[The following notes were generated by Sandra Haudek, PhD.]

The Winter 2022 IAMSE Webinar Seminar Series, titled “How Science Educators Still Matter. Leveraging The Basic Sciences for Student Success” continued with its third seminar on Thursday January 20, 2022, titled “Integrating Basic Science in the Clerkships: Innovative Strategies and Persistent Challenges”. This seminar was presented by Dr. Michelle Daniel, Vice Dean for Medical Education at the University of California San Diego, School of Medicine and former Assistant Dean for Curriculum at the University of Michigan. She discussed the challenges of integrating basic and clinical sciences into core clerkship curricula to promote transfer of knowledge into practice, a main goal of many curricular reforms in medical education. She highlighted innovative instructional and assessment strategies designed to encourage the integration of the basic sciences during clerkships. She also discussed emerging data concerning learner perceptions of basic science integration, noting opportunities and barriers. Her presentation was based on two of her published studies (Academic Medicine, 96(8), 1125-1130; Kercheval et al., Teaching and Learning in Medicine, in press).

Dr. Daniel started with discussing the rationale for basic science integration in clerkships: Since the time of A. Flexner, the basic and clinical sciences have been taught in discreet consecutive blocks, which has led to the compartmentalization of knowledge. The resulting failure to transfer basic science principles into clinical practice negatively impacts diagnostic and management reasoning, as well as clinical outcomes. Over the last years, several institutions embarked on integrating the foundational and clinical sciences across all years of the medical school curriculum using different curricular models. Basic science education in the pre-clerkship years now commonly occurs in the context of clinical cases through a variety of pedagogies. However, incorporation of basic sciences instruction during the clinical years has proven very challenging to systematize. She quoted a 25-year old statement from H. Schmith underlining that this problem is very persistent until today.

Dr. Daniel explained that in medical education, “integration” usually refers to curricular integration that involves the organization of teaching materials in a manner that interrelates subjects frequently taught in separate academic courses or departments. She described three types of curricular integration: (1) Horizontal integration occurs between parallel disciplines, such as anatomy, physiology, and biochemistry that are typically taught in the same phase of the curriculum. (2) Vertical integration occurs between disciplines typically taught in different phases of the curriculum, such as the basic and clinical sciences. (3) Spiral integration refers to a combination of both horizontal and vertical integration that unites across both disciplines and time.

Dr. Daniel then emphasized that a key goal of curricular integration is cognitive integration. Cognitive integration occurs when individual learners appreciate the relationships between foundational science constructs and clinical care, when they understand the cause of mechanisms in context, and when they appreciate the relevance of basic science principles to clinical decision making. This occurs to a process known as conceptual coherence. It is important to understand that curricular integration alone may not achieve cognitive integration. She further cited work by R. Harden who described 11 types of curricular integration on a continuum between two extremes ranging from isolation to complete transdisciplinary teaching and learning. As one moves up the ladder, there is less emphasis on the role of disciplines and an increased requirement for centralized curricular control and collaboration. She mentioned that the strategies discussed in her presentation span multiple rounds on Harden’s ladder and were often developed centrally by curricular committees with input from clinicians and basic scientists.

Dr. Daniel continued with outlining instructional strategies to promote the integration of foundational sciences during clinical clerkships. She stated that such strategies include program level interventions, clerkship level interventions, bedside level interventions, and assessments. Referring to her study, she listed different strategies employed by 11 different medical schools illustrating that a multimodal approach to integration of clerkships is key. The table showed that a few strategies were used by almost all schools, such as emphasizing the basic science content in clerkship didactics, access to question banks purchased by institution, and administration of USMLE Step 1 exam post-clerkships.

