US Medical School Curriculum Design and Transformation: Past, Present & Future Michele P Pugnaire, MD Senior Associate Dean Office of Educational Affairs University of Massachusetts Medical School September 2015

Acknowledgments Peking University Health Science Center US Medical School Curriculum Design and Transformation: Past, Present & FutureSeptember 2015

Introduction to UMass Medical School September 2015 US Medical School Curriculum Design and Transformation: Past, Present & Future MP Pugnaire MD

I have no financial conflict of interest to disclose My roles Senior Associate Dean for Educational Affairs Executive Director, interprofessional Center for Experiential Learning and Simulation (iCELS) Professor, Family Medicine and Community Health UMass Medical School Family Physician, Health Alliance Fitchburg Family Practice Disclosure September 2015 US Medical School Curriculum Design and Transformation: Past, Present & Future MP Pugnaire MD

How does medical education work? Why is medical education changing? What are the trends? Where we are heading? What We Will Learn about today September 2015 US Medical School Curriculum Design and Transformation: Past, Present & Future MPPugnaire MD

THE BIG PICTURE snap shot of US medical education today The MAP of trends:  The MODEL of change: A “visual” framework for change The DRIVERS of change: Key educational innovations PREVIEW 2025 of the future 2025 How we will learn about this …. September 2015 US Medical School Curriculum Design and Transformation: Past, Present & Future MPPugnaireMD

PREMED 4 years college BA degree with Pre- med courses UME Undergraduate Medical Education 4 yearsGME Graduate Medical Education years Residency FellowshipCME Continuing Medical Education Pre-clinical Courses 1-2 years Biomed Sciences Anatomy Pharm Biochem Physiol. Clinical Skills Clinical Experiences Yr 3 Core Clerkships Medicine Surgery, Pediatrics, Psychiatry Ob/gyn Neurology Family Med Emergency Senior Studies Yr 4 Advanced ‘Subintern ships’ Electives across US and the world PGYPGY11PGYPGY111 PGY 2,3,4,5 Specialty Board Certified PGY 6, 7… Sub Specialty Board Certified Maintenance of board certification Every 10 years State RE-licensure Every 2 year, with CME credits 3 Licensing exams ClassofClassof ClassofClassof PGY 2 Licensure by State Licensing Boards PUBLICSCHOO L The Continuum of US medical education: The big picture SpecialtySubspecialtyCertificationbySpecialtyBoards MD Degree Board Exams Board Recertification Exams SpecialtySubspecialtyRE-Certificationand State re-licensure MD License US Medical School Curriculum Design and Transformation: Past, Present & Future MPPugnaire MD Sept 2015

SNAP SHOT IN TIME, ALONG THE CONTINUUM THEN NOW TOMORROW 1910 … UGC US Medical School Curriculum Design and Transformation: Past, Present & Future MPPugnaire MD

SNAP SHOT IN TIME, ALONG THE CONTINUUM THEN NOW TOMORROW 1910 … UGC Flexner Report: Medical Education in the United States and Canada: A report of the Carnegie Foundation for the Advancement of Teaching US Medical School Curriculum Design and Transformation: Past, Present & Future MPPugnaire MD

SNAP SHOT IN TIME, ALONG THE CONTINUUM THEN NOW TOMORROW 1910….. Stand-alone … UGC 2000 IOM To Err is Human: Building a Safer Health System 2001 IOM Crossing the Quality Chasm: A New Health System for the 21 st Century 2002 IOM Health Professions Education: A Bridge to Quality launch of 6 GME competencies (ACGME.org) 1.Patient Care 2.Medical Knowledge 3.Practice Based Learning and Improvement 4.Systems Based Practice 5.Professionalism 6.Interpersonal Skills and Communication US Medical School Curriculum Design and Transformation: Past, Present & Future MPPugnaire MD

2004 ACCME Report Competency and Continuum (ACCME.org) Adoption of 6 competencies as Continuing Medical Education (CME) accreditation criteria 2004 Competency standard required for medical schools, UME (LCME.org) 2006 : Maintenance of Certification (MOC) for all 24 certified specialties (ABMS..org) No more life-long certification MOC as an ongoing process for Continuous learning and self-assessment Concept of CPD continuous professional development, replaces CME SNAP SHOT IN TIME, ALONG THE CONTINUUM THEN NOW TOMORROW 1910….. Stand-alone Contiguous … UGC UGPD US Medical School Curriculum Design and Transformation: Past, Present & Future MPPugnaire MD

