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Medical Education
Bridges Curriculum

UCSF Receives AMA Accelerating Change in Medical Education Grant

The UCSF School of Medicine is one of 11 medical schools selected by the American Medical Association (AMA) to receive $1 million over five years to develop and implement innovative curricula around the best medical practices. The 11 grants were selected from among 119 proposals submitted, representing more than 80 percent of eligible medical schools nationwide.  The $1 million will be issued through the AMA’s Accelerating Change in Medical Education initiative, the association announced Friday.

“We are excited that the AMA has recognized the importance of UCSF's vision for a curriculum designed to prepare graduates who are experts in providing patient-centered care, as well as in working collaboratively within interprofessional systems to continuously improve the quality, safety and equity of health care for all,” said Catherine Lucey, MD, vice dean for education at the UCSF School of Medicine.

In October 2013 the AMA sponsored the Accelerating Change in Medical Education Conference in Chicago. The presentations and audiocasts are available on the AMA website

UCSF’s proposal, “Bridges to High Quality Health Care Curriculum,” seeks to create the “collaboratively expert physician,” one who embraces the responsibility to work within interprofessional teams to continually improve the safety, quality and value of health care. The AMA acknowledges that UCSF faculty members are still defining the attributes of the new Bridges curriculum and that our grant proposal, outlined in the following section, serves as a preliminary roadmap to its development. 

 
 

UCSF Bridges Curriculum: Achieving High Quality Health Care by Educating the Collaboratively Expert Physician

The University of California, San Francisco (UCSF) School of Medicine is designing and implementing the Bridges Curriculum, crafted so that our students work to improve health care today while they learn to become collaboratively expert physicians: capable of and committed to working within complex inter professional systems to achieve high quality health care for all.

In May 2013 the UC San Francisco School of Medicine successfully competed for a grant from the American Medical Associate designed to “accelerate change in medical education. “ The grant provides funding for a portion of the Bridges Curriculum design process underway since May 2012.  For more information on the AMA Accelerating Change in Medical Education grant program visit the AMA’s website.

Project description

The University of California, San Francisco (UCSF) School of Medicine will design and implement the Bridges Curriculum, crafted so that our students work to improve health care today while they learn to become collaboratively expert physicians: capable of and committed to working within complex interprofessional systems to achieve high quality health care for all.

The need and rationale for change

Despite years of dramatic advances in biomedical science and over a decade of attention to the problems of quality and safety issues,5,6 progress towards achieving the IOM goals for high quality health care has been slow. Medical education is part of the problem. Even though systems based practice is identified as a core physician competency7 and interprofessional education is considered essential,8,9 graduates of our medical education programs still prize the development of autonomy and individual expertise over the development of skills needed to work collaboratively within and be accountable for the continuous improvement of clinical microsystems10 (the front line care delivery units in which physicians and other health professionals care for patients).11,12 If medical education is to fulfill our social contract13 and work to ensure that all members of our society have access to care that is safe, timely, effective, efficient, cost conscious and patient centered, it is time for a major change.

Changing health care today requires a transformation in the relationship between undergraduate medical education programs and their partner health care institutions from one in which students use the clinical settings to further their education to one in which students contribute to advancing the quality, safety and value of health care for all.

Changing health care in 2020, when today’s matriculating students first enter the workplace, requires a transformation of the physician’s professional identity. The solitary “hero” physician14,15 must give way to the collaboratively expert physician, one who commits to personal excellence, favors interdependence over autonomy, embraces accountability for patient experiences and outcomes, integrates technology, measurement and improvement into his or her daily work, and effectively participates in a diverse set of interprofessional and interdisciplinary collaborative work models to improve the health of patients and populations.10-17

Achieving these transformative changes will require disruptive innovations in medical education. The current structure of medical education represents an incomplete translation of our deep pedagogical knowledge about how young physicians best learn. Research has demonstrated the benefits of: authentic workplace learning experiences;18 longitudinal assignments and continuity of relationships to students, faculty, patients and clinical sites;19-21 integration of basic and clinical science as well as classroom and workplace learning;1an explicit focus on professional identity formation;1 interprofessional education22; and individualized student educational trajectories with standardized outcomes1. Despite this wisdom, current medical education strategies often separate workplace learning from classroom experiences, assign students to brief clinical rotations where their roles are primarily observational and self focused rather than contributory and patient focused, relegate professional identity formation to passive role modeling, imbed students in predominantly mono-profession teams, and advance students through the curriculum based on time rather than competence.

