Review of Y 2 SBM Repro Course Preclinical

Review of Y 2 SBM Repro Course Preclinical Subcommittee January, 2014 Aaron Barnes (Geisel 2), Rich Comi MD, Hal Manning MD 1. Course learning objectives 2. Course learning opportunities 3. Learning assessments for students 4. Measures of overall quality for the course 5. Specific suggestions for improving course

SBM Reproductive Endocrinology Review of Objectives Rich Comi, MD

Course Objectives from Ilios 1) Define terms common to the discussion of patients with disorders in repro system (RS) 2) Describe the normal structure and physiology of RS 3) Describes normal stages of maturation and involution of RS 4) Describe processes of normal pregnancy, labor, delivery and issues in family planning 5) Explain signs, sx, processes of dx of common disorders of male and female RS 6) Explain signs, sx, processes of male RS 7) Describe disorders of male and female RS in early and late life 8) Describe appropriate use of dx testing in patients with disorders of RS 9) Discuss epidemiology and population health aspects of disorders of the RS 10)Discuss public health and ethical issues of disorders of the RS

Course Objectives from Ilios (cont’d) 11) Describe the pathology and pathophysiology of disorders of the RS 12) Explain the basis for pharm and nonpharm interventions for common repro disease 13) Describe how various medical disciplines are integrated in disorders of the RS 14) Utilize the results of outcome and cost utility studies to evaluate pt care, prevention and screening in disorders of the RS 15) Describe how operations and processes in a complex healthcare system have an impact in disorders of the RS 16) Practice and demonstrate systematic problem solving skills in disorders of the RS 17) Explain ethical issues involved in mgmt of patients with disorders of the RS 18) Communicate with fellow students an faculty about disorders of the RS 19) Discuss methods of communication with pts and families about disorders of the RS 20) Demonstrate team skills by participating in team exercises

Course Objectives from Ilios (continued) 21) Take responsibility for your own education 22) Read critically , evaluate and assess information about disorders of RS 23) Search efficiently for high quality relevant info about disorders of the RS Review of Objectives: Objectives 5 and 6 are redundant Objective 11 seems too broad Objective 12 is vague Objectives 20 , 21 and 23 are not specific to this course but seem reasonable There are several typos # 23 is mislabeled as 22 and always paired with 22 – “ 22, 22”

Session mapping to course objectives 100 F R E Q U E N C y 50 20 10 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 This shows that all course objectives are addressed multiple times in the sessions, but that #11 may be too broad

Mapping Geisel to the NBME Step 1 curriculum 1 -4 Normal processes embryonic development, fetal maturation, and perinatal changes, including gametogenesis 1 -4 organ structure and function female structure, including breast female function male structure male function intercourse, orgasm pregnancy, including ovulation, fertilization, implantation, labor and delivery, the puerperium, lactation, gestational uterus, placenta 1 -3 ? cell/tissue structure and function, including hypothalamic-pituitary-gonadal axis, sex steroids, and gestational hormones reproductive system defense mechanisms and normal flora

57, 11 Abnormal processes infectious, inflammatory, and immunologic disorders (female and male) traumatic and mechanical disorders (female and male) neoplastic disorders (including female reproductive, breast [including fibrocystic changes], trophoblastic disease) ? metabolic and regulatory processes (female and male) 10, prenatal and perinatal counseling and screening 17, 19 ? systemic disorders affecting reproductive function 5, 11 5 -7, 11 disorders relating to pregnancy, the puerperium, and the postpartum period obstetric problems complications affecting other organ systems disorders associated with the puerperium antepartum, intrapartum, postpartum disorders of the fetus idiopathic disorders drug-induced adverse effects on the reproductive system degenerative disorders congenital and genetic disorders affecting the reproductive system

12 Principles of therapeutics mechanisms of action and use of drugs for treatment of disorders of the reproductive system and management of normal reproductive function female reproductive tract fertility drugs oral contraception, other methods of contraception estrogen, progesterone replacement, treatment of menopause stimulants and inhibitors of labor estrogen and progesterone antagonists stimulators and inhibitors of lactation male reproductive tract fertility drugs androgen replacement and antagonists gonadotropin-releasing hormone and gonadotropin replacement, including all gonadotropin-releasing hormone antagonists abortifacients antimicrobial and antiparasitic agents antineoplastics restoration of potency otherapeutic modalities affecting the reproductive system