First, Dr. Daniel discussed program level interventions, which are central curricular structural changes to increase emphasis on basic science education in the clerkships. These interventions typically require students to leave their clinical teams and return to the main medical school campus. There were 3 common types of program level interventions amongst the 11 medical schools in her study: (1) Multi-week transition to clerkship courses that focused on integrating basic and clinical science applied to patient care, (2) Longitudinal ½ or full day sessions, offered weekly or bi-weekly, dedicated to basic science content, and (3) Week-long science intensives interspersed between clerkships. As an example, Dr. Daniel introduced the Harvard Medical School 5-week pre-clerkship bootcamp that provides a second pass through foundational content while providing clinical context for standardized patient encounters in anticipation of patient care, thus allowing students to consolidate their knowledge and skills from the pre-clerkship curriculum. Clinical case-based instruction provides direct clinical application of basic science principles while demonstrating relevance. The University of Michigan, Vanderbilt University, and New York University offer similar transition courses of varying duration. As a second example, Dr. Daniel showed an overview of the University of California San Francisco’s Foundational Sciences course in which, every other week, all clinical students leave their clerkships and engage in a full day of basic science instruction. The morning session is attended by all clinical students, the afternoon sessions are clerkship specific. The sessions focus on high yield foundational science topics relevant to all clerkships such as shock, infection, pain, cancer, hemostasis & thrombosis, and aging. The University of Michigan, the University of Pennsylvania, Baylor College of Medicine, and Florida International University have similar longitudinal basic sciences curricula during their clerkships, yet their foci are slightly different ranging from emphasis on USMLE content, to application of the scientific methods, to evidence based medicine.

Second, Dr. Daniel discussed clerkship level interventions, which are departmentally based activities that highlight basic science as an integral part of clerkship education activities. The most common type is emphasizing basic science content in clerkship didactics. As an example, the University of Wisconsin uses case-based learning with online modules in which students are expected to review an online model prior to each case-based learning session and that focused on the basic science content underpinning the case. An interdisciplinary team of faculty developed over 300 new interactive electronic resources to support these sessions. Another school uses multidisciplinary clerkships dedicated to applied science. As a third example, Dr. Daniel described the 12-week surgery and applied science clerkship at the University of Michigan that is comprised of 4 weeks of general surgery, 4 weeks of a surgical subspecialty, and 4 weeks of pathology, radiology, advanced anatomy, and anesthesiology. Case-based teaching sessions are integrated across the 12 weeks with all the disciplines involved in their planning and implementation. The 4 weeks of applied science allows students to explore basic science linkages at a more relaxed pace while allowing added time to prepare for the surgical shelf exam. Dr. Daniel then showed a table that provided more details: In the anatomy portion, students return to the lab to engage in dissection. During the anesthesia portion, students spend time learning about cardio pulmonary physiology and pharmacology, including mechanisms of action of anesthetics and analgesic medications used for pain management. They also spend time in the operating room for asking questions and participating in patient care. In the pathology portion, students review normal histology, participate in clinical pathology sign outs and slide reviews, as well as observe an autopsy. In the radiology portion, students interpret clinical images in the reading room, including cardiothoracic, abdominal, neuro, and musculoskeletal plane fills, CT scans, and MRIs. They also observe interventional procedures.

Third, Dr. Daniel discussed bedside level interventions, which are point of care activities that directly connect caring for patients with basic science principles. She pointed out that faculty development and preparation was key, as practicing clinicians are often nervous about teaching basic science concepts because they feel they lack expertise or the are distant from the content. As an example, Dr. Daniel discusses the process at the University of Michigan: They encouraged clinicians to develop basic science teaching scripts. These are 5 to 10 minute, pre-prepared basic science chalk talks. The clinicians draw on then when appropriate. Today, APGO (www.apgp.org/basicscience) has a repository of OBGYN mini modules for pre and post USMLE step 1 questions that can either be used by educators as teaching scripts or by students for self-directed learning. As a second example, Dr. Daniel mentioned the Uniformed Services University of the Health Sciences, which introduced a form of self-directed learning component that encourages students to develop and research a clinically relevant question related to the basic sciences.

