Minutes 12.13.07

Minutes 12.13.07

University of Virginia School of  Medicine
Curriculum Committee

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

  1. Announcements.

    A brief synopsis provided by Debra Perina of what was covered in the first meeting of the Basic Science for Careers Planning Group was read to the Committee.

    Dr. Perina brought everyone up to date on the vision for the course and its development as well as what was learned from the pilot course in September.  Students were supportive and excited about the course's design and felt it important to convey the same information to the whole class, as there have been misconceptions about the course to date. 

    Committee members liked that the sessions will be primarily case-based using actual case scenarios encountered and that the course will help students review the basic sciences.  Students requested that the committee look at workshops currently being offered in AIM and Family Medicine clerkships so as not to repeat those offerings if there will be a focus on reviewing physical diagnosis skills.

    There was a discussion of the incorporation of the currently existing "War Games" activities in the course either as a supplement for students during the three weeks or as sessions being offered. The War Games scenarios are focused on critical thinking and decision-making which ties in well with the Basic Science for Careers format as students will be given cases to manage.

  2. Cultural Competency in the UVA School of Medicine Curriculum.    Fern Hauck reviewed her progress examining "cultural competency" in the School of Medicine curriculum.    She outlined the background of the investigation into cultural competency in the School of Medicine, the progress thus far, and suggestions for future implementation.  In the February 28, 2007 LCME letter of accreditation, the LCME found areas of "partial or substantial noncompliance" with standard ED-22.  

    Dr. Hauck has been charged with leading an assessment of the current educational activities adressing cultural competency in years 1-4 of the School of Medicine curriculum to determine the adequacy of these activities, and  proposing an action plan if needed and approved by the Curriculum Committee.   It was recommended that she organize a group of educators and students to accomplish these objectives.  

    The group specific tasks are to:

    •     Briefly summarize institutional objectives for cultural competency (see the "12 Competencies" below). 
    •     Identify all required courses or clerkships that provide instruction related to such objectives. Course objectives and content should derive from the "12 Competencies".
    •     Identify the methods employed to determine whether students have achieved the objectives.
    •     Note in particular any courses of clerkships which provide formal instruction or experiences that allow students to address gender and cultural biases in themselves and in others, and in the process of health care delivery. 
    •     Ultimately, expanding from one or more of the 12 competencies to more directly address issues of cultural competency in detail is what is needed.

    The first step in the assessment process was to query each of the required course and clerkship directors about the content of their curriculum as related to cultural competency. Dr. Hauck attended a Principles of Medicine Committee meeting and a Clinical Medicine Committee meeting to describe this project and request that each director complete the Tool for Assessing Cultural Competence Training (TACCT).  Responses were received from all clerkship directors and most course directors. The remaining course directors will be contacted again to request the information.

    Grace Milad, 4th year undergraduate UVA student and University Internship Program intern working with Dr. Hauck on this project, entered all the responses into an excel spreadsheet and summarized these in a report, Cultural Competency in the UVA SOM Curriculum. The report includes for each required course/clerkship: course description; summary of competencies covered in the course/clerkship including knowledge, skills, and attitudes based on responses to the TACCT; and evaluation method. Information about the course description and evaluation were obtained from course websites where available, and course directors were also queried about evaluation methods, specifically if cultural competency areas were evaluated.

    The next step was to form an advisory committee to review the report and TACCT survey results to respond to the charge and make recommendations as described above. Dr. Hauck is now inviting prospective faculty and staff to join the committee. A meeting will be scheduled as soon, so that the final report to the Curriculum Committee can be prepared and presented. The invitees will include medical students, residents, faculty and staff representing a variety of relevant disciplines, experiences, and expertise.

    Regarding evaluation, Dr. Hauck has met with Anne Chapin, Coordinator of the Clinical Skills Training and Assessment Program, to discuss ways to incorporate cultural competency into the CPX exam. She will be meeting with her again to identify 2-3 specific cases and the specific skills that can be incorporated into these cases. After the approval of the respective clerkship directors, these will be used in the 2009 exam cycle. 

    Grace Milad conducted a literature review related to cultural competency education of medical students and residents. She compiled summaries of articles in a report including information on specific curricula conducted at other medical institutions and programs.

