Fantone, Joseph MD; White, Casey PhD; Kolars, Joseph C. MD; Woolliscroft, James O. MD
Curriculum Management and Governance Structure
♢ The medical school adopted a centralized governance structure with its revised curriculum in 1992.
♢ Centralized governance has worked very well to ensure student achievement, interdisciplinary approaches to teaching and learning, ample and centralized support for medical education, high-quality courses and instructors, innovative programs, and continuous improvement.
♢ Under the guidance of the Associate Dean for Medical Education, the curriculum is managed by Directors in Component I, Component II, and Components III/IV, who all meet biweekly as a steering committee; directors of the major second-year and graduation OSCEs are also members of the steering committee.
♢ Component Directors and Assistant Directors are appointed and funded by the Associate Dean for Medical Education.
♢ Major policy issues are managed by the Curriculum Policy Committee (CPC), which comprises elected and appointed faculty members and medical students.
♢ Data yielded by a rigorous evaluation system (managed by a distinct office and staff with direction from the Associate Dean and the Assistant Dean) are monitored by the CPC.
Office of Medical Education
♢ The school's centralized governance structure for undergraduate medical education is administered through the Office of Medical Education.
♢ All activities in support of the curriculum for the MD degree were centralized in the Medical School's Learning Resource Center (LRC) more than 10 years ago, and that has worked very well. In the LRC, students and faculty have access to support staff and resources, computers and printers, professional computer consultants, computer-based faculty development stations, small-group study rooms, classrooms and lecture halls, microscopes, the Standardized Patient Program, and clinical skills examination rooms.
Budget to Support Educational Programs
♢ The Associate Dean for Medical Education provides direct funding (to support clinical release time) to faculty who lead each of the components of the curriculum (Component Directors and Assistant Directors), the Director and Associate Director of the Family Centered Experience and Small-Group Education (and each of the 30 small-group faculty facilitators), the Director of the Clinical Foundations of Medicine course (and the 30 faculty who teach in the Clinical Educator Program small groups), the Standardized Patient Program, and the Directors of the required Clerkships and the Comprehensive Clinical Assessments (OSCEs).
♢ There is also centralized funding available for curriculum innovations and improvements, including development of new courses, sequences, and electives, new approaches to education and assessment, and computer-based enhancements and exercises.
♢ In 1997, the school began quantifying the cost of medical education using an activity-based cost accounting model based on Educational Value Units (EVUs). With information from faculty and administrators applied to the model, the school is now redistributing funding to departments based on actual educational costs and also centralizing additional funding to support medical education.
♢ The dean's office directly funds faculty members who are key leaders and administrators in the curriculum for the MD degree.
♢ In the first two years, every faculty member with three or more contact hours in the curriculum is evaluated by students, and in the clinical years, students evaluate residents and faculty with whom they work.
♢ Individual faculty, course/clerkship directors, and department chairs may request student evaluations at any time.
♢ Documentation of the amount and quality of teaching provided is required by the Medical School's promotion committees; a teaching portfolio template is provided via the web for faculty to document their teaching contributions.
♢ All teaching faculty are encouraged to use evaluations of their courses and access to educational experts and computer consultants to develop innovative approaches to teaching and learning. Funding for such efforts is provided to faculty by the Associate Dean for Medical Education and through grants from the Center for Research on Learning and Teaching (CRLT).
♢ The medical school has expanded its recognition of teaching by adding the Medical Student Award for Teaching Excellence to its more traditional awards. This award recognizes those faculty evaluated most highly by the medical students for their outstanding teaching and is bestowed on eight faculty each year.
♢ Faculty members who are small-group facilitators in the Family Centered Experience and in the Clinical Educator Program undergo extensive annual faculty development (based on principles and theories that support the curriculum).
♢ Faculty members who are interested are encouraged to participate in educational research related to teaching and learning. Expertise and collaboration are available from the Assistant Dean for Medical Education, through faculty in the Department of Medical Education and through the Center for Research on Learning and Teaching.
Curriculum Renewal Process
♢ Curriculum renewal is ongoing, based on continuous monitoring and evaluation of the curriculum. Faculty de-briefings, student evaluations, student performance on internal and external measures, published evidence, and internal research findings contribute to curriculum improvement.
♢ Feedback from students and faculty development are essential to assure the curriculum remains aligned with the principles that guided curriculum change several years ago (see List 1).
