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Academic Medicine:
doi: 10.1097/ACM.0b013e3180332f33
Educational Innovations

The University of Missouri-Kansas City School of Medicine: Thirty-Five Years of Experience with a Nontraditional Approach to Medical Education

Drees, Betty M. MD; Arnold, Louise PhD; Jonas, Harry S. MD

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Author Information

Dr. Drees is professor, Department of Internal Medicine, and dean, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri.

Dr. Arnold is professor, Office of Medical Education and Research, and associate dean for medical education, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri.

Dr. Jonas is professor, Department of Obstetrics-Gynecology, and special consultant to the dean, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri.

Correspondence should be addressed to Dr. Drees, Dean, University of Missouri-Kansas City School of Medicine, 2411 Holmes Street, Kansas City, MO 64108; telephone: (816) 235-1808; e-mail: (dreesb@umkc.edu).

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Abstract

The University of Missouri-Kansas City (UMKC) School of Medicine is a public medical school that opened in 1971 in response to a need to train more physicians in Missouri. As a six-year, integrated, combined-degree program leading to the baccalaureate and medical degrees, the school offers an innovative, nontraditional approach to medical education. In the past 35 years, UMKC has graduated over 2,400 physicians who are successful according to outcomes measures used at other medical schools. With recent interest in reforming medical education to prepare physicians for a changing world, a review of alternative models may be especially instructive.

UMKC's academic plan offers a blueprint for the curriculum plan and governance of the school. The plan is built on four hallmarks: (1) a combined baccalaureate/MD program, (2) early exposure to clinical medicine, (3) small-group learning through the docent system, and (4) a continuing ambulatory care clinic experience for four years.

This article catalogs the results of this plan including student, faculty, and graduates' perceptions of and satisfaction with the school's educational approach, students' achievement on licensing examinations and in the residency match, graduates' performance in residency programs, and their subsequent career patterns. The authors also discuss lessons learned and adjustments made in response to local needs in the context of a changing environment in education, health care, and health care delivery while continually improving the school's nontraditional approach to medical education. These include changes in basic and clinical science instruction, student assessment, faculty development, and funding and governance.

In the early 1970s, a significant number of new medical schools were launched to address a projected physician shortage in the United States. The University of Missouri-Kansas City (UMKC) School of Medicine opened in 1971 in response to health care needs in Missouri, but it chose to do so using an innovative and nontraditional approach to medical education. The program offers a six-year integrated educational program leading to combined baccalaureate and medical degrees (baccalaureate/MD). This experimental medical education program was designed to address the full sweep of education of physicians from high school through the receipt of the MD degree. The design of the UMKC educational program is similar in many aspects to the approaches used for many years in Europe, Asia, and the United Kingdom, in terms of admission from high school and length of training.

To educate physicians to be equipped to practice in a rapidly changing world, there is an increasing interest in reforming medical education, cited by recent reports from the Institute of Medicine (Health Professions Education: A Bridge to Quality)1 and from the Association of American Medical Colleges (AAMC) (Educating Doctors to Provide High Quality Medical Care).2 After 35 years of experience with UMKC'S nontraditional approach to medical education, and in keeping with medical education's long tradition of self-study directed toward improvement, it is instructive to look at the outcomes of the UMKC experience at this time. In particular, six- and seven-year baccalaureate/MD programs deserve more attention as models, because offering more combined-degree programs is one of the recommendations from the AAMC's recent report. Of note, a persuasive case has been made for shortening the duration of educational programs training future physicians.3 There are now 39 medical school programs accredited by the Liaison Committee on Medical Education (LCME) that offer combined baccalaureate/MD degree programs.4

This paper will catalog the experiment in medical education at UMKC, examine the educational end product of this effort, and discuss adjustments made and lessons learned.

