Collaborative Development and Implementation of a Hybrid Virtual Surgery Clerkship Curriculum in a Vietnamese Medical School.

OBJECTIVE: To collaboratively develop a hybrid virtual curriculum for a medical school surgery clerkship within an emerging medical university in Vietnam. DESIGN: A hybrid virtual surgery clerkship curriculum was collaboratively developed by Vietnamese and American surgeons as part of an international partnership between their respective universities. A set of 25 virtual lectures with associated materials were created and deployed in tandem with live, in-person review and skills sessions. Student quantitative and qualitative evaluation methods were developed and deployed to allow continuous iteration. A 6-month course was deployed to develop surgical faculty into effective teachers. SETTING: The curriculum was deployed at VinUniversity College of Health Sciences, the youngest medical university in Vietnam. It was developed in collaboration with the University of Pennsylvania Perelman School of Medicine. Each cohort of 12 students in the surgical clerkship will participate in the curriculum. CONCLUSIONS: The development of this hybrid surgical clerkship in Vietnam leveraged local resources and expertise with those available remotely. Lessons learned are directly applicable to future collaborative curriculum development efforts at other emerging medical schools.

The Optimal Timing of Step 1 in Medical Education Following the Transition to Pass/Fail: A Unique Perspective from Post-clerkship Step 1 Schools.

The National Board of Medical Examiners' decision to change Step 1 of the United States Medical Licensing Examination (USMLE) from a three-digit score to Pass/Fail (P/F) represents a disruptive change for students, faculty, and leaders in the academic community. In the context of this change, some schools may re-consider the optimal timing of Step 1 as they strive to align their assessment practices with sound educational principles. Currently, over 20 schools administer USMLE Step 1 after the core clerkships. In this commentary, we review the educational rationale for a post-clerkship Step 1, highlighting how adult learning theories support this placement. We discuss some short-term challenges post-clerkship Step 1 schools may encounter due to the proposed timing of the change in scoring, which creates three unique scenarios for learners that can introduce inequity in the system and provoke anxiety. We review outcomes of potentially heightened importance when Step 1 is P/F, including lower clinical subject exam scores in some clerkships, lower failure rates on Step 1 and stable Step 2 Clinical Knowledge scores with implications for the residency match. We outline the future potential for performance-based time-variable Step 1 study periods that are facilitated by post-clerkship placement of the exam. Finally, we discuss opportunities to achieve the goal of enhancing student well-being, which was a major rationale for eliminating the three-digit score.

Strategies From 11 U.S. Medical Schools for Integrating Basic Science Into Core Clerkships.

Calls for curricular reform in medical schools and enhanced integration of basic and clinical science have resulted in a shift toward preclerkship curricula that enhance the clinical relevance of foundational science instruction and provide students with earlier immersion in the clinical environment. These reforms have resulted in shortened preclerkship curricula, yet the promise of integrated basic science education into clerkships has not been sufficiently realized because of barriers such as the nature of clinical practice, time constraints, and limited faculty knowledge. As personalized medicine requires that physicians have a more nuanced understanding of basic science, this is cause for alarm. To address this problem, several schools have developed instructional and assessment strategies to better integrate basic science into the clinical curriculum. In this article, faculty and deans from 11 U.S. medical schools discuss the strategies they implemented and the lessons they learned to provide guidance to other schools seeking to enhance basic science education during clerkships. The strategies include program-level interventions (e.g., longitudinal sessions dedicated to basic science during clerkships, weeks of lessons dedicated to basic science interspersed in clerkships), clerkship-level interventions (e.g., case-based learning with online modules, multidisciplinary clerkship dedicated to applied science), bedside-level interventions (e.g., basic science teaching scripts, self-directed learning), and changes to formative and summative assessments (e.g., spaced repetition/leveraging test-enhanced learning, developing customized examinations). The authors discovered that: interventions were more successful when buy-in from faculty and students was considered, central oversight by curricular committees collaborating with faculty was key, and some integration efforts may require schools to provide significant resources. All schools administered the United States Medical Licensing Examination Step 1 exam to students after clerkship, with positive outcomes. The authors have demonstrated that it is feasible to incorporate basic science into clinical clerkships, but certain challenges remain.

