University of Arizona College of Medicine–Phoenix

Medical Education Program Highlights The University of Arizona College of Medicine–Phoenix (COM-P) evolved substantially in the past decade, from a 48-student-per-year branch campus of the College of Medicine–Tucson (COM-T) to an independently accredited medical school in 2017. Its educational program emphasizes early, robust clinical skills training and patient experiences, active learning modalities, and personalization of medical education according to each student’s career aspirations and preferences. Early robust clinical training and patient exposure begins during the first week of medical school in the Doctoring course and Introduction to Medicine block. Standards are high and consistently enforced, enabling students to contribute increasingly to patient care while honing their skills in the community clinical experience, which alternates weeks with Doctoring. Active learning modalities include small-group case-based instruction, team-based learning, and various interactive exercises and formats generally requiring preparatory work by students. Independent learning modules—typically 10- to 20-minute topic-related video presentations—are developed by faculty and the instructional design team to support interactive sessions. In 2017–2018, the college embarked on a 5-year plan to virtually eliminate traditional lectures. Three years in, approximately 65% of preclerkship basic science sessions are built on active learning modalities. Personalized medical education is supported by several major curriculum features in addition to electives and selectives. Additional curriculum modifications further enabling personalization are in development. Scholarly projects: All students are required to complete a hypothesis-driven, faculty-mentored research project as a graduation requirement. Choice of project is individually determined by students and spans a wide range of subjects and methods, including traditional laboratory research; retrospective or prospective patient-based research; and population-based, public health, health care system, and education-related topics. Projects span 4 years, and nearly half of students opt to work on a second scholarly project during their enrollment. Each project culminates in a thesis and poster presentation at the annual Student Research Symposium. One-fourth are presented at external conferences and 1 in 6 is published in a peer-reviewed journal. Certificates of distinction: Students have the option to participate in 1 of 5 certificates of distinction: global health; health humanities; primary care, rural health, or service; and community health. One-third of students currently participate in one such program. Dual-degree programs: Current offerings include MD–PhD, MD–MS (clinical translational science), and 4-year combined MD–MPH program. An MD–MBA is underdevelopment. Approximately 18% of students currently participate a dual-degree program. Personalized active learning block: Between years 1 and 2, students design or select from an extensive list a 1-credit learning experience to further their medical education in line with interests and career goals. Experiences have included service learning trips to the Dominican Republic, medical Spanish, scholarly projects, and working with a local clinician to gain exposure to a specialty. Curriculum Curriculum description See Supplemental Digital Appendix 1—Curriculum Overview—at https://links.lww.com/ACADMED/A945. Curriculum changes since 2010 The curriculum in place in 2010—an expanded version of Tucson’s faculty-developed curriculum—was replaced in 2013 with the current curriculum structure. The preclerkship curriculum features organ system blocks interspersed with 1- to 2-week capstone experiences in which students apply newly gained basic sciences knowledge in clinical settings while learning about the health care system. Capstone weeks also provide time to work on scholarly projects. The 6-week Transition to Clerkships course uses simulation, standardized patients, and a variety of learning modalities to prepare students for effective clerkship functioning. Required clerkships include the 6 traditional core clerkships in year 3, neurology in year 3 and emergency medicine in year 4. The COM-P strategic plan includes development of a 3-year curriculum with competency-based time-variable transition to residency. The COM-P facilities on the downtown Phoenix Biomedical Campus were built for a class size of 120. From a branch campus with 24 students per class, the program expanded to 80 in 2013 and to 100 in 2020. The clinical teaching model is distributed, with hospitals in the Banner Health system—the college’s primary clinical affiliate—hosting the most student rotations. Students rotate at additional clinical affiliates: Veterans Affairs Medical Center of Phoenix, Phoenix Children’s Hospital, Valleywise Medical Center (formerly Maricopa Integrated Health System), Barrow Neurological Institute, Hospice of the Valley, and others. A rural longitudinal integrated clerkship will begin in Payson, Arizona, in summer 2020. Medical education program objectives COM-P’s educational program objectives (EPOs) are based on the 6 ACGME competencies, replacing practice-based learning and improvement with critical appraisal and quality improvement, and systems-based practice with societal awareness and responsiveness, to clarify these domains’ focus. EPOs are based on compilation of the AAMC’s Medical School Objectives Project, general competencies of physicians developed by the ACGME and American Board of Medical Specialties, and the physician roles of the CanMEDS 2005 report of the Royal College of Physicians and Surgeons of Canada. Assessment During development of the new curriculum and pursuit of independent accreditation, the assessment system was redesigned to evaluate student performance in the new EPOs. The assessment system combines formative and summative assessment using a variety of assessment modalities. See Supplemental Digital Appendix 2—Competencies, Objectives, and Outcome Measures—at https://links.lww.com/ACADMED/A945. Parallel curriculum or tracks COM-P is launching a rural longitudinal integrated clerkship in Payson, Arizona (90 miles from downtown Phoenix), for a subset of students enrolled in the rural health certificate of distinction. This program will span 8 months of year 3 and include training in emergency medicine, family medicine, outpatient internal medicine, obstetrics–gynecology, pediatrics, and surgery. Clinical experiences will emphasize continuity with patients and preceptors. Preceding this experience, students spend the personalized active learning block between years 1 and 2 in Payson or another rural setting. As part of the COM-P strategic plan, a 3-year core curriculum with competency-based, time-variable progression to residency is in the early stages of development. Pedagogy Pedagogical approaches at COM-P have changed extensively since 2010 with the changes in curriculum and independent accreditation. The following constitute the vast majority of learning sessions: Case-based instruction is used in all preclerkship curriculum blocks. Cases are usually explored on 2 days, with self-directed study between opening and closing sessions. Each group comprises 1 faculty member and 8 students. Clinical experiences include both ambulatory and inpatient rotations