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History, Mission, and Setting

Health care needs in western Missouri prompted the opening of a second state-supported medical school in 1971. The state legislature commissioned the Olsen report that identified and characterized underserved areas, particularly in inner cities and in rural counties, and concluded that a new medical school to educate physicians who would serve the state was an important need. To supplement the establishment of an additional site for a new medical school, civic leaders presented the case that building a medical school in Kansas City could employ existing clinical resources and improve the quality of health care then delivered by the existing safety net hospital. As a result, the Missouri state legislature provided initial planning funds for a medical school in Kansas City, which would be a part of the University of Missouri system that in previous years had been expanded to a four-campus system. The Kansas City campus of the University of Missouri had increased its offerings to include professional schools in law, dentistry, and pharmacy through mergers with existing private schools in those professions. Thus, an opportunity presented itself to become the only university in the state that had a full offering of health science schools: medicine, dentistry, nursing, and pharmacy.

Two basic objectives were developed in driving the design of the proposed medical school. The first was that the approach to medical education should address key educational issues inherent in the traditional models that were employed by U.S. medical schools at the time. The second was to design a medical school that represented a true model of a community-based medical school, devoid of ownership of a hospital, but establishing affiliations with the major hospitals, both public and private, that existed in Kansas City.

E. Grey Dimond, MD, a well-known cardiologist and medical educator versed in educational models for training physicians, was engaged as a consultant to present a plan that would fulfill the first objective of using a nontraditional approach. The resulting academic plan5 is still in place after 35 years, with minimal revisions, and provides the blueprint for the innovative approach in the design of medical education. Its essential hallmarks continue unchanged:

* Hallmark I: Combined baccalaureate/MD program: The curriculum extends through six calendar years, with a one-month vacation each year, and fully integrates liberal arts/humanities, basic science, and clinical education throughout the continuum, with credit for 30 hours of medical school coursework assigned to both the baccalaureate and MD degrees. It thereby provides a similar number of required weeks of study for the combined degrees as the duration of a traditional program of four years of college and four years of medical school with time off for summer vacations.

* Hallmark II: Early exposure to clinical medicine: The early exposure to clinical medicine in the first two years of the curriculum introduces students who are recent high school graduates to patients, hospital settings, and courses designed to teach communication skills, professionalism, and clinical problem-solving and to build, early on, a full understanding of the language and culture of medicine.

* Hallmark III: Small-group learning through the docent system: An environment fostering small-group, active, and interactive learning was designed with students assigned to a learning community known as a docent team, under the tutelage of a physician scholar referred to as their docent (from the Latin docere, to teach). The docent team concept is continued throughout the final four years of the six-year program, thus providing ready access to patient-centered teaching, mentoring, and role modeling.

* Hallmark IV: Continuing ambulatory care clinic experience for four years: A required continuing care ambulatory clinic experience for every student consists of weekly exposure to a group of patients extending for four years. This concept, in existence since the school started, represented one of the earliest examples of a successful approach to longitudinal ambulatory care teaching, at a time when few other medical schools employed such a concept.

As this educational program has evolved, comprehensive evaluation of the process has occurred, and the educational outcomes have been regularly evaluated. Thus, we have learned some important lessons and made appropriate adjustments. Curriculum design and management is in a constant state of flux at most medical schools, and we have likewise made a number of important adjustments in the delivery of the original academic plan, but the original hallmarks of the plan, which we describe in detail below, remain intact.

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Student Profile

The school was designed to accommodate 100 students per class, for a total student body of 600. The gender and age composition of the students at the school varies from the profile of traditional medical schools. Because the vast majority of students enter directly after high school graduation, the average age of matriculants is 18, and the average age of graduates is 24. In addition, the student body, 634 students strong in the academic year 2005–2006, is ethnically diverse, with 245 students (39%) from Asian backgrounds and 58 students (9%) from underrepresented minorities (black, American Indian, and Hispanic). The vast majority of the student body (517 out of the 634 students or 82%) is considered in-state. Most of the students who lived in Missouri during high school (326 or 72%) have come from urban areas, although throughout the years, students from at least 71 of the state's 101 rural counties have entered the school.