LIST 1: Goals for Me...Image Tools
♢ Pilot experiences and exercises are conducted on a routine basis and provide critical information for curriculum renewal. Those we have conducted recently include new Comprehensive Clinical Assessment stations, interprofessional health care teams, online collaborative learning, learning management system, ePortfolios, and distance education.
♢ Flexible funding for new initiatives (e.g., new Feedback on Clinical Skills, blended simulation center/standardized patient experiences, handheld technologies upgrades) assures ongoing curriculum renewal.
♢ Access to expertise in educational and assessment theory and application is critical for effective curriculum renewal.
The school's Goals of Medical Education were created by the faculty in 1991 and have been reviewed and modified several times since, most recently when the 2003 curriculum was in the development phase. The goals are high-level expectations of the knowledge, skills, and attitudes our students will possess at graduation (see List 1 for the Goals for Medical Student Education).
♢ A series of 82 intended learning outcomes was created in 2001 to guide curriculum development. These are more specific than the goals, include expected level of mastery (advanced, intermediate), and also traverse knowledge, skills, and attitudes/behaviors domains. Course and clerkship learning objectives can be mapped to the 82 learning outcomes. The high-level intended learning outcomes can be found at: http://www.med.umich.edu/lrc/medcurriculum/pdf/Learning%20Outcomes.pdf.
♢ Each course, sequence, and clerkship has specific published objectives to be achieved by medical students as measured by the course director. Each clerkship director also has responsibility for ensuring student learning in specific areas (e.g., signs and symptoms) identified and agreed upon by the faculty director of the clinical years and the clerkship directors.
New Topics in the Curriculum Since 2000
♢ Efforts to integrate interdisciplinary topics within and across the curriculum are ongoing.
♢ Topics include advanced directives, integrative/complementary medicine, evidence-based medicine, palliative care, geriatrics, health economics, interpersonal violence, ethics, gender identity, socioculturalism, nutrition, patient safety, poverty, and health care and spirituality.
♢ The Family Centered Experience helps students understand the principles of humanistic medicine, the patient's perspective related to illness and health, and the importance of the physician–patient relationship.
♢ While individual sessions are devoted to each of the topics, mostly for foundational information, continuous monitoring and effort is devoted to assuring the topics are presented in realistic contexts, simultaneously and in an integrated manner where it makes sense (e.g., socioculturalism and poverty/health care; poverty/health care and nutrition; spirituality and palliative care).
♢ Initiatives to expand interprofessional education are ongoing.
Changes in Pedagogy
We believe it is the responsibility of medical educators to assure that students achieve goals and outcomes related to knowledge, skills, and attitude. We also believe students need specific pedagogical contexts in which to develop necessary professional skills including effective self-assessment and self-education.
♢ Within the curriculum we adopted in 2003, we integrated small groups in which the students moderate the discussions (leadership skills) and in which the students teach and evaluate each other (peer teaching and peer assessment).
♢ Active learning methods, which specifically foster development, and clinical contexts, which promote effective retention of knowledge and skills, are key to the adopted pedagogy.
♢ The first and second years of the current curriculum are presented in organ system-based contexts, sequentially (i.e., students work on one organ system at a time).
♢ Each sequence includes small-group discussions that are student-centered and that foster application of concepts; many of the sequences use computer-based technology to enhance student learning.
♢ Weekly multidisciplinary conferences, many of which include patient presentations, augment student learning in the sequences.
♢ First- and second-year students meet in small groups weekly with a faculty facilitator to discuss the Family Centered Experience visits and to discuss psychosocial topics that influence health and health care (e.g., socioculturalism, poverty, health economics, ethics, complementary/ alternative medicine) that are presented through patient presentations and computer- or paper-based clinical cases. The faculty facilitator and student groups (10–11 per group) are stable into the third year.
♢ Clinical skills are learned in the Clinical Foundations in Medicine (CFM) weeks, which occur periodically in between the sequences (i.e., students complete two to three sequences of approximately two to three weeks each, and then participate in a week or two focused on clinical skills).
♢ The Clinical Educator Program, which is scheduled within the CFM weeks, comprises one faculty clinician with a small group of six students. The faculty clinician and the students are stable in the first and second years.
♢ Standardized Patient Instructors (SPIs) are effective tools for learning and for assessment of learning, particularly in the context of communication, and in topic areas in which students do not necessarily have experience in the clinical setting (e.g., behavioral counseling, breaking bad news, informed consent).
