been well received by both students and faculty. ♦ Students believe that the medical student educators add value to their clinical experiences and support both their clinical education and personal and professional development. ♦ Preliminary data suggest that student performance has improved, and additional measures of quantitative impact are under way (Elliott D, Ingersoll S, Sullivan M, Bruning M, Logan M, Taylor C. The nonphysician ‘medical student educator’: A formal addition to the clerkships and key programs at an academic medical center. Teaching Learning Med. 2007; 19(2): 154–161). ♦ Introduction to Clinical Medicine (ICM): The ICM program celebrates its 40th birthday this year and is considered by many students and faculty to be the “jewel in the crown” of the KSOM curriculum. ♦ Students spend one to two half days per week during Years I and II with a clinical faculty member as they learn interviewing and physical examination skills and the art and science of medicine. ♦ The majority of the ICM experience takes place in the clinical setting, with students beginning their clinical encounters in the first few weeks of medical school. ♦ Professionalism and the Practice of Medicine (PPM): With increasing emphasis placed on the teaching and assessment of professionalism in the continuum of medical education, KSOM aimed to develop a novel longitudinal course in professionalism spanning the first two years of the curriculum. Using the conceptual framework of constructivism, principles of adult learning, experiential learning, and reflective practice to integrate learning with experience, we include student input in session development. ♦ Faculty mentors serve as role models to guide, assist, and counsel students. Assessment of learners is accomplished using self, peer, and mentor evaluation and a student portfolio. Program evaluation is by course and faculty evaluation. ♦ The Student Practice Profile (SPP), as described above, integrates case studies within all portions of the curriculum, providing a structure for clinical relevance and curriculum organization across the four-year curriculum. ♦ Program in Medical Humanities, Arts, and Ethics: In 2006–07, KSOM rejuvenated its Humanities, Ethics, Art, and Law (HEAL) curriculum and implemented an integrated four-year longitudinal program. Students experience these curricular components in ICM, PPM, the core clerkships, the Senior Seminar Series, and in year IV electives. ♦ Additionally, the extracurricular components include a faculty-student reading group, a faculty-staff-student art gallery (home to two shows per year), life-drawing classes, museum visits, and the opportunity to experience cultural and artistic events in Los Angeles through the University's Arts and Humanities Initiative.

Curriculum Management and Governance Structure ♦ The Medical School Curriculum Committee is a standing committee of the Faculty Senate and is responsible for the management of the entire medical school educational program (Figure 1).FIGURE 1:: Curriculum Management and Governance Structure♦ The Curriculum Committee is composed of faculty members from medical school departments including course and clerkship directors, representatives from the Office of Educational Programs and the Office of Admissions and Student Affairs, and student representatives from each year. Faculty members are approved for three-year terms, renewable once. The Chair and Vice Chair are appointed for three-year terms. ♦ The Chair and Vice Chair of the Curriculum Committee are members of the general medical school faculty. ♦ The Curriculum Committee has six subcommittees: Educational Policy Subcommittee, MSI and MSII Evaluation Subcommittee, MSIII and MSIV Evaluation Subcommittee, Curriculum Integration Subcommittee, Technology in Education Advisory Committee, and Scholarly Concentrations Advisory Committee. Office of Education ♦ There is a designated Office of Educational Programs (OEP) to support the educational activities of the school, course and clerkship directors, and teaching faculty. ♦ The OEP works cooperatively with the Curriculum Committee in the development, implementation, and evaluation of all curricular offerings. ♦ The OEP provides faculty development and resident teaching workshops in the areas of educational theory and practice, including curriculum design, program evaluation, and learner assessment. ♦ The Associate Dean for Educational Programs, who is also responsible for Graduate Medical Education and Continuing Medical Education, reports directly to the Dean of the Medical School. ♦ There are four Assistant Deans who support various aspects of the educational program. They also hold leadership positions on the Curriculum Committee and its subcommittees and direct the Pre-Entry Program, the Summer Research Program, the UTMS-H Academy of Medical Educators, and the Scholarly Concentrations Program. ♦ The Director of the OEP is a full-time (PhD) medical educator. ♦ The OEP is supported currently by three medical educators (one of whom is the director), a director of educational technology, an education specialist (PhD), two health education coordinators, an instructional developer, a special programs coordinator, a director of the standardized patient program, and a training specialist for the standardized patient program; in addition, there is a senior executive assistant and a staff assistant. Financial Management of Educational Programs ♦ The undergraduate medical education program is supported in part by funding from the State of Texas. ♦ Support for the Office of Educational Programs is primarily from state funds. ♦ In response to a decline in state support for education and reduced growth in clinical income, and to emphasize and preserve the educational mission of the Medical School, an educational relative value unit system was developed initially for clinical departments in FY2005 and implemented for all departments in FY2007. ♦ This method of funding was designed to provide an equitable distribution of state funds to basic science and clinical departments for teaching activities. ♦ The system has been relatively successful in correctly aligning the allocation of state funds with departmental teaching activities. Valuing Teaching ♦ In 2008, the Dean appointed seven faculty as charter members of The University of Texas Medical School at Houston Academy of Medical Educators (AME). ♦ The AME was designed to enhance and focus attention on the educational mission of the medical school. The AME began accepting applications from full-time basic science and clinical faculty in the spring of 2010. ♦ Faculty are recognized for their contributions to the educational program through the promotion and tenure process. ♦ Members of the UTMS-H full-time faculty, whose professional and scholarly activity involves a major commitment to clinical service and teaching, may be appointed and promoted on the Clinician/Educator (tenured) Pathway. ♦ Members of the faculty whose major professional and scholarly activity involves research and teaching may be appointed and promoted on the Scientist/Educator (tenured) Pathway. ♦ Faculty whose professional activities involve patient care, teaching activities related to patient care, and clinical administration with limited research or other scholarly activities may be appointed and promoted on the Clinician (nontenured) Track. Full-time faculty with training or clinical backgrounds, but who are engaged primarily in teaching and educational activities may also be promoted on this track. ♦ Full-time faculty whose primary professional activity is research, with limited teaching or institutional service, may be promoted on the Research (non-tenured) track. Full-time faculty with training or research backgrounds, but who are engaged primarily in teaching and educational activities may also be promoted on this track. Curriculum Renewal Process ♦ During 2005-06, the Curriculum Committee approved the transition of the required four-week Neurology clerkship from the fourth-year curriculum to the third-year curriculum (effective during the 2006-07 academic year). ♦ The Obstetrics and Gynecology and Psychiatry clerkships were each reduced from eight weeks to six weeks to accommodate this change. ♦ Additionally, several revisions to the fourth-year curriculum were approved including three required four-week selectives (Ambulatory Medicine, Advanced Patient Care, and Critical Care) and a required Transition to Residency Month. ♦ The Transition to Residency Month, held in March of the senior year, was designed to help prepare the students for entering their residency programs. The revised fourth-year