Dr. Powell stated that we have an exciting day ahead of us and was looking forward to hearing new ideas and opportunities.Dr. Greenberger outlined the day: Drs. Bonaminio and Greenberger would begin with a perspective of where we were, where we are and where we are going, four discussion groups with two leaders per group would follow, at noon there would be a presentation by Dr. Jordan Cohen, President of the American Association of American Colleges (AAMC), after lunch the small group leaders would present the results from their small group discussions, and at the end of the day, Dr. Cohen would provide feedback.
Dr. Bonaminio provided the background of the changes in governance structure from 1992. The Education Council was implemented in 1992 to establish policy and provide oversight for the curriculum. The committee is constituted of faculty from courses and clerkships.The Year 1-2 and Year 3-4 Oversight Committees were also established. The Office of the Executive Dean and departments were responsible for implementing the curriculum. The Medical Education Support Unit (MESU) was established in 1997. It coordinates/supports educational committees, Introduction to Clinical Medicine (ICM) courses, Standardized Patient Program (SPP), outreach educational activities and assessment and evaluation. A couple of years ago, MESU was officially changed to the Office of Medical Education.A Curriculum Planning Committee was created in 1994. In 1996, the Faculty Council approved the new curriculum. The first and third years of the new curriculum were implemented in 1997 and the second and fourth years in 1998. Under development is a competency-based curriculum that clearly identifies knowledge, skills and attitudes/behaviors required of all medical graduates.The URL for this document is http://www2.kumc.edu/mesu/SumComp1.html.
Some of the themes for curriculum renewal included
The following planning resources are needed
To implement change, the resource needs include
* This document has not been edited to preserve the full impact of the discussion that took place.
Strategies Used
Evaluation Methodologies
Additional Curriculum Innovations
The Clinical Skills Assessment using Standardized Patients to evaluate fourth year students is overseen by Drs. Joe Gladden, Director and David Virtue, Coordinator for the Kansas City Campus and John Dorsch, Director on the Wichita Campus.The plan is to repeat this assessment in the fall. Each course/clerkship undergoes a comprehensive systematic course review every 3 years.Course directors are required to complete a questionnaire and must provide their syllabus and copies of their course evaluation results. A subcommittee reviews all the information then writes a report that includes the issues, concerns and recommendations. Oversight committee membership includes the course and clerkship directors.Dr. Powell initiated the Academic Societies to help medical students with professional development and career programs.Dr. Greenberger organizes the Advanced Diagnostic and Therapeutics elective that revisits the basic science courses in the fourth year. It is offered twice a year with twenty or more students enrolled in the course.
The USMLE results were discussed and faculty raised the issue of whether we are going in the right direction. Dr. Bonaminio emphasized that the USMLE is only one measure of knowledge and it does not assess skills.KUMC graduates are good at history taking and interpersonal skills according to residency director evaluations that are done by the OME as well as results from the Clinical Skills Assessment (CSA).Dr. Gladden will be meeting with clerkship directors and chairs to discuss these issues. The computerization of the USMLE exams may have had an impact.Dr. Bonaminio stresses that it does not mean that we are bad teachers, but the increased failures could be due to multiple reasons. Some of those reasons could include the delivery of material, content or testing methodology.The SoM curriculum may need to be more integrated and include more computer-assisted instruction. Dr. Bonaminio announced that the USMLE would allow faculty to review the exams at the testing sites.Wichita is a testing site, so faculty could log on as a student and take the exam. The Academic Committee and Education Council are looking at data regarding the issue of NBME exam failures. Dr. Meyers has a board prep program this year.Questions have been raised whether the board failures are because of the curriculum, admissions criteria or both. The Offices of Graduate Medical Education, Student Affairs, Admissions and Medical Education are working together to gather the data. A suggestion was made to have a session at the Faculty Retreat regarding this issue.
