Shield of the SOM Committee on Medical Education
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Summary of 4-11-02 CME Minutes 

  1. Clinical Rotation Development Council (CRDC) Update
    The steering committee is holding a retreat later in May.  Recruiting of third and fourth year students for focus groups meeting Wednesday, May 1, from 6:00 to 8:00 p.m., is underway.

  2. Flexible Program Update
    Dr. Tarvez, Tucker and Dr. Charles Malemud, Co-Coordinators
    The Flexible Program Advisory Committee (FPAC)
    presented a proposal comparing current policy with suggested changes.  Proposed changes, once endorsed, would start with the Class of 2006, entering in August 2002.

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 requirements
he 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.

Under the 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 Studies

  • Minimum of 3 from Manifestations of Disease—or—Medicine and Social Structures

  • Maximum of 3 from Early Clinical Experiences (includes MAPs).

The proposal 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 electives.

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.

New requirements of all Type A New and Existing Electives
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.


The proposal 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 electives.

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

  • The Student 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.

  • Whether the Flexible Program policy changes have to go before the Faculty Council.

Rationale behind increasing the number of required basic science courses from 4 to 5 and subsequent discussion

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.

When the 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. 

Dr. Tucker 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.

Discussants 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 education.

Given this 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 sciences

  • To provide opportunities for meaningful student involvement in scholarly activities, both independently and in consort with professional colleagues

  • 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.

Discussion continued 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.

Dr. Malemud 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.

See Curriculum Revision Update section.

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This page was last updated on 04/15/02 by John Graham.

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