In Years 3 and 4, the 4 threads started in Years 1 and 2 continue; however, the format adopted in these 2 years is different in that there are few structured classroom courses. In Year 3, students pass through 6 clerkships, wherein the core competencies in clinical medicine are learnt: Internal Medicine, Surgery, Pediatrics, Obstetrics and Gynecology, Psychiatry, and Anesthesiology (figure 3). In general, learning of knowledge, skills, attitudes and behaviors in the clinical years, including the social and moral context of medicine, ethics, professionalism and personal development, occur in the context of patient care and the students' daily experience and interaction with patient and colleagues. Sessions in evidence-based medicine, embedded within the clerkships, reinforce what was learnt in the pre-clerkship curriculum. In addition, students attend 2 longitudinal courses that run throughout third year: clinical pharmacology and Physicians Patients and Society-3, which is primarily a bioethics course
In year 4, students reinforce their knowledge and skills in internal medicine (where they serve as acting interns), pediatrics, emergency medicine, and family medicine, and are given the chance to explore their interests through electives and subspecialty rotations (figure 4).
During Year 4 as well, students will gain an understanding of the role of the social factors and the health care system in the overall delivery and quality of care through a rotation in Social and Preventive Medicine/Public Health, in which they engage in a scholarly group project that addresses an aspect of public health, community practice, or the health care system in Lebanon. In addition, the principles of epidemiology become directly intertwined with practice through sessions in Evidence Based Medicine
- Standardized patients
- Electronic simulations
- Case scenarios
- Clinical conferences
- Occasional lectures
- Problem Based Learning or Team Based Learning exercises
A. Learning Activities:
- Lectures (in-person and VOPs): cover the main learning objectives of the course. They serve to introduce topics, explain complex processes and concepts, and direct the students to focus on the essential and important aspects of a topic. They are not meant to be comprehensive presentations of a topic and do not replace the required reading assignments. In addition, some material on lectures may not be found in textbooks as teachers continually update their lectures with recent research findings or use resources other than the assigned textbook(s).
- Interactive sessions: in-person session where faculty guide students in exploring complex concepts introduced in the lectures/VOPs and applying the knowledge gained through problem solving, using probing questions and cases. The sessions usually employ Automated Response Systems such as Classpoint.
- Laboratory sessions: these sessions aim to enable the student to:
Team based learning (TBL) sessions: engage the students in team work that aims to solve complex, real, and usually clinically-oriented or experimental problems related to the topics being studied. Students apply the knowledge that they have gained through lectures and readings to solve these problems. TBL exercises may integrate basic and clinical sciences and cover all disciplines including molecular biology, genetics, histology, pathology, physiology, pathophysiology, pharmacology and clinical medicine. Students are expected to come prepared having read the assignments and reviewed the relevant lectures or VOPs. In class, the TBL process involves 3 activities: an initial individual test to ensure that students have prepared their material; this is followed by having the team of students take the same test with immediate feedback to their responses. The last phase is the bulk of the exercise where students are provided with problems/cases and are required to provide specific answers. This process requires interaction within teams, among teams and between teams and the instructor.
- Learn the anatomy of the human body through dissection and through examining prosected specimens
- Analyze histological or pathological slides or virtual images and describe the various components of cells, tissues and organs
- Conduct experiments or procedures/techniques illustrating principles being learned in the lectures or readings.
- Analyze results of experiments
- Correlate laboratory findings with clinical findings and reasoning
Case or problem-based learning: like TBL, involve small group work (sometimes large groups are involved), and clinically based cases and scenarios or experimental studies that require reasoning skills, but involve more open ended questions and discussion. Students are provided the cases and questions in advance and are expected to come to the session prepared to answer the questions and engage in discussion.
Clinical Skills sessions: These are hands on sessions in which students learn the art of history taking, physical examination, communicating with the patient and clinical reasoning. Students are also exposed to various diagnostic procedures (e.g., radiography, blood withdrawal). Reading material is distributed ahead of the session for students to prepare.
Reflective discussion sessions: conducted in small groups (or occasionally in large groups) these sessions allow students to reflect on experiences, events and ideas, express opinions, and argue and defend positions. This approach is particularly employed in sessions related to ethics, humanities, and personal and professional development.
Teaching Rounds: Students rounding on the wards conduct rounds with the resident in charge and with the attending physician in which they present and discuss their patients focusing on their problems, the diagnostic and management plan followed and the bases for their decisions that integrate scientific, social, economic, cultural and other factors. Students are required to prepare for these teaching rounds and may be asked to make presentations about specific topics.
One-on-one teaching: in ambulatory settings and on the wards, students interact with attending physicians and residents in one-on-one encounters during which patients are presented and discussed.
Clinical Conferences: focus on presentations of patients seen on the ward or in ambulatory settings or medical topics: include OPD conferences, mortality and morbidity conferences, grand rounds…
B. Student Assessment and Feedback
Learning outcomes and competencies are clearly defined for each component of the curriculum, and students must pass each component. The student assessment approaches are aligned with the outcomes and competencies of medical education and are, therefore, multiple. They include:
- Assessment of knowledge: mainly through objective written tests
- Assessment of skills: through observed structured clinical examinations (OSCE) or other forms of performance assessment using rubrics and descriptive evaluation
- Assessment of attitudes and behaviors: through use of essays and instructor evaluation using specific behavior-based rubrics.
- Narrative and/or questionnaire-based assessments are provided by mentors based upon the student portfolios or logbooks which contain their reflections, accomplishments, experiences, exam results, formal and informal evaluations, patient encounters…
In all aspects of education and at all levels of the program, students have a chance to evaluate themselves, their peers, their teachers and the program of study. This process develops their self-reflection and self-assessment skills and their ability to give and receive constructive feedback.
