Present: Dr. Richard Davidson, Dr. Richard Rathe, Dr. Judy Bowers, Omayra Marrero, Dr. William Winter, Dr. Sigurd Normann, Dr. Robert Watson, Dr. Kyle Rarey, Linda Butson, Karen Bodnar, Dr. Tim Flynn, Dr. Margaret Wallace, Dr. Heather Harrell, Dr. Cendan, Dr. Chen, Dr. Ritz, Cynthia Karle, Dr. Meuleman, Dr. Hatch
Student announcements: Omayra Marrero stated that 2nd year classes are doing well and are in their last push before break. They have five exercises in the next eight academic days, which is a challenge. The class has set the date for the Fungus Ball as Saturday, March 31st.
Karen Bodnar stated that she hasn’t seen much of her class because everyone is jet-setting around the country racking up fantastic bills. She says everyone is really enjoying fourth year and making the most of it and that she felt fortunate to go to the AAMC conference. She stated there were some really neat presentations done by students that were part of the new forum, which involves having four or five schools each present a ten minute presentation on some innovative curriculum change they’re having at their school. There were three in particular that she wanted to briefly highlight.
The one she felt would be most applicable to this committee was a program from UCSF called Curriculum Ambassadors. It is a summer program that is similar in some ways to students doing research after their first year of medical school. It has similar funding and stipends for students to work on projects during the summer. The projects are all curriculum reform; students come up with ideas of ways they think the curriculum can improve and they work on that over the summer. She understands that some students at UF have done that and that the online PETA was an example of a project that students worked on over the summer to create new learning tools for their classmates. She stated this is really popular at their school. They get as much advertising for it as summer research does here and there are a lot of students involved. Karen stated that one of the projects a student had done that everyone was excited to hear about was the Timeline of Deans. She said it’s similar to UF’s calendar that the students have access to which gives them lecture times, etc. The student took an online calendar and made it into a four year longitudinal calendar that showed all of the places that different themes came up in the curriculum. She used Ethics as an example, which is scattered throughout the four years. A student could go into their personal calendar to access different lectures given throughout the four years and refer to it again if needed. Some of the other projects were smaller such as a video interactive kidney. The other thing that made this program such a great success was having support from their Office of Educational Technology.
The second program Karen mentioned was Locus from the University of Wisconsin. It provided students an opportunity to deal with communities with underserved populations. The idea of that program is to regain that certain something that students tend to lose during medical school, usually their idealism. They have a fellowship within medical school that accepts 15 students each year who participate in a four year longitudinal elective where they have monthly meetings and semester retreats to try and form a community of students throughout the four years. They meet and have mentors and have lectures on underserved populations and try to keep everyone enthusiastic and motivated during the tough times. They have ongoing projects during their third and fourth years which are similar to our mission trips, as well as other projects to work in the underserved areas. She stated it was interesting to see the how they integrated students between the different classes.
She stated that they had a meeting with representatives from each year at Dr. Watson’s house when they returned from the AAMC meeting. They talked about the curriculum and she stated it was interesting to see the perspectives and ideas that came out.
She stated that they also had something they called clerkships, which don’t necessarily fit what we call a clerkship, at the University of Tennessee. It was on patient safety and quality improvement. It was also longitudinal in that students near the end of spring of their third year start working in groups on a patient safety initiative. They had some didactics that were scattered throughout the spring and formed teams and decided on projects to improve patient safety in their hospital. She felt it was a good way to implement students getting involved in patient safety. Students who don’t prefer a longitudinal commitment can opt to do an intensive one for the fourth year.
She stated there was also a very good program on teaching students interpretation skills and working with medical interpreters. She suggested possibly telling students during the third year orientation how they can access interpreters in our hospital.
Announcements: Dr. Winter stated that the course directors have talked about a lot of different subjects over the last three or four months to include professionalism, faculty attendance at exam reviews, excused absences and exam proctoring. He stated he would like to possibly bring forward the topic of professionalism at the next meeting. Dr. Davidson stated that Dr. Harrell will present at the January meeting, but stated that before that they will have a presentation by Dr. Winter about some of the issues involved in test reviews, etc. and professionalism, which has been a topic of great conversation amongst the course directors.
Dr. Flynn brought attention to today’s issue of USA Today, which had another article concerning how the lack of sleep is bad for residents. He feels we will be looking at yet another push to reduce the number of hours residents can work. He stated there are many people upset about this, but that it’s not going to go away. He also stated that new institutional requirements are being stressed, which include linking patient safety and GME, a topic which has been discussed around here for years but has not gone far. He stated that the ACGME clearly believes that patient safety and resident education go hand in glove. Institutions that don’t demonstrate a strong track record for promoting patient safety and looking at their outcomes are not going to be places where GME can occur. He agrees with linking the continuum of education around the patient safety value.