Gender, ethnic, and behavioral considerations affecting disease treatment 9, 10, 14, and prevention, including psychosocial, cultural, occupational, and 15, 17, 19, environmental emotional and behavioral factors influence on person, family, and society occupational and other environmental risk factors family planning and pregnancy gender identity, sexual orientation, sexuality, libido effects of traumatic stress syndrome, violence, rape, child abus In excess of NBME 1: 8 (diagnostics), 13 (team integration), 16 (problem solving skills), 18 (communicate with professionals), 20 )team skills), 22( read literature), 23 (search literature)

Mapping Geisel to the LCME Content Emphases 14, 15 ED-10. The curriculum of a medical education program must include behavioral and socioeconomic subjects in addition to basic science and clinical disciplines. 5, 6, 16, 22, 23 ED-11. The curriculum of a medical education program must include content from the biomedical sciences that supports students' mastery of the contemporary scientific knowledge, concepts, and methods fundamental to acquiring and applying science to the health of individuals and populations and to the contemporary practice of medicine. ? ED-12. The curriculum of a medical education program should include laboratory or other practical opportunities for the direct application of the scientific method, accurate observation of biomedical phenomena, and critical analysis of data. ? ED-13. The curriculum of a medical education program must cover all organ systems, and include the important aspects of preventive, acute, chronic, continuing, rehabilitative, and end-of-life care. n/a ED-14. The curriculum of a medical education program must include clinical experience in primary care.

7, 9, 10, 14, 16, 17 ED-15. The curriculum of a medical education program must prepare students to enter any field of graduate medical education and include content and clinical experiences related to each phase of the human life cycle that will prepare students to recognize wellness, determinants of health, and opportunities for health promotion; recognize and interpret symptoms and signs of disease; develop differential diagnoses and treatment plans; and assist patients in addressing healthrelated issues involving all organ systems. n/a ED-16. The clinical experiences provided to medical students by a medical education program must utilize both outpatient and inpatient settings. n/a ED-17. Educational opportunities must be available in a medical education program in multidisciplinary content areas (e. g. , emergency medicine, geriatrics) and in the disciplines that support general medical practice (e. g. , diagnostic imaging, clinical pathology). ? ED-17 -A. The curriculum of a medical education program must introduce medical students to the basic scientific and ethical principles of clinical and translational research, including the ways in which such research is conducted, evaluated, explained to patients, and applied to patient care. n/a ED-18. The curriculum of a medical education program must include elective opportunities to supplement required courses and clerkships (or, in Canada, clerkship rotations).

18, 19 13 ED-19. The curriculum of a medical education program must include specific instruction in communication skills as they relate to physician responsibilities, including communication with patients and their families, colleagues, and other health professionals. ED-19 -A. The core curriculum of a medical education program must prepare medical students to function collaboratively on health care teams that include health professionals from other disciplines as they provide coordinated services to patients. These curricular experiences include practitioners and/or students from other health professions. ED-20. The curriculum of a medical education program must prepare medical students for their role in addressing the medical consequences of common societal problems (e. g. , 10, 14, provide instruction in the diagnosis, prevention, appropriate reporting, and treatment of 15 violence and abuse). ? ED-21. The faculty and medical students of a medical education program must demonstrate an understanding of the manner in which people of diverse cultures and belief systems perceive health and illness and respond to various symptoms, diseases, and treatments. ? ED-22. Medical students in a medical education program must learn to recognize and appropriately address gender and cultural biases in themselves, in others, and in the process of health care delivery. 17, 19 ED-23. A medical education program must include instruction in medical ethics and human values and require its medical students to exhibit scrupulous ethical principles in caring for patients and in relating to patients' families and to others involved in patient care.

