This solution deals only with the present and the near future—a generation, at most. In the course of the next thirty years, needs will develop of which we here take no account.1(p143)
In September 2000, thanks to the contributions of many medical school faculty and the support of the AAMC, a supplement to Academic Medicine was published, “Snapshots of Medical Education at the Beginning of the 21st Century.” That supplement was created, in large measure, to demonstrate the degree of change that had occurred in medical education in recent years and to refute the claim that little has changed since the initial reforms that followed the publication of the Flexner Report.1 The 2000 supplement certainly put that claim to rest and also has served as a useful reference. But there has been continued change in the education of medical students since 2000, and since 2010 marks the 100th anniversary of the publication of the Flexner Report, we took advantage of the 100th anniversary celebration to create the present supplement to show how much has changed both in the past 100 years and in the past ten, a decade that, among other important educational changes, has seen the establishment of eight new medical schools and the promise of several more in the coming years. With the support, again, of the AAMC and the editor of Academic Medicine, and also of the AMA, the Josiah Macy, Jr. Foundation, and the Carnegie Corporation of New York, we offer this supplement as a picture of medical education in the United States and Canada, 100 years after Abraham Flexner wrote his landmark report.
In “The Actual Basis of Medical Education” in his report, Flexner devoted chapters to explain the need for standards to accredit both medical schools and the students who enter them1; his recommendations have been discussed at length since then. The focus of the collection of information included in the following pages is on the medical student education program, the infrastructure to support that program, and the assessment of the student. Like the original Flexner Report, this supplement provides details about curriculum management, the support for the educational program, and the many approaches to pedagogy and assessment that medical schools are employing.
In 1910 there were 155 North American medical schools; Flexner visited each of these. You are invited to read this supplement and “visit” 128 medical schools in the United States and Canada, some a mere two years old, others more than 200 years old. It is interesting to consider that with the introduction of eight new schools in a decade and the prospect of another 10 or more, the United States and Canada will again soon have 155 medical schools, if not more.
How This Supplement Was Created
In October 2009 one of us (BA) sent a letter to the academic deans (sometimes called vice deans for education, senior associate deans, or associate deans) at all U.S. and Canadian medical schools, explaining the plan to create a second “snapshots” supplement and asking them to answer a set of questions about their schools' educational programs. While schools received a template and questions, there was room for the authors to present information they thought was important to highlight about their programs, and as you read the school reports, you will find that the authors adopted different formats to respond to the template. Overall, the same types of information about each medical school are presented, which was the goal.
The time available to create the present supplement was short; even so, the response from the schools was gratifying. This supplement presents a wealth of information contributed by representatives of 128 of the 148 LCME-accredited medical schools in the United States and Canada. The school reports are called “snapshots” because, like camera snapshots, they reveal considerable information about each school at a particular point in time, even though there is more that could have been said in each case. While each snapshot presents a single view of a school, taken as a whole the snapshots form a three-dimensional picture of the tremendous breadth, richness, and diversity of North America's medical school programs.
In addition to the reports from the schools, the supplement presents five essays about medical education. The two by Barzansky and Skochelak consider aspects of the history of medical student education. The essays by Hodges, Nora, and Berwick explore the forces that have had an impact on the educational program, the faculty, and the health care system and posit some provocative thoughts for the future of medical education. These essays provide an important context in which to consider the school reports.
Explanations and Examples from the Snapshots Reports
In the following paragraphs we present short explanations of the main categories that are stated as headings in each of the school reports (e.g., “Changes in Pedagogy”) and provide highlights from some reports to illustrate each category. We also created Appendix 1 (see the end of this essay) to provide a bird's-eye view of a number of the major topics in the medical school program and show where each school is aligned across those topics. Finally, we developed a glossary of terms used throughout the reports, which can be found at the very end of this supplement.
The stories that unfold in the following pages illustrate the constantly changing and evolving picture that is medical education in 2010. Some of the stories are from schools that have just initiated a major curriculum reform; others are from schools that are tweaking major curricular changes that occurred in the early part of the 21st century. These reports document the dedication of the medical school faculty and administrators to educate physicians for practice in the 21st century. They are working to provide students opportunities in their communities and to help them appreciate the complexities of different cultures, sometimes in their own schools. They are wrestling with the thorny challenges of fostering and assessing professionalism and clinical reasoning, and of defining and implementing their schools' responsibilities to their communities and to society as a whole. We have identified schools, from their reports, as examples that illustrate many of the significant changes under way, but these in no way capture all the schools that are making changes in each of these areas, they are strictly illustrative. Read on to discover just how much has changed in the past decade and certainly since the publication of the Flexner Report.
