Medical Education Program Highlights The University of Arizona College of Medicine–Tucson (COM-T) offers an integrative 4-year MD program in the newly constructed, state-of-the-art Health Sciences and Innovations Building (HSIB). The curriculum features a 3-semester-long preclerkship phase to allow more time for clinical electives and making a specialty career choice. The Commitment to Underserved People (CUP) program is a student-directed, cocurricular program that provides students with clinical learning opportunities in 38 program clinics to serve medically underserved populations statewide. The state-funded Rural Health Professions Program (RHPP) matches 26 students per class with physicians working in rural areas throughout Arizona to nurture students’ interest in rural health care and primary care careers. The Societies Program is a 4-year longitudinal mentoring program designed to assure that students acquire robust clinical skills, develop clinical thinking strategies, and begin professional identity formation. The program encourages meaningful, longitudinal relationships among the groups and their mentors; promotes student well-being; and establishes a sense of community. The House Advisory System is made up of 4 Societies Houses, each with 20 Societies groups (mentor and students) from each class. Each of the 4 houses is led by a student affairs dean (house dean), who serves as students’ points of contact addressing immediate needs and providing individualized career counseling. The house deans work collaboratively with Societies mentors to ensure student success. The COM-T offers 8 distinction tracks. Students engage in additional coursework, mentorship, and a thesis or project to satisfy track requirements; successful completion results in students graduating with distinction in that track. Track offerings are bilingual medical Spanish, community service, global health, integrative medicine, leadership and innovation in health care, medical education, research, and rural health. The college also offers several dual-degree programs: MD–MPH, MD–PhD, MD–MBA, and soon, the MD–MEd program. The premedical admissions pathway (PMAP) is a 13-month postbaccalaureate program offering conditional acceptance to medical school for approximately 10 students annually who have had greater than average challenges in becoming competitive medical school applicants. Curriculum Curriculum description The curriculum is organized into 3 phases: preclerkship phase, clerkship phase, and transition to residency (T2R) phase. Preclerkship: Students proceed through a series of 7 sequenced blocks. Longitudinal themes via Pathways to Health and Medicine (PHM) and the spiraling curricula are integrated throughout this phase. Concurrently with the blocks, students complete the Clinical Reasoning course and Doctor and Patient course. A primary focus of the phase is to expose students to basic sciences translated to clinical medicine framed in social determinants of health, clinical reasoning, and exposure to patients. Clerkship: Begins with the Transition to Clerkship course, followed by the required rotations. Students also complete intersessions within the phase building upon longitudinal curricula in the preclerkship phase, covering such topics as health law, physician wellness, and medical ethics. T2R: Includes required rotations in emergency medicine—critical care, a surgical subspecialty, and a subinternship. Students may individualize their T2R curriculum to support their medical specialty choice. Transition to Residency Bootcamp and Basic Sciences in Clinical Medicine are 2 new courses. The bootcamp provides education and training in skills necessary for postgraduate training and includes separate tracks in surgery and medicine. The Basic Sciences in Clinical Medicine course provides a return to evidence-based medicine and opportunities to revisit the basic sciences as they inform clinical decision-making. See Supplemental Digital Appendix 1—Curriculum Description—at https://links.lww.com/ACADMED/A816. Curriculum changes since 2010 The most significant curricular change has been the full accreditation of the Phoenix regional campus program separate from COM-T’s program, affording the opportunity to undergo a curriculum modification. After extensive preparation and faculty engagement, in academic year 2017–2018, COM-T’s curriculum transitioned from a 24-month to a 20-month preclerkship phase, including a new 6-week basic sciences capstone course designed to support student preparation for the USMLE Step 1 examination. Areas of overlap and redundancy were streamlined to underscore the developmental and spiral curricular design. The clerkship phase underwent similar rigorous review. In this process, the internal medicine clerkship was divided into inpatient and ambulatory components, the surgery clerkship was increased from 6 to 8 weeks, and the neurology clerkship was increased from 3 to 4 weeks. Preclerkship block directors emphasized more clinical application and social and behavioral science content, and made greater use of learning technology, including online sources of content, study, and exam preparation. COM-T also formalized USMLE Step 1 preparation into the curriculum. In the clerkship phase, with the successful development of additional clinical sites necessary to accommodate the overlap between students in the legacy and the modified clerkship curricula, COM-T has expanded its faculty resources for clinical instruction. In the T2R phase, the Transition to Residency bootcamp and the Basic Sciences in Clinical Medicine courses were developed based on student feedback, national trends in graduate medical education, and results of the AAMC Graduate Questionnaires preceding the curricular transition. Assessment The medical education program objectives were designed based on the ACGME domains of competence. See Supplemental Digital Appendix 2—Medical Educational Program Objectives and Assessment Methods—at https://links.lww.com/ACADMED/A816. Since 2010, more opportunities are available for formative and summative assessment, which include: Block self-assessments through interactive home-grown and vended, online modules and practice exams More diagnostic practices exams for USMLE Step 1 preparation OSCEs administered in the required clerkships Formative narrative assessment of clinical skills sessions in the Bootcamp and Basic Sciences in Clinical Medicine courses in the T2R phase The year 2 OSCE and end-of-clerkship OSCE have been maintained. Additional improvement changes have resulted in increased uniformity in student assessment strategies among the clerkships. Also, COM-T has piloted the introduction of Entrustable Professional Activities into its student assessment and curricular evaluation approach while expanding the use of OSCEs in the clerkships. Pedagogy The recent curriculum modification provided an opportunity to integrate more active learning strategies since 2010 to achieve the program objectives. Pedagogical approaches used throughout the curriculum include flipped classroom, case-based learning, independent and self-directed learning, reflective writing and journaling, portfolio review, simulations, and standardized/simulated patients. In addition, the preclerkship phase content is also delivered through team-based learning, virtual labs, and in small- and large-group discussions. Lectures are podcasted for students as additional reference material. The learning in the clerkship phase is based on preceptorship and clinical experience in ambulatory and inpatient settings throughout the rotations. The new simulation center and teaching clinic in the HSIB provides more space to expand patient care–based interprofessional education. Clinical experiences COM-T has a long-standing and productive relationship with a university-based teaching hospital system, community hospitals, community and rural clinics, the Southern Arizona Veteran’s Affairs Health Care System (SAVAHCS), and multiple Indian Health Services sites. All are components of the medical students’ required and elective clinical experiences, and align with the college’s mission and vision goals of exposure to broad diversity of patient care and engagement. Medical students have their first clinical encounter on the first day of medical school. They meet their Societies mentor and interview a patient selected through the program. This first encounter is designed for students to understand their patient’s experience. Subsequently, students have clinical experiences weekly in the curriculum, as well as in the student-run CUP clinics. Required and elective community-based rotations As noted, a significant component of medical students’ clinical experiences occurs with community partners in both urban and rural settings. Clerkships maintain an active roster of participating sites and preceptors and evaluate them annually for comparability in student experiences, patient exposure, education, and assessment. Instructional development is offered to sites that have either new teaching faculty or opportunities for improvement in the current staff. To align with the mission of training and retaining students interested in providing community-based health care, all clerkships provide community-based experiences as part of their rotations. Similarly, the SAVAHCS is a vital component of clerkship training in veterans’ health care for the medicine, psychiatry, neurology, and surgery clerkships. Through their active engagement with veterans in these rotations, students are able to build on the instruction in veterans’ health care they received as part of the PHM curriculum. Challenges in designing and implementing clinical experiences for medical students An ongoing challenge is monitoring clinical experiences for their impact, benefit, and safety for students’ experiences; however, the curriculum committee’s monitoring system using annual site reviews has been successful in this regard. Another emerging challenge is competing with 2 osteopathic schools of medicine in Arizona that are able to offer financial support to clinical sites. Not unique to the COM-T, there is also the pressure for teaching faculty to generate significant clinical income to retain their practice and/or position. Curricular Governance The curriculum management and governance structure is designed to oversee the medical education program. The Tucson Educational Policy Committee (TEPC) provides program-wide oversight and is made up of faculty elected by the general faculty and students elected by their peers. The TEPC has several subcommittees that oversee major curricular components, as shown in Figure 1.Figure 1: Curricular governance.See Figure 1—Curricular governance. Education Staff The Office of Curricular Affairs is made up of 26 full- and part-time educational faculty and professional staff who provide leadership, planning, evaluation, and support for the undergraduate medical education program and the TEPC and its subcommittees at COM-T. The office provides organizational responsibility for the CUP community outreach programs, the RHPP, the student development program, and the dual-degree programs. Central to the role of the Office of Curricular Affairs is providing administrative support for all 3 curricular phases. This role includes rigorous assessment and evaluation strategies and support, with cross-linking of educational design and feedback to grow the educational mission further.Figure 2: Medical education leadership.See Figure 2—Medical education leadership. Faculty Development and Support in Education Through the Office of Curricular Affairs, COM-T provides professional development to faculty through the services of the director of faculty instructional development. In this role, the director supports faculty in improving their classroom-based and clinical teaching by offering both in-person and online modules. This support extends to all house staff, adjunct faculty, and affiliate clinical teaching faculty at clinical teaching sites through online training. Such development is provided routinely and codified in TEPC policy. Additionally, the Academy of Medical Educators and Scholars (AMES) provides peer-based instructional assessment and instruction. The role of educational scholarship has grown rapidly in COM-T’s promotion and tenure process over the last 10 years. Today, all new faculty candidates and faculty candidates for promotion must demonstrate effective teaching in their respective departments and provide peer assessment as demonstration of that educational contribution. Further, the college has created faculty promotion tracks, for example, an educator Scholar track, that require evidence of increasing impact and recognition of the candidate’s educational efforts, which are documented in an educational portfolio. Academy for educators and scholars The mission for AMES is to develop and retain outstanding educators and promote excellence in teaching and educational scholarship. AMES recruits its membership from COM-T faculty in all departments, including senior, highly experienced faculty and junior or midlevel faculty who show great promise in education and educational scholarship. AMES offers robust faculty development and mentorship and supports COM-T’s success in maintaining a pool of strong educators to support its mission and vision goals. AMES has an annual budget to fund education-based research, educational scholarship travel grants, and outreach efforts (education-based journal club, speakers, research forums). Initiatives in Progress The COM-T has launched an early acceptance program in partnership with the University of Arizona Honors College. Approximately 10 students enrolled in the Honors College will be accepted during their junior year. Students will experience an individualized curriculum as well as participate in an immersive summer research experience at the COM-T between their junior and senior years before starting medical school. The COM-T is currently also exploring a 7-year combined University of Arizona undergraduate and medical school program, in conjunction with the recently approved Bachelor of Medicine degree that the college plans to offer. Finally, the COM-T is launching an MD–MEd dual-degree program in collaboration with the University of Arizona College of Education.