SNAP SHOT IN TIME, ALONG THE CONTINUUM THEN NOW TOMORROW 1910….. Stand-alone Contiguous … Integrated UGC UGPD U G EI 2010 Educating Physicians: A Call for Reform of Medical School and Residency Carnegie Foundation report (D Irby Acad Med 2010) Standardizing outcomes/individualizing learning: Competency-based vs time-based Multiple forms of integration: includes ‘real practice’ experience (IPE & team work) Habits of inquiry & improvement: Self-assessment & improvement, patient safety/QI Professional identity formation: Professionalism, ethics, commitment to excellence 2011 Core Competencies for Interprofessional Collaborative Practice report of an expert panel, IPEC (AAMC Interprofessional Education Collaborative Expert Panel, 2011) AACN(nursing); AACOM (osteopathy); ADEA (dental); ASPH (public health); AAMC (medicine); AACP (pharmacy) 2012 AAMC CEI: Continuing Education & Improvement ( Transforming CPD with best educational methods to close the clinical care gap Focus on Quality and Performance Improvement US Medical School Curriculum Design and Transformation: Past, Present & Future MPPugnaire MD

1. IPE = Team-based learning “The need for persons trained in related health fields to work as members of the team under the leadership and coordination of the physician” The Coggeshall Report, AAMC Simulation = Practice-based learning ‘Practice makes perfect’ “ No excuse today for the surgeon to learn on the patient ” William J Mayo, Competencies = Outcome-based learning “If you don't know where you are going, you might wind up someplace else” Y Berra 4. Pt Safety and Quality = Improvement-based learning “Texas hospital apologizes for Ebola mistakes” Boston Globe Oct 2014 – The 10 Year Snap Shot of Med Ed 4 Drivers of Educational Innovation US Medical School Curriculum Design and Transformation: Past, Present & Future MPPugnaire MD

IPE: “ Students from two or more professions learn[ing] about, from, with each other” (WHO 2010, IPEC report 20110) A New LCME accreditation requirement (lcme.org) AAMC survey : ‘At Least Some’ IPE experience 71.1% ( Analysis in Brief AAMC Oct 2014 ) % ALL % of those with IPE Nursing Pharmacy Physician Assistants Social Work Physical Therapists Occ. Therapists CONCLUSION: Room for more IPE and more diversity in IPE The 10 Year Snap Shot of Med Ed IPE as a Driver of Educational Innovation US Medical School Curriculum Design and Transformation: Past, Present & Future MPPugnaire MD

Simulation... a technique—not a technology –Evokes/replicates substantial aspects of the real world in a fully interactive manner.” (D Gaba, Qual and Safety in Healthcare 2004 ) Learning: –From mistakes, safe to make mistakes –‘Deliberate’ practice, ‘til you get it right’ Technology enhanced simulation: improved outcomes compared to no intervention (Cooke, JAMA 2011) –Across a range of health professions, clinical topics, and outcomes –Large effect on clinician behavior –Moderate effects on patient care Conclusion BE-ME (best evidence medical education) supports simulation for active learning The 10 Year Snap Shot of Med Ed Simulation as a Driver of Educational Innovation US Medical School Curriculum Design and Transformation: Past, Present & Future MPPugnaire MD

Competency: Observable personal ability or quality Allows outcomes-based, time-variable assessment In place across the continuum: UME, GME, CPD Competency based Medical Education limitations: Applicability to real world practice Attributes, not activities Specificity to specialties (Carraccio J Grad Med Ed 2010) The 10 Year Snap Shot of Med Ed Competencies as a Driver of Educational Innovation US Medical School Curriculum Design and Transformation: Past, Present & Future MPPugnaire MD

Six Guiding GOALS: For our curriculum, its learning objectives, all assessments “A graduating physician is a”…… –Professional –Scientist –Communicator –Clinical Problem Solver –Patient and Community Advocate –Person Our pledge to our students, faculty, institution The Six Competencies at UMMS September 2015 US Medical School Curriculum Design and Transformation: Past, Present & Future MPPugnaire MD

1.Professional –Professionalism, Ethical reasoning, Commitment to excellence 2.Scientist –Core scientific principles, Intellectual curiosity, critical thinking 3.Communicator –Doctor-patient communication, cultural awareness, Team communication, 4.Clinical Problem Solver –Patient-centered care, team work, technical skills 5.Patient and Community Advocate –Advocacy, Community Education, Volunteerism, Determinants of health 6.Person –Self Awareness, Wellness, Relationships The Six Competencies at UMMS US Medical School Curriculum Design and Transformation: Past, Present & Future MPPugnaire MD

