The 6 degrees of curriculum integration in medical education in the United States

Despite explicit expectations and accreditation requirements for integrated curriculum, there needs to be more clarity around an accepted common definition, best practices for implementation, and criteria for successful curriculum integration. To address the lack of consensus surrounding integration, we reviewed the literature and herein propose a definition for curriculum integration for the health professions education audience. We further believe that health professions education is ready to move beyond "horizontal" (one-dimensional) and "vertical" (two-dimensional) integration and propose a model of "six degrees of curriculum integration" to expand the two-dimensional concept for future designs of health professions programs and best prepare learners to meet the needs of patients. These six degrees include: interdisciplinary, timing and sequencing, instruction and assessment, incorporation of basic and clinical sciences, knowledge and skills-based competency progression, and graduated responsibilities in patient care. We encourage medical educators to look beyond two-dimensional integration to best prepare physicians of the future.

Assessing the Efficacy of a Novel Massive Open Online Soft Skills Course for South Asian Healthcare Professionals.

In healthcare professions, soft skills contribute to critical thinking, decision-making, and patient-centered care. While important to the delivery of high-quality medical care, soft skills are often underemphasized during healthcare training in low-and-middle-income countries. Despite South Asia's large population, the efficacy and viability of a digital soft skills curriculum for South Asian healthcare practitioners has not been studied to date. We hypothesized that a web-based, multilingual, soft skills course could aid the understanding and application of soft skills to improve healthcare practitioner knowledge, confidence, attitudes, and intent-to-change clinical practice.In September 2019 a needs assessment observing soft skills practices was conducted in several Indian states. We developed a communication-focused soft skills curriculum that comprised seven 10-minute video lectures, recorded in spoken English and Hindi. Participants consisted of any practicing healthcare professionals and trainees in select South Asian countries age 18 and over. Participant knowledge, confidence, attitudes, and intent-to-change clinical practice were evaluated using pre- and post-course tests and surveys. Statistical analyses were performed using STATA and SPSS.From July 26, 2021 to September 26, 2021, 5750 registered and attempted the course, 2628 unique participants completed the pre-test, and 1566 unique participants completed the post-test. Participants demonstrated small but statistically significant gains in confidence (𝑝<0.001), attitudes toward course topics relevance (𝑝<0.001), and intent-to-change clinical practice (𝑝<0.001). There was no statistically significant gain in knowledge. A digital soft-skills massive open online course for healthcare practitioners in South Asia could serve as a viable approach to improve the quality of soft skills training in low-to-middle income countries.

Research Methodologies in Health Professions Education Publications: Breadth and Rigor.

PURPOSE: Research methodologies represent assumptions about knowledge and ways of knowing. Diverse research methodologies and methodological standards for rigor are essential in shaping the collective set of knowledge in health professions education (HPE). Given this relationship between methodologies and knowledge, it is important to understand the breadth of research methodologies and their rigor in HPE research publications. However, there are limited studies examining these questions. This study synthesized current trends in methodologies and rigor in HPE papers to inform how evidence is gathered and collectively shapes knowledge in HPE. METHOD: This descriptive quantitative study used stepwise stratified cluster random sampling to analyze 90 papers from 15 HPE journals published in 2018 and 2019. Using a research design codebook, the authors conducted group coding processes for fidelity, response process validity, and rater agreement; an index quantifying methodological rigor was developed and applied for each paper. RESULTS: Over half of research methodologies were quantitative (51%), followed by qualitative (28%), and mixed methods (20%). No quantitative and mixed methods papers reported an epistemological approach. All qualitative papers that reported an epistemological approach (48%) used social constructivism. Most papers included participants from North America (49%) and Europe (20%). The majority of papers did not specify participant sampling strategies (56%) or a rationale for sample size (80%). Among those reported, most studies (81%) collected data within 1 year.The average rigor score of the papers was 56% (SD = 17). Rigor scores varied by journal categories and research methodologies. Rigor scores differed between general HPE journals and discipline-specific journals. Qualitative papers had significantly higher rigor scores than quantitative and mixed methods papers. CONCLUSIONS: This review of methodological breadth and rigor in HPE papers raises awareness in addressing methodological gaps and calls for future research on how the authors shape the nature of knowledge in HPE.

Neurosurgery Lectures Benefit from a Flipped Class Approach.

