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Education Strategies

A Model for Integration of Formal Knowledge and Clinical Experience: The Advanced Doctoring Course at Mayo Medical School

Dyrbye, Liselotte N. MD, MHPE; Starr, Stephanie R. MD; Thompson, Geoffery B. MD; Lindor, Keith D. MD

Author Information
doi: 10.1097/ACM.0b013e31822519d4

Improved integration of hands-on clinical experience and formal knowledge acquired through reading, small-group discussions, and classroom instruction is one of four goals for medical education reform identified in a recent report on physician education sponsored by the Carnegie Foundation for the Advancement of Teaching.1 The report calls for medical schools to foster integration rather than leave it to medical students to “connect, combine, and integrate” learning that occurs in separate domains. Such integration, the report proposes, will enable early medical students to appreciate the relevance and clinical context of information encountered in the classroom, to build experiential knowledge to complement formal knowledge, to transfer and apply formal knowledge to the clinical setting, and, ultimately, to be better prepared for complex tasks involved in patient care.

These ideas echo John Dewey's2 thoughts, first shared nearly three-quarters of a century ago. Dewey believed that information learned in isolation is disconnected from other experiences and hence not available when life circumstances require one to recall that knowledge. Dewey's belief that every experience must prepare the learner for a future experience epitomizes how medical schools' preclinical curricula should be designed. Although medical students today have early clinical experiences, as advocated by the Association of American Medical Colleges (AAMC),3,4 these experiences often occur in parallel (and often in competition) with the other aspects of the preclerkship curriculum, rather than in an integrated fashion.

At Mayo Medical School prior to curricular reform, year 2 clinical skills training occurred in the mornings without regard for the formal knowledge students were acquiring in didactic/small-group sessions in the afternoons. This mismatch resulted in lost opportunities for learners. The curriculum as designed did not show students the relevance of basic/clinical science content or provide clinical context for content. It did not allow them to practically apply content to facilitate learning or “try out” knowledge to reinforce self-efficacy. In this article, we describe Advanced Doctoring, our new multidisciplinary year 2 clinical skills training course, as an example of how formal knowledge acquisition and experiential learning can be structured to provide integrated, learner-centered experiences that bring relevance to didactic content, build clinical skills, and support the formation of individual professional integrity.

Advanced Doctoring: Overview and Framework

For the 2006–2007 academic year, Mayo Medical School implemented revised year 1 and 2 curricula consisting of multidisciplinary blocks (designed to relay basic/clinical science) and parallel longitudinal clinical skills courses. In year 1, students (approximately 50 per class year) have didactic/small-group learning and independent study in basic/clinical science blocks in the mornings. In the afternoons, they take Basic Doctoring, in which they learn patient interview techniques and physical examination skills. Basic Doctoring relies primarily on small-group teaching, peer physical examination, and standardized patients.

In year 2, the basic/clinical science curriculum's multidisciplinary blocks include fluids, circulation, nutrition and digestion, oxygen, endocrine and musculoskeletal, and immunity and blood. This curriculum's didactic/small-group learning and independent study occur in the afternoons, allowing students to take the multidisciplinary, longitudinal Advanced Doctoring course in the mornings. The Advanced Doctoring course, which is the focus of this article, takes place approximately three to four mornings per week during each block. Of the course's 197 hours, 163 (83%) are spent in experiential settings related to the formal knowledge curriculum delivered in the afternoons. Throughout the academic year, second-year students also provide care to medically underserved patients in a student-staffed clinic for eight mornings; this experience has been previously described.5 A mock-up of a second-year student's morning schedule is provided in Supplemental Digital Chart 1 (http://links.lww.com/ACADMED/A54).

Prior to curricular reform, the clinical skills curriculum in year 2 consisted of 10 distinct, discipline-specific, patient-oriented experiences (pediatrics; internal medicine; family medicine; surgery; urology; breast clinic; ophthalmology; ear, nose, and throat; dermatology; and physical medicine and rehabilitation) that occurred most mornings throughout 29 weeks of the academic year. Those experiences were scheduled without regard for the content being conveyed during the didactic basic/clinical science sessions occurring in the afternoons.

Guided by AAMC publications,3,4,6,7 publications on clinical skills curricula,1,8–14 feedback from local stakeholders (medical students, core physician faculty, medical education leaders), and models of preclerkship education elsewhere (e.g., Northwestern University Feinberg School of Medicine,15 University of Dundee School of Medicine,16,17 University of Miami Miller School of Medicine,18 University of Nebraska College of Medicine,19 University of Washington School of Medicine,20 and the Warren Alpert Medical School of Brown University21 among others22,23), a task force (led by L.N.D.) used a process of consensus building to generate year 2 clinical skills competency expectations that served as the framework to guide curriculum development for the Advanced Doctoring course.

