Monica L. Lypson

Beyond Cultural Competence: Critical Consciousness, Social Justice, and Multicultural Education

In response to the Liaison Committee on Medical Education mandate that medical education must address both the needs of an increasingly diverse society and disparities in health care, medical schools have implemented a wide variety of programs in cultural competency. The authors critically analyze the concept of cultural competency and propose that multicultural education must go beyond the traditional notions of “competency” (i.e., knowledge, skills, and attitudes). It must involve the fostering of a critical awareness—a critical consciousness—of the self, others, and the world and a commitment to addressing issues of societal relevance in health care. They describe critical consciousness and posit that it is different from, albeit complementary to, critical thinking, and suggest that both are essential in the training of physicians. The authors also propose that the object of knowledge involved in critical consciousness and in learning about areas of medicine with social relevance—multicultural education, professionalism, medical ethics, etc.—is fundamentally different from that acquired in the biomedical sciences. They discuss how aspects of multicultural education are addressed at the University of Michigan Medical School. Central to the fostering of critical consciousness are engaging dialogue in a safe environment, a change in the traditional relationship between teachers and students, faculty development, and critical assessment of individual development and programmatic goals. Such an orientation will lead to the training of physicians equally skilled in the biomedical aspects of medicine and in the role medicine plays in ensuring social justice and meeting human needs.

Assessing residents' competencies at baseline: identifying the gaps.

Purpose. Entering residents have variable medical school experiences and differing knowledge and skill levels. To structure curricula, enhance patient safety, and begin to meet accreditation requirements, baseline assessment of individual residents knowledge and skills is needed. To this end, in 2001 the University of Michigan Health System created the Postgraduate Orientation Assessment (POA), an eight-station, objective structured clinical examination for incoming residents. Method. The POA, administered at orientation, included items addressing critical laboratory values, cross-cultural communication, evidence-based medicine, radiographic image interpretation, informed consent, pain assessment and management, aseptic technique, and system compliance such as fire safety. The POA assessed many of the skills needed by interns in their initial months of training when supervision by senior physicians might not be present. Results. In 2002, 132 interns from 14 different specialties and 59 different schools participated in the POA. The mean score was 74.8% (SD = 5.8). When scores were controlled for U.S. Medical Licensing Examination scores, there were no significant differences in performance across specialties. There were differences between University of Michigan Medical School graduates and those from other institutions (p < .001). Eighty-one percent of the residents would recommend the POA. Conclusions. The POA provides a feasible format to measure initial knowledge and skills and identify learning needs. Orientation is an effective time to identify important gaps in learning between medical school and residency. This is the first step in a continuing evaluation of the Accreditation Council for Graduate Medical Educations general competencies.

Advancing Medical Education by Teaching Health Policy

Standards for health policy curricula in medical education are long overdue. Matters affected by health policy, such as health care systems, quality improvement, and medical economics, ultimately affect patient care, and physicians need the skills to address them.

Medical student perceptions of education in health care systems

Purpose Undergraduate medical education has been criticized for not keeping pace with the increasing complexity of the U.S. health care system. The authors assessed medical students’ perceptions of training in clinical decision making, clinical care, and the practice of medicine, and the degree to which the intensity of education in health care systems can affect perceptions. Method The authors studied data from 58,294 U.S. medical graduates who completed the Association of American Medical Colleges annual Medical School Graduation Questionnaire (2003–2007). In a second analysis, they compared responses of 1,045 medical school graduates (2003–2007) from two similar medical schools with curricula of different intensity in health care systems. Results The percentage of students reporting “appropriate” training was 90% to 92% for clinical decision making, 80% to 82% for clinical care, and 40% to 50% for the practice of medicine. Students from the school with a higher-intensity curriculum in health care systems reported higher satisfaction than students from the school with a lower-intensity curriculum for training in four of five practice of medicine components: medical economics, health care systems, managed care, and practice management. Importantly, the high commitment to education in health care systems in the higher-intensity curriculum did not lead to lower perceived levels of adequate training in other domains of instruction. Conclusions Nationally, students consistently reported that inadequate instructional time was devoted to the practice of medicine, specifically medical economics. A higher-intensity curriculum in health care systems may hold substantial potential to overcome these perceptions of training inadequacy.

