Health Justice and Systems of Care: A Required Longitudinal Course for MD Students

Perspectives on Medical Education · 2024 · 6 citations

• Computer Science
• Medical education
• Political Science

Problem & Background: Medical education has acknowledged the impact of structural societal factors on health, prompting the need for curricula seeking to eliminate health inequities upstream while simultaneously caring for downstream effects of existing inequities. The Keck School of Medicine of USC (KSOM) implemented one such comprehensive curriculum, Health Justice and Systems of Care (HJSC), integrating health systems science, structural competency, and service-learning in a required course spanning the pre-clerkship and clerkship phases with an optional post clerkship elective. Approach: The HJSC course addresses topics including racism in medicine, health inequities, and health systems science. Using transformative learning theory, it fosters critical consciousness and structural competency. Assessments include case analyses, reflections, team-based learning sessions, and group projects related to social justice in healthcare. The program aims to instill cultural humility and practical application, fostering a holistic approach to medical education that implores physicians to become advocates for health justice. Outcomes of the Innovation: Feedback from students indicated generally positive perceptions of the curriculum. Students provided overall positive comments about discussions with guest speakers. However, students expressed a desire for more concrete examples of how health inequities can be remedied. Some found small-group activities less engaging. Other challenges included providing students of different readiness levels with tailored experiences and seamlessly integrating HJSC content within basic and clinical sciences courses. Critical Reflection: Next steps include continuing to integrate content into the science curriculum and clerkships, improving opportunities for meaningful student interactions, and enhancing faculty development to address health justice concerns in clinical settings.

Preparing Effective Narrative Evaluations for the Medical School Performance Evaluation (MSPE)

MedEdPORTAL · 2022 · 12 citations

• Computer Science
• Medical education
• Psychology

Introduction: In 2016, the AAMC Medical School Performance Evaluation (MSPE) Task Force issued recommendations to standardize the MSPE but did not address the quality of the written narratives in that document. Narrative evaluations are hampered by code words, polite rhetoric, and bias to the detriment of students. To address this, the AAMC's Group on Student Affairs and Group on Educational Affairs convened an expert group to consider the state of narratives in the MSPE and develop resources to improve their quality. Methods: A series of interactive workshops was developed and presented at an AAMC webinar and national meetings. A presentation outlining challenges and possible approaches to improvement was followed with large-group discussion and/or small-group breakout activity to analyze and improve upon sample clinical comments and create summary clerkship paragraphs. The initial webinar used polling questions and free-text prompts to gather feedback for future workshops. Anonymous survey responses were collected at the end of each subsequent workshop to determine perceived effectiveness and potential utility at participants' institutions. Results: Over 680 administrators, faculty, and staff participated in the webinar or in one of four national-level workshops. Respondents agreed that the modules would be useful in faculty development and wanted to replicate their learning at their own institutions for overall better impact on the quality of MSPE narratives. Discussion: This resource addresses an important gap in the medical education literature. A variety of stakeholders affirmed that these workshops have value in training writers to improve their narrative comments for the MSPE.

Stances Toward Anti-Racist Medical Education: A Qualitative Analysis of Critical Consciousness in First-Year Medical Students

AERA Open · 2022 · 9 citations

• Sociology
• Political Science
• Psychology

As future physicians, first-year medical students are well positioned to work on the long-term creation of a more equitable healthcare system. But how prepared are first-year medical students to begin the work of dismantling structural racism in the US healthcare system? In this study, we analyzed a sample of 75 medical-student reflective responses to a book focused on the legacy of racism in medicine. Our findings indicate that students enter medical school in a range of states of critical consciousness that are visible in their “stances” toward addressing racial inequality in the healthcare system. The stances described in our findings extend the critical consciousness framework, providing a more nuanced understanding of students’ starting orientations to health justice. Because students arrive in different stances toward confronting the systemic inequalities inherent to the US healthcare system, understanding these stances may help medical educators tailor learning experiences to medical students’ needs more effectively.