The gender mix, with a balanced representation of women and men at the school, has been increasingly evident for 30 years. Men were predominant in the first entering classes admitted in 1970 through 1974 (99 men out of 130 students, 76%). However, the school enrolled substantial percentages of women long before women entered four-year schools in increasing numbers. By the middle- to late 1970s, two classes were 50% female (82 women out of 162 students); in the 1980s, most classes were at least 40% female (468 women out of 973 students, 48%), and since the early 1990s, the percentage of female students has hovered around 60% (1,021 women out of 1,718 students).

As might be expected, the attrition rate in this school is higher than those of traditional four-year medical schools. Of all 3,377 students admitted at year one from 1970 through 2005, 20.6% left the program without the MD degree. However, attrition in years three through six is lower; only 161 out of the 3,377 admitted students (4.8%) withdrew or were dismissed during the last four years of the curriculum. Attrition occurs most commonly because of academic difficulty, personal problems, or change of career interest. To restore class size to its original 100 at the start of year three, the school admits students with a minimum of a baccalaureate; they must complete the final four years of the program to achieve the MD degree. These students have varied career and educational backgrounds, including advanced degrees. We believe that mixing in this group of older students with our younger students is beneficial, and the two groups learn from each other in a generally positive way, which enhances the educational environment.

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Combined Baccalaureate/MD Program

A solid liberal arts education is important for future physicians, and the design of this program is structured so that there is full integration of liberal arts/humanities/social sciences, the sciences basic to medicine, and clinical education throughout the six-year continuum. Of the total 120 hours needed for the bachelor degree, 42 hours must be in the humanities and social sciences as breadth requirements. Students must also complete an intensive course in writing. Students spend three fourths of their time in the first two years on the main UMKC liberal arts campus and one fourth of their time in a clinical setting with their docent and in courses related to medicine. In years three and four, the curricular mix reverses; students spend three fourths of their time on the medical school campus and one fourth of their time on the liberal arts campus. In the final two years of the six-year program, students concentrate on the medical degree, but they must complete a month-long course in the humanities in relationship to medicine.

The majority of students elect a liberal arts major, with about 10% choosing a major in biology, chemistry, sociology, or psychology. Students must complete an interdisciplinary course that examines a topic from several perspectives. Minor areas of concentration are available, including women's studies and medical humanities. Students who prefer a liberal arts education with a major in an area such as history, music, or political science would need to extend their program from six to seven years. Although students who have an interest in pursuing such areas are encouraged to extend their curriculum, few have done that to date.

This curricular design requires a close partnership with the UMKC College of Arts and Sciences and the School of Biological Sciences, which provide the academic underpinning to a baccalaureate education for the students. Appendix 1 shows the curriculum design in each of the six years, covering undergraduate degree courses, basic science courses, and medical school educational experiences.

Integration is not achieved at the expense of breadth or depth of exposure to any major disciplinary area. The total number of contact hours in the basic sciences is comparable with national averages. The number of months required for completion of the MD degree exceeds that required for Missouri state licensure. Students must fulfill breadth requirements in the liberal arts identical to those set for all candidates for the baccalaureate degree in UMKC's College of Arts and Sciences, but dual credit is offered for some medical school science courses.

Integration of disciplines is also achieved within many individual courses and rotations. For example, the human structure and function series, using a predominantly systems-based approach, integrates anatomy, physiology, and biochemistry along with clinical cases that illustrate key basic science concepts. The self-paced pharmacology course in year five interdigitates prescribing for target populations with appropriate clerkships, for instance, prescribing for women as practiced in the obstetrics-gynecology clerkship. The longitudinal curriculum across six years lends itself to incorporation of subjects to fill gaps, such as geriatrics, communication skills, medical decision making, public health, and the socioeconomics of medicine.

On graduating, students have completed six months of inpatient internal medicine, with graduated responsibility for patient care as they move from one year to the next. This inpatient experience and the ambulatory care clinic experience in general medicine also provide students with multidisciplinary exposure to the subspecialties, pharmacy, social work, and chaplaincy. Year-specific learning objectives related to nine competency areas guide the experience.

