A new approach to bridging content gaps in the clinical curriculum

Abstract

Background: In 2004–05 Tulane University School of Medicine implemented a longitudinal Interdisciplinary Seminar Series composed of small-group interactive exercises to address topics that are often overlooked during the clinical education of medical students. The series utilizes five adult learning principles.

Methods: Each of 13 seminars is offered at a fixed time slot, repeated two to six times per year. Students are required to attend a minimum of five seminars, of their choice, during years three and four. Students access an online pre-enrollment system that maximizes learning opportunities by limiting the number of participants. Seminars emphasize active learning with small-group problem-solving exercises and multiple interactive techniques. Clinical vignettes, standardized patients, journal articles, and case-based learning are among the learning methods.

Results: Seminar evaluations showed strong support in program content and effectiveness (mean = 4.47 on a five-point scale), facilitators (4.63), and learning opportunities (4.51). Additionally, students strongly endorsed individual seminars to classmates (4.47). Twelve of 13 (92%) seminars received scores higher than 4.0 for program content and effectiveness, facilitators and learning opportunities.

Conclusions: The Interdisciplinary Seminar Series has been a valuable addition to the Tulane clinical curriculum. Students report that the success of the series is due to: (a) their ability to select seminars based on their individualized interests and needs; and (b) faculty development of student-centered seminars with active learning opportunities. This Seminar Series differs from interclerkship initiatives at other medical schools where topics are offered less frequently and to a class as a whole. Tulane's program is a longitudinal intervention with multiple opportunities for student participation during their clinical education. Seminars are repeated to allow greater flexibility in student scheduling. Seminar discussions are rich in content since attendees include both third- and fourth-year students with variable levels of clinical skills and experiences.

Introduction

Traditional medical education provides essential patient interactions during the clinical years for students to develop knowledge, skills and attitudes for patient care. However, many critical topics (e.g. complex issues at the end of life) may be addressed inadequately by individual clerkships. Given the limited time available for medical student training in any one specialty, it is often difficult to address topics that are not specific to individual disciplines, even though these topics are vitally important in modern healthcare. As a result, the clinical curriculum may have significant content gaps if additional learning opportunities are not provided.

Medical schools have begun to develop innovative approaches to teach topics important to the clinical curriculum that may not represent core content within individual specialties. Concentrated periods of time have been established that typically fall between clerkships (interclerkships) to address these topics in the clinical curriculum. The University of Massachusetts Medical School reported on the organization and efficacy of a variety of one- or two-day interclerkships: environment and health Rest et al. (1997), hunger and malnutrition Cardasis et al. (1998), domestic violence Jonassen et al. (1999), genetic testing and ethics Demmer et al. (2001), end-of-life care Clay et al. (2001), multiculturalism Godkin et al. (2002), and substance abuse Matthews et al. (2002). Similarly, the University of California San Francisco Medical School has implemented three one-week intersessions on evidence-based medicine, ethics, health systems, advances in science affecting clinical practice, and professional development Fenton et al. (2002). Finally, Creighton University School of Medicine recently reported on a series of two-day interclerkships addressing evidence-based medicine, sexuality in clinical medicine, professionalism, cultural sensitivity/awareness, complementary and alternative medicine, bioterrorism, and clinical ethics Sakowski et al. (2005). Earlier UCLA introduced a longitudinal, multidisciplinary third-year course that included a small-group component in which underrepresented topics such as ethics, domestic violence and nutrition were addressed through the use of standardized patients Slavin et al. (1995).

Table

Practice points
•In the Interdisciplinary Seminar Series students learn about many critical topics inadequately addressed in the traditional medical student curriculum.
•The Interdisciplinary Seminar Series was constructed on the basis of adult learning principles: creation of a supportive learning environment, inclusion of active learning strategies, emphasis on problem-centered learning, focusing on past learner experiences, and ample opportunity for feedback.
•Students have numerous scheduling opportunities to select from 13 seminar topics that match their clinical interests and self-perceived deficiencies.
•Students appreciate the interactive nature of seminar programs and rate the Series highly on program content and effectiveness, facilitators, learning opportunities, and recommendation to classmates.
•The Interdisciplinary Seminar Series was implemented with reasonable annual costs, largely for personnel support, and benefited from the voluntary contribution of faculty time.

Medical educators at these four medical schools suggest that the effectiveness of interclerkships or intersessions can be attributed largely to two factors: (a) an emphasis on small-group, interactive learning and (b) opportunities for students to relate their recent patient experiences to the conference topic. In contrast to the interclerkship model, Tulane University School of Medicine has pioneered a unique approach to address ‘neglected’ topics by creating a longitudinal seminar series.

