Title: Adding Value to the Fourth Year The 4th Year Colleges Model
1Adding Value to the Fourth YearThe 4th Year
Colleges Model
- Ashley Christiani, MD
- Chair Primary Care College
- Assistant Clinical Professor
- Department of Family Medicine
- David Geffen School of Medicine at UCLA
2Objectives
- Reflect on strengths and weaknesses of 4th Year
- Consider challenges and benefits associated of
building structure into the 4th year - Discuss the 4th Year Colleges model
- Discuss how structure in 4th year can scaffold
and support curricular innovation - Examine how UCLA experience with 4th year
colleges might apply to curricular innovation at
UMDNJ
3- The practice of medicine has changed
dramatically over the last three decades. Medical
education has struggled to keep up with these
changes, with only limited success. The 4th year
of medical school offers tremendous opportunity
for curricular innovation, but little change has
occurred in the past 30 years . -
-
-
- Curricular reform of the 4th year of medical
school the colleges model. Slavin SJ, Wilkes MS,
Usatine RP, Hoffman JR. Teach Learn Med. 2003
Summer15(3)186-93.
4Curricular Innovation
- Most educational innovations have occurred in the
basic science years (PBL,organ/system-based
courses, small group teaching, use of SPs,
Doctoring courses) - Some extension to 3rd year (integrated ambulatory
medicine w/FM, IM, Peds) - Little change occurring at 4th year level where
so much potential lays.
5Opportunities in 4th Year
- Crucial juncture in transition to residency
- 4th year students at ideal developmental level
for educational purposes (solid grounding in
sciences/year of clerkships/socialization) - Opportunity for individualized learning,
exploration, career development, defining
mission. - Opportunity to bring it all together, focus on
clinical skills, remediation of deficiencies,
professionalism, information mastery, develop
teaching, mentoring, research skills.
64th Year from Historical Perspective
- The ignorance and general incompetency of the
average graduate of American Medical Schools at
the time when he receives the degree which turns
him loose upon the community, is something
horrible to contemplate. - -Annual Report of the President of Harvard
College 1869-1870
7Evolution in Medical Education
- Flexner Report 2 years basic sciences followed
by two years of required clerkships - In 50s-60s programs began to include elective
time in 4th year - 1971 Health Manpower legislation incentives to
increase physician supply some offer 3 year
programs - 1985 Swanson pre-residency syndrome
- 80s-present increasing elective time 4th year
8The 4th Year
- 2000 AAMC Curriculum Directory reveals structure
of 4th year unchanged since 1970 for many
schools. Primarily elective time. Average number
required weeks 14 (0-28). Most require at least
an inpatient sub internship.
9Strengths of 4th Year
- Flexibility allows personalized choices, allows
for travel and away electives, research. - Sub-Internships- help prepare for residency,
assume more responsibility for patient care. - Relatively relaxing period between the rigourous
3rd year and demanding internship and residency.
Opportunity for self reflection, time for friends
and family.
10Weaknesses of 4th Year
- Without adequate guidance, may be unfocussed or
lacking in intellectual rigor - Advising and mentoring is often inadequate
- Opportunities to educate in important content
areas are missed AAMC Graduation Survey 1999
shows more than 50 felt time devoted to
nutrition, pain management, occupational health,
law and medicine, alternative medicine, cost
effective care, quality assurance, practice
management was inadequate. - Students widely dispersed may feel disconnected
from peers, faculty and medical school
114th Year Colleges
- Community of students and faculty sharing common
interests who work together to maximize
educational value of 4th year (Acute Care,
Applied Anatomy, Medical Science, Primary Care,
Urban Underserved, MD-MBA/MD-MPH) - Goal to maximize the potential of 4th year while
preserving benefits of the old model-
flexibility, opportunity to explore,
self-reflection, research, etc.
124th Year Colleges
- A curricular structure to...
- Update new scientific and medical findings
relevant to medical practice - Enhance clinical reasoning
- Provide individual feedback
- A society of faculty and students
- Provide career advising and mentoring
- Promote habits of inquiry
13College Components
- Career Mentoring and Advising
- Core Foundation block
- Electives
- Longitudinal Experience/Community Service
- Dinner Seminars
- Research
- CPX Feedback and Remediation
14Primary Care College
- To support students who are
- considering a career in primary care.
- seeking a solid foundation in general clinical
medicine.
15Typical Careers
- Family Medicine
- Geriatrics
- Internal Medicine
- Obstetrics Gynecology
- Pediatrics
- Psychiatry
16Mentoring Advising
- Organized structure of mentoring and support.