♢ We have a robust SPI program through which we meet learning outcomes across skills domains and through which we conduct the two major OSCEs.
♢ Student progress in the specific disciplines is assessed several times a year, and models to allow students to self-assess their knowledge and skills in these areas have been developed.
♢ Instructional modules available via the web have been integrated into several of the required clerkships to ensure consistent student learning and mastery of educational objectives.
♢ The modules were developed by the clerkship directors with their colleagues and with computer consultants in the Office of Medical Education; they are case based, interactive, and incorporate self-paced instruction and self-assessment.
♢ Several of the clerkships have integrated simulation available in the Clinical Simulation Center to assure achievement of learning objectives consistently across clinical sites and experiences.
♢ A required senior-level course on advanced medical therapeutics has been developed using distance education technology and principles. This online course provides flexibility for M4s who are traveling to interviews; they can complete the course while they are out of town.
♢ Multimedia cases, resources, and quizzes comprise the course; a final project displaying depth in a particular related area concludes the learning experience.
Application of Computer Technology
♢ Because so many curriculum enhancements and self-study modules, including virtual microscopy and the Professional Skill Builder (PSB), are technology based, medical students are required to bring laptops with them when they matriculate.
♢ Detailed information on models and configuration is provided in advance, and comprehensive support is available throughout the four-year curriculum by staff in the Learning Resource Center (LRC).
♢ There are 90 computers in the LRC, another 35 computers in medical student study areas to which they have access 24 hours a day, 7 days a week, and 15 computers in the UM Hospitals medical student call rooms.
♢ There are “Email Express” computers available to students in the LRC and the student study areas.
♢ Quizzes and examinations are taken online using Question Mark Perception software.
♢ In the first two years, assessments are flexible; students must take them on-campus but they can take them any time from 5:00 pm on Friday to 12:00 midnight Sunday.
♢ We use “CTools” software (developed at the University of Michigan, built on the SAKKAI platform that was also developed at the UM) to organize the curriculum and to provide students with comprehensive course information (announcements, syllabi, daily schedules, discussion threads, and so on).
♢ Students have 24 × 7 access to all lectures via streaming video; they can speed up or slow down the video when watching.
♢ The Professional Skill Builder (PSB) is a web-based, multimedia-rich, interactive program developed at the Medical School.
♢ Students work through authentic clinical cases to practice and develop their history taking, physical examination, and diagnostic test selection skills.
♢ The PSB is used throughout all four years of medical school to reinforce and integrate classroom and clinical learning.
♢ Faculty and professional (programming) staff continue efforts to develop a robust Learning Management System to support learning through medical school and into residency and professional life.
♢ The Learning Resource Center has received substantial external funding to develop high-quality educational modules that can be delivered “just in time” using handheld devices including smart phones.
♢ The Learning Resource Center's Faculty Development Stations provide faculty with state-of-the-art hardware, software, and professional consultation to introduce them to technology they can use to upgrade existing teaching materials or create new computer-based materials for use in the classroom. There is no charge to the faculty for use of the stations or for consultation.
Changes in Assessment
♢ Grading during the first and second years is pass/fail, with third- and fourth-year grading honors, high pass, pass, fail.
♢ Students are assessed in the small groups (five times over two years) in the following domains: problem solving skills, reflective skills, psychosocial aspects of health care, leadership skills, research skills, peer teaching skills, peer interactions, self-assessment, and professionalism.
♢ Anchors on the assessment instrument are based on student development; the low end of the scale is that the student is functioning at a late undergraduate level, and the high end of the scale is that the student is ready to begin internship.
♢ Students complete self-assessments; one-on-one meetings with faculty facilitators emphasize self-assessment.
♢ The M2 Clinical Comprehensive Assessment (OSCE) comprises nine stations. Six stations assess physical examination skills, two stations assess history taking/communication skills, and one station assesses verbal presentation skills.
♢ There is also a written examination consisting of approximately 90–100 multiple-choice questions covering general principles of the physical examination, including basic physiology and pathophysiology relevant to the diagnosis of common clinical conditions covered in the Clinical Foundations of Medicine course.
♢ The physical examination stations include the abdominal, cardiac, musculoskeletal, neurologic, and pulmonary examinations.
