CURRICULUM COMMITTEE MEETING
May 13, 2008
Present: Dr. Richard Davidson, Chair; Drs. Rob Averbuch, Wayne Bottom, Judy Bowers, David Caro, Mike Chen, Lou Ann Cooper, Margaret Duerson, Heather Harrell, Robert Hatch, Caridad Hernandez, Bruce Kone, John Meuleman, Sigurd Normann, Maureen Novak, Mohan Raizada, Kyle Rarey, Richard Rathe, Margaret Wallace, William Winter; George Heck, Cynthia Karle, Robyn Sheppard; Students: Sarah Smith-Vaniz MS4
Members not present: Students: Chris Bucciarelli, MS1, JR Taylor MS2, Omayra Marrero MS3, Bhavin Adhyaru MS4; MS2; Dr. Louis Ritz
REPORTS:
Sarah Smith-Vaniz MS4: Went
to the AAMC regional meeting in
Sarah said they also gave an update on Steps 1-3 examinations. What they have agreed upon so far is to break it up into gateways for a provisional exam to get into residency and then an unrestricted exam to go on beyond residency. She said it sounds like they’re going to add a lot of things in order to exam how professionals work in this modern environment with technology. They’ll have a computer simulated database that the test taker will have to go through and retrieve information, doing a lot of EBM and literature evaluation. The Pass/Fail vs. Score issue is still unresolved. When asked about specific timelines when changes would begin to affect students, a rough guess was the entering class of 2010. They emphasized that these changes are an attempt to adapt what is currently deemed an ineffective learning format, and that school curriculums should be making changes regardless of when the testing will reflect the trend among medical schools.
Sarah said the students enjoyed the breakout sessions, which helped bring new ideas to UF and to demonstrate all of the things such as opportunities to experience rural medicine, and standardization of grading at satellite campuses.
Sarah gave an update from the AAMC – The Committee on Admissions has proposed that all medical schools drop out of the US News and World Report rankings, which has been identified as a major barrier to Holistic Admissions. The GSA Steering Committee is currently creating a ranking working group to create a multiplicity of rankings based on the mission of the medical school (for example, recruit rural providers).
Dr. Robert Hatch: Clerkship Directors – getting ready for their annual retreat. There will be a session on the millennial generation. Dr. Davidson said the Patient Safety curriculum will also be presented to the Course and Clerkship Directors at that point. This curriculum will be voted on at the Curriculum Committee meeting next month. He said he has been talking with Dr. Rarey and the Registrar’s Office to see if you can have a Pass/Fail course that doesn’t have any credits associated with it. There actually is a precedent for that. We’ll discuss that at the next meeting to get voted on and passed. It will be impossible to get the four year curriculum done at once, but this will be a good start.
Dr. William Winter: Dr. Winter said that they discussed in an open forum things that Basic Science Course Directors thought might change and we’re going to continue that discussion today. Dr. Novak is going to report unofficially to the course directors a summary of the meeting at Saturday’s Educational Retreat (June 17th).
Dr. Frank Genuardi: The
biggest change is that
Dr. Kyle Rarey: This is a
time to celebrate and for all of us faculty to look towards our graduates and
be happy and pleased for them as they walk across the stage on Saturday and
receive their M.D. degrees. We’ve been contacted by Dr. Darrell Kirch’s office
in terms of his itinerary. He is
President of the AAMC and will be Saturday’s graduation speaker. He is on a three graduation tour and was
gracious to stop in
1.
Presentation
of the Master Educator Program: Dr. Cari Hernandez:
Dr. Davidson said that for quite a while he wanted Dr. Hernandez to present the Master Educators Program. For those who go to national meetings and other places, there are other programs like this, but over the last couple of years, this program has really flowered. Drs. Kyle Rarey and Andrea Klioze started with meager beginnings and it has grown to be something special and unique for this institution. He said, surprisingly, not everyone knows about it.
SLIDES
Dr. Hernandez thanked Dr. Davidson and the Curriculum Committee for allowing her time to share some information about the Program. She said that four years ago, Dr. Rarey invited her to become involved in Faculty Development and it has become one of the things that has been most gratifying for her; second only to teaching the medical students and being involved with faculty and working in this type of setting.
