A New Approach to Undergraduate Medical Education

Daniel M. Clinchot, M.D. explains the steps taken and the guiding principles used to revise the Ohio State University Medical Undergraduate Curriculum, Lead. Serve. Inspire and why it will produce a better equipped more effective physician.

Undergraduate medical education is undergoing a period of fervent curriculum renewal. Many forces such as global and national health disparities, rising cost of care without concomitant rise in quality and patient safety and the changing means by which care is delivered have come together to create a milieu that supports the need for change.

Traditional methods of medical instruction have left graduates ill prepared to meet the Institute of Medicine’s expectations of providing care that is patient centered, effective, efficient, equitable and safe. The transition to the graduate medical educational environment has left many learners struggling to deal with the increased responsibility. In addition graduates describe difficulty dealing with uncertainty, patient relationships, and with the competencies required in a multi-professional care environment where patient care is a team rather than solo effort. These skill deficiencies coupled with the lack of continuity with patients and faculty contribute to the observed movement away from careers that are focused on the longitudinal care of patients with undifferentiated complaints to more episodic management of patient problems at the subspecialty level. Longitudinal clinical educational experiences not only serve to benefit the learner but also their future patients by making medical education more effective and efficient.

The Ohio State University ensures that their graduates are better equipped to face the challenges of medical practice. (Photo: The Ohio State University)

The tenants of any future curriculum renewal should include core themes of multi-modal learning, scientific inquiry and critical thinking, service learning, trans-disciplinary team work and self-directed learning and assessment. Many of these skills cannot be learned through classroom activities, by episodic encounters with a variety of clinicians and for that matter through episodic encounters with a variety of patients. Instead, they must be nurtured and coached by an expert clinician who works with the learner over time to help them develop the requisite skills. Furthermore, these skills cannot be learned independent of clinical context. For example, it is difficult for the learner to really understand the longitudinal management of patients with chronic disease if the clinical context is a four week clerkship. This is especially true when we consider the development of critical thinking skills in the venue of clinical reasoning and problem solving. A model critical thinker will continually analyze, assess and improve upon the process by which they are applying information through reasoning and problem solving in a clinical contextual framework. At the Ohio State University College of Medicine we have redesigned our curriculum to include an early longitudinal immersion coupled with a linked longitudinal curriculum that supports the development of these skills. The desired outcome being a graduate who is measurably better-equipped to face the challenges of medical practice today and well into the future.

The Lead.Serve.Inspire curriculum at the Ohio State University College of Medicine was designed from a set of competency based core educational objectives developed by a multi-professional team that included physicians, foundational scientists, students, residents, program directors, patients, nurses, systems specialists, quality officers and pharmacists. Hallmarks of this curriculum include:

The Lead.Serve.Inspire curriculum is a three part four year curriculum (Figure 1) that infuses foundational science throughout all three parts. Curricular content is presented in an integrated fashion enabling students to learn foundational science content in association with the clinical contextual framework. Thus learners build the structural foundation of basic and behavioral science in a way that overlays the clinical framework creating integrated building blocks. In Part 1 of the curriculum teams of foundational scientists and clinicians develop a content delivery framework that combines different learning methods with exemplar disease states. For example, in week 6 of the curriculum (Figure 2) the central foundational science concept is membrane transport. The exemplar clinical conditions are Cystic Fibrosis and Cholera, each representing dysfunction of chloride ion transport. Early in the week learners interact with the foundational science content through lectures, e-learning technologies and readings. Throughout the rest of the week students are exposed to the associated epidemiologic concepts, behavioral social science concepts and clinical context in a way that makes the content seamless. This design is carried throughout all aspects of Part 1.

Curricular Outline

Longitudinal and integrated clerkships have been shown to be both feasible and effective. Longitudinal experiences enhance student satisfaction and reduce the impact of the hidden curriculum that acts to erode student empathy. Interestingly, longitudinal integrated clerkships have also been shown to increase the number of students selecting primary care residencies. In a focused longitudinal family medicine clerkship experience student interaction with patients over a longer period of time has lead to improvements in multiple measures of patient satisfaction.Students who participate in longitudinal care experiences report an enhanced understanding of illness and disease management by seeing the same patient at the time of presentation and through different stages of disease management.