In fact, the competencies and associated learning objectives drive each of the curricular years and are woven into each medicine course and clinical rotation throughout the six years. The competencies focus on communication skills; clinical skills; diagnosis, management, continuing care, and prevention; problem-solving skills; application of basic science to clinical medicine as well as self-awareness and professionalism; lifelong learning; moral and ethical reasoning; and diversity and the social and cultural aspects of medicine. More details are available at (http://www.umkc.edu/medicine/curriculum/ebc/default.htm). Because of the longitudinal integration of the competencies into the curriculum and the interdigitation of baccalaureate with medical studies, the curricular years at UMKC do not mirror those at more traditional schools, with the possible exception of year five, which is essentially a clerkship year.

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Early Clinical Exposure

At the time UMKC's educational program was being planned, student contact with patients in most medical schools was confined to the last two curricular years, and it was poorly linked to basic science instruction. Thus, early and continuous exposure to patients became a major part of the new school's curricular design, and it has remained so to this day. During the first two years of the program, groups of students meet regularly with their docent, who is a community physician; students interact with patients whom their docents select from their community-based practices to help them acquire basic competencies in effective communication skills and patient-centered interviewing, professional behavior, diversity, and the social and community contexts of health care. A didactic lecture series provides the cognitive underpinning for these competencies. Rudimentary procedural skills are also taught.

Although most medical schools are now providing students an early exposure to clinical education, this format at UMKC began 35 years ago, and it is cited by applicants considered for admission to the program as one of the features that has most stimulated their interest in the school. This is particularly true for this combined baccalaureate/MD program, in which students of 17 to 18 years of age have the opportunity to see patients in their first year of the program.

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The Docent System

Recognizing that medical schools typically promoted passive learning in a heavily didactic lecture format without close student-faculty relationships, the original UMKC academic plan5 designed a learning environment to foster active collaborative learning with students assigned to small groups of 12 led by physician scholars called docents.

Beginning in year three, each student joins a docent unit and remains a part of that unit until graduation. The 12 students on that unit (three from each of the final four years of the program) participate in the continuing ambulatory care experience and in a two-month inpatient internal medicine docent rotation in years four through six. The docent unit is the centerpiece to teaching and learning clinical knowledge, skills, and judgment along with professional values and behaviors.

The school's architecture, developed after adoption of the educational concept in the academic plan, reflects and reinforces the docent system. The medical school building has four docent team units on two floors, with 12 student offices/cubicles in four quadrants on each floor, a central conference area, and an adjacent office for the docent.

The docent is the major support figure for each of the third- through sixth-year students on the unit and functions first and foremost as a teacher, but also as a role model/mentor who demonstrates the practice of medicine for students on the unit. In addition, the docent is a student evaluator who identifies the strengths and weaknesses of each student and plans for appropriate educational experiences with each student. Further, the docent acts as a student ombudsman and counselor to promote a student's personal, professional, and career development. As needed, the docent can refer students to support services available within the unit, the school's student affairs office, and the university campus.

The docent role is a demanding one in and of itself. In addition to the roles previously described, the docent is expected to carry out other responsibilities, including clinical service and scholarly activity. A study conducted in 1986 on docents' and students' perceptions of the position indicated that the docent role is workable and relatively free of conflict.6 At the same time, docents reported that a chief area where actual practice fell short of the ideal was scholarly activity. More recently, docent faculty (along with colleagues throughout academic medicine) have felt the tension between the need to be more productive clinically, on the one hand, and the need to meet their educational responsibilities to medical students and engage in scholarly activity, on the other. Striking a balance between these roles can be challenging, with some docents more adept than others in resolving these roles; thus, the turnover rate of docents has been variable, but some docents have given decades of service. Nevertheless, throughout our 35 years, graduating students have singled out the docent and the docent team experience as a chief strength of the school, as reported in the annual AAMC graduation questionnaire.

