May 8th, 2007
Members present: Dr. Rob Averbuch, Dr. Richard Davidson, Dr. Heather Harrell, Dr. Rob Hatch, Tiffany Lacross, Omayra Marrero, Dr. John Meuleman, Dr. Sig Normann, Dr. Maureen Novak, Dr. Louis Ritz, Dr. Margaret Wallace, Dr. Robert Watson, Dr. Lynn Romrell, Dr. Whit Curry, Dr. Bob Cook, Dr. Kyle Rarey, Dr. Frank Genuardi, Dr. Tim Flynn, Dr. Richard Rathe, Dr. Juan Cendan, Dr. William Winter, and Dr. Cari Hernandez
Student announcements: Omayra stated that the second year class will be done in a week and two days. Dr. Watson mentioned that the second year class had a lunch in the MDL where they made food, including males making desserts, for all of the faculty and staff in the first two years that helped them get this far. He told Omayra that was a wonderful gesture.
Tiffany stated that they went to the AAMC conference last week and are trying to find the time to get together to talk about it.
Announcements: Dr. Rarey stated that we have received the written draft report of the LCME site team. The LCME steering committee looked through it Friday and will get it back to them sometime this week in order for the LCME to meet in June and give us the final recommendations. He stated that he counted about 50-60 times that the Curriculum Committee was praised in the write-up in terms of how well it has operated and how functional it is.
Dr. Genuardi stated that a couple of weeks ago they did a workshop in Jacksonville for faculty that are interested in the difficult learner, which was patterned after one that was done here a few months ago. They’re in the process now of establishing a monthly faculty development series for various topics for folks in Jacksonville. May 10th is Research Day in Jacksonville which will be an all day event with both platform and poster presentations mostly from their residents and fellows, as well as a few from faculty. They expect over 100 posters to be presented as well as 5 or 6 different awards to various residents and fellows.
Dr. Winter stated that the course directors are preparing for next year. At the last meeting, Dr. Paul Gulig brought up the topic of what type of expectations they should have for students as far as reading assignments, etc.
Dr. Hatch stated they are also getting ready for next year. Dr. Harrell has been trying to condense our online log information to a more manageable list of things to make it more streamlined and usable. They’re trying to move orientation closer to the start of third year.
Dr. Harrell stated they are uncovering interesting things about what happened after Match Day with the fourth year students. She stated that Amy Roberson has been phenomenal and Dr. Harrell had no idea how many reminders Amy had to send out to students to turn in their work to get grades certified before graduation. She stated that everyone has their grades in now. There are a few people on hold because of independent studies. They are discussing ways to improve some of that next year so that it doesn’t take 10 months to get their independent studies turned in. She meets with Jocelyn Gravely soon about the new elective in procedures that she is designing.
Dr. Flynn stated there is a lot of buzz right now about portfolio-use in GME and the desire to have those portfolios be continuous across the spectrum from undergraduate to graduate to the main certification process that we all have. He’s going to a AAMC meeting on it in about three weeks. The ACGME is going to roll out a portfolio for residents that may be part of an overall plan. Secondly, GME is providing a million dollars for the support of program directors which partially satisfies our need for non-institutional support for program directors. It would be about two-and-a-half times that if you include fringes and other benefits. Thirdly, there are two new requirements for the institutional requirements; one is a policy on disaster planning which speaks not just to training of the other interruptions in healthcare systems to include pandemics or earthquakes or other national disasters but additionally to keep track of records and maintain residency training programs in case of a disaster. There is a policy on interaction with industry, which in his opinion, should be a system-wide policy that affects medical students, residents and faculty. He knows Dr. Watson is interested in this topic and is anticipating that the committee that looks at all three of those aspects will be forthcoming. Prior to that, he will write a policy of some sort that will speak to the residency part of it.
Dr. Juan Cendan got a nice educational research grant for three years for surgical simulation and it’s in combination with the computer sciences engineering with NIH imaging and bioengineering grant to support the development of surgical simulation which the students will take part in.
Dr. Watson stated that the new dean comes on May 15th and we’re all ready for graduation on May 19th and the White Coat Ceremony on May 20th.
