Curriculum Committee Meeting Minutes for April 25th, 2006
Members present: Dr. Robert Watson, Dr. Richard Davidson, Baligh Yehia, Wayne Bottom, Vee Gosein, Dr. David Caro, Dr. Mike Chen, Dr. Heather Harrell, Dr. Robert Hatch, Dr. Andrew Kaunitz, Omayra Marrero, Dr. John Meuleman, Dr. Sigurd Normann, Dr. Maureen Novak, Dr. Louis Ritz, Dr. Colin Sumners, Dr. Kyle Rarey, Dr. Lynn Romrell, Dr. William Winter, Dr. Cari Hernandez, Cynthia Karle and Beth Layton
Dr. Caro’s presentation:
Dr. Davidson stated that part of the reason for the trip to Jacksonville is to see the Simulation Center and he wanted Dr. Caro to make a few comments about Jacksonville and the Simulation Center. Dr. Watson stated that the trip to Jacksonville is not just for the Course and Clerkship Directors and Program Directors; from the outset it was to get everybody together. Dr. Caro said it is fun to see the attendance list grow and says they are humbled, thrilled and excited to have everyone come up. He thinks one of the things they want to determine is what they can offer as far as resources go, realizing that the Sim Center is early in its development. He stated that they are currently trying to meet a number of different needs including residency training and CME related topics for the attending staff, as well as the student curriculum. They are trying to hone it down so that they don’t overstep and overshoot, and they want to try and figure out what in particular would be a set of goals they could set for student curriculum. They have been in contact with a number of different schools that have Simulation Centers to question how they put them to use and he stated that their basic curriculum is varied depending on the school. He stated they want to know from the Curriculum Committee what they should focus on specifically, knowing that they have a limited amount of resources to develop with. Do we want to spend time on specific critical procedures? Do we want to spend time on some of the basics to make sure everybody has gotten to a certain level of competency and consistency? Where do we put this in the curriculum? He stated that obviously since it’s located in Jacksonville they are not certain that every single student will be able to come through. Folks that are over there have to be structured at certain times to get as many students as possible into a couple of Simulator sessions. They will structure which students they bring in and when. He questioned at what point in their development should students be brought into the Simulation Center, which will have ramifications for what kind of procedure and tests that they are trying to tackle while they’ve got them there. He stated that obviously everyone will see the amount of space they have when they show up and said that the space itself is a lot bigger than right now they can put to full use, which is a good problem to have. He stated they also have to start focusing on who and where and when in the curriculum they start to target. He thinks one of the first things that they really would need from the Curriculum Committee is to address what tasks are seen as essential for students who will come through Simulation Center and at which point in their training do we want them to come. Dr. Watson stated that we don’t want a Simulation Center that sits fairly unused. He wants the Curriculum Committee to start thinking very broadly about how simulation and standardized patients be integrated throughout the curriculum from day one till the end. How can they be used in many cases to overcome deficiencies that we presently find in ED-2? How can we think of ways to incorporate interdisciplinary learning along the continuum from medical school into the residency years? It is hard for the Curriculum Committee to look at it as a big picture item without having a much better sense of the potential of having simulated standardized patients. He stated that someday we are going to have a new education building; the 3rd floor on that building will be a very large combined Simulation Center and Standardized Patient Center/Information Technology, so the Curriculum Committee really needs to start thinking about this now in a very broad sense. Dr. Davidson stated that he thinks one of the strengths of having both the clerkship directors and the program directors there is this continuum and to have those groups in particular along with the Curriculum Committee; the clerkship directors and some course directors may have more definitive and more obvious needs and uses for the Simulation Center and how it might fit into their clerkships and courses. He is encouraging everyone to please go if possible. He said it sounds like an amazing place and he is interested in seeing what it looks like. Dr. Meuleman stated what he felt would be helpful is for everyone to have a better understanding of what is presently in the curriculum. Right now Anesthesia has every student work on simulators here, although he does not know what kind of cases. Baligh stated that he went through Anesthesia and stated they don’t really use a simulator that much. They use it in terms of studying some of the effects of medicine, but they only have two weeks and most of the time is spent in OR. When they do have lectures, the only things they really have used it for is to practice running codes and they have only done that a couple of times. He states they use the simulator in ER as well. Dr. Caro stated that there are a number of different ways you can simulate, including LP modules and wound care modules that you can do, how to scrub for an OR and those kinds of things. They have ED beds available and a number of different places they can turn into clinic beds and office space. You can, he thinks, come up with a simulated scenario for just about any competency that you want, you just have to be able to direct it and you’ll have to be creative as far as what you use as far as tools and simulators. If the Curriculum Committee says this is important to get done, we need to start thinking of innovative and clever ways to get it done.
