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The Reports: United States: North Carolina

Duke University School of Medicine

Buckley, Edward G. MD; Grochowski, Colleen O'Connor PhD

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doi: 10.1097/ACM.0b013e3181ea3687
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Curriculum Management and Governance Structure

  • ♦ The Curriculum Committee (CC) governs the integrated four-year curriculum with strong administrative support from the Dean and Vice Deans. Authority is granted to the CC by the Dean (see Figure 1).
  • FIGURE 1:
    FIGURE 1::
    Curriculum Management and Governance
  • ♦ Decisions made by the CC are sent to the Vice Dean for Education, the Dean of the School of Medicine, and the Medical Center Executive Committee (MCEC) for review and approval.
  • ♦ The CC is chaired by the Vice Dean for Education (who also serves on the MCEC) and meets once a month.
  • ♦ The Curriculum Administration Group (CAG) manages the day-to-day matters of the curriculum and reviews and prepares items for presentation to the CC.
  • ♦ The CAG consists of the education associate and assistant deans, as well as course directors for the interdisciplinary courses and the third year.
  • ♦ The CAG is chaired by the Vice Dean for Education.
  • ♦ Subcommittees representing each year of the curriculum and the interdisciplinary courses report to the CC through the CAG.
  • ♦ The CC and the CAG are chaired by the Vice Dean for Education. Chairs of each of the standing subcommittees are voting members of the CAG and the CC.

Office of Education

  • ♦ The Office of Curriculum, under the supervision of the Associate Dean for Curricular Affairs, provides program and logistical support for the medical students' educational program.
  • ♦ The Office of Curriculum consists of a director, several program coordinators, more than a dozen administrative specialists, and two professional educators.
  • ♦ Services provided by the Office of Curriculum include:
    • Support of teaching facilities
    • Laboratory setup
    • Learner assessment, course evaluation, and program evaluation conducted by the Assessment Office
    • Maintenance of the curriculum management system
    • Standardized patient training
  • ♦ Additionally, the Associate Dean for Curricular Affairs is responsible for the following:
    • Implementing decisions made by the Curriculum Committee
    • Assuring compliance with LCME standards
    • Collaborating with our sister school in Singapore
    • Consulting on curricular development and assessment initiatives
    • Engaging in medical education research
    • Pursuing innovations in medical education, including (for example):
      • Interprofessional education
      • Team-Based Learning
      • Educational initiatives across the continuum on medical education

Financial Management of Educational Program

  • ♦ The curriculum management system is used to track faculty teaching time and associated preparation time, referred to as educational relative value units (eRVUs).
  • ♦ Allocations from the Dean's office to department chairs for educational effort are based on their faculty members' eRVUs.
  • ♦ The Office of Curriculum has a separate operating budget that is funded through the Office of the Vice Dean for Education.

Valuing Teaching

  • ♦ Medical student teaching is rewarded in the promotion and tenure process, and the School of Medicine has two tracks for educators:
    • Track 1: a tenure track for clinician educators
    • Track 4: a non-tenure track for education professionals
  • ♦ Allocations based on teaching effort are distributed to departments on an annual basis (see above).
  • ♦ Each year, medical students select clinical and basic science faculty members to receive teaching awards.

Curriculum Renewal Process

  • ♦ The new Foundations for Excellence curriculum was launched in 2004 after several years of development involving more than 300 faculty members, students, and staff. The objectives for the new curriculum included:
    • Clarity in the articulation of learning objectives
    • Integration of basic science material
    • Inclusion of interdisciplinary topics and opportunities for interprofessional education
    • Student self-care

Elements of the new curriculum included:

  • ♦ Integration of 11 departmentally based basic science courses into four courses organized and delivered around organ systems in year one.
  • ♦ Shortening of several clerkships to allow for the addition of the following elements in year two:
    • Five one-week Clinical Core courses
    • Two two-week selectives
    • One four-week elective
    • Clinical Skills Assessment Week
  • ♦ The third year, devoted to scholarly investigation, was lengthened from a minimum of eight months to a minimum of ten months.
  • ♦ Addition of three requirements in the fourth year:
    • A subinternship
    • A critical care rotation
    • A four-week Capstone course

Learning Outcomes/Competencies

  • ♦ The learning objectives approved in 2004 as the basis for the Foundation for Excellence curriculum were revised and renewed in 2009.
  • ♦ All educational activities are mapped to learning objective(s) in the curriculum management system.
  • ♦ All assessment items and activities are mapped to learning objectives in the curriculum management system.
  • ♦ Reporting of these data demonstrates where each objective is taught and how each is assessed.

