Abstract
Vanderbilt University School of Medicine recently changed from 2 pre-clerkship years (Traditional curriculum) to a 1.5-year pre-clerkship phase for one class (Hybrid curriculum) to a 1-year pre-clerkship phase (Curriculum 2.0). This study investigated the relationship between shortened pre-clerkship training and stress associated with selecting a residency field. The surveyed graduating medical student population included one cohort from the Traditional and Hybrid curricula, and the first two cohorts from Curriculum 2.0. The authors modeled recollected stress levels using a Zero-Inflated Linear Mixed Model with additional covariate and random effects adjustments. Specialty decision-related stress levels increased in the Hybrid curriculum by 10.208 points [p = 0.0115, 95% CI 2.293, 18.122] on a 0–100 point scale. Curriculum 2.0 students had an insignificant increase in stress of 4.062 points [p = 0.304, 95% CI − 3.690, 11.814] relative to the Traditional curriculum. Time since starting medical school and time when a specialty was chosen were the largest factors associated with stress. While this study only evaluated a single facet of the potential downstream effects of curricular change, these data should inspire confidence for reform efforts as a significant increase in specialty decision-related stress present in Hybrid curriculum resolved in both cohorts of Curriculum 2.0.
Similar content being viewed by others
References
Irby DM, Cooke M, O’Brien BC. Calls for reform of medical education by the Carnegie Foundation for the Advancement of Teaching: 1910 and 2010. Acad Med. 2010;85:220–7.
Lucey C. Medical education: part of the problem and part of the solution. JAMA Intern Med. 2013;173:1639–43.
Barzansky B, SI E. Medical schools in the United States, 2015-2016. JAMA. 2016;316:2283–90. Available from. https://doi.org/10.1001/jama.2016.13620.
Krane N. Length of academic levels distribution in U.S. and Canadian medical schools [Internet]. Curric. Invent. Context. AAMC. 2016. Available from: https://www.aamc.org/initiatives/cir/451832/ci05.html. Accessed 13 Feb 2019.
Association of American Medical Colleges. Length of academic levels distribution in US and Canadian medical schools [Internet]. AAMC Curric. Invent. 2012-2013 through 2016-2017. 2018 [cited 2018 Mar 21]. Available from: https://www.aamc.org/initiatives/cir/.
Flexner A. Medical education in the United States and Canada. Washington, DC: Science and Health Publications, Inc; 1910.
West CP, Dyrbye L, Erwin PJ, Shanafelt T. Interventions to reduce physician burnout: Systematic review and meta-analysis. J Gen Intern Med. 2016;31:S283–4.
Ishak W, Nikravesh R, Lederer S, Perry R, Ogunyemi D, Bernstein C. Burnout in medical students: a systematic review. Clin Teach. 2013;10:242–5.
Dyrbye LN, Thomas MR, Massie FS, Power DV, Eacker A, Harper W, et al. Burnout and suicidal ideation among U.S. medical students. Ann Intern Med. 2008;149:334–41.
Netterstrøm B, Conrad N, Bech P, Fink P, Olsen O, Rugulies R, et al. The relation between work-related psychosocial factors and the development of depression. Epidemiol Rev. 2008;30:118–32.
Dyrbye L, Shanafelt T. A narrative review on burnout experienced by medical students and residents. Med Educ. 2016;50:132–49.
Tyssen R, Vaglum P, Grønvold NT, Ekeberg I. Factors in medical school that predict postgraduate mental health problems in need of treatment. A nationwide and longitudinal study. Med Educ. 2001;35:110–20.
Firth-Cozens J, Greenhalgh J. Doctors’ perceptions of the links between stress and lowered clinical care. Soc Sci Med. 1997;44:1017–22.
Dyrbye LN, Massie FS, Eacker A, Harper W, Power D, Durning SJ, et al. Relationship Between Burnout and Professional Conduct and Attitudes Among US Medical Students. JAMA. 2010;304:1173.
Dyrbye LN, Thomas MR, Huschka MM, Lawson KL, Novotny PJ, Sloan JA, et al. A multicenter study of burnout, depression, and quality of life in minority and nonminority US medical students. Mayo Clin Proc. 2006;81:1435–42.
Dyrbye LN, West CP, Satele D, Boone S, Tan L, Sloan J, et al. Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population. Acad Med. 2014;89:443–51.
Rotenstein LS, Ramos MA, Torre M, Bradley Segal J, Peluso MJ, Guille C, et al. Prevalence of depression, depressive symptoms, and suicidal ideation among medical students a systematic review and meta-analysis. JAMA. 2016;316:2214–36.
Slavin SJ, Schindler DL, Chibnall JT. Medical student mental health 3.0: improving student wellness through curricular changes. Acad Med. 2014;89:573–7.
Drolet BC, Rodgers S. A comprehensive medical student wellness program-design and implementation at Vanderbilt School of Medicine. Acad Med. 2010;85:103–10.
Daya Z, Hearn JH. Mindfulness interventions in medical education: a systematic review of their impact on medical student stress, depression, fatigue and burnout. Med Teach 2017;1–8. Available from: https://doi.org/10.1080/0142159X.2017.1394999.
