Interdisciplinary Curriculum to Train Internal Medicine and Obstetrics-Gynecology Residents in Ambulatory Women's Health: Adapting Problem-Based Learning to Residency Education

Abstract

Objective:

Although residents in internal medicine (IM) and obstetrics-gynecology (OG) must provide primary care for women, studies indicate that both groups require more skills and training in women's health. Our goals were to assess the needs of residents at our academic medical center and to design an interdisciplinary curriculum that addresses these needs utilizing a modified problem-based learning (PBL) format. The aim of this article is to report on the development, logistics, and successful implementation of our innovative curriculum.

Methods:

Based on results from a targeted needs-assessment, we designed a curriculum for both IM and OG residents to address curricular deficiencies in an efficient and effective manner. Procurement of support was achieved by reviewing overlapping competency requirements and results of the needs-assessment with the program directors. The curriculum consists of six ambulatory clinical cases which lead residents through a discussion of screening, diagnosis, prevention, and management within a modified PBL format. Residents select one learning objective each week which allows them to serve as content experts during case discussions, applying what they learned from their literature review to guide the group as they decide upon the next step for the case. This format helps accommodate different experience levels of learners, encourages discussion from less-vocal residents, and utilizes theories of adult learning.

Results:

Sixty-five residents have participated in the curriculum since it was successfully implemented. IM residents report that the cases were their first opportunity to discuss the health concerns of younger women; OG residents felt similarly about cases related to older women. Implementation challenges included resident accountability. Residents identified the timing of the sessions and clinical coverage requirements as barriers to conference attendance.

Conclusions:

Interdisciplinary modified PBL conferences focusing on shared curricular needs in ambulatory women's health are well-received by both IM and OG residents. This format utilizes theories of adult learning and maximizes limited time and resources by teaching IM and OG residents concurrently, and can be successfuly implemented at a large academic medical center.

Introduction

Although residents in internal medicine (IM) and in obstetrics-gynecology (OG) must be able to provide effective and evidence-based care for women in the ambulatory setting, the literature in both disciplines points to large gaps in residents' knowledge, comfort, and competencies in providing this care.^1
–3 For example, a national survey of primary care program directors recently found a significant discrepancy between what program directors thought their residents should know and what they believed their residents actually know about ambulatory women's health.¹ Program directors perceived the competencies among their primary care residents to be particularly poor for issues related to contraception, domestic violence, menopause, polycystic ovarian syndrome, and osteoporosis.¹ Similarly, a 2004 survey of generalist obstetrician-gynecologists identified physicians' levels of preparedness to handle common primary care complaints.² The results revealed that only 59% of surveyed obstetrician-gynecologists felt that residents receive adequate training in outpatient medical care. A 1995 survey of over 4000 OG residents revealed that while 85% of residents planned to provide primary care services to their patients, 85–94% reported no primary care rotation in their residency, 53% reported no identifiable primary care teaching faculty, and 77% reported fewer than two didactic teaching sessions per month on primary care.³

There are several reasons to teach IM and OG residents together in an interdisciplinary curriculum. While IM and OG residents both provide primary care to women, neither set of residents are trained adequately or are comfortable in providing this care. Additionally, because IM and OG share the common goal to promote excellent, comprehensive, and evidence-based health care for women, there is substantial overlap of the women's health competencies mandated by national guidelines governing both residency programs.^4

–7 Lastly, when faculty time and expertise are limited, it is prudent to produce curricula that are both effective and efficient. For this reason, we assessed the particular learning needs of our IM and OG residents at the University of Pittsburgh Medical Center and then designed a collaborative and interdisciplinary curriculum in ambulatory women's health. The objectives of our curriculum are twofold: (1) to provide increased exposure to identified women's health curricular deficiencies for both IM and OG residents, and (2) to develop a modified problem-based learning (PBL) format for residency education that maximizes the benefits and avoids identified concerns of traditional PBL curricula while building community between residency programs by invoking interdepartmental peer-teaching and learning. The aim of this article is to report on the process of the development, logistics, acceptability, and successful implementation of our innovative curriculum.

Methods

Assessment of curricular needs

To assess the learning needs of residents at our large urban medical center, we developed a 65-item cross-sectional survey that measured the residents' knowledge and comfort levels concerning specific topics in ambulatory medicine.

