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Summary of September 23, 2004 CME Minutes

  1. Report from the Basic Science Curriculum Council

Dr. Amy Wilson-Delfosse, Basic Science Curriculum Council Chair, presented highlights of the council’s first meeting, held September 14. 

  • Dean Ralph Horwitz addressed the council on curriculum reform

  • Dr. Tim O’Brien, Year II Hematology/Oncology co-chair, explained the immediate audience response system as used in his committee.  Students take a mini-quiz at the end of a lecture and then discuss the results.  One function of the Basic Science Curriculum Council is to share teaching innovations. 

  • Dr. Nick Ziats, Year I Histopathology chair, provided an introduction to this integrated committee, which incorporates longitudinal pathology into histology as of this year.

  • Dr. William Bligh-Glover provided an overview of the tutoring program.

  • Dr. Terry Wolpaw announced the series of faculty development opportunities that will be starting soon.

Another major issue addressed was that of student attendance—at lectures, small groups, patient-attended clinical correlation conferences, and team-based learning experiences.  Recognizing attendance as 1) an important component of professionalism, and 2) fostering a positive learning experience, basic science council members recommended requiring attendance at small groups, patient-attended clinical correlation conferences, and team-based learning experiences.  Discussion examined various aspects of the attendance problem and its repercussions, how attendance can be improved by changing the intellectual culture/assessment, yet ended with reluctance of the CME to endorse mandatory attendance.

Dr. Wilson-Delfosse mentioned that Year II student Ms. Shernett Griffiths conducted a survey, resulting in student support for required attendance at clinical correlation conferences and team learning activities.  Students were opposed, however, to requiring small group attendance.  Dr. Wilson-Delfosse mentioned that student attendance at small groups is skewed, as students often ignore their assigned small group assignment to attend a different group led by a faculty member perceived to be a superior teacher.

One means of increasing student attendance at small groups is having individual students lead the groups.  One CME member, a clinician and also a participant in the Hematology/Oncology committee, noted that for the first time in his 15 years, a student leader failed to show up and he had to lead the small group.  Attendance is never optional in clinical activities—the absent student risks failing the clerkship or a substantially lowered grade.

One member supported the development of professionalism but noted that the design of our current exams allows students not attending class to pass at the same rate as those who do show up.  Merely reading a text/syllabus and taking a test is like passing a “correspondence course.”  In his opinion, we offer little to those students who attend class; there is a need for a value-added component.  He placed responsibility on both parties:  1) students to be accountable, and 2) course directors to set a higher standard, incorporating the student’s interaction with the faculty in the assessment.

Continued discussion developed along two themes:  1) incorporating a “value-added” component that only classroom attendance makes possible, and 2) re-designing assessment to measure what the student has gained from that value-added experience.  Focus, for the most part, was on small groups and how we use them.

Dr. Wilson-Delfosse mentioned the council’s rationale behind mandating required attendance.  There is a desire for conformity among subject committees.  Inconsistency has been a problem in the past.  Additionally, the curriculum reform will require teaching the students very differently.  As a proactive step, why not address small group learning now?

Discussants acknowledged the demonstrated skill of our students in passing multiple-choice-question exams—interims, the Year I Comprehensive Examination and the USMLE Step 1.  However, multiple-choice-question examinations reflect “surface” learning.  Small group learning should be different from a mini-lecture.  The small group is the venue where the students struggle with the issues, gain knowledge from their peers, and learn to articulate their conceptual thinking.  How do we use the small group setting as a method of assessment?  We need to be able to create enough continuity over a committee so that some assessment occurs in small groups.  We need innovative ways to assess students in small group.  Students can be assessed for their preparedness and participation in the group process using a 5-point Likert scale, for example.  A move away from multiple-choice-question examinations is anticipated in the new curriculum, and an Alternative Assessment Committee is exploring new ways to assess student performance.

Variations in the size of small groups and its impact were discussed.  A “small” group of 25 students over a three-week-long committee cannot be viewed the same as a Foundations of Clinical Medicine continuity group of 8 or 9 students staying together for three years.  Basic science small groups range in size from 20 to 50 students per group.  This large number of students per basic science small group has basically been determined by the number of rooms available in the medical school.  The basic science course directors have been restricted to six rooms of 25 students each for their small group teaching.  Additionally, Foundations of Clinical Medicine has required small group attendance since inception of its various components; there was never a need to mandate a policy change.