    A grant was recently submitted to HRSA proposing to develop new and enhance existing classroom based and experiential learning activities that prepare students to provide culturally competent care to vulnerable populations. Entitled, Enhancing the Culturally Competent Care of Vulnerable Populations: Global Health in Your Own Back Yard, this project would involve all 4 years of the curriculum, and includes: POM-1; Social Issues in Medicine; Family Medicine, Ambulatory Internal Medicine, and Pediatrics clerkships; offering new classroom-based and clinical electives; expanding the summer preceptorship program; offer more slots for summer research students that focus on cultural competence and vulnerable populations. The grant proposal also addresses the need for faculty development and identifies methods that will be conducted to this purpose. The focus of each department in terms of vulnerable populations will be refugees and immigrants for Family Medicine, geriatric and HIV/AIDS patients for Internal Medicine, and lower income, rural, and/or other vulnerable children for Pediatrics. Workshops will be developed in each of these clerkships addressing these areas. Finally, student evaluation methods to explicitly measure the competencies of students related to the above areas will be developed. 

    TACCT Results Pre-clinical:
    The following courses have a fairly high number of items checked under the five domains: Cells to Society, POM-1 Clinical Skills, Medical Microbiology, Psychiatric Medicine, Social Issues in Medicine (SIM), but with the exception of SIM, the number of specific K/A/S (Knowledge, Attitudes and Skills) checked under each domain decreases considerably.  The following courses, some as would be expected, have few or no domains checked: Pathology, Physiology, Medical Neuroscience, Gross and Developmental Anatomy, Cell and Tissue Structure, Medical Biochemistry, Medical and Molecular Genetics, and Clinical Epidemiology.

    TACCT Results Clinical
    The following clerkships/educational activities have a fairly high number of items checked under the five domains: Family Medicine, Obstetrics and Gynecology, Surgery and Clinical Connections (Cultural Competency Day, which is also the only one for which data were returned).  The number of specific K/A/ S (Knowledge, Attitudes and Skills) checked under each domain decreases for Surgery.  In Ambulatory Internal Medicine, Neurology and Psychiatric Medicine, a fairly high number of domains were checked as well as K/A/S, but these were noted to be dependent upon the preceptors and not a "guaranteed" part of the curriculum.

    For the preclinical courses that provide some content in cultural competency, a few of the course directors indicated that "if it is covered in class, it is fair game for exams."  We did not obtain actual tests or more detail than that.  It is probably fair to say at this point that his area does not get a lot of attention on most exams.  We would need additional information to draw final conclusions.

    For the clerkships, the Uniform Evaluation Form does not specify skills associated with cultural competency, but has some items that are related:  ability to engage and communicate with patients; humanistic attributes; and relationships with staff and colleagues.  Unless it is specifically asked, it is not likely to be evaluated.  Clinical Connections does not include evaluation of students.

    The Advisory Committee will be convened to review the current results and identify additional data needs (if indicated) and ultimately make recommendations as outlined in the charge from Dr. Innes and the School of Medicine.  This will be done expeditiously, as Dr. Hostler would like to send a response to LCME in the next few months.

    At this point, my recommendation would be that our focus needs to be on the following areas as identified by LCME:  1) increasing the exposure of students to cultural competency K/A/S in the clinical rotations; 2) evaluate what we are teaching in cultural competency throughout the curriculum; 3) be sure we can cover areas related to recognizing as well as teaching and evaluation methods in cultural competence.  We should also examine the 12 competencies and introduce some language that clearly covers cultural competence.  The proposal submitted to HRSA would more than adequately cover these four recommendations and will be considered by the Advisory Committee.

  3. Curriculum Management Tool.  John Jackson outlined the work that has been done here at UVA on a curriculum management tool - ACT or Achieving Competence Today. ACT is a teaching resource for health care educators. We develop and provide resources for the ACGME Systems-based Practice and Practice-based Learning and for the AACN Essentials of Doctoral Nursing Practice competencies. This project is funded by the Robert Wood Johnson Foundation. A grant for more funding to continue and expand the program has been applied for.  The system once fully developed will allow better curriculum management as well as resource sharing among all institutions.   The work of the UVA developers will be demonstrated at the next ACGME meeting in Texas. 

Donald Innes