A multispecialty ethnographic study of clinical competency committees (CCCs).

PURPOSE: Clinical competency committees (CCCs) assess residents' performance on their specialty specific milestones, however there is no 'one-size fits all' blueprint for accomplishing this. Thus, CCCs have had to develop their own procedures. The goal of this study was to examine these efforts to assist new programs embarking on this venture and established programs looking to improve their CCC practices and processes. METHODS: We purposefully sampled CCCs across multiple specialties and institutions. Data from three sources were triangulated: (1) online demographic survey, (2) ethnographic observations of CCC meetings and (3) post-observation semi-structured interviews with the program director and/or CCC chairperson. Template analysis was used to build the coding structure. RESULTS: Sixteen observations were completed with 15 different CCCs at 9 institutions. Three main thematic categories that impact the operations of CCCs emerged: (1) Membership structure and members roles, (2) Roles of the CCC in residency and 3) CCC processes, including trainee presentation to the committee and decision-making. While effective practices were observed, substantial variation existed in all three thematic areas. CONCLUSIONS: While CCCs used some known effective practices, substantial variation in structure and processes was notable across CCCs. Future work should explore the impact of this variation on educational outcomes.

Development of Learning Objectives to Guide Enhancement of Chronic Disease Prevention and Management Curricula in Undergraduate Medical Education.

Phenomenon: Chronic disease is a leading cause of death and disability in the United States. With an increase in the demand for healthcare and rising costs related to chronic care, physicians need to be better trained to address chronic disease at various stages of illness in a collaborative and cost-effective manner. Specific and measurable learning objectives are key to the design and evaluation of effective training, but there has been no consensus on chronic disease learning objectives appropriate to medical student education. Approach: Wagner's Chronic Care Model (CCM) was selected as a theoretical framework to guide development of an enhanced chronic disease prevention and management (CDPM) curriculum. Findings of a literature review of CDPM competencies, objectives, and topical statements were mapped to each of the six domains of the CCM to understand the breadth of existing learning topics within each domain. At an in-person meeting, medical educators prepared a survey for the modified Delphi approach. Attendees identified 51 possible learning objectives from the literature review mapping, rephrased the CCM domains as competencies, constructed possible CDPM learning objectives for each competency with the goal of reaching multi-institutional consensus on a limited number of CDPM learning objectives that would be feasible for institutions to use to guide enhancement of medical student curricula related to CDPM. After the meeting, the group developed a survey which included 39 learning objectives. In the study phase of the modified Delphi approach, 32 physician CDPM experts and educators completed an online survey to prioritize the top 20 objectives. The next step occurred at a CDPM interest group in-person meeting with the goal of identifying the top 10 objectives. Findings: The CCM domains were reframed as the following competencies for medical student education: patient self-care management, decision support, clinical information systems, community resources, delivery systems and teams, and health system practice and improvement. Eleven CDPM learning objectives were identified within the six competencies that were most important in developing curriculum for medical students. Insights: These learning objectives cut across education on the prevention and management of individual chronic diseases and frame chronic disease care as requiring the health system science competencies identified in the CCM. They are intended to be used in combination with traditional disease-specific pathophysiology and treatment objectives. Additional efforts are needed to identify specific curricular strategies and assessment tools for each learning objective.

Continuity in Undergraduate Medical Education: Mission Not Accomplished.

Evidence is mounting that longitudinal medical student clerkships provide better educational experiences than traditional block clerkship "silos." Education studies across institutions demonstrate positive effects of continuity on medical students, including creating patient-centered learning environments, improving fidelity of evaluations and feedback, improving medical student patient-centeredness, enabling more autonomous functioning in the clinical workplace, and increased recruitment and retention of students into primary care careers. Outcome studies show potential for longitudinal students to add value to patient care. This perspective piece summarizes the current evidence basis for longitudinal clerkships broken down by Kirkpatrick level (reactions, perceptions/attitudes, knowledge, behaviors, and patient benefits). Despite this evidence, expansion of longitudinal clerkships has been slow-i.e., fewer than half of current US medical schools offer one. While more recent curricular innovations center around Entrustable Professional Activities (EPAs), there are clear opportunities for medical schools to use longitudinal clerkships as a lens through which EPAs can be effectively evaluated. This perspective highlights the synergy between longitudinal clerkships and EPAs, showing that successful implementation of the former should empower the latter. While large, complex educational interventions are daunting tasks, change is needed. Regulatory organizations should mandate continuity-focused experiences for US medical graduates.