The docent unit is interdisciplinary. In addition to the docents who are internists, other unit members regularly include a doctor of pharmacy and a clinical medical librarian who round with students during the two-month internal medicine inpatient rotation. Doctors of pharmacy reinforce and expand pharmacology instruction that students receive in a longitudinal self-paced course and an intensive two-month course devoted to pharmacology. Clinical medical librarians help students identify learning needs and teach them how to retrieve information and evaluate the medical literature. As part of the interdisciplinary care team, the clinical medical librarians may also provide relevant literature for the care of specific patients. On occasion, ethicists and psychiatrists participate in unit activities. An important source of staff support assigned to each docent unit comes from education team coordinators who perform routine academic advising and enrollment management. Administrative assistants in each docent unit provide secretarial services.

To evaluate the student learning environment under this system, in 1984, Arnold and Jensen7 surveyed students about their perceptions of the UMKC system. This study showed that students rated few situations in their learning environment as stressful. Students were significantly concerned about information overload and related time problems, just as students in more traditionally organized schools were. However, unlike their counterparts in other schools, UMKC students did not see their relationships with other students, their contact with faculty, and the availability of role models as problematic. Administered 10 years later, the same survey obtained similar results.8

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The 4-Year Ambulatory Continuing Care Clinic

Because of factors such as the changing health care system, shortened hospital stays, the vast majority of physician-patient contacts being office based, and hospital sites no longer adequate to provide a full range of clinical education, beginning in the early 1980s medical schools were alerted to the need to provide clinical education increasingly in ambulatory care settings. There was a perception that moving clinical education to an ambulatory setting would be difficult and costly. However, at its inception in 1971, UMKC realized the need for a continuing care ambulatory experience for its students. Once students reach the third year of the curriculum, a continuing care internal medicine ambulatory care experience becomes mandatory for all students. Initially, students assume a role in the clinic, under guidance from their senior student partner and docent, to develop the physical examination skills they are studying in an introduction to clinical skills course. As they build their repertoire of clinical skills, their responsibility for participating in patient care grows. Clinical education involves exposure to the use of the electronic medical record.

Students' experiences in the continuing care clinics have been described. An early study9 and 2005 unpublished data show that students see patients with problems generally representative of those seen nationally by office-based internists and family practice physicians. A multiinstitutional study of longitudinal ambulatory clinics in which UMKC participated found that students' perceptions of their learning in those clinics were quite positive.10 Students observed that, compared with inpatient rotations, these experiences enabled them to improve their communication skills, their clinical skills, their abilities to manage chronic problems and psychosocial problems, and their evaluation of hidden patient agendas. In the 2005 AAMC graduation questionnaire, students gave more positive responses to items relevant to their continuing care clinic than did students nationally, even though UMKC students reported that the time allotted to ambulatory patients was excessive.

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Ongoing Comprehensive Student Assessment

In addition to the four hallmarks of the UMKC program, assessment has also been an important component of the school's approach to educating students. Docent faculty and the student promotion committee (called the council on evaluation at UMKC) are key to the continuous comprehensive assessment of students' academic and professional development.

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The role of docents

The docent's close and long-term association with each student enables the docent to make informed judgments about students' progress through regular and direct firsthand observation. In the continuing ambulatory care clinic, docents assess their 12 students' clinical performance weekly with formative feedback, a process that continues throughout four years. A formal formative assessment at midyear and a summative assessment at year's end are recorded on a standard clinical performance evaluation form, assessing competencies in medical knowledge; application of basic science to medicine; communication skills; clinical skills; diagnosis, management and prevention; and professionalism. The docent rates each of these areas and is encouraged to offer narrative comments. A similar assessment process takes place in the two-month inpatient internal medicine docent rotation that occurs in years four through six. The results of comprehensive performance-based assessments of the clinical skills of year five students in encounters with standardized patients are provided to each docent. Docents meet semiannually with each of their students. Together, they review the student's complete file, available to the docent and student through an electronic database, and they discuss academic and professional progress. Each docent must submit a final letter of competency near the end of year 6, attesting to each student's competency and readiness to perform as a compassionate, caring, and safe physician in the supervised practice of medicine. A favorable letter is required for the student to graduate.

