Revision of a Medical Student Curriculum Using the Delphi Method to Build Consensus

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Revision of a Medical Student Curriculum Using
the Delphi Method to Build Consensus

• Kimberly Hoffman, Ph.D.
• Michael Hosokawa, Ed.D.

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Participant Introduction

• Present position
• Experience with curricular design and revision
• Experience with the Delphi

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Setting the Stage for Change

• 1989, new dean with a vision for education
• 1992, Curriculum Design Committee
• 1993, New curriculum
• 1995, First students do well on USMLE 1
• and scores improve each year
• 1997, First class graduates, Step 2 scores as
  impressive and improve each year

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Setting the Stage for Change cont.

• Totally integrated basic science curriculum
• No department or discipline-based courses
• Core learning experiences in small groups, PBL
• First and second year4 10-week blocks per year
• 8 weeks for learning, 1-week evaluation, 1-week
  break
• PBL model, 32 cases in the first year and 32 in
  the second year
• Third year--6 8-week core clerkships
• Fourth year3 sub-internships, 1 advanced
  biomedical science, 4 electives

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Setting the Stage for Change cont.

• Curriculum emulated by other schools
• Curriculum becoming stagnant
• Faculty beginning to fatigue
• Regression and lecture creep
• Need for new ideas and new faculty energy
• Over-dependence on senior faculty
• Over-dependence on a core of teaching faculty

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Players and Stakeholders

• New Dean
• New Senior Dean for Education and Faculty
  Development
• Curriculum Committee
• Office of Medical Education
• Faculty
• Graduates
• Students

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MU 2020

• Impetus for change Crossing the Quality Chasm
  Institute of Medicine
• ACGME Competencies
• Goal Create the first step in a continually
  improving curriculum

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MU 2020

• Mission to teach future physicians to deliver
  patient-centered care
• 2020 Key Characteristics ACGME
• Effective patient-centered care Patient
  care
• Knowledgeable in biomedical Medical
  Knowledge
• sciences, EBM, societal and
• cultural issues, critical thinker.
• problem solver

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MU 2020

• MU 2020 Key Characteristics ACGME
• Committed to improving Practice-based
• quality and safety learning and
• Committed to lifelong learning improvement
• and information mastery
• Able to communicate with Interpersonal and
  patients and others communication
  skills

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MU 2020

• MU 2020 Key Characteristics ACGME
• Honest with high ethical standards Professionalism
  
• Able to collaborate with patients Systems-based
• and other members of the health practice
• care team

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Delphi

• Expand the Key Characteristics (Qualities of the
  Graduates) into curricular objectives using the
  Delphi
• Identify the stakeholders
• Successive mailings to
• Curriculum Committee
• MU 2020 Steering Committee
• Pre-clinical curriculum block directors
• Clinical clerkship directors
• Program directors
• Department chairs

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Delphi Rounds

• ROUND ONE Translate key characteristics into
  measurable endpoint
• UME Revise Exit Goals
• GME Show Relationship to ACGME Core Competencies
• ROUND TWO Identify data needed as evidence that
  these measurable outcomes have been met
• ROUND THREE Determine if data are available and
  if not design strategies for obtaining data

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Delphi

• Mailing 1
• What knowledge, skills and attitudes does the
  student need to satisfactorily demonstrate as a
  graduate of this medical school?
• Mailing 2
• What knowledge, skills and attitudes does the
  student need to satisfactorily demonstrate as a
  graduate of this medical school?

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Panel Size

• Mu2020 Steering Committee N23
• Curriculum Board N14
• Clinical Curriculum Steering Committee N20
• Curriculum Block Directors N16

• Program Directors N 14
• Department Chairs N21
• Alumni N7
• Medical Student N ?
• Residents N ?

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Number of Individuals

• Faculty 89
• Alumni 7
• Medical Students 8 standing committees (
  others ?)
• Residents ?
• Total 97 faculty residents students

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Implementing the Delphi

• All panel members sent e-mail with link to MU2020
  web site.
• Panel members invited to provide comments through
  the MU2020 web site.
• Panel members log in.
• Entries are linked to a group not an individual.

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Implementing the Delphi

• Participants are provided the key characteristics
  and invited to comment on the knowledge
  behavior/skills and attitudes needed for each of
  the eight key characteristics.
• Participants have opportunity to enter free text
  8 times
• Text fields are not limited in length.

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Example Question to Panelists

• Able to deliver effective patient-centered care
  Our graduates are able to deliver care that
  improves the health of individuals and
  communities. Patient-centered care reflects a
  respect for individual patient values,
  preferences, and expressed needs. This care is
  grounded in the best available evidence and
  conserves limited resources. It depends on shared
  decision-making and active patient participation.
  Our graduates' care will be marked by compassion,
  empathy and patient advocacy.
• What knowledge, attitudes, behavior/skill does
  the medical student need to posses to be able to
  satisfactorily demonstrate s/he is able to
  deliver effective patient centered care?

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Round One Responses

• 44 persons from a possible 120 respondents
• 37 response rate
• Responses from at least one person in each of the
  stakeholder groups
• Quantity of responses varied across the eight
  questions

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Example Responses To Patient Centered Care

• As a PBL tutor, I see a wide range of student
  attitudes and behaviors that, in my limited
  experience, reflect on the student's ability to
  deliver effective patient centered care. The best
  students always have the patients needs foremost
  in their minds, even as they are working to
  effectively identify the essential basic science
  and clinical learning issues that each PBL case
  affords. Too many students, however, tend to
  ignore the PBL patient as a person and focus only
  on the matter at hand, i.e. working the case for
  the intellectual or factual aspects they believe
  will best serve them, either in practice or for
  the block test or Boards. Of course these
  students shouldn't really be blamed for this
  since too many of our PBL cases fail to
  effectively incorporate the overall well being of
  the patient into the essence of the case. Of
  greatest concern, though, are the few students
  who seem totally oblivious of the patient as a
  human being and in some cases are not only
  completely insensitive to human weaknesses,
  fears, and anxieties, but treat them with
  contempt. Since I do not interact with these
  students in any meaningful way as M3''s and
  M4''s, I have no way of knowing if these
  attitudes and behaviors are modified by the time
  they leave the School. Thus, my comment speaks
  more to how the curriculum must prepare students
  in the first two years to developed the essential
  attitudes and behaviors necessary for effective
  patient centered care than to how students can
  demonstrate the ability to effectively deliver
  such care (As a non-physician, the latter is
  beyond my capabilities). Our curriculum must
  improve in the first two years in the area of
  case development and presentation of patient
  needs beyond the basic and clinical science
  without sacrificing the basic and clinical
  science learning that is central to PBL (MU2020
  Steering Committee Member)

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Example Responses To Patient Centered Care

• Knowledge of differing cultures. This would
  include nationality, socioeconomic status, race,
  gender, etc. This knowledge would alleviate
  conflicts such as language, dialect, non-verbal
  communication issues, and increase cooperation
  between patient and physician. Bias and attitudes
  need to in check. Ability to establish rapport,
  listen and show compassion (Clinical Curriculum
  Steering Committee Member).

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• Robust Information Distilled into
• 19 Knowledge Themes
• 24 Skill Themes
• 23 Attitude Themes
• These data sent to Delphi Panels for Ranking.

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Guidelines for Constructing Educational
Experiences

• Develop design principles for the educational
  process the architecture for the educational
  processes