Faculty development to enhance humanistic teaching and role modeling: a collaborative study at eight institutions.

BACKGROUND: There is increased emphasis on practicing humanism in medicine but explicit methods for faculty development in humanism are rare. OBJECTIVE: We sought to demonstrate improved faculty teaching and role modeling of humanistic and professional values by participants in a multi-institutional faculty development program as rated by their learners in clinical settings compared to contemporaneous controls. DESIGN: Blinded learners in clinical settings rated their clinical teachers, either participants or controls, on the previously validated 10-item Humanistic Teaching Practices Effectiveness (HTPE) questionnaire. PARTICIPANTS: Groups of 7-9 participants at 8 academic medical centers completed an 18-month faculty development program. Participating faculty were chosen by program facilitators at each institution on the basis of being promising teachers, willing to participate in the longitudinal faculty development program. INTERVENTION: Our 18-month curriculum combined experiential learning of teaching skills with critical reflection using appreciative inquiry narratives about their experiences as teachers and other reflective discussions. MAIN MEASURES: The main outcome was the aggregate score of the ten items on the questionnaire at all institutions. KEY RESULTS: The aggregate score favored participants over controls (P = 0.019) independently of gender, experience on faculty, specialty area, and/or overall teaching skills. CONCLUSIONS: Longitudinal, intensive faculty development that employs experiential learning and critical reflection likely enhances humanistic teaching and role modeling. Almost all participants completed the program. Results are generalizable to other schools.

Clinical clerkship timing revisited: Support for non-uniform sequencing.

BACKGROUND: The logistical necessity of students taking required clinical clerkship rotations in non-uniform sequences may have significant consequences on performance. AIMS: To investigate (1) the impact of previous clinical clerkship experience and the national licensing examination (USMLE Step 1) rankings on end-of-clerkship overall skills assessments and (2) the effect of clinical clerkship order on end-of-year objective structured clinical examination (OSCE) performance. METHOD: The core clinical phase of UCLA consists at six clinical clerkships during a 48-week continuum. The clerkships are structured in two different tracks with different rotation order. Clinical performance scores were analyzed for 124 year-3 students in the two different tracks. RESULTS: Performance, as reviewed on a standardized clinical clerkship evaluation form by faculty and residents, improved significantly across the clinical year, regardless of track suggesting an accumulated advantage of previous experiences. There were no significant differences between tracks on the OSCE. CONCLUSIONS: Overall clinical skills are more directly impacted by the time-of-year and not order whereas knowledge of specific specialties may be impacted by the order rotations that are taken. While this may not be obvious to students, perhaps we should share these results for their use in tracking their personal growth in clinical skills.

A Call to Action From the California Consortium for the Assessment of Clinical Competence: Making the Case for Regional Collaboration.

The discontinuation of the United States Medical Licensing Examination Step 2 Clinical Skills Examination emphasizes the need for other reliable standardized assessments of medical student clinical skills. For 30 years, the California Consortium for the Assessment of Clinical Competence (CCACC) has collaborated in the development of clinical skills assessments and has become a valuable resource for clinicians, standardized patient educators, psychometricians, and medical educators. There are many merits to strong multi-institutional partnerships, including the integration of data across multiple schools to provide feedback to both students and curricula, pooled test performance statistics for analysis and quality assurance, shared best practices and resources, individual professional development, and opportunities for research and scholarship. The infrastructure of the CCACC allows member schools to adapt to a changing medical landscape, from emerging trends in clinical medicine to the limitations imposed by a global pandemic. In the absence of a national examination, there is now a greater need for all medical schools to develop a comprehensive, dynamic, and psychometrically sound assessment that accurately evaluates clinical skills. Medical schools working together in regional consortia have the opportunity to create and implement innovative and robust assessments that evaluate a wide range of clinical skills, ensure that medical students have met an expected level of clinical competency before graduation, and provide a framework that contributes to ongoing efforts for the development of new national clinical skills standards.

