The American College of Surgeons Entering Resident Readiness Assessment (ACS ERRA): Validity Evidence From a Three-Year National Study.

OBJECTIVE: To gather validity evidence supporting the use and interpretation of scores from the American College of Surgeons Entering Resident Readiness Assessment (ACS ERRA) Program. SUMMARY AND BACKGROUND DATA: ACS ERRA is an online formative assessment program developed to assess entering surgery residents' ability to make critical clinical decisions, and includes 12 clinical areas and 20 topics identified by a national panel of surgeon educators and residency program directors. METHODS: Data from 3 national testing administrations of ACS ERRA (2018-2020) were used to gather validity evidence regarding content, response process, internal structure (reliability), relations to other variables, and consequences. RESULTS: Over the 3 administrations, 1975 surgery residents participated from 125 distinct residency programs. Overall scores [Mean = 64% (SD = 7%)] remained consistent across the 3 years ( P = 0.670). There were no significant differences among resident characteristics (gender, age, international medical graduate status). The mean case discrimination index was 0.54 [SD = 0.15]. Kappa inter-rater reliability for scoring was 0.87; the overall test score reliability (G-coefficient) was 0.86 (Ф-coefficient = 0.83). Residents who completed residency readiness programs had higher ACS ERRA scores (66% versus 63%, Cohen's d = 0.23, P < 0.001). On average, 15% of decisions made (21/140 per test) involved potentially harmful actions. Variability in scores from graduating medical schools (7%) carried over twice as much weight than from matched residency programs (3%). CONCLUSIONS: ACS ERRA scores provide valuable information to entering surgery residents and surgery program directors to aid in development of individual and group learning plans.

Understanding How Experts Do It: A Conceptual Framework for the Open Transversus Abdominis Release Procedure.

BACKGROUND: The safe and effective performance of a posterior component separation via a transversus abdominis release (TAR) requires intraoperative judgement and decision-making skills that are difficult to define, standardize, and teach. We herein present the first qualitative study which builds a framework upon which training and objective evaluation of a TAR can be based. METHODS: Hierarchical and cognitive task analyses for a TAR procedure were performed using semistructured interviews of hernia experts to describe the thoughts and behaviors that exemplify optimal performance. Verbal data was recorded, transcribed, coded, and thematically analyzed. RESULTS: A conceptual framework was synthesized based on literary sources (4 book chapters, 4 peer-reviewed articles, 3 online videos), 2 field observations, and interviews of 4 hernia experts [median 66 minutes (44-78)]. Subject matter experts practiced a median of 6.5 years (1.5-16) and have completed a median of 300 (60-500) TARs. After 5 rounds of inductive analysis, 80 subtasks, 86 potential errors, 36 cognitive behaviors, and 17 decision points were identified and categorized into 10 procedural steps (midline laparotomy, adhesiolysis, retrorectus dissection, etc.) and 9 fundamental principles: patient physiology and disease burden; tactical modification; tissue reconstruction and wound healing; task completion; choice of technique and instruments; safe planes and danger zones; exposure, ergonomics, environmental limitations; anticipation and forward planning; and tissue trauma and handling. CONCLUSION: This is the first study to define the key tasks, decisions, and cognitive behaviors that are essential to a successful TAR procedure.

Perceptions of General Surgery Program Leadership and Residents on Research Sabbatical.

INTRODUCTION: The incorporation of a 1-y- or 2-y research period during general surgery residency is increasingly common in many academic programs, yet often, it is heterogeneously structured and ill-defined. This survey-based observational study aimed to characterize the perceptions of general surgery program directors (PDs) and residents regarding an in-training, dedicated research sabbatical. METHODS: Two surveys were conducted using Qualtrics software. One survey was sent to general surgery residency PDs, and the other was sent to general surgery residents currently on a research sabbatical. The primary aim of the survey was to assess the PDs' and research residents' perceptions of the research sabbatical. RESULTS: Seven hundred and fifty-two surveys were analyzed, of which 120 were from PDs and 632 from research residents. Among the residents, 44.1% felt that the research time delayed their surgical training. Regarding research funding, 46.7% of the responding residents said that their residency program funded their research, 30.9% said they acquired funding independently, and 19.1% said that it came from a combination of residency program and independent funding. Finally, regarding how residents found their research opportunity, 42.7% said they found it independently and 53.3% said their program provided it. CONCLUSIONS: Research sabbaticals during residency may be considered essential to academic development. However, in this survey-based study, perceptions of research time and its structure varied greatly between PDs and residents. An intentional push toward developing guidelines for research sabbaticals may benefit residency program leadership and residents.