The steps in designing and validating the survey are described in detail elsewhere.⁸ Briefly, we began by reviewing the competency requirements of the American Board of Internal Medicine,⁴ Council on Resident Education in Obstetrics and Gynecology,⁶ American College of Obstetrics and Gynecology,⁷ and Council on Graduate Medical Education.⁹ We selected 14 areas in ambulatory women's health that were considered important by both the IM and the OG governing bodies, and were listed in the comprehensive curriculum guidelines of the Federated Council for Internal Medicine.⁵ We asked a convenience sample of 15 IM residents and 15 OG residents to rank these areas in the order of what they felt would be most useful to their education. Among their top choices, both sets of residents listed diabetes, thyroid disease, polycystic ovarian syndrome (PCOS), and menopause (including topics of sexual dysfunction, osteoporosis, and use of hormone therapy). This step was critical to establish the similarity of needs of both sets of learners, develop specific questions to include in our pre-curricular survey, and procure support from the two departments for the idea of an interdisciplinary curriculum.

In the survey, we included test questions and clinical scenarios to assess residents' knowledge (multiple-choice questions) and comfort levels in diagnosing and managing the selected conditions (with levels ranging from “very comfortable” to “very uncomfortable”). Additional details about the knowledge and comfort questions have been described.⁸

With approval from our institutional review board, we invited all 61 second- and third-year IM residents and all 18 third- and fourth-year OG residents to complete the survey. The response rates were 82% (50/61) for IM residents and 83% (15/18) for OG residents. The only important difference in the sociodemographic characteristics of the groups was that 49% of IM respondents and 100% of OG respondents were women.

For each group, Figure 1 shows the mean correct knowledge score concerning the four topics and the percentage of residents who reported feeling “very comfortable” with the topics. Table 1 lists questions that < 50% of residents answered correctly and clinical scenarios about which < 50% felt comfortable. The results confirmed that the groups had overlapping curricular needs and helped us narrow the focus of our curriculum by selecting particular domains within clinical areas that required the most attention. Areas with the lowest knowledge scores and least comfort were selected.

FIG.1.

Results of a survey of internal medicine residents and obstetrics-gynecology residents concerning knowledge of and comfort with the diagnosis and management of diabetes, thyroid disease, polycystic ovarian syndrome [PCOS] and menopause. Black bars show the mean correct knowledge score for each group of residents. Gray bars show the percentage of each group that reported feeling “very comfortable.”

Table 1.

Results of a Survey Administered to Internal Medicine (IM) and Obstetrics-Gynecology (OG) Residents Concerning Their Knowledge of and Levels of Comfort with Women's Health Care

Question type, topic, and result	IM residents	OG residents
Knowledge questions that <50% of residents answered correctly
Diagnosis of polycystic ovarian syndrome (PCOS)	X	X
Indications for hormone replacement therapy	X
Indications for metformin use in women with PCOS	X
Cardiovascular implications of hyperthyroidism	X	X
Synthroid dose adjustments during pregnancy	X
Treatment of hyperthyroidism during pregnancy	X
Screening guidelines for osteoporosis	X	X
Diagnostic criteria for diabetes		X
Identifying risk of endometrial hyperplasia in women with untreated PCOS	X
Clinical scenarios with which <50% of residents felt comfortable
Interpretation of an oral glucose tolerance test	X
Initiation of a diagnostic workup in a patient with suspected PCOS	X
Construction of a management plan for hirsutism	X	X
Construction of a management plan for oligomenorrhea	X
Initiation of a management plan for a patient with insulin resistance	X	X
Initiation of a management plan for a patient with hyperthyroidism	X	X
Initiation of medical treatment for type 2 diabetes mellitus		X
Initiation of a workup in a patient with a low level of thyroid-stimulating hormone (TSH)	X	X
Initiation of a workup in a patient with a high level of TSH		X
Determination of a target low-density lipoprotein (LDL) cholesterol level based on a patient's risk factors		X
Initiation of a workup in a patient with a palpable thyroid nodule	X	X
Construction of a management plan for hot flashes	X	X
Initiation of a management plan for vaginal atrophy	X
Initiation of a management plan for a woman with sexual dysfunction	X	X
Interpretation of a dual energy x-ray absorptiometry (DEXA) scan report		X

