Adding Value to the Fourth Year The 4th Year Colleges Model

1
Adding 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

2
Objectives

• 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.

4
Curricular 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.

5
Opportunities 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.

6
4th 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

7
Evolution 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

8
The 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.

9
Strengths 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.

10
Weaknesses 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

11
4th 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.

12
4th 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

13
College Components

• Career Mentoring and Advising
• Core Foundation block
• Electives
• Longitudinal Experience/Community Service
• Dinner Seminars
• Research
• CPX Feedback and Remediation

14
Primary Care College

• To support students who are
• considering a career in primary care.
• seeking a solid foundation in general clinical
  medicine.

15
Typical Careers

• Family Medicine
• Geriatrics
• Internal Medicine
• Obstetrics Gynecology
• Pediatrics
• Psychiatry

16
Mentoring 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

17
PCC 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.

18
Foundations 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

19
Procedural Labs
20
Electives

• 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.

21
Community 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

22
Dinner 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

23
Creative 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

24
Senior 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

• Evaluation Data

26
Mentoring 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)

27
Definitions

• 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.

28
Pre-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.
29
Role 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.

30
Career 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.

31
4th 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.

32
4th 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.

33
4th 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.

34
Challenges

• 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.

35
Unanticipated 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

36
PCC 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

37
Pathway 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.

38
Seminar 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

39
Summary

• 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

40
Additional 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.

41
Curricular 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

42
Questions?

• 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
• [phone]