curriculum was implemented during the 2007-08 academic year. ♦ Clinical Applications was added to the first-year curriculum as a separate course during the 2007-08 academic year. ♦ This course consists of seven 90-minute team-based learning sessions. Each session integrates content from at least two basic science courses with a clinical case presented in the Introduction to Clinical Medicine course. ♦ During each session, students work in teams (6–7 students) to solve problem sets within the context of clinical scenarios. ♦ The course is a joint effort of all the first-year course directors, supported by the Office of Educational Programs. The course is positively received by the first-year students. ♦ Scholarly Concentrations were introduced in the spring of 2010. These Scholarly Concentrations are not a required component of the curriculum, but they provide interested students an opportunity to receive an expanded and enriched learning and scholarly experience in a non-specialty-based area of emphasis while completing the four-year medical school curriculum. ♦ The Scholarly Concentrations will include a defined combination of elective and selective student experiences during the four-year curriculum, culminating in completion of a required scholarly project. Learning Outcomes/Competencies ♦ The Curriculum Committee approved Core Competencies for the undergraduate medical education curriculum in June 2006. ♦ Competency areas include patient care, clinical procedures (routine and specialized), medical knowledge, interpretation of medical data/practice-based learning and improvement, interpersonal and communication skills, and professionalism. New Topics in the Curriculum Since 2000 ♦ Patient safety and quality improvement topics are integrated throughout the curriculum beginning in the second-year Integrated Clinical Experience/Problem-Based Learning (ICE/PBL) course and continuing through the third-year required clerkships, the fourth-year required Critical Care selective, and the Transition to Residency Month. ♦ Specific topics include the following: Problem-Based Learning (PBL) Cases: Need for appropriate medication dosing in the elderly and in patients with renal disease; drug–drug interactions; delayed diagnosis; poor communication between physician and patient resulting in nonadherence to prescribed medication regimen; inappropriate drug dose (medication error) in an infant; missed diagnosis; poor communication with non-English-speaking parent; disclosing medical error; and root cause analysis. Critical Care: During the fourth-year required Critical Care selective, students are introduced to recognizing patient safety issues during their daily rounds with the ICU team. At the conclusion of the month, students participate in a 2-hour session on patient safety, which includes a 30-minute discussion on human error and the factors that can contribute to errors in the medical environment. The ICU teams then present two to three cases encountered during the month; each case is analyzed based on the type of patient safety concern and factors that contributed to the issue. The goal is to have students actively identify patient safety issues in daily practice and become engaged in system processes to address quality concerns and to emphasize the importance of disclosure. Transition to Residency Month: Instruction includes patient safety, reducing medical errors, and common prescribing errors. ♦ Team-Based Learning: Team-based learning is used in four of the first-year courses including the Clinical Applications course (see description under “Curriculum Renewal Process”), Histology and Cell Biology, Immunology, and Physiology. ♦ Simulations/training in new surgical techniques Third-year pediatric clerkship: Students spend one half day in the Surgical and Clinical Skills Center (SCSC) during the third-year pediatric clerkship. During this session, students practice venipuncture and interosseous line placement on infant simulators and lumbar punctures on adult-sized trainers. Students have presession reading material available that explains the procedures, anatomic landmarks, indications, contraindications, and complications. During the session students are encouraged to repeat the procedure several times until they feel comfortable performing the procedure. The session is facilitated by the Clerkship Director and two other general pediatric faculty members. Third-year surgery clerkship: Students spend 3 hours in the SCSC during the third-year surgery clerkship. During the session, students practice Foley catheter insertion, nasogastric tube insertion, and IV insertion. In addition, students use simulators to learn the suturing of lacerations and knot tying. The session is facilitated by the Surgery Clerkship Director and other surgical faculty. Changes in Pedagogy ♦ Gross Anatomy and Introduction to Clinical Medicine: Several years ago, the Gross Anatomy course implemented a change in the format of its Anatomy Laboratory in order to integrate the teaching of Gross Anatomy with the Introduction to Clinical Medicine (ICM) course. ♦ By coordinating the schedules of the two courses, students were able to learn the physical examination that correlated with dissection of a particular region. For example, the cardiopulmonary examination was coordinated with dissection of the thorax. ♦ To better coordinate the time-sharing arrangement, two teams were assigned to each cadaver. This new arrangement introduced the students to the professional responsibilities involved in teamwork. The first 30 minutes of each laboratory was devoted to demonstration of the previous dissection under faculty supervision. This peer teaching provided the student an opportunity to practice creating positive expectations within and between the teams. Changes in Assessment ♦ In May 2004, the Comprehensive Clinical Competency Examination (CCCE) was developed. The examination is designed to assess students' skills in history-taking, physical examination, communication, and diagnostic reasoning at the conclusion of the required third-year clinical clerkships. ♦ The examination consists of 10 common primary care cases that students should have encountered during their clerkships. ♦ The CCCE replaced the fourth-year clinical skills examination. ♦ A committee of faculty from each of the third-year clerkships with support from the Office of Educational Programs oversees and manages the examination. Clinical Experiences ♦ Clinical education occurs in multiple sites: inpatient wards outpatient clinics preceptors' offices ♦ Challenges associated with the clinical education of our students are related to large ward team sizes and faculty time for education. The latter is a result of administrative demands on faculty and the increasing pressure on faculty to maintain clinical/research income. Highlights of the Program/School ♦ The location of The University of Texas Medical School at Houston in the Texas Medical Center, the largest medical center in the world, provides a high volume and rich diversity of patient care and research experiences for students. ♦ The medical school basic science and clinical faculty are committed to medical student education that includes providing opportunities for shadowing, precepting, and research. ♦ The Medical School, including the Curriculum Committee, supports and encourages innovation in education. The Medical School is relatively young and therefore not hampered by longstanding educational traditions. Faculty are encouraged to be creative and innovative in their educational activities. ♦ UTMS-H's Surgical and Clinical Skills Center combines a well-established clinical training program with sophisticated surgical and clinical procedure simulation in one state-of-the-art learning center. ♦ The facility houses a surgical suite and a clinical suite, which combined includes the UTMS-H standardized patient program, two operating rooms, two conference rooms, a virtual reality personal computer (PC) laboratory, a microsurgical skills laboratory, nine surgical skills stations, 14 patient examination rooms, two conference rooms, and two multipurpose skills laboratories. ♦ Students begin their clinical skills training with standardized patients during the first-year Introduction to Clinical Medicine course. ♦ To emphasize clinical skills education throughout the curriculum, the Dean of the Medical School has recently appointed a core group of 26 clinical faculty members who are charged with the responsibility for assisting students practice and refine their basic clinical skills during the required third-year clerkships.

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.

