RECIPROCAL INTEGRATION: Medical Curriculum Model University of Iowa Carver College of Medicine Curriculum Renewal Modeling Committee Report September 27, 2010

Team Members Anderson, Jason Anderson, Jason Axelson, Rick D Axelson, Rick D Brown, Donald Brown, Donald Christine, Paul J Christine, Paul J England, Sarah K England, Sarah K Fox, Daniel K Fox, Daniel K Haugsdal, Michael L Haugsdal, Michael L Hoffmann, Darren S Hoffmann, Darren S Khaja, Sobia Khaja, Sobia Lenoch, Susan Lenoch, Susan Liu, Vincent Liu, Vincent Longley, Thomas W Longley, Thomas W Murray, Jeff Murray, Jeff Rahhal, Amal Rahhal, Amal Rowat, Jane Rowat, Jane Smith, Mark C Smith, Mark C Sugg, Sonia Sugg, Sonia Takacs, Elizabeth B Takacs, Elizabeth B Wickham, Gerald P Wickham, Gerald P Willemsen-Dunlap, Ann Willemsen-Dunlap, Ann Zeitler, William A Zeitler, William A

Overview I. Strategy I. Strategy II. Permeating Themes II. Permeating Themes III. Pedagogical Considerations III. Pedagogical Considerations IV. Reciprocal Integration Model IV. Reciprocal Integration Model V. Model Analysis V. Model Analysis VI. Conclusions VI. Conclusions

Overview I. Strategy I. Strategy II. Permeating Themes II. Permeating Themes III. Pedagogical Considerations III. Pedagogical Considerations IV. Reciprocal Integration Model IV. Reciprocal Integration Model V. Model Analysis V. Model Analysis VI. Conclusions VI. Conclusions

Strategy Charge Charge Approach Approach

Charge Provide flexibility to accommodate new knowledge Provide flexibility to accommodate new knowledge Improve of basic, clinical, social sciences Improve integration of basic, clinical, social sciences Address patient & societal needs Address patient & societal needs Provide clinical experience Provide earlier clinical experience Encompass competencies Encompass competencies Promote learning Promote student-centered learning Maximize use of educational & informational technologies Maximize use of educational & informational technologies Enable individualized progress Enable individualized progress

Approach Create ideal Iowa medical graduate Create ideal Iowa medical graduate Propose original curricular elements Propose original curricular elements Review literature Review literature Draft original curricula Draft original curricula Consider curricula at other medical schools Consider curricula at other medical schools Integrate into one model Integrate into one model

Overview I. Strategy I. Strategy II. Permeating Themes II. Permeating Themes III. Pedagogical Considerations III. Pedagogical Considerations IV. Reciprocal Integration Model IV. Reciprocal Integration Model V. Model Analysis V. Model Analysis VI. Conclusions VI. Conclusions

Permeating Themes Integrate basic and clinical sciences, both vertically and horizontally Integrate basic and clinical sciences, both vertically and horizontally Optimize opportunity for career exploration Optimize opportunity for career exploration Ensure exposure to spectrum of conditions encountered in primary care Ensure exposure to spectrum of conditions encountered in primary care Optimize pedagogical aspects of curriculum Optimize pedagogical aspects of curriculum Provide “core” and “dynamic” components to curriculum to accommodate changing medical knowledge and to accommodate different learning styles Provide “core” and “dynamic” components to curriculum to accommodate changing medical knowledge and to accommodate different learning styles Attend to personal as well as professional needs of students Attend to personal as well as professional needs of students

Overview I. Strategy I. Strategy II. Permeating Themes II. Permeating Themes III. Pedagogical Considerations III. Pedagogical Considerations IV. Reciprocal Integration Model IV. Reciprocal Integration Model V. Model Analysis V. Model Analysis VI. Conclusions VI. Conclusions

Pedagogical Considerations Curricular oversight critical=> Curriculum Oversight Committee Curricular oversight critical=> Curriculum Oversight Committee Evaluation of process and goals of student evaluations Evaluation of process and goals of student evaluations Eclectic combination of various curricular models Eclectic combination of various curricular models –Organ-based –Case-based –Presenting-complaint based