At the beginning of the discussion of each category below, we have presented in italics the instructions and questions about the category that were sent to the representatives of each medical school.
Curriculum Management and Governance Structure
- Please provide a diagram of the curriculum management and governance structure, if possible.
- Identify the committees or groups responsible for the curriculum (i.e., is there a curriculum committee? Is it a standing committee? Are there curriculum committees organized by year of the curriculum in addition to a committee with responsibility for the entire educational program?).
The majority of the reports contain one, sometimes more than one, diagram of the management of the educational program and/or the curriculum. There are more diagrams than there were in the 2000 Supplement, and in almost every case, the structures they depict are more complex than they were in 2000. There is more integration of the program, and typically the activities of the committees are coordinated in a single office of a “vice dean for education”; the University of California, San Diego, School of Medicine and Loma Linda University School of Medicine are two of the schools that use this approach.
In some cases, schools reduced the number of individuals involved in the educational program because the members of the committee no longer represent departments but instead represent the educational program. In some schools, for example, the University of Arizona College of Medicine at Tucson and Phoenix and UMDNJ–New Jersey Medical School, the committee structure became more complex to accommodate change in the educational program.
One of the significant changes from 2000 is the inclusion of medical school librarians as members of the curriculum governance.
Office of Medical Education
- Is there an office with responsibility for support of the medical student education program?
- Is there a designated office of medical education or department of medical education with staff (full or part-time)? How many professionals/ educators are associated with this office/ department?
- What is the role of the office of education/medical education unit in the educational program?
- If there is no office of education, who holds the primary responsibility to organize and support medical education activities (other than the committees responsible for the curriculum)?
All but six of the responding 128 schools have a designated office of medical education and those without a designated office have an office for support of the educational program. In her essay in this supplement, “A Decade of Reports Calling for Change in Medical Education: What Do They Say?”,2 Skochelak identifies eight themes common to a variety of published reports about the need to change medical education. One of the themes is the importance of the support of senior leadership if true change is to occur. In every school and in every diagram provided, the office or administrative unit that supports the educational program is advisory to the dean, and the dean and/or his or her designee is responsible for the administration of the educational program.
While many schools created new offices, some are more than 30 years old – the unit at the Keck School of Medicine of the University of Southern California was established in 1963, while the unit at the University of Illinois College of Medicine at Chicago began in 1958.
These offices do more than support the curriculum, and in the majority of the schools, they include faculty who are conducting research to determine whether changes being made to the educational program have an impact (another of the themes identified by Skochelak in her essay). These offices support faculty development and the development of residents as teachers; among the many duties of members of these offices are work with student services and student affairs and the support and implementation of educational technology.
The offices of medical education provide more support now than in 2000 for interdisciplinary programs. For example, George Washington University School of Medicine and Health Sciences expanded a small office, which is now the Office of Interdisciplinary Education, in 2002; New York University School of Medicine and Florida State University College of Medicine reorganized their existing offices in 2009 to better support education programs, and at the University of Louisville School of Medicine and Northwestern University The Feinberg School of Medicine, offices were expanded to include student programs.
In schools such as Loyola University Stritch School of Medicine, the physical location of the office of medical education is deliberately located in the midst of learning communities. A significant illustration of the attention medical schools are giving to their educational programs is the large number of schools that have funded and constructed buildings devoted to medical student education, as shown in List 1.
In addition to the new medical schools, the University of Colorado Denver School of Medicine (Anschutz Medical Campus), the University of Hawaii at Mãnoa John A. Burns School of Medicine, and Michigan State University College of Human Medicine have new locations and entirely new campuses for their medical schools.
Financial Management of Educational Programs
It is important that our universities realize that medical education is a serious and costly venture; and that they should reject or terminate all connection with a medical school unless prepared to foot its bills and to pitch its instruction on a university plane.1(p13)
- How have you addressed the current financial crises to continue to support the educational programs?
