In case you missed yesterday’s Webcast Audio Seminar (WAS) Session, here are the highlights of this session:

Integrating Wellness & Nutrition: Lessons from University of Cincinnati
Presenter: Sian Cotton, PhD
March 22, 12 PM ET

Objectives:

1. Briefly review the crisis of chronic disease and minimal attention to lifestyle education in medical schools and healthcare provider burnout as background
2. Highlight 2 programs at UC that constitute a preventive and educational approach to fostering well-being
3. Provide overview of first program: Turner Farm Student Wellness retreats
4. Provide overview of second program: Mind-Body course, modeled after Georgetown University
5. Present information on development, outcomes, and sustainability plans for both programs as models

Program #1

Teaching Kitchen: idea is to pair the culinary science with the nutritional science.

• To transform Disease Care to Wellness Care, need to educate health providers
• Transformation starts with education of students -traditional curriculum does not emphasize lifestyle modification
• Inter-professional learning grows into inter-professional team-based care
• Turner Farm’s Teaching Kitchen as platform

Have Student Wellness Retreats

• Retreats are 6 hours usually on a Saturday
• Evaluations are over whelming supportive of the Wellness Retreats with regards to presentations, experience and opportunities for both professional and personal changes.

Conclusion/Future Directions

• Student Wellness Retreats at Turner Farm were highly successful
• Sought after –Student Affairs promotes
• Development of personal wellness skills
• Increasing interest in Integrative Health
• Greatest challenge: funding/faculty time to sustain
• Future longitudinal student teaching kitchen sessions for continued healthy behavior change and knowledge

Program #2

Mind-Body Course

• One out of two physicians experience burnout
• This is not just limited to physicians but to all health care professionals
• “Burnout is a response to chronic stressors that wear on a person over time – not acute ones such as a big event or a big change” Christina Maslack, PhD
• According to John Kabat-Zinn Mindfulness is “The awareness that emerges through paying attention, in a particular way, on purpose, in the present moment, and nonjudgmentally, to the unfolding of experience moment to moment.”

Conclusion 1

• Although the rates of chronic stress and burnout among physicians are rising, practicing mindfulness can reduce burnout and increase empathy
• Student outcomes saw increase in mindfulness, empathy, positive affect, resilience and a decrease in perceived stress and negative affect.

Summary and Final Thoughts

• Wellness, through nutrition, movement, mindfulness and connectivity is critical to expose students to early on
• Experiential versus didactic-only
• What is Required?
  • Faculty modelling
  • Integration, rather than “one-offs”
  • Resources

“Tell me and I forget, teach me and I may remember, involve me and I learn”

For more information on the next session or to register, please click here.

In case you missed the March 15th Webcast Audio Seminar (WAS) Session, here are the highlights of this session:

Fat Chance for Obesity Medicine Education in Medical Schools
Presenter: Nicholas Pennings
March 15, 12 PM ET

• Obesity trends are rising at alarming rates across the United States.
• 57% of children today are projected to have obesity by age 35 (NEJM, 2107)
• The WHO projects that the worldwide cost of obesity will be $1.2 trillion dollars by 2025.
• Obesity can be framed as a disease process, a chronic condition with pathological consequences, which is responsive to lifestyle changes.
• Obesity is both a physical and psychological condition.
• Obesity education is relevant for all medical specialties as it impacts all body systems.
• Currently, 23% of medical schools in the US cover obesity medicine across their undergraduate curriculum and 66% of US medical schools dedicate 2-6 hours to obesity medicine in the their curriculum.
• Barriers to integrating an adequate obesity curriculum into undergraduate medical education include: not enough time, competing curricular demands and lack of prioritization.
• According to studies, there is a predominant “weight bias” in health care that leads to “weight stigma,” which negatively impacts patients with obesity from seeking health care.
• According to the Gayer study (2018), early introduction of an obesity curriculum for students in health care professions demonstrated a sustained reduction in weight bias over four years.
• A brief synopsis of the 2007 AAMC guiding principles for obesity education in undergraduate medical education includes the following:
  • Vertically and horizontally integrate obesity education into the medical school curriculum.
  • Highlight the universal importance of weight management and the prevention of obesity.
  • Utilize a multidisciplinary team to provide social support and behavioral treatment.
  • Provide self-awareness training about weight bias and weight stigma.
  • Employ population-based/community efforts to better prevent, support, and control obesity.
  • Direct basic science instruction to identify and explore the metabolic, genetic and environmental effects of obesity and the metabolic and immunologic responses to obesity.
  • Provide opportunities for learners to do a history and physical on patients with obesity and assess these patients in terms of nutrition (impact of different diets), physical activity, behavioral interventions and surgery.
• The ongoing expansion of knowledge in the science of obesity has created a growing chasm between knowledge acquisition and knowledge application for practitioners in the real world.
• Northwestern University, Oklahoma State University College of Osteopathic Medicine and Campbell University College of Osteopathic Medicine are three institutions that have longitudinally integrated Obesity Education. For further details about these, please contact Dr. Nicholas Pennings (pennings@Campbell.edu)
• Additional resources for Obesity Education include the following:
  • Obesity Medicine Association (provides free obesity educational materials) www.obesitymedicine.org
  • The Obesity Society www.obesity.org
  • American Society of Metabolic and Bariatric Surgeons www.asmbs.org
  • Obesity Action Coalition (gives voice to patients with obesity)