Assessing patient-centered care: one approach to health disparities education.

BACKGROUND: Patient-centered care has been described as one approach to cultural competency education that could reduce racial and ethnic health disparities by preparing providers to deliver care that is respectful and responsive to the preferences of each patient. In order to evaluate the effectiveness of a curriculum in teaching patient-centered care (PCC) behaviors to medical students, we drew on the work of Kleinman, Eisenberg, and Good to develop a scale that could be embedded across cases in an objective structured clinical examination (OSCE). OBJECTIVE: To compare the reliability, validity, and feasibility of an embedded patient-centered care scale with the use of a single culturally challenging case in measuring students' use of PCC behaviors as part of a comprehensive OSCE. METHODS: A total of 322 students from two California medical schools participated in the OSCE as beginning seniors. Cronbach's alpha was used to assess the internal consistency of each approach. Construct validity was addressed by establishing convergent and divergent validity using the cultural challenge case total score and OSCE component scores. Feasibility assessment considered cost and training needs for the standardized patients (SPs). RESULTS: Medical students demonstrated a moderate level of patient-centered skill (mean = 63%, SD = 11%). The PCC Scale demonstrated an acceptable level of internal consistency (alpha = 0.68) over the single case scale (alpha = 0.60). Both convergent and divergent validities were established through low to moderate correlation coefficients. DISCUSSION: The insertion of PCC items across multiple cases in a comprehensive OSCE can provide a reliable estimate of students' use of PCC behaviors without incurring extra costs associated with implementing a special cross-cultural OSCE. This approach is particularly feasible when an OSCE is already part of the standard assessment of clinical skills. Reliability may be increased with an additional investment in SP training.

A strategy for improving health disparities education in medicine.

INTRODUCTION: A health disparities curriculum that uses evidence-based knowledge rooted in pedagogic theory is needed to educate health care providers to meet the needs of an increasingly diverse U.S. population. DESCRIPTION: The Health Disparities Education: Beyond Cultural Competency Precourse, along with its accompanying Train the Trainer Guide: Health Disparities Education (2008), developed by the Society of General Internal Medicine (SGIM) Disparities Task Force (DTF), is a comprehensive tool to facilitate developing, implementing and evaluating health disparities education. The curriculum includes five modules highlighting several fundamental concepts in health disparities, suggestions for teaching about health disparities in a wide range of settings and strategies for curriculum evaluation. The modules are Disparities Foundations, Teaching Disparities in the Clinical Setting, Disparities Beyond the Clinical Setting, Teaching about Disparities Through Community Involvement, and Curriculum Evaluation. EVALUATION: All five modules were delivered as a precourse at the 31st Annual SGIM Annual Meeting in Pittsburgh, PA and received the "Best Precourse Award". This award is given to the most highly rated precourse based on participant evaluations. The modules have also been adapted into a web-based guide that has been downloaded at least 59 times. CONCLUSION: Ultimately, the modules are designed to develop a professional commitment to eliminating racial and ethnic disparities in health care quality, promote an understanding of the role of health care providers in reducing health care disparities through comprehensive education and training, and provide a framework with which providers can address the causes of disparities in various educational settings.

A framework for developing, implementing, and evaluating a cancer survivorship curriculum for medical students.