Overview I. Strategy I. Strategy II. Permeating Themes II. Permeating Themes III. Pedagogical Considerations III. Pedagogical Considerations IV. Reciprocal Integration Model IV. Reciprocal Integration Model V. Model Analysis V. Model Analysis VI. Conclusions VI. Conclusions

RECIPROCAL INTEGRATION CURRICULAR MODEL JulyAugSeptOctNovDecJanFebMarchAprilMayJune 1st Year Basic Sciences Boot camp Foundations of Basic Sciences Intersession Break Systems and Disease Intersession Break Anatomy, Neuroanatomy, EmbryologyHuman Organ SystemsPharmacology BiochemistryGeneticsPhysiologyPathology Cell biology(Intro/Basic) histology*HistologyMicrobiology Immunology Foundations of Clinical Practice ** Integrated Small Group ** PPD Re-evaluation of pedagogical techniques (e.g. small groups) CommunicationFoundations of Clinical Practice*** MentoringLearning Communities ConnectionPhysical Exam Skills Small Group Component Re-evaluation of assessment, value, resources, and time Introduction to Presenting Complaint Learning (PCL) Attaching EMR to H&PEvidence based medicine Continuity of Care Clerkship JulyAugSeptOctNovDecJanFebMarchAprilMayJune 2nd Year Break Systems and Disease Intersession Break Foundations of Clinical Practice Intersession Boards Preparation Complete Step 1 Clinical Beginnings Intersession Internal Medicine Block (Composed of Inpatient and Outpatient) Human Organ SystemsPharmacology PhysiologyPathology HistologyMicrobiology Immunology ** Integrated Small Group ** **Must be taken during the M3 Year** Foundations of Clinical Practice*** Physical Exam Skills Introduction to Presenting Complaint Learning (PCL) Evidence based medicine Continuity of Care Clerkship JulyAugSeptOctNovDecJanFebMarchAprilMayJune 3rd Year Intersession Surgical Block (Encompassing General Surgery, Ophthalmology, Orthopedic, Otolaryngology, and Urology) Intersession Family Medicine and Cognitive Behavioral Sciences (Encompassing Family Medicine, Community Based Primary Care, Dermatology, Psychiatry, and Neurology) Intersession OB/GYN and Pediatrics Block Elective **Must be taken during the M3 Year** **Student must take either FM/CBS block or OB/GYN Pediatric block during the M3 year. One could be moved to a different position allowing 3 more electives in the M3 year** Continuity of Care Clerkship JulyAugSeptOctNovDecJanFebMarchAprilMayJune 4th Year Elective Sub-Internship **Pre-requisites of Medicine, Surgical, and either FM/CGS or OBG/Peds Block required** Elective Complete Step 2 Elective Intersession Critical Care Block (Encompassing Emergency Medicine, Critical Care, Anesthesia, EKG, and Radiology) Commencement Residency **Must be taken in the M4 Year** Continuity of Care Clerkship

“Reciprocal Integration” Mutual integration Mutual integration –Interweaving of basic and clinical sciences throughout the four years of medical school –Collaboration across medical specialties/fields as well as across the health care team Goal: to prepare a versatile, complete physician who is equipped to act in the best interest of the patient and society through teamwork and an ability to stay current with medical knowledge Goal: to prepare a versatile, complete physician who is equipped to act in the best interest of the patient and society through teamwork and an ability to stay current with medical knowledge

AugSeptOctNovDecJanFebMarchAprilMayJune Basic Sciences Boot camp Foundations of Basic Sciences Intersession Break Systems and Disease Intersession Break Anatomy, Neuroanatomy, EmbryologyHuman Organ SystemsPharmacology BiochemistryGeneticsPhysiologyPathology Cell biology(Intro/Basic) histology*HistologyMicrobiology Immunology Foundations of Clinical Practice ** Integrated Small Group ** PPD Re-evaluation of pedagogical techniques (e.g. small groups) CommunicationFoundations of Clinical Practice*** Mentoring Learning Communities Connection Physical Exam Skills Small Group Component Re-evaluation of assessment, value, resources, and time Introduction to Presenting Complaint Learning (PCL) Attaching EMR to H&PEvidence based medicine Continuity of Care Clerkship 1 st year (M1)—

