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Competency-Based Curriculum Resource for Preclerkship Education (using ACGME Structure):

Practice-Based Learning and Improvement

Lead Authors: John C. Rogers, MD, MPH and Eric Bass, MD

Workgroup Members
Christine Matson, MD, Chair Eastern Virginia Medical School
Scott A. Fields, MD
Oregon Health and Science University
Jeffrey Stearns, MD, Executive Committee Liaison
University of Wisconsin Milwaukee Clinical Campus
Eric Bass, MD
 Johns Hopkins University
Thomas Defer, MD
Washington University
Allan Goroll, MD
Harvard University
Larrie Greenberg, MD
George Washington University
Mary Ann Kuzma, MD
Drexel University
Steve Miller, MD
Columbia University
William Raszka, MD
University of Vermont
Rick E. Ricer, MD
University of Cincinnati
John C. Rogers, MD, MPH
Baylor Medical College
William Wilson, MD
University of Virginia

Rationale

When entering core clerkships, students must be prepared to manage their learning about their patients' problems with minimal direction from the attending physician, residents, or other students on the rotation. This self-directed learning will require a commitment to assessing one's own needs for learning, an ability to identify the types of information pertinent to the care of their patients (e.g., physical examination findings, diagnostic testing, treatment options, medication side-effects, and diagnostic and therapeutic procedures), a listing of perceived gaps in knowledge in those areas, and a strategy for finding and assessing the necessary information. To search for information, the student will need to be able to identify up-to-date information through on-line resources. Assessing information will depend on an ability to assess the validity of evidence in clinical guidelines, reviews, and studies about diagnosis or treatment of disease.

Competency

Students must be committed and able to appraise and assimilate scientific evidence for improvement of patient care practices.

Goals

Demonstrate commitment to personal role in providing health care outcomes.

  • Describe the concept of a paradigm shift in physician responsibility (from apprenticeship model to continuous improvement).
  • Give examples of clinical problems for which outcomes can be changed through process improvement.
  • Contrast the benefits of team-based process improvement vs. physician sanctions for error in improving health outcomes.

Effectively employ recursive strategy for lifelong learning.

Learn to direct own learning about patient's problems.

  • Assess own learning needs.
  • Identify information pertinent to the care of patients.
  • List perceived personal gaps in knowledge.
  • Demonstrate skills in self-directed learning by developing clinical questions about their patients and using on-line, or just-in-time, medical information systems to find relevant information sources.
  • Describe strategies for finding and assessing necessary information.

Learn to locate, appraise, and assimilate evidence from clinical guidelines, systematic reviews, and articles related to patients' problems.

  • Demonstrate the use of Web sites, on-line search engines, PDA-based programs, information services, and journals to locate information related to patients' health needs.
  • Demonstrate clinical problem-solving skills using information resources.
  • Demonstrate skills in hypothesis-building and deductive problem solving.
  • Demonstrate the ability to appraise suitability of the information for clinical questions.
  • Demonstrate the ability to assimilate the new information into care for health problems.

Learn to apply knowledge of study designs and statistical methods to appraise information about diagnostic tests and therapeutic interventions.

  • Explain the principle of clinical uncertainty in clinical judgments.
  • Define basic epidemiological terms and concepts.
  • Describe frequently used study designs.
  • Define basic biostatistical terms and applications.
  • Describe the relationship among incidence, duration, and prevalence of a disease in a population.
  • Describe "risk factor" and identify how risk factor information is determined.
  • Define sensitivity, specificity, and predictive values of a test.
  • Understand the trade-off between sensitivity and specificity of a test upon changing the cut-off values for normal/abnormal test results.
  • Understand how predictive values are affected by disease prevalence.
  • Demonstrate the use of essential concepts of epidemiology, including pre- and post-test probabilities.
  • Know what is meant by the term "gold standard."
  • Describe the difference between efficacy and effectiveness.
  • Demonstrate principles associated with critical appraisal of a clinical trial.
  • Know when /when not to perform population screening for a disease.
  • Describe sources of systematic error that can affect study conclusions.
  • Describe principles that lead to prudent ordering of diagnostic and screening tests.
  • Describe limits that every physician/medical student has in knowledge, skills, and attitudes and present strategies for recognizing and coping with these limitations.

