Curriculum Committee Minutes

January 24, 2006

Members present:  Dr. David Caro, Bhavin Adhyaru, Dr. Robert Watson, Omayra Marrero, Dr. Bill Winter, Dr. Beverly Vidauretta, Dr. Peggy Wallace, Wayne Bottom, Dr. Richard Davidson, Dr. Mike Chen, Suki Subbiah, Dr. Sigurd Normann, Linda Butson, Dr. Lynn Romrell, Dr. Heather Harrell, Doug Arnold, Dr. Mark Gold, Dr. Robert Hatch, Dr. John Meuleman, Dr. Maureen Novak, Dr. Louis Ritz, Dr. Kyle Rarey, Cynthia Karle, and Dr. Cari Hernandez

Guests:  Dr. Tom Morrissey, Dr. Robin Hoelle, Dr. Rich Stair

Student announcements:  Omayra Marrero (MSI) reported their class is doing well and are now in their third week of neuroscience.  Doug Arnold (MSII) reported that everything is going well.  He said that they are currently involved in Clinical Diagnosis and Pathology and stated that everyone is looking forward to finishing up Pathology.  He stated that the invitations to the Fungus Ball should be sent out soon.  Suki Subbiah (MSIV) reported that they are finishing up their interviews right now and had a successful early match and are anxiously anticipating the regular Match Day on March 16th.  Doug Arnold (MSIII) reports they are in the thick of the clerkships and that things are going well.  He said they are all trying to figure out “what they want to be when they grow up” and says that some of them are starting to get nervous about it. 

Announcements:  Dr. Winter reported that the clerkship directors had a lively debate/discussion about the guidelines consequent to the Harris Report identifying the goal of 17-34% A’s and the policy stating that if there are consistently more than 50% A’s it was advised that the committee would be petitioned for permission to have more A’s or alternatively make the course pass/fail.  He states that at next month’s meeting they will look at the New England Journal article that just came out that links performance in medical school to subsequent disciplinary events, which he thinks is really interesting and has great timing.  Dr. Romrell stated that they’re almost complete with the scores on Step 2 and states that most likely the senior class will set a record on the level of performance on Step 2, which is great timing for the LCME visit so we can share with them on how well the students are performing.  Dr. Watson stated that he formed an Educational Continuum Committee with Drs. Davidson and Romrell representing UME, Dr. Flynn representing GME, Dr. Dewar representing CME and Dr. Good representing the clinical enterprise will meet and discuss issues that might have applications for our education continuum.  He states that the Agency for Healthcare Research and Quality has given the AAMC a meeting grant and we were invited to be 1 of 6 schools to come to Richmond for this meeting.  This will be used as a research project to see how GME can add to healthcare quality and states we are excited about our participation. Drs. Betsy Shenkman, Whit Curry, Carolyn Stalvey and Bruce Vogel will be coming on as part of the team.  He states that we are trying to decide who would be the best person to go to represent medical education research and we are trying to decide if one of the team members should be from Jacksonville.  Dr. Watson also mentioned that he would like to get some informal feedback from the Curriculum Committee as the new bed tower goes up, as there are going to be some issues which will need representation on the planning committee, one of which would be call room facilities.    Dr. Watson stated that Dr. Flynn mentioned that he feels the day is rapidly approaching because of sleep issues, (i.e. an 80-hour work week), where there will be shift work and the fact that the idea of on-call will probably go away.   He states that instead of being on-call, someone would work a 12-16 hour shift and hopefully be able to take a nap sometime during the shift.  He thinks it is a good idea if there could be a common area for students or residents that are on-call.  Dr. Watson also mentioned that the Curriculum Committee and Clerkship Directors are all going to go to Jacksonville to take a look at the simulator center, which may be done at the next Clerkship Directors Retreat in June.  Dr. Davidson said that trip might take the place of the June Curriculum Committee meeting.  Dr. Hatch reported that the clerkship directors have been doing well with ED2 and how to get everything up to speed for that.  He thinks that the system is coming along slowly but surely.  He states they have been on the listserv and compared to what the other schools are going through, we seem to be doing a whole lot better with our in-house system than a lot of other people are doing with their pre-bought systems.  He states that there has been a joint meeting with residency program directors and that they have regular meetings planned and will hopefully work more collaboratively in the future with them, which is important.  He states that there will be a guest speaker from Vanderbilt, Dr. Pichert, at lunchtime on February 15th.  Dr. Pichert is an expert on communication and risk management for medical errors and will be speaking for the program directors and clerkship directors.  He assumes that the Curriculum Committee will also be welcome.  Dr. Watson stated that the latest two things from the AAMC came out, one on musculoskeletal medicine, and one on clinical education of medical students.  He is going to make copies of this for everyone and feels it would especially be helpful to the clerkship directors as it has a list of specific skills that medical students should learn and states that it uses a developmental approach.

