Dean Ralph Horwitz
expressed his excitement about embarking on a renewal of the Case Medical
School curriculum. He commended the Case faculty on their expertise and
commitment to the educational enterprise. He pointed out the selectivity
and competitiveness of the Case program and the high quality of its
students—important factors in the success of an innovative educational
program. He acknowledged that a considerable amount of innovation has
already taken place at Case leading to improvement in the educational
process. The thesis requirement, endorsed last year, will begin with
the Class of 2009, entering in the fall of 2005. Dean Horwitz regards
research and scholarship as essential in preparing students for the
changing field of medicine. Dean Horwitz welcomed the faculty’s support
for the general conceptual approach of integrating medicine and health
with an emphasis on population-based medicine along with treatment
of the individual, scholarship and research, clinical mastery, leadership,
and civic professionalism honoring the social contract to community.
As a start-up for the curriculum renewal initiative, Dean Horwitz has
established an advisory Policy Steering Committee and several working
groups. Dr. Altose, as Chair of the CME, was asked by the Dean to head
the Curriculum Work Group. A relatively small number of faculty members
are currently involved in curriculum planning, and Dean Horwitz would like
to engage a larger group of faculty. He views the curricular changes as
not only “thematic” but also “creative” in deciding how best to educate
the students.
Dean Horwitz
presented the following concepts as the “starting point” for discussion of
the new curriculum:
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Integration of
medicine and health
-
Incorporation of
adult learning principles to effectively present the material
-
Creation of an
environment where students take responsibility for their own
education, similar to a “graduate school” approach
-
Departure from the
current separation of basic science (the first two years) and clinical
science (the last two years) and replacement by a continuous
intermingling of basic science and clinical science. This can be
accomplished by simultaneous exposure to basic science core principles
and experiences in clinical medicine with a return for more
sophisticated, advanced basic science and clinical medicine as the
student proceeds through the curriculum. This would be a definite move
away from what Dean Horwitz views as our current demarcated curriculum:
Year I – the biology of health, Year II – the biology of disease, Year
III – the clinical clerkships, Year IV – electives.
Dean Horwitz
emphasized the importance of an early focus on population health and
the social, economic, and environmental determinants of disease. That
concept, as a starting point, would then be followed by an introduction
to biological systems and then the cellular molecular mechanisms of
disease. Relevant and in-depth clinical experiences would be
interspersed. He referred to Dr. Pedro Delgado’s choice of the word
“humane” in describing this approach to the practice of medicine. Dean
Horwitz acknowledged that this is a far-reaching change in how we approach
medical education. Medical education must reflect the way physicians
practice medicine. In his view, the new curriculum would again position
Case Medical School as a pioneering and innovative institution. Dean
Horwitz readily admits that he is “impatient for progress.” He has
targeted fall 2006 as presentation of the new curriculum to
the entering class. Therefore, spring 2005 is the target date for
the faculty to reach both understanding and a consensus endorsing the new
curricular model. Students applying September 2005 will need to know in
detail the configuration/expectations of the new curriculum. Dean Horwitz
concluded his presentation by stating that the School of Medicine has
committed resources, not just at the planning stage of the new curriculum,
but at all levels of curriculum development. Faculty significantly
involved in curriculum development will be financially supported. The
School of Medicine is linked to the success of its educational programs.
Dean Horwitz next
addressed questions raised by CME members. Later in the meeting,
Drs. Dan Wolpaw, Terry Wolpaw, David Aron, and Murray Altose fielded
questions regarding the new curriculum.
What is the role
of the CME in the evolution of the new curriculum? What are the
expectations of the CME?
Dean Horwitz regards
the CME as the committee of the faculty that is responsible for defining
the overall objectives and reviewing and evaluating the content and
appropriateness of the educational programs. He would like to see faculty
take “ownership” of the new curriculum and for the CME to take a
leadership role in the curriculum renewal initiative.
Dr. Altose added that
the CME is a broad and diverse committee of the faculty that establishes
curricular policies. While Dean Horwitz’s white paper was used as a guide
to the new curricular model, we need to achieve consensus over that model
among all faculty, department chairs, and students. Only
through a broad consensus is success possible. This endeavor to design
and implement a new curriculum will require the involvement of many people
from a wide range of constituencies.
What percent of
students would you like to see elect to take the fifth year option?
Dean Horwitz expressed a
desire to see as many students as possible select a fifth year. The fifth
year would provide an enlarging perspective as students prepare for
careers ranging from clinical practice to medical education to research.
Dean Horwitz acknowledged that the majority-held opinion, particularly
among non-medical people, favors shortening the medical school
curriculum. If the faculty opt for a four-year curriculum, Dean Horwitz
hopes that at least one-half of the students would choose to pursue
in-depth study in diverse areas such as ethics, public policy, research,
education, etc.
Dr. Altose clarified
that the new curriculum model is conceived as a four-year core curriculum
with opportunities for an additional year for enrichment in a variety of
areas.
How will the
student pay for the fifth year?
Dean Horwitz
explained that students would pay for four years of tuition. Those
seeking a fifth year would pay a continuation fee of 5% of the tuition
rate. He added that Dr. Claire Doerschuk is already submitting
applications for training funds to provide stipends for students who
choose to pursue research.