In sum, 1) There are minor typos to be fixed 2) Objective 11 is too broad 3) The objectives do a nice job of covering the NBME curriculum and LCME emphases but there a few areas that could be improved (yellow boxes with “? ” NBME topics: metabolic, systemic disorders and “protective systems ( bacterial biome? ) LCME topics: diversity gender and cultural biases translational research observation/measurement of biophenomena rehab medicine

1 g. Overlap/ILIOS word search: “Estrogen” Does not appear in any course objectives Appears in 2 course-level Me. SH (Pharm 217) Appears in 9 sessions in 5 different courses Course Session Objective Neuroscience (MDED 115) Hypothalamus Describe the HPG axis (Gn. RH, FSH, LH) and how gonadal steroids (estrogens, progestins, androgens) and other environmental factors (e. g. , leptin) influence Gn. RH neurons (through presynaptic afferents such as kisspeptin neurons). Endocrine Physiology (PHSL 120 Endo) The Male and Female Reproductive System To explain how estrogens, progestins androgens regulate nonreproductive tract tissues, including their mechanism(s) of action. Endocrine Physiology (PHSL 120 Endo) Conference 2: To recall the sources of estrogen in pre- and postmenopausal women and to consider ways in which tumor growth might be slowed in the two groups of individuals. Endocrine Physiology (PHSL 120 Endo) Endocrine control of growth To describe interactive roles of key hormones HGH, thyroid hormones, androgens/estrogens, insulin, PTH, Vit. D, cortisol, somatomedins, in skeletal growth Organ Based Pharmacology (PHAR 217) F-7 Kinlaw - Bone/Calcium Pharmacology 2 -Feb 11: 15 am Recognize medications used in treating disorders of calcium metabolism (including: diuretics, bisphonates; calcium salts; vitamin D; calcimimetics; estrogen replacement therapy; selective estrogen receptor modulator (SERM); parathyroid hormone; and monoclonal antibodies). Organ Based Pharmacology (PHAR 217) H-3 Craig/Di. Renzo - Gonadal Hormones and Inhibitors Review the physiologic role of estrogen and progesterone in the female reproductive cycle. Organ Based Pharmacology (PHAR 217) H-3 Craig/Di. Renzo - Gonadal Hormones and Inhibitors Describe the basics of the biosynthesis of estrogen and progesterone. Organ Based Pharmacology (PHAR 217) H-3 Craig/Di. Renzo - Gonadal Hormones and Inhibitors Discuss the effect of tamoxifen on estrogen receptors. Reproduction (SBM 206) Contraception Compare and contrast pregnancy rates and efficacy between unprotected coital activity, estrogen containing contraceptives, IUDs, medroxyprogesterone acetate contraception, withdrawal, and condoms. Reproduction (SBM 206) Contraception Recognize the "absolute" contraindications to estrogen containing hormonal contraceptives in clinical patient cases. Reproduction (SBM 206) The Menopause Transition Describe the common short- and long-term effects of estrogen deficiency. Reproduction (SBM 206) PBL - Breast Cancer Discuss the role of estrogens in breast cancer. Clinical Pharmacology and Therapeutics (PHAR 405) Using glucocorticoids wisely Explain the common structures of glucocorticoids, mineralocorticoids, androgens, progestins, and estrogens

1 g. Overlap/ILIOS word search: “Eclampsia” Does not appear in any course objectives Does not appear in any session title Appears in 5 sessions in 2 different courses Course Session Objective Reproduction (SBM 206) Small Groups/Speed Dating Format Discuss potential mechanisms in the pathogenesis of preeclampsia. Reproduction (SBM 206) Small Groups/Speed Dating Format List the physical manifestations and risks of preeclampsia. Reproduction (SBM 206) Small Groups/Speed Dating Format Discuss the risk factors for the development of preeclampsia. The Kidney in Pregnancy Discuss vascular endothelial growth factor (VGEF) and s. FIT-1 in pre-eclampsia. Review with Faculty Describe kidney function and dysfunction in pregnancy, including pre-eclampsia. Kidney and Urinary System (SBM 212)

2. Course Learning Opportunities 2012 -13 (Hal) Total hours: 55. 5 h § Traditional lectures = 23. 5 h (42% of total hrs) § Large group discussion/review = 12 h § Lab (classical) = 2 § Small groups/conferences = 3 § PBL groups = 7 § Panel discussion (Hearts and Minds) = 5 § “Other formats” = 3