Workplace learning experiences must be re-designed to support the development of authentic and sustained relationships with the clinical microsystem so that the process of education adds value rather than burden to the patients and professionals. Course content must be developed based on a reconceptualization of foundational science and clinical skills needed by the 21st century physician.11,12,15,16 Assessment must comprehensively and reliably measure the spectrum of competencies needed for graduates to assume the new 21st century physician roles and responsibilities so that our profession can fulfill our commitment to society.

Goals of the Bridges Curriculum

The UCSF health professions education and care delivery communities will work together to educate a new type of physician: the collaboratively expert physician, who embraces the responsibility to develop personal expertise and to work effectively with others within complex systems to promote health and reduce the burden of suffering and disease for our communities. In collaboration with our partners and with the support of the AMA grant, we will build and implement the Bridges Curriculum, designed so that in the process of becoming the collaboratively expert physician, our students contribute to the transformation of the health care system so that all patients receive care that is reliably evidence based, safe, high quality, high value, and patient centered.

Our Vision:

The UCSF Bridges Curriculum will explicitly contribute to improving health care outcomes today while educating physicians capable of working within complex systems to continuously improve health care tomorrow.

Our Goals:

Goal 1: Begin medical school with each student assigned to a clinical microsystem in a new authentic role: the student systems partner, who is prepared and committed to add value to the system’s efforts to improve health outcomes.
 
Goal 2: Redesign classroom-learning activities to integrate foundational sciences relevant to improving health outcomes with the biomedical and behavioral sciences needed to understand disease and therapeutics.
 
Goal 3: Implement the Bridges Curriculum to allow students to accelerate through their medical education while ensuring that all graduates can effectively execute the comprehensive set of responsibilities of the collaboratively expert physician.
 

Goal 1: Begin medical school with each student assigned to a clinical microsystem in a new authentic role: the student systems partner, who is prepared and committed to add value to the system’s efforts to improve health outcomes.

We believe that successfully changing physician identity requires introducing new roles and responsibilities at the start of medical school and continuously reinforcing those new roles as the student masters more traditional responsibilities. Because we also are committed to working collaboratively with the clinical delivery system to improve health, we have chosen to design our workplace learning and supporting curriculum to ensure that students learn optimally while contributing maximally to the important work of the clinical microsystem.

We will achieve this goal with a strategy for both early and advanced students. In the UCSF Bridges Curriculum, each student will begin his or her medical education as a student systems partner in a student systems improvement team, assigned to an interprofessional clinical microsystem. Students and teams will focus their authentic systems work on three domains: understanding and improving patient experience and outcomes; understanding and improving population outcomes and experiences; and understanding and improving systems for safety, quality and value. Teams should be imbedded longitudinally in a microsystem for a minimum of 20 weeks, sufficient time for the students to understand the workings of the microsystem, build relationships with the diverse professionals and patients within the system, participate in several types and cycles of process improvement activities, and share in ownership for the outcomes of the system. For example, each student on the team might spend at least 2 half days per week working within the microsystem. First-year and early second-year students will engage in legitimate systems improvement activities in three longitudinal, sequential assignments in four categories of microsystems: acute care, chronic disease management, diagnostic or interventional procedures, and prevention (Table 1). In the first microsystem, students will focus exclusively on developing skills in continuous systems improvement (CSI). In the second and third microsystems, they will continue their systems improvement responsibilities and also begin to develop direct, individual patient encounter and care delivery (DIPEC) skills. During their third year, advanced students might be assigned to at least one longitudinal clerkship experience at a single institution, lasting a minimum of five months. During this clerkship experience, they will focus not only on developing competency in DIPEC skills but also will continue to participate in site specific integrated quality improvement activities as mentors to early student systems improvement teams. A final microsystem might be one relevant to their chosen career and will include their subinternship experience. Figure 1 illustrates the integration of authentic CSI workplace learning with DIPEC workplace learning experiences.

