The 6 degrees of curriculum integration in medical education in the United States

Despite explicit expectations and accreditation requirements for integrated curriculum, there needs to be more clarity around an accepted common definition, best practices for implementation, and criteria for successful curriculum integration. To address the lack of consensus surrounding integration, we reviewed the literature and herein propose a definition for curriculum integration for the medical education audience. We further believe that medical education is ready to move beyond "horizontal" (1-dimensional) and "vertical" (2-dimensional) integration and propose a model of "6 degrees of curriculum integration" to expand the 2-dimensional concept for future designs of medical education programs and best prepare learners to meet the needs of patients. These 6 degrees include: interdisciplinary, timing and sequencing, instruction and assessment, incorporation of basic and clinical sciences, knowledge and skills-based competency progression, and graduated responsibilities in patient care. We encourage medical educators to look beyond 2-dimensional integration to this holistic and interconnected representation of curriculum integration.

Competency-Based Frameworks in Medical School Education Programs: A Thematic Analysis of the Academic Medicine Snapshots, 2020.

PURPOSE: Educational program objectives (EPOs) provide the foundation for a medical school's curriculum. In recent years, the Liaison Committee on Medical Education (LCME) endorsed an outcomes-based approach to objectives, to embrace the movement toward competency-based medical education (CBME). The purpose of this study was to explore the CBME frameworks used by medical schools in formulating their EPOs. A secondary aim was to determine factors related to the selection of specific frameworks. METHOD: The authors performed a quantitative content analysis of entries to the 2020 Academic Medicine Snapshot. Publicly available data gathered included demographic features of each program (e.g., year founded, accreditation status, affiliation, etc.), participation in national medical education consortia, and presence of specific CBME frameworks identified in EPOs. Descriptive statistics were used to examine trends in frameworks used by medical schools. Bivariate comparisons between factors and frameworks were conducted using chi-square tests. Logistic regression was used to examine factors predicting use of more recently developed CBME frameworks. RESULTS: A total of 135 institutions submitted Snapshots (RR = 88%). All institutions endorsed 1 or more CBME frameworks, with 37% endorsing 2 and 20% endorsing 3 or more. The most common was the Accreditation Council for Graduate Medical Education core competencies (63%). In addition to published frameworks, 36% of institutions developed their own competencies. Schools with pending LCME visits were 2.61 times more likely to use a more recently developed curricular framework, P = .022. CONCLUSIONS: Medical schools in the United States have embraced the CBME movement through incorporation of competency-based frameworks in their EPOs. While it is encouraging that CBME frameworks have been integrated in medical school EPOs, the variability and use of multiple frameworks identifies the pressing need for a unified CBME framework in undergraduate medical education.

Simulation-Based Curricula for Enhanced Retention of Pediatric Resuscitation Skills: A Randomized Controlled Study.

INTRODUCTION: Resuscitation skills decay as early as 4 months after course acquisition. Gaps in research remain regarding ideal educational modalities, timing, and frequency of curricula required to optimize skills retention. Our objective was to evaluate the impact on retention of resuscitation skills 8 months after the Pediatric Advanced Life Support (PALS) course when reinforced by an adjunct simulation-based curriculum 4 months after PALS certification. We hypothesized there would be improved retention in the intervention group. METHODS: This is a partial, double-blind, randomized controlled study. First-year pediatric residents were randomized to an intervention or control group. The intervention group participated in a simulation-based curriculum grounded in principles of deliberate practice and debriefing. The control group received no intervention. T-tests were used to compare mean percent scores (M) from simulation-based assessments and multiple-choice tests immediately following the PALS course and after 8 months. RESULTS: Intervention group (n = 12) had overall improved retention of resuscitation skills at 8 months when compared with the control group (n = 12) (mean, 0.57 ± 0.05 vs 0.52 ± 0.06; P = 0.037). No significant difference existed between individual skills stations. The intervention group had greater retention of cognitive knowledge (mean, 0.78 ± 0.09 vs 0.68 ± 0.14; P = 0.049). Residents performed 61% of assessment items correctly immediately following the PALS course. CONCLUSIONS: Resuscitation skills acquisition from the PALS course and retention are suboptimal. These findings support the use of simulation-based curricula as course adjuncts to extend retention beyond 4 months.

Finding Time For Compassion In A Busy Emergency Department.

