The events of September 11, 2001, and the threat of weapons of mass destruction (WMD) in the hands of determined terrorists have highlighted the limitations of the United States health care system in responding to large-scale public health emergencies. The key for an effective response to any mass casualty event is a trained cadre of health care professionals. Thus, educating medical students about disaster response has become a priority. In 2003, the Association of American Medical Colleges (AAMC) issued a report recommending that the nation's medical schools thoroughly educate students about the public health and emergency services systems to ensure coordinated responses to WMD or other public health threats, and that schools incorporate bioterrorism education into all four years of medical education.1
In response to the AAMC's recommendation, the Texas A&M University System Health Science Center College of Medicine (hereafter, “the COM”) partnered with the Defense Institute for Medical Operations (DIMO) to offer second-year medical students an 18-hour block of instruction over four days in a course entitled “Leadership in Disaster Response.” The course was first given in December 2003 during the 2003–04 academic year to 72 second-year medical students at the COM.
In response to the AAMC recommendations for medical education on terrorism, the associate dean for undergraduate medical education charged our Year II curriculum subcommittee to develop a block of instruction for second year students. The first task was to identify the time available in the curriculum to offer the course. The week prior to the Christmas break was available on the schedule. Given the newness of the concept and the brevity of the course, it was decided that attendance would be mandatory but the course would not be formally graded.
Through connections between the COM and the U.S. Department of Defense, a contact was made with DIMO, an institute whose mission is to “strengthen global medical capabilities in disaster response and health care management through education and training”. A meeting between representatives from DIMO, based in San Antonio, Texas, and the Year II curriculum subcommittee was arranged. The DIMO faculty presented an overview of their standard 40-hour course, which focused on emergency response, acute care, and public health. It was mutually decided that guest faculty from DIMO would present a modified version of the course to the second year medical students. This was on a one-time basis, utilizing the train-the-trainer format used by DIMO and suggested by the AAMC.1 Over the next several weeks, the Year II curriculum subcommittee revised the DIMO curriculum from 40 contact hours to 18 hours, attempting to tailor content to meet the AAMC recommendations. The course was approved by the subcommittee, the COM's curriculum committee, and the COM's academic council in October 2003.
When the course was first offered in 2003–04, it consisted of both lecture and experiential elements delivered by six military experts from DIMO. The specific objectives of this curriculum were to
1. educate students on resources available for regional disaster response (Federal Emergency Management Agency, public health agencies, legal issues),
2. define principles of resource management in disaster response (triage, medical modular resources),
3. identify specific agents (chemical, infectious, radiation) that are associated with bioterrorism, and
4. understand the psychosocial aspects of disasters.
In the development of the specific objectives for the course, the faculty adopted the three general principles set forth in the AAMC report1:
1. In the medical school curriculum, WMD education should be considered in the context of any threats that may result in mass casualties, including the use of biologic, chemical, physical, and radiological agents.
2. General concepts should be emphasized rather than details regarding every potential agent.
3. The roles and responsibilities of physicians during a WMD event should be presented, including the need to work in multidisciplinary teams and in coordination with public health system.
By using an all-hazards approach to the curriculum and by carrying out objective 3, the course embodied principles 1 and 2. The criterion of principle 3 was met by implementing objectives 1 and 2. In these ways, the students learned to use public health data and public health teams in managing natural disasters and outbreaks of infectious disease.
An overview of the course's topics in academic years 2003–04 and 2004–05 is outlined in Table 1 and described in more detail in the following paragraphs.
▪ The first day of the course was designed to introduce students to disaster response systems, specifically focusing on the role of regional trauma centers in the emergency medical response to a disaster. Overview presentations focusing on key concepts in approaching any natural or potential WMD disaster were presented.
▪ The second day included an experiential exercise at a first-responder training site, Disaster City, an educational component of the Texas Engineering Extension (TEEX) Service of the Texas A&M University System. Disaster City has a number of full-scale simulations, including derailed trains (freight and passenger), collapsed buildings, and airplane crashes. During this exercise, the students were divided into six small groups and presented a refugee scenario in which they were asked to develop a detailed emergency management plan necessary to meet the critical public health, medical, and social needs of the stricken population. Two hours of lectures dealing with the role of public health systems in disaster response, as well as legal and media issues to be considered during a disaster, were also presented. The information on trauma systems, public health, and legal issues have previously been identified as important issues in educating health care professionals on a bioterrorism response.2,3
▪ On the third day, DIMO faculty presented lectures on the public health aspects of specific WMD (biological, chemical, and nuclear) and triage principles for mass casualty scenarios. In the afternoon, students participated in a practical interactive exercise involving the use of biostatistics and epidemiology in an outbreak investigation process to track and identify the causative agent for an outbreak of diarrhea. Students were given free time later in the afternoon to further develop their emergency management plan for the displaced persons scenario.
