"The ever-renewing organization (or society) is not one which is convinced that it enjoys eternal youth. It knows that it is forever growing old and must be doing something about it. It knows that it is always producing deadwood and must, for that reason, attend to its seedbeds. The seedlings are new ideas, new ways of doing things, new approaches."John W. Gardner. Self-Renewal: The Individual and the Innovative Society. New York; Harper & Row, Publ. 1964, p. 68.
We are experiencing the consequences of rapid changes in the medical/health care field, which pose considerable challenges to medical educational institutions. For some of these changes we are the leaders, for others the followers.
What are the origins of these challenges? They stem from the rapidly evolving changes in the organization of health care, reimbursement for physician services, and financing; the logarithmic increase of the scientific and technology base of medicine; a revolution of information management, among many others.
What has been our response? Faculty and administration of the College of Medicine have responded swiftly with initiatives that deeply affected its various missions. Over the past eight years, upon recommendations by the Curriculum Committee, the faculty approved and implemented significant innovations in the educational program for medical students requiring adjustments by faculty and students. Changes included: (1) a new sequence in the first two years, entitled Essentials of Patient Care, which includes a student preceptorship with practicing primary care physicians, a revised history and physical exam sequence correlated with basic science teaching, a course Keeping Families Healthy, all integrated with the teaching of ethics, and prevention and epidemiology; (2) enhanced integration of basic science and clinical teaching; (3) reorganization of the clinical clerkships to create an interdisciplinary ambulatory care clerkship; (4) introduction of competency-based examinations in the new Harrell Professional Development and Assessment Center; and (5) application of informatics technology to various aspects of instruction and learning. To enable the faculty to carry out these changes several support structures were created, including the College of Medicine Education Center, the Division of Medical Informatics, and a comprehensive student and alumni database 1. As a further important step, the Executive Committee of the College approved a plan for mission-based budgeting; a process by which funding is allocated in accordance with actual performance by individual faculty, educational program units, and departments.
What next? Stimulated by innovative approaches to development of curricula in the U.S. and Canada 2, 3, 4, the Curriculum Committee engaged in a comprehensive review of the curriculum and its conceptual and real life foundations. As a result of this effort, the Curriculum Committee is presenting to the faculty the Educational Program Renewal Plan for implementation.
A set of twelve principles (shown in Exhibit 1) were developed and approved by the Curriculum Committee and subsequently by the Executive Committee of the College of Medicine. The purpose of these principles is to remind us that we strive for high standards for the educational programs, to guide course and clerkship directors in planning and implementing instructional units, and to be used as criteria for program evaluation.
Goals of the educational program are derived from the principles of educational planning. The current goals for the college of Medicine are matched to their underlying principle and listed in Exhibit 2.
The principles and derived goals in Exhibits 1 and 2 have been prioritized and work has been proceeding as described below.
Defining the content of the general professional education is a central task in our curriculum planning. The primary assertion is that there exist a set of knowledge, skills and behaviors that all students must master in order to be eligible for graduation. We have approached this task by articulating a list of competencies, which serve as the boundaries for the knowledge domain of medical school.
The development of a competency-based curriculum is a central theme in our educational plan. The curriculum committee has adopted a set of competencies organized in categories, which describe our educational end product. It lists the complete set of knowledge, skills, and behaviors which we expect all of our graduates to acquire during the educational program. (See Exhibit 3) The competency list serves as the guide for development of course learning objectives and the student evaluation system. The procedure for making the transition to a competency-based system is outlined below:
Competency: A knowledge, skill or behavior which must be demonstrated by medical students in order to achieve the primary goal of the medical education program-the general medical professional education.
Competency Category: A set of competencies grouped around a common theme.
Learning Objective: A competency or competency category utilized in a course as a statement of educational intent. For practical purposes learning objective and a competency are the same. A competency becomes a learning objective when it is utilized to express educational intent in a course.
Clinical clerkship core discipline learning objectives contain two components:
Basic science course core discipline learning objectives should include two components:
The rapid and continuous growth of the basic science knowledge base makes complete coverage of these disciplines impossible and thus requires judicious selection of what is considered essential for future physicians. The clinical presentation model, originally described by Mandin of the University of Calgary Faculty of Medicine 4, provides a rational basis for selecting the medical science base and encourages collaboration of the basic science and clinical faculty in the process of deriving course and clerkship objectives. The rationale of this model purports that the basic science foundation of medical graduates should encompass the knowledge needed to solve the most commonly encountered patient presentations. The use of this model is extended into the clinical years as the core clinical disciplines continue to develop problem-solving skills focusing on the same set of clinical presentations. The Curriculum Committee developed a list of patient clinical presentations, which has been extensively reviewed by the clerkship faculty and the students. It is interesting to note that the listings developed independently by us and the faculty at Calgary are very similar, but not identical. This model serves to guide course directors in determining the specific content of their course. It describes the knowledge base of medical school and links it to a clinical problem-solving context. This knowledge base is labeled Core Discipline Competency in the competency set above. The clinical presentation list is shown in Exhibit 4, and the process of deriving learning objectives and instructional strategies from this listing is described below:
The steps recommended by the Curriculum Committee to implement the clinical presentation model are described in the following:
The faculty should review and, if necessary revise, the clinical presentation list developed by the Curriculum Committee (see Exhibit 4).