New Topics in the Curriculum Since 2000

Year 1

  • ♦ Increased emphasis on clinical correlations in the integrated basic science curriculum
  • ♦ Inclusion of an Introduction to Science seminar series

Year 2

  • ♦ Five one-week Clinical Core courses have been added to the clerkship year. Each covers interdisciplinary topics, clinical decision making, the history of medicine, health care teams, and clerkship-specific skills. Each Clinical Core is organized around a theme:
    • Patient Safety (includes quality improvement)
    • Aging and Chronic Disease
    • Health Economics and Health Policy
    • Critical Care
    • Disaster Preparedness and Response (interprofessional course attended together by students of medicine, nursing, physical therapy, and physician assistant)

Year 3

  • ♦ Medical Statistics course

Year 4

  • ♦ Capstone course—topics include the following:
    • Patient Safety and Quality Improvement (interprofessional element attended by students of medicine and nursing)
    • On-call topics/Preparation for PGY1 (e.g., chest pain, shock, pediatric rashes, GI bleed, etc.)
    • Humanities
    • Integrative Medicine
    • Health Policy
    • Advanced Communication Skills
    • ACLS
    • BLS
    • Phlebotomy
    • ECG
    • Acid base disorders
    • Clinical reasoning
    • Physician self-care
    • Mandatory reporting
    • Fatigue impairment

Changes in Pedagogy

The Foundation for Excellence curriculum features the following:

  • ♦ Decreased emphasis on lecture-based instruction: 35% of first year is didactic.
  • ♦ Increased emphasis on small group/interactive learning: 30% of first year is active learning.
  • ♦ Increased emphasis on time for independent study: 30% of first year is unstructured.
  • ♦ The remaining time in the first year (5%) is spent in assessment activities.
  • ♦ Some faculty members have incorporated Team-Based Learning into their courses/clerkships.
  • ♦ The Obstetrics and Gynecology clerkship and the Surgery clerkship conduct hands-on workshops to give students practice in performing clerkship-specific procedures.
  • ♦ The Medicine clerkship and the Pediatrics clerkship have clinical skills trainers—physicians who provide focused instruction on physical examination and diagnosis skills.
  • ♦ The Pediatrics clerkship uses the Computer-assisted Learning in Pediatrics Program as the foundation for its core curriculum.
  • ♦ The Family Medicine clerkship requires students to conduct a project in chronic disease management.

Changes in Assessment

  • ♦ Integrated basic science courses administer integrated written, practical, and oral examinations.
  • ♦ An NBME customized exam is administered as a summative assessment at the conclusion of the 20-week Body and Disease course.
  • ♦ The Medicine clerkship administers a four-station Clinical Skills Examination using standardized patients at the conclusion of the clerkship.
  • ♦ Students are required to complete group projects at the conclusion of each Clinical Core course.
  • ♦ A week-long comprehensive clinical skills assessment is administered at the conclusion of the clerkship year, including the following elements:
    • Eight-station Clinical Performance Examination, using standardized patients
    • ECG
    • Radiology
    • Laboratory reports
    • Information management
    • Self-evaluation of clinical skills

Clinical Experiences

  • ♦ Clinical training occurs in both inpatient and outpatient settings. Inpatient venues include Duke Hospital, Durham Regional Hospital, and the Durham Veteran's Administration Hospital. Outpatient venues include community-based ambulatory clinics.
  • ♦ Modification to the clerkship year in the new Foundations for Excellence Curriculum resulted in the challenge of more learners per rotation.

Highlights of Program/School

  • ♦ Duke has just one year of basic science instruction.
  • ♦ Clerkship training occurs in the second year.
  • ♦ Students have three elective opportunities during their clerkship year.
  • ♦ Students spend an entire year in scholarly investigation within the four-year curricular framework.
  • ♦ There are nine approved dual-degree options available for students to pursue beginning in their third year.
  • ♦ Several interprofessional educational activities are woven throughout the four-year curriculum.
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