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Dis-Integration or Re-Integration of the Pre-Clinical Sciences in Medical Education? Part 2

Continued from Part 1

Part 2: Re-Integration of Core Pre-Clinical Content into Clinical Experiences or Exercises

Potential Impact of Competency-Based Initiatives

According to Emanuel, there is a shift toward demonstration of competencies rather than time spent memorizing content in a medical school curriculum.

He notes:

Incorporating all these changes is slow—inordinately slow for many people. But these changes seem inevitable.9

As early as 2013, the American Osteopathic Association and American Association of Colleges of Osteopathic Medicine recommended creation of “a new education model that is based on achievement of competencies without a prescribed number of months of study.”6 In veterinary education, the Competency Based Veterinary Education (CBVE) initiative of the American Association of Veterinary Medical Colleges11 has the potential (opportunity?) to remove the focus on a fixed training timeline. This process has proceeded to the following list of 8 general Entrustable Professional Activities (EPAs):

  1. Gather a history, perform an examination, and create a prioritized differential diagnosis list
  2. Develop a diagnostic plan and interpret results
  3. Develop and implement a management/treatment plan
  4. Recognize a patient requiring urgent or emergent care and initiate evaluation and management
  5. Formulate relevant questions and retrieve evidence to advance care
  6. Perform a common surgical procedure on a stable patient, including pre-operative and post-operative management
  7. Perform general anesthesia and recovery of a stable patient including monitoring and support
  8. Formulate recommendations for preventive healthcare

These are all clearly “Day 1” general clinical skillsets, as they should be.  Several questions about their curricular implementation would be:

1. To what extent will each school or national curricular groups map pre-clinical content the EPA’s?

2. How will current species “tracks” within the training accommodate these EPA’s?

3. Will veterinary schools expect demonstration of these skillsets?

4. Will there be additional flexibility in the timeline to demonstrate these skillsets?

What would thoughtful re-integration of core content look like? Examples might be the inclusion of anatomy in imaging and surgery, physiology in medicine, and pharmacology in medicine and anesthesia instruction. Eventually, at the University of Illinois, after paring down the core content, and after seeing blank stares from 3rd and 4th year students, clinical faculty started asking why some “core” concepts were not being taught!  This experience highlights the difficulty with using traditional curricular and even disciplinary constructs to connect pre-clinical concepts to the “Day 1” skillsets.  A crucial question is whether core content can really be “mastered” in a meaningful way when divorced from the EPA skillsets. Given the rapid expansion of medical knowledge, as well as these species differences, it seems that EPA #5 implies that an appropriate didactic approach would include just-in-time learning carefully framed through case scenarios.

For all these reasons, the next phase of mapping curricular content to these EPAs will be quite interesting and challenging.   And for this reason, short video or readings such as is found on VetMedAcademy might be used for initial learning, for discovery during a case analysis exercise, and/or for review during the clinical exercises and experiences.  The key point made by Emanuel is that there should be multiple pathways and timelines to reach appropriate competence, as long as that competence can be demonstrated.9 This brings us to how both students and curricula as a whole have been traditionally assessed.

The Impact of High Stakes Licensing Exams

It is well known that the nature of an examination impacts how students will study. The same might be said for national licensing examinations defining both the nature of the bar and the height of the bar for veterinary schools. Unlike the single North American Veterinary Licensing Examination (NAVLE) near the end of veterinary training, physician licensing has involved the United States Medical Licensing Examination (USMLE) Step 1 at the end of the second year of training, focusing on basic sciences, and Step 2 near the end of medical school.  In facilitation of re-thinking assessment of pre-clinical training period, as of 2022, the Step 1 examination will become a pass/fail examination, reducing its quantitative weight for internship/residency competition.12

In veterinary medicine, the NAVLE has long since evolved into a clinical and disease-focused examination, with little explicit assessment of pre-clinical topics.  As such, it has become more difficult to use this examination to assess the capabilities of graduates in these topics and vice versa to assess a pre-clinical curriculum for efficacy in instruction of the same topics.  For example, to a pharmacologist (DCF), the composition of the NAVLE would suggest that this discipline has scant clinical relevance.  And yet it is central to at least 3 of the 8 proposed EPAs for a veterinary graduate: #3, #4, and #7 listed above. Furthermore, as carefully as they are designed, such standardized exams are reliant on machine-graded multiple-choice formats, which have intrinsic limitations for evaluating many of the competencies of interest.  More subtly, the national licensing examination has tended to discourage the most creative curricular ideas by veterinary schools, while encouraging some to “teach to the test.” Better alternatives need to be established to fairly and consistently assess complex biomedical reasoning that reflects faculty standards, but does not consume their precious time. We propose the consideration of educational platforms like Common Ground Scholar (https://cgscholar.com) that allow faculty to set standards of competence, collegiality and performance, while leverage peer review, analytics, and artificial intelligence.5

