O'Connell, Mark T. MD; Mechaber, Alex J. MD; Hernandez, Robert L. MD
Curriculum Management and Governance Structure
♢ In 2000, the Executive Faculty Curriculum Steering Committee (EFCSC) of the University of Miami Leonard M. Miller School of Medicine (UMMSM) was created with the institutional responsibility for governance of the curriculum.
♢ The EFCSC, a standing committee appointed by the school's Faculty Council, meets weekly and works in collaboration with the medical education administration to make all decisions regarding the curriculum design and content.
♢ As outlined in Figure 1, the curriculum management and governance structure underwent revision to include the addition of a regional medical campus at Florida Atlantic University (FAU).
FIGURE 1: Management...Image Tools
♢ Each required course in the preclinical curriculum is reviewed by the Basic Science Curriculum Advisory Committee (BSCAC).
♢ The curriculum for each of the clerkships is reviewed by the Clinical Curriculum Advisory Committee (CCAC).
♢ These advisory curriculum committees review courses, propose curriculum policies, discuss and identify specific issues, and report their findings to the EFCSC.
♢ The EFCSC provides overall oversight of the curriculum to ensure that gaps or unwanted redundancies do not occur and to ensure a high-quality, coordinated, and coherent curriculum.
♢ A similar structure is in place at the Boca Raton FAU regional medical campus, where the Year 1 and 2 Curriculum Advisory Committee is analogous to the BSCAC and the Year 3 and 4 Curriculum Advisory Committee is analogous to the CCAC on the main campus. These committees advise the Curriculum Steering Committee at FAU, which in turn reports to the overall EFCSC.
♢ With current demands for clinical productivity and relative value units (RVUs), plans are in place to provide salary support to EFCSC members for committee work.
Office of Education
♢ The central medical education administration provides significant support to the medical student education program.
♢ The Office of Medical Curriculum, the Doctoring Program Office, the Generalist Education in Medicine Office, and the Educational Development Office include 10 faculty who are assisted by 12 staff.
♢ Courses in the first two-year preclinical curriculum are integrated and are not department based.
♢ The basic sciences are integrated into four structure/function courses, whereas the nine organ-system modules integrate the learning of normal physiology with pathophysiology and the basics of diagnosis and treatment.
♢ The Office of Medical Curriculum provides administrative and clerical support to the faculty course directors and the interdepartmental teaching faculty.
♢ The two-year Doctoring Program is a longitudinal theme-based interdisciplinary program supported by the Doctoring Office, which provides administrative and clerical support to the faculty director of the doctoring program, who is a 40% FTE in this central office.
♢ The Generalist Education in Medicine office manages the four-week Generalist Primary Care core clinical clerkship and the Tobacco Cessation Skills program. The faculty director of these programs is a 50% FTE in this central office.
♢ The Educational Development Office (EDO) was established in 2002 to direct the school's organizational development, curriculum development, and faculty development efforts in medical student education.
♢ One of EDO's core goals is to promote the value of teaching within the University of Miami Miller School of Medicine academic community. This office has implemented important changes and made valuable contributions to the educational program and to the educator faculty.
♢ Of particular note are the following contributions from EDO over the past decade:
* design and implementation of educator portfolios in promotions process for Clinician-Educators
* design and implementation of problem-based learning curriculum
* faculty development programs in teaching, mentoring, and educational research
* implementation of monthly Medical Education Grand Rounds with international speakers
* established EDO Associates, a group of faculty from all departments with demonstrated interest and excellence in medical education who advise EDO
♢ A major initiative to promote the value of teaching is the current work being done to establish an Academy of Distinguished Educators. The new Academy is planned to be launched AY10-11.
♢ A Faculty Rewards Program has been initiated this year to measure the quantity and quality of the teaching efforts of individual faculty to properly recognize, reimburse, and reward those educational efforts.
♢ This program has gained added importance to the school's ability to recruit faculty to teach in light of the rollout of the school's RVU-based incentive program for paying faculty for clinical services provided.
