[The following notes were generated by Sandra Haudek, PhD.]

The Spring 2022 IAMSE Webinar Seminar Series, titled “To infinity and Beyond: Expanding the scope of Basic Sciences in Meeting Accreditation standards” continued with its second seminar on Thursday March 10, 2022, titled “The Construction of a Social Medicine Curriculum at the University of Vermont”. In this session, Dr. Timothy Lahey, Professor of Medicine and Director of Ethics at the University of Vermont’s Larner College of Medicine, reviewed principles underlying social medicine, the collaborative design and implementation of a highly interactive preclinical social medicine curriculum including success and challenges encountered, and next steps in social medicine curriculum development.

Dr. Lahey started with stating that physicians need more time and better tools to address social medicine in practice. He mentioned two surveys, one estimated that only 24% of physician practices screen for the five major social determinates of health, the other revealed that although family medicine physicians are deeply concerned about diversity, inclusivity, and equity, most have too little time and inadequate staffing to address social determinates of health. Awareness is a challenge; many publications discuss the importance of social determinates of health and major organizations like AAMC call for enhanced social medicine training. He summarized that social inequity influences health and health care delivery, that not teaching social inequity delivers the message if being unimportant, and that simply knowing inequities exist is inadequate. The goal is to give trainees specific skills, not just awareness.

Dr. Lahey stated that there are several benefits for a medical school to offer a social medicine curriculum: Students will be better prepared for the realities of clinical practice, like risk of illness, access to care likelihood of presentation, quality of care, and access to medications. It will also empower trainees to faster rectification of health inequities (system reform and individual care), and it will be compelling to students who often enter medical school to make a difference. He then confessed that we do not know how the most competent physician should look like, how such competencies are best assessed, what the ideal instructional approach to teach social medicine content is, and what the long-term outcomes will be. Yet practicing physicians are confronted with health inequities far more often than what is tested on USMLE step 1.

Dr. Lahey then explained that he was involved in a social justice curriculum design at Dartmouth’s Geisel School of Medicine but unfortunately left before its implementation [1]. When he started at the University of Vermont, there was a team, faculty and students, already working on a similar curriculum (Social Justice Coalition) [2]. Their institutional strategy was the following: (1) Integration of social medicine material with foundational science content is better than having it segregated apart from other materials. (2) Rich in active learning (discussions, TBL). (3) Curricular change equals QI training for student leaders. (4) Complement service learning.

The Social Justice Coalition team started with terrain mapping by performing needs assessments among patients, students, faculty, and administration. He illustrated the curriculum before intervention which included secrete sections in which ethics, public health, global health, palliative care, and similar were scheduled throughout the 4 years of medical school. Yet feedback from students was not encouraging: “Although SDH content existed, this content was separated from the foundational sciences curriculum in discrete courses, informally assessed, lacked space for critical reflection, had no centralized coordination, and lacked direct clinical integration.” He speculated that many schools have similar issues despite efforts to cover social medicine content.

The Social Justice Coalition team then continued with setting high-level curricular objectives, followed by more specific learning objectives that can be mapped to all the courses and integration with other learning objectives [2]. They then strategically identified appropriate courses across the curriculum in which the social medicine content can be incorporated. The team reached out to course directors to initiate and support this integration. Dr. Lahey gave several examples of topics. He then reviewed the Social Medicine Theme of the Week initiative. This initiative was developed by students, and is lead and taught by students (with faculty oversight). It contained strategically located sessions across the curriculum (mostly linked to foundational content) addressing social medicine themes and providing infographics and links to reading material.

Dr. Lahey illustrated how the curriculum changed after intervention: The courses itself did not change, yet the core social medicine content was distributed throughout the foundational science phase with every week having a theme and offering regular Social Determinates of Health Rounds during the clinical years.

Dr. Lahey then discussed successes and challenges. His team realized that there were numerous curricular points of attachment, yet only few deeply engaged faculty champions. The theme of the week initiative was compelling but fragile since it was run by students and would need durable centralized oversight and linkages to faculty curricular oversight and competencies. Lastly, they noticed a hidden curriculum, meaning topics can be inspiring but also alienating if said in a way that pays lip service. He concludes that the curriculum is continuously driven by circular evaluation, changes, and faculty development. He mentioned several examples of lessons learned based on surveys of first-year medical students and social medicine faculty that included Likert responses and free text input [3]. The survey revealed that most students were aware of the social medicine curriculum, thought the curriculum was helpful, a good variety of topics was addressed (race, sex & gender, LGBTQ, poverty, global health, structural violence), and adequate pedagogy was used, with emphasis on the importance of storytelling. By contrast, the faculty was less aware and engaged. Specifically, faculty asked for more guidance and orientation to the curriculum. He then stated that the team used these data to develop a road map for developing the social determinates of health curriculum.

The presentation lasted about 45 minutes. During the ensuing discussion, Dr. Lahey addressed several questions from the audience, including: How do you measure outcomes? How do you define the difference between public health and social medicine? Do you incorporate other health are providers other than faculty? What type of training was provided to faculty and was this mandatory?

1. Coria at al. Academic Medicine (2013). The design of a medical school social justices curriculum
2. Goyal et al. BMC Medical Education (2021) 21:131. The design and implementation of a longitudinal social medicine curriculum at the University of Vermont’s Larner College of Medicine.
3. Finnie at al. BMC Medical Education (2021) 21:442. A new roadmap for social medicine curriculum design based on mixed methods student and faculty evaluations of the preclinical curriculum.