For more information on the next session or to register, please click here.

In case you missed the March 8th Webcast Audio Seminar (WAS) Session, here are the highlights of this session:

The Importance of Nutrition in Physician Performance and Well-Being
Presenters: Angela M. Cheung and Maryam S. Hamidi
March 8, 12 PM ET

The Importance of Nutrition in Physician Performance and Well-Being

• Improving physician dietary habits and hydration is a novel approach to supporting wellness and preventing burnout.
• According to a 2017 AMA survey, the burnout rate for physicians had increased to 51%, up from 40% in 2013. Conservative estimates show that physician suicide rates in the US are between 300 and 400 per year.
• Physician burnout negatively affects patient care.
• Emergent studies demonstrate a link between nutrition and physician performance.
• Physicians report that inadequate nutrition and hydration impact their work performance.
• Diet is important in brain health.
• High cognitive demands require proper nutrition for optimal performance.
• Physicians identify the following barriers to healthy eating: lack of nutrition breaks, limited healthy food options in the workplace, limited food storage and eating areas in the workplace, prioritization of clinical work over self-care.
• Nutritional strategies for improving short-term cognitive performance include: hydration, meal timing, meal composition, meal size and strategic use of caffeine.
• Hydration enhances the nervous system. Dehydration can impair cognitive function and mood modulation.
• Coordinating meal times with one’s own circadian rhythms optimizes nutritional effectiveness.
• Thoughtfully balanced meal composition and portion control can enhance cognitive and functional performance.
• Nutritional strategies for increased alertness include: eat larger meals before 10 pm, eat light snacks after lunch that contain protein and carbs, hydrate often, drink coffee or tea (caffeine increases core body temperature), chew gum (improves blood flow to the brain).
• Sustainable individual and institutional interventions are needed to support and improve physicians’ nutrition.
• These nutritional strategies can be applied across all health professions.
• Taking care of oneself leads to better patient care.

For more information on the next session or to register, please click here.

In case you missed yesterday’s Webcast Audio Seminar (WAS) Session, here are the highlights of this session:

Competency Based Education Across the UME-GME Continuum: the EPAC Program
Presenter: Deborah E. Powell, MD
February 8, 12 PM ET

Education in Pediatrics Across the Continuum (EPAC): a pilot program that seeks to establish a model for competence based-medical education (CBME) through variable-time, meaningfully assessed demonstration of competence across the continuum of undergraduate and graduate medical education using pediatrics as a test specialty.

EPAC was never intended to be a model or all medical education, but rather a model to prove the feasibility of CBME.

Why Pediatrics?

• American Board of Pediatrics was involved innovation initiatives and was interested in considering time variable advancement.
• Pediatrics and surgery had been identified in previous studies as two specialty areas where a relatively high percentage of students could remain committed to the specialty throughout medical school.

EPAC in a Nutshell

• 4 cohorts of medical students (up to 4 per cohort) at 4 participating medical schools would be selected before their first clinical year and offered a pediatrics residency position at the institution at that time.
• EPAC curriculum designed by a school team which included pediatrics clerkship director, pediatrics residency program director and EPAC faculty director
• Data collected on cohort students and non-cohort peers interested in pediatrics
• Longitudinal outpatient pediatrics clinic with designated preceptors begun in Year 2 or 3 and continued into GME
• In addition to required school specific assessments, a common assessment system will be used for all EPAC students (core EPAs, specific pediatrics EPAs and milestones as well as common standardized tests) with specific uniform thresholds for advancement to GME
• 8 of 12 students in cohort 1 met the threshold for advancement to GME during the first semester of their fourth year in medical school in a time variable progression
• 3 students in cohort 1 left EPAC during or after their first clinical year using the pre- designed opt-out path
• Students are being followed in GME in comparison with their non-EPAC peers