Keck School of Medicine of the University of Southern California

Academic Medicine · 2020-08-21 · 1 citations

Medical Education Program Highlights The Keck School of Medicine (KSOM) medical education curriculum is integrated and system based with substantial emphasis on the early and progressive development of clinical skills; the clinical relevance of basic science; direct experience with patients or simulations representing a set of common and/or important diseases and conditions; gaining skills in hypothesis-driven research; well-being; professional identity formation; and the roles of the humanities, ethics, art, and law in medicine. The following courses and programs are highlights within the KSOM curriculum and illustrate how we address select areas of emphasis listed above: Clinical skills development: The Introduction to Clinical Medicine (ICM) course is over 50 years old and ensures that students develop clinical skills early in medical school. It is a longitudinal course during years 1–2 with a faculty-to-student ratio of 1:6. Students systematically acquire clinical skills and competency in interviewing, history taking, and physical examination through workshops with standardized patients and hone their skills through encounters with actual patients every other week beginning the first few weeks of medical school. ICM also introduces students to clinical problem solving and documentation in the medical record. Mentoring and professional identity formation: The Professionalism and the Practice of Medicine (PPM) course pairs 2 faculty mentors with a group of 24 students in years 1–2 to gain skills and competence in communication, the social and community contexts of health care, ethical judgment, self-awareness and reflection, self-care and personal growth, professionalism, cultural competence, and lifelong learning. Mentoring is extended into year 3 with the Track Mentor Program (a faculty member meets regularly with students on each clerkship track) to continue student professional identity formation and to support a positive learning environment. Student well-being: The KSOM hired a director of medical student wellness and has integrated 34 hours of required well-being curriculum throughout years 1–3 and additional optional activities to facilitate student wellness. The content is not tested/graded and focuses on the lived experience of the medical students, the link between physician well-being and quality/patient safety outcomes, incorporation of student self-reflection, and promotion of appropriate self-disclosure/role modeling by instructors. Humanities, ethics, art, and law curriculum: This 4-year curricular thread is integrated into courses including ICM, required clerkships, and year 3 intersessions. In years 1 and 2, the focus is on collaborative discourse to help students learn to identify, analyze, and resolve clinical ethical problems. Years 3 and 4 include ethics education by clinical role models. Curriculum Curriculum description The KSOM is currently a 4-year curriculum. Years 1–2 are delivered as integrated systems and longitudinal courses (ICM, PPM, and the Scholarly Project course). USMLE Step 1 is taken at the end of year 2. Years 3–4 are designed as a continuum and include the core required clerkships (family medicine, internal medicine, internal medicine subinternship, neurology, obstetrics–gynecology, pediatrics, surgery, and surgery subspecialty) and individualized selective and elective rotations, enabling senior students to pursue independent learning plans in pursuit of their specific career goals. See Supplemental Digital Appendix 1—Curriculum Description—at https://links.lww.com/ACADMED/A831. Curriculum changes since 2010 Changes made to the curriculum since 2010 are highlighted below: Learning by cadaveric dissection was better integrated with system content. A Transition to Clinical Practice course was established to precede start of core clerkships in year 3. Two single-week intersession courses during year 3 were added for students to pause, reflect, and consolidate clinical/educational experiences of year 3. The requirement of a scholarly project was implemented through the Scholarly Project course to engage all students in hypothesis-driven research. The longitudinal year 3 Track Mentor Program to continue to promote professional identity formation and a positive learning environment was established. A number of year 4 electives were made flexible by self-directed asynchronous learning, distance learning, and/or flexible clinical shifts to enable students to participate in residency interviews while achieving the objectives of the electives. Assessment The KSOM medical education program objectives are adapted from the ACGME domains of competence to meet the needs of the KSOM curriculum. See Supplemental Digital Appendix 2—Program Objectives and Assessment Methods—at https://links.lww.com/ACADMED/A831. Changes