 

Table 1: Examples of Systems Improvement Activities in Four Different Categories of Microsystems

 

Domains of Systems Improvement

Categories of Clinical Microsystems

Patient Experiences and Outcomes

Population Experiences and Outcomes

Systems Processes: Quality, Safety, Waste Avoidance

Acute Care (e.g. inpatient Neurology)

Improving satisfaction of stroke patients with discharge instructions

Decreasing the incidence of catheter related UTIs in stroke patients

Decreasing overuse of IV nicardipine in hemorrhagic stroke patients

Chronic Care (e.g. pediatric asthma clinic)

Providing health coaching and intervention for teens with asthma

Monitoring evidence based guideline adherence using the EMR

Decreasing overuse of allergy skin testing

Prevention (e.g., women’s health clinic)

Improving access for homeless teens to reproductive health care

Improving follow up for abnormal Pap smears

Implementing best practice guidelines for postmenopausal bleeding

Intervention and Diagnostic

(e.g., interven-tional radiology)

Decreasing frequency of cancelled cases due to missing information

Increasing the frequency of statin use following renal artery angioplasty

Decreasing the use of gastrostomy tubes in patients with advanced dementi

 

As clinical microsystems opportunities are added, students could have the opportunity to individualize their education by selecting specialty tracks within each category of microsystem to allow them to meet their milestones in their primary area of interest. For example, a student interested in surgery could engage in authentic CSI teams in trauma surgery (acute care), violence prevention clinics (prevention), surgical pathology (diagnostics), breast oncology (chronic care) and conduct a study on the molecular biology of wound infection through the Molecular Medicine Pathway.

Goal 2: Redesign classroom-learning activities to integrate foundational sciences relevant to improving health outcomes with the biomedical and behavioral sciences needed to understand disease and therapeutics.

The collaboratively expert physician must master a new set of foundational science constructs that underpin the continuous improvement of health outcomes in addition to and integrated with the existing and emerging basic biomedical, behavioral and social sciences that support the diagnosis and management of individual patients (Table 2).

 

Table 2: Examples of Emerging Foundational Sciences

Improvement of Health Outcomes

Diagnosis and Management

  • Customer Patient preferences and values
  • Continuous quality and safety improvement
  • Measurement and variation
  • Interprofessional team leadership, collaboration and change management
  • Clinical informatics
  • Stewardship of resources
  • Genomics, proteomics, metabolomics
  • Bioinformatics and knowledge networks

 

We might accomplish this goal in two ways. First, we could design a systems improvement immersion school that will teach health professions students the essentials of interprofessional work and systems improvement so that the students are prepared to contribute to the first microsystem in which they work. To reinforce core principles of health professions work and learning, this immersion school could be taught in a blended learning format by interprofessional faculty from our partner health professions schools and our care delivery sites. Second, we could design a comprehensive set of essential knowledge courses that integrate new and existing content, reinforcing the continuum of knowledge from basic science to clinical decisions to improved health outcomes for patients and populations throughout the curriculum. In all courses, we will use technology to enhance learning, provide more time in workplace learning, enable students to revisit content when relevant to their clinical work and facilitate sharing of new components of the curriculum with other interested members of the interprofessional care team.

Goal 3. Implement the Bridges Curriculum to allow students to accelerate through their medical education while ensuring that all graduates can effectively execute the comprehensive set of responsibilities of the collaboratively expert physician.

Achieving this goal requires three strategies. First, we should structure the curriculum to allow motivated students to complete all required course work within three academic years while meeting all accreditation and licensing requirements. Successful students could either enter residency early or pursue additional in-depth course work, currently the choice of more than 40% of UCSF medical students.

Second, we could design a comprehensive, multifaceted assessment system based on Entrustable Professional Activities (EPAs), the brainchild of University of Utrecht and UCSF faculty member Olle ten Cate.23 EPAs are an intuitive way of understanding and assessing the new physician’s roles and responsibilities. EPAs will be mapped to competencies and milestones to help students identify personal developmental opportunities.24 The assessment system should include knowledge tests; simulation based standardized skills assessment; work environment tools such as 360 degree evaluations; work product tools such as reports on improvement projects; and self-assessment tools. Students should have an individual competency coach to help them manage and analyze their own performance data, in themselves critical competencies. Assessment weeks could be sequenced throughout the curriculum to ensure that students are prepared to engage productively in each microsystem, advance through the curriculum based on their demonstrable achievements and execute the responsibilities of the collaboratively expert physician upon graduation. Students who experience difficulty will have remediation options.

Third, we must develop a comprehensive faculty development system to ensure that the faculty, residents, and professional staff with whom students interact are personally well versed in the roles and responsibilities of the collaboratively expert physician as well as in teaching and assessment strategies that contribute to student development.