Discussion returned
to the curriculum. Dr. Altose mentioned that we are currently considering
how to make the Dean’s ideas operational. This will entail a
change in the configuration, organization, and presentation of the
curriculum and will require a significant amount of work.
The Curriculum Work
Group, headed by Dr. Altose, developed a set of “Guiding Principles for
a New Curriculum.” Dr. Altose emphasized a few of the guiding
principles: “experiential” learning (learning done in a context),
greater continuity over the full four years (greater continuity of
basic science, greater continuity of clinical science, and better
integration of both basic science and clinical science), an in-depth
mentored experience for every student, and the health care delivery
perspective such that there will be an emphasis on health as well
as disease and on society as a whole not just the
individual.
Dr. Altose
distributed a second handout in very early stages of development,
depicting the new curriculum model as a continuum intermingling basic
science and clinical science in blocks. It is proposed that the new
curriculum would be primarily case-based, with specific clinical cases
used as a starting point and serving as the basis for population
considerations and the basic science underpinnings.
Dr. Terry Wolpaw
described “experiential learning” as valuable, because adults learn better
“in context,” by problem solving. The plan is to create this context
early on. Case has always been known for its early clinical exposure.
The new curriculum model builds on the systems approach and integrates
basic and clinical sciences. It progresses from a “macro” (society) to a
“micro” (cellular/molecular) level.
Dr.
Dan Wolpaw
described our current curriculum as “keeping students as students” for the
first two years, as we teach them the building blocks, for the most part,
without context. Students concentrate on studying for tests, and their
exposure to medicine is limited and variably meaningful. By contrast, the
thrust of the new curriculum entails deciding what the students need to
know for meaningful patient care. Students will “cycle back and forth”
between basic science and clinical science in a progression known as
“spiraling.” “Incremental learning” will take place. The basic
concept—“learning in context”—is thought to produce better retention,
because the learner has a “relation” with
the information. In the model of the new
curriculum developed thus far, the student will go on the wards to take
care of patients after seven or eight months. This will entail
rearranging and intensifying the clinical skills curriculum. The Clinical
Science blocks will move students in a sequential way,
building on their strengths. By contrast, students are “thrown into” our
current curriculum, all of them going in different directions and without
guidance. The new curriculum requires creating strategies to move the
students through various experiences and bring them back to the classroom
to re-evaluate. The general concept is to begin at a “macro”
level—populations, organs—and work down to the molecular infrastructure
when a clinical context and rationale for that information have been
developed. This is in contrast to the traditional smallest building block
up approach. It is important to note that all of the material currently
included in the basic science curriculum will be included—it is the order
and placement that will change.
One CME member
requested reference to a similar or parallel existing curriculum in order
to give the faculty a sense of direction.
While this
particular curriculum, with its spiraling and intermingling of basic
science and clinical science, is unique, there are existing examples of
shortened basic science curricula. At Duke University, students only have
one year of basic science before they enter the wards, and they do not
return to study basic science. At the University of Pennsylvania,
students go on the wards in January of their second year.
A specific example
of how a concept would weave through the spiraling process was requested.
Dr. Dan Wolpaw
explained that cases would be used as the starting point for basic
science and as a focus for teaching clinical skills. One case, for
example, would deal with Congestive Heart Failure. It would be difficult
to begin with a presentation such as shortness of breath because of the
complex and broad differential diagnosis. The Congestive Heart Failure
case would incorporate elements of the Cardiovascular I and II committees
into the first Basic Science block, with more complex and less clinically
proximate information moved to the later Basic Science Blocks. It is
expected that much of the first block will focus on Anatomy and
Physiology, with areas such as Biochemistry and Pharmacology introduced as
needed. The first 7-8 months would also focus on clinical skills,
utilizing the specific demands of cases such as Congestive Heart Failure
in order to provide the opportunity and context required.
Dr. Terry Wolpaw
added that basic scientists Dr. George Dubyak and Dr. Bob Harvey helped
develop the Congestive Heart Failure case for the new curriculum. She
mentioned the following points for consideration:
-
Reorganizing and
re-ordering of content
-
Now that the
student has context, how do we take him/her to all the levels faculty
decide that he/she should reach?
-
Interviewing skills
needed for a patient with Congestive Heart Failure
One CME member
stressed the importance of a time for reflection, for examination, when
the student is spiraling back and forth between basic science and clinical
science.
Is the new
curriculum model still organ-systems based?
The intention is to
retain as much of the currently successful curricular organization as
possible. So the basic answer is yes, although as Dr. Altose added, one
committee may present in two or three blocks—not just one block—in the new
curriculum.
One CME member’s
perception of the new curriculum
as re-defining all of the following: basic science, the context in which
basic science is taught, clinical science, the context in which clinical
science is taught. This re-definition of basic science will enhance the
study of epidemiology, population-based medicine, and public health.
Dr. Aron added that
the Congestive Heart Failure case could lead to a study of risk factors in
health care delivery that lead to poor outcome delivery.