Toward Defining the Foundation of the MD Degree: Core Entrustable Professional Activities for Entering Residency.

Currently, no standard defines the clinical skills that medical students must demonstrate upon graduation. The Liaison Committee on Medical Education bases its standards on required subject matter and student experiences rather than on observable educational outcomes. The absence of such established outcomes for MD graduates contributes to the gap between program directors’ expectations and new residents’ performance. In response, in 2013, the Association of American Medical Colleges convened a panel of experts from undergraduate and graduate medical education to define the professional activities that every resident should be able to do without direct supervision on day one of residency, regardless of specialty. Using a conceptual framework of entrustable professional activities (EPAs), this Drafting Panel reviewed the literature and sought input from the health professions education community. The result of this process was the publication of 13 core EPAs for entering residency in 2014. Each EPA includes a description, a list of key functions, links to critical competencies and milestones, and narrative descriptions of expected behaviors and clinical vignettes for both novice learners and learners ready for entrustment. The medical education community has already begun to develop the curricula, assessment tools, faculty development resources, and pathways to entrustment for each of the 13 EPAs. Adoption of these core EPAs could significantly narrow the gap between program directors’ expectations and new residents’ performance, enhancing patient safety and increasing residents’, educators’, and patients’ confidence in the care these learners provide in the first months of their residency training.

Teaching while learning while practicing: reframing faculty development for the patient-centered medical home.

Soaring costs of health care, patients living longer with chronic illnesses, and continued attrition of interest in primary care contribute to the urgency of developing an improved model of health care delivery. Out of this need, the concept of the team-based, patient-centered medical home (PCMH) has developed. Amidst implementation in academic settings, clinical teachers face complex challenges not previously encountered: teaching while simultaneously learning about the PCMH model, redesigning clinical delivery systems while simultaneously delivering care within them, and working more closely in expanded interprofessional teams.To address these challenges, the authors reviewed three existing faculty development models and recommended four important adaptations for preparing clinical teachers for their roles as system change agents and facilitators of learning in these new settings. First, many faculty find themselves in the awkward position of teaching concepts they have yet to master themselves. Professional development programs must recognize that, at least initially, health professions learners and faculty will be learning system redesign content and skills together while practicing in the evolving workplace. Second, all care delivery team members influence learning in the workplace. Thus, the definition of faculty must expand to include nurses, pharmacists, social workers, medical assistants, patients, and others. These team members will need to accept their roles as educators. Third, learning to deliver health care in teams will require support of both interprofessional collaboration and intraprofessional identity development. Fourth, learning to manage change and uncertainty should be part of the core content of any faculty development program within the PCMH.

A strategy for improving health disparities education in medicine.

IntroductionA health disparities curriculum that uses evidence-based knowledge rooted in pedagogic theory is needed to educate health care providers to meet the needs of an increasingly diverse U.S. population.DescriptionThe Health Disparities Education: Beyond Cultural Competency Precourse, along with its accompanying Train the Trainer Guide: Health Disparities Education (2008), developed by the Society of General Internal Medicine (SGIM) Disparities Task Force (DTF), is a comprehensive tool to facilitate developing, implementing and evaluating health disparities education. The curriculum includes five modules highlighting several fundamental concepts in health disparities, suggestions for teaching about health disparities in a wide range of settings and strategies for curriculum evaluation. The modules are Disparities Foundations, Teaching Disparities in the Clinical Setting, Disparities Beyond the Clinical Setting, Teaching about Disparities Through Community Involvement, and Curriculum Evaluation.EvaluationAll five modules were delivered as a precourse at the 31st Annual SGIM Annual Meeting in Pittsburgh, PA and received the “Best Precourse Award”. This award is given to the most highly rated precourse based on participant evaluations. The modules have also been adapted into a web-based guide that has been downloaded at least 59 times.ConclusionUltimately, the modules are designed to develop a professional commitment to eliminating racial and ethnic disparities in health care quality, promote an understanding of the role of health care providers in reducing health care disparities through comprehensive education and training, and provide a framework with which providers can address the causes of disparities in various educational settings.