Background: Step 2 Clinical Skills (CS) was recently introduced into the United States Medical Licensing Examination (USMLE™) to ensure that successful candidates for licensure possess the clinical skills to provide safe and effective patient care.Aims: To explore if medical schools had changed the objectives, content, or emphasis in their pre-clinical curriculum in response to its implementation.Methods: In April 2005, the Clerkship Directors in Internal Medicine (CDIM) sent an electronic survey to a single member from each medical school with a CDIM member. The survey instrument included 26 pre-clinical curricular questions with nine questions specifically addressing changes in response to implementation of the Step 2 CS.Results: Forty-five percent of respondents reported changes to the Introduction to Clinical Medicine (ICM) course objectives while 39% and 40% reported changes in content and emphasis. Seventy-four percent felt their students were adequately prepared for the Step 2 CS and 18% were unsure.Conclusions: Over a third of medical schools are implementing changes to the objectives, content, and/or emphasis of their curriculum, at least partially in response to the institution of Step 2 CS.

Backgroundï¼Newly revised cardiopulmonary resuscitation (CPR) guideline in 2005 recommends 30 chest compressions and 2 rescue breaths during CPR for all rescuers to use for all adult victims. We would compare the accuracy of the CPR methods by revised CPR guideline in 2005 and previous guideline in 2000. Materials and Methodsï¼Fifty medical students during the introduction to clinical medicine (ICM) were investigated after 30 minutes lecture and brief education of CPR methods. Each students performed twice both CPR methods, the one by guideline 2005 (method A), 4 cycles of 30 compressions every 2 breaths, and the other by guideline 2000 (method B), 10 cycles of 15 compressions every 2 breaths. ResciÂ® Anne mannekin and LaerdalÂ® skillmeter were used and paper reports were printed after each tests. After then, we compared the technical accuracy of the results between method A (30:2) and method B (15:2). Resultsï¼Total fifty students (37 males, 13 females) were tested, their mean age was 25.1, mean body weight was 63.5 kg. The technical accuracy on chest compression was not different between two methods and also the technical accuracy on ventilation was not different between two methods except total ventilation number (p>0.05). Conclusionï¼We could not find significant differences of technical accuracy between both CPR methods. So we donât think new guideline 2005 is superior to previous guideline 2000 by technical efforts although itâs hemodynamic responses and other clinical benefits is excluded in this study.

Background: Sexual history taking is a core clinical skill for all physicians, yet many medical schools do not adequately address this important topic within the curriculum. This article describes a sexual-history-taking module that was initiated, designed, and presented by 2nd-year medical students for their peers as part of the required Introduction to Clinical Medicine (ICM) course. Description: As part of this module, a group of 2nd-year medical students developed a large-group presentation and small-group role play cases to enhance students' basic sexual-history-taking skills in challenging situations, teach ways to ask nonjudgmental questions, and introduce legal issues that may arise. Under faculty supervision, the students recruited and trained peer and faculty facilitators and designed, developed, and analyzed the survey evaluation tools. Evaluation: Both the students and facilitators completed an anonymous questionnaire within 1 to 4 weeks of completing the activity. Of the 92 students completing an online survey, 92% rated the large group presentation good or excellent, and 89% rated the small-group role playing activities as good or excellent, as compared to overall ICM course ratings of 68% good or excellent. Facilitators were well prepared for their roles and reported that the students responded to them positively. Participating students reported that having students as teachers positively enhanced their small group learning experience. Students performed better on the sexual-history-taking questions on the final examination (97.5%) than on the final examination overall (89%). Conclusions: Medical students can successfully create and implement a curriculum module for their peers in a sensitive area such as sexual history taking. Due to changing responsibilities for students as they progress through medical school, sustainability may be challenging.

Background: Despite the nearly universal practice of using standardized patients in introduction to clinical medicine (ICM) courses, no studies have compared the performance of students trained with standardized patients to that of those trained with hospitalized patients with regard to short- and long-term educational outcomes.Purpose: To examine the differential effect of the use of standardized patients in a simulation center versus the use of hospitalized patients in affiliated teaching hospitals for teaching history-taking and physical examination skills.Methods: This was a nonrandomized cohort study based on self-selection involving students from 2 academic years enrolled in an ICM course who received the final block of their ICM instruction with either standardized patients in the simulation center or hospitalized patients in affiliated hospitals. The primary, end-of-ICM (preclerkship)-outcome variables (k = 10) were data from a final observed history and physical examination, an observed structured clinical examination, a National Board of Medical Examiners subject examination for clinical medicine, and ICM preceptor evaluations. Secondary, postclerkship outcome variables (k = 5) included internal medicine clerkship scores, teacher ratings from the clerkship, and examination scores from end-of-clerkship tests. The statistical significance was set at p <. 05.Results: No statistical differences were found between the means of the 2 groups in any of the primary or secondary outcome variables; there was significant power.Conclusions: The use of standardized patients in a simulated setting compared to the use of hospitalized patients in affiliated teaching hospitals is not a disadvantage in the education of students in ICM courses.

Change in Japanese medical education has been accelerating over the last 10 years. Historically, clinical departments in each medical school played a crucial role, but reports in the mass media tried to refute the feudal ‘ikyoku-koza’ system with a number of malpractice cases, inappropriate patient–doctor communication, etc. At that time policies by the Ministries of Education and Health (rationalized in 2001) independently became more influential in medical education. In particular the network of governmental medical schools has been restructured, merged and privatized since 2001. In the 1990s several private medical schools developed distinctive curricula including problem-based learning (PBL), the objective structured clinical examination (OSCE) and introduction to clinical medicine (ICM). The curriculum for clinical medicine is still a critical issue and will be a major challenge for the management of each medical school. The effectiveness of the National Model Curriculum consisting of more than 1200 objectives might be questionable but the National Common Achievement Test (CAT) will make a strong impact on the preclinical curriculum. In the future each medical school should adopt an outcome-based education system to close the loop of curriculum development. An evaluation system based on the entire medical school or curriculum will be the key to successful education.