Dr. Greenberger reviewed all the required courses and clerkships offered and their directors.A survey was sent out to the course directors related to clinical correlations and 10 responded.About half considered the number of clinical correlations about right, about half and too little and half felt the quality could be improved, but no suggestions were provided.Course directors also responded yes to specific requests for topics to add to the clinical correlations.Radiology would like more radiology input and Biochemistry would like more input on cancer topics and collagen disease.Redundancy in the curriculum with a content analysis within courses is critical. Medical students think in the “least testable unit”.They are not growing as learners, but need to be lifelong learners. Students do not take integrated exams. They are not exposed to diagnostic reasoning skills and are not able to expand their thinking. Some of the basic science materials are less useful than expected in the clinical years.The barriers include faculty time with increased pressure on clinical faculty to generate more money and departmental control over courses. The better-rated courses have fewer (3) faculty teaching. Basic science faculty are discouraged from putting more time into teaching due to research activities.Another obstacle is that some departments are unwilling to change. The problem needs to be looked at the problem from a systematic approach.
According to the AAMC Graduation Questionnaire, only 50% of students feel prepared for their clinical rotations. Pathology and Pharmacology have received excellent to good ratings from over 85% of students for the last 3 years. This past year, Dr. Greenberger integrated material in Physical Diagnosis and Pathology for 3 weeks.Many students contacted him wanting to know what material would be on which test. Dr. Greenberger discussed the different views for integrating curricula, which include fragmented, connected, nested, sequenced, shared, webbed and threaded.
Fragmented
Connected
Nested
Sequenced
Shared
Webbed
Threaded
In preparation for the ADT elective, a planning committee was set up. The course had 31 faculty from 12 departments, covered 20 topics and emphasized evidence based medicine. It had a large syllabus that contained journal articles.Students and faculty gave suggestions for improving the course, but overall the students liked the course and thought the format worked. The working groups need to look at improving integration and discuss the different methods.Another key point is how to change the culture from how students currently operate. A schedule has to be the focus, but it doesn’t have to be in concrete.
Issues for discussion in the working groups include:
Dr. Dismuke discussed population health issues.Patients can be identified in many different ways or “populations” such as managed care company, disease type, and other form of insurance, age, uninsured, Medicare or Medicaid.
Question is: Do you believe that the time devoted to your instruction in the following areas was inadequate, appropriate, or excessive?
| Question | Inadequate % (Kansas %) | Excessive % (Kansas %) |
|---|---|---|
| Literature reviews/critiques | 23.5 | 0.7 |
| Decision analysis | 20.8 | 0.0 |
| Role of community health and social service agencies | 18.2 | 6.1 |
| Clinical epidemiology | 13.4 | 4.0 |
| Biostatistics | 16.8 | 5.4 |
| Health issues for underserved populations | 34.2 | 3.4 |
| Risk assessment and counseling | 21.5 | 1.3 |
| Occupational medicine | 39.6 | 4.0 |
| Care of hospital patients | 4.0 | 2.0 |
| Care of ambulatory patients | 4.0 | 14.8 |
| Evidence-based medicine | 16.1 | 2.0 |
| Interpretation of clinical data and research reports | 19.5 | 0.7 |
| Cultural differences and health related behaviors/customs | 46.3 | 0.7 |
| Culturally appropriate care for diverse populations | 51.7 | 2.7 |
| Cost effective medical practice | 47.7 | 1.3 |
| Quality assurance in medicine | 44.3 | .07 |
| Practice Management | 65.8 | 0.0 |
| Medical record-keeping | 55.7 | 0.0 |
| Managed care | 60.4 | 0.0 |
| Subject Areas | ||||
|---|---|---|---|---|
| Clinical Prevention | Quantitative Methods | Health Services Organization and Delivery | Community Decisions of Medical Practice | Totals |
| 293 | 40 | 37 | 23 | 393 |
| Numbers represent the number of times a topic was considered by students to be covered in that course | ||||
| Courses Evaluated | ||||
| Medical Genetics | Clinical Sciences I | Clinical Sciences II | Physical Diagnosis | Pathology |
| Preceptorship | Family Medicine | Obstetrics and Gynecology | Medicine | Geriatrics |
| Pediatrics | Psychiatry | Surgery | ||
The Future is always uncertain
21st Century Challenges
Citizens are becoming more knowledgeable.He noted that 75% of all health care expenditures are from decisions made by a physician.It is a major responsibility of physicians to realize that health care costs will increase. More families are multi-racial and multi-cultural.Information technology will continue to grow. It will affect patient-physician interaction, gathering information, and communication. The transforming influence of human genomics and education of these responsibilities also plays a factor. Trust in the doctor-patient relationship.Commercialization of medicine has also played a key role in undermining the value of medicine and the trust of doctors.An increased quality of service needs to be a high priority. Physicians must protect the patient and their interest and deal with the negative sides of commercialization.