1.  Update on student background checks. 

Wayne Bottom attended a meeting on campus on December 20th regarding student background checks.  He reported that it is a very diverse problem and stated that there were several colleges from the Health Center, although the College of Education, who will have a big part of this by law, was not there.  He said that each college discussed different things that they were experiencing as colleges and programs with this issue.  The suggestion was made that if this is a big enough deal, if it would be worth an office that would actually coordinate the background checks and drug tests.  It would be university-wide if you put all of these disciplines that under regulatory or statutory guidelines would be required to participate.  He mentioned that Susan Collingwood also attended the meeting.  He said that they did not come to any closure and stated that it would need to be explored with higher administration at the university level.  Dr. Watson stated that maybe the UF Police Department would be the ideal choice and that they could hire a few people who could do fingerprinting, etc., although we are in a little different situation because we need the information before the person comes here.  Wayne Bottom stated that there are regional labs and authorities across America that are doing the drug checks, so we really don’t have to wait for them to be on campus.    It is turning out that a lot of hospitals only want to hear yes or no to the drugs and they don’t even want to know what they are, they just say not acceptable, so it is zero tolerance at, for instance, Mayo Clinic or for Tallahassee Memorial, which are the two schools right now that won’t let you in the door until this topic is settled on the drug issue.  Dr. Davidson pointed out that this is particularly crucial for Mr. Bottom’s PA program and Mr. Bottom agreed, stating that he has 150 rotations around the state and that every hospital seems to be in a tailspin of excitement about doing this but they don’t have the details worked out, and sometimes they don’t even know what drugs they want to screen for and its quite a costly thing.  They are also trying to decide how long the test will be valid for.  They don’t have any answers to the questions and are just saying “do it”.  Dr. Watson attended an AAMC meeting in which the topic of background checks was discussed.  He stated that it is anticipated that the AAMC will set up a central testing clearance service for the admissions process and that the next level is to decide what to do when we get the data.  After returning from that meeting Dr. Watson appointed a Criminal Background Check committee chaired by Pat Duff that includes Susan Collingwood, Frank Genuardi, Ira Gessner, Rob Hatch and Robyn Sheppard.  The thing that he felt should be the most discussed was to set up a process for the chair of the Admissions Committee to use.  The outcome of their meeting and subsequent conversations with Pat Duff is that we know that this is going to happen and that every applicant is going to have to go through a screening.  Dr. Watson stated that he is already receiving emails from companies offering to perform this service.  He states that the general consensus is that this should be nationally centralized and people shouldn’t be going and doing their own thing.  He stated that applicants will have to pay for the background checks.  Our committee decided that it should be considered at every step along the admissions process.  The AAMC recommended considering it only when a final decision is made.  Our committee suggested that we could establish a second level background check between the second and the third year, which would contain updated criminal information and drug screening at a cost of about $50.  Dr. Gold stated that the Olympics’ drug testing costs $125 for essentially fool-proof testing with the exception of designer steroids and says you get what you pay for.  He states that what you pay for in the test and what we may be able to save on would be paying for medical review officers, someone who is board certified in that discipline and also is qualified to interpret tests and minimize the number of false positives.  The main thing is that you wouldn’t want to harm someone with a false positive and that’s where an expert comes in.   The test itself is point of service testing you would do in an emergency room, but that is unlikely to be the kind of testing that would be offered for physicians where the test is basically $30, but the liability for the test is close to $1 million.  If you do the test and the neurosurgeon loses his right to practice, it’s a different test.  Dr. Watson mentioned the issue of affiliated hospitals and stated that Brad Bender said we are fine with the VA and that wouldn’t be an issue at all.  Frank Genuardi checked with Wilson and Baptist Hospitals and confirmed that those hospitals are willing to accept a statement that the medical students have passed our background checks.  There would be a nine-drug urine screening that would cover the last two years of medical school.   A state/federal form is required, social security numbers would be used, and no fingerprints would be required.  The committee agreed that there would be some offenses so egregious that no one will ever be able to get a medical license.  Susan Collingwood is going to generate a list of those offenses.  He thinks that the next step would be to have Dr. Pat Duff and Amy Roberson develop some kind of process with other state hospitals where students might be doing electives.  Wayne Bottom questioned whether or not the positive students would have a contract from day one at PRN (Impaired Physician Policy and Professionals Resource Network) and Dr. Watson confirmed that they would.  Mr. Bottom has called the PRN program four times to ask if the PA students would be accepted into that program, although he has not yet received a phone call back.  Dr. Watson said that is actually an issue that is currently going on between the FMA and the legislature. There is great expense involved in supporting even the medical students in PRN, which is why there is a dispute in accepting students from PA programs, PT programs, etc. 