Overview of the Geriatrics Curriculum The preclinical curriculum incorporates geriatrics content in the majority of basic science courses, either during didactic sessions, small-group/case-based learning exercises, assigned readings, or material available on the Albert Einstein College of Medicine (AECOM) curriculum Web site. The Introduction to Clinical Medicine (ICM) experience consists of three separate year-long courses in Years 1 and 2 during which students learn interviewing techniques and fundamentals of the physical exam. The ICM curriculum has significant geriatrics material and the opportunity for clinical placements in that specialty. A two-week geriatrics clerkship has been a requirement at AECOM since 1995; it is completed during the third or fourth year. Fourth-year clinical electives are offered in palliative care and will be available in osteoporosis and bone health in 2005. Geriatrics research electives are offered in the fourth year. Curriculum Management and Governance Structure The medical school curriculum is managed through a committee structure governed by the Division of Education (DOE). The DOE executive committee consists of the AECOM dean, associate deans, and the education division co-chairs. The DOE governs eight committees, which oversee curriculum management. In 2003, AECOM expanded the curriculum governance structure to include four committees: the foundations of medical science committee; the clinical committee; the ethics, humanism, and professionalism committee; and the preventive medicine and population sciences committee. In addition, the DOE maintains the committees on the library, medical student research, computer-based education, and faculty education and support. (See Figure 1.)FIGURE 1.: Educational Committee and Governance StructureThe clinical committee consists of course and clerkship directors, teaching faculty from AECOM and its clinical affiliates, and administrative staff from the dean's office and the Office of Educational Resources and Students. AECOM does not own or manage any clinical facilities. All medical student clinical education occurs at three affiliated academic health centers and a large number of other affiliated hospitals, long-term care facilities, and ambulatory settings. Site directors at each affiliate administer clinical curriculum. Geriatrics faculty has been represented on the clinical committee since 1980. The current head of the Division of Geriatrics has been a member of this committee since 1991, advocating for increased curricular time for geriatrics, which resulted in the clerkship requirement in 1995. THE AAMC/HARTFORD GERIATRICS CURRICULUM PROGRAM Institutional Involvement in Curricular Change The initial AAMC/Hartford grant proposal was reviewed by members of the executive committee, the clinical committee, and the preclinical committee; it was approved by the full DOE. All significant alterations to the curriculum were presented to the full DOE meetings and the pertinent subcommittees. Changes in the basic science curriculum were first presented to the subcommittee of basic science course directors and the clinical committee. Submission of a lecture curriculum and teaching materials to the course directors was then required prior to their approval. The ICM curriculum changes were achieved through direct discussion with, and the participation of, the course director, who was involved from the first steps of writing the grant proposal. This cooperative relationship assured a smooth transition after the grant was awarded. The ICM geriatrics program is staffed and funded by the Division of Geriatrics through grant funds, dean's funds, and other sources, thus providing additional resources for the course. The geriatrics clerkship is well established and has historically received excellent student evaluations; the clinical committee therefore easily approved changes in the clerkship curriculum. Web-based case exercises were implemented and evaluated in the geriatrics clerkship with active involvement and review by the DOE and the clinical committee at the mid-grant review period. A palliative care elective was designed through cooperation between the Division of Geriatrics and the Palliative Care Service. The DOE, recognizing the need for a rotation in end-of life care, supported creation of the new program. Theme for the Geriatrics Program Physicians are treating older adults more frequently in almost all disciplines; familiarity with the physiologic changes of aging, geriatric pharmacology, geriatric systems of health care, and the role of other providers is critical for the education and training of all physicians. Learning Outcomes for the Geriatrics Curriculum To influence positively the attitudes and interests of medical students toward care of the elderly To introduce gerontology and geriatrics into the current biopsychosocial model, including social gerontology, an expanded physician–patient relationship, bioethical principles in decision making and the social implications of decisions, the role of spirituality, and an appreciation of loss and grief To enhance the student's knowledge of aging bioscience to include normative changes and the pathophysiologic basis of diseases common in aging To inform students about health care systems and insurance, including changes in the current structure and regulations To familiarize students with providing care for older adults as part of a multidisciplinary team To enhance students’ clinical knowledge of disease presentation, diagnosis, and treatment for the elderly, with a focus on “geriatric syndromes” Special Programs Senior–mentor program As an outgrowth of this grant, a senior–mentor program is being instituted in the fall 2003 as an elective within the first-year geriatrics ICM program. Both the course directors and the dean's office have supported this program, in which students have a continuity experience with a community-dwelling older adult. Community partnerships Community sites conducive to ambulatory teaching of medical students have been identified within our community, along with potential mentors for students. These sites include nursing homes, an assisted living center, and community-based ambulatory care programs. Faculty members were successfully recruited as mentors for the first-year ICM program and received academic appointments as appropriate. They were also included in the faculty development programs described below. Faculty development As an outgrowth of this grant, a competitive grant to enhance medical education at AECOM was obtained from the dean's office. With this funding, the Division of Geriatrics is sponsoring a half-day faculty development workshop on medical student education for both internal and community faculty. Student chapter A student chapter of the American Geriatrics Society was founded in 2002 as a result of student interest in and faculty commitment to these programs. Meetings occur regularly, with planned activities and presentations. Palliative care Palliative care and end-of-life content were inserted across the curriculum through a prior cooperative effort between the Division of Geriatrics and the Palliative Care Service. This includes a half-day exposure to hospice care during the required geriatrics clerkship and a palliative care elective for fourth-year students. Resulting Pedagogical Changes The curricular content presented in the two-year ICM course reflects a consideration of relevance across the lifespan as well as in health and disease. Case-based learning exercises, which focus on geriatrics content, were added to several basic science classes. Small-group sessions, in which multidisciplinary faculty members interview geriatric patients and their families, were added to ICM. Web-based/case-based learning exercises will become a required component of the geriatrics clerkship in order to standardize curricular exposure. Application of Computer Technology The AECOM curriculum Web site lists and tracks the geriatrics curriculum. Case-based required exercises, which include geriatrics content, are used on the AECOM Web site during selected basic science courses. Case-based required exercises for use during the geriatrics clerkship were introduced in 2004. Students’ Clinical Experiences in Geriatrics Introduction to Clinical Medicine (ICM) consists (as stated earlier) of three separate year-long courses in which students learn interviewing techniques and the physical exam. Year One: Introduction to the Patient. Students are introduced to the art of taking a medical history through lectures followed by small-group sessions. Interactive workshops are utilized to cover select topics in more depth. Geriatrics material is introduced in several core lectures and explored in more detail in workshops on sexual history, examining mental status, loss and grief, violence, health policy, and bioethics. The Clinical Experience. In this half-day practicum, which runs for five months, students gain clinical experience in interviewing at a variety of clinical sites. A geriatrics program exposes students to older adults in multiple settings, including long-term care and home care. Group sessions led by multidisciplinary faculty explore the impact of dementia, depression, and chronic illness through interviews with patients and their families. The geriatrics program enrolls 18 students who are placed at seven clinical