1. Presentation by Baligh Yehia, graduating senior, which will be a review of four years of education from a student's perspective.
Dr. Davidson stated that he asked Baligh to review our educational principles for us and let us know from a graduating senior’s prospective what we can do better and what we do well. Baligh will be moving to Baltimore shortly and we are going to take advantage of having his insight before he leaves.
Baligh stated it was a pleasure to be here and address everyone and stated it’s not everyday that he can give out a handout to his professors. He stated it was a real honor to be here and, as Dr. Davidson said, he was asked to look over principles that the College of Medicine has outlined. The way that he has it set up is to go through each of the different educational principles and their goals and objectives. He’ll then do an evaluation of where he feels the college is currently at in meeting those principles and any suggestions for improvements if they exist. There are 12 principles that the College of Medicine has in terms of its educational program and they are really broad in nature and cover a spectrum of different things and deal with healthcare delivery, learning environment, curriculum, patient care, etc. He will be going through and introducing each of them individually and addressing them.
Principle 1 states that general professional education is the goal of the curriculum. The goal for this principle is to provide a program that defines a core curriculum designed to provide the foundations of medical science and practice and prepares students for any residency of their choosing. It states that we want to create a curriculum that is general in nature so that as a graduating fourth year, a student can go into any internship and residency they want with any specialty of their choosing. He is going to review where we currently stand with information he obtained from Dr. Romrell’s office. He states that in general, we want to teach students what’s normal. There is Anatomy, Biology, and Neuroscience, and in the spring there is Physiology, Biochemistry, Genetics and Human Behavior. Students also learn basic history and physical exam skills, EPC1 and 2 and also have the opportunity to work in a clinical preceptorship and interact with families and communities in IFH. Year 2 focuses on the abnormal, which are Pathology, Oncology, Microbiology, Pharmacology, Ethics and EBM in the spring. There is a more intense focus on clinical experience in EPC 3 and 4 and clinical diagnosis and more sophisticated history and physical exam skills, as well as communication techniques are taught. The current 3rd year structure is 6 weeks of OB, Psychology, and Family Medicine, three weeks of Geriatrics and Ambulatory Medicine, three weeks of Neurology and then Medicine and Pediatrics are each 8 weeks, which is divided among various sites. In terms of 4th year there are only three required months, which is one month of a sub-internship, one month of ER, two weeks of Anesthesia and two weeks of Geriatrics, which leaves senior students with 7 months of electives to really round off their education. He is going to introduce three different suggestions that he has, which are mainly going to be focused on the 3rd and 4th year. He feels that during the 1st and 2nd years the course directors and the basic science faculty do a really good job of laying a foundation to prepare students to enter into their clinical years. He is going to focus on three different aspects of the curriculum in the 3rd and 4th year and will then have a summary slide and open it up for discussion to see what people think.
The first point that he wanted to make is critical care training. He feels critical care training is a very vital part of most internships and residency programs and in fact many specialties somehow interact with critically ill patients. If you are a student and you ask for advice from your interns and residents on the wards, one of the points of advice that they usually tell you is that you need to make sure you take some sort of ICU time during your medical school because they felt it was very beneficial for them in preparation for internships and residencies. The current status is that there are two weeks of Anesthesiology, but most of the time anesthesia is really in the OR and not in the ICU setting. Information he obtained from Dr. Romrell’s office showed that many of the students in his class took some sort of ICU. There were 18 students that were enrolled in MICU, 11 students that were enrolled in PICU, 10 students that were enrolled in SICU, and 4 enrolled in NICU. That is a total of 43 people, or well over a third of his class. He brings this out because this is not a required rotation to have some sort of ICU time and actually the MICU rotation is the 10th most popular rotation. Among the top 10 are Radiology, Ethics, and becoming a good teacher, which are classes that are a little bit lighter, which fourth year medical students use to study for boards, etc. He thinks that the fact that a very stringent rotation such as an MICU is ranked the 10th most popular elective really says something. His suggestion would be that critical care training is important for medical students to get. Whereas anesthesiology does a really good job of preparing students by teaching them how to intubate and some basic ventilatory management, it really is a focused specialty, two weeks, which is mainly learning about the effects of anesthetics on patients and mainly spending OR time. He thinks it is very beneficial for a few people, but not the majority of people when we’re thinking about providing a general professional education. He thinks that something to consider might be including an ICU rotation instead of an Anesthesia rotation.
