ACEing Cognitive Integration: Evidence from a Structural Equation Model

630) in this study. A structural equation model assessed the mediating role of developmental clinical skills on the relationship between foundational knowledge, as demonstrated by course summative exam performance, and an end-of-third-year clinical skills assessment. Using a theory-driven (cognitive integration) evaluation approach, we predicted that, if cognitive integration was achieved, foundational knowledge during the first two years of medical school would have a direct relationship to clinical skills and that developmental clinical skills would partially or fully mediate that relationship. We also assessed the mediating role of developmental clinical knowledge, as demonstrated by NBME Subject Exam performance, on the relationship between foundational knowledge and clinical knowledge (United States Medical Licensing Exam Step 2 Clinical Knowledge exam (USMLE Step 2 CK) scores. Foundational knowledge had a strong relationship with a comprehensive clinical skills assessment, which was fully mediated by developmental clinical skills. Foundational knowledge also had a strong relationship with USMLE Step 2 CK scores, which was fully mediated by developmental clinical knowledge. Students who demonstrated greater foundational knowledge tended to score higher on a comprehensive clinical skills assessment at the end of the third year. This suggests that foundational knowledge acquired in the first two years of an integrated curriculum is strongly related to clinical skills and clinical knowledge in the clerkship year. Although this is not a causal test, the structural relationships suggest the ACE curriculum was successful in promoting cognitive integration in students.