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The role of the promotions committee

This committee meets monthly to identify those students who are having academic difficulties and, together with the student and docent, the committee develops a remediation plan. At the end of the academic year, using a set of guidelines, the committee reviews each student's eligibility for promotion to the next year level.

Indicators of students' academic and professional development include the cumulative grade point average and scores on subject examinations of the National Board of Medical Examiners (NBME) and Steps 1 and 2 of the USMLE. The Comprehensive Basic Science Subject Examination is administered longitudinally. Students' scores on this exam achieved in year four accurately predict performance on USMLE Step 1, which students take at the end of year four or early in year five. Also reviewed are ratings and comments from the clinical performance evaluation forms, peer assessments, and a professional behavior evaluation form.

Our use of peer assessment has been in place for more than two decades. A study by Arnold and colleagues has shown that as a formative assessment, peer assessment among students has acceptable psychometric characteristics.11 Later studies of peer assessment have identified conditions that would enhance students' candid participation in peer assessment,12,13 and the school's peer assessment system has been revised accordingly.

Over time, research has demonstrated that several of these markers of student performance in medical school are correlated to performance in residency programs.14,15 We have surveyed residency program directors regarding the performance of our graduates in comparison with graduates of other schools, and repeated surveys of this type have revealed that our graduates perform equal to or better than graduates of other schools.

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The End Product of This Educational Program

To graduate, students must pass Steps 1 and 2 (both the clinical knowledge and the clinical skills portions) of the USMLE. Under the current curriculum, pass rates of first-time takers approximate the national rates. UMKC graduates have competed successfully for residency positions; in the last five years, 371 out of 403 graduates (92%) participating in the National Residency Matching Program were initially matched. Typically through the years, more UMKC graduates have chosen internal medicine as a specialty than any other discipline. Of the 2,436 UMKC graduates, 1,096 (45%) are currently located in Missouri and adjacent counties of Kansas and Illinois. Surveys of graduates administered from 1989 to 2003 have demonstrated that compared with graduates of other schools, UMKC graduates have been rated higher in professional responsibility, relations with patients, relations with colleagues, work in groups, clinical skills, self-appraisal ability, and problem solving at a statistically significant level (P < .01). Further, of 191 out of 424 graduates in 1993–1997 who responded to the school's latest survey administered at 5- to 10-year intervals, 171 (90%) said they spend most of their professional time in patient care. One fifth, or 38, of them practice in a socioeconomically deprived area. All of the respondents were either board certified or board eligible, and all were licensed to practice medicine in at least one state.

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Lessons Learned and Adjustments Made

Although we still retain the original four hallmark concepts of our academic plan, we have learned a number of lessons through systematic analysis of educational outcomes, ranging from student performance and course evaluations through faculty achievements and satisfaction. Applying continuous quality improvement, we have made a number of adjustments in light of the lessons learned while building a new nontraditional educational program in a changing environment. For example, basic and clinical sciences have both become more complex; faculty expectations for scholarship and clinical productivity have grown; the number of our clinical affiliates has increased; and the delivery and financing of health and medical care have shifted markedly since 1971. Given the ever-changing context of the school, several lessons and adjustments are worth highlighting.

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Basic science instruction

We originally attempted to incorporate basic science education into the docent rotation, but this was discontinued because a large number of basic science as well as clinical faculty were not prepared to deliver basic science information at the bedside. One exception to this has been in the discipline of pharmacology, where bedside teaching has been successful.

A better pedagogical approach to the teaching of basic sciences, with improved integration with clinical medicine, has been achieved, primarily with the Human Structure & Function course, as well as with a rescheduling of course offerings.

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Clinical science instruction

Because the ambulatory continuity clinic runs concurrently with all other courses and clerkships, rescheduling of the ambulatory continuing care clinic has been shifted so that all students attend clinic in the morning to accommodate scheduling of basic science courses. Maintaining a consistent panel of patients for students to follow for the four years in the longitudinal ambulatory care clinic has been a continuing issue because of many factors present in a safety-net hospital, such as walk-ins and patient absence.