Early contact with preceptors in a clinical environment in undergraduate medical education has been shown to improve motivation to learn foundational science material. In addition early clinical exposure is associated with improved student confidence during the clinical encounter. Unfortunately preceptors often view this experience as increasing their workload with little if any additional support.7 Thuia

Thus creating a framework where students can meaningfully contribute within the practice setting can act to mitigate some of the increased workload.

In the Lead.Serve.Inspire curriculum, all learners participate in a longitudinal practice based experience, which begins shortly after entry into medical school. This model was originally piloted in a small group of 12 students that expanded to 100 students the following year. The early pilot feedback helped us to create a design that models an early service-learning hybrid environment for students. This is accomplished by having the students undergo intense skills based training that allows them to function as contributing members of the health care team. This model highlights the learning of skills from all members of the team in service to the patient whose health issues will shape their education. Modeled after the Utah School of Medicine the procedure based training includes skills such as: rooming the patient, taking vital signs, venipuncture, blood glucometry, spirometry, pulse oximetry, basic wound care/dressing changes, electrocardiogram, urine dipstick, ppd placement, rapid strep, throat culture, injections and vaccinations. Students will also receive training in the use of the electronic medical record, basic medical history taking and physical examination prior to beginning their longitudinal practice experience. Satisfactory performance in a competency based objective structured clinical exam (OSCE) ensures that students have the requisite skill level prior to participating in the experience. During the longitudinal practice experience students will empanel patients with key predetermined diagnoses and behavioral/social science problems. Students will learn the empanelled patient case history well enough to be able to discuss the patient’s presentation and management in a facilitated small group setting. Therefore the longitudinal practice based experience will be linked with a longitudinal small group that is longitudinally facilitated by clinical faculty member. The small group sessions will function to ensure:

1. Linkage of practice based clinical context with the foundational science concepts learned throughout the first and second year through case based presentation and discussion. Exemplar cases will be used to demonstrate the prototypical case presentation and management. Then students will discuss the way their empanelled patient was managed. This will not only highlight the reasoning associated with the variability in management but also depending on the students’ clinical assignment (free clinic, community health center, private practice primary care etc.) bring fourth health care systems, health care disparities and equitable care into the discussion.
2. Faculty guided progressive development of the knowledge, skills, attitudes and behaviors that are required of a graduate who is ready to fully participate in post- graduate training.
3. Faculty guided development of clinical reasoning and critical thinking skills.

In Part 2 of the curriculum, longitudinal small group sessions continue so that students can work on longitudinal skill development, critical thinking and clinical reasoning and problem solving. This is accomplished by the development of small group case based discussions that include foundational scientists and clinicians. The translational application of scientific discoveries is integral to these discussions. Through this process students learn to apply scientific advances to patient care.

Sample Week 6 of the Curriculum.

Part 2 of the Lead.Serve.Inspire curriculum joins clinical disciplines in 4 month thematic experiences (Figure 3). Each of these three components of Part 2 starts out with a week-long ground school that delivers advanced foundational science concepts, building upon content already covered in Part 1. During the clinical immersion experiences learners take advantage of point-of-care technology to ensure that patients receive care that is safe, effective and evidence based. For example, utilization of i-touch technology at the bedside can have a significant impact on student learning and patient education. In addition students use mobile devices to document procedures and track performance. For example a direct observation mobile application allows faculty supervisors to directly input their observations of learners in the clinical environment so that it is available to the student, faculty coach and course directors. Learners in Part 2 will maintain contact with their assigned longitudinal practice from Part 1 by continuing to follow the management of their empanelled patients through the use of the electronic medical record. In addition Part 2 learners will mentor the students who took over for them in the practice, relieving the individual practices of this time intensive responsibility.

Uniquely designed and building upon Parts 1 & 2, Part 3 of the Lead.Serve.Inspire curriculum will allow learners to develop advanced skills based competencies and advanced clinical competencies. Learners will have exposure to Advanced Management in Hospital Based Care through combined clinical experiences in emergency medicine and a sub-internship. They will also have exposure to Advanced Management in Ambulatory and Relationship Centered Care through experiences in ambulatory internal medicine and the management of patients with long-term needs.

