– InnovativeMedicalCurriculum–TrainingtheGlobalPhysicianofthe21stCenturybyincludingGlobalHealthinallMedicalSchool

Curricula

PedagogicalParadigmsinGlobalHealth:AnoverviewofTheory,ToolsandInnovations

CUGHConference,WashingtonDC,June2017

AnvarVelji.MD,FRCP(c.),FIDSA,FACP

ProfessorofMedicineandMedicalEducation

AssociateDeanGlobalHealth

CaliforniaUniversityofScienceandMedicine(CalMed)SchoolofMedicine.

Copyright2016

Objectives:

1. Discusshistoricalevolutionofmedicalcurricula2. IntroducetheinnovativeCalMed-SOMGlobalActiveLearningCurriculum3. Explainhorizontal,verticalandspiralIntegrationofbasicandclinicalsciences.4. DiscusstheAllActiveAdultLearningPedagogies5. DiscusshowglobalhealthisintegratedintotheCalMedcurriculumforall

medicalstudents6. DiscussModesofAssessment7. Discussmethodofselectingglobalhealthcompetenciesinexistingcurricula

Copyright2016

Copyright2016

AFactoryApproachwithaStandardCurriculum

ModifiedfromHardenRMandLaidlawJM,2012.

The Lancet Global Commission & Report on Education of Health Professionals for the 21st Century

OneDefinitionofGlobalHealth

“…anareaforstudy,research,andpracticethatplacesapriorityonimprovinghealthandachievingequityinhealthforallpeopleworldwide”(Koplanetal,Lancet2009)

TheLancetGlobalCommissionReport,onEducationofHealthProfessionalsforthe21st

Century(FrenkJetal)statesthattoday’scurriculaare…“fragmented,outdated,pedagogicallystaticandnotdrawingoncurrentglobaleducationalandcurricularresourcestocorrecttherapidlychanginglocalconditions”TheLancetReportFrenkJet.al.TheLancet,2010:376:1923-1958 Lancet Report. Frenk J.(lancet et al. The Lance:376: 1923-1

Copyright2016

Curricular Models Currently Being Used World–wideCurricularModels*

Characteristics Apprenticeship-Based(1765– )

Discipline-Based(1871– )

System-Based(1951– )

Problem-Based(1971– )

ClinicalPresentation-Based(1991– )

GlobalActive-Learning(2015– )

Organizationofcoursecontent(knowledge,skills,attitudes)

Relatedtoasubject Relatedtoadiscipline

Relatedtoanorgansystem

Relatedtoaclinicalcase

Relatedto120clinicalpresentations

Clinicalpresentationdriven;System- &Competency-based;

Person-centered,clinicalapproach

Controllersofcontent Faculty Departments Topiccommittee Curriculumcommittee Curriculumcommittee Curriculumcommittee

Relationshipofclinicaltobasicsciences

Separated;Emphasisonclinical

work

Separated;Emphasisonbasic

sciences

Interdigitated50– 50

withincontextoforgansystems

Integratedwithincontextofclinicalcases(emphasisonclinical)

Integrated50–50withincontextofproblem-specific

schemata

Fullyintegratedthroughoutthe4yrs.(horizontal,verticalandspiral)

Organizationofconceptinformation

Focusedonindividualcourses

Focusedonindividualdisciplines

Focusedonorgansystems;Definitionsofnormal,abnormal;

patient;signs&symptoms

Focusedonclinicalproblemsasdefinedbylearner,smallgroups,

andtutors

Focusedonpresentation-specific,

expert-derivedschemata

Focused,fromday1,onthe“patient”asaperson,andtheclinicalapproachto

diagnosis&management

Teachingmethod(s) Lecture Lecture Primarilylecture,somesmallgroups

Emphasisonsmallgroups

50– 50lecturesandsmallgroups

Fullyadult-learningoriented.Flippedclassroom;Allsmallgroup(i.e.,

"teams”)-basedactivities

Timingofpatient/caseexposure Delayed Delayeduntil3rd

year Earlybutlimited Early,singleexemplarycases

Early,multipleexemplarycases Day1,multipleexemplarycasesalways

integratingbasic&clinicalknowledgeCognitiveskill(s)emphasized Rotememorization Criticalthinking Problemsolving Problemsolving Categorization Activeintegration**ofcognitive,

psychomotor&affectivedomains

Primarylearningguides Lecturenotesandtextbooks

Lecturenotesandtextbooks

Lectureobjectivesandtextbooks

Learningobjectivesandclinicalproblems

Teachingandlearningobjectives,expert

schemata

Teachingobjectives,competency-basedlearningoutcomesrelatedtoknowledge,skills&attitudes;Structured-guidedinquiry