[The following notes were generated by Sandra Haudek, PhD.]

The Spring 2022 IAMSE Webinar Seminar Series, titled “To infinity and Beyond: Expanding the scope of Basic Sciences in Meeting Accreditation standards” opened on Thursday March 3, 2022. This series continues to explore how basic science education can be leveraged for student success. It expanded upon the traditional roles of basic sciences and ventured into unexplored areas: What is the role of basic science education in (1) interprofessional training, (2) social sciences curricula, (3) service-learning, (4) pre-clerkship integration, (5) and self-directed learning? These domains are cornerstones of medical education and closely align with accreditation elements for the LCME, COCA, and other accreditation bodies within the health professions. The first session in the series was titled “Developing IPE Utilizing Current Simulation Approaches” [IPE = interprofessional education] and was presented by Dr. Brian Mann, EdD, MS, PA-C, Chief of Simulation Operations for Philadelphia College of Osteopathic Medicine. During this session, Dr. Mann explained current terminology used in medical simulation, explained the different technologies used in medical simulation, and presented a curricular process linking simulations to accreditation standards.

Dr. Mann started with emphasizing on the importance of creating objectives using the most appropriate Bloom Taxonomy action verbs, particularly when addressing foundational science content such as anatomy and physiology. Since simulation activities are applications of skills, he advised to use verbs such as analyze, create, and evaluate. He then clarified the meaning of key terms used in simulation: (1) OSCE (Objective Structured Clinical Examination) – Approach to the assessment of clinical and professional competency or performance. OCSE are often related to standardized patient or history taking, but also include task training and other applications including anatomy. (2) Simulation (SIM, a component of the Simulation Activity) – A technique that creates a situation or environment that allows a representation of a real event for the purpose of practicing, evaluating, testing, or just understanding of an action in a safe environment. Simulation needs expert pedagogy from novice to expert level. Evaluations may be part of a simulation. (3)Simulation (SIM) Activity – A set of actions including initiation (pre-briefing), simulation, and debriefing including assessment. One simulation opportunity may include different activities. (4) Standardized Patient – Very well trained actors who simulate an actual patient (cannot be distinguished from real patients), including body language, anxiety and metal state levels, give limited information, emotionally personality skills. Actors may also provide assessment and verbal feedback to students. (5) High Fidelity Simulator – Mannequins who can mimic high-level human body functions, such as heart and lung sounds, blood pressure, urinating, bleeding, and swelling. (6) Task Trainer – Devises to train elements or procedures, such as starting an IV, performing CPR, suturing, and phlebotomy. Dr. Mann finished this part of his presentation with showing pictures of different simulation settings, explaining that some rooms are set up to manage communication and team work skills rather than clinical skills. He concluded that high fidelity simulator and task trainer models lend themselves to cover foundational science content, only limited by imagination. He also emphasized on the importance of diversity including actors and mannequins of different skin colors, ethnicities, gender, and ages.

Dr. Mann continued with highlighting that simulation activities provide valuable teaching experiences also for foundational sciences. He stressed on the importance of generating goals and objectives that are specific and simple, appropriate for the student’s level. All content should be familiar to students before the simulation activity. He recommended a backwards approach to curriculum design starting from the schools educational learning objectives, to course objectives, so session objectives. IPE competencies should also address competencies required for the particular program by their accrediting body (e.g., from the American Psychological Association) and the four IPE core (sub)-competencies from 2016 as listed: Values and ethics, roles and responsibilities, interprofessional communication (between different groups, families, healthcare professionals), teams and teamwork. If schools collaborate with schools in other countries, those international IPE components should be also addressed. For instance, in Canada one needs to include role clarification, patient/client/family/community-centered care, team functioning, collaborative leadership, interprofessional communication, and interprofessional conflict resolution.

Dr. Mann then provided an example of a learning theory used in medical simulation: Kolb’s Experiential Learning Theory. This theory includes a concrete experience (the simulation experience), reflective observation (debriefing), abstract conceptualization (evaluate each task), and active experimentation (repeat simulation activity ~3 weeks later). Another theory he mentioned but not discussed is the cognitive load theory. He then explored how simulation can be used to develop IPE activities. He encouraged the audience that this is really up to individuals what content or topic they want to address, from clinical situations, to psychological & physiological cases, to foundational sciences, as long as they align to the school’s competencies. The most effective way to integrate simulating is to make sure there is spaced repetition, small amounts of content at a time, and knowledge is covered before application. The biggest challenges are the different schedules between different programs and schools.

The presentation lasted about 40 minutes. During the ensuing 15 min, many questions were discussed: How often do you do simulation during pre-clerkship years and in which courses (2-3 times per semester)? How are OSCEs used for assessment (formative exam in middle, summative at end of semester; emphasis on spaced repetition throughout the semester)? How long is a simulation activity and how many students attend (logistics are difficult but manageable)? Which foundational sciences topics are mostly addressed (physiology is the easiest one, anatomy is easy as well, pathology can also be brought in e.g., taking a biopsy)? What if learners are on different levels (it is hard to make sure all learners from different programs are on the same level – may need a “retraining component”)? How important is debriefing (very important; allow learners to make mistakes and provide chances to do better next time)?