As someone who oversees education and curriculum at Southern Illinois University (SIU) School of Medicine, Senior Associate Dean Debra Klamen thought her school was adequately preparing students with what it takes to be good doctors. But after taking a hard look at her school’s model of education, the standard approach used by most medical schools in the country, she and her colleagues concluded that the crucial third year of medical school was broken. Their research revealed that one of the primary goals of the third year—improving clinical reasoning—was not being realized.
Over the course of their third year, medical students go through a series of six or seven rotations. These clerkship rotations, interspersed with classroom lectures, are intended to give students practical experience and achieve three main goals:
- Socialize students into medicine so they become familiar with what a medical setting is like.
- Help students determine the specialty they would like to pursue.
- Improve students’ clinical reasoning, the process by which clinicians take in information about a patient and their medical situation, diagnose the problem, implement a treatment plan and evaluate the outcomes.
Beyond these overarching goals, the six core clerkships that students rotate through (internal medicine, pediatrics, surgery, psychiatry, family medicine, and obstetrics-gynecology) each have more than 100 goals and objectives recommended by their educational bodies. The SIU analysis found there was a gap between the expectations for third-year students and the reality of what they were learning in clinical reasoning. So, with a grant from the Macy Foundation, they set out to drastically reform their approach.
The New Approach
First, to help students improve their clinical reasoning even before reaching their third-year clerkships, Dr. Klamen and her team created an online Critical Clinical Competency (CCC) program with high-quality videos. While the videos walk students through an exam and diagnosis, the students generate their own list of differential diagnoses based on what they see and compare them to a panel of three physicians. Since we last wrote about this innovative approach to clinical reasoning, the school has now made the cases available online, and medical schools in the United States and abroad have begun to use the online portal.
But this was just the beginning. SIU changed the third-year rotations to eight specialties over eight months, adding emergency medicine and neurology to the typical specialties mentioned above. They cut out classroom lectures entirely and did away with the traditional multiple-choice exams at the end of each rotation. In place of this assessment, students are graded by a faculty member linked to them for their entire four-week rotation. They even created an app for faculty to give students feedback on-the-fly. This data is summarized and goes back to the clerkship director who, along with other members of the clerkship committee, assigns a pass or fail grade.
Following their rotations, students debrief on their clerkships in a one-week medical humanities rotation. They then take the Summative Clinical Competency Exam (SCCX), a three-day, 14-station practical exam that SIU moved from the fourth year to the third. For the rest of the year, students, in consultation with their clerkship advisor, create their Personalized Education Plan (PEP). The PEP is an individually designed curriculum based on the students’ interests and needs. For instance, a student interested in surgery but unsure of the specialty could rotate through 15 weeks of different surgical specialties. A student who is torn between family medicine or emergency medicine could do half of one and half of the other. A student who needs to further improve their clinical reasoning could do a three-week clinical remediation course. All throughout, the student meets with their advisor to track their progress and receive feedback and coaching.
Shifting from Assessment to Coaching
Shifting the emphasis from grading to coaching was a fundamental change that had a significant impact on students as well as faculty. The SIU team discovered that the assessment model was outdated and failing both students and faculty because it didn’t allow for the provision of real-time feedback that can help students improve. It was also impractical given the limited time faculty had to spend with students during their rotations. “It was not uncommon for faculty to need pictures of recently supervised students in order to remember who they were when it came time to assign the final grade,” said Dr. Klamen. “This fact helped in convincing some skeptical faculty members that a better approach was needed.”
Moving to a greater focus on coaching has also empowered students. To help faculty be better coaches, the student-organized Medical Education Interest Group at SIU developed a student-led coachability workshop to train students to be more coachable. Fourth-year students lead their second- and first-year peers through discussions, exercises, and role-playing scenarios to teach students how to ask for feedback, how to use feedback effectively, and how to make the most of their coaching relationship with their clerkship advisor. They also incorporated discussions of emotional intelligence as well as lessons from the corporate world on goal setting using SMART goals (Specific, Measurable, Attainable, Relevant and Timely).
While this new approach is still very nascent, the initial results are positive. In the SCCX exams, students in the new curriculum model performed at the same levels as those under the previous model despite the exams being moved up six months. Dr. Klamen and her team are optimistic that as more classes go through the new curriculum model, students will eventually score better on the exams. SIU, a relatively small school in the Midwest that only accepts residents of Illinois, has also seen students accepted into residencies at top-tier institutions, including places that had never accepted SIU students previously. Dr. Klamen is sharing what they’ve learned around the country, and close to 50 schools have inquired about the CCC program.
SIU students and faculty also are also embracing the change. Students love the flexibility of the PEP and the shift to coaching. Faculty are better equipped to provide students with the information they need to pass their exams and successfully move on to the next stage of their training. And despite some initial reluctance to give up on lectures entirely, they’ve recognized the impact of this new model. When one faculty member who initially resisted the change saw how students in the new model scored comparably to students in the traditional model, she started questioning the need for her lectures. “When I heard that, I nearly fell on the floor,” said Dr. Klamen. “This was a faculty member who was very attached to lectures.” Dr. Klamen said this faculty member’s response, while anecdotal, further evinced that “we were headed in the right direction.”