Problemsolvingmodel None Hypothetical–Deductive

Hypothetical–Deductive

Hypothetical–Deductive

Problem– specificschemata

Adultlearningskills(assoc. betweenstruct.& funct;abductive,inductive&deductivereasoning;criticalthinking;culturalcompetency/socialdeterminantsofhealth;

Problem-specificalgorithm

StructuralOrganization SingleDept.ofMedicalEducation

*PapaFRandHarasym PH.Acad.Med.1999;74:154-164

the Global Active-Learning CurriculumName of CalMed’s Curriculum:

Person-Centered Clinical Approach Learning Method(PC–CalMed)

Organization of Course content related to:

Clinical Presentation-driven, System– and competency–based,

Person–centered, Clinical Approach

Curricular Models Currently Being Used World–wideCurricularModels*

Characteristics Apprenticeship-Based(1765– )

Discipline-Based(1871– )

System-Based(1951– )

Problem-Based(1971– )

ClinicalPresentation-Based(1991– )

GlobalActive-Learning(2015– )

Organizationofcoursecontent(knowledge,skills,attitudes)

Relatedtoasubject Relatedtoadiscipline

Relatedtoanorgansystem

Relatedtoaclinicalcase

Relatedto120clinicalpresentations

Clinicalpresentationdriven;System- &Competency-based;

Person-centered,clinicalapproach

Controllersofcontent Faculty Departments Topiccommittee Curriculumcommittee Curriculumcommittee Curriculumcommittee

Relationshipofclinicaltobasicsciences

Separated;Emphasisonclinical

work

Separated;Emphasisonbasic

sciences

Interdigitated50– 50

withincontextoforgansystems

Integratedwithincontextofclinicalcases(emphasisonclinical)

Integrated50–50withincontextofproblem-specific

schemata

Fullyintegratedthroughoutthe4yrs.(horizontal,verticalandspiral)

Organizationofconceptinformation

Focusedonindividualcourses

Focusedonindividualdisciplines

Focusedonorgansystems;Definitionsofnormal,abnormal;

patient;signs&symptoms

Focusedonclinicalproblemsasdefinedbylearner,smallgroups,

andtutors

Focusedonpresentation-specific,

expert-derivedschemata

Focused,fromday1,onthe“patient”asaperson,andtheclinicalapproachto

diagnosis&management

Teachingmethod(s) Lecture Lecture Primarilylecture,somesmallgroups

Emphasisonsmallgroups

50– 50lecturesandsmallgroups

Fullyadult-learningoriented.Flippedclassroom;Allsmallgroup(i.e.,

"teams”)-basedactivities

Timingofpatient/caseexposure Delayed Delayeduntil3rd

year Earlybutlimited Early,singleexemplarycases

Early,multipleexemplarycases Day1,multipleexemplarycasesalways

integratingbasic&clinicalknowledgeCognitiveskill(s)emphasized Rotememorization Criticalthinking Problemsolving Problemsolving Categorization Activeintegration**ofcognitive,

psychomotor&affectivedomains

Primarylearningguides Lecturenotesandtextbooks

Lecturenotesandtextbooks

Lectureobjectivesandtextbooks

Learningobjectivesandclinicalproblems

Teachingandlearningobjectives,expert

schemata

Teachingobjectives,competency-basedlearningoutcomesrelatedtoknowledge,skills&attitudes;Structured-guidedinquiry

Problemsolvingmodel None Hypothetical–Deductive

Hypothetical–Deductive

Hypothetical–Deductive

Problem– specificschemata

Adultlearningskills(assoc. betweenstruct.& funct;abductive,inductive&deductivereasoning;criticalthinking;culturalcompetency/socialdeterminantsofhealth;

Problem-specificalgorithm

StructuralOrganization SingleDept.ofMedicalEducation

*PapaFRandHarasym PH.Acad.Med.1999;74:154-164

1) The competency-based CALMED-SOM’s curriculum incorporates different approaches and methodologies to learning and,

2) All of the learning methodologies used in the curriculum are guided by adult learning strategies.

draws upon and incorporates global medical knowledge . . . . .realizing that the practice of today’s medicine has no geographical (ethnic, racial, cultural) boundaries

(A.Tenore,modifiedfromHardenetal.1997).

