Medical Education Program Highlights The University of North Dakota (UND) School of Medicine and Health Sciences (SMHS) is the only medical school in North Dakota. We are a 4-year community-based medical school leading to the MD degree. The preclerkship phase in Grand Forks covers the first 2 years of the program. Third- and fourth-year students are based on 1 of 4 campuses (Grand Forks, Minot, Fargo, Bismarck) and rotate through rural sites. We emphasize skills to provide care for rural and Native American communities. Highlights include: The SMHS employs a hybrid problem-based learning (PBL) and team-based learning (TBL) preclerkship curriculum emphasizing small-group, patient-focused learning. Preclinical interprofessional education involving psychology, communication sciences, medicine, nursing, dietetics, occupational therapy, physical therapy, and social work is emphasized. In clerkships, students translate interprofessional concepts through experiences such as the Interprofessional Student Community-Based Learning Experiences program. Our new (2016) 325,000-square-foot, 4-story SMHS building emphasizes progressive educational infrastructure, including 8 interprofessional learning communities: student-led, noncurricular shared spaces where students from each of the 9 SMHS programs practice clinical skills and interact. A state-of-the-art simulation facility is used. The Indians Into Medicine Program (INMED) is a national program to help American Indian students meet tribal community needs. INMED provides placements for fully qualified students and offers support, advising, a learning resource center, financial assistance, and tutoring. Member of the American Medical Association’s Accelerating Change in Medical Education Consortium from 2015 to present. Innovative projects include longitudinal interprofessional continuity of care, rural telemedicine simulations (350+ students in 5 professions), a handbook for designing these simulations, and badging for medical education competencies including interprofessional teamwork and wellness. See Supplemental Digital Appendix 1—Curriculum Map as of 2019—at https://links.lww.com/ACADMED/A823. Curriculum Curriculum changes since 2010 Program goals and objectives for undergraduate medical education were revised to reflect moves toward competency-based education and expectations of leadership organizations in medical education. Developmental, form-based standardized assessment and longitudinal tracking of student leadership behaviors in the first-year patient-centered learning (PCL) experience were added. Weekly “Professor Rounds” convene all students on each clerkship at each campus to practice patient presentation and differential diagnosis. Acting internships help students achieve predefined levels of competence in Entrustable Professional Activities (EPAs). Integrating USMLE-purchased standardized exams into assessment has increased student exposure to board-style questions and helps gauge student readiness to progress. Integrating faculty-selected primary literature into patient-centered TBL cases teaches appraisal of basic, translational, and clinical research. Emotional, physical, occupational, and financial wellness activities have been incorporated. A second longitudinal clerkship track was added. A substantially revised curriculum will include earlier clinical electives, compress the preclinical experience, integrate basic and clinical sciences, increase active learning, and strengthen USMLE preparation. Incremental changes are being incorporated with full transition to the new curriculum in 2021. See Supplemental Digital Appendix 2—Proposed Curriculum to Take Effect in 2021—at https://links.lww.com/ACADMED/A823. Changes in class size since 2010 Class size has increased from 66 to 78, facilitated by a state-supported Healthcare Workforce Initiative (started in 2011) partially aimed at training more practitioners, which also expanded postgraduate residency/fellowship programs. Our new building was constructed to accommodate this increased class. The low student/faculty ratio remains unchanged. Assessment In 2017, we replaced our program goals and objectives with program competencies drawn from national sources and the SMHS mission to “educate physicians … to enhance the quality of life in North Dakota.” Assessments include clinical performance rating/checklists, institutionally developed clinical performance exams, institutionally developed laboratory practical exams, institutionally developed written/computer-based exams, licensure clinical performance exams, licensure written/computer-based exams, oral presentation, participation, peer assessment, portfolio-based assessment, research or project assessment, and self-assessment. See Supplemental Digital Appendix 3—Medical Education Program Competencies and Assessment Methods—at https://links.lww.com/ACADMED/A823. The most substantial assessment changes since 2010 are described below. We began using the Comprehensive Basic Science Exam (CBSE) as formative testing after each instructional unit to expose students to NBME-style questions, better track performance, identify early intervention opportunities, and refine curriculum. In the final 2 units of Phase I, the CBSE serves as a “gateway” to Step 1 during the third year. In 2016, we modified the communication and teamwork skills assessment of interprofessional collaboration to measure telemedicine competency during interprofessional education simulations and to measure interprofessional skills in telemedicine. We use this tool to measure performance during 3 longitudinal continuity-of-care interprofessional simulations every year across 5 disciplines. In 2017, we identified the need for