Dr. Dan Wolpaw
pointed out that using cases as the starting point allows you to focus
the students vertically through the layers of the curriculum.
Dr. Aron emphasized
that the new curriculum uses cases that students are likely to see.
Dr. Terry Wolpaw
added that the “blurring” aspect of the curriculum ensures that nothing
ever stops, nothing will ever be separate.
Our current
Primary Care Track could at times be viewed as a micro-model of this
curriculum. Anecdotally, a preceptor recalled a second year student’s
weekly treatment of a patient in her clinic as the perfect juxtaposition
of a clinical experience with the endocrine system in basic science.
Concern over the
potential loss of collegiality among students
in the new curriculum was expressed. “Colleagues in medicine” learn from
their peers as much as from the student/teacher relationship. There may
be less time for the students to bond as a peer group.
Dr. Terry Wolpaw felt
that collegiality would in fact be reinforced as students keep coming back
as a community.
Concern over
evaluation/assessment was also
expressed. How do you assess student performance? How do you evaluate
the program?
Dr. Dan Wolpaw
replied that currently, we are using ongoing groups in the Foundations of
Clinical Medicine, where the continuity lasts for three or four years.
These continuity groups serve as the venue for collegiality and for
providing an overview where the students are and where they need to go
next. With respect to assessment, Dr. Wolpaw anticipated building on the
learner portfolio that is the subject of a pilot this year in the
University Program and is the major assessment tool at the Cleveland
Clinic Lerner College of Medicine.
Dr. Terry Wolpaw
added that the Alternative Assessment Committee is looking into innovative
ways to assess student performance.
Year II student Mr.
Christopher Utz mentioned the value of his own MAP (Medical Apprenticeship
Program) last year, when he encountered a case of diabetic acidosis in a
clinical setting. In his words, “it cemented everything.”
Dr. Aron stated that
working with a team develops collegiality. A growing problem with the
current curriculum is that students are often pulled away from their
clerkships and do not feel part of a team.
Dr. Terry Wolpaw
mentioned that the American system is the only medical education system in
the world that lets students participate in patient care. It also
provides the student with the opportunity to be part of a team.
Dr. Altose summed up
today’s CME meeting as a forum for putting the concept of
the new curriculum on the table. This will be the CME’s major agenda item
for the coming year. The next step is determining how this model is to be
operationalized. More details are needed. Once those have been
developed, the CME will be entitled to a “return engagement.” When
questioned as to how information about the new curriculum will be
disseminated, Dr. Altose anticipates an ongoing dialog back and forth.
Dr. Horwitz has already spoken to the department chairs. There will be
meetings with students, basic scientists, and clerkship directors. A
town hall meeting for the faculty has been scheduled for Tuesday, October
12.
Dr. Dan Wolpaw,
Co-Director of the Foundations for Clinical Medicine, returned to the CME
today to seek endorsement of a proposal for student assessment in
the Foundations program. “Foundations” consists of 1) The Science of
Clinical Practice (SCP), a new curriculum for both College and University
students on Tuesday mornings from 8:00 to 9:30, 2) Clinical skills
training, and 3) Patient-based programs.
Foundations
Co-Director Dr. Ted Parran spoke of the desire for assessment
pertaining to the overall program as contrasted with the seven-year
history of treating each component as a separate entity: Physical
Diagnosis, the Interviewing Program, the Family Clinic, the Tuesday
morning program, CPDP, CLICS. All these programs are now clearly united
under the Foundations umbrella and work together to shape a
three-to-four-year program of training and experience. The program is
analogous to a longitudinal clerkship. Therefore, the proposal is that
student assessment should be similar to that of the clerkship and hold the
student to rigorous standards.
Dr.
Wolpaw mentioned that overall assessment would be based on a point
system that would encourage a student to excel. Students would know
in advance the expectations for each standard. The Foundations grading
system was intentionally designed to mimic the clerkship grading system.
Like the existing clerkship system, Foundations grades would be Honors,
Commendable, Pass, Fail, and Incomplete. As a criterion-based
system, there would be no set limit as to
the number of Honors or Commendable that could be awarded. Students
would be required to achieve a passing assessment in
every component in order to pass the course as a whole. Dr.
Wolpaw would like to present this assessment proposal to the
students at the end of this month, as it could go into effect for the
Year I class and pertain to all Foundations components occurring on or
after the date of the proposal’s adoption.
The Year II student
representative Mr. Chris Utz observed that the new grading system would
motivate some students to put more effort into Foundations. Not much
effort is required to merely pass a course.
Discussion took place
on when to evaluate and when to assign the grade. Foundations is
basically a two-year program with currently only one component in Year III
(CLICS). The benefits of mid-term formative assessment in addition to
yearly versus end-of-second-year summative assessment were discussed.
Considering the differences in the first two years, the problems presented
by a single, distant end-of-second-year evaluation, and the need to
provide some assessment of performance in CLICS and potentially other Year
III activities, the consensus was in favor of a yearly summative format
periodically supported by formative feedback. There was a suggestion to
record only the final grade for the Dean’s Letter.
The CME endorsed the
Foundations of Clinical Medicine student assessment proposal.