Horizontal,VerticalandSpiralIntegrationofCurriculum

Copyright2016

class-roomeducationandguidance

Increasingindependenceandresponsibility

(A.Tenore)

Horizontal Vertical

Spiral

System-based

ClinicalPresentation

ActiveLearningmode ofdelivery

Fully integratedHorizontalVerticalSpiral

California University of Science and Medicine (CALMED-SOM) – CURRICULUM

Mapping: Course and Session Learning Outcomes

Copyright2016

life-long values,attitude of caringprofessionalism

Transform medical students

intoprofessionals

with

At the heart of the course are

Ethical & Moral Values, Global Health, One Health,Planetary Health

which truly distinguishes and brings respect to the medical profession

College Colloquium Longitudinal Courses

(First 2 Years)

California University of Science and Medicine (CALMED-SOM) - CURRICULUMIntegration of Global Health for All Students

College Colloquium(first 2 weeks)

StudentconductedActivity

(per College Team)

JournalClub

(3rd week)

alternating every third week

with

California University of Science and Medicine (CALMED-SOM) – CURRICULUM

Voice-over PowerPoint PresentationActivities related to

Last slide of “Presentation” ends with a clinical case containing 2-3 questions for student to answer

California University of Science and Medicine (CALMED-SOM) – CURRICULUM

DIPLOPIA

NO(Binocular)

Diplopia*

YES(Monocular)

Resolved

Pinholetest

CataractCornealirregularDrynessofeyeLensdisloca4on(MarfanSyndr;Homocys4nuria)Refrac4veerror

NotResolved

Re,nalabnormalityCor,calabnormality

Persistswitheacheyecoveredseparately

Sudden(vascular/isch)

Pain/discomf

NO(Non-inflamm)

YES(Inflammatory)

VascularMicrovascul.ischInflammatoryOphthalmoplegicmigraineTraumaOrbitalfracture

VascularImpendingBasilara.thrombosisBrainstemlacune

VascularBasilara.thrombAneurysmIsch.neuropathyInfec,onsBasilarmeningo-encephali4sCavernouss.vascOrbitalabscessNeoplasiaBrain-stemtumor

NeurologicWernickeencephMul4plesclerosisBotulismAutoimmuneMiller-FisherS.Orbitalmyosi4sMyastheniagravisMul4plesclerosis

Slowwith/without

pain

Onset

*Considerpsychosoma4ce4ologyifaboveorganiccausesareexcluded

Endo/MetabGravesdiseaseDiabetesmellitus

Separa,onofvisualimages

Seenextpage

A

B C

A ChiefcomplaintB HistoryC Physicalexam

California University of Science and Medicine – (CALMED-SOM)

1) Handout (and reading) of 2 clinical cases/team (students will elaborate during week and report on Friday

afternoon) 2) Clinical instructor presents algorithm and reasoning guide of

the “clinical presentation” of the week

California University of Science and Medicine – (CALMED-SOM)

1) Handout (and reading) of 1/2 clinical cases/team (students will elaborate during week and report on Friday afternoon) 2) Clinical instructor presents algorithm and reasoning guide of the “clinical presentation” of the week

IntegratingGlobalHealthCompetencies

1.GlobalBurdenofDisease2. HealthImplicationsoftravel,migrationanddisplacement3. SocialandEconomicDeterminantsofHealth&Population,Resourcesand

Environment4. GlobalizationofHealthandHealthcare5. HealthinLowResourceSettings6. HumanRightsinGlobalHealth

TeachingtheBasics:CoreCompetenciesinGlobalHealth.MeganAMArthur,BattatR,BrewerTF.InfectDisClin NAm(2011)347-358

Copyright2016

Liaison Committee on Medical Education Standards and Elements & Global Health/Public Health/Population Health

Standard1:Mission,Planning,OrganizationandIntegrity:SocialAccountabilityVision-FrametheMissionandOrganizationoftheMedicalSchool

“…themedicalschooliscommittedtoaddressthepriorityhealthconcernsofthepopulationsforwhichithasresponsibilitytoserve”(CACMSStandard1.1.1)

Standard2:LeadershipandAdministrationCriticaltotheVision:e.g. DeanandPresidentshouldbesupportive.e.g. prominence/visibilityofglobalhealthintheschool

andcommunityitserves

PreviousStandard10–CurricularContentinclude:• Globalhealth• Communityhealth• Population-basedmedicine• Epidemiology• Nutrition• Healthcaresystems• Prevention• Healthmaintenance• Medicalsocioeconomics• Occupationalmedicine• Healthdisparities• Culturalcompetency• Ethicsandmedicalhumanities.

