Outcomes of a Longitudinal Quality Improvement and Patient Safety Preclerkship Curriculum.

PURPOSE: To evaluate whether quality improvement (QI) and patient safety (PS) training in preclerkship medical education resulted in students' development and retention of knowledge, application-based and perceived skills, and attitudes throughout clerkships. METHOD: A longitudinal QI/PS curriculum with multimodal curricular components was implemented in the preclerkship curriculum between 2015 and 2017 at the Warren Alpert Medical School of Brown University, Rhode Island. Assessments were administered at baseline (T1), end of year 1 (T2), Clinical Skills Clerkship (T3), and end of clerkships (T4) in the intervention cohort (n = 97). In 2018, T4 data for this cohort were compared with a prior control cohort (n = 97) at T4. RESULTS: Results of knowledge-based multiple-choice questions (MCQs) (t[134] = -1.57, P < .001) and application-based skills (t[132] = -8.91, P < .001) demonstrated significant improvement from T1 to T2 (intervention cohort). Assessments of perceived skills showed significant growth from T1 to T2 (t[137] = -23.38, P < .001). Performance on application-based skills significantly improved from T2 to T3 (t[123] = -4.11, P < .001). Compared with the control cohort, the intervention cohort had significantly higher scores on MCQs (t[187.88] = 3.98, P < .001), application-based skills (t[72.69] = 6.40, P < .001), perceived skills (t[106.99] = 5.24, P < .001), and attitudes (t[152] = 5.86, P < .001). CONCLUSIONS: Incorporation of preclerkship QI/PS training resulted in improvements in knowledge, application-based and perceived skills, and attitudes that were retained throughout clerkships.

Contrasting Incoming Medical Students' Attitudes Dual Degree vs Traditional Tracks.

BACKGROUND AND OBJECTIVES: The Warren Alpert Medical School of Brown University (AMS) recently implemented a novel dual degree MD-ScM program in primary care and population medicine (PC-PM) that enrolls up to 24 of its nearly 144 yearly matriculants. The overarching goal of this track is to train medical students to become physician leaders who focus on issues in population medicine within primary care. METHODS: We conducted a baseline assessment of the students enrolled in this parallel track in comparison to our traditional students to identify characteristics of and group differences between students in the PC-PM program and traditional students. Data was collected from first-year students matriculating in the 2015 and 2016 academic years (N=277) using portions of nine validated surveys with an emphasis on caring for the underserved and cultural competence, professionalism, working in interprofessional teams, tolerance of ambiguity, empathy, patient-provider interactions, and patient safety/quality improvement. RESULTS: We identified slightly higher significant baseline differences on three scales in which the PC-PM students (n=38) were higher than those in the traditional track students (n=239). These measured cultural competency (t[275]=-3.05, P=.003), professionalism (t[273]=-3.10, P=.002), and attitudes toward working with underserved populations (t[267]=2.31, P=.02). CONCLUSIONS: The higher differences for these three elements may be important to the success of the PC-PM program. We plan to track the growth of the PC-PM students as well as our traditional students through their 4 years of medical school to investigate growth and development throughout the academic career.

An Interactive Quality Improvement and Patient Safety Workshop for First-Year Medical Students.

Introduction: There is a call to incorporate quality improvement and patient safety (QI/PS) content into undergraduate medical education, though limited literature exists on optimal teaching strategies. We designed a required, interactive workshop for first-year medical students to introduce principles of QI/PS, specifically focusing on student attitudes, knowledge, and skills. Methods: We used active learning principles from existing literature and included the application of QI/PS concepts, engaging in PDSA (plan, do, study, act) cycles, conducting root cause analyses, and creating a fishbone diagram. Evaluation of student knowledge included pre/post assessments with locally designed multiple-choice items and a case scenario from the Quality Improvement Knowledge Application Tool. Additional students' self-assessments included perceived knowledge and problem-solving skills. We also evaluated student satisfaction with the workshop. Results: Results on the direct assessment total score (n = 136) indicated significant growth from pretest (65%) to posttest (89%). Indirect assessments (n = 138) targeting perceived ability to define QI/PS principles, identify key components in a QI case scenario, explain the purpose of a fishbone diagram, apply a PDSA cycle, and create a fishbone diagram for a QI case scenario all significantly increased from pre- to postworkshop. The mean overall rating across the 2 years the workshop was administered (ns = 134, 137) was 75% (i.e., good to very good). Discussion: First-year medical students' knowledge and perceived skills significantly increased from start to end of the workshop. The workshop was placed in an appropriate stage of the curriculum and contained relevant information for our learners.

