The Flexible Program
is a large program involving over 200 faculty members who offer electives
with student capacity ranging from only one opening, such as in a Medical
Apprenticeship (MAP = Medical Apprenticeship Program), and one or two
openings, such as found in Lifeflight—to many openings, as offered in
graduate courses. Because of the vast and varied nature of the Flexible
Program, it is difficult to formulate general policy that will accurately
apply to the entire program. After much discussion, there still exists a
divergence in what is perceived as the purpose of the electives program.
Issues were raised that will be revisited by the Flexible Program Advisory
Committee and in turn brought back before the CME.
The Flexible Program
Advisory Committee (FPAC) has started by focusing on the Type A
electives component that occurs during the first and second years.
Type A electives are typically offered afternoons in a two-to-three hour
session once a week during 5 six-week periods that comprise the school
year. Research, CWRU graduate courses, Medical Apprenticeships, and
student-initiated electives fulfill the Type A requirements.
Proposed change in Type A elective
current requirement consists of a total of 13 electives,
usually taken in the following manner: 2 electives per period (excluding
the first period) in the first year and one
elective per period (including all 5 periods) in the second
year. This typical pattern would break down into 8 Type A electives in
the first year and 5 Type A electives in the second year. The proposal
suggests reducing the total number of required Type A electives from 13 to
10. This decision was influenced by two already implemented
curriculum changes: 1) the addition of Physical Diagnosis to Year I, and
2) the addition of two longitudinal committees (Histology and Human Gross
Anatomy) in Year I. There is a total of 10 six-week elective periods
during the first and second years. Students could typically take one Type
A elective per slot. The original proposal suggested that any student
wishing to take more than two electives per period would need permission
from the Office of Student Affairs. However, later in the CME meeting, it
was suggested that this stipulation be dropped. Students have acted
responsibility in deciding their own elective course load so far. (The
Office of Student Affairs is aware of students at risk. They feel they
are capable of handling the situation confidentially should a problem
arise without necessitating an explicit policy statement.) It was also
explained that the decision to allow Year I students to begin taking
Type A electives in Period 1 was based on the assumption that Year I
students starting August 5 would have had enough time to become acclimated
before the September 17 start date of the first period. In fact, some
first year students already start their electives during the first
period. Under the proposed 10-elective requirement system, a student
could choose to fulfill his/her elective requirement within the first year
by taking two electives per period.
current system, electives are classified into 5 loosely defined,
somewhat overlapping categories: 1) Basis of Clinical Reasoning, 2)
Pathogenesis of Disease, 3) Manifestations of Disease, 4) Medicine and
Social Structure, and 5) Early Clinical Experiences. The current
distribution of Type A requirements breaks down into:
Minimum of 4 in
“Basic Science:” Pathogenesis of Disease, Research, or Graduate
Minimum of 3 from
Manifestations of Disease—or—Medicine and Social Structures
Maximum of 3 from
Early Clinical Experiences (includes MAPs).
suggests changing the required distribution to 5 Type A electives in
Basic Science, Research, or Graduate and 5 Type A electives in
Clinical. Thus, the 10
Proposed change in
the Area of Concentration (AoC) requirements
Most students do 13 or more
electives whether or not they are in an Area of Concentration. An Area of
Concentration offers the student the opportunity to choose a single area
and pursue it in depth. Students who do not choose to pursue an Area of
Concentration fulfill the Diversified Medical Sciences requirement.
Under the proposal, the total of Type A electives required for the Area of
Concentration would be the same as for Diversified students: 10.
With regard to
grading system, the current system awards “Satisfactory”
and “Unsatisfactory.” “Unsatisfactory” has always existed, although it is
rarely given. The proposed system would award “Pass” and
“No record.” The “No record” is not a notation appearing anywhere. No
“fails” would appear on the transcript. A student receiving an
“Incomplete” would not receive credit and would need to complete the
elective for credit by the end of the next elective period. Concern from
the faculty perspective was expressed in that there are no consequences
for the student who signs up for an elective and never shows up.
requirements of all Type A
New and Existing
The Flexible Program Advisory
Committee (FPAC) discussed the benefits of proposing a two-tiered
electives system and decided against it. The idea was to elevate every
elective to a higher standard.
stipulated that the faculty sponsor will decide:
To which category
the elective belongs, i.e. basic science or clinical science
The criteria for
successful completion of the elective—i.e., whether attendance-based or
requiring an end product such as a paper, oral presentation,
examination, reading requirement, etc.
How the individual
student met the educational objectives of the elective as outlined in
the Type A Catalog (This means more than 200 faculty sponsors must have
specified their criteria for successful completion of their elective
prior to July 1.)
According to Dr.
Richard Eckert, chair of the Committee on Appointments, Promotion and
Tenure, there exists “equivalency across the board” in
weighting faculty teaching whether in the Flexible Program, Core Academic
Program, or clerkships. Basic science faculty who do not have a lab or
graduate students can be recognized for sponsoring electives as long as
medical students are involved.
