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Purpose Thirty years ago, academies were conceived as a sociocultural approach to revitalize the teaching mission of medical schools and to promote educators' career advancement. The academy movement has grown rapidly and now reaches a broad range of health professions education organizations. The authors conducted a scoping review to map the literature and describe the evidence that guides the formation of new academies and justifies the continuation of existing ones. Method The authors searched MEDLINE (via Ovid), Embase (via Elsevier and Ovid), CINAHL (via EBSCOhost), and Web of Science (via Clarivate Analytics) from inception through March 6, 2020, for publications regarding academy-like organizations. They mapped the relevant literature using logic modeling as an organizing framework and included the mission, resources, activities, output, outcomes, and impact of the included academies. Results Of the 513 publications identified, 43 met the inclusion criteria, the oldest of which was published in 2000. Most publications were either case reports or perspective/opinion pieces (26, 57.8%), while studies presenting empirical findings were less common (11, 24.4%). Publications showed that academies were diversifying and increasingly were part of a broad range of organizations, including departments, hospitals, health science campuses, and national organizations. The mission, resources, and activities were similar across academies. Evaluation studies were largely limited to process measures, and rigorous studies examining outcomes (i.e., changes in academy participants) and impact on the organization at large were rare. Conclusions The increase in the number of academy-related publications parallels the accelerating speed of the academy movement. To sustain this movement, rigorous studies must provide evidence that academies contribute to the revitalization of organizations' teaching mission and bring about an academic culture where educators thrive and where education is a legitimate career path.

Issue: Calls to change medical education have been frequent, persistent, and generally limited to alterations in content or structural re-organization. Self-imposed barriers have prevented adoption of more radical pedagogical approaches, so recent predictions of the 'inevitability' of medical education transitioning to online delivery seemed unlikely. Then in March 2020 the COVID-19 pandemic forced medical schools to overcome established barriers overnight and make the most rapid curricular shift in medical education's history. We share the collated reports of nine medical schools and postulate how recent responses may influence future medical education. Evidence: While extraneous pandemic-related factors make it impossible to scientifically distinguish the impact of the curricular changes, some themes emerged. The rapid transition to online delivery was made possible by all schools having learning management systems and key electronic resources already blended into their curricula; we were closer to online delivery than anticipated. Student engagement with online delivery varied with different pedagogies used and the importance of social learning and interaction along with autonomy in learning were apparent. These are factors known to enhance online learning, and the student-centered modalities (e.g. problem-based learning) that included them appeared to be more engaging. Assumptions that the new online environment would be easily adopted and embraced by 'technophilic' students did not always hold true. Achieving true distance medical education will take longer than this 'overnight' response, but adhering to best practices for online education may open a new realm of possibilities. Implications: While this experience did not confirm that online medical education is really 'inevitable,' it revealed that it is possible. Thoughtfully blending more online components into a medical curriculum will allow us to take advantage of this environment's strengths such as efficiency and the ability to support asynchronous and autonomous learning that engage and foster intrinsic learning in our students. While maintaining aspects of social interaction, online learning could enhance pre-clinical medical education by allowing integration and collaboration among classes of medical students, other health professionals, and even between medical schools. What remains to be seen is whether COVID-19 provided the experience, vision and courage for medical education to change, or whether the old barriers will rise again when the pandemic is over.

The large classroom lecture remains the predominant model for teaching medical and health sciences learners. This approach has persisted in part due to the perception that lectures offer an efficient and cost-effective way to teach large numbers of learners. The financial advantages of the single-instructor lecture model are apparent when comparing to the small group model, i.e., small group activities require multiple faculty facilitators and small group rooms. Less convincing is the claim that large group lectures promote efficiency in learning. Although a tremendous amount of information can be transmitted in a 50-min time period, the learner is the passive recipient of this information, which can impede learning [1]. Typically, learners will take notes but not engage with the material. This model assumes learners will spend time completing required readings prior to the lecture and then devote additional time after the lecture to assimilate the new information. In reality, many learners will arrive for lecture unprepared, and many will not arrive at all, except via virtual, asynchronous recordings of lectures. Likewise, some learners may devote time after the lecture to review their notes and consult the lecturer or required materials—but many will move on to their next class and not revisit the material until the next quiz or exam. By then, they will have likely have forgotten some of the content and context and will need to relearn the material—possibly without accurate understanding and application. Ultimately, this passive model is less efficient than it appears.