In 2004–05, Tulane introduced broad reforms to the clinical curriculum (Figure 1), creating new two- and four-week clerkships. Students are now allowed great flexibility in scheduling clerkships during years 3 and 4, thus creating an individualized clinical continuum. The new curriculum encourages students to schedule electives in year 3. In addition, a longitudinal interdisciplinary seminar series was created to address topics that commonly fall ‘between’ clerkships (topics that cannot be confined to individual patients or specific specialties). The Interdisciplinary Seminar Series augments the content of the new clinical curriculum model and utilizes five adult learning principles often cited in the literature: (1) creation of a supportive learning environment, (2) inclusion of active learning strategies, (3) emphasis on problem-centered learning, (4) focusing on past learner experiences, and (5) ample opportunity for feedback (e.g. Cross 1981; Knowles et al. 1984; Resnick 1987; Mezirow et al. 1990; Merriam 1996; Merriam & Caffarella 1999).

Figure 1. Prior and New Curriculum Models at Tulane University of Medicine.

Description

The Interdisciplinary Seminar Series was created to address those topics that are relevant to patient care, but may not be fully addressed in the typical discipline-based clinical curriculum model. Based on feedback from a clinical curriculum retreat, initial seminar topics were identified for development. Subsequently, an Interdisciplinary Seminar Series Committee, which comprised both faculty and students, was formed. The Committee agreed that each seminar would emphasize active learning opportunities for students, with lecture time limited to 20–30 minutes followed by a 2.5 hour period of small-group problem-solving exercises utilizing multiple interactive learning techniques. Clinical vignettes, standardized patients, journal articles, case-based learning and other approaches are used to enhance student involvement and discussion. These small-group exercises promote active learning and are related to students’ clinical and life experiences. Additional topics are generated through student and faculty suggestions and are approved by the Committee. The ideal seminar involves faculty from multiple disciplines working together to develop a program that addresses the proposed topic in an interactive fashion. Community-based resources and organizations are also used to augment seminar topics.

Each seminar is offered at one of several fixed time slots, repeated two to six times per year. Students are required to attend a minimum of five seminars, of their choice, during years three and four. Students access an online pre-enrollment system that limits attendance in order to maximize learning opportunities for individual students. Thirteen seminars are currently offered including: Appropriate Antibiotic Use, Negotiating Complex Issues at the End of Life, Ethics, Evidence Based Medicine, Gay/Lesbian/Transgender Issues, Geriatrics, Grief, History of Medical Specialization, Medical Emergency Preparedness, Medical Malpractice, Medical-Legal Communication, Critical Incidents, and Palliative Care. Seminars currently in development include Organ Procurement/Donation, Domestic Violence, Principles of Medical Practice, Cultural Competency, Professionalism, Art of Communication, Breastfeeding, and Illicit Drug Use/Toxicology.

Evaluation

Tulane's Office of Medical Education evaluates the Interdisciplinary Seminar Series. Immediately following each seminar, a 10-question anonymous survey divided into three domains and utilizing a five-point Likert scale is administered to all participants. Written comments are also solicited with open-ended questions. All seminar leaders receive a complete report of student feedback within 24 hours of presentation.

Student ratings were obtained from 351 students attending a total of 37 seminars and are given in Table 1. Support for the seminars was strong in the three domains assessed via the exit survey: seminar content and effectiveness (4.47), seminar facilitators (4.63), and learning opportunities (4.51). Additionally, students were asked whether they would recommend the seminar to fellow classmates, and again seminar approval rating was high, receiving a score of 4.47. Evaluations showed strong support for Interdisciplinary Seminar Series programs with 12 of 13 (92%) receiving scores higher than 4.0 for all three domains assessed (program content and effectiveness, facilitators, and learning opportunities).

Table 1.  Interdisciplinary Seminar Series: mean ratings (1 = low; 5 = high)

Program	Student n	Program content and effectiveness	Facilitators	Learning opportunity
Critical Incidents	15	4.49	4.87	4.69
Ethics	38	4.59	4.76	4.72
Evidence Based Medicine—Therapy	27	4.79	4.93	4.69
Geriatrics	11	4.82	5.00	4.94
Grief	38	4.19	4.47	4.20
History of Specialization	9	4.22	4.56	4.44
Hospice/Palliative Care/Pain Management	24	4.64	4.75	4.44
Judicious Use of Antibiotics	26	4.34	4.58	4.58
Medical Emergency Preparedness	45	3.56	3.64	3.61
Medical Malpractice	48	4.78	4.88	4.71
Medical/Legal Communications	7	4.66	4.86	4.76
Negotiating Complex Issues at the End of Life	36	4.87	4.92	4.93
Sexuality/Gay, Lesbian, Transgender Issues	27	4.67	4.81	4.68
Total	351	4.47	4.63	4.51

Open-ended questions provide recommendations for improvement and highlight areas that contribute significantly to the learning experience. Open-ended questions are also used to solicit topics from the students for future seminar development. Representative student replies to the open-ended question, ‘What did you like best about this seminar?’ include:

It was a chance to talk about issues that don’t really get covered anywhere else.