Identifying and Supporting Students to Prevent USMLE Step 1 Failures When Testing Follows Clerkships: Insights From 9 Schools.

Several schools have moved the United States Medical Licensing Examination Step 1 exam after core clerkships, and others are considering this change. Delaying Step 1 may improve Step 1 performance and lower Step 1 failure rates. Schools considering moving Step 1 are particularly concerned about late identification of struggling students and late Step failures, which can be particularly problematic due to reduced time to remediate and accumulated debt if remediation is ultimately unsuccessful. In the literature published to date, little attention has been given to these students. In this article, authors from 9 medical schools with a postclerkship Step 1 exam share their experiences. The authors describe curricular policies, early warning and identification strategies, and interventions to enhance success for all students and struggling students in particular. Such learners can be identified by understanding challenges that place them "at risk" and by tracking performance outcomes, particularly on other standardized assessments. All learners can benefit from early coaching and advising, mechanisms to ensure early feedback on performance, commercial study tools, learning specialists or resources to enhance learning skills, and wellness programs. Some students may need intensive tutoring, neuropsychological testing and exam accommodations, board preparation courses, deceleration pathways, and options to postpone Step 1. In rare instances, a student may need a compassionate off-ramp from medical school. With the National Board of Medical Examiner's announcement that Step 1 scoring will change to pass/fail as early as January 2022, residency program directors might use failing Step 1 scores to screen out candidates. Institutions altering the timing of Step 1 can benefit from practical guidance by those who have made the change, to both prevent Step 1 failures and minimize adverse effects on those who fail.

Why Not Wait? Eight Institutions Share Their Experiences Moving United States Medical Licensing Examination Step 1 After Core Clinical Clerkships.

The majority of medical students complete the United States Medical Licensing Examination Step 1 after their foundational sciences; however, there are compelling reasons to examine this practice. This article provides the perspectives of eight MD-granting medical schools that have moved Step 1 after the core clerkships, describing their rationale, logistics of the change, outcomes, and lessons learned. The primary reasons these institutions cite for moving Step 1 after clerkships are to foster more enduring and integrated basic science learning connected to clinical care and to better prepare students for the increasingly clinical focus of Step 1. Each school provides key features of the preclerkship and clinical curricula and details concerning taking Steps 1 and 2, to allow other schools contemplating change to understand the landscape. Most schools report an increase in aggregate Step 1 scores after the change. Despite early positive outcomes, there may be unintended consequences to later scheduling of Step 1, including relatively late student reevaluations of their career choice if Step 1 scores are not competitive in the specialty area of their choice. The score increases should be interpreted with caution: These schools may not be representative with regard to mean Step 1 scores and failure rates. Other aspects of curricular transformation and rising national Step 1 scores confound the data. Although the optimal timing of Step 1 has yet to be determined, this article summarizes the perspectives of eight schools that changed Step 1 timing, filling a gap in the literature on this important topic.

Accelerating medical education: a survey of deans and program directors.

BACKGROUND: A handful of medical schools in the U.S. are awarding medical degrees after three years. While the number of three-year pathway programs is slowly increasing there is little data on the opinions of medical education leaders on the need for shortening training. PURPOSE: To survey deans and program directors (PDs) to understand the current status of 3-year medical degree programs and to elicit perceptions of the need for shortening medical school and the benefits and liabilities of 3-year pathway programs (3YPP). METHODS: Online surveys were emailed to the academic deans of all U.S. medical schools and to a convenience sample of residency and fellowship PDs. Frequency distributions are reported for key survey items and content analysis was used to describe open-ended responses. RESULTS: Of the respondents, 7% have a 3YPP, 4% were developing one, and 35% were considering development. In 2014, 47% of educational deans and 32% of PDs agreed that there may be a need to shorten medical school. From a list of benefits, both deans and PDs agreed that the greatest benefit to a 3YPP was debt reduction (68%). PDs and deans felt reduced readiness for independence, reduced exposure to complementary curricula regarding safety and quality improvement, premature commitment to a specialty, and burnout were all potential liabilities. From a list of concerns, PDs were concerned about depth of clinical exposure, direct patient care experience, ability to assume increased responsibility, level of maturity, and certainty regarding career choice. CONCLUSIONS: Over one-third of medical schools are considering the development of a 3YPP. While there may be benefits for a select group of students, concerns regarding maturity, depth of clinical exposure, and competency must be addressed for these programs to be well received.

