Review of SBM Connective Tissue/Musculoskeletal Course occurs in the spring of Year 2 Course Director – Lin Brown Course has 39 curricular hours Course was last reviewed Nov 2013

Action Plan from Prior Review Revisions to learning objectives (less vague; have objectives for each session – this has not occurred Reduce reliance on standard lectures – still an issue but made some progress with more small groups Assure that objectives not assessed on final exam are assessed some other way – assignment added to reflect on lie patient exam session Improve course organization by better grouping of topics – this occurred both last year and this year with better grouping

Course Objectives 1.Describe the pathophysiology, diagnosis, and treatment options for osteoarthritis 2.Describe the pathophysiology, diagnosis, and treatment options for rheumatoid arthritis (including juvenile rheumatoid arthritis) 3.Describe the pathophysiology, diagnosis, and treatment options for less common types of arthritis (e.g. sero-negative, psoriatic, etc.) 4.Describe the pathophysiology, diagnosis, and treatment options for diseases of the lumbar and cervical spine (including DJD, ankylosing spondylitis, disc disease, low back pain, etc.) 5.Describe the pathophysiology, diagnosis, and treatment options for complications of uric acid and other crystals (including gout, pseudogout) 6.Describe the pathophysiology, diagnosis, and treatment options for common infections of the MS system (e.g. Lyme disease, septic arthritis) 7.Describe the pathophysiology, diagnosis, and treatment options for diseases of skeletal muscle (e.g. myositis, polymyositis, etc.)

Course Objectives 8.Describe the pathophysiology, diagnosis, and treatment options for connective tissue diseases (e.g. systemic lupus erythematosus, 9.Describe the pathophysiology, diagnosis, and treatment options for the various types of vasculitis (e.g. Polymyalgia rheumatica, giant cell arteritis, granulomatosis with polyangiitis, polyarteritis) 10.Describe the pathophysiology, diagnosis, and treatment options for bone and soft tissue diseases (e.g. tumors, fractures, sprains) 11.Describe the pathophysiology, diagnosis, and treatment options for common pediatric and developmental diseases (e.g. juvenile rheumatoid arthritis, genetic conditions) 12.Describe the advantages and disadvantages of major diagnostic testing modalities for the MS system (e.g. radiography, CT, MRI, ultrasound, serologic testing, etc.) 13.Describe the most common symptoms of rheumatic and musculoskeletal diseases, and use that knowledge to help develop a differential diagnosis

Course Objectives 8.Describe the pathophysiology, diagnosis, and treatment options for connective tissue diseases (e.g. systemic lupus erythematosus, 9.Describe the pathophysiology, diagnosis, and treatment options for the various types of vasculitis (e.g. Polymyalgia rheumatica, giant cell arteritis, granulomatosis with polyangitis, polyarteritis) 10.Describe the pathophysiology, diagnosis, and treatment options for bone and soft tissue diseases (e.g. tumors, fractures, sprains) 11.Describe the pathopysiology, diagnosis, and treatment options for common pediatric and developmental diseases (e.g. juvenile rhumatoid arthritis, genetic conditions) 12.Describe the advantages and disadvantages of major diagnostic testing modalities for the MS system (e.g. radiography, CT, MRI, ultrasound, serologic testing, etc.) 13.Describe the most common symptoms of rheumatic and musculoskeletal diseases, and use that knowledge to help develop a differential diagnosis

Course Objectives 14.Explain how patients with MS/CT disorders can be skillfully and respectfully examined, with appropriate attention to cleanliness and privacy 15.Explain the indications, complications and limitations of common diagnostic modalities including imaging studies, EMG, NCS, and tissue biopsies 16.Correctly identify common abnormalities seen on plain radiographs, CT scans, and MRI's of the MS system 17.Communicate effectively, verbally and in writing, with colleagues and physicians 18.Demonstrate how to assist patients in understanding their treatment options, and prognosis of their diseases 19.Meet professional responsibilities (meetings, assignments, etc.) in a timely and professional manner

Course Objectives 20.Demonstrate the ability to take responsibility for one's own medical education 21.Describe how barriers to access for care of MS/CT problems adversely effects the health of vulnerable populations 22.Demonstrate the ability to identify and evaluate information about evidence-based and cost-conscious strategies in managing MS/CT disorders 23.Identify appropriate resources to help support patients with MS/CT disorders, and describe the roles of all members of the inter-professional HC team 24.Describe the appropriate role of rehabilitation (physiatry) and related services (OT, PT, etc.) in the care of patients with MS/CT diseases

Course Objectives – Comments The CTMS course lists 24 objectives that pertain to 28 learning sessions. In general, the course objectives and the learning content are congruent. Some suggestions for the course objectives: Most of the objectives are written in the form “describe …….pathophysiology, diagnosis and treatment options” for a particular topic. This could be more active: e.g. “describe the pathophysiology, use the pathophysiology to develop differential diagnosis, and explain the treatment options and how they would work” done

