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Summary of March 11, 2004 CME Minutes

  1. Comments from the Chair

Dr. Murray Altose welcomed Dr. Lindsey Henson in her new position as the Vice Dean for Education for the Cleveland Clinic Lerner College of Medicine and Dr. Robert Daroff as the Interim Vice Dean for Education and Academic Affairs for the University Program.  He also welcomed Year IV student representative Mr. Jim Lan in town for the month of March and able to attend a CME meeting.

  1. Report from the Student CME

Year IV temporary student representative Mr. Kimathi Blackwood relayed fourth year recommendations made to Dean Horwitz, specifically, that the first two years be shortened to expand third year options for exposure to areas relevant to early match.  This configuration allows students 1) more time to prepare for the USMLE Step 1, and 2) exposure to opportunities useful for early match.  Case is currently working on restructuring the third and fourth year clerkships without shortening the first two years that will nevertheless provide more flexibility for desired options.  Mr. Blackwood also mentioned student support for establishing “strongly suggested” electives in necessary areas such as radiology, as physicians need familiarity with imaging.  The administration’s endorsement of such electives could lead to better structuring and organization of the electives and help to correct the variability in quality.

Year II student representative Mr. Jason Garnreiter provided an update on the voluntary shadowing program, where a Year II student shadows either a Year III or Year IV student.  The pilot starts this weekend in the Medicine rotation at University Hospitals.  If the pilot proves successful, the intent is to expand the shadowing program on a voluntary basis to the whole Year II class next year.  Mr. Garnreiter emphasized that students will carefully evaluate the pilot to determine how well it was received not only by students but also by the attendings and residents.  The objective is to make the program as unobtrusive as possible.

  1. Comments from the CCLCM Vice Dean for Education

As of March 1, 2004, Dr. Lindsey Henson became the new Vice Dean for Education for the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University The first class of the CCLCM consists of 30 students who will start July 6, 2004.  Orientation will take place July 6 through 9.  Monday, July 12 is the start of the Year I summer research component, which precedes the PBL organ systems curriculum.  There will be a joint white coat ceremony for both the College and University Year I students on Sunday, August 8.  The LCME limited site visit to the College will take place September 12 to 15.  Dr. Henson is currently compiling the LCME database for the Year I and Year II curriculum, admissions, faculty affairs, and other aspects of the College Program.  The database is due to the site visitors in mid-July.

Dr. Henson devoted the remainder of her presentation to explaining the process for assessment in the College Program.  She recognized Dr. Elaine Dannefer as the person in charge of student assessment for the College.  Dr. Henson distributed a handout delineating both assessment principles and competencies and containing a Year I pyramid of the student portfolio system progression and a Year I course schedule indicating competencies assessed.

Dr. Henson began her discussion of assessment principles (formally presented to the Committee on Medical Education March 27, 2003) by stating that the goal of the College Program is to train M.D. researchers.  Each College student conducts a 12- to 15-month long independent research project.  Students must be able to assess their own strengths and weaknesses.  The entire College curriculum—basic science, clinical, research—involves student-directed learning.  Assessment at the College consists of students collecting evidence of their learning in portfolios. Mastery learning is individualized in that the time period varies from student to student, depending on how long it takes the individual to master the competency.  Progress is based on competency assessment, not grades.  No grades are given in the Year III College clerkships.  A challenge will occur as both College and University students will be in the same clerkships but assessed differently.  Currently, there exist highly variable assessments in the clerkships.  In response to correcting this variability, faculty development on assessment is planned to take place over the next few years.

Dr. Henson next delineated the nine competencies expected of College students.  These were derived after examining the 6 ACGME (Accreditation Council for Graduate Medical Education) core competencies, which reflect a shift from process-oriented accreditation to demonstration of competencies.  College competency mastery sets high standards, definitely exceeding minimal levels of accomplishment.  Students are assessed on each of these competencies:

  1. Research – This is the focus of the College.

  2. Medical knowledge in the basic, clinical, and social sciences

  3. Communication

  4. Professionalism

  5. Personal development – Note that professionalism and personal development are separate competencies.

  6. Clinical skills

  7. Clinical reasoning – Note that clinical skills and clinical reasoning have been divided into two separate competencies.

  8. Health care systems

  9. Reflective practice

A “final competency report” designating the student’s achievements in the nine required areas will be furnished to program directors when College students are applying for residency.

Students are in charge of their own learning.  A pyramid diagram distributed at the CME meeting explains how the student portfolio system works. Students begin by collecting their evidence database pertaining to accomplishments in the following areas:  research, organ systems, and clinical.  Students begin compiling their e-portfolio with the start of the first research summer.  Students continue to collect and manage the evidence via an e-portfolio throughout medical school.  Each student has a physician adviser, who is not an evaluator.  To ensure ample advising time, the ratio is one adviser to four students.  Students receive informal feedback from the physician adviser electronically or during regularly scheduled appointments.  Students meet with the physician adviser for formative assessment three times a year.  For this meeting, students prepare 1) evidence from their e-portfolio demonstrating progress in achieving the designated competencies, 2) a reflective essay on their continuing development into a physician and researcher, and 3) learning goals accompanied by written learning plans for the physician adviser’s approval.  Summative assessment takes place at the end of each year, as students prepare a Summary Portfolio for the Promotions and Review Committee (a body similar to the University Program’s Committee on Students) that determines if the level of achievement in the nine competencies warrants advancement to the next year.  The final competency report indicating achievement in the nine competencies acts as the equivalent of the “Dean’s Letter.”

