Review of Y2 SBM/CT and MS Course
PreClinical Subcommittee
November, 2013
Chris Rees (Geisel 2), Steve Benson MD, Dave Nierenberg 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
1. 2012-2013 Course Learning Objectives
#
Objective
Maps to
1
Apply current knowledge in MS Medicine to Dx and Rx decisions
1a
2
Apply current clinical and translational science to Dx and Rx questions
1b,c,d
3
Apply knowledge of prevention, risk factor modification, substance abuse, pain
management, medical ethics, and medical-legal issues to clinical problem solving
1e
4
Apply knowledge of impact of social, economic, cultural and personal factors on
health to clinical problems in MS medicine
1f
5
Establish mutually respectful student-patient and student-family interactions with
diverse patients
2a,c,
3a,b
6
Interview patients skillfully, using a MS-focused history
2b,2c
7
Examine patients with MS conditions skillfully, with attention to cleanliness, infection
control, and patient comfort
2c
8
Generate an appropriate differential Dx for patients with MS disorders
2d,e
9
Explain the indications, complications, and performance of diagnostic tests (e.g. CT,
MRI, EMG, NC, tissue biopsy)
2f,g
10
Identify common abnormal findings on plain radiographs, CT scans, and MRI scans
2h
11
Communicate effectively with patients and families especially when special barriers
to communication exist (eg. Cultural, socioeconomic, linguistic, etc)
3c
2012-2013 ILIOS Course Objectives (cont’d)
#
Objective
Maps to
12
Assist patients in understanding their treatment options and prognosis
3d
13
Communicate collegially and effectively, verbally and in writing, with physician
colleagues and other members of the HC team
3e,f,g,h
14
Behave respectfully and responsibly towards patients, families, colleagues, and
other members of the HC team, and remain aware of different concerns, opinions,
and cultural perspectives
4a,e
15
Meet professional responsibilities fully
4b
16
Adhere to high ethical and moral standards,, accept constructive criticism, and
respect patient confidentiality
4d,f,g
17
Take responsibility for one’s own medical education, and develop habits of
mindfulness and reflection
4h,j
18
Describe barriers to access basic health services, and its effect on vulnerable
populations
4k
19
Contribute constructive feedback during peer review
4l
20
Identify and critically evaluate evidence-based and cost-conscious strategies for
patients with MS diseases, and apply these approaches to patient care
5a,b,e,f
21
Assess the effect of social environment on clinical care and patient outcomes
5c
22
Identify appropriate resources to support patient care, and collaborate effectively
with all members of the inter-professional team
6a,b
1a. Learning Objectives (Dave)
 In the course syllabus 2013, the course objectives are listed as
follows:
 To provide a thorough and detailed introduction to
rheumatologic conditions and musculoskeletal medicine
 To know the important historical features, physical findings,
laboratory and radiographic findings that help differentiate one
connective tissue disease from another
 To develop a structured approach to the patient with
musculoskeletal symptoms in order to construct an appropriate
differential diagnosis and develop rational diagnostic and
therapeutic plans.