BACKGROUND: Cancer survivorship care is not adequately addressed in current medical school curricula. OBJECTIVES: To develop, implement, and evaluate a modular cancer survivorship curriculum that is portable to other educational settings and is designed to provide medical students with a foundation of knowledge, attitudes, and skills related to care for cancer survivors. PROGRAM DESCRIPTION: An expert consensus panel developed a set of learning objectives related to cancer survivorship to guide the development of educational modules, such as computer-based self-instructional modules, problem-based learning cases, videos, and clinical exercises. Course and clerkship chairs were directly involved in the development and implementation of the modules. EVALUATION: A cohort study with a historical control group demonstrated that fourth-year medical students increased their knowledge in survivorship issues and their self-reported level of comfort in care activities compared to similar students who did not receive the survivorship curriculum. CONCLUSIONS: Our framework resulted in a cancer survivorship curriculum that was implemented in a modular manner across the medical curriculum that improved learning and that is potentially portable to other educational settings.

No content without context: integrating basic, clinical, and social sciences in a pre-clerkship curriculum.

BACKGROUND: The basic science curricula in medical schools ultimately succeed or fail at the bedside when students must draw on their pre-clerkship experiences as they learn to form nuanced clinical decisions. Given this expectation, learning context becomes as decisive as content in determining students' recall and application. AIMS: Using the pre-clerkship medical curriculum at the University of California, Los Angeles, as an example, we illustrate how traditional biomedical sciences can be integrated with clinical sciences in a comprehensive foundational curriculum following curricular design features and teaching methods based on learning principles from cognitive psychology and education. METHODS: Multiple planning teams of faculty and students collaborated in the design of the Human Biology and Disease (HB&D) curriculum. Broad participation, careful selection of course chairs, the assistance of educational consultants, ongoing oversight structures, and faculty development were used to develop and sustain the curriculum. RESULTS: The resulting HB&D curriculum features an interdisciplinary spiral block structure including interactive lecture formats, integrative formative and summative examinations, self- and peer-taught laboratories, and problem-based learning with innovative variations. CONCLUSION: Our fully integrated, spiral, pre-clerkship curriculum built on repeating interdisciplinary blocks and longitudinal threads has yielded encouraging results as well as some specific innovations that other schools or individual teachers may find valuable to adapt for use in their own settings.

Preparedness for caring of cancer survivors: a multi-institutional study of medical students and oncology fellows.

BACKGROUND: Despite recent advances in cancer survivorship knowledge and care, most medical schools lack a comprehensive survivorship curriculum, potentially leaving students ill-prepared for caring of survivors. METHODS: A total of 211 students and 22 oncology fellows in 3 institutions completed a questionnaire assessing knowledge and experience in survivorship care. RESULTS: Medical students and oncology fellows lack knowledge in key survivorship issues. Students were exposed to cancer survivors frequently in medical school but only half received instruction or practiced critical components of survivorship care. CONCLUSIONS: Improvement of both undergraduate and postgraduate training in survivorship care is urgently warranted.

Using Interactive Learning Modules to Teach Value-Based Health Care to Health Professions Trainees Across the United States.

PROBLEM: Despite prominent calls to incorporate value-based health care (VBHC) into medical education, there is still a global need for robust programs to teach VBHC concepts throughout health professions training. APPROACH: In June 2017, Dell Medical School released the first collection (three modules) of a set of free interactive online learning modules, which aim to teach the basic foundations of VBHC to health professions learners at any stage of training and can be incorporated across diverse educational settings. These modules were designed by an interprofessional team based on principles of cognitive engagement for active learning. OUTCOMES: From June 2017 to September 2018, the website received 130,098 pageviews from 8,546 unique users (2,072 registered users), representing 45 states in the United States and 10 foreign countries. As of October 15, 2018, 568 (27%) of registered users completed modules 1-3. Five-hundred thirty-five of these users completed a survey (94% response rate). Nearly all (484/535; 90%) reported overall satisfaction with the curriculum, 522/535 (98%) agreed "after completing the modules, I can define value in health care," and 520/535 (97%) agreed "after completing the modules, I can provide examples of low- and high-value care." Second-year Dell Medical School students reported that they have incorporated value into their clinical clerkships (e.g., by discussing VBHC with peers [43/45; 96%]) as a result of completing the modules. NEXT STEPS: Future plans for the curriculum include the release of additional modules, more robust knowledge assessment, and an expanded learning platform that allows for further community engagement.