Curriculum Renewal Process
♢ At the time of the last report in 2000, we were immersed in a curriculum renewal process, which was implemented in 2001.
♢ Through the governance processes implemented in 2000, the faculty and administration have made continued modifications to the school's institutional objectives, the curriculum map, the competencies required for graduation, and focused content areas.
♢ For the past several years, our major curriculum renewal efforts have focused on the creation of a regional medical campus (RMC) program at Florida Atlantic University in Boca Raton, Florida (2002) and the expansion of that program to a separate four-year educational track beginning in 2007.
♢ Some of the characteristics of the educational track at the RMC are:
* a major emphasis on community-based training in a setting that is very different than the University of Miami/Jackson Memorial Hospital Medical Center in terms of patient population, clinical resources, and faculty who are aligned with the program's goals and priorities
* extensive experience with continuity care of chronic illness, health maintenance/disease prevention, and team-based complex disease management with an emphasis on caring for the aging population in a community setting
* the centrality of collaborative relationships in defining the role of a physician in providing care and in life-long learning
* the emphasis on “new competencies” such as reflective practice; self-improvement; professionalism; principles of quality management; use of information technology to provide safe, high-quality, evidence-based care; and population-based health care
♢ The RMC has introduced a new layer of complexity in monitoring and managing the medical student educational programs for faculty and staff at both campuses.
♢ The nature of the private–public partnership between the University of Miami and Florida Atlantic University also has provided challenges to the leadership of both universities and the medical school.
♢ The educational track at the Miami campus can evaluate and incorporate new learning objectives and methodologies piloted at our RMC. Perhaps the greatest example is using RMC's curriculum map and new, unique topic areas of emphasis to inform our efforts to develop a new combined MD/MPH program as a four-year curriculum in Miami.
♢ The educational tracks at both campuses increasingly rely on simulation and structured skills training in the instruction and objective structured assessment of medical student competencies.
♢ A new five-year combined MD/MBA degree program was established in AY07-08.
♢ The patient safety curriculum is being modified and moved into a new week-long course at the beginning of the third-year clerkships, Transition to the Clinical Years.
♢ The school's institutional educational objectives (IEOs) were established through a consensus-building process involving a broad range of faculty. They were approved as part of the last major curriculum revision implemented in 2001 and were used to guide the changes made in the medical education program at that time.
♢ The IEOs were used to develop the medical student competency assessment program and its component exercises conducted at the end of the first year, at the end of the second year, and at the end of the third year (see Changes in Assessment section).
♢ In 2003, a series of developmental physical examination benchmarks were created via consensus from a faculty committee–students master level one benchmarks by the end of Year 1 and level two benchmarks by the end of Year 2.
♢ In 2008, after an extensive review of other institution's educational objectives and numerous revisions, a new education mission statement and revised IEOs were established. These measurable and competency-based objectives were submitted to the school's faculty council in October 2008 and were unanimously approved:
♢ Institutional Objectives of the Educational Program: After completing the educational program for the MD degree, our graduates will demonstrate:
1. knowledge of the biomedical and behavioral sciences appropriate for the practice of clinical medicine by all physicians
2. proficiency in clinical skills: eliciting a medical history, performing a physical examination, and performing basic technical procedures
3. application of their knowledge and skills to the practice of medicine, including formulating an appropriate problem list, a set of competing hypotheses, and a diagnostic and therapeutic plan
4. knowledge and skills in preventive medicine, including the ability to identify persons at risk for common and important health problems and to apply appropriate preventive measures, including screening, health education, and other forms of risk reduction
5. ability to critically assess biomedical literature and apply this to the evidence-based management of health problems
6. progress in the development of self-directed life-long learning skills, including the recognition of personal educational needs, selection of appropriate learning resources, and evaluation of progress
7. professionalism through a commitment to professional responsibility, ethical principles, reflective practice, and self-improvement
8. communication skills, including effective and humane interactions with patients, colleagues, health care personnel, and members of the community
9. ability to function as a collaborative member of the health care team
10. understanding of the role and responsibility of the physician as a leader in the health care delivery system and in society
Changes in Assessment
♢ Schoolwide competency assessment exercises ensure that students are meeting the institutional educational objectives of each year of the curriculum. All students must successfully complete standardized competency assessment exercises at the end of the first, second, and third years to progress to the next year. At the end of the first and second years, students complete a series of week-long competency assessment exercises, which include the following:
* bedside physical examination with standardized patient
* medical history with standardized patient (videotaped)
* self-critique and then peer-group critique of medical history videotape
* clinical problem-solving exercise including evidence-based assessment
* computer-based test on interpretation of clinical findings and pathophysiology
* peer assessment
* design learning plan or professional development plan for self-improvement
* review of learning portfolio, learning plan, and general advisement with faculty mentor
♢ All students must successfully complete a 10-station OSCE at the end of the third year.