The Advanced Doctoring course was built on the conceptual framework that patients and their problems are central to medical students' learning.24 During this course, students see, feel, and hear exam findings, interview patients of all ages, develop preliminary clinical reasoning skills, learn presentation skills, apply basic/clinical science knowledge, and reflect on the process of becoming a physician. Faculty preceptors support and challenge students, correct errors in understanding, role-model bedside behavior, and promote lifelong learning skills. The overarching goal of the Advanced Doctoring curriculum is to prepare each student to function as an active member of the health care team on the first day of his or her first clerkship.

Course Components

Advanced Doctoring consists of six discrete, collaborative components:

  • integrated clinical experiences,
  • integrated surgical experiences,
  • integrated diagnostic experiences,
  • integrated simulation experiences,
  • outpatient community pediatric clinic, and
  • reflective writing.

Table 1 shows the types of integrated experiences that occur within each basic/clinical science block and the time each second-year student spends in each experience. The integrated experiences are explicitly designed to complement the corresponding block's didactic/small-group curriculum. This integration allows students to learn when, where, and why to apply the knowledge gained in the block, thus improving their usable knowledge.25 The other, parallel experiences (pediatric clinic, reflective writing) are not directly related to block content but serve the purpose of ensuring longitudinal clinical skills development and attainment of professionalism objectives.

Table 1
Table 1:
Integrated Components of the Advanced Doctoring Course at Mayo Medical School by Basic/Clinical Science Curriculum Block
Table 1
Table 1:
(Continued)

Integrated clinical experiences

Inpatient setting.

During the inpatient integrated clinical experiences, students work up patients independently, present cases orally and in writing, and participate in physical examination rounds. These are designed to be repetitive, student-centered experiences in which students apply their clinical skills and receive rigorous formative assessment. Students are not allowed to access patients' medical records.

On typical Monday and Wednesday mornings, two physician preceptors identify and consent adult inpatients with chief complaints and physical examination findings related to the current (preferably) or recently completed block for student workups and physical examination rounds. The preceptors share their identified patients with each other (to prevent assigning more than one student to each patient and to increase the pool of patients with predetermined abnormal physical examination findings) and then meet their groups of eight students at 9:00 am. Once preceptors and students are gathered, each preceptor sends four students to interview and examine a patient on their own and then generate a write-up with a supported differential diagnosis and initial plan. Each preceptor then proceeds to conduct physical examination rounds with another four students until 11:30 am. During rounds, preceptors make efforts to compare and contrast physical examination findings (e.g., systolic and diastolic murmurs) to help students solidify their skills and conceptual understanding and to promote transfer of knowledge.25

The next day (i.e., Tuesday or Thursday), each of the students who did an inpatient workup presents the case orally to his or her preceptor and three peers and hands in the write-up. During these small-group case presentations, the preceptor tunes case presentation skills, engages the students in case-based discussions, corrects misunderstandings, teaches to the students' needs, and returns with the students to the patients' bedsides to ask additional questions and confirm findings. Within a few days, the preceptor provides students with written feedback on their write-ups.

Outpatient setting.

Because students' inpatient experiences may not be equivalent and direct observation of clinical skills is logistically difficult (preceptors conduct physical examination rounds while students complete inpatient workups), the Advanced Doctoring course includes integrated clinical skills sessions in which groups of four students are directly observed while they examine several adult community patients with specific physical examination findings. For example, during the circulation block, students examine patients who have systolic and diastolic heart murmurs, vascular bruits, and findings consistent with vascular insufficiency. During the oxygen block, students compare and contrast physical examination findings, pulmonary function tests, and chest X-rays of patients who have restrictive and obstructive lung disease. In the outpatient setting, students have multiple opportunities for practice, observation, and comparison, and they receive feedback from experienced physician preceptors who are knowledgeable about learner-level expectations, appropriate teaching methods, and how to give feedback—all aspects that are essential for learning to occur.26 Physician preceptors also engage students in dialogue about related pathophysiology (e.g., risk factors, natural history of disease, mechanisms of disease) and pharmacology (e.g., treatment options, side effects, cost) to help build connections between students' formal knowledge and experiential knowledge.