additional assessment of self-directed learning skills, professionalism, and personal and professional development. The curriculum promotes these outcomes through PCL, a form of PBL in which students rotate case leadership over 64 cases. An observational assessment form1 facilitates faculty assessment and student feedback. Students use this feedback to generate future PCL goals. By the 16th case, students are competent to lead future PCL groups. In 2016, we instituted weekly assessment of students’ skills in case presentation, differential diagnosis, and developing therapeutic plans during the clinical phase.2 Specially trained faculty use a modified version of a tool developed by Lewin and colleagues.3 In 2017, we reconstituted our acting internships to focus on the EPAs, using a modified Ottawa scale4 for evaluation. Parallel curriculum or tracks We offer 2 parallel tracks for clerkship completion in addition to our standard curriculum. MILE (Minot Integrated Longitudinal Experience) consists of 44-week longitudinal clerkships in family medicine, internal medicine, obstetrics–gynecology, pediatrics, psychiatry, and surgery. Students also spend 25% of their time in a neurology longitudinal curriculum. Students spend 1 week on each clerkship over the first 6 weeks to get to know the clinic, preceptors, and staff in each specialty. The other 4 weeks of the academic year are spent in a rural location to complete 4 weeks of family medicine to fulfill the UND SMHS rural rotation requirement. MILE allows students to experience continuity of care and longer-term preceptor relationships for ongoing formative feedback. ROME (Rural Opportunities in Medical Education) sends students for 20–28 weeks to a rural site where they complete family medicine and fulfill requirements for half of their internal medicine, obstetrics–gynecology, and pediatrics clerkships. Students on ROME sites for 24–28 weeks have surgical preceptors, and complete half or all of their surgery clerkship depending on experience. ROME students complete neurology and psychiatry and the remainder of internal medicine, obstetrics–gynecology, pediatrics, and surgery at 1 of 3 traditional home campuses. ROME allows students to experience rural medicine, continuity of care, and long-term preceptor relationships. Pedagogy We employ case-based learning, small- and large-group discussion, laboratory, lecture, peer teaching, TBL, PBL, role play/dramatization, self-directed learning/tutorial, video/podcast, simulation, standardized/simulated patients, and ambulatory and inpatient clinical experience. Since 2010, we have increased self-directed learning and TBL. Clinical experiences Students begin clinical experiences in week 1 via standardized patients and simulations. Additional clinical exposure occurs in weekly case wrap-ups during years 1 and 2 PCL and TBL. Required experiences at clinical sites currently begin in year 3, but all students will begin clerkships midway through the second year and will participate in clinical electives as early as the end of year 1 starting in fall 2021. Required clinical educational experiences are completed in a regional campus model. This includes major health systems, the Fargo Veterans Administration, and rural sites in North Dakota and Minnesota. All students complete at least 4 weeks at a rural site. The MILE curriculum is completed in Minot other than a 4-week period at a rural family medicine site. In ROME, students complete 20–28 weeks at a rural site and the remainder of the year on the Bismarck, Fargo, or Grand Forks regional campus. Although ROME and MILE represent elective longitudinal tracks, all students undertake 2 formal longitudinal experiences during their clinical years regardless of track: a third-year longitudinal epidemiology course that includes a research project, performed in pairs, and a fourth-year longitudinal patient safety quality improvement curriculum that includes 10 online modules and a safety/QI proposal. Curricular Governance The dean is the chief academic officer of SMHS. Faculty governs the curriculum through the faculty governance structure. Since SMHS offers the MD degree and 7 allied health, public health, and PhD degrees, the Faculty Advisory Council (FAC) representing all programs has traditionally reviewed medical curricular actions. Through planned streamlining, individual degree-granting programs will be governed by committees limited to that program. Overall issues such as promotion and tenure will continue to be governed by all SMHS through FAC. A proposed new governance structure is targeted for 2020 adoption. See Figure 1—Current governance structure.Figure 1: Current governance structure. FAC: Faculty Academic Council. Standing Committees: Bylaws Committee; Committee on Promotion and Tenure (CPT); Nominating Committee (Nominations); Research Committee; Committee for Resources for Education (Resources Education); Medical Curriculum Committee (MCC); Medical Student Academic Performance Committee (MSAPC); Admissions Committee; Graduate Medical Education Committee (GMEC); Biomedical and Health Sciences Curriculum Committee (Biomed HS CC).See Figure 2—Proposed new governance structure.Figure 2: Proposed new governance structure. Faculty Academic Council (FAC); Biomedical and Health Sciences Curriculum Committee (BHSCC); Medical Education Committee (MEC); Graduate Medical Education Committee (GMEC); MP Admissions, Medical Student Academic Performance Committee (MSAPC); Bylaws Committee, Committee on Promotion and Tenure (CPT); Research Committee; Nominating Committee; Committee for Resources for Education (Resources Education).Preclinical curricular governance is centralized. Clinical curricular governance is