IMPORTANCE Concerns have been raised about the adequacy of health care access among patients cared for within the United States Department of Veterans Affairs (VA) health care system. OBJECTIVES To determine wait times for new patients receiving care at VA medical centers and compare wait times in the VA medical centers with wait times in the private sector (PS). DESIGN, SETTING, AND PARTICIPANTS A retrospective, repeated cross-sectional study was conducted of new appointment wait times for primary care, dermatology, cardiology, or orthopedics at VA medical centers in 15 major metropolitan areas in 2014 and 2017. Comparison data from the PS came from a published survey that used a secret shopper survey approach. Secondary analyses evaluated the change in overall and unique patients seen in the entire VA system and patient satisfaction survey measures of care access between 2014 and 2017. MAIN OUTCOMES AND MEASURES The outcome of interest was patient wait time. Wait times in the VA were determined directly from patient scheduling. Wait times in the PS were as reported in Merritt Hawkins surveys using the secret shopper method. RESULTS Compared with the PS, overall mean VA wait times for new appointments in 2014 were similar (mean [SD] wait time, 18.7 [7.9] days PS vs 22.5 [7.3] days VA; P =.20). Department of Veterans Affairs wait times in 2014 were similar to those in the PS across specialties and regions. In 2017, overall wait times for new appointments in the VA were shorter than in the PS (mean [SD], 17.7 [5.9] vs 29.8 [16.6] days; P <.001). This was true in primary care (mean [SD], 20.0 [10.4] vs 40.7 [35.0] days; P =.005), dermatology (mean [SD], 15.6 [12.2] vs 32.6 [16.5] days; P <.001), and cardiology (mean [SD], 15.3 [12.6] vs 22.8 [10.1] days; P =.04). Wait times for orthopedics remained longer in the VA than the PS (mean [SD], 20.9 [13.3] vs 12.4 [5.5] days; P =.01), although wait time improved significantly between 2014 and 2017 in the VA for orthopedics while wait times in the PS did not change (change in mean wait times, increased 1.5 days vs decreased 5.4 days; P =.02). Secondary analysis demonstrated an increase in the number of unique patients seen and appointment encounters in the VA between 2014 and 2017 (4 996 564 to 5 118 446, and 16 476 461 to 17 331 538, respectively), and patient satisfaction measures of access also improved (satisfaction scores increased by 1.4%, 3.0%, and 4.0% for specialty care, routine primary care, and urgent primary care, P <.05). CONCLUSIONS AND RELEVANCE Although wait times in the VA and PS appeared to be similar in 2014, there have been interval improvements in VA wait times since then, while wait times in the PS appear to be static. These findings suggest that access to care within the VA has improved over time.

Competency-based medical education (CBME) is an approach to the design of educational systems or curricula that focuses on graduate abilities or competencies. It has been adopted in many jurisdictions, and in recent years an explosion of publications has examined its implementation and provided a critique of the approach. Assessment in a CBME context is often based on observations or judgments about an individual's level of expertise; it emphasizes frequent, direct observation of performance along with constructive and timely feedback to ensure that learners, including clinicians, have the expertise they need to perform entrusted tasks. This paper explores recent developments since the publication in 2010 of Holmboe and colleagues' description of CBME assessment. Seven themes regarding assessment that arose at the second invitational summit on CBME, held in 2013, are described: competency frameworks, the reconceptualization of validity, qualitative methods, milestones, feedback, assessment processes, and assessment across the medical education continuum. Medical educators interested in CBME, or assessment more generally, should consider the implications for their practice of the review of these emerging concepts.