Assessment of Student Performance Final exam: 85% Small group “speed” dating: 6% Team-based learning: 6% Breast exam session: 1% Self-directed learning exercise: 2%

3. Content of Final exam (current topics 2013) – 85% of grade Topic # Abortion 1 Male pathology 1 Adolescent sexuality 1 Male sexual dysfunction 2 Breast disease 5 Menopause 1 Cervical dysplasia 1 Menstrual cycle 2 Complications of pregnancy 3 Ovarian 4 Endo/Pregnancy 2 Placenta 4 Erectile dysfunction 2 Pregnancy 5 Genetics 2. 5 Prostate 1 HPG axis 1 Puberty 6 Imaging 2 Reproduction pharmacology 5 Incontinence 1 Sex differentiation 2 Infertility 3 Sexual abuse 1 Labor/Delivery 2 Uterus/fallopian 1 Lactation 1 Vulva/uterus 2

3. 2012 -2013 Exam items sorted by current course learning objectives (Hal) # Objective Maps to # items 1 Define terms common to the discussion of patients with disorders of the reproductive system. 1 a, 1 c 0 2 Describe the normal structure and physiology of the reproductive system. 1 a 1 3 Describe normal stages of maturation and involution of the reproductive system. 1 a 3 4 Describe the processes involved in normal pregnancy, labor and delivery and issues in family planning/contraception. 1 a 8 5 Explain signs, symptoms and process of diagnosis of common disorders of the male and female reproductive system, including: benign and malignant neoplasms; infections; menstrual disorders; sexual dysfunction; disorders of sexual differentiation; abnormal pregnancy, infertility; pubertal disorders; urinary tract disorders. 1 c 36 6 Explain signs, symptoms and process of diagnosis of common disorders of the male reproductive tract, including: benign and malignant neoplasms; infections; sexual dysfunction; disorders of sexual differentiation; infertility; urinary tract (including prostate) disorders. 1 c 9 7 Describe the disorders of the reproductive system that affect patients early and late in life. 1 c 5 8 Describe the appropriate use of diagnostic testing in patients with disorders of the reproductive system. 1 c, 2 g 3 9 Discuss the epidemiology and population health implications of disorders of the reproductive system. 1 c 1 10 Discuss the public health and ethical issues involved with reproductive health, including sexual abuse, sexually transmitted diseases, and unintended pregnancy. 1 e 0 11 Describe the pathology and pathophysiology of disorders of the reproductive system 1 c 3 12 Explain the basis for pharmacological and non-pharmacological interventions for common reproductive diseases. 1 c 4

2012 -2013 Exam items (cont’d) # Objective Maps to # items 13 Describe how various medical disciplines are integrated and involved with the care, research and prevention of the disorders of the reproductive system (OB/GYN. urology, radiology, pathology, pediatrics, psychology, social work, etc) 1 c 0 14 Utilize the results of outcome and cost utility studies to evaluate the effectiveness of patient care, disease prevention and screening in regards to the reproductive system. 5 c, 6 h 0 15 Describe how operations and processes that occur within a complex healthcare system have an impact on cost and quality of effective care of reproductive system diseases 1 f, 6 d, 6 e 0 16 Practice and demonstrate systematic problem-solving skills with regard to patients with reproductive disease. 1 c 0 17 Explain ethical issues involved in management of patients with disorders of the reproductive system. 1 e, 4 d 0 18 Communicate with fellow students and faculty about patients with reproductive system disease. 3 e, 3 g 0 19 Discuss methods of communication with patients and patient families about reproductive diseases. 2 a, 3 b, 3 d 1 20 Demonstrate team skills by participating in team exercises. 4 a, 4 b 0 21 Take responsibility for his- or her-own medical education. 4 h 0 22 Read critically, evaluate, and assess medical information and scientific literature about important reproduction topics and questions. 1 b, 5 b 0 23 Search efficiently for and obtain recent, high quality, relevant medical information and scientific literature about important clinical topics and questions. 5 a 0