Student body racial and ethnic composition and diversity-related outcomes in US medical schools.

CONTEXT: Many medical schools assert that a racially and ethnically diverse student body is an important element in educating physicians to meet the needs of a diverse society. However, there is limited evidence addressing the educational effects of student body racial diversity. OBJECTIVE: To determine whether student body racial and ethnic diversity is associated with diversity-related outcomes among US medical students. DESIGN, SETTING, AND PARTICIPANTS: A Web-based survey (Graduation Questionnaire) administered by the Association of American Medical Colleges of 20,112 graduating medical students (64% of all graduating students in 2003 and 2004) from 118 allopathic medical schools in the United States. Historically black and Puerto Rican medical schools were excluded. MAIN OUTCOME MEASURES: Students' self-rated preparedness to care for patients from other racial and ethnic backgrounds, attitudes about equity and access to care, and intent to practice in an underserved area. RESULTS: White students within the highest quintile for student body racial and ethnic diversity, measured by the proportion of underrepresented minority (URM) students, were more likely to rate themselves as highly prepared to care for minority populations than those in the lowest diversity quintile (61.1% vs 53.9%, respectively; P < .001; adjusted odds ratio [OR], 1.33; 95% confidence interval [CI], 1.13-1.57). This association was strongest in schools in which students perceived a positive climate for interracial interaction. White students in the highest URM quintile were also more likely to have strong attitudes endorsing equitable access to care (54.8% vs 44.2%, respectively; P < .001; adjusted OR, 1.42; 95% CI, 1.15-1.74). For nonwhite students, after adjustment there were no significant associations between student body URM proportions and diversity-related outcomes. Student body URM proportions were not associated with white or nonwhite students' plans to practice in underserved communities, although URM students were substantially more likely than white or nonwhite/non-URM students to plan to serve the underserved (48.7% vs 18.8% vs 16.2%, respectively; P < .001). CONCLUSION: Student body racial and ethnic diversity within US medical schools is associated with outcomes consistent with the goal of preparing students to meet the needs of a diverse population.

The relationship between medical students' knowledge, confidence, experience, and skills related to colorectal cancer screening.

BACKGROUND: Medical student colorectal cancer prevention education is crucial to improving cancer screening rates. METHODS: We surveyed 146 medical students about their knowledge, confidence, and experience with colorectal cancer screening. We then used a multivariate general linear model to assess the relationships between these variables and colorectal cancer screening skills as measured in a standardized patient evaluation. RESULTS: Type and amount of experience providing colorectal cancer screening counseling predicted student performance in the standardized patient encounter, although knowledge and confidence did not. CONCLUSIONS: Increased practice performing cancer screening may improve medical students' ability to implement cancer prevention strategies with patients.

Student body diversity: relationship to medical students' experiences and attitudes.

BACKGROUND: Multiple studies of undergraduate college students have demonstrated the effects of cross-cultural interaction and exposure to diverse ideas on a variety of educational outcomes. The current study was designed to extend this work into medical education, examining student body diversity and school-supported cross-cultural experiences on students' attitudes about diversity. METHOD: Four-hundred forty-one rising fourth-year medical students from three schools with differing levels of student body diversity completed a 55-item questionnaire on their background, experiences, and attitudes related to cross-cultural diversity. RESULTS: Medical students' attitudes about culture and health and their perspectives on societal issues related to diversity were influenced by their medical school experiences. Informal instructional interactions seem to have been most influential in shaping these beliefs. DISCUSSION: The opportunity for students from diverse backgrounds to interact as part of the curriculum is an important means of promoting positive attitudes toward diversity in educational and social environments.

Demystifying "learning" in clinical rotations: do immersive patient encounters predict achievement on the clinical performance examination (CPX)?