Interdisciplinary modified problem-based learning curriculum

Our interdisciplinary curriculum uses interactive, small-group, case-based, and peer-taught sessions, all of which have been shown to be effective in adult learning.^10
–12,18 Adult learning is best accomplished when (1) goals and objectives are considered realistic and important to learners; (2) participants have some control over the content and process of their learning; (3) learning is applied directly and concretely in a timely fashion; (4) opportunities exist to allow learners to practice what they have learned in a safe environment; (5) small-group activities allow learners to move beyond understanding to application, analysis, and synthesis; (6) diversity of previous experiences, knowledge, self-direction, and interests are taken into account; and (7) learning is facilitated and supported to allow learners to translate and apply newly acquired knowledge into practice.¹⁸ This is accomplished via modified PBL conferences which maximize the tenets of adult learning theory described above. According to Camp,¹⁹ PBL is active, adult-oriented, problem-centered, collaborative, integrated, and interdisciplinary. It uses small groups and operates in a clinical context.

The University of Pittsburgh School of Medicine has a long history of PBL curricular development and implementation. The medical school adopted a PBL curriculum in 1990, and both case authors have substantial PBL experience both from the student perspective (A.S.) and from the faculty perspective (M.M., A.S.). Cases for the resident curriculum were thus developed and reviewed with attention to the known strengths and weaknesses of PBL education. One of our primary goals was to modify PBL for residency education (Table 2).

Table 2.

Differences between Traditional Problem-Based Learning (PBL) and Our Modified PBL^a

Traditional PBL	Modified PBL
Two separate sessions separated in time requiring multiple faculty sessions	One 90-minute session
Faculty ask questions, do not give answers	Faculty teach when appropriate
Resolution session has learners report back on what they learned	Resolution session involves clinical problem solving where newly acquired knowledge is used to work through a clinical vignette
May allow learners to pursue tangential ideas or derive wrong learning objectives	Learning objectives are predetermined and selected by learners
May arrive at mistaken conclusions	Faculty facilitate and guide discussion to ensure that correct information and correct interpretation of the literature is occurring
Attendance is key or learning objectives are lost	Learning objective can be covered by faculty facilitator and by group discussion and problem solving if a resident is absent
Directed towards similar levels of learners, usually medical students	Can teach multiple levels of learners including residents

According to Camp¹⁹, PBL is active, adult-oriented, problem-centered, collaborative, integrated, and interdisciplinary. It uses small groups and operates in a clinical context. “Pure” PBL allows students to generate their own learning objectives, whereas modified PBL allows students to select from predetermined learning objectives.

Traditional PBL conferences typically offer progressive disclosure of an unknown case to learners who must generate their own hypotheses and learning objectives, and return for a second session to report back what they have found and then work together to solve the case.¹³ This approach stimulates teamwork and independent learning and focuses on the process of discovery.^13,14 While it can provide an effective way to increase learners' awareness of women's health issues in the ambulatory setting,¹⁵ it has been criticized for allowing learners to pursue tangential ideas and arrive at mistaken conclusions and for making inefficient use of time, resources, and faculty expertise.^14,16 In addition, adapting a traditional PBL format to residency education poses other challenges not present in medical school PBL curricula; these include inconsistent attendance due to competing clinical duties, mandated days off, and learners of different levels and experience.

Modified PBL differs from traditional PBL in several ways (Table 2). While traditional PBL involves two sessions separated in time requiring multiple faculty sessions, modified PBL has only one 90-min session. During traditional PBL session, faculty ask questions but are encouraged to never give answers; modified PBL allows faculty to teach when appropriate and facilitate active discussion. This is especially important given that resident attendance is inherently more inconsistent than medical school attendance, and learning objectives could be lost if the traditional PBL model were followed in residency. Faculty facilitation and guidance also ensures that correct information and correct interpretation of the literature is occurring. This reduces the potential for learners to pursue tangential ideas, derive inaccurate learning objectives, or arrive at mistaken conclusions which can occur with traditional PBL. Lastly, while traditional PBL has learners report back on what they learned in “mini-lecture” format, modified PBL involves clinical problem solving where newly acquired knowledge is used to work through a clinical vignette rather than simply presented or lectured.

