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Review of Y2 SBM/CT and MS CoursePreClinical Subcommittee
November, 2013Chris Rees (Geisel 2), Steve Benson MD, Dave Nierenberg
MD
1. Course learning objectives
2. Course learning opportunities
3. Learning assessments for students
4. Measures of overall quality for the course
5. Specific suggestions for improving course
1. 2012-2013 Course Learning Objectives # Objective Maps to
1 Apply current knowledge in MS Medicine to Dx and Rx decisions 1a
2 Apply current clinical and translational science to Dx and Rx questions 1b,c,d
3 Apply knowledge of prevention, risk factor modification, substance abuse, pain management, medical ethics, and medical-legal issues to clinical problem solving
1e
4 Apply knowledge of impact of social, economic, cultural and personal factors on health to clinical problems in MS medicine
1f
5 Establish mutually respectful student-patient and student-family interactions with diverse patients
2a,c,3a,b
6 Interview patients skillfully, using a MS-focused history 2b,2c
7 Examine patients with MS conditions skillfully, with attention to cleanliness, infection control, and patient comfort
2c
8 Generate an appropriate differential Dx for patients with MS disorders 2d,e
9 Explain the indications, complications, and performance of diagnostic tests (e.g. CT, MRI, EMG, NC, tissue biopsy)
2f,g
10 Identify common abnormal findings on plain radiographs, CT scans, and MRI scans
2h
11 Communicate effectively with patients and families especially when special barriers to communication exist (eg. Cultural, socioeconomic, linguistic, etc)
3c
2012-2013 ILIOS Course Objectives (cont’d)# Objective Maps to
12 Assist patients in understanding their treatment options and prognosis 3d
13 Communicate collegially and effectively, verbally and in writing, with physician colleagues and other members of the HC team
3e,f,g,h
14 Behave respectfully and responsibly towards patients, families, colleagues, and other members of the HC team, and remain aware of different concerns, opinions, and cultural perspectives
4a,e
15 Meet professional responsibilities fully 4b
16 Adhere to high ethical and moral standards,, accept constructive criticism, and respect patient confidentiality
4d,f,g
17 Take responsibility for one’s own medical education, and develop habits of mindfulness and reflection
4h,j
18 Describe barriers to access basic health services, and its effect on vulnerable populations
4k
19 Contribute constructive feedback during peer review 4l
20 Identify and critically evaluate evidence-based and cost-conscious strategies for patients with MS diseases, and apply these approaches to patient care
5a,b,e,f
21 Assess the effect of social environment on clinical care and patient outcomes
5c
22 Identify appropriate resources to support patient care, and collaborate effectively with all members of the inter-professional team
6a,b
1a. Learning Objectives (Dave) In the course syllabus 2013, the course objectives are listed
as follows: To provide a thorough and detailed introduction to
rheumatologic conditions and musculoskeletal medicine To know the important historical features, physical
findings, laboratory and radiographic findings that help differentiate one connective tissue disease from another
To develop a structured approach to the patient with musculoskeletal symptoms in order to construct an appropriate differential diagnosis and develop rational diagnostic and therapeutic plans.
Students are not provided with the ILIOS course objectives
Important to have one shared set of core learning objectives, presented right at the beginning of the course
Continued (Dave) From the lecture topics, and also the categories on the final exam, we can see the
core topics of the course include: Overview of course, and the approach to the patient Elements of the joint and MS exam Osteoarthritis Rheumatoid arthritis Pediatric conditions and JRA Lyme disease Other types of arthritis: seronegative, crystal, infectious Muscle conditions, myositis and myofascial pain Vasculitis, SLE, and scleroderma Lab testing Soft tissue problems and injuries Bone diseases, fractures, and tumors DJD and other Diseases of the spine Congenital and developmental problems Imaging the MS and CT systems Common genetic conditions
1. Topics in national textbook(Cecil Essentials of Medicine, 2013)
Approach to patient with rheumatic disease (Yes)
Rheumatoid arthritis (Yes)
Spondyloarthropathies (Yes)
SLE (Yes)
Antiphospholipid antibody syndrome (yes)
Systemic sclerosis (Yes) and Sjogren’s syndrome
Idiopathic inflammatory myopathies (Yes)
Sjogren syndrome (no in 2013, yes in 2014)
Systemic vasculitis (Yes)
Crystal arthropathies (Yes)
Osteoarthritis (Yes)
Non-articular soft tissue disorders (Yes)
Rheumatic manifestations of systemic disorders (Yes)
1f. Learning objectives addressing additional specific LCME topics (with Nicole) Health of populations:
Senior epidemic of OA, and how obesity contributes to the clinical progression
Chronic pain syndromes, e.g. fibromyalgia
Basic and ethical principles of clinical and translational research: How the intricate process of basic and translational immunology
research is changing the way we approach pts with RA (William Rigby)