A Nationwide Survey Study on Medical Student Experience in Acute Care Surgery.

BACKGROUND: There is little known about medical student education in acute care surgery (ACS)-how much and what type of exposure students receive in the specialty. The aim of this study was to investigate the current status of ACS education provided to students in U.S. medical schools. MATERIALS AND METHODS: We created an online survey tool covering the surgical clerkship and ACS curriculum and distributed this survey to the official email list of the Association for Surgical Education Committee on Clerkship Directors. RESULTS: A total of 57 of 294 (19.4%) responses were received. All respondents reported that at least some of their major teaching hospitals are affiliated with an ACS service and have a level 1 or 2 trauma center. Although almost two-thirds (61.8%) of respondents believe that medical students should have formal ACS education in the form of a clinical rotation, an ACS rotation is mandatory at only 16.4% of programs and is optional at 69.1% of programs as part of the surgical clerkship curriculum. The duration of ACS rotations ranges from 1 to 6 wk, and half of programs require students to take overnight call (most often 1-2 nights/wk). The most common pathologies that students see on ACS include appendicitis, biliary disease and cholecystitis, intestinal obstruction, and trauma. CONCLUSIONS: Medical students across the nation have varying exposure to ACS during their clinical training. With the continued growth of the ACS specialty, further study is warranted to examine the impact of undergraduate ACS education on student career planning.

Selecting the Next Generation of Surgeons: General Surgery Program Directors and Coordinators Perspective on USMLE Changes and Holistic Approach.

INTRODUCTION: The United States Medical Licensing Examination (USMLE) was designed as a universal assessment tool for states to determine physician's medical licensure's candidacy. Recent changes in the USMLE exam have changed the way future surgical residency candidate applications will be reviewed. The survey aimed to assess the effect of changes in USMLE exams-USMLE Step 1 pass/fail, complete dissolution of USMLE clinical skills exam, and the role of holistic review in future surgical residency candidacy selection. METHODS: An anonymous online survey was created and distributed to general surgery program directors and coordinators across the USA. The survey aimed to assess attitudes toward changes to USMLE exams and the potential changes with a holistic review of candidate applications. RESULTS: The response rate was 63.7%. Most program directors and coordinators disagree with changing USMLE Step 1 to a pass/fail scoring system. The majority felt that contacts, the medical school's name, and performance in clinical electives and sub-internships would hold more significance. They also believe that a holistic review of application will decrease socioeconomic discrepancies and promote a more diverse and inclusive resident cohort. CONCLUSION: Step 2 clinical knowledge (CK) will gain more importance in future residency matches because of the change in the scoring system of Step 1. The medical school's name, personal contacts, and clinical performance in rotations will hold more significance.

The American College of Surgeons Entering Resident Readiness Assessment Program: Development and National Pilot Testing Results.

OBJECTIVE: To assess the readiness of entering residents for clinical responsibilities, the American College of Surgeons (ACS) Division of Education developed the "Entering Resident Readiness Assessment" (ACS-ERRA) Program. SUMMARY BACKGROUND: ACS-ERRA is an online formative assessment that uses a key features approach to measure clinical decision-making skills and focuses on cases encountered at the beginning of residency. Results can be used to develop learning plans to address areas that may need reinforcement. METHODS: A national panel of 16 content experts, 3 medical educators, and a psychometrician developed 98 short, key features cases. Each case required medical knowledge to be applied appropriately at challenging decision points during case management. Four pilot testing studies were conducted sequentially to gather validity evidence. RESULTS: Residents from programs across the United States participated in the studies (n = 58, 20, 87, 154, respectively). Results from the pilot studies enabled improvements after each pilot test. For the psychometric pilot (final pilot test), 2 parallel test forms of the ACS-ERRA were administered, each containing 40 cases, resulting in overall mean testing time of 2 hours 2 minutes (SD = 43 min). The mean test score was 61% (SD = 9%) and the G-coefficient reliability was 0.90. CONCLUSIONS: Results can be used to identify strengths and weaknesses in residents' decision-making skills and yield valuable information to create individualized learning plans. The data can also support efforts directed at the transition into residency training and inform discussions about levels of supervision. In addition, surgery program directors can use the aggregate test results to make curricular changes.

