Nelson, Elizabeth A. MD; Oster, Kenda; Goodman, J. Clay MD
Curriculum Management and Governance Structure
♢ The educational administration was reorganized in 1993 with the development of the Office of Curriculum and the creation of the position of Dean of Medical Education.
♢ Deans from all levels of medical education including Undergraduate (UME), Graduate (GME), and Continuing (CME) report to the Dean of Medical Education (Figure 1).
FIGURE 1: Management...Image Tools
♢ In 2008, the Office of Curriculum was renamed Office of Undergraduate Medical Education to more accurately reflect the breadth of activities of the office.
♢ The Curriculum Committee (CC), chaired by a senior educational faculty member, provides centralized oversight for the medical school curriculum.
♢ The Curriculum Executive Committee advises the CC and consists of the Senior Associate Dean of UME, Associate Dean of UME, CC Chair, and the Director of Educational Evaluation and Research.
♢ The CC reports directly to the Deans in the Office of Undergraduate Medical Education (Figure 2). Key subcommittees of the CC include
FIGURE 2: Curriculum...Image Tools
* Preclinical Course Directors: Meet biyearly to evaluate summative data on the curriculum and plan educational improvements for the following year. The preclinical curriculum is overseen by the Associate Dean for Preclinical Programs.
* Clinical Core Clerkships: Coordinate evaluation across the core clerkships and share educational strategies.
* Subinternship Directors: Develop shared curricula across the four departments hosting the required subinternship rotations (Medicine, Surgery, Pediatrics, and Family and Community Medicine).
* Evaluation: Overseen by the Director of Educational Evaluation and Research, a PhD-level educational evaluation expert, this group reviews all preclinical and clinical evaluations by students and provides feedback to the course and clerkship directors on strengths and targeted areas for improvement.
* Competencies: Assists the CC in maintaining a comprehensive list of graduation competencies that guide curriculum decisions about content, instruction, and assessment. Oversees the Baylor Clinical Skills Examinations for third-year students.
* Electives: Approves new electives and monitors existing ones for quality and utilization.
* Professionalism Appraisal and Competency Evaluation (PACE): Monitors minor and moderate professionalism concerns, offers student remediation, recommends professionalism curricular changes, and works with the Dean of Student Affairs when disciplinary action is appropriate.
* There is a confidential web-based mechanism for students, faculty, and others to report breeches of professionalism.
* Mentoring Program: Currently developing a medical student–centered curriculum focusing on medical school transitions, portfolio management of the graduation competency goals, and stress management.
♢ The UME office is led by the Senior Associate Dean of UME. This office works closely with the Offices of Admissions and Student Affairs.
♢ The UME office provides the following academic services directed at implementation and continuous quality improvement of medical student education:
* Course Administrative Support: Eight staff assist in the administration of course materials, course faculty and course director administrative support, and the logistical administration of all preclinical and centrally administered courses.
* Curricular Development: In conjunction with the CC, the UME office participates in all curricular development activities for student programs. Course content and structure are monitored through this office.
* Educational Innovation: Through the faculty and the CC, efforts to drive curricular innovation are implemented. The UME office helps develop and integrate these efforts into the existing curriculum.
* Evaluation: Student, course, faculty, and overall curricular evaluation are administered and overseen by the Director of Educational Evaluation and Research. Longitudinal performance assessment is done for courses, faculty, and students.
* Simulation Activities: The Claire Huckins Simulation Laboratory for Clinical Performance Improvement houses the Baylor College of Medicine (BCM) central Simulation and Standardized Patient (SP) programs.
* These programs provide resources and infrastructure for clinical skills development and assessment for medical students, house officers, and students in the School of Allied Health Professionals (http://www.bcm.edu/spprogram/?PMID=0).
* Faculty Development: A nationally recognized program with a rich curriculum and system of awards is administered from within the UME office. These efforts are available to any faculty member at BCM regardless of the faculty member's involvement with the UME mission.
* Educational Scholarship: The UME office is currently participating in three funded grants including an NIH-funded grant for $1,349,600 on Relationship Centered Care.
* The UME office, under the leadership of the Deans and the Director of Evaluation and Research, evaluates the curricular innovations and outcomes of the school. Results of these activities are routinely presented and published nationally.