Clinical presentation schematics, to be developed by clinical experts, must illustrate graphically the relationships between the major ideas necessary to understand the problem associated with each clinical presentation.
Experts will develop a series of case scenarios that explore different regions of a clinical presentation schematic. The complexity of the clinical presentation defines the scenarios necessary for its analysis.
Using the schematics, basic science course directors and their faculties will develop learning objectives relevant to an appropriate set of clinical presentations most relevant to their discipline. This should ensure that course content is directed toward students acquiring knowledge, skills, and behaviors implied by the schematics. Directors may want to include in their course syllabi relevant schematics to identify ideas on the map to be addressed in the course.
Basic science courses, if they do not already do it, should dedicate some of their scheduled time to small group, case-based discussions using case scenarios developed as described in step 4. To promote incorporation of basic science in the clinical problem solving process students should prepare for the discussions by seeking to answer basic science questions related to the case.
Clerkship directors should choose clinical presentations based on their relatedness to the disciplineŐs clerkship content and the likelihood of encountering the presentations on either their inpatient or outpatient service(s). In addition to their traditional instructional approach to clinical teaching, they should engage basic science faculty, whenever possible, to reinforce scientific concepts relevant to clinical practice.
Two strategies have been employed to address this principle. We have made a structural change to the first two years that will make available more block time for the students to study and learn independently. Phasing in with the class of 2002 all basic science teaching will end by noon with afternoons available for independent study. In addition we are developing new teaching modalities such as computer assisted learning to aid the students in their study.
The faculty should define and model exemplary professional behavior. We began this process by adopting a statement of exemplary professionalism. From this statement we derived a set of professionalism competencies which are included in the master competency list. Students are held accountable for these behaviors and their assessment has become part of student performance evaluation. Some of these behavior characteristics should also guide the selection of candidates by the admissions interview. The statement of exemplary professionalism is presented in Exhibit 5. The professional behaviors derived from this statement are in included in the master competency list under the category of Professional Behavior. We have required all clerkships to assess professionalism as part of their student evaluation plan. We are also encouraging basic science courses to do the same. In addition, we continue to develop curriculum designed to teach and model exemplary professional behavior.
We have for many years had a required rotation in family medicine which stresses the context in which health care is delivered. This principle is also stressed in our Interdisciplinary Generalist Clerkship, which is organized around the theme of general practice. Students rotate in multiple community-based practices starting with a 3-week preceptorship in the first semester of medical school.
We continue to identify and engage our most talented teaching faculty. Our new faculty teaching effort reporting system is able to track educational effort and reward faculty for time and quality. We utilize multiple types of training sites and continue to diversify as the location of health care delivery shifts.
The changing face of health care requires us to constantly reexamine our curriculum. We have added curriculum covering managed care and have improved our efforts in geriatrics as our population grows older. We will continue to respond to contemporary issues in order to prepare our students for the world in which they will practice. We will be developing a lecture series entitled "Contemporary Issues in Medicine" which will focus on the most recent changes in medicine.
The curriculum committee has approved an informatics curriculum plan, which comprehensively deals with an information management knowledge base as well as a menu of information services to add student learning and facilitate patient care.
First year medical students participate in a research project during a one-week experience in the second semester. In addition curriculum addressing the critique of medical literature is offered in the second year. Students also participate in writing several papers as part of their required courses. Mini grants and first summer stipends are offered to students who wish to pursue research interest. The college will continue to offer the MD/Ph.D. degree program for those who which to enter a medical research career.
The college has opened a new clinic on the east side of Gainesville, which will develop a team approach to health care delivery. Students will have the opportunity to rotate through this site. We have also worked with our AHEC program to develop sites, which are multidisciplinary in their approach. We continue to look for opportunities to develop this aspect of our curriculum. Currently we have only a few interdisciplinary sites but intend through our program at the Eastside Clinic to create health care team models, which can utilize in other clinics in the system.
We have long enjoyed a strong student affairs office with a well deserved reputation of student advocacy. We have also created counseling services for medical students as well as an active mentoring and advisor program for students in all four years. The Essentials of Patient Care focuses on understanding and nurturing the self in order to provide caring for others. Students have requested that we develop curriculum and support services to address the issues of death and dying. We are proceeding with their request.
Evaluations must become an integral part of the renewal plan. They must address all aspects of the program and must be designed to achieve identified goals. A special subcommittee of the Curriculum Committee was charged with the development of a comprehensive evaluation plan. Such a plan was presented to the Curriculum Committee and approved in May of 1997. A summary of the plan is shown as Exhibit 6. To design implementation procedures the Curriculum Committee has appointed a standing evaluation subcommittee.
The model outlined above is consistent with our principles of educational program design. Competencies are clearly defined and, next to students learning, the assessment of the program becomes a major focus. The competency categories define the scope of what we consider undifferentiated physicians to be able to do and how to behave in the patient care situation, and the clinical presentations outline the boundaries of content for courses and clerkships. Integration is promoted by focusing basic science content on the clinical presentations.
We are convinced that verbalization and documentation of the vision and values, to which the faculty can adhere, strengthen the quality of an educational program. Moreover, the process of arriving at such documentation contributes to an institutional conscience and memory, helpful to current and future generations of faculty and students. We also believe with John Gardner that renewal is essential for maintaining and enhancing quality. Promotion of innovation and change is not an admission of failure but rather an expression of strength and vitality.