Currently, no standard defines the clinical skills that medical students must demonstrate upon graduation. The Liaison Committee on Medical Education bases its standards on required subject matter and student experiences rather than on observable educational outcomes. The absence of such established outcomes for MD graduates contributes to the gap between program directors' expectations and new residents' performance.In response, in 2013, the Association of American Medical Colleges convened a panel of experts from undergraduate and graduate medical education to define the professional activities that every resident should be able to do without direct supervision on day one of residency, regardless of specialty. Using a conceptual framework of entrustable professional activities (EPAs), this Drafting Panel reviewed the literature and sought input from the health professions education community. The result of this process was the publication of 13 core EPAs for entering residency in 2014. Each EPA includes a description, a list of key functions, links to critical competencies and milestones, and narrative descriptions of expected behaviors and clinical vignettes for both novice learners and learners ready for entrustment.The medical education community has already begun to develop the curricula, assessment tools, faculty development resources, and pathways to entrustment for each of the 13 EPAs. Adoption of these core EPAs could significantly narrow the gap between program directors' expectations and new residents' performance, enhancing patient safety and increasing residents', educators', and patients' confidence in the care these learners provide in the first months of their residency training.

Background: The academy movement developed in the United States as an important approach to enhance the educational mission and facilitate the recognition and work of educators at medical schools and health science institutions. Objectives: Academies initially formed at individual medical schools. Educators and leaders in The University of Texas System (the UT System, UTS) recognized the academy movement as a means both to address special challenges and pursue opportunities for advancing the educational mission of academic health sciences institutions. Methods: The UTS academy process was started by the appointment of a Chancellor's Health Fellow for Education in 2004. Subsequently, the University of Texas Academy of Health Science Education (UTAHSE) was formed by bringing together esteemed faculty educators from the six UTS health science institutions. Results: Currently, the UTAHSE has 132 voting members who were selected through a rigorous, system-wide peer review and who represent multiple professional backgrounds and all six campuses. With support from the UTS, the UTAHSE has developed and sustained an annual Innovations in Health Science Education conference, a small grants program and an Innovations in Health Science Education Award, among other UTS health science educational activities. The UTAHSE represents one university system's innovative approach to enhancing its educational mission through multi- and interdisciplinary as well as inter-institutional collaboration. Conclusions: The UTAHSE is presented as a model for the development of other consortia-type academies that could involve several components of a university system or coalitions of several institutions.

Suboptimal public health is an intrinsic (if unintentional) feature of the American health care system. Because of the reactive nature of patients and providers to illness, conditions that could be managed successfully in outpatient settings often deteriorate before patients receive care. That care, typically provided in emergency rooms and hospitals, then becomes far more expensive than proactive outpatient management would have been. As a result, the system is unintentionally prone to generate the “worst of both worlds”—poor health and high costs. Traditional approaches to clinical education reinforce these features, as most training remains rooted in reactive, inpatient-oriented systems. In many fields, short, high-acuity hospitalizations decrease the educational value of inpatient training and raise questions of the relevance to trainees' ultimate practice, as many specialties are increasingly practiced in ambulatory settings. This gap between training experiences and practice needs1 as well as the Flexner centennial in 2010 have contributed to a crescendo of calls for medical education reform. But the reform of both health care delivery and medical education faces a “catch-22.” Although educational modernization seems a logical route to improving the health care system, teaching innovative delivery models in the classroom will produce little change if students are then trained in traditional clinical settings. Alternately, if trainees do not learn about new practice models during their formal education, their ability to function effectively in such systems and to serve as change agents will be diminished. The next few years provide an opportunity to escape this quandary, with health care delivery undergoing transition and medical education primed to do so as well. Academic health centers (AHCs) can upgrade both their clinical and education missions by nurturing the coevolution of medical homes for patients as education homes for trainees. An education home is envisioned here as an ambulatory site with a stable practice staff and patient population where a student or resident receives the bulk of his or her clinical training over several years. Although political and judicial uncertainties prevent full clarity, two pending changes in the health care system loom large. First, an expected influx of newly insured patients in 2014 will require increased capacity that AHCs can meet through new outpatient delivery models, which strategically incorporate practitioners and trainees from a variety of health professions under the supervision of faculty physicians. Second, as payment models transition from a fee-for-service structure to one that rewards efficiency and quality rather than volume, delivery systems that reduce costs-per-patient-served and emphasize chronic disease management and after-hours care to avoid emergency treatment will lower expenses and improve outcomes. A medical and education home model structured as an interprofessional, multitrainee outpatient center—in which patients have 24/7 access and each team member's role requires the routine use of his or her most advanced competencies—will instill the values and skills of teamwork in learners while reducing health care costs.2 Competency assessment provides a conceptual framework for including all students as members of a functional clinic team, with early learners participating in clinic operations and progressing to patient evaluations, presentations, differential diagnoses, and management. As learners acquire competencies, they teach junior colleagues, solidifying their own mastery. Beyond feedback from faculty and team members, clinic operational and outcome metrics would increasingly reflect trainees' efforts and contributions as their responsibilities grow. More important, trainees would form their professional identities in a native habitat focused on patient-centeredness, interprofessional teamwork, quality, and efficiency.3 Additional educational benefits include longitudinal mentoring by a small, clinic-based faculty team and opportunities for students to form long-term relationships with patients and observe the progression of illness. Service in after-hours clinics would provide experience in acute diagnosis, around-the-clock access for patients, and demonstration of commitment to patient-centered care by AHCs. Achieving these benefits will require a substantial change in the nature of clinical education. To align trainees' experiences with new practice models, their education homes should serve as the backbone of clinical training throughout medical school and/or residency, supplemented by appropriate outpatient and inpatient specialty experiences. Inpatient education under academic hospitalists will allow trainees to learn and practice efficiency and quality improvement from experts in inpatient medicine. The coevolution of medical homes for patients as education homes for trainees can cost-effectively increase outpatient capacity, decrease high-cost emergency and inpatient care, and emphasize proactive prevention and chronic disease management—all while educating trainees in new models of health care delivery and providing them abundant clinical experience. It will be a significant challenge to overcome the inertia of teacher-centered education and doctor-centered clinical care. This may be a once-in-a-century opportunity, and we must take advantage of it.