Parallel sessions focus on common pediatric chief complaints and physical examination findings. Using multimedia resources (e.g., showing children in respiratory distress or shock), students observe ill children, compare and contrast the approach to and physical examination findings of children and adults who have a problem related to the organ system in the block, and practice using appropriate medical nomenclature to describe what they see.

Adult outpatients for these sessions are primarily recruited during regular office visits in the primary care clinic by physicians who are familiar with the Advanced Doctoring course. These physicians ask patients who have certain physical examination findings (e.g., heart murmurs, lung crackles) whether they are interested in learning more about being a paid patient for a physical examination course and request permission to forward the patient's contact information to a colleague who chairs the Advanced Doctoring course (L.N.D.). The course chair telephones potential patients, informs them of the pertinent details related to the course and participation, and inquires about interest and availability.

Integrated surgical experiences

During three of the basic/clinical science blocks, students spend two mornings with a faculty surgeon who operates within the system related to the block. Typically, students round with the surgeon and the surgeon's resident team and observe at least one surgery. Although students are taught sterile technique, the surgical experience is designed to complement the organ system in the current block rather than to build surgical knowledge or skills. Prior to the start of year 3, students participate in the Advanced Doctoring course's surgical workshop designed to familiarize them with surgical instruments and basic suturing techniques.

Integrated diagnostic experiences

During four of the basic/clinical science blocks, students observe diagnostic tests being performed on patients. As the diagnostic tests are selected for their relevance to the block (see Table 1), students have ample opportunity to see pathology and discuss pathophysiology with an experienced subspecialist in the field.

Integrated simulation experiences

A variety of simulation experiences complement “real” patient experiences and the didactic curriculum during four of the basic/clinical science blocks. For example, following lectures on heart physiology, valvular disease, and heart murmurs, students listen to murmurs on the Harvey simulator under the guidance of a cardiologist during the circulation block. This session prepares the learners to hear and describe heart murmurs on real patients when they encounter these conditions during the circulation block's outpatient integrated clinical experiences. During two blocks (nutrition and digestion; immunity and blood), each student individually examines and interviews two simulated patients who present with a complaint related to the block's content. Physician preceptors observe students and provide immediate formative feedback. During the oxygen block, students practice psychomotor procedural skills using a bronchoscopy simulator under the supervision of a pulmonologist. In groups, students receive formative feedback from the oxygen block faculty as they work through simulated cases using a sophisticated mannequin that highlights practical relevance of knowledge gained during the block.

Parallel course components

Because we have not found it feasible to integrate all components of the Advanced Doctoring course with the block content, some experiences that we consider essential to clinical skills development occur in parallel. One such experience is the outpatient community pediatric clinic. Over the course of the academic year, second-year students spend seven mornings with a pediatrician in clinic interviewing and examining pediatric outpatients, presenting cases, and receiving feedback. Students also participate in a simulated parent exercise in which they are videotaped as they interview a standardized parent of an ill child. Students self-review the video of their encounter and receive feedback from another trained parent on their interviewing technique, including nonverbal communication and demonstration of empathy.

To promote formation of professional attributes, second-year students are assigned three reflective writing assignments during the academic year. They are asked to reflect about the intellectual and emotional terrain of their journey during this course and to discuss in a specific, concrete, and honest fashion events that they can recall vividly that pertain to a patient encounter and the preassigned topic (e.g., patient safety, influence of socioeconomic and personal beliefs on patient's choices and access to care, professionalism). Students meet in groups of eight with a physician preceptor, who has read the reflections in advance, to discuss their experiences and reflections.

Physician Faculty Time, Recruitment, and Development

Physicians at Mayo Clinic are salaried. Because the time they spend teaching rather than providing patient care affects their department's revenue, the Mayo Medical School provides reimbursement from its budget to physicians' departments according to the time committed to teaching. The physician faculty time commitment for teaching aspects of the Advanced Doctoring course equates to approximately two full-time equivalent physicians. Most of this faculty time is spent in the integrated clinical experiences. In addition, the course leaders (L.N.D., S.R.S., G.B.T.) have one half-day per week supported by the medical school for the course.

Course leaders recruit physician faculty through a process of e-mail solicitations and personal inquiries. Although recruitment is difficult at times because of competing demands, the medical school's ability to support teaching time has enabled a core group of physicians interested in undergraduate medical education to precept regularly in the course, optimizing the possibility for continuity of supervision.27 These physicians also participate regularly in faculty development opportunities offered by the Mayo Medical School and Mayo School of Graduate Medical Education. Faculty receive just-in-time information about learning objectives and instructional format before each Advanced Doctoring session.

