Competency-based and less time-bound: a new approach to the macro-structure of a medical school curriculum

ABSTRACT

Shifting to a competency-based (CBME) and not time-bound curricular structure is challenging in the undergraduate medical education (UME) setting for a number of reasons. There are few examples of broad scale CBME-driven interventions that make the UME program less time-bound. However, given the range of student ability and varying speed of acquisition of competencies, this is an area in need of focus. This paper describes a model that uses the macro structure of a UME program to make UME curricula less time-bound, and driven more by student competency acquisition and individual student goals. The 3 + 1 curricular model was derived from the mission of the school, and includes a 3-year core curriculum that all students complete and an individualized phase. Students have an 18 month individualized educational program that meets their developmental needs and their educational and professional goals. This is achieved through a highly structured advising system, including the creation of an Individualized Learning Plan, driven by specific goals and targeted Entrustable Professional Activities (EPA). Students who struggle in achieving core competencies can use individualized time to support competency development and EPA acquisition. For students who have mastered core competencies, options include obtaining a masters degree, clinical immersion, research, and community-based experiences. Students can also graduate after the 3-year core curriculum, and enter residency one year early. Structural approaches such as this may contribute to the norming of the developmental nature of medical education, and can advance culture and systems that support CBME implementation at the UME level.

KEYWORDS:

• Competency-based medical education
• undergraduate medical education
• individualized education
• accelerated pathways in medical education
• curricular design

Introduction/problem

Shifting to a competency-based and not time-bound curricular structure is challenging within undergraduate medical education (UME) given the scale of class size and fixed aspects of UME, such as the timing and nature of the residency selection process. A few schools have created small-scale programs for students applying in selected fields to accelerate their UME curriculum and enter residency earlier [1–3]. Even fewer are trying to create school-wide infrastructure to flex the length of courses and clerkships based on student achievement of competency [4,5]. Few, if any, schools have created non time-bound UME training on a broad scale. However, given the range of student ability and varying rate of acquisition of competencies, this is an area in need of focus, both to support students who need more time to achieve competencies and those who achieve competencies quickly and can therefore progress farther during medical school [6]. The structure of our educational program aims to make UME curricula less time-bound, and driven more by student competency acquisition and individual goals.

Approach/intervention

As a new medical school, we embraced the opportunity to build a mission-driven school [7]. This informed the what (content), the how (instructional methods), and the structure of the educational program and school. During initial development, we identified key societal problems we aimed to address. This included challenges the United States faces in health outcomes and health equity, as well as educational and healthcare workforce issues. Given the cost of medical education and student debt-burden, particularly on students from backgrounds underrepresented in medicine, we focused on the macro-structure of our educational program. Additionally, we set a high target-level competency for our learners in clinical reasoning and clinical skills. We noted that students acquire competency at developmentally different rates. Many are able and driven to achieve more in four years than simply core content, while other students need more than the allotted time to achieve required competencies.

These considerations led to the 3 + 1 macro-structure of our curriculum, including a generally 3 year core-curriculum that all students complete (Phases 1 and 2) and an individualized Phase 3, as seen in Figures 1–3. Combined with the individualized final 6 months of Phase 2, students have an 18 month individualized educational program. These are developed through a highly structured advising system and the creation of an Individualized Learning Plan (ILP) for each student. Students work with their advisors and faculty mentors from the beginning of the UME curriculum to build a program that meets their educational and professional goals and their developmental needs. Each student’s ILP is driven by specific goals and targeted Entrustable Professional Activities (EPAs) [8] from our 18 EPAs (13 from the Core EPA Pilot and 5 developed internally). Students who struggle in achieving competencies within Phases 1 and/or 2 can use Phase 3 time at the relevant time for curricular experiences to support competency development and EPA acquisition. This includes additional time to complete courses/clerkships, clinical skills intensives to remediate deficiencies, and time to build metacognitive academic and clinical skills.

Figure 1. Overall HMSOM curriculum.

All students complete the same core curriculum in Phases 1 and 2. The last part of Phase 2 (Advanced Clinical Rotations) and Phase 3 are individualized to meet each student’s educational and professional goals and developmental needs.

Figure 2. Phase 1 (pre-clerkship) Curriculum.

Figure 3. Phase 2 Curriculum.

For students who have mastered core competencies, Phase 3 options include masters degrees, clinical immersion, intensive research, and community-based projects. Students can also graduate after the 3-year core curriculum, and enter residency one year early, generally within the Hackensack Meridian Health System. Likewise, if a student needs a significant amount of additional time to achieve their core competencies, they can extend their enrollment past 4 years at minimal cost. Table 1 provides descriptions of Phase 3 educational activities.

Table 1. Examples of educational activities within each category of phase 3 (individualized) portion of the Hackensack Meridian School of Medicine curriculum.