Mentorship is recognized as a critical approach to support successful careers in academic medicine. Obstacles to successful mentoring relationships include difficulty finding appropriate mentors and poor alignment of mentee/mentor interests and goals. We set out to investigate if concordance or discordance in personality traits of mentees and mentors impacts perceived success of mentoring relationships. Our findings indicated that concordance and discordance on one personality trait, neuroticism, seemed to significantly impact the perceived mentoring relationship success related to career progression. Further work to refine criteria for matching mentees and mentors considering personality traits may impact the effectiveness of mentoring relationships.

Introduction Mentoring is a widely regarded faculty development strategy in academic medicine. However, the lack of understanding about mentoring relationship dynamics limits effective recruitment, implementation, and evaluation. Despite decades of publications describing adult mentoring initiatives, few studies examine personality influence in mentoring relationships. This scoping review examined the extent, range, and nature of the research on personality matching in mentoring relationships, and identified research gaps in the literature. Methods Scoping review methodology guided a search of six databases representing higher education, health sciences education, and professional contexts where mentoring is used. Consistent with the inclusive approach of a scoping review, authors included academic papers and other article types. Results The scoping review yielded 39 articles. Literature mostly originated in the United States, publication sources represented multiple disciplines, and the context for the majority of articles was the workplace. The most common publication type was a research report. Although all articles addressed personality or mentoring, only three articles examined personality matching and its contribution to the mentoring relationship. Finally, although the Big Five personality traits were cited in multiple studies, other personality frameworks were used. Discussion Academic medicine expends resources developing and supporting mentoring programs but there remains limited understanding of how best to identify and match mentors and proteges. Further understanding of the role of joint and unique personality traits in academic medicine mentoring relationships seems necessary, if the field continues to invest, time, money, and resources for mentoring programs.

Nocturnal ICU staffing gained favor after correlation was shown between intensivist presence and better patient outcomes. We conducted a cross-sectional survey of stakeholders at a tertiary care academic medical center to evaluate the impact of 24-h attending presence on overnight educational environment, learner autonomy, and attending quality of life. Our results showed an improved sense of educational quality along with diminished trainee autonomy. Attending job satisfaction was poor and this was not entirely explained by persistent daytime demands. This identifies areas for initiatives to encourage trainee autonomy and system evaluations of how best to staff attending nocturnal coverage.

A central mission of the International Association of Medical Science Educators (IAMSE) is to support the efforts of medical science educators (MSE) and to facilitate communication about critical issues affecting medical science education and educators. One potential issue we explored relates to whether published guidelines for the recognition, reward, and promotion of MSE have been widely adopted by institutions and whether faculty is aware of them. To address this, we surveyed the international membership of IAMSE to collect the following data: (1) perceptions and understanding of institutional promotion and tenure practices, institutional metrics for evaluating MSE, and methods of institutional recognition and reward of MSE, (2) perceptions of the adequacy of these processes, and (3) awareness of published guidelines for the evaluation and promotion of MSE. While the results of this survey identified a need for more time to pursue scholarship and innovation in medical education, greater recognition of MSE and their contributions, and increased institutional support of and resources for MSE activities, the results also showed that some MSE do feel recognized and rewarded for their work and that over half (57%) of respondents indicated that MSE can be promoted at their institutions based on their work as educators. We anticipate that the outcomes of this study will be used to inform institutional development and implementation of promotion and tenure guidelines, to facilitate the development of initiatives to help institutions better support the professional development and recognition of MSE, and to help MSE better advocate for these initiatives.

Clinical workplace interprofessional education (IPE) is distinguished from classroom IPE by its emphasis on patients rather than learners as top priority. Drawing on the expertise of 59 educators and clinicians from across the USA and multiple health professions, we summarized critical variables associated with IPE success in the clinical workplace including leadership, clinical site readiness, need for shared language across professions, defining scope of supervised practice, and value added by IPE trainees. Derived from experience and the literature, these IPE workplace variables should be considered by those deliberating, implementing, sustaining, and/or expanding IPE into the clinical workplace.

Our institution introduced team-based learning (TBL(®)) in 2015. Students shared concerns that the interactivity and loud volume of TBL might disadvantage students uncomfortable with group work, with auditory processing disorders, or who need testing accommodations. We share our efforts to ensure all students can benefit from TBL.

