We piloted a QI curriculum in a year-long longitudinal integrated clerkship for third-year medical students that was based on actual clinical experiences, allowed students to select a QI gap, and required self-directed learning to meet specific competencies. While students were able to meet most of the targeted competencies, higher order skills such as establishing timely and measurable goals for a proposed intervention were lacking. Students showed increased confidence in their ability to perform QI as well as improved perceptions of value of QI for individuals and institutions. However, measurements of QI knowledge did not show improvement over the course of the year – a deficiency of either our assessment tools or the curriculum.
Four major lessons emerged from this experiment. First, the project was feasible. Assessment of student final presentations demonstrated appropriateness of the majority of preselected competencies: groups were able to identify and quantify a quality gap based on observations from their own clinical experiences, complete literature reviews to analyze the extent of the gap, make efforts to understand previous local work to address the problem, and identify relevant stakeholders. They accomplished these objectives in the context of busy clerkship schedules, demonstrating that these are achievable goals for clinical year medical students.
Second, we learned that students did not perform well in our knowledge assessment, suggesting that knowledge objectives should be explicitly taught with the aid of scheduled instructional sessions throughout the curriculum. We experimented with a curricular model that emphasized self-directed learning. However, basic concepts that we believed would have easily emerged through ongoing involvement with a QI project were not demonstrated by our measures. Supplementing the single introductory lecture with additional didactics may have filled this gap.
Third, we discovered that early establishment of project specific mentorship is essential. The success of QI curricula at other levels can be attributed to motivated faculty mentorship (19
). We had anticipated that requiring students to select projects based on their own experiences would result in greater motivation and self-directed learning. However, implementing this strategy revealed that even with the extensive QI expertise available at our institution, it can be difficult for students to find faculty willing to devote the time needed to actively mentor a group on a de novo project. The experience of group 1, who had difficulty finding a mentor, was diminished in comparison to the second group who had an actively engaged expert mentor for the majority of the project. Thus, we conclude that students should either join ongoing projects that approximate their interests or find a mentor who can commit to their project early in the academic year.
Finally, students struggled with the higher order competencies (such as identification of appropriate process and outcome measures, ability to recommend changes in clinical processes) required of ‘advanced beginners’ as defined by Ogrinc et al. (16
) and would have benefited from explicit instruction and mentorship to help them develop clear project goals as well a plan for evaluating the impact of their proposed intervention. For example, despite the consistent emphasis on measurable outcomes that was reinforced throughout the year, students found it difficult to define clear improvement goals and measures by which to gauge the success of their proposed interventions (see ). Increased focused didactics, more frequent and specific feedback, and consistent mentorship could address this finding.
This pilot study has several limitations. First, the sample size was necessarily small, given the predetermined size of the longitudinal clerkship. Second, our measurements of knowledge and attitudes were developed for the purposes of our curriculum, and thus not independently validated. Finally, the curriculum was piloted in a longitudinal integrated clerkship in which students are immersed in a single healthcare system and instilled with a longitudinal, patient-centered perspective. Piloting the curriculum in this setting, which remains rare in most medical schools, limits the generalizability of our conclusions. Despite this limitation, we feel that the lessons we learned may be largely applicable for self-directed and experiential QI educational efforts for clinical year students. This curriculum may be applicable for any clerkship student who spends a significant continuous period of time within a single system, even with a traditional clerkship structure.
Since the IOM's reports on safety and quality 10 years ago, the need for physicians to be competent in quality improvement has emerged as a major area of focus in medical education (1
). In response to this need, we developed a self-directed, experiential QI curriculum for third-year medical students in which they gain experience in systems-based practice and subsequently value the important role of physicians in QI efforts. We share four major lessons from this effort: clinical-year medical students are able to conduct a self-directed QI project, mentorship is vital, self-directed learning in this domain may be insufficient without targeted didactics or other pedagogical strategies, and higher level skills such as the measurement of efficacy of interventions would benefit from explicit instruction and consistent mentorship. As the focus on systems-based practice in undergraduate medical education increases, lessons learned from our pilot curriculum can allow educators teaching QI to better target developmentally appropriate competencies in clinical-year medical students.