The next point that he wants to bring up is third year elective time. He feels this ducktails very well with this principle, which really deals with providing a general professional education so that students can go into any residency field of their choice. The problem is, not a lot of students have contacts to various different clinical opportunities and careers and so they really don’t have what he feels are the proper tools to really evaluate if a specialty is for them or not. What he points out is that elective time can help a student decide between various fields. Although a mechanism currently exists in the curriculum to do this, for example you can defer some of your family medicine time, as a student there really is a perceived or maybe a real barrier to that. A lot of people think that it is negative to do something outside of the set curriculum that we have for them during the third year and a lot of them do not want to see that incomplete on their residency application, even though it is explained in the dean’s letter. One of the suggestions that he has is to introduce a two week block during the third year. The way that would be done is to remove the two weeks of Ambulatory Medicine as part of Family Medicine and move it to the fourth year. In reference to the general professional education, we have the opportunity to have an ambulatory block in the fourth year to really expand it to not just Medicine or Family Medicine outpatient experience. These could be more geared in the Medicine, Surgical and Pediatric subspecialties to allow students to learn that valuable outpatient experience in the specialty that they are going to be entering.
The third point he brought up in terms of the general professional education is Emergency Medicine. He thinks it is valuable to have some sort of ER time during your fourth year. It helps introduce and identify the treating of acute problems, as well as gain a lot of procedural skills. He thinks in general it is important for students to get a good solvent feeling of how the ER operates and how an admission process takes place from a patient walking in to getting admitted onto the ward. He thinks it is beneficial to have that perspective. One of the interesting things about ER is that the curriculum they have overlaps a lot with a lot of the other specialties. They have lectures on chest pain, acute abdomen, etc. and many of these have already been covered in Medicine or Surgery and even a lot of the different types of patients they see such as first trimester bleeding which they get while on OB. Whereas repetition for certain topics is very good, a lot of times the types of patients that they see and the lectures they get are repetitive and there are things they have gotten in other clerkships. He suggests that the goals of this clerkship could be accomplished in a two week block. Part of that would also be to re-evaluate the ER curriculum as it stands now and have them focus on information and material that is not presented in other clerkships such as hyper/hypothermia, drowning, animal bites, reptile bites, and drug overdoses. Baligh states that these are things that students need to know how to deal with and are not part of their Medicine or Surgery or third year clerkship, but can really help round-off the education. He thinks that could be accomplished in two weeks instead of four. In the summary slide, taking into account all the things he mentioned, what a current third year would look like would be six weeks of OB, Psychology and Family Medicine and one week of Geriatrics, three weeks of Neurology and 8 weeks of Pediatrics, Medicine and Surgery, and then the two week elective block. In the fourth year you would still have your Sub-I, two weeks of ER and two weeks of critical care and then two weeks of Geriatrics and Ambulatory Medicine. Things that he wanted to point out are that he didn’t increase the amount of time required in the fourth year, so there are still only three months of required courses. That allows students the flexibility to take classes they want to take and also schedule lighter rotations during their interview months. The other thing that he would like to mention is that this two week elective in the third year students do not necessarily have to do if they already know their specialty, so they can elect to do two weeks of Ambulatory Medicine and with the way he has it setup, they could even do two weeks of Geriatrics if they chose to. Just having a two week elective block doesn’t mean that everyone is going to be doing electives, he would probably venture the majority would want to get one of the required courses out of the way. The fact that it is an elective really opens up the door and people don’t see it as a barrier. He stated it would probably be wise to group the ER and critical care and Geriatrics and ambulatory together; when you have a month clerkship it really helps solidify things and also provides some flexibility in terms of lecture schedule and better organization. Similar to how the Family Medicine and Neurology really work well together, by grouping these together, as you can see geriatric and ambulatory tend to be more outpatient, ER and critical care can be more acute and critically sick patients, they really mesh well together. Having them integrated together in a month long clerkship really will allow for better organization and flexibility for different lecturers. He opened up the floor for discussion before he moved on.