in student assessment implemented since 2010 are highlighted below: An end-of-year 2 cumulative exam was discontinued because it did not provide additional student performance information. An end-of-year 1 cumulative exam was changed from summative to formative. A clinical assessment tool based on observable behaviors was implemented in all required clerkships. Narrative assessments by research mentors and some small-group facilitators were added. OSCEs in required clerkships were supplanted by twice yearly multistation mini-clinical performance examinations with OSCEs reflective of each student’s prior clerkship experiences. Pedagogy The KSOM uses a variety of pedagogical approaches within courses and across all 4 years to achieve medical education program objectives. See Table 1—Pedagogy.Table 1: PedagogyChanges in pedagogy implemented since 2010 are highlighted below: The use of audience response systems in lectures has been promoted and increased. Approximately 50% of the 6-week hematology and clinical immunology system and 100% of the obstetrics–gynecology clerkship curriculum were converted to flipped classroom teaching models. The internal medicine subinternship curriculum was converted to a predominantly workshop-based learning approach. A year 4 elective, Teaching and Leading in Residency, made up of web-based meetings and distance learning was created. Clinical experiences LAC+USC Medical Center is one of the largest public health care hospital and ambulatory networks in the country and serves as the primary inpatient and ambulatory teaching site for KSOM students. Other health care settings include Keck Hospital and the Norris Comprehensive Cancer Center (USC-owned private healthcare facilities), community-based clinics, private physician offices, and Children’s Hospital Los Angeles. The principal challenge in designing and implementing clinical experiences is in identifying new clinical sites for required clerkships, especially in psychiatry and obstetrics–gynecology. Required longitudinal experiences ICM is delivered in years 1–2 and enables students to achieve competency in basic clinical skills through workshops and encounters with real patients. Students learn from real patients and are exposed to patient care activities in the ICM course in the first few weeks of medical school and every other week in years 1–2. PPM is delivered in years 1–2 as a mentoring and professional identity formation program. The Track Mentor Program in year 3 promotes the continued development of professional identity formation and a positive learning environment. Required and elective community-based rotations The family medicine clerkship provides all students with individualized opportunities to experience community-based practices and to understand the role of a primary care physician. A variety of elective community-based experiences are also offered in general internal medicine, neurology, and integrative medicine. Curricular Governance See Figure 1—Medical Education Curriculum Committee governance.Figure 1: Medical Education Curriculum Committee governance.The KSOM provides stipends for the roles of system chairs and clerkship directors and funding for salaries of medical student educators (MSEs). Departments may provide additional funds for MSEs and they support all other faculty time and activities. Departments that oversee required clerkships fund clerkship coordinator positions. Each department receives funding allocations from the Office of the Dean to assist with faculty and staff compensation, which are based on department undergraduate education effort. Education Staff The Office of Curriculum is responsible for overseeing and ensuring the development, implementation, and delivery of the 4-year MD curriculum. The Office of Curriculum provides direct support to faculty course directors, instructors, and medical students. It oversees the scheduling and coordination of courses and faculty and the development and distribution of supporting materials. The Office of Curriculum organizes and administers the Medical Education Curriculum Committee and its subcommittees to ensure continuous quality improvement efforts in all aspects of the MD curriculum. The Evaluation, Assessment, and Reporting unit within the Department of Medical Education manages the entire evaluation process of all core learning and teaching events throughout the 4-year MD program. It oversees the development of tools (examinations, questionnaires, focus groups, etc.) and produces relevant reports for assessment of outcomes and continuous quality improvement activities. The role of primary medical education staff and administrative faculty in the Office of Medical Education is to support all aspects of the MD program. The office is responsible for multiple areas outside of educational programming relevant to medical students, that is, admissions, student