Applying the science of learning to the teaching and learning of surgical skills: The basics of surgical education.

The changing climate of surgical education has led to a renewed interest in the process of learning. Research from the fields of cognitive and educational psychology, neuroscience, sociology, and behavioral economics have clear implications for the teaching and learning of psychomotor skills. This article summarizes how key learning theories impact the field of surgical education and proposes practical tips, supported by the science of learning, that can be applied to optimize resident and fellow education.

The American Board of Thoracic Surgery Congenital Fellowship: Have We Lost Our International Heritage?

Since 2005 there have been very few (if any) individuals trained outside of the United States in congenital surgery. Confining congenital training to only programs in the US has with it some unintended consequences. First, we need to recognize that progress is made around the world and not only in the US. Second, we decrease our opportunity to establish international peers, which leads to less opportunity for multi-institutional and multi-national studies and intellectual isolation. Third, we are in a new age of globalization. Advances in technology, E-learning platforms, transportation, Internet, and other means of telecommunication have all expedited our capabilities to transmit knowledge and have created for us a "global village." I believe that it is time for us to reorganize and extend our programs beyond our own borders. To do this, we must think about creating Exchange Programs within our congenital fellowships. International fellowships will expose our trainees to new practice environments and help to open our minds to new ways of thinking. To be successful, our current board requirements will need to reflect these changes. The programs will need oversight, coordination, time and resources. In addition, and most importantly, we must make sure that it is a good learning experience. It will not be enough to "just send fellows abroad"; the programs must be guided by specific goals and objectives that need to be continually monitored and revised as needed.

Landmark lecture on surgery: paediatric cardiothoracic surgery - training the next generation of congenital heart surgeons.

Introduction Recent changes in surgical education have had an impact on our congenital training programmes. The mandate of the 8-hour workweek, a rapidly expanding knowledge base, and a host of other mandates has had an impact on the readiness of the fellows who are entering congenital programmes. To understand these issues completely, we interviewed the top congenital experts in the United States of America. The purpose of this paper is to share their insight and offer suggestions to address these challenges. METHODS: We used a qualitative thematic analysis approach and performed phone interviews with the top five congenital experts in the United States of America. RESULTS: Experts unanimously felt that duty-hour restrictions have negatively affected congenital training programmes in the following ways: current fellows do not seem as conditioned as fellows in the past, patient handoffs are not consistent with excellent performance, the mentor-mentee relationship has been affected by duty-hour restrictions, and fellows may be less prepared for real-world practice. Three positive themes emerged in response to duty-hour restrictions: fellows appear to be doing less menial task work, fellows are now better rested for learning, and we are attracting more individuals into the speciality. Experts agreed that congenital fellowships should be increased to 2 years. There was support for both the traditional and integrated residency pathways. Discussion We are in a new era of education and must work together to overcome the challenges that have arisen in recent years.

Multi-decadal drought and amplified moisture variability drove rapid forest community change in a humid region.

Climate variability, particularly the frequency of extreme events, is likely to increase in the coming decades, with poorly understood consequences for terrestrial ecosystems. Hydroclimatic variations of the Medieval Climate Anomaly (MCA) provide a setting for studying ecological responses to recent climate variability at magnitudes and timescales comparable to expectations of coming centuries. We examined forest response to the MCA in the humid western Great Lakes region of North America, using proxy records of vegetation, fire, and hydroclimate. Multi-decadal moisture variability during the MCA was associated with a widespread, episodic decline in Fagus grandifolia (beech) populations. Spatial patterns of drought and forest changes were coherent, with beech declining only in areas where proxy-climate records indicate that severe MCA droughts occurred. The occurrence of widespread, drought-induced ecological changes in the Great Lakes region indicates that ecosystems in humid regions are vulnerable to rapid changes in drought magnitude and frequency.

The use of cognitive task analysis to improve instructional descriptions of procedures.