geriatrics sites. Year Two: The Clinical Examination. Students learn physical examination and bedside skills in an inpatient setting. The core faculty includes a geriatrician, providing an opportunity for increased geriatrics content, small-group teaching, and increased use of older patients as subjects. Years Three or Four: The geriatrics clerkship. In 1995, AECOM began requiring a two-week geriatrics clerkship to be completed during the third or fourth year. The clerkship is offered at four sites, with groups of from two to eight students. All of them are exposed to the continuum of care, including hospital, ambulatory, nursing home, hospice, and home care, although the proportion varies among the four clerkship sites. Students are precepted by a geriatrician site director. Case-based exercises will be available on the AECOM Web site and required for the clerkship in 2004-05 in order to standardize the curriculum across the clerkship sites. Year Four: Clinical elective. Fourth-year electives include a clinical elective in palliative care with an active inpatient palliative care consultation service and clinic. An elective in osteoporosis and bone health will be offered in an ambulatory bone center in 2005. The Program’s Assessment and Evaluation Instruments The assistant dean for educational resources at AECOM has conducted an evaluation of the program's components. Each didactic session and workshop in the preclinical years is assessed individually. The ICM practicum and the geriatrics clerkship are assessed as a whole. The data collected are anonymous, composite, and site-specific, with answers and ratings in response to objective questions, as well as subjective feedback to questions and statements. The case-based learning exercises were originally designed for small-group learning and were evaluated with an instrument designed for problem-based learning exercises. These cases have been converted to Web-based cases and will be reevaluated electronically. Data regarding clerkship and students’ evaluation of each site are distributed to site directors quarterly. The Division of Education also reviews them yearly. Requirements to Sustain the Program Faculty support is required for the geriatricians directing both the first-year geriatrics ICM practicum and the second-year ICM segment of the course. This support has been forthcoming from the dean's office, with a supplement from the Division of Geriatric’s budget. Support from the dean's office for the clerkship course director has been provided from the beginning. A cadre of committed voluntary physicians has been established who precept and mentor in both the first- and second-year ICM experiences. Efforts to recognize the commitment of these volunteer faculty members have been undertaken through public recognition, faculty appointments, and invitations to continuing medical education (CME) courses. A CME-credited faculty development course, supported with a grant from the dean's office, will expand and support current full-time and voluntary faculty members who participate in all of the geriatrics educational programs across the four years. Continued support for time in the curriculum is ultimately at the discretion of the Division of Education, which monitors student evaluations and content on a yearly basis. To date, results for all evaluations of the geriatrics clerkship and geriatrics ICM programs have been at the same level or significantly higher than those for comparable students’ experiences. In 2002–03, the AECOM Award for Clinical Teaching was awarded to a geriatrician site director in recognition of outstanding clinical teaching. The high clinical standing of the geriatrics programs helps to assure a future in the curriculum. Unanticipated Outcomes Student enthusiasm following the first-year ICM experience was very high and led to the development of an active student chapter of the American Geriatrics Society. Student's enthusiasm after the first-year experience also resulted in increased interest in the summer research experience in the Division of Geriatrics. Recent students have completed projects on Medicare prescription benefit proposals, treatment of osteoporosis after hip fracture, completion and language of health care proxy forms, and an evaluation of elderly patients with minor burns who present to the emergency department. The development of the geriatrics ICM practicum led to enhanced relationships with voluntary physicians who participated in teaching, some for the first time. The success of this educational program led to a successful competitive grant application to the dean's office, which is sponsoring a CME-credited faculty development course in geriatrics education and teaching, in 2003 directed by a geriatrician funded by this grant. A study of attitudes toward aging and the response to program exposure was initiated, following discussion of how to increase the interest of incoming students in selecting the geriatrics practicum for ICM. Impact of External Funding The external funding was one mechanism by which the issues of geriatrics education could be brought to the course leaders and curriculum committees with authority. This funding also provided seed money, to be matched from other sources, in order to begin initiatives in geriatrics education. The imprimatur of the AAMC in funding such a program brought the initiative to the interest of those at the highest level in planning the activities. For further information, contact Amy R. Ehrlich, MD, at 〈[email protected]〉.

Overview of the Geriatrics Curriculum In recent years, we have developed and strengthened the geriatrics curriculum through a deliberate process of specifying learning outcomes, identifying existing geriatrics content, designing and implementing new learning activities and resources, and assessing students’ geriatrics-related knowledge, skills, and attitudes. Further, recent changes in the curriculum governance structure ensure ongoing assessment and improvement of the geriatrics curriculum. The geriatrics curriculum now is fully integrated in required courses across all four years of the curriculum, providing a coherent and comprehensive program that prepares students to care effectively and compassionately for older adults. A unique feature of our curriculum is its focus on preparing students to improve the health of the state’s population, which includes a growing number of citizens over the age of 65. Approximately 40% of clinical teaching takes place in communities throughout the state, where students learn about caring for diverse populations in a variety of communities and health care settings. Curriculum Management and Governance Structure (see Figure 1)FIGURE 1. Governance StructureIn January 2002, the Curriculum Management and Policy Committee (CMPC) was established as the central body responsible for curriculum management and governance. The CMPC is chaired by the executive associate dean for medical education, who reports to the dean, and its members are the co-chairs of the three course directors’ committees and the associate deans for admission, student affairs, and educational development. The following committees report to and advise the CMPC and are the avenue by which the geriatrics curriculum has been integrated in the overall curriculum: Three course directors’ committees, one each for the first and second year, and one for the third and fourth years combined, are responsible for overseeing, coordinating, and improving the individual courses and overall curriculum for each year. The co-chairs of these committees are appointed by the executive associate dean for medical education. Each committee is composed of all of the course directors for the respective year(s). Ex-officio members include staff from the Office of Medical Education and student representatives. The director of the Program on Aging, as a second-year course director, is a member of that committee and also attends the first-, third- and fourth-year committee meetings. The Curriculum Advisory Board convenes quarterly to serve as a forum for all constituencies and stakeholders involved with the educational program for the MD degree, to share ideas about the curriculum, and discuss current practice, concerns, and plans. The director of the Program on Aging is a member of this committee. Two additional committees report to the CMPC and have supported the development of the geriatrics curriculum: The Faculty Advisory Committee on Educational Technology advises the executive associate dean for medical education on matters regarding effective selection and use of educational technology and information systems. Much of the computer-assisted geriatrics instruction has been facilitated by this group. The Whitehead Curriculum Committee, an arm of the Whitehead Medical Society (the student government), works to improve individual courses and the overall curriculum and serves as the liaison among students, student government, and the Curriculum Management and Policy Committee. Each year the two second-year students who are elected co-vice presidents for curriculum of the Whitehead Medical Society serve as co-chairs of the committee, which is composed of student representatives from each class, the co-chairs of the course directors’ committees, the executive associate dean for medical education, and the associate deans for student affairs and educational