Dr. Daniel then continued with outlining assessment strategies to promote the integration of foundational sciences during clinical clerkships. Assessment strategies include low stakes formative and high stakes summative assessments. As an example, the New York University developed a clinical science inquiry mobile platform for integrating clinically relevant basic science concepts into the core clerkships. As a second example, the Uniformed Services University of Health Sciences developed an approach that leverages the principles of space based education, in which students receive basic science questions related to identified weaknesses that are repeated at random intervals until they are correctly answered twice. In general, most schools offer access to third party question banks for USMLE step 1 preparation. Summative assessments in the form of customized NBME basic science exams or comprehensive basic science exams were used by the University of Wisconsin, New York University, the University of Michigan, and the University of California San Francisco. All schools in this study placed USMLE step 1 after the clerkships to use the motivation of that major national assessment to help drive integration. As another example, Dr. Daniel detailed the clinical science inquiry platform used by the New York University. This platform was constructed based on principles of just-in-time learning and situated learning theories. Questions were curated by a team of clinicians and basic sciences scientists for each clerkship. The application sends students 2-3 questions per week based on their clerkship schedule. Each question begins with a clinical vignette and includes high quality graphical elements. Questions take about 10 minutes to answer, so they fit into the busy schedule of a clerkship student. Question completion is tracked centrally but responses do not contribute to a student’s formal grade.

Dr. Daniel then eluded to spaced repetition of assessment as an educational principle leveraged by homegrown question banks as well as numerous third-party vendors, which comprise a lot of the informal clerkship assessment system. These platforms are embraced for their value for learning basic science content related to USMLE step 1 performance and ease of use during busy clerkship rotations by students.

Dr. Daniel further explained that the post-clerkship administration of USMLE step 1 is an assessment strategy used by all 11 schools to attempt to facilitate cognitive integration. Delaying USMLE step 1 until after clerkships encourages students to review basic science concepts overtime directly connected to patient care. It also fosters cognitive integration during the USMLE step 1 study period after students have had more extensive exposure to patient care and have a cadre of illness scripts in their repertoire. Dr. Daniel explained that her group collaborated with the NBME to perform multiple studies evaluating the impact of post-clerkship USMLE step 1 administration: In their first study, they found that the mean USMLE step 1 scores increased and fewer students failed after moving the exam to post-clerkship. In their second study, they found that after rising national USMLE step 2 scores were accounted for, there were no significant differences in USMLE step 2 scores or failure rates. In their third study, they found that shelf scores decreased, particularly in medicine and neurology, while OBGYN and psychiatry shelf scores largely remained unchanged. They concluded that performance on clerkships taken earliest in the sequence were most affected and differences gradually disappeared with subsequent examination as students gain clinical experience. In summary, the outcomes of moving USMLE step 1 after the core clerkships demonstrate noninferiority when it came to USMLE step 1, step2, and CSE scores.

Dr. Daniel then debated the question if the post-clerkship USMLE step 1, or if curricular integration strategies during clerkships, or if both promote cognitive integration? To explore this question, her team engaged in another study in which they collected student perspectives on basic science integration, including barriers and facilitators. This study was performed at the University of Michigan and the University of California San Francisco with 33 students participating in 6 focus groups and a thematic analysis of their responses. They found that pulling students off their clerkships for full or half-day basic science instruction was not an effective integration strategy (longitudinal returns to basic science). Many students reported tuning out during these sessions and focusing on studying clinical materials instead. They also found that clerkship didactics and bedside teaching in which basic science was explicitly linked to patient care promoted cognitive integration and made content stick. Even a year after completing clerkships, students were able to recall multiple specific examples. Further, they found that clerkships with applied science components, as well as subspecialty rotations on medicine and surgery clerkships were quite effective at driving cognitive integration. Lastly, they found that the placement of USMLE step 1 after the core clerkships had mixed impacts on cognitive integration during clerkships. When students began their clerkships, they did not have the benefit of knowledge consolidation that often occurred during the USMLE step 1 study period. The students felt like their science foundation was on shaky ground, making learning more challenging. Later on however, students were poised to take advantage of the dedicated USMLE step 1 study period, having clinical experience to facilitate cognitive integration. In summary, their study showed that barriers included their tenuous basic science foundation as a result of both shorted pre-clerkship curricula well as the lack of the pre-clerkship USMLE step 1 to consolidate knowledge. Cognitive overload and demands on time during clerkships led students to prioritize clinical over basic science learning. Basic Science was often perceived as irrelevant to patient care due to lack of explicit connections by educators. Educators also focused on teaching clinical science to the exclusion of basic science, and longitudinal basic science curricula were often perceived as well intended but somewhat disconnected from clinical care. Facilitators of integration included basic science instruction explicitly linked to patient care, either at the bedside or via clerkship didactics. Some specialties or disciplines that demonstrated direct application of basic science to clinical care were valued. A post-clerkship USMLE step 1 exam with a dedicated study used as an opportunity to revisit basic science once a clinical foundation has been established was a facilitator of cognitive integration.