♢ The clinical exercises at each station have been designed by the core clerkships to assess fundamental clinical skills and behaviors as described in the institutional educational objectives and the clerkship objectives.
♢ National Board of Medical Examiners (NBME) examinations are used throughout the curriculum to assess knowledge and retention of core content and provide students with formative feedback.
* Customized, computerized examinations (Blueprint exams) created by faculty on both campuses are used in Years 1 and 2 to assess retention of content from core modules and organ-system modules.
* Standard comprehensive basic science examinations are used at the end of Year 2 as part of preparation for the USMLE Step 1 Examination.
* In 2010, we began administering a series of NBME progress tests starting with Year 2 students. Students are given progress tests at the start of Years 2–4 to assess knowledge over time.
Highlights of the Program/School
♢ We have established a rich professionalism program that includes required course work in the Doctoring Program and in several of the core clerkships; the Pinning Ceremony, which is analogous to a white coat ceremony; the Code of Honorable and Professional Conduct and its associated Council for Honorable and Professional Conduct; the Physicianship and Professionalism Advocacy Program; the Physicianship Incident Reporting System; the Professional Development Program; and the competitive Pathway of Emphasis in Humanities and Ethics.
♢ These components of the professionalism program are the infrastructure that supports the learning, reinforcement, monitoring, intervention, and remediation of professionalism in the medical student education program. Some of the more notable components of our professionalism programs are as follows:
* The Code of Honorable and Professional Conduct (Code) serves as a guide to medical students in matters related to academic integrity and professional conduct.
* All medical students are required to sign the Code each academic year.
* The Code defines the role and processes of the Council for Honorable and Professional Conduct (CHPC), a medical student body with some faculty representation through which our medical students participate in a peer review process and make recommendations to the administration in matters of unprofessional or unethical behavior of medical students.
* The Physicianship and Professionalism Advocacy Program (PPAP) at the UMMSM establishes a process used to monitor, evaluate, and improve the professional behaviors of medical students at the UMMSM.
* In contrast to the Code, the PPAC is used by all members of our academic community to monitor unprofessional and unethical behaviors in anyone: student, faculty, house staff, administration, hospital employees, and occasionally even patients.
* At its core, it outlines the process for reporting concerns about medical student professionalism and sets forth the outcomes that may result from this process.
* Concerning behaviors and incidents are reported to the medical education administration through a Web-based “Physicianship Incident Reporting System.”
* An incident that raises serious concerns about a medical student's character and professionalism can trigger a Professionalism Evaluation Form (PEF). PEFs can be generated by a promotions committee, a course/clerkship coordinator, the school's CHPC, or the medical education administration.
* The Assistant Dean for Student Affairs monitors all PEFs and contacts all students who have PEFs reported. The student is then asked to respond to the concerns, and a corrective plan is recorded by the Assistant Dean for Student Affairs.
* Based on the nature of the concerns or the number of PEFs generated on a particular student, disciplinary sanctions, up to and including dismissal, can be prescribed by the medical education administration.
* Physicians Universal Leadership Skills Education (PULSE) Surveys: During each academic year, students are required to complete peer evaluations on up to 10 peers they have interacted with throughout the year.