A medical error in the emergency department causes emotional trauma for a patient, who seeks compassion in the aftermath.

Curriculum Changes and Trends 2010-2020: A Focused National Review Using the AAMC Curriculum Inventory and the LCME Annual Medical School Questionnaire Part II.

Medical school curricula have evolved from 2010 to 2020. Numerous pressures and influences affect medical school curricula, including those from external sources, academic medical institutions, clinical teaching faculty, and undergraduate medical students. Using data from the AAMC Curriculum Inventory and the LCME Annual Medical School Questionnaire Part II, the nature of curriculum change is illuminated. Most medical schools are undertaking curriculum change, both in small cycles of continuous quality improvement and through significant change to curricular structure and content. Four topic areas are explored: cost consciousness, guns and firearms, nutrition, and opioids and addiction medicine. The authors examine how these topic areas are taught and assessed, where in the curriculum they are located, and how much time is dedicated to them in relation to the curriculum as a whole. When examining instructional methods overall, notable findings include (1) the decrease of lecture, although lecture remains the most used instructional method, (2) the increase of collaborative instructional methods, (3) the decrease of laboratory, and (4) the prevalence of clinical instructional methods in academic levels 3 and 4. Regarding assessment methods overall, notable findings include (1) the recent change of the USMLE Step 1 examination to a pass/fail reporting system, (2) a modest increase in narrative assessment, (3) the decline of practical labs, and (4) the predominance of institutionally developed written/computer-based examinations and participation. Among instructional and assessment methods, the most used methods tend to cluster by academic level. It is critical that faculty development evolves alongside curricula. Continued diversity in the use of instructional and assessment methods is necessary to adequately prepare tomorrow's physicians. Future research into the life cycle of a curriculum, as well optional curriculum content, is warranted.

Approaches to Teaching the Physical Exam to Preclerkship Medical Students: Results of a National Survey.

PURPOSE: To assess current approaches to teaching the physical exam to preclerkship students at U.S. medical schools. METHOD: The Directors of Clinical Skills Courses developed a 49-question survey addressing the approach, pedagogical methods, and assessment methods of preclerkship physical exam curricula. The survey was administered to all 141 Liaison Committee on Medical Education-accredited U.S. medical schools in October 2015. Results were aggregated across schools, and survey weights were used to adjust for response rate and school size. RESULTS: One hundred six medical schools (75%) responded. Seventy-nine percent of schools (84) began teaching the physical exam within the first two months of medical school. Fifty-six percent of schools (59) employed both a "head-to-toe" comprehensive approach and a clinical reasoning approach. Twenty-three percent (24) taught a portion of the physical exam interprofessionally. Videos, online modules, and simulators were used widely, and 39% of schools (41) used bedside ultrasonography. Schools reported a median of 4 formative assessments and 3 summative assessments, with 16% of schools (17) using criterion-based standard-setting methods for physical exam assessments. Results did not vary significantly by school size. CONCLUSIONS: There was wide variation in how medical schools taught the physical exam to preclerkship students. Common pedagogical approaches included early initiation of physical exam instruction, use of technology, and methods that support clinical reasoning and competency-based medical education. Approaches used by a minority of schools included interprofessional education, ultrasound, and criterion-based standard-setting methods for assessments. Opportunities abound for research into the optimal methods for teaching the physical exam.

Resources Used to Teach the Physical Exam to Preclerkship Medical Students: Results of a National Survey.

PURPOSE: To examine resources used in teaching the physical exam to preclerkship students at U.S. medical schools. METHOD: The Directors of Clinical Skills Courses developed a 49-question survey addressing resources and pedagogical methods employed in preclerkship physical exam curricula. The survey was sent to all 141 Liaison Committee on Medical Education-accredited medical schools in October 2015. Results were averaged across schools, and data were weighted by class size. RESULTS: Results from 106 medical schools (75% response rate) identified a median of 59 hours devoted to teaching the physical exam. Thirty-eight percent of time spent teaching the physical exam involved the use of standardized patients, 30% used peer-to-peer practice, and 25% involved examining actual patients. Approximately half of practice time with actual patients was observed by faculty. At 48% of schools (51), less than 15% of practice time was with actual patients, and at 20% of schools (21) faculty never observed students practicing with actual patients. Forty-eight percent of schools (51) did not provide compensation for their outpatient clinical preceptors. CONCLUSIONS: There is wide variation in the resources used to teach the physical examination to preclerkship medical students. At some schools, the amount of faculty observation of students examining actual patients may not be enough for students to achieve competency. A significant percentage of faculty teaching the physical exam remain uncompensated for their effort. Improving faculty compensation and increasing use of senior students as teachers might allow for greater observation and feedback and improved physical exam skills among students.

