Shield of the SOM Committee on Medical Education
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Summary of September 9, 2004 CME Minutes

  1. Comments from the Chair

Dr. Murray Altose, CME chair, welcomed attendees to the first meeting of the CME for the new academic year and set the primary focus of the agenda for the coming year as the curriculum renewal.

  1. Curriculum Update by the Dean

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:

  • 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 diseaseRelevant 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.

  1. Foundations of Clinical Medicine Update

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.

See Curriculum Revision Update section.

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