Predicting United States Medical Licensure Examination Step 2 clinical knowledge scores from previous academic indicators.

The use of multiple academic indicators to identify students at risk of experiencing difficulty completing licensure requirements provides an opportunity to increase support services prior to high-stakes licensure examinations, including the United States Medical Licensure Examination (USMLE) Step 2 clinical knowledge (CK). Step 2 CK is becoming increasingly important in decision-making by residency directors because of increasing undergraduate medical enrollment and limited available residency vacancies. We created and validated a regression equation to predict students' Step 2 CK scores from previous academic indicators to identify students at risk, with sufficient time to intervene with additional support services as necessary. Data from three cohorts of students (N=218) with preclinical mean course exam score, National Board of Medical Examination subject examinations, and USMLE Step 1 and Step 2 CK between 2011 and 2013 were used in analyses. The authors created models capable of predicting Step 2 CK scores from academic indicators to identify at-risk students. In model 1, preclinical mean course exam score and Step 1 score accounted for 56% of the variance in Step 2 CK score. The second series of models included mean preclinical course exam score, Step 1 score, and scores on three NBME subject exams, and accounted for 67%-69% of the variance in Step 2 CK score. The authors validated the findings on the most recent cohort of graduating students (N=89) and predicted Step 2 CK score within a mean of four points (SD=8). The authors suggest using the first model as a needs assessment to gauge the level of future support required after completion of preclinical course requirements, and rescreening after three of six clerkships to identify students who might benefit from additional support before taking USMLE Step 2 CK.

Proceedings from Bridging Health Disparities to Address the Opioid Epidemic: A Symposium at the Warren Alpert Medical School of Brown University.

OBJECTIVE/BACKGROUND: In response to the unprecedented rates of illicit drug use, including opioid addiction and overdose in Rhode Island, local healthcare institutions, led by the Warren Alpert Medical School (AMS) of Brown University, collaborated to present "Bridging Health Disparities to Address the Opioid Epidemic." This symposium sought to educate a wide array of healthcare providers and professionals around opioid use disorder, including the state of the opioid crisis in Rhode Island, national efforts around opioid misuse and how providers can work together to stem the opioid crisis in the state. DESIGN AND METHODS: The symposium included a keynote session which aimed to increase knowledge and decrease stigma. This was followed by two rounds of breakout sessions which focused on various components of opioid disorder treatment. We elicited feedback from participants in order to plan further interventions to educate providers in Rhode Island around the opioid epidemic. Primary Results: Initial feedback was positive. More importantly, this workshop allowed us to identify gaps in knowledge amongst healthcare providers in Rhode Island in order to plan further interventions for healthcare providers, including physicians, around opioid misuse, in Rhode Island. PRINCIPAL CONCLUSIONS: This symposium is one of the first steps that a consortium of healthcare institutions, including AMS, will take to address the opioid crisis in Rhode Island. Feedback from the event was elicited to identify gaps in healthcare provider knowledge and will be used to design and implement further interventions. [Full article available at http://rimed.org/rimedicaljournal-2017-04.asp].

Access to treatment for opioid use disorders: Medical student preparation.

The current opioid epidemic requires new approaches to increasing access to treatment for patients with opioid use disorders and to improve availability of medication assisted treatment. We propose a model where medical students complete the necessary training to be eligible for the waiver to prescribe opioid medications to treat these disorders by the time of medical school graduation. This plan would increase the number of Drug Abuse Treatment Act of 2000 (DATA 2000) waivered physicians who could gain additional experience in treating substance use disorders during residency and provide the access to clinical care needed for individuals suffering with opioid use disorder. (Am J Addict 2017;26:316-318).

An interprofessional education workshop to develop health professional student opioid misuse knowledge, attitudes, and skills.

