Dean’s Teaching Fellowship
Endowed program provides time and support for a cadre of faculty committed to teaching and enhancing the curriculum.
By Michael Wentzel
What can be done to give third-year students in the inpatient internal medicine clerkship a more active instructional tool that would replace a series of less engaging lectures?
How can communication between obstetric and pediatric providers in the delivery room be improved?
What is the best way to evaluate student musculoskeletal knowledge and clinical skills in order to develop a basis for curriculum changes that could boost competence?
These are questions asked and answered by faculty who received a Dean’s Teaching Fellowship, a unique program at the University of Rochester School of Medicine and Dentistry designed to build a cadre of committed medical educators.
“The Dean’s Teaching Fellowship is making our curriculum better,” said Ronald M. Epstein, M.D. (R ’87, FLW ’90), director of the program. “The program also produces opportunity for career development. The program is increasing faculty enthusiasm and capability for leadership in medical education, and therefore the quality of teaching. It’s making faculty members want to stay here and the enthusiasm is felt by their students.”
Valerie J. Lang, M.D. (R ’00), assistant professor of medicine, began her fellowship in 2004 with a goal of infusing more energy in the inpatient medicine clerkship.
“My project was to create online virtual patient cases to teach the content that had previously been covered in the lecture series while helping students organize their knowledge in a way that would help them reason through common internal medicine problems,” she said.
As director of the clerkship, Lang had found that students frequently saw patients after a diagnosis had been established and treatment was initiated.
“Losing the opportunity to see patients earlier in the course of their illness was associated with poorer performance on a student’s final exam,” she said. “Working through virtual patient cases guaranteed that students would be able to practice the cognitive tasks of identifying the key information to obtain in the interview and physical exam and diagnostic studies for patients who present with a symptom but had no diagnosis.”
As she worked on her project, Lang realized that covering the entire clerkship curriculum was too broad for her to accomplish alone. She began to work with a national organization, Clerkship Directors in Internal Medicine (CDIM), and a non-profit foundation, the Institute for Innovative Technology in Medical Education. She and her collaborators trained 33 clerkship directors from around the country to write 36 virtual patient cases that now comprehensively cover the entire national curriculum. Each has been peer-reviewed for content and pedagogical format and is available on-line.
The program is called SIMPLE: Simulated Internal Medicine Patient Learning Experience. There is a parallel program in pediatrics, and a program for family medicine was just launched. Today, 75 medical schools subscribe to SIMPLE.
“It’s gratifying, but daunting, to know that the majority of medical students in the United States will use our virtual patient program before they graduate,” Lang said.
Origins of the fellowship
The Dean’s Teaching Fellowship is one of only a few programs of its kind in the country for medical school faculty, and is atypical in that it is supported by an endowment and requires a completed project suitable for presentation at a national meeting and publication in a peer-reviewed journal.
Jules Cohen, M.D. (BA ’53, M ’57), a former senior associate dean for medical education at the School of Medicine and Dentistry, created the program almost 20 years ago as a reward for excellence in teaching.
In 2001, the program was expanded to provide a rigorous curriculum for faculty members who want to focus on medical education. The endowment, raised by Cohen, has grown enough to support fellowships for seven or eight faculty members annually.
An advisory panel reviews fellowship applications and recommends candidates to the School of Medicine and Dentistry dean who makes the final selections. The fellowships bear a name, honoring a donor or a person of note.
Fellows are expected to spend 15 percent of their time on the program for two years. This includes seminars that meet two times a month for three hours to discuss a variety of topics, including educational theory and technology, research and teaching methods, curriculum design, student assessments and faculty development. Each fellow undertakes an educational project for the two years. Fellows work closely with a mentor and with each other.
Each fellow is provided with a stipend of $13,000 for salary relief and up to $3,000 in support of expenses for research and travel to educational conferences. A fellow’s department contributes the difference between the stipend and the fellow’s salary. In addition to publications or presentations, many fellows develop new courses, Web-based educational programs and evaluation systems.
Since the program’s inception, almost 80 faculty members have been Dean’s Teaching Fellows.