Copyright2016

Copyright2016

OpportunitieswithinthecurriculumtointegrateGlobalHealthStandard6: CompetenciesandCurricularObjectivesandCurricularDesigns.

6.1: ServiceLearning(Structured&GLOCAL)

Standard7:CurricularContent:“…ensurethatthemedicalcurriculumprovidessufficientbreadthanddepthtopreparemedicalstudents(forthe21st Century)forentryintoanyresidencyprogramandforthesubsequentcontemporarypracticeofmedicine”(globallyandlocally)7.1:Biomedical,Behavioral,SocialSciences:Knowledge/concepts-Healthofindividualsandpopulations(wellness,determinantsofhealth,socio-economicdeterminantsofhealth,healthpromotion,diseaseprevention)+acute,chronic,rehabilitative-care,end-of-lifecareandprimarycare).

7.3:Researchopportunities.

7.5:Societalproblems(e.g.globaltobacco/STDS/etc.)

7.6:Culturalcompetence(Culturallycompetenthealthcare/healthdisparities)/underservedpopulations/altruismandaccountability)

(multidimensionaldiversesociety)

7.7:Ethics(GLOCAL)

7.8:Communicationskillsand7.9:interprofessionalcollaborativeskills

LCME Standards & Integration of Global Health/Public Health/Population Health in all Curricula

PreviousStandard10–CurricularContentinclude:• Globalhealth• Communityhealth• Population-basedmedicine• Epidemiology• Nutrition• Healthcaresystems• Prevention• Healthmaintenance• Medicalsocioeconomics• Occupationalmedicine• Healthdisparities• Culturalcompetency• Ethicsandmedicalhumanities.

Copyright2016

ExamplesofTopicsCovered:

• PatientPhysicianRelationship- CommunicationacrosstheCulturalRacial,EthnicandGenderDivide• Globalburdenofdiseaseanditsmeasurement• PreventiveandPromotiveHealththroughallstagesofLife• HumanRightsApplicationsinAccessingHealthcare• OneHealth:AnimalandEnvironmentalHealth• AccesstoEssentialMedicinesandVaccines• CulturalCompetency:CaringAcrosstheCultural,LinguisticandLiteracyDivide• PlanetaryHealthandHumanHealth:Population,ResourcesandEnvironment• GlobalBurdenofDisease/QualityandPatientSafety:Hypertension&EvidenceBasedGuidelines• GlobalBurdenofDisease/QualityandPatientSafety:Hospital-Acquired,Ventilator-AssociatedandHealthcareassociatedPneumoniaEvidenceBasedGuidelines

IntegratingGlobalHealthCompetencies:CollegeColloquiumYear1

Copyright2016

ExamplesofTopicsCovered:

• Defining Death (Death with Dignity)• Ethics of Health Care Disparities: Barrier to effective communication: Physician andpatient/family belief dissonance

• Applied Medical Ethics: Physician’s Obligation in Preventing, Identifying and TreatingViolence and Abuse

• Relationship between diabetes and social determinants of health• Legal and ethical aspects of abortion• Ethics of stem cell research and cloning• Ethical issues in Carrier Screening of Genetic Disorders• Ethical and Legal issues surrounding artificial Insemination by known donor, unknowndonor, and surrogacy.

• Persons with disabilities as an unrecognized population- health disparity

IntegratingGlobalHealthCompetencies:CollegeColloquiumYear2

Copyright2016

Copyright2016

Contentof:ClinicalPresentations.Skills,andCollegeColloquium

Da Vinci College Colloquium

da Vinci CollegeColloquium

Copyright2016

Mapping: Session Plan Template Using MEDTRICS

Copyright2016

Table3:SYSTEM-BASEDCOURSESINYEARS1&2FORMATIVE ASSESSMENT

KNOWLEDGEASSESSMENTMODALITY: ReadinessAssuranceTests,CBSE(NBME)SKILLSASSESSMENTTOOLS/MODALITIES: [ClinicalCasePresentationrubric(CriticalThinking),Teamworkrubric]=first2/3ofcourseATTITUDESASSESSMENTTOOLS: Professionalismrubric,Self-AssessmentClinicalSkillssessionsineachcourse Rubrics=Oralpresentation,Roleplay,ObservedperformanceCollegeColloq.sessionsineachcourse Rubrics=Teamwork,Oralpresentation,Debate,Roleplay

JournalClubsessionsineachcourse Rubrics=Journalclub

SUMMATIVE ASSESSMENT

KNOWLEDGEASSESSMENTMODALITY: 65% End-of-courseMCQexaminationSKILLSASSESSMENTTOOLS/MODALITIES: 15%

10%ObjectiveStructuredPracticalExaminationOSPE.[ClinicalPresentationrubrics=Teamwork,Oralpresentation,ClinicalCasePresentation]=last1/3ofcourse.