Basic Science Primer Description: Course providing fundamental basic science Description: Course providing fundamental basic science Duration: 2 weeks Duration: 2 weeks Goal: Ensure all students of diverse backgrounds equipped with tools for successful mastery of basic science Goal: Ensure all students of diverse backgrounds equipped with tools for successful mastery of basic science Components Components –Molecular/cell biology –Biochemistry –Immunology –Biostatistics –Introduction to evidence-based medicine –Introduction to ethics

Personal Wellness Exploration Description: Longitudinal care experience utilizing one’s own personal health and wellness as a venue for learning the application of basic science to clinical care Description: Longitudinal care experience utilizing one’s own personal health and wellness as a venue for learning the application of basic science to clinical care Duration: over 4 years Duration: over 4 years Goal: To expose students to the principles of public health, wellness (including nutrition, diet, exercise, and other identifiable environmental components, as well as genetic predisposition) at the personal level. Goal: To expose students to the principles of public health, wellness (including nutrition, diet, exercise, and other identifiable environmental components, as well as genetic predisposition) at the personal level. Components Components –A series of short lectures –Coupled to small groups –Incorporate wellness aspects such as nutrition, exercise, public health, and genetics –Opportunity for self-reflection

Continuity of Care Clerkship Description: Longitudinal care experience Description: Longitudinal care experience Duration: 4 years x ½ day/week Duration: 4 years x ½ day/week Goal: To progressively develop clinical skills in a closely monitored fashion, thereby offering early clinical exposure, mentorship, and development of independence. Goal: To progressively develop clinical skills in a closely monitored fashion, thereby offering early clinical exposure, mentorship, and development of independence. Components Components –Pairing with a “Master Clinician” mentor –Weekly 1/2-day clinical sessions –May utilize rotating schedule of 2-3 mentors

Foundations of Basic Science Description: Course on core basic sciences that serve as the basis for clinical practice Description: Course on core basic sciences that serve as the basis for clinical practice Duration: 16 weeks Duration: 16 weeks Lectures and complementary small group interaction Lectures and complementary small group interaction Goal: Provides the tools required for learning in an organ-based approach. Goal: Provides the tools required for learning in an organ-based approach. Components Components –Biochemistry –Cell biology –Anatomy/neuroanatomy/embryology/histology –Genetics

Human Organ Systems & Disease Description: Organ-systems approach to the normal and abnormal human condition Description: Organ-systems approach to the normal and abnormal human condition Duration: 38 weeks Duration: 38 weeks Goal: Provides understanding of how disease states represent disturbances of the normal human condition on a molecular, cellular, and organ level Goal: Provides understanding of how disease states represent disturbances of the normal human condition on a molecular, cellular, and organ level Components Components –Encompasses current HOS curriculum –Plus integration of microbiology and immunology

Foundations of Basic Science: Biochemistry Cell biology Anatomy/neuroanatomy/embryology/histology Genetics Systems and Disease: HOS (normal): physiology, histology, anatomy Path (abnormal): pathology, pharmacology Cellular: Histology, Immunology, Microbiology Integration: Small groups, Continuity of Care clerkship etc…

AugSeptOctNovDecJanFebMarchAprilMayJune Basic Sciences Boot camp Foundations of Basic Sciences Intersession Break Systems and Disease Intersession Break Anatomy, Neuroanatomy, EmbryologyHuman Organ SystemsPharmacology BiochemistryGeneticsPhysiologyPathology Cell biology(Intro/Basic) histology*HistologyMicrobiology Immunology Foundations of Clinical Practice ** Integrated Small Group ** PPD Re-evaluation of pedagogical techniques (e.g. small groups) CommunicationFoundations of Clinical Practice*** Mentoring Learning Communities Connection Physical Exam Skills Small Group Component Re-evaluation of assessment, value, resources, and time Introduction to Presenting Complaint Learning (PCL) Attaching EMR to H&PEvidence based medicine Continuity of Care Clerkship 1 st year (M1)—

Foundations of Clinical Practice Description: Course providing the practical skills and knowledge for the practice of clinical medicine Description: Course providing the practical skills and knowledge for the practice of clinical medicine Duration: 66 weeks Duration: 66 weeks Goal: To train medical students to think and act like physicians, with emphasis on basic science application Goal: To train medical students to think and act like physicians, with emphasis on basic science application Components Components –Expansion of current FCP curriculum –Specific adoption of presenting complaints learning paradigm