Over the five years of the grant, UCSF will transform our curriculum to help improve the quality and safety of healthcare today while educating our students to master the competencies needed to function as collaboratively expert physicians of tomorrow. Our graduates will enter residency careers poised to serve as change agents and improvement partners in hospitals around the country, accelerating the transformation needed in health care and in the education of subsequent generations of medical students. The first class to train entirely under this new curriculum will matriculate in the fall quarter of 2016, the beginning of year 4 of the grant. Ongoing evaluation and improvement in the curriculum will be undertaken in year 4. The second class will enroll in year 5 of the grant, academic year 2017-2018.

Organizational capacity

The UCSF School of Medicine is one of four nationally ranked health professions schools that comprise the nation’s premier health sciences only campus. UCSF receives more NIH funding than any other public university. In 2013, the School of Medicine ranked first among both private and public institutions in NIH dollars awarded. U.S. News & World Report ranked UCSF fourth in both primary care education and research education (the only school in the nation to rank this highly in both categories). In addition, UCSF received the 2012 AAMC Spencer Forman Award for its longstanding commitment to public partnerships that enhance the health and well being of the diverse and vibrant San Francisco community. The educational programs of the School of Medicine take place in San Francisco, Berkeley and Fresno. Each year, UCSF School of Medicine admits 149 students, each of whom enter one of three programs: the traditional program, the physician scientist training MD-PhD program; and the Program in Medical Education for the Urban Underserved (PRIME-US), a five year joint MS-MD program. UCSF partners with UC Berkeley to sponsor the Joint Medical Program, in which 16 students begin medical school and complete a MS degree at UC Berkeley prior to pursuing clinical studies at UCSF.

The current curriculum, initiated in 2001, integrates basic, clinical, and social science content into every block course, and promotes active, collaborative, and continuous learning. Innovations include six-month and yearlong longitudinal integrated clerkships in all of our major hospitals, including Kaiser Oakland and UCSF Fresno; a competency-based curriculum with milestones across all four years; and Pathways to Discovery, an elective program enabling health professions students from all UCSF schools (medical, pharmacy, nursing, dental, physical therapy) as well as residents and fellows to develop scholarly expertise in one of five areas: molecular medicine, clinical and translational research, health professions education, global health sciences, or health and society. Over the past decade, a dozen medical schools have used the UCSF curriculum as a blueprint for change.

UCSF’s experience, capability and resources to achieve the goals of your project

A pioneering spirit of innovation and change imbues UCSF as a direct result of almost two decades of creative efforts aimed at improving learning across the continuum of medical education. UCSF, with its extensive experience in innovations in education,1 learning technologies,2 scholarship of teaching and learning,1 and research in care delivery3,4 is ideally suited to move the bold vision proposed in this initiative into reality. A sample of innovations that characterize UCSF include:

  • Education in Pediatrics across the Continuum (EPAC), a partnership with the AAMC to pilot a truly competency-based model of seamless medical education across the UME/GME continuum.
  • VA Centers of Excellence in Primary Care Education, developing novel strategies to improve patient centered primary care through innovations in interprofessional, team-based health professions education.
  • The UCSF Center for Innovation in Interprofessional Education, led by Scott Reeves PhD, an internationally recognized scholar in interprofessional education, supports innovative curricular experiences for students in all health professions at UCSF and conducts research on interprofessional learning and practice.
  • The UCSF Office of Research and Development in Medical Education (RaDME), with its core of five distinguished scholars in medical education research, has propelled UCSF to one of the top producers of scholarly publications in medical education, excelling in program evaluation. This group supports 30 faculty development workshops annually, a yearlong Teaching Scholars Program as well as masters and doctoral degree work, the latter in collaboration with Olle ten Cate, PhD from the University of Utrecht.
  • The nationally recognized Haile T. Debas Academy of Medical Educators provides faculty talent and substantial financial support for curricular innovations at UCSF.
  • The Office of Technology Enhanced Learning, a nationally recognized leader in instructional and educational technology, pioneered and shares Ilios, an award-winning curriculum management system and supports faculty innovation in digital content delivery, such as digital textbooks and a recent MOOC (Massive, Open, Online Course) on Clinical Problem Solving.