Dr. Henson responded to discussants’ questions regarding the distinction, if any, between “competency” and “mastery.”  She explained that the “competencies” reflect high standards and student performance must exceed the bare minimum.  Dr. Henson described the College environment as “ungraded” graduate school, which, like regular graduate school, requires solid performance in every area.  Outstanding students may be recognized via 1) letters of recommendation, and/or 2) the thesis committee.  The portfolio system concept as used in the College derives from Dundee and Peninsula in the UK and Maastricht University in the Netherlands.  There exists a scholarly literature around this assessment process, and we are consulting with experienced people.  A grant has been submitted to the Cleveland Foundation specifically to bring knowledgeable people to collaborate with us.  ICM will be similar on both campuses and all students (in both the College and University Programs) will study together Tuesday mornings in small groups in a new course being designed called “Science of Clinical Practice.”

A grid of the student portfolio for Year I distributed at the CME meeting designates the schedule of research and organ system components with a gradual incorporation of all the nine competencies by the second to the last organ systems course.  The ninth competency, reflective practice, runs throughout the entire first year.  Students continually collect assessment information.  They use this evidence database of competency mastery to write reflective essays on their development as a doctor and researcher and to formulate learning plans.

Dr. Henson emphasized that the electronic portfolio system is an innovative approach to assessment, and it will be systematically evaluated to monitor how well the system is working for us.  The excellent student/teacher ratio is intended to ensure fast intervention so that a student does not fall behind on remediation.  There are only six or eight weeks for the College student to remediate.

Dr. Henson addressed discussants’ questions.  She hopes that the Clinical Transaction Portfolio Project, a grant financed by the Macy Foundation and administered by the New York Academy of Medicine and the Association of American Medical Colleges (AAMC), will lead to results that can be incorporated into the College portfolios, when these students enter their third and fourth years.  The College portfolios are a more comprehensive project than that project, which uses one adviser for six or eight students.  When asked how the College research project compares with Dr. Horwitz’s vision for the University Program, Dr. Henson described similarities and differences.  College students spend between 12 to 15 months on their independent research project during a five-year program.  The University Program requires some substantive research within the four years of medical school from each student.  Dr. Horwitz hopes that some students will become so enamored of their research project that they decide to spend five years in medical school without added cost.  However, the University Program’s M.D. thesis is designed to fit within the four-year framework.  Dr. Henson confirmed that College students will have completed a master’s level thesis along with their M.D.

  1. Basic Science Curriculum Report on the Cardiovascular Committee

Dr. Robert Harvey, chair of the Cardiovascular subject committee in Homeostasis I, distributed an outline of the committee.  He provided a description of the committee’s content and format and highlighted recent changes and plans for next year.  Cardiovascular is a concentrated committee consisting of 43 hours during a two-week period.  Dr. Harvey indicated the allocation of hours dedicated to each of the following formats:  lecture, lab, small group, and exam—for each of the following individual components occurring during cardiovascular:  Physiology/Pharmacology, Histology, and Anatomy. 

When Dr. Harvey took over as chair of the committee, the cardiovascular interim examination was combined with that of the subsequent pulmonary committee.  This arrangement caused problems because, in addition to the pulmonary committee, Christmas break came between when the cardiovascular material was taught and when the exam was given.  Furthermore, the combined exam contained both histology and anatomy practicals.  This arrangement appeared to adversely affect the student’s performance on the cardiovascular exam.  This year the exam was changed so that cardiovascular was a separate exam no longer combined with pulmonary.  In addition, the cardiovascular exam was no longer tied to a histology or anatomy practical exam.  A significant improvement in cardiovascular test scores occurred.  The mean on secure cardiovascular exam questions rose from approximately 70% to 86% this year.  Furthermore, student comments reflected approval for this change. 

In spite of losing hours, which necessitated reducing the number of lectures, the amount of material covered was not changed.  Two lecturers deliver approximately 75% of the material. 

Dr. Harvey feels the cardiovascular committee integrates well within the committee and with other committees—it builds on material in previous committees, such as biochemistry, cell physiology, and neuromuscular, and it has ties to what follows.  How blood circulates through the organs is the thrust of many committees.  A cardiac patient is presented in Year I ICM (Introduction to Clinical Medicine).  The cardiovascular committee also integrates well with the cardiovascular pharmacology lab that is part of the Fundamentals of Therapeutic Agents (FTA) committee.  In addition, Year I cardiovascular is solid preparation for the Year II cardiovascular committee in Homeostasis II.