Dr. Harrell mentioned the relationship between resident’s lack of sleep due to the long work hours and how it may affect their professionalism. Dr. Flynn agreed and stated that has been discussed, as well as the data that suggests that performance falls off when a person has been awake for a long time and the intuitive sense to the public that when they’re tired they don’t feel very good and may make mistakes. Dr. Flynn stated there is a lot of conversation about the professionalism issue, as well as the handoffs and the interface between these things. Right now the thing that seems to resonate the most is that being tired equals errors.
Dr. Harrell questioned the value of residents who take care of patients that they know well while they’re tired versus taking care of patients they don’t know well while they’re rested and awake. Dr. Flynn stated that it’s just going to have to inculcate another ethic; somehow we’re going to have to create a system that allows residents to bond with a patient even though they may not have operated on them, etc. He stated that somehow the system needs to adapt to accommodate it because it’s not going to change.
Dr. Davidson stated that it will be interesting to see Dr. Dewar’s grant applications for his grant program that is looking at issues of quality and patient safety. Several of the titles of those appear to be germane to this discussion. He said we may be able to develop a small research focus in looking at issues here.
Dr. Romrell stated that yesterday there was water damage to our student records. He stated it was a funny coincidence because over the last 10 days he, Dr. Duff and Dr. Watson have had email conversations about protecting our student records. He stated there was a broken pipe on the fourth floor and the water shorted out two elevators and damaged a lot of paperwork and a lot of offices. He stated it caused about 250 records to be severely damaged temporarily. A potential disaster was avoided due to the quick response of the staff.
Dr. Davidson asked whatever happened with the discussions there were after the hurricanes about a centralized storage area for all of the medical schools where all the student records would be safe. Dr. Romrell stated he is on a state task force which is looking at all of the medical schools in the state. He stated that the real answer is that all of the student records need to be digitized, which will be difficult. In a school such as UF where there is an incredibly comprehensive back up system for our servers, we should digitize it and get it mirrored somewhere else. Dr. Romrell stated that UF established a policy three years ago that required records be microfiched. He stated we have to keep it in a format that can be read that will keep up with the technology as it changes. Dr. Rathe stated that the microfiche records can be scanned.
Dr. Romrell stated that they are moving along with students taking the Step 2 exam. They are doing extraordinarily well and will beat last year’s record if they maintain their current pace. He stated they have the highest score yet on Step 2, although they’ll really have to kick it up if they want to beat their performance on Step 1. He stated that this is wonderful reinforcement that we have external measures which show our students succeed beyond expectations. He stated that when the class of 2010 took their subject exams in Human Anatomy and Cell and Tissue Biology they scored the highest scores ever on that exam; the average score was in the 73rd percentile. In Anatomy the percentile average was the 82nd percentile. There were several students who had scores that were literally off the scale. He stated the first year class has a remarkably strong performance. There are a couple of students who will be considered by the Academic Status Committee, although most students are doing very well. He stated we have excellent students, excellent faculty and an incredible environment here.
Dr. Romrell stated that the national board and the state licensing boards are considering revamping USLME Steps 1, 2 and 3. The whole thing is up for discussion right now and they’re considering every option including maybe going to a single exam that would be taken in their first year residency or just before they graduate from medical school. They are meeting with groups of faculty and administrators from medical schools around the country and are gathering information before they have a committee convene and make final recommendations. He stated that they have to be careful when they start looking at changing exams that have become major indicators of the success of students as well as institutions. On our LCME report, the cover sheet for the educational report component is data on pass rates and scores on Steps 1, 2, and 3 and that data becomes one of the measures of how well you’re doing your program. He told them they need to think about this hard and maybe talk to the AAMC and LCME about doing away with the current exam. He states that right now, Step 1 is used as a gatekeeper before students go onto the clerkship years; it’s not the only piece of data used, but it is information which is carefully assessed. If they don’t pass that, they don’t continue through the clerkships.
Dr. Harrell stated that it is also a barrier to any reform because it keeps the curriculum locked in certain materials that may not be relevant. Dr. Romrell agrees that is a consideration, but he doesn’t think we teach towards Step 1 or the subject exams. Dr. Harrell stated that we don’t teach to the exams, but the detail of our basic science curriculum, which is not relevant to the majority of practicing physicians, is totally based on that. The faculty use it as a defense mechanism. Dr. Harrell stated that she is in a unique position in that she was just asked multiple practice questions from these study guides and she didn’t know any of them. The few that she thought she might know she completely disagreed with. Dr. Watson states that these issues are real, but that they actually begin at the MCAT.
Karen Bodnar stated that she is participating in a practice of a new MCAT section of their testing. They asked current students to go to the testing center to take the new section of MCAT to try and gather data on how it works. It is some sort of logic or other component. Dr. Romrell stated this is a new thing they’re proposing to improve student’s communication skills. There are some videos and the students will answer questions about encounters.