BACKGROUND: Surgical training relies heavily on the ability of expert surgeons to provide complete and accurate descriptions of a complex procedure. However, research from a variety of domains suggests that experts often omit critical information about the judgments, analysis, and decisions they make when solving a difficult problem or performing a complex task. In this study, we compared three methods for capturing surgeons' descriptions of how to perform the procedure for inserting a femoral artery shunt (unaided free-recall, unaided free-recall with simulation, and cognitive task analysis methods) to determine which method produced more accurate and complete results. Cognitive task analysis was approximately 70% more complete and accurate than free-recall and or free-recall during a simulation of the procedure. METHODS: Ten expert trauma surgeons at a major urban trauma center were interviewed separately and asked to describe how to perform an emergency shunt procedure. Four surgeons provided an unaided free-recall description of the shunt procedure, five surgeons provided an unaided free-recall description of the procedure using visual aids and surgical instruments (simulation), and one (chosen randomly) was interviewed using cognitive task analysis (CTA) methods. An 11th vascular surgeon approved the final CTA protocol. RESULTS: The CTA interview with only one expert surgeon resulted in significantly greater accuracy and completeness of the descriptions compared with the unaided free-recall interviews with multiple expert surgeons. Surgeons in the unaided group omitted nearly 70% of necessary decision steps. In the free-recall group, heavy use of simulation improved surgeons' completeness when describing the steps of the procedure. CONCLUSION: CTA significantly increases the completeness and accuracy of surgeons' instructional descriptions of surgical procedures. In addition, simulation during unaided free-recall interviews may improve the completeness of interview data.

The results of a needs assessment to guide a vascular surgery skills simulation curriculum.

BACKGROUND: In response to economic and societal pressures, a new integrated model of vascular surgery training has emerged that will condense training into 5 years. These new requirements challenge educators to develop innovative training programs that produce competent surgeons despite time constraints. Surgical skills simulation is a proven effective method to teach and evaluate learners in surgery residency programs. METHODS: To determine which skills are the most important to include in a vascular surgical skills training curriculum, a needs assessment survey was administered to all attending surgeons and fellows at vascular surgery training institutions in Southern California. Participants were asked to rank 52 vascular procedures and skills on a Likert scale (with scores ranging from 1 [not necessary] to 5 [essential]) based on perceived need for simulation training. RESULTS: Nineteen (48.7%) surveys were returned (6 fellows [60%], 13 attending surgeons [44.8%]). Carotid artery stenting was ranked by both fellows and attendings as the most essential procedure for simulation, with a mean score of 4.26. This was followed by open repair of ruptured infrarenal aortic aneurysm (R-AAA) (3.79), renal angioplasty/stent (3.68), thoracic endovascular aortic aneurysm repair (3.53), and open repair of juxtarenal/suprarenal aortic aneurysm (3.47). In addition, fellows gave a rank of 4 or higher to R-AAA, thoracic endovascular aortic aneurysm repair, mesenteric artery angioplasty/bypass, renal angioplasty/stent, and intravascular ultrasonography. Attendings did not give a mean rank score of 4 or higher to any procedures other than carotid artery stenting. CONCLUSIONS: Our needs assessment identified vascular procedures where simulation may be beneficial to improve the skill level of vascular trainees in Southern California. With economic and logistical constraints for simulation at each individual training facility, a potential approach to this educational challenge is a regional Southern California vascular surgery skills simulation center.

The case of the entitled resident: a composite case study of a resident performance problem syndrome with interdisciplinary commentary.

BACKGROUND: Residents with performance problems create substantial burden on programs and institutions. Understanding the nature and quality of performance problems can help in learning to address performance problems. AIM: We sought to illuminate the effects of resident performance problems and the potential solutions for those problems from the perspectives of people with various roles in health care. METHODS: We created a composite portrait from several residents who demonstrated a cluster of common performance characteristics and whose chronic or serious maladaptive behavior and response to situations created problems for themselves, for their clinical colleagues, and for faculty of their residency program. The composite was derived from in-depth interviews of program directors and review of resident records. We solicited practitioners from multiple fields to respond to the portrait by answering a series of questions about severity, prognosis, and how and whether one could reliably remediate a person with these performance characteristics. We present their perspectives in a manner borrowed from the New England Journal of Medicine's "Case Records of the Massachusetts General Hospital." RESULTS: We created a composite portrait of a resident whose behavior suggested he felt entitled to benefits his peers were not entitled to. Experts reflecting on his behavior varied in their opinion about the effect the resident would have on the health care system. They suggested approaches to remediation that required substantial time and effort from the faculty. CONCLUSION: Programs must balance the needs of individual residents to adjust their behaviors with the needs of the health care system and other people within it.

Evaluating General Surgical Residency Education Structure and Incorporation of the Resident as Educator Model.