The practical drawbacks of mandating attendance were mentioned.  Monitors would be needed.  The society deans would be forced into an adversarial relationship with students failing to attend class.  What would be the consequences for a student failing to attend?

There was consensus among CME members on the importance of professionalism, especially in regard to any activity involving patients.  In the clinical program, there are established repercussions for students failing to attend Family Clinic or their clerkships.  Dr. Wilson-Delfosse mentioned that during Years I and II, a significant percentage of students fail to attend class when a patient is brought in.  One discussant’s suggestion requested that the Dean issue a letter via the ListServ stating the expectation that all students be present, in proper attire, and demonstrate a professional attitude when patients are brought to class.  A suggestion to improve small group attendance was inclusion of parts of the value-added evaluation in the Dean’s Letter.  This practice already occurs, as CPDP small group comments for highly motivated students are quoted verbatim in the Dean’s Letter.

In conclusion, Dr. Altose stated that although the CME believed in the importance of attendance, it did not consider that legislating mandatory attendance even in small groups, clinical correlation conferences, or team-learning activities in the subject committees would be helpful or productive.  He suggested that Dr. Wilson-Delfosse take back to the subject committee chairs the charge to enhance small groups—make them more attractive and productive—and come up with new ways to assess the students in their small groups, as suggested earlier in the meeting.  It had also been suggested earlier to link assessment—not only of the material but also of group process—to the small groups.  Perhaps the basic science council members could elaborate on the size of particular groups, the type of teaching that goes on—for suggestions on improving them.  Dr. Wilson-Delfosse stressed that without the CME endorsement of required attendance, it would be up to each course director to decide his/her own assessment and the issue of establishing consistency across subject committees would remain unresolved.

  1. Report from the Clinical Curriculum Council

Dr. Michael Nieder, Clinical Curriculum Council Chair, reported that all Type B electives—including all Acting Internships (AIs)—will be on the same four-week schedule for the 2005-2006 academic year.  With the CCC Chair’s support, the Registrar has been working on getting the clerkship directors to return the core clerkship evaluations in a more timely manner.  Dr. Nieder mentioned that Dr. Wile has done an analysis on the NBME subject (shelf) examinations.  Dr. Wile added that there will be one change in the passing score established on the NBME  Surgery Subject (shelf) Examinations.  For the 2004-2005 academic year, Surgery will use the “NBME Quarterly Norms for Examinee Performance.”  Surgical clerkship students must achieve a minimum passing score of the 10th percentile on the NBME Surgery Subject Examination.  Quarter 1 percentile ranks were used on the August 27, 2004 examination and will be used on the October 22, 2004 examination; Quarter 2 percentile ranks will be used for the December 17, 2004 examination; Quarter 3 percentile ranks will be used for the February 25, 2005 and April 22, 2005 examinations; and Quarter 4 percentile ranks will be used for the June 17, 2005 examination.  The 10th percentile in Quarter 1 is 56; 59 in Quarter 2; and 60 in Quarters 3 and 4.  As students tend not to do as well early on in surgery, the NBME pass mark changes to offer a “handicap” and provides equivalence across examination performance.

  1. Report from the Flexible Program

Dr. Kent Smith, Flexible Program Coordinator, mentioned successful implementation of a policy change authorized last year by the CME:  Permission for Year I students to take 1 Type A elective during Period 1.  Dr. Smith suggested another agenda item for CME consideration at a future meeting:  Are additional hours related to a course permissible as an elective?

  1. Report from the CCLCM Curriculum Steering Council

Dr. Andrew Fishleder, Cleveland Clinic Lerner College of Medicine Curriculum Steering Council Co-Chair, mentioned that all 32 CCLCM students successfully completed the nine-week summer basic science research block by producing a research project and presenting an oral presentation on their research.  The LCME visit to the CCLCM took place September 12, and a written report is expected within three or four months.

  1. Cleveland Health Sciences Library Update and Discussion

Mrs. Virginia Saha, Cleveland Health Sciences Library Director, announced the completion of the library’s orientation season for the students.  This year Mrs. Saha and her staff presented a full-class lecture in E301 for Year I medical students that coordinated with research topics for the Fundamentals of Medical Decision Making (FMDM) subject committee.

