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Academic Medicine:
doi: 10.1097/ACM.0b013e31803327f3
Educational Innovations

The New Formal Competency-Based Curriculum and Informal Curriculum at Indiana University School of Medicine: Overview and Five-Year Analysis

Litzelman, Debra K. MD, MA; Cottingham, Ann H. MAR

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Author Information

Dr. Litzelman is associate dean of medical education and curricular affairs and Richard Powell Professor of Medicine, Indiana University School of Medicine, Indianapolis, Indiana.

Ms. Cottingham is director of special programs in medical education and curricular affairs, Indiana University School of Medicine, Indianapolis, Indiana.

Correspondence should be addressed to Debra Litzelman, MD, Medical Education and Curricular Affairs, Indiana University School of Medicine, 714 N. Senate Ave, EF-200, Indianapolis, IN 46202; telephone: (317) 274-0783; fax: (317) 278-8165; e-mail: (dklitzel@iupui.edu).

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Abstract

There is growing recognition in the medical community that being a good doctor requires more than strong scientific knowledge and excellent clinical skills. Many key qualities are essential to providing comprehensive care, including the abilities to communicate effectively with patients and colleagues, act in a professional manner, cultivate an awareness of one’s own values and prejudices, and provide care with an understanding of the cultural and spiritual dimensions of patients’ lives. To ensure that Indiana University School of Medicine (IUSM) graduates demonstrate this range of abilities, IUSM has undertaken a substantial transformation of both its formal curriculum and learning environment (informal curriculum). The authors provide an overview of IUSM’s two-part initiative to develop and implement a competency-based formal curriculum that requires students to demonstrate proficiency in nine core competencies and to create simultaneously an informal curriculum that models and supports the moral, professional, and humane values expressed in the formal curriculum. The authors describe the institutional and curricular transformations that have enabled and furthered the new IUSM curricular goals: changes in education administration; education implementation, assessment, and curricular design; admissions procedures; performance tracking; and the development of an electronic infrastructure to facilitate the expanded curriculum. The authors address the cost of reform and the results of two progress reviews. Specific case examples illustrate the interweaving of the formal competency curriculum through the students’ four years of training, as well as techniques that are being used to positively influence the IUSM informal curriculum.

Editor’s Note: A commentary on this article appears on page 321.

The outcome of the successful competency-based curriculum should be evident in the individual … what kind of behavior they exhibit to their associates (hospital staff, etc.), especially when they are sleep deprived. - —Richard Kohler, MD

Excellent patient care involves a range of knowledge and abilities that may not be taught or learned in a traditional medical school curriculum. At Indiana University School of Medicine (IUSM), we are engaged in a curricular initiative to improve undergraduate medical education. We have begun a two-pronged initiative to transform both the formal and the informal (hidden) curricula at each of our nine campuses, affecting more than 1,120 medical students. Our goal is to teach explicitly, model implicitly, and support consistently a vision of medical practice as health-enhancing action taken in an intricate web of human relationships, skillfully enacted, and founded on an integrated knowledge of biological, psychological, sociological, and cultural information. In this article we detail this far-reaching curricular reform initiative and organizational change project, which have together involved hundreds of members of the IUSM community. We intentionally invited key leaders of these initiatives to partner with us in the writing, reviewing, and editing of this article, to ensure that the article represents the work that has been done as accurately and completely as possible (List 1).

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Background

A little more than a decade ago, IUSM began a process of curricular review and discovered that many of the qualities and abilities we expect our graduates to demonstrate as physicians—including professionalism, self-awareness, and moral reasoning—were not explicitly taught and assessed in a robust way in our formal curriculum. Shortly thereafter, we were introduced to Brown University Medical School’s competency-based curriculum. Their approach focused on curricular outcomes and outlined criteria for assessing students in many areas we had identified as underrepresented in our curriculum at the time. IUSM recognized that a curricular focus on developing competent students, broadly defined, was the solution we were looking for, and in 1996, we began to revise our curriculum on this basis. The curricular change process, administrative structures, competency descriptions, knowledge base, and criteria for achievement are documented in IUSM’s Educational Blueprint for The Indiana Initiative: Physicians for the 21st Century.1 In developing our own competency-based curriculum, IUSM borrowed heavily from the groundbreaking work of Brown University, as documented in Smith and Fuller’s Educational Blueprint for the Brown University School of Medicine.2

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Implementation of the IUSM Competency Curriculum

In 1999, IUSM’s formal curriculum and graduation requirements were officially expanded to include nine competency areas in which students were required to attain specified levels of proficiency during the course of their undergraduate education: (1) effective communication, (2) basic clinical skills, (3) using science to guide diagnosis, management, therapeutics, and prevention, (4) lifelong learning, (5) self-awareness, self-care, and personal growth, (6) social and community contexts of health care, (7) moral reasoning and ethical judgment, (8) problem solving, and (9) professionalism and role recognition. The third competency—using science to guide diagnosis, management, therapeutics, and prevention—has traditionally guided medical school education in the United States. To achieve the new, broader curricular goals, IUSM has taken the following steps, each of which we explain in further detail throughout this article. We have

* ▪ expanded our existing education administrative faculty and staff infrastructure;

* ▪ developed and integrated educational experiences and assessments for all competencies in courses and clerkships throughout all four years;

* ▪ initiated a process of cultural change in our informal curriculum to further the goals and processes of the formal competency curriculum;

* ▪ introduced new teaching methodologies to allow further incorporation of competencies into existing courses;

* ▪ added competency achievement data to the student transcript and dean’s performance-appraisal letter;

* ▪ developed an electronic system to track, record, and facilitate all competency activities;

* ▪ determined the cost of the new curricular reform; and

* ▪ conducted two significant progress reviews.