“The fellowship program fills an important need in faculty development,” said Denham S. Ward, M.D., Ph.D., the School of Medicine and Dentistry’s associate dean for faculty development and co-director of the program. “It allows for networking of key faculty who are interested in education across all the departments in the medical center. Over the years, the program has developed a very strong group of faculty who have taken on or enhanced leadership positions in medical education. We are fortunate to have an endowed program such as this and it complements the other programs that we have for medical school faculty development in education.”
Team approach to high-risk deliveries
Rita Dadiz, D.O., assistant professor of pediatrics and a George W. Merck fellow, collaborated with a team of doctors and nurses from the obstetric and pediatric departments when she began her fellowship project in 2008. They developed an interdisciplinary team training program for those who care for women and their newborns during high-risk deliveries.
“This project is particularly innovative in fostering collaboration between different teams, disciplines and professions through a communication and teamwork-focused curriculum,” Dadiz said.
The project also uses simulation-based training (SBT) and highly realistic, computerized mother and baby mannequins to help portray a delivery. The baby, for example, can be delivered vaginally or via cesarean section. The mannequins breathe and the baby vocalizes sounds.
Doctors and nurses participate in the simulated delivery as they would during an actual delivery. The simulation is followed by a debriefing during which participants discuss what went well and identify areas for improvement. The simulation is videotaped so that during the debriefing the participants can review the video and reflect as a team on team dynamics.
Dadiz’s project has been incorporated into the training of residents, fellows, faculty, nurses and nurse practitioners from the obstetric and pediatric departments. The Medical Center has recognized simulation-based team training for the obstetric and pediatric teams as away to reduce malpractice premiums.
Dadiz is evaluating the effect of this program on communication during actual deliveries. As part of the evaluation process, her group is analyzing how teams communicate with each other by using videotaped deliveries. They have developed evaluation tools that include a survey for the care providers and a checklist for handoff communication in the delivery room.
“If we can show that SBT has a positive impact on patient care, then we can also potentially improve patient outcomes,” Dadiz said.
Musculoskeletal knowledge and confidence
Benedict DiGiovanni, M.D., associate professor of orthopaedics and rehabilitation and a Marshall A. Lichtman fellow, focused on musculoskeletal curricular evaluation and the level of medical student knowledge and clinical confidence for his project that began in 2007.
“How optimally are we educating our medical students in this area?” he said. “Some studies suggested we were not doing as good as job we should, that many students lacked the knowledge and lacked the confidence to evaluate musculoskeletal problems. If true, that is significant because 25 percent of what is seen in a primary care doctor’s office is musculoskeletal in nature.”
DiGiovanni and others questioned the reliability of tools used to assess medical student knowledge. He worked with the National Board of Medical Examiners to evaluate a musculoskeletal exam similar to subject or shelf exams in pediatrics, medicine, psychiatry and other areas.
For his curricular evaluation study, DiGiovanni assessed students for three years. With second year students, he found the knowledge level performance was “just OK.”
“Seventy percent is considered a good score but they scored in the mid 50s. But this was second-year students taking a fourth-year exam,” he said. “When they took the exam again two years later, the class score went up to an average of 70 percent. This is very exciting. We now have a valid and reliable tool that shows a high level of musculoskeletal knowledge among our graduating medical students. Yet, a problem is still noted in clinical confidence. The score was low in the second year and, even though the students had good knowledge levels by the fourth year, their confidence in being able to diagnose common musculoskeletal problems was still pretty low. We’re not sure why confidence has not followed knowledge.
“We are trying to figure out what factors are at play,” DiGiovanni said. “You would think less confidence could lead to ordering more tests and more referrals to specialists when they don’t need to. That could drive up costs. We need to identify those who have more confidence, tease out the factors that build confidence and promote those factors in our teaching here.”
A terrific experience
Recipients of the Dean’s Teaching Fellowship are virtually unanimous in their praise for the program.
In a survey of all past and present fellows conducted in 2009, more than 74 percent said their roles in medical education have increased due to their participation in the fellowship program. As a result of the fellowship, they have developed new curricula for their division or department, served on additional education related committees, begun mentoring junior faculty, residents and students, presented at national education related meetings, and jump started their teaching careers.
Almost 70 percent of the Dean’s Teaching Fellows said participation in the program positively influenced their commitment to medical education as a major component of their career. Fellows stressed the importance of the relationships they made both personally and professionally, while the cross specialty interactions among faculty enhanced the already rich experience.
