Contemporary Clerkships, Selectives and Electives Curriculum Retreat

January 31, 2004

Summary report

Retreat Overview:
Introduction
Why change?
Goals and objectives for the curriculum
Expectations; Guidelines; Criteria for Curriculum Design
Review Foundations & Core Systems, D&D Teams & others
Contemporary Clerkships/Selectives/Electives
Session 1 - Working Groups:
     - content proportion & sequence -> model for CCSE
Session 2 - Working Groups:
     - improving teaching/learning in the clerkships/selectives
     - knowledge & clinical skills

 We need to continue to attract motivated, capable students and provide them unfettered opportunities to learn, providing good laboratories and libraries, an ample and diverse supply of patients, and stimulating teachers and colleagues.  Most important of all was the fact that learners were provided sufficient time with patients so that patients could be studied and understood.”         Paraphrased from - Ludmerer: A Time to Heal

Curriculum Goals:

• Focus on learning and commit to programs of active learning to meet the educational needs of medical students
• Increase clinical experience - increasing time available for acquiring patient-care knowledge and skills - including development of cultural, social and self-awareness; learning medical information acquisition and decision making; developing communication skills; accepting responsibility for patient care; acquiring life-long learning skills and learning the art of medicine through patient encounters and guidance from practicing physicians (informal & hidden curriculum) while assuring continued acquisition of scientific knowledge, principal to medical practice
• Teach and apply medical problem solving and management of medical information
• Sequence the basic scientific and cultural information
• Increase the efficiency of learning for both content and process

Objectives [Clinical Care Experiences]:

• Begin Clerkships May 1 to increase clinical time
• Return Neurology to the clerkship environment
• Basic Science for Careers course where basic sciences are specifically applied to residency and career choices
• Improve the clinical learning environment - knowledge and skills - in contemporary clerkships, selectives and electives
• ACE – Advanced Clinical Elective
• Career Practice Enhancement (4^th year) - the social, economic and political aspects of medical practice
• Selectives - maintain patient experience - increase responsibility, increase student choice, focus application (relate to other disciplines)
• Electives - increase the number of 2-week electives

Objectives [General Enhancement]:

• Joint degree and program access, e.g., MD/PhD, MPH, MS, MBA, LLB
• Incorporate simulation technology to prepare for and augment patient encounters and to increase the safety and efficiency of learning [develop a Simulation Center for education of medical professionals]
• Continue limitation of class hours to allow for study and self-learning activities with the 20 + 4 model
• Provide an educational environment supportive of personal and professional development for students and faculty

Design & Development Teams

• Basic Science for Careers - Vern Juel
• Career Practice Enhancement - Ruth Gaare and Tom Massaro
• Cells to Society - Chris Peterson and Gene Corbett
• Foundations of Medicine & Core Systems – Eve Bargmann & Bob Bloodgood
• Exploratory - David Cattell-Gordon, Don Innes & John Gazewood
• Medical Decisions & Critical Thinking – Linda Watson
• The Contemporary Clerkship/Elective/Selective – Bill Wilson & Meg Keeley
• Simulation Training in Medical Education – Marcus Martin
• Professionalism - Don Innes

The Contemporary Clerkship/Elective/Selective – Bill Wilson & Meg Keeley
 

Core Clinical Clerkships (Begin May 1)

8 weeks Internal Medicine
8 weeks General Surgery
8 weeks Pediatrics
4 weeks Neurology
4 weeks Family Medicine
4 weeks Obstetrics/Gynecology
4 weeks Psychiatry

40 weeks Total (will end late February)

Selectives & Electives (Begin in late February)

2 week Internal Medicine Selective
2 week Internal Medicine Selective
2 week General Surgery Selective
2 week General Surgery Selective
2 week Obstetrics/Gynecology Selective
2 week Psychiatry Selective
4 week Advanced Clinical Elective
4 week Basic Sciences for Careers
2 week [Public Health – social, economic, health policy]

23 weeks Electives

45 weeks of scheduled Electives and Selectives

12 weeks of free time (vacation, interview, study)

57 weeks from ~March 1 to following ~April 30

Develop a core group of third year advisors to assist students with planning their schedules for clinical experiences.  Students would then select a specialty specific advisor to assist with residency application and selection

Support of at least 80% for “Teaching Attendings” in each department.  These faculty would be dedicated to the third year clerks while on service.

 A web based scheduling program would be necessary to keep track of requirements

Develop several two week elective opportunities such as dermatology, radiology, ophthalmology, orthopedics for students applying to other specialty programs who would benefit from some exposure but may not need a four week experience

Discussion points:

Students will have the opportunity to experience non-clerkship specialties well before choosing a specialty and beginning the residency application process.

Compressed clerkships will have to alter lecture series, etc. in order to cover material for testing. May consider computer modules or other self directed learning.

Students will have an advantage in scheduling away or audition electives by starting  in late February.