Dr. Romrell stated that in the last year we’ve gotten out-of-state tuition and fee waivers for students who come from out of state. It took years to accomplish that and those have been implemented this year. For even a longer period of time he has been working with campus trying to get them to understand that there are medical students who don’t make it through in four years and if they have to extend their medical education they shouldn’t have to pay more tuition than they would in four years. Working with the registrar, he has listened carefully this year and he sent Dr. Romrell an email last evening confirming that we now have full agreement that those medical students who have to extend their medical education because of illness or because they want to reduce the intensity of the first two years will have proportional tuition. They end up paying four years of tuition and fees, but they’ll pay reduced tuition and fees when they take a lesser load. It’s a remarkable achievement and is the logical thing to do.
1. Update on Surgery Clerkship: Drs. Davidson and Romrell. As mentioned in the last meeting, we discussed with Surgery the possibility of making some alterations in the rotations available to third year students. Dr. Romrell will give background data on this and will discuss what will happen with Surgery. We have made some alterations in the clerkship for this coming year and then we will expect Surgery to present something to us next year. The clerkships work out all the details and Dr. Romrell schedules it in his office. He gives the students some choice on the sequence they take through the year because they all have their own biases on which way through the curriculum is the best. Surgery, Pediatrics and Medicine is by far the most popular way to go through the year and then the second half of the year would be Family Medicine, Obstetrics, Psychiatry and Neurology. The second half of the class would do the opposite. They have options for experiences in certain surgical areas. As far as success doing it this way, 72% got their first choice, 14% got their second choice and 7% got their third choice. 93% get one of their top three choices. Students really do get some input into what they’re going to do.
He showed statistics on a Surgery evaluation of what the overall experience was in each one of these surgical areas. He asked if they were learning the basics. There’s a little variation in how well he thinks these various disciplines teach the basics of surgery. In the top three are trauma which everyone who wants to go into Emergency Medicine feels they need to do, and Jacksonville for which the word is out about among students that you get to do a little more in Jacksonville because you have less competition with residents. Looking at the specialties that they get to pick from, over the years through work with the Department of Surgery, we’ve allowed students to do various surgical disciplines both within Surgery and outside of Surgery. Their choices include Anesthesiology, Burn, Critical Care in VA and Jacksonville, ENT Gainesville/Jacksonville, Neurosurgery, Ophthalmology, Orthopedics Gainesville/Jacksonville, Pediatrics Gainesville/Jacksonville, Plastic, Thoracic Gainesville/Jacksonville, Urology Gainesville/Jacksonville, and Vascular Jacksonville, Shands, and VA. It has been very helpful to have Surgery be flexible and allow students to have time. This year the decision was that the department would maintain this option, but none more than two weeks.
Dr. Novak asked if there is any difference in the Shelf Exam scores for the Surgery people depending on what two week period they took. Dr. Cendan stated there isn’t that much difference. There’s a fairly wide variability in the Shelf scores. He stated that the thing that brought this up for them is that last year’s evaluation of the year as a whole was not great. The surgical rotation had the lowest scores across the board. They recognize the value of the sampler plate of all things surgical and it’s nice that they have the opportunity to see those specialties sometime during their years here, but he’s not sure if that needs to come during those eight weeks. They’re challenged by having to teach a five or six year training program in eight weeks of which half of their time is spent on the simplest, easiest rotation that they can possibly get on and go home. General Surgery still accounts for curing 65% of cancers, treating a million diabetics, treating obesity, etc. Surgery is still an important topic and the basic core knowledge of surgery is hard to teach in eight, much less three weeks. In short, they want the rotation to be good, they want the students to get the most out of it, and maybe what they need to agree on is what the value is of the eight weeks of general Surgery rotation from a curricular standpoint.
Dr. Harrell stated we have to word the objectives of a surgery clerkship. She feels that it comes to what the national objectives are for surgery. She stated that it seems like this needs to come from the top down. What are our objectives and how can we best meet these objectives? Some of it may be improving teaching in the existing system, but others may be redesigned. She stated that what’s not clear in her mind is what are considered to be appropriate objectives for a third year level.