* Education Resource Center (ERC): The ERC works in partnership with the UME office to provide Information Technology support and educational resource support to all three schools at BCM (Medical, Graduate, and Allied Health).
Financial Management of Educational Programs
♢ BCM has two primary sources of UME educational support:
* The school receives substantial support from the state of Texas for the medical education of Texas residents.
* The other source is tuition and fees. BCM is a private institution but, because of state support, is able to keep tuition among the lowest in the country.
♢ BCM is implementing a transparent mission-based budgeting process for educational fund distribution in the next fiscal budget.
* Although the distribution methodology does not provide additional funding to the school as a whole, it will provide departmental leadership and faculty with greater insight into how educational efforts are funded within the college. Methodology details are available upon request.
♢ In response to the development of an integrated curriculum in the mid-1990s, BCM developed an extensive faculty development program that has not only improved teaching and educational scholarship, but has also created increased opportunities for promotion and tenure of those faculty members engaged in the educational missions of the College.
♢ In addition to more than 100 hours per year of faculty educational workshops, we offer an Educational Scholars Fellowship Program and a Master of Education degree with the University of Houston School of Education.
♢ We support three medical education learning communities for faculty: two fellowship programs and an Academy of Distinguished Educators.
♢ Our self-nominated, peer-reviewed, criterion-based teaching award (Fulbright and Jaworski, LLP Faculty Excellence Award) rewards excellence in four areas of educational activity (Direct Teaching, Leadership, Enduring Materials, and Research).
♢ The peer-reviewed Barbara and Corbin J. Robertson, Jr. Presidential Award for Excellence in Education provides recognition for up to four senior educators each year.
♢ Because of the demonstrated rigor of the criterion-based and peer-reviewed teaching awards, the promotions and tenure committee strongly encourages those faculty members who are involved extensively in the educational mission of the college to work toward receipt of one of these awards. This has translated into actual promotion of clinician educators with tenure.
Curriculum Renewal Process
♢ Initial curricular reform began in 1993, with complete implementation of the integrated preclinical curriculum in 2001.
♢ The goals of this process were to
* Integrate the preclinical curriculum using an 18-month organ-based rubric. In addition to internal evaluation processes, student performance on the NBME Comprehensive Basic Science Examination has been used as an external benchmark of performance. Students must demonstrate competence in basic science knowledge equivalent to a passing USMLE score in order to progress to the clinical curriculum.
* Provide early clinical exposure through our “doctoring” course called Physician, Patient and Society. In this course, our students encounter their first real patient within the first month of medical school.
* Increase the opportunities for longitudinal ambulatory experiences within the third-year Longitudinal Ambulatory Care Experience (LACE) course.
* Increase student access to and application of medical informatics.
♢ In 2005, we adopted our Core Competency Graduation Goals (CCGGs) and have focused on explicitly linking all curriculum and assessment strategies to these goals.
* This has led to formal consideration of the specific attributes we seek in entering and graduating students. We have focused on developing more robust assessment strategies of attainment of competencies in the clinical years.
♢ In addition, we have introduced a fourth-year capstone course called APEX to help students transition to their roles as house officers by providing a vehicle to consolidate medical school experiences and provide explicit guidance about the cognitive, behavioral, ethical, legal, and practice expectations for house officers.
♢ As the curriculum evolves and is continually renewed, the physical spaces in which education occurs become an important element of the process.
♢ We have been fortunate to have the resources to recently renovate the educational spaces at BCM to reflect our curricular philosophy.
* In 2007, the UME office and Student Services section of Student Affairs were physically united in one office located in close proximity to the student classrooms, auditoria, and the Education Resource Center, all of which were also renovated.
* All anatomical sciences laboratories are done in 8 student rooms that can be reconfigured to accommodate the differing requirements of Gross Anatomy and Neuroscience.
* For large-group activities, auditoria were reconfigured to provide power and Internet access for student laptops, modern audiovisual support capabilities, and traditional blackboards so that teaching can be dynamic and multimodal.
* For small-group activities, classrooms of varying sizes, some with moveable partitions, were created and outfitted with LCD projectors, large LCD monitors, and computers. Audio broadcasting is available for individual rooms or groups of rooms.
