Meeting COCA Standards with Aquifer
December 9, 2022
December 9, 2022

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By: J’Aimee Lippert, DO | Associate Professor, Department of Osteopathic Manipulative Medicine | Michigan State University College of Osteopathic Medicine

Meeting the requirements for continuous accreditation of the educational program is a core focus for osteopathic medical schools. Currently serving 66% of US osteopathic medical schools, Aquifer is a trusted tool in medical education. Aquifer’s teaching and learning tools help osteopathic medical schools of all shapes and sizes meet many of the Commission on Osteopathic College Accreditation (COCA) Standards.


Standard 5: Learning Environment

Element 5.1: Professionalism (CORE)

A COM must ensure that the learning environment of its osteopathic medical education program is conducive to the ongoing development of professional behaviors in its osteopathic medical students, faculty, and staff at all locations and is one in which all individuals are treated with respect. This should also include exposure to aspects of patient safety, cultural competence, and interprofessional collaborative practice.

How Aquifer Helps

Following a thorough review of all existing Aquifer cases according to our peer-reviewed and published criteria (Academic Medicine), our cases continue to be regularly reviewed based on these principles by teams of medical educators to ensure that current best practices are consistently integrated across our content library.

Aquifer’s Social Determinants of Health course includes teaching on the core principles, as well as two application cases that cover poverty and language as social determinants of health and teach evidence-based strategies to help improve health outcomes and equity for patients. Aquifer’s three Social Determinants of Health Cases and accompanying active learning modules build a foundational understanding of SDOH and teach evidence-based strategies to help improve health outcomes and equity for patients. The overview and resources module provides an understanding of how cultural beliefs and community culture affect health outcomes and strategies for improving clinician-patient interactions. The two virtual patient cases provide an opportunity for students to learn in the context of a realistic patient scenario and practice the application of the information in a safe space, working through patient and family interactions, and practice using the tools when caring for a patient.

Aquifer Diagnostic Excellence cases include teaching on cognitive bias, with supporting active learning sessions to drive discussions and enhance the learning through sharing experiences.

The Course on Addiction and Recovery Education (CARE) – distributed by Aquifer on behalf of the Hazelden Betty Ford Foundation – concentrates on critical addiction and substance use topics that medical students and healthcare professionals need to be able to address. CARE prepares students to identify, intervene, and address substance use disorders, filling a critical gap in formal education surrounding substance use disorders and addiction.

The cases in Aquifer Trauma-Informed Care address a range of core competencies and critical learning objectives, including the prevalence and health effects of trauma, the principles of trauma-informed care, the neurobiology of trauma, clinical management of persons who have experienced traumatic events, and interprofessional collaboration methods for working with trauma-affected patients.

Aquifer Radiology case 18 covers professionalism topics that apply to all disciplines. Excellence in Palliative Care case 5 focuses specifically on the roles and responsibilities of an interprofessional team.

Additional teaching that meets this qualification is also found throughout the Aquifer signature cases.


Standard 6: Curriculum

Element 6.4: Osteopathic Core Competencies (CORE)

A COM must teach and educate students in order to ensure the development of the seven osteopathic core competencies of medical knowledge, patient care, communication, professionalism, practice- based learning, systems-based practice, and osteopathic principles and practice/osteopathic manipulative treatment.

How Aquifer Helps

Integrated Illness Scripts are designed specifically to promote cognitive integration and provide a framework for learners to link basic science and clinical knowledge. Building on the traditional illness script format, Integrated Illness Scripts (IIS) embed basic science core concepts and causal mechanisms within each clinical feature and display the connections visually through Mechanism of Disease Maps. A variety of rich, fully-developed active learning sessions are available to accompany Integrated Illness Scripts to extend the learning to case-based learning or other didactic sessions.

Aquifer cases provide practice with virtual patients at all stages, from birth, through childhood and adulthood, to end of life. With courses in Pediatrics, Family Medicine, Internal Medicine, Geriatrics, Radiology, and Palliative Care, Aquifer covers the full continuum of care.

Several virtual patient cases address wellness and preventive care (including Family Medicine Cases 1&2, Pediatrics Cases 2, 3, 4, 5 & 6, Internal Medicine Cases 13,14), and Geriatrics Case 13 ). Other cases provide students the opportunity to practice clinical reasoning for common medical conditions, including interpreting abnormal clinical findings, developing differential diagnoses, selecting appropriate diagnostic tests, and developing treatment plans. Rather than providing rote, depersonalized clinical data, Aquifer virtual patients are deliberately designed to illustrate a variety of socioeconomic backgrounds in order to teach students how biopsychosocial factors interact to impact patients’ health.