 Students are not provided with the ILIOS course objectives
 Important to have one shared set of core learning objectives,
presented right at the beginning of the course
Continued (Dave)

From the lecture topics, and also the categories on the final exam, we can see the core topics of the
course include:
 Overview of course, and the approach to the patient
 Elements of the joint and MS exam
 Osteoarthritis
 Rheumatoid arthritis
 Pediatric conditions and JRA
 Lyme disease
 Other types of arthritis: seronegative, crystal, infectious
 Muscle conditions, myositis and myofascial pain
 Vasculitis, SLE, and scleroderma
 Lab testing
 Soft tissue problems and injuries
 Bone diseases, fractures, and tumors
 DJD and other Diseases of the spine
 Congenital and developmental problems
 Imaging the MS and CT systems
 Common genetic conditions
1. Topics in national textbook
(Cecil Essentials of Medicine, 2013)
 Approach to patient with
rheumatic disease (Yes)
 Sjogren syndrome (no in 2013,
yes in 2014)
 Rheumatoid arthritis (Yes)
 Systemic vasculitis (Yes)
 Spondyloarthropathies (Yes)
 Crystal arthropathies (Yes)
 SLE (Yes)
 Osteoarthritis (Yes)
 Antiphospholipid antibody
 Non-articular soft tissue
syndrome (yes)
 Systemic sclerosis (Yes) and
Sjogren’s syndrome
 Idiopathic inflammatory
myopathies (Yes)
disorders (Yes)
 Rheumatic manifestations of
systemic disorders (Yes)
1f. Learning objectives addressing additional
specific LCME topics (with Nicole)
 Health of populations:
 Senior epidemic of OA, and how obesity contributes to the clinical
progression
 Chronic pain syndromes, e.g. fibromyalgia
 Basic and ethical principles of clinical and translational
research:
 How the intricate process of basic and translational immunology research
is changing the way we approach pts with RA (William Rigby)
 Gender and cultural biases in students themselves:
 Not at this time
 Instruction in medical ethics and human values
 In 2014 will be their first Hearts and Minds session about a patient with
fibromyalgia (chronic pain syndrome) and her long-term use of opioids for
pain management
1g. Overlap/ILIOS word search: “Vasculitis”
 Does not appear in any course objectives
 Appears in one session title (SBM/MS)
 Appears in 3 sessions in 3 different courses
1g. Overlap/ILIOS word search: “Rheumatoid Arthritis”
 Does not appear in any course objectives
 Appears in one session title (SBM/MS)
 Appears in 5 sessions in 3 different courses
1g. Overlap/ILIOS word search: “uric acid”
(note: there are other “hits” when “gout” is searched)
 Does not appear in any course objectives
 Does not appear in any session title
 Appears in 4 sessions in 4 different courses
1. Learning Objectives: Summary
Issue
Learning objectives in ILIOS are
vague
Learning objectives in ILIOS differ
from those posted in the course
Group learning objectives by major
competency domain, and map to
specific competency tasks
Current course objectives in ILIOS do
not contain the key words of the
major diseases and conditions
Make sure that exam topics track
nicely to new learning objectives
List learning objectives for each
session at the beginning of each
session
Proposed Fix
2. Course Learning Opportunities 2012-13 (Dave)
 Total hours: 39 h
 Traditional lectures = 29 h (74% of total hours)







Large group discussion/review = 0 h
Lab (classical) = 0
Small groups/conferences = 6
PBL groups = 3
Direct patient contact or PE session = 1 (2 groups)
Panel discussion (Hearts and Minds) = 0
Other formats = 0
2. Learning Opportunities Summary
Issue
Over-reliance on standard lectures
(29/39=74%)
Not enough engaged large group
sessions (0)
Only 6 h of conference groups
Didn’t have Hearts and Minds panel
discussion in 2013
Current 1 h PE demonstration clinic is
excellent
Proposed Fix
3. Content of Final exam (current topics 2013)
Topic
#
Topic
#
Acute soft tissue
6
Myositis
3
Bone pathology
3
Osteoarthritis
7
Bone tumors
1
Pediatric topics
3
Development
1
Physical dx
4
DJD of spine
2
Imaging
1
Fibromyalgia
4
Rheumatoid arthritis
11
Fractures
1
Scleroderma
5
Genetics
1
Seronegative arthritis
3
Gout
7
SLE
10
Infectious arthritis
4
Testing
2
JRA
3
Vasculitis
5
Lyme disease
5
Pharmacology
6
3. 2012-2013 Exam items sorted by current course
learning objectives (Steve)
#
Objective
Maps to
# items
1
Apply current knowledge in MS Medicine to Dx and Rx decisions