Student Assessment Methods
1. Written quizzes or examinations
Written examinations are mostly objective, single-answer, multiple-choice questions that aim to test the cognitive abilities of the students, i.e. knowledge acquisition and application in problem solving, synthesis, analysis and judgment. Check policy on examinations in the appendices.
2. Oral examinations
Oral examinations are rarely used to test knowledge, application of knowledge, problem solving and clinical reasoning skills.
3. Practical Examinations: to demonstrate mastery of anatomical knowledge and in some cases histo-pathological and radiological skills.
4. Observed structured clinical examinations (OSCE's)
OSCE's are used to test specific skills (clinical skills and reasoning, procedural skills, communication skills, professional conduct, ethical reasoning) in students, particularly during the clinical years and also in the clinical skills courses in years 1 and 2. They consist of multiple stations in which students are instructed to perform specific tasks (e.g. history taking, physical examination, communication with patient…), frequently involving simulated or real patients.
5.Direct observation of performance
Daily performance of students during the clinical rotations in years 3 and 4 or during case-based discussion sessions, TBL or laboratory work is assessed by their seniors, their peers, and others they interact with, through direct observation of performance and through examination of their written records. Assessors provide descriptive prose and/or pre-set questionnaires using rubrics with specific behavioral anchors that pertain to the course objectives, e.g., history taking, physical examination, clinical reasoning, professional behavior, presentation skills, communication, teamwork….
Short essays or papers, contributions to discussion forums, and similar approaches are used to assess students' ethical and professional sensitivity and understanding, and their attitudes, personal development and reflective skills.
7.E-portfolio and logbook
In most clinical clerkships, student must fill a logbook describing the patients/cases they have encountered and managed, and the procedures they have performed. E-portfolios consist of a repository of all the students' learning experiences and reflections, arranged by the students to demonstrate achievement of the required learning objectives and competencies and development of scholarship.
8. Assessment of professionalism
Specific rubrics are used to assess professionalism using multisource feedback and direct observation and achievement of targets within the classrooms and laboratories on the wards and in the clinics.
Formative feedback is provided to students to point out their strengths and weaknesses. In the basic science years this is frequently built into the instructional and assessment approaches used (e.g. team based learning individual and group readiness assurance tests). In clinical years, clerkship coordinators have designated sessions for providing feedback, but also this can happen after every encounter with attending physicians or seniors. Students are encouraged to actively request feedback from seniors.
In years 1 and 2 of the Impact Curriculum, courses are graded as Pass/Fail. The Pass/Fail score is set for each form of assessment or assignment based on its content and difficulty. Thus, students are compared to an absolute standard determined by the professors designing the examination and are not scored relative to each other. Students will receive their numerical grades on tests in order to know how well they performed relative to the standard. The official grades on the various courses and on the official transcripts of the university are, however, either Pass or Fail. Nevertheless, the numerical grades are kept on record and may be used to decide on graduating students with distinction, granting of certain awards (e.g. Penrose Award, Alpha Omega Alpha Honor Medical Society), writing recommendations for individual students, and if requested by students, for reporting to scholarship or financial aid granting bodies that require them. There is no official ranking of students in years 1 and 2.
In years 3 and 4, 4 grade categories are adopted using norm-based (relative) grading: Excellent (top 10-15%), Good (next 35-40%), Pass (the remaining 50%) and Fail (those who do not achieve the expected standard of performance). These are the official grades and are reported on official transcripts. As in the first two years, the standards of performance that determine the Pass-Fail margins are based, for each form of assessment, on absolute (not relative) standards; following that determination, the passing students are distributed to the Excellent Good and Pass categories as described. In years 3 and 4, students are ranked according to the weighted letter grades and the credits assigned to the corresponding course or clerkship.
Professionalism, communication skills and personal development scores are, in some cases, incorporated into course and clerkship grades. Students must demonstrate competence in these domains as well, separately from the overall course or clerkship grade. Those who fail to do so may be asked to conduct appropriate remedial work, repeat a course, repeat the year or to leave the Faculty, even if they have performed satisfactorily otherwise. If there are major ethical or professional infractions, disciplinary action may be taken.
Attendance is expected at all learning activities and contributes to the final grade (see attendance policy below).
Grading policy will continue to be reviewed and modified as the Impact Curriculum continues to be implemented with the following guiding principles:
- All students admitted to medical school have already proven their high academic standards and achievement and have competed hard to be part of AUBFM
- The spirit the curriculum nurtures is one of cooperation and teamwork rather than competition and individualism; the grading system must reduce negative competition and enhance collaboration. The aim is for the students to be the best they can and help others achieve the same, rather than to “be better" than their peers
- A competency based curriculum ensures that students have achieved the minimum necessary knowledge, skills and attitudes to be able to proceed further in their education
- A curriculum that aims to produce excellence must recognize and give incentive for students; the grading system is one way of so doing
- A written narrative should accompany the overall grade assignment to summarize the students' strengths and weaknesses and fill in important gaps left by merely assigning a grade
D. Alternative Scholarship Track
In 2019-2020 AUBFM implemented an alternative “scholarship track" where students can elect to pursue an extended research project spanning years 2-4 of the program. This fulfills one of the goals of the Impact Curriculum, which is to allow students interested in pursuing in depth scholarship work under the mentorship of a faculty member at AUB to do so within the curriculum itself. This scholarly work can be in the form of original research or projects in any discipline as long as it is related somehow to medicine, including, among others, the basic medical sciences, clinical sciences, nutrition, public health, social medicine, history and philosophy of medicine or science, medical education, medical ethics, medicine and culture (e.g. art and literature), business administration, management, economics, medical engineering, and medical anthropology. The Faculty of Medicine will continue to work with other faculties to further explore these possibilities and to develop structured programs in these or other areas.