Dr. Watson stated that he is glad to have AAMC student representatives. He stated that it has become pretty robust and it happened because we’ve always been so supportive of the AMA students and we’re now trying to put equal emphasis on the AAMC. UF has done the same things that these groups support to include summer projects in education as well as interactive activities.
Dr. Watson stated that he agrees with professionalism training and mentioned that three times as many people attended Dr. Harrell’s lecture on professionalism than usually do. He said that one of the issues that kept bouncing out of there was that at the medical student level we beat it to death with things such as the Academic Status Committee and the Health Science Center Student Conduct Code Committee, but that the residents and faculty, who are their role models, sometimes don’t act as professionally as they might.
Dr. Flynn asked what we plan to do about this because he’s not hearing the complaints. Dr. Watson said that we need something similar to the Health Science Center Student Conduct Committee and a centralized place with some reasonable way to deal with it. He feels that what UCSF is doing has a ring of intuitive sense of having some way to deal with it in a more non-punitive fashion so that you get the culture change. With the students, the intent is not to kick them out of school, but to help them be a better professional and better physician.
Dr. Davidson stated that he thinks Papadakis and Irby (from UCSF) simply don’t allow those residents or faculty to teach students. He feels that it’s not a bad idea. Dr. Watson stated that now because of privacy protection there are all kinds of things that go on that we just don’t know about. He stated it is a system problem and a cultural problem; it starts early in the premed experience and keeps going.
Dr. Romrell stated that the questions Dr. Harrell was asked were from the BSR review books, not the exams. He stated that our students do well and the grades they get in medical school correlate well with their scores on the exams. He stated that our students do extremely well when they apply for residency and that a factor in that are their outstanding USMLE scores. When you look at the success of our students from all levels of the class getting into the most competitive residencies, our students do extremely well. He thinks it is because they excel on these exams. Dr. Watson stated that you would hope that the environment helps.
Dr. Watson stated that we have gotten away from taking oral exams, but that hopefully with the combination of simulators and standardized patients it may become possible again and will be a lot more valid and reliable. He feels we’ll be able to find a better way to evaluate students and stated that Clinical Skills Step 2 Exam is a little step in the right direction. He states there are things out there that we can adapt to, but that it will be a continuum issue.
Dr. Watson stated that at the AAMC meeting he enjoyed the lectures about leadership. He stated that he spent almost an hour talking with Mike Whitcomb and learning about the trials and tribulations of the AAMC going through its current reorganization. He thought Darrell Kirsch’s talk was excellent. They are trying to bring the AAMC back more towards its fundamental role in the education of physicians.
Dr. Hatch stated that the main thing coming up for the clerkship directors is that they’re having an annual retreat where the clerkship directors from Jacksonville get together with the program directors here in Gainesville and get on the same page and strategize for the coming year. They ordinarily do that in June but because of LCME they’re moving it up to January. The mock LCME site visit will be done then to get everyone prepared at the same time.
The issue that he wants to bring up to this committee is similar to what Dr. Winter was saying about professionalism and attendance with students in the first two years. He states that a lot of times there is no clear policy on things that impact third year students. One example is that there is no consistent policy that they’re aware of as clerkship directors with what to do with make-ups for exams, how restrictive can they be, what kinds of policies they can have in place, and what to do with attendance issues. The way they typically approach this is to confer with people who have the institutional knowledge and experience dealing with this, therefore Drs. Watson, Romrell and Rarey come to all of their meetings and they consult with Dr. Duff when necessary. They would like the Curriculum Committee’s blessing to be able to set policies on those sorts of things for the third year students. Dr. Hatch clarified that they’re not requesting specific policies, but the authority to set those policies. Dr. Rathe stated that it would need to be added to the catalog because if it’s not in the catalog it is unenforceable. Dr. Davidson gave an example of excused and unexcused absences during the third and fourth years. Given the fact that the schedules need to be made up in advance, how much advanced notice should a clerkship director expect someone to give them when they come to them and say when they’re going to be gone and why. He stated that they are faced with challenging and humorous situations and that there are times when it is presented to the clerkship directors almost as if it is an accomplished fact. The clerkship directors are not very supportive of that kind of behavior.
Dr. Flynn suggested that there needs to be an oversight from this group concerning the rules that will be developed so that it won’t divert too much from everyone else’s rules. Dr. Watson stated that they just need to complete the feedback loop to the Curriculum Committee. Dr. Rathe stated we need to start by defining the rules, getting them approved and getting them in the catalog. Dr. Hatch stated a lot of it is leave time issues, which Dr. Watson said is pretty much a logistical detail.