Element 6.5: Scientific Method

A COM must ensure that the curriculum includes instruction in the scientific method including data collection to test and verify hypotheses or address questions regarding biomedical phenomena and in the basic scientific and ethical principles of clinical and translational research. The curriculum must include the methods by which such research is conducted, evaluated, explained to patients who are part of clinical studies, and applied to patient care.

How Aquifer Helps

Aquifer patient cases are evidence-based, include references to supporting literature, and are peer-reviewed. They provide students multiple opportunities to practice evidence-based clinical problem solving through embedded questions and receive expert feedback on their work through answer comments and teaching points. In most cases, students practice differential diagnoses, critical thinking, and evidence appraisal. Many cases require students to synthesize the information and write a summary statement.

Additional teaching tools, designed to accompany the cases, can enhance these skills as well, including:

  • Case Analysis Tool (a structured worksheet to be completed by the student as they work through an Aquifer case, allowing faculty to provide feedback on clinical reasoning skills).
  • Other active learning sessions were created to accompany Aquifer cases and further support this aspect of critical judgment.

Aquifer also offers the Internal Medicine Clinical Decision-Making Exam, which provides the unique ability to assess students’ individual abilities to apply their knowledge to make the decisions needed to provide quality patient care.

Element 6.6: Principles of Osteopathic Medicine (CORE)

In each year of the curriculum, a COM must provide each student with instruction in Osteopathic Principles and Practice (OPP), including both observation and hands-on application of Osteopathic Manipulative Medicine (OMM) supervised by COM-credentialed physicians (DO or MD).

How Aquifer Helps

Creating opportunities for students to explore OPP and OMM concepts with curated cases augments the optimal hands-on education provided throughout the four-year curriculum.  The Aquifer DO Task Force has developed several active learning modules designed to reinforce student learning and understanding of osteopathic principles as well as diagnosis and treatment.  These modules are linked to existing Aquifer cases and provide both small group and large group collaborative learning opportunities.

Aquifer Geriatrics 11: 75-year-old female with neck pain (authored by Pam Basehore, EdD, MPH; Millicent King Channell, DO; Anita Chopra, MD; Susan Huff), includes in-depth information on osteopathic approaches, including video content showing osteopathic manipulative techniques.

Element 6.7: Self-Directed Learning

A COM must ensure that the curriculum includes self-directed learning experiences and time for independent study to allow students to develop skills for lifelong learning. Self-directed learning includes students’ self-assessment of learning needs; independent identification, analysis, and synthesis of relevant information; and appraisal of the credibility of sources of information.

How Aquifer Helps

Calibrate, Aquifer’s formative assessment system for clinical learning, drives self-directed learning by providing detailed feedback early (and late) in the clerkship to enable targeted study planning. This assessment system provides guidance for students to create a learning plan early in their clerkship, and objective information about individual learners to drive meaningful feedback and inform coaching conversations.

Aquifer cases also contain self-assessment questions, helping students extend their learning beyond the case into new, related scenarios.

Element 6.9: Clinical Education (CORE)

A COM must:

  1. define eligibility for an OMS II and/or other student to enter clinical rotations;
  2. define the types of patients and clinical conditions that osteopathic medical students are required to encounter, the skills to be performed by the students, the appropriate clinical setting for these experiences, and the expected levels of student responsibilities;
  3. be able to provide clinical education rotations, including demonstration of adequate faculty, for the three-year rolling average of the number of eligible second-year and repeating students; and
  4. have published policies and procedures (protocols) addressing methodologies by which students can complete the entire clinical education curriculum.
How Aquifer Helps

Enhancing the Range of Clinical Encounters

In addition to caring for patients, Aquifer cases provide a meaningful clinical learning experience. To fully and optimally utilize the case, students should be given independent learning time to work through them, and the content of the cases should be integrated into the clerkship curriculum in methods similar to patient care (i.e., didactics, bedside teaching, discussion, etc.).

There are numerous ways to classify the spectrum of patients to be seen. With the Aquifer Content Library, it’s easy to search cases to find the content you need and assign it to students. For example, filters can cover:

  • Ages/developmental stages
  • Types of illnesses
  • Systems-based categories

Suggested methods for assigning cases include:

  • Assign strategically selected cases at the beginning of the clerkship to:
    • prepare students to see patients with conditions they are likely to encounter
    • fill known clinical gaps
  • Assign cases individually throughout the clerkship, based on a review of each student’s clinical logs.
  • A combination of both.

