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Medical Education  |   November 2016
Faculty Development Directed at Curricular Reforms Designed to Improve Patient Outcomes
Author Notes
  • From Curricular Design and Faculty Development (Dr Papa) and Community Health (Dr D’Agostino) at the University of North Texas Health Science Center Texas College of Osteopathic Medicine in Fort Worth. 
  • Financial Disclosures: Dr Papa is the chief executive officer and principle owner of ACDET, a company producing software and simulation training devices for medical education. No software or simulation devices offered by ACDET are referenced in this artcile. 
  •  *Address correspondence to Frank J. Papa, DO, PhD, University of North Texas Health Science Center, 3500 Camp Bowie Blvd, Fort Worth, TX 76107-2644. E-mail: frank.papa@unthsc.edu
     
Article Information
Medical Education / Professional Issues / Curriculum
Medical Education   |   November 2016
Faculty Development Directed at Curricular Reforms Designed to Improve Patient Outcomes
The Journal of the American Osteopathic Association, November 2016, Vol. 116, 736-741. doi:10.7556/jaoa.2016.144
The Journal of the American Osteopathic Association, November 2016, Vol. 116, 736-741. doi:10.7556/jaoa.2016.144
Web of Science® Times Cited: 1
Abstract

Three initiatives involving quality of patient outcomes that evolved in the late 1990s must be considered in the design of 21st century undergraduate medical curricula. They involve (1) the question of how to best teach and assess medical competencies, (2) growing concerns regarding the frequency and severity of error in medical care, and (3) the role physicians might play in weaving together the overlapping elements of population-, community-, and systems-based practice into a codified approach to medical care. With these initiatives in mind, the University of North Texas Health Science Center Texas College of Osteopathic Medicine has formed an Academy of Medical Educators whose goal is to develop faculty programs intended to expedite curricular modifications and reforms.

This Medical Education section represents a collaboration between the JAOA and the American Association of Colleges of Osteopathic Medicine (AACOM) to recruit, peer review, edit, and distribute articles through the JAOA on osteopathic medical education research and other scholarly issues related to medical education.

Keywords: competencies, curricular reform, medical education, model of mind, quality of care