- 4th year schedule and electives
- Residency application and interviews
- Special electives or away electives
- Creative projects
- Student Scholarship Day poster or presentation
- Career planning
- Senior Thesis
- General advice and guidance
17PCC Foundations Week
- PCC Foundations Week Curriculum designed by
incoming class with the help of suggestions from
the prior class. - Goal to provide advance training in areas
perceived to be under-taught in first 3 years
of medical school or important in sub-internships
and residency.
18Foundations Week 2004
- Success in the 4th Year - Resident panel
discussion - Diagnostic Imaging
- Practical Dermatology
- In-House Emergencies
- Geriatric/Pediatric Emergencies
- Ventilator Management
- EKG Interpretation
- Pain Management
- Simulator Sessions
- CPX Review Step 2 CS Preparation
19Procedural Labs
20Electives
- One Inpatient Sub-Internship, One Ambulatory
Sub-Internship. Advisors provided list of
recommended electives that can be tailored to the
students individual needs or interest. - Students encouraged to participate in
international or away electives during their
4th year. A special elective in cross cultural
medicine in rural Jamaica has been designed for
PCC students.
21Community Service
- Clinical or academic experience that serves
community. May include teaching activities,
research or direct patient care. Minimum
equivalent of 6 half-day sessions over course of
year. - Clinical experiences with underserved populations
- UMMA Free Clinic
- Union Rescue Mission
- Salvation Army Clinic
- Venice Family Clinic
- Nursing Home Clinic
- Prenatal Clinic
- Teaching Assistantship (Doctoring 4), PBL
- Mentored research or special project
22Dinner Seminars
- Behavioral Medicine and Psychiatry
- Career Residency Planning
- Complementary Medicine and Nutrition
- Geriatrics
- International Health
- Pediatrics
- Public Health Care for Underserved Populations
- Sports Medicine
- Womens Health
23Creative Project
- Required creative or scholarly project may
include - Presentation at Senior Scholarship Day
- Scholarly Paper or Abstract
- Presentation to colleagues in the Dinner Seminar
Series or other venues - Curricular innovation
- Community outreach
24Senior Scholarship Day
- Forum for presentation of original research or
projects done in the 4th year. Attendance and /
or submission of presentation is required for
2004-5 academic year.
25 26Mentoring Survey
- Telephone Format 25 Questions
- Post-Match, Pre-Graduation
- Random Sample with Replacements
- 100 response rate annually
- Control Group UCLA Class of 2001 (n30)
- Intervention Groups
- UCLA Class of 2002 (n60)
- UCLA Class of 2003 (n70)
27Definitions
- Faculty Advisor - Clinicians that provided
information during years 3 and 4 on 4th year
schedule and application to residency. - Role Model - Someone you model your career upon.
- Career Mentor Someone who takes an active role
in your career development.
28Pre-Colleges Post-Colleges
- faculty advisors
- None 33.3
- One 33.3
- Two 30.0
- Three 3.3
- faculty advisors
- Post 1 Post 2
- None 0 2.9
- One 6.7 28.6
- Two 31.7 48.6
- Three 16.7 15.7
- Four 5.0 2.9
- Five 3.3 1.4
Finding (Post Colleges) Increase in of
advisors students identified, sharp decrease in
those identifying no advisor.
29Role Models at UCLA
- Pre Post 1 Post 2
- Identified a Role Model 47 68 91
- Adequate opportunity 70 65 76
- to find role models
- Adequate Accessibility 63 73 89
- to role models
-
- Post Colleges Nearly doubled the of students
identifying a role model. Increases noted in
opportunity and accessibility to role models.
30Career Mentors at UCLA
- Pre Post 1 Post 2
- Identified a career mentor 37 35 73
- Adequate opportunity 70 45 70
- to find career mentors
- Adequate Accessibility 47 74 70
- to career mentors
-
- Post Colleges 36 increase among students
identifying career mentors. Opportunities to find
mentors remained stable, while accessibility to
mentors increased 23.
314th Year Opinions
- Pre Post 1 Post 2
- Connected w/ faculty 47 57 70
- Connected w/ my classmates 37 80 43
- Connected w/ medical school/ 93 52 80
- student affairs office
- Greater percentage of the class now reports
feeling connected with the faculty and their
classmates. Slight decrease in connectedness
with the medical school noted.
324th Year-Beneficial Components
- Pre Post 1 Post 2
- Access to career mentors 50 45 87
- Advising on elective choice 37 48 74
- Longitudinal Experiences
- Clinical experience 43 42 60
- Research experience 17 43 49
- 1 wk foundations course 13 63 64
- Connect w/ faculty/classmates 68 63 69
- Post Colleges Students reported increases in
all components of this new curricular
organization for 4th year and its approach to
mentoring and advising.