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Expanded Education Administrative Infrastructure

IUSM completely reorganized its education administrative infrastructure to develop, implement, and manage the competency curriculum. We now have directors, campus coordinators, and teams of faculty, students, and administrators to lead, administer, and develop each competency.

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Statewide competency directors

IUSM appointed nine competency directors (one for each competency) to develop and implement the competency curriculum. Competency directors oversee the development and implementation of appropriate competency experiences and assessments, make decisions regarding appropriate student competency achievement, and oversee remediation. Competency directors also have been included as voting members on all education committees across IUSM.

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Campus competency coordinators

IUSM, the only medical school in the state of Indiana, has nine statewide campuses. Eight of the nine IUSM campuses appointed a competency coordinator to work with the statewide competency directors to develop, implement, and administer the competencies at their respective locations in the first and second years of medical school. (All students from every campus are in Indianapolis for their third and fourth years.) The nine IUSM campuses are in Bloomington, Evansville, Forth Wayne, Indianapolis, Lafayette, Muncie, Northwest, South Bend, and Terre Haute.

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Competency teams

To improve the development and implementation of competency-learning experiences and assessments, teams were created around each competency that included key individuals involved in all levels of IUSM medical education, including clinicians, basic scientists, campus coordinators, educators, students, and content experts. Each competency team meets once or twice per month to develop new competency-learning experiences and assessments, improve the integration of the competency within existing courses, improve the conceptual link between competency experiences within each year of medical school and across all four years of medical school, and improve the way competency activities and requirements are communicated to students and faculty.

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Development of the Competencies into the IUSM Formal Curriculum

The topics that we address through the competencies are items that I desperately want from my medical education. They are the things that I cannot just look up in any textbook to get the correct answers. I can humbly say that if I weren’t participating in the competencies I would in all likelihood be both a scholastically and interpersonally competent physician … but that is not the point; the point is to enhance “the database” so that we can be better than the minimum. - —First-year medical student, class of 2007

Our development of the competency curriculum falls into three phases. In phase I (roughly 1999 to 2001), we believed that we were already doing a good job teaching most of the competencies, though not explicitly labeling it as such, and that our main task was to document student achievement and identify, early on, students who needed extra help in any of the nine competency areas. We began by identifying competency-learning experiences already present in the curriculum and incorporating carefully constructed assessments for these exposures. We created specially designed assessment tools, including competency-rating scales with carefully worded anchor language tied to behavioral and attitudinal descriptions3 for seven of the nine competencies. Basic clinical skills, and using science to guide diagnosis, management, therapeutics, and prevention—competencies 2 and 3—were already well assessed in the curriculum.

In phase II (2002 to 2004), we began to develop new learning experiences to cover areas of each competency that needed additional instruction, to create a wider range of assessment tools, and to label more explicitly the existing learning experiences that addressed a particular competency.

Finally, on the basis of student feedback, increasing faculty receptivity, and our growing experience with the competencies, we have begun phase III (2005 to present). In this phase, we are moving beyond isolated competency exposures and assessments and are creating sequentially linked experiences that span the four years of medical school.

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IUSM Formal Curriculum Competency Integration

The competency curriculum is implemented throughout all four years of medical school in a matrix design. Courses occupy time blocks in the first and second years of medical school, and students spend their time in clerkships and clinical subspecialty disciplines in the third and fourth years of medical school. Throughout the four years of medical education, competency content and assessments are woven through these existing basic science courses and clerkships. Appendix 1 illustrates how the professionalism and role recognition competency is integrated throughout a student’s training. Each of the other competencies has a similar map that outlines the courses, clerkships, or other venues where teaching and/or assessment of that competency occurs.

Each course and clerkship director, working in partnership with the appropriate competency director(s), establishes specific competency-directed objectives in one or more of the nine domains on the basis of course director interest, degree of logical fit between the course and the competency, and the competency director’s need to include certain specific competency elements in the curriculum. These courses and clerkships provide competency exposure (some form of education in the content of each of the selected competencies, either led by the course director, competency director, or other competency expert) and competency assessment. Competency directors ensure that all the exposures and assessments in their competency, though taught in many different courses and clerkships across the four years, are sequentially linked and integrated and together form a comprehensive curriculum in that content area.