Dr. Davidson questioned where the Operative Anesthesia content would be. Baligh stated that the principles that Anesthesia teaches that are geared towards critical care, which he assumes is why Anesthesia is in the clerkship. To have a very specific niche which 9 students out of 120 are going into from his class may not make sense for the general professional education of students, whereas critical care medicine is important. In critical care medicine you’ll learn intubation skills and ventilatory skills which can be easily taught in an MICU or SICU setting or even if you’re going to Peds in PICU. Dr. Normann stated that he really is attracted to the idea of putting the two week elective in the third year. He thinks there is a lot of merit in that for people trying to make a decision to go into a specialty, having to make that in the fall of the fourth year. The question he has is if Baligh would envision that elective would be at the end of the clerkship because you’d want to them to go through all the clerkships before the required clerkships and then have the two week elective. Baligh said no, it would have to be, as it stands now, grouped with Family Medicine and Geriatrics, because there is no way that you can include two extra weeks at the end for everyone to take. It would have to be specific block, which technically means some people might have to do that first. It is not ideal, what would be ideal if at the end of the third year a student would have two weeks to take an elective, but still be considered a third year student before you enter your fourth year and get bombarded with residency and standardized exams. For the majority of people it would work out to their advantage. Dr. Normann argued that the elective would lose a lot of its power if it occurs too soon, for example before they have had an introduction to some of the core clerkships such as Medicine, Pediatrics, Surgery and so forth. That would disturb him a little bit in terms of how the scheduling would work out. He thinks it is a great idea, but it is a question of where it would be most effective. Dr. Harrell stated that logistically what she likes about this is that she could actually see how it could work. She also stated that when you talk to students and see how they rotate through and when some of them come in right away, she really thinks it would appeal to them. She stated that for some students it is how they choose their third year schedule, they plan it knowing they want to get those things out of the way first, even though doing that was a deferment, because they know they can defer in their Family Medicine. She thinks it could still work, but she just wanted to say even though Ambulatory Medicine is something that would be displaced, she has no problem with that. She suggested it was possible it wouldn’t apply to only internal medicine; it could be other specialties combining with Geriatrics. The idea of client care curriculum could be addressed and you could really have some themes go over a month that perhaps even in Geriatrics, one of the highlights that could be accomplished in an outpatient clinic, whether it’s internal medicine or even other subspecialties.
Dr. Davidson questioned what Baligh means by electives because what he said was ambulatory elective so that would, for instance, probably not be Ophthalmology or some of the other inpatient based rotations. The advantage of making it ambulatory is that that is an ambulatory clerkship. He stated that having a two week block that is not ambulatory in nature would probably detract from the overall learning in the clerkship. Baligh stated he wanted it to be an ambulatory block, mainly outpatient setting and dealing not with just Medicine subspecialties, but also Pediatrics or Surgery. Dr. Davidson stated that if you make that two weeks elective, which is now ambulatory medicine, it would make more sense if it were limited to ambulatory care because that is what that clerkship is about.
Dr. Watson stated that obviously we are not going to design it right now, but he wanted to remind people why this resonates well is that these are ideas that have been discussed several times in the past. He hates this artificial barrier between 3rd and 4th year. He thinks it is not healthy as part of the developmental process for the students. A long time ago he suggested that in fact 3rd year extends until the time when you take step 2 or whatever. He agrees with Baligh that a lot of this is psychological; students don’t like the idea of having an incomplete on their transcript. He stated that you can argue about whether or not Emergency Medicine and critical care could be combined, but the truth of the matter is that the idea of having more ambulatory training and then to break down this barrier so that students don’t feel that they’re having to defer something, which is in fact what they’re doing. The bottom line so far has been logistics. He would think everyone would agree with the philosophy behind these suggestions. Dr. Romrell agrees with the context in general as well. He states that the problem with electives early in the third year is that students don’t have enough background to really do an elective. He thinks it should be in the second half of the third year. It could be either out of ambulatory or another clerkship to create that block. To start off third year with an elective would be impossible. Dr. Meuleman questioned how many students are currently deferring. Dr. Romrell responded that 10-20 students are currently deferring. He stated that the other thing to remember when you look at our list of things students want to take, about ¾ of them are surgical which we do offer as part of the surgery clerkship now, so we do have flexibility there and that has alleviated some of the pressure. A student can take Urology, Orthopedics, or Ophthalmology. Dr. Meuleman stated that as we go forward we can keep this in mind; he doesn’t think the present schedule does a big disservice to people. In terms of ICU, he is a big proponent, but Baligh’s point was that a third of the students are choosing it as an elective, that means 2/3 are not. The people who need to do ICU need more than two weeks. He spoke with a student recently who stated he has talked to other students about that rotation that said it’s kind of scary at first, but by the end you are very comfortable, by the end of four weeks. He thinks the students who need ICU, 1/3 of the class, will need more than two weeks, and the other 2/3 he doesn’t see that it is appreciatively better than Anesthesia for two weeks. Dr. Hernandez stated that she thinks the underlying theme is that during the third year we are so inpatient acute care based as opposed to ambulatory experience, whether it is a primary care field or a subspecialty surgery field.