BACKGROUND: Although the Liaison Committee on Medical Education required U.S. medical schools to quantify students' clinical encounters, optimum patient exposure needed to predict performance has been elusive. This study explored the relationship between comprehensive patient encounters logged on personal digital assistants (PDAs) during three medicine clerkships, to performance on a clinical performance examination (CPX). METHOD: PDA log data for 166 medical students were used to identify educationally "rich" patient encounters, where students were assigned full responsibility for patient care. RESULTS: Univariate regression analyses predicting the effect of immersive patient encounters on CPX case scores did not show statistical significance. CONCLUSIONS: Amount of patient exposure defined by the richness of student-patient interaction did not reflect on the CPX performance for six selected cases. Further research should examine qualitatively different learning experiences occurring with patient encounters and a higher volume of exposure to predict outcomes.

Two perspectives on the effects of a curriculum change: student experience and the United States medical licensing examination, step 1.

BACKGROUND: Students' perceptions of curricular experience and study effort were compared for a traditional and a new integrative, interdisciplinary curriculum at a single institution. United States Medical Licensing Exam (USMLE) Step 1 scores were examined for subgroup interactions. METHOD: Medical students from four cohorts completed an educational goals survey and USMLE Step 1. Analysis included subgroup performance based on admissions data. RESULTS: Students rated the new curriculum as more helpful in achieving educational goals. USMLE Step 1 was significantly higher for students in the lowest quartile of MCAT scores in the new compared with the previous curriculum. CONCLUSIONS: To understand the outcomes of a large-scale curricular intervention, interactions of curriculum and aptitude should be examined.

Increasing the pool of educational leaders for UCLA.

The dual goals of the faculty Fellowship in Medical Education (MEF) program at the David Geffen School of Medicine at UCLA, established in 1992, are to prepare excellent teachers to serve as clerkship chairs, course chairs, or residency program directors while strengthening their dossiers for promotion based on a scholarly approach to curriculum development, implementation, and evaluation. Fellows are nominated from their departments and must demonstrate a strong interest in assuming educational leadership in their respective specialties. A total of eight fellows are accommodated each year based on interviews with the MEF faculty. The two-year program consists of two seminars and two projects focused on four objectives: to critique teaching and testing practices in medical education in light of current theories of learning; to develop and implement curricula that reflect these theories; to improve personal teaching skills through reflection and feedback; and to design and conduct an educational research or program evaluation study. An analysis of the curricula vitae of faculty members who have completed the fellowship suggest that this program continues to provide educational leaders for the school as originally intended. Of the 71 medical school faculty members who completed the MEF between 1993 and 2004 and have remained at the university, 43 (61%) have assumed new leadership roles in medical education. The evaluation data strongly suggest that the MEF has had a major role since its inception in creating a pool of faculty members with the confidence to manage the tasks of educational planning and implementation.

Why invest in an educational fellowship program?

Expanding and refining the repertoire of medical school teaching faculty is required by the many current and changing demands of medical education. To meet this challenge academic medical institutions have begun to establish programs--including educational fellowship programs--to improve the teaching toolboxes of faculty and to empower them to assume leadership roles within both institutional and educational arenas. In this article, the authors (1) provide historical background on educational fellowship programs; (2) describe the prevalence and focus of these programs in North American medical schools, based on data from a recent (2005) survey; and (3) give a brief overview of the nine fellowship programs that are discussed fully in other articles in this issue of Academic Medicine. These articles describe very different types of educational fellowships that, nevertheless, share common features: a cohort of faculty members who are selected to participate in a longitudinal set of faculty development activities to improve participants' teaching skills and to build a cadre of educational leaders for the institution. Evaluation of educational fellowships remains a challenging issue, but the authors contend that one way to evaluate the programs' effectiveness is to look at the educational improvements that have been instigated by program graduates. The authors hope that the various program descriptions will help readers to improve their existing programs and/or to initiate new programs.