The responses to this question presented a happy surprise. While the schools acknowledged that the downturn in the economy had an impact, the result was most often a move to protect the educational program and a subsequent strengthening of the importance of the program. The need to centralize resources led to greater efficiency. At only two schools was there actual downsizing of staff. In a few cases, faculty were forced to take extended “vacations” or furloughs, and at the University of California, San Diego, School of Medicine, there was an increase in student fees. Harvard Medical School and Washington University in St. Louis School of Medicine noted there were no salary increases.
The schools developed partnerships with communities and with regional campus communities to provide the necessary support for clinical rotations and to generate revenue to support the educational program. Almost every school noted the support from the dean's office and a dean's fund for the educational program, in addition to that allocated from department budgets.
Several schools have a mission-based budget management, and budgets are allocated to departments based on medical student teaching effort. Among those schools are Boston University School of Medicine, the University of Massachusetts Medical School, UMDNJ–New Jersey Medical School, Mount Sinai School of Medicine, Baylor College of Medicne, and Pennsylvania State University College of Medicine.
In more than one school, the financial exigencies fostered the development of new methodology to link the level of funds distributed and a department's participation in education and research.
There are schools with a discrete budget for the educational program, including the University of Alabama School of Medicine and the University of Tennessee Health Science Center, College of Medicine, for the first two years of the program, and for the entire curriculum at the University of Utah School of Medicine (which, in turn, highlights the importance of education at that school). The University of Ottawa Faculty of Medicine has dedicated funds for education.
On the other hand, it will never happen that every professor in either the medical school or the university faculty is a genuinely productive scientist. There is room for men of another type, the nonproductive, assimilative teacher of wide learning, continuous receptivity, critical sense, and responsive interest. Not infrequently these men, catholic in their sympathies, scholarly in spirit and method, prove the purveyors and distributors through whom new ideas are harmonized and made current. They preserve balance and make connections. The one person for whom there is no place in the medical school….the scientifically dead practitioner, whose knowledge has long since come to a standstill and whose lectures, composed when he first took the chair, like pebbles rolling in a brook get smoother and smoother as the stream of time washes over them.1
- ♦ Does your school have an academy/ institute for educators?
- ♦ How does the promotion and tenure process value teaching?
In her essay in this supplement, “The 21st-Century Faculty Member in the Educational Process – What Should be on the Horizon?”3 Lois Nora writes about four ways to advance the educational mission through support of the faculty. In our comments below, we report in part how the medical schools are supporting their medical education faculty.
In 2000, two schools (the University of California, San Francisco, School of Medicine, and the University of Illinois College of Medicine at Chicago) had identified academies to support the faculty. Schools with academies in 2010 are identified in Appendix 1; as of this writing, there are 65 in existence or about to be launched. In addition, some of the schools—the University of California, San Francisco, School of Medicine, the Medical College of Georgia, and Harvard Medical School—have published articles about the impact and the outcomes of the academies. In 2008, at Harvard, teaching was elevated to a new level in the areas of promotion and tenure because “teaching and educational leadership” was designated as an area of excellence for faculty.
The schools without designated academies offer various teaching awards, often conferred during commencement, and all have strong faculty development programs. Throughout the reports, there is a decided increase in attention to faculty development. At Universidad Central del Caribe School of Medicine in Puerto Rico, a new committee has been named devoted to establishing criteria for the evaluation of and tools to support faculty teaching. And at the University of Utah School of Medicine, a new office has been created that is devoted to professionalism, accountability, and assessment; one of the goals is to evaluate faculty contributions to medical education. At Columbia University College of Physicians and Surgeons there is a faculty development program to promote reflective practice, and at New York Medical College there is a “Resident as Teacher” program.
Some schools do not have a formal academy but have societies (Emory University School of Medicine) where students are assigned to societies and faculty in the societies are supported so they can devote time (30%) to medical student education. At the University of Washington School of Medicine the Colleges program has created a learning community of medical school faculty. Wake Forest University Health Sciences School of Medicine has instituted a mechanism to designate a core group of teaching faculty.
Schools have developed different tracks to acknowledge Flexner's assertion that there are different and equally valuable kinds of faculty. A clinical educator track was initiated at Yale University School of Medicine in 1997. A similar track exists at places like Boston University School of Medicine and Ponce School of Medicine. In some instances the “teaching track” is a nontenure track, but in every instance the basis for promotion is excellence in teaching. One school notes that its curriculum reform focused on the importance of faculty teaching and on protecting faculty members' time so they could succeed in implementing the new curriculum.