The involvement of the medical school's clinical partners or other collaborators in the development, implementation and support of the project

We have the enthusiastic support and engagement of our key clinical partners for the Bridges Curriculum. They are energized by this opportunity to collaborate with the educational mission to design the education of their future employees while improving the care of their current patients. The project’s Co-PI, Mark Laret, CEO of UCSF Medical Center and the UCSF Benioff Children’s Hospital, is strongly committed to this initiative. Our two other university partners are equally enthused: San Francisco General Hospital (SFGH), a safety net hospital and network of community clinics; and the San Francisco VA Medical Center (SFVAMC), which contains five National Centers of Excellence and ranks first among funded research programs in the Veterans Health system. We are delighted with our partnership with Kaiser Permanente Northern California and especially Kaiser Oakland, where we offer a yearlong longitudinal integrated clerkship in addition to other undergraduate and graduate medical education and faculty development programs. In all, our clinical partners represent the spectrum of delivery systems, each with a track record of innovation in care delivery.

Equally important to the success of our proposal is the tremendous support and excitement of the leaders of the other UCSF health professions schools. Deans David Vlahov, PhD (School of Nursing), John Featherstone, MSc, PhD (School of Dentistry), B. Joseph Guglielmo, PharmD (School of Pharmacy) as well as Kimberly Topp, PT, PhD (Professor and Chair of the Department of Physical Therapy) have all supported the active participation of their educational leaders in the visioning, design and implementation of this project.

Leadership support—administrative and organizational support for the project

With the strong support of Dean Sam Hawgood, MBBS, this effort will be led by Catherine Lucey, MD, Vice Dean for Education (PI) and Mark Laret, CEO of UCSF Medical Center and Benioff Children’s Hospital (Co-PI). Dr. Lucey oversees undergraduate, graduate and continuing medical education as well as the Office of Research and Development in Medical Education (RaDME), the Academy of Medical Educators and the Office of Technology Enhanced Learning. She has budgetary authority over the education mission and has committed funds for faculty, staff and student participation in this curriculum redesign in a greater than 1:1 match over the next five years to ensure the success of this project. The San Francisco VA and the San Francisco General Hospital leaders have committed the participation of their quality and safety experts and infrastructure to this project. Bruce Blumberg, MD, Director of Physician Education for Kaiser Permanent Northern California has already guided the participation of dozens of faculty in our longitudinal clerkship and engaged the Kaiser quality, safety and patient experience experts in support of this project. Joining Dr. Lucey as leaders on this project are Anna Chang, MD, Director of the Foundations of Patient Care course, Susan Masters, PhD, Associate Dean for Curriculum, and Patricia O’Sullivan, EdD. Kevin H. Souza MS, Associate Dean for Medical Education will provide organizational support and David Irby, PhD will serve as a consultant to the project leadership team. Karen Hauer, MD, Director of Student Assessment and Arianne Teherani, PhD, Director of the Educational Evaluations will oversee the student performance assessment and program evaluation, respectively.

Resolution of challenges

Several challenges exist. First, we must identify a diverse set of microsystems in which to educate our students and their interprofessional health partners. We are actively working to recruit additional partner hospitals and care delivery systems. We are delighted that as the health care community has learned about this initiative, other institutions, such as Alameda County Medical Center and community health clinics have asked to be included. Additionally, as the project matures, we will need to change our requirements for clinical placements in Foundations of Patient Care (years 1 and 2) and longitudinal clinical experience (year 3), which will free time currently being used for these clinical experiences. Second, we must work creatively to identify ways to include other health professions students in the systems improvement teams. We are collaborating with the deans of those schools and the Center for Innovations in Interprofessional Education to establish flexible teaching and participation strategies. Third, we must educate the faculty about the new model of care. The faculty development working group and the Academy of Medical Educators are partnering to define a curriculum and begin offering it as part of the CME-accredited UCSF Educational Skills workshop series. We will incentivize participation using the established UCSF tradition of offering innovations grants and travel awards for relevant meetings and by awarding certificates of merit for those who successfully master new competencies. Fourth, we will face inevitable tensions between assigning curricular time to new content and maintaining important existing content. A commitment to stakeholder engagement and flexible content delivery will help us navigate this challenge. Finally, we must work to ensure that participation in this new curriculum is compatible with successful performance on the current licensing exams. We will use our established exam support structures while working nationally to adapt the exam to changes in practice.

Sustainability

Grant funding will enhance our ability to support the faculty and staff efforts needed to innovate while continuing to administer the existing curriculum. Once the innovation is established, the organization can maintain the change, as we have demonstrated in our previous curricular transformations. Furthermore, when we achieve our goal of efficient and effective educational programs that improve patient outcomes, sustainability of the educational programs will be viewed as a critical factor in the success of our clinical partners and they will work with us to ensure that the Bridges Curriculum endures.

References

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