Fostering Collaboration between Undergraduate and Postgraduate Education Directors: An Essential Step to Developing a Continuum of Pediatric Education
Article Outline
An article in Pediatric News challenged the benefit of the senior year of medical school.1 L.D. Britt, MD, MPH, chair of surgery at Eastern Virginia Medical School, stated that “the most wasted year in all medical education is the fourth year of medical school” and eliminating fourth year would decrease student debt burden and make medical school more attractive. The president of the Association of American Medical Colleges, Darrell G. Kirch, MD, noted that some students would benefit from having the fourth year of medical school count as the first year of residency training.
We believe the senior year should be a bridge between the undifferentiated medical student and the focused postgraduate trainee. Management of this bridge year requires collaboration between undergraduate and graduate medical education administrators. Although clerkship directors provide a pediatric curriculum for undifferentiated students going into varied disciplines, residency program directors manage the postgraduate education of future pediatricians. Both have vested interest in making sure undergraduates are well prepared. The Residency Review and Redesign in Pediatrics (R3P) Project has outlined a number of goals for innovation in pediatric education, including the recommendation that pediatric education provide a continuum of learning that begins in medical school.2 Collaboration between clerkship directors and program directors will be critical in creating an effective senior curriculum. Collaboration at a national level has begun to guide this process, resulting in plans for the first joint meeting between the Council on Medical Student Education in Pediatrics (COMSEP) and the Association of Pediatric Residency Program Directors (APPD) in May 2009. The COMSEP and APPD Curriculum Task Forces have been collaborating on development of a senior curriculum. These conversations need to occur at the local institutional level as well.
Two years ago at the Medical College of Georgia, we began discussions to improve the fourth year curriculum for students planning a career in pediatrics. This has resulted in a stronger collaboration between the pediatric clerkship director (who has responsibility for both third and fourth year student pediatric rotations) and the pediatric residency program director. We present a review of the senior year curriculum at our institution, our efforts to define expectations for entering pediatric interns, and the changes we made in the curriculum to begin integrating the fourth year of medical school into the continuum of pediatric education. We also outline lessons learned in this process and highlight questions that we believe need to be addressed as COMSEP and APPD move forward with national efforts in this area.
We believe the senior year can serve an important purpose within the continuum of pediatric education, but we must provide more direction. The traditional unstructured senior year curriculum was often developed to achieve short-term goals without considering long-term educational objectives. Other than completing graduation requirements, students took electives for many reasons: to secure letters of recommendation, to “mock interview” during an away rotation, to have an easy schedule, or to explore interests. At the Medical College of Georgia, we have attempted to create a senior curriculum for pediatrics that allows students to explore interests while gaining knowledge and skills to prepare them for postgraduate training.
We began our senior curriculum design with a review of competency expectations for post-graduate trainees focusing on the knowledge and skills we expect trainees to have on day one. Focus groups with first and second year post-graduate trainees gave us insight for what students need to be prepared during internship. The first phase of our senior curriculum design began with restructuring the substitute internships by adding a portfolio and a requirement for documentation of direct observation of written notes, orders, and physical examination skills with a pre-defined checklist. The portfolio is a web-based document that encourages goal-setting and self-reflection about learning styles, challenging situations, and areas for continued improvement. Our hope is that mastery of these skills will allow students to advance further along during post-graduate training.
The second phase of our senior curriculum design improved the overall senior year experience for students going into pediatrics by facilitating group meetings with students and their advisors and beginning a small group discussion series. “This is the beginning of your pediatric career,” begins our first group meeting with students going into pediatrics, in which we discuss the senior curriculum and give advice about electives, curriculum vitae, personal statements, and applying to residency programs. Although many students going into pediatrics would prefer it, we do not advise taking all pediatric electives during senior year. Electives should be scheduled intentionally for one of the following reasons: 1) to fulfill a graduation requirement, 2) to strengthen areas of weakness, 3) to supplement experiences they will have during residency, or 4) to explore an area of interest. For example, senior students in our institution must fulfill graduation requirements by taking electives in a substitute internship, critical care, emergency medicine, and ambulatory care. Students who performed poorly in renal physiology and dislike nephrology may benefit from taking an elective in nephrology to conquer their weakness, just as a student planning a career in pediatric critical care may benefit from an elective in pediatric surgery, respiratory care, or radiology. Students may also enjoy the opportunity to take an elective abroad to explore interests and provide services they may not have time for during residency. Students are encouraged to plan their senior electives with guidance from their faculty advisor with their long-term goals in mind. We meet with the advisors before the group meeting to review the senior curriculum and our recommendations. Two additional advisor/advisee meetings focus on interviewing and the match process.
The small-group discussion series is open to pediatric advisees and students taking pediatric electives. Topics include ethical dilemmas, prioritization and organization, teaching skills, feedback/evaluation, nutrition, pediatric resuscitation skills, and night-call problems such as dehydration, shock, respiratory distress, and anaphylaxis. The faculty- or resident-facilitated sessions are interactive and often include cultural or ethical issues.
One challenge was determining the optimal timing for the small group sessions. During the first year, we offered the sessions between September and November to minimize interference with interview season. Unfortunately, many of our pediatric advisees were completing graduation requirements off-campus, taking time off to study for USMLE Step 2, or away interviewing. On the basis of feedback and perceived demand, we repeated the series in February and March, but we had poor participation, in part because many seniors had completed their requirements and were no longer on campus. This year we scheduled some sessions in July, but again had poor participation. Most of the sessions conflicted with resident noon-conferences that the students chose to attend. There were also many students rotating off-campus or taking a month off to study for USMLE Step 2. We now schedule the sessions one day per week when the residents are elsewhere. By minimizing conflicts and standardizing the day of week, we have improved participation.
Dedicated faculty time is another challenge to the creation of a senior curriculum. Curriculum planning and implementation require significant time. The clerkship director and residency program director already have responsibility for the clerkship and the residency with the accompanying Liaison Committee for Medical Education (LCME) and Accreditation Council for Graduate Medical Education (ACGME) requirements. Advising students also takes significant time for faculty already stretched by other academic commitments. The senior year activities are an added responsibility, and could be viewed as a burden in light of the financial pressures to produce clinically and academic pressures to produce scholarly work. We are fortunate to have leadership with a strong interest in the continuum of education who are willing to support us professionally.
Another challenge to implementation is the long-standing perception of the senior year being easy. Students may not be as enthusiastic about our changes as we are. The challenge will be to excite medical students about becoming reflective practitioners and intentional in their continuing medical education decisions. Residency programs struggle with getting faculty and resident “buy-in” to the concept of individualized learning plans that are required by the ACGME. We hope that introducing the concept of practice-based learning and improvement during the senior year will ease the transition in residency and gain more support.
Evaluation of curricular change is another area that has challenged us. How does one measure the impact of change? With small numbers of students in each institution and no national senior curriculum (yet), how does one get sufficient numbers to randomize and assess whether a program really makes a difference? How do we integrate what we do with what occurs at other institutions? One of the issues that needs to be addressed nationally is how to measure impact of changes in curriculum. And what exactly are we trying to change? In the short term, we want to prepare students for postgraduate training, but in the long term, we want to impact their pediatric career by creating a cohort of reflective practitioners. The bridge between undergraduate and postgraduate education is the senior year. Developing a continuum of pediatric education beginning in medical school will require collaboration between undergraduate and postgraduate education directors committed to implementing a senior curriculum and answering the inevitable questions and challenges.
References
PII: S0022-3476(08)01138-4
doi:10.1016/j.jpeds.2008.12.027
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