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

2. 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.

3. 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)

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

5. 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 weeks
Coursework 7 weeks
44 weeks in the year (minus Thanksgiving and Winter vacation)
9 weeks for Step 2 study and completion, interviews, vacation

6. 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

7. 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

8. 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

9. 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

10. 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

11. Subcommittee Survey Developed by the subcommittee for the subcommittee
14 respondents

12. 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 days
Applied physiology days
Advance Com. Skills days
QI Project days
New or Emerging Concepts 2.43 days
Personal/Professional Refl days
ACLS/PALS days
Other days
Other included: Medical Imaging, Critical care, Intern panel

13. 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

14. 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%)

15. 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

16. 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

17. 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

18. 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.

19. 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

20. 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

21. 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

22. 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