This paper describes the stimuli and rationale for and the nature of assessment changes implemented after embarking on a new student-centered, problem-based learning curriculum. In 1998, the University of Texas Medical Branch implemented the Integrated Medical Curriculum (IMC), a problem-based curriculum with sequential, interdepartmental, clinically relevant basic science courses and a concurrent Practice of Medicine course. The IMC’s aim was to improve educational quality by emphasizing knowledge application over rote memorization, student-directed learning, problem-solving skills development, basic science and clinical concepts integration, early acquisition of clinical skills, and professional teamwork. During the initial years of the IMC, students’ learning outcomes did not improve over those of the former curriculum because, in part, we did not initially modify student assessment (a driving force for student study habits) to align with the new curricular goals and philosophies. We subsequently took several steps to modify our assessment practices in order to improve student learning and understanding. These steps included (1) increasing the number and quality of higher -order exam questions, (2) sequestering examinations, (3) increasing the number of practice exam items in each course, (4) and emphasizing in-depth discussion in problem-based learning sessions by introducing small-group quiz exercises. Following the assessment modifications, our students’ USMLE Step 1 scores and our pass rate for first-time test takers rose from being consistently below the national Step 1 average to above the national average. This improvement has been sustained for the past seven years. We believe that implementing those assessment modifications within the framework of the newly devised student-centered, problem-based curriculum in an interdepartmental environment resulted in a critical mass of “local” changes. The changes, initiated and supported by students, faculty and administration, catalyzed, produced and sustained more “global” changes that improved students’ learning, thus better preparing them for the USMLE Step 1 examination.

CONTEXT Calls for medical curriculum reform and increased student diversity in the USA have seen mixed success: performance outcomes following curriculum revisions have been inconsistent and national matriculation of under-represented minority (URM) students has not met aspirations. Published innovations in curricula, academic support and pipeline programmes usually describe isolated interventions that fail to affect curriculum-level outcomes.METHODS United States Medical Licensing Examination (USMLE) Step 1 performance and graduation rates were analysed for three classes of medical students before (matriculated 1995-1997, n = 517) and after (matriculated 2003-2005, n = 597) implementing broad-based reforms in our education system. The changes in pipeline recruitment and preparation programmes, instructional methods, assessment systems, academic support and board preparation were based on sound educational principles and best practices.RESULTS Post-reform classes were diverse with respect to ethnicity (25.8% URM students), gender (51.8% female), and Medical College Admissions Test (MCAT) score (range 20-40; 24.1% scored < 25). Mean +/- standard deviation MCAT scores were minimally changed (from 27.2 +/- 4.7 to 27.8 +/- 3.6). The Step 1 failure rate decreased by 69.3% and mean score increased by 14.0 points (effect size: d = 0.67) overall. Improvements were greater among women (failure rate decreased by 78.9%, mean score increased by 15.6 points; d = 0.76) and URM students (failure rate decreased by 76.5%, mean score increased by 14.6 points; d = 0.74), especially African-American students (failure rate decreased by 93.6%, mean score increased by 20.8 points; d = 1.12). Step 1 scores increased across the entire MCAT range. Four- and 5-year graduation rates increased by 7.1% and 5.8%, respectively.CONCLUSIONS The effect sizes in these performance improvements surpassed those previously reported for isolated interventions in curriculum and student support. This success is likely to have resulted from the broad-based, mutually reinforcing nature of reforms in multiple components of the education system. The results suggest that a narrow reductionist view of educational programme reform is less likely to result in improved educational outcomes than a system perspective that addresses the coordinated functioning of multiple aspects of the academic enterprise.

Abraham Flexner's focus on science in medical school curricula was not intended to exclude or marginalize the importance of service in training American physicians. The erosion of service in academic medicine in the century after his report was the result of forces as wide ranging as research priorities, health care financing, and industry's influence. The authors review the historical context of these changes and make the case that reintroducing service into medical school curricula has never been more important. They describe the impact that neglecting service has had on society, patients, the medical profession, medical students, and medical education. After defining what is meant by social, public, or community service, they go on to detail signature programs at University of Texas Medical Branch, University of New Mexico Health Sciences Center, and Mount Sinai School of Medicine, focusing on the two major categories of health care delivery and education. These examples, in geographically and demographically disparate schools of medicine, demonstrate that it is possible to successfully reintegrate service into the missions of academic medical centers and medical schools.