  1. Request from Genetics:  changing to S/U grading.  Dr. Peggy Wallace stated that she has been involved as the co-director of genetics since 1994.  She stated that they are at the very end of the first year of medical school and are a 2 credit hour course.  She states that over the years of trying a lot of different methods of teaching and evaluation they have consistently come up with greater than 50% A’s by the end of the course.  She feels that they are one of the courses that it would be logical to make a pass/fail course.  In addition, because they are such a short course, they can’t do very much with additional types of discrimination in terms of grades and formative feedback.  They are a fairly clean-cut course because they have a widely diverse set of topics including case presentations.  She stated that out of necessity those need to be moderated by a physician or a genetic counselor.  They try to get people who are experts in a particular area especially if they are medical doctors because they will really appeal to the students and have some extra insight that will be helpful to them as future physicians.  They end up with 17 lectures and a total of 6 or 8 different faculty involved, no small groups, which was tried before but they just can’t get enough faculty to do that.  The only formative feedback they gather is the midterm exam with the ability to go over the answers on that and they allow 10% of the grades to be used for a professionalism grade, but again none of them know very many of the students well enough to be discriminatory about that.  She states that this year they are starting a new system which is going to make it even harder to get to know students because they have reorganized the schedule such that Biochemistry will end before Genetics starts, which means they are literally only the last two-and-a-half weeks of the year.  During that time they are going to have all of the lectures, case presentations and midterms.  So they will have been in class for one week and have a midterm.  She thinks that because of that especially, moving it to a pass/fail course might take some of the unnecessary stress off of the students.  She says that the students generally do very well in the class.  The professors try really hard on exams to be discriminatory in developing the questions, but by the nature of coming towards the end of the class and the more and more courses putting in genetics in their own courses, there is actually some repetition in a few topics that are scattered throughout the year.  The students say that they like that and that it is a review for them and if they didn’t get it the first time, now they got it.  That actually helps them do well on the exams.  She thinks that the only way they could become a course that gave less than 50% A’s would be to put a lot of questions that had nit-picky memorization details, which is something they don’t really want to do or think is necessary.  They think that this course would be an ideal one to experiment with in terms of turning it into a pass/fail course based on some of the new criteria that has been discussed.   Dr. Normann asked how many students over the years have actually gotten less than a C.  Dr. Wallace stated that they usually have maybe 5-10% of students that have less than 80%.  Over the years she has only known two students that have had D’s and no one has failed and those two had remediation.  Other than that they have never had anybody under 72%.  She says that the students still bring enough pressure upon themselves that she does not think it will be detrimental to this course in terms of learning and ability of their field and the area.   The students generally do well on it from the feedback they can get from Step 1.  There is no shelf exam for Genetics and a lot of times the questions are setup to be separate, but formally and informally they can get some sort of feedback and they seem to be on target.  A good question would be where to put the cutoff and what they would do for those students at the end of the year.  In the past they have had students who had D’s do something over the summer.  In one case there was a student who she suspected maybe had some potential learning disabilities, so she administered an oral exam and the student did beautifully.  This course has a lot of interesting topics and some of it touches on things that they’ve learned throughout the year.  Dr. Watson asked Dr. Wallace that, looking down the longer road, if she felt students got enough genetics.  Dr. Wallace stated that is what is happening now is that genetics is being integrated more and more into scattered courses.  In a lot of schools that she has talked to, Genetics is in the first semester of the first year to set-up groundwork.  At UF, in a few cases, they have to be aware of what they are going to learn and in some cases clarify disagreements of what they’ve learned in one course versus another, so there is the potential for some misinformation, but in general they are getting more genetics across the board.  The students are definitely going to need it for the future; however, there is also going to be an increasing cadre of associate professionals such as genetic counselors so that the physicians themselves won’t necessarily have to go into some of the complicated genetic probability problems so much.   Dr. Watson says that this discussion brings up the age-old question of why all courses aren’t pass/fail in the first year.  Dr. Meuleman is interested to see if their grades change or their performance on the tests changes.  Dr. Wallace said that by and large the distributions have been similar so they will be able to evaluate pretty quickly if they think the students are slacking off.  She said she can let the students know that 5-10% of them may be on the borderline and that if they are one of them they need to be careful.  She said that overall the students tend to over-perform and really live up to their own expectations.  Dr. Harrell stated that the only other variable is that they are also moving to the very last two weeks at the same time they’re doing this, which Dr. Wallace said would mean even less ability to evaluate performance.  She said that they don’t have any other good way to address the greater than 50% A’s system and that this would be a good time to try this as an experiment and see how it goes.  She doubts that there will be any drop in performance.  Dr. Novak asked which other courses were pass/fail.  Dr. Davidson said there are a number of pass/fail courses in that year to include EPC, IFH, and radiology. 