affairs, diversity, and inclusion, and the undergraduate minor in health care studies. The Office of Curriculum is responsible for overseeing and administering curricular aspects of the MD program or the MD component of dual-degree options. See Figure 2—Medical education leadership.Figure 2: Medical education leadership.The Department of Medical Education is composed primarily of PhD/EdD educator faculty members and part-time or voluntary faculty instructors in required longitudinal courses. The department is composed of multiple units, including clinical skills education and evaluation, evaluation and assessment, educational technologies, faculty development, academic support, and instructional design. The department has offered a Masters of Academic Medicine program since 2009 and graduated 103 individuals to date, including many KSOM faculty. The department also sponsors an annual Innovations in Medical Education conference. Faculty Development and Support in Education The Faculty Development Unit in the Department of Medical Education provides direct support for Keck faculty and residents who wish to improve teaching skills and educational scholarship. The unit provides a wide range of services and offerings including customizable faculty development sessions on assessment and feedback, curriculum design, instructional design and strategies, program evaluation, and educational scholarship and research. Interactive workshops are targeted to specific teaching needs including, but not limited to, creating a positive learning environment, identifying learners in difficulty, assessing learners, providing effective feedback, small-group teaching, and teaching in the clinical setting. Small-group or 1-on-1 consultation sessions addressing the specific needs of individual faculty or small groups (disciplines, systems, clerkships, etc.) are available upon request. The department also oversees residents-as-teachers training by directly delivering content or by coordinating with departmental training programs. The KSOM has established 7 promotion tracks that reflect the different profiles of activities and contributions of faculty. Each track includes expectations for contributions in scholarship, education, and service and, in the case of the clinician–educator and practitioner series, clinical practice. The amount of time devoted to individual areas and expectations in each area differ among the promotion series. Aggregate evaluation reports from students and residents of teaching/education activities are included in the promotion dossiers. Letters from mentees are also solicited and, in the case of the clinician–educator series, evaluation of teaching effectiveness by residency and/or fellowship directors may be requested. Teaching evaluation data are provided annually to each department chair at the time of faculty merit review. Initiatives in Progress The KSOM curriculum will transition to a renewed 4-year physician–citizen–scholar curriculum effective 2021 with the class of 2025. The renewed curriculum will be delivered in 3 phases: preclerkship (18 months), clerkship (12 months), advanced clinical experiences (18 months). Planned features of the renewed physician–citizen–scholar curriculum are: Four hours of active case-based learning each week of the preclerkship phase. Enhanced clinical skills and clinical reasoning development in the preclerkship phase. Emphasis on active learning strategies throughout the curriculum, early clinical immersion, and a learning environment that fosters the well-being and professional development of students. Engagement of students with surrounding communities. Enhanced offerings in humanities, ethics, art, and law. Provision of a certificate in Social Justice in Medicine. A new longitudinal coaching program to guide professional identity formation. Integration of health systems science instruction and related clinical experiences throughout the preclerkship and clerkship phases. Immersive clinical training in the clerkship phase through a series of core clerkships organized into two 26-week blocks of grouped clinical rotations: 1 block of internal medicine/family medicine/psychiatry/neurology and 1 block of surgery/anesthesia/obstetrics–gynecology/pediatrics. The blocks will be enhanced by “just in time” training and by longitudinal cross-cutting themes covering geriatric medicine, chronic disease prevention and management, and mental health during the internal medicine/family medicine/psychiatry/neurology block; and health systems science, social justice, and quality and patient safety during the surgery/anesthesia/obstetrics–gynecology/pediatrics block. Individualized training in the advanced clinical experiences phase to enable the determination and pursuit of one’s areas of interest and ultimate career goals. An end-of-year 4 Transition to Residency course. Step 1 will be taken after the clerkship phase.