OBJECTIVE: To implement and evaluate an interprofessional workshop focused on increasing student knowledge, skills, and attitudes toward opioid misuse. SETTING: The Warren Alpert Medical School of Brown University in Providence, Rhode Island, April 2016. PRACTICE DESCRIPTION: Health professional students from medicine, nursing, pharmacy, social work, and physical therapy participated in an interprofessional education workshop focused on opioid use disorder. PRACTICE INNOVATION: This workshop included 4 main components: a patient panel, a simulated standardized patient encounter, a paper-based case session focused on a homeless individual misusing opioids, and naloxone training. EVALUATION: Direct assessment included a pretest and a posttest adapted from the Opioid Overdose Knowledge Scale administered to medical students measuring knowledge of opioid overdose at baseline and at 12 weeks after the workshop. Indirect assessment included a satisfaction survey administered to medical, nursing, pharmacy, and social work students. RESULTS: Medical students scored a mean of 40.84 out of 54 (SD = 5.36) points at baseline (n = 120) and a mean of 47.94 out of 54 (SD = 3.20) points at 12-week follow-up (n = 72), demonstrating a significant increase in knowledge from pretest to posttest (P <0.001). Student satisfaction data from medicine, nursing, pharmacy, social work, and physical therapy (n = 272) revealed a high degree of satisfaction regarding the overall quality of the training (4.47/5; SD = 0.75), quality of instruction (4.53/5; SD = 0.73), quality of training materials (4.46/5; SD = 0.77), the training experience (4.52/5; SD = 0.75), and the organization of the training (4.50/5; SD = 0.73). CONCLUSION: Our results demonstrate that an interprofessional education workshop focused exclusively on opioid misuse was well received with high levels of satisfaction among health professional students. Workshops such as these can be used in health professions curricula to simulate the complex issues surrounding substance use disorder and to highlight the importance of interprofessional teams.

Substance Use Disorder Training Workshop for Future Interprofessional Health Care Providers.

INTRODUCTION: Rates of substance use disorders, including opioid misuse, continue to rise despite national initiatives. Because of this, health professional schools from Rhode Island joined together to design and implement a single-day interprofessional education workshop on substance use disorder training. METHODS: This workshop consists of four sessions. The first is a patient panel featuring both patients recovering from substance use disorders and their health care providers. Next is a naloxone administration training session. This is followed by a standardized patient session featuring an individual who requires nonopioid options for chronic pain treatment and in which health professional students work together to take a history, perform a physical examination, and develop a treatment plan. Finally, the last session is a complex paper-based case study focusing on a homeless individual with diverse medical problems requiring multifaceted care. RESULTS: A total of 540 students from a variety of health care professions participated in the workshop. Students were asked to evaluate each component of the workshop, as well as the workshop overall, on a 6-point Likert scale (1 = poor, 6 = outstanding). Students rated the overall workshop at 76% (4.54 out of 6), and the sessions received ratings ranging from 67% (4.01 out of 6 for the case study) to 83% (4.96 out of 6 for the patient/provider panel). DISCUSSION: This curriculum can be adapted and implemented at other medical schools to provide opportunities for future health care professionals to learn how to work effectively in interprofessional teams to manage substance use disorders.

Playing in the "Gutter": Cultivating Creativity in Medical Education and Practice.

In comics, "gutters" are the empty spaces between panels that readers must navigate to weave disjointed visual sequences into coherent narratives. A gutter, however, is more than a blank space--it represents a creative zone for making connections and for constructing meaning from disparate ideas, values, and experiences. Over the course of medical training, learners encounter various "gutters" created by the disconnected subject blocks and learning experiences within the curriculum, the ambiguity and uncertainty of medical practice, and the conflicts and tensions within clinical encounters. Navigating these gutters requires not only medical knowledge and skills but also creativity, defined as the ability to make connections between disparate fragments to create meaningful, new configurations. To cultivate medical students' creative capacity, the authors developed the Integrated Clinical Arts (ICA) program, a required component of the first-year curriculum at the Warren Alpert Medical School of Brown University. ICA workshops are designed to place students in a metaphorical gutter, wherein they can practice making connections between medicine and arts-based disciplines. By playing in the gutter, students have opportunities to broaden their perspectives, gain new insights into both medical practice and themselves, and explore different ways of making meaning. Student feedback on the ICA program highlights an important role for creativity and the arts in medicine: to transform gutters from potential learning barriers into opportunities for discovery, self-reflection, and personal growth.

