Shield of the SOM Committee on Medical Education
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Summary of March 25, 2004 CME Minutes

  1. 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.

  1. 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.

  1. Basic Science 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 practice.

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.

Last year’s 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 extremely rewarding.

Seventy-one percent of the students rated the Mind committee as “good” to “excellent.”

Dr. Agle addressed student complaints:

  • Incomplete 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:

  • Recruitment

  • Secretarial support—criticized as detracting from revenue-generating activities

  • Organizing clinical interviewing—labor intensive activity.

Dr. Agle 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.

  1. Update on 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 process

  • To add rigor and accountability

  • To re-design this program so that it can be done jointly with the College.

This 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:

  • Science of Clinical Practice Seminars (Tuesday mornings) that include students from both the University and College Programs and will occur on a weekly basis.

  • Clinical Skills Training:  physical diagnosis, interviewing, communication skills and clinical procedures workshops

  • Patient Care 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.

Clinical Skills 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 College Programs.

Dr. Wolpaw 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

  • To integrate 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 clerkship years

  • To increase 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 prime example.

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 preceptorshipsCollege 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:

  • Improving the connection between Years I and II with Year III

  • Maximizing flexibility in order to allow time for students in both the University and College Programs to do research and electives in non-core disciplines

  • Improving specifics 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 weeksEvery 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.

Electives 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 in 2006.

The new 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 be determined.

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.

Dr. Altose 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.

  1. Announcement

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 representativesMssrs. Kimathi Blackwood, Brian Chow, Jason Garnreiter, and Chris Utz—along with faculty members Drs. Louis Binder, Mireille Boutry, Robert Haynie, and Kent Smith.

See Curriculum Revision Update section.

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