Dr. Wile, an FPAC
member, will review the evaluation forms of both Type A and Type B
Students are invited
to attend meetings of the FPAC. The perspective of third and fourth year
students is of particular interest.
The new Flexible
Program requirements would be explained to the students during orientation
if possible or, at the latest, before the first elective period.
The Year I student
representative liked the idea of starting electives earlier. That way the
afternoons would not already be filled. Concern, however, was expressed
for how offering Year I students electives during Period 1 would impact on
second year students. For example, an elective could be filled up for
Period 1 and offered again only Period 5, when second year students would
be busy studying for the USMLE Step 1. Suggestions were made to contact
the faculty sponsor individually of an oversubscribed elective. Often the
sponsor will make allowances for another student. If the problem still
exists, contact the Flexible Program co-coordinators. A suggestion was
made to give the second year students priority during Period 1 electives.
Issues for consideration:
Whether 1) reducing
the Flexible Program Type A elective requirement from 13 to 10, and 2)
changing the required distribution to 50% basic science and 50% clinical
science needs to be approved by the CME
Handbook containing this information must be completed by May. The
Office of the Registrar needs all information for the Type A catalog by
the end of June.
Flexible Program policy changes have to go before the Faculty Council.
increasing the number of required basic science courses from 4 to 5 and
Original requirement was 4 basic science and 6 clinical Type A
electives. The Flexible Program Advisory Committee proposed changing the
requirement to 5 basic science and 5 clinical Type A electives. The
feeling was that there are several strong basic science offerings
available. One discussant cautioned against underestimating student
enthusiasm for seeing actual patients during the first two years.
Currently, 15% of the electives are basic science. (The 15% figure is
derived from Dr. Malemud’s calculation based on the 2000-2001 Type A
catalog, where he characterized the electives as either basic science or
clinical science.) Some graduate courses have a much larger student
capacity than say, Lifeflight that can accommodate only 2 people at a
time, or many other electives which are limited to 8 students. Graduate
courses taken as electives were not represented in the 15% basic
science figure given. One discussant felt that requiring more elective
time in basic science is a curricular issue. He viewed this change as
making the Flexible Program less “flexible,” transforming it into a
“one-size-fits-all” arrangement for the students. It was pointed out,
however, that currently, most students take more than 13 electives. A
basic science elective allows the student to pursue in depth a topic that
may be only superficially addressed in the Core Academic Program. One
FPAC member and then, later, in the meeting, Dr. Tucker suggested: Change
the total of Type A electives to 10 but do not specify as to the amount of
basic science and clinical science courses.
Dr. LaManna voiced
his preference for a two-tiered elective system, requiring a certain
number of electives where the student is more rigorously evaluated. He
raised the dilemma of how to entice students to take graded electives
(pertaining particularly to basic science electives) that require a paper,
when other electives are only attendance-based. Main reason for the
FPAC’s decision to reject the two-tiered elective system: View that the
first year students take many interim exams (evaluative tools) and
increasing the number of evaluate tools could be detrimental. This would
be defeating the purpose of flexibility in the electives program. The
Flexible Program Advisory Committee had discussed the pros and cons of the
two-tiered elective system. The Flexible Program Advisory Committee
was committed to the individual elective sponsor defining the requirement.
One FPAC member felt that the “bar” had been raised for all electives. It
was no longer “attendance only” as the requirement. Dr. LaManna
cautioned that strong basic science electives will be eliminated if
attendance is the only requirement for earning credit.
hypothetical “20-page paper with 10 reference citations” was mentioned
as a plausible end product requirement, it drew mixed reviews. Dr.
LaManna felt that every medical student should have to write such a
scholarly paper on either a basic science or clinical topic, and there is
no place in our four-year curriculum to do this. He felt that students
need to demonstrate that they can read references, evaluate them, and
write a scholarly paper. He regards this activity as part of the
enrichment component. Dr. Tucker reminded that we had tried
requiring a thesis, and this did not work.
emphasized that the individuality of the Flexible Program is what
is unique about it. It is not stringent—by design. It is up to the
individual faculty sponsor to set his/her expectation for the students.
The more rigor you
add, the less student participation you get. Dr. LaManna felt that if you
do not make it a requirement to take a certain number of stringent
electives, students will not take them. Dr. LaManna suggested that the
more rigorous electives could be designated as “A'” (“A prime”) as opposed
to the “A” electives. Dr. Tucker felt that the first step is to have the
faculty make the more rigorous electives a requirement. Dr. LaManna
emphasized the problem he has getting his faculty to
offer basic science electives when no students will show up. A few
discussants mentioned that they had tried teaching basic science electives
and stopped. Students often came in late and unprepared without any
consequences built into the program. Dr. LaManna suggested starting by
requiring two of the more rigorous electives of any kind (basic science or
clinical science) per year. Dr. Tucker felt that no faculty in Medicine
or Pediatrics would offer the A' elective. In her opinion, this policy
would be weighted toward basic science.
questioned the purpose of the Flexible Program. Dr. McCoy stated that he
was on the initial committee that created the electives program. The
Flexible Program was intended for what was not covered in the Core
Academic Program. The Flexible Program is a huge selling point to
applicants. It enables the student to customize his/her medical
background, one discussant questioned whether requiring 5 basic science
electives would be a waste of time.
