EARLY CLINICAL LEARNING: WHAT FOR, WHAT IF, AND HOW?

Association for Medical Education in EuropeGlasgow, Scotland

2010

Sharon Morang, MBA-Director of CurriculumJames Grogan, PhD-Assistant Dean of CurriculumMary Coleman, PhD, MD-Dean

What is unique?

The medical university is a propriety school held by a publicly traded company with commitment toward developing healthcare education leadership.

Enrollment is nearly 400 students per entering class, beginning three times per year.

1. Large percentage (65%) enter primary care2. Student body and faculty are diverse3. Faculty work assigned is primarily teaching4. The education program occurs in

geographically distinct regions:a. Basic sciences in the

Caribbean region b. Clinical clerkship training

in the United States

BackgroundSeveral factors contribute to the trend toward earlier clinical learning in undergraduate medical education programs. We outline factors driving significant change at a large Caribbean medical school preparing students for practice in the United States that are consistent with adult learning theory.

Summary of WorkPlanning for curriculum change has involved modification of the existing clinical education program and increased emphasis on learning competencies related to professionalism, systems, improvement, and patient centered care. Factors which were challenging in creating a strategy toward inclusion of greater clinical learning were increased class sizes and faculty ambivalence towards change.

Summary of Results We summarize measures and parameters of these factors which have led to formulation of plans for curricular change.

ConclusionsThe resulting program implementation suggests that students’ earlier clinical learning experiences can be improved by enhancing existing programs, such as community medicine projects and problem-based learning, while also implementing new early learning experiences through the use of standardized patients and simulations.

Abstract

Institute of Medicine recommendations

Drivers for Change

Student performance on internal assessments

(Comprehensive NBME)

Recommendations from Accrediting

Organizations

Proposed changes to

Licensure Exam

Feedback from Clinical Faculty

regarding student preparation

Drivers of Curriculum Change

Address patient safety, systems,

cultural competence,

science foundations

Increase early clinical exposure

Greater emphasis on competencies, clinical education, and EBM

Inadequate writing and examination

skills

40% first time pass rate

These drivers were integral to underscoring the need for change while providing an opportunity to apply adult learning theory.

Outcomes of Curriculum RevisionsGreater requirements for written case histories

Creation of a Department of Integrated Medicine

Doubled semester 3 clinical exposure

Expansion of hi-fi simulation and task-trainers into first 4 semesters

Hired more US trained clinicians and visiting faculty

Initiated Standardized Patient Program

Use of WebSP and Doc.com for feedback on clinical skills

Addition of service learning to allow more contact with real patients

Adoption of an organ systems-based curriculum

Reflections on TransitionProcess

What went well: Key changes implemented:

Engagement of faculty in module development teams across departments..

Increased number and feedback on written case histories (H & Ps) for students...

Adoption of team approach to integrated interactive clinical cases that emphasize relevance of basic science concepts and applications to clinical medicine.

Clarification of processes and ideas through workshops:.

Simulation...

Clinical Cases

Support of students by participation in development teams

Utilization of technology software to improve education

Incremental change process with respect for requested implementation delays

Barriers to Change

A. Lack of engagement of all department chairs

B. Increased enrollment simultaneous with curriculum change with closing of a second campus

C. Unclear communications to students regarding registration caused delays in implementation

D. Not all faculty provided new learning objective to support the implementation

Reflections continued…

Findings

1. Clinical learning experiences were increased demonstrating the application of adult learning theory.

2. In an environment of sustained growth in student numbers, making curricular changes is challenging and evokes strain on mid-level administration.

3. Despite efforts to communicate reasons for change and processes to achieve outcomes, morale was a continual challenge.

4. Curricular change needs resources such as software technology to support database maintenance and extra administrative assistance.

5. Changes not directly related to original goals can be implemented during periods of curriculum change.

6. Incremental changes contribute to easing anxiety amongst faculty toward curriculum change.

References

Grant, J. (2006). Principles of curriculum design. Understanding Medical Educationmonograph series. Oxford: Education, Blackwells Press.

AAMC. (2008). Recommendations for Clinical Skills Curricula for Undergraduate MedicalEducation. Association of AmericanMedical Colleges.

Merriam, S., Caffarella, R. & Baumgartner, L. (2007). Learning in Adulthood: A comprehensive guide, 2nd edition. SanFrancisco: Jossey-Bass.