Dahlin ME, Runeson B. Burnout and psychiatric morbidity among medical students entering clinical training: a three year prospective questionnaire and interview-based study. BMC Med Educ. 2007;7.
Williams D, Tricomi G, Gupta J, Janise A. Efficacy of burnout interventions in the medical education pipeline. Acad Psychiatry. 2015;39:47–54.
Fleming A, Cutrer W, Moutsios S, Heavrin B, Pilla M, Eichbaum Q, et al. Building learning communities: Evolution of the colleges at vanderbilt university school of medicine. Acad Med. 2013;88:1246–51.
Real FJ, Zackoff MW, Davidson MA, Yakes EA. Medical student distress and the impact of a school-sponsored wellness initiative. Med Sci Educ. 2015;25:397–406. Available from. https://doi.org/10.1007/s40670-015-0156-0.
Allos BM, Yakes EA, Fleming A, Cutrer WB, Pilla M, Clair W, et al. Framing medicine as a moral practice: an introductory medical school course. Acad Med. 2018;93:1310–4.
Loeser H, O’Sullivan P, Irby DM. Leadership lessons from curricular change at the University of California, San Francisco, School of Medicine. Acad Med. 2007;82:324–30.
Lyndon M, Henning M, Hill A, Alyami H, Krishna S, Yu T-C. The Impact of a Revised Curriculum on Academic Motivation, Burnout, and Quality of Life Among Medical Students. J Med Educ Curric Dev. 2017;4. https://doi.org/10.1177/2382120517721901.
Dare AJ, Petrie KJ, Bagg W. Prepared for practice? Medical students’ perceptions of a shortened final year medical programme. N Z Med J. 2009;122:32–43.
Yengo-Kahn AM, Baker CE, Lomis AKD. Medical students’ perspectives on implementing curriculum change at one institution. Acad Med. 2017;92:455–61.
Bernier GM, Adler S, Kanter S, Meyer WJ. On changing curricula: lessons learned at two dissimilar medical schools. Acad Med. 2000;75:595–601.
Wayne SJ, Fortner SA, Kitzes JA, Timm C, Kalishman S. Cause or effect? The relationship between student perception of the medical school learning environment and academic performance on USMLE Step 1. Med Teach. 2013;35:376–80.
Strowd RE, Lambros A. Impacting student anxiety for the USMLE Step 1 through process-oriented preparation. Med Educ Online. 2010;15. https://doi.org/10.3402/meo.v15i0.4880.
Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Acad Med. 2006;81:354–73.
National Resident Matching Program, Press realease: 2017 NRMP main residency match the largest match on record with more than 43,000 applicants registered and more than 31,000 positions offered [internet]. The Match. 2017 [cited 2018 Mar 25]. Available from: http://www.nrmp.org/press-release-2017-nrmp-main-residency-match-the-largest-match-on-record/.
Compton MT, Frank E, Elon L, Carrera J. Changes in U.S. medical students’ specialty interests over the course of medical school. J Gen Intern Med. 2008;23:1095–100.
Association of American Medical Colleges. Continuity of Speciality Preference on the Matriculating Student Questionnaire and the 2018 Graduation Questionnaire [Internet]. AAMC Rep. Resid. 2017. Available from: https://www.aamc.org/data/493916/report-on-residents-2018-a1table.html. Accessed 13 Feb 2019.
Wolf SJ, Lockspeiser TM, Gong J, Guiton G. Students’ perspectives on the fourth year of medical school: a mixed-methods analysis. Acad Med. 2014;89:602–7.
Aagaard EM, Abaza M. The residency application process—burden and consequences. N Engl J Med. 2016;374:303–5. Available from. https://doi.org/10.1056/NEJMp1510394.
Dyrbye LN, Eacker AM, Harper W, Power DV, Massie FS, Satele D, et al. Distress and empathy do not drive changes in specialty preference among US medical students. Med Teach. 2012;34:e116–22.
Walling A, Merando A. The fourth year of medical education: a literature review. Acad Med. 2010;85:1698–704.
Association of American Medical Colleges. Time required per clerkship [Internet]. LCME Annu. Med. Sch. Quest. Part II, 2006-2007, 2011-2012, 2016-2017. 2018. Available from: https://www.aamc.org/initiatives/cir/426756/05e.html. Accessed 13 Feb 2019.
Reed DA, Shanafelt TD, Satele DW, Power DV, Eacker A, Harper W, et al. Relationship of pass/fail grading and curriculum structure with well-being among preclinical medical students: a multi-institutional study. Acad Med. 2011;86:1367–73.
Vanderbilt University School of Medicine. Undergraduate medical education MD curriculum: curriculum schematic [internet]. 2019 [cited 2019 Jul 13]. Available from: https://medschool.vanderbilt.edu/ume/academic-program/md-curriculum/.
Spickard A, Ahmed T, Lomis K, Johnson K, Miller B. Changing medical school IT to support medical education transformation. Teach Learn Med. 2016;28:80–7.