Because first- and second-year instruction occurs at all nine IUSM campuses, integration has not been identical across the institution. Rather, the nine sites have served as educational laboratories, allowing the faculty to experiment with different approaches while all adhering to uniform standards for achievement.1

IUSM students are required to demonstrate proficiency in each of the nine competencies at beginner (level I, by the end of the second year of training) and intermediate (level II, by the end of the third year of training) levels and in three of the nine competencies at an advanced level (level III, by the end of the fourth year of training) to be eligible for graduation. Achievement of levels I and II depends on successful completion of competency exposures and assessments that are part of the required curriculum in each of the first three years. At level III, students have the opportunity to focus on areas that will enhance their application to a particular residency program or further develop a particular interest. Students may create individualized learning plans and products, with approval by the appropriate competency director and elective director (if done through an elective), or they may complete existing level III curricular activities.

In the professionalism and role recognition competency, the goal is to foster each student’s ability to translate the abstract, core values of professionalism into day-to-day practice. To accomplish professional development as a living competency, we have chosen to focus on student independent journaling interspersed with small-group dialogue.

At level I, students are expected to interact effectively with fellow students, faculty, and administrators; to project a professional image in manner, dress, and action; to move toward self-regulation, accepting responsibility for their own and their peers’ behavior; and to be able to identify and describe elements of professionalism (both positive and negative) that they see and experience in the formal and informal curricula. For example, students begin their first week of medical school by reviewing narratives written by second- and third-year IUSM medical students that describe experiences of professionalism in medical school. They are then asked to identify key elements of professionalism and to describe these elements’ significance to the excellent practice of medicine. In the first-year course Introduction to Clinical Medicine I, students review key articles describing elements of professionalism and write papers that reflect their visions of themselves in their professional role as good doctors. In first- and second-year courses that include small-group experiences, small-group faculty facilitators assess students on their professional deportment.

At level II, in addition to the objectives described in level I, students are expected to interact effectively with patients, family members, and other members of the health care team. They should demonstrate appropriate behavior in their roles as student–physicians, recognizing limitations and opportunities in patient care; as team members; and as liaisons among the patient, family, and attending physicians. In the family medicine and pediatric clerkships, students are evaluated on these elements of professionalism using a carefully constructed description of expected professional behaviors. During the pediatric rotation, student performance is evaluated using comments from parents of patients. The following is a sample quote from a family member of a patient; the quote was added to the student’s competency performance profile:

… she took me to a private area and talked with me until I had stopped crying and was reassured of my daughter’s progress she asked us if she could give us some personal information. After being told “yes,” she told us she is a Ewing sarcoma survivor. She didn’t have to tell us this but it helped us immeasurably … she was open and honest about her own medical complications but reminded us that my daughter’s cancer was in a different place with different side effects possible. She also checked on us without feeling intrusive and respected our privacy. She will make a wonderful, caring, intelligent doctor… - —Parent of a pediatric patient, 2006

At level III, students will also demonstrate an advanced understanding of the demands and possible conflicts that are inherent in the physician role. To achieve level III, students often develop projects that allow them to explore particular areas of interest further. In professionalism and role recognition, for example, one student convened a cadre of student colleagues to work together to create, institutionalize, and help implement an honor code for our school. A second student created and described an oil painting. The painting depicts the estrangement a patient feels when cared for in the hospital by multitudes of health care providers, and it points to the physician’s need to improve patient trust by developing real relationships with patients.

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IUSM Informal Curriculum Initiative

Even in the earliest phases of our reform of the formal curriculum, it was apparent that our goal of graduating knowledgeable, compassionate physicians could not be achieved merely by adopting a competency-based curriculum. It was imperative that students experience a social environment (the informal curriculum) that would consistently reflect and reinforce the moral, ethical, professional, and humane values expressed in IUSM’s formal curriculum.4,5 If we desire our graduates to demonstrate empathy, thoughtful inquiry, and positive, respectful, and collaborative interactions, then these are what our community must consciously model. To this end, in January 2003, IUSM began a process of self-study and organizational change known as the relationship-centered care initiative (RCCI), funded by the Fetzer Institute. The RCCI began with a small leadership group, two external consultants, and a discovery team consisting of faculty, residents, students, and staff.

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Healing relationships

Affirming the Pew-Fetzer task force’s conclusion that healing relationships are at the core of humane, effective medical care,6 the RCCI organizational change strategy seeks to transform the informal curriculum of IUSM by fostering meaningful, health-enhancing relationships—mindfully cultivated in all domains of human interactions—in all aspects of medical school life and practice. Theoretical underpinnings for IUSM’s cultural change processes include complex responsive processes of relating (CRPR), a theory of human interaction.7 CRPR describes how patterns of meaning and patterns of relating arise, propagate, and evolve in a spontaneous, self-organizing manner.8 The theory focuses attention on the here-and-now relationships and conversations of an organization as the effective locus for organizational change. How one is in each moment can either further or alter the existing organizational culture by replicating or disturbing the relationships and language that maintain that culture. Thus, seemingly small changes in the way one talks in a meeting or the way one engages a colleague can have a widespread, rippling impact throughout the organization. With this in mind, many faculty and staff at IUSM have begun to consider carefully how better to design critical spheres of interaction to create spaces for participants to engage with colleagues fully in an open, relational manner.

