University of Rochester School of Medicine and Dentistry

Curriculum Management and Governance Structure ♦ After a series of major leadership retreats throughout the calendar year 1997, the Medical School Advisory Council (MEDSAC) voted unanimously in December 1997 to completely change the governance structure and management of the medical student education program. ♦ MEDSAC is the governing body of the school, made up of all chairs and center directors, the head of the faculty council, and senior associate deans, and is chaired by the dean. ♦ The vote was to create a curriculum steering committee (CSC), to be chaired by the senior associate dean for medical education and to be made up of a small number of committed faculty and educators. ♦ The size of the CSC since then has varied from seven to nine members. It always includes at least one department chair—each of whom is expected to be there not to represent his or her particular department, but to take an institutional view for the education mission of the school. ♦ The CSC meets weekly (in addition to regular half- and full-day retreats) and is accountable to MEDSAC via monthly reports on the medical education program. ♦ The CSC was charged to develop, deliver, assess, and continually improve an entirely new curriculum, to begin with the entering class of 1999—a curriculum whose ambitious goal is to completely integrate the basic and clinical sciences through the four-year curriculum like the two strands of a double helix. ♦ The “Double Helix Curriculum” was launched in August 1999 with the class of 2003. ♦ Reporting to the CSC are two larger committees, a committee on years one and two, and a committee on years three and four. ♦ These committees are more representational, with each course, clerkship, and theme represented to work out issues of implementation and quality control. ♦ Both committees have both course and clerkship directors, since the “basic science strand” and the “clinical strand” of the Double Helix Curriculum each run through the four years. ♦ Since the integration of the two strands is the ultimate goal, a decision was made not to have separate basic and clinical committees (which had been more the model of the first and second-year committee and the third and fourth-year committee in the previous curriculum), but to still divide the work into two integrated committees of manageable size. ♦ Course, clerkship, and theme design teams are responsible for each component of the curriculum (in addition to the Comprehensive Assessment Design Team) and these groups are asked to make regular presentations to the CSC. Office of Education ♦ In 1997, URSMD also created a unit called the Offices for Medical Education (OME) under the leadership of a new senior associate dean for medical education, whose responsibilities span undergraduate, graduate, and continuing medical education. ♦ The OME is divided into several offices, including a central administrative unit, the Curricular Affairs Office, the Office of Educational Resources, the Office of Admissions, the Office of Student Services, the Office of Graduate Medical Education, and the Office of Continuing Professional Education. ♦ The Division of Medical Humanities is also housed within the OME. ♦ Each unit has an associate dean or director. ♦ The Office of Student Services administers financial aid, houses the registrar and the bursar, and oversees student affairs and advising, ethnic and multicultural affairs, and student enrichment programs (student research, international medicine, and community service). ♦ The Office of Educational Resources provides all logistical support for courses, including laboratories, room scheduling, syllabi, videotaping, etc., plus a new standardized patient program. ♦ The creation of the Curricular Affairs Office in 1997-98 was a major step for the new curriculum. That office houses faculty educators with responsibility for assessment, curricular development, faculty development, informatics (see below), and educational grants. ♦ The Longitudinal Ambulatory Clerkship is housed in the Curricular Affairs Office, which is also responsible for tracking the educational contributions of all faculty for the mission-based education budgeting process. ♦ The medical center's library also plays an important role in the curriculum, and the director of the Miner Library is a full member of the Curricular Affairs Office, so that all informatics support for the curriculum flows out of the library. Budget to Support Educational Programs ♦ There are several elements to the budgeting for medical student education. ♦ The first is the support for all of the offices described above, most of which comes from hard-money tuition dollars, but with an increasing number of education grants as well to support the start-up costs of novel elements of the Double Helix Curriculum. ♦ The second and largest element is hard-money support to departments for faculty. While historically this money from both the school and the hospital to support faculty was not “cost accounted” to one mission or another, the university has been phasing in a mission-based management system that tracks productivity in all three missions. ♦ The third element is a defined “education budget,” which is given as a separate allocation to departments each year based on the actual teaching of medical and graduate students. ♦ Funds being channeled into this education budget have formed a higher percentage each year of all departmental budgets, with an ultimate goal of approximately 20% of the hard money that flows to all departments from the dean. Valuing Teaching ♦ Both the director of faculty development and the director of curriculum development are very involved in both formal and informal faculty development programs. ♦ These functions were new when the Curricular Affairs Office was established in academic year 1997-98. ♦ Workshops and