The University of Florida College of Medicine has a history of success.1 We have been successful in educating our students, making scientific discoveries, and providing high quality patient care. We have collected an excellent faculty and we have attracted high quality medical students who have flourished in their profession following their training here. We have become comfortable in our ability to train competent physicians but our level of comfort must always be challenged. A current challenge comes from several quarters: the rapidly evolving changes in health care organization, financing, and reimbursement; the logarithmic increase of the scientific and clinical knowledge bases and corresponding technology; the revolution in information management, to mention a few. Our role as teachers is coming more and more into conflict with the pressure to generate revenue from the clinical practice necessary for the health center's survival, and to compete for research grants. Consequently, faculty and staff have been vigorously engaged in restructuring the clinical service component of the health center. The curriculum committee suggests that the education aspects of the College of Medicine, which represent the core mission of the College, must undergo a similar and continuous process of review and renewal to address the challenges, current and future.
Scrutiny of the educational program began in earnest about eight years ago. We have been engaged in a series of improvements, which have added to the quality of our effort. This document summarizes the conceptual basis on which those changes were made. It restates the assumptions that have been the roots of our continuous quality improvement and organizes them into discrete components. It moves us forward as we continue to strive for the following goals:
1. Achieve a curriculum based on a unifying conceptual framework derived from the reality of the physician's daily role as a professional health care provider for individuals, community and society.
2. Strive for effective integration of the basic and clinical sciences to prepare students for the practice of scientifically based competent and patient oriented medicine.
3. Apply knowledge from the cognitive and social sciences to educational program design.
4. Identify and preserve what has been successful in the curriculum
The outcome of this effort is a strategic plan for continuing educational development and renewal. The strategic plan should serve as a framework into which the Curriculum Committee and departmental faculties, especially course and clerkship directors and the teaching faculty, will fit their instructional units.
The planning process resulted in identifying the following four major components considered critical for designing a program for educating physicians for the 21st century: (A) Goals of the Education Program; (B) the Faculty's Vision of Exemplary Professionalism in Medicine; Principles for Educational Program Planning and Implementation; and (D) A Conceptual Framework for Educational Program Design. These components provide the conceptual basis for the curriculum.
The faculty should agree to a set of broad goal statements that provide general direction to all instructional units without dictating content or instructional strategy. The medical school curriculum should:
1. Provide an educational program that helps prepare our students for any residency they may choose, the general professional education of the physician.
2. Prepare students to be exemplary house officers.
3. Combine the science and art of medicine that form the foundation as a learned and humane profession.
4. Display concern for preventing, caring and curing the individual, family, community, and society.
5. Prepare students for the changing role of the physician due to scientific and technologic advances, socioeconomic conditions of health care delivery, increasing information accessibility, and other contingencies.
6. Have well defined outcomes in terms of competencies and learning objectives.
7. Provide effective learning environments that reflect contemporary health care.
8. Actively engage the students in the learning process, promote self-directed learning, and provide opportunity for information management skills through the use of computer and networking technology.
9. Engage, recognize, and reward the most talented members of the faculty in the teaching/learning process.
10. Have an evaluation and feedback system on all aspects of the educational program: students, faculty, courses and clerkships, and the curriculum.
It is the responsibility of the faculty to define for students the characteristics of exemplary behavior in the medical profession. This will ensure greater consistency of faculty role modeling for students in a variety of settings. It also serves as a basis for identifying specific measurable behaviors reflecting those characteristics for which the students will be held accountable. The faculty of the University of Florida College of Medicine believes the following elements define the highest standards of professionalism in medicine:
A commitment to excellence in the practice of medicine
A commitment to the generation and dissemination of new knowledge
A commitment to serve the interests and welfare of patients
A commitment to be responsive to the health needs of society
A commitment to life long learning
A commitment to uphold high professional standards
Elements of professionalism are further defined as:
Altruism. Service to patients without self-interest.
Accountability. Accountable to patients to fulfill the implied physician/patient relationship. Accountable to society for addressing the health needs of the public. Accountable to the profession for adhering to medicine's time honored ethical precepts.
Excellence. Conscientious effort to exceed ordinary expectations.
Duty. A commitment to service
Honor and integrity. Being honest and uncompromising in oneŐs pursuit of high quality patient care.
Respect for others.
Patients, their families, physicians and professional colleagues2.
The principles were developed with the expectation they would:
A set of eleven Principles was developed and approved by the Curriculum Committee in January of 1994. The Principles were reviewed, revised, and, after lively debates, unanimously approved in March of 1997. The Principles are as follows:
1. The general professional education of the physician is the goal of the curriculum:
The General Professional Education is represented as a set of competencies to be acquired by the students as cognitive and psychomotor skills, and professional behaviors, which all physicians must master regardless of specialty.