We reduced the length of the inpatient internal medicine docent rotation from its original design of three months each year for the last four years of the program to two months each year to occur over three years, from years four through six. This was done because of changes in the health care delivery system, with shorter hospital stays and a shift to ambulatory care, as well as a need to incorporate more basic science instruction into the curriculum. This change was accomplished readily because of the generous time allocation devoted to internal medicine in the original academic plan.

We now share responsibility for the docent rotation between two docents, instead of having one docent responsible for both months of the inpatient rotation. This was done to accommodate increased demands placed on docents for clinical responsibilities and scholarly activity and to give students a broader exposure to different physician styles in the provision of clinical care.

As new hospital affiliations have been established, the docent team instructional model has been exported to another of our community hospitals. The students on these docent teams have office space at the other hospital where they have their ambulatory and inpatient internal medicine rotations. They also have study space assigned in the school of medicine building. Thus, we know that the docent team concept may be successfully applied at more than one setting, at least within our own set of affiliated hospitals and our own curriculum.

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Student assessment

We developed our own internally designed evaluation system in 1971, marked by the administration of a 400-question examination known as the quarterly profile examination (QPE), covering both basic and clinical sciences, administered to students in all six years of the program. The QPE was designed to track students' progress and knowledge acquisition/retention and to apply remediation where indicated, but it was never used as a grading system. Although studies indicated that it was a valid and reliable indicator of student knowledge,16 it was discontinued one year ago because the costs of keeping the question bank current required excessive financial resources. Cost-effective alternatives available through the subject examination program of the NBME and the cumulative science grade point average were substituted.

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Faculty development

We have identified a need for stronger faculty development among docents regarding teaching skills and student counseling skills, particularly because the docent rotation has become packed with interdisciplinary topics.

We acknowledge a continuing need to provide infrastructure and training for scholarly academic work by docent faculty. Therefore, because the vast majority of clinical faculty are employed by hospitals or practice plans, the purchased teaching time contracts for education are now explicit regarding protected time for teaching and other scholarly activities. To facilitate and support scholarship, promotion guidelines have been developed that explicitly recognize scholarship, not only in research, but also in education, clinical care, and service.

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Funding and governance

An ongoing challenge since the program's inception has been to sustain adequate financial support for this state-supported school, particularly at a time when state budgets are tight. This situation has moved us to align our tuition revenues and state appropriation with our teaching mission, which has always been a primary objective at UMKC. Currently, approximately 90% of revenues from the state and from tuition directly support undergraduate instructional costs. Separate, explicit revenue streams support research and graduate medical education.

The medical school was founded on a governance system of councils, but without specific departments. Institutional management of the education programs, especially graduate medical education, has required establishment of clinical departments.

All docents are internists and are members of the council of docents. To provide oversight of faculty recruitment and performance evaluations, as well as academic oversight, the council of docents now reports to the department of internal medicine for personnel issues and to the council on curriculum for academic issues.

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Institutional culture

As a new medical school, development of an institutional culture was important. This culture has been built over time around the core educational program, namely, the docent team. Important ceremonies are centered around the docent team, such as the coating of new team members by their docents at the white coat ceremony and the hooding of graduating students by their docents at commencement.

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Summary

The foresight in the design of this nontraditional approach to undergraduate medical education has now been recognized, with most of UMKC's four hallmarks now underway some years later in many U.S. medical schools. Although the six-year combined baccalaureate/MD program should not be considered as the only model for educating future physicians, the UMKC program was a pioneer in several educational concepts that are now accepted as mandatory.