Integrated Small Group Bridge Description: Course bridging Human Organ Systems & Disease with Foundations of Clinical Practice Description: Course bridging Human Organ Systems & Disease with Foundations of Clinical Practice Duration: 38 weeks Duration: 38 weeks Goal: Provides explicit platform for integration of clinical context to basic science instruction Goal: Provides explicit platform for integration of clinical context to basic science instruction Components Components –“Patient-centered Vertical Vignette” –hypothetical patient cases that serve as curricular vehicles that move with the students as they progress through the chronological curriculum sequence –serve as educational strands that unify the curriculum longitudinally –e.g. autoimmunity topic addressed in HOS-D is illustrated in hypothetical patient with lupus erythematosus, whose clinical findings are mastered in FCP, and re-addressed later in discussion of renal pathophysiology, etc. –Case-presentation and presenting complaint-based series of cases

2nd year (M2)— JulyAugSeptOctNovDecJanFebMarchAprilMayJune Break Systems and Disease Intersession Break Foundations of Clinical Practice Intersession Boards Preparation Complete Step 1 Clinical Beginnings Intersession Internal Medicine Block (Composed of Inpatient and Outpatient) Human Organ SystemsPharmacology PhysiologyPathology HistologyMicrobiology Immunology ** Integrated Small Group ** **Must be taken during the M3 Year** Foundations of Clinical Practice*** Physical Exam Skills Introduction to Presenting Complaint Learning (PCL) Evidence based medicine Continuity of Care Clerkship

Intersessions Description: Periodic week-long intervening sessions at the start of each clinical clerkship and between basic science courses Description: Periodic week-long intervening sessions at the start of each clinical clerkship and between basic science courses Duration: 1 week Duration: 1 week Goal: To provide dedicated time to basic science integration into the clinical years, and for explicit incorporation of other health-related issues (e.g. ethics, safety/quality, etc) into the basic science years Goal: To provide dedicated time to basic science integration into the clinical years, and for explicit incorporation of other health-related issues (e.g. ethics, safety/quality, etc) into the basic science years Components Components –Basic science review and application during clinical clerkships to provide the basic science groundings for the subsequent clinical experience –Allied health issues incorporated into basic science years –Potential time for addressing remediation issues –Dynamic curriculum

3rd year (M3)— JulyAugSeptOctNovDecJanFebMarchAprilMayJune Intersession Surgical Block (Encompassing General Surgery, Ophthalmology, Orthopedic, Otolaryngology, and Urology) Intersession Family Medicine and Cognitive Behavioral Sciences (Encompassing Family Medicine, Community Based Primary Care, Dermatology, Psychiatry, and Neurology) Intersession OB/GYN and Pediatrics Block Elective **Must be taken during the M3 Year** **Student must take either FM/CBS block or OB/GYN Pediatric block during the M3 year. One could be moved to a different position allowing 3 more electives in the M3 year** Continuity of Care Clerkship

Required Clinical Blocks/Clerkships Description: Core clinical experiences deemed necessary for all medical graduates Description: Core clinical experiences deemed necessary for all medical graduates Duration: 5 blocks x 12 weeks/block = 60 weeks Duration: 5 blocks x 12 weeks/block = 60 weeks Goal: To provide spectrum of clinical experiences required of primary care and to offer career exploration Goal: To provide spectrum of clinical experiences required of primary care and to offer career exploration Components: Components: –Cerkships grouped into integrated blocks to facilitate interdisciplinary integration Internal medicine (inpatient + outpatient) Internal medicine (inpatient + outpatient) Surgery (general surgery + surgical subspecialties) Surgery (general surgery + surgical subspecialties) Family medicine + Cognitive/behavioral medicine (neurology + psychiatry) Family medicine + Cognitive/behavioral medicine (neurology + psychiatry) OB/Gyn + Pediatrics OB/Gyn + Pediatrics Critical care (emergency medicine + critical care unit + anesthesia + radiology) (M4) Critical care (emergency medicine + critical care unit + anesthesia + radiology) (M4) –M3: IM + Surg + either FM/CBM or Ob/Gyn/Peds –Within the integrated block, different sequences/tracks of experiences may be offered –Sub-internship (4 weeks)

