Academic Medicine Supplement 2000
Curriculum Changes in Recent Years
The curriculum at the University of Virginia has been updated in recent years in response to changes in the medical practice environment and advances in scientific knowledge. The major revisions have included
- The development of a small-group problem-based course, Introduction to Clinical Medicine, in the second year and the coordination of other second year courses with it.
- The development of a new clinical medicine course in the first year, The Doctor/Patient/Illness.
- The introduction of additional ambulatory and general clinical experiences in the first three years of medical school:
- First year: afternoons in physicians’ offices.
- Second year: a one-week preceptorship in physician offices throughout Virginia.
- Third year: Clerkships in Family Medicine and Ambulatory Internal Medicine (one month each) at medical practices throughout Virginia.
- The increased use of computers, information technology, and evidence-based medicine in courses.
- The development of a Generalist Scholars program.
- The use of standardized patients to teach and evaluate clinical skills. (including the gynecological and male urological exams).
- The creation of a comprehensive Clinical Performance Exam (CPX) given at the end of the third-year to assess and improve students clinical skills.
Transforming Initiatives for 2000
Throughout the 1990s, student performance as measured by USMLE scores, CPX performance, residency placement, and ratings of graduates by residency directors remained high. For example, the students’ mean USMLE scores remained at about the 70th percentile on national norms and student satisfaction as measured by school surveys and the AAMC Graduation Questionnaire was high. However, students and faculty expressed desires for:
- More integration of courses, especially in the first year.
- Placement of basic science information in the context of clinical cases.
- The need for increased clinical experience and contact with patients in the first two years.
- Decreased hours of scheduled classes.
- Decreased time devoted to lectures; increased time devoted to small-group, problem-based learning,
- Increased instruction by physicians in the first two years.
- A mechanism to effect change in the curriculum
Governance Structure and Management
In 1999 the School of Medicine changed the decision-making process for the curriculum to allow for an integrated vision and to facilitate the implementation process for curriculum change while enhancing faculty and student input into the design of the curriculum for both the content and process of teaching and learning. The Council on Medical Education, a large, representative body without direct connection to the Dean’s office, was dissolved and replaced with a smaller Curriculum Committee to actively manage the curriculum through a process of monitoring, evaluation and response. New responsibilities and lines of authority were established. The position of Associate Dean for Curriculum, reporting to the Senior Associate Dean for Education and Faculty Affairs, was created (Figure 1).
Figure 1. New Curriculum Governance
The Curriculum Committee is responsible for defining the goals and objectives of the curriculum; for the design and management of the undergraduate medical curriculum: and for establishing a process for reviewing, evaluating, and revising the curriculum on a recurring time line to ensure that the curriculum is coherent, coordinated, fully integrated, current, and effective. In addition, the Committee makes recommendations to the Dean about the system of incentives for teaching effort, salary support for faculty who teach, space required by the curriculum design, and other support requirements needed to make the curriculum operational.
The Committee has given the authority, with the approval of the Dean, to set educational objectives, establish educational requirements, allocate curriculum time, specify teaching methods, approve course directors, and evaluate educational outcomes. In addition, the Committee has given the authority to set performance standards for instructors, initiate faculty development efforts, and evaluate instructor performance.
The Principles of Medicine and Clinical Medicine committees were established and made responsible to the Curriculum Committee and Dean for effecting the goals, objectives and teaching responsibilities of the curriculum for each course and clerkship, and for the electives program.
Office of Educational Support
Since the 1970’s, an Office of Medical Education has provided educational, evaluation, and administrative support to the educational program. In the 1990s, the Office expanded its role to include a standardized patient program, computer applications, the administrative support of clinical and ambulatory courses and clerkships, management of a Learning Center, and faculty development. These activities were added to continuing responsibilities for scheduling and maintaining instructional space, publishing a combined course schedule, scoring and analyzing tests, evaluating courses and instructors, and consulting with course directors and faculty about instructional design and evaluation. In addition, the Office supports the Student Advocacy Committee which is devoted to ensuring a professional environment for students, and the Mini-Med School, an educational program for the community.
Educational Program Budget
The Dean supports the educational program with funds to departments and discreet budgets to the offices of Curriculum, Medical Education, Admissions, and Student Affairs.
Application and Integration of Computer Technology
Computer and information technology to gather, manipulate and apply knowledge is integrated into the curriculum rather than taught in a separate course. Computer training is offered to medical students on a just-in-time basis when a need arises. For example, e-mail accounts are set up during orientation and workshops are offered at the time students need to do their first medical literature searches for Biochemistry, Genetics and Epidemiology. This integrated approach considers the computer as a necessary tool for physicians, with training provided at the time the tool is needed.
