Minutes 09.20.07

Minutes 09.20.07

University of Virginia School of  Medicine
Curriculum Committee

Pediatric Conference Room, 4:00 p.m.                       

Present (underlined) were: Reid Adams, Gretchen Arnold, Eve Bargmann, Dan Becker, Robert Bloodgood, Brad Bradenham, Gene Corbett, Wendy Golden, Donald Innes (Chair),  Howard Kutchai, Marcus Martin, Chris Peterson, Jerry Short, Bill Wilson, Emily Clarke, Sixtine Valdelievre, Dean Kedes (guest) Debra Reed (secretary) 

  1. Clinical Skills Training and Assessment Program (CSTAP). Today it was learned that a move is planned for the CSTAP headquarters (our Standardized Patient Program) in Room 1520 of the Primary Care Center.

    Room 1520, which also serves as the Director's Office, is key to the operation of the entire clinical skills program. It is across the hall from the seven exam rooms in the Family Medicine Clinic which serves as the clinical space for the standardized patient (SP) program. The location of Room 1520 next to these exam spaces is vitally important because it is the hub of the operation of the clinic, serving as the training space for SPs, orientation space for students, and assembly room for students and SPs during the programs. Without this room, it will be difficult if not impossible to continue to operate the standardized patient program at its current level in support of both UME and GME programs. In addition, Room 1520 is equipped with cameras and recording devices like the seven exam rooms, so that it can serve as an additional exam room when large clinical skills programs and special programs are scheduled.

    Our understanding is that the planned new use for Room 1520 is as a conference room for the Telemedicine program. The Curriculum Committee requests that Room 152 remain the headquarters of the Clinical Skills Training and Assessment Program until the new Medical Education Building is completed.

  2. Class Size and the Commission on the Future of the University. President John T. Casteen, III has requested input into the Commission on the Future of the University as it forges directions for the University for the next decade and beyond. Dr. Robert Bloodgood forwarded to the Curriculum Committee a proposal from the Principles of Medicine Committee in regard to the medical school class size. In the draft report of the Commission on the Future of the University's Committee on Schools and the Medical Center, the School Plan Summary from the School of Medicine states: "When the [Claude Moore Medical Education Building] opens, class size will increase by approximately 20 students (15%) from 142 to162 per year." 

    The recommendation of the Principles of Medicine Committee was for the UVa School of Medicine to NOT increase the medical student class size beyond the current level of 142 students per year (by a vote of 25-1). Reasons for this recommendation can be read by going to the following website:

    Principles of Medicine Committee statement and recommendation to the Medical Curriculum Committee on UVa Medical School Class Size

  3. A long and intense discussion began with consideration of the relevance of the 2000 Engelhard Report on the "Quantity, Quality, and Medical Education: Would Less Mean More if We Reduced UME Class Size at UVA?"  Many of the social and economic conditions on which the report is based have changed since the late 1990s; however, "the need to identify resources for teaching and assessment of clinical skills, an expansion of ambulatory care experiences for students, a commitment to maintain diversity in the institution, and the primacy of frequent patient encounters" was noted in the report.  The report noted that "reducing the class size would not alleviate all these concerns [resources for teaching and assessment, diversity, etc.], but might begin to address some of the current shortfalls in the medical education program and relieve the pressure many in the institution are now experiencing."  The report ends with the statement that "adjusting class size, as part of a larger plan to recommit medical education to the tradition of serving the public good, may function as a guidepost for the University of Virginia School of Medicine as they continue to pursue excellence in these difficult times."

    The discussion focused on maintaining or even decreasing the class size to improve the quality of our medical education. The discussion led off with a suggestion to decrease the current size to attract a more academically oriented student body and to allow our school to emerge as the producers of the academic clinicians and researchers - the future state and national medical leaders - especially in light of the expanding classes and new medical school proposed in our state at other institutions.

    The AAMC, under the direction of Jordan Cohen, MD, has proposed an increase in the physician workforce by 30% by 2015, and with this, a desire/obligation to increase diversity. 

