Abstract
The authors present a model of an interdisciplinary, longitudinal (lifecycle), generalist “doctoring” course that spans the first 2 years of osteopathic medical education and training. This course is intended to run concurrently with a nongeneralist curriculum and to link this curriculum sequentially. The educational topics and objectives show a unique alignment with anatomy and osteopathic principles. The course encompasses (1) logical sequencing of curricular content; (2) a strong interconnection between the didactic and clinical practice experiences throughout the continuum of education and training; (3) additional exposure to clinical applications during the early and formative stages of medical education; and (4) additional coverage of specific clinical competency areas.
The osteopathic approach to patient care is to treat the patient as a person. In his book,
Doctoring: The Nature of Primary Care Medicine, Eric Cassel, MD, advises, “teach the physician as a person.”
1 This method requires adapting medical education curricula and teaching methods to the diverse ways in which students learn and respond to their educational experiences. It also requires that medical educators consider how students' emotions, concerns, fears, and values can diminish or enhance their development as future physicians. Therefore, questions that medical educators should consider when evaluating their programs include:
Does the curricular structure accommodate individual differences?
Does it help or hinder the learning process?
Does the curriculum address values?
Does it reflect the art of medicine as well as the science?
Does it encourage individual growth and self-evaluation?
Does it address the need to educate and train a “complete” physician?
The faculty and staff of the Department of Family Medicine, Preventive Medicine, and Community Health and the Curriculum Committee at Kirksville (Mo) College of Osteopathic Medicine of A.T. Still University of Health Sciences (KCOM/ATSU) sought answers to these questions. One area of concern was the sequence of clinical courses, which was disjointed and illogically structured. Lectures on death and dying preceded training in general care and physical examinations. In other words, education and training were not following the lifecycle. Students had to rearrange for themselves the fragmented segments of information in order to apply this knowledge and skill at various points in time.
Integration on many levels was needed to ensure high-quality educational experiences and to increase student competence in clinical reasoning. In addition, students needed more learning tools for accessing and absorbing an ever-increasing knowledge base in the basic and clinical sciences and enhancing osteopathic integration. Finally, it was important to incorporate the biopsychosocial, as well as the biomedical, components of caring for patients.
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Course Development and Implementation
In the fall of 1998, the Department of Family Medicine, Preventive Medicine, and Community Health inaugurated a new course, “The Complete DOctor” (
Appendix), to respond in part to educational reform recommendations in medical education literature.
8,9 The interdisciplinary, longitudinal (lifecycle) generalist course spans the first and second years of medical education and training. The course's subject matter is linked to concurrent coursework through anatomy and osteopathic manipulative treatment (OMT) specific to each topic area (such as cardiopulmonary, neurologic, and visceral examinations).
To capitalize on existing models, we closely examined other leading medical schools that have implemented innovative longitudinal doctoring tracks (also commonly referred to as “introduction to patient care” tracks), including those designed for the University of Missouri–Columbia School of Medicine and the David Geffen School of Medicine at the University of California, Los Angeles. The course design of The Complete DOctor” is based mainly on the curriculum called “doctoring” developed by faculty at the David Geffen School of Medicine.
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The goal of the course is to prepare “complete” primary care physicians, who care for patients, families, and communities in a compassionate and competent manner. The course includes psychological and social aspects of medicine in addition to teaching an appreciation for humanistic behavior as recommended by Coutts and Rogers.
10 Reliance on scientific and subjective assessments of patients' overall needs, as discussed by Cassel,
1 are taught and encouraged.
“The Complete DOctor” I and II have been implemented, and “The Complete DOctor” III and IV are being developed. The course is continually being evaluated and modified.
Course Description and Objectives
Eight generalist courses were merged to create “The Complete DOctor”:
Concepts of Primary Care
Physical Exam Skills Symposium
Public Health/Preventive Medicine
Introduction to Physical Exam Skills
Advanced Physical Exam Skills
Clinical Experiences I
Clinical Experiences II
Introduction to Medical Interviewing
“The Complete DOctor” was designed to create (1) logical sequencing of curricular content; (2) a strong interconnection between the didactic and clinical practice experiences throughout the continuum of education and training; (3) opportunities for additional exposure to clinical applications during the early stages of medical education; and (4) additional coverage of specific clinical competency areas.
This longitudinal course provides a primary care emphasis while integrating important clinical experiences early and steadily throughout the course. Students gain proficiency in interviewing patients, documenting patient encounters, developing clinical evaluation skills, and presenting cases. During the 2 years of the course, students must complete a 2-week primary care preceptorship, as well as three 2-hour clinical experiences—one in a physician's office, one with a community agency (such as a hospice), and one in a hospital.