Dr. Hernandez
said the Master Educator Fellowship Program used to be called Medical Education
Master Educators (MEME’s), so some of the previous educators still refer to
themselves as MEMEs. Dr. Hernandez went
over the objectives of the fellowship, which is a certificate program, its
history, and some of the outcomes that have been collected. She said it is a formal 18 month certificate
program and the goal is to support the educational development of selected
faculty who are extremely interested and dedicated to medical education, who
have been acknowledged for their superior teaching, and who really want to develop
careers in medical education via academics or scholarship. The goal is to create a cadre of educational
leaders and scholars and to promote the scholarship of teaching. As published years ago, the scholarship of
teaching is being recognized as truly academic scholarship and meritorious of
promotion and all that goes with that. The
educators at the
Dr. Hernandez said there are sessions on learning theory, teaching methods, and curriculum development and evaluation. Also, in leadership and organizational change, there is some career development. Fellows are nominated by their Chairs or Division Chiefs. They commit to participate in 80% of the sessions, they also get videotaped with standardized students and carry out a project either in educational research or curriculum development. Dr. Hernandez said that in the most recent cohort when meeting with them during orientation they were given a tight timeline for identifying the research project which is one of the major things, designing it, and submitting it for IRB approval. She said one of the goals for them is to really be prepared by the fall to submit an abstract at the SGEA (regional Southern Group on Educational Affairs) of the AAMC. Dr. Hernandez said they have been successful in getting fellows to present at that meeting and that is specifically one of the objectives. They can also submit to one of their national organizations. Dr. Dave Caro has submitted his to one of the national organizations. Another goal is for them to develop a product that ultimately will be submitted for manuscript publication.
Dr. Hernandez said the program started in 2001. This past year, the program has been enriched by the addition of Dr. Lou Ann Cooper who is the psychometrician of measurement expert. Dr. Cooper has been 40% for our office with part of that time mentoring the fellows. Her participation has been very helpful in terms of the quality of the research. In addition, Biostatistics has provided valuable statistical support, as well as support for consultants and qualitative research. One of the key things this past year in the success of the Fellows has been having this infrastructure in place. Dr. Hernandez said that office support is provided to assist in conducting their projects and submitting things for regional meetings and publications. Travel is provided to meetings that are related to medical education and their projects in the Fellowship.
Data – The
program started with 9 Fellows. The
current cohort is 22 Fellows, giving a total of 64. Most
are Assistant Professors, but we have Associate Professors and full Professors
participate in the program. In terms of
the breakdown, there are 11% for underrepresented minorities; the majority is
from clinical departments and there is good representation from both
Dr. Hernandez asked, “Does this make a difference?” She showed slides looking at valuable outcomes, showing promotion – do Assistants go to Associate Professor, tenure – non-tenured track, do they leadership positions…either leadership in the department as course and clerkship directors, major committees, do they become Assistant or Associate Deans, Residency Program Directors, or major national leadership committees? Data shows in Cohort 1 – 9 who enrolled – 1 has left the college, but 8 are still here, 3 have been promoted to Associate Professor and one to full Professor, 1 is Vice Chair for Education in their department, there are 5 course or clerkship directors, 11 individuals on COM committees, 2 have been promoted to assistant or associate dean, and we had 2 residency program directors from that group, 14 have some national leadership roles. She summarized the data, including publications, curriculum development related to medical education, extramural national and international publications. The most recent cohort, there are 12 SGEA presentations this year (3 oral, 1 demonstration and 8 other abstracts/posters). In terms of presence at regional and national meetings, the Fellows have done very well as well as education manuscripts. She said there were good funding efforts from the different cohorts. Dr. Hernandez mentioned the substantial teaching awards received by the Fellows.
Dr. Hernandez discussed the cost. The estimate calculated for Fellow participation, on average is $5,000 per Fellow. She said that our faculty are our most important resource. The program is cost-effective; it has supported educational scholarship; our faculty are presenting regionally, nationally and internationally. Subjectively, we have improved teaching and objectively, if you look at the number of teaching awards the Fellows have received, they have been recognized for their teaching abilities and dedication.
Dr. Rarey thanked Dr. Hernandez for the overview in terms of where we’ve been and where we’re going. He said that in 2002 at the conclusion of the first cohort, the decision was to step forward with the Master Educator Program. He said that what has been accomplished as a college for the last 3 cohorts is a great job. The second is to thank the Dean’s Office for the support that has been provided for this and that it is an investment from the Dean’s Office. He is particularly pleased on behalf of the College to look around the room and see 5: Drs. Dave Caro, Judy Bowers, Rob Averbuch, Heather Harrell, and Maureen Novak. Dr. Rarey said that these are individuals who found time, made a decision to follow the program, and to contribute back as members of the Curriculum Committee.
2.