Dr. Wallace made a motion that the Curriculum Committee agree to Genetics moving to a pass/fail grading system and Dr. Harrell seconded it.  It was clarified that academic standing is based on graded courses.  Dr. Davidson stated that a student should not be motivated solely by grades and said for that reason he believes the entire first year should be pass/fail.  Dr. Vidauretta questioned how well Radiology has done as a pass/fail course and Dr. Romrell replied that there has not been any significant drop in the level of performance.

All were in favor that Genetics become a pass/fail course; none were opposed.  The motion has passed and Dr. Romrell will submit the necessary paperwork.

Dr. Rarey distributed a handout regarding the LCME update.    He stated that we will host site team members 57 weeks from now.  He explains that the Liaison Committee on Medical Education (LCME) is a joint commission of the AAMC and AMA that is a sole accrediting Body of the Department of Education that will accredit the educational program.  He states that it reviews the educational program and not the institution, so an educational program leading to the MD degree is what would be looked at as well as associated programs.  The purpose of the LCME is to ensure that we are adhering to the prescribed standards (126 standards) of our educational program.  The last site visit was in March 2000 and we received full accreditation, which lasts for seven years.  The next site visit is February 18-21, 2007.  He states that many members of the Curriculum Committee will be involved in the site visit in terms of interacting with other site team members.  A task force was formed in order to prepare for the accreditation process, site visit, etc.  The Steering Committee consists of:  Drs. Watson, Romrell, Pauly and Rarey.  The Task Force Chairs are:  Drs. Good, Sumners, Davidson, Romrell, Duff, Crawford, Flanegan, Berns and Mr. Tharp.  There are approximately 67 faculty members involved in the process right now who will give input with regards to different aspects of educational programs.  At this point there are 40 medical students who are involved in the process.  The objective of the task force is to help all of us as teaching faculty undergo a self-study, which is the most important aspect of the LCME process to identify where our strengths and areas for improvement need to be.  We are preparing a database, after which that database will be analyzed and synthesized so that we can have a 3-5 page summary report, which will occur during the spring and fall.  There are five sections of the database:  Institutional Setting, Education Program, Medical Students, Faculty and Educational Resources and those five subcommittees refer to various portions of the LCME standards.  The task force of those five subcommittees is divided up into 17 subsets that, for example, under Educational Program are actually five subcomponents of the 17 that we are looking at.  So the committees and students independently will look at our educational objectives such as looking at the design content of our educational program, the teaching and evaluation processes involved in all of our courses and clerkships and electives, the curriculum management, and finally, it questions whether the evaluation of the program is acceptable in terms of the outcomes- what are outcomes that show we have a viable educational program?   Dr. Rarey stated that he wanted to be sure that the members of the Curriculum Committee are aware that there are 17 aspects of the LCME and that it’s not just represented in self-study, but there are specifics.  We have the resources, we have the governance, and we have a quality education program that will demonstrate that we are graduating competent, caring residents and physicians. The timeline states that the database was formulated in the fall of 2005 and we are entering into a period now that the various five task force committees will be putting in their data for analysis and on June 15th the Executive Committee will see the data.  He states that he is sure between now and June that this committee will review the materials from the Educational program committee headed by Dr. Romrell and Dr. Davidson.  In the fall we will do the summary report and 57 weeks from now we will host site team members.  Dr. Davidson stated that the Curriculum Committee members will be involved in the process once we reach a certain point because part of the LCME accreditation says that the Curriculum Committee needs to have control of the curriculum and understand it.  The LCME site visitors will meet with representatives of the Curriculum Committee, so the members will take an increasing role in this as we move forward to the accreditation visit.  Dr. Davidson stated that the educational database is nearly complete; there has not been 100% compliance, but they are close.  There are some parts that may need to be edited, but by and large they are making good progress with that.  They will be looking for feedback from our committee with regards to the completeness of that and also from the Executive Committee.  He thanked everyone for their participation and future participation.

