In the first study to show system-wide outcomes of such reform, at UTMB Health reported that failure rates of the Step 1 licensing exam dropped dramatically among some students while significantly increasing graduation rates.
Published in the December issue of Medical Education, the outcomes demonstrate a more effective way of educating a diverse corps of much-needed doctors and challenge previous studies of discrete curriculum revisions that have shown mixed success. The findings underscore the importance of a broad-based, systemic approach to reforming the education system at a time when the U.S. Department of Health and Human Services projects a shortage of 100,000 physicians by 2020, including minority physicians who currently account for only six percent of practicing doctors.
A comparison of the final three classes of students taught under UTMB's traditional curriculum (1995-1997; 517 students) with three classes that studied under the institution's "integrated medical curriculum" (2003-2005; 597 students) showed a nearly 70 percent decrease in the failure rate – from 7.5 percent to 2.3 percent – of the United States Medical Licensing Examination Step 1. Nationally, for all students, the failure rate for the exam in the periods studied was six to seven percent.
African Americans showed the greatest improvement, with the failure rate decreasing by 94 percent, from 25 percent to 1.6 percent. Hispanic students' failure rates dropped 56 percent, from 12.9 percent to 5.7 percent. Failure rates among women decreased 79 percent, from 9 percent to 1.9 percent, and gender differences in mean scores narrowed.
Four-year graduation rates, the norm at UTMB Health and the majority of medical schools, also increased from 81 percent under the traditional curriculum to 88.1 percent under the integrated medical curriculum. Five-year graduation rates grew from 89 percent to 94.8 percent.
"Over the last two decades, many medical schools have made various reforms but even well-implemented changes may not realize their full potential unless they are coordinated across the multiple, interdependent components of the medical education system," said the study's lead investigator, Dr. Steven Lieberman, vice dean for academic affairs and a professor of internal medicine. "Our hope is that education leaders recognize that fully aligning institutional values and priorities with sound educational approaches across the organization is key to successfully engineering change."
These findings build on a 2008 UTMB study published in Academic Medicine that showed all students who studied under the integrated curriculum fared much better on the Step 1 exam even when they entered with below average MCAT scores (20-25 out of possible 45). On average, the low MCAT students' scores were approximately 10 points higher than those studying under the TC (210.8 vs. 201.1).
### UTMB's Integrated Medical Curriculum
Despite a long history of student diversity and focused educational innovation, in the mid-1990s UTMB students' academic performance lagged behind national benchmarks. With a goal of promoting academic excellence, UTMB Health implemented a series of sweeping changes in its recruitment, preparation, instruction, assessment and support programs over several years.
The resulting curriculum, based on proven best practices, included the adoption of training methods that place a primary emphasis on problem-based learning, which stresses real-world instruction over rote memorization and lecture-based learning. The curriculum also requires early clinical experiences, with student-patient interaction speeded up to the beginning of students' academic careers.
UTMB Health also developed a safety net of support including peer tutoring, exam preparation and academic counseling to support students experiencing difficulties. At-risk students identified through a pre-matriculation program receive support even before academic problems occur.
Finally, a number of pipeline programs identify high-potential candidates from underserved populations and bring them on campus for intensive training and early exposure to medical school. Many students are offered early acceptance, and receive academic support before matriculation.
Raising the Bar on Medical Education Diversity
One of the oldest medical schools in the U.S., founded in 1891 with a heritage of serving underserved and at-risk populations, UTMB continues to be among the most diverse academic medical institutions in the nation. From 2000-2007, UTMB had the highest percentage of underrepresented minority graduates and ranked first for the number of Hispanic graduates among U.S. medical schools.
More than 25 percent of the integrated curriculum students included in the study were from underrepresented minority groups, compared to 15.7 percent nationally during the same time period.
The students overall showed an average 14 point difference in Step 1 scores compared to traditional curriculum students, and for underrepresented minority students the difference was 14.6 points. African American integrated curriculum students showed a 20.8 point difference compared to their traditional counterparts. For Hispanic students, the difference was 11.3 points. Female integrated medical students showed a 15.6 point difference.
"These findings presage a more effective course of recruiting and training doctors who will reflect a diverse society and provide care in underserved regions," said Lieberman. "Our approach can serve as a model for reform in medical education, preparing physicians that will mirror our nation's diversity and improve the lives of their future patients."
ABOUT UTMB Health
Established in 1891, Texas' first academic health center comprises four health sciences schools, three institutes for advanced study, a research enterprise that includes one of only two national laboratories dedicated to the safe study of infectious threats to human health, and a health system offering a full range of primary and specialized medical services throughout Galveston County and the Texas Gulf Coast region. UTMB is a component of the University of Texas System.