Throughout all three parts of the Lead.Serve.Inspire curriculum an educational portfolio will serve as a basis for individual student coaching by a faculty member. Students will develop a four year relationship with their faculty coach who will guide them in the process of educational goal setting, reflective practice, and self-assessment. The longitudinal nature of this relationship is designed to facilitate the learner’s ability to critically assess their own performance through the use of objective data and with this assessment create a clear path to improving performance.

Longitudinal project work is another unique characteristic of the Lead.Serve.Inspire curriculum. Longitudinal projects will occur throughout various parts of the curriculum. The Community Health Education project will empower the learner with the skills needed to complete an effective needs assessment in order to determine the educational needs of a community of patients within their longitudinal practice. After the needs assessment the students will work in teams to develop a patient education program that will serve the need that was previously identified. Ideally this will benefit not only the patients but also the practice caring for these patients. The Longitudinal Health Coaching project involves learners being taught how to act as effective health coaches. Once students successfully demonstrate the requisite competency in health coaching they will be linked with a patient who has a chronic disease that is not well controlled. The learner will work with this patient over the course of an entire year to develop healthy behaviors in the context of their chronic disease that will allow them to be more successful in their chronic disease management. The Quality and Patient Safety project occurs throughout all four years of the curriculum. Learners work in an inter-professional manner to understand the tenants of systems thinking and apply these concepts to quality and patient safety. The inter-professional group works on a culminating patient safety project that will utilize a medical informatics-Electronic Health Record interface that will help with assessing potential risk but also be utilized to determine the effectiveness of their intervention. Students gain a true understanding of quality and patient safety as a team effort both in identification of concerns and the implementation of effective mechanisms to prevent poor outcomes.

Another key feature of the Lead.Serve.Inspire curriculum is the use of simulation as a means to deliver curricular content in an interactive fashion. For example in the small group setting learners work through exemplar patients portrayed in a standardized fashion. Prior to working with the standardized patients in small group, learners independently work through medical history taking and doctor patient relationship challenges by interviewing virtual patients. The interface of student voice recognition and artificial intelligence associated with a real-life avatar that can react physically in ways that are appropriate to the context enables students to practice their skills in a low stakes interactive environment. In Parts 2 and 3 of the curriculum use of a simulated operating room, trauma bay, delivery room and hospital room experiences allow students to work through difficult and challenging scenarios in a high fidelity environment. Digital recording allows learners to debrief the interaction in a fashion that identifies domains of excellence and domains of difficulty. Working with the faculty coach, learners develop specific plans to improve performance. These types of environments also allow learners to clearly demonstrate competencies before doing more advanced work in the clinical environment.

Part 2 Clinical Immersions.

Evaluation and assessment is an integral component of the Lead.Serve.Inspire curriculum. Learners are assessed over time with multi-modal measures that have competency based criteria. Learners are expected to meet developmentally appropriate milestones by key branch points within the curriculum. Learners who are not able to demonstrate competency at these points will be required to remediate. The core educational competencies are not compensatory. Therefore learners will be unable to offset deficiencies in one domain by strengths in others. This approach to evaluation and assessment will enable those who receive graduates from our program to be confident in the skill level of these individuals.

The Lead.Serve.Inspire curriculum strives to create a unique and comprehensive learning environment for future physicians. The development of longitudinal relationships with faculty who can attest to the learner’s skills and help guide them in the achievement of competencies assures consistency among graduates. In addition multimodal and competency based education and assessment provides a framework that the learners can carry with them into competency based graduate medical education. Continuous themes of quality and patient safety as well as critical thinking and scientific inquiry facilitates the ability of learners to bridge the gap of foundational science and clinical science. Learning the skill of valid self assessment and remediation strategies creates a practical understanding of continuous improvement within the learner. All recognizable characteristics of an effective physician.

About the Author

Dr. Daniel Clinchot, an associate professor with tenure in the Department of Physical Medicine and Rehabilitation earned his MD degree at the Health Sciences Center at Syracuse of the State University of New York and served an internship in internal medicine and a residency in physical medicine and rehabilitation at Ohio State University Medical Center. Dr. Clinchot is the Associate Dean for Medical Education in the College of Medicine. He has been recognized for excellence in teaching at the undergraduate and graduate levels of medical education. Dr. Clinchot has led a tremendous team effort to re-envision the undergraduate medical curriculum within the College of Medicine.