Introduction of Entrustable Professional Activities: EPA’s –“Routine professional activities of physicians in their specialty” –A bridge to professional practice: GME to CPD –Entrustable: “unsupervised” practice: trusted to perform independently –Mappable to multiple competencies Core EPA’s for Entry into Residency: CEPAER’s (AAMC 2014) –A bridge from UME to GME –What PGY1’s should do, day 1 of residency without direct supervision, regardless of specialty. The 10 Year Snap Shot of Med Ed EPA’s as a Driver of Educational Innovation September 2015 US Medical School Curriculum Design and Transformation: Past, Present & Future MPPugnaire MD

Core EPAs for Entering Residency 1) Gather a history and perform a physical examination 2) Prioritize a differential diagnosis following a clinical encounter 3) Recommend and interpret common diagnostic and screening tests 4) Enter and discuss orders/prescriptions 5) Document a clinical encounter in the patient record 6) Provide an oral presentation of a clinical encounter 7) Form Clinical Questions and retrieve evidence to advance patient care 8) Give or receive a patient handover to transition care responsibility 9) Collaborate as a member of an interprofessional team 10) Recognize a patient requiring urgent or emergent care, initiate evaluation and management 11) Obtain informed consent for tests and/or procedures 12) Perform general procedures of a physician 13) Identify system failures and contribute to a culture of safety and improvement The 13 CEPAERS: Drivers of Educational Innovation US Medical School Curriculum Design and Transformation: Past, Present & Future MPPugnaire MD

Introducing IHI: Institute for Healthcare Improvement –A world leader in healthcare innovation since 1991 –Redesigning health care into a system without errors, waste, delay, and unsustainable costs –Based in Cambridge MA Vision: Everyone has the best care and health possible. Mission: Improve health and health care worldwide. The “IHI triple aim”…. The 10 Year Snap Shot of Med Ed Safe ty & Quality as a Driver of Educational Innovation September 2015 US Medical School Curriculum Design and Transformation: Past, Present & Future MPPugnaire MD

The “IHI triple aim” A framework for optimizing health system performance by simultaneously focusing on the health of a population, the experience of care for individuals within that population, and the per capita cost of providing that care. ( The 10 Year Snap Shot of Med Ed The Triple Aim as a Driver of Educational Innovation US Medical School Curriculum Design and Transformation: Past, Present & Future MPPugnaire MD Sept 2015

2015: WHERE WE ARE NOW U G PD US Medical School Curriculum Design and Transformation: Past, Present & Future MPPugnaire MD

2015: WHERE WE ARE NOW U G PD Pt Safety/Quality= Improvement-based learning IHI triple aim ( US Medical School Curriculum Design and Transformation: Past, Present & Future MPPugnaire MD

todayspaper/2014/10/25 todayspaper/2014/10/25 US Medical School Curriculum Design and Transformation: Past, Present & Future MPPugnaire MD Sept 2015

todayspaper/2014/10/25 todayspaper/2014/10/25InterprofessionalTeams Simulationbased Competency-EPADriven Triple aim focused US Medical School Curriculum Design and Transformation: Past, Present & Future MPPugnaire MD Sept 2015

todayspaper/2014/10/25 todayspaper/2014/10/25InterprofessionalTeams Simulationbased Competency-EPADriven Triple aim focused US Medical School Curriculum Design and Transformation: Past, Present & Future MPPugnaire MD Sept 2015

todayspaper/2014/10/25 todayspaper/2014/10/25InterprofessionalTeams Simulationbased Competency-EPADriven Triple aim focused US Medical School Curriculum Design and Transformation: Past, Present & Future MPPugnaire MD Sept 2015

todayspaper/2014/10/25 todayspaper/2014/10/25InterprofessionalTeams Simulationbased Competency-EPADriven Triple aim focused US Medical School Curriculum Design and Transformation: Past, Present & Future MPPugnaire MD Sept 2015

todayspaper/2014/10/25 todayspaper/2014/10/25InterprofessionalTeams Simulationbased Competency-EPADriven Triple aim focused US Medical School Curriculum Design and Transformation: Past, Present & Future MPPugnaire MD Sept 2015

Integrated UGC UGPD U G PD WHERE WE ARE GOING IN 2025 THEN NOW TOMORROW 1910….. Stand-alone Contiguous … US Medical School Curriculum Design and Transformation: Past, Present & FutureMPPugnaire MD Sept 2015

September 2015 …in good hands. US Medical School Curriculum Design and Transformation: Past, Present & Future MPPugnaire MD Sept 2015

Thank You