U.S. Department of Education. Information about the protection of human subjects in research supported by the Department of Education—overview [Internet]. Laws Guid. / Grants Contract. 2011 [cited 2018 Jun 22]. Available from: https://www2.ed.gov/policy/fund/guid/humansub/overview.html.
Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42:377–81.
McGraw KO, Wong SP. Forming inferences about some intraclass correlation coefficients. Psychol Methods. 1996;1:30–46.
Koo TK, Li MY. A guideline of selecting and reporting intraclass correlation coefficients for reliability research. J Chiropr Med. 2016;15:155–63.
Association of American Medical Colleges. Statistics [Internet]. [cited 2018 Jul 22]. Available from: https://www.aamc.org/services/eras/stats/359278/stats.html.
Miller BM, Moore DE, Stead WW, Balser JR. Beyond Flexner: a new model for continuous learning in the health professions. Acad Med. 2010;85:266–72.
Świerszcz J, Stalmach-Przygoda A, Kuźma M, Jabłoński K, Cegielny T, Skrzypek A, et al. How does preclinical laboratory training impact physical examination skills during the first clinical year? A retrospective analysis of routinely collected objective structured clinical examination scores among the first two matriculating classes of a ref. BMJ Open. 2017;7:e017748.
McBride JM, Drake RL. Longitudinal cohort study on medical student retention of anatomical knowledge in an integrated problem-based learning curriculum. Med Teach. 2016;38:1209–13.
American Medical Association Initiative to Transform Medical Education (ITME). Recommendations for change in the system of medical education. Chicago: American Medical Association; 2007.
Gonzalo JD, Haidet P, Papp KK, Wolpaw DR, Moser E, Wittenstein RD, et al. Educating for the 21st-Century Health Care System. Acad Med. 2017;92:35–9.
Bloom SW. Structure and ideology in medical education: an analysis of resistance to change. J Health Soc Behav. 1988;29:294–306.
O’Brien BC, Irby DM. Enacting the Carnegie Foundation call for reform of medical school and residency. Teach Learn Med. 2013;25:S1–8.
Arvandi Z, Emami A, Zarghi N, Alavinia SM, Shirazi M, Parikh SV. Linking medical faculty stress/burnout to willingness to implement medical school curriculum change: a preliminary investigation. J Eval Clin Pract. 2016;22:86–92.
Sheu L, Burke C, Masters D, O’Sullivan PS. Understanding clerkship student roles in the context of 21st-century healthcare systems and curricular reform. Teach Learn Med. 2018:1–10.
Parsons C, Fidler B. A new theory of educational change—punctuated equilibrium: the case of the internationalisation of higher education institutions. Br J Educ Stud. 2005;53:447–65.
Stevens CD. Repeal and Replace? A Note of Caution for Medical School Curriculum Reformers. Acad Med. 2018;93(10):1425–1427.
Dyrbye LN, Thomas MR, Huntington JL, Lawson KL, Novotny PJ, J a S, et al. Personal life events and medical student burnout: a multicenter study. Acad Med. 2006;81:374–84.
Woloschuk W, Harasym PH, Temple W. Attitude change during medical school: a cohort study. Med Educ. 2004;38:522–34.
Daniel M, Fleming A, Grochowski COC, Harnik V, Klimstra S, Morrison G, et al. Why not wait? Eight institutions share their experiences moving United States Medical Licensing Examination Step 1 after core clinical clerkships. Acad Med. 2017;92:1515–24.
Pock A, Daniel M, Santen SA, Swan-Sein A, Fleming A, Harnik V. Challenges associated with moving the United States Medical Licensing Examination (USMLE) Step 1 to after the core clerkships and how to approach them. Acad Med. 2019;94:775–80.
Green M, Jones P, Thomas JX. Selection criteria for residency: results of a national program directors survey. Acad Med. 2009;84:326–67.
Monteiro K, George P, Dollase R, Dumenco L. Predicting United States Medical Licensure Examination Step 2 clinical knowledge scores from previous academic indicators. Adv Med Educ Pract. 2017;8:385–91.
Shanafelt TD, Hasan O, Dyrbye LN, Sinsky C, Satele D, Sloan J, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc. 2015;90:1600–13.
Lomis KD, Russell RG, Davidson MA, Fleming AE, Pettepher CC, Cutrer WB, et al. Competency milestones for medical students: design, implementation, and analysis at one medical school. Med Teach. 2017;39:494–504.
Acknowledgments
The authors wish to thank Susan Lewis for her support in preparing poster presentations for this work.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Ethical Approval
NA
Informed Consent
NA
Conflict of Interest
The authors report no conflicts of interest or disclosures.
Additional information
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Electronic Supplementary Material
ESM 1
(PDF 43 kb)
Rights and permissions
About this article
Cite this article
Scudder, D.R., Sherry, A.D., Jarrett, R.T. et al. Fundamental Curriculum Change with 1-Year Pre-Clerkship Phase and Effect on Stress Associated with Residency Specialty Selection. Med.Sci.Educ. 29, 1033–1042 (2019). https://doi.org/10.1007/s40670-019-00800-7
Published:
Issue Date:
DOI: https://doi.org/10.1007/s40670-019-00800-7