Using educational prescriptions to teach medical students evidence-based medicine.

PURPOSE: To evaluate feasibility and impact of evidence-based medicine (EBM) educational prescriptions (EPs) in medical student clerkships. METHODS: Students answered clinical questions during clerkships using EPs, which guide learners through the "four As" of EBM. Epidemiology fellows graded EPs using a rubric. Feasibility was assessed using descriptive statistics and student and fellow end-of-study questionnaires, which also measured impact. In addition, for each EP, students reported patient impact. Impact on EBM skills was assessed by change in EP scores over time and scores on an EBM objective structured clinical exam (OSCE) that were compared to controls from the prior year. RESULTS: 117 students completed 402 EPs evaluated by 24 fellows. Average score was 7.34/9.00 (SD 1.58). 69 students (59%) and 21 fellows (88%) completed questionnaires. Most students thought EPs improved "Acquiring" and "Appraising". Almost half thought EPs improved "Asking" and "Applying". Fellows did not value grading EPs. For 18% of EPs, students reported a "change" or "potential change" in treatment. 56% "confirmed" treatment. EP scores increased by 1.27 (95% CI: 0.81-1.72). There were no differences in OSCE scores between cohorts. CONCLUSIONS: Integrating EPs into clerkships is feasible and has impact, yet OSCEs were unchanged, and research fellows had limitations as evaluators.

Continuous curricular feedback: a formative evaluation approach to curricular improvement.

Curriculum evaluations are used to plan future revisions and other improvements in curriculum design. Most models are summative and occur at the end of a course, so improvements in instruction may be delayed. In this article, the authors describe the formative curriculum evaluation model adopted at the Raymond and Ruth Perelman School of Medicine at the University of Pennsylvania. In their model, representative student feedback is gathered in real time and used to modify courses and improve instruction. The central features of their continuous feedback model include developing a small cadre of preclinical and clinical student evaluators who are trained to obtain classwide input regarding all aspects of the curriculum, including teacher effectiveness, and meet regularly (weekly or monthly) with relevant faculty and administrators. The authors show how this curriculum evaluation approach maximizes student involvement in course development and provides opportunities for rapid improvements in course content and instruction as well as for the identification of barriers to effective clinical and preclinical educational experiences.

Blood and body fluid exposures among US medical students in Botswana.

INTRODUCTION: Medical students from resource-rich countries who rotate in resource-limited settings have little pre-departure experience performing procedures, and lack familiarity with local equipment. The risk of blood and body fluid exposures during such rotations is significant. AIM: 1) Determine whether a simulation-based intervention reduced exposures among US medical students on a rotation in Botswana; 2) determine whether exposures were underreported; 3) describe exposures and provision of human immunodeficiency virus (HIV) post-exposure prophylaxis (PEP). SETTING: University of Pennsylvania medical students who traveled to Botswana for a clinical rotation from July 2007 to February 2010 were eligible to participate. PROGRAM DESCRIPTION: Twenty-two students participated in the simulation-based intervention. PROGRAM EVALUATION: To evaluate the intervention, we used a pre/post quasi-experimental design and administered a retrospective survey. The response rate was 81.7% (67/82). Needlesticks were eliminated [8/48 (16.7%) to 0/19 (0.0%), p = 0.07]. Splashes were unchanged (6/48 [12.5%) to 3/19 (15.8%), p=>0.99]. Three students did not report their exposure. Fifteen exposures were reported to an attending, who counseled the student regarding HIV PEP. Three students did not take PEP because the exposure was low-risk. DISCUSSION: Our intervention was associated with a decrease in needlestick exposures. Medical schools should consider training to reduce exposures abroad.

Team training of medical students in the 21st century: would Flexner approve?