1a
70
2
Apply current clinical and translational science to Dx and Rx questions
1b,c,d
1
3
Apply knowledge of prevention, risk factor modification, substance abuse,
pain management, medical ethics, and medical-legal issues to clinical
problem solving
1e
2
4
Apply knowledge of impact of social, economic, cultural and personal
factors on health to clinical problems in MS medicine
1f
0
5
Establish mutually respectful student-patient and student-family
interactions with diverse patients
2a,c,
3a,b
0
6
Interview patients skillfully, using a MS-focused history
2b,2c
0
7
Examine patients with MS conditions skillfully, with attention to
cleanliness, infection control, and patient comfort
2c
7 PE
findings
8
Generate an appropriate differential Dx for patients with MS disorders
2d,e
1
9
Explain the indications, complications, and performance of diagnostic
tests (e.g. CT, MRI, EMG, NC, tissue biopsy)
2f,g
2
10
Identify common abnormal findings on plain radiographs, CT scans, and
MRI scans
2h
9
11
Communicate effectively with patients and families especially when
special barriers to communication exist (eg. Cultural, socioeconomic,
linguistic, etc)
3c
0
2012-2013 Exam items (cont’d)
#
Objective
Maps to
# items
12
Assist patients in understanding their treatment options and prognosis
3d
0
13
Communicate collegially and effectively, verbally and in writing, with physician
colleagues and other members of the HC team
3e,f,g,h
0
14
Behave respectfully and responsibly towards patients, families, colleagues, and
other members of the HC team, and remain aware of different concerns,
opinions, and cultural perspectives
4a,e
0
15
Meet professional responsibilities fully
4b
0
16
Adhere to high ethical and moral standards,, accept constructive criticism, and
respect patient confidentiality
4d,f,g
0
17
Take responsibility for one’s own medical education, and develop habits of
mindfulness and reflection
4h,j
0
18
Describe barriers to access basic health services, and its effect on vulnerable
populations
4k
0
19
Contribute constructive feedback during peer review
4l
0
20
Identify and critically evaluate evidence-based and cost-conscious strategies for
patients with MS diseases, and apply these approaches to patient care
5a,b,e,f
0
21
Assess the effect of social environment on clinical care and patient outcomes
5c
0
22
Identify appropriate resources to support patient care, and collaborate
effectively with all members of the inter-professional team
6a,b
0
3. Exam content (MS final exam)
Question style
#
Factual only, test recognition/memorization
Important concepts, avoid test fatigue
15
Clinical vignette with reasoning
Excellent, well written, pertinent
Application of knowledge
Interpret findings, data
7
Photos of PE findings
59
8
Negative stem
2 (only!)
Multiple T/F format
1 (only!)
Pharmacology questions
4 were simple recall, 2 clinical vignettes
6
3. Evaluating Students, Summary
Issue
Learning issues need to be granular
enough that major exam areas map
well to them
Learning objectives not assessed on
written final exam must be assessed
in some other way
Conference leaders may not know
students well enough to assess their
competency in multiple areas
Conference size may be too large to
enable faculty to get to know each
student
Written final exam made good use of
vignettes, fewer factoid questions,
very few negative stem
Proposed Fix
4. Performance on USMLE Step 1 over last
3 years
4. Feedback about course
from March 2012 AAMC GQ
 How well did each of the following sciences basic to
medicine prepare you for clinical clerkships and
electives?
 All Year 1 disciplines (n=9): mean = 3.1
 All Year 2 disciplines (n=4): mean = 3.4 (3.3)
 Renal course was not broken out
4. Feedback about course:
Student survey scores (Dave)
Results from recent student
course reviews
Data from 2012-2013 evaluations:
Strongest areas:
• “Overall usefulness of attending laboratory sessions or simulated
laboratory sessions.” 4.22
• “How well this course provided me with a useful and appropriate
introduction to this field of discipline.” 4.05
• “Overall quality of the entire course” 4.00
Among the questions asked on the course review pertaining to the
“usefulness” of course elements, none scored below at 3.48.
All faculty were rated at a 3.16 or higher, with 16 of 20 lecturers
receiving a score of 3.70 or higher.