Principle 2 states that the educational program and evaluation are competency based and the goals and objectives state that the learning objectives should be competency based and evaluation should be competency based. He thinks that the University of Florida and especially the medical students here have a very good appreciation of what competencies are. When you talk to them in comparison to other medical students from other medical schools, they really have an appreciation of the competencies. They know the six ACGME competencies and obviously UF had competencies before the ACGME ones came out. Our competencies are intermixed with them and he has outlined them on his presentation. Throughout all of the basic science classes and then also throughout the clerkships, everything is based on those competencies, learning objectives, activities and our evaluation methods. He thinks in terms of this principle, just keep on doing what you’re doing because he thinks the medical students really have an understanding of the competencies and how important they are as they progress through medical school. That is how they are going to get evaluated as residents so he thinks they definitely have an advantage when they enter residency. He thinks this is stressed from day one and people really have bought into this notion and they know that is how they are graded. Dr. Ritz questioned whether Baligh thought the first and second years were tuned into the competencies. Baligh thinks they are. He stated that all of the syllabi they get from day one and when they hear the course director explain how they are getting evaluated, they all mention the word competencies. He remembers doing his formative feedback with Dr. Romrell in Anatomy that was on an actual evaluation form that looked like the competencies he ended up getting in his third year. He definitely thinks they are exposed to it early and students have an appreciation of it. He thinks that you expand those competencies in the clinical arena because you are including history, physical exam, AP, communication skills, and other things that are more relevant in the clinical setting, but even in the basic sciences he thinks they have a good understanding of them. Dr. Davidson stated that he thinks one of the things that Dr. Ritz may be getting at is that students seem much more interested in grades than they do competencies. The fact is that in the clinical years many of the grades are based on competencies specifically, they are used to calculate grades whereas that may not be the case in the first two years. He thinks those that don’t like grades would prefer that students in the first two years were more attentive to the competencies and not so much to their grades. Omayra stated that there is no question that while students tend to know the competencies, a lot of her classmates do not believe in the competencies. She agrees with Dr. Davidson that students really don’t get what a competency means until they are in the clinical setting and understand why they need professionalism, etc.
Principle 3 states that the conceptual framework of defining knowledge promotes learning and effective utilization of that knowledge and serves as a basis for curriculum integration. He states that all of the basic science courses should be clinically relevant and there should be a lot of involvement of clinical faculty and especially EPC during the first two years. He stated that during the first two years of medical school, your pre-clinical years, there are certain classes that are all clinically oriented, (such as EPC 1 and 2, preceptorship, IFH and Human Behavior). About 40% of contact hours spent in year 1 are in clinically oriented courses. EPC III and IV, radiology, EBM, Ethics and Clinical Diagnosis are the ones in 2nd year. In 2nd year, 90% of student contact hours are with clinical faculty. On top of that, there are a lot of things that students do outside of the curriculum: Equal Access, Diabetes Camp, and OR time where they are interacting in a clinical setting, which is in addition to what they already to. He thinks that we do a pretty good job of integrating the clinical concept in the pre-clinical classes.
If he had to offer a suggestion, one of them would be to strengthen EPC. He feels that EPC serves as the foundation of their clinical training. It is where they initially learn how to take histories and physical exams, and they are going to need these skills and the way that they learn them throughout their careers both in medical school and after they graduate. He remembers that EPC was one of the lowest attended classes. The other thing that goes with it is the pass/fail mentality because it’s a pass/fail class. In the mind of a college student and a graduate student, saying a class is pass/fail means they don’t have to spend that much time or energy into it, which is definitely not true, but that is a perception. He definitely thinks that EPC sometimes is diminished by the heavy emphasis on the basic science courses. When he thinks about it, it really should be on par with Anatomy and Pathology; when you talk to a medical student, those are the big classes they think in their mind. EPC should be on that same level playing field with those strong basic science classes. Some ways to improve that are to stress its importance, so this will have to come all the way up from our administration, course directors and core of teaching faculty that this is an important class. Just because it right now stands as a pass/fail course, doesn’t mean that it’s a soft class or that it’s not of value. He stated we also need to develop new and innovative teaching and evaluation techniques. Right now it’s mainly lecture format with some small group sessions and then the Harrell Center. Many other classes utilize different media and one suggestion he mentioned was to develop an online tutorial. There are online tutorials in Anatomy and Pathology, as well as clinical courses in Psychiatry and Anesthesia. It would be helpful if there were some sort of activities outside of the actual lecture hall where students would have, for instance, some sort of interactive session about a physical exam. He thinks that would increase the amount of time that students spent preparing for EPC outside of class. He also mentioned the attendance policy and grading system. He states in a student’s mind that if attendance is not required and there is no grading system, it is much easier to not show up. He stated that EPC tended to be scheduled late in the afternoon and he would have to decide if he should go home and rest a little and study for his classes or attend EPC. He stated that sometimes medical students don’t have a lot of foresight about this being important to become a good physician in the future; they are thinking ahead to that test that they have. An attendance policy or a grading scale of some sort should be considered. Dr. Sumners stated that he has noticed in physiology the last couple of years that the attendance has been way down and that often there are a lot of people missing. Their class is graded and he just wonders if that really is related there. His feeling has been sometimes that the more we put our information online in terms of how points are downloadable, the student just sits at home and says okay, I’ll download it and read it and they tend not to come to class. Baligh definitely thinks there is value to attending a class, but there is a difference in terms of some of these skills that are taught, such as history taking and physical exam. You can’t just look at a lecture and get those. The EPC classes include visual demonstrations or skits because you have to get some of these nuances. He thinks it is a different story if you actually have a class that the course directors have some material that they present and those lecture slides are online, but here a lot of it is visualizing and communicating and interacting during the lectures and not just looking at the lecture notes.