Educational Methods

The knowledge, skills, and attitudes of Practice-Based Learning and Improvement are best learned in an interactive environment where a variety of teaching strategies are used to facilitate student learning. Basic knowledge can be transmitted through lectures, computer-assisted instruction (such as Web-based curricula), or readings, but understanding and applying the material to actual patient care problems is best accomplished through problem-based methods using small-group experiences and active participation and problem solving. Learning activities need to involve a collaborative, interdisciplinary approach to learning and improvement that demonstrates the synergism of incorporating multiple perspectives. Some involvement with actual practice-based improvement activity during early clinical experience or interaction with local EBM experts would be ideal but probably not attainable for all students. Mentoring relationships with practicing physicians who practice the concepts of process improvement can reinforce these principles of Practice-Based Learning and Improvement. Additionally, Practice-Based Learning and Improvement principles and practices need reinforcement during clinical experiences when students develop clinical questions and search for helpful information.

Resources

Current Approaches

Additional resources:

    • From the American Academy of Family Physicians Web site
      http://www.aafp.org/x16578.xml
    • "Quality of Health Care"(6 part series) New England Journal of Medicine Sep.-Oct. 96
    • "Users' Guides to the Medical Literature" (Multipart Series) Journal of American Medical Association 1993-2000 http://www.cche.net/principles/main.asp
    • Berwick DM. On Quality. Jossey-Bass, 1995
    • Berwick DM, Roessner JA, Godfrey B. Curing Health Care: New Strategies for Quality Improvement. Jossey-Bass, 1991.
    • Eddy DM. Clinical Decision Making: From Theory to Practice: A Collection of Essays from JAMA. Jones & Bartlett, 1996.
    • IOM Committee on Quality of Health Care in America, Crossing the Quality Chasm: A New Health System for the 21st Century, Institute of Medicine 2000.
    • Kohn L. To Err Is Human: Building a Safer Health System, Institute of Medicine 1999.
    • Medical Informatics and Computer Applications, Recommended Core Educational Guidelines for Family Practice Residents, AAFP Reprint No. 288 http://www.aafp.org/eduguide.xml
    • Research and Scholarly Activity, Recommended Core Educational Guidelines for Family Practice Residents, AAFP Reprint No. 280 http://www.aafp.org/eduguide.xml
    • Sackett D. Evidence-Based Medicine: How to Practice and Teach EBM. Churchill Livingston, 2000.
    • Silverman WA and Sackett DL. Where's the Evidence?: Debates in Modern Medicine. Oxford Univ. Press, 1999.

Other books

    • Evidence-Based Medicine Working Group, Rennie D, Guyatt GH (Eds). Users' Guides to the Medical Literature: Essentials of Evidence-Based Clinical Practice. American Medical Association, 2002.
    • Guyatt G, Gilbert DN, Rennie D, Moellering RC, Sande MA (Eds). Users' Guide to the Medical Literature: A Manual for Evidence-Based Clinical Practice. Antimicrobial Therapy, Inc.; Book and CD-ROM edition, 2002.

Web Resources

Assessment Strategies

The full application of Practice-Based Learning and Improvement requires an ongoing clinical practice with information systems that allow retrieval of practice information and data from patient records. Preclerkship students need to learn the attitudinal and intellectual foundations that can be applied later to their residency practices. Assessment of students' knowledge and skill should be case-based and could include multiple-choice questions, short answers, calculations, and written critical reviews of guidelines, clinical reviews, or original research articles. Since being able to quickly access information is an important skill, one potential strategy is testing of students' ability to retrieve information from a PDA, such as a clinical guideline, to answer questions.

Faculty Development

Faculty development should be focused on increasing knowledge about evidence-based medicine, clinical epidemiology, and print and electronic sources for reviews and guidelines. Modeling of practice-based learning and improvement by medical school and community-based faculty may be the most powerful way to positively influence student attitudes toward their role ion this area. However, often there is faculty resistance to application of the concepts of evidence-based medicine, clinical epidemiology, and quantitative approaches to decision making, because they are sometimes viewed as counter-intuitive, impractical, and undermining the "art of medicine" as well as physician discretion to individualize patient care. Faculty skill development is critical in this area, especially skills in problem-based or case-based teaching strategies, small-group instruction, and methods of quick access to information through the World Wide Web or hand-held devices. Students and residents, having grown up in an age with widespread Web and hand-held technology, are increasingly adept with these methods of information management. Faculty must become adept as well if they are to maintain credibility with this generation of learners. Helping faculty model timely applications of information mastery is essential.

 

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This page last updated November 6, 2004