development. Whitehead representatives attend meetings of the course directors’ committees and Curriculum Advisory Board. The new governance structure has permitted organizational and administrative flexibility to manage and coordinate the curriculum and to react to a rapidly changing academic medical center environment to facilitate change if and when it is deemed necessary. The strengthening of the geriatrics curriculum has been and continues to be a critical focus. In addition to the overall curriculum governance structure of the medical school, the Geriatrics Curriculum Committee (GCC), centered in the Program on Aging, serves as a major force in the development of the geriatrics curriculum. The seven-member interdisciplinary GCC, chaired by the director of the Program on Aging, was created to remedy gaps in the geriatrics curriculum. The group’s accomplishments include: development of a comprehensive syllabus outlining geriatrics learning objectives and content that all medical students should master prior to graduation; thiswas done through surveying practicing physicians to determine the skills needed to work effectively with elders in the community and following guidelines from the American Geriatrics Society (“Areas of Basic Competency for the Care of Older Patients for Medical and Osteopathic Schools,” 1998); evaluation of existing geriatrics content and learning activities to assess where and how well these topics are taught in the curriculum; and implementation of educationally sound methods to address geriatrics components that may not be fully incorporated into the medical curriculum. Plans developed by the GCC are shared with the three course directors’ committees and the Curriculum Advisory Board via the Program on Aging representative. THE AAMC/HARTFORD GERIATRICS CURRICULUM PROGRAM Institutional Involvement in Curricular Change The John A. Hartford Foundation grant received through the AAMC in June 2000 provided the resources that allowed us to strengthen and build the geriatrics curriculum across all four years, expand our outreach to students interested in geriatrics medicine, and document those areas in the curriculum where geriatrics knowledge and skills were inadequate or lacking. Specifically, our goals were to increase (1) the exposure of all students to core geriatrics content to help ensure a sound knowledge base for practice, (2) the number of opportunities for student exposure to older adults to support empathic practice, based upon an appreciation of normal and successful aging as well as its challenges, and (3) educational experiences to engage students in applying their knowledge and skills to solve complex problems in geriatrics medicine. These efforts were well received by faculty and students and resulted in increased visibility throughout the School of Medicine and increased awareness of the importance of geriatric medicine as an inherent component of core competencies. Both before and midway through the grant period, institutional involvement in curriculum change permitted even greater achievements in enhancing the geriatrics program. Prior to this, the Program on Aging had limited opportunities to make formal recommendations regarding medical school curriculum design and content, with virtually no active, authoritative role in the decision-making process. In 1999, the large and unwieldy First- and Second-Year Course Directors’ Committee was divided in two, so that each committee could focus exclusively on a single year’s curriculum. This promoted more intense and focused work on analyzing the curriculum and determining ways to strengthen it. In 2001, the dean appointed the Leadership Task Force on the Outcomes of the Medical School Curriculum, composed of nine department chairs representing both basic and clinical sciences. This committee was charged with describing the core competencies (learning objectives) to be achieved by graduating medical students and with revising the curriculum governance structure to promote efficient and effective decision making. The subsequent establishment of a set of core competencies and the reconfiguration of the governance structure (described above) resulted in major curriculum changes, with significant implications for expanding the depth and breath of geriatrics content throughout the four-year curriculum. The Second-Year Course Directors’ Committee transformed the second-year curriculum from separate courses generated by each department into integrated block courses focusing on organ systems. The committee also established both an introductory and a capstone block to begin and end the year, with each of these blocks using case-based learning with a strong geriatrics focus. Theme for the Geriatrics Curriculum The teaching mission of the Division of Geriatric Medicine and the Program on Aging is to build the capacity of UNC to prepare health care providers at all levels for evidence-based, outcomes-oriented health care for older adults and ultimately, to improve or preserve their level of function and quality of life. The major theme for the geriatrics dimension of the UNC medical school curriculum is twofold, to ensure (1) that the geriatrics curriculum is a recognizable and integral component throughout all four years of the medical curriculum; and (2) that students, faculty, and administrators recognize that the mastery of geriatrics competencies is most effectively achieved within an interdisciplinary system of care delivery that recognizes the interdependence of education; research; primary, subspecialty, and ancillary care; and public policy and regulation. The questions that must be addressed for each curricular activity are “How does this intervention affect the student’s acquisition of identifiable geriatric core competencies?” and “How does this intervention increase the student’s understanding and implementation of interdisciplinary team skills?” An additional theme is the commitment to recognize and encourage those students who have a particular interest in geriatrics and the potential to be leaders in the field, regardless of their subspecialty interest. Learning Outcomes for the Geriatrics Curriculum After completion of the enhanced four-year geriatrics curriculum, students will be able to describe age-related physiological changes, differentiate between normal aging and disease processes, demonstrate the problem-solving ability necessary to provide care to older persons, exhibit the professional qualities of integrity, compassion, thoroughness, responsibility, and commitment to caring for older persons, identify political, financial, and social factors that affect delivery of care, and recognize their own potential and that of their patients for subscribing to aging stereotypes. Special Programs Community partnerships Community partnerships play an essential role in fulfilling the university’s commitment to prepare professionals to meet the health care needs of North Carolina’s citizens. The Program on Aging facilitates student involvement in two partnerships that offer a variety of opportunities for work with older adults across the spectrum of geriatrics issues: The Program on Aging enjoys a strong and longstanding relationship with the North Carolina Area Health Education Centers (AHEC) program, a nationally recognized model for interdisciplinary education and training of health care providers. Several regional AHECs collaborate with us on innovative projects to ensure that there are community clinical training sites with well-qualified preceptors available to teach geriatrics knowledge and clinical skills. The Education for Lifelong Service (ELS) Program provides students with community service opportunities, complemented by a curriculum designed to foster leadership skills in service delivery. ELS has responsibility for the newly established Office of Community Service and sponsors courses on the care of underserved and vulnerable populations, including activities that emphasize services to older adults. Program on Aging representatives participate on the ELS leadership team. Standardized geriatric patients The UNC School of Medicine Standardized Patient (SP) Program, administered by the Office of Educational Development, gives students opportunities to practice communication and diagnostic and examination skills before they encounter patients in the actual clinical setting. In addition, the program provides a mechanism to assess these same skills in a standardized format. The program maintains an active database of SPs, including those who are suitable for presentation of geriatric illnesses and situations. Simulated case presentations using geriatric standardized patients are frequently requested for classroom learning, most notably in the first- and second-year Introduction to Clinical Medicine course, in second- year integrated cases, and as part of the fourth-year Clinical Performance Examination, which students must pass in order to graduate. Faculty development The Office of Educational Development provides several faculty development programs and activities in which geriatrics faculty participate and that help to strengthen the geriatrics curriculum. The Expert Preceptor Program, designed for practitioners in community-based clinical settings, is available in an online, interactive format known as the Expert Preceptor Interactive Curriculum. This is a self-paced program comprising modules