Operationalizing a 3-year standalone, accelerated medical school curriculum to nurture physicians to become primary care and health system leaders

Figures & data

Figure 1. Process map for curriculum development.

Table 1. Problem-based learning and longitudinal course director interviews.

Longitudinal Courses & PBL	Guiding Principle	Primary Key Driver
Continuity Ambulatory Practice Experience Course (CAPE) is a longitudinal ambulatory experience in the primary care setting with the goal of transitioning students from being observers to direct providers of patient care. The students practice their skillsets by taking patient histories, performing physical exams and assessments, and clinical management.	CAPE provides a patient- and learner-centered curriculum, emphasizing longitudinal patient care in the primary care setting. CAPE provides learners with a clinical setting where the principles of the practice of medicine, health system science, organ systems, basic sciences, ethics, and humanities can be put into practice.	One key driver was the development of measurable learning objectives (LO) in the clinical setting. Development of a CAPE passport outlined learning objectives and catalogued achievement of milestones (Appendix 1). For example, faculty look for opportunities in the clinical setting to cover the learning objectives focused on patient communication about vaccines reviewed in the Year 1 basic science and organ system courses. Thus, the CAPE passport was designed to make learning more intentional.
The Health Systems Science (HSS) curriculum consists of three threads: I: HSS Core domains [26] Healthcare structures and processes Population, Public, and Social Determinants of Health. Clinical informatics and Health Information Technology, Value in Health care, Healthcare Policy & Economics Health System Improvement II: Evidence-based Medicine and Clinical Epidemiology III: Interprofessional Collaborative Care and Practice	The HSS curriculum’s overall objective is to develop a mindset for systems thinking [27]. System thinking is defined as an approach to problem-solving that recognizes and prioritizes the understanding of linkages, relationships, interactions and interdependencies among the components of the system that give rise to the system’s observed behavior [28]. We want our students to appreciate the dynamic nature and complexity of our healthcare system and how the various components interact to optimize patient outcomes. Year 1 focuses on building knowledge around HSS core domains whereas Years II and III focus on experiential learning utilizing capstone projects and integration of clinical experience to drive learning within the students’ practice environment	The primary key driver is the integration of HSS throughout the curriculum leveraging experiential learning. Students complete a capstone initiative in one of two tracks: quality improvement and patient safety or population health/clinical epidemiology research. We ensure alignment of the capstone to the student’s primary care residency track to nurture a system thinking mindset focused on primary care throughout their careers. One example of a capstone initiative is the improvement of screening for social determinants of health by a student in the pediatric track.
Learning Community - Social Sciences Humanities Ethics and Professionalism (LC-SHEP) prepares students to negotiate the complexities of clinical care and medicine in society. The four content domains of LC-SHEP: psychology of decision-making, history of medicine, systemic racism, and professional identity formation appear as longitudinal threads.	We worked deliberately to make the non-bio scientific and less tangible parts of medicine (social sciences, humanities, and ethics) into an outcomes-based curriculum. This ensures that the material reflected in the learning objectives is real, relevant, and integrated into the everyday work of our students as physicians. Content from a variety of disciplines within social sciences and humanities are woven together along with active skill development in moral self-awareness, self-reflection, moral reasoning, and ethical analysis.	We deeply integrated principles of sociology, cultural anthropology, humanities, ethics, and professionalism into students learning. These content areas were woven into longitudinal strands within a spiral curricular structure. For example, discussions of shaping the organization of allopathic medicine, definition of codes of ethics and medical professionalism, and ways in which elitism, bias, and racism have caused harm in LC-SHEP allow patient encounters with their primary care doctors to be viewed within these social contexts.
The Problem Based Learning (PBL) curriculum consists of 65 cases across Years 1–3. Students are evaluated and receive feedback on their group and individual PBL skills.	The overarching principle that guided PBL curriculum development was creating independent, self-directed, life-long learners and nurturing core clinical skills from day one of medical school. PBL has allowed us to reap the benefits of this learner centered approach to promote both knowledge goals (independent identification of knowledge gaps and analysis and synthesis of relevant information) and process goals (clinical reasoning, interprofessional collaboration, and critical, appraisal of literature).	PBL cases are adapted from real life clinical scenarios, which students will see in their day-to-day practice as primary care physicians. HSS LOs embedded in each case help define the unique role of the primary care physician-family partnership in provision of integrated, comprehensive healthcare delivery. This is critical to nurturing holistic primary care physicians.