2. The educational program and evaluations are competency based:
The general professional education must be defined in terms of specific competencies expected to be mastered by students. The competencies fall into the following categories:
Student evaluations must assess mastery of the stated competencies.
3. Effective health care delivery requires the consideration of family and community contexts:
The student must have the opportunity to learn the socioeconomic and psychological conditions, which define context and are important factors in the outcome of health care delivery.
4. A conceptual framework for defining knowledge promotes learning and effective utilization of that knowledge and serves as a basis for curriculum integration:
The conceptual framework should relate all components to each other and provide the basis for internal consistency of the curriculum.
5. Appropriate faculty and appropriate clinical settings are essential for students acquiring the mastery of the competencies:
Curriculum implementation should be based on careful assessment of faculty resources and clinical settings to provide the best conditions for competency achievement by the students.
6. Informatics is essential for effective utilization of information by students and practitioners:
Whenever appropriate, information technology should be applied to instruction, assessment, clinical decision making, and clinical care.
7. The ability to learn independently is essential for the physician to provide quality health care:
Students must become independent lifelong learners to be able to adapt to continuous, substantial, and unpredictable changes due to scientific, technological, socioeconomic developments in health care.
8. The educational program must be responsive to emerging needs of society:
These needs and expectations must be considered in curricular content and design.
9. Discovery of new knowledge and solutions are part of the medical profession:
Students must be encouraged to pursue research interests in the basic, clinical or socioeconomic sciences. They should also attain an understanding of the processes underlying discovery in the context of health care. Students wanting to participate in this process should be provided adequate time, resources, and preceptorship to do so.
10. Health care delivery requires individual and team efforts:
The educational program should include learning opportunities which demonstrate the team approach to health care delivery.
11. Incorporation of the characteristics of outstanding scientists and physicians in the educational program is essential for complete professional development of students:
The faculty must identify these characteristics and the specific professional behaviors that reflect them. These behaviors, which include interpersonal skills, ethical and legal competence, and a continuing effort to improve one's own performance and the profession of medicine, must be taught, modeled and evaluated.
Clinical presentations are health concerns or major symptoms if actual or presumed illness and disease manifested by an individual, community or society. This model starts with a comprehensive list of clinical presentations, generated by the faculty, which all students are expected to be able to address upon completion of the four-year curriculum. Competency is defined broadly as a studentŐs ability to deliver effective health care when confronted with a clinical presentation. Courses and clerkships, teaching methodologies, and the curriculum will be judged by their ability to contribute to the student's attainment of competence. The model yields the core content of the curriculum but does not exclude other content. It defines the essential components of the general professional education.
The goal of medical education is to prepare students to become practitioners of the art and science of medicine. The four years in medical school, which precede graduate medical education, must provide the fundamentals of clinical medicine including the scientific knowledge base and the clinical skills essential for the general professional education of the physician (GPEP)3. It is the purpose of this section to describe the underlying conceptual framework, which will serve as a guide for faculty to derive content and appropriate learning methods in instruction.
As medical knowledge continues to expand, we recognize the need for a rational basis to identify the boundaries of undergraduate medical education. For many years the content of the curriculum attempted to parallel the rapid growth of medical knowledge and was organized around basic science and clinical disciplines. This resulted in departmentally isolated courses, which made it difficult to achieve institutional prioritization and integration of content. It lacked a comprehensive concept, which transcends discipline domains and encompasses a broader view of the overall usefulness of knowledge gained in medical school. In searching for such an integrated framework the curriculum committee considered the clinical presentation model developed by the faculty at the University of Calgary4. Inherent in this model is several assumptions:
1. The organizing principle of the curriculum should be derived from the description of how physicians actually serve their patients.
2. What a physician actually does when providing health care is to address a set of clinical presentations that patients, communities or society manifest. The patient presents with abdominal pain; the community with an infectious disease outbreak; the society with a high rate of teenage pregnancy. The physician needs to be equipped with knowledge, skills and professional attributes required to analyze and resolve the problem underlying the presentation.
3. There are a finite number of major clinical presentations that can be identified since there are a limited number of responses to multiple types of insults. When we compared our list of patient presentations with that of the Calgary faculty, they were similar but not identical. The number of clinical presentations identified by several colleges who generated a list averaged about 120.
4. Deriving course objectives from clinical presentations is a rational way to organize and integrate basic science and clinical medicine because the physicians define content in terms of value at the point of utilization.
The curriculum committee in consultation with the faculty generates the clinical presentation list.
It is helpful to subdivide competence into categories, which describe the types of abilities that coalesce to produce the overall competence defined above. This is useful because all courses are capable of teaching all aspects of competence. Course directors should choose which categories could best be addressed in their course. Course objectives should be grouped in these categories.
