Announcement from the CCLCM Vice Dean for Education
Dr. Lindsey Henson,
Vice Dean for Education for the Cleveland Clinic Lerner College of
Medicine, announced that the Cleveland Foundation, recognizing the
beautiful grant crafted by Dr. Elaine Dannefer and the
collaboration of both the Cleveland Clinic and Case School of Medicine,
has awarded the College a $1 million grant to develop
portfolios over the next two years.
Report from the Student CME
Both the CME and the
Dean’s office will follow up on two issues concerning two Year II
longitudinal committees raised by Mr. Jason Garnreiter, Year II
student representative: 1) the desire to meet the longitudinal
Pathology section chair, Dr. Joseph Tomashefski, at the beginning of
the year instead of waiting until the onset of the Pulmonary committee and
to receive more information about administrative issues (i.e., test
structure and weighting of pathology interim questions for the final
pathology grade, etc.), and 2) the desire to further expand
Pharmacology as either a longitudinal committee or increased presence
in every committee, as antibiotic coverage is currently scant, and it is
heavily tested on the USMLE Step 1.
Curriculum Report on the Mind Committee
Dr. David Agle,
veteran chair of the Year II Mind committee, began his
presentation by providing background. Psychiatric treatment today
ranges from the historic psychoanalysis to emphasis on biologic factors.
The focus of the Case Year II Mind committee is a biopsychosocial
perspective. When the Nervous System/Mind committee first emerged, it was
expected to be a “homogenized” committee. Psychiatry and neurology,
however, have different focus of interests and clinical approaches. The
combined committee, however, has allowed excellent collaboration. The
series on PAIN is one example of combined teaching. Dr. Agle and Dr.
Kathleen Clegg, the psychiatry clerkship director at University Hospitals,
co-chair the Mind committee. This affords seamless vertical integration
of the Year II and Year III psychiatry curriculum. Dr. Clegg is training
to replace Dr. Agle as chair of the Mind committee when he steps down.
Dr. Agle heads the Consult-Liaison Psychiatry Service at University
Hospitals, which Interim Vice Dean Robert Daroff referred to during the
CME meeting as “the best consult-liaison service of any U.S. hospital.”
Dr. Agle explained that the consult-liaison experience in the general
medical hospital has allowed a careful assessment of what the general
physician needs to know from “Mind Committee.” The committee is NOT a
mini-course in psychiatry but rather teaches the psychiatry of medical
Dr. Agle delineated
the learning objectives of the Mind committee which include
expanding the student’s knowledge regarding: 1) the impact of
experiential (human relationship) factors in shaping mental
development, 2) the biologic basis of behavior and mental
disorders, 3) deviations in behavior, and 4) the importance of
self-knowledge in interacting with patients.
structure for the Mind committee included 60 hours of lecture, 11
hours in small groups, 3 hours in large groups, 2 afternoons in Clinical
Interviewing, 9 noon options (pertaining to subjects off-core but of great
interest), and a three-hour interim exam. Eighteen percent of the work is
done in groups, which is an effective yet expensive way to teach.
Dr. Agle outlined the
content. An introduction provides broad focus on neurochemistry
and theories of the mind/brain. Developmental phases concentrate on a)
psychodynamics, and b) cognitive behavior. Dr. Agle explained that
general physicians write the majority of anti-depressants and anti-anxiety
prescriptions and need to be able to recognize and assess suicide risk.
Dr. Agle presented
student opinion on lectures as based on last year’s
post-examination online evaluations completed by the students.
Attendance ranged from 75 to 100%, with an overall rating of 77% of the
lectures as “valuable” to “extremely valuable.” The videotapes and live
patients were well received by the students.
The 12 small
groups, each consisting of 11 to 12 students, used primary practice
type cases, with the same case used for all groups. Points awarded toward
the final exam score were used to motivate students to attend the small
groups, and overall attendance was estimated at 75%.
Much work goes into
organizing clinical interviewing at the hospitals, which takes
place two afternoons. Students do one interview and observe three
interviews. Despite initial anxiety, students find this activity
percent of the students rated
the Mind committee as “good” to “excellent.”
Dr. Agle addressed
syllabus—While there exist holes in the syllabus, the Mind committee
leadership does not intend for familiarity with the syllabus to
comprise total preparation for the exam.
Only 60% of this
year’s students felt that the exam matched well with what is taught.
Desire for answers
to small group problems—The Mind committee intentionally does not
give answers. This would be in contradiction with the reality of the
clinical world. The goal is for students to think things through.
Dr. Agle listed the
following as faculty problems:
expressed concern about the approximately 8% of students who do NOT attend
class exercises. Computer and syllabus learning allows memorization of
biomedical facts that can lead to
exam success but does NOT convey the how to think and how to work with
patients, so important in Mind Committee teaching.
Dr. Agle discussed
faculty morale. Faculty continue to regard it as an honor to teach in
the Mind committee. Small group discussion leader meetings take place
twice during the committee. The end-of-committee report based on student
feedback is distributed to all faculty. Dr. Agle gives each individual
faculty member his/her personal student feedback, especially the
compliments, along with the end-of-committee report.