The Primary Care-Population Medicine Program at The Warren Alpert Medical School of Brown University.

The United States healthcare system has been in a period of rapid evolution over the past decade, a trend that is anticipated to continue for the foreseeable future. Physicians are increasingly responsible for the quality of care they provide, and are being held accountable not just for the patient in front of them, but also for the outcomes of their patient panels, communities, and populations. In response to these changes, as well as the projected shortage of primary care physicians, the Warren Alpert Medical School of Brown University (AMS) developed the Primary Care-Population Medicine (PC-PM) program, which builds upon the traditional curriculum with major integrated curricular innovations. The first is a Master of Science Degree in Population Medicine that requires students to take nine additional courses over four years, complete a thesis project focused on an area of Population Medicine, and take part in significant leadership training. Another significant innovative element is the development of a Longitudinal Integrated Clerkship (LIC) during the 3rd year of medical school in which the students complete a longitudinal outpatient experience with the same preceptors and patients. During the LIC students will follow a panel of patients wherever care is provided, while focusing on population health and healthcare delivery issues, in addition to medical topics throughout their clinical and didactic experiences. Though several of the innovative elements are being piloted, the inaugural PC-PM class of up to 24 students will only begin in August 2015. While the outcomes from this program will not be known for many years, the potential impact of the program is significant for AMS, medical education, and the future of healthcare delivery.

Health disparity curriculum at the Warren Alpert Medical School of Brown University.

There is increasing recognition that, in addition to acquiring knowledge of basic sciences and clinical skills, medical students must also gain an understanding of health disparities, and develop a defined skill set to address these inequalities. There are few descriptions in the literature of a systematic, longitudinal curriculum in health disparities. Using Kern's six-step approach to curriculum development along with principles of experiential and active learning, student champions and the Office of Medical Education developed a multimodal health disparities curriculum. This curriculum includes required experiences for medical students in the 1st, 2nd and 3rd year, along with elective experiences throughout medical school. Students are examined on their knowledge, skills and attitudes towards health disparities prior to graduation. It is our hope this curriculum empowers students with the knowledge, skills and attitudes to care for patients while helping patients navigate the socioeconomic and cultural issues that may affect their health.

Future health disparity initiatives at the Warren Alpert Medical School of Brown University.

As the United States embarks on health care reform through the Affordable Care Act (ACA), the knowledge, skills and attitudes necessary to practice medicine will change. Education centered on health disparities and social determinants of health will become increasingly more important as 32 million Americans receive coverage through the ACA. In this paper, we describe future initiatives at the Warren Alpert Medical School of Brown University in training medical students on health disparities and social determinants of health through mechanisms such as the Primary Care-Population Medicine Program, the Rhode Island Area Health Education Center, the Scholarly Concentration program and other mechanisms.

An intensive medical education elective for senior medical students.

Peer teaching by medical students is increasingly consid- ered an effective and efficient instructional modality with value for both teachers and learners. In 2012, twelve senior medical students participated in an inaugural, four-week Medical Education Elective at The Alpert Medical School of Brown University. The first week emphasized education theory and skills. During the remaining three weeks, participants served as a core group of instructors in a Clinical Skills Clerkship (CSC), a three-week required course transitioning rising third-year students to clinical clerkships. Senior near-peer instructors (NPIs) gained substantive experience in developing curriculum, facilitating small group sessions, teaching clinical skills, mentoring, providing feedback, and grading an Objective Structured Clinical Examination (OSCE). Based on direct observation by faculty and written anonymous evaluations by learners (n=98), NPIs demonstrated a high degree of teaching competence. This innovative, by-invitation-only, annual elective is the most substantive medical education experience for medical students described in the literature.

A new clinical skills clerkship for medical students.