In the late 1990s, 3 quality-of-care initiatives1-4 involving quality of patient outcomes emerged. These initiatives, which continue to evolve, should be considered in the design of 21st century undergraduate medical curricula. 
The first initiative asked how the health care profession can best teach and assess medical competencies. This question was originally addressed by the Accreditation Council for Graduate Medical Education in their Outcomes Project, which intended to help residency program directors develop an explicit definition of the core elements comprising competence within 6 broader domains of medical competencies. This initiative continues to undergo refinements through new residency rubrics involving the inclusion of developmental milestones and, more recently, preresidency entrustable professional activities, which are beginning to influence the design of undergraduate medical training programs.1,2 
The second initiative addressed growing concerns about the frequency and severity of error in medical care. These concerns subsequently evolved into a movement broadly referred to as patient safety. This initiative has been nurtured by a series of reports authored by the Health and Medicine Division (HMD) in the National Academies of Science, Engineering, and Medicine (previously the Institute of Medicine) in its Quality Chasm series.3 
The third initiative involved growing awareness that no single public entity, private sector organization, or professional discipline or group had the responsibility for organizing, monitoring, and improving the overall health of society. Some posit that a physician could play a leading role in weaving together the evolving and overlapping rubrics of population-, community-, and systems-based practice.4 
The University of North Texas Health Science Center Texas College of Osteopathic Medicine (UNTHSC/TCOM) has ongoing faculty development programs intended to expedite curricular modifications and reforms that will enable graduates to lead in the delivery of 21st century US health care innovations, which will improve patient outcomes. The following is a description of how UNTHSC/TCOM’s model of mind framework and core principles were used to establish faculty development programming guided by the 3 quality-of-care initiatives. 
Academy of Medical Educators
In 2010, UNTHSC/TCOM launched the Academy of Medical Educators (AME), which consisted of approximately 40 participants primarily drawn from clinical faculty and a few from basic science faculty. Members of the AME established a tripartite mission statement focused on undergraduate medical curricula predicated on a learning sciences–based approach; programming designed to support faculty in acquiring declarative knowledge and developing procedural knowledge sufficient to advance their capabilities and careers as physicians and educators; and programming designed to train faculty to conduct education-oriented research and scholarly activities. 
Implementing new curricula and programming does not serve as an end point. Rather, these reforms are intended to create enduring and meaningful changes in the learner’s behavior. The development of these behaviors would be driven by formalized, learning sciences–derived models of mind, competence, and education. 
Models of Mind as a Foundation for Faculty Development
The AME used a foundational framework for a learning sciences–derived model of mind that is based on Gagne’s 9-step model and robust descriptions of 5 core learned human capabilities likely to lead to enduring and meaningful changes in behaviors.5 Those capabilities involve the development of information acquisition skills, intellectual skills, cognitive strategies, motor skills, and attitudes. In addition to Gagne’s model, other models were considered that demonstrated areas of convergence with Gagne’s theoretical framework to formulate an in-house model of mind through which the curricular reform initiatives might be implemented. 
Concepts representing particularly important areas of convergence across these various models were subsequently identified as UNTHSC/TCOM’s curricular design principles. Several of the core principles selected to guide AME faculty and curricular development initiatives are as follows: 
  • ■ Competence is domain-, problem-, and task-specific because its development is more heavily predicated on the construction and use of domain-, problem-, and task-specific knowledge rather than generalizable processes.
  • ■ Declarative (ie, what) and procedural (ie, how to) knowledge are essential to the development of domain-, problem-, and task-specific competence.
  • ■ Procedural knowledge plays a greater role in the development of competence than declarative knowledge.
  • ■ The development of competence largely revolves around the establishment of a training environment that enables learners to transform declarative knowledge into procedural knowledge.
  • ■ The development of procedural knowledge (and thereby competence) is expedited by means of multiple domain-, problem-, and task-focused practice opportunities.
  • ■ After each practice opportunity, feedback in the form of immediate reinforcement or corrective remediation will expedite the refinement of procedural knowledge, thus enabling the development of competence.
  • ■ The order and sequence of course content (primarily declarative knowledge) and instructional processes (ie, efforts designed to support the development of intellectual skills, cognitive strategies, motor skills, and attitudes) need to be considered if the intended curricular outcome is the optimization of domain-, problem-, and task-specific competencies.
Considerations for 21st Century Medical Education
Teaching and Assessing Medical Competencies
The first 2 years of AME meetings were dedicated to providing faculty with declarative knowledge related to a vast array of learning sciences theories, their respective models of minds and competence, learning sciences–based models, and methods of education. Throughout that period, faculty were encouraged to consider how and where these models, theories, and principles could be used to create evidence-based changes in their own instructional activities. Essentially, they were asked to take steps toward the proceduralizaton of their newly acquired declarative knowledge. Those considerations included the following faculty reflections: 
  • ■ how their course content and processes were organized and sequenced
  • ■ whether their course was explicitly designed to support the development of domain-, problem-, and task-specific competencies
  • ■ whether they could recognize the explicit use of a specific learning sciences–derived model, theory, principle, evidence base, or methods in the organization of their existent course content and its instructional processes
  • ■ how well their respective course content and processes were interdigitated with other courses or instructional activities
  • ■ whether efforts at the interdigitation of content and processes across courses or other instructional activities might produce a learning environment wherein domain-, problem-, and task-specific competencies were likely to be optimized
By the end of the second year of AME meetings, the course directors responsible for year-2 systems, clinical medicine, and OMM courses were ready to use these considerations to formulate their own learning sciences–based approach to their respective instructional activities. A 20-item survey was formulated to gather data from students and use analytics to provide evidence of the benefits of the learning sciences–based curricular reform efforts. 
The 20 questions were organized into 3 categories of intended course improvements: course preparations and instructional activities, integration of course instruction with assessment, and integration of instruction across courses. The questions were approved by an institutional review board and shared the same general format: “Compared to last semester’s Year Two Systems, OMM and Clinical Medicine courses, this semester’s Year Two Systems, OMM and Clinical Medicine courses were improved in terms of….” The 5-point Likert-type scale survey (1 indicating strongly agree and 5 indicating strongly disagree) was administered at the end of the spring 2012 semester to 151 second-year students. Overall, 111 students completed the survey, yielding a 74% response rate. The data were analyzed using a series of χ2 calculations and the Bonferroni-based correction procedure (.05/20 systems) to reduce the likelihood of type-1 errors. This analytical method provided evidence of statistically significant improvements along 15 of the 20 evaluation items. 