Plans for next
year may revolve around working
with decreased hours. Dr. Agle hopes to convert remaining large groups to
an all-small-group format. One major accomplishment is the rebuilding of
the substance use disorder curriculum last year to coordinate with ICM.
With the conclusion
of Dr. Agle’s presentation, discussants raised the universal
problem: Things that faculty value most are not tested and therefore,
particularly among those students that do not attend class, not mastered.
Dr. Agle acknowledged that efficacy and time/cost ratio promote the use of
multiple-choice exam questions. Ways of addressing this issue include
incorporating vignettes and problem solving cases into exams. Popularity
of the lunchtime discussion “Alternatives to Multiple Choice Exams”
at the February 27 Landerhaven retreat suggested further pursuing this
issue. In response to the competition for resources for secretarial
support, the Office of Curricular Affairs has developed an
Instructional Support Team (IST) that is available to the subject
committee leadership. One discussant suggested incorporating
generalists as small group leaders in the Mind committee, since they
need to be aware of psychiatric factors in diagnosing their patients.
Year II student
representative, Mr. Jason Garnreiter praised the Mind committee for
its integration of pharmacology and the use of therapeutics. This
committee provides the best preparation for major pharmacologic thinking.
He also agreed with Dr. Agle as to the value of the clinical interviews,
once students overcame their animosity and anxiety at the onset of the
initiative. One last suggestion would be to update the videos,
which were shot in black and white.
ICM/Modifications in the Core Clerkship Program
Dr. Dan Wolpaw
began by explaining the
motivation for taking a new look at ICM (Introduction to Clinical
Medicine) as defined by the following needs:
To reinvigorate the
To add rigor and
To re-design this
program so that it can be done jointly with the College.
new approach to Clinical Science for both the University and
College Programs emphasizes in its mission statement that it is no
longer confined to the first two years as an “Introduction to Clinical
Medicine” but will span the entire undergraduate medical
education curriculum. There has been continuing debate as to the new
name: Foundations of Medicine. After the presentation, some
discussants urged reconsidering the name, as this umbrella label
unwittingly designates whatever courses do not belong to
the program as being irrelevant to the
foundation of medicine. Dr. Wolpaw replied that the group is open to new
name suggestions. The Foundations of Medicine uses an integrated approach
to classroom and laboratory activities and patient and community-based
experiences. The course consists of three parts:
Clinical Practice Seminars
(Tuesday mornings) that include students from both the University
and College Programs and will occur on a weekly basis.
diagnosis, interviewing, communication skills and clinical procedures
Activities: At the
University, this will include the Family Clinic and, in the second year,
office preceptorships. At the College, this will include a longitudinal
clinic with a primary care preceptor beginning in the first year, as
well as other patient care activities described below.
Training and Patient Care Activities will be integrated into one afternoon
for each student.
Dr. Wolpaw recapped
reasons for the change: to add rigor to the curriculum, to
engage students in active learning, to set standards for
student accountability, to dedicate and consolidate time for one
afternoon per week of clinical activities, to establish a
simultaneously shared course between the University and
highlighted program goals:
To elevate the
course to the status of a quasi-clerkship, with “honors,” “commendable,”
“satisfactory,” and “unsatisfactory” grades for the University Program
and competency mastery for the College Program
Tuesday morning Science of Clinical Practice Seminars with hands-on
clinical skills training and patient care
To develop a
curriculum linking Foundations of Medicine skills to those needed in the
participation of Year IV students in teaching activities with students
from the first two years, where the senior student is re-exposed to
familiar concepts and continues to learn—Year I Physical Diagnosis is a
Dr. Wolpaw elaborated
on the three parts of the Foundations of Medicine course. The Tuesday
morning Science of Clinical Practice has been decreased to one and
one-half hours to allow for travel time between the university and the
Cleveland Clinic. This course component mixes both College and University
students through joint participation. Team-learning, case-based teaching,
and clinical correlation conferences are planned to engage students.
Clinical Skills Training
will take place one afternoon weekly. The whole class will be
divided so that each student has one standing half-day (Monday through
Thursday) dedicated to clinical skills. Major focus of the Clinical
Skills Program is on Interviewing and Communication Skills and Physical
Diagnosis. The College Program will coordinate teaching
sessions and office preceptorships during the dedicated afternoon by
staggering the afternoons. Dr. J.H. Isaacson explained that the
student will spend one week in clinical skills sessions (physical
diagnosis, communication skills, etc.)
and the next week in the office of a
general internist or a family practice physician, practicing the skills
learned the preceding week. The College Program will also introduce a
patient-based experience in pediatrics and geriatrics in the second half
of the first year. In the second year, College students will be with
their longitudinal preceptors every week.
Dr. Wolpaw described
three types of Patient Care Activities. Preceptors will observe
the students directly, and students will have patients. The Family
Clinic patient-based experience fosters development of the student’s
relationship with one particular mother/child or geriatric patient
and is a component of the University Program only. The
Practice-based component offers the student continuity of both site
and practitioner in developing clinical skills through office
preceptorships. College Program students begin the
practice-based component in Year I, whereas University
Program students begin it in Year II. The Acute Care-based
component affords Year II students the opportunity to observe acute care
in an Emergency Room or in an Intensive Care Unit with an attending one
afternoon per week for six weeks before they go on the wards in Year III.
