Oregon Health & Science University and competency-based curricula

Each month, the AMA highlights institutions that are part of the AMA Accelerating Change in Medical Education Consortium to showcase their work with the consortium and innovations in medical education.

Tracy Bumsted, MD, MPH

Tracy Bumsted, MD, MPH

Associate dean, undergraduate medical education and professor, pediatrics

Oregon Health & Science University

Number of years in the consortium: Since the beginning (~2014, 8 years)

1. Shift to competency-based, integrated curriculum, called YourMD

As of July 1, 2021, all of our courses in the entire UME program changed to pass/no pass grading. Now, individual competencies are linked to all courses in our program, and students are provided an assessment for each linked competency by a qualified assessor (i.e., course director). We have markedly increased our use of the spiraling thread icons we created to place in course materials and during instructional sessions for the Foundations of Medicine (FoM) phase, so students have visual cues when integrated content is taught.

This was an important addition to our [Accelerating Change in Medical Education] project because we designed the new curriculum with a three science integrated model, incorporating basic, clinical and health systems science content as threads running throughout all FoM blocks instead of discrete courses. While this approach is pedagogically sound as students learn foundational content in proper context, with the use of our icons it is now more clearly evident where individual thread content is taught within an integrated block as well as spiraled later in the curriculum with increasing complexity. Three examples of the thread icons [represent] introductory, reinforcing and mastery levels for the professionalism, microbiology and physiology threads, respectively.

The UME Entrustment Group (EG) also tracks evidence of entrustment for the 13 Core Entrustable Professional Activities (EPAs), as part of our competency-based assessment framework. After three reviews for each student, the UME EG awarded the 2021 graduates a total of 1,080 EPA badges. This was the first graduating cohort in which we displayed the students’ awarded EPA badges on their Medical Student Performance Evaluations (MSPEs) as well as in their (OHSU-specific) MSPE Supplement we send to all of their matched PGY-1 GME program directors, which serves as our “educational handoff.” Our 2022 graduates have earned even more with a total of 1,212 EPA badges following the third and final review.

2. Competency milestones and EPAs tracked by a web-based electronic portfolio (REDEI)

Students and the UME EG are able to review in real time students’ progression in competency attainment and badging for EPAs. The OHSU-specific e-portfolio, REDEI, houses all student assessment and performance data (e.g., USMLE Step scores), and our REDEI System Programmer continues to make ongoing improvements to displays and functionality. Part of the original funds from our [Accelerating Change in Medical Education] grant were instrumental in building the REDEI electronic platform and this has enabled our students to see, in real-time, all of their assessments and progress toward competency and earning EPA badges.

3. Time-variable progression

With one of our original [Accelerating Change in Medical Education] project goals, we have been very successful in reducing time to degree for students who have met all graduation requirements, earlier than the typical four years. Since implementing our competency-based curriculum in 2014, students have increasingly been able to graduate on an accelerated pace, reducing their educational debt by approximately $17,000 per student. The results below now show that the vast majority of our students are now graduating at least one term early:

• 2018 graduates: 25% graduated a term early
• 2019 graduates: ~60% graduated a term early
• 2020 graduates: 66% graduated a term early
• 2021 graduates: 77% graduated a term early
• 2022 graduates: 93% graduated at least a term early

Our transformed YourMD curriculum, developed and implemented with the generous support of the grant funding, incorporated a new requirement for all students to complete a scholarly project. A student in the inaugural class of our new curriculum, (now) Dr. Skender Najibi, pursued his project goals by developing a proposal to create several new faculty leadership positions in the MD program as diversity navigators. Dr. Najibi identified a gap in how our program assisted students from underrepresented and diverse backgrounds navigate medical school and become physician graduates who thrive in the profession of medicine. From his project proposal, we created new positions and have had two faculty UME diversity navigators since 2018.

This year, we expanded the UME diversity navigator program to four positions, recently appointing faculty members from a variety of diverse racial, gender and cultural backgrounds who will work individually with students and also plan and deliver large group programming events and activities to promote equity, diversity and belonging in our UME and University community.

In addition, in 2020, our UME Curriculum Committee approved the creation of the Equity & Justice Sub-Committee, following a collaborative proposal from medical students and faculty in the dean’s office. The Sub-Committee oversees the development and continuous improvement of curricular elements in YourMD related to the elimination of health inequities and the promotion of an anti-racist and anti-oppressive medical education. The Equity & Justice Sub-Committee regularly reviews each aspect of the YourMD curriculum, recommends curricular changes that promote the identification and elimination of health inequities and systemic racism, and assists in the implementation of those changes.

The Sub-Committee has both a faculty and student Co-Chair, along with many faculty, several residents, staff members, and medical students, and also includes three deans–two from UME and one from the larger School of Medicine.

The adoption of competency-based curricula and assessment with subsequent elimination of tiered grading in medical school courses across the country, along with the changes to the scoring of USMLE Step 1 to pass/fail, will provide a strong impetus for UME educators, students, and GME program directors to adapt how we conceptualize the UME to GME continuum. The Coalition for Physician Accountability’s workgroup report and recommendations provide a comprehensive framework for how we can make important changes to improve the transition from medical school to residency training.

Healthy teams are not automatic, nor magically created. We have deliberately tried to maintain team comradery and encourage wellness in our faculty educators and staff members with transparent communication despite the tremendous uncertainty that still exists due to the pandemic. Wellness activities–both for individuals and groups–are important aspects that should be built into the day-to-day work we do.

A lot of attention is paid to monitoring and developing activities that promote student wellness, but far less has been given for faculty and staff wellness. We have found that (1) authentic conversations that name the realities, stress and ongoing challenges we are experiencing as educators, (2) a system that supports individuals during particularly trying times and (3) acknowledging that the hard work we do every day will not produce universal happiness for students, have all helped set expectations and refocus our efforts on the outcomes we desire: graduating the most competent, professional, compassionate, resilient and fulfilled physicians who are willing and prepared to serve society in the 21st century.