Results from recent student
course reviews
Representative comments (strengths):
 Many students commented on the fairness and congruence of the
final exam.
 “The clinic visit was fantastic. This should be standard for all
courses.”
 “The best part of the course was the conferences.”
 The majority of faculty received overwhelmingly positive scores
from the students.
Results from recent student
course reviews
Representative comments (weaknesses):
 Several students commented that the clinical experience would be
more useful later in the term. (done for 2014)
 “Perhaps one or two more conference groups would be helpful.”
(done for 2014)
 “The organization of the course could be a little better. The arthritis
lectures could be grouped together and the bone lectures could be
grouped together.” (done for 2014)
 Some students commented that the required paper felt like
“busywork.”(replaced in 2014 by off-line quizzes)
4. Global measures of quality
Issue
Shift clinical experience (PDX
session) later into term
Having one or two more conference
group meetings would be helpful
(highlight of course)
Improve course organization by better
grouping of topics (e.g. arthritis
material, bone material)
Required written paper (analyzing a
journal article) felt like “busywork” to a
few students
Proposed Fix
PLANS FOR ADDRESSING
CONCERNS AND ISSUES
FOR NEXT CYCLE, TERM 4,
2014
1. Learning Objectives: Summary
Issue
Proposed Fix
Learning objectives in ILIOS are
vague
Rewrite new set of course learning
objectives
Learning objectives in ILIOS differ
from those posted in the course
Post the new ILIOS objectives in
syllabus on first day of course
Group learning objectives by major
competency domain, and map to
specific competency tasks
Done in new version
Have enough detail in new course
learning objectives to permit ILIOS
word searches
Done in new objectives
Make sure that exam topics track to
new learning objectives
Done in new objectives
List learning objectives for each
session at the beginning of each
session
Will do next cycle
DRAFT New Course Learning
Objectives for 2013-14
 Each student should demonstrate an appropriate
level of understanding of the pathophysiology of
the musculoskeletal/connective tissues system,
such that the student is prepared to recognize,
diagnose, and describe effective treatment options
for the most common and severe diseases and
disorders of this organ/system that may be
encountered during the clinical clerkships or in
clinical practice.
Possible Course Learning Objectives 2013-14
#
Objective
Domain
Assessment
1
Describe the pathophysiology, diagnosis, and treatment options for osteoarthritis
1abcde
Conference, PBL,
exam
2
Describe the pathophysiology, diagnosis, and treatment options for rheumatoid arthritis
(including juvenile rheumatoid arthritis)
1abcde
Conference, PBL,
exam
3
Describe the pathophysiology, diagnosis, and treatment options for less common types of
arthritis (e.g. sero-negative, psoriatic, etc)
1abcd
Conference, PBL,
exam
4
Describe the pathophysiology, diagnosis, and treatment options for diseases of the lumbar and
cervical spine (including DJD, ankylosing spondylitis, disc disease, low back pain,etc)
1abcd
Conference, PBL,
exam
5
Describe the pathophysiology, diagnosis, and treatment options for complications of uric acid
and other crystals (including gout, pseudogout)
1abcd
Conference, PBL,
exam
6
Describe the pathophysiology, diagnosis, and treatment options for common infections of the MS
system (e.g. Lyme disease, septic arthritis)
1abcd
Conference, PBL,
exam
7
Describe the pathophysiology, diagnosis, and treatment options for diseases of skeletal muscle
(e.g. myositis, polymyositis, etc.)
1abcd
Conference, PBL,
exam
8
Describe the pathophysiology, diagnosis, and treatment options for connective tissue diseases
(eg. systemic lupus erythematosus, scleroderma, mixed CT disease, Sjogren’s syndrome)
1abcd
Conference, PBL,
exam
9
Describe the pathophysiology, diagnosis and treatment options for the various types of vasculitis
(eg. Polymyalgia rheumatica, giant cell arteritis, granulomatosis with polyangiitis, polyarteritis)
1abcd
Conference, PBL,
exam
10
Describe the pathophysiology, diagnosis, and treatment options for bone and soft tissue
diseases (e.g. tumors, fractures, sprains)
1abcd
Conference, PBL,
exam
11
Describe the pathophysiology, diagnosis, and treatment options for common pediatric and
developmental diseases (e.g. juvenile rheumatoid arthritis, genetic conditions)
1abcd
Conference, PBL,
exam
12
Describe the advantages and disadvantages of major diagnostic testing modalities for the
MS system (e.g. radiography, CT, MRI, ultrasound, serologic testing, etc.)