Dr. Davidson cut this discussion off because we’ve made a change for this year and he thinks that surgery can evaluate it because it’s increased by 25% the amount of time students will spend on general surgery and they can assess that and determine if that’s an improvement from students only having two weeks available for subspecialty rotations. If we want to discuss this in any more detail in the fall we can do that. Dr. Watson stated that Surgery is going to work hard to make sure that they have sufficient and appropriate sites and better teaching from their faculty and residents.
Dr. Davidson stated the students will be at another subspecialty service, but it will be a subspecialty service selected by and within the Department of Surgery.
4. Subcommittee updates: Drs. Davidson, Hatch and Curry. Dr. Davidson stated that one of his pet projects for several years now has been looking at clinical decision making skills and if this is something that we can integrate into the curriculum. He appointed two subcommittees to look at and collect information about and collect opinions from faculty who are teaching clinical skills education. He stated that he uses a lot of terms interchangeably, one being advanced clinical skills. Dr. Davidson stated that advanced clinical skills to him means the ability to integrate information and to work toward an appropriate diagnosis and management plan. It’s assumed that students pick that up by watching us on the wards. We don’t really evaluate it particularly well. We don’t teach it; it’s not in the curriculum. This has been a challenge for people everywhere. Dr. Curry chairs the preclinical subcommittee whose charge is to review the continuum of clinical skills instruction in the first two years for consistency, content and evaluation. We raised some specific questions and specific issues and we decided that we were not going to rush either of these subcommittees because they were appointed prior to the LCME visit and we knew that everyone was going to be busy. He showed a summary of coursework and a summary of the survey that was sent out to the basic science courses in which they responded about the number and kinds of clinical correlation conferences they have.
Dr. Curry stated that it was clear from the discussions of the group that there’s a fair amount of variety about how much clinical content is built into basic science courses. It sounds like if we wanted a model, Dr. Romrell’s course would be a model where they’ve already incorporated Grand Rounds and focused their teaching around clinical problem solving and clinical issues. One of the suggestions was to simply take that model and try and expand it throughout the basic sciences. There was a lot of discussion about some sort of a weekly Grand Rounds for medical students. The Clinical Continuum Subcommittee is also working on a Grand Rounds for the third and fourth years. The concept would be a Grand Rounds in the first and second year that’s focused on whatever students are learning at a particular point in time. It would have to be interdisciplinary with a clinical focus. The logistics of doing it got rather difficult. There was a lot of discussion about courses being pass/fail or graded. One of the useful ideas Dr. Curry feels came out of that discussion was consideration of including some of the EPC content into basic science evaluation and testing. There are a number of reasons for EPC to remain a non-graded course. The problem is that students then tend to blow it off and it’s not until their third year that they realize the importance of certain things. He stated that students only pay attention to grades in the first two years. We could keep EPC as a non-graded course yet test the students on some of the EPC material on their various tests. There could be questions built in so that students would understand that they are going to be tested and it is going to impact their grade, but still keep EPC a non-graded course. Our next meeting ought to focus on going over the survey and trying to understand exactly what’s happening.
Dr. Curry stated that the students in his group pointed-out that the clinical correlations in the first and second year vary tremendously from course to course. It felt like whatever model we do implement to try and increase clinical correlations needed to be implemented across the entire continuum. There was a fair amount of discussion about using EPC as a way to do that. EPC now is seen as not being particularly well correlated with what’s happening in basic science courses. The feeling was it was relatively untapped as far as using EPC as the vehicle to better bring the clinical correlations out.
Dr. Rathe stated that would solve about five of the basic problems he brought out because all of these faculty are in interaction because of having to coordinate it; it becomes more of a curriculum rather than just spot correlation. Dr. Winter stated that when you make the curriculum cross course boundaries a team could be created that works in all of the courses. Having more people involved is going to make it very difficult to run efficiently. If you have a core group that see themselves as a team it could really be exciting to work across courses.
Dr. Normann commented on the suggestion of putting exam questions on other people’s courses. He stated that was actually done for oncology and radiology in the pathology exam and it turned out to be administratively a very difficult issue. The problem is what Dr. Winter said, they never got the questions on time and they’re faced with having to put the exam together.
Dr. Curry stated that every suggestion that was made in this group was faced with lots of logistical types of problems, so any kind of change is going to be hard. To change anything in this is going to be a difficult path, but there are those kinds of logistical issues with any kind of change that we might consider.