Course Objectives – Comments Objective 11 is written as “common pediatric and developmental diseases” but really means “common pediatric and developmental disorders of the musculoskeletal system” and should be clarified done Objective 13 is vague: “…use that knowledge to help develop a differential diagnosis” might be to changed to “describe the common signs, symptoms, and laboratory abnormalities of rheumatic and musculoskeletal disease and use that information to develop a differential diagnosis.” done

Course Objectives – Comments Objective 14 asks to “explain how patients can be examined with appropriate attention to “cleanliness and privacy”. It is hard to know what this means in terms of examining the musculoskeletal system and could be a better described objective for knowledge of the physical exam done Objectives 12, 15 and 16 involve significant redundancy and could be restated as one objective for imaging and one for other types of testing done

Course Objectives – Comments When comparing the learning sessions with the objectives, it is not clear where fibromyalgia falls within the objectives, or ethics, orthopedics, or rheumatologic syndromes in systemic disease. Each of these important topics deserves an objective. added The final objective concerning physical therapy and rehab has no obvious place in the lecture series removed

Format of Course & Session Objectives Course objectives are provided in the syllabus Course objectives are written in the correct format Many sessions are missing objectives: – CT clinical cases 1 and 2 – Bone overview – Orthopedics – Congenital/developmental problems – Joint examination – DJD of the spine – Bone tumors – Bone radiology – Fractures

Format of Course & Session Objectives Some of the session objectives are vague. For example, spondyloarthropathy session: – ‘Discuss the major types of spondyloarthropathies and their features” – “Discuss cases” – “Review treatment options” Rheumatologic syndromes in systemic disease: – “Appreciate the extent that diseases not considered to be rheumatologic can present or include musculoskeletal complaints”

Format of Course & Session Objectives Acute soft tissue: – “At the end of this lecture, the student should be able to recognize and diagnose most derangements about the shoulder and knee. You should also be able to suggest a proper course of treatment for these sports related joint injuries and diseases.”

Format of Course & Session Objectives Some of the session objectives are not written in the correct format: – “Become familiar with the serologic tests for evaluating SLE” (lupus) – “Know when to consider a diagnosis of vasculitis” (vasculitis) – “Appreciate the pathologic changes in PM/DM/IBM.”

Issues of Redundancy The subcommittee did not find unplanned redundancy in the CTMS course

Exploration of Health and Values The course discusses ethical issues in the management of chronic pain

Summary regarding Objectives Course objectives: – Consider adding objectives for some of the major content areas (e.g. fibromyalgia). – Consider consolidating some of the course objectives that entail significant redundancy Session objectives: – Objectives need to be added for many of the course sessions – Some of the session objectives are vague and/or not written in the correct format Correct minor spelling errors in the course objectives

Course Learning Opportunities Lecture: 29 hours (75%) Small group sessions: 6 hours (16%) PBL/sim center: 3.6 hours (9%)

Summary regarding Pedagogy The course needs to reduce the number of lectures in the course. The current percentage (75%) does not meet the Geisel policy on Active Learning/Lecture Time or LCME recommendations.

Assessment Medical knowledge (75%): – Final Written Exam Attendance, participation, and engagement (25%): – 3 small group sessions (3 pts each, total 9 pts) – 3 short quizzes (3 pts each, total 9 pts) – Attend joint exam session (5 pts) – Patient write-up (2 pts) – based on participation, attendance and timeliness

Summary regarding Assessment The grading system for the course seems appropriate The course is currently assessing all of its objectives

Measures of Quality – Step I *values reported for core disciplines are SD above the US/Can mean for Geisel mean scores Mean last 3 years ( ) Pass rate98.8% 97.5% 98.4% Mean score SYSTEM-BASED TOPICS** Behavioral sciences Cardiovascular system Gastrointestinal system Hematopoietic/lymph systems Immune system Musculoskeletal, skin, CT systems Nervous system0.21na 0.21 Nervous system & Behavioral health (2014)na Nutrition Renal/urinary system Reproductive/endocrine systems0.39na 0.39 Reproductive system (2014)na Endocrine system (2014)na Respiratory system Multisystem processes & disorders (2014)na mean 0.20

Measures of Quality – Course Evaluation scale [1=poor; 2=fair; 3=good; 4=very good; 5=excellent] Year 2 Courses 2014/15 Clarity of the learning objectives Congruence of quiz and exam questions to the learning objectives Effectivenes s of the organization of the course How useful and relevant introduction to this field or discipline Overall quality of this course Mean Lecturer/Lar ge Group Instruction Score Mean Small Group Leader Score Overall mean score CT/MS /15 MEAN

Measures of Quality – Student Comments Strengths: Well-organized lectures Rheumatology small group sessions Sim center session

Measures of Quality – Student Comments Suggestions for Improvement: Better integration of and organization of orthopedics content into course: – “Some of the orthopedic lectures were poorly organized and it was difficult to understand the level of detail for which students were responsible.” Improve congruence between lecture and small group sessions and exam: – “The final exam did not correlate well with what was covered in class, including several questions that were not covered at all.’ Improve small group materials: – “The conferences did not have a very uniform answers. I understand that rheumatology is constantly changing, but a lot of the material presented conflicted with what another small group leader or lecturer would present or emphasize.” ? Congruence between course and USMLE: – “the focus of the course during the latter half did not sufficiently cover what is expected of us on step 1. I would have liked to hear less orthopedics/peds and more on gout, septic arthritis, bone tumors ”