4th year (M4)— JulyAugSeptOctNovDecJanFebMarchAprilMayJune Elective Sub-Internship **Pre-requisites of Medicine, Surgical, and either FM/CGS or OBG/Peds Block required** Elective Complete Step 2 Elective Intersession Critical Care Block (Encompassing Emergency Medicine, Critical Care, Anesthesia, EKG, and Radiology) Commencement Residency **Must be taken in the M4 Year** Continuity of Care Clerkship

Clinical Electives Description: Non-required, multidisciplinary, clinical experiences Description: Non-required, multidisciplinary, clinical experiences Duration: 32 weeks Duration: 32 weeks Goal: To offer a breadth and depth of clinical experiences to enable students to make informed career decisions and to enhance their clinical knowledge and skills Goal: To offer a breadth and depth of clinical experiences to enable students to make informed career decisions and to enhance their clinical knowledge and skills Components Components –Emphasis on multidisciplinary approach –e.g. cutaneous oncology=onc, derm, surg, etc.

Overview I. Strategy I. Strategy II. Permeating Themes II. Permeating Themes III. Pedagogical Considerations III. Pedagogical Considerations IV. Reciprocal Integration Model IV. Reciprocal Integration Model V. Model Analysis V. Model Analysis VI. Conclusions VI. Conclusions

Model Analysis Charge Resource implications

Charge Provide flexibility to accommodate new knowledge Provide flexibility to accommodate new knowledge Improve of basic, clinical, social sciences Improve integration of basic, clinical, social sciences Address patient & societal needs Address patient & societal needs Provide clinical experience Provide earlier clinical experience Encompass competencies Encompass competencies Promote learning Promote student-centered learning Maximize use of educational & informational technologies Maximize use of educational & informational technologies Enable individualized progress Enable individualized progress

Charge Provide flexibility to accommodate new knowledge Provide flexibility to accommodate new knowledge –“Core-dynamic” concept- intersessions –Clinical experience blocks –Attention to pedagogy –Curriculum Oversight Committee –Increased and earlier elective time Improve of basic, clinical, social sciences Improve integration of basic, clinical, social sciences Address patient & societal needs Address patient & societal needs Provide clinical experience Provide earlier clinical experience Encompass competencies Encompass competencies Promote learning Promote student-centered learning Maximize use of educational & informational technologies Maximize use of educational & informational technologies Enable individualized progress Enable individualized progress

Charge Provide flexibility to accommodate new knowledge Provide flexibility to accommodate new knowledge Improve of basic, clinical, social sciences Improve integration of basic, clinical, social sciences –Intersessions –Curriculum Oversight Committee –Personal Wellness Exploration –Integrated Small Group –Clinical experience blocks –Multidisciplinary electives Address patient & societal needs Address patient & societal needs Provide clinical experience Provide earlier clinical experience Encompass competencies Encompass competencies Promote learning Promote student-centered learning Maximize use of educational & informational technologies Maximize use of educational & informational technologies Enable individualized progress Enable individualized progress

Charge Provide flexibility to accommodate new knowledge Provide flexibility to accommodate new knowledge Improve of basic, clinical, social sciences Improve integration of basic, clinical, social sciences Address patient & societal needs Address patient & societal needs –Intersessions –Focus on primary care issues in curricular design –Personal wellness exploration –Preservation of service distinction tracts –Preservation of learning commuities Provide clinical experience Provide earlier clinical experience Encompass competencies Encompass competencies Promote learning Promote student-centered learning Maximize use of educational & informational technologies Maximize use of educational & informational technologies Enable individualized progress Enable individualized progress

Charge Provide flexibility to accommodate new knowledge Provide flexibility to accommodate new knowledge Improve of basic, clinical, social sciences Improve integration of basic, clinical, social sciences Address patient & societal needs Address patient & societal needs Provide clinical experience Provide earlier clinical experience –Continuity of Care clerkship –Earlier formal entrance to clinical clerkships (April, 2 nd year) Encompass competencies Encompass competencies Promote learning Promote student-centered learning Maximize use of educational & informational technologies Maximize use of educational & informational technologies Enable individualized progress Enable individualized progress