As the 100-year anniversary of the Flexner Report approaches us, the physician workforce in the 21st century faces a radically different health care environment. To function effectively in this environment, future physicians, including medical students, will need educational programs that incorporate the theory and practice of teams and teamwork. Medical school graduates will be expected to understand how teams function and be capable themselves of functioning in a team. They will need to be competent in the knowledge, skills, and attitudes of teams and teamwork. Numerous reports during the past 10 years from national oversight and safety institutes and agencies have supported the need for team training in the health care environment, especially as a means to decrease errors and increase patient safety. Hospital training programs have begun implementing interdisciplinary team training around high-risk scenarios for their trainees and staff. However, for most medical schools, competence in team training has not been an instructional objective of educating medical students. Most instruction has been individual learning (i.e., lectures) or group learning (i.e., team-based or problem-based learning) even though there is strong evidence for team learning to be effective. With the ongoing changes in health care, it is argued that Flexner would concur that team training is necessary for medical students.

The development and implementation of a health-system-wide evaluation system for education activities: build it and they will come.

Academic health centers (AHCs) use education evaluation data for multiple purposes, and they also use multiple methods to collect data in an effort to evaluate the quality of student and faculty performance. Collecting evaluation data in a standardized manner enabling collation and subsequent assessment and interpretation is critically important if the information is to be maximally useful. A case study is presented of PENN Medicine's education evaluation program and the complicated mission of developing a multiprogram, multipurpose evaluation system, developed and implemented from 2003 to 2007. The proposed solution is generalizable to other comparable AHCs. The article begins with a structured analysis of needs, continues with a description of the conceptual evaluation model guiding the system, and offers a summary of the amounts and types of data collected in the years leading to full implementation. The article concludes with a brief list of needs that emerged during implementation and suggestions for future growth. The resulting system is described as supporting the evaluation of clinical teaching of more than 1,200 clinical faculty, students, residents, and fellows across 18 clinical departments with a common set of items. For the 2006-2007 academic year, more than 30,000 faculty evaluations were collected, combined, and then presented in a Web-based teaching dossier. A by-product of this effort was the creation of an ever-expanding data set that supports medical education research.

Professionalism in clerkships: an analysis of MSPE commentary.

BACKGROUND: Professionalism in medical school predicts future behaviors. The authors assessed prevalence of references to professionalism behaviors in the clerkship commentary portion of Medical School Performance Evaluations (MSPEs). METHOD: Content analyses of 293 MSPEs submitted for 2005 graduates. RESULTS: Overall, 70% of MSPEs specifically mentioned professionalism; 96% included information about at least 1 of 16 professional behaviors. Internal Medicine referenced significantly more behaviors than other clerkships. Commentary about behaviors such as interactions (94%) and motivation (91%) was common; behaviors such as truthfulness (8%) and confidentiality (6%) were rarely mentioned. Fewer than 1% of comments could be considered negative. CONCLUSIONS: Most professionalism comments in MSPEs are generic and somewhat bland, tending to be about students' collegial interactions and hard work. More detail and breadth may be facilitated by wider use of behavior-centered evaluation in clerkships.

Medical Student Performance Evaluations in 2005: an improvement over the former dean's letter?

PURPOSE: To collect information regarding preparation, content, and format of Medical Student Performance Evaluations (MSPEs) and evaluate a sample of 2005 MSPEs to assess compliance with the 2002 Association of American Medical Colleges-issued MSPE guidelines. METHOD: Cross-sectional survey with all 126 U.S. allopathic medical schools. Associate deans of students affairs were sent an eight-item questionnaire in June 2006 and asked to submit a sample of redacted MSPEs for 2005 graduates, choosing one from each tertile of the class. Survey data are summarized. MSPEs were abstracted, and results are presented descriptively. RESULTS: The survey response rate was 84%. Most associate deans (71%) reported having primary responsibility for composing MSPEs; 78% adhered to the format and content guidelines three fourths of the time. The abstraction of 293 MSPEs (78%) showed that more than 80% adhered to format recommendations. However, only 70% to 80% stated grades clearly, avoided the word recommendation, and stated whether the student had completed remediation. Fewer than 70% indicated whether the student had had any adverse actions or provided adequate comparative data. Strikingly, only 17% provide comparative data in the summary paragraph. Overall, 75% of the MSPEs were judged to be "adequate." CONCLUSIONS: MSPEs are somewhat variable in terms of which specific items are included. There has been steady quality improvement since prior surveys, primarily in formatting and labeling. However, a sizable minority of writers are still using the MSPE as a recommendation, and too few are providing helpful comparative data.