Dr. Daniel summarized: Integration can overcome compartmentalization of knowledge and facilitate transfer into clinical practice. A key goal of curricular integration is cognitive integration, yet one does not necessarily produce the other. Strategies to integrate basic science in the clerkship include program-, clerkship-, and bedside- level interventions as well as assessments. Longitudinal returns to basic science that pull learners off clerkships are largely ineffective. Students emphasize the value of explicit basic science teaching directly linked to patient care; and this is where we need a lot more investment. Students note the dedicated post-clerkship USMLE step 1 study period is an ideal opportunity for cognitive integration once a strong clinical foundation is established.

The presentation lasted about 35 minutes and a rich discussion followed. 4th-year student Nicole Mott, a leading collaborator of her study team, joined Dr. Daniel.  Among other topics, questions from the audience addressed: placement of transition courses to clerkships, how to better train faculty to integrate basic science better during clinical activities, how can basic science faculty be more effective, is there feedback from clerkship faculty on student performance, optimal timing of USLME step 2, how are basic science concepts bets integrated into post clerkship training, and transfer of basic science knowledge from one case to other cases.

[The following notes were generated by Sandra Haudek, PhD.]

The Winter 2022 IAMSE Webinar Seminar Series, titled “How Science Educators Still Matter. Leveraging The Basic Sciences for Student Success” continued with its second seminar on Thursday January 13, 2022, titled “Research in Medical School – Impact on Career Path”. This seminar was presented by Dr. Rachel Wolfson, Assistant Dean of Medical School Research and Associate Professor of Pediatrics at the University of Chicago Pritzker School of Medicine. Using data from the medical education literature and the National Resident Matching Program, she discussed the impact of medical student scholarly activities on their skill development and career trajectory. She also debated how scholarly research might be addressed in the residency application process, including how program directors might use research participation and productivity as proxy measures of desirable characteristics among program applicants.

Dr. Wolfson started with discussing the landscape of medical student research participation. She explained that research during medical school is increasingly common and often supported by structured scholarly concentration programs providing protected time, dedicated mentors, and benchmarks for completion. However, a comparison of medical school curricula is difficult due to different elements such as optional versus required research projects, amount of protected time, nature of essential deliverables (e.g., poster versus published manuscript), different tracks in which inquiry projects have different emphasizes, and the definitions of what counts as scholarly (e.g., hypothesis-driven, statistical analysis). She points out that critical thinking skills can be learned from many different projects, and that these projects do not need to be a basic science research project. She further mentioned the Scholarly Concentration Collaborative (sccollaborative.uchichago.edu), a multi-center collaborative aimed to improve and grow opportunities for student research and discovery. Using AAMC medical school graduation questionnaire data of the last 6 year, she showed that with the number of medical research opportunities also the number of publications and poster presentations increased. Lastly, Dr. Rachel reviewed several papers that measured the impact of research on medical student education in single-center studies: Clin Trans Sci 2015, 8:479-483; Acad Med 2017,95(8):1196-1203; Acd Med 2018, 93:1727-1731; J Investing Med 2019, 67(6): 1018-23; Med Educ Online 2020, 25(1):176210; Acad Med 2012, 87:1582-1593. All discussed studies showed a positive correlation of research fellowships with increased number of publications, better residency match results, and more likely to attain academic positions.