Most courses have web pages which include instructional materials such as notes, demonstrations, clinical cases, and quizzes. The Medical Education home page, http://www.med.virginia.edu/med-ed/MedEdHome.html, provides students with a convenient gateway to all these web-based materials. The computer staff of the Office of Medical Education has also developed an image database to be shared among courses and templates for clinical cases, quizzes, and other web-based instructional materials.
Students are not required to buy a particular model of computer, but they are required to have access to a computer at home. Eighty-five percent of incoming students already have access when they enter medical school. A pilot group of third-year students receive palmtop computers and medical software for the clerkship year. Students in the Family Medicine and Ambulatory Internal Medicine clerkships receive laptop computers, appropriate software, and communication access during the two months they are away from the medical school in doctors’ offices throughout the state.
Identification and Recognition of Faculty with Primary Responsibility for Medical Student Education
Salary support is provided to course directors and other faculty receive credit for teaching on their personal effort reports. The plan for supporting teaching effort differs by department.
There are a number of teaching awards. The Dean’s Office funds five faculty teaching awards annually, each consisting of a $2500 stipend. The Dean’s Office and the University fund ten resident teaching awards annually, one for $1000 and the others at $250. The student body gives outstanding teaching awards to a basic science instructor, a clinical instructor, and a clinical department each year as well as providing additional awards to teachers in the first two years.
Identification and Adaptation of Learning Outcomes Students Must Demonstrate Prior to Graduation
The Curriculum Committee adapted a set of objectives for undergraduate medical education based on findings of the 1998 University of Virginia School of Medicine Task Force on Medical School Objectives. These are presented in outline form.
Competencies Required of the Contemporary Physician:
- Developing and practicing of a set of personal and professional attributes that enable the independent performance of the responsibilities of a physician, including the ability to adapt to the evolving practice of medicine.
- Achieving competence in the human sciences:
- in the understanding of current clinically relevant medical science
- n the understanding of scientific principles as they apply to the analysis and further expansion of medical knowledge.
- Achieving the ability to engage and involve any patient in a relationship for the purpose of clinical problem solving and care throughout the duration of the relationship,
- Eliciting a clinical history, including consideration of the patient’s use of alternative or complementary medicine,
- Performing a physical examination,
- Generating and refining a prioritized differential diagnosis for a clinical finding or set of findings,
- Developing and refining a plan of care for both the prevention and treatment of illness and the relief of symptoms and suffering,
- Developing a prognosis for an individual, family or population based upon health risk or diagnosis, with and without intervention, and planning appropriate follow-up,
- Selecting and interpreting clinical tests for the purpose of health screening and prevention, diagnosis, prognosis or intervention,
- Organizing, recording, presenting, researching, critiquing and managing clinical information,
- Selecting and performing procedural skills related to physical examination, clinical testing and therapeutic intervention, and
- Understanding of the cultural, social, economic, ethical, legal and historical context within which medicine is practiced.
Recent Pedagogical Changes
The history of education seems to suggest cycles in pedagogy between emphasis on content and emphasis on process, between passive and active learning, between large-group and small-group instruction, between required courses and student choice, and between discipline-based and case-based organization. Currently the school is at the midpoint of this cycle, moving from an emphasis on content organized by disciplines delivered in large-group lectures to an emphasis on case-based, small-group, and interactive instruction. Current curriculum innovations involve coordinating content with clinical cases, reducing the number of scheduled hours devoted to lectures, and providing more clinical experiences with patients, standardized patients and virtual patients, both for teaching and assessment. This change from a traditional discrete basic science–clinical format to an integrated format is illustrated in Figure 2.
Figure 2. Old and new curriculum structure.
Students are assigned to physicians’ offices during the first three years of medical school and many students take electives in ambulatory settings during their fourth year. All clerkships have in-patient wards and out-patient clinics with students integrated into the health care team.
Curriculum Review Process
A process for review of the curriculum has recently been instituted (1999).
Themes and Goals of Curriculum Renewal"Central to the medical education program at the University of Virginia School of Medicine is our vision (1) to attract, motivate and guide outstanding people by nurturing the dreams of those embarking on a career in medicine, (2) to engage the creative abilities of people to generate new knowledge and improve the quality of life and (3) to foster excellence in medical education that blends compassion, technical ability and thirst for knowledge."
"Our primary reason for being is the education and training of physicians to help people achieve healthy and productive lives and to advance knowledge in the medical sciences."
These statements define the core values and purpose of the education program at the School of Medicine. From these statements we derive the following goals and objectives of curriculum renewal.