BACKGROUND: In a flipped classroom, students learn lecture material before class and then participate in active learning during in-person sessions. This study examines preferences for flipped classroom activities during a neurosurgery presentation on traumatic brain injury. METHODS: Two hundred twenty-five third- and fourth-year medical students on their core neurology rotation watched an online podcast about traumatic brain injury before meeting for in-person, active learning activities with a neurological surgeon. Before and after the class, students were given rank-based surveys with an optional section for comments. The initial survey assessed preference for specific active learning activities, and the final survey assessed satisfaction with the experience. The students also answered an online 20-question postlecture test as part of the standard neurology class assessment. RESULTS: Every student scored over 90% on the postlecture test. Of the 81 students who answered the first survey, most students (83.95%) strongly preferred or preferred case scenarios with group discussion. The average Likert score for case scenario preference (4.37/5) was significantly higher than the score for all other activities (P < 0.05). Of the 207 students who answered the second survey, 80.19% of students reported that they would probably or definitely like to see more flipped classroom activities. CONCLUSIONS: Medical students highly preferred case scenarios because according to their comments, this method was relevant to real-life situations and led to higher information retention. This information suggests that the flipped classroom model for neurosurgical-based lectures is preferred, is beneficial, and should incorporate case scenarios. This methodology may also apply to neurosurgical residency training.

The Applied Weighted Slide Metric (AWSM) Tool: Creation of a Standard Slide Design Rubric.

Introduction: Lectures are a standard aspect across all realms of medical education. Previous studies have shown that visual design of presentation slides can affect learner outcomes. The purpose of this study was to develop a slide design rubric grounded in evidence-based, multimedia principles to enable objective evaluation of slide design. Method: Using the principles described in Mayers' Principles of Multimedia Learning and Duarte's Slide:ology, the authors extracted nineteen items important for slide design. We developed an online, rank-item, survey tool to identify the importance of each item among medical educators. Respondents selected which slide design principles they felt were important when attending a lecture/didactic session and ranked their relative importance. Results: We received 225 responses to the survey. When asked to specifically rank elements from most important to least important, participants gave the most weight to "readability of figures and data" and "[lack of] busy-ness of slide." The lowest ranked elements were "transitions and animations" and "color schemes". Using the results of the survey, including the free response, we developed a rubric with relative weighting that followed our survey data. Conclusion: With this information we have applied values to the various aspects of the rubric for a total score of 100. We hope that this rubric can be used for self-assessment or to evaluate and improve slides for educators. Future research will be focused on implementing and validating the slide design survey and ensuring it is easily usable with a high inter-rater reliability and whether self-assessment with the rubric improves presentation design and education quality.

An Effective COVID-19 Medical Student Elective.

BACKGROUND: The COVID-19 pandemic has revealed the importance of teaching medical students pandemic preparedness and COVID-19 related clinical knowledge. To fill the gap of COVID-19 instruction backed by evaluation data, we present a comprehensive COVID-19 pilot curriculum with multiple levels of evaluation data. METHODS: In the spring of 2020, the University of California, Irvine (UCI) School of Medicine piloted a two-week, primarily asynchronous COVID-19 elective course for medical students. The goal of the course is to provide a foundation in clinical care for COVID-19 while introducing students to emerging issues of a modern pandemic. Objectives align with institutional objectives, and instruction is delivered in thematic modules. Our curriculum utilizes numerous instructional strategies effective in distance learning including independent learning modules (ILM), reading, video lectures, discussion board debates, simulation and evidence-based argument writing. We designed a three-level, blended evaluation plan grounded in the Kirkpatrick and Kirkpatrick evaluation model that assessed student satisfaction, relevance, confidence, knowledge and behavior. RESULTS: Our end of course survey revealed that students had high levels of satisfaction with the curriculum, and felt the course was relevant to their clinical education. Various assessment tools showed excellent levels of knowledge attainment. All respondents rated themselves as highly confident with the use of personal protective equipment, though fewer were confident with ventilator management. CONCLUSION: Overall our pilot showed that we were able to deliver relevant, satisfying COVID-19 instruction while allowing students to demonstrate knowledge and desired behaviors in COVID-19 patient care.

What Is an Innovation Article? A Systematic Overview of Innovation in Health Professions Education Journals.

PURPOSE: Innovation articles have their own submission category and guidelines in health professions education (HPE) journals, which suggests innovation might be a unique genre of scholarship. Yet, the requirements for innovation submissions vary among journals, suggesting ambiguity about the core content of this type of scholarship. To reduce this ambiguity, the researchers conducted a systematic overview to identify key features of innovation articles and evaluate their consistency in use across journals. Findings from this review may have implications for further development of innovation scholarship within HPE. METHOD: In this systematic overview, conducted in 2020, the researchers identified 13 HPE journals with innovation-type articles and used content analysis to identify key features from author guidelines and publications describing what editors look for in innovation articles. The researchers then audited a sample of 39 innovation articles (3/journal) published in 2019 to determine presence and consistency of 12 innovation features within and across HPE journals. Audit findings informed the researchers' evaluation of innovation as a genre in HPE. RESULTS: Findings show variability of innovation feature presence within and across journals. On average, articles included 7.8 of the 12 innovation features (SD 2.1, range 3-11). The most common features were description of: how the innovation was implemented (92%), a problem (90%), what was new or novel (79%), and data or outcomes (77%). On average, 5.5 (SD 1.5) out of 12 innovation features were consistently used in articles within each journal. CONCLUSIONS: The authors identified common features of innovation article types based on journal guidelines, but there was variability in presence and consistency of these features, suggesting HPE innovations are in an emerging state of genre development. The authors discuss potential reasons for variability within this article type and highlight the need for further discussion among authors, editors, and reviewers to improve clarity.