Dr. Wolfson then continued with discussing the impact that research participation has on student career trajectory. She debated if students should do research during medical school? Her institution’s curricular goals are the following: Become critical scientific thinkers (hypothesis, approach, evaluation, dissemination), develop self-directed learning skills, and develop and sustain interest in career-long research even if these students do not become NIH-funded researchers. Yet when medical students were asked about their goals, they listed “developing a strong mentoring relationship with a faculty mentor” and “enhancing competitiveness for residency match” above any skill development goals (Medical Education 2017; 51(8): 852-860). Listing anecdotal but consistent data, Dr. Wolfson further elaborated on students’ concerns which included: Success in research is important in highly competitive specialties and probably even more important when USMLE Step 1 becomes pass/fail, thus publications or scholarly work in these competitive fields of interest (not in other fields) are critical. Yet research projects are not always possible or easily attainable in such fields, and/or at the beginning of medical school, students do not know yet which specialty they will choose.

Dr. Wolfson then discussed how resident program directors regard scholarly work in evaluating applicants. She reviewed several papers addressing the program directors’ point of view. One large survey study from 2009 indicated that scholarly work was at the bottom of their selection criteria, yet was decisive for ranking when all applicants were “outstanding” in their score criteria (Academic Medicine 2009, 84:362-367). She then lists a sampler of several specialty-specific studies indicating that the emphasis on research as an important selection criteria increased over the last years. Lately, the concern arose that when Step 1 goes pass/fail, students will look more similar and research may be emphasized even more. This leads to the question if today’s goal to include research in the medical school curriculum is really to educate future researchers or is actually to enhance residency matching? And further, is success in research an independent variable, or is it a proxy for another applicant characteristic, such as for enhanced communication and teamwork skills, intellectual curiosity, perseverance, or commitment?

Dr. Wolfson then reviewed data from the National Resident Matching Program (NRMP). She first presented the 2020 match data illustrating the mean number of research experiences of US medical students correlated to matching results per specialty field. These data showed very clearly that only in the highly competitive specialties, such as dermatology, neurological surgery, plastic surgery, and radiation oncology, students who matched had more research publications and poster presentations than students who did not match. Dr. Wolfson then continued with a discussion of the NRMP program director survey 2021. Interestingly, NRMP groups the criteria “involvement of research” and “interest in an academic career” not under the “education and academic performance characteristics” but under the “personal characteristics and other knowledge of applicants”. The data then indicated that only 41% of program directors scored the first criteria and 24% the second criteria as important decision factors for selecting an applicant for an interview. Even fewer program directors considered these two criteria as important for ranking applicants. To highlight these trends, Dr. Wolfson further discussed the breakdown data for neurosurgery, dermatology, and pediatrics as examples. Lastly, she mentioned that, as part of the Scholarly Concentration Collaborative, her team is currently involved in a similar, still ongoing study. In this study, they are surveying >5000 program directors with the goal to understand and describe the relevance of medical student research among residency program directors. Their goal is to obtain more details as to what type of research and in which specialty field research may be important, and how this will change with USMLE Step 1 going pass/fail.

In conclusion, Dr. Wolfson summarized that the USMLE step 1 score was important for getting an interview (which, unfortunately, may be USMLE step 2CS in the future), but other characteristics such as scholarly work, including number of research presentations and publications, were decisive for ranking especially in highly competitive specialty fields. This emphasis on research may intensify even more, as well may become visible on other less competitive specialties once USMLE Step goes pass/fail. Dr. Wolfson then stated that scholarly concentration programs are opportunities for mentorship, role modeling, teaching beyond project completions (soft skills), and balance between critical thinking, research development, and success in residency match. The presentation lasted about 45 minutes, followed by a lively discussion addressing questions from the audience. These questions probed if students should take a year off before, during, or after medical school to do scholarly work, and how students deal with the effects of the pandemic during which scholarly research may have been less accessible.