The schools report an increased focus on scholarship4 in their promotion and tenure policies and the inclusion of teaching as an expectation for tenure (University of Arkansas for Medical Sciences College of Medicine) and educational excellence as one criteria on which promotion and tenure are granted (University of Alabama School of Medicine).
The Educational Value Unit (EVU—also called the Relative Value Unit (RVU)—is the alignment of resources with teaching effort that has been instituted at the University of South Florida College of Medicine and at the Virginia Commonwealth University School of Medicine. At the University of Iowa Carver College of Medicine, where it was implemented in a department, its success led a new dean to implement it throughout the medical school.
Curriculum Renewal Process
- ‘Was there a particular date on which this process was launched in addition to being an ongoing quality improvement activity?
- ‘Identify the key objectives for the curriculum renewal process.
- ‘Identify the components of the renewal process.
The dates in the “curriculum renewal” column of Appendix 1 indicate that every responding school has an ongoing process for curriculum review and renewal and the years in which they have been engaged in this process. Many of them have trademarked names for their new curricula including:
- Genes to Society —Johns Hopkins University School of Medicine
- Jubilee Curriculum—University of Medicine and Dentistry of New Jersey (UMDNJ)–New Jersey Medical School
- Columbia Curriculum—Columbia University College of Physicians and Surgeons
- Curriculum for the 21st Century—New York University School of Medicine
- Double Helix—University of Rochester School of Medicine and Dentistry
- Foundations for Excellence—Duke University School of Medicine
- Patient-Centered Learning—University of North Dakota School of Medicine and Health Sciences
- Curriculum 2000—University of Pennsylvania School of Medicine
- The Vermont Integrated Curriculum (the VIC) —University of Vermont College of Medicine
- COMPASS curriculum—Michael G. DeGroote School of Medicine Faculty of Health Sciences, McMaster University
The curriculum renewal has been motivated by the need for medical education to address societal concerns, health care disparities, quality improvement, care for the elderly, palliative care, and end-of-life care, among other areas; integration is a key ingredient of each program. Creating flexibility in the students' programs motivated others, coupled with an increased emphasis on cultural competency, diversity, and geriatrics. It is interesting to note that each of these motivating factors are identified in Skochelak's review.2
Woven throughout the curricula described in most of the reports is early exposure to clinical medicine with a solid grounding in the sciences basic to medicine. Additional motivation to reform has come from changes in inpatient teaching sites, the movement of clinical education out of the hospital, and the recognition that there is a new and different kind of medical student, one described as having increased sophistication and world experience.
The University of Alabama School of Medicine, Northwestern University The Feinberg School of Medicine, and the University of Virginia School of Medicine all provide examples of curricular integration of the clinical and basic sciences, emphasizing the importance of the sciences basic to medicine; the University of Arizona College of Medicine includes the behavioral and social sciences, including the humanities. In every case, the approach is one of collaborative learning, as illustrated by the program at the University of California, San Francisco, School of Medicine.
An example of a curriculum that emphasizes professionalism in medicine throughout the medical school experience is the physicianship program at McGill University Faculty of Medicine, which consists of courses emphasizing those areas that run as “ribbons” through the four years.
The topic of professionalism is a focus in almost all schools–for example, at the University of Maryland School of Medicine, Drexel University College of Medicine (which includes Professional Peer Review), and Jefferson Medical College of Thomas Jefferson University.
As the dates in Appendix 1 and the descriptions there and in the reports indicate, the schools devote considerable time and effort to transforming the curriculum with seminal and ongoing retreats, regular committee meetings, and engagement of faculty at all levels.
- Does your institution have competencies or learning outcomes identified for your graduates? If so, please include a copy.
This question was posed to the schools because ten years ago, only a handful of the schools had identified learning outcomes that were articulated. Now, not only does every school have these learning outcomes, sometimes called competencies, but they have lists available, usually on the school Web site. Appendix 1 provides an indication of all the schools with these learning outcomes, and the individual articles contain the URLs for the objectives, wherever possible. The schools formulated their learning outcomes using the ACGME core competencies,5 the Medical School Objectives Project Report I,6 Canmeds,7 and in one case, Good Medical Practice – USA.8
The obvious purpose of the learning outcomes and competencies is to articulate the goals that the educational program should achieve. The schools' efforts to achieve those goals are summarized under the next three sections.
New Topics in the Curriculum
- Identify any topics that are new to your school's curriculum since 2000.