Gender and cultural biases in students themselves: Not at this time
Instruction in medical ethics and human values In 2014 will be their first Hearts and Minds session about a patient with
fibromyalgia (chronic pain syndrome) and her long-term use of opioids for pain management
1g. Overlap/ILIOS word search: “Vasculitis”
Does not appear in any course objectives
Appears in one session title (SBM/MS)
Appears in 3 sessions in 3 different courses
1g. Overlap/ILIOS word search: “Rheumatoid Arthritis”
Does not appear in any course objectives
Appears in one session title (SBM/MS)
Appears in 5 sessions in 3 different courses
1g. Overlap/ILIOS word search: “uric acid”(note: there are other “hits” when “gout” is searched)
Does not appear in any course objectives
Does not appear in any session title
Appears in 4 sessions in 4 different courses
1. Learning Objectives: Summary
Issue Proposed Fix
Learning objectives in ILIOS are vague
Learning objectives in ILIOS differ from those posted in the course
Group learning objectives by major competency domain, and map to specific competency tasks
Current course objectives in ILIOS do not contain the key words of the major diseases and conditions
Make sure that exam topics track nicely to new learning objectives
List learning objectives for each session at the beginning of each session
2. Course Learning Opportunities 2012-13 (Dave)
Total hours: 39 h Traditional lectures = 29 h (74% of total hours)
Large group discussion/review = 0 h Lab (classical) = 0 Small groups/conferences = 6 PBL groups = 3 Direct patient contact or PE session = 1 (2 groups) Panel discussion (Hearts and Minds) = 0 Other formats = 0
2. Learning Opportunities Summary
Issue Proposed Fix
Over-reliance on standard lectures (29/39=74%)
Not enough engaged large group sessions (0)
Only 6 h of conference groups
Didn’t have Hearts and Minds panel discussion in 2013
Current 1 h PE demonstration clinic is excellent
3. Content of Final exam (current topics 2013)
Topic # Topic #
Acute soft tissue 6 Myositis 3
Bone pathology 3 Osteoarthritis 7
Bone tumors 1 Pediatric topics 3
Development 1 Physical dx 4
DJD of spine 2 Imaging 1
Fibromyalgia 4 Rheumatoid arthritis 11
Fractures 1 Scleroderma 5
Genetics 1 Seronegative arthritis 3
Gout 7 SLE 10
Infectious arthritis 4 Testing 2
JRA 3 Vasculitis 5
Lyme disease 5 Pharmacology 6
3. 2012-2013 Exam items sorted by current course learning objectives (Steve)
# Objective Maps to
# items
1 Apply current knowledge in MS Medicine to Dx and Rx decisions 1a 70
2 Apply current clinical and translational science to Dx and Rx questions
1b,c,d 1
3 Apply knowledge of prevention, risk factor modification, substance abuse, pain management, medical ethics, and medical-legal issues to clinical problem solving
1e 2
4 Apply knowledge of impact of social, economic, cultural and personal factors on health to clinical problems in MS medicine
1f 0
5 Establish mutually respectful student-patient and student-family interactions with diverse patients
2a,c,3a,b
0
6 Interview patients skillfully, using a MS-focused history 2b,2c 0
7 Examine patients with MS conditions skillfully, with attention to cleanliness, infection control, and patient comfort
2c 7 PE findings
8 Generate an appropriate differential Dx for patients with MS disorders
2d,e 1
9 Explain the indications, complications, and performance of diagnostic tests (e.g. CT, MRI, EMG, NC, tissue biopsy)
2f,g 2
10 Identify common abnormal findings on plain radiographs, CT scans, and MRI scans
2h 9
11 Communicate effectively with patients and families especially when special barriers to communication exist (eg. Cultural, socioeconomic, linguistic, etc)
3c 0
2012-2013 Exam items (cont’d)# Objective Maps to # items
12 Assist patients in understanding their treatment options and prognosis
3d 0
13 Communicate collegially and effectively, verbally and in writing, with physician colleagues and other members of the HC team
3e,f,g,h 0
14 Behave respectfully and responsibly towards patients, families, colleagues, and other members of the HC team, and remain aware of different concerns, opinions, and cultural perspectives
4a,e 0
15 Meet professional responsibilities fully 4b 0
16 Adhere to high ethical and moral standards,, accept constructive criticism, and respect patient confidentiality
4d,f,g 0
17 Take responsibility for one’s own medical education, and develop habits of mindfulness and reflection
4h,j 0
18 Describe barriers to access basic health services, and its effect on vulnerable populations
4k 0
19 Contribute constructive feedback during peer review 4l 0
20 Identify and critically evaluate evidence-based and cost-conscious strategies for patients with MS diseases, and apply these approaches to patient care
5a,b,e,f 0
21 Assess the effect of social environment on clinical care and patient outcomes
5c 0
22 Identify appropriate resources to support patient care, and collaborate effectively with all members of the inter-professional team
6a,b 0
3. Exam content (MS final exam)
Question style # Factual only, test recognition/memorization
Important concepts, avoid test fatigue 15 Clinical vignette with reasoning
Excellent, well written, pertinent 59
Application of knowledge Interpret findings, data 7 Photos of PE findings 8
Negative stem 2 (only!) Multiple T/F format 1 (only!)