  1. Request from Emergency Medicine for an advanced clerkship, which is a required 4th year clerkship.  Dr. Davidson states that this proposal is very interesting and that they have an intriguing idea.  One of the issues is about, for instance, if someone wanted to go into Internal Medicine and they do their 3rd year Internal Medicine clerkship and they decide that’s what they want to do, they then have the opportunity to do an Acting Internship during their 4th year in Internal Medicine.  Since Emergency Medicine is a 4th year clerkship, that puts them in an untimely situation in terms of people that are particularly interested in going into Emergency Medicine.  Dr. Caro introduced Dr. Rich Stair, Dr. Robyn Hoelle who is the clerkship director here on the Gainesville campus and was a former UF student, and Dr. Tom Morrissey who is also on the Jacksonville campus and is running the Jacksonville clerkship.  Dr. Caro reported that what they would like to discuss is having an AI in Emergency Medicine, which has generated a lot of discussion for them.  He states that before this became a required clerkship, what they typically had were outside students that were coming in and essentially auditioning for Emergency Medicine in Jacksonville and interested UF students that would really want exposure to Emergency Medicine that would rotate through Jacksonville and Gainesville. The Emergency Medicine clerkship became a requirement in the 4th year in 2001, which increased the number of students and changed the dynamics between Jacksonville and Gainesville as far as Emergency Medicine goes.  Attending staffs at both institutions are increasing in size, but not necessarily at the pace that they have increased student numbers.  Things that are unique to Emergency Medicine as far as the rotation goes and why they are bringing this up is the shift work that they do in Emergency Medicine.  The attendings that do shifts in the emergency department and the residents that do shifts is all over the map and there is no way to gauge the students and their ability to pair a student with an attending or with a resident.  What they have to rely on are shift evaluations and it could be that a 4th year student comes through the rotation and never has the same attending and never has the same senior resident twice.  So they are getting a very broad stripe of what the students are doing and how they are functioning, but they are not necessarily getting a parallel and ongoing assessment of what the students are doing.  They do have weekly didactic meetings, so there is a time where Dr. Morrissey or Dr. Hoelle will sit down with that group of students so they know the clerkship directors and make one-on-one comments with them and get feedback from them and see how the clerkship is going.  The difficulty that this causes for them is that it allows the students to remain relatively anonymous if they would like to be.  There are some students that become well-known by their performance, but other students may be somewhat quiet and cannot really be assessed without having someone who is continually with them.  They have a templated student schedule that adds to the complexity and he is sure that there will not be somebody with an attending for more than one or two shifts.  They have specifically arranged the templated schedule to be able to accommodate as many students as they possibly can.  With a templated schedule, they can accommodate 12-14 students in Jacksonville, as well as a lesser number in Gainesville, but it limits the total number of students they can take.  There is an average of 6-7 students per year from UF that want to go into Emergency Medicine, which does not include other students that want to do an outside rotation in Emergency Medicine.  They are concerned from a residency administration standpoint that they are unable to mentor the students who are going into Emergency Medicine as well as they would like. As they are spreading their focus to try and make sure they are providing a good educational experience for everybody, they feel they are not doing a service to the students that are going into Emergency Medicine when they are unable to give them a true, formative, longstanding evaluation.  This brings up a number of different questions and how they should go about focusing some attention on a separate track for students that are going into Emergency Medicine.  One of the things they really want to focus on is maintaining the current level of training that they are doing for their 4th year students because they are getting good feedback about the rotation.  They are doing an adequate job of teaching and training and giving them exposure, so they don’t want to lose that experience.  At the same time, for the students going into Emergency Medicine, they want to help cultivate their interest and give them better feedback.  This brings up the question as to whether they should do an AI.  This would be different because it is a 4th year rotation so they do not have the ability to send a student through a 3rd year rotation and then take them as an AI in the 4th year.  They prefer not to do that because they need the base that is built in the 3rd year; they would rather them have Internal Medicine, Surgery, Psychiatry and Pediatrics before they get to them because they need that base to actually cope.  Looking at the 4th year, they could possibly separate out the students that are interested in Emergency Medicine, including those that are coming from outside institutions, and put them through a separate experience that is the same didactically plus.  