Curriculum Management and Governance Structure ♦ A single standing Curriculum Committee oversees education throughout the four years (Figure 1).FIGURE 1:: Curriculum Management and Governance♦ Each of 12 courses in Years 1 and 2 and each of eight clerkships in Years 3 and 4 have committees, led by faculty directors, who are responsible to the Curriculum Committee for their educational programs. ♦ The Curriculum Committee conducts reviews of every course and clerkship to ensure adherence to curriculum objectives. ♦ A Curriculum Operations Committee consisting of the Vice Dean for Academic Affairs, Associate Dean for Educational Affairs, Assistant Dean for Years 1 and 2, Assistant Dean for Years 3 and 4, Assistant Dean for Educational Development, and the Curriculum Committee Chair assist the Curriculum Committee by prioritizing agenda topics, providing background information on complex issues, and conducting special projects. Office of Education The Associate Dean for Educational Affairs oversees the efforts of three offices related to medical student education. ♦ The Office of Educational Development (OED), led by the Assistant Dean for Educational Development, assists teaching faculty and course/clerkship directors in their roles of curriculum planning, instruction, and evaluation. The office consists of a full-time director, two doctorate-level professional faculty, and two data entry and analysis staff. The Standardized Patient Program, a component of OED, consists of a full-time program director, half-time medical director, two standardized patient trainers, and support staff. ♦ The Instructional Management Office, led by an Assistant Dean for Educational Affairs, provides coordination and support to course directors of Year-1 and -2 courses, all of which are interdisciplinary. ♦ The Office of Clinical Education, led by an Assistant Dean for Educational Affairs, provides coordination of interdisciplinary activities in Years 3 and 4 and supports the effort of each department-based clerkship. Financial Management of Educational Programs ♦ In 2006, in order to protect the education mission, the SOM implemented a methodology for allocating state education funds to departments based on faculty efforts in teaching medical students. ♦ The methodology establishes effort equivalents (fractional FTEs) for each teaching role in Years 1 and 2 (e.g., small-group facilitation, lecture, laboratory) based on contact hours. ♦ In Year-3 and -4 allocations to departments are based on the number of student months of education provided by each department and a literature-based estimate of the decrease in clinical productivity incurred by medical student education (converted to fractional FTEs). ♦ Course and clerkship directors also earn credit for their department. Although the use of these funds by departments remains at the Chair's discretion, the intent is to provide departments with funds to compensate them for their faculty teaching efforts. ♦ The system's transparency has led most departments to provide direct credit to faculty members for these efforts and has facilitated the recruitment of faculty for various education roles (e.g., small-group facilitation, medical school interviews). Valuing Teaching ♦ The Academy of Master Teachers (AMT) was established in 2006 as a service organization to support the efforts of junior faculty through grants and workshops and as a recognition program to highlight the outstanding achievements of the UTMB community of educators. It comprises six service teams working in tandem to complete the mission of the Academy and is overseen by a director and an outside Advisory Committee. ♦ Educational contributions (direct teaching, educational administration, and educational scholarship) are explicitly identified in current promotion and tenure guidelines. ♦ Teaching is central to the mission of the School of Medicine and the University and is an essential consideration for appointment or promotion to any rank or to the granting of tenure. It is assumed that, except in special situations, all tenure-track faculty members will be involved in teaching. ♦ To ensure proper documentation, submission of a teaching portfolio that tracks direct teaching activities, educational leadership, and educational scholarship is strongly suggested. Curriculum Renewal Process ♦ In addition to continuous quality improvement by courses and clerkships under the auspices of the Curriculum Committee, in the past decade there have been two major curriculum renewal initiatives. ♦ Beginning in 2001, planning for revision of the clinical curriculum began, with implementation in 2003. ♦ Major changes included increasing the emphasis on basic science education in clerkships, adding a requirement for a scholarly project in Year 4, adding a community-based ambulatory requirement in Year 4, adding a Clinical Skills Week before Year 3, establishing standards for rigor of selectives and electives in Year 4, establishing elective time in Year 3, and improving coordination and communication among clerkships. ♦ An education strategic plan completed in 2006 focused on the need for more coordinated education in nontraditional topics (“Longitudinal Themes” described later). ♦ In addition to these two major initiatives, the landfall of Hurricane Ike on Galveston Island in 2008 prompted a rapid-response planning effort to address the consequences of temporary loss of campus educational and clinical facilities. ♦ Immediate changes included developing distance education techniques for dispersed clinical students, development of a Year 3 formative standardized patient examination, and conversion of two Year-4 required clerkships to selective experiences due to effects of the storm on clinical operations. ♦ Through the assistance of sister institutions throughout the state and hard work on campus, no student's advancement or graduation was delayed as a consequence of the storm. Learning Outcomes/Competencies ♦ UTMB uses the 29 curriculum goals of the AAMC Medical School Objectives Project. New Topics in the Curriculum Since 2000 ♦ Patient safety and quality improvement are included as longitudinal curricular “themes” with the goal of appropriate inclusion of these topics within courses and clerkships throughout the four-year curriculum. ♦ Faculty Theme Directors are responsible for coordinating this effort and are provided 0.25 FTE salary support for these duties. ♦ Documentation of Theme topics inclusion is part of periodic course and clerkship reviews conducted by the Curriculum Committee. ♦ Team-based learning is the chief didactic method for the Psychiatry and OB/Gyn Clerkships in Years 3 and 4. It is also used in Year 1 as part of the Neuroscience/Human Behavior and the Practice of Medicine courses. ♦ Second-year medical students are introduced to cardiovascular pharmacology using a high-fidelity, portable patient simulator with realistic anatomy, and computer-simulated functionality. A 1-hour interactive lecture challenges the students' clinical and basic science knowledge and their clinical decision making skills. ♦ Medical students have a clinical skills week immediately prior to their third-year clinical rotations where they are introduced to the following basic topics: hand washing and gloving, clinical note writing, presentation skills, wound care, IV and ABG skills, Foley and NGT skills, suturing, clinical-based laboratory testing, SIM-man human patient simulation scenarios, ♦ Additional training then takes place during their third-year Surgery clerkship rotation. ♦ The Surgery Skills laboratory is made available to all the students during their clerkship, where they may practice basic suturing, knot tying, and even basic laparoscopic skills. ♦ A skills laboratory for new surgical techniques mainly serves the resident and faculty surgeon learners, but medical students (both third- and fourth-year elective students) may participate in the skills laboratory. ♦ Industry supports our laboratory with the introduction and practice of new surgical technologies or techniques (i.e., stapling devices, energy sources, single incision laparoscopy skills, and even robotic surgery). ♦ The education strategic planning initiative in 2006 identified five themes to be incorporated longitudinally throughout required courses and clerkships: public health and prevention, health care economics and policy, evidence-based medicine, health care delivery (including quality improvement/patient safety, interprofessional teams, electronic health records), professionalism. ♦ Coordinated instruction and assessment of these topics have occurred through their integration into ongoing course activities (e.g., problem-based learning) and addition of new activities (e.g., team-based learning) under the leadership of “Theme Directors,” who receive educational credit and funding for their efforts analogous to course/clerkship directors. ♦ Phased implementation of the themes has occurred over several years. Changes in Pedagogy ♦ Small-group problem-based learning (PBL) has been part of the curriculum in each Year-1 and −2 course since 1998, averaging 6 hours per week. ♦ Courses are required to have a minimum of 50% of scheduled time in active learning settings, such as PBL and laboratories. ♦ Total student contact time is limited to 25 hours per week. ♦ Standardized patient-based teaching of clinical skills has been emphasized for decades. Changes in Assessment ♦ To emphasize problem solving skills development, all first- and second-year multiple-choice examinations have been modified to include a significant number of higher-order questions with clinical stems. ♦ Graded discussion exercises are included in the small-group PBL sessions, where the group (eight to nine students) works as a team to answer difficult questions in an open-book, open discussion format. ♦ Since 2000 all major examinations have been sequestered and used for assessment only. After the examination, the only information provided to students is their scores, the general topic (course objective) of each examination item, and the examination items they missed. The sequestered examination policy helps improve examination quality by allowing reuse of test items with superior statistics. ♦ To allay students' concerns about sequestered examinations, each course provides a pre-examination practice test with faculty feedback. These practice tests are equivalent to the real examinations in quality and degree of difficulty. Clinical Experiences ♦ In the first year, visits to a community physician's office are integrated into the clinical skills course. Students also make a home visit along with students from the School of Nursing and/or School of Health Professions. ♦ Clinical preceptorships are available in many disciplines between Years 1 and 2; these are voluntary, but >75% of the class participates. Many of these placements are in community ambulatory sites. ♦ In the second year, clinical experiences are scheduled through hospital departments and academic subspecialty outpatient clinics. ♦ Third-year students complete clerkships in a variety of settings, including UTMB hospitals, Austin and Houston affiliated hospitals, UTMB outpatient clinics, and community- based ambulatory practices. Third-year students complete at least one four-week elective and have an option for a second such experience. ♦ The fourth year of training includes an ambulatory community selective that may be in any specialty but must focus on outpatient care. ♦ More than 350 community faculty participate in the education of our students. This is a strength of our program that also leads to challenges in faculty development. ♦ Hurricane Ike presented new challenges in 2008 for clinical education as inpatient beds were reduced in number. We seized on this as an opportunity to increase our use of ambulatory sites for education, especially in the Internal Medicine, Psychiatry, and Neurology courses. Regional Campus ♦ The Austin regional campus offers all required Year-3 and -4 courses and also has a broad range of options for elective and selective clinical courses. ♦ Clinical sites are offered through the Seton Family of Hospitals, including Brackenridge Hospital and Dell Children's Medical Center of Central Texas. ♦ A cadre of students opt to complete their entire third year in Austin; an additional number of students complete one or more individual courses there. Highlights of the Program/School ♦ Students have the option of pursuing special Scholarly Program Tracks that provide five to six months of extensive education and experience in a wide range of fields: Global Health: More than 400 international rotations have been completed by UTMB students since 2003. Aerospace Medicine: Students learn about the pathophysiologic consequences of space travel in conjunction with scientists at UTMB and NASA's Johnson Space Center, 25 miles north of Galveston. Rural Medicine: Interested students are provided the opportunity to become part of a community during required rotations and electives in a rural setting of their choosing. ♦ HABLE Program (Healing in A Bilingual Learning Environment) provides first- and second-year students with instruction in clinical skills and cultural competency in both English and Spanish and opportunities for rotations at domestic and international sites where Spanish is the primary language. ♦ UTMB's John P. McGovern Academy of Oslerian Medicine was founded to recognize physicians in the faculty of medicine who personify these qualities and to encourage the teaching and modeling of such care to medical students. The Academy of Oslerian Medicine is fully dedicated to the principles of excellence, compassion, integrity, and respect in patient care exemplified by Sir William Osler. Created in 2001 and generously supported by the John P. McGovern Foundation of Houston, the McGovern Academy sponsors a wide range of academic events, recognizes outstanding faculty teaching and student scholarship, supports the Osler Student Societies, and awards prestigious scholarships to students who emulate Oslerian ideals. ♦ The Osler Student Societies provide structure, financial support, and encouragement to help medical students bring their altruistic leanings to fruition through a wide variety of activities including fundraisers, health fairs, food drives, blood drives, toy drives, senior citizen services, science fair judging, beach clean-up, recycling, and World AIDS Day activities. ♦ Community service is a pillar of UTMB student life. UTMB students have initiated two community-based health facilities: St. Vincent's Clinic in Galveston and Frontera de Salud in Cameron Park, Texas, along the border with Mexico. These facilities provide venues for students to express their altruism and service orientation while developing both their clinical skills and their professional identity. ♦ In addition to professional behavior being incorporated into the grading of each preclinical course (through problem-based learning session faculty evaluations) and each clinical clerkship, faculty also have the opportunity to report student behavioral issues through an Early Concern Note (ECN) process. ♦ The ECN process is designed to bring matters that raise concern about professional behavior to a student's attention, to provide a progressively formal series of actions that allow such incidents to be tracked over time, and to allow intervention when a pattern of behaviors is identified. Multiple ECNs can form the basis for formal academic consequences. ♦ Practice of Medicine Year 3 (POM-3) is a one-year, longitudinal course available on a voluntary basis for clerkship students. More than two thirds of the class participates. Through assigned readings, reflective essays, and evening small-group discussions, students explore topics important to the delivery of health care such as medical errors, health care financing, physician burnout, and domestic violence. Many students go on to complete related projects during Year 4.