Discussion
about the development of “new” curricular additions: Drs. Rick Davidson and Heather
Harrell
Dr. Davidson said that in the last couple of years there have been many questions regarding curriculum additions: Clinical reasoning, patient safety, humanism, end of life care, cultural medicine and competencies, international health, and leadership. Dr. Davidson said that as he reflected over the years of curriculum, he wondered if you put in additions what will come back. He said that regarding patient safety, there has been a strong deficiency for a number of years. He and Dr. Eric Rosenberg reviewed what existed in the curriculum at that point and felt that it is essential that something be done. Dr. Davidson said that Dr. Kone has been very supportive in their being able to accomplish that. Regarding the other additions, Dr. Davidson said that as long as the current curriculum is still active, repositories for adding content are pre-clinical courses; EPC, IFH and the Internal Medicine clerkship. Dr. Hatch said that Family Medicine does a lot of everything. Dr. Davidson said that Essentials of Patient Care has become a repository for important content. He said the question is how much time is available in that course, how much does content taught in that course register with the students, and the same with IFH. If you add clinical relevance to material that is Pass/Fail in the pre-clinical years, that is always a challenge. He said that the changes need to be made in the clinical years as well. He said that experiential learning theories suggest that the students are not going to remember things that are added in the first couple of years. Dr. Davidson said that everything needs to be organized and arranged so that it flows reasonably.
Dr. Harrell – SLIDES - Dr. Harrell said she loves curriculum and has been lucky enough to get involved on both a national and local level. She said she learned a lot of lessons the hard way and that a systematic approach needs to be taken in the principles of curriculum development. Dr. Harrell used a local example that was developed and had a linked outcome; nutrition curriculum. She said that one of the key things is that there needs to be some clear cut justification. A compelling case needs to be made to the Curriculum Committee that all of our students need to have the experience. Dr. Harrell discussed the set up of the nutrition curriculum. She said a task force was formed and the Course and Clerkship Directors were surveyed to get a good idea about what was going on in the curriculum regarding nutrition. Then a survey was developed to specifically see what they perceived as strengths, what they felt comfortable with and what their weaknesses were in nutrition. There was also a needs assessment to gather data with the second year students. She said from that they went to goals and objectives. Dr. Harrell said she visited a program at Harvard to see what they were doing and based on all of that information, the goals and objectives were set up for the program. She said the next step was figuring out the educational strategies – not just another lecture added here and there. She said that it was important to have other disciplines, like a dietician, and that many departments would need to be involved in the delivery. She said at this point she included students who were interested enough to actively participate in the discussion and development of the curriculum. Dr. Harrell said that although there are wonderful ideas, you need to know how you are going to go about implementing those. Traditionally, the Curriculum Committee does not get involved in that piece. She said regarding needs assessment – they were talking about doing capstones and recruited many passionate outsiders; dieticians and different students in a different year. She said they wanted to have a home for this curriculum. Dr. Harrell said she chose this curriculum example because so many of the things that are being discussed about planning in curriculum development follow the same model in a really integrated four year curriculum. Dr. Harrell said the task force started in 2002 midway and the curriculum was rolled out in the 2004 academic year. She said the product was a very thoughtful well done product but the implementation and sustainability was affected by the lack of having a director. She said nutrition still exists but she’s not sure in exactly what form. Some of the material was cut back drastically and she’s not even sure if this year the students received any of the information.
Dr. Davidson said that when Dr. Harrell initially did this, she had 4 half days; 16 hours of content which has now been cut back. Dr. Harrell said, this illustrates the process and has brought home some key issues that are facing us. She said the potential for curriculum change right now is exciting, particularly the change in how the Step process is going to work. She said that Dr. Davidson wanted her to go through some of this process because nutrition is small but shows the kind of things that we’re facing. The framework is going to be a long process. Drs. Davidson and Novak used tobacco in the curriculum as an example.
Dr. Kone said that there is a whole body of potential educators that are residents, attendings, etc. He said attendings should emphasize on rounds the cultural sensitivity, patient safety and other issues. He said that to him, it gives a lot broader breadth to a medical student’s education when they get, for example, cultural sensitivity for unwed mothers, cultural sensitivity to dialysis patients, etc., but there should be elements of that content integrated into already available hours that don’t require didactic time. He said that if we give the attendings and residents on the various services more tools and more of the expectations and measure the outcomes, that a lot more can be integrated. Dr. Kone said the second thing is that we received $4.5 million more recurring dollars and we can go for more next year. To do major curriculum reform requires a lot of money and that he believes it can be done. He said the third thing is what we are supposed to be as a medical school. He said that is probably going to be the most important question as we define what the curriculum is supposed to produce. He said we have proliferations of medical schools now in the State. Are we the best of the same product or are we a different product? What is our differentiating characteristic? Curriculum reform is a huge product; it is a lot of money and will take a lot of vision. Dr. Kone said we have a lot of talent to do it but he thinks one of the fundamental things is going to be what UF will be compared to; UCF, USC, and all the others in the State. Dr. Kone said we have this phenomenal program but everybody in the state is going after our money to develop the exact kind of program. UCF will have it in 4 or 5 years.