Although in our early years understanding and acceptance of this educational model was not widespread, with time and experience and with the favorable educational outcomes achieved by this program, our goals have been achieved. In the 1989 survey report of UMKC prepared by the ad hoc accreditation survey team, the LCME noted that this combined-degree program “has exorcised the premedical syndrome … and instills the joy of learning in students.” Further, in the 2003 report of the survey of UMKC by the ad hoc accreditation survey team and in the transmittal letter of October 2003, the LCME considered the docent system and the humanities educational offerings as strengths, commenting that the docent system “provides a sound and abiding framework in which students cannot only learn contemporary medical content but also mature as effective, compassionate, and professional health care providers.” The humanities approach, according to the same 2003 LCME report, “has been effective in helping students develop ethical values, interpersonal skills, and professional values.”

A continuing challenge remains in the selection of students who will thrive and be appropriately nurtured in this program. The selection of applicants, most of whom are 17- to 18-year-old high school graduates, proceeds without the benefit of a college record indicative of applicants' academic skill and life experiences extensive enough to adequately judge their maturity and depth of commitment to medicine. Yet, the admissions committee has found that high school class rank and standardized test scores on a college entrance examination offer a useful initial screen; that interviewers blinded to the specifics of applicants' academic achievement can then explore noncognitive characteristics such as motivation for medicine and maturity on the basis of applicants' behavioral track record; and that the committee's comprehensive review of the applicants' cognitive and noncognitive credentials can determine who is best suited for acceptance into the combined-degree curriculum. For some students, a four-year college experience to help them mature and be more assured as to their future career goals, followed by four years of medical school, is essential. But for those highly mature and academically talented high school graduates who are solid in their commitment to become a physician, the UMKC model presents an ideal approach. In some respects, we have the opportunity to select the best and brightest of high school graduates and prepare them to be physicians who are knowledgeable, skilled, and professionally competent and caring. And, throughout the 35-year history of the UMKC School of Medicine, we have maintained our commitment to continue patient-centered education and to consider undergraduate medical education and the needs of medical students as our highest priority. As a result, we have graduated over 2,400 physicians who are successful by the measures used at other medical schools.

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References

1 Institute of Medicine. Health Professions' Education. A Bridge to Quality. Washington, DC: National Academy Press; 2003.

2 Report of the Ad Hoc Committee of Deans. Educating Doctors to Provide High Quality Medical Care. A Vision for Medical Education in the United States. Washington, DC: Association of American Medical Colleges; 2004.

3 Whitcomb M. Who will study medicine in the future? Acad Med. 2006;81:205–206.

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5 The Academic Plan of the University of Missouri—Kansas City School of Medicine. Available at: (http://www.med.umkc.edu/academic/sections/academicplan/default.html). Accessed December 11, 2006.

6 Calkins EV, Arnold LM, Willoughby TL, Hamburger SC. Docents' and students' perceptions of the ideal and actual role of the docent. J Med Educ. 1986;61:743–748.

7 Arnold L, Jensen TB. Students' perceptions of stress in a baccalaureate-MD degree program. Percept Mot Skills. 1984;58:651–662.

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9 Duckwall J, Alul I, Arnold L, Willoughby TL, Sirridge MS, Hamburger SC. Educating students in a general medicine ambulatory clinic: a pilot study. Teach Learn Med. 1989;1:92–96.

10 Prislin MD, Feighny KM, Sterns JA, et al. What students say about learning and teaching in longitudinal ambulatory primary care clerkships. Acad Med. 1998;73:680–687.

11 Arnold L, Willoughby T, Calkins V, Gammon L, Eberhart G. Use of peer evaluation in the formal assessment of medical students. J Med Educ. 1981;56:35–42.

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13 Shue CK, Arnold L, Stern DT. Maximizing participation in peer assessment of professionalism: the students speak. Acad Med. 2005;80(10 suppl):S1–S5.

14 Keck JW, Arnold L, Willoughby L, Calkins V. Efficacy of cognitive/noncognitive measures in predicting resident-physician performance. J Med Educ. 1979;54:759–765.

15 Arnold L, Willoughby TL. The empirical association between student and resident physician performances. Acad Med. 1993;68:(2 suppl):S35–S40.

16 Arnold L, Willoughby TL. The quarterly profile examination. Acad Med. 1990;65:515–516.

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