that can be used individually as information resources or collectively as a complete curriculum. Each module focuses on a skill related to clinical teaching in the community practice setting or on strategies for teaching contemporary health issues. The Teaching Scholars Program is a year-long series of monthly seminars designed to promote expertise and scholarship in medical education for fellows and faculty. In addition, participants choose a specific area of educational interest to pursue in depth and present their results to colleagues at a symposium at the conclusion of the program. Completion of the program confers recognition as a scholar in medical education, and graduates are targeted for positions of leadership in the curriculum. Each year, ten teaching scholars are chosen from faculty nominated by their department chairs, with at least one participant from the Program on Aging. The Excellence in Teaching Series consists of monthly seminars and workshops focused on innovative approaches that enhance learning and instruction in medical education. These sessions provide a forum for participants to discuss practical approaches that facilitate and maximize student learning. The series is designed for faculty and residents who have responsibility for teaching in the classroom, lab, and/or clinical setting. Consultations on teaching and curriculum development issues are provided for individuals or groups of faculty as needed. Faculty and staff from the Office of Educational Development work closely with the Program on Aging to provide ongoing support for efforts to enhance the geriatrics curriculum. Student interest group The UNC Student Chapter of the American Geriatrics Society is a student-led organization for physicians-in-training who have an interest in geriatrics medicine regardless of intended area of specialty. The group focuses on ways to enhance the visibility of geriatrics issues at the UNC School of Medicine and to provide educational programs on geriatric medicine. For those students specifically interested in careers in geriatrics, the chapter seeks to develop leadership skills in geriatrics medicine by sponsoring interdisciplinary educational programs, encouraging research participation, and creating geriatrics-related community service opportunities. The leaders of this student group have initiated a one-hour orientation to geriatric patient care for first year students prior to their community week experience. (See the discussion of “Students’ Clinical Experiences” below.) Palliative care and end-of-life issues In the first year, the required Medicine and Society course provides multiple opportunities for exploration of the social aspects of aging in our society and in politics, as well as the economic factors affecting geriatrics health care. Students discuss various medical-ethical issues found most often among the elderly, e.g., palliative care and end-of-life decisions. In the second year, up to 20 students may select the seminar entitled The Good Death or the Good Fight: Ethnical, Legal, and Policy Issues in Medical Choices as their required humanities and social sciences seminar. A fourth-year elective course sponsored by the Department of Medicine specifically addresses palliative care and end-of-life issues. Palliative Medicine is a six semester-hour, interdisciplinary course taught by faculty from the Departments of Medicine (including a certified geriatrician) and Psychiatry; the Schools of Social Work, Pharmacy, and Nursing; and the Hospital Chaplaincy Office. Resulting Pedagogical Changes Program on Aging faculty promote the importance of teaching methods that encourage students’ active engagement in learning processes that are both self-directed and collaborative. One approach that has proven particularly effective is a merger of evidence-based and problem-based methods. Students are given a clinical vignette in which a patient presents with symptoms and complaints (a problem-based case). Students work in teams to define the problem and set priorities for self-directed (evidence-based) study. This approach is especially appropriate where students must understand the unique and complex presentation of common illnesses among older adults. Specific curricular enhancements include: The Introduction to Clinical Medicine course for first-year students (ICM-1), which devotes time for more in-depth presentations of topics that traditionally have not been an inherent component of the medical curriculum. When these “special topics” were introduced into the curriculum in 1998, geriatrics medicine was included as a three-hour roundtable discussion. Today, the day-long seminar on aging is a firmly established component of ICM-1. Through the AAMC-Hartford program, we further developed this activity to include a lecture and exercise on ageism and aging stereotypes. Strengthened geriatrics content in the following targeted first- and second-year courses: Psychiatry, Gross Anatomy, Immunology, Cardiovascular System, and Respiratory System. The success of this collaborative effort with individual course directors led to an invitation to participate in the design and implementation of the new second-year integrated curriculum. Other regularly scheduled, geriatrics-specific teaching opportunities for required first- and second-year courses. These include geriatrics assessment interviews with standardized patients, a polypharmacy component for the pharmacy course, a geriatrics problem-based case that addresses end-of-life issues, and geriatrics case exercises; they were developed for use in the new introductory and capstone block courses in the second-year curriculum. An interactive, Web-based geriatrics case exercise for the first-year Introduction to Clinical Medicine (ICM) course, which was developed, integrated, and titled “Meet Mrs. Jefferson.” A problem-based case, “Robert Waters,” was developed for the second-year ICM course. A “patient bank” of geriatric subjects for student interviews for the required first-year Medicine and Society course. Students are assigned two patients to interview in teams (two to three students per team). The assignment required recruitment of a significant number of patient-volunteers. Geriatricians from the Program on Aging assisted with recruitment, providing an additional opportunity to ensure a geriatrics component in course content. Additions of geriatrics content to the third-year family medicine, internal medicine, psychiatry, and obstetrics - gynecology clerkships. (See “Students’ Clinical Experiences in Geriatrics” below.) Expansion of the required fourth-year ambulatory care selective to include two additional primary care geriatrics sites. These two sites are in communities with the fastest growing elderly populations in the state. In addition to the required courses and activities described above, the Program on Aging sponsors the following elective activities: For many years, the Program on Aging has sponsored a popular elective course, known as “Geri-Action,” designed to provide first- and second-year students with hands-on clinical care of older patients in inpatient facilities and ambulatory care clinics, and occasional opportunities for home visits. The Senior House Calls Program extends the “Geri-Action” concept by assigning small groups of students to an experienced geriatrics clinician to make house calls to older patients and to follow patients over an extended period. Interdisciplinary Geriatric Education Consultations provide a forum for students to travel with a master geriatrics clinical team to community-based sites for interdisciplinary consultations with local practitioners regarding complex geriatric patient issues. Students who are based in the community are often actively engaged in preliminary home visits with patients or family members and take responsibility for case presentations and follow-up. Seven other electives on geriatrics are offered through the Departments of Medicine and Family Medicine, including Interdisciplinary Teamwork in Geriatrics, Current Topics in Geriatric Health Care, and Rural and Underserved: An Interdisciplinary Approach to Health. Application of Computer Technology The School of Medicine requires that all first-year medical students purchase a laptop computer (first year) and PDA (second year) that are specifically configured to ensure that all students have equal and ready access to all online resources needed for the medical school curriculum. Each student has a dedicated 1000 MB Ethernet connection at his or her assigned lab desk, and each lecture hall has Internet connectivity as well. Online resources are extensive and begin with the online course syllabi that serve as the starting point for course activities. The first-year pre-clinical informatics course teaches students how to best access and evaluate online information, create research presentations, and build Web pages. The Educational Technology Group provides faculty and staff with consultation, workshops, and access to multimedia equipment for curricular projects. They assist course directors with online syllabi and provide expertise necessary to link computer-based teaching resources to the classroom, the lab, and the clinical setting. This strong electronic learning environment supports our commitment to evidence-based practice and learning, as described above in “Resulting Pedagogical Changes.” Examples of the