334th Year Rated Good-Excellent
- Pre Post 1 Post 2
- Educational Value 83 92 91
- Flexibility 97 97 98
- Quality of Elective Advising 32 55 76
- Quality of Res App Advising 63 73 91
- Overall Satisfaction 100 97 99
- 4 pt Likert scale (1-poor, 2 fair, 3good, 4
excellent) - Post Colleges Gains reported in overall
ratings of the 4th year modified curricular
components. Overall satisfaction remained
stable.
34Challenges
- Students fear of losing flexibility and comfort
of the 4th year. Concern that they will come out
the losers. Involve students early, look for
areas to add value for them (management skills,
preparing for residency), preserve flexibility.
One versus two week Foundations block. - Financial Resources Support for Chairs,
programming supplies. Grants, Deans Office - Students want prep for Sub-Is, hands on
workshops less interested in soft subjects
like nutrition, alternative medicine, other
under-taught areas of medicine identified in
AAMC.
35Unanticipated Benefits
- Multidisciplinary community of College faculty
allows leveraging of strengths, transcend
departments (or turf battles), create
multidisciplinary curriculum - College Chairs meet monthly- responsible for QA
and development of 4th year electives, provide
support for the Deans - College Chairs write MSPEs close relationship
with students - Colleges reach down to years 1-3 to support and
develop students i.e. PCC Pathway program - Responsive to student/MEC needs (i.e. Radiology
enhancement for 2005, Healers Art, Step 2 CS
36PCC Pathway Program International Health
Poverty Medicine
-
- Multidisciplinary program with curriculum to
enhance cultural competency, community health,
and care for underserved populations encompassing
areas of - Health Care
- Public Health
- Research
- Advocacy
37Pathway Components
- Program Director
- Dinner Seminar Series
- Longitudinal Experiences Years 1-3 (clinical or
research based) - Scholarly Project/Research Health disparities,
community health, care for underserved. Link to
STTP. - Workshops and Panel discussions
- Film Series
- Faculty Advisors Public Health, SOM, School of
Nursing - Syllabus Recommended readings
- PDA tools (clinical resources, calendar of events
and seminars, evaluations, specialized 'procedure
cards' and other materials) - ANGEL support with "chat room"
- Highlighted as special area of focus on MSPE.
38Seminar Topics
- Healthcare Policy
- Border Health
- Effects of War, Globalization, Sanctions on
Health - A look at the Cuban, Haitian and the Dominican
Republican Healthcare System - Socialized Medicine
- Community Based Primary Healthcare
- Gangs and Violence
- Infectious Diseases and the Poor (Malaria, TB,
AIDS) - International Health Experiences a look at
Doctors Without Borders, Doctors for Global
Health. - Homelessness and Healthcare
- Poverty Medicine
- Torture Medicine
- Travel Medicine The Ten Commandments
- Alternative Medicine from other Cultures
- Cultural Sensitivity
39Summary
- 4th Year Colleges preserve flexibility while
providing enhanced opportunities for - Advanced training in clinical skills
- Mentoring and Advising
- Research
- Community involvement
- Teamwork skills and communication
- Developing habits of life-long learning
- Integration and synthesis of basic sciences into
clinical framework - Professionalism
40Additional Considerations
- 4th Year Colleges integrate well into a
progressive stepwise remodeling of curriculum. - Provide an automatic mechanism for continued
innovation so schools arent stuck in a static
model for another 3 decades allowing outreach
and insertion of novel curriculum in years 1-3 - Colleges assist in creating community -bring
faculty together as well as students - Allows more flexibility than Colleges that divide
in first year students are supported without
being prematurely tracked.
41Curricular Innovation at UMDNJ
- Goal 1 Mastery of Clinical Knowledge with
Integration of Basic Sciences - Goal 2 Excellence in Clinical Skills
- Goal 3 Excellence in Professionalism and
Humanism - Goal 4 Commitment to the Health of the
Community and Appreciation of Social and Cultural
Diversity - Goal 5 Dedication to Life-Long Learning
- Goal 6 Development of Effective Skills in
Education and Communication
42Questions?
-
- Ashley Christiani, MD
- Primary Care College Chair
- achristiani_at_mednet.ucla.edu
- 50-071 Center for Health Sciences
- David Geffen School of Medicine at UCLA
- Los Angeles, CA 90095
- (310) 825-5469