There would be no clinical clerks rotating during the months of March and April.  This could provide clinical opportunities for first and second year medical students at UVA but would leave openings at our satellite sites.  Students would be rotating on selectives and electives during those months.

All students will be exposed to the same clinical clerkship experiences and be expected to master a core curriculum.  Students then will individualize the required selectives and the “free choice” electives.

Selectives likely will be limited in numbers of students providing more focused faculty interaction.  They will need to be sufficiently rigorous perhaps involving projects or presentations.

Students will continue to have ample elective opportunities.

Neurology will require two years to move back to the clerkship period.

Basic Science for Career

Vision:

Bring basic science to clinical relevance.

Goals:

1. Relate basic science to the individual student’s chosen discipline (future residency), focusing on the application of basic science principles used in the daily practice of the chosen discipline.
   
2. Place appropriate basic science from Principles of Medicine courses in post-clerkship period.
3. Motivate and mentor students in their chosen field.
   
4. Increase interest in academic medicine.

Objective: 

Create a program Basic Science for Careers (BS4C) in the undergraduate medical curriculum following the clerkships to review, expand and focus on basic sciences as applied to a particular discipline.

The BS4C curriculum must be:

- Comprehensive - include relevant scientific competencies related to the discipline
- Focused - built specifically for the chosen discipline
- Advanced - built sequentially on prior achievements

The format should combine limited didactic teaching with small group learning including active discussion and student presentations

Implementation:

• Required of all students
• Use discipline specific didactic and small group sessions to demonstrate basic science necessary for discipline specific clinical care and problem solving

Direction and coordination:

• General oversight (an Office of Clerkship & Elective Oversight) as well as directors and coordinators at the departmental or discipline level.

Facilities:

• Need for simultaneously available (~10-15) small group rooms*

Student Objectives:

The students will be better able to apply the scientific principles of medicine to a chosen career and improve their clinical competency

Increased interest in scholarly pursuits academic career

Strengthened UVA residency candidates

Improved USMLE-2 performance

Improve faculty & resident knowledge and attitudes toward teaching

Career Practice Enhancement (Public Health) - Ruth Gaare and Tom Massaro

Goals

• Introduce fourth-year medical students to the public policy dimensions of patient care, including economic and legal dimensions
• Prepare medical students to recognize their responsibilities as stewards of health resources and their roles in health policy development

Objectives

• Provide students with an understanding of the relevant regulatory, economic, and legal frameworks in the practice of medicine and in health policy
• Introduce important learning experiences

Case discussions that include the use of economic, public policy, and legal frameworks and vocabularies

Interactions with health policy leaders regarding their perspectives on health care and the roles and responsibilities of physicians

Schedule for 8-day course   3/7/05 – 3/16/05  (Match Day is 3/17/05)

• Format
• Morning lecture or panel
• Afternoon small group case discussion led by faculty from medicine, law, and related disciplines
• Topic Examples   (All topics will be case-based)
• Structure and Finance of the U.S. Health System
• Regulation of Medical Practice:  Drugs, Quality, and Patient Safety

Michael Rein, the Internal Medicine clerkship director, raised five concerns regarding the proposed curricular changes and how they would affect the Internal Medicine clerkship.

1. The Internal Medicine Clerkship (IMC) argues that it is on the IMC that physical diagnosis, medical reasoning, systems-based care, and communication skills are most emphasized and are best taught, and that decreasing the early exposure to internal medicine will reduce the skills that many of our students bring to their fourth-year rotations.
   
   
2. Reducing students’ early exposure to internal medicine will most likely accelerate a trend (national) toward a decrease in the number of applicants to internal medicine residencies.
   
   
3. The breadth of internal medicine is such that general internists are expected to manage patients in gastroenterology, hematology/oncology, cardiology, renal, endocrine and pulmonary disease, etc. Initial training in internal medicine should include exposure to each of these fields.  Such training has been made difficult by the Service Center structure.  Exposure to more fields in a shortened IMC would reduce the depth of learning in each and would reduce the continuity of interaction with patients.
   
   
4. Decreasing exposure to faculty could reduce the ability of students to obtain letters of recommendation from physicians in internal medicine. Letters are needed for residency applicants in a number of specialties and for preliminary training slots.
   
   
5. Teaching internal medicine in a continuous period is considered by many to be superior to fragmenting the exposure.

Other topics for consideration included the belief that all students need [should have the opportunity to experience] a radiology, geriatrics and emergent (acute) care medicine experience by all students.

Integrate geriatrics into the medicine clerkship in a formal way. A series of small group discussions, lectures and special clinical patient sessions should be considered.

Integrate emergent (acute/life saving) care into the surgery clerkship in a formal way. A series of small group discussions, lectures, ER Trauma team and simulation training should be used.

Should radiology remain an elective, become a requirement or be integrated into a current course(s).

Accountability for teaching: Teaching is the responsibility of individual faculty and of the departments. Clarifying the financial aspects of education, service and research will place us in a better position to call for accountability.

Curriculum/CMC Retreat Participants