[The following notes were generated by Sandra Haudek, PhD.]

The Winter 2022 IAMSE Webinar Seminar Series, titled “How Science Educators Still Matter. Leveraging The Basic Sciences for Student Success” opened on Thursday January 6, 2022 with its first presentation, titled “New Horizons: Restructuring the basic and clinical sciences beyond USMLE”. This seminar was presented by Dr. Nadia Ismail, Senior Associated Dean of Curriculum, Dr. David Rowley, Assistant Dean of Foundational Sciences, and Dr. Munder Zagaar, Associate Professor of Foundational Sciences, at Baylor College of Medicine, School of Medicine, Houston, Texas. They discussed their experiences with shortening the foundational sciences curriculum, curricular challenges and opportunities, and how they are addressing the incorporation of the foundational sciences using a spiral integration and focused exposure to basic science concepts.

Dr. Ismail began with discussing curricula trends by presenting AAMC data (Curriculum Reports) showing curricula changes in US medical schools since 2017: ~20% completed curricular changes, ~65% planned or are in process of implementation, and 15% have no plans for changes. AAMC further reports that the majority of curricula changes target the pre-clerkship (also referred to as “foundational sciences”) phase typically by shortening its length. Other efforts of curricula changes target the enhancement of clerkship coordination and use of simulation, and more emphasis on interprofessional education, competency based education, team-based learning, self-directed learning formats, and online instruction.

Dr. Ismail then emphasized that in the context of USMLE Step 1 exam changes, the goal of curricula change is not to cut foundation sciences content but to better integrate basic science content throughout the whole curriculum, emphasizing on foundational thinking in clinical relevance and providing application or action opportunities for foundational sciences. Citing an issue of the Journal of IAMSE (before it was renamed to Medical Science Educator) from 2010, Dr. Ismail reviewed the value and role of foundational sciences in medical school education. She discussed that foundational sciences serve as basis of critical thinking and clinical problem solving, they enable learners to understand normal homeostasis, its disruption and management, and they require a fund of knowledge to base hypothetical possibilities and take action. Dr. Ismail finished her part of the presentation with highlighting that the majority of medical practice is routine with cases based on pattern recognition, but expert physicians rely on the understanding of basic sciences for difficult cases and require a strong foundational science background in order to write and deviate from guidelines.

Dr. Rowley continued with discussing curricular challenges at Baylor College of Medicine. He stated that the first step to meaningful integration of foundational sciences is accountability. Baylor College of Medicine has a history of experimenting with curricular changes. In the 1970, they explored an optional 3-year program with a truncated basic science curriculum, yet ultimately settled on an 18-month foundational science phase in a 4-year overall medical school curriculum. One major challenge was the departmental accountability for curricular content as courses were directed by experts in different departments resulting in “siloed management”, e.g., biochemistry in the Department of Biochemistry, pharmacology in the Department of Pharmacology. In the late 1990, Baylor College of Medicine started to centralize oversight and thus accountability to curriculum deans and the curriculum committee, which was a first and necessary step to address meaningful integration. As an example, a long foundational course emerged covering a human biology approach in which different disciplines were integrated in one course. However, over time it became apparent that content accountability was still managed more in a siloed manner and thus a curricular shift took place, from the intended curriculum to an implemented curriculum. A key question emerged: How do we best get back to the purposeful design and implementation of an intentionally curriculum that appropriately integrates basic sciences and foundational principles in clinical medicine?