Documentation Method

Aquifer automatically creates a log of students’ completion of virtual patient cases. The Student Report, only accessible to people with specific administrative privileges in Aqueduct’s platform, shows the detailed progress of an individual student in each case in a course, including:

  • The cases the student has completed, partially completed, or not yet not begun
  • Time from case start to completion
  • Additional details on the date the case was started, completed, and last accessed
  • Summary Statements submitted by students for cases that require them

Element 6.10: Clinical Experience

A COM must ensure that each student participates in one or more required core rotation(s) prior to the fourth-year clinical clerkship experience that is conducted in a health care setting in which the student works with resident physicians currently enrolled in an accredited program of graduate medical education. In addition to the above expectation, a minimum of one required third-year clinical clerkship must be completed under the supervision of an osteopathic physician and more than one of the required third-year clinical clerkship experiences must include an inpatient component.

How Aquifer Helps

Each Aquifer case is written from the medical student perspective and includes details that model communication with preceptors and patients, providing invaluable “scripts” and guidance on interacting with students for new teachers.

Cases are available to teaching residents and preceptors at no cost to the school allowing them to provide access to preceptors and other teaching clinicians in a FERPA-compliant way (no access to student reporting – known as the “Teacher” role in the Aquifer platform).

Educator Resources such as the Radiology Flipped Classroom modules and the many active learning sessions that accompany other courses make it easy for teachers to provide a quality didactic experience by providing fully-developed sessions and facilitator guides.

Element 6.11: Comparability across Clinical Education Sites

A COM must ensure that the curriculum includes comparable educational experiences and equivalent methods of assessment across all core clinical educational sites where students learn, ensuring all students achieve similar outcomes based on core educational learning objectives.

How Aquifer Helps

Aquifer cases provide comparable learning experiences across training sites and times of year, standardizing the availability of patients and key conditions. Because the cases are available both online and offline via our iOS and Android apps, students have access to them from all training sites, facilitating student placement in rural or community settings.

Faculty Development

Standard 7: Faculty and Staff

Element 7.6: Faculty Development

A COM must develop and implement an ongoing needs-based, assessment-driven, faculty development program that is in keeping with the COM’s mission.

How Aquifer Helps

Aquifer regularly offers free webinars designed to highlight important concepts in medical education with practical tips from national experts. Aquifer’s blogs and podcasts provide access to successful teaching strategies aimed at helping educators elevate their work and engage students with Aquifer’s content and teaching tools.

Aquifer webshops are highly interactive virtual workshops that deliver deep engagement with expert faculty around innovative new teaching and learning tools and methods. Faculty receive confirmation of attendance and learning objectives for all sessions.

The Aquifer Sciences Curriculum is the first nationally-developed and publicly available curriculum that comprehensively outlines the core basic sciences concepts that must be understood and mastered by health professions learners in order to provide safe, routine patient care. The Curriculum is freely available and provides an ideal tool for those undergoing curricular planning.

Program and Student Assessment and Outcomes

Standard 11: Program and Student Assessment and Outcomes

Element 11.1: Program Assessment (CORE)

A COM must connect its learning outcomes assessment to its program mission, goals, and objectives to continuously improve the educational quality of its osteopathic medical education program.

How Aquifer Helps

Aquifer has a variety of tools that support formative feedback.

Calibrate, Aquifer’s formative assessment system for clinical learning, drives self-directed learning by providing detailed feedback early (and late) in the clerkship. Faculty view high-level student performance data that allows them to identify students in need to coaching or remediation early in the clerkship.

Calibrate also provides faculty and administrators with reports that show cohort performance on learning objectives to identify curricular gaps.  Learn more about Calibrate…

Many cases require students to write a summary statement, which is visible in faculty reports alongside an expert comment, providing an opportunity for faculty to provide feedback on developing clinical communication skills.

Aquifer’s Case Analysis Tool (CAT) is a structured worksheet to be completed by the student as they work through an Aquifer case, designed to enhance the development of clinical reasoning skills. CAT helps students by walking them through each step of the Aquifer case and aiding in organizing their critical thinking. By using it in conjunction with Aquifer cases, it helps students better explain their decision-making and learn to navigate clinical situations independently. The CAT can be used as a graded assignment, or to provide formative feedback to students.

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