Dr. Harrell asked Dr. Kone to elaborate more on his ideas on how we can incentify our faculty. She said there is so much potential for day to day small things that add up to a bigger effect than one lecture. She said that some of them may attend two weeks for the whole year versus some of the core teaching faculty who do it all the time.
Dr. Kone said that first of all he thinks there are two different things. One is the patient service component where you take care of the patients and the other is the actual attending component where you are a teaching physician. There should be certain expectations and requirements for teaching physicians. Dr. Kone said we have increased our clinical faculty by 20% or so and we are still growing rapidly. He said we should be able to provide some expectations for what that is and we’ll probably have more money but that we’re still losing a lot of money. We need $18 million and have $4.5 million, but that’s better than nothing. Dr. Kone said we can actually provide more incentives to cover protected time or having specialists who either shadow and attending or have a separate attending. There are a lot of different ways of doing this but there are two components: There’s the patient service component, getting people in and out – there’s a lot to learn from that. The whole debt flow situation, paid care management is perfect for evidence-based medicine learning, data base learning, patient safety learning; and all of the things being discussed. He said the compensation committee is looking at education incentives; Dr. Mike Mahla’s going to be heading up a subcommittee to look at the educator path for Tenure and Promotions. Dr. Kone said he thinks there are going to be different incentives but the main thing is all of the lost opportunities that need to be shown by the core educators. He said that the length of stay issue and getting out by 10 AM – there are 3 things that we have talked about as curriculum things, database management, the evidence-based learning cause it’s all evidence-based practices that we’re trying to do and patient safety. Dr. Kone said he thinks in order to do a really good job we need to look at every available didactic content hour. He said he thinks we really need to spend more time than we have on brainstorming ways to ease the clinical content hours and make more out of this army of people that are doctors and residents and interns. He said that recruitment of the right people is the essential thing right up front and that there could be a training period before becoming an attending or granted access to students.
Dr. Hernandez suggested that just like there is required CME, there should be required teaching. She said that when you’re appointed to faculty you’re automatically supposed to know what to do on rounds and what to do to teach a small group.
Dr. Davidson said that when he was a junior faculty member starting out at UNC, you were not allowed to teach in any small group course unless they did a 6 hour small group teaching that was run by the Office of Medical Education. They were videotaped the first couple of lectures and then an educational specialist went over them. He said that when he first came to UF he was videotaped giving one of his first lectures.
Dr. Meuleman mentioned faculty not attending faculty development and questioned why every department doesn’t have this as part of their core of medicine grand rounds. He said he could easily see devoting an hour or two hours of medicine grand rounds in using case based approaches. He said faculty development should be a core of lectures and not part of the ancillary stuff.
Dr. Kone said he thinks the continuum of education across medical school and across residency and then CME has to be integrated more because any major curriculum change is going to be dead on arrival if we don’t get the residents and attendings on board thinking the same thoughts. He said that he knows a lot of this has been integrated, like patient safety into GME and CME. He said that you have to exploit this workforce and have outcomes and assessments. Dr. Kone said that every student knows who a great attending is. Was it just their personality or content? We should be able to put together a map on how to do it and provide it to everyone and have that kind of a baseline expectation.
Dr. Rathe said to take the example from Emergency Medicine – one of the issues that he always thought was a key barrier is the idea of seeing what is taught modeled by the clinician so that the closer at the bedside, what do they actually do? He said for example, if nutrition is sufficient and that is obviously a clinical thing then the question he would ask is to see how things on nutrition is actually dealt with on rounds, etc., to discover if that is a medicine deficiency at large and not just in our curriculum. He asked if the attendings and residents are actually doing what we would like them to do as models.