ways in which technology supports the geriatrics curriculum include use of an online geriatrics case-based exercise in the Introduction to Clinical Medicine course, and providing students with the appropriate online information resources needed to complete the case-based exercises in the introductory and capstone block courses in the second year. Students’ Clinical Experiences in Geriatrics Years One and Two Although the first two years of the medical curriculum focus on helping students acquire a solid foundation in the basic sciences, the Introduction to Clinical Medicine course provides clinical experiences as well. Students are introduced to basic clinical skills on campus in weekly small-group sessions with faculty tutors. In addition, they spend five one-week periods in community-based primary care practices. Students learn the complete physical exam and history-taking in the context of a patient-centered approach to care. Both in the classroom and during their five one-week clinical rotations in the community, students are exposed to the entire spectrum of care, from preventive to end-of-life. The Student Chapter of the American Geriatrics Society has initiated a one-hour precommunity week seminar for first-year students focusing on basic care issues common to older patients. Third-Year Clerkships During the 12-week internal medicine clerkship, at least one of the 12 required patient write-ups must focus on a patient aged 65 or older. During the six-week obstetrics and gynecology clerkship, each student is required to complete two weeks of urogynecology and two weeks of oncology and attend 21 hours of lectures and seminars, two of which address issues often seen in geriatric patients, e.g., gynecologic oncology and urinary incontinence. Students are responsible for five case presentations, one of which must be of a patient age 65 or older. The Geriatric Evaluation and Management (GEM) Unit on the psychiatry inpatient service is one of six rotation options students can choose to meet the psychiatry clerkship requirement. This geriatrics clinical experience is available for six rotation periods during the academic year and can accommodate six students per rotation. Through the GEM, students learn clinical skills in the specialized treatment of psychiatric disorders among geriatric patients. Although geriatrics content during the six-week family medicine clerkship varies significantly among sites, overall at least 20% of patients seen by students are age 65 or older, and lectures on geriatrics issues are offered throughout the rotation period. Fourth Year The required ambulatory care selective has two newly established geriatrics-specific sites where students have clinical preceptors who are certified geriatricians. In the academic year 2003–04, five students received geriatrics clinical training at these sites. Electives provide additional opportunities for fourth-year students to complete clinical geriatric rotations. One is a four-week rotation where the student is assigned to a variety of clinical settings to work one-on-one with certified geriatricians. The second option is a six-month longitudinal rotation where the student works one-on-one with a certified geriatrics preceptor to provide comprehensive evaluations and interventions for specifically assigned patients. In both instances, the students are encouraged to focus on a specific area of interest. The Program’s Assessment and Evaluation Instruments An objective structured clinical examination (OSCE) is used to assess students in the Introduction to Clinical Medicine course, allowing faculty to observe and evaluate how well students perform specific clinical skills and behaviors. Students rotate through a series of patient encounters. For each patient, the student is asked to perform a specific, measurable task and a faculty observer evaluates the student’s performance using a structured assessment tool. Standardized geriatrics patients are included in this assessment. Assessment of geriatrics content that is embedded in the courses and clerkships is accomplished by including appropriate items on the various course-related tests and assessments. In conjunction with the Third and Fourth-Year Course Directors’ Committee, the Office of Educational Development administers the Clinical Performance Examination (CPX), a high-stakes authentic assessment required of all fourth-year students. Designed to reflect patient demographics in North Carolina, the CPX contains a patient sample that reflects personal demographics and medical problems most frequently encountered in primary care practices in this region. Typically, geriatrics cases compose approximately one quarter to one third of the total cases used. The exam matrix is designed to ensure that relationship and communication skills, physical examination skills, history-taking skills, and management and assessment skills are evaluated across 12 to 16 cases. Students receive a performance profile that provides a brief description of each case, pass/fail status for each case, overall exam score (pass/fail), and five skill scores. In conjunction with the CPX, students are given a supplemental written, case-based geriatrics test, developed by the Program on Aging. For both the OSCE and the CPX, the Program on Aging works collaboratively with the Office of Educational Development to ensure that core geriatrics competencies are included in the assessment. Requirements to Sustain the Program As a result of the success we have experienced in bringing geriatrics needs to the forefront, we are now confronted with the pressing need for ongoing dedicated faculty teaching time and significant staff support. To maintain and expand our educational programs in all desired directions, we must engage new faculty geriatricians, as well as others who can add a geriatrics component to the training they offer in their respective domains. The success of the John A. Hartford/AAMC grant has confirmed the need for a coordinated, comprehensive approach to geriatrics education. We must continue to explore new ways to address the needs of learners at different levels, to assess the flood of new research, and to rapidly disseminate new information and methods to our students. Unanticipated Outcomes The recent transformation of the second-year curriculum from discrete departmentally-based courses to integrated organ-system blocks gave us an unexpected opportunity to more fully develop the geriatrics curriculum. The redesign provides an ideal context for incorporating geriatrics-focused case-based learning activities. Because the AAMC-Hartford project already had given new prominence to geriatrics content, we were able to argue successfully for additional case-based geriatrics teaching. The introductory block concludes with a two-day problem-based, evidence-based case using a simulated geriatric patient. The case provided an opportunity to demonstrate how diagnostic information is used in patient care, to emphasize the patient-specific nature of high-quality geriatrics care, and to heighten students’ awareness regarding the urgency of health care issues presented by this rapidly growing segment of the population. The final capstone block focuses on two patient cases, one of which involves an elderly patient. Both cases are designed to integrate multiple aspects of medical care that were addressed in previous organ-based blocks. Students work collaboratively in small groups to explore the patients’ problems, including presentation, diagnosis and treatment strategies, and quality-of-life consequences. The restructuring of the curriculum governance system allowed for more Program on Aging involvement in curriculum planning. Through personalized committee contacts, the Program on Aging continues to receive new and renewed requests from faculty to assist in developing and implementing geriatrics teaching resources and strategies. Impact of External Funding The Program on Aging has achieved an unprecedented level of visibility and credibility within the School of Medicine and throughout all the schools and programs in the UNC Division of Health Affairs. There is a growing, mutually supportive relationship with the Office of Medical Education and with individual course directors, affirming a commitment to ensure that geriatrics content evolves and becomes an integral component of required courses. External funding available between 2000 and 2002 made possible the staff time needed to collaborate with course directors and offer geriatrics-specific classroom and small-group teaching/ learning activities. Over the past two years, these individualized course connections have evolved, and the Program on Aging has representation on all course directors’ committees and actively participates in curriculum design and implementation. The foundation laid by the AAMC-Hartford funding allowed us to compete successfully for additional funding from the Donald W. Reynolds Foundation. Our newly-funded initiative is helping us both further expand the medical student curriculum and also build educational programs for residents, fellows, and faculty, including community-based preceptors. For further information, contact Jan Busby-Whitehead, MD, at 〈[email protected]〉.

Academic medicine : journal of the Association of American Medical Colleges

Jul 1, 2004
Jan Busby-Whitehead + 2

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