Generally, students agreed that course preparations and instructional activities were consistently presented, well organized, and effective. Students also reported that the integration of year-2 systems and clinical medicine courses prepared them for course examinations. However, approximately half of the surveyed students indicated that the OMM course did not prepare them well for the course examination and that professionalism, ethics, and communications topics were not integrated well. These overall findings provide evidence that faculty were able to apply their evolving understanding of these models, theories, and principles toward the development of a learning sciences–based approach to curricular design (ie, the AME’s first mission element) and are also making progress in acquiring declarative knowledge and developing procedural knowledge sufficient to advance their capabilities and careers as physicians and educators (ie, the AME’s second mission element). 
Curricular Reform to Improve Patient Safety
Beginning with the HMD’s first Quality Chasm series report in 2000, To Err Is Human,6 and through the most recent publication in this series, Improving Diagnosis in Health Care,7 the HMD makes clear that essentially all US residents will experience at least 1 substantial diagnostic error in their lifetime, with many having devastating consequences. Their findings report that diagnostic error occurs in 5% of all adults seeking medical care each year, 10% of all patient deaths, 6% to 17% of adverse events in hospitals, and the majority of paid medical malpractice claims. 
The magnitude of the negative impact that medical error has on society is brought into focus with evidence suggesting that diagnostic error is the third leading cause of death in the United States (behind cardiovascular disease and cancer), with approximately 250,000 to 400,000 premature and unnecessary deaths occurring annually.8 Although the number and variety of factors contributing to suboptimal health care and medical errors is unknown, the HMD implicated medical education as a root source of error in practice. Subsequently, UNTHSC/TCOM’s AME was designed to enrich faculty’s understanding of how learning sciences models, theories, and principles might be applied to curricula aimed at developing the intellectual skills and procedural knowledge students need to demonstrate improving levels of diagnostic competencies. 
In general, when physicians and medical faculty are asked to describe how they approach the task of differential diagnosis (DD), they often refer to it as a problem-solving process or skill. They believe that once developed, this skill is generalizable across any and every medical problem a patient can present with. Furthermore, they describe this generalizable skill with phrases such as “clinical reasoning,” “critical reasoning,” and “problem solving.” Curiously, learning sciences research has determined that diagnostic competence is much more heavily predicated on the development of knowledge (especially procedural knowledge) than generalizable reasoning skills.9 Over the course of 4 to 5 decades, a series of emerging, learning sciences–based theoretical frameworks have provided insights describing how the task of DD is performed.10 These insights might be used to create a codified, evidence-based approach to diagnostic training in medical education. Currently, the learning sciences model that best describes the cognitive elements enabling DD is referred to as the dual processing theory. 
The duel processing theory suggests that 2 distinct yet interrelated cognitive systems play critical roles during ill-defined categorization or classification tasks such as DD (ie, system I and system II).11-13 As applied to DD, system I is theorized as a rapid, nonanalytical pattern recognition or similarity-driven approach to diagnostic reasoning, and system II enables a more conscious, analytical rule-based approach. Each system, in turn, comprises at least 2 core subcomponents: (1) system-specific information processing mechanisms and (2) system-specific procedural knowledge. Research at UNTHSC/TCOM involving computer-based, dual processing theory–driven approaches to DD training has demonstrated that first- and second-year students and practicing physicians achieve improved DD accuracy.14-16 
Two additional semesters of AME coursework were subsequently devoted to supporting faculty in the development of a rudimentary understanding of the dual processing theory and its respective system I and system II knowledge-based structures and information-processing elements. This dual processing theory training served as a theoretical framework underlying the creation of a new, small group–based approach to diagnostic training in second-year students. Although little empirical evidence of the success of this formalized dual processing theory–based approach to diagnostic training exists, students have a better grasp of what they need to learn (eg, DD-oriented procedural knowledge) and how to apply what they have learned (eg, by means of systems I and II processing mechanisms involving pattern recognition and rule-based constructs) during case-based practice opportunities conducted in a small group, faculty-facilitated learning environment. The AME faculty now have the opportunity and challenge to organize and produce institutional review board–approved research protocols to determine whether these innovations are leading to improved DD performance. Such activities would provide AME faculty the opportunity to attain the AME’s third mission element: the conduction of education-oriented research and scholarly activities. 
Curricular Development for a New Type of Physician
Physician assistants and nurse practitioners are increasing in numbers and providing patient care in areas that were previously exclusive to physicians. Given the influx of these health care professionals, medical schools must consider how future physicians will demonstrate their own distinct contribution to the health care work force. One such consideration is creating a medical school curriculum that prepares students to play leadership roles in the development of population-, community-, and systems-based practice. 
To prepare for such potential curricular innovations, AME programming initiated 3 concurrent lines of AME coursework and broader institutional discussions. First is the creation of AME coursework designed to introduce faculty to fundamental definitions and concepts associated with population-oriented health care, systems-based practice, and explorations of the meaning of health in terms other than the absence of disease. Second are AME discussions inviting faculty to reflect on whether and to what degree they provide or might be able to introduce notions of population, systems, and health into their respective practices. Third are discussions intended to go beyond AME faculty. Such discussions aim to engage faculty across the institution so they can collectively consider how population-, systems-, and health-oriented approaches to patient care might be established as an institution-wide initiative. 
Conclusion
Over the past 5 decades, an enormous body of research in the learning sciences has made it clear that traditional, passive approaches to the imparting of knowledge from an experienced teacher to a novice learner is not sufficient if the goal is for the learner to gain competence. Rather, competence requires the development of 5 core human capabilities involving the acquisition of information and information-gathering skills as well as the development of intellectual skills, cognitive strategies, sensorimotor skills, and appropriate attitudes. We hope that this brief elucidation of learning sciences–derived models of mind and other relevant principles will motivate medical training programs to explore and adopt their own learning sciences–based framework for faculty programming. Although the programming is a relatively novel initiative within the osteopathic medical profession, we believe that the development of learning sciences–based approaches to designing medical curricula will produce osteopathic graduates who will lead in the development of population- and systems-driven, outcomes-oriented solutions for the communities they will serve. 
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