The VALUE Framework: Training Residents to Provide Value-Based Care for their Patients

National efforts to improve the value of health care must include graduate medical education (GME) if they are to succeed. Proposals to teach residents to provide value-based care have come from the Medicare Payment Advisory Commission (MedPAC), the Accreditation Council for Graduate Medical Education (ACGME) and the American College of Physicians (ACP). Such proposals skip a key step: residency programs currently lack a clear strategy to prepare residents to assess and deliver value-based care. In this article, we present the VALUE Framework for programs to utilize to teach residents to assess and deliver value-based care for their patients. We then present more than 20 opportunities for residency programs to incorporate training in value-based care.

Standardized Patient Instructor (SPI) interactions are a viable way to teach medical students about health behavior counseling

OBJECTIVES We explored comfort levels of third-year medical (M3) students through two health behavior counseling (HBC) interactions with Standardized Patient Instructors (SPIs) in tobacco cessation (TCC) and nutrition and physical activity (NPA). METHODS Nearly 200 M3s participated in two SPI HBC interactions; including a role-play interview and subsequent feedback session on performance. Students completed a 5-point Likert scale evaluation measuring pre- and post-comfort level on two HBC sessions. RESULTS Both interactions resulted in statistically significant increases in students pre- and post-interaction comfort levels. A paired-sample t-test revealed a mean increase of 0.91 for TCC (t = 14.01, df = 197, p<0.001), and a mean increase of 0.69 for NPA (t = 12.65, df = 198, p<0.001). CONCLUSION The use of SPIs is a viable approach to exposing medical students and future doctors to health behavior counseling, and increasing comfort level with such skills. The SPI experience ensures that HBC opportunities are available and contain meaningful feedback on performance. PRACTICE IMPLICATIONS Encouraging patient behavior modification is a skill that can be developed during undergraduate medical training. Combining HBC with SPI sessions and traditional learning approaches could prove effective in a curriculum intended to teach students strategies that improve patient health behavior.

Reporting Achievement of Medical Student Milestones to Residency Program Directors: An Educational Handover.

PROBLEM Competency-based education, including assessment of specialty-specific milestones, has become the dominant medical education paradigm; however, how to determine baseline competency of entering interns is unclear-as is to whom this responsibility falls. Medical schools should take responsibility for providing residency programs with accurate, competency-based assessments of their graduates. APPROACH A University of Michigan ad hoc committee developed (spring 2013) a post-Match, milestone-based medical student performance evaluation for seven students matched into emergency medicine (EM) residencies. The committee determined EM milestone levels for each student based on assessments from the EM clerkship, end-of-third-year multistation standardized patient exam, EM boot camp elective, and other medical school data. OUTCOMES In this feasibility study, the committee assessed nearly all 23 EM milestones for all seven graduates, shared these performance evaluations with the program director (PD) where each student matched, and subsequently surveyed the PDs regarding this pilot. Of the five responding PDs, none reported using the traditional medical student performance evaluation to customize training, four (80%) indicated that the proposed assessment provided novel information, and 100% answered that the assessment would be useful for all incoming trainees. NEXT STEPS An EM milestone-based, post-Match assessment that uses existing assessment data is feasible and may be effective for communicating competency-based information about medical school graduates to receiving residency programs. Next steps include further aligning assessments with competencies, determining the benefit of such an assessment for other specialties, and articulating the national need for an effective educational handover tool between undergraduate and graduate medical education institutions.