Summary regarding Measures of Quality The course is rated in the good to very good range; overall course rating was in the mid-range of all SBM courses The small group and sim center sessions were very highly rated Students were less happy with the organization, integration, and quality of the orthopedics sessions A number of students questioned the congruence between the course sessions/materials and the exam Student performance on the CT/MS content of USMLE part 1 was similar to overall performance of Geisel students

Recommendations Consider adding/clarifying/consolidating course objectives as previously outlined; correct numerous misspellings in course objectives – Instead of deleting the objective related to rehab, see if you can find ways to incorporate this into the course in a meaningful way Insure that objectives are provided for all sessions Reduce the amount of lecture time

Recommendations Consider ways to better integrate orthopedics content and to improve the quality of the orthopedics sessions Review the exam to make sure that questions reflect course content

Action Plan Course objectives revised (see next slides) – Will see if rehab can be incorporated into orthopedics sessions Will have lecturers add objectives for the sessions without them and revise the vague objectives Have added two ortho small groups (4 hours) – Lecture time now 63% (down from 75%) – Will add additional small group and/or interactive sessions to further reduce lecture time

Action Plan Ortho lectures now better reflect the areas that should be covered The exam will be re-considered; I wanted one year without change when I assumed the course directorship Not sure how to homogenize the experience in small groups; rheumatology is not an exact science…..

Revised Course Objectives (proposed) 1.Describe the pathophysiology, and use the pathophysiology to develop a differential diagnosis, and explain the treatment options and how they would work for osteoarthritis. 2.Describe the pathophysiology, and use the pathophysiology to develop differential diagnosis, and explain the treatment options and how they would work for rheumatoid arthritis (including juvenile rheumatoid arthritis). 3.Describe the pathophysiology, and use the pathophysiology to develop differential diagnosis, and explain the treatment options and how they would work for the seronegative spondyloarthropathies (psoriatic arthritis, arthropathy of inflammatory bowel disease, ankylosing spondylitis, reactive arthritis). 4.Describe the pathophysiology, and use the pathophysiology to develop differential diagnosis, and explain the treatment options and how they would work for diseases of the lumbar and cervical spine (including DJD, ankylosing spondylitis, disc disease, low back pain, etc.)

Revised Course Objectives (proposed) 5.Describe the pathophysiology, and use the pathophysiology to develop differential diagnosis, and explain the treatment options and how they would work for diseases of uric acid and other crystals (including gout, pseudogout). 6.Describe the pathophysiology, and use the pathophysiology to develop differential diagnosis, and explain the treatment options and how they would work for common infections of the MS system (e.g. Lyme arthritis, septic arthritis). 7.Describe the pathophysiology, and use the pathophysiology to develop differential diagnosis, and explain the treatment options and how they would work for diseases of skeletal muscle (e.g. myositis, polymyositis, etc.). 8.Describe the pathophysiology, use the pathophysiology to develop differential diagnosis, and explain the treatment options and how they would work for connective tissue diseases (e.g. systemic lupus erythematosus, Sjogren’s syndrome, scleroderma).

Revised Course Objectives (proposed) 9.Describe the pathophysiology, and use the pathophysiology to develop differential diagnosis, and explain the treatment options and how they would work for bone and soft tissue diseases (e.g. tumors, fractures, sprains). 10.Describe the pathophysiology, and use the pathophysiology to develop differential diagnosis, and explain the treatment options and how they would work for common pediatric and developmental diseases of the musculoskeletal system(e.g. juvenile rheumatoid arthritis, genetic conditions). 11.Describe the advantages and disadvantages of major diagnostic testing modalities for the MS system (e.g. radiography, CT, MRI, ultrasound, serologic testing, etc.). 12.Describe the common signs, symptoms, and laboratory abnormalities of rheumatic and musculoskeletal disease and use that information to develop a differential diagnosis.

Course Objectives 13.Demonstrate how to interact with patients with MS/CT disorders including attention to hand washing and sensitive interviewing. 14.Communicate effectively, verbally and in writing, with colleagues and physicians. 15.Demonstrate how to assist patients in understanding their treatment options, and prognosis of their diseases. 16.Meet professional responsibilities (meetings, assignments, etc.) in a timely and professional manner. 17.Describe how barriers to access for care of MS/CT problems adversely effects the health of vulnerable populations. 18.Demonstrate the ability to identify and evaluate information about evidence-based and cost-conscious strategies in managing MS/CT disorders.

Course Objectives 17.Identify appropriate resources to help support patients with MS/CT disorders, and describe the roles of all members of the inter-professional HC team 18.Describe the appropriate role of rehabilitation (physiatry) and related services (OT, PT, etc.) in the care of patients with MS/CT diseases 19.Describe how fibromyalgia as a model of chronic musculoskeletal pain is a model of chronic pain in other disorders.