Expect What You Inspect

Advances in medical education, research, and ethics (AMERE) book series · 2019-12-27

The Liaison Committee on Medical Education (LCME) requires that medical schools track compliance and continuous quality improvement (CQI) efforts across a broad range of LCME standards. However, LCME does not state what form these tracking efforts should take, or how medical schools should represent this information to the Committee or internally. This chapter provides an overview of the Keck School of Medicine of the University of Southern California's (KSOM) new approach to CQI tracking using an online dashboard. The project resulted in an online platform that represents the CQI project progress across a range of elements, maintains visual consistency across a range of data sources and file types, and is easily accessible by relevant stakeholders. This innovation from KSOM illustrates how a web-based platform supports CQI efforts, and how this design can be translated to other contexts. The design presented in this chapter provides guidelines for the development and innovation of CQI tracking initiatives at other schools.

A Continuum of Innovation: Curricular Renewal Strategies in Undergraduate Medical Education, 2010–2018

Academic Medicine · 2019-07-31 · 26 citations

PURPOSE: Since 2010, medical schools across the United States have engaged in a new cycle of curricular revision and renewal for their undergraduate medical curricula. But what structures, features, and trends have emerged in U.S. medical schools as a result of deliberate curricular redesign efforts? An analysis of the ways that medical schools have approached the reorganization of their curricula to prepare their students for the growing complexity of medical practice is presented. METHOD: This study drew a total pool of 40 U.S. MD-granting programs, of which 25 met the inclusion criteria for the study. The authors used a qualitative coding approach to materials from the undergraduate medical education (UME) program websites to identify 4 dimensions of strategies that these programs used to renew their curricula. RESULTS: The analysis of the curricular maps and website content of the UME programs provided evidence for a continuum approach to the description of innovation strategies: 96% of schools employed a cohort-based linear pathway, 80% of schools used thematic basic science blocks, 47% placed their Step 1 exams outside of the second year, and 68% moved their clerkships to the second year. CONCLUSIONS: The Continuum of Innovation strategies will enable programs to renew their curricula in ways that promote deliberate curricular changes that are consistent with emerging needs in the field. This study and future research may be useful for UME programs with limited resources by providing consensus practices that enable them to plan curricular changes in ways that best serve their institutions.

Medical Student Perceptions of the Learning Environment in Medical School Change as Students Transition to Clinical Training in Undergraduate Medical School

Teaching and Learning in Medicine · 2017-03-20 · 121 citations

Phenomenon: The learning environment is the physical, social, and psychological context in which a student learns. A supportive learning environment contributes to student well-being and enhances student empathy, professionalism, and academic success, whereas an unsupportive learning environment may lead to burnout, exhaustion, and cynicism. Student perceptions of the medical school learning environment may change over time and be associated with students' year of training and may differ significantly depending on the student's gender or race/ethnicity. Understanding the changes in perceptions of the learning environment related to student characteristics and year of training could inform interventions that facilitate positive experiences in undergraduate medical education. APPROACH: The Medical School Learning Environment Survey (MSLES) was administered to 4,262 students who matriculated at one of 23 U.S. and Canadian medical schools in 2010 and 2011. Students completed the survey at the end of each year of medical school as part of a battery of surveys in the Learning Environment Study. A mixed-effects longitudinal model, t tests, Cohen's d effect size, and analysis of variance assessed the relationship between MSLES score, year of training, and demographic variables. FINDINGS: After controlling for gender, race/ethnicity, and school, students reported worsening perceptions toward the medical school learning environment, with the worst perceptions in the 3rd year of medical school as students begin their clinical experiences, and some recovery in the 4th year after Match Day. The drop in MSLES scores associated with the transition to the clinical learning environment (-0.26 point drop in addition to yearly change, effect size = 0.52, p < .0001) is more than 3 times greater than the drop between the 1st and 2nd year (0.07 points, effect size = 0.14, p < .0001). The largest declines were from items related to work-life balance and informal student relationships. There was some, but not complete, recovery in perceptions of the medical school learning environment in the 4th year. Insights: Perceptions of the medical school learning environment worsen as students continue through medical school, with a stronger decline in perception scores as students' transition to the clinical learning environment. Students reported the greatest drop in finding time for outside activities and students helping one another in the 3rd year. Perceptions differed based on gender and race/ethnicity. Future studies should investigate the specific features of medical schools that contribute most significantly to student perceptions of the medical school learning environment, both positive and negative, to pinpoint potential interventions and improvements.