Early in medical education, physicians must develop competencies needed for tobacco dependence treatment.To assess the effect of a multi-modal tobacco dependence treatment curriculum on medical students' counseling skills.A group-randomized controlled trial (2010-2014) included ten U.S. medical schools that were randomized to receive either multi-modal tobacco treatment education (MME) or traditional tobacco treatment education (TE).Students from the classes of 2012 and 2014 at ten medical schools participated. Students from the class of 2012 (N = 1345) completed objective structured clinical examinations (OSCEs), and 50 % (N = 660) were randomly selected for pre-intervention evaluation. A total of 72.9 % of eligible students (N = 1096) from the class of 2014 completed an OSCE and 69.7 % (N = 1047) completed pre and post surveys.The MME included a Web-based course, a role-play classroom demonstration, and a clerkship booster session. Clerkship preceptors in MME schools participated in an academic detailing module and were encouraged to be role models for third-year students.The primary outcome was student tobacco treatment skills using the 5As measured by an objective structured clinical examination (OSCE) scored on a 33-item behavior checklist. Secondary outcomes were student self-reported skills for performing 5As and pharmacotherapy counseling.Although the difference was not statistically significant, MME students completed more tobacco counseling behaviors on the OSCE checklist (mean 8.7 [SE 0.6] vs. mean 8.0 [SE 0.6], p = 0.52) than TE students. Several of the individual Assist and Arrange items were significantly more likely to have been completed by MME students, including suggesting behavioral strategies (11.8 % vs. 4.5 %, p 0.001) and providing information regarding quitline (21.0 % vs. 3.8 %, p 0.001). MME students reported higher self-efficacy for Assist, Arrange, and Pharmacotherapy counseling items (ps ≤0.05).Inclusion of only ten schools limits generalizability.Subsequent interventions should incorporate lessons learned from this first randomized controlled trial of a multi-modal longitudinal tobacco treatment curriculum in multiple U.S. medical schools. NIH Trial Registry Number: NCT01905618.

This chapter describes the development and implementation of an innovative course in interprofessional education (IPE), which ensures a large number and variety of health professions students have the appropriate foundations to collaborate. A description of the institution and the process of implementing interprofessional education is followed by a presentation of challenges and then solutions to address them in the creation of the course. Future research avenues in interprofessional education will be explored. This chapter will provide practical application of concepts for other institutions attempting to design and implement introductory interprofessional education for large numbers of students.

Substance use disorders are often missed when patients present for medical care. The purpose of this report is to describe the pilot implementation of a curriculum module designed to influence medical student beliefs and attitudes toward patients with substance use disorders. Third-year medical students rotating through the two-month Ambulatory Primary Care clerkship (N = 99) were contacted by email and directed to a brief survey addressing students’ personal views regarding patients with substance use disorders. After the survey was submitted, students were directed to the Drexel University College of Medicine Doc.com online module about substance use. After one week, students received another email asking them to complete the same survey. Results from the pre- and postmodule surveys were compared using paired samples t-tests. Statistically significant changes were detected in 5 of13 items. The results of this study indicate that the one-hour, online Doc.com module can effectively influence medical student beliefs and attitudes toward patients with substance use disorders.

Every year in the U.S., fourth-year medical students participate in audition electives with the expectation that the experience will increase their competitiveness in the match. Although many students devote considerable time and money to pursue these elective rotations, the process is not well documented or understood. The purpose of the study reported here was to identify the perspectives and beliefs held by medical students, residency program directors, and Careers in Medicine Liaisons about the significance of audition electives via online surveys. Despite the unpredictability of audition elective experiences, some students believe they are necessary and are willing to devote considerable resources for the opportunity. Further research is needed to examine audition elective outcomes at the individual student level and characterize program director feedback by specialty area.