BACKGROUND: General surgery education has continued to evolve regarding test preparation, simulation, and skill acquisition. The "Resident as Educator" (RAE) model has been proposed and enacted by programs as a viable education model for general surgery education. This study examines the current education structures in general surgery residency programs in the United States and how many programs have adopted the RAE model or aspects of the model. METHODS: A 20-question survey regarding education structure was distributed to all program directors in October 2021. Questions focused on the involvement of residents in leading education sessions, creating the weekly education schedule, program feedback to residents on teaching, and recognition for distinguished resident educators. RESULTS: A total of 156 programs responded to the survey. The response rate was 60%. 76.4% of the respondents have a combination of resident and faculty-led didactic sessions, 8.5% have an RAE model, and 15% have faculty-led education sessions. In terms of concerns regarding resident-led didactics-24.4% of respondents stated that their main concern would be the quality of education provided, and 20.4% referenced low resident satisfaction levels with resident-led education. There were no differences among the groups regarding the American Board of Surgery board passage rates. CONCLUSIONS: Most residency programs have adopted a model in which residents have significant involvement in creating and maintaining the education calendar and leading formal education sessions. However, only 8.5% have a purely resident-led educational curriculum among the responding programs. More studies are needed to assess how to implement a resident as educator model successfully.

Resident Readiness for Senior Level Decision Making: Identifying the Domains for Formative Assessment and Feedback.

OBJECTIVE: To establish expert consensus regarding the domains and topics for senior surgery residents (PGY-4) to make critical decisions and assume senior-level responsibilities, and to develop the formative American College of Surgeons Senior Resident Readiness Assessment (ACS SRRA) Program. DESIGN: The American College of Surgeons (ACS) education leadership team conducted a focus group with surgical experts to identify the content for an assessment tool to evaluate senior residents' readiness for their increased levels of responsibility. After the focus group, national experts were recruited to develop consensus on the topics through three rounds of surveys using Delphi methodology. The Delphi participants rated topics using Likert-type scales and their comments were incorporated into subsequent rounds. Consensus was defined as ≥ 80% agreement with internal-consistency reliability (Cronbach's alpha) ≥ 0.8. In a stepwise fashion, topics that did not achieve consensus for inclusion were removed from subsequent survey rounds. SETTING: The surveys were administered via an online questionnaire. PARTICIPANTS: Twelve program directors and assistant program directors made up the focus group. The 39 Delphi participants represented seven different surgical subspecialties and were from diverse practice settings. The median length of experience in general surgery resident education was 20 years (IQR 14.3-30.0) with 64% of the experts being either current or past general surgery residency program directors. RESULTS: The response rate was 100% and Cronbach's alpha was ≥ 0.9 for each round. The Delphi participants contributed a large number of comments. Of the 201 topics that were evaluated initially, 120 topics in 25 core clinical areas were included to create the final domains of ACS SRRA. CONCLUSIONS: National consensus on the domain of the ACS SRRA has been achieved via the modified Delphi method among expert surgeon educators. ACS SRRA will identify clinical topics and areas in which each senior resident needs improvement and provide data to residents and residency programs to develop individualized learning plans. This would help in preparing the senior residents to assume their responsibilities and support their readiness for future fellowship training or surgical practice.

The potential influence of short-term environmental variability on the composition of testate amoeba communities in Sphagnum peatlands.

Testate amoebae are a group of moisture-sensitive, shell-producing protozoa that have been widely used as indicators of changes in mean water-table depth within oligotrophic peatlands. However, short-term environmental variability (i.e., sub-annual) also probably influences community composition. The objective of this study was to assess the potential influence of short-term environmental variability on the composition of testate amoeba communities in Sphagnum-dominated peatlands. Testate amoebae and environmental conditions, including hourly measurements of relative humidity within the upper centimeter of the peatland surface, were examined throughout the 2008 growing season at 72 microsites within 11 peatlands of Pennsylvania and Wisconsin, USA. Relationships among testate amoeba communities, vegetation, depth to water table, pH, and an index of short-term environmental variability (EVI), were examined using nonmetric multidimensional scaling and correlation analysis. Results suggest that EVI influences testate amoeba communities, with some taxa more abundant under highly variable conditions (e.g., Arcella discoides, Difflugia pulex, and Hyalosphenia subflava) and others more abundant when environmental conditions at the peatland surface were relatively stable (e.g., Archerella flavum and Bullinularia indica). The magnitude of environmental variability experienced at the peatland surface appears to be primarily controlled by vegetation composition and density. In particular, sites with dense Sphagnum cover had lower EVI values than sites with loose-growing Sphagnum or vegetation dominated by vascular plants and/or non-Sphagnum bryophytes. Our results suggest that more environmental information may be inferred from testate amoebae than previously recognized. Knowledge of relationships between testate amoebae and short-term environmental variability should lead to more detailed and refined environmental inferences.