A Comparison of Medical Students’ Learning Approaches between the First and Fourth Years

Southern Medical Journal · 2015-04-01 · 20 citations

OBJECTIVES: We hypothesized that medical students exposed to a case-based curriculum in years 1 and 2 and clinical cases in the year 3 clerkship would demonstrate a longitudinal increase in the deep approach to learning and a decrease in the surface apathetic approach. METHODS: A cohort of first-year medical students completed the Approaches and Study Skills Inventory for Students at the beginning of their first term and again at the beginning of their fourth year. Approaches and Study Skills Inventory for Students scores were aggregated into three main learning approach scales: deep, strategic, and surface apathetic. RESULTS: On average, deep and strategic scores did not significantly change between years 1 and 4, but the surface apathetic mean score decreased as a result of lower syllabus boundness and fear of failure subscale scores. Effect sizes were small (d = 0.30, 0.34, respectively). CONCLUSIONS: The deep approach to learning is a complex process and did not change in our students after 3 years of medical school, even though a case-based curriculum was believed to foster deeper learning. By the end of year 3, our students were, on average, less bound to syllabi and feared failure less.

“Being the Best We Can Be”

Academic Medicine · 2012-12-24 · 42 citations

PURPOSE: To examine attitudes, self-reported behaviors, and intended actions related to medical students' use of online social media after an educational intervention. METHOD: In 2011, 180 first-year medical students at the Keck School of Medicine participated in a required two-hour session on the relevance of online social media use to professionalism. Students submitted postsession written reflections about their online presence and professional roles. The authors qualitatively analyzed and coded these reflections for emerging themes. They also examined postsession evaluations and conducted a four-month follow-up survey to identify changes in students' online social networking behaviors. RESULTS: All 180 students submitted written reflections and postsession evaluations. The authors identified 10 theme categories within three domains (immediate action, intended future action, value change) from the reflections. The most common themes were "role awareness" (144/539), "did nothing" (94/539), and "intention to edit" (84/539). On a scale of 1 to 5, students rated the overall session quality at 3.92 (standard deviation 0.28). Sixty-four percent (115/180) of the students responded to the follow-up survey. Of those, 40% (46/115) reported editing or changing their Web presence after the session, and 24% (28/115) anticipated spending less time on online social networking. CONCLUSIONS: Attending a required session in a professionalism course led to thoughtful reflection, increased professional role awareness, and intention to edit and monitor future online presence among first-year medical students. After four months, students reported continued monitoring and editing of their online presence. Future studies should examine whether reinforcement throughout training is needed to maintain vigilance.

The relationship between medical students’ learning approaches and performance on a summative high-stakes clinical performance examination

Medical Teacher · 2012-03-28 · 89 citations

BACKGROUND: A learning approach embeds the intention of the student when starting a task and the learning processes and strategies used to carry out a task. Student approaches to learning have been categorized as deep, strategic, and surface. AIM: To explore the relationships among medical students' learning approaches, gender, and performance on a summative high-stakes clinical performance examination (CPX). METHODS: We measured medical students' learning approaches at the beginning of year four using the Approaches and Study Skills Inventory for Students and compared results with CPX scores. RESULTS: Student scores in the top two quartiles of the CPX were significantly higher on the deep approach than student CPX scores in the bottom quartile, and student scores in the bottom quartile of the CPX were significantly higher on the surface approach than scores for the other three CPX quartiles. CPX patient-physician interaction scores showed a significant positive correlation with deep approach scores, and CPX overall patient satisfaction scores showed a significant positive correlation with deep and strategic approach scores. Surface approach scores correlated negatively with all CPX score categories. CONCLUSION: Approach to learning was associated with performance on a high-stakes CPX.