retreats are scheduled as needs are identified, including such examples as workshops for ambulatory preceptors, how to use multimedia in lectures, and the like. ♦ Routine programs include a required tutor training workshop for every new PBL tutor and a major annual faculty development workshop for the entire faculty each year on some central topic, such as assessment or adult learning. In some courses, videotapes of faculty teaching are routinely provided to faculty with an offer to review them with the director of faculty development. ♦ The director of curriculum development also works with all course directors on case development and assessment quality. ♦ The school's philosophy is that the workshops and conferences are a valuable part of the faculty development program, but that the best faculty development takes place in the course of faculty members' working together to create the curriculum. ♦ Every course, clerkship, and theme design team has a liaison from the Curricular Affairs Office and from the Curriculum Steering Committee to support its curriculum development and continuous improvement efforts. ♦ Student feedback not only on courses but also on individual faculty is collected through a Web-based system and sent to faculty from the Curricular Affairs Office via the course and clerkship directors. ♦ The associate dean for curricular affairs, who heads the Curricular Affairs Office, has primary responsibility for assessment. Assessment is also viewed as a central part of faculty development. ♦ Approximately ten years ago, in conjunction with a major Robert Wood Johnson Foundation grant and alumni fund-raising effort, URSMD established a program called the Dean's Teaching Scholars. ♦ The endowment now supports 12 faculty in this program at any given time. The term of the award is three years, and each year there are three Dean's Teaching Scholars named, along with one Senior Dean's Teaching Scholar. ♦ Throughout the three years of the scholarship, these faculty are given special recognition, in addition to extra money that is sent to their departments, including $4,000 per year of extra compensation and $1,000 per year to support travel to educational conferences, education-related software, and the like. CURRICULUM RENEWAL PROCESS Learning Outcomes ♦ Every course, clerkship, and theme has published learning objectives. ♦ In addition to the block-by-block assessments of all specific learning objectives, there is a two-week comprehensive assessment at the end of both the second and the third year, to assess these objectives in a more global and integrated way. (The current draft of the global objectives for the medical student program, which are being revised, is available from the author.) Changes in Pedagogy ♦ With the launch of the Double Helix Curriculum, the school has moved from a lecture-based curriculum to a hybrid PBL curriculum, with a mix of weekly PBL cases, lectures, labs, conferences, and self-study. ♦ The strategy to facilitate students' learning is unique among PBL curricula in that students start clinical clerk-ships during the first two years, so that not only paper PBL cases but the students' own patients drive the learning of basic science. ♦ Perhaps the clearest symbol of the difference is the new medical education building, which includes state-of-the-art small-group PBL rooms, each of which not only has modern information technology built in, but also includes a fully equipped doctor's office in the same room. ♦ The curriculum is designed to use both sides of the room in an integrated way throughout all four years. ♦ There is built-in video technology in every room, so that tapes can easily be made of either side of the room for use in student learning, faculty development, or assessment (the clinical sides of all the rooms are used for OSCEs as well). ♦ This extensive use of video technology has been a new and very transforming strategy, employed to create reflective practitioners of evidence-based medicine. ♦ Another major change is the connection of the curriculum to the school's Healthy City initiative, a collaboration with the county health department to improve the health of the people of Rochester. ♦ This public health perspective permeates the curriculum, from the design of the Mastering Medical Information course to the fourth-year Community Health Improvement Project, a required month of community public health service on one of the Healthy City interventions identified as a real need by the health department. ♦ The main educational strategy employed to facilitate students' learning is a radical attempt to “shuffle the deck” of the Flexnerian “two-plus-two” paradigm and fully integrate the basic and clinical sciences throughout the four years. ♦ This strategy is designed to tap into the near-universal experience of fourth-year students, who report that “now that I know a little clinical medicine, I wish I could go back and really learn the basic sciences!” By creating a four-year “clinical strand” and a four-year “basic science strand” of the curriculum, the Double Helix Curriculum is an effort to instill that same drive for students to learn the basic sciences throughout the four years, and, by habit, throughout the graduates' medical careers. ♦ The strategy may be described briefly as follows: After an intensive, month-long introduction to information management, students learn anatomy, histology, and physiology through the rest of the first semester as they learn history taking and physical examination at the same time, system by system. This means that when students are dissecting the knee, looking at cartilage under the microscope, and learning musculoskeletal physiology, that is also when they learn to examine the knee. When they dissect the heart, look at myocardium under the microscope, and learn cardiac physiology, that is also when they learn to examine the heart. This