Year 4 Curriculum Subcommittee Recommendations May 2017 Dartmouth Geisel School of Medicine MEC Year 4 Subcommittee

Subcommittee Purpose and Charge Background Year 4 has not been reviewed as a whole for several years and may benefit from a global review. Prior Curriculum Redesign work indicated both student and faculty enthusiasm and interest in making adjustments to Year 4. More time/flexibility, move Neuro and GAM into “Phase 2” Individual reviews of current required 4th Year courses (CPT, HSP, AMS) and clerkships (Neurology and GAM) raised questions regarding coordination, content and sequencing. Charge Evaluate Year 4 Curriculum to determine if current structure and curriculum are meeting our students’ educational needs.

Members Chair – John Dick, Associate Dean for Clinical Education Year 4 Course Directors, MEC members, additional interested students and faculty Residents invited by none attended Alison V. Holmes (PEDS), Virginia A. Reed (CFM/HSP), Harold L. Manning (MED), Petra J. Lewis (RADS), Adam R. Weinstein (PEDS, Alison D. Ricker (OCE); David W. Nierenberg (MED/CPT), Kenneth W. Burchard (SURG), Marietta E. Smith (MEC Student), Michele W. Jaeger (Registrar), Nancy E. Cochran (MED), Rand S. Swenson (Chair Med Ed), Sarah C. Crockett (ED), Sarah G. Johansen (ED), Stephanie N. Morton (MEC Student), Susan N. Harper (OCE), Tiffany L. Brazile (Student), Gregory S. Ogrinc (SADME), Tim Lahey (MED/ AMS), Cathleen Morrow (CFM/HSP)

Process Introduction Meeting Review existing curriculum Review recent literature Brainstorm ideas Survey development / deployment Survey Review Consensus process

Geisel Requirements 35 weeks of requirements (but some done in Year 3 for most students) Sub-internship 4 weeks Neurology 4 weeks GAM 4 weeks Electives 16 weeks Coursework 7 weeks 44 weeks in the year (minus Thanksgiving and Winter vacation) 9 weeks for Step 2 study and completion, interviews, vacation

Current Curriculum by Month July - SubI Aug - Elective Sept – Step 2/Elective Oct – Elective / Interview Nov - Interview Dec - Interview Jan – Interview / Elective Feb – Capstone* Mar – Capstone* - Match April - Neuro May - GAM June - Graduation *Capstone = CPT, HSP, ACLS, AMS

Major Findings Goals of Year 4 = Unique balancing of 2 major areas: Complete predoctoral phase of required Geisel medical education Finish required courses Gain broader educational experiences Prepare for transition to residency Assume higher level of clinical responsibility Develop and demonstrate skills expected of interns Complete residency application process

Major Findings Internal and External Forces Create less flexible Year 4 timeline at Geisel External Residency Applications Due on Sept 15th, MSPE on Oct 1st Residency position bottleneck leading to more interviews (12) , longer interview season, more competitive process, more away rotations (1-2) Step 2 CS and CK results expected earlier in match process Internal Traditional 2 year preclinical curriculum and requirement of GAM and NEURO clerkship leading to less flexible time in year 4 Limited clinical teaching sites “forces” some students to take GAM and NEURO at inconvenient times

National UME Trends Residency programs asking for better prepared students and expecting more UME field specific training Specialty specific Milestones moving down into UME Entrustable Professional Activities (EPAs) – AAMC Majority of schools moving to earlier clinical year allowing more time for traditional 4th year Capstone courses and Intern readiness courses increasing More schools requiring EM as required rotation

Overarching Geisel Goals Advanced level training different from clerkships Residency application preparation Qualities/Training Unique to Geisel Pharmacology Quality Improvement Citizenship/Community Engagement Qualities for all Medical Students Critical Thinking / Diagnostic Reasoning

Subcommittee Survey Developed by the subcommittee for the subcommittee 14 respondents

Survey Results Time spent on various topics (sum must total 35 days) Specialty Specific “boot camp” 8.93 days Advanced clinical reasoning 4.57 days Advanced Pharm 4.14 days Applied physiology 3.86 days Advance Com. Skills 3.36 days QI Project 3.21 days New or Emerging Concepts 2.43 days Personal/Professional Refl. 1.71 days ACLS/PALS 1.64 days Other 1.14 days Other included: Medical Imaging, Critical care, Intern panel

Survey Results One combined course vs multiple shorter courses How EM should be addressed in curriculum No change to current: 1 Required 4 week clerkship: 0 Required 2 week clerkship: 3 Required acute care selective (EM or CCS): 7 Other 3 How CCM should be addressed in curriculum No change: 1 Required 2 weeks clerkship: 3 Required selective: 7 Other: 3

Survey Results - EPAs Where in curriculum they should be assessed and certified. Majority in clerkship or SubI Those with > 20 % respondents stating 4th Year Coursework Identify system failures and contribute to a culture of safety and improvement (57%) Perform general procedures of a physician (21%)

Content Areas Needing More Attention Acute Care (critical care, emergency care) Diagnosing and Managing Sick vs Not Sick Intern readiness (“Bootcamp”) Both general and specialty specific Communication, Diagnostic Reasoning, Procedures Critical Thinking

Capstone Coursework Discussion Each course valuable, has strong leadership and advocacy and addresses current curricular needs. Timing and duration seem appropriate Increased coordination between courses recommended Reweighting of time allocation per content area recommended Certain topics covered in HSP may now be covered in PPH AMS evolving more towards intern readiness, professional formation/reflection than “foundational science” HSP has been evolving over time with broad objectives

Recommendations 5 year plan 2 year plan Consider starting clinical year earlier to allow required clerkships (including Neuro and GAM) and career exploration in electives to occur sooner to allow our students more flexibility to prepare for residency application. Add required experience in Acute Care (EM or Critical Care) Allow for earlier graduation 2 year plan Continue with current structure Redesign existing capstone coursework

Recommendations - Capstone Rework as 1 course with distinct sub-components instead of 4 separate courses as currently exist Assign Course Director whose responsibility will be to coordinate and make more cohesive the various sub components. Alter pedagogy to make it more case based and connected. PBL, Team Based New case each week or evolving case with concepts that force inquiry or skills practice in each of the sub components Each sub component has director, allotted hours.

Capstone Recommendation 7 Weeks Pre Match Intro/ Case 1 Advanced Pharmacology and Therapeutics Week 2/ Case 2 Week3/ Case 3 Week4/ Case 4 Week5/ Case 5 Week6/ Case 6 Week7/ Case 7 Conclusion Advanced Medical Sciences Advanced Professional Development Advanced Clinical Skills Advanced Health Care Delivery Sciences

Example Case 14 year old boy with seizure history presenting with uro-sepsis. CPT: Antibiotic review, Prescription writing, Drug-Drug interactions AMS: Pathophysiology of sepsis, lactic acidosis, ARDS APD: Patient advocacy, End of Life Care, Personal Resiliency AHCDS: Protocol development (sepsis), IPE in ICU ACS: Pressor/Vent management, Difficult conversations Intern readiness / Advanced Clinical Skills could be specialty focused where desired – PEDS vs ADULT; Procedural vs Non-Procedural

Operationalize Assign Overall Director and Assign Subcomponent Directors/Teams Give roughly equal time to 5 areas (about 25 – 30 hours) and request proposals of use for that time. Co-develop PBL cases – Focus on acute care (EM/Critical Care) topics to ensure emphasis in these areas

Additional Information Desired Intern / Program Director Survey to further hone areas of need, retain areas of strength Current 4th Year Student Survey Faculty wide Survey