DiGiovanni, who now is the director of the musculoskeletal curriculum for the School of Medicine and Dentistry, calls the program a “terrific experience.”
“I’m a full-time orthopaedic surgeon. I am active in clinical research and have published a good deal in the orthopaedic realm. Yet I’ve always had this drive to be a medical educator, to work on improving musculoskeletal knowledge and expertise among medical students, but it was difficult to find the time and appropriate mentoring” he said. “The fellowship provides the support and dedicated time you need to do some good medical education work. It gives you the tools to go to the next level as a medical educator. The Dean’s Teaching Fellowship program is a tremendous asset to the School.”
Lang said the fellowship program provided her with a foundation in the principles of medical education, learning theory, instructional tools and teaching skills that she utilizes in her role as director of faculty development for the Hospital Medicine Division. The fellowship also inspired her to pursue a master’s degree in health professions education and conduct additional educational research projects.
“This project has ballooned well beyond the original goals and has provided me with innumerable opportunities to collaborate with medical educators around the country,” Lang said.
The program’s leaders, Epstein and Ward, and other fellows advised and guided her whenever her project encountered obstacles, Dadiz said.
“The fellows all have very different backgrounds and projects. The diversity of the program’s fellows is one reason for the program’s strength and its ability to provide a richness to the way we learn from each other,” she said. “On some level, we all teach medical students, either in the classroom or while precepting them during patient care. Because the Dean’s Teaching Fellowship program encourages us to think critically about the way we teach, we are able to incorporate innovation to medical education.”
Dadiz has received a three-year grant from the federal Human Resources and Services Administration to introduce the training program she helped develop as a fellow to community hospitals throughout the Finger Lakes region.
“The fellowship helped me think about education in a thoughtful and exciting way,” Dadiz said. “I believe that the way we train our students and house staff has a profound effect on the way they train others after they graduate from residency or fellowship programs and begin their practice and care for patients.”
A sample of fellowship projects
Fellows have launched dozens of project that have tested or improved the School of Medicine and Dentistry curriculum. They include:
-- Anne C. Nofziger, M.D. (R ’00), associate professor of family medicine and a fellow from 2005 to 2007, studied peer assessments, in particular the narrative comments, and the impact of the assessments on the professional development of medical students, finding that assessments can be a powerful tool in encouraging the formation of professional behaviors.
-- Alec B. O’Connor, M.D., M.P.H. (R ’00, MPH ’07), associate professor of medicine and a current fellow, is investigating the effects on residents, medical students, and patients of structural changes in medical resident inpatient teams at Strong Memorial Hospital designed to improve the experience for residents and students.
-- Carol Ann Diachun, M.D., associate professor of anesthesiology, is developing an electronic portfolio to increase feedback to her department’s faculty that includes a program of 360-degree evaluations as well as individual quality improvement data collection.
-- Matthew Spencer, M.D., associate professor of emergency medicine and a fellow from 2006 to 2008, created a comprehensive assessment of clinical competence for graduate medical education in emergency medicine.
-- Nicole Stassen, M.D., associate professor of surgery and a fellow from 2005 to 2007, developed a standardized patient program for third-year surgery students that has been incorporated into the curriculum.
-- Scott Tripler, M.D. (M ’85, R ’90), associate professor of family medicine and a fellow from 2003 to 2005, put together a curriculum to educate students in writing prescriptions appropriately, avoiding errors and reviewing medications that includes an appreciation for the value of collaboration with clinical pharmacists.
Simulation and Medical Education
Linda Spillane, M.D., assistant dean for medical simulation at the School of Medicine and Dentistry, discusses the value of simulation in medical education and its future at the School of Medicine and Dentistry.
School of Medicine and Dentistry students who want to improve their language skills and expand their knowledge of Latino culture to develop the skills necessary to work with Spanish-speaking patients can choose a unique certification program, the Latino Health Pathway, which includes electives, community outreach activities and research projects.
An alumnus and his camera with soldiers in Afghanistan
Barry M. Goldstein, M.D., Ph. D., (M ’81, PhD ’82), has become a student of soldiers under pressure, recording what he sees with his camera. See his most recent collection of photos called Battle Mind, from a stay in Afganistan with a reserve unit that oversees mental health caare for soldiers on deployment.