Ambulatory training in neurology education.

Much of the care provided by practicing neurologists takes place in outpatient clinics. However, neurology trainees often have limited exposure to this setting. Adequate incorporation of outpatient care in neurology training is vital; however it is often hampered by numerous challenges. We detail a number of these challenges and suggest potential means for improvement.

Targeted Simulation Instructor Course for Nursing Professional Development Specialists.

Practical training for nursing professional development specialists in the facilitation of clinical simulations was implemented using a six-step curriculum development framework. General and targeted needs assessments were conducted. Methods used to apply needs assessment findings into the course design and delivery and the participant's responses via program evaluations are described. The process used to develop this training may be applied by other nursing professional development departments to prepare educators in the delivery of simulated-based learning experiences.

Teaching professionalism in graduate medical education: What is the role of simulation?

BACKGROUND: We systematically reviewed the literature concerning simulation-based teaching and assessment of the Accreditation Council for Graduate Medical Education professionalism competencies to elucidate best practices and facilitate further research. METHODS: A systematic review of English literature for "professionalism" and "simulation(s)" yielded 697 abstracts. Two independent raters chose abstracts that (1) focused on graduate medical education, (2) described the simulation method, and (3) used simulation to train or assess professionalism. Fifty abstracts met the criteria, and seven were excluded for lack of relevant information. The raters, 6 professionals with medical education, simulation, and clinical experience, discussed 5 of these articles as a group; they calibrated coding and applied further refinements, resulting in a final, iteratively developed evaluation form. The raters then divided into 2 teams to read and assess the remaining articles. Overall, 15 articles were eliminated, and 28 articles underwent final analysis. RESULTS: Papers addressed a heterogeneous range of professionalism content via multiple methods. Common specialties represented were surgery (46.4%), pediatrics (17.9%), and emergency medicine (14.3%). Sixteen articles (57%) referenced a professionalism framework; 14 (50%) incorporated an assessment tool; and 17 (60.7%) reported debriefing participants, though in limited detail. Twenty-three (82.1%) articles evaluated programs, mostly using subjective trainee reports. CONCLUSION: Despite early innovation, reporting of simulation-based professionalism training and assessment is nonstandardized in methods and terminology and lacks the details required for replication. We offer minimum standards for reporting of future professionalism-focused simulation training and assessment as well as a basic framework for better mapping proper simulation methods to the targeted domain of professionalism.

Breadth versus volume: Neurology outpatient clinic cases in medical education.

This study examined how volume in certain patient case types and breadth across patient case types in the outpatient clinic setting are related to Neurology Clerkship student performance. Case logs from the outpatient clinic experience of 486 students from The University of Chicago Pritzker School of Medicine, USA, participating in the 4week Neurology Clerkship from July 2008 to June 2013 were reviewed. A total of 12,381 patient encounters were logged and then classified into 13 diagnostic categories. How volume of cases within categories and the breadth of cases across categories relate to the National Board of Medical Examiners Clinical Subject Examination for Neurology and a Neurology Clerkship Objective Structured Clinical Examination was analyzed. Volume of cases was significantly correlated with the National Board of Medical Examiners Clinical Subject Examination for Neurology (r=.290, p<.001), the Objective Structured Clinical Examination physical examination (r=.236, p=.011), and the Objective Structured Clinical Examination patient note (r=.238, p=.010). Breadth of cases was significantly correlated with the National Board of Medical Examiners Clinical Subject Examination for Neurology (r=.231, p=.017), however was not significantly correlated with any component of the Objective Structured Clinical Examination. Volume of cases correlated with higher performance on measures of specialty knowledge and clinical skill. Fewer relationships emerged correlating breadth of cases and performance on the same measures. This study provides guidance to educators who must decide how much emphasis to place on volume versus breadth of cases in outpatient clinic learning experiences.

Neurology objective structured clinical examination reliability using generalizability theory.