* These validated surveys are analyzed and reports are generated with both numerical and descriptive information on the student's ethical and professional behavior.
* Students scoring low on these surveys are mandated to meet with either the Senior Associate Dean for Educational Development or the Assistant Dean for Student Services for reflection and to discuss improvement plans.
* No other members of the medical education administration are informed about the results of these surveys.
* The Physician Development Program (PDP): Medical students with serious professionalism problems are referred to the PDP for intervention, remediation, and ongoing monitoring.
* The PDP exists outside of the medical school and is used by the Florida Board of Medicine to improve the professionalism of practicing physicians who have experienced problems with their medical licensure as a result of disruptive and unprofessional behaviors.
* This program provides psychological assessments, screening for substance use, instructional materials to improve professional behaviors, and ongoing monitoring of a student's behaviors in the academic and clinical workplaces through the use of repeated PULSE surveys of groups who work with the student of interest.
♢ The Academic Societies (AS) Program, created in 2001, provides an infrastructure that promotes leadership, mentoring, peer teaching, and teamwork.
* Through AS, medical students are divided into 15 unique groups of 12–15 students each, to which they become members for the entirety of their medical school education.
* Each society includes students from each class and faculty mentors, providing an ideal forum for peer-to-peer teaching, including clinical skills training.
* AS also organizes an anatomy and basic sciences tutoring programs, pre-medical and high school mentoring programs, and a monthly student clinical report.
♢ The Department of Community Service (DOCS) is a medical-student-managed organization that coordinates multiple clinical community service projects including nine annual health promotion and screening community health fairs in Southeast Florida and a free evening continuity clinic offering primary and some specialty care for no charge.
* These projects allow the medical student organizations to form community partnerships with public health departments, local government organizations, local NGOs, faith-based organizations, and local residents in our diverse and underserved communities. Essentially all graduates of UMMSM have participated in a clinical community service project produced by the DOCS organization.
♢ Many of today's medical students are interested in an international medical experience during medical school. For some students, this leads to a career that includes work in global health and social policy.
* Currently, there are at least three major international medical initiatives each school year: Medishare goes to Haiti two or three times each year; Medical Students in Action goes to the Dominican Republic twice each year; and a community church takes medical students to Nicaragua each year. Other trips are also organized by various student groups.
♢ A Professional Leadership Development course is offered to all medical students holding positions of leadership in Student Government, The Academic Societies Program, and the DOCS Department of Community Service. The goal of this course is to enhance the effective leadership, teaching, mentoring, and teamwork skills of the student leaders for the upcoming academic year. The students receive two credits of senior elective course work for completing this program.
♢ Progress has been made in developing Pathways of Emphasis for the medical students.
* Currently, there are three pathways in operation with approximately 70 students enrolled: Medical Genetics (20 students), Jay Weiss Social Medicine (45 students); and Medical Humanities and Ethics (5 students).
* These pathways provide structured learning opportunities throughout all four years of the curriculum in the form of didactic sessions, required coursework, research under the direction of faculty mentors, experiential learning, professional development through participation in organizations, societies and scientific meetings, and self-directed learning activities (both conventional and Web based).
* Students apply for selection into these pathways in the fall of the first year. By allowing medical students to engage in advanced studies and research in an area of personal interest, the pathways provide a “minor” degree-like experience in a medically related field.
* For example, the Jay Weiss Pathway in Social Medicine began in March 2007. The Pathway provides students with a broad overview of the major themes of social medicine and health equity including the social determinants of health, clinical care in resource-poor settings, minority and immigrant health, health and development economics, gender equity, health as a human right, and many other relevant topics. The program includes didactic coursework, both required and elective, experiential learning, and self-learning activities (both conventional and Web based).
♢ Two important future initiatives for the UMMSM's medical student education program are as follows: (1) the construction of a new medical education building with planning for this new facility currently under way and (2) the expansion of our residency and medical student programs into our new private University of Miami Hospital, which was purchased two years ago.