Dr. Hernandez
said that last July faculty development did a needs assessment on the COM
faculty, with Dr. Zenni doing it first in
Dr. Kone said that as the State support has gone down, the faculty group practices have this cross-subsidized medical education and that every year it’s been less than what it was so that the amount of cross-subsidy has gone up – almost 25% a year. Dr. Kone said we don’t have the money to cross-subsidize anything else, so when you talk about all the things you’d like to do and what we should do, think about that $4.5 million that’s less cross-subsidy and that represents our views that are now covered that didn’t have to be generated. Dr. Kone said that in talking about needs assessment, it would be good if students could identify where they thought there was an opportunity and helped figure out how to do these teachable moments. He said it would be a lot easier for attendings if they had a menu of possibilities and tools to use in teachable moments when they come up. Dr. Kone said this goes into a perfect patient safety teachable moment…this is a perfect nutrition teachable moment.
Dr. Davidson said that from his perspective the positive thing about this discussion is that it didn’t focus on cramming things into the first two years, but talking about trying to integrate this into clinical teaching where it will have the most impact. He said the clerkship directors are the population of people working with the program directors that really need to have an impact on how the students are taught on the clerkships.
3. Report on the Educational Retreat DATE –
Dr. Maureen Novak
Dr. Novak said there were 40 faculty who attended the Saturday morning Retreat. She said they took the original principles and divided into small groups with questions developed by Dr. Larry Rooks in how to go through the principles. She said a couple of things that did come up was the ideas that Dr. Davidson and Dr. Harrell brought up about how to add more things into the curriculum when there’s too much already, how do we whittle out what can come out, and how to better integrate. A humane environment for our students was a topic for discussion as well as professionalism. Dr. Rarey said that the group of individuals that were there, weren’t just Course and Clerkship Directors, but were some of our teacher educators who are teaching every day. Dr. Novak said there were no solutions to the retreat and Dr. Davidson said that it wasn’t designed for that. There was discussion on the issue of humane environments. Dr. Novak said that some of the descriptors of the environment were: competitive, cynical, changed personality, and that the worse thing in the third year is still better than the second year. Dr. Kone said that on Friends and Family Day he was startled by how many parents accosted him that the students don’t ever get a break and there’s too much work. He said there was a fair amount of concern. Dr. Genuardi said that one of our third year students talked about the fairly significant number of classmates during the first two years that had to take antidepressants and anxiety medication. Dr. Davidson said that Dr. Kendall Campbell moderated the session about community and team. Dr. Campbell said that every time he sees a UF and Shands commercial on TV that mentions “the science of hope,” he thinks about the people on the east side of town. Dr. Novak said that Dr. Campbell said the medical students are not part of the community and do not have access to the healthcare needs in the eastside and are not taught about that. Dr. Campbell said on the other hand, the students have gone on mission trips and really enjoyed it but we’re not part of providing appropriate healthcare.
Sarah Smith-Vaniz agreed that you don’t get a break and that she felt depressed. She said a student can really lose sight of what they’re learning. She started feeling depressed being in the MDLs with no sunlight.
Dr. Winter mentioned that how well our students do on Boards; especially Step 1 is the result of their hard work. He said that we need to accept the fact that if we back down, which is very appropriate, that we’re not going to necessarily get home runs. He said you can’t get the same without the same. Dr. Winter said that there has been a tremendous pride from many of the deans about how well we’ve done and he believes if a more relaxed curriculum is in place, the students will probably be healthier and better doctors. Dr. Kone agreed. Dr. Meuleman said that there was a change in the top about 5 or 6 years ago both at the recruitment level and the focus of these scores going up. He said the students fed right into that. The average student feels they are a laggard if they are only in the 80%. Dr. Kone said that Dr. Lynn Romrell brought this up to him that whatever we decide is important to do and produce in a student and if we provide feedback to them, we’ll get it. Dr. Davidson said that Robyn Sheppard recruited him to talk to the applicants and he mentioned to the recruits to look at the handout on the scores and that they would see our students do very well, but he let them know that the great scores didn’t mean they would be a good doctor. He said all his teaching life he felt there needed to be less emphasis on grades and he has been pushing for a Pass/Fail for about 11 years because you are emphasizing those things that are important to some but not necessarily important to the kind of physicians we want to train.
Dr. Kone said that when thinking about curriculum changes, to be keeping the new medical education building in mind and what the structure would need to be to facilitate small group learning, etc. He said that when he talked to the people at Emory, they did their curriculum first and used that to form what their building structure was like. In thinking about the curriculum, be thinking about what the ideal structure would be. He said hopefully things will be started on the building this summer.
Dr. Davidson thanked the committee and said
that next month there would be a discussion about the patient safety curriculum
and then to get it passed.