Dr. Cohen suggested that we try to prepare students to meet these challenges.Things are changing in the health care system and therefore need to change within medical education.
Shifting Paradigms in Health Care
| The individual | The community |
|---|---|
| Cure of disease | Preservation of health |
| Episodic Care | Continuous care |
| Physician provider | Teams of providers |
| Paternalism | Partnership with patients |
| Provider Centered | Patient/family centered |
| Anecdotal Care | Evidenced-Based Medicine |
| In-patient focused | Ambulatory/home centered |
| Individual Accountability | System accountability |
With the shifting paradigms, the individual needs to recognize, diagnosis, treat and preventCure of disease versus preservation of health will be an important issue. Students need to prepare for this different world. Patients demand more participation in the way they are treated. Managed care has taught us to be more customer-friendly with the patient and family. With EBM, medicine is more systematically clear and robust systematic approaches as a way of gathering information have increased. Students should be aware of the effectiveness. With the advances in technology, more care is done in the home and patients can be monitored at home. Medical schools need to inform students how to interact in preparation for the future.
Shifting Paradigms in Medical Education
| Passive “spoon feeding | Active, student directed |
| Rote learning | Curiosity driven, PBL |
| Regurgitate facts | Demonstrate competence |
| Organ pathophysiology | Genetic predisposition |
| Departmental courses | Interdisciplinary segments |
| Etiology of disease | Determinants of illness |
| Physical Examination | Comprehensive clinical skills |
| Curriculum structure | Learning objectives |
Passive “spoon feeding ” learning is where students sit in lectures for hours covering tons of materials. More active, self-directed learning helps the students learn better.EBM makes good adult learners.Rote learning is becoming more curiosity-driven with problem-based learning (PBL) and problem solving.Instead of regurgitating facts, students need to able to demonstrate competence and perform skills.It depends on the individuals’ perspective in how they interact with the environment. Department courses, which are artifacts of history, have shifted to interdisciplinary segments. The main challenge to obtain this type of learning environment is time.Students are not confronting problems in disciplines when they are encountering their patients.The determinants of illness/health have replaced the etiology of disease. Factors of this include lifestyles, socioeconomic and racial consequences. Curriculum structure has absolved into learning objectives.Adults need to learn skills and need to know what is expected of them. Learning objectives are given ahead of time. One of the challenges will be organizing the students’ culture.
Contemporary Issues to be Embedded into the New Model
Who owns these topics?
Dr. Cohen quoted Daniel Burnham “make no small plans; They lack power to stir men’s souls.” He recommended that we don’t tinker around the edges and that we think creatively.
The inoculation of habits of life-long learning is one of the biggest challenges as educators. The school needs to preserve what is enduring. Educators do a good job and should take pride in the gifted group of physicians.Faculty should have the freedom to do private office activities with good outcomes. We need to re-engineer commitment to increase standards.
The question was asked about how big a role the culture plays in medical education. Dr. Cohen replied that it absolutely plays a part. The department structure is valid for many reasons, but the main reason should be because of student learning not history. Students want to learn medicine and how to deal with patients.Patients do not come in with labels.Dr. Cohen suggested that the first thing to do is identify what is expected of a student to obtain a MD degree at KUMC.A layout can be done of the consensus of objectives and assessment of those objectives.
How do we get there:
Solutions
How can we do this?
In conclusion, time costs money and it will take faculty time to create an integrated curriuclum.