Dr. Hatch stated that he thinks Baligh hit on something crucial. He sees it in the preceptorship where people are about to go out and have their first significant patient contact and they blow off their lectures on what they should do when they are on the preceptorship. Their reasoning is “We are exhausted, we just finished all our exams last Friday, we’re burned out and we need a break”. Subsequently, the argument he would make is that the problem is somehow with our culture; that the culture of the first two years, basic science and grades are valued, the students get the message that that’s the important thing and they downplay the clinical aspects. Baligh agrees with Dr. Hatch and says that’s why he thinks it should be on equal par with Anatomy and Pathology and as he said, administration and teaching faculty, really the whole culture has to change because grade scale attendance policies must not be the best motivator. If as faculty you say this is important for your future and your patients and really start creating that sort of environment and let the students buy into that, he thinks attendance will increase and activities to do outside will increase.
The next point is to strengthen course organization and presentation. Some classes such as Anatomy and Pathology are so extremely organized that when you enter, the course deserves respect. He remembers when he heard Dr. Rarey’s and Dr. Normann’s presentations that they thought about everything and everything was meticulously planned. Because of that, it shows that the teachers are really invested in it, they really put a lot of time in it, and it is an automatic reflection by the students and they recognize that. He understands that EPC is a very hard course to organize because it involves a lot of clinical faculty, small groups and a Harrell session, but it would be beneficial if the course directors and the faculty involved in that course really sit down and strengthen how the course is organized and how they present it on that first day. Baligh stated that Dr. Pauly was his course director and she was so nice and all the clinical faculty are so warm and welcoming that sometimes they gloss over things or don’t mention things. That is definitely not the case because they care about the course and they are very kind and warm, but the way that the course should be presented should probably be increased and worked on. This goes along with clinical faculty and making sure that people show up for lectures. If you have a couple of lecturers that don’t show up, the whole environment and atmosphere that we want to create will be diminished.
The last point is to improve access to the Harrell Center and create a teaching space. He felt it was very beneficial for him to go outside of the required Harrell Center classes and be in that setting and practice with his classmates using the instrumentation and using the whole sense of feeling that you are in the clinic. It is one thing to sit around and review history taking and physical exam and MDL, but it isn’t the same. What would be ideal is to have the new Medical Education Building or at least have 24/7 access to one patient exam room where you can go in at any time of the night. He remembers sometimes he was preparing for EPC after he finished working on his core basic sciences and after he went home from the hospital at about 12am and would not have access to the Harrell Center. Creating some sort of space or having the equipment available in a designated area would be helpful.
