In 1991, the Liaison Committee on Medical Education (LCME) adopted new standards for medical education. Prominent among the new standards was a statement regarding governance:
Institutions must integrate responsibility under the chief academic officer for the design and management of a coherent and coordinated curriculum, and sufficient resources and authority must be allocated to fulfill this function.
Coincidentally, although unrelated to revision of these standards, the University of Michigan Medical School (UMMS) was examining both its curriculum and its system of curriculum management. Under the direction of its new dean, Giles G. Bole, MD, the UMMS began a process of curriculum review that would be completed within one year (1990-1991), and a process of design and full implementation of a new curriculum that would be completed in less than three years (1991 - 1994).
Review of the curriculum revealed strengths and problems. A common theme among many of the problems was the decentralized management, or governance, of the educational program.
PREVIOUS STRUCTURE
Before 1991, responsibility for the curriculum had been delegated to the individual departments. One curriculum committee managed the basic science phase (first two years of the program), and another curriculum committee managed the clinical phase (second two years of the program). Each basic science department was represented on the Basic Science Phase Committee, and each clinical department was represented on the Clinical Phase Committee. A fatal flaw in this system was that the committee members represented their departments. This handicapped all efforts to integrate the curriculum among courses or clerkships, because each department felt it was essential to protect its "turf" (course or clerkship.)
The phase committees reported to an oversight committee, the Academic Affairs Council (AAC). The MC was composed of nine elected members, four appointed members from the phase committees, and three ex-officio members without a vote. The elected, voting members were often not especially familiar with the curriculum. In addition, the AAC perceived itself to have no real authority. Lack of familiarity combined with lack of authority limited the role of the AAC to gathering and evaluating information, rather than managing by using the information to implement curriculum improvements. When recommendations were made by this group, there were no effective means of implementation.
The intent of the at-large elected membership of the AAC was to represent the executive faculty. Ultimately, the executive faculty, according to the regents' bylaws, "owned" the medical school curriculum. However, bimonthly faculty meetings were poorly attended, which made them an inappropriate vehicle for discussing and voting on curriculum issues. Added to this milieu was the fact that income-generating activities--research and patient care--had nudged education to third place among the medical school's priorities; the inertia of the curriculum committees was a reflection of these priorities.
SEEDS OF CHANGE
Dean Bole emphasized education from the start. As an active chief academic officer, he promised support for teachers and teaching activities, and funding for revitalizing the curriculum. He vowed to return education to a top priority and immediately set about doing so by appointing an associate dean for medical education.
In October 1990, Bole and the associate dean appointed faculty members to the Dean's Committee on Curriculum Improvement (DCCI), a blue-ribbon committee created to study the educational program and to identify strengths, problems, and the framework for a new curriculum. Senior, respected faculty were selected and asked to step outside departmental boundaries as members of the DCCI. This was not a standing curriculum committee. It did not have representation from every department, and it was not elected. It was an ad hoc group of senior faculty, chaired by the associate dean for medical education, with a limited term and a specific charge. The committee reported to the dean.
The DCCI accomplished its goals in one year. In October 1991, at a full-day, wellattended faculty retreat, the DCCI presented the framework for a new curriculum that retained the strengths of the then-current program and addressed its weaknesses and problems. Because DCCI members believed that thoughtful and well-supported management of the new program would be essential, they also presented the framework for a new system of curriculum management. At the end of the day, both proposals were supported by more than 200 faculty members in attendance; there were only two dissenting votes.
NEW MANAGEMENT
In the new management structure, the faculty responsible for administering the curriculum have authority to make decisions about curriculum content and educational methods. The associate dean for medical education, who chairs the two major curriculum committees (Component Directors and Assistant Directors Committee, and Curriculum Policy Committee), has the authority to implement decisions. The organizational chart for the curriculum management system at the UMMS is illustrated in Figure 1.
Each year of the new curriculum is labeled a component (e.g., Component II for the second year). The dean and associate dean carefully selected and recruited from among the faculty a director and an assistant director to manage each of the components. These eight faculty members were recruited because they were well-respected scholars and clinicians with tenure who had demonstrated significant commitments to teaching and the ability and willingness to represent the institution rather than their departments. With the associate dean for medical education, these faculty members make up the Component Director/Assistant Director Committee (CD/ACD). This committee meets every week to discuss and make decisions about curriculum issues and to ensure careful planning across the four components. The members world as a team whose goal is to develop, implement, and administer an integrated four-year curriculum for the MD degree.
Policy-level decisions made by the CD/ ACD are forwarded to the Curriculum Policy Committee (CPC), which is composed of the component directors, six faculty members elected at-large, three students, and the associate dean for medical education. The CPC is responsible for setting curriculum policy, which it does based on recommendations received from the CD/ACD. As the CPC endorses those policies, they are returned to the CD/ ACD for implementation.
An example of how the new management structure works involves a recent Component III committee recommendation to reduce two of the eight-week clerkships to six weeks each. A representative for each of those clerkships serves on the Component III committee, each spoke forcefully against the proposal. The associate dean for medical education discussed the proposal with each chair whose clerkship would be affected. One chair agreed to the reduction; the other felt that his clerkship would be compromised unacceptably. When the CD/ACD convened to review the proposal submitted by Component III, they felt it was first necessary to give the chair and clerkship director who were still opposed an opportunity to present their arguments.
At a special CD/ACD meeting, the chair and clerkship director presented a strong and well-planned argument against the reduction that focused on clinical instNction that would be sacrificed because of insufficient teaching time. The CD/ACD countered with a proposal to distribute the "lost" material among the curriculum's four years. This would maintain what all felt was important material would increase its integration, and might actually result in more emphasis on those particular topics.
The proposed third-year curriculum was presented to the CPC and was approved for implementation with cooperation of the two chairs and course directors who had originally opposed reduction of their clerkships.
The CPC's membership is one of the key factors to its success. Component directors offer program and management expertise and are responsible for implementation; elected members offer an institutional perspective that can be provided only by those external to the actual hands-on management process. The associate dean for medical education chairs both the CD/ACD and the CPC. As such he is responsible for the implementation process and provides continuity among the faculty and among the committees.
In approving the new management structure in 1991, the executive faculty delegated to the CD/ACD, the CPC, and the associate dean for medical education full responsibility for curriculum implementation and management. Through the CPC and its subcommittee that evaluates the program, the Curriculum Evaluation Advisory Committee, the executive faculty has a mechanism for receiving feedback about the status of the curriculum.
The structure has worked well for initial development and implementation of the new curriculum, which began in August 199'2, and is expected to continue working well through the remainder of the implementation phase and into the management phase. Component director and assistant director appointments, and elected positions on the CPC, are purposely limited so that newly active faculty can be recruited and enthusiasm and innovation can be continued.
The University of Michigan Medical School has designed and implemented a successful curricular management struccture that also complies with new LCME requirements. This structure places the control of content in the hands of faculty content experts. Decisions regarding instructional objectives and course stryccture are in the hands of senior faculty recruited to direct the curriculum. Responsibility for overall management and funding resides in the dean's office. It is essential to understand that the people involved in the structure are as important as the structure itself, and an appropnate balance of both must be achieved to ensure success.