Illustrating clinical relevance in the preclerkship medical school curriculum through active learning with KardiaMobile electrocardiography.

We introduced the AliveCor KardiaMobile electrocardiogram (ECG), a Food and Drug Administration (FDA)-approved, iPad-enabled medical device, into the preclerkship curriculum to demonstrate the clinical relevance of cardiac electrophysiology with active learning. An evaluation showed that medical students considered the KardiaMobile ECG active learning activity to be a valuable educational tool for teaching cardiac physiology.

Medical Student Attitudes toward USMLE Step 1 and Health Systems Science - A Multi-Institutional Survey.

Phenomenon: Because of its importance in residency selection, the United States Medical Licensing Examination Step 1 occupies a critical position in medical education, stimulating national debate about appropriate score use, equitable selection criteria, and the goals of undergraduate medical education. Yet, student perspectives on these issues and their implications for engagement with health systems science-related curricular content are relatively underexplored. Approach: We conducted an online survey of medical students at 19 American allopathic medical schools from March-July, 2019. Survey items were designed to elicit student opinions on the Step 1 examination and the impact of the examination on their engagement with new, non-test curricular content related to health systems science. Findings: A total of 2856 students participated in the survey, representing 23.5% of those invited. While 87% of students agreed that doing well on the Step 1 exam was their top priority, 56% disagreed that studying for Step 1 had a positive impact on engagement in the medical school curriculum. Eighty-two percent of students disagreed that Step 1 scores should be the top item residency programs use to offer interviews. When asked whether Step 1 results should be reported pass/fail with no numeric score, 55% of students agreed, while 33% disagreed. The majority of medical students agreed that health systems science topics were important but disagreed that studying for Step 1 helped learn this content. Students reported being more motivated to study a topic if it was on the exam, part of a course grade, prioritized by residency program directors, or if it would make them a better physician in the future. Insights: These results confirm the primacy of the United States Medical Licensing Examination Step 1 exam in preclinical medical education and demonstrate the need to balance the objectives of medical licensure and residency selection with the goals of the broader medical profession. The survey responses suggest several potential solutions to increase student engagement in health systems science curricula which may be especially important after Step 1 examination results are reported as pass/fail.

#MDsToo: A student mistreatment prevention curriculum for faculty members and residents.

BACKGROUND: Medical student mistreatment has detrimental effects on student well-being and poses a patient safety risk, yet 40% of medical school graduates report being mistreated during their training. Unfortunately, this statistic has not changed significantly since 2013. The 'hidden curriculum' contributes to the pervasiveness of mistreatment in medical schools in the USA. The #MDsToo curriculum was developed to mitigate the effects of the hidden curriculum by sensitising faculty members and residents to mistreatment. METHODS: During the curriculum, participants are introduced to the KIND (knowledge-sharing, inclusive, non-discriminatory, developmentally appropriate) framework for modelling positive teacher-learner interactions and detecting mistreatment. Using KIND, faculty members and residents identify and categorise mistreatment in eight video cases depicting mistreatment, and reflect on their own experiences with mistreatment. RESULTS: Two hundred and forty-eight participants responded to a course survey. Most had experienced mistreatment. After the training, almost half stated that there were situations in the past that they did not recognize as mistreatment that they would now classify as mistreatment, and most stated that they were likely to report mistreatment now. CONCLUSION: The #MDsToo curriculum may provide an effective design for mistreatment prevention training. Next steps include multi-institutional implementation and longitudinal outcome studies.

The human kindness curriculum: An innovative preclinical initiative to highlight kindness and empathy in medicine.