Results

Our modified PBL curriculum emphasizes the merits of cooperative learning (Table 2), while it avoids many of the problems associated with traditional PBL. The curriculum explores ambulatory clinical cases that focus on six topics: osteoporosis, sexual dysfunction, thyroid disease, menopausal symptoms, diabetes, and PCOS. The material that was chosen for emphasis in each case was determined by our needs-assessment. For example, with regard to PCOS, comfort scores were low across all domains, including diagnosis of the disease, management of symptoms such as hirsutism and abnormal menses, and assessment of cardiovascular risk. With regard to thyroid disease, comfort scores were low for management but not diagnosis. This type of information was central to developing targeted cases to serve as the framework of the curriculum. Knowledge and comfort was so poor for menopause, we decided to split the larger topic into managing hot flashes, osteoporosis, and sexual dysfunction. Cases were developed in conjunction with women's health faculty from IM and OG, and piloted during the first 2 months of the curriculum. Changes were made in response to poor flow of discussion as identified by the facilitators and unclear objectives as identified by the learners. After the first 2 months of curriculum implementation, no further changes were made to either case content or learning objectives.

As designed, each case leads six to eight residents through a progressive clinical vignette with a series of discussion questions which cover pre-identified curricular objectives including screening, prevention, diagnosis, and treatment in a 90-min stand-alone session. The week prior to the conference, residents are given a list of learning objectives stemming from the precurricular needs assessment, and each resident is asked to choose one learning objective each week; this self-selection of learning objectives allows residents to focus their preparation on content areas either of particular interest or weakness. Residents then serve as content experts during case discussions and are expected to apply what they have learned from their literature review to help the group decide what next step to take in the case. The format facilitates discussion and participation across all levels of learners, as each resident has a turn to be the expert. A resident who is usually less vocal or who may be overpowered in a typical PBL discussion has the opportunity to participate in the group learning, teaching, and problem-solving when his or her content expertise is required. This format can also be referred to as the jigsaw approach to cooperative learning wherein each student is responsible for gathering information about one aspect of a case and each learner contributes a piece to the learning puzzle.

The cases unfold forward in real time and call on the residents to make decisions regarding ordering diagnostic tests, interpreting test results, and making case management decisions. Prior to the session, the residents have not seen the clinical case and do not know what direction the case will take. The modified PBL format more closely mimics real life, as the residents need to know when to chime in regarding how their knowledge gleaned from researching their learning objectives can be applied to the medical decision at hand. While the residents each come prepared as content experts of their learning objective, they do not necessarily know when their knowledge will be pertinent and how it will apply to the case. They are not just required to report the facts but are instead being called upon to apply their newly acquired knowledge to a management decision. As the residents make decisions reflecting their movement from “know” to “know how,” they move upwards on Miller's learning pyramid¹⁷ demonstrating application of newly acquired knowledge, a key aspect of adult learning theory.

The modified PBL format (or jigsaw approach) applies additional theories of adult learning, including self-directed learning and timely application of new information. The residents select a learning objective of interest to them, research their objective by obtaining and interpreting the relevant literature, and subsequently apply their newly learned information to a clinical vignette unknown to them. Like the traditional PBL, the modified PBL allows residents to problem-solve together and invoke cooperative learning. However, the modified PBL focuses the attention of learners, minimizes inefficiency, and allows the group facilitator to participate and share expertise to a greater extent than does the traditional PBL (Table 2). The facilitator does not give lectures or tutorials, but rather focuses the discussion, aids in the interpretation of the literature presented by the residents, and pushes the residents to expand and explain their diagnostic or management reasoning.

Implementation

Procurement of support from the two departments was achieved after the residency program directors reviewed the overlapping competency requirements and the results of the needs assessment. Logistical issues of bringing residents together from two different programs and training sites were managed by finding a neutral location and choosing a 7:00 a.m. time slot that was acceptable to most.

Excused absences for clinic coverage, interviews, and scheduled vacations caused some erratic attendance. However, the dissemination of printed conference schedules, required resident sign-in, and continued emphasis on otherwise mandatory attendance by both program directors boosted conference attendance and ensured resident accountability. When unavoidable absences occurred, the modified PBL format allowed a faculty expert to “cover” for the content expert and thereby prevent the absence from disrupting the flow of the case.