The next thing that he wants to bring up is an approach to differential diagnosis. This also ties in with EPC. Currently as it stands, EPC does a very good job of history taking and physical exam skills, but he feels that throughout the curriculum there is disconnect in terms of approaching differential diagnosis which all future practicing physicians will have to participate in. It really helps develop a systematic approach to problem solving and increase the chance of identifying correct diagnoses and not missing these “must not miss” diagnoses. Where it stands right now is that there is some mention of it in EPC and sometimes different clinical faculty when they do a lecture for clinical diagnosis might at the beginning say this is how I think about a problem, but it is not as heavily emphasized as the history taking and the physical exam skills. In his mind, these are the three parts, the history, physical and problem solving clinical diagnosis differential making skills. (Right now, this approach is most prominent in Medicine “Doc in the Box” and also in preparation for their surgery and Pediatrics oral exams and then Neurology and Neuroscience name the lesions). Those are the courses and clerkships that are mainly utilizing it, but this should be something that is equal to the history and physical exam skills. Some suggestions that he has would be to start with a systematic approach to differential diagnosis training during EPC 3 and 4, which are the advanced EPC courses. He states that there should not be just a lecture, but also some sort of small group interactive where you have a case-based lecture and you ask people in the group to think about problem solving and how would you approach this patient. Lectures should be encouraged, especially during the clinical diagnosis class, to not just give us a list of different things that cause chest pain or different things that cause abdominal pain, but to help us get insight on how they approach those problems when they see a patient. How do they conceptualize that in their heads? That is something that is hard to mark because you’re teaching people how to think. He thinks there is definitely a right way to do it and it’s very challenging. He mentioned an acronym they are taught in Pediatrics (VINDICATE) as a way to organize thought processes and they use that when they are in Medicine Doc in the Box. They list an acronym and go through it. He thinks that Dr. Harrell or Dr. Lynch once mentioned that if it is not on your initial differential diagnosis list, it is probably not going to pop-up after you make that initial list. It is a valuable process to learn and it should be introduced and more heavily emphasized during the EPC class. Dr. Watson states that this goes back to the old days that what you’re fundamentally saying is that lectures should be good clinicians (during this EPC). Dr. Davidson said Baligh was exactly right that they do not approach this in a standardized fashion. What we do is we assume that on the clerkships when students are rotating to Internal Medicine, Pediatrics and Surgery that they observe the process and therefore will osmose the method. That may work just fine; the problem is that we don’t have any way of measuring that. He stated that in his opinion what we ought to have is working some kind of evaluative mechanism in with the PBE so that we can find out if students are absorbing this or not. We can measure people’s H&P skills and communication because we have four required PBE’s, but we don’t have a way of measuring their skills in differential diagnosis. Baligh states that he agrees, but that it is a very vital thing and sometimes it is hit or miss if a student gets it or not. It is highlighted a few places throughout the curriculum in the third year, but it is one of those things that you learn by being around people and having a systematic approach to it would be beneficial. Dr. Winter questioned whether there was a consensus among clinicians as to what the best acronym is because if you saw it day after day and we started to do it in Pathology, we could link the two from a process point of view. Dr. Harrell stated she would guess we do not feel strongly about it, so whichever one someone could pick we would all get behind it because we don’t really do the acronyms anymore. Dr. Romrell stated that Baligh’s presentation has been very valuable and he hopes he’ll come back to continue it.
Principle 4 deals with the ability to learn independently which is essential for the physician to provide quality healthcare and promotes the development of lifelong learning habits. He wasn’t even aware that this principle existed and when he read it he was very excited to hear that because he felt that we were going to get overpowered by small groups during the first two years because they were really in class a lot of time. The fact that this exists is a really good safeguard for that because if someone comes up with an idea that they want to do this, there definitely is value to independent study time. He thinks we do a pretty good job of that. His evaluation is that we should continue to be mindful of the number of lecture hours and small groups that we have and also maintain vigilance in how we structure them, which he thinks Dr. Romrell does a good job of. The issue is not just having one hour of independent study here or there, it is definitely valuable for students to have blocks of time when its most appropriate. He makes this comment without even knowing that Dr. Watson was going to talk about the Education Building, but to work to develop physical space that is safe, comfortable, accessible, and conducive to learning. He feels our MDL’s are great and good for group and lab study, but he mentioned the Blue Room which is where a lot of students go to study. There are no windows, it is all white, and it is very dark and drab; he hated studying there. His ideal space would be something that only medical students would have access to, has windows, tables and cubicles, computers, probably include all the Caroline Cody materials, safe, esthetically pleasing. You would want to create a whole environment and make it fun to study. He used to study up the hill at one of the older libraries and it is enjoyable to be up in that sort of academic environment rather than being in a cubicle in a cold, white-walled room. Dr. Watson briefly explained where the study areas would be in the proposed Education Building.