- Comment specifically on the topics of patient safety, quality improvement, Team-Based Learnin, and simulations.
We have summarized the schools' specific responses in Appendix 1, but of equal interest are the many new topics described in the school reports. These include:
- Critical thinking/clinical reasoning: Saint Louis University School of Medicine and New York Medical College
- Bioterrorism, disaster preparation: required at Loma Linda University School of Medicine; Howard University College of Medicine; Tulane University School of Medicine; Uniformed Services University of the Health Sciences F. Edward Hébert School of Medicine; Albany Medical College; University of Cincinnati College of Medicine; and the University of Pittsburgh School of Medicine, among others
- Geriatrics: University of Chicago Division of the Biological Sciences Pritzker School of Medicine (including palliative care); University of Missouri– Kansas City School of Medicine (integrated throughout); University of Oklahoma College of Medicine; and the University of South Carolina School of Medicine (their “Senior Mentor” program)
- Health care disparities: University of Chicago Division of the Biological Sciences Pritzker School of Medicine; Ponce School of Medicine; Medical College of Wisconsin
- Cultural diversity/cultural competence: University of Medicine and Dentistry of New Jersey Robert Wood Johnson Medical School; University of North Dakota School of Medicine and Health Sciences (Indians into Medicine); Texas Tech University Health Sciences Center School of Medicine (medical Spanish); Texas Tech University Health Sciences Center Paul L. Foster School of Medicine; and University of Washington School of Medicine
- Required scholarly/research activity for students: Among many others, the following schools have in place a required research or scholarly activity for medical students: University of Alabama School of Medicine; University of Arizona College of Medicine, Phoenix; University of Iowa Carver College of Medicine; Stanford University School of Medicine; University of Colorado Denver School of Medicine; Northwestern University The Feinberg School of Medicine; University of Medicine and Dentistry of New Jersey Robert Wood Johnson Medical School; University of New Mexico School of Medicine; Albert Einstein College of Medicine of Yeshiva University; Columbia University College of Physicians and Surgeons; Duke University School of Medicine; Case Western Reserve University School of Medicine and Cleveland Clinic; Pennsylvania State University College of Medicine; University of Central Florida College of Medicine; and University of Pittsburgh School of Medicine.
- Focused individualized research experience: the University of Florida College of Medicine; University of Vermont College of Medicine, Emory University School of Medicine; and the University of Chicago Division of the Biological Sciences Pritzker School of Medicine (where more than 60% of students have published their research)
- Lesbian, gay, bisexual, and transsexual topics – Boston University School of Medicine
- Yale University School of Medicine reports on “Power dynamics” to introduce students to the complicated power dynamics in the hospital and the practice of medicine and interprofessionalism.
Social accountability is one of the themes Skochelak identified in her essay2 and many of the schools report on the relationship of the school to the community, its social responsibility, and service learning opportunities. These service learning experiences can be found at the University of Iowa Carver College of Medicine; University of Arizona College of Medicine; Georgetown University School of Medicine with its “Social Justice Scholars” program; Florida International University Herbert Wertheim College of Medicine with the NeighborhoodHELP program; Morehouse School of Medicine (a first-year program); University of Hawaii at Mãnoa John A. Burns School of Medicine; Tulane University School of Medicine; Boston University School of Medicine; Michigan State University College of Human Medicine (The Contract for Social Commitment); University of Missouri – Kansas City School of Medicine; University of Medicine and Dentistry of New Jersey Robert Wood Johnson Medical School and the University of New Mexico School of Medicine; interprofessional service learning is taught at Virginia Tech Carilion School of Medicine and Research Institute. The State University of New York, Stony Brook University Medical Center describes a student-run clinic, and the MUSHROOM project at West Virginia University School of Medicine is a student-initiated clinic for the homeless.
Schools with community service programs include Temple University School of Medicine, Universidad Central del Caribe School of Medicine, and East Tennessee State University. Texas Tech University Health Sciences Center Paul L. Foster School of Medicine has a commitment to community and to providing students with experiences at the Mexico/US border. Opportunity to work with community organizations are also found at the Community Health Alliance Program (CHAP) at McGill University Faculty of Medicine.