    Notes from the Annual AAMC Meeting 2006 - The Future of Allopathic Medicine
    Jordan Cohen, MD has said we must consider allopathic medicine in context of workforce shortage projections:

    1. 11 states and 12 MD specialties reporting current shortages

    2. Physicians aging faster than population (1985 majority of physicians < 50,  now majority >50)

    3. Factors impacting supply include: Gender and generational differences, Lifestyle choices, Changing practice patterns, Productivity changes (NPs/PAs)

    4. Factors impacting need include: Population growth, Aging?, Chronic disease epidemic, Public expectations, Economic growth, National investment in healthcare innovations, Improved diagnosis/treatments, Changes in organization, delivery, and financing healthcare, Cost containment efforts

    Other issues: 

    • There is a recognized need for robust concentration on primary care but MDs not responding (40% MD grads chose primary care in 1995, 20% in 2004)
    • Maldistribution is a major problem in HPSAs, rural areas
    • There is a great diversity gap and it is growing (25% of population minority, but 10% of physicians)
    • 80% of MD students from top 20% socioeconomic groups
    • Increased cost and debt for medical students a problem

    Michael Johns, MD, CEO Emory Healthcare countered that we do not know what the future has in store for us and that we have often been wrong in our predictions of the nations need for physicians. “Quality and humanity of what we do for others is the most important, not the money.” He noted that many new factors will be affecting physicians:

    • Rising expectations re. evidence based medicine
    • Globalization
    • Acceleration of technological change and medical knowledge, e.g. molecular biology, nanotechnology, imaging, robotics
    • Public-private innovation, e.g. "Medical Home", CVS Minute Clinics: "Their business model is working out very well financially. Is this good or not? What if high quality of care is demonstrated?"
    • Convergence of many factors a major force, i.e. business models with technology
    • What will emerge is "Predictive healthcare", where we shift from targeting care to targeting prevention based upon new knowledge of individual risks and population health factors.

Most of the discussion centered on the availability of resources for medical education, especially considering the historical context in which medical education has traditionally been under "resourced". Enlarging the class size will require new resources. The new School of Medicine education building is designed for a maximum of ~160.  No provision has been made to enlarge laboratory facilities, which are barely adequate for the current 142 students. Additional space and equipment (microscopes, computers, and audiovisual aids) and faculty time will be needed. The gross anatomy facility is in need of major technology upgrades to link to the current medical world of CAT scans, MRI and PET for the study of anatomy. Small group space for team learning and problem solving exercises has improved greatly in the last three years, but remains a constraint on innovative small group curricular activities in the first, second, and third years of medical school.

Clinical training for our medical student classes is limited by the relatively small, and rural population of the Charlottesville region. This results in the small number and limited diversity of our patients available for teaching. A Patient-Clinician Encounter Program for students in the first two years had to be limited to the first year and to every other week because of the limited patient population. During the third year we must use remote clerkship training sites requiring that students spend about one-half of their training away from Charlottesville. Despite this a number of our students report never participating in a delivery. Ensuring a comparable experience across sites is difficult and one for which we were cited in the recent LCME accreditation report. [Noncompliance Item 1, Feb 28, 2007, letter from the LCME to President Casteen]. [In certain clerkships with the hospitals currently used, we "frankly couldn't handle the extra students and give them any meaningful experience."] The UVa requirement for students to serve some clerkship and selective requirements at away sites, e.g. Fairfax, Roanoke, or Salem, has a negative impact on the Office of Admissions recruitment efforts.

The Principles of Medicine Committee report concluded that "If we are to maintain the quality of the educational experience for the physicians we train, the quality and selectivity of our entering medical school classes and increase the national ranking of the school of medicine, we think that the School of Medicine is well advised to emphasize quality over quantity in medical education and to maximize faculty-student ratio and patient-student ratio, especially in an atmosphere laden with challenges (pressures on away training sites, LCME concerns, pressure on clinical faculty to maximize clinical income, pressure on basic science faculty to maximize research grant income)."

Several people noted that there where good social, ethical, and professional reasons to increase the class size along the same reasoning as outlined by Jordan Cohen, MD.

The Mulholland Society president reported that that the society voted unanimously to oppose any increase in class size.

At the end of the meeting (the last straw, so to speak) two straw votes were taken:

1. Would it be good for social, ethical, and professional reasons for UVa to increase the size of its medical class?   13 yes / 0 no / 0 abstentions
2.  Is it realistic, given available resources (laboratories, clinical sites, etc.) and while maintaining the quality of our medical education, to increase the size of our medical class in the near future?  0 yes / 12 no / 1 abstention

September 27, 2007 is our next meeting to conclude our discussion of class size at UVa.