Thinking Creatively About the Future

In summary, both medical and veterinary schools have the opportunity to re-think the role of faculty outside of “content delivery,” focused on modeling professional competence to students and effective evaluation of student achievement. Using well-designed case exercises encouraging just-in-time learning by students, faculty could introduce or reinforce basic science concepts in the form of digitally available micro-content. In veterinary education, with widely accepted EPA’s of the CBVE mapped to content, this approach becomes more feasible and also should allow veterinary schools to share content and case resources and encourage a licensing examination that better reflects this refined curricular design.  In a world where scientific knowledge is doubling roughly once a semester, isn’t it time to take a different approach?

Featured image modified from ntr23 on https://www.flickr.com/photos/ntr23/4977246975License: https://creativecommons.org/licenses/by-nc-sa/2.0/

References
1. Flexner A (1924). Medical education, 1909–1924. JAMA. 82:833–838.
2. Mattson K (2019): 2+2 programs add up: Veterinary colleges partner with other universities to educate more students across state lines.
https://www.avma.org/javma-news/2019-04-15/22-programs-add
3. Foreman JH, Morin DE, Graves TK, Mitchell MA, Zuckermann FA, Whiteley HE (2017). Veterinary Curriculum Transformation at the University of Illinois, 2006–2016. J Vet Med Ed 44 (3): 471-479.  https://doi.org/10.3138/jvme.0316-060R1
4. Ferguson DC, McNeil LK, Schaeffer DJ, Mills EM (2017): Encouraging critical clinical thinking (CCT) skills in first-year veterinary students. J Vet Med Ed 44(3): 531–54. DOI: https://doi.org/10.3138/jvme.0216-032R1
5. McMichael MA, Ferguson DC, Allender MC, Cope W, Kalantzis M, Haniya S, Searsmith MCS (2020). Use of a multimodal, peer-to-peer learning management system for introduction of critical clinical thinking to first year veterinary students. J. Vet. Med. Ed., in press.
6. Raymond JR, Kerschner JE, Hueston WJ, Maurana CA (2015): The Merits and Challenges of Three-Year Medical School Curricula: Time for an Evidence-Based Discussion. Academic Medicine 90(10): 1318-1323.
7. Center for Health Workforce Studies. The Relationship Between Physician Education Debt and Income, Research Brief, July, 2019.
https://www.chwsny.org/wp-content/uploads/2019/07/CHWS_Education-Debt-Brief_2019.pdf
8. Larkin M. (2017) Divided by debt: How the growing division between the wealthy and the poor is impacting veterinary students and recent graduates. J Am Vet Assoc. News, published December 13, 2017. https://www.avma.org/javma-news/2018-01-01/divided-debt

9. Emanuel EJ (2020): The Inevitable Reimagining of Medical Education. JAMA 323 (12): 1127. https://doi.org/10.1001/jama.2020.1227
10. Lucey CR, Johnston SC. The transformational effects of COVID-19 on medical education. JAMA.  https://doi.org/10.1001/jama.2020.14136
11. Competency-Based Veterinary Education. American Assoc of Veterinary Medical Colleges. AAVMC website. (https://www.aavmc.org/programs/faculty-educators/cbve/).
12. Chaudhry HJ, Katsufrakis PJ, Tallia AF (2020):The USMLE Step 1 Decision: An Opportunity for Medical Education and Training. JAMA 323 (20): 2017-2018. https://doi.org/10.1001/jama.2020.3198   

Submitted by:

Duncan C. Ferguson, VMD, PhD, DACVIM, DACVCP, Emeritus Professor of Clinical Pharmacology, College of Veterinary Medicine, University of Illinois at Urbana-Champaign
Bill Cope, PhD, Professor of Education Policy, Organization and Leadership, College of Education, University of Illinois at Urbana-Champaign
Mary Kalantzis, PhD, Professor of Education Policy, Organization and Leadership, College of Education, University of Illinois at Urbana-Champaign