Student Assessment

Assessment of students is both formative and summative. Formative assessment occurs throughout the Advanced Doctoring course by faculty preceptors (e.g., direct observation of clinical skills, feedback after case presentations), by peers (anonymous peer evaluations), and by trained parents (after the simulated patient/parent sessions). Summative assessments include students' attendance, professionalism, evaluations completed by their physician preceptors, performance on the National Board of Medical Examiners (NBME) Introduction to Clinical Diagnosis examination, performance on a six-case objective structured clinical examination (OSCE), and completion of reflective writing assignments. The Advanced Doctoring course is graded on a pass/fail basis.

Student Evaluation of Course

The Advanced Doctoring course is highly regarded by the students. Students' narrative comments on course evaluation forms illustrate their appreciation for the integrative experiences. Students have described how the course immersed them in clinical training, provided hands-on experiences, and enabled them to experience the clinical relevance of block content. They considered this integration to be profoundly valuable for learning. For example, one student wrote that the integrated clinical and diagnostic experiences were “phenomenal for correlating concepts learned in class, and integral to clinical skills development.” Students recognize the uniqueness of this integrated curriculum and how it promotes a patient-centered approach. One student commented that “Advanced Doctoring really embodied ... patient centeredness in a way that may be overshadowed in didactic courses with knowledge- (rather than skill-) based testing.” Another student wrote, “This is what separates our school [curriculum] from other curricula. It's really a great course and really helps us be better physicians.” Data concerning faculty perspectives on the course are not collected, but preceptors' enthusiasm for ongoing participation is high.

Students' responses on the AAMC Graduation Questionnaire (GQ) further support the robustness of the integration. In 2007, 11.4% of graduating Mayo medical students strongly agreed that the basic science content was sufficiently integrated. By 2009, 46.4% of graduating Mayo medical students (the first cohort to take the Advanced Doctoring course) strongly agreed that the basic science content was sufficiently integrated; by comparison, 23.1% of U.S. medical students strongly agreed.28 Similarly, the percentage of Mayo medical students who strongly agreed that basic science content had sufficient illustrations of clinical relevance rose from 17.1% in 2007 to 46.4% in 2009—more than twice the 2009 national percentage of 20.4%. Although students' perceptions of how well their preclinical skills training prepared them for clinical clerkship did not improve between 2007 and 2009, substantially more Mayo medical students than U.S. medical students nationally rated their preclinical training as excellent in 2009 (75% versus 53.8%). Several Mayo students' free-text entries on the 2009 AAMC GQ also highlighted preclinical experiences that correlated classroom lessons with clinical activities as a great strength of the medical school.

Unfortunately, neither the NBME Introduction to Clinical Diagnosis exam nor the six-case OSCE currently administered at the end of year 2 was in place prior to the curriculum reform. Hence, we cannot assess the effect of the reforms on students' learning specific clinical skills.

Provisos, Challenges, and Future Directions

Mayo Medical School has a small student body (approximately 50 students per class year), two teaching hospitals, and a large clinical campus. Although these factors facilitate our ability to implement an integrated clinical skills course, we face many of the same challenges as other medical schools. Our outpatient primary care practices are saturated with resident learners who compete with students for patients and faculty. Identifying and recruiting adult community patients with physical examination findings takes persistence, organization, and a substantial amount of willpower. Similarly, we are not immune to the difficulties of recruiting physician preceptors, who already struggle to meet productivity and research demands. As others have recognized, clinical experiences are difficult to arrange.19,29,30 Finding ways to integrate clinical experiences with the basic/clinical science curriculum amplifies the challenge, but, as we have shown, it is feasible using a longitudinal, multidisciplinary approach.

Future directions for the Advanced Doctoring course include adding more direct observation of students' clinical skills using standardized adult and adolescent patients, identifying new opportunities for integrative clinical sessions (particularly in the immunity and blood block, and also throughout Basic Doctoring in year 1), and ensuring more consistent reinforcement in year 2 of the clinical skills content taught in year 1 (e.g., risk behavior interview). Nevertheless, we believe Advanced Doctoring models how formal learning in didactic/small-group sessions can be integrated with clinical experiences to promote development of clinical skills, professional attributes, and usable knowledge that can be retrieved.25

Acknowledgments:

The authors wish to thank Drs. J. Gregoire, W. Freeman, J. Poterucha, D. Midthun, N. Natt, K. Newcomer, and A. Wolanskyj for their leadership and willingness to integrate components of the Advanced Doctoring course into their blocks.

Funding/Support:

None.

Other disclosures:

None.

Ethical approval:

Not applicable.

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