Pharmacology questions 64 were simple recall, 2 clinical vignettes
3. Evaluating Students, Summary
Issue Proposed Fix
Learning issues need to be granular enough that major exam areas map well to them
Learning objectives not assessed on written final exam must be assessed in some other way
Conference leaders may not know students well enough to assess their competency in multiple areas
Conference size may be too large to enable faculty to get to know each student
Written final exam made good use of vignettes, fewer factoid questions, very few negative stem
4. Feedback about course from March 2012 AAMC
GQHow well did each of the following sciences
basic to medicine prepare you for clinical clerkships and electives?
All Year 1 disciplines (n=9): mean = 3.1
All Year 2 disciplines (n=4): mean = 3.4 (3.3)
Renal course was not broken out
Results from recent student course reviews
Data from 2012-2013 evaluations:
Strongest areas:
• “Overall usefulness of attending laboratory sessions or simulated laboratory sessions.” 4.22
• “How well this course provided me with a useful and appropriate introduction to this field of discipline.” 4.05
• “Overall quality of the entire course” 4.00
Among the questions asked on the course review pertaining to the “usefulness” of course elements, none scored below at 3.48.
All faculty were rated at a 3.16 or higher, with 16 of 20 lecturers receiving a score of 3.70 or higher.
Results from recent student course reviews
Representative comments (strengths):
Many students commented on the fairness and congruence of the final exam.
“The clinic visit was fantastic. This should be standard for all courses.”
“The best part of the course was the conferences.”
The majority of faculty received overwhelmingly positive scores from the students.
Results from recent student course reviews
Representative comments (weaknesses):
Several students commented that the clinical experience would be more useful later in the term. (done for 2014)
“Perhaps one or two more conference groups would be helpful.” (done for 2014)
“The organization of the course could be a little better. The arthritis lectures could be grouped together and the bone lectures could be grouped together.” (done for 2014)
Some students commented that the required paper felt like “busywork.”(replaced in 2014 by off-line quizzes)
4. Global measures of quality
Issue Proposed Fix
Shift clinical experience (PDX session) later into term
Having one or two more conference group meetings would be helpful (highlight of course)
Improve course organization by better grouping of topics (e.g. arthritis material, bone material)
Required written paper (analyzing a journal article) felt like “busywork” to a few students
1. Learning Objectives: SummaryIssue Proposed Fix
Learning objectives in ILIOS are vague
Rewrite new set of course learning objectives
Learning objectives in ILIOS differ from those posted in the course
Post the new ILIOS objectives in syllabus on first day of course
Group learning objectives by major competency domain, and map to specific competency tasks
Done in new version
Have enough detail in new course learning objectives to permit ILIOS word searches
Done in new objectives
Make sure that exam topics track to new learning objectives
Done in new objectives
List learning objectives for each session at the beginning of each session
Will do next cycle
DRAFT New Course Learning Objectives for 2013-14
Each student should demonstrate an appropriate level of understanding of the pathophysiology of the musculoskeletal/connective tissues system, such that the student is prepared to recognize, diagnose, and describe effective treatment options for the most common and severe diseases and disorders of this organ/system that may be encountered during the clinical clerkships or in clinical practice.
Possible Course Learning Objectives 2013-14# Objective Domain Assessment
1 Describe the pathophysiology, diagnosis, and treatment options for osteoarthritis 1abcde Conference, PBL, exam
2 Describe the pathophysiology, diagnosis, and treatment options for rheumatoid arthritis (including juvenile rheumatoid arthritis)
1abcde Conference, PBL, exam
3 Describe the pathophysiology, diagnosis, and treatment options for less common types of arthritis (e.g. sero-negative, psoriatic, etc)
1abcd Conference, PBL, exam
4 Describe the pathophysiology, diagnosis, and treatment options for diseases of the lumbar and cervical spine (including DJD, ankylosing spondylitis, disc disease, low back pain,etc)
1abcd Conference, PBL, exam
5 Describe the pathophysiology, diagnosis, and treatment options for complications of uric acid and other crystals (including gout, pseudogout)
1abcd Conference, PBL, exam
6 Describe the pathophysiology, diagnosis, and treatment options for common infections of the MS system (e.g. Lyme disease, septic arthritis)
1abcd Conference, PBL, exam
7 Describe the pathophysiology, diagnosis, and treatment options for diseases of skeletal muscle (e.g. myositis, polymyositis, etc.)