Curriculum is different at each of the 4 schools participating in EPAC (University of California, San Francisco, University of Colorado, University of Minnesota, University of Utah)

Consistent for all four Schools

1. Longitudinal continuity pediatric clinic, beginning in Year 2 or 3, extending through all residency
2. Residency slots guaranteed at each school when a student is selected for an EPAC cohort
3. Emphasis on pediatrics throughout curriculum (early pediatric clinic experiences, service learning projects, summer “internships” after Year one) starting in year 1
4. Each school agreed to take 4 annual cohorts of students with up to 4 students per cohort. First group of students entered medical school in 2013

Differences

1. Third year LIC in Minnesota and San Francisco (MN LIC is pediatric centric)
2. Selection of final cohort at end of Year 1 in Colorado, mid-Year 2 in Utah and Minnesota, end of Year 2 in San Francisco
3. Special pediatrics clerkship and other pediatric focused clerkship experiences in Utah

Year 1 – EPAC Explore

• Students are introduced to pediatrics and to the EPAC program in a variety of ways in the different schools, including pediatric interest groups, targeted sessions with pediatric faculty, school service learning projects, etc.
• MN offers a summer 2-week internship in pediatrics with a general pediatrician

Year 2 EPAC Focus and EPAC Match

• In EPAC Focus students are offered different activities in each school which immerse them more in pediatrics as a specialty – these may include focused pediatric physical exams, evening sessions with pediatric faculty, etc.
• EPAC Match is the selection of the final cohort. All schools have an application process that includes interviews.
• One school (CO) selects candidates at the end of year 1 so phases are accelerated

Since all of the clinical years at the four schools are different, the 3^rd and 4^th years are from the University of MN model.

“Year 3” and beyond University of Minnesota

• Longitudinal Integrated Clerkship (LIC)
  • Meets the requirements of all the standard core clerkships with exception of the sub-internship

• Up to 12-month prototype but time-variable depending on student achievement

• Transition Phase Curriculum:
  • “Preparation for residency” experiences focusing on inpatient medicine
  • Includes required sub-internship (NICU) and pediatric hospitalist “sub-internship”
  • USMLE Step 2 CK and Step 2 CS
  • Enrichment:
    • Time-variable experiences tailored to address specific competency areas requiring further development

• Pediatric Residency at the University of Minnesota (GME)

Guiding Principles about Assessment

AAMC Core EPAs and EPAs for a general pediatrician are the framework for the program – we focus on 5 of the Core EPAs in particular which are mapped to the corresponding pediatric EPAs

EPAC students will meet all of the school and LCME graduation requirements

AND

Common learner assessments for all EPAC sites will be performed Advancement according to demonstrated ability that results in entrustment will be the primary criterion. Learner progress in the program must be based on performance against specific outcomes (the competencies as demonstrated through certifiable or Entrustable activities), not only on time. Have agreed on specific

EPA milestone level (3a) for progression to residency across the 4 schools

Specific outcomes Individualized progress

In addition, in order to assure the entrustment needed for advancement to GME, the EPAC group decided to evaluate the core EPAs in a variety of clinical settings

Well care
Simple acute illness
Chronic care, single disease
Chronic care, complex
Urgent, emergent or escalating care

There are 17 Core EPAs for General Pediatrics. Five for the Core EPAs for entering Residency were matched with the corresponding Core EPAs for General Pediatrics.

Core EPA #1 matched with Core EPA for Pediatrics #1
Core EPA #7 matched with Core EPA for Pediatrics #2
Core EPA #9 matched with Core EPA for Pediatrics #4
Core EPA #10 matched with Core EPA for Pediatrics #5
Core EPA #13 matched with Core EPA for Pediatrics #7

Assessment: Summative

• Each continuity preceptor also completes quarterly summative assessment of student on the 13 core EPAS
• Can display each preceptor’s data, average and self-assessment over time for any given student

Assessment Clinical Competency Committee (CCC)

• Quarterly: September, December, March and May
• Modeled after residency CCCs
• Committee composition (at MN): EPAC leadership team and continuity preceptors
• Reviews all assessment data for each student
• Reports de-identified ratings for each student to APPD LEARN database to allow tracking of student progress over time from all schools

CCC provides:

• Longitudinal, developmental, individualized assessment
• Feedback given to student in individual meeting with EPAC course director
• Shared with preceptors

Program Evaluation

In addition to individual student assessment, we are working on evaluating the EPAC program across the 4 schools.