* Spacious comfortable student study areas were built on multiple floors, and four suites of offices and classrooms were included to provide an enduring physical home for the Mentoring Program.
* In 2009, a clinical performance laboratory was created with 14 rooms outfitted to resemble doctors' offices and a command center to monitor the testing activities in the rooms. These rooms include webcams for the monitoring of the practice examinations and computer stations outside each room for immediate assessment by the SPs.
* A student relaxation center with kitchen, tables, comfortable chairs, and gaming equipment was created near the auditoria and classrooms to facilitate relaxation and socialization. In addition to this facility, there is a gym within the College building.
♢ In 2005, the CC approved a set of CCGGs modeled in large part on the ACGME competency goals.
♢ In addition to the six ACGME competency domains, BCM added the competency of Leadership (http://www.bcm.edu/osa/handbook/?PMID=15562).
♢ These competency statements serve as the backbone of our curricular development and assessment.
♢ It is our goal for all educational activities to be explicitly linked to the CCGGs.
♢ Students use self-assessment questionnaires administered yearly in addition to an electronic portfolio to monitor their progress toward graduation competency.
New Topics in the Curriculum Since 2000
In the past 10 years, there have been multiple new topics introduced into or augmented in the student curriculum:
♢ Public Health has been embedded within our Integrated Problem Solving (IPS) course to help students juxtapose the needs of the individual patient with the larger scope of public health.
♢ Medical Informatics principles and application have also been embedded within IPS to facilitate direct application of these skills to clinical practice from the first weeks of medical school.
♢ Although there has been some use of standardized patients for the past 20 years at BCM, over the past 10 years this program formerly based in the Family and Community Medicine Department was moved centrally into the UME office. With this change, there has been increased use of simulation and SPs both to teach clinical skills, communication, and professionalism and to meaningfully assess these topics.
♢ Our Capstone course (APEX) has provided a rich opportunity to explore topics such as interprofessional team development; patient safety; communication styles across clinical disciplines and across health providers; leadership skill development; humanism; and practical aspects of transitioning to GME, including stress and debt management, legal and regulatory affairs, and consideration of medical emergencies that the new house officer may encounter. Included are medical–legal, business, and risk management issues and ACLS and PCLS certification.
Changes in Pedagogy
♢ Digital educational resources: We are transitioning from paper-based syllabi and handouts to documents, presentations, media, and Internet links that reside on students' laptops. A conscious effort is made to render all digital teaching materials independent of computer operating systems.
♢ Interactive educational activities: There is increased use of interactive educational activities including use of audience response systems and Team-Based Learning.
♢ Streaming video: Most core lectures are captured and are available online. In addition to routine use, this resource has allowed us to recover gracefully from major regional disasters such as hurricanes and floods.
♢ Simulation and standardized patients: These experiences have been increased in terms of amount of utilization, fidelity, and case difficulty.
♢ Virtual microscopy: Optical microscopy was replaced by digital histology software that allows students to move the virtual slide, change magnifications, and compare images on their laptops. This change has been well received and reflects the increasing role of digital microscopy in the practice of pathology and histology.
♢ Informed use of the electronic medical record (EMR): All BCM clinical facilities use an EMR.
♢ Longitudinal monitoring of professionalism: The PACE committee and mentors can track professional development and any breaches that may occur across the entire undergraduate medical school experience.
♢ Focusing on a competency-based assessment: Clinical skills assessments are embedded throughout the clerkships centered around the expectation of increasing skill attainment over time.
♢ Increasing longitudinal relationships between faculty and learners through the Mentoring Program and the Scholarly Project.
♢ Increased use of near peer educators within our preclinical courses such as Neuroscience, Anatomy, Pharmacology, IPS, and Patient Physician and Society. The students are very engaged in learning from students a few years senior to them. The student teachers are closely supervised by senior master teachers. They receive personalized guidance and evaluation, making this experience a benefit to both the learner and the student teacher.
♢ Opportunities for students to personalize and diversify their educational experiences.
♢ Dual-degree programs: BCM understands that many of today's students are interested in careers that benefit from expertise in two fields of study. In response, the College has partnered with other excellent institutions to offer our students several dual-degree programs.