Table

Family Medicine Resident	- “Clinical experience right from the get-go…paired with the same physician throughout.” - “The Health System Science program was helpful for teaching us how the health system works…Having this broader knowledge…I am better able to coach my patients through the system by modifying their plans of care to accommodate for barriers.” - “The curriculum prepared us well for what it means to be a leader in a health system and what opportunities there are for better care for patients.”
Internal Medicine Resident	- “The inclusion of the impact of sociocultural factors on access to care in our curriculum was essential to our learning and growth as primary care physicians.” - “Most of my colleagues in residency have received zero training on the issues of billing and insurance, but…I feel fortunate that my medical school curriculum included these.” - “I find myself thinking about health…in the context of the broader range of healthcare as a health system.” - “Excellent faculty and early integration allowed me to feel prepared to deliver primary care as a change agent.”
Obstetrics & Gynecology Resident	- “Our CAPE experience throughout all three years really allowed us to get more exposure in the primary care field.” - “Our HSS course equipped us with tools like the HSS patient safety matrix, which continues to help me evaluate problems within the hospital through my residency.”
Pediatric Resident	- “Longitudinal aspects of the curriculum through CAPE: frequent and early exposure to pediatric patients…with the same preceptor for all of my years” - “The Quality Improvement (QI) project prepared me to think through the methodology for improving primary care practices and developing a QI mindset. Every resident in my program will have to do a QI project, and it is great that I already know how to structure one and the lessons from this are already impacting my work.”

Table

Family Medicine Resident	- ‘Simulation experiences were phenomenal and emphasized the importance of being able to meet the patient where they are…with great feedback.’ - ‘My knowledge and comfort with formal quality improvement was much further along than many of my resident colleagues… a mindset that we can apply to the work we are doing daily.’ - The organ-system based model ‘allowed us to connect the dots much quicker…in learning physiology, anatomy, pharmacology, etc.’
Internal Medicine Resident	- ‘It was a formative experience to learn how to build trust, empathy, and relationships with your patients in every situation during our first year.’ - ‘I rely on many of the practical skillsets we learned in our LC-SHEP course…when I am having difficult conversations with patients and their families.’ - ‘I find myself leaps and bounds beyond my colleagues.’
Obstetrics & Gynecology Resident	- ‘Our medical ethics course [LC-SHEP] was excellent at helping us develop strategies for addressing the mental load we experience in the hospital and being able to identify things we are uncomfortable with.’ - PBL helped us ‘learn how to look up information and find pitfalls in [our] knowledge.’
Pediatric Resident	- ‘The content of the curriculum and the fast-paced rigger also helped prepare me for the challenging work and pace of residency.’ - ‘I really liked the PBL learning environment of breaking down and dissecting cases in a collaborative format.’ - ‘It was also helpful to have simulation sessions for leading a code or sepsis … compared to some of my co-residents, I feel more comfortable performing these.’ - ‘Practicing difficult conversations and delivering bad news in a safe environment helped me feel much more comfortable doing so in residency.’

Table

Family Medicine Resident	- ‘It is hard to think of an idea for what should be added or improved, as I feel more prepared for residency than my peers.’
Internal Medicine Resident	- ‘Medical education is a huge component of being an academic physician…I had wished that in my 3rd year I had more opportunities to teach.’
Obstetrics & Gynecology Resident	- ‘I think the program could flesh out more about what it means to have a primary care medical school on a campus that is very specialized.’
Pediatric Resident	- ‘I think having more experiences in clinics that serve underserved communities would be beneficial to further cultivating health system leaders.’

Table 2. Strengths, weaknesses, opportunities and threats analysis.