Background Despite the stabilization of match rates, negative perceptions toward general surgery are still rife among medical students. The aim of this study was to describe the attitudes of fourth-year medical students towards general surgery at a regional level. Method All fourth-year medical students in the state of Nebraska were invited to complete an online survey about their perceptions of the field of general surgery and the factors that influenced their residency choice. Results Of the 145 respondents, 10% were interested in general surgery; this result is slightly higher than the national average. The main reasons cited by those who are choosing general surgery were personal factors; the perceived adverse external factors did not influence their career choice. In contrast, students who chose nonsurgical careers did so because of external factors, such as poor lifestyle and perceptions of an unfriendly environment. Conclusions The results of this study suggested regional variations in the level of interest toward general surgery and that interest in the field among medical students in Nebraska may be higher than what has been reported nationally. Students who chose general surgery did so for personal reasons, which were independent of external factors. Recruitment efforts into the field should be focused on those students who choose non-general surgery careers and on rectifying the negative influences that steered them away from the field.

Objective To explore students' tobacco dependence counseling experiences prior to medical school and their associations with tobacco counseling self-efficacy, and familiarity with and perceived effectiveness of tobacco dependence treatment among first-year medical students in the United States. Method In 2010, 1266 first-year medical students from 10 US medical schools completed a survey reporting their clinical experiences with specific tobacco counseling skills (e.g., 5As) prior to medical school. The survey also included questions on tobacco counseling self-efficacy, perceived physician impact on smokers, and familiarity and effectiveness of tobacco-related treatments. Results Half (50.4%) reported some tobacco counseling experiences prior to medical school (i.e. at least one 5A). Students with prior counseling experiences were more likely to have higher tobacco counseling self-efficacy, and greater familiarity with medication treatment, nicotine replacement treatment, and behavioral counseling for smoking cessation, compared to those with no prior experiences. Perceived physician impact on patient smoking outcomes did not differ by prior tobacco counseling experiences. Conclusions Many first-year medical students may already be primed to learn tobacco dependence counseling skills. Enhancing early exposure to learning these skills in medical school is likely to be beneficial to the skillset of our future physicians.

Anatomy laboratory sessions offer opportunities for hands-on, active learning. The innovation implements Lightning Rounds as a team-based learning exercise in a first-year human anatomy laboratory. Lightning Rounds provided students self-assessment in a low-stress environment and an opportunity to practice knowledge retrieval, clinical reasoning, inter-team collaboration, and communication.

In-class and laboratory team-based learning (TBL) activities were piloted in a first-year medical human anatomy course to promote active learning and problem-solving. The activities were well-received by students and added small group problem-solving opportunities, decreased didactic lecture time without compromising exam performance, and provided practice delivering professional feedback.

In this chapter, we discuss a new movement among educators that goes beyond simply enhancing lectures. Here the lecture is replaced entirely with new types of learning, while preserving the efficiencies of the large group format. In this model, the aim is to maximize the availability of faculty expertise and feedback, take advantage of group learning, and ensure that learning is reinforced through application rather than memorization. This chapter details how to prepare, implement and troubleshoot a “flipped” classroom through a variety of customizable strategies.

Introduction Clinical cases are essential teaching tools in helping students move from didactic knowledge, theory, and skills to the application of their emerging abilities to patient/client cases that represent authentic clinical contexts of practice. This resource is a team-based learning module created so that students will be able to analyze, deconstruct, discuss, and formulate a care plan for a standardized patient/client case as part of a multidisciplinary team using the Interprofessional Team Reasoning Framework, an algorithm developed to facilitate teaching and learning case studies with health professions students. Methods The module includes the Interprofessional Team Reasoning Framework, sample cases, instructor's guide, learning objectives and questions, videotaped examples of poor and stellar team interactions, and a grading rubric. Results In the pilot study, 18 interprofessional students were randomized to teams of six and were videotaped while completing a case. Team 1 (control) received only the case, Team 2 received the case plus framework, and Team 3 received the case, framework, and was shown videotaped examples of interprofessional interactions. The results revealed that students' perception of team skills were significantly improved in Team 2 and Team 3 but not Team 1. Students' performance of their case as assessed by blinded faculty was significantly better in Team 3 compared to Teams 1 and 2. Discussion Since completion of the pilot study, the framework and associated toolkit (videotaped models, case studies, learning objectives and study questions, as well as the individual and team assessment and plan) have also been incorporated into a community-based learning experience to prevent falls in older adults and integrated into an interprofessional health promotion course with vulnerable populations. The interprofessional fall risk program has been replicated in a second independent living facility as well as a nursing home environment on a Native American Indian reservation.