Graduate programs	Clinical experiences	Research	Community	Medical education, health systems science, other	Foundational competency development
Institutions: − Seton Hall University − Thomas Jefferson University − Stevens Institute of Technology	− All medical specialties − Across Hackensack Meridian Health network − Outpatient, inpatient, critical care settings	− Basic science/bench − Translational − Clinical − Population Health − Medical Education − Community- based	− Education − Public health − Research − Advocacy − Government/municipalities − Service learning − Pathway programs	− Curriculum development − Medical education research − Teaching − Health systems and leadership − Information sciences − Business and medicine	− Clinical skills intensives to reinforce/develop competencies and EPAs − Development of metacognitive academic and clinical skills
Degrees: − MS − MPH − MBA − MA − Graduate certificates	− 3–4 month specialty immersions − 2 and 4 week block electives − Part time longitudinal electives	− Full-time intensive − Part-time longitudinal	− Full-time intensive − Part-time longitudinal	− Full-time intensive − Part-time longitudinal	− Individualized programs − Various structures
Examples of disciplines: − Public health − Law − Biomedical engineering − Global Health − Healthcare administration − Basic sciences − Population health − Religious studies	− Sub-internship level expectations and experiences − Residency preparation − Broad clinical exposure − Driven by EPAs	− Student initiated research projects − Faculty principal investigator driven projects − Dean’s research awards	− Student proposed projects − Extension of student Human Dimension capstone projects − Collaboration with community partners − Integration with the health system	− Student proposed projects − Scholarship and research − Integration with the health system − Collaboration with industry	− Coaching − Goal setting process driven by EPAs − Metacognitive skill development linked to professional identity formation − Clinical work − Academic support − Advising and mentorship

The scale of UME, as compared to Graduate Medical Education, makes the separation of competency-acquisition from time challenging. Medical school class sizes of 100–200 are orders of magnitude larger than a typical residency class. Our approach enables us to individualize the UME program for each student in our class of 165, releasing us from the traditional time-bound and fixed nature of UME. In addition to providing needed time and experiences to students who have not yet mastered core competencies, this also enables us to support students who are able to achieve more within their 4 years of medical school. They can graduate with 2 degrees, complete an intensive 12–18 month project, or accelerate their graduation and enter residency after 3 years.

Outcomes

To date, two cohorts have completed all Phases of the curriculum. Each student created and completed their individualized plan. These plans included various combinations of types of educational activities; students are able to participate in more than one activity at a time. For example, a student can complete a research project that they work on part time for 10 months, while during that time they complete clinical rotations. In the most recent cohort, 32% of students graduated after 3 years (range of all classes to date 18–32%). For students who stayed for the fourth year, of the total amount of curricular activities completed, 55.3% were clinical, 22.4% were research, 8.5% were graduate programs, 4.9% were foundational competency development, and 8.9% were medical education, Health Systems Science, community, and other. Table 2 shows examples of student’s schedules from different curricular paths.

Table 2. Individualization Phase. This includes the final 6 months of Phase 2 and all of Phase 3. Shown here are examples of student schedules in different types of individualized programs. The specialty the student is going into is shown in parentheses. Note that the length of rotations varies; therefore, the table only shows the components and sequence of the curricular activities. For longitudinal experiences students are able to combine two different activities, shown here within a block separated by a slash.

Clinical immersion (Surgery)	Graduate after 3 years (Family medicine)	MBA (Neurology)	Community-based project (Pediatrics)	Foundational competency development (Internal medicine)
Sub-internship – surgery	Sub-internship – family medicine	Sub-internship – internal medicine	Critical care selective – neonatal intensive care unit	Core clerkship
Anesthesia elective	Critical care selective – cardiac care unit	Neurology elective	Sub-internship – pediatrics	Core clerkship
Critical care selective – surgical intensive care unit	Endocrinology elective	Critical care selective – neurologic critical care unit	Pediatric infectious disease elective	Metacognition course
Vascular surgery elective	Family medicine elective	Rheumatology elective	Maternal fetal medicine elective
General surgery elective	Psychiatry elective	Psychiatry elective	Community-based project	Sub-internship – Internal medicine
Pathology elective/research	Begin residency	MBA	Community-based project	Critical care selective – medical intensive care unit
Radiology elective/research				Outpatient internal medicine elective
Research/residency interviews		MBA/residency interviews	Community-based project/residency interviews	Residency interviews
				Gastroenterology elective
			Community-based project
		MBA		Health systems science elective
Medical education curriculum development elective			Psychiatry elective	Family medicine elective
Surgery specialty immersion		MBA/radiology elective	Family medicine integrative health elective	Psychiatry elective
		MBA/neurology elective	Adolescent health elective	Cardiology elective
		MBA	Gastroenterology elective	Infectious diseases elective
Emergency medicine elective			Pediatric emergency medicine elective	Neurology elective
Prep for residency		MBA/prep for residency	Physician leadership elective/prep for residency	Radiology elective/prep for residency

Discussion: next steps and lessons learned

As our class size reaches steady state, we continue to build out and scale up processes for advising and ILP plan review and approval. This requires a robust team of advisors, faculty, and staff, and integrated systems. Data systems and reporting are critical to the success of the program.

A percentage of the class utilizes some portion of Phase 3 to achieve core competencies of Phase 1 and/or 2. This has necessitated the development of significant curricular structures to support students on alternate schedules to ensure they are identified, supported, and provided with feedback and experiences that enable their success.

A further challenge relates to the conflicting goals that UME educators strive for: (1) building competent physicians using a mastery approach including the sharing and integration of feedback and (2) differentiating students for residency application. This conflict will continue to obstruct the full implementation of CBME within UME. However, our structural approach may contribute to the norming of the developmental nature of medical education, and the fact that students will achieve goals (both core required and advanced) at different rates. The medical education community needs to build the systems and culture to support this important effort.

Acknowledgment

The authors wish to thank the faculty, staff, and students of the Hackensack Meridian School of Medicine.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The authors have no funding sources to report and no competing interests to declare that are relevant to the content of this article.