Just imagine: new paradigms for medical education.

For all its traditional successes, the current model of medical education in the United States and Canada is being challenged on issues of quality, throughput, and cost, a process that has exposed numerous shortcomings in its efforts to meet the needs of the nations' health care systems. A radical change in direction is required because the current path will not lead to a solution.The 2010 publication Educating Physicians: A Call for Reform of Medical School and Residency identifies several goals for improving the medical education system, and proposals have been made to reform medical education to meet these goals. Enacting these recommendations practically and efficiently, while training more health care providers at a lower cost, is challenging.To advance solutions, the authors review innovations that are disrupting higher education and describe a vision for using these to create a new model for competency-based, learner-centered medical education that can better meet the needs of the health care system while adhering to the spirit of the above proposals. These innovations include collaboration amongst medical schools to develop massive open online courses for didactic content; faculty working in small groups to leverage this online content in a "flipped-classroom" model; and digital badges for credentialing entrustable professional activities over the continuum of learning.

Methods to assess students' acquisition, application and integration of basic science knowledge in an innovative competency-based curriculum.

BACKGROUND: The Cleveland Clinic Lerner College of Medicine was designed to encourage medical students to pursue careers as physician investigators. Our faculty decided that assessment should enhance learning and adopted only formative assessments to document student performance in relation to nine broad-based competencies. No grades are used to judge student performance throughout the 5-year program. Instead, assessments are competency-based, relate directly to performance standards, and are stored in e-Portfolios to track progress and document student achievement. The class size is limited to 32 students a year. AIMS: Schools with competency-based curricula must provide students with formative feedback to identify performance gaps and monitor progress. We describe a systematic approach to assess medical knowledge using essay-type questions (CAPPs) and multiple choice questions (SAQs) to provide medical students with weekly, formative feedback about their abilities to acquire, apply and integrate basic and clinical science concepts. METHOD: Processes for developing performance standards, creating assessment items, training faculty, reporting student performance and monitoring outcomes are described. A case study of a Year 1 course is presented with specific examples of CAPPs and SAQs to illustrate how formative assessment data are interpreted and reported in students' e-Portfolios. RESULTS: Preliminary evidence suggests that CAPPs and SAQs have a positive impact on students' education, a justifiable cost in light of obtained benefits and growing acceptance among stakeholders. Two student cohorts performed significantly above the population mean on USMLE Step 1, which suggests that these assessment methods have not disadvantaged students. More evidence is needed to assess the reliability and validity of these tools for formative purposes. CONCLUSIONS: Using assessment data for formative purposes may encourage application and integration of knowledge, help students identify performance gaps, foster student development of learning plans and promote student responsibility for learning. Discussion provides applications for institutions with larger classes to consider.

Examination of a clinical teaching effectiveness instrument used for summative faculty assessment.

This study explores whether a clinical teaching effectiveness (CTE) instrument provides valid scores for summative faculty assessment. The sample included all CTE instruments (n = 10,087) that learners (N = 1,194) completed to assess clinical teachers (N = 872) during 1 academic year. The authors investigated response processes (e.g., missing data, straight-line responses, level of learner), internal structure (e.g., confirmatory and exploratory factor analysis), teaching ratings by learner group (medical student or resident), and relation to other variables (e.g., correlation with global rating). Response processes identified a high prevalence of straight-line responses (same rating across all items) and differential patterns of missing data by learner group. Medical students rated their teachers higher than residents, and CTE scores had different factor structures depending on learner group. High correlation coefficients of CTE items with a single rating of overall teaching performance suggest that learners consider global performance when assessing clinical teaching performance.

Developing a mentorship program for clinical researchers.

INTRODUCTION: In academic health centers, the number of physician investigators and the number of research studies headed by clinicians has been declining. The U.S. Institute of Medicine and the National Institutes of Health suggest improved mentoring is important to reversing these trends. METHODS: This is a case study review of the role of mentors in developing and sustaining clinical investigators at the Cleveland Clinic. RESULTS: Issues influencing mentoring relationships at the Cleveland Clinic include whether mentoring contracts are formally or informally related and are agreed on; whether there are scheduled meetings for mentors and protégés; whether there are clearly articulated benchmarks and manageable steps; and whether there is a code of mentorship. CONCLUSIONS: Interactive group formats can lead to development of a code of mentorship and increased awareness of faculty regarding clinical investigation.

Cleveland Clinic Lerner College of Medicine: an innovative approach to medical education and the training of physician investigators.

Cleveland Clinic Lerner College of Medicine (CCLCM) is an innovative, five-year medical education track within Case Western Reserve University School of Medicine (Case) with a focused mission to attract and educate a limited number of highly qualified persons who seek to become physician investigators. CCLCM curriculum governance, faculty appointments and promotions, and admissions committees are integrated with respective Case committees. The CCLCM curriculum is based on faculty-defined professional attributes that graduates are expected to develop. These attributes were used to create curricular and assessment principles that guided the development of an integrated basic science, clinical science, and research curriculum, conducted in an active learning environment. An organ-system approach is used to solidify an understanding of basic science discipline threads in the context of relevant clinical problems presented in PBL and case-based discussion formats. Clinical skills are introduced in the first year as part of the two-year longitudinal experience with a family practice or internal medicine physician. The research program provides all students with opportunities to learn and experience basic and translational research and clinical research before selecting a research topic for their 12- to 15-month master-level thesis project. All Case students participate in required and elective clinical curriculum after the second year, but CCLCM students return to the Cleveland Clinic on selected Friday afternoons for program-specific research and professionalism-learning activities. A unique portfolio-based assessment system is used to assess student achievements in nine competency areas, seven of which reflect the Accreditation Council for Graduate Medical Education competencies.

Psychometric properties of an instrument designed to measure the educational quality of graduate training programs.

To assess the quality of residency education programs at an academic medical center for purposes of enhancing individual graduate medical education programs, we asked residents and fellows (N = 419) to evaluate their training programs using a Web-based questionnaire (response rate = 70%). Kruskal-Wallis tests, factor analysis, correlations, generalizability/decision studies, and mean plots were used to examine trainee responses and to assess the questionnaire's measurement properties. Exploratory factor analysis indicated that the instrument had a three-factor structure that correlated highly with overall program rating. Cronbach's alpha exceeded .80 for all factors, and decision studies revealed that 13 to 23 raters were needed to obtain G-coefficients greater than .70. Mean plots showed that the instrument could discriminate within and among training programs at the item level and the factor level, which should help target improvements across graduate training programs within large institutions.

A 47-year-old alcoholic man with progressive abnormal gait.

Central pontine myelinolysis should be considered in the differential diagnosis of a patient with a history of alcoholism and malnutrition presenting with ataxia, regardless of serum sodium values. T2-weighted images are the most sensitive imaging technique, but changes may not be evident for weeks after the insult, and in addition, the insult may not be known. Supportive care is important to prevent complications, but no treatment has been found to be effective in treating the illness. Patient outcomes vary considerably and are difficult to predict.