A student stated that we are selling students shorts when we say grades relate to popularity. Student evaluations indicate that 40-50% of students feel the curriculum is not well integrated.Pathology grading scale was altered this year, which created a neurotic environment. Students are not automatically equipped to be a physician.They do not know what is needed to become one. We have multiple methods of teaching, so we should also have multiple methods of evaluation. Some of the most rigorous courses are rated better. Courses with better grades are not always the ones rated better.Then the discussion centered on the section on the curriculum evaluation summaries where students can write anonymous comments. Faculty names are removed. One reply was to have thick skin regarding the comments.A proposal was made for the faculty to use peer evaluation using a standardized form that would give faculty more feedback about their performance. It would be used formatively not just for Promotion and Tenure or at the end of the semester. Preventive Medicine has a form and Cell and Tissue Biology also has peer evaluation.Other models are also available.One comment was made that they like the concept of the students being life-long learners and to continually be self-educating. Students have so many lectures and small groups that they don’t have enough time to study.Students need to be taught to be independent learners. One request has already been made to have one body of educators to focus on this integration and for them to be able to be promoted solely on being an educator. We are facing a revolution versus an evolution. KUMC has to be ready to change.Leadership (Deans and Chairs) need to help the course directors. The clinicians are under a lot of pressure to see patients and make money.The faculty need to support this effort as well as the planning for it. It will take a lot of time. A commitment needs to be made to make this kind of change. Objectives are needed and expectations of what KUMC expects of students to graduate from the basic principles to the skills.Competencies are fundamental to start the process. The focus should start with the content. Students need direction.The report will include the doable things, make things better, integration, communication and content.A proposed solution will be made to the problems mentioned today. The grading system and the class size is hard. Dr. Powell responded that the State of Kansas requires us to have a certain number of students to get funding. If we ask to reduce the number of students, the State will reduce our funding and state budget. Several mentioned resources, but we need to face the fiscal realities. Another suggestion was made to evaluate the curriculum and to define what is expected from a student. We need to explain why we need to have a revolution with the curriculum.A measured base line is needed to make change. Evaluation up front should be done prior to measuring the outcome. Dr. Paolo has begun analyzing the Clinical Skills Assessment (CSA) that was required for fourth year medical students. A performance evaluation could be done at the end of each year or in courses/clerkships with standardized patient assessment that would give summative feedback, but it requires funding. A lot of things can be done with clinical evaluation methodology.In one year, the clinical skills lab will be available. It will have 14 rooms. If anyone would like information of how and what to measure, they can contact Dr. Giulia Bonaminio. The Office of Medical Education (OME) and the Standardized Patient Program help with the summative exam, geriatrics clerkship and Clinical Skills in the first year.The Summative Competency document and appendices, which are being worked on are good starting points.
Dr. Cohen commended us that we came together to discuss the situation and indicated that this is half the battle. It also means that we take education seriously. He commented on where KUMC is as a school on curriculum reform/innovation. He feels that we are a traditional school. Dr. Cohen suggests that we charge a small group to look at other schools to find out what they are doing in regards to innovations. The AAMC can assist us with a list of those schools. We seem more dependent on a lecture format than other schools. It is simpler, but we should look at other modes of teaching.Some are more expensive.We should look into more self-directed teaching and motivational learning. The summative competency document is a good starting point with more specifics. Dr. Cohen was not sure of the Information Technology structure here, but should use more computer based testing than paper-pencil. The USMLE is a tough issue.Residency directors do use the scores as a screening mechanism. He advises that we be careful about taking that observation and organizing the curriculum toward that goal. It should not set the curriculum and he personally believes the USMLE exam should be pass/fail. We should look at the content, distribution and assessment tools.The best approach to medical education is not to have a parade of stars. It is better to have a smaller group of faculty teach in a course. This helps students develop a relationship and is a more consistent approach.An academy of educators was suggested.It is a good idea to have a core of teaching faculty that can dedicate more intensive time for the curriculum.It was suggested that we get a different consensus on the objectives and identify real accountability.A central authority is needed, which should start in the Dean’s office. A few schools have department accountability to do things, then the clinical years are multidisciplinary with different disease states and research activities cross disciplines. Dr. Cohen urges KUMC to think about it. It will be revolutionary and the institution needs to be ready. In looking at the future, it looks very different from today.If KUMC decides to stay in the traditional mode, the question that will need to be asked, “Will we be compatible using the old apparatus with a different future coming?” Dr. Powell is surprised and pleased with the wonderful discussions and stated that this is the best retreat so far. She commented that we had reflected on things and were ready to start the process. She feels that Kansas is ready for a cautious revolution.After the Faculty Retreat next Fall, we can start talking about initiatives. She is ready to support and join us in the revolutionary process.
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