Goals of Curriculum Renewal:
- Create an environment conducive to learning core knowledge and skills and developing professionalism, appropriate attitudes and social responsibility.
- Enhance the student’s medical problem solving ability and medical information management through use of information technology.
- Provide an experience of early and progressive student-patient contact and a context in which students learn patient-care skills and evaluate their own progress.
- Foster the creation of new knowledge through engagement of the student’s creative abilities and exposure to a variety of clinical and research experiences, furthering an appreciation of the potential contributions of research to the diagnosis, treatment, and prevention of disease.
Objectives of Curriculum Renewal:
- Integrate and coordinate basic science and clinical experiences horizontally and vertically throughout the four years.
- Create time for imaginative and creative expression in the basic sciences, in clinical medicine and in service to the community while including elective opportunities to explore the alternative pathways of general medicine, specialty medicine and research.
- Achieve a balance of lecture, problem-based learning, patient experiences and blocks of productive open study time to optimize the learning environment. Encourage a problem solving approach to learning.
- Create time in the early years for regular and frequent patient contact, integrate and coordinate patient experiences with the clinical sciences.
Planning Resources Required
- Dean’s championing call for adaptation in medical education
- Dean’s support of the teaching enterprise
- Management restructuring – new committees, responsibilities and authority
- Mulholland Society - strong student government
- Retreats of faculty and students addressing educational issues
- Curriculum committee "Open House" for faculty and students
- Curriculum Web page for communication with faculty and students
Implementation Resources Required
- Strong backing of curriculum changes by the Dean
- Space for educational activities – lecture, small group, laboratory, self-study, computer facilities, recreation
- Faculty time and funding
- Strong administrative support for education by departmental chairs and service center directors
- Support for interdisciplinary educational programs needed
- Expanded educational design and development programs to support instructional development, eg. computer programs, Web page construction and audiovisual materials.
Challenges and Unanticipated Outcomes of the Process
- Improved faculty communication
- Faculty recognition of need for adaptation and growth in medical education
- Improved management of information content, balancing an increasingly complex basic science background with essential humanistic values and skills needed for patient-care.
- Recognized need for an expanded faculty development program
- Increased enthusiasm of faculty to teach; counterweighted by clinical and research financial and time demands
- Perceived primacy of research and clinical service
- Difficulty of finding adequate numbers of faculty for small group teaching.
- Difficulty of finding faculty with the expertise needed to teach aspects of medical physiology, anatomy, neuroscience.
Evaluation and Review of the Educational Program
One of the major tasks of the new Curriculum Committee is to develop a plan and a timeline for continuing evaluation and revision of the curriculum. In the past, there were many sources of evaluation data, but no comprehensive plan to review and act on the information in a systematic and timely manner. We now have an effective mechanism to evaluate our curriculum and implement change when needed.
Evaluation of the Teaching Process and of the Outcomes of Teaching are viewed as essential.
Figure 3. Diagrammatic representation of the evaluation process.
The School uses the usual evaluation resources (e.g., USMLE scores; course exams; clerkship evaluations; grades; shelf-exam scores; student evaluations of courses, clerkships and faculty; AAMC Matriculation and Graduation Questionnaires). In addition, the school has created other evaluation resources:
- Dean’s Town Meetings (focus groups of students from all years),
- Looking Back Surveys at the end of the second and third years focusing on the curriculum as a whole rather than on individual courses.
- Student representatives on course committees.
- Annual student government report evaluating clerkships and a
- Residency Directors' Evaluation of graduates at end of PGY-1
- OSCE for physical examination skills
- Comprehensive Clinical Practice Exam
A major function of the Curriculum Committee is to review the data from evaluations of both teaching processes and outcomes to define areas that need improvement and to make recommendations or proposals, working through the Principles of Medicine and Clinical Medicine committees. This is illustrated in figure 4. The Principles of Medicine or Clinical Medicine committee responds to the recommendations or proposals from the Curriculum Committee as appropriate. This might be direct action on a request, a plan for action or a call for clarification and/or counterproposal. In all cases, a dialogue is set up between the Curriculum Committee and the "Principles" and/or "Clinical" committees. Proposed changes to the curriculum are reviewed by the Curriculum Committee for adherence to the vision, goals and objectives of the School of Medicine. The Curriculum Committee provides guidelines to the course directors. The course directors translate the guidelines into working plans, and then with the approval of the Curriculum Committee, put these plans into effect. The Curriculum Committee provides direction and may initiate change when basic structural modifications are necessary, especially when these changes cut across current course domains. A regular review by both inside and outside reviewers should ensure ongoing discussion of medical education and provide a mechanism to recognize and react to change.
Figure 4. Illustration of process for evaluation of teaching processes and outcomes.