OBJECTIVES: This study examines factors affecting reliability, or consistency of assessment scores, from an objective structured clinical examination (OSCE) in neurology through generalizability theory (G theory). METHODS: Data include assessments from a multistation OSCE taken by 194 medical students at the completion of a neurology clerkship. Facets evaluated in this study include cases, domains, and items. Domains refer to areas of skill (or constructs) that the OSCE measures. G theory is used to estimate variance components associated with each facet, derive reliability, and project the number of cases required to obtain a reliable (consistent, precise) score. RESULTS: Reliability using G theory is moderate (Φ coefficient = 0.61, G coefficient = 0.64). Performance is similar across cases but differs by the particular domain, such that the majority of variance is attributed to the domain. Projections in reliability estimates reveal that students need to participate in 3 OSCE cases in order to increase reliability beyond the 0.70 threshold. CONCLUSIONS: This novel use of G theory in evaluating an OSCE in neurology provides meaningful measurement characteristics of the assessment. Differing from prior work in other medical specialties, the cases students were randomly assigned did not influence their OSCE score; rather, scores varied in expected fashion by domain assessed.

A modified Delphi method to create a scoring system for assessing team performance during maternal cardiopulmonary arrest.

BACKGROUND: Maternal cardiopulmonary arrest is a rare but often fatal emergency. The authors used a modified Delphi method to create a checklist of tasks for practitioners. METHODS: Within each round, experts ranked tasks on a scale from zero through five. Consensus was defined a priori as 80% exact agreement. RESULTS: Three rounds were required to achieve consensus resulting in a checklist of 45 tasks. Round One results revealed five tasks, Round Two included 25 tasks, and Round Three resulted in 29 tasks with 80% exact agreement. CONCLUSIONS: The modified Delphi method resulted in a weighted scoring system that can be used to objectively assess team performance.

Assessment of neurological clinical management reasoning in medical students.

In neurology education there is evidence that trainees may have greater ability in general localization and diagnosis than they do in treatment decisions, particularly with considering longer term care and supportive care. We hypothesized that medical students completing a neurology clerkship would exhibit greater skill at considering the acute diagnostic and therapeutic management than at considering supportive management measures. Data from 720 standardized patient encounters by 360 medical students completing a neurology clerkship being evaluated via an objective structured clinical examination were analyzed for skill in three components of clinical decision making: diagnostic evaluation, therapeutic intervention, and supportive intervention. Scores for all standardized patient encounters over the 2008-2012 interval revealed a significantly higher percentage of correct responses in both the diagnostic (mean [M]=62.6%, standard deviation [SD]=20.3%) and therapeutic (M=63.0%, SD=28.8%) categories in comparison to the supportive (M=31.8%, SD=45.2%) category. However, only scores in therapeutic and supportive treatment plans were found to be significant predictors of the USA National Board of Medical Examiners (NBME) clinical neurology subject examination scores; on average, a percent increase in therapeutic and support scores led to 5 and 2 point increases in NBME scores, respectively. We demonstrate empirical evidence of deficits in a specific component of clinical reasoning in medical students at the completion of a neurology clerkship.

Student assessment by objective structured examination in a neurology clerkship.

OBJECTIVES: We evaluated the reliability and predictive ability of an objective structured clinical examination (OSCE) in the assessment of medical students at the completion of a neurology clerkship. METHODS: We analyzed data from 195 third-year medical students who took the OSCE. For each student, the OSCE consisted of 2 standardized patient encounters. The scores obtained from each encounter were compared. Faculty clinical evaluations of each student for 2 clinical inpatient rotations were also compared. Hierarchical regression analysis was applied to test the ability of the averaged OSCE scores to predict standardized written examination scores and composite clinical scores. RESULTS: Students' OSCE scores from the 2 standardized patient encounters were significantly correlated with each other (r = 0.347, p < 0.001), and the scores for all students were normally distributed. In contrast, students' faculty clinical evaluation scores from 2 different clinical inpatient rotations were uncorrelated, and scores were skewed toward the highest ratings. After accounting for clerkship order, better OSCE scores were predictive of better National Board of Medical Examiners standardized examination scores (R(2)Δ = 0.131, p < 0.001) and of better faculty clinical scores (R(2)Δ = 0.078, p < 0.001). CONCLUSIONS: Student assessment by an OSCE provides a reliable and predictive objective assessment of clinical performance in a neurology clerkship.