The Biology and Psychology of Surgical Learning.

Surgical education requires proficiency with multiple types of learning to create capable surgeons. This article reviews a conceptual framework of learning that starts with the biological basis of learning and how neural networks encode memory. We then focus on how information can be absorbed, organized, and recalled, discussing concepts such as cognitive load, knowledge retrieval, and adult learning. Influences on memory and learning such as stress, sleep, and unconscious bias are explored. This overview of the biological and psychological aspects to learning provides a foundation for the articles to follow.

Development and emergency implementation of an online surgical education curriculum for a General Surgery program during a global pandemic: The University of Southern California experience.

BACKGROUND: Physical distancing required by coronavirus disease 2019 (COVID-19) has limited traditional in-person resident education. We present our novel online curriculum for incorporation into traditional surgical educational programs. METHODS: The online curriculum utilized weekly sub-specialty themed faculty and resident created lectures, ABSITE practice questions, and weekly sub-specialty synchronized readings. Attendance, resident and faculty surveys, and completed ABSITE practice questions evaluated for curriculum success. Curriculum was adapted as COVID-19 clinical restructuring ended. RESULTS: 77% and 80% of clinical residents attended faculty lectures and resident led topic discussions as compared to 66% and 48% attending traditional in-person grand rounds and SCORE curriculum (both p > 0.05). 71.9% of residents and 16.6% of faculty reported improved resident participation while none reported decreased levels of participation (p < 0.001). 87.1% of residents and 66.7% of faculty preferred the online curriculum (p = 0.374). Completed ABSITE practice questions per resident increased from 21 to 31 questions/week (p = 0.541). CONCLUSION: Our online educational curriculum demonstrates success and can serve as a model for online restructuring of resident education.

Effect of COVID-19 on Surgical Training Across the United States: A National Survey of General Surgery Residents.

INTRODUCTION: COVID-19 emerged as a global pandemic in 2020 and has affected millions of lives. Surgical training has also been significantly affected by this pandemic, but the exact effect remains unknown. We sought to perform a national survey of general surgery residents in the United States to assess the effect of COVID-19 on surgical resident training, education, and burnout. METHODS: An anonymous online survey was created and distributed to general surgery residents across the United States. The survey aimed to assess changes to surgical residents' clinical schedules, operative volume, and educational curricula as a result of the COVID-19 pandemic. Additionally, we sought to assess the impact of COVID-19 on resident burnout. RESULTS: One thousand one hundred and two general surgery residents completed the survey. Residents reported a significant decline in the number of cases performed during the pandemic. Educational curricula were largely shifted toward online didactics. The majority of residents reported spending more time on educational didactics than before the pandemic. The majority of residents feared contracting COVID-19 or transmitting it to their family during the pandemic. CONCLUSIONS: COVID-19 has had significant impact on surgical training and education. One positive consequence of the pandemic is increased educational didactics. Online didactics should continue to be a part of surgical education in the post-COVID-19 era. Steps need to be taken to ensure that graduating surgical residents are adequately prepared for fellowship and independent practice despite the significantly decreased case volumes during this pandemic. Surgery training programs should focus on providing nontechnical clinical training and professional development during this time.

A "medical student practice profile" as the foundation for a case-based curriculum revision.

BACKGROUND: In 2001, the Keck School of Medicine of the University of Southern California initiated a major curriculum reform with fully integrated teaching of the basic sciences. DESCRIPTION: The new curriculum integrated a set of selected clinical cases called the student practice profile (SPP). The SPP cases were designed to (a) define the core target knowledge base and essential clinical experience of all graduating students, (b) to improve the relevance of basic science teaching, and (c) to serve as the overarching organizational structure for the 4-year curriculum. EVALUATION: Evaluation data demonstrated that implementation of the SPP project has been moderately successful and students have reported high exposure to the SPP cases and confidence in their ability to diagnose and manage problems. Improvement in teaching the basic sciences in a clinically relevant manner is suggested by a small continued improvement in USMLE scores since the SPP project was fully implemented. CONCLUSIONS: The SPP design represents a uniquely successful pathway to curriculum redesign.