Background: Prior studies have shown a marked drop in empathy among students during their third (clinical) year of medical school. Curricula developed to address this problem have varied greatly in content and have not always been subjected to validated measures of impact. Methods: In 2015, we initiated a Human Kindness (HK) curriculum for the initial 2 years of medical school. This mandatory 12-h curriculum (6 h/year) included an innovative series of lectures and patient interactions with regard to compassion and empathy in the clinical setting. Both quantitative (Jefferson Scale of Empathy [JSE]) and qualitative data were collected prospectively to evaluate the impact of the HK curriculum. Results: In the initial Pilot Year, neither 1st (Group 1) nor 2nd (Group 2) year medical students showed pre-post changes in JSE scores. Substantial changes were made to the curriculum based on faculty and student evaluations. In the following Implementation Year, both the new 1st (Group 3) and the now 2nd year (Group 4) students, who previously experienced the Pilot Year, showed significant improvements in post-course JSE scores; this improvement remained valid across subanalyses of gender, age, and student career focus (e.g., internal medicine, surgery, etc.). Despite the disappointingly flat initial Pilot Year JSE scores, the 3rd year students (Group 2) who experienced only the Pilot Year of the curriculum (i.e., 2nd year students at the time of the Pilot Year) had subsequent JSE scores that did not show the typical decline associated with the clinical years. Students generally evaluated the HK curriculum positively and rated it as being important to their medical education and development as a physician. Discussion: A required preclinical curriculum focused on HK resulted in significant improvements in medical student empathy; this improvement was maintained during the 1st clinical year of training.

Technological Pedagogical Content Knowledge Among Medical Educators: What Is Our Readiness to Teach With Technology?

PURPOSE: This study aimed to empirically assess medical educator knowledge of pedagogy and technology to inform the direction of faculty development efforts. METHOD: The technological pedagogical content knowledge (TPACK) framework survey is a validated instrument for understanding educators' knowledge of content (CK), pedagogy (PK), and technology (TK) in teaching. A modified version of the TPACK was administered to medical educators (N = 76) at 2 public institutions: University of California, Irvine School of Medicine (UC Irvine); and University of Colorado School of Medicine (CU). RESULTS: An independent-samples t test compared TK with PK and CK within each institution. The means of TK (UC Irvine: 3.4; CU: 3.4) and both PK for didactic sessions (UC Irvine: 3.9; CU: 4.4) and PK for clinical settings (UC Irvine: 4.0; CU: 4.4) were compared using a t test and statistically different, P < .01. Similarly, the means of TK and CK (UC Irvine: 4.5; CU: 4.7) were statistically different, P < .01. A Wilcoxon rank sum test indicated that the CU PK for a didactic session (mean: 4.4) was greater than the UC Irvine PK for a didactic session (mean: 3.9), P < .01. Similarly, the CU PK for a clinical setting (mean: 4.4) was greater than the UC Irvine PK for a clinical setting (mean: 4.0), P < .01. CONCLUSIONS: There is a clear need for faculty development programs for medical educators to focus on how to teach with technology if medical schools continue to adopt technology within their curricula.

Medical Students' Efforts to Integrate and/or Reclaim Authentic Identity: Insights from a Mask-Making Exercise.

Medical students' mask-making can provide valuable insights into personal and professional identity formation and wellness. A subset of first- and second-year medical students attending a medical school wellness retreat participated in a mask-making workshop. Faculty-student teams examined student masks and explanatory narratives using visual and textual analysis techniques. A quantitative survey assessed student perceptions of the experience. We identified an overarching theme: "Reconciliation/reclamation of authentic identity." The combination of nonverbal mask-making and narrative offers rich insights into medical students' experience and thinking. This activity promoted reflection and self-care, while providing insight regarding personal and professional development.

Comparing the Results of Written Testing for Advanced Cardiac Life Support Teaching Using Team-based Learning and the "Flipped Classroom" Strategy.

Objectives We sought to further determine whether cognitive test results changed for advanced cardiac life support (ACLS) taught in the team-based learning/flipped classroom format (TBL/FC) versus a lecture-based (LB) control. Methods We delivered 2010 ACLS to two classes of fourth-year medical students in the TBL/FC format (2015-2016), compared to three classes in the LB format (2012-2014). There were 27.5 hours of instruction for the TBL/FC model (TBL - 10.5 hours, podcasts - nine hours, small-group simulation - eight hours), and 20 hours (lectures - 12 hours, simulation - eight hours) in LB. We taught TBL for 13 cardiac cases while LB had none. Didactic content and seven simulated cases were the same in lecture (2012-2014) or in podcast formats (2015-2016). Testing was the same using 50 multiple-choice (MC) format questions, 20 rhythm-matching questions, and seven fill-in management of simulated cases. Results Some 468 students enrolled in the course 259 (55.4%) in the LB format in 2012-2014, and 209 (44.6%) in the TBL/FC format in 2015-2016. The scores for two out of three tests (MC and fill-in) increased with TBL/FC. Combined, median scores increased from 93.5% (IQR 90.6, 95.4) to 95.1% (92.5, 96.8, p = 0.0001). More students did not pass one of three tests with LB versus TBL/FC (24.7% versus 18.2%), and two or three parts of the test (8.1% versus 4.3%, p = 0.01). On the contrary, 77.5% passed all three with TBL/FC versus 67.2% with LB (change 10.3%, 95% CI 2.2%-18.2%). Conclusion TBL/FC teaching for ACLS improved written test results compared with the LB format.