Dr. Harrell asked Dr. Curry to elaborate on why it’s out of the question to make EPC graded. She’s heard that it will make the students more competitive in small groups, but there are so many structured activities and observations and write-ups and skills that could be tested that don’t have anything to do with group interaction that she’s never quite understood why that has to be pass/fail. Dr. Curry stated that Dr. Pauly who is the course director felt strongly that it needed to be pass/fail. Her concern is that interaction in the small groups if it becomes graded would interrupt the dynamics. EPC when it started was a graded course and was a graded course for several years. The challenges with that are that it’s not just interfering or putting competition, it’s that those small groups serve multiple purposes. This varies from group leader to group leader, but having the small groups graded then could change the tone. Dr. Harrell stated that saying having the small groups graded is where we go awry. Dr. Davidson stated that he understands what Dr. Harrell is saying that they could just get a participation grade in a small group and be graded on the basis of other parts of the course, such as in the Harrell Center. He stated that this gets back to the subject of an objective grading system in which first year students have never been subjectively graded. They do not like subjective grading. Dr. Romrell stated that there needs to be another component other than the input from one small group leader. Dr. Rathe stated as a former course director in what used to be called Basic Clinical Skills and EPC I for a couple of years, he always felt strongly that it should be graded. He knows there are structural problems, but the spring PBE is sort of at the same time as you would want to have an EPC final so there’s an issue there, which is logistic and could be addressed. Dr. Curry stated that we’re trying to have our cake and eat it too by having some way to grade but still call it a non-graded course. His experience in a couple of courses has been that if it’s not graded, students don’t take it seriously. Dr. Rathe stated that is human behavior and the way the world works and doesn’t necessarily reflect negatively on students. Dr. Davidson stated there is another way to deal with that problem, which is to make all of the courses in the first year pass/fail.
Dr. Curry stated there was considerable discussion about if there was integration and if you did use EPC to bring the clinical correlations in, there would need to be a lot better interaction with the basic science faculty and course directors. We had some discussion about audience response devices and teaching with students with laptops. There may be some ways that we can do Grand Rounds and clinical correlation-type things using technology better than we’re doing them right now. One of the goals was to get students having more direct patient interactions for histories and physicals and basic history taking physical exam skills particularly in the latter part of the second year.
Dr. Hernandez stated that she feels like students when they finish the first two years still are not going to be as good as they should be on some of the basic skills. She thinks the only way around it is for them to have more exposure to patients. She suggested one of the ways to structure it is that they have inpatient encounters and time in the Harrell Center. She stated that the students in EPC 4 are still afraid to touch and move patients. She feels we need to make sure that the fundamentals are in place before we add on other things.
Dr. Davidson stated that at one point he remembers that they were seeing five to seven inpatients second semester second year. It is now down to two patients.
Dr. Watson asked Dr. Curry what his average daily census is in Family Medicine at AGH. He stated it is about 100. Dr. Watson asked how many students going through this actually go over there to examine any of those patients. Dr. Curry stated that none of them do. Dr. Watson doesn’t feel that we need to hire coordinators; he thinks it’s an attitude problem. There are approximately 100 patients over there in Family Medicine and somehow we have this mindset that we’re going to need to find the sickest people possible. He stated that we have this tremendous resource and it escapes him why we don’t utilize it.
Dr. Davidson stated that with regards to EPC, he wanted to get some ideas that we can propose to EPC. He thinks that the first year EPC course works very well, although he’s not as sure about the second year. It’s very difficult to integrate all of the stuff that goes on in the second year with the Clinical Diagnosis course.
Dr. Harrell stated that every year in the debriefing of EPC I and II the same issue comes up that is never addressed. She agrees that the small groups in EPC I and II work very well and there’s a lot of good curricular things that happen there, but for some reason our medical school, unlike almost every other one in the country, chooses to teach higher order pertinent SOAP notes first and then go second to the basics of how to do a full history and physical. It creates confusion every year because you’re asking them to go from higher order to lower order.
Dr. Davidson stated that this is a work in progress and we will involve EPC course leaders because they, as well as the basic science clinical correlations, hold the key to developing some kind of longitudinal clinical experience that will better prepare the students to start their third year.
The meeting was adjourned.