Oregon Health & Science University School of Medicine

Abstract

Oregon Health & Science University (OHSU) is the only academic health center in the state of Oregon. It is has a 123-year history of training outstanding physicians who have practiced or who will practice medicine not only in the Northwest, but also the nation. It is dedicated to preparing physicians in a collegial environment that is replete with faculty at the forefront of educational innovation and scientific advancement. OHSU has a long history of being on the cutting edge of medical education. Our interdisciplinary teaching format in the first two years of medical school facilitates not only the acquisition of basic science knowledge, but also the application of this knowledge in clinical settings. Our medical school training is designed to give future physicians the knowledge, skills, attitudes, and values that will be necessary to practice medicine in the year 2020 and beyond. Our curriculum encourages students to engage in self-reflection and self-assessment to help them identify their individual areas of strength and needed improvement. This type of self-assessment leads to improved life-long learning and enhanced patient care. Collaboration is central to future generations of health care professionals. With this in mind, interprofessional education is another important focus of medical education at OHSU. We strive to provide our students with a range of learning experiences that promote knowledge of working in interprofessional teams. We anticipate that our graduates will ultimately serve in leadership roles in their chosen areas of expertise, whether that is in a rural community, an academic health center, or a large interspecialty and interprofessional health care practice setting. Curriculum Management and Governance Structure ♦ The Education and Student Affairs (EDSA) Office, within the Office of the Dean at OHSU, has primary responsibility for support of medical student education (Figure 1).FIGURE 1:: Curriculum Organizational Structure♦ This office is composed of two physician associate deans (Associate Dean for Medical Education—0.80 FTE and Associate Dean for Student Affairs—0.70 FTE), an Assistant Dean for Medical Education (1.0 FTE), and an Assistant Dean for Admissions (0.25FTE). ♦ There are 18 additional staff members within EDSA whose responsibilities include medical student admissions (4.5 FTE), student affairs/student records (3 FTE), medical student evaluation/medical education (2 FTE), teaching services (6 FTE), and clinical skills/assessment (2 FTE). ♦ Education and Student Affairs is responsible for all aspects of medical student education from admission through graduation, including curriculum renewal, oversight, management, and evaluation. ♦ A faculty-led Curriculum Committee works in concert with the Associate and Assistant Deans for Medical Education in the review of the medical school curriculum. The Curriculum Committee is a standing committee comprising 13 faculty members with representation from the basic and clinical science departments. Committee members are jointly appointed by the Associate Dean for Medical Education and the Dean of the Medical School based on recommendations from the University Committee on Committees. There are four subcommittees of the Curriculum Committee: the first- and second-year Course Director Subcommittee, comprised of all first- and second-year course directors, including leadership of the clinical courses; the Clerkship Director Subcommittee, which includes all required third- and fourth-year clerkships; the Electives Subcommittee; and the Medical Informatics Subcommittee. ♦ The Curriculum Committee Subcommittee structure will likely be revised to reflect our curriculum renewal efforts to include a task force or subcommittee for Educational Technology and Simulation. Financial Management of Educational Programs ♦ A financial model for supporting education has been in evolution at OHSU for the past several years. A model that provides financial support to basic science and clinical departments based on faculty contact hours (with an emphasis on the first two years of medical school) has been created and implemented over the past four years. ♦ The Dean's Office also provides a fixed-dollar amount in support of course and clerkship leadership. ♦ We have been able to continue to provide the aforementioned level of support for medical education during the current global and local economic crises as a result of the continued diligent work of our superb faculty and staff. ♦ Over the past year, clinicians and basic scientists have worked assiduously in their clinical practices or research laboratories, which has