Longitudinal curricula in topics such as spirituality and medicine are found at the University of Louisville School of Medicine and at the Brody School of Medicine East Carolina University. The University of Vermont College of Medicine has introduced longitudinal curricula on topics such as spiritual care, global health, and nutrition (to name a few). There is a chronic illness curriculum threaded through years 1–3 at Vanderbilt University School of Medicine, and a longitudinal curriculum at Virginia Commonwealth University School of Medicine
Advances in Pedagogy
As a matter of fact, many of the schools mentioned in the course of this recital are probably without redeeming features of any kind…The teaching is an uninstructive rehearsal of textbook or quiz compend; one encounters surgery taught without patient, instrument, model or drawing. 1(p142)
- What changes, if any, in pedagogy have been implemented since 2000?
- How was the success of such pedagogical changes measured?
One school (Jefferson Medical College of Thomas Jefferson University) notes that “there is not one element of the…. curriculum that has not been affected by changes in pedagogy.” This is a fair description of the changes in pedagogy since 2000 and certainly since the Flexner Report.
Most of the schools noted a continued reduction in lecture time and an increase in active learning, including continued growth of problem-based learning and Team-Based Learning.
Simulation is included as an area on Table 1, and every single school writes about the application of simulations in their various forms.
The use of online materials for instruction— for example, at Morehouse School of Medicine; the University of Central Florida College of Medicine (ITunesU); the University of Chicago Division of the Biological Sciences Pritzker School of Medicine (the Technology in Medical Education (TIME) project)—makes the entire curriculum available through online media, fostering integration between preclinical and clinical years. There is learning management software in place at many schools, including Johns Hopkins University School of Medicine and Tufts University School of Medicine. Vanderbilt University School of Medicine has a new Center for Experiential Learning and Assessment (CELA), and there is a simulation center opening this year at the University of Ottawa Faculty of Medicine.
The University of South Carolina School of Medicine is a wireless campus and has implemented a vertical ultrasound curriculum.
Several schools have implemented audience response systems throughout the educational program, including the University of South Alabama College of Medicine and Tufts University School of Medicine. Material is delivered not through textbooks as often as through podcasts of lectures and teaching materials, and via audio and/or video recorded lectures (Chicago Medical School at Rosalind Franklin University of Medicine and Science). Streaming videos are also used to foster consistency in teaching across distributed education sites.
Many schools have implemented case-based learning. Schools that have organized the curriculum around clinical presentations include Northeastern Ohio Universities College of Medicine; Texas Tech University Health Sciences Center Paul L. Foster School of Medicine; and the University of Calgary Faculty of Medicine. The University of Utah School of Medicine, like several schools, no longer has organized the curriculum along departmental lines; rather, it is integrated and disease-based.
Almost every school report notes an increased use of standardized patients (SPs) for teaching and assessment. The University of South Florida College of Medicine. has a new SP center; Rush Medical College has a physicianship program in which student encounters with an SP are reviewed with a behavioral scientist. Mercer University School of Medicine has a program in which students work with one “designated” SP in a continuity setting in years one and two. The University of Louisville School of Medicine has an SP and simulation center, and the University of Cincinnati College of Medicine reports on their SimCenter.
As noted previously, Team Based Learning is in place in many of the schools including Wright State University Boonshoft School of Medicine and the University of Oklahoma College of Medicine. Northern Ontario School of Medicine refers to team learning as interprofessional learning, and the University of Pennsylvania incorporates team training based on the Wharton School MBA model to foster being both a member and a leader of a team.
“Use of new technology in education and medical practice” is another of the themes identified by Skochelak,2 and it is in place throughout the medical schools in both pedagogy and assessment.
Advances in Assessment
- What changes, if any, in student assessment have been implemented since 2000?
The focus of assessment is on measuring outcomes of learning objectives and evaluating mastery of the educational objectives. Every school describes the increased use of the OSCE for assessment as well as for comprehensive clinical assessments. There are many changes to the application of technology to assessment, and the focus of the assessment has shifted to emphasize formative assessment, not just summative assessment. Schools have incorporated online logs of patient encounters at the University of Colorado Denver School of Medicine and Rush Medical College. The University of Illinois campuses have Web-based testing in place. The University of Calgary Faculty of Medicine has developed systems for the delivery of online formative evaluations.
Reflective writings and portfolios are in place as assessment tools at Florida State University College of Medicine; University of Minnesota Medical School; the University of Miami Leonard M. Miller School of Medicine; University of Michigan Medical School; University of Missouri School of Medicine in Columbia; State University of New York, Stony Brook University Medical Center; Case Western Reserve University School of Medicine and Cleveland Clinic.; and Baylor College of Medicine.