Dr. Harvey highlighted recent changes:

  1. Separate cardiovascular interim exam (no longer combined with pulmonary)

  2. Inclusion of a post-exam review

  3. A computer simulation lab that allows viewing the cardiac cycle and pressure volume loops in both an isolated heart and an intact heart model has been in place for the past two years.  The simulation offers the student the capability to return at his/her leisure to review the lab, which is located free of charge on the university Web site.  The simulation is another way to promote interactive learning.

  4. Introduction of a quiz that students are given to work on throughout the committee.  Then, using a system developed by Dr. Nosek and the Office of Biomedical Information Technologies, students enter their answers in class during a final review session.  The results are tabulated instantaneously, incorrect answers are identified, and any misconceptions are discussed.

Dr. Harvey will focus on implementing the following changes for the coming year:  1) recruiting faculty committed to teaching, particularly small group teaching, and 2) introducing new lectures.  Currently, there are 7 or 8 small groups of roughly 20 students.  When questioned about the possibility of reversing the approximate 7 to 3 ratio of number of lectures to small groups, Dr. Harvey felt this would be difficult using the present system.  However, he was impressed by the team-based learning workshop at the February 27 Landerhaven retreat and is interested in incorporating this format into his committee.  However, he emphasized that we need adequate space for this concept to work.  The Cleveland Clinic Lerner College of Medicine is offering faculty development workshops on team-based learning, and the Tuesday morning ICM group preceptors as well as basic scientists in the University Program are also interested in exploring this concept.  Dr. Altose proposed setting up sessions on team-based learning to accommodate all interested faculty in both the College and University Programs.  Dr. Terry Wolpaw will develop a plan in collaboration with Dr. Alan Hull on team-based learning faculty development and report back to the CME.

Year I student representative Mr. Chris Utz felt that the cardiovascular committee was very well organized and agreed with Dr. Harvey’s perceptions presented during his overview.  Mr. Utz found the computer simulation lab especially useful.  The decision to complete the cardiovascular committee before the Christmas break was very well received by the students.

  1. Clinical Curriculum Council Report

Dr. Linda Lewin, Clinical Curriculum Council Chair, announced the next CCC meeting for March 12, at 7:30 a.m.  Agenda items for the meeting include:

  • Distribution of grades in the clinical clerkships:  Should there be quotas?  Should a histogram of the grade distribution accompany each Dean’s Letter?

  • Review of the new form developed for the students to evaluate the clerkships via a centrally run computer-based system.  This should improve the both the rate and timeliness of return, which will in turn lead to dissemination of action plans to the students based on their feedback.

  • Ongoing review of grading in the OB/GYN clerkship, which will bring about changes for this year

  • Search for a new CCC chair, as Dr. Lewin is relocating.

Year IV student Mr. Jim Lan inquired whether clerkship evaluations still take place at the end of the rotation.  He suggested that mid-clerkship evaluations offer stronger incentives for student participation, as the students themselves can still benefit from the changes made during the current clerkship.  One discussant pointed out that this concept also offers a formative evaluation of the clerkship.  The Office of Curricular Affairs is developing an “evaluation cycle” that will result in formulation of an action plan based on student feedback.  The action plan can then be documented to the CME and conveyed back to the students.  Dr. Altose recommended communicating the student feedback from evaluations to the institutional representatives at the affiliated medical centers as well as to the clerkship directors.

  1. Office of Curricular Affairs Update

Ms. Minoo Golestaneh, Director of Administration, mentioned two major ongoing initiatives:  1) the cycle of evaluation, and 2) the Instructional Support Team (IST).  The Instructional Support Team is currently being piloted with the Year I Fundamentals of Therapeutic Agents (FTA) committee and the Year II Gastrointestinal/Metabolism/Nutrition (GINUT) committee.  The IST provides direct support for the day-to-day running of the committee and for syllabus revision. 

  1. Suggestions for Future CME Agenda Items

Discussants suggested that the following topics be added to future CME agendas:

  • Report on the Instructional Support Team Pilot

  • Modification of Years III and IV based on the work groups

  • Plans for the Research Thesis

  • Clinical Skills (CS) Examination Preparation

  1. Announcements

The meeting concluded with the following announcements/developments:

  • Year II representative Mr. Jason Garnreiter’s “appeal” to faculty for an infusion of creative ideas to renovate the student feedback system results in an upcoming collaboration of the Committee on Student Representatives (CSR) and the Office of Curricular Affairs “cycle of evaluation” team.

  • Material relevant to the CME in the Cleveland Clinic Lerner College of Medicine database will be determined and presented to the CME at a later date.

  • The Match celebration will take place Thursday, March 18 at the Iris S. and Bert L. Wolstein Research Building.

  • Aviad Haramati, Ph.D., Professor, Department of Physiology and Biophysics, Georgetown University School of Medicine, will discuss “Lessons Learned from the Educational Initiative in Complementary and Alternative Medicine at Georgetown University,” Thursday, March 25, 5:30 to 6:30 p.m. at the Cleveland Clinic, Lerner NA5-03/04.

 

See Curriculum Revision Update section.

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