shared between departments and the curriculum committee. Department chairs manage courses in the standard curriculum, overseeing statewide course directors and individual campus-level course directors. MILE and ROME are governed by central boards where each relevant department is represented. All departments report about their courses to the curriculum committee, which has final oversight. Education Staff The dean has ultimate authority over the medical program. The senior associate dean for medicine and research provides direct oversight. Other associate and assistant deans provide additional support and oversight, including undergraduate medical education, faculty development, and learner support. Education Resources, overseen by the associate dean for faculty affairs, provides academic support for the medical program and the school’s other degree-granting programs. Nineteen Education Resources faculty and staff assist curriculum committees through administration, implementation, and management of the medical program in addition to providing assessment and instructional design expertise. See Supplemental Digital Appendix 4—Organizational Chart—at https://links.lww.com/ACADMED/A823. The role of the primary medical education staff and administration is educational programming for undergraduate medical education. The senior associate dean for medicine and research manages graduate and continuing medical education, respectively, using different staff. Faculty Development and Support in Education Excellence in teaching is integral to promotion and tenure. SMHS provides a wide range of faculty development and support. The associate dean for faculty affairs oversees SMHS faculty development, emphasizing promotion and tenure. The associate dean for teaching and learning oversees SMHS faculty development initiatives, emphasizing teaching, innovation, education scholarship, and curriculum design and evaluation. An instructional designer provides faculty development and support regarding curriculum design, education scholarship, teaching and assessment, and technology-based learning tools. The senior associate dean for medicine and research is focused particularly on developing the clinical faculty. The clinical department chairs and statewide clerkship directors, under leadership of the senior associate dean for medicine and research, provide more specialized feedback and faculty development for clinical faculty. The assistant dean for medical education focuses on faculty development for the medical curriculum. Chairs can direct faculty to meet with an instructional designer for remediation, including individual consultation, recommended workshops, teaching observation, and analysis of teaching materials and documentation. Faculty can also seek professional development from Education Resources. Faculty development programming is advertised by emails, e-newsletter, website, digital signage, and lobby kiosks. Sessions are livestreamed and recorded. Individual consultations are available in person, by phone, or via conferencing software. Key leadership travels to the regional campuses. See List 1—Formal Faculty Development Sessions at the SMHS Grand Forks Campus Over One Year. Regional Medical Campuses To maintain an equivalent educational experience across the 4 regional campuses, performance by campus is monitored by each department and the curriculum committee. Campus deans meet regularly to standardize solutions across campuses for nonclerkship educational experiences. See Table 1—Type and Enrollment for Regional Campuses.Table 1: Type and Enrollment for Regional CampusesEach required clerkship has a statewide clerkship director who coordinates campus clerkship directors to ensure consistent educational experience. The senior associate dean for medicine and research meets regularly with statewide clerkship directors, and separately with campus deans, and with department chairs, to further assure consistency of educational experience across sites and clerkships. Two faculty from the Department of Family and Community Medicine coordinate rural site education and meet regularly with students and preceptors at each rural site. The chairs also monitor student experiences at rural sites by meeting with each student either in person onsite or by teleconference. Finally, each clerkship reports annually by campus overall grades, shelf exam performance, preceptor scores, and completion of required clinical encounters to the curriculum committee, which addresses discrepancies. Feedback such as the AAMC Graduation Questionnaire is also reviewed separately by campus. List 1 Formal Faculty Development Sessions at the SMHS Grand Forks Campus Over One Year Topic Strategies to promote student success Measuring development of competencies over time Use of concept maps to synthesize knowledge Game-based learning in medical education Teaching critical thinking Research poster design (part 1 of 3) Research poster design (part 2 of 3) Interprofessional education Research poster design (part 3 of 3) Universal design and accessibility Converting to active learning Curricular design: Classifying outcomes Curricular design: Writing objectives Book study: “Make It Stick: The Science of Successful Learning” (session 1) Book study: “Make It Stick: The Science of Successful Learning” (session 2) Book study: “Make It Stick: The Science of Successful Learning” (session 3) Faculty lecture on improvement of teaching How to use asynchronous methods Small-Group Peer- and Self-Evaluations Reveal Behaviors Correlated with Learning Outcomes Book study: “Telling Ain’t Training” (session 1) Book study: “Telling Ain’t Training” (session 2) Book study: “Telling Ain’t Training” (session 3)