ClinicalSkillssessionsineachcourse 10% MiniClinicalSkillsExamination(mini-CSE).CollegeColloq.sessionsineachcourse Multiplechoicequestionsincludedinend-of-courseMCQexamination.JournalClubsessionsineachcourse Multiplechoicequestionsincludedinend-of-courseMCQexamination.

Professionalism:AcopyoftheSelf-Assessmentrubricmustbeco-signedattheendofeachcourse.AcopyoftheInstitutional/Program(self-assessment)Competenciesrubricmustbesubmittedattheendofeachsemester.Professionalconductwillbeassessedinall sessionsandinevery courseofthe4-yearcurriculum.Areportwillbefiledwhennegativemanifestationsrelatedtoethicalorprofessionalconductaredisplayedbyastudent.TheCollegeColloquiumsessionsmustproduceafilled-outrubricattheendofeachsystem-basedcourse.Shouldunethicalorunprofessionalconductofanystudentbenotedinanyothercoursesession,thefacultyofthatsessionwillsendareporttothestudent’sCollegementor,whowillactaccordinglyanddecidewhetherthereportwillinfluencetheoverallevaluationofthestuent’s professionalbehaviorandaffectpromotion.

Dr. Ettarh OverviewofAssessment

AssessmentinYear1&2Courses

1. AssuranceTests2. Clinical

Presentationswithrubrics

3. ClinicalSkillswithrubric

4. Laboratories(includesrubric)

5. CollegeColloquiumwithrubric

Dr. Ettarh OverviewofAssessment

OfficeofAssessment

InstitutionalCompetencies

SESSIONLearningOutcomes

Course/ClerkshipAssessment

AssessmentItems

COURELearningOutcomes

OfficeofAssessmenthascentralcoordinatingroleforsupportingfacultyinallassessmentsandevaluationsinYears1-4

OFFICEOF

ASSESSMENT

PROGRAMLearningOutcomes

1. Select LCME/CACMAS Accreditation standards as a framework to map the global healthcompetencies previously identified by Association of Medical Faculty of Canada and GlobalHealth Education Consortium.

2. Integrate desired global health program outcomes-knowledge, skills, ethics, social accountabilityand professionalism; identify outcomes at Institutional (ILO), Program (PLO), Course (CLO), andSession Level (SLO).

3. Identify curricular materials and cross-competencies that already exist and are required forgraduation in medicine, public health, population health, ethics, cultural competency, behavioralhealth and global health.

4. Specify mode of delivery of the curriculum e.g., active learning-flipped class room, voice over PPT.5. Specify modes of formative and summative assessment, using tools such as Individual Readiness

Assessment Test (i-RAT) and Team-based Readiness Assessment Test (t-RAT), MCQs, Rubrics andProgress Tests.

6. Adapt and utilize learning and teaching tools e.g., Objective Structured Clinical Examination,Simulations, and Virtual Reality.

Recommendations for Institutionalizing Global Health in all Medical Schools

Copyright2016

• Dr.RobertSuskind,DeanofCalMed

• Dr.AlfredTenore,SeniorAssociateDeanofMedicalEducation,CalMed

• Dr.GhaithAl-Eyd,AssociateDeanCurriculum(Year1&2)andDirectorofMapping,CalMed

References:1. UniversityConsortiaandtheDevelopmentofEducationalStandardsinGlobalHealth.VeljiA,MartinK,and

HallTIn:eds.N.Arya,J.Evert,K.Standish.FromTheorytoPractice-EthicsandPedagogy(InPress)

2. IntegrationofGlobalHealthinAllMedicalSchoolCurriculatoMeettheNeedsofthe21st CenturyPhysician.LearnServeLeadLearninginMedicineandScience(AAMC,Seattle,November2016).

3. FrameworkforIdentificationofGlobalHealthCompetencies:developinganintegratedbasicscienceandclinicalsciencemedicalcurriculum Facilitator:AnvarVelji,CaliforniaNorthstateUniversityCollegeofMedicine(AAMCMeetingNov8,2014.)

Acknowledgements and References

Copyright2016