completely changes the context of learning, so that by the end of the first semester, students can competently take a history and do a physical exam in the context of a check-up of a normal, healthy patient. Starting in the second semester of the first year, the students under the new curriculum are in a pedagogic place medical students have not been in before. They are ready to start a longitudinal clerkship that will be more than the kind of shadowing of experiences most students have in preclinical “doctoring” courses, and through which they will learn to treat patients while they are going through their courses in the basic science strand of the curriculum. Finally, by moving approximately four months of the former block ambulatory care clerkships into the first half of the curriculum's clinical strand (years one and two), time is thus freed up during years three and four for approximately three months of advanced basic science work plus a month for the Community Health Improvement Project. This includes three two-week advanced basic science blocks in the third year and one four-week advanced basic science block in the fourth year (during which no inpatient clerkships are scheduled). Application of Computer Technology ♦ There are many networked computers in all settings, so students are not required to purchase computers (although the specifications for a computer compatible with the systems are sent to all admitted students in case they wish to buy one). ♦ The Double Helix Curriculum opens with four full weeks of the Mastering Medical Information course (actually a six-week course that also makes up the last two weeks of the first year). Before any of the biological sciences begin, students have a full month of training in how to search the literature, how to assess the studies they find (clinical trial design, biostatistics), how to decide the appropriate level to search (when to use a textbook and when to use the Web), and all the epidemiology and other information sciences basic to the practice of evidence-based medicine. ♦ The assessment of this course includes novel approaches to assess the efficiency of the students' searching strategies and the quality of their interpretations of the literature. ♦ The entire curriculum is run through a Web-based system called TopClass, and students all routinely use information technology in both the basic and the clinical strands of the curriculum. Curriculum Review Process ♦ At the end of each component of the curriculum, a formal assessment is done, including a Web-based student evaluation (which is required of all students to receive credit for the course), feedback from all faculty, a focus group of students and faculty, and review of student performance outcomes. ♦ This information is summarized in a report prepared by the Curricular Affairs Office and sent to the course design team to make a plan for the next year. ♦ The elements of that plan then become the first page of the final assessment report, which is given to all students, course faculty, and all department chairs. ♦ For more global reviews, the Curriculum Steering Committee conducts regular reviews of all components of the educational program, and the two-day annual education conference focuses on major program assessment. ♦ The curricular reform was launched in 1997 for implementation with the entering class in 1999. From the dean to the senior vice president for health affairs to the president of the university, a major commitment of resources to build a new medical education building for the Double Helix Curriculum to the increase the support for medical education has been crucial to the success of that curriculum. ♦ In addition to the capital requirements for the building and all the computer and audiovisual infrastructure for novel educational spaces, support included ongoing budgetary commitments to curricular development and renewal. ♦ A “resource” perhaps even bigger than administrative financial and priority support has been the commitment of the faculty and student body. ♦ The longstanding dedication of the faculty to the medical student education mission has never been demonstrated more clearly than in this curricular reform, coming as it has during a time of simultaneous building of the research and clinical missions. Indeed, the biggest barrier to overcome has been the conflicting demands created by a research-intensive academic medical center trying to excel in all three missions. With increasing demands on the faculty for clinical productivity and research grants, the enthusiasm with which the Double Helix Curriculum has been developed and launched stands as a real example of what a faculty can do if it is committed to its students. ♦ As mentioned above, the creation of exciting new space in which to teach and learn and the building of the Offices for Curricular Affairs and Educational Resources (which take a service-oriented view of the teaching faculty as their valued clients) and the involvement of the Miner Library (with that same orientation) have also been central to the success of the enterprise. ♦ As stated earlier, the Double Helix Curriculum is being phased in with the class of 2003. ♦ The first year has already been fully implemented and the second year is very far into the detailed development phase at this time (hour-by-hour schedules nearly complete, PBL cases being finished, tutor training under way). ♦ The design of the third and fourth years is also finalized, but many of the details of the advanced basic science curriculum are still being developed. ♦ The entire faculty and student body are deeply engaged in this continuing development (and continuous improvement of the parts already implemented). Future Goals ♦ The major issues in the next five years surround the continued implementation of the Double Helix Curriculum and the assessment of its success in meeting its ambitious goals.