▪ On the final day, lectures were given on blast injuries and the crush syndrome associated with suicide bombings as well as the psychiatric and psychosocial aspects of disasters. The block ended with each of the small groups presenting their emergency management response to the displaced persons scenario and the students taking a posttest and postattitudinal questionnaire.
Students' acceptance of the course and its effect on their attitudes.
The 72 second-year medical students from the COM who attended the mandatory educational block all signed informed consent forms to participate in the evaluation component of the course. The proposed study was found to be exempt from institutional review board review. The average course evaluation score was 4.4 on a Likert scale of 1 (strongly disagree that the course was useful) to 5 (strongly agree), with the range from 2 to 5. There was a statistically significant difference (p < .001) between the responses to each of the matched pre- and postattitudinal questionnaires. After the course, students were more favorable in their attitudes toward their professional preparedness and the local/state government preparedness for a bioterrorist event. The least change in attitude was in their confidence that their health would be protected in the event of a biological or chemical attack. There were no statistically significant differences in attitudes by students' life experiences.
Course's effect on students' knowledge of disaster preparedness.
A statistically significant improvement (8.64 to 10.50, p < .001) was seen between all students' pre- and posttest scores regarding their knowledge of disaster preparedness. There was also a statistically significant improvement in the knowledge of the men as a group (8.82 to 10.48) and that of the women as a group (8.51 to 10.56). While the women improved their scores more than the men improved theirs, the difference was not significant. Together, these data suggest that modified DIMO curriculum was a useful tool to educate students about disaster response medicine.
Changes in the second year
Based on the student evaluations and input from faculty, several changes have been made for the 2004–05 academic year (outlined in Table 1). First, we believe that the importance of the material justifies administering an exam and reporting a final course grade. In addition, the course has been moved to the end of the second year, given that its content blends important components of the basic and clinical sciences.
A strength of the original design was the emphasis on public health and the use of a problem-based-learning exercise on communicable disease. Thus, we have expanded the public health offering and retained the problem-based-learning exercise (see Table 1). Faculty input indicated, however, that too little time and focus were spent on the basic science elements of chemical and biological agents. Therefore we used specific AAMC guidelines dealing with the basic sciences1 and recommendations from the Association of Medical School Microbiology and Immunology chairs4 to formulate new objectives and develop lectures on these subjects. As a result, we have eliminated the lectures on dealing with the media and the discussion of regional trauma centers. In addition, the coverage of blast injuries and the crush syndrome will be moved into the clinical training component of our curriculum.
Previous studies have shown that a short course (three hours) was associated with changes in physician knowledge, attitudes, and concerns regarding bioterrorism.5 We believe that the present article is the first report to describe the content and evaluation of an integrated curriculum for medical students that addresses current recommended guidelines set forth by the AAMC. Importantly, our “Leadership in Disaster Response” course was associated with a statistically significant change in students' knowledge and attitudes concerning disaster response. In addition, the format of concentrated experience was well received by the students, as evidenced by their favorable course evaluations. A unique feature was the combination of lecture and experiential formats and stimulated models, which we believe makes possible an ideal “self-reinforcing” approach to the material. In fact, student feedback suggested that the simulation scenarios were the most valuable elements of the course, and future development of our curriculum will include the use of clinical simulations.
Additional challenges for the future include (1) integrating the curriculum vertically through all four years of the medical school curriculum, as suggested by the AAMC and modeled at the University of Pittsburgh6; and (2) broadening the depth and breadth of student exposure from the foundation established by this 18-hour block of instruction. This may include simulation of mass casualties (facilitated by the proximity of the COM to the TEEX Disaster City, the COM could partner with their established courses for first responders); identifying and assessing core competencies in disaster training; and, finally, maintaining levels of preparedness of health professionals, including students, for disaster response.
Training health care professionals about the principles and practices of disaster preparedness has become extremely relevant in contemporary society. The fundamental content for such curriculum must include the disciplines of medicine, behavioral science, public health, and health policy. No single discipline can manage the complex issues found in disaster response, either natural or manmade. The challenges are how to create an integrated four-year medical school curriculum that teaches and build upon the core principles and how to translate knowledge of disaster preparedness into clinical competence for events we hope will never happen, but inevitably do. We believe our development of a short introductory course is a first step in the right direction.
The authors wish to thank Dr. P.K. Carlton for his assistance in facilitating the interaction between the A&M Health Science Center College of Medicine and the Defense Institute for Medical Operations.