Creighton University is a Jesuit university, rooted in the Catholic tradition, located in Omaha, Nebraska. It is a complex institution, with a broad range of professional education programs that brings together on one campus nine different undergraduate, graduate and professional schools. Despite the complexity, there is a rich tradition of faculty collaboration and interprofessional engagement. This is particularly true within the health professions programs. In 2005, associate deans for education from the Schools of Medicine, Nursing, and Pharmacy and Health Professions, along with the Director of Medical Education Development and Assessment from the School of Medicine, convened to explore the possibility of a collaborative faculty development opportunity.

Institutional teaching awards have been used widely in higher education since the 1970s. Nevertheless, a comprehensive review of the literature on such awards has not been published since 1997.We conducted a literature review to learn as much as possible about the design (e.g., formats, selection processes) and utility (e.g., impact on individuals and institutions) of teaching awards in order to provide information for use in designing, implementing, or evaluating award programs.We searched electronic databases for English-language publications on awards for exemplary teaching. Targeted publications included descriptions and/or investigations of award programs, their impact, and theoretical or conceptual models for awards programs. Screening was conducted by dual review; a third reviewer was assigned for disagreements. Data were analyzed qualitatively. Results were summarized descriptively.We identified 1302 publications for initial relevancy screening by title and abstract. We identified an additional 23 publications in a follow-up search. The full text of 126 publications was reviewed for further relevance. A total of 62 publications were identified as relevant, and of these 43 met our criteria for inclusion. Of the 43, 19 described the design features of 24 awards; 20 reports discussed award utility. Nomination and selection processes and benefits (e.g., plaques) varied as did perceived impact on individuals and institutions.Limited evidence exists regarding design and utility of teaching awards. Awards are perceived as having potential for positive impact, including promotions, but may also have unintended negative consequences. Future research should investigate the impact of awards on personal and professional development, and how promotion and tenure committees perceive awards.

The Core Competencies for Collaborative Practice identify the skills needed by every health care provider to be successful in implementing interprofessional practice. Health professions students need to build skills for interprofessional practice as emerging professionals. Reflection is a core skill needed for successful interprofessional practices. This study identifies themes from an interprofessional education research project and discusses their congruency with the Competencies.

Introduction This interclerkship curriculum provides third-year medical students with important information about the significance of methamphetamine abuse and dependence, and its effects on the individual and society. This curriculum is typically offered in the third year of medical school, when students have started their clinical education and are most likely to encounter patients with methamphetamine-related issues. Methods This resource provides an outline for medical school faculty who want to offer a 1-day (8 hours) or half day (4 hours) interclerkship course. The module includes a lecture via PowerPoint presentation. Video clips can be shown, followed by a facilitated panel discussion. The course ends with a debriefing and learning assessment. Results One hundred and eleven students attended this seminar (56 males, 55 females). The summary report, especially the feedback from questions 1, 2, 3, 5, 6, 8, 10, 12, and 13, reflect a strong response to the learning objectives and content of this pilot. The item analysis of the learning assessment performed after the seminar was completed also indicated that our students understood the material well enough to answer the questions correctly. Discussion Recommendations for future iterations of this curriculum resource include extending the 4-hour session to emphasize more content areas, such as a more in-depth discussion of the treatment process, including the addition of a former methamphetamine-abuse patient in the discussion panel.

Background: Developing and ensuring successful collaborative research in medical education is no small task, but the rewards to researchers can be great. Collaborative research in medical education offers significant opportunities for investigators who wish to pool limited resources and expand professional networks. Despite this, collaboration often occurs without advance planning for the logistical aspects of collaborative work. Aims and Methods: These 12 tips, derived from developing and presenting a session on strategies for effective collaboration conducted at a national meeting, will assist readers who are planning to collaborate or are already engaged in collaborative scholarship. The tips are organized into items to consider in three phases of collaboration: planning, implementation, and dissemination of outcomes. Results and Conclusions: From selecting a topic to recognizing when the collaboration should end, the tips underscore the importance of good communication, and clear expectations for participants.