As multicore systems become the dominant mainstream computing technology, one of the most difficult challenges the industry faces is the software. Applications with large amounts of explicit thread-level parallelism naturally scale performance with the number of cores, but single-threaded applications realize little to no gains with additional cores. One solution to this problem is automatic parallelization that frees the programmer from the difficult task of parallel programming and offers hope for handling the vast amount of legacy single-threaded software. There is a long history of automatic parallelization for scientific applications, but the techniques have generally failed in the context of general-purpose software. Thread-level speculation overcomes the problem of memory dependence analysis by speculating unlikely dependences that serialize execution. However, this approach has lead to only modest performance gains. In this paper, we take another look at exploiting loop-level parallelism in single-threaded applications. We show that substantial amounts of loop-level parallelism is available in general-purpose applications, but it lurks beneath the surface and is often obfuscated by a small number of data and control dependences. We adapt and extend several code transformations from the instruction-level and scientific parallelization communities to uncover the hidden parallelism. Our results show that 61% of the dynamic execution of studied benchmarks can be parallelized with our techniques compared to 27% using traditional thread-level speculation techniques, resulting in a speedup of 1.84 on a four core system compared to 1.41 without transformations.

Background During the past 10 years at our institution, a number of changes have been instituted in the learning environment, including instructional techniques, assessment methods, academic support, and explicit board preparation. Method The authors studied the Step 1 performance of students with MCAT scores of 20 to 25 in our former and current curricula. Effect sizes were calculated for score improvement using adjusted means from ANCOVA with covariates of MCAT and age. Results The overall effect size was 0.48, with larger effects seen for underrepresented minority students overall (d = 0.64) and African American students especially (d = 0.77), representing medium to large effects. Overall failure rates decreased by two thirds. Conclusions Comprehensive changes in the learning environment were followed by substantial improvement in Step 1 performance among academically at-risk students.

Chip multiprocessors with multiple simpler cores are gaining popularity because they have the potential to drive future performance gains without exacerbating the problems of power dissipation and complexity. Current chip multiprocessors increase throughput by utilizing multiple cores to perform computation in parallel. These designs provide real benefits for server-class applications that are explicitly multi-threaded. However, for desktop and other systems where single-thread applications dominate, multicore systems have yet to offer much benefit. Chip multiprocessors are most efficient at executing coarse-grain threads that have little communication. However, general-purpose applications do not provide many opportunities for identifying such threads, due to frequent use of pointers, recursive data structures, if-then-else branches, small function bodies, and loops with small trip counts. To attack this mismatch, this paper proposes a multicore architecture, referred to as Voltron that extends traditional multicore systems in two ways. First, it provides a dual-mode scalar operand network to enable efficient inter-core communication and lightweight synchronization. Second, Voltron can organize the cores for execution in either coupled or decoupled mode. In coupled mode, the cores execute multiple instruction streams in lock-step to collectively function as a wide-issue VLIW. In decoupled mode, the cores execute a set of fine-grain communicating threads extracted by the compiler. This paper describes the Voltron architecture and associated compiler support for orchestrating bi-modal execution

Chip multiprocessors with multiple simpler cores are gaining popularity because they have the potential to drive future performance gains without exacerbating the problems of power dissipation and hardware complexity. These designs provide real benefits for server-class applications that are explicitly multi-threaded. However, for desktop and other systems, there is a large code base of single-thread applications that have yet to see any benefit from multicore systems. While these applications were designed for execution on a single processor, many regions of computation have statistically suitable structure for extracting threadlevel parallelism. In this work, we examine automatic extraction of statistical loop-level parallelism from single-thread applications. Our approach is to utilize simple hardware mechanisms combined with intelligent compiler code generation to perform low-cost targeted thread-level speculation. Our technique combines memory dependence profiling to identify suitable loops, stylized code generation to untangle register dependences between iterations, and a hybrid compiler/hardware recovery mechanism to handle infrequent memory dependences. We show that significant amounts of statistical loop-level parallelism indeed exist in non-numeric applications, and present the architectural extensions and detailed compiler algorithms required to exploit it.

Most medical school curricula do not equip students with adequate attitudes, knowledge and skills to care for elderly populations. We describe an effective geriatric curricular infusion model compatible with preserving the overall curricula schema. Course and clerkship directors, staff and faculty from the Office of Educational Development, Center on Aging, curriculum committee and Associate/Assistant Deans of Education, and faculty from the schools of medicine, nursing, and allied health collaborated in the effort. Each of these components and institutional financial commitment were critical to successful basic science and clinical geriatric content infusion addressing the American Geriatric Society (AGS) Core Competencies. Delivery modalities included problem-based learning cases, lectures, standardized patient portrayals for teaching and assessment, and experiential activities with elderly. Assessments were conducted and outcomes tracked in several ways, including: (1) annual course reviews, focus groups, and student evaluations; (2) mandatory geriatrics 4th year graduation competency exam; and, (3) AAMC Graduation Questionnaire responses. Initial data indicate that student knowledge and competencies have increased with increasing exposure in the desired areas, and support infusion as a viable approach to enhancing gerontology and geriatric curricular content.