There is an increase since 2000 in the number of schools with clinical skills laboratories. Examples include the University of Illinois College of Medicine at Chicago; Indiana University School of Medicine's simulation center (largest of its kind in the United States); University of Texas Health Science Center at San Antonio School of Medicine; University of Wisconsin School of Medicine and Public Health; Northeastern Ohio Universities College of Medicine; Vanderbilt University School of Medicine, and Ohio State University College of Medicine, where task trainers are in place.
Loyola University Chicago Stritch School of Medicine has a longitudinal performance assessment program in place to evaluate students' progress, and Southern Illinois University School of Medicine has a longitudinal performance examination to test clinical reasoning and its growth over time.
- Please identify the site(s) for clinical education
- What are the challenges and the unanticipated outcomes with your students' clinical education
Clinical experiences have been a point of significant change in almost every school reported in this supplement. At schools like Dartmouth Medical School, clinical experiences begin early in the educational program – usually in the first month of medical school. In addition, Dartmouth has formed an affiliation with California-Pacific Medical Center, San Francisco, to provide students with exposure to a large urban center. The University of Wisconsin School of Medicine and Public Health has a required program called Generalist Partners, where all students are matched with a generalist community physician.
The challenges to clinical education are several. They include:
- Need for expanded sites
- Competition for sites, including competition because of the development of new medical schools in the area
- Increasing demands on the faculty, and balancing clinical demands and educational needs for faculty
- Need to enlist the continued support and availability of volunteer faculty members
- Travel challenges, caused by distances to clinical teaching sites, which require time and ability to reach
- Decreasing lengths of stay and declining reimbursements, which present a challenge to virtually all academic medical centers to provide meaningful clinical learning opportunities for students
- Challenge to recognize faculty contributions in clinical settings
- Need to ensure comparable educational experiences
- Need to identify appropriate patients for continuity-of-care clinical experiences
Both of the schools that responded from Puerto Rico noted the impact of the 1993 health care reform there and of new laws to establish regional academic medical centers that should relieve some of the burden of identifying clinical teaching sites.
But there is little reason to believe that the divided school will ever function as an organic whole, though it may be tolerable as a halfway stage on the road from the proprietary school to the complete university department. “I cannot help wondering,” said President Pritchett, “how it would affect the pedagogic and professional ideals of an engineering school if the first two years were given in one place and the last two years in a place two hundred miles away. 1(p73)
- Is there a regional campus or campuses associated with the educational program? Please describe.
There are as many variations in regional campuses as there are in medical schools. Some of the regional campuses identified in Appendix 1 are moving toward becoming four-year programs (University of Arizona College of Medicine at Tucson and at Phoenix; University of Illinois; Mercer University School of Medicine (sister campus in Savannah).
Creighton University School of Medicine will establish a regional campus in Phoenix, Arizona, and the University of Toronto, Faculty of Medicine is opening a new regional site. Perhaps the most unique regional system is that of the University of Washington School of Medicine, which serves as the medical school for five states. The University of British Columbia Faculty of Medicine has changed its educational program to a distributed education model.
Highlights of the Programs
There is not enough space on these pages to capture fully the rich texture and innovativeness of the medical schools described in these “snapshots.” The following are highlights of many of the programs you can read about more completely in the school reports later in this supplement. We chose these highlights because they were written about in more than three schools, they represent areas of change since the 2000 supplement, and because they respond to some of the ongoing themes identified by Skochelak2 and in continued calls for change in medical student education.
- Programs in rural health are in place at the University of Nebraska College of Medicine; University of Alabama School of Medicine; University of Arizona College of Medicine; University of Illinois College of Medicine at Rockford; Indiana University School of Medicine, Terre Haute program; University of Kansas School of Medicine; University of Kentucky College of Medicine; Louisiana State University Health Sciences Center School of Medicine at New Orleans; University of Minnesota Medical School (since 1971); University of Missouri School of Medicine in Columbia; Oregon Health and Science University School of Medicine; East Tennessee State University James H. Quillen College of Medicine; and University of Calgary Faculty of Medicine. There is a newly created position at Dalhousie University, Faculty of Medicine, of Senior Associate Dean, Rural and Regional Medicine.