This curriculum module contains two problem-based learning (PBL) cases that provide clinical presentations of substance abuse problems. These cases can be used in teaching situations where it may not be feasible to use clinical material or standardized patients. The PBL cases can be used to augment lecture material about the topic of drug abuse and dependence with clinically relevant cases that depict real-life scenarios for students to work through––either in a small-group format or an interclerkship seminar. The PBL cases introduce students to clinical presentations of substance abuse problems. The cases are realistic and can be adapted for use in different courses or clerkships. Case 1 is designed for three sessions, each approximately 60 to 90 minutes. Case 2 is designed for two sessions, each approximately 60 to 90 minutes. Both cases should be offered to third-year medical students or advanced second-year medical students. First-year medical students and some second-year medical students do not possess sufficient knowledge for participation. Results of Pilot Implementation: The Principal Investigator facilitated a pilot PBL session using the case, “Diagnosis and Treatment of a Middle-Aged Man With Chest Pain.” The student group included first, second and third-year medical students. Students in the pilot implementation group evaluated the experience favorably, including items about the length of the case, realism, and size of the group. The lowest rated item, “the case provided me with new information about methamphetamine abuse and addiction,” may be due to local interest in the topic. Students enrolled in medical schools that are located in geographical areas that have been affected less by methamphetamine abuse and addiction may be less knowledgeable about this topic, and may find the case provides new information. Students' narrative comments indicated the organization of the session was good. In particular, students commented that they liked the staggered presentation of case material because it made it seem “more like solving a puzzle.”

There are many unique benefits to teaching and learning in small groups. Recognizing this, many medical schools have increased the amount of time devoted to small group learning. Very few faculty members, however, have received instruction for leading small groups. This has contributed to misperceptions about the value of small group learning. It also explains why many faculty members do not feel confident teaching in this setting. Teaching in small groups can be satisfying and even inspiring, but it can also be time consuming and dispiriting when difficulties arise. To ensure effective small group teaching, you must first understand the purpose for the small group and then select activities for the group that will enable learners to achieve the learning objectives. Understanding both your role as the teacher and the dynamics of the group will help you foster participation among group members.

Medical education in the US has adapted to the shift of patient care from hospital to ambulatory settings by developing educational opportunities in outpatient settings. Faculty development efforts must acknowledge learners’ perspectives to be effective in improving teaching and learning. Clinics provide important and unique learning opportunities, but also present different challenges for preceptors (i.e., physician teachers) and learners. Multiple studies have identified characteristics of effective preceptors of ambulatory care medicine. However, most of these studies were conducted among residents or students with clinical experience. To investigate preclinical, second-year medical students’ perceptions of preceptor quality, we conducted an exploratory qualitative study using analysis of student learning journals. The purposive sample included 120 medical students in a private, Midwestern medical school in the United States. Learning journals of 110 students for two semesters were reviewed. Five attributes of an effective preceptor emerged: (1) Demonstrates professional expertise (2) Actively engages students in learning (3) Creates a positive environment for teaching and learning (4) Demonstrates collegiality and professionalism (5) Discusses career-related topics and concerns. Our findings suggest preclinical learners often begin initial clinical experiences with sophisticated definitions of professional expertise, and hold specific expectations for professionalism. These are based on previous coursework and personal experience. These expectations influence their perceptions of effective preceptors and learning experiences. Early clinical experiences can also influence perceptions about career and specialty choice. Improving our understanding of preclinical learners’ perceptions of preceptor quality will improve the efficacy of faculty development efforts and learning experiences.

The authors analyze the challenges to using academic measures (MCAT scores and GPAs) as thresholds for admissions and, for applicants exceeding the threshold, using personal qualities for admission decisions; review the literature on using the medical school interview and other admission data to assess personal qualities of applicants; identify challenges of developing better methods of assessing personal qualities; and propose a unified system for assessment. The authors discuss three challenges to using the threshold approach: institutional self-interest, inertia, and philosophical and historical factors. Institutional self-interest arises from the potential for admitting students with lower academic credentials, which could negatively influence indicators used to rank medical schools. Inertia can make introducing a new system complex. Philosophical and historical factors are those that tend to value maximizing academic measures. The literature identifies up to 87 different personal qualities relevant to the practice of medicine, and selecting the most salient of these that can be practically measured is a challenging task. The challenges to developing better personal quality measures include selecting and operationally defining the most important qualities, measuring the qualities in a cost-effective manner, and overcoming "cunning" adversaries who, with the incentive and resourcefulness, can potentially invalidate such measures. The authors discuss potential methods of measuring personal qualities and propose a unified system of assessment that would pool resources from certification and recertification efforts to develop competencies across the continuum with a dynamic, integrated approach to assessment.