Dr. Meuleman stated that he had an interesting issue come up regarding a student missing a couple of days that was already approved somewhere else. Dr. Harrell stated that she understood that most clerkship directors felt they already had written policies in their syllabus about the days off, etc., but that it could be usurped from the larger college. The point was that each clerkship knows their structure. A student may be able to miss a day that they can make up, but if they missed very specific patient experiences, they may not be able to make that up. Only the clerkship director in that setting could know those types of things and it is frustrating if other people tell them they can do this. It was probably felt that our policies are stricter than what the students were used to in the preclinical years, but that is part of becoming a physician. Dr. Davidson stated that they won’t be doing that during their intern year and asked at what point they are expected to become accountable for their clinical responsibilities. Dr. Romrell stated that there has to be consistency; otherwise students may have faculty playing against one another.
Dr. Rathe asked if it should be at the level of the clerkships or if it should be at the level of the third year. He asked if the main problem was that another entity is usurping our rules. Dr. Hatch stated that occasionally students are told things without input from the clerkship directors. Dr. Harrell stated that an example would be student attendance at the AMA meeting, which didn’t get approval through the clerkship directors. Dr. Watson stated that one of the rules which must remain consistent is that the students must obtain permission from the clerkship directors; no one else can approve anything. Dr. Davidson said that he has always thought that was a policy and therefore he didn’t see much reason for changing it. Apparently there have been situations in which that policy has not been followed. Dr. Davidson stated that it may need to be reaffirmed that students, at the discretion of the clerkship director, may be released or may not be released to go to any national meeting or wedding or whatever. It strikes him that the clerkship director is responsible for the education during that clerkship. Dr. Watson stated that there is a straightforward policy that states the clerkship directors have total and complete control over what the students do during their clerkships. The only problem that comes up, which is a problem between the clerkship directors themselves, is that some are more lenient than others.
Karen Bodnar stated that it is pretty well understood by the third year students that in general you have to clear it through the clerkship directors if you have an absence. She suggested maybe setting up specific guidelines for the students to follow so there will be no question in their minds. She stated that the clerkship directors are very understanding in her experience. Dr. Watson suggested that Dr. Hatch may want to provide specific questions and bring them back before the Curriculum Committee so that everyone is clear exactly what needs to be accomplished.
2. LCME update: Dr. Rarey.
He stated that the faculty has done a wonderful job since July of 2005 in compiling data about our educational program, our educational resources, facilities, etc. and all of that data has been compiled and forwarded and is being reviewed right now. It’s now eight weeks until the LCME site team will be here. Phillip McHale is the secretary of the LCME site team and it is his responsibility to coordinate the visit, as well as to make sure each team member receives what they request. We have updated the information to 2005-2006, so there may be something they’d like to see that we may not currently have in there. The site team has received the materials and as of last week we were in contact with Phillip McHale. He has received a proposal from us in terms of what we think the format should be for the visit. We recommended individuals who should be meeting with members of the site team to go over our program. We’re waiting to hear from McHale to verify any changes he may want. In preparation for the February meeting, we will have a mock site visit in January. We will use the template of the February meeting as the January mock site visit where we meet with various members of the educational community and ask questions that we think the site team will ask in February. The steering committee of the Task Force will serve as the mock site team; i.e. Dr. Watson, Dr. Romrell, Dr. Pauly and Dr. Rarey. There is a survey report guide that everyone who is going to meet with the team will have a copy of. The five members of the LCME site team are accountable to provide evidence to the LCME committee in terms of how sound our educational program and educational resources are. He provided example questions such as “Describe the mechanisms used for curriculum planning, implementation, evaluation management and oversight including the roles of faculty committees, departments, and central medical school administration” and “Site evidence as to whether the curriculum is coherent and coordinated”. Those are questions that are being asked and they have to provide answers for the LCME committee. Dr Rathe asked if the proposed schedules are set and Dr. Rarey stated we won’t know for sure until we hear back from the LCME site team members. The mock site visit schedule is basically the same as the proposed LCME visit. Dr. Rarey thinks we are positioned well because of everyone’s efforts in our education community and feels that it’s a matter doing more and above.
Dr. Rarey stated that the LCME had several meetings during the AAMC conference. One topic was that there are currently five standards, three of which are being revised and two new ones. The only one that really impacts us is ED2. ED2 is a standard whereby each of the required clerkships is identified and which types of patients are to be seen by students as they go through the various clerkships. They have taken the word “quantified” out in terms of not looking for the numbers. They want to make sure that it is more important to know what kind of patient encounters the students are requested to have rather than whether they see 3 or 4 patients with a certain illness.
Dr. Davidson stated that next month Dr. Harrell will present an overview of her plan for the fourth year and Dr. Winter will discuss professionalism for the course director’s comments.
The meeting adjourned 8:45am.