Based on her own experience working with our medical, dental, and nursing students, Mrs. Saha indicated an area needing attention.  Our students seem to know little about the organization of literature:  the fundamentals, “key words” vs. “subject headings,” their erroneous assumptions that Google is a research database and that short-lived URLs can be used as footnotes.  The problem extends to faculty as well.  Investigators using animals in their research must comply with Federal requirements for literature searches on unnecessary duplication and alternatives to using animals and must search at least two (2) databases to satisfy the law.  Beyond trying a keyword search in PubMed, many faculty are frustrated and ineffective in trying to search another database.  Mrs. Saha emphasized that the library staff would like to be more responsive in helping students and faculty learn these skills at the time when such instruction will do the most good, i.e., when there is a real need to use them.

The topic of critical thinking and searching skills led to the following observations/responses by discussants.

  • Our current curriculum fosters over-reliance on the syllabus.  Perhaps in the new curriculum, we could mandate use of the primary scientific literature.

  • The new Foundations course has integrated a mentored component on how to approach the medical literature.  Students will read a journal article and appraise it the following week.  Foundations seeks to address the past inconsistency of expectations in critiquing the scientific literature and lack of guidance.

  • The AAMC has learning objectives on this topic.  Perhaps we could integrate them into the new curriculum or each of the subject committees.

  • What are the expectations for students in medical school?  The BSTP (Biomedical Sciences Training Program) has a course to teach its graduate students how to read and dissect a manuscript.  Mrs. Saha added that we are still talking about how to equip our students to find the manuscript!

Dr. Altose summarized a common theme that also occurred earlier in the meeting:  How do we promote the desire to go “beyond the syllabus” among our students?  At every student feedback lunch, students request that more material be included in the syllabus.  The expectation among Case students seems to be that everything in the first two years should be included in the syllabus.  How do we change this culture?

  • One solution could consist of explicit learning objectives including references to primary sources.

  • The Foundations program will give quizzes on the journal articles that students are to read prior to coming to class.

  • While multiple-choice-question examinations tend to focus on details contained in the syllabus, essay examinations would not be as dependent on the syllabus.  “Assessment drives learning.”

  • The CCLCM summer course requires students to use the literary search skills that they are taught, as they go out and develop answers to the problem sets that they are given.

  • A few years ago, the Internal Medicine/Family Medicine clerkship had librarians teach the students evidence-based learning skills for a year.  Student input was that they already knew these skills, and subsequently, this teaching activity was dropped.  Today, unlike a few years ago, Year III students are not doing the required reading and are coming to class unprepared.

Dr. Altose summarized the issues raised during discussion:

  1. Do our students have the skills necessary to find the appropriate material in a reasonably efficient manner?

  2. Students are not using what they find.  They are not “engaged.”

  3. How do we structure what we do to promote the students to look “beyond” the syllabus?

What steps do we take between now and the curriculum renewal project?  What are our plans for immediate change and for long term change?  One member suggested that the CME could define values that should characterize the new curriculum.  Dr. Altose proposed that the CME revisit the “Guiding Principles for a New Curriculum,” developed by the Curriculum Work Group, that he presented at the September 9 CME meeting.

  1. Update on Faculty Development

Dr. Terry Wolpaw, Associate Dean for Curricular Affairs, announced the new faculty development workshop series designed for this year and offered under the auspices of the Office of Curricular Affairs.  The initiative began with an e-mail survey to CME, Basic Science Curriculum Council, and Clinical Curriculum Council faculty, requesting individual preferences with regard to day, time, and site for workshops offered as well as preferences from among 20 suggested topics with a write-in option for personal interests.  The goal of the initiative is the encouragement of personal growth via a substantial and scholarly effort that can be noted on the curriculum vitae.  Faculty participating in the program have four options:

  1. To earn a Certificate in Active Learning, a multi-session lecture development series, led by Dr. Mark Gelula (visiting Case from the Department of Medical Education at the University of Illinois at Chicago)

  2. To earn a Certificate in Team Learning, application of a small group technique to the large group setting via a multi-session series, led by Dr. Dan Wolpaw

  3. To earn a Certificate in Teaching and Learning, individual choice to attend any 6 of the 11 topics offered and selection of one teaching intervention to use in actual teaching and evaluate, led by Dr. Terry Wolpaw

  4. To attend on a session-by-session basis with no certificate

The eleven different theme sessions will be repeated and offered at various times, dates, and sites.

See Curriculum Revision Update section.

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