1abcd Conference, PBL, exam
8 Describe the pathophysiology, diagnosis, and treatment options for connective tissue diseases (eg. systemic lupus erythematosus, scleroderma, mixed CT disease, Sjogren’s syndrome)
1abcd Conference, PBL, exam
9 Describe the pathophysiology, diagnosis and treatment options for the various types of vasculitis (eg. Polymyalgia rheumatica, giant cell arteritis, granulomatosis with polyangiitis, polyarteritis)
1abcd Conference, PBL, exam
10 Describe the pathophysiology, diagnosis, and treatment options for bone and soft tissue diseases (e.g. tumors, fractures, sprains)
1abcd Conference, PBL, exam
11 Describe the pathophysiology, diagnosis, and treatment options for common pediatric and developmental diseases (e.g. juvenile rheumatoid arthritis, genetic conditions)
1abcd Conference, PBL, exam
12 Describe the advantages and disadvantages of major diagnostic testing modalities for the MS system (e.g. radiography, CT, MRI, ultrasound, serologic testing, etc.)
2fgh Conference, PBL, exam
Possible Course Learning Objectives 2013-14# Objective Domain Assessment
13 Describe the most common symptoms of rheumatic and musculoskeletal diseases, and use that knowledge to help develop a differential diagnosis
2ab Conferences, PBL
14 Explain how patients with MS/CT disorders can be skillfully and respectfully examined, with appropriate attention to cleanliness and privacy
2ac Rheumatology clinic
15 Explain the indications, complications, and limitations of common diagnostic modalities including imaging studies, EMG, NCS, and tissue biopsies
2fg Exam
16 Correctly identify common abnormalities seen on plain radiographs, CT scans, and MRI’s of the MS system
2gh Conference, PBL, exam
17 Communicate effectively, verbally and in writing, with colleagues and physicians 3efg Conference, PBL
18 Demonstrate how to assist patients in understanding their treatment options, and prognosis of their diseases
3abcd Conference, PBL
19 Meet professional responsibilities (meetings, assignments, etc) in a timely and professional manner
4bdfh Conference, PBL
20 Demonstrate the ability to take responsibility for one’s own medical education 4h Conference, PBL
21 Describe how barriers to access for care of MS/CT problems adversely effects the health of vulnerable populations
4k Conference, PBL
22 Demonstrate the ability to identify and evaluate information about evidence-based and cost-conscious strategies in managing MS/CT disorders
5abce Conference, PBL, exam
23 Identify appropriate resources to help support patients with MS/CT disorders, and describe the rolls of all members of the inter-professional HC team
6abef Conference, PBL
24 Describe the appropriate role of rehabilitation (physiatry) and related services (OT, PT, etc) in the care of patients with MS/CT diseases
6abce Conference, PBL
2. Learning Opportunities Summary
Issue Proposed Fix
Over-reliance on standard lectures (29/39=74%)
In 2014, will reduce to 23/39 (59%)
Not enough engaged large group sessions
Will increase from 0 to 3 in 2014
Only 6 h of conference groups Will increase to 8 h in 2014
Don’t have Hearts and Minds panel discussion in 2013
Will introduce new 1h session in 2014
Current 1 h demonstration clinic is excellent
This will be continued in 2014
3. Evaluating Students Summary
Issue Proposed Fix
Learning issues need to be granular enough that major exam areas map well to them
Fixed with new course learning objectives
Learning objectives not assessed on written final exam must be assessed in some other way
Assigned in new course learning objectives to observation of students in conference, PBL groups
Conference leaders may not know students well enough to assess their competency in multiple areas
Increase hours spent with same conference leader
Conference size may be too large to enable faculty to get to know each student
Increase number of faculty-led conference groups
Written final exam made good use of vignettes, fewer factoid questions, very few negative stem
Continue to develop new items for final exam
4. Feedback from Students
Issue Proposed Fix
Shift clinical experience (PDX session) later into term
Fixed for 2014
Having one or two more conference group meetings would be helpful (highlight of course)
Fixed for 2014
Improve course organization by better grouping of topics (e.g. arthritis material, bone material)
Done for 2014
Required written paper (analyzing a journal article) felt like “busywork” to a few students
Re-evaluate goals of this exercise: consider asking for a shorter paper, earlier in the course, that will help students develop the skills to translate translational research findings into language patients can understand