Dr. Tucker felt that
Dr. LaManna was asking the Flexible Program to do something for which it
was not designed. She suggested looking into the Core Academic Program
and the fourth year as logical places for including the mandated rigorous
courses. When asked for the purpose of the Flexible Program, Dr. Tucker
cited the objectives listed in the Flexible Program Type A Catalog:
To increase the
student’s capacity for critical and analytical thinking in the medical
opportunities for meaningful student involvement in scholarly
activities, both independently and in consort with professional
To allow students
to pursue individual areas of concentrated study in-depth and across
traditional disciplinary boundaries
To expose students
to newer concepts, areas of controversy, issues of social relevance, and
changing technology in medical science
To increase the
student’s initiative, responsibility, and capacity in self-education in
the medical sciences.
There was brief
discussion of the perceived problem of lack of basic science
involvement in the Flexible Program in that its relaxed structure acts as
a deterrent to teaching of basic science courses as electives.
The Registrar noted
that right now we cancel many Type A electives, even though the students
like the clinical electives. If the amount of clinical electives were
decreased to 5, we will have less courses offered. At this particular
time of year, no second year students are taking electives; they are busy
studying for the USMLE Step 1. In addition, the Primary Care Track
students get elective credit for certain of their courses and are not
taking other electives.
along the divergent points of view. Should every student be required to
do something scholarly? Is it acceptable to have only a core of
intellectually eager students choose to pursue the more vigorous
electives, while the majority of students would concentrate on the
clinical electives? Can the fourth year be used effectively to further
this end? Problems include its proximity to graduation and the need for
preceptors. Is the Flexible Program not rigorous enough? Can it use its
time more efficiently? Is it desirable for the Co-Coordinators of the
Flexible Program to meet with every department chair (as did Dr.
Greenfield, then-chair of the Clinical Rotation Development Council) to
hear what they have to say? Should any faculty member be able to give an
elective? What is the responsibility of the faculty member giving the
elective? What areas do we want the Flexible Program to cover? The wide
range of student participation would also have to be taken into
consideration: from little beyond attendance-based to significant as
required in a graduate course. Retaining the breadth of offerings for
flexibility was considered of prime importance.
In light of today’s
discussion, Dr. Tucker wished to balance the critique. Clinical educators
have been extremely enthusiastic about the Flexible Program.
acknowledged that today’s discussion provided the FPAC with a number of
issues to be discussed further. He wished to go on record as expressing
his own personal opinion that the Flexible Program Advisory
Committee is being held to a greater degree of rigor by the CME than
either the Curriculum Leadership Council or the Clinical Rotation
Development Council. The other two councils were approved by the Dean.
Dr. Malemud requested that a parallel council be created for the Flexible
Program that will elevate it to the same status. Dr. Smith replied that
he felt such action is taking place. There is a Flexible Program
committee. The coordinator of the Flexible Program sits as a voting
member on the CME. The Vice Dean’s office will continue to work with the
Flexible Program co-coordinators.
Dr. Malemud said that
the Flexible Program Advisory Committee will further examine the issues of
rigor, scholarship, and objectives in the Flexible Program. However, he
emphasized that monitoring the success or failure of the Flexible Program
is an immense job. We have only begun by focusing on the Type A
electives, which comprise the smallest component of the program.
Dr. Tucker stressed
that the infrastructure of the large number of faculty that teach in the
Flexible Program, each with their own program, is far different from the
third year core clerkship program. However, Dr. LaManna felt there is
still value in talking to the chairs to get their input. In particular,
the basic science chairs feel that they are estranged from the Flexible
Program. Dr. Arnold suggested that Dr. Tucker might want to meet with the
Council of Medical Chairmen, chaired by Dr. Martin Resnick, at University
Hospitals. Unsure as to whether a parallel group exists at Metro, it was
suggested that Dr. Tucker start by contacting Dr. Ben Brouhard.
In response to a
question about equating graduate course credits for elective credits, Dr.
Tucker answered that typically a 3-credit graduate course is worth 4
elective credits. Dr. Malemud mentioned that the Flexible Program
Advisory Committee will do an analysis to ascertain how many medical
students take graduate courses for elective credit. He concluded the
discussion by recognizing the Registrar, Mr. Joe Corrao, for his help in
providing all the data.