Cultural and Religious Competencies
One of the course objectives is to develop cultural and religious competency skills and enhance communication and interpersonal skills to establish and maintain positive and productive relationships with patients of all ages and backgrounds. Physicians-in-training must be sensitive to patients' diverse social and cultural backgrounds and know how to explore these issues insofar as they are relevant to patients' health status.
Biopsychosocial Component
The theoretical perspectives of lifecycle development and the major stages from birth to death are presented. In addition, students learn how to identify and screen patients for mental health problems, such as depression, anxiety, addiction, eating and sleep disorders, violence/abuse, and suicide.
Integration With Other Disciplines
“The Complete DOctor” aligns anatomy with osteopathic principles and practice to focus on the clinical application of anatomical concepts. The integration of basic and clinical sciences serves as a unifying thread through individual courses to aid students' long-term retention of information and to reinforce the clinical usefulness of the knowledge gained. For example, when a particular anatomic region is being dissected, physical examination skills from The Compete DOctor, the manual skills from the OMT course, and radiologic and histologic perspectives are covered concurrently. Numerous clinical cases and SOAP (subjective, objective, assessment, plan) notes have been developed by the faculty in all of the involved disciplines with this integration in mind.
Clinical Experiences
The educational objectives of this course include mastery of the basic principles of key areas, such as community and population-based medicine; community resources and partnerships; cultural diversity and sensitivity regarding rural, minority, low-income, and underserved patients; and the Healthy People 2000 and 2010 objectives in the public health model.
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“The Complete DOctor” I and II offer many clinical experiences with underserved rural populations. For example, the completion of a 2-week family medicine preceptorship coordinated by the Missouri Area Health Education Centers network is required by the end of the first year.
The faculty and staff at KCOM/ATSU target local elementary schools, middle schools, and high schools that need these services the most. Students are trained early in “The Complete DOctor” to conduct elementary school physical examinations, fitness assessments, and healthcare screenings. During implementation, our services are negotiated and coordinated with local school districts, including the appropriate avenues for obtaining referrals for additional medical care as indicated.
In our House Call program, students conduct healthcare visits with elderly volunteers in their homes. When possible, students are paired with nursing and communication students from Truman State University in Kirksville, Mo, to develop interdisciplinary collaboration and communication. Four visits are conducted during 2 years, each with specific objectives. After each visit, a faculty facilitator conducts a review session with the interdisciplinary team.
During these home visits, students focus on how to better communicate with older patients, while examining the patients' overall living environment as it relates to their health. A medical history is taken, and physical, hearing, and vision screenings are conducted. During the final visit, spirituality is discussed as it relates to the patients' healthcare. The students are then assessed by the volunteer patient.
Small-group assignments to devise projects geared toward changing health behavior for communities are given. Topics include smoking, substance abuse, and teen pregnancy. This portion of the course is based on Healthy People 2000 and 2010.
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Seminar Series
An ongoing generalist seminar series conducted by internal and external experts focuses on various medical topics (eg, critical thinking, evidence-based medicine, geriatrics, managed care, and spirituality in medicine) and on issues that allow students to make a smoother transition from medical student to physician (eg, residency selection, final preparation for rotations, and final preparation for the first night of internship). When possible, seminars are conducted like a professional continuing medical education course. This experience exposes students to a professional environment with their peers and internal/external guest faculty.
Teaching and Learning Methods
Several interdisciplinary teaching methods are used in “The Complete DOctor,” including clinical ambulatory and laboratory experiences, lectures/workshops, panel discussions, problem-based learning (self-directed learning and computerized/standardized case studies), role playing, small group (tutorial) experiences, and standardized patients. These methods encourage active learning instead of passive acquisition of facts.
The use of various teaching methods taught by an interdisciplinary team of educators supports the intent of the program to adapt to individual differences among students and to “teach the physician as a person.”
Assessment
The educational objectives of “The Complete DOctor” are closely correlated with KCOM/ATSU's learning objectives for the entire medical school curriculum and the Comprehensive Osteopathic Medical Licensing Examination USA (COMLEX-USA).
12 Multiple assessment tools are used to gain a sharper focus on the achievement of educational objectives, to facilitate course improvement and renewal, and to better ensure student attainment of critical competencies.
Evaluation of Students
First- and second-year students are assessed in conjunction with KCOM/ATSU's department of medical education in a multilevel process, including clinical classroom assessments using multiple-choice questions on a cumulative knowledge base, videotaped patient simulation encounters, and prerotation objective structured clinical examinations (OSCEs) on physical examination skills, ethical issues, communication skills, and OMT.
Evaluation of physical examination and OMT skills is obtained via written and practical formats. Testing is presented as a clinical case in the COMLEX-USA format followed by questions related to the case that are designed and written with input from all of the involved disciplines. The performance skill section of testing integrates the clinical skills with basic science knowledge.