♢ Specialized tracks: In an effort to meet the varying interests of our students, BCM offers several tracks for medical students to explore particular areas of medicine. Participants in these tracks can receive certifications in the following areas:
* Medical School Research: This five-year program is for medical students who desire increased exposure to basic or clinical research. Our goal is to select highly motivated students to participate in the planning and publication of medical research and to create life-long research-oriented physicians.
* International health: This four-year program is for students interested in global health issues. Graduates of the track have an opportunity to sit for the examination leading to the Certificate of Knowledge in Clinical Tropical Medicine and Traveler's Health.
* Care for the underserved: This four-year program provides students with the specific knowledge, skills, and attitudes they need to provide care to underserved patients in the future, recognizes students for their accomplishments while here at Baylor, and encourages them to seek future residency and practice positions that will enable them to continue caring for underserved patients.
* Geriatrics: The four-year Geriatrics Track helps better prepare medical students to care for older adults in their professional careers. This track introduces the important psychosocial, behavioral, functional, and physical issues of aging through patient care experiences and working with faculty mentors.
* Medical ethics: Begun in 1992, the BCM Ethics Track is the first medical ethics track in any medical school in the United States, and other medical schools have used it as a model in developing their own medical ethics tracks. The track was created by students for medical students seeking to develop greater knowledge and expertise in medical ethics.
* Research/scholarly project: BCM medical students may undertake a Scholarly Project (longitudinal 18-month experience) during the course of their training. The Scholarly Project is intended to foster skills in analytical thinking, rational decision making, and problem solving. Although the projects can be conducted in a laboratory, students are free to pursue any topic that relates to medicine, including clinical studies, the humanities, health policy, and ethics. Based on their interests, each student will be matched with a faculty advisor.
Changes in Assessment
* Increased use of simulation and SPs in the clinical skill arena.
* Use of an electronic portfolio system to provide a framework for the student and their mentor to monitor progress and develop “Individual Learning Plans” every six months to help guide student progress through the curriculum in a purposeful way.
* In 2009, we moved to a preclinical grading system of Pass/Fail with a passing bar of 70%.
* A third-year Clinical Performance Examination uses simulation and SP scenarios to assess competency expectations of students having completed the core clerkships.
* The UME Office implemented a program for item banking, automated test generation, scoring, analysis, and quality control.
♢ BCM has eight primary clinical affiliations within a short distance of the medical school within the Texas Medical Center. Students may rotate to all or some of them depending on the clinical rotation:
* St. Luke's Episcopal Hospital (private adult care)
* Ben Taub General Hospital (county hospital high-acuity adult and pediatric care)
* The Methodist Hospital (private adult care)
* MD Anderson Hospital (state cancer hospital)
* Texas Children's Hospital (private pediatric hospital)
* Michael E. DeBakey Veterans Medical Center (federal adult care)
* The Menninger Clinic (private psychiatric care)
* Memorial Hermann Texas Institute for Rehabilitation Medicine (private physical medicine and rehabilitation care)
♢ The breadth of clinical rotation sites is a major strength of our program. Medical students are exposed to ambulatory and inpatient care in private, public, and clinically focused institutions.
♢ The students experience multiple types of bioinformatic, imaging, and laboratory infrastructure in addition to the full range of health care acuity.
♢ The diverse clinical venues require that students be flexible and adaptable, but by the time of graduation, our students can function effectively in virtually any clinical environment.
♢ Since 2004 BCM has renegotiated affiliation agreements with both St. Luke's Episcopal and The Methodist Hospitals. This has led to some shifts in faculty and clinical rotation location.
* Although there has been some student anxiety during this time, the student experience has generally been shielded from any direct impact from these faculty shifts.
* The biggest change was the movement of the surgical core clerkship out of The Methodist Hospital to St. Luke's Episcopal Hospital. There was no degradation in the quality of the Surgery Core Clerkship as a result of this transition.
Highlights of the Program/School
♢ Competency-based curriculum and graduation goals
♢ Accelerated 18-month preclinical experience
♢ Early patient contact and diverse clinical venues
♢ Flexible clinical rotation scheduling
♢ Mentoring Program
♢ Electronic portfolio and digital educational resources
♢ Opportunities for students to personalize and diversify their educational experiences