Although we were concerned that OG residents would feel outnumbered by IM residents, this did not prove to be an issue. At least two OG residents attended each conference, and all residents had a turn to be the content expert, so no resident had the opportunity to withdraw or stay silent. Moreover, given the popularity of the curriculum among residents, OG interns would often attend the conferences, thereby enhancing the OG numbers. The modified PBL format allowed even the most junior members to participate in group discussions.

Sixty-five (82%) of 79 required residents (61 IM and 16 OG) have participated in the curriculum since its inception in July 2006. Residents appeared enthusiastic about the case-based PBL format and the self-directed learning involved, and they have identified the curriculum as a positive learning experience. Informal feedback has indicated that the curriculum offers IM residents an opportunity to discuss health concerns of younger women (PCOS and abnormal menses) and offers OG residents an opportunity to discuss concerns of older women (menopause, osteoporosis, and sexual dysfunction). Residents also enjoy case discussions with colleagues from another discipline. Teaching the OG and IM residents together is not only efficient use of faculty time, but also offers significant enrichment to the clinical discussions. For example, discussions between the residents on their approach to and interpretation of data in the IM and OG literature regarding the management of gestational diabetes, thyroid disease in pregnancy, hormonal treatment of osteoporosis, and different approaches to managing PCOS were extremely rich and could not have been so meaningful were the conferences not interdisciplinary. The collaboration and discussion between the sets of residents illustrated just how interdisciplinary these topics are, and stressed to the residents the need for multidisciplinary approaches to many aspects of women's health.

Discussion

This article describes the development and implementation of a collaborative and interdisciplinary curriculum in ambulatory women's health designed to provide an innovative solution to the problem of curricular deficiencies that were shared by IM and OG residency training programs and were revealed by administering a precurricular needs assessment survey to IM and OG residents. Reporting the results of the survey to the various stakeholders in the two disciplines, including the residency program directors, administrators, and residents, ensured that we had sufficient support from both groups.

Our curriculum uses a modified PBL format to explore ambulatory women's health issues via clinical case discussions. This jigsaw approach allows each learner to contribute a piece to the learning puzzle and maximizes important tenets of adult learning theory. While many medical schools use a traditional PBL format for teaching in the preclinical years, our modified PBL format offers several advantages to the more mature learners involved in residency programs. For example, it is more time-efficient because it completes cases in one session, and it is more resource- and space-efficient because it teaches two sets of residents concurrently and allows them to interact on a regular basis. On the one hand, it takes full advantage of faculty expertise in IM and OG to enhance group discussion and control group dynamics. On the other hand, it allows each resident to be a content expert who guides the group through an aspect of decision making in the clinical case. This helps to accommodate different levels of learners, elicit the ideas of the less-vocal residents, and prevent domination by any one individual. Indeed, residents demonstrate their ability to apply newly acquired information to move through a clinical case indicating their progression from “knows” to “knows how” on Miller's learning pyramid.¹⁷

The curriculum utilizes other components of adult learning theory, including self-directed learning and timely application of newly acquired knowledge. Residents enjoy being the content expert and learning to apply their new knowledge to a clinical case. This type of peer teaching has been shown to improve educational outcomes¹⁰ and allows learners to take an active role in their education.

While we are pleased with the development and implementation of our novel curriculum in response to identified needs, there are certainly other measures that might have worked just as well or better to ultimately improve ambulatory women's health skills. While it is important to practice new skills and apply new knowledge in a safe environment such as the small group sessions used in our curriculum, the merits of increased actual clinical exposure can not be over emphasized. Developing an actual multidisciplinary clinic where OG and IM could evaluate and manage patients together would be an extraordinary learning experience and might provide the ultimate evaluation for curricular success. This has actually been attempted by various training programs with varying degrees of success.²⁰ Funding and sustaining such a clinic has proven to be difficult, though the learning prior to closure was terrific. Additionally, while we are confident that the richness of the resident discussions generated from the cases and the thoughtfulness of the questions asked of each other by the residents could not be captured by a simple post-test of knowledge or satisfaction, our report could be strengthened by post-curricular data that could illustrate to readers what we observed. A post-test very likely would have showed an increase in knowledge, but we believe the true success of the project was manifested by its multi-step developmental process, successful implementation into the curriculum of two large residency programs, and the quality of the discussions generated by the curriculum on topics about which the residents previously knew little about and with which residents were previously uncomfortable.