BACKGROUND AND OBJECTIVES: The transition to clinical clerkships can be challenging for medical students. In the context of a formal clinical curriculum redesign, a curriculum team led by family physicians systematically planned and implemented a 3-week course to prepare new third-year students for specialty-specific clerkships. METHODS: Informed by a formal needs assessment, we developed a classroom-based Clinical Skills Clerkship (CSC) with varied instructional approaches. The three major curriculum components are (1) specialty-specific, longitudinal clinical care of a three-generation virtual family that is taught in lectures and small groups and assessed with an objective structured clinical examination (OSCE), (2) clinical skills including procedure stations and interprofessional education experiences, and (3) a series of professional development activities. The CSC has 90 hours of curriculum taught by more than 120 faculty members from a wide variety of specialties and disciplines. A cohort of senior medical students teach in the course as part of a medical education elective. RESULTS: The CSC was first delivered to 98 students in 2012 who performed well on the course's OSCE. Quantitative and qualitative evaluations of both the curriculum components and the senior medical student teachers were positive. Performance on comparable CSC and Internal Medicine Clerkship OSCE stations and a series of student focus groups demonstrate longer-term impact. CONCLUSIONS: A successful curriculum redesign requires considerable planning and coordination. We designed and implemented a comprehensive CSC that was both well received and effective. Peer teaching programs can provide medical education leadership experiences with benefits for learners, teachers, and medical educators.

Introducing technology into medical education: two pilot studies.

OBJECTIVES: Educators are integrating new technology into medical curriculum. The impact of newer technology on educational outcomes remains unclear. We aimed to determine if two pilot interventions, (1) introducing iPads into problem-based learning (PBL) sessions and (2) online tutoring would improve the educational experience of our learners. METHODS: We voluntarily assigned 26 second-year medical students to iPad-based PBL sessions. Five students were assigned to Skype for exam remediation. We performed a mixed-method evaluation to determine efficacy. RESULTS: Pilot 1: Seventeen students completed a survey following their use of an iPad during the second-year PBL curriculum. Students noted the iPad allows for researching information in real time, annotating lecture notes, and viewing sharper images. Data indicate that iPads have value in medical education and are a positive addition to the curriculum. Pilot 2: Students agreed that online tutoring is at least or more effective than in-person tutoring. CONCLUSIONS: In our pilot studies, students experienced that iPads and Skype are beneficial in medical education and can be successfully employed in areas such as PBL and remediation. PRACTICE IMPLICATIONS: Educators should continue to further examine innovative opportunities for introducing technology into medical education.

Incorporating iPads into a preclinical curriculum: a pilot study.

BACKGROUND: The incorporation of technology into medical education is critical for learners. Little is known about the effect of integrating iPad technology into undergraduate medical education. AIMS: We introduced iPads into the first-year curriculum in 2011-2012. We aimed to evaluate students' use of, and attitudes toward, the iPad. METHODS: We administered two surveys to students during the 2011-2012 academic year. Additionally, we conducted focus groups to further evaluate the effectiveness of iPad integration into the curriculum. RESULTS: Survey data reflect mixed attitudes toward the use of the iPad in the preclinical curriculum. While a vast majority of students agree "the iPad has value in the medical curriculum" (79% in the first survey; 65% in the second survey), there was a decrease over time in the view that "the iPad is a positive addition to the curriculum" (75% in the first survey; 49% in the second survey). Focus group data indicate students appreciate certain aspects of iPad use in the curriculum, including improved curriculum interactivity, but the majority believe it cannot replace printed handouts at this time. DISCUSSION: The iPad provides some benefits in undergraduate medical education. More studies are necessary to determine how the iPad is best incorporated into medical education.

Developing a peer-mentor program for medical students.

BACKGROUND: Doctoring is a 2-year preclinical course designed to teach medical students fundamental clinical skills. PURPOSE: We designed, implemented, and evaluated an innovative and cost-effective peer-mentoring program embedded within Doctoring. Our Teaching Academy (TA) included a formal orientation for teaching "Fellows." METHODS: During academic years 2008-09 and 2009-10, 2nd-year students were systematically selected by course faculty and then trained as TA Fellows to peer-mentor 1st-year students. Both TA Fellows and 1st-year medical students completed anonymous written surveys. RESULTS: Peer-mentors reported a significant increase of confidence in their ability to provide feedback (p < .001). First-year students reported a significant increase of confidence in their ability to conduct a medical interview and perform a physical exam (p < .001 for each). CONCLUSIONS: Student participation in a formal peer-mentor program embedded within a clinical skills course significantly increased, for both teachers and learners, confidence in their skills. Our program is easily transferrable to other courses and institutions.