Dr. Rowley stated that, in 2018, Baylor College of Medicine embarked on an intentional curriculum renewal. Decisions were made to strategically incorporate foundational sciences throughout the 4 years by starting with the bulk of foundational content including their clinical relevance during the first 12 months followed by deliberate threading of foundational material into the clinical curriculum. To do so, they used the method of Understanding by Design. According to this backwards design framework, the team started with developing desired outcomes, then assessments, followed by generating course goals, followed by session objections. The goal of this curriculum renewal process is to align fully the intended curriculum with the implemented curriculum.

Dr. Zagaar continued with discussing cultural reset of expectations and biases that can often hinder the curriculum viability and explained how a shared framework was helpful in keeping everyone focused and on target. He explained the three major components of the Understanding by Design framework that are well suited for a competency-based (or outcome-focused) medical education program: 1) Start with the end in mind, 2) Assess for understanding, and 3) Design learning experiences to teach. This process, starting with outcomes and working backwards to develop appropriate assessment tools before curricular content, is the opposite of the typical forward design method in which content is determined first. A clear understanding at the beginning of the destination assures that the steps taken are always in the right direction and encourages deeper understanding of transferrable concepts or skills (enduring knowledge) as opposed to just covering facts.

Dr. Zagaar then explained how Baylor College of Medicine used the principles of the Understanding by Design framework to guide their curriculum renewal process while maintaining a shared focus. First, the team had to establish essential understandings that are basic to the practice of medicine, including foundational sciences, clinical skills, metacognitive awareness, and inquiry. Second, they had to clarify acceptable evidence of learning that embraces individual student challenges; specifically they pivoted from a traditional approach to assessment towards a multifaceted assessment that included qualitative and quantitative formative assessment with build-in remediation that encourages students to progress from competence towards excellence. Third, they developed an integration mechanism for tracking alignment of curriculum by using curricular threads that helped them moving away from siloed structures towards a system accountability for learners, faculty, and curricular administrates.

Dr. Zagaar then illustrated their integrated framework as a staircase representing foundational sciences structured across the curriculum incorporating metacognition, clinical reasoning, and inquiry. Transitioning into medical school starts with basic understanding and board exposures to the principals of health and disease. From there, the foundational sciences are introduced from molecular to psychosocial levels, anchored with metacognitive and clinical context and delivered using different learning methods like self-directed learning (“Why?”). Thereafter the students will progress to an integrated system based framework of applied sciences in which foundational knowledge will be applied to clinical actions (“How?”). Build-in remediation is meant to capture all students by providing support, time, and opportunities to progress towards the desired outcomes. In the last phase, foundational science knowledge and thinking skills continue to be reinforced by purposeful repetition through integrated teaching sessions and mentored experiences to apply foundational science towards the discovery of new knowledge and dissemination.

Using another diagram Dr. Zagaar demonstrated the mechanisms of their curricular threads. The foundational science and clinical sciences were shown as two opposing triangles, with an overlapping diamond through which the three main curricular thread families are intertwined: foundational sciences, metacognitive skills, and clinical preparation skills. These threads ensure flexible movement from understanding to reasoning to taking action, and provide an accountability system for outcomes, assessments, and instructional content. Such threading of instruction and assessment encourages foundational thinking. The connect can be delivered in individual steps: Hybrid case-based clinical scenarios, hybrid clinical encounters, simulation-based learning, clinical teaching integrative sessions, applied foundational science electives, and an inquiry project that deliberately tie in foundational sciences into clinical decision making. Dr. Zagaar then gives a specific example of how a pharmacology skillset could be achieved using this framework.

In conclusion, Dr. Zagaar listed the three take home points: 1) Changes to USMLE are an opportunity to innovate, 2) Foundational sciences are essential for clinical-reasoning and decision-making, and 3) The Understanding by Design framework is well suited for competency-based medical education.
The presentation lasted about 30 minutes. During the ensuing 30 min, an engaging discussion followed addressing a record number of >60 questions from the audience, including change management, faculty development, specific challenges, who and how many individuals were/are involved in the process, how were content domains identified, etc. Dr. Ismail, Dr. Rowley, and Dr. Zagaar answered live and responded via the Q&A Chat function.