Very useful information for clinical interactions.

Awesome—multidisciplinary—this is great.

Made me consider topics I hadn’t.

Sharing our stories was great because we realized that we’ve all had the same experiences.

The fact that we actually experience this with real patients. This is much better than just listening to someone lecture. It was great!

Best seminar I’ve been to yet—everyone should have an opportunity to take this. Made us feel like we were the patient population!

Excellent seminar. Very good use of different teaching modes—PowerPoint, video, small group exercises, hand-on examples. One of the best seminars I’ve been involved with. Interesting and informative. Was very, very good.

In the future seminar leaders will be asked to develop pre-test and post-test assessment instruments with the assistance of the Office of Medical Education to measure the impact of individual seminars on the students’ knowledge, attitudes and behaviors.

Discussion

The newly implemented longitudinal Interdisciplinary Seminar Series has been a strong addition to the Tulane clinical curriculum. Students report that the success of the Seminar Series is due to: (a) their ability to select seminars based on their individualized interests and needs; and (b) faculty development of student-centered seminars with active learning opportunities.

As students develop professionally, they recognize knowledge deficits through patient interactions and clinical encounters; these self-perceived deficiencies may evolve on a daily, weekly or monthly basis. The Seminar Series allows students to participate in an active learning environment to fill these self-identified gaps in knowledge without waiting for an annual or single fixed learning opportunity. Elective scheduling of seminars provides an opportunity for students to address self-perceived deficits in clinical knowledge and more generally adds to the richness of the Tulane curriculum. Students also have significant input into the evolution of the seminar series as topics they suggest are developed and implemented. Several seminars now in development (e.g. Organ Procurement/Donation, Breastfeeding) escaped faculty recognition but were identified by students as valuable offerings.

While student self-selection of individual programs is at the core of the Interdisciplinary Seminar Series, some medical educators view this aspect of adult learning as ‘mythical’ Norman (1999). It is argued that prescribed and pressurized learning environments inhibit true self-assessment, and hence self-selection skills. Consequently, medical students may not be capable of choosing educational programs that enhance their development. Others propose that learners in medical education may have to achieve a balance between training requirements and innate interests Cassidy (2004). In our study support for the self-selection and personal interest components of adult learning comes only from qualitative data (i.e. student written comments) but is compelling.

The Interdisciplinary Seminar Series could easily be adapted by other institutions, with recognition of the importance of faculty and student input in generating and developing seminar topics. By coordinating its existing curriculum with the perceived needs of students, a medical school can produce an interdisciplinary seminar series that both complements and augments the medical student's learning experience. As with many curricular innovations, cost is always a concern. For the academic year 2004–05 financial support for the Interdisciplinary Seminar Series at Tulane required less than US$10,000. Major expenses were for personnel—i.e. funding of standardized patients, a stipend for the Series faculty director, and support for a staff coordinator. Fortunately, professional interest in gaining visibility for often ‘neglected’ topics has led to the voluntary contribution of faculty time to the Seminar Series.

This Seminar Series differs from interclerkship initiatives at other medical schools. Program topics at other institutions are offered less frequently and to a single class in the clinical years during an interclerkship period. Tulane's program is a longitudinal intervention with multiple opportunities for student participation throughout the third and fourth years of their clinical education. Seminars are repeated to allow greater flexibility in student scheduling. Seminar discussions are rich in content since attendees include both third- and fourth-year students with variable levels of clinical skills and experiences.

At least two limitations to our report on the Interdisciplinary Seminar Series should be acknowledged. First, to our knowledge the longitudinal model has only been implemented at Tulane, and there has been no comparison between the longitudinal and interclerkship approaches. Thus, whether the two approaches are equal or different in learning effectiveness remains to be assessed. Second, student accomplishment of specific educational objectives has not been measured and is a major challenge to effective student assessment and sound program evaluation of the Seminar Series.

Tulane University School of Medicine has implemented an innovative approach to addressing important topics that are easily overlooked in clinical education. Utilizing the principles of adult learning, the Interdisciplinary Seminar Series creates a learner-centered educational experience that has been an important addition to students’ clinical education. Evaluation of this program has demonstrated that students have found this experience to be a valuable learning opportunity. Tulane's new Interdisciplinary Seminar Series provides an excellent model for bridging content gaps in the clinical curriculum.