News and Commentary Improving the Clinical Reasoning of Medical Students at SIUSOM: Guaranteeing Competency of Graduates

Debra Klamen, MD, MHPE, is the Associate Dean for Education & Curriculum, and Professor and Head, Department of Medical Education at Southern Illinois University School of Medicine in Springfield, Illinois. She is the PI of the Macy project entitled, “Improving the Clinical Reasoning of Medical Students: Guaranteeing Competency of Graduates.”

It’s been almost a year since our project was funded. During that time we have achieved major progress toward the implementation of our new curriculum, and learned some lessons along the way. Ah, but I get ahead of myself, so first I’ll give some context.

We at SIUSOM are reforming our entire curriculum with an emphasis on changes in the clerkship year. With Macy support we are attempting to improve clinical reasoning and critical thinking of medical students by the time of graduation as well as provide a much more flexible, individualized learning plan for students than is currently available. We plan to ensure that all of our students will have the ability to diagnose and initially manage twelve defined critical clinical competencies encompassing 144 separate diagnoses. Indeed, it is going to be an absolute requirement for graduation. We plan to implement a deliberate practice model in which students will practice a subset of these diagnoses in each of years 1-3, paced at the student’s speed of learning. Since this curriculum will be standardized, we will free up the third year to be a more intensive, immersion clinical experience in the first 8 months, with the last 4 months focused on individualizing and optimizing the learning environment in relation to each student’s needs. For example, a student interested in rural health could do a four month rotation in an ambulatory family medicine clinic at a rural site; or a student needing extensive remediation could get it during this time. Thus we hope that in addition to students acquiring a standardized and broad set of competencies, they will have had a richer educational experience. We also hope that this program can then be disseminated to other interested medical schools. To facilitate dissemination, all of the videos (described below) will be available to any school.

Lesson Learned #1: Expect the Unexpected, and Use the Resources You Have
Our first year of funding has been spent working to build a customized online platform to deliver this curricular model to medical students. We needed to create 36 cases to illustrate the CCCs, videotape them using a standardized patient and a faculty member, and videotape a panel of physicians discussing their differential diagnoses and their explicit reasoning. I thought getting the online program built to our specifications would be the most difficult part, and filming the one hour panels would be the least difficult. Boy was I wrong! The online program is almost completely built. Everyone seems to love the platform; students had some very useful suggestions; and we are actually ahead of schedule. Writing the cases proved to be difficult. Even though the faculty said they would help, they never actually wrote any of the cases. I gave fourth year medical students elective credit to write cases, and voila! Although the scheduling of a faculty member to be filmed with a standardized patient was difficult, it was not impossible to do. What has also turned out to be difficult is getting four physicians from different specialties in the same room at the same time to watch and comment on the video. I had no idea that scheduling a single hour could be so hard. Live and learn!

Lesson Learned #2: Culture Change is Hard
As you might imagine, the key to success for this project is a combination of politics, buy-in, and faculty development, with lots and lots of communication. In my favor is that Southern Illinois University School of Medicine was built on the idea that innovation is desirable. However, it is a massive culture change to

  1. shorten all clerkships to 4 weeks apiece;
  2. not allow didactics;
  3. eliminate shelf exams at the end of every clerkship;
  4. create multiple educational modules for the final PEP; and
  5. implement massive faculty development as we move to a coaching model.

This, for clinical faculty, is akin to the change basic scientists had to embrace when switching from lecturers to small group facilitators. Lessons learned include:

  1. Get students on board early, and make sure there are representatives from the student classes in every planning subcommittee.
  2. Encourage early adopters talk about the change whenever the chance comes up.
  3. Keep the Dean informed.
  4. Bring chairs and co-chairs together often and try, as the leader of the change, to attend all subcommittee meetings.
  5. Try to remain positive and don’t burn any bridges, no matter what pot shots may be taken at you by unhappy faculty.
  6. Lean on those around you who are supportive of the change, as well as friends and family. This is a marathon, not a sprint, and it is a huge amount of work!

This has certainly been an interesting journey so far. I have learned a lot about organizational change, and most importantly we have made a great deal of progress toward successful implementation of this curriculum. I am always looking for creative ideas, potential pitfalls, and other thoughts with respect to this project, so please share your ideas in the comments box below.

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