Most medical school curricula do not equip students with adequate attitudes, knowledge and skills to care for elderly populations. We describe an effective geriatric curricular infusion model compatible with preserving the overall curricula schema. Course and clerkship directors, staff and faculty from the Office of Educational Development, Center on Aging, curriculum committee and Associate/Assistant Deans of Education, and faculty from the schools of medicine, nursing, and allied health collaborated in the effort. Each of these components and institutional financial commitment were critical to successful basic science and clinical geriatric content infusion addressing the American Geriatric Society (AGS) Core Competencies. Delivery modalities included problem- based learning cases, lectures, standardized patient portrayals for teaching and assessment, and experiential activities with elderly. Assessments were conducted and outcomes tracked in several ways, including: (1) annual course reviews, focus groups, and student evaluations; (2) mandatory geriatrics 4th year graduation competency exam; and, (3) AAMC Graduation Questionnaire responses. Initial data indicate that student knowledge and competencies have increased with increasing exposure in the desired areas, and support infusion as a viable approach to enhancing gerontology and geriatric curricular content.

As medical schools revise preclinical curricula to emphasize active learning, clinical relevance of the basic sciences, and early clinical experiences, critical evaluation of the results of the changes is important. Such changes in preclinical curricula are expected to help students develop better skills in communication, interpersonal relationships, critical thinking, and other areas essential to the practice of medicine, resulting in better preparation to begin clinical clerkships. How does changing foundational aspects of preclinical curricula affect students' preparedness for clinical work? How can that be assessed? Performance on the USMLE Step 1 is certainly the most visible outcome of preclinical education. Although the Step 1 is commonly taken just before clinical clerkships are undertaken, its scores are not likely to reflect effects of all curricular changes. Changes such as adopting small-group, problem-based learning (PBL) or early clinical experiences might be expected to impact noncognitive aspects of students' performances beyond the cognitive outcomes measured by Step 1 scores. Scores on knowledge-based examinations are not likely to be useful measures of students' preparedness for noncognitive elements of clinical clerkships, such as cross-disciplinary teamwork or patient communication, in which procedural knowledge must be applied in clinical tasks. Might students' preclinical course performances predict their readiness for clinical clerkships? Studies of preclinical course performances as predictors of clerkship performance, such as those by Baciewicz et al.1 and Roop and Pangaro,2 tend to demonstrate a relationship between those measures and students' clinical course examination scores or grades. We felt, however, that preclinical course grades had not been shown to be a sensitive measure of readiness for the noncognitive demands of clinical training. While students are frequently asked to evaluate course objectives, instructional delivery, and other curriculum features, they are not often asked how well their curriculum has prepared them to undertake the next training level. Fincher, Lewis, and Kuske3 used interns' self-assessments to examine their preparedness in competencies required to begin the intern year, including history and physical examination, patient diagnosis and management, and interpersonal skills. We adopted a similar approach to study important noncognitive outcomes of preclinical curriculum change. Over the past seven years, the University of Texas Medical Branch (UTMB) implemented stepwise preclinical curricular reform. In 1995, a problem-based learning (PBL) track featuring self-directed learning in small groups and early clinical experiences opened to 24 students chosen by lottery from approximately twice that number of volunteer students per class, running parallel to the traditional didactic curriculum (TC). The PBL track's student assessment procedures relied heavily on essay tests, standardized-patient (SP) examinations, and evaluation of small-group work; the TC assessments relied predominantly on multiple-choice questions (MCQs), with less use of SP examinations. In 1998, the TC was replaced with the Integrated Medical Curriculum (IMC), a hybrid curriculum combining the problem-based, small-group, self-directed aspects of the PBL track with some didactic teaching.4 The hybrid IMC retained the TC's heavy reliance on MCQs for cognitive assessment with some SP-based examinations but added the PBL track's small-group assessment. The PBL track, meanwhile, remained essentially unchanged. All three tracks featured early clinical experiences, but the PBL track's emphasis was heavier than that of the TC or IMC. The curriculum labels used in this study (“PBL,” “traditional,” “hybrid IMC”) may unintentionally call attention to each curriculum's instructional characteristics more than the curriculum features more relevant to this study. Our use of these labels references all features of each curriculum, including amount of early clinical experience and array of assessment methods. UTMB's curriculum evolution process provided an uncommon opportunity to examine the effects of three distinct preclinical curricula within a single institution on students' perceptions of their preparedness for clinical training. To that end, we developed a clinical-preparedness survey and administered it to students as they finished their preclinical curriculum. We hypothesized that if differences were found between students' self-assessments of preparedness for clinical training those differences would correspond to the differing emphases in the three preclinical curricula. Method A group of UTMB faculty developed a 22-item clinical-preparedness survey to measure how prepared students felt to undertake tasks expected of beginning third-year students: communicating with patients and faculty, working collaboratively with other health care students and professionals, gathering patient data, integrating basic science knowledge with clinical work, assessing and managing patient problems. The 1-5 response scale (converted to 0–4 for analysis) was defined with endpoints 1 = “not at all [prepared]” and 5 = “extremely [prepared].” Seventeen additional items not analyzed in this study asked students about their readiness to use different information sources to learn about patient problems. We analyzed responses from UTMB medical students expected to graduate in 2001 (class of 2001) and in 2003 (class of 2003). The class of 2001 was the last class that could choose between the PBL curriculum and the TC. The class of 2003 was the second class with the PBL and hybrid IMC choice. We elected to omit survey data from the class of 2002, the “pioneer” IMC class. The first IMC class was subjected to all the uncertainties associated with a new curriculum, which could have been reflected in their self-assessments. Completed clinical preparedness surveys were received from 193 of the 198 class of 2001 students (28 PBL, 165 TC) on the first day of the first third-year clinical clerkship in 1999. Similarly, 177 of 193 students in the class of 2003 (22 PBL, 155 hybrid IMC) turned in completed surveys during the last month of their second-year studies in 2001. Mean MCAT scores were computed as a tentative overall measure of curriculum-group characteristics prior to students' experiencing their respective curricula. The groups' cumulative second-year GPAs were not used to describe the groups, as they were not comparable measures. Each curriculum had its own assessment system and grading scale, and one curriculum (the IMC) did not assign numerical values to its grades. We conducted exploratory factor analysis of class of 2003 survey responses, applying standards of simple structure, interpretable factors, and consistency with the survey's intended structure to select the best factor structure. The factors were assigned labels consistent with their items' content. We constructed subscale scores by averaging item responses across items associated with each subscale and computed an internal consistency reliability estimate (Cronbach's alpha) for each subscale. Group means and standard deviations for subscale scores were computed for both classes and the subscale scores' intercor-relational structure investigated. Finally, differences between mean subscale scores by curriculum were investigated separately for both classes with multivariate and univariate analyses of variances. The MANOVA procedures