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Case study: The Dean’s Office of Medical Education and Curricular Affairs.

In the fall of 2003, the Dean’s Office of Medical Education and Curricular Affairs (MECA) began to facilitate a competency curriculum review process. We brought together all nine competency directors along with the eight competency coordinators. After three years of struggling to realize a major curricular reform, many felt tired, overburdened, and somewhat demoralized. Moreover, because of the physical distances between our nine centers, many of the faculty did not know each other well, and there existed a certain level of suspicion. With the RCCI in mind, MECA staff intentionally worked to create an agenda and an environment that would change our traditional patterns of interacting by fostering relationships among participants and encouraging open participation.

We began the first meeting (and every meeting thereafter) with an invitation to check in—an invitation to share some bit of personal or professional information that would help participants know each other at a deeper level than a strict focus on the task at hand would allow. The check-in was accepted by many and was uncomfortable to a few. One participant replied, “I’m checked in,” for the first few meetings, then began arriving late in hopes of avoiding the check-in. One year later, this same participant had reached a level of ease that allowed him to comfortably share a personal story about his children with the group. For the first meeting, we also invited participants to form pairs and to share with each other the gifts (or personal strengths) they each could bring to the group process. Individuals then shared the gifts of their partners (with the partner’s permission) with the large group. Most important, we intentionally planned an open process. We had no long-term, predetermined outcome in mind other than to assist the participants in moving forward productively in whatever way seemed to make the most sense to them. We brainstormed, discussed, voted, and made decisions to proceed that often countered what the facilitators had anticipated.

These techniques of stimulating change, or creative disturbances, have led to perceptible differences. A year into the process, one participant noted a major change in how the competency directors were working together, finding their meetings more dialogic, personal, supportive, and appreciative. Two years later, the group is still meeting enthusiastically, though with a different goal. Having addressed the most difficult issues, the group has transformed into a learning community, working together to develop and implement increasingly refined competency curricula for each of the nine competencies.

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Professional development to increase personal awareness: The Courage to Lead

We complement these effective relationship-building practices by giving IUSM faculty and staff the opportunity to participate in a professional development program to deepen personal awareness. Our program, The Courage to Lead (CTL), is based on Parker Palmer’s9,10 Courage to Teach program, which is designed to improve elementary school education by helping teachers learn to integrate their lives and bring their whole selves into their work. Our program comprises four seasonal retreats during the course of one year and has been offered at IUSM for three consecutive years. The goal of CTL is to deepen participants’ capacity to bring relationship-centered activities into the medical school through experiencing a personal formation process, learning how to create evocative and trustworthy spaces for learning and reflection, and bringing greater depth to the work they are already doing. CTL retreats provide time and support to reflect on the connection between tending to the inner dimension of our lives and the relationship-centered values and practices we wish to live and to extend to the entire medical school.

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Case study: CTL.

The CTL retreats provide the opportunity for participants to reflect on aspects of both their personal and professional lives. Participants find this opportunity to be extremely valuable and unique; in one participant’s words,

The CTL retreats, more than any other professional development effort I have been engaged in, have had a substantial impact on my ability to lead change within this organization. I participated in the 2003 session. Each season, for an evening and full day, about 20 colleagues and two facilitators met for guided reflection and self-exploration. Using poems, readings, and artwork as springboards, we journaled, spent silent time in nature, and reflected together in small and large groups, working to identify and name the inner resources that we bring to our work. The retreats are not group therapy or spiritual renewal (though they are renewing) but an opportunity to slow down, take a break from our hectic pace, and renew an appreciation for our natural gifts, gifts that may have lain dormant and uncultivated for many years. The gifts I discovered, or remembered, were often those aspects of my being that give me the deepest joy and guide my sense of purpose in life. By recognizing these gifts, the core of who I am, I realized that I can foster the strengths I already possess.

As a fellow, I was groomed to appreciate the importance of creating clear one-, three-, and five-year strategic plans and developing personal goals to achieve them. The focus was always on the future, the next step. In the CTL retreats I learned that what matters the most is staying centered on who I am when I am at my best, and seeking, even in the daily chaos and confusion of medicine, to respond moment to moment from this place. I have been able to translate this new perspective into practice on many occasions in my clinical teaching, responding to trauma and distress in a very different, more healing way than I would have before this experience, providing a different model of care for my team. - —CTL participant, 2003

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Appreciative inquiry

A third technique used to create disturbances in our traditional culture is a process of appreciative inquiry (AI).11 AI describes how we tend to direct our action and energy toward those things on which we choose to focus. It suggests that by changing our focus of attention, we change our organization. At IUSM, we have begun to redirect the focus of attention and conversations away from problems and barriers toward what is working well in our organization and toward replicating or building on those successes we are already achieving.

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Case study: discovery team interviews.