Students will meet their requirements for the 4th year Emergency Medicine elective and on top of that get some career oriented advice, mentoring, discussion, etc.  Dr. Normann asked if that would require a longer rotation.  Dr. Caro responded that it would be the same length of time as far as the month goes, although the shift numbers would change so that those going into Emergency Medicine would parallel a 1st year resident experience. The reason that this comes up is because there is a recommendation letter that they write for Emergency Medicine students when they go out.  There is a standardized form that Emergency Medicine has come up with so that their program directors are talking the same language.  He states that it makes it a little easier, but states that it can get confusing.  If they write a standardized letter, there are very specific areas on the form regarding how the students perform in Emergency Medicine as far as their abilities, personality, etc.  There are things that are put into this letter that mean certain things to certain residency directors.  They want to make sure that what they are putting on the forms actually fits what the student’s strengths are.  It is difficult for them to tell if they’re giving the students the best look possible when they write the letters of recommendation.  They are trying to come up with different ideas of how to make this work.  One of their ideas is to make this a separate track that does everything they want it to do for their 4th year students, but also gives them the mentoring.  One of the first questions that arose if they created a separate track is what to call it so that they differentiate it from a required Sub Internships that the students have now.  They obviously do not want to get it confused with what is being presented by Internal Medicine, CHFM and Pediatrics as the required SubI.  They want to call it something different, but still maintain that sense of it being a more rigorous experience.  They felt that Acting Internship would be a good name.  There are a few other Emergency Medicine programs around the country with this type of program, which they call Acting Internship.  He felt that if he changed the name to AI it would help differentiate the two and make sure they don’t overlap.  Career Track is another idea for a name.  They are open to suggestions and ideas.  He stated they definitely want to keep a letter grading system for the AI and questioned whether they should keep a letter grading system for the required 4th year clerkship or should they make it pass/fail.  Dr. Normann asked if they have to grade that experience on the competencies that the college has.  Dr. Caro confirmed that they do a competency evaluation and they do a letter grade that goes along with it, so they would still retain the competency requirements even if they went pass/fail.  The mechanics of the rotation would look like a month long rotation, but instead of fifteen 8-hour shifts, which is what their 4th year students are doing right now, they would do something similar to fifteen 12-hour shifts that met all the RRC duty requirements and would parallel 1st year resident’s rotation schedules.  As an intern comes on a shift in the emergency department, they would have a parallel AI shift, and what it allows them to do is compare the 1st year resident and the 4th year student.  Are they competing?  Are they doing the same amount of work?  That would allow us to give them a better look and also allow them to see what it feels like to be an Emergency resident and get a more of a sense of what the residents are doing.  Dr. Romrell responded in regards to the letter of evaluation for residencies.  He feels they should maintain grading in both tracks so that when they’re sending out data on how well the students did, it shows us basically the same educational components, but better mentoring and other things that go along with it as they are in that Acting Internship class.  Their grade can be compared to everybody in the class and we give them a better chance than just being compared in their subgroups, which could put them at a disadvantage.   Dr. Morrissey does not think it would.  He stated that if he was a program director interviewing people and he saw that a student got a B+ to an A in the general, run of the mill training it would not be a big deal, but if he sees that a student came out of an Acting Internship and worked parallel to an intern, where he was held to the fire and learned the importance of Emergency Medicine triage, even if he got a B+ in that, this student has put on the shoes of Emergency Medicine physicians and as a student was able to get a B+ and this would be the guy he would want in his residency.  He explains that how they see this is if a student wants a letter of recommendation and wants our program directors to sit down and truly evaluate them as a potential candidate for Emergency Medicine residency, they have to enroll in the AI.  Dr. Stair stated that the distinguishing feature historically has been what usually separates A, B+, B, C students is the written exam, not really their performance.  Regardless of whether they have seen all sore throats and sprained ankles for 8 hours every shift, they are looking the same as someone who would go through and see resuscitations, traumas, MRIs, etc.  