1. Human Relationship Competencies
Includes communication skills, ability to detect emotional states in oneself and others, detect non-verbal cues, understanding family systems etc.
2. Professional Behavior Competencies
Includes behaviors addressing informed consent, confidentiality, identifying and addressing ethical dilemmas, identify and addressing legal issues.
3. Health Service Delivery Competencies
Health promotion, disease prevention, health care access, population based medicine, evidence based medicine, quality assurance, health care economics, managed care and other health delivery systems.
4. Core Discipline Competencies
Discipline defined competencies reflecting specific core content necessary for the general professional education of medical students
5. Applied Medical Science Competencies
Integrated basic science competencies reflecting the students' ability to understand and communicate relevant scientific concepts; biological, physical and psychosocial. Examples: What is a fever? How do wounds heal? What happens when one is infected? This list of competencies is developed from the clinical presentation list.
6. Diagnostic Competencies
Includes skills of problem-focused history, physical examination, diagnostic procedures, and use and interpretation of data from the laboratory.
7. Information Management Competencies
Includes mastering the traditional organization of medical data (cc, hpi, med hist, ros, fam hist. etc.), medical presentation skills, data and information access, medical record keeping, life long information access strategies, etc.
8. Physician Scholar Competencies
Development of strategies for keeping current, identifying, discovering and communicating knowledge, and analyzing medical literature.
9. Health Care Team Competencies
Understanding and engaging the various roles and competencies provided by nonphysician providers in the team approach to health care delivery.
10.Contemporary Issue Competencies
Competencies necessary to deal with specific temporal issues in medicine, e.g. AIDS, substance abuse, family violence, women's health.
11.Procedure Competencies E.g. venipuncture, BP, skin closure.
12.Career Development Competencies
Includes strategies for specialty choice and integrating career with other life goals.
Each clinical presentation is developed by experts (at least one clinician and one basic scientist) producing a concept map which allows the students and faculty to visualize the relationships between the major ideas necessary to understand the problems and solutions represented by the clinical presentation. The following is the concept map for shortness of breath. (Develop with Bob)
The experts will develop a series of cases, which explore different regions of a clinical presentation concept map. The characters in the cases will be developed as life like personalities who respond and interact with the health care delivery process. The number of case studies necessary will vary depending on the complexity of the clinical presentation and the characteristics of the individual presenting.
Basic science course directors study the concept maps and develop course learning objectives in competency categories selected in step 1. Below are examples of course learning objectives derived from the shortness of breath concept map which relate to the pulmonary section of the physiology course.
Each basic science course will be required to include clinical correlations and relate them to the clinical presentations. They may use any format they choose. If case-based discussions are utilized the cases will be selected from those developed in step four above.
Clinical presentations will be assigned to the various clinical clerkships based on their relevance to traditional discipline content and the likelihood of encountering the presentations in clinical practice. Clerkships may use whatever methods they choose to help students learn an approach to the clinical presentation. It is recommended that they utilize basic science faculty, whenever possible, to reinforce scientific concepts relevant to clinical practice.
The student's ability to address a clinical presentation and understand the underlying scientific principles is assessed in a series of performance based evaluations utilizing standardized patients simulating cases developed in step 4 and computer assisted response exercises.
The above model is consistent with our principles of educational program design. Competency is clearly defined and its assessment becomes the central focus of the curriculum. The competency categories define the scope of competence in terms of abilities necessary to deliver effective health care. Clinical presentations become the conceptual framework from which course and clerkship objectives are derived. Integration is achieved by focusing all discipline content on clinical presentations. Not all of our principles are addressed directly by this model and further scrutiny of the curriculum from other perspectives is still necessary.
We are convinced that verbalization and documentation of the vision and values to which the faculty can adhere can strengthen the quality of an educational program. Furthermore, the process of arriving at such documentation can help establish an institutional conscience and memory, helpful to both current and future generations of faculty and students.
1. Suter E, Watson RT, Romrell LJ, Harman EM, Rooks LG, Neims AH. Moving a Graveyard: Creating an Institutional Climate Conducive to Curriculum Renewal (accepted for publication in Academic Medicine)
2. Adapted from Project Professionalism by the ABIM, Philadelphia 1995, p. 5.
3. Muller S (chairman). Physicians for the Twenty-First Century: Report on the Project Panel on the General Professional Education of the Physician and College Preparation for Medicine. J Med Educ 59, Part 2 (Nov. 1994).
4. Mandin H, Harasym P, Eagle C, Watanabe M. Developing a Clinical Presentation
Curriculum: at the University of Calgary. Acad Med 1995, 70 (3) 186- 193.