Principle 5 states that the incorporation of the characteristics of outstanding physicians in the educational program is essential for complete professional development of students. He states that this states that curriculum and the program should encourage the highest standard of professionalism. He feels that we do a good job of stressing this important competency. When he talks to other medical students about various issues and sometimes as being part of the student section of the AMA, they bring up different resolutions that deal with professionalism and education issues. A lot of people don’t have a good grasp of it or it is not stressed as much in the medical schools, although he thinks we do a good job from day one. Examples include Orientation, our Code of Ethics, the way that we approach orientation in the Anatomy course and the Cadaver Ceremony; all of those are very touching and moving experiences. To have this really moldable group of individuals when they enter on day one of medical school and expose them to these sort of ceremonies and the atmosphere of the great faculty that you get in contact with right at the start of medical school really sets the tone and is carried on throughout the rest of the pre-clinical years. In clinical years, we have professional competency as the top competency on each of the evaluations, which is something that always sticks out in his mind because it’s number one. He thinks that fact that we have a professional competency helps remind students and faculty of how important it is. Just like the basic sciences, we have a core group of clinicians that are excellent role models. Because there are a lot of faculty that are maybe part of teaching groups or are not part of this core group of teaching faculty, there are definitely some outliers. Even among residents, there is probably more variability than the faculty.
He suggests that we should continue to emphasize the competency which he feels is done excellently during the pre-clinical years and even during the clinical years during orientation. He stated that we should also encourage discussion on what is appropriate and inappropriate behavior, which they do in Internal Medicine. Somewhere in the middle of the clerkship they have a small group session where they sit there and talk about what is appropriate and what is inappropriate, and share experiences they had on the wards. The value of this is because sometimes it is easy to tell what is professional and not professional when you are in your first two years. When you are on the wards and you’re in a different environment and you’re dealing with patients that you haven’t dealt with before and you’re seeing your schoolmates or residents or attendings act a certain way, these are people who are superior to you, you almost automatically assume that they’re doing it right when sometimes they’re not and sometimes the way they’re approaching a patient or talking about a colleague, whatever the situation is, might not be the best example of professionalism. When you get together in a small group and discuss this and you have faculty members that hold this ideal up high and can guide you through what’s appropriate and what’s not appropriate, he thinks is beneficial to the students. He feels some sort of small group discussion should occur in EPC and be incorporated into each of the clerkships. He thinks this is only going to help increase the whole environment of the departments that the clerkships run, as well as the residents, faculty and students. It will allow us to have some time to reflect, sit down and look at what’s right and not right. Students may absorb behavior and incorporate it even if it’s not correct. It needs to be identified, talked about and corrected if necessary.
Dr. Meuleman brought up the discussion regarding differential diagnosis, which he feels we need to frame differently. He thinks that differential diagnosis when you’re first teaching a certain topic its fine, but in the real world 95% of cases have a fairly well established diagnosis. He stated that differential diagnosis is really not in most situations what you’re dealing with, its why is there an exacerbation or a progression. Baligh states that is the point; what are the different things that can cause this, why am I ruling things out or ruling things in, and the next step will be if something is worsening, why it worsened. Dr. Harrell stated that on the Medicine clerkship they emphasize that and they get mixed messages. She thinks part of what of Baligh is saying is that if we as faculty had a more consistent message starting day one, the students would feel more comfortable in what the message is. When they get on the wards they do get all confused, they get mixed messages and go back to what they heard in EPC which is a foundation, but is not practical to what they’re doing at the time.
Dr. Watson stated that the key is a developmental process of what you’re trying to learn the first day of medical school and building up to what you learn in the third year. His hope is that our new fourth year elective, which he is predicting will be taken by every single medical student, is called Clinical Judgment/Clinical Decision Making. That’s where you take this sort of raw differential diagnosis and you are naturally going to ask questions like why, you are going to use judgment. Dr. Harrell stated that developmentally they haven’t yet in EPC gotten the differentials, so they’re still back a page earlier than they want to be, at least on the Medicine clerkship. She feels we still haven’t gotten that first part quite worked through. Dr. Watson stated that the continuum issue is critical and he thinks that residents forget everything that they learn because they are under this time pressure situation and are at times being efficient at the cost of being effective.
Dr. Kaunitz questioned if the reason house officers may not focus on the why is because they had an inpatient focus whereas the residents get much closer to that patient’s life in the ambulatory session and might better appreciate why the patient’s condition worsened. He feels you can sort of lose that focus in the acute care inpatient setting. Dr. Meuleman stated that it is partly because we teach differential diagnosis, which he doesn’t think in most situations is the right thing to talk about on teaching rounds and yet that is what we judge them on.
Baligh stated that the point that he tried to make is that whatever you want to call it they don’t get a lot of it. Whatever it is, we want to learn how to think like our attending. Dr. Davidson stated that we will meet again in two weeks to continue Baligh’s discussion.
The meeting was adjourned at 9:15am.