Strengths	Weaknesses	Opportunities	Threats
Intentional design to support student primary care interest	Speed of Learning/accelerated program	Collaboration across the system	Regulatory Changes in GME
Integration of longitudinal course and PBL	Limited exposure to underserved communities	Strengthening local Primary Care Workforce and residency program	Increasing complexity of the patient population requiring redesign of primary care
Tuition Free	Current health systems focus on tertiary versus primary care	Faculty Development in population-based cares and health systems science	Increasing faculty and healthcare provider burnout

Table

Longitudinal Themes & Tags
Access to Care (ATC)	End of Life Care (ELC)	Human Sexuality (SEX)	Opioid Epidemic (OPI)
Acute Care (ACC)	Ethics (ETH)	Identifying and Providing Solutions for Health Disparities (SOL)	Pain Management (PMG)
Adolescent Medicine (ADM)	Evidence Based Medicine (EBM)	Introduction to Clinical Medicine to the Patient (ICX)	Palliative Care (PAL)
Aging Population (AGP)	Genetics (GEX)	Law and Medicine (LAW)	Problem Based Learning (PBL)
Biomedical Informatics (BII)	Global Health Issues (GHI)	Medical Socioeconomics (MSF)	Radiology (RDG)
Chronic Care (CHC)	Healthcare Delivery Structure and Processes (HDP)	Medication Management and Compliance (MMC)	Rehabilitative Care (RHB)
Complementary Alternative (CAM)	Healthcare Policy (HCP)	Meeting the Healthcare Needs of Medically Underserved Populations (MUP)	Scientific and Ethical Principles of Translational Research (ETR)
Continuity of Care/Primary Care (CPC)	Healthcare Quality and Effectiveness (HQE)	Nutrition (NUT)	Scientific Methods (SCM)
Cultural Competence (CCP)	Health Promotion/Wellness (HPW)	Obesity (OBS)
Determinants of Health (DOH)	Human Development/Life Cycle (HDV)	Oncology (ONC)

Table

GQ Domain	NYU GLISOM 2022 (50–90% Benchmark, N = 152 Schools)	NYU GLISOM 2023 (50–90% Benchmark, N = 153 Schools)
Overall, I am satisfied with the quality of my medical education	100.0** (90.4–95.7)	95.5* (89.8–95.7)
Biostatistics & Epidemiology (Longitudinal Course Domain)	89.5** (71.0–85.3)	72.7 (74.1–85.3)
Behavior Science (Longitudinal Course Domain)	100.0** (89.3–94.4)	95.5* (91.0–95.7)
I have the communication skills necessary to interact with patients and health professionals.	100.0** (98.6–100)	100.0** (98.7–100)
I have basic skills in clinical decision making and the application of evidence-based information to medical practice.	100.0** (95.5–98.6)	100.0** (96.3–98.8)
I have a fundamental understanding of the issues in the social sciences of medicine (e.g., ethics, humanism, professionalism, organization and structure of the health care system).	100.0** (95.1–98.6)	95.5 (95.8–98.7)
I understand the ethical and professional values that are expected of the profession.	100.0** (98.1–100)	100.0** (98.3–100)
I believe I am adequately prepared to care for patients from different backgrounds.	100.0** (95.2–99.0)	100.0** (96.5–99.0)
I have the skills to apply the principles of high value care (e.g., quality, safety, cost) in medical decision-making.	100.0** (83–91.2)	90.9* (85.9–92.3)
I have the skills to address the social determinants that differentially influence the health status of patients.	100.0** (90.3–96.4)	95.5* (92.2–96.5)
My medical school has done a good job of fostering and nurturing my development as a person.	100.0** (70.5–83.6)	86.4** (71.3–83.9)
My medical school has done a good job of fostering and nurturing my development as a physician.	100.0** (92.1–96.8)	95.5* (92.4–97)

**Indicates above 90^th percentile; *Indicates above 75^th percentile.

Gonzalo JD, Dekhtyar M, Starr SR, et al. Health systems science curricula in undergraduate medical education: identifying and defining a potential curricular framework. Acad Med. 2017 Jan;92(1):123–131. doi: 10.1097/ACM.0000000000001177

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