He states that this allows a much better experience.  He has never had a student come to him and say that they wished they could have seen more of the minor care patients.  What they say is that they really wish they would have had the opportunity to get to more of those more emergent patients.  He thinks that this has the potential to allow them that type of experience a little more.  Dr. Watson stated from what he has gathered from students is that more and more of them are going into Emergency Medicine.  He stated that it seems to him the only thing that distinguishes this from Medicine and Family Medicine is that those clerkships happen to occur in the 3rd year and Emergency Medicine occurs in the 4th year.   He questioned whether a student could defer and take the routine Emergency Medicine course in the 3rd year and then took this Emergency Medicine course in the 4th   year and asked if it could serve as a SubI because that would mean they would have the four weeks in the 4th year because they will be doing the SubI in Emergency Medicine.    Dr. Caro stated that they had not approached it from that angle and have actually actively avoided that because they did not want to encroach on the Sub Internship status and they have had 3rd year students come through who have done well, but would rather the students have the basics underneath them before they get to Emergency Medicine.  Dr. Davidson pointed out the logistic problems of that scenario, stating that they no longer have a four-week block anymore in the 3rd year because of Neurology.  Dr. Romrell stated that they have allowed students to defer to Emergency Medicine early, but the students who did it early, even though they were very good students by every indication before that, struggled because they hadn’t been through all those clinical experiences of 3rd year and especially if they hadn’t gotten Medicine or Surgery, they are not ready to walk in and do that.  They had a student that actually got an unsatisfactory grade and it was a disaster for that student who had to get remediation because they just weren’t ready.  Dr. Caro stated this brought up the other question of whether a 4th year student who wants to go into Emergency Medicine should do their regular required 4th year and then do the AI secondarily.  Dr. Caro’s answer would be that his suggestion to their Emergency Medicine interested students is that they do a rotation at home and then do a rotation abroad at any other Emergency Medicine institution.  He states the reason he tells students that is that most Emergency Medicine Directors are looking for that standardized letter not only from a student’s home institution because we have a reason to “fluff them up”, but also an outside pair of eyes that can give an objective look.  So the students are going to go out and do another AI.  Dr. Caro stated that it is not a formal requirement that students do this, but if a student doesn’t do this there will be a question asked in the interview why they did not go out and do another rotation in Emergency Medicine.  They see part of their job as going out and teaching students to do a better job at another institution.  He states they will probably do more didactic in a mentoring kind of format, addressing for instance how well they polished they are or how well they present themselves, where they don’t necessarily focus on that in the general 4th year required curriculum.  Dr. Hatch asked if they would focus on this in the first few months of the 4th year and Dr. Caro confirmed that, stating it would be during the first 5-6 weeks.  Dr. Hatch asked if any of the regular 4th year students would be displaced since these students would be doing more shifts.  Dr. Caro stated that is one of the things they are trying to work out now, but they don’t think it will.  He stated that it will be easier to identify who is in AI now because they will be paired with a 1st year resident and will be put up on the board as a 1st year resident.  There will be two 1st year residents in the spot where there was one.  As a 4th year student, they are still going to be going and seeing patients and doing overseeing and that kind of thing.  He thinks they will be able to do that and accommodate those students as well.  Dr. Davidson said that one of things that needs to be made clear is that the committee would really prefer that this not be called an AI because we want to make it clear to the students that this does not do away with their requirement to do a required SubI in Medicine, Pediatrics or Family Medicine.  He feels that the use of the term AI may be a problem and stated that Dr. Harrell suggested using the term Advanced Emergency Medicine or something like that to clarify to the students that it does not take the place of the required SubI.  Dr. Harrell stated that it would help to think of it as having a regular ER and an advanced ER, with both meeting the same requirement.  Dr. Davidson stated that he had never heard of this before and he thought it would raise an interesting thought for Anesthesia who has been very vigorous in their desire to move into the 3rd year and he doesn’t see why Anesthesia couldn’t do a similar kind of thing during their 4th year clerkship.  Dr. Romrell stated that with Anesthesia there is actually an option within Surgery to do perioperative Medicine which means they can elect as part of Surgery to get some anesthesiology experience.  