♢ All stations are observed and scored by faculty. Students must pass the M2 CCA to progress into the clinical clerkships.
♢ The Feedback on Clinical Skills (FCS) is a formative assessment experience developed to provide third-year medical students with feedback on their ability to work through a patient case from start to finish.
♢ In the FCS, which each student completes one quarter and one half through the third year, the student conducts a history and physical examination with a standardized patient, followed by a series of additional steps that comprise ordering laboratory tests, accessing, assessing and synthesizing evidence, and finally integrating all of this evidence and information into a comprehensive plan for treatment.
♢ A faculty preceptor observes the student's knowledge and skills in obtaining and processing information and evaluating and synthesizing the patient's problem. The experience culminates with an oral presentation of the patient to the faculty preceptor, followed immediately by formative feedback to the student about specific and overall performance. The student then writes a personal learning plan based on self-reflection, self-assessment, and feedback.
♢ The FCS fosters development of lifelong learning habits by including steps where students reflect and self-assess their communication skills, write a learning plan, and use that learning plan to guide their continuous clinical development.
♢ The M4 Comprehensive Clinical Assessment (OSCE) measures knowledge, skills, and competencies the faculty has identified as fundamental for graduation. This assessment comprises 12 stations including physical examination, history taking, post encounter notes, patient presentation, imaging, EKGs, critical values, and evidence-based medicine.
♢ Content varies year to year on the M4 OSCE to ensure appropriate sampling of critical clinical skills and competencies and is determined by a faculty director and committee using the curriculum blueprint as a guide. Students must pass the M4 CCA to graduate.
♢ Clinical experiences begin early in the first year with students shadowing physicians in physicians' offices and clinic settings. Small-group discussions of specific topics, with each group facilitated by a physician and an educational expert, augment the shadowing experience.
♢ In the Clinical Educator Program (CEP), students are assigned to a group of six students led by a faculty facilitator with whom they will conduct five histories and physical examinations (one at the end of the first year; four throughout the second year).
♢ In each of the CEPs, students do a history and physical examination on the patient under supervision, write up findings/observations, and present the patient to their faculty facilitator.
♢ The faculty facilitator provides each student with oral and written feedback. The same group of students remains with the same facilitator throughout the CEP so development of clinical skills can be documented.
♢ Sites for clinical clerkships include UM Hospital and Health System, the Ann Arbor VA Health System, St. Joseph Hospital in Ann Arbor, William Beaumont Hospital, and Henry Ford Hospital.
♢ As new medical schools are instituted (Beaumont, Michigan State/Grand Rapids, and Central Michigan University) and class size is increased (Wayne State and Michigan State), we are monitoring the need to maintain sufficient capacity for our clinical students. However, at this time, our capacity is stable.
♢ A national concern is the availability of faculty and house officers to observe clinical students and to provide them with directed formative feedback, especially given restricted duty hours and expectations for patients throughout. The FCS experience was designed and adopted to address this issue.
Future Goals and Challenges
♢ More, earlier exposure to the clinical milieu.
♢ Sustaining sufficient centralized funding for small-group facilitators and for innovation.
♢ Sufficient, appropriate space for small groups.
♢ Sustaining rigorous faculty development to assure achievement of learning objectives.
♢ Expansion of our current clinical assessment center.
♢ More interprofessional learning modules (collaborations across the health sciences schools).
♢ Continuous curriculum improvement.
♢ Development of “Paths of Excellence”; students would choose a particular path (e.g., health disparities, global health, women's health, health economics) and work with a mentor to create an individual learning plan that crosses disciplines (e.g., public health and medicine or sociology and medicine) and that guides their learning through medical school.
♢ Refinement of the funds distribution model to assure individual faculty recognition for teaching effort and quality.
Highlights of the University of Michigan Medical School
♢ Strong history of promoting opportunities for excellence (Medical Scientist Training Program and other dual degree programs: MD/MPH, MD/MA (education), MD/Public Policy, MD/Business).
♢ Significant opportunities in global health.
♢ Pedagogy based on evidence that fosters development of autonomy, problem solving, leadership, and critical thinking.
♢ Robust clinical assessment; formative and summative.
♢ The Family Centered Experience.
♢ Innovation in technology and pedagogy.
♢ Flexible assessment/testing in first and second years with pass/fail grading.
♢ Supportive environment for students (professional and person counseling).
♢ Growing number of interprofessional learning and assessment modules.