Self-administered surveys are used for some topics early in the course and again at the end of the course to determine whether students' attitudes toward some of the psychosocial aspects of patient care have changed.
The special seminar series is evaluated by pre- and posttesting student knowledge on the given topics and by asking students to rate the speakers' effectiveness as well as seminar content, value, and relevance.
Outreach projects, such as K-12 physical examinations, are evaluated by the family medicine faculty and local community-based physicians for their demonstration of student skill, competency, skill, techniques, and professionalism. For programmatic purposes, the number of physical examinations, assessments, screenings, and educational programs conducted by our students are tracked, as well as the number of local children who receive their care.
Student Evaluation of Course
Student feedback has played a key role in the ongoing assessment of “The Complete DOctor.” In addition to quarterly online evaluations for the course and instructors, students also evaluate the small group or laboratory exercises. The faculty development coordinator meets with department faculty to review student feedback and suggest strategies for improvement if necessary. A potential limitation exists, however, because of the subjective nature of student surveys and discussion.
Student feedback has also been obtained through small discussion groups based on the Small Group Instructional Diagnosis.
13 Students evaluate the lectures and lecturers with a written survey and then discuss what worked well and what should be changed. Also, first- and second-year classes have course liasons who bring course issues to the course director and department chairperson.
The faculty and staff and the Curriculum Committee of KCOM/ATSU are using the feedback to assess the educational outcomes under the previous and current curricular models and to modify subsequent course offerings as indicated. In addition, COMLEX-USA Level 1 scores are reviewed on a longitudinal basis.
Challenges and Lessons Learned
In the implementation of a longitudinal, continuous course with limited full-time faculty, a number of challenges have been encountered. The course methods require a large cohort of instructors and well-trained facilitators who are dedicated to and who comply with the course objectives so that there is reliability and consistency across small groups. Also, changes made to the course require the involvement of a large number of individuals at multiple locations.
Greater attention needs to be directed toward educating students and faculty about the longitudinal structure and how topics are presented and then revisited. A certain amount of foundation-building is necessary for this method to be effective. You must start with basic skills/core material and then expand the focus incrementally.
We gained a greater appreciation for the value of early clinical experiences integrated with basic science curriculum and the enhancing effect a longitudinal curriculum has on these educational components.
“The Complete DOctor” III and IV
Efforts are underway to implement “The Complete DOctor” in the third and fourth years of medical school. However, the course faces obstacles related to KCOM/ATSU's decentralized clinical training regions. Students spend the first and second years on the KCOM/ATSU campus, but the third and fourth years are spent in clinical training in a number of geographic regions across the country. Another challenge is in the number of faculty members needed to cover curriculum throughout all regions.
Efforts to expand “The Complete DOctor” into the third and fourth years have included purchasing a cadre of virtual case modules. The faculty members from the Department of Family Medicine, Preventive Medicine, and Community Health have developed the clinical objectives and have written the postrotation examinations given at the end of each core site rotation. In addition, elective courses, such as medical Spanish, have been developed. Web-based, computer-interactive, and classroom-based electives are being planned for content related to evidence-based medicine, geriatric medicine, humanism in medicine, literature and medicine, professionalism, and religion/spirituality in medicine. Web-based cases will also be developed on topics such as oral health, patient safety, and quality improvement.
Preceptors will evaluate students in the third and fourth years on clinical performance, and additional evaluation will include analysis of student logs, case presentations, core knowledge–based examinations, end-of-core OSCEs, clinical practice examinations with standardized patients, and a Promotion Board review. In turn, the students will evaluate preceptors and rotation sites.
Comment
“The Complete DOctor” has enriched KCOM/ATSU's medical education program. It has effectively integrated the existing primary care courses with one another, as well as with other curricular offerings, while enhancing students' diagnostic skills. We believe that the course is helping to educate and train complete physicians—those who are competent, compassionate, and who incorporate OMT in their practices.
It is our hope that “The Complete DOctor” can serve as model for other medical educators who want to develop a similar curriculum. This model is supported by calls for medical education reform.
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Because of the accelerated rate of change in healthcare policies and practices, as well as the demands of society, we expect that “The Complete DOctor” will always be in an evolutionary state. As a philosopher once said in relation to change, “You cannot step twice into the same river; for other waters are continually flowing in” (Heraclitus). Therefore, rigorous curricular evaluation and reform will always be required to ensure that we are providing the best education for future osteopathic physicians.
The Complete DOctor course development was supported in part by grant No. 5D05 HP80153 from United States Department of Health and Human Services (DHHS), United States Public Health Service Commissioned Corps, and the DHHS Health Resources and Services Administration Bureau of Health Professions, Division of Medicine and Dentistry, 1997-2000.
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