Resident Evaluation of a Web-based Integrative Medicine Curriculum: The Function of Formative Evaluation Ben Kligler, M.D., Patricia Lebensohn, M.D., Sally Dodds, Ph.D., Raymond Teets, M.D., & Victoria Maizes, M.D.

Presentation Objectives The objectives of this presentation are to: ▫Describe the function of formative evaluation for curriculum development. ▫Review the results from learners’ evaluation of the Integrative Medicine in Residency curriculum. ▫Describe the procedures used in applying feedback from learners’ evaluations to guide curriculum changes and revisions.

Integrative Medicine in Residency (IMR) is… Competency-based, online, 200-hour, curriculum. In-depth training in Integrative Medicine. Incorporated through all 3 years of Family Medicine residency. Piloted at 8 residencies nationwide. Seamless, online evaluation of the curriculum and the residents. Responds to ACGME competency requirements. Evaluation developed simultaneously with the curriculum.

University of Arizona University of Texas Medical Branch Hennepin County Carolinas Medical Center Beth Israel Maine-Dartmouth Maine Medical Center University of Connecticut IMR Program Locations

IMR Curriculum Units

Introduction to Integrative Medicine Prevention and Wellness: U.S. Preventive Health Services Nutrition and Diet Supplements for Prevention Physical Activity Sleep Stress and Mind-Body Medicine Spirituality Clinical Integration Tools in Integrative Medicine: Integrative Medicine Intake and Care Plan Botanicals Mind-Body Medicine Manual Medicine Introduction to Energy Medicine and Whole Systems Practice Management Motivational Interviewing for Behavioral Change Acute Care: Acute Back Pain, Urinary Tract Infection, Gastroenteritis, Otitis Media, Vaginitis, Atypical Chest Pain, Upper Respiratory Infection Pediatric Topics: ADD/ADHD Chronic Pain Syndrome Asthma and Allergies Women’s Health Topics: PMS/PMDD Dysmenorrhea Menopause Fibromyalgia Osteoporosis Depression Eating Disorders Pregnancy and Lactation Chronic Illness: Cardiovascular Disease Type II Diabetes Osteoarthritis Rheumatoid Arthritis Obesity Irritable Bowel Syndrome Chronic Back Pain Special Topics: HIV/AIDS Cancer Survivorship Environmental Medicine Units and Courses

IMR: Educational Methods  Needs assessment informed curriculum design.  Web-based curriculum written and edited by Integrative Medicine educators.  Competencies aligned with the ACGME Outcomes Project.  Flexible modular format to meet the needs of residency schedules.  Case-based, interactive learning and streaming video.  Experiential exercises and process-oriented group activities at the residency sites.  A community of learners through online dialogues with faculty and peers.  Emphasis on teaching and promoting physician well- being and self-care.

IMR User Interface Online portfolios Flexible modular format Resources and Links Direct Observation Checklists Reflections

“When the cook tastes the soup, that’s formative; when the guests taste the soup, that’s summative.” - Robert Stakes What is Formative Evaluation?

Formative Evaluation… Helps form and strengthen programs by: ▫Examining the need for them, ▫Their delivery or technology ▫The quality of their implementation ▫Assessing their organizational contexts, procedures, and resources (Scriven, 1991). Methods emphasize data collection and analysis prior to completion.

Why Use Formative Evaluation in the IMR? Medical knowledge in Integrative Medicine is dynamic, evolving rapidly; revisions are largely driven by new information. Distributed, web-based curricula requires feedback from learners to be successful. In the IMR, formative methods include: 1.Preliminary needs assessment 2.Feedback from resident evaluation of courses

1. IMR Needs Assessment (Benn, Maizes, Guerrera, Sierpina, Cook, & Lebensohn, 2009) Methods ▫222 faculty and residents from 8 family medicine programs (60.2% response rate). ▫Online survey w/ structured and open-ended questions. Results ▫Preferred IM be woven throughout all curriculum areas (67%). ▫Top topics: Nutrition, Supplements, and Physician Wellness. ▫Top curricular areas for IM enhancement: Chronic illness, behavioral health, and outpatient medicine ▫Viewed IM central to family medicine training, patient care, and the field of family medicine (84%). ▫Top challenges: Limitations in time, resources, and acceptance.

2. IMR Course Evaluations Measures assess learners’ ratings of the course in: ▫Meeting course objectives ▫Clinical utility of the course ▫Time needed to complete the course ▫Functionality of the online technology  Analyzed when 50% of pilot residents complete a course. ▫Ratings < 8o% and open-ended comments targeted for review.  Review of 01 pilot group suggested Likert-type response categories be changed from 4 to 5 points to increase precision and variability.

Resident Demographics 2011 (n = 67)2012 (n = 64)Controls (n = 31) Sex Female Male 64% 36% 64% 36% 45% 55% Mean Age range 32 (27 – 43) 32 (24 – 56) 30 (26 – 38) Marital Status Married Live w/ partner Single Unk. 45% 13% 27% 15% 27% 6% 34% 33% 58% 10% 32% 0% Graduate Status US MD US DO FMG Unk. 51% 18% 27% 4% 41% 26% 28% 5% 55% 16% 13%

Did Course Meet Learning Objectives? Year 01 Content *Currently, data are available for 4 courses for the 2012 class.

Clinical Utility of the Course? Year 01 Content *Currently, indicators are available for 4 courses for the 2012 class.

How Smooth was the Online Technology? Year 01 Content *Currently, indicators are available for 4 courses for the 2012 class.

Meet Learning Objectives?Clinical Utility? Year 02 Course Evaluations Courses currently at 50% threshold

Smooth Online technology?

Length of Time Spent Year 01 &Year 02 Content ClassCourse< 1 hr1-2 hr2-3 hr3-4 hr4-5 hr5-6 hr 2011 Introduction34%44%13%5%4% %36%26%4% 2011 Supplements32%35%12% 5%3% %36%9%5% 2011 Nutrition & Diet13%25%31%16%6%7% %42%29%4% 2011 Physical Activity61%38%2% %28%7% 2011 Stress & Mind Body34%43%17%3%2% 2011 Spirituality72%26%2% 2011 Sleep & Health94%6% 2011 Preventive Services59%32%7% 2011 Clinical Integration17%38%21%8%9%8% 2011 Allergy/Asthma11%43%27%11%3%5% 2011 ADHD48% 4% 2011 Pediatric Pain55%27%14%4% 2011 PMD/PMDD53%40%7% Year 1 Year 2

What Residents Say… I enjoyed the interactive nature of the modules. The tools are amazing! Did an excellent job of relating spirituality to health care. I think sleep is one thing most neglected in health care topics. This course has rightly identified it. The ability to self reflect as well as think about our patients. I loved the video lecture – very engaging and interesting. This is a very comprehensive topic. Great links and resources. The seven cases. Great way to pull all of these courses together! The buttons aren’t working. There was a lot of data in this module [Nutrition and Diet], but not enough interactive learning. Too lengthy and too in-depth. Some links were not available. Too many resources were given and I did not have enough time to thoroughly review them. Too much reading, too many links, and too many videos.

Discussion Acknowledgements University of ArizonaPilot Sites Emily SherbrookeVictor Sierpina, M.D. Paula CookSelma Sroka, M.D. Rhonda HallquistMary Guerrera, M.D. Tieraona Low Dog, M.D.Dael Waxman, M.D. Craig Schneider, M.D. John Woytowicz, M.D.