capitalized on the intercorrelated nature of the subscale scores. We computed effect size estimates (eta2 or R2) for each difference. Results Subscale Construction and Reliability Factor analysis of responses from both classes, using principal-axis factoring and oblique rotation, revealed that survey questions loaded onto the four expected factors, with most items loading on only one factor each. Two survey items (“incorporate knowledge of basic sciences” and “find learning resources”) did not load cleanly on any factor and were subsequently omitted from subscale analyses. For subscale construction, the remaining 20 items were assigned to the factors on which they loaded most heavily and that their content matched best (Table 1). Four to six items each composed the teamwork (TW), history and physical (H&P), clinical reasoning (CR), and doctor—patient relationship (D/P) subscales, with internal consistency reliability (Cronbach's alpha) coefficients ranging from .76 to .93. The four subscales were substantially intercorrelated, with correlation coefficients from .22 to .41.TABLE 1: Subscales and Factor Analysis of the Clinical Preparedness Survey for University of Texas Medical Branch Medical Students (Class of 2003)Curriculum-related Differences in Subscale Scores The mean MCAT score for class of 2001 PBL students was 28.1 (SD = 3.5); it was 26.2 for TC students (SD = 4.6). The mean MCAT score for class of 2003 PBL students was 27.3 (SD = 5.4); it was 26.3 for IMC students (SD = 4.9). As shown in Table 2, the class of 2001 PBL students' mean scores exceeded the TC students' mean scores for all four subscales, with differences from .36 to .58 scale points. That is, PBL students on average indicated that they felt more prepared in each subscale area than did TC students. Multivariate analysis of variance (MANOVA) of the class of 2001 subscale scores yielded an overall F statistic of 4.54 with 4, 188 df (p = .0016), with an effect size (eta2) of .088. Subsequent univariate analysis of mean differences on the four subscale scores also yielded F statistics of 7.34 to 14.48 (1, 191 df), p < .01. The greatest difference between curricula for these students, .58, was observed on the CR subscale (R2 = 0.070) and the smallest, .36, on the D/P subscale (R2 = .037). Since students were not randomly assigned to curricula, interpretation of F statistics using statistical inference techniques is not particularly helpful. Examination of the absolute sizes of the mean score differences, however, reveals that differences between groups ranged from just over ⅓ to more than ½ of a scale point. These differences on a 0-4 response scale are large enough to indicate meaningful differences between curriculum groups.TABLE 2: Curriculum-related Differences in UTMB Medical Students' Self-Assessments of Preparedness for Four Elements of Clinical Training (Classes of 2001 and 2003): Overall and Subscale Differences, Standard Deviations of Differences, F Statistics, and Effect-size Estimates by Curricular Track*In the class of 2003, PBL students' subscale scores were higher than hybrid IMC students' scores on three of the four subscales, with observed mean differences ranging from .18 to .73 scale points and associated effect sizes (R2) from .008 to .089. Mean scores on the D/P subscale were the same for both groups. MANOVA yielded an overall F statistic of 5.53 with 4, 172 df (p = .0003), effect size (eta2) = .114, supporting investigation of the sizes of differences among groups on one or more subscales. Subsequent univariate analyses of differences on the three subscale scores with non-zero differences produced F statistics of 1.47 (H&P), 5.18 (TW), and 17.11 (CR), each with 1, 175 df. Curriculum-group differences for the TW and CR subscales were .39 and .73 scale points and r2 values of .029 and .089, respectively, each large enough to indicate a meaningful difference in scores. Discussion Factor analysis of the clinical-preparedness survey responses supported construction of four intercorrelated, reliable subscale scores for each student. Subscales' emphases, TW, H&P, CR, and D/P, were consistent with the survey's intention of addressing noncognitive areas associated with readiness for clinical clerkships. The small differences observed in the curricular groups' mean MCAT scores in both classes are of limited significance. There is no agreement among researchers in this area on expected associations between MCAT scores (or other primarily knowledge-based measures) and the areas addressed in our survey. The differences observed in students' perceptions of readiness for noncognitive aspects of clinical training indicated that changes in foundational aspects of preclinical curricula (dominant instructional modality, amount of early clinical experience, and assessment methods) were associated with differences in self-assessment of clinical preparedness. Recall that the TC featured didactic instruction, a moderate level of clinical experience, and heavy MCQ/light SP exams for assessment. The PBL track featured problem-based learning, heavy clinical experience, and essay exams/heavy use of SP exams/small-group evaluations for assessment. The hybrid IMC featured problem-based learning plus didactic instruction, a moderate level of clinical experience, and heavy MCQ/light SP exams/small-group evaluations for assessment. Correspondingly, we observed that PBL students' mean teamwork scores were greater than those of TC students, with a “medium” effect size r2 estimate of .051, consistent with greater opportunity for student—faculty and student—student interactions in the PBL small groups. We observed a smaller difference between PBL and hybrid IMC teamwork scores and a “low” r2 of .029, consistent with the incorporation of some problem-based learning in the IMC. The pattern of differences in the H&P subscale scores, with PBL track scores greater than TC scores (“medium” effect size estimate of .059) but about the same as IMC scores, was not completely consistent with predictions based on students' early clinical experience. It may be that consistent exposure to PBL case information also affects students' sense of preparedness in this area, thus increasing the IMC mean score. That hypothesis clearly warrants investigation. As the IMC's clinical experiences evolve, we plan to track changes in this subscale carefully, expecting IMC students to report increased perceptions of preparedness for clinical clerkship H&P. The PBL students' clinical reasoning mean scores were higher than those of either the TC or the IMC group, both differences showing medium effect sizes. This may indicate that the use of problem-based learning, common to the PBL and IMC curricular groups, may not be enough alone to impact students' sense of preparedness in clinical reasoning. Further exploration of the effect of the PBL track's use of essay tests with their greater emphasis on higher-order thinking on students' perceptions of readiness for CR-related tasks is warranted. On the other hand, the pattern of differences on the D/P subscale in which PBL scores were somewhat higher than TC scores, with an effect size characterized as “low,” but equal to IMC scores, suggests that the use of problem-based learning alone may increase students' confidence in patient education, delivering bad news, and the like. The exact mechanism of this effect also remains to be explored. The effect of students' self-selection into the curriculum track on their perceptions of readiness for clerkships cannot be assessed with the design employed in this study. Investigation of the effect of self-selection by introduction of appropriate covariates, once identified, would add to the interpretation of these findings. We believe that these findings are best interpreted with both the instructional and the assessment modalities of the three curricula in mind. It is reasonable to speculate that either or both together might explain this study's findings. We acknowledge the inherent limitations of self-assessment as the sole mechanism for investigating effects of curricular change. Students are unlikely to employ the same definitions of constructs or the same standards as faculty would. Studies are presently under way to compare students' self-assessments with clinical preceptors' evaluations of student readiness. Nevertheless, this study demonstrated that students' self-assessments of readiness for clinical clerkships exhibited differences consistent with characteristics of their curriculum tracks. The differences we observed would not have been detected had we examined USMLE Step 1 scores or preclinical grade-point averages alone. Effective assessment of effects of curricular change must be directed toward all important outcomes, both cognitive and noncognitive. Student self-assessments provide useful information to that end.