One of the first efforts to create organizational change was a series of AI interviews conducted by the RCCI discovery team. Each discovery team member was randomly assigned the names of several key faculty and staff, identified by the team, and asked to invite those individuals to participate in a one-on-one interview for about an hour. The interviews were intentionally focused on identifying elements of success already embodied in our organization. For example, interviewees were asked to recall and describe a time when they felt most engaged in their work or when they felt most empowered to fulfill an important task, or to envision IUSM at its best. The discovery team collected over 100 interview stories that illustrate what is currently working well at IUSM. The team analyzed the stories and themes that were identified in the interviews and shared them with IUSM faculty and staff in several open forums.

Perhaps the most powerful intervention was the actual interview experience itself. Telling and hearing stories about successes at IUSM was new and inspiring. Many members of the discovery team were truly amazed to hear the many moving experiences of colleagues working well together, sometimes in adverse circumstances, to create something good. Because we had never intentionally focused on positive experiences before, many, if not all, of those stories had never been heard or discussed. This exercise had a palpable positive impact on all those involved. Many expressed a new sense of pride and possibility.12

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Uniting the IUSM Formal and Informal Curricula

As our focus on the informal curriculum has grown, we have begun to use narratives culled from experiences within the informal curriculum to inform our formal curriculum. Stories from AI interviews, student observations on rounds, pediatric patients’ parents, and faculty have become a source for thoughtful reflection and education in required first- through fourth-year curricular experiences, as well as faculty development activities (Figure 1).

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For example, in the professionalism and role recognition competency, as part of the third-year clerkship in medicine, all students keep a professionalism journal, recording what they see happening anywhere around them—in the clinics, hospitals, elevators, staffing rooms, call rooms, and elsewhere—as positive or negative examples of professionalism. In addition to their narratives, students identify in their journals specific elements of the professionalism they have observed. For example, students note whether an experience involves issues of responsibility and accountability, respect, caring, compassion and communication, or altruism—in this way moving back and forth between the values of professionalism that we teach in the formal curriculum and the students’ day-to-day lived experience of the informal curriculum. At the end of the rotation, the students gather together with a faculty member and discuss the collection of narratives from their cohort. For these discussions, the students’ personal identifications are removed. We find that the students’ experience is more meaningful to them when we let them talk together to analyze their own experiences, rather than pushing suggested interpretations or predetermined discussion points at the students through didactic presentations or preengineered small-group discussion.

Here is a sample narrative from one of the professionalism journals:

Our team and the ICU team were rounding and we all entered a patient’s room. There were at least 15 of us in the room. Our teams spoke about the patient, examined him, adjusted the ventilator setting, and then left—all oblivious to the family member who was in the room the entire time. After we had all left, I noticed that the intern—who had just started the service that morning—kneeled down beside the patient’s wife and began explaining what the team had just done. No one else noticed what she had done, but I was very impressed by her behavior. - —Third-year medical student, class of 2006

On the list of professional elements, this student checked caring and compassion and communication.

In discussing their own narratives in a small group, the students are being professional as they talk and learn about professionalism. As the students examine their experiences together, they are bringing their lived encounters—the informal curriculum—into the explicit, formal curriculum. Students report that the experience of being present for others’ stories of professionalism helps them to feel less isolated and alone in their own experiences and helps them to recognize professional issues that might otherwise go unacknowledged and unaddressed.

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Initiation of New Teaching and Assessment Methodologies to Improve Competency Integration and Evaluation

To facilitate the integration and assessment of the nine competencies in our courses, clerkships, and electives while simultaneously shaping our informal curriculum, IUSM has made some significant changes in our admissions procedures, teaching, and assessment.

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Admissions procedures

IUSM admissions committee members have all participated in professional development workshops that employ trained “standardized applicants” to help us more uniformly screen our applicants for their aptitude to excel in the competency-based curriculum and for shared values compatible with our organization’s mission.

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Teaching
First-year medical student’s first week (MS1 Week 1).

In August 2005, we implemented the First-Year Medical Student’s First Week (MS1 week 1), a competency-focused first week of medical school for first-year medical students. A single case, woven through the week, is successively examined from the perspectives of each of the competencies in active small-group experiences. The goal of the week is to provide incoming medical students with an in-depth introduction to the content and methods of each of the competencies, an understanding of how the competencies work together, and an overview of the four-year curricular integration of each of the nine competencies. For example, introduction and integration of anatomy and the self-awareness competency includes small-group discussion of the poem that appears in the box on this page in concert with students’ introduction to the gross anatomy lab (“Our Fallen Teacher”).

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Third-year intersessions.

We have developed third-year intersessions, two days of competency-focused education for each of the three 16-week blocks of the third year of medical school. The goal of these intersessions is to integrate explicitly the clinical material from the block disciplines with the competencies addressed in the block. Intersession activities are developed by the competency directors working together with the course directors from each block. The activities consist of interactive, participatory clinical experiences and provide an experience with, and assessment of, the relevant competencies. For example, a mini-curriculum on substance abuse addresses the communication, self-awareness, and professionalism and role recognition competencies. Students, in groups of three, with a facilitator, practice complex communication challenges in a series of objective structured clinical training stations with standardized patients portraying alcoholics, chronic pain patients, and family members who are enabling patients’ substance abuse. Students practice collecting sensitive information about patterns of addictive behavior, negotiate with patients regarding narcotic prescribing and work-release information, and coach families on ways to avoid their enabling behaviors. Issues raised in the scenarios also stimulate discussion of the self-regulatory roles of physicians. Students provide self- and peer assessment during and between this series of stations.