Dr. Wolpaw emphasized
that Ms. Kathy Cole-Kelly, Dr. Ted Parran, Dr. J. H. Isaacson, and he
invested a long, ongoing process in defining the curricular competencies
and are now working on their implementation.
Dr. Linda Lewin
continued the presentation by explaining proposed Modifications in the
Core Clerkships. She stressed that at this stage in the planning, the
projected model is just that—a model—open to modifications and up for
discussion. The goals for revising Year III include:
connection between Years I and II with Year III
flexibility in order to allow time for students in both the University
and College Programs to do research and electives in non-core
not currently mastered in the clerkships.
The new Year III
Basic Core Clerkships consist of 32 weeks.
The concept is still open to change, but as of this point in time, there
are two 16-week blocks. One 16-week block consists of Medicine,
Surgery, and Family Medicine, and another 16-week block consists of OB/Gyn,
Pediatrics, Psychiatry, and Neurosciences. These 32 weeks represent the
“breadth of medical practice,”—what every student needs to know.
Scattered throughout each block are Learning Groups, with a ratio
of four-to-six students per continuity faculty preceptor. Learning Groups
make it possible to address the clinical skills mastery necessary for
progression to the next level, a step that is missing from the current
curriculum. We will need to develop an advanced clinical skills
curriculum. Learning objectives will be coordinated with each 16-week
block. Implementation of each core clerkship will be site-specific
so that the team at University Hospitals, Cleveland Clinic, or Metro,
etc., can decide how to make optimal use of its own particular resources.
The student will be able to choose the site of his/her clerkship.
The 32 weeks of Basic
Core Clerkships must be completed before taking the Advanced Core
Clerkships, which consist of 4- or 8-week experiences for a total
of 16 weeks. Every student will take
“selectives” that focus on in-depth learning (clinical and basic
science) in disciplines of the student’s choosing. The student will
concentrate in one area--seeing patients in clinical settings, attending
related conferences, revisiting the pathophysiology and pharmacology, and
perhaps preparing a project or presentation. Every student will not
have the same experience.
include at least one required
“Acting Internship” for 4 weeks. Most Case students already
opt to do this. Electives also include other clinical and non-clinical
electives with minimum clinical time determined by requirements for
licensure. There will be a total of 16 to 18 weeks available for
research or electives in Year III.
Dr. Dan Wolpaw
mentioned an impromptu survey given to Year III students asking them to
reflect on their ICM experiences. Approximately 80 students responded,
providing interesting insights and citing many strengths of the program.
Students felt comfortable with and very cognizant of the doctor-patient
relationship. However, they felt that they were not as well prepared as
they should be for case and oral presentation.
Dr. Henson wished to
emphasize that the Science of Clinical Practice is a new course. With
regard to assessment, students will be assessed by faculty
objectively—using the honors-commendable-satisfactory-unsatisfactory
grading system for the University Program and competency mastery for the
College Program. One CME member expressed concern over the potentially
divisive dichotomy resulting between one “honors”-driven group and one
group unconcerned about grades. The new Year III curriculum will start
Foundations of Medicine curriculum will be implemented with the incoming
first year class this summer (2004). The Class of 2007, however, will
use the current curriculum that has been in effect for Year II ICM. The
plan for the Year III curriculum would also include a continuation of the
Foundations of Medicine Program, although the exact format still needs to
Next steps mentioned
by discussants include getting feedback from the CME, recruiting
additional faculty leadership, and presenting the revised ICM/Core
Clerkship proposal to the Dean. No one will retain the same hours as
before. Everyone will have a reduction in hours. The Basic Core
Clerkships involve faculty working together to form a curriculum, but the
basic cores represent a reduction in hours and an absence of territorial
boundaries. It is important to convince the chairs that students have the
opportunity for greater depth with these new activities, although each
student will not be doing the same kinds of things.
felt that progress has been made and looks forward to engaging the Dean
and additional faculty leadership.
Dr. David Katz
recommended that the CME recognize the achievements of Ms. Kathy
Cole-Kelly over the years who nurtured the original Clinical Science
program and participated in its transformation into the current ICM
program. Dr. Katz recalled as head of the Curriculum Leadership
Council working with Ms. Cole-Kelly, who enthusiastically endorsed the
concept of increased basic science integration in the first two years of
the curriculum and incorporated it into the ICM curriculum.
Don’t miss Doc
Opera, Saturday, April 3, 8:00 p.m. at the Allen Theatre, Playhouse Square
Center. The CME takes pride in its record of participation this year—all
four student representatives—Mssrs. Kimathi
Blackwood, Brian Chow, Jason Garnreiter, and Chris Utz—along with
faculty members Drs. Louis Binder, Mireille Boutry, Robert Haynie, and
See Curriculum Revision Update section.
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