3. Exam content (Repro final exam) Question style # Factual only, test recognition/memorization Important concepts, avoid test fatigue 17 Clinical vignette with reasoning 27 Application of knowledge: --Interpret findings, data --Photos of pathology 17 14 3 Negative stem 0 Multiple T/F format 3 Pharmacology questions 5

3. Exam content (cont’d) Question style # Short answer/essay -- Facts (list some of the…. . ) -- Comment on brief clinical vignette 3 1 2 “Multiple Matching) “Use each item once, more than once, or not at all”. 9

4. Performance on USMLE Step 1 over last 3 years

4. Performance on USMLE Step 1 over last 3 years

4. Feedback about course: Student survey scores (Aaron)

Results from recent student course reviews Data from 2012 -2013 evaluations: Strongest areas: • “Overall usefulness of reading Text(s). ” 3. 95 • “How well this course provided me with a useful and appropriate introduction to this field of discipline. ” 3. 85 “Overall clarity of the learning objectives for the entire course and for each individual learning session. ” 3. 81 Among the questions asked on the course review pertaining to the “usefulness” of course elements, none scored below a 3. 12. All faculty were rated at a 3. 26 or higher, with 19 of 28 lecturers receiving a score of 3. 70 or higher.

Results from recent student course reviews Representative comments (strengths): Many students commented on the strength and quality of the lecturers. “The course focused on principals that I will probably retain rather than memorizing facts that I definitely won’t. ” “TBL was helpful for emphasizing key points. ” “I also really appreciated the books and the correlation between the book chapters and what was taught. ”

Results from recent student course reviews Representative comments (weaknesses): Several students commented that lecture notes should be given for every lecture in order to more clearly communicate important points and remedy the incongruence between lectures and the textbook. “I think there was a lot of ambiguity in what we needed to know, despite the fact that we were supposed to be using our textbook as a guide. ” The number of TBL cases was overwhelming early on in the conceptually heavy portion of the course Some students felt that greater coordination between clinician lecturers and pathologist lecturers would increase the clarity and effectiveness of their lectures. “Combining multiple topics into one session, or having multiple speakers at one lecture, sometimes felt overwhelming. The flow of these sessions should be practiced. ”

PLANS FOR ADDRESSING CONCERNS AND ISSUES FOR NEXT CYCLE, TERM 4, 2014

1. Learning Objectives: Summary Issue Proposed Fix Some of learning objectives too broad See new set of course learning (e. g. 11); some redundancy among objectives obejctives (e. g. 5 and 6) Group learning objectives by major competency domain, and map to specific competency tasks Done Make sure that exam topics track to new learning objectives In progress for current exam cycle Consider enhanced coverage of topics with LCME emphasis (e. g gender and cultural biases, diversity, etc. ) Introducing material this year in both small group sessions and a panel discussion

2. Learning Opportunities Summary Good use of non-lecture formats (58% in 2013, projected to be > 60% in 2014) Outside of PBL, limited opportunities to observe (and evaluate) individual students

3. Evaluating Students, Summary Issue Proposed Fix Learning objectives need to be granular enough that major exam areas map well to them Learning objectives revised for 2014 Learning objectives not assessed on written final exam must be assessed in some other way Some objectives are assessed in small groups, team based learning, and self directed learning Conference leaders may not know students well enough to assess their competency in multiple areas Format was changed to improve continuity. Faculty have more longitudinal exposure to students Written final exam made good use of vignettes, no negative stems! Need to eliminate matching questions. Will be eliminated

4. Feedback from Students Issue Proposed Fix Consider providing lecture notes to helpful in identifying important points; lecture notes may be more congruent with the course than a textbook Some lecture notes are provided in the event the text is not congruent. Powerpoint presentations are posted as a resource Clarifying objectives would make it easier to prepare for the exam Objective have been revised Consider decreasing the amount of TBL sessions early on in the course and/or using TBL session in a directed manner to assist in the learning of particularly confusing topics TBL session topics revised Sessions given by both pathologists and clinicians could be better organized and orchestrated Feedback given to these dyads for 2014