Charge Provide flexibility to accommodate new knowledge Provide flexibility to accommodate new knowledge Improve of basic, clinical, social sciences Improve integration of basic, clinical, social sciences Address patient & societal needs Address patient & societal needs Provide clinical experience Provide earlier clinical experience Encompass competencies Encompass competencies –Call to re-evaluate evaluation methods –Curricular Oversight Committee Promote learning Promote student-centered learning Maximize use of educational & informational technologies Maximize use of educational & informational technologies Enable individualized progress Enable individualized progress

Charge Provide flexibility to accommodate new knowledge Provide flexibility to accommodate new knowledge Improve of basic, clinical, social sciences Improve integration of basic, clinical, social sciences Address patient & societal needs Address patient & societal needs Provide clinical experience Provide earlier clinical experience Encompass competencies Encompass competencies Promote learning Promote student-centered learning –Personal wellness exploration –Continuity of care clerkship (mentorship) –Greater schedule flexibility –Call to re-evaluate evaluation methods Maximize use of educational & informational technologies Maximize use of educational & informational technologies Enable individualized progress Enable individualized progress

Charge Provide flexibility to accommodate new knowledge Provide flexibility to accommodate new knowledge Improve of basic, clinical, social sciences Improve integration of basic, clinical, social sciences Address patient & societal needs Address patient & societal needs Provide clinical experience Provide earlier clinical experience Encompass competencies Encompass competencies Promote learning Promote student-centered learning Maximize use of educational & informational technologies Maximize use of educational & informational technologies –Personal Wellness exploration –Attention to safety and quality (explicitly during intersessions) Enable individualized progress Enable individualized progress

Charge Provide flexibility to accommodate new knowledge Provide flexibility to accommodate new knowledge Improve of basic, clinical, social sciences Improve integration of basic, clinical, social sciences Address patient & societal needs Address patient & societal needs Provide clinical experience Provide earlier clinical experience Encompass competencies Encompass competencies Promote learning Promote student-centered learning Maximize use of educational & informational technologies Maximize use of educational & informational technologies Enable individualized progress Enable individualized progress –Greater flexibility in scheduling –Continuity of care clerkship for longitudinal evaluation –Intersessions

Resource Implications Creation of Curriculum Oversight Committee Creation of Curriculum Oversight Committee Continuity of Care clerkship Continuity of Care clerkship Intersessions scheduling requirements Intersessions scheduling requirements

Overview I. Strategy I. Strategy II. Permeating Themes II. Permeating Themes III. Pedagogical Considerations III. Pedagogical Considerations IV. Reciprocal Integration Model IV. Reciprocal Integration Model V. Model Analysis V. Model Analysis VI. Conclusions VI. Conclusions

Conclusions: Key Features of “Reciprocal Integration” Model Earlier clinical exposure (e.g. through Continuity of Care clerkship, earlier entrance into the formal clinical clerkships [by April of 2nd year], etc.) emphasizing relevance of basic science to clinical medicine and allowing for achievement of more advanced clinical skill level by graduation Earlier clinical exposure (e.g. through Continuity of Care clerkship, earlier entrance into the formal clinical clerkships [by April of 2nd year], etc.) emphasizing relevance of basic science to clinical medicine and allowing for achievement of more advanced clinical skill level by graduation Conscious attention to integration of basic and clinical sciences (e.g. through Intersessions, Personal wellness course, etc) and to pedagogy (through curricular oversight, etc) fosters conceptual connections to be made by the student and facilitates broader and deeper learning (‘spiral model’) Conscious attention to integration of basic and clinical sciences (e.g. through Intersessions, Personal wellness course, etc) and to pedagogy (through curricular oversight, etc) fosters conceptual connections to be made by the student and facilitates broader and deeper learning (‘spiral model’) Increased (8 months) and earlier (as soon as April of second year) elective time opportunities that allow for individualized learning and greater opportunities for exploration of career goals Increased (8 months) and earlier (as soon as April of second year) elective time opportunities that allow for individualized learning and greater opportunities for exploration of career goals Provision of longitudinal mentorship opportunities (e.g. through Continuity of Care clerkship, etc.) to cultivate personal and professional development Provision of longitudinal mentorship opportunities (e.g. through Continuity of Care clerkship, etc.) to cultivate personal and professional development