- Many schools wrote about “scholarly concentrations” – an opportunity for students to focus on an area such as global health, informatics, or disaster medicine. There are enough schools that have scholarly concentrations that a collaborative of these has formed. A few of the schools that have this feature are the University of Texas Medical School at Houston; Vanderbilt University School of Medicine; The Warren Alpert Medical School at Brown University; Texas Tech University Health Sciences Center Paul L. Foster School of Medicine; and the Medical College of Wisconsin (the Pathways program).
- At the University of California, San Diego, School of Medicine, students have the opportunity to spend two months studying a disease from the point of view of the patient.
- Electronic health records are part of the educational program at the University of Arkansas for Medical Sciences College of Medicine, The Ohio State University College of Medicine, Baylor College of Medicine, Florida International University Herbert Wertheim College of Medicine, Southern Illinois University School of Medicine, and Mayo Medical School.
- A special focus on interprofessional education is in place at a number of schools, including Chicago Medical School at Rosalind Franklin University of Medicine and Science, the University of Kentucky College of Medicine, the Medical University of South Carolina College of Medicine, East Tennessee State University James H. Quillen College of Medicine, Michael G. DeGroote School of Medicine Faculty of Health Sciences, McMaster University, and Loyola University Chicago Stritch School of Medicine, where a new nursing school is opening and a Center for Collaborative Learning will be established. Northwestern University The Feinberg School of Medicine has a collaboration with engineering, law, and business schools where the focus is on new product development in a Team-Based Learning setting. At the University at Buffalo, School of Medicine and Biomedical Sciences, State University of New York, five health science schools train together with simulated patients.
- There is an increased emphasis on public health at many of the schools. The University of New Mexico School of Medicine has instituted a certificate in public health for its graduates; there is a required public health course at Weill Cornell Medical College of Cornell University and at the University of Toledo, College of Medicine. The University of Wisconsin School of Medicine and Public Health has become an integrated school of medicine and public health.
- The continuum of education is receiving increasing attention and is supported through programs like APEX at Baylor College of Medicine, a required capstone course to prepare students for the transition to residency. The University of Texas Medical School at Houston has a required “Transition to Residency” month.
Even as we write this essay, there is change occurring in North America's medical schools, for they are not static but, instead, are constantly evolving entities. The number of medical schools will change in the next year or two, and it was not possible to include reports from all of the newly accredited schools in this supplement because some were accredited too recently to have written about their institutions. We know we will be hearing more from them as they create innovative programs to educate physicians for the 21st century.
We would be remiss if we did not comment on the impact of natural disasters on at least three of the medical schools. The effect that Hurricanes Ike and Katrina had on the University of Texas Medical Branch School of Medicine, Tulane University School of Medicine, and the Louisiana State University Health Sciences Center School of Medicine at New Orleans would have closed less resilient institutions. Yet these schools responded valiantly to the loss of educational and clinical facilities and have written about their experiences here.
Their stories, and those of everyone in this supplement, about their continued efforts to improve their educational programs are testaments to the faculty, administrators, residents, and students of all of the medical schools in the United States and Canada. We think Abraham Flexner would have been pleased, perhaps even amazed, at the substantive changes that have occurred not only in the past 100 years, but in the past decade.
To all of the authors who condensed into a few thousand words the richness and complexity of their schools' unique medical education experiences, especially to those who wrote and proofed their reports under tight deadlines.
To our colleagues at the AAMC for their support of this endeavor and the hope that we can convert this supplement into a searchable database.
Special thanks from M. Brownell Anderson to Ara Tekian, PhD, University of Illinois at Chicago, who supported this idea from the outset, and to Evan Collins, who contributed to the Glossary and in other ways he doesn't even realize.
Many thanks also to Suzanne Iler, the publisher's editor of Academic Medicine, whose flexibility, inventiveness, and hard work at the journal's publishing house made an impossible project possible. And also to Toni Gallo of the journal staff, who provided invaluable and extensive technical assistance in all phases of this project.
And, most especially to Al Bradford for his unstinting support, his childlike curiosity about each and every educational program and the resulting questions that always helped me see a new perspective, his skillful planning, hard work, and sense of humor in the face of a 600-plus-page supplement to the journal, and his unfailing ability to help me figure out what I really meant to say all along.
This supplement was made possible by generous grants from the Association of American Medical Colleges, the American Medical Association, the Josiah Macy Jr., Foundation, and the Carnegie Corporation of New York.