2fgh
Conference, PBL,
exam
Possible Course Learning Objectives 2013-14
#
Objective
Domain
Assessment
13
Describe the most common symptoms of rheumatic and musculoskeletal diseases, and use
that knowledge to help develop a differential diagnosis
2ab
Conferences, PBL
14
Explain how patients with MS/CT disorders can be skillfully and respectfully examined, with
appropriate attention to cleanliness and privacy
2ac
Rheumatology
clinic
15
Explain the indications, complications, and limitations of common diagnostic modalities including
imaging studies, EMG, NCS, and tissue biopsies
2fg
Exam
16
Correctly identify common abnormalities seen on plain radiographs, CT scans, and MRI’s of the
MS system
2gh
Conference, PBL,
exam
17
Communicate effectively, verbally and in writing, with colleagues and physicians
3efg
Conference, PBL
18
Demonstrate how to assist patients in understanding their treatment options, and prognosis of
their diseases
3abcd
Conference, PBL
19
Meet professional responsibilities (meetings, assignments, etc) in a timely and professional
manner
4bdfh
Conference, PBL
20
Demonstrate the ability to take responsibility for one’s own medical education
4h
Conference, PBL
21
Describe how barriers to access for care of MS/CT problems adversely effects the health of
vulnerable populations
4k
Conference, PBL
22
Demonstrate the ability to identify and evaluate information about evidence-based and costconscious strategies in managing MS/CT disorders
5abce
Conference, PBL,
exam
23
Identify appropriate resources to help support patients with MS/CT disorders, and describe the
rolls of all members of the inter-professional HC team
6abef
Conference, PBL
24
Describe the appropriate role of rehabilitation (physiatry) and related services (OT, PT, etc) in
the care of patients with MS/CT diseases
6abce
Conference, PBL
2. Learning Opportunities Summary
Issue
Proposed Fix
Over-reliance on standard lectures
(29/39=74%)
In 2014, will reduce to 23/39 (59%)
Not enough engaged large group
sessions
Will increase from 0 to 3 in 2014
Only 6 h of conference groups
Will increase to 8 h in 2014
Don’t have Hearts and Minds panel
discussion in 2013
Will introduce new 1h session in 2014
Current 1 h demonstration clinic is
excellent
This will be continued in 2014
3. Evaluating Students Summary
Issue
Proposed Fix
Learning issues need to be granular
enough that major exam areas map
well to them
Fixed with new course learning
objectives
Learning objectives not assessed on
written final exam must be assessed
in some other way
Assigned in new course learning
objectives to observation of students
in conference, PBL groups
Conference leaders may not know
students well enough to assess their
competency in multiple areas
Increase hours spent with same
conference leader
Conference size may be too large to
enable faculty to get to know each
student
Increase number of faculty-led
conference groups
Written final exam made good use of
vignettes, fewer factoid questions,
very few negative stem
Continue to develop new items for
final exam
4. Feedback from Students
Issue
Proposed Fix
Shift clinical experience (PDX
session) later into term
Fixed for 2014
Having one or two more conference
group meetings would be helpful
(highlight of course)
Fixed for 2014
Improve course organization by better Done for 2014
grouping of topics (e.g. arthritis
material, bone material)
Required written paper (analyzing a
Re-evaluate goals of this exercise:
journal article) felt like “busywork” to a consider asking for a shorter paper,
few students
earlier in the course, that will help
students develop the skills to
translate translational research
findings into language patients can
understand