Goals are to address the following issues with a variety of methods including surveys, site visits and focus groups and for a varied group of stakeholders (including faculty, trainees, regulatory bodies and funders):

• Feasibility – can we do it
• Fidelity – can we do it equally well at all sites
• Safety – will we do no harm
• Significance – professional identity, burn-out, etc. using standardized survey instruments and controls

To date seven students have left the EPAC program

Why is EPAC Working?

1. Dedication of the medical educators involved with the project
2. Willingness of students to trust and experiment with something new
3. Support of regulatory groups – in particular:
   AAMC
   American Board of Pediatrics (ABP)
   ACGME
   FSMB
   NRMP

Continuing Work

• We are continuing to follow our EPAC students in GME and compare them to their non-EPAC GME peers (Stemmler grant)
• We need to show that our EPAC students are at least comparable to their non- EPAC peers in their progress through GME and into fellowship or practice

What Can We Learn from EPAC (and projects like EPAC)

• Regulations can be flexible for pilot projects
• When (how early) can students make lasting decisions about career choice? How are those decisions made?
• Better definition of readiness for residency
• Can we assess “competency (clinical competency)” accurately
• Can we move trainees into and through residency “early”? Is four years of medical school necessary?
• Can we redefine the “generalist” education of medical school?
• What do we really need out of our UME tracks?
• Can we develop more pathways/choices for our students?
• What are the long-term effects of these efforts. Better? Worse?

We hope you’ll join us for the Spring WAS series, which begins on March 8! For more information or to register for the Spring WAS, please click here.

In case you missed yesterday’s Webcast Audio Seminar (WAS) Session, here are the highlights of this session:

Continuity, LICs and Competency-based Education
Presenter: Molly Cooke, MD, MACP
February 1, 12 PM ET

Today’s Goals

• What actually happens in a Longitudinal Integrated Clerkships (LICs)
• Outcomes of Longitudinal Integrated Clerkships (LICs)
• How Longitudinal Integrated Clerkships (LICs) support competency-based medical education

What actually happens in a LICs?

LICs move away from the Block Clerkships.

• For example: one week in a LIC at UCSF may have the students spend ½ day in each of family medicine, internal medicine, surgery clinic, pediatrics, neurology and surgery OR.
• The week also includes “white space” which allows the student to study on their own, follow up with a patient or to prepare for case presentations, etc.

LIC can be somewhat overwhelming for the student. Over time during the year, their preceptor burden decreases as their confidence increases.

Learning Map for the student with the same patient over the course of the year. Over the year the student gains a great understanding of who this patient truly is. Starts to see the person with a diagnosis and not in an isolated way!

First few encounters

• Gathering and documenting clinical information

Early focus

• Increasing emphasis on diagnostic skills

Mid-year focus

• Increasing emphasis on management skills

End of the year

• Highlight system of case and quality issues

Keep feature of LICs is Continuity.

Five steps:

1. With curriculum (which is the patient)
2. With peers
3. With site and staff
4. With preceptor
5. With patients

Overview of the Outcomes of LICs

• Improve learning outcomes and psychological outcomes of the students
  • More mentoring
  • Better learning atmosphere
  • Better quality of feedback
  • Better quality of clerkship overall
  • Don’t show the “binge and purge” format normally seen in the Block Format
  • Show better retention of specialty knowledge over the course of the year.
  • Tend to “de-silo” specialty knowledge
• Improve the patient’s experience
  • The patient feels better quality of care
  • The patient feels comfortable with the medical student and is a liaison between the patient and the doctor.
  • The patient feels the student is learning and growing with them.
• Improve the preceptor’s experience
  • Get to know their students better
  • Know the student well enough to tailor their teaching and provide more individualize mentoring.

How Longitudinal Integrated Clerkships (LICs) support competency-based medical education

• LICs support competency-based education

Van Melle’s Core Components of Competency-Based Medical Education

1. Competencies required for practice are clearly articulated.
2. Competencies are arranged progressively.
3. Learning experiences facilitate the progressive development of competencies.
4. Teaching practices promote the progressive development of competencies.
5. Assessment practices support and document the progressive development of competencies.

Curiosity-drive learning

1. Clinical medicine, including the presentation, differential diagnosis and management of the conditions seen in practice.
2. The basic science foundations of clinical findings, disease pathogenesis, evidence-based medicine and treatments.
3. Emotional and psychosocial issues (ours and the patients’).
4. The clinical microsystem, community resources and barriers and the larger US health system.

For more information on the next session or to register, please click here.