There are many potential implications from our project. While our short-term goal was to fill a curricular need shared by two disciplines by developing and implementing a multidisciplinary curriculum, long-term goals are to ultimately improve how residents approach ambulatory women's health and improve patient care. Whether residents choose to pursue primary care careers or not, ambulatory women's health skills will likely serve them well in whatever field they choose, and we are hopeful that innovative curricula which encourage self-directed and life-long learning techniques will be of benefit to all residents.

Developing and implementing our novel curriculum has proven to be feasible, enjoyable, and practical. It appears well-received by IM and OG residents and is accomplishing its goal of building community ties among IM and OG faculty and residents by fostering interdepartmental teaching and learning. While the clinical cases allow residents to move up Miller's Pyramid, the next step in evaluating curricular success will be to look at the peak of the pyramid (“do”) to see how residents apply what they've learned to actual clinical practice.

Footnotes

Acknowledgments

We gratefully acknowledge Drs. Kevin Kraemer and Teresa Brosenitsch for their editorial suggestions. An earlier version of this work was presented at the National Meeting of the Society of General Internal Medicine on April 26, 2007.

Disclosure Statement

There are no financial conflicts of interest for any of the authors.

References

Spencer

, Kern

. Primary care program directors' perceptions of women's health education. J Womens Health, 2008; 17:549–556.

Kacmar

, Weitzen

. Identification of educational objectives for obstetrics and gynecology residents in the ambulatory setting. Am J Obstet Gynecol, 2004; 191:1757–1761.

Laube

, Ling

. Primary care in obstetrics and gynecology resident education: a baseline survey of residents' perceptions and experiences. Obstet Gynecol, 1999; 94:632–636.

American Board of Internal Medicine (ABIM). Policies and Procedures for Certification in Internal Medicine, 1995. www.abim.org/pubs/0699womn.htm. 2006 February .

Federated Council of Internal Medicine (FCIM). FCIM Internal Medicine Curriculum: A Resource Guide to Curriculum Development, 2nd www.acponline.org/fcim/. 2007 August 24.

Council on Resident Education in Obstetrics and Gynecology (CREOG). Educational Objectives: A Core Curriculum in Obstetrics and Gynecology, 8th www.gynob.emory.edu/pdf/creogeducationalobjectives.pdf. 2007 August 28.

American College of Obstetrics and Gynecology (ACOG). www.acog.org. 2006 February 15.

Spencer

, Bost

, McNeil

. Do women's health residency tracks make a difference? J Womens Health, 2007; 16:1219–1223.

Council on Graduate Medical Education (COGME). Fifth Report: Women and Medicine. Washington, DC: Department of Health and Human Services, 1995.

10.

Krych

, March

, Bryan

et al. Reciprocal peer teaching: students teaching students in the gross anatomy laboratory. Clin Anat, 2005; 18:296–301.

11.

Weberschock

, Ginn

, Reinhold

et al. Change in knowledge and skills of year 3 undergraduates in evidence-based medicine seminars. Med Educ, 2005; 39:665–667.

12.

Nnodim

. A controlled trial of peer-teaching in practical gross anatomy. Clin Anat, 1997; 10:112–117.

13.

Barrows

. A taxonomy of problem-based learning concepts. Med Educ, 1986; 20:481–486.

14.

Srinivasan

, Wilkes

, Stevenson

et al. Comparing problem-based learning with case-based learning: effects of a major curricular shift at two institutions. Acad Med, 2007; 82:74–82.

15.

Kuzma

, Rutenberg

, Gracely

et al.

Does the integration of women's health into a problem-based curriculum affect the learning issues that students generate in the ambulatory clinical setting?

Acad Med, 1997; 72:913–915.

16.

Colliver

. Effectiveness of problem-based learning curricula: research and theory. Acad Med, 2000; 753:259–266.

17.

Miller

. The assessment of clinical skills/competence/performance. Acad Med, 1990; 65:S63–S67.

18.

Speck

Best practice in professional development for sustained educational change. www.ncrel.org/sdrs/areas/issues/methods/technlgy/te10lk12.htm. 2009 June 30.

19.

Camp

Problem-based learning: a paradigm shift or a passing fad?

MEO, 1996; 1:2.

20.

Henrich

, Chambers

, Steiner

. Development of an interdisciplinary women's health training model. Acad Med, 2003; 78:877–884.