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Assessment
Peer and self-assessment.

We have added a peer- and self-assessment (PSA) program to years 1, 2, and 3 of medical school. The purpose of this program is to improve the professional development and self-awareness of IUSM students and to provide an opportunity for students to gain experience in receiving and offering constructive feedback to peers. As part of our PSA program, first-, second-, and third-year students meet yearly with their self-selected faculty advisors to review their PSA reports and discuss how they might work toward their vision of the ideal professional physician. A sample of one student’s comments and personal goals generated during his meeting with his advisor follows:

… the ideal professional physician must be respectful, tolerant, patient, and a good listener. From my peer assessment, I realize I don’t need to be the first to speak when I think an underdog is being exploited … it is better to first listen to understand before making assumptions about whether a colleague is demonstrating tolerance … this will help me be a better doctor. - —Second-year medical student, class of 2008

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Unannounced standardized patients.

Instructors use trained unannounced standardized patients who present with challenging professionalism issues in the outpatient clinics to train and assess students in aspects of professionalism in the third-year medicine clerkship.

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Competency Achievement Data Added to Student Transcripts

We recognize that a student’s grades in courses and clerkships are not always reflective of his or her actual performance in areas involving broader professional development. The competency-based curriculum has allowed instructors to assess not only a student’s academic performance but also his or her performance in each of the competencies.

A few students have been identified whose academic performance, at worst, was quite satisfactory but whose performances specifically were recognized as problematic in areas related to professionalism and self-awareness. The competency curriculum led the faculty to be more diagnostic (even at the basic science level). In some instances, it has led to remediation activities to help students succeed. In other instances, it has led to students leaving medical training. - —Richard Kohler, MD, chair, competency committee

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Certification

At each of the three levels, students’ progress is recorded and monitored electronically (we discuss this process below in the IUSM’s Electronic Competency Infrastructure section). Competency directors review all competency-assessment data and other feedback (submitted online by course, clerkship, or elective directors) and determine competency achievement on the basis of a predetermined weighting of multiple evaluations. Competency directors certify that students have successfully completed the requirements for each level by recording the dateof achievement on the student’s competency transcript. The competency transcript is generated in the fourth year and accompanies the academic transcript (Appendix 2).

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Deficiency

If a student has not made appropriate progress at any level in any competency as determined by a competency director in consultation with the course director, clerkship director, elective director, or involved faculty advisor, the student’s name and description of the competency deficiency is forwarded to the student promotions committee (SPC) for action (the student is usually placed on academic probation). On the basis of a thorough review of the circumstances, the SPC recommends remediation or dismissal from school. If the committee recommends remediation, the appropriate competency director designs, oversees, and assesses progress for the student. Once the remediation plan is satisfactorily completed, the competency director sends notice to the SPC, and the student is removed from academic probation and proceeds to the next competency-level work. Identifications of deficiency and remediation are reflected on the student’s competency transcript.

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IUSM’s Electronic Competency Infrastructure

As IUSM began to implement the competency curriculum, it became necessary to develop a multidimensional electronic infrastructure. IUSM needed to track the new curriculum, record student achievements in each of the nine competencies across the four years of medical school, and facilitate the expanded educational and assessment methodologies across the statewide system. An internal information technologist working within the MECA allowed us to be responsive to evaluation and training needs as they emerged. This was true for initial development as well as serial modifications to improve the integrated technology systems on the basis of input from competency, course, and clerkship directors and also from faculty and students. Several interactive systems have now been developed.

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Competency Evaluation System (CompES)

The competency-evaluation system (CompES) allows faculty across the state to submit level I and II competency evaluations for each of the nine competencies for students in their courses or under their supervision outside the classroom. Students can review this feedback at any time by logging into the online site. CompES also facilitates the electronic generation of competency transcripts for residency applications.

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Electronic Competency Management System (ECMS)

Third- and fourth-year medical students use an electronic competency-management system (ECMS) to register for all level III competency experiences (either in existing clerkships and electives or by creating independent studies). On completion of the competency experience, students are required to upload their final projects (PowerPoint presentation, video, paper, etc.) into ECMS. The faculty evaluate the final projects and submit feedback to the student via ECMS. The appropriate competency director reviews the projects and feedback and makes final approval, which is recorded in the student’s file in ECMS (as well as on the student’s competency transcript). ECMS thus functions like an electronic portfolio.