Dr. Morrissey stated that they have struggled for quite a while about what to call it and he understands Dr. Harrell’s point about competing with other SubIs and people trying to use this as a way to get out of their required SubI.  He states that a true SubI is not only Advanced Pediatrics, Advanced Family Medicine, Advanced Internal Medicine, but it is also kind of a growing up and testing period of when a student proves they are mature, responsible, and they are no longer just standing around and doing what their senior resident tells them to do.    He states that we also have to have a name for this that carries some respect in our community because when our program directors from other high intensity institutions such as Grady, Charity, Carolina’s Medical Center who are looking at the name of it, they are looking through 120-130 people a year for residency positions and they need to be able to pick it up and know at a quick glance that this was a high intensity rotation, this is somebody who was tested at a SubI level in Emergency Medicine.  That is specifically why they went to Acting Internship.   The first line of their course description in the MedCat can be “This is not replacing your standard SubI experience; this is an Acting Internship experience in Emergency Medicine”.  He states a student would want that trial by fire in Emergency Medicine so it can be held up against their other competitive peers.  Dr. Rarey asked about faculty resources.  He addressed Dr. Caro’s comment about there not being enough faculty when the students came through and questioned whether adding another elective would have any impact on the student’s regular education.  Dr. Davidson also mentioned the fact that there will be 135 students next year compared to 120 this year.  Dr. Caro stated that they have struggled with that since they started the rotation, but that the good thing is that they have gone from having 13 core faculty members that were doing shifts in 2001 to currently having 21 faculty and there has also been a blessing by the dean to add four more faculty members.  He reports that the UF faculty has also increased.  He states they are trying to be as proactive as possible about training of their student residents as far as how they are evaluated.  Dr. Romrell stated that there is a 70/30 split of students going to Jacksonville over Gainesville because they want a more intensive Emergency Medicine experience even if they aren’t going into that, so the load really is more on Jacksonville.  He states with the other issue of trying to give the course its own unique identity, one way is to put it through with a unique course number so when their transcripts are looked over its number will be unique.  He suggests calling it Comprehensive Emergency Medicine to set it apart.  Dr. Davidson suggested calling the course Advanced Emergency Medicine here, but on the transcript calling it an Acting Internship.  Dr. Morrissey says he can see the concern of not wanting a student trying to pass it off as a SubI, but he doesn’t see the problem if you tell them they just can’t.   Dr. Harrell stated that students do not always have a clear understanding of things they are told.  Dr. Novak pointed-out that the students will have an advisor who can help them.  Dr. Harrell stated that primary confusion is due to naming it so close to a SubI.  Suki stated that students use Acting Internship and Sub Internship interchangeably.  She states if this primarily affects students who are interested in going into Emergency Medicine, this can be explained to those students separately and the other students won’t necessarily be affected.  Dr. Caro stated that students who are interested in going into Emergency Medicine can be told that they would do either the 4th year required which will not entitle them to receive a letter of recommendation or go through the AI  which will entitle them to receive a letter of recommendation from the standardized form from Emergency Medicine.  It was stated that this is not going to remove things from the clerkship course and ignore that and then treat this as a whole separate class, this is a nice way of saying “Thank you sir may I have another”.   This is more time in the emergency department and more requirements in terms of what they are going to be exposed to.    Dr. Romrell suggested that they call it Career Track Emergency Medicine and the first line of the course description could be “You will be expected to act at an intern level”.  This would make it clear to students that they would have the option to either take Career Track or take regular Emergency Medicine.  Dr. Normann questioned if the students will have another outside rotation and Dr. Caro confirmed that they will have an externship.  It was again stated that the student would only receive a written letter of recommendation from the program directors if they did the Acting Internship.  Dr. Vidaurettta stated that a student’s advisor should direct the student in which course to take, but Dr. Harrell stated that some students who may not have as active advisors may become confused if it is called an Acting Internship.  Dr. Davidson thanked the visitors from Jacksonville for coming and informed them that we will continue discussion on the idea of an Emergency Medicine Acting Internship.  He stated that it will be determined whether there is a general consensus that this is a rational idea and stated that the details can be worked out.  Dr. Caro thanked everyone as well.

The meeting was adjourned at 9am.