at a variety of clinical sites (below). Discussion sessions in small and large groups occur throughout the curriculum on a wide range of topics including basic science disciplines, communication skills, and professionalism. Laboratory sessions are prominent in the Clinical Anatomy course and neuroscience blocks. Lectures are diminishing as part of a 5-year plan to replace passive with active learning approaches. Preceptorships comprise the Community Clinical Experience course in the first 2 years and the personalized active learning block for many students. Simulation exercises with formative feedback occur in almost all blocks and clerkships. Simulated physiology laboratories permit students to gather data from each other to test hypotheses and apply foundational science knowledge. Standardized patients are used extensively to train and assess basic clinical skills development in the Doctoring course (years 1–2), as assessments in clerkship OSCEs, and in the summative OSCE at the beginning of year 4. Team-based learning is used to variable degrees in most of preclerkship blocks. Online videos, locally produced by COM-P faculty members, are used extensively in preclerkship blocks as independent learning modules for viewing before active learning sessions. Clinical experiences Most students complete the standard block clerkship curriculum. In addition to rotations in the Banner Health system (COM-P’s primary affiliate), the college’s distributed model of clinical education provides a wide variety of settings and patient populations for required, selective, and elective rotations. Inpatient opportunities include public, children’s, veterans, and community hospitals, while ambulatory experiences include private practice, group practice, and federally qualified health center settings. Special opportunities regularly afforded to students include rural and American Indian reservation rotations and a volunteer street medicine program in Phoenix. An educational experience in rural or underserved communities is a graduation requirement. In the 2019–2020 academic year, the initial pilot of a longitudinal clinical experience was implemented to provide students continuity with patients, faculty, and clinic teams over 3–4 years. Following the intensive Doctoring curriculum in the summer and fall of year 1, and after demonstrating a required level of competence in history and physical exam skills, students begin authentic clinical experiences in January of year 1. Students receive extensive experience in community-based locations, as most inpatient and outpatient affiliates, including Banner University Medical Center–Phoenix, are community based. These experiences provide students insight into modern medical practice. COM-P has adequate clinical training sites for its students and continues to add more in the Banner Health system in preparation for class size expansion. Identification of additional sites is ongoing, with faculty development being a key activity as new sites and faculty members are recruited. Curricular Governance Virtually all aspects of UME are centralized under the Office of Academic Affairs, including oversight and implementation of curriculum units (blocks, courses, clerkships, electives, selectives) by the Office of Curricular Affairs. In the distributed model of clinical education, educational time for clerkship directors and other leadership positions are “purchased” by the college from clinical affiliates or compensated directly to independent clinicians. Staff support is provided by the college. Some heavily used clinical sites have an appointed site director who reports to the clerkship director. Student assessment, program evaluation, and all other functions are managed centrally. Academic support and career counseling are housed in the Office of Student Affairs. See Figure 1—Committee structure.Figure 1: Committee structure.Education Staff The Office of Academic Affairs and its units are responsible for virtually all curricular aspects, from design and implementation to program evaluation and CQI. Instructional faculty development, instructional technology, the simulation center, the clinical skills center, and other supporting functions are also housed within academic affairs. The Research Office for Medical Education (ROME) promotes scholarship among faculty and staff and hosts an annual ROME Forum for showcasing these efforts. See Figure 2—Medical education leadership.Figure 2: Medical education leadership.In addition to the UME program and its supporting offices and functions, the Office of Academic Affairs oversees pipeline recruitment programs, admissions, and student affairs. Faculty Development and Support in Education Numerous and varied faculty educational development opportunities are provided. Workshops and small-group sessions on case-based instruction, instructional design, educational technology, and NBME-style item writing are offered annually or more often as needed. The director of faculty development offers a yearlong faculty fellowship for clinical faculty members with a strong interest in teaching. Online modules (with CME credit) include “Tips for effective feedback,” “Teaching motivational interviewing,” “Communication skills for team-based learning,” “Tailoring your teaching to learner needs,” “Theory and practice of teaching medicine,” and “Optimizing teaching when time is limited.” Tenure-track faculty members are expected to teach, which is an essential part of evaluation for promotion and tenure. Criteria include the quality and quantity of teaching activities, creation and innovativeness of teaching methods and materials, extramural recognition, and educational scholarship. Many education-intensive faculty members are on the education scholar track (non-tenure-eligible). Promotion in this track requires scholarship, much of which is based on scholarship in teaching. Regional Medical Campuses COM-P is launching an 8-month longitudinal integrated clerkship in Payson, Arizona, in the summer of 2020 for a subset of students in the rural health certificate of distinction. Assessing comparability of educational experiences at this site, as at all distributed sites, is part of the regular clerkship review process and includes comparison of student evaluations, grade distributions, NBME subject exam performance, student competency assessment, and required clinical experiences across sites. Initiatives in Progress Two major interrelated curriculum initiatives are included in the COM-P strategic plan: developing a 3-year curriculum and implementing competency-based, time-variable progression to residency. Pilot projects to develop enabling aspects for these initiatives are currently underway, including: A longitudinal ambulatory clinical experience beginning in year 1 and continuing throughout medical school Implementation of Entrustable Professional Activity–based assessment in the longitudinal clinic, community clinical experience (years 1–2), longitudinal integrated clerkship (year 3), and several clerkships (year 3) Identification of GME programs interested in partnering to create linkages COM-P envisions creating a 3-year core curriculum with competency assessment that will either confirm student preparedness for GME training or identify a need for additional time for competency development before transition to GME.

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