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Database of Competency Curriculum (DoCC)

The database of competency curriculum (DoCC) tracks all competency-related activities across the nine IUSM campuses and facilitates sharing ideas and making enhancements that will further benefit IUSM students. Faculty may use the system to communicate with competency directors to propose the addition of an innovative learning activity or to request approval of new competency-assessment tools and to share these ideas statewide. Additional links provide access to competency video clips, teaching and assessment resources, external curricular innovations, and professional literature relating to the IUSM competencies.

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Cost of the Curricular Reform Process

The competency-based formal curricular reform process at IUSM has been internally funded through the dean’s office without grant support since its inception in 1999. No new education dollars were made available; rather, existing education funds were shifted to cover new curricular priorities. The major costs of creating, implementing, and sustaining the new curriculum were leadership, administrative support, and infrastructure costs. The IUSM dean made agreements with department chairs to use the departments’ education allocations from the dean’s office to cover 20% of the competency director’s time. In 2002, the new MECA was split from the prior combined office of student and curricular affairs to provide more focused administrative leadership, support for department-based education leaders, educational assessment (including oversight of the clinical skills education center), and the development and maintenance of all curriculum-related integrated technology. This office has an annual operating budget of approximately $1.3 million to cover all education, assessment, and tracking activities for the nine campuses across the state.

Complementing the internally funded work on the formal curriculum, IUSM received a generous grant from the Fetzer Institute to influence the informal curriculum. The educational formation arm of this grant provided $1 million to fund internal leadership, administrative support, monthly visits from two external consultants, and numerous special events (such as an internal change agent program, a national cultural immersion conference, the initial CTL program, and several IUSM open forums to share information and dialogue about efforts to change the informal curriculum) from 2003 to 2006. Much of the work funded by this grant was devoted to the purposeful identification, collaboration, and peer coaching with internal change agents in various educational posts throughout the organization. Thus, sustainability was built in by fostering relationship-centered communication skills and styles in the personnel within MECA, leaders of all major culture-minding education and professional standards committees (e.g., academic standards committee, teacher–learner advocacy committee), and student–leaders. As with the formal curriculum, MECA and the dean’s office have repeatedly demonstrated through the reallocation of resources the continued commitment to positively shaping the informal curriculum.

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Progress Reviews: Are IUSM Curricular Change Initiatives Making a Difference?

We have completed two extensive reviews of our progress with competency integration and administration to date. One review covered a period of 1.5 years and included all competency directors, campus competency coordinators, and MECA professional staff. We also worked with external consultants to conduct a qualitative study of 38 focus groups comprising students and faculty at all nine IUSM campuses. These reviews indicate that nearly all students and many faculty fully support the concept of the competency curriculum. Anecdotally, students have mentioned that the new competency curriculum was a significant factor in their decision to attend IUSM. The studies have given us important data and feedback on our process of competency integration in thecurriculum and are now being used by competency teams to improve competency-learning experiences, assessment, and communication.

We have also reviewed traditional curricular measures to assess our progress. Trended program-evaluation data for local courses and clerkships indicate improvement during the past three years. Our USMLE Step 1 and 2 board scores, which have consistently been above the national average, are now higher than they have been in the past 10 years, with the point differential between our school’s mean and the national mean also increasing over this time period. Also at a 10-year high, student satisfaction scores on the overall quality of their medical education reported in the Association of American Medical Colleges graduation questionnairesummary reports have progressively risen from 77% (below the national mean) in 2003 to 96% (above the national mean) in 2006.

Although traditional measures are extremely important, they many not be the most telling assessment of change in our institution. What might be more telling is the new organizational culture we have begun to see evidenced. The formal and informal curricular initiatives have clearly brought a new sense of purpose and newfound energy for students and faculty who dream of more consistently aligning IUSM community members’ behaviors with our institutional values. Some of our dreams of how IUSM would manifest itself at its best have been translated into real-time action during workday meetings, new patterns of campus conversations, and general patterns of relating with one another.

An awareness and acceptance of the importance of personal and community-formation work has allowed many IUSM community members to more fully show up for work each day with a renewed sense of self. Now, IUSM community members regularly check in rather than checking their personal lives at the door of their professional offices. Increasingly, we invite committee members, team members, and other groups to share something of personal or professional interest before moving on to the remainder of a meeting, changing the context and conversation that frame the work that will be done there. We have noticed, as predicted by CRPR theory (described above), that changing conversations truly does change the process and the products of organizational activity. We have formed teams of trust and cooperation from individuals who felt mutually distanced and disrespected, and only on this foundation have we been able to accomplish much of our formal and informal curricular change. An informal network of individuals who act in support of value-based school mission actions has emerged.

Students have enthusiastically embraced the RCCI, creating amazing products tailored for students that make the competency curriculum meaningful on a daily basis, sharing stories of trial and hope from students at all nine campuses, and weaving together the poetry, art, and reflections on medicine that our students and faculty create—all of which present a new image of IUSM to classmates and faculty alike.

In 2005, students and faculty joined together to form an editorial board and forum to publish “Mindfulness in Medicine” (M&M), a column published bimonthly in SCOPE, IUSM’s faculty newsletter distributed electronically on a monthly basis that is intended to engage our medical school community in discussion and reflection about our organization culture. Each column features real stories, letters, poetry, or art from members of our campus community. Some featured content speaks for itself, and in other instances a written response is included. Many M&M stories highlight behaviors that express the highest moral, ethical, professional, and humane values expressed in the school’s formal curriculum. In some cases, stories prompt reflection on what we can learn from our medical and/or interpersonal missteps. The goal of these discussions is never to complain or place blame. Rather, they place value on mindfulness and seek understanding in the interest of becoming better professionals.

We have developed a dean-appointed RCCI student leadership position, responsible for communicating and furthering RCCI within the IUSM student population. This brings a considerable change to the medical student council, which has been traditionally focused primarily on the formal curricular issues, and signals an important evolution in the school’s educational focus.

These are just a sample of the very tangible changes we have seen in our organization since beginning our transformation of the formal and informal curricula three years ago.

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Challenges with Change

IUSM has faced challenges along with the positive results of its work to change the formal and informal curricula. As the competency curriculum was developed, faculty were reluctant to give curricular time to the new competencies, uneasy with teaching or assessing content in their courses that was outside their area of expertise, and skeptical that this new initiative was actually here to stay. Students worried that the competency curriculum simply meant an increased workload and more hoops to jump through in their already tight schedules, and they were concerned that competency assessments initially were not always clearly linked to competency-learning experiences.

Concerns related to the informal curricular initiative have been broader and less specific. Some have expressed doubt that it is possible to change academic culture or to measure change attributable to one initiative when so many changes are occurring simultaneously within our organization. However, no prior initiatives focused on professionalism or professional culture have been temporally correlated with the numerous changes now seen at IUSM. As this observation has been recognized and discussed, skepticism has been dissipating.

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A Continuous Pursuit of Success

Major curricular and cultural change is a process, not a single event or even a destination. As we begin our third phase of competency integration, constructing sequentially linked competency curricula for each of the nine competencies while continuing our work to improve the informal curriculum, there is widespread agreement at IUSM that our work with the formal and informal curricula has led to tangible improvement in the school’s overall educational experience. It has provided us a significantly enhanced framework for curricular development and assessment as well as for admissions and graduation decisions. Students overwhelmingly support the concept of the competency curriculum (though not always the growing pains of its execution). Faculty are increasingly coming on board as they better understand the goals of the new curriculum and as competency directors and education administrators better adapt competency exposures and assessments to the individual needs of faculty. Perhaps most important, IUSM has intentionally and mindfully taken bold steps to foster a social learning environment enabling the competency-based curriculum to be meaningfully implemented.

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Acknowledgments

IUSM gratefully acknowledges the groundbreaking work of Brown University Medical School in developing and documenting their competency-based curriculum, which has formed the foundation and framework of the IUSM competency curriculum.

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References

1 Indiana University School of Medicine. Educational Blueprint for The Indiana Initiative: Physicians for the 21st Century. Available at: (http://meded.iusm.iu.edu/programs/comptmanual.pdf). Accessed December 11, 2006.

2 Smith SR, Fuller B. An Educational Blueprint for the Brown University School of Medicine. Available at: (http://biomed.brown.edu/Medicine_Programs/MD2000/Blueprint_for_the_Web_04.pdf). Accessed February 2, 2007.

3 Indiana University School of Medicine Office of Medical Education and Curricular Affairs. Competency Curriculum. Available at: (http://meca.iusm.iu.edu/Programs/comptCurriculum.htm). Accessed December 21, 2006.

4 Inui TS. A Flag in the Wind: Educating for Professionalism in Medicine. Washington, DC: Association of American Medical Colleges; 2003.

5 Inui TS, Cottingham AH, Frankel RM, et al. Educating for professionalism at Indiana University School of Medicine: feet on the ground and fresh eyes. In: Wear D, Aultman JM, eds. Educating for Professionalism: Critical Perspectives. New York, New York: Springer; 2006:165–184.

6 Tresolini CP; Pew-Fetzer Task Force. Health Professions Education and Relationship-Centered Care. San Francisco, Calif: Pew Health Professions Commission; 1994.

7 Stacey RD. Complex Responsive Processes in Organizations. London, UK: Routledge; 2001.

8 Suchman AL, Williamson PR. Changing the culture of a medical school using appreciative inquiry and an emergent process. Appreciative Inq Pract. May 2004:22–25.

9 Palmer PJ. A Hidden Wholeness: The Journey Toward an Undivided Life. San Francisco, Calif: Jossey-Bass; 2004.

10 Palmer PJ. The Courage to Teach: Exploring the Inner Landscape of a Teacher’s Life. San Francisco, Calif: Jossey-Bass; 1998.

11 Watkins JM, Moh BJ. Appreciative Inquiry: Change at the Speed of Imagination. San Francisco, Calif: Jossey-Bass/Pfeiffer; 2001.

12 Suchman AL, Williamson PR, Litzelman DL, et al. Towards an informal curriculum that teaches professionalism: transforming the social environment of a medical school. J Gen Intern Med. 2004;19:501–504.

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