Summary of 6-13-02 CME Minutes
 

1. This is the last CME meeting of the academic year and also marks the end of Dr. LaManna’s six-year tenure as CME chair.  Dr. LaManna announced that the Faculty Council approved the appointment of Dr. Murray Altose as the next CME chair and welcomed him to today’s meeting and into his new position, officially starting as of July.
    

2. There was no formal Student CME report.  Year I student representative Mr. Brian Chow, currently participating in an NIH summer internship, sent the CME a brief description of the diverse summer activities of the Class of 2005.  The CME welcomed back Year III student representative Mr. Scott Walker after a busy year of clinical rotations.
    

3. The majority of the meeting consisted of the remaining annual report presentations.  The unanimous conclusion reached was that this had been a good year on many levels.  While there are always areas needing attention, improvement seems to have been made, reforms and refinements instituted, high standards met, and progress taking place toward building a strong curriculum and satisfying students and faculty.
    

4. CLC Chair, Dr. William Merrick presented the Curriculum Leadership Council Annual Report for 2001-2002.  The CLC meets quarterly and just held its year-end retreat Friday, June 7.  Dr. Merrick highlighted new CLC developments.

The proposal of Drs. Miller and Tomashefski to include a glass slide histology/histopathology practical as part of the Year I Comprehensive Examination was approved by the CLC by a vote of 14 in favor and 5 opposed.  This proposal has now been forwarded to Drs. Wile and Malemud, Co-Chairs of the Year I Comprehensive Examination Committee.  This proposal resulted due to the number of first year students who did not master differential diagnosis by examining glass slides under the microscope and, consequently, had problems in Year II Pathology.  Students would have to be notified, even if this exists only as a possibility, at the beginning of the academic year.  Dr. Merrick said that he will request a rapid response from the Year I Comprehensive Exam Committee once the new academic year starts.  Practicals have never used glass slides.  Dr. Merrick said that there would be a pre-test format including glass slides during the year in preparation for this activity should it be included in the comprehensive examination.

The new CLC constitution now exists in draft form, pending input from the new Vice Dean.

• The constitution provides a definition of the CLC as consisting of all the committee chairs for the first two years of the curriculum—including what constituted both the Core Academic Program and the Patient-Based Program faculty.

• The constitution lists individual responsibilities for teachers and lecturers and committee chairs.

• There is a defined process for replacing the CLC chair, who has a four-year term.

• Any new subject committee chair must have his/her department chair provide a letter guaranteeing support and relief time to the CLC chair.  This requirement came about due to the difficulty that clinician teaching faculty face often resulting in a 10-20% decrease in their patient revenue.  A five-year commitment is desired for a subject committee chair.  There is no term limit for subject committee chairs.

• The CLC has 2 subcommittees.  The Student Performance Subcommittee identifies weaknesses in the curriculum, where we are not sufficiently preparing our students for entering either the second or the third year.  The main challenge is for this subcommittee to prepare an evaluation tool to determine these deficiencies.

• The Faculty Performance Subcommittee evaluates performance of lecturers and subject committee chairs.

Experimentation with the “carrots” (where bonus points are added) and “sticks” (where points are subtracted) policies on interim exams resulted in keeping students more current and small groups becoming more dynamic.

Dr. Merrick described Dr. Wile’s report to the CLC covering student performance relative to previous first, second, and third years as well as USMLE performance as “positive on all fronts.”  Students performed as well or better than previously.  Only one student did not pass the Year I Comprehensive Examination.  Scores increased on the USMLE Step 1 taken by the Class of 2003 (the current third year class).  The average for CWRU students continues to climb at a faster rate than the national average, and, for the first time, the subtest mean values in all areas were at or above the national average.  For the first students of the new curriculum currently just finishing the third year clerkships (the Class of 2003), the NBME subject (shelf) exam scores are up in all areas.

According to student evaluations and the LCME report, our students are happy here!

Faculty were highly appreciative of the efforts by the professional Audio Visual staff from the Office of Biomedical Information Technologies.  The consistency of having the same person take care of lighting, slides, and computer issues greatly pleased the faculty.

Student end-of-year attendance was examined.  This year, Year I student attendance stayed strong across all committees.  During Year II, however, the third- and second-to-last committees experienced a precipitous fall-off due mainly to students studying for the USMLE Step 1 and, sometimes, because students had become self-learners able to master the material without attending lecture (although still dependent on a good syllabus).  However, this is still extremely frustrating to faculty lecturing to only 10 students.

At the retreat, Dr. Ted Parran and Ms. Kathy Cole-Kelly presented a future plan to measure clinical skills and professionalism in quantitative fashion for ICM (the Introduction to Clinical Medicine program).  With respect to faculty and professionalism, Dr. Merrick mentioned that most faculty are professional.  However, the most disappointing example of non-professionalism on the part of the faculty were three instances where Year II lecturers failed to show

5. Patient-Based Program Coordinator, Dr. Jay Wish presented the Patient-Based Program Annual Report for 2001-2002.  Dr. Wish mentioned major changes:  1) the continued “evolution” of the CWRU relationship with the Cleveland Clinic (our students participate in Neurology, OB/GYN, Family Medicine, and starting this July Surgery clerkships at CCF), and 2) the “de-evolution” of our affiliation with Henry Ford, which is withdrawing the Primary Care Track positions.  Three students in the Class of 2004 will be spending all or part of their third year in the traditional track at Henry Ford, but individual clerkships are not available.

Dr. Wish next talked about outcome parameters.  Ms. Minoo Golestaneh has summarized the student online clerkship evaluations.  Approximately two-thirds of the students have responded as of April 2002 (5/6 year) to provide us with Web-Based feedback.  Using a scale of 1 to 5, with “1” being the best rating and “5” the lowest, most clerkship sites ranked in the 1 to 3 range.  Most ratings are close to last year’s scores, demonstrating a consistency in the sites.  Other valuable feedback came from the student-initiated self-study of the curriculum for the LCME accreditation review, which included an evaluation of CLICS (Contemporary Learning in Clinical Settings).  A bi-modal distribution emerged with regard to CLICS:  one/third of the students highly enthusiastic, while one-quarter of the students feeling that the time could be better spent elsewhere.  Dr. Wile had provided a summary of the NBME subject exam performance for Cleveland sites for the Classes of 2003, 2002, 2001, and 2000.  Dr. LaManna clarified descriptors of the following third year classes surveyed:

• Class of 2003:  the first class to go though the new two-year curriculum and the second class to go through the 12-month core clerkship third year (2001-2002)

• Class of 2002:  the first class to go through the 12-month core clerkship third year (2000-2001)

• Class of 2001:  went through the 13-month transitional core clerkship third year (1999-2000)

• Class of 2000:  had the original 14-month core clerkship third year (1998-1999).

There has been a shrinking or disappearance of failure to achieve the minimum level of mastery on the NBME subject exams.  Dr. Wish considered the consistency of performance across the various clerkship sites a remarkable achievement.  All the clerkship directors meet quarterly.  There exists a “convener” (chosen from among the clerkship directors) for each core clerkship to determine a common set of goals regarding content areas to be covered and a common evaluation process.  Then, each site determines how it wants to meet those goals.  Dr. Wish described his own job as the Patient-Based Program Coordinator as overseeing implementation of the Patient-Based Program.  It is the CRDC (Clinical Rotation Development Council) that looks at opportunities for continuous improvement.

Discussion followed.  The integration of Family Medicine and Internal Medicine led to increased scores on the NBME subject exams.  The organized delivery of the educational core content also helped.  Lectures are no longer randomly scattered throughout a clerkship.  Every clerkship has one half-day didactic session each week that enables incorporation of orphan topics appearing on the NBME subject examinations that have previously been absent from the third year curriculum.  A few discussants pointed to the need to review data presented in the tables more critically, particularly if we want to distribute these figures.  Dr. Altose inquired where the NBME subject exam score data and clerkship site evaluations go.  He was interested in the data reaching the institutions—the educational deans of the hospitals.  He would like to concentrate on sharing the information with people who are the stakeholders.  Currently, the Patient-Based Program Coordinator, the CRDC, the CME, the Vice Dean, and the clerkship directors receive these statistics.  Again, discussants advocated making certain that the clerkship site data were comprehensive and correct.  It was pointed out that it would be July before we receive all the NBME scores.  Brief discussion favored keeping the end-of-year reports in June and perhaps having an update in September.

6. Ms. Kathy Cole-Kelly presented the Macy Initiative in Healthcare Communication Update.  This is the fourth year of the Macy initiative.  The first year was for planning.  The last two years have been spent implementing the workshops with each of the core clerkships.  The workshop topics were negotiated with the clerkship directors after a survey sent to all clerkship directors and other significant stakeholders in Year III.  Feedback from student focus groups was also taken into consideration.  Communication issues are in the forefront of medical education.  The focus was on choosing useful topics.  Through the Macy workshops, standardized patients were used in the clerkships, and they were very well received by the students.  Ms. Cole-Kelly distributed a handout listing the topics with “scenarios,” for each of the six core clerkships and the various time allotments.

• Psychiatry:  The Angry Patient

• Medicine/Family Medicine:  Screening for Addiction with the Chronic Pain Patient:  Sickle Cell Anemia

• Pediatrics:  Talking with Multiple Family Members with Differing Perspectives

• OB/GYN:  Screening for Domestic Violence with the Pregnant Patient

• Neurosciences:  Giving Bad News

• Surgery:  Informed and Shared Decision Making

Each workshop happens during every clerkship cycle, and everyone has all six experiences.  At the meeting, Ms. Cole-Kelly circulated a sample set of pocket-sized laminated “cue cards”—each card containing key points for that particular scenario.  Ms. Cole-Kelly hopes that we will be able to put this material on the e-Curriculum so that students can download it onto their Palm Pilots.  Ms. Cole-Kelly explained that the students learn their communication skills from the role modeling of their clerkship directors demonstrating the skill, from the standardized patients, and from their peers’ feedback.  The students use a checklist to evaluate the role model—the clerkship director.  Later, the checklist is used in turn to evaluate the students.  One student specifically recommended that “the residents should get this.”

Ms. Cole-Kelly also spoke of a new initiative that is being explored that would involve a collaboration between the medical school and the teaching hospitals.  With the ACGME (Accreditation Council for Graduate Medical Education) now requiring residencies to demonstrate how they are teaching and evaluating interpersonal and communication skills as well as professionalism skills (as two of the six ACGME competencies), Ms. Cole-Kelly felt it made great sense to protect the investment of teaching these skills to our third years, to improve the skills of the teachers of the third years (interns and other residents most often), and to meet the ACGME requirements by offering a series of workshops for interns in the hospitals.  Using the expertise of those involved in Macy, as well as collaborating with other interested parties at each hospital, Ms. Cole-Kelly would like to start an initiative that would meet these needs.  She has met with Dr. Charles Emerman of the MetroHealth Medical Center’s Emergency Medicine Department, who chairs Graduate Medical Education (GME) at Metro, and Dr. Lou Binder, faculty member in Emergency Medicine who has an interest in this area.  Ms. Cole-Kelly would like to see collaboration between the hospitals and medical students so that interns would be evaluated on the basic communication skills that all interns should be able to demonstrate.  Then, remediation and more advanced skills could be negotiated with each residency.  Ms. Cole-Kelly and Dr. Binder are developing a proposal to be presented at the GME meeting at MetroHealth Medical Center for implementing a pilot project.  Ms. Cole-Kelly felt it would be very exciting to have CWRU, in collaboration with the hospital, be actively involved in medical education from the entering first undergraduate year through the seventh year occurring during postgraduate training.

Discussion followed.  There was an interest in seeing those involved in teaching third year students participate in the Macy communication skills program.  All the clerkship directors have been supportive.  Both Dr. Hundert and Dr. Henson are perceived as wanting more interaction with residency medical education.  Our “partners” in the Macy initiative, New York University and the University of Massachusetts, also appear to be doing well.  Communication skills has been recognized as a “hot topic” and is included in the new ACGME (Accreditation Council for Graduate Medical Education) guidelines.  Dr. Armitage would like to pass out the pocket-sized laminated cards that Ms. Cole-Kelly circulated at today’s CME meeting to use with his Medicine residents at University Hospitals.

7. CRDC Chair, Dr. Chris Brandt, presented the Clinical Rotation Development Council Annual Report for 2001-2002.  The focus of this past year has been to review and assess the Year III curriculum, implemented in its revised form in the 2000-2001 academic year.  Review and assessment occurred mainly via monthly meetings of the Steering Committee, retreats of the CRDC faculty and CRDC Steering Committee, and a focus group composed of some Year III students.  We are in good shape, as evidenced particularly by student evaluations and examination scores and Dr. Aach’s survey on CWRU graduates’ performance as residents.  The CRDC endorses continuing support of the Macy and CLICS programs.  As the Macy money runs out in January, Dr. LaManna suggested that Dr. Brandt contact Dr. Henson in reference to the educational endowment budget.  Dr. Wile mentioned that the Class of 2005 will be the first class to take the USMLE Step 2½, if it is implemented as originally planned.

CRDC concerns:

• The one-week rotations interspersed throughout Year III are not working well.  They tend to be observational.  They are difficult to schedule and disruptive.

• Psychiatry Department faculty feel that they cannot achieve all their educational objectives given the amount of time allotted them.  The CRDC did look at alternative configurations; however, they caused too many other disadvantages, thus, discouraging change at the present moment.  However, the ongoing Psychiatry rotation configuration issue will be revisited.

• Students in the current Year III 12-month core curriculum have limited exposure to certain areas, such as otolaryngology, ophthalmology, dermatology, and anesthesia, from a career standpoint.  One option is to shorten the second year and use some of that time.  Students can currently go through the Patient-Based Program Coordinator to postpone the Neurosciences core clerkship until the fourth year to participate in the aforementioned fields.  Students need a letter of reference by July or August prior to the fourth year for certain specialties in the Early Match.

Dr. Brandt mentioned the CRDC Steering Committee’s desire for an end-of-third-year OSCE for all students.  Currently, the OSCE takes place only in the Primary Care Track and in the Medicine clerkship.  Reasons for this comprehensive OSCE include:  1) anticipation of the USMLE Step 2½, and 2) providing an alternative means of evaluating students that can be formative.  The Year III comprehensive OSCE will require additional resources to support the required standardized patients and space.  The Year III OSCE would fit in well with the proposed Mount Sinai Clinical Skills Center.

In addition to the Year III comprehensive OSCE, the CRDC plans to look into the establishment of continuity clinics for all Year III students, enhancement of the electronic and PDA-based curriculum, and collaboration with the Cleveland Clinic faculty to form the clinical curriculum of the Cleveland Clinic College of Medicine (CCCM) of CWRU.

Dr. Brandt recognized the valued contributions of those serving on the CRDC Steering Committee with him.

8. Remarks from outgoing CME Chair, Dr. Joseph LaManna
   Dr. LaManna thanked all those people who served on the CME during the course of the past six years, a period which spanned two comprehensive LCME reports and the revision of the CME Charge.  Dr. LaManna believes that our medical school is better now than it was six years ago.  He felt that our overriding concern has always been the betterment of the students.  Two items remain for the CME as “unfinished business:”  1) the “vertical” themes, and 2) the Flexible Program revision.  In looking to the future, he strongly encouraged the CME to take as proactive a stance as possible in the CCCM initiative so that it becomes a collaborative effort for students and faculty of both institutions.  We have the potential to provide the best medical education possible in the city of Cleveland.  Dr. LaManna feels that we have succeeded in establishing an infrastructure that enables us to adapt our curriculum whenever necessary.  We might normally be poised for a letdown finding ourselves at the end of a major revision.  (The first class of the “new curriculum” graduates next year.)  However, instead, Dr. LaManna sees us infused with a new sense of enthusiasm that accompanies change:  the deepening relationship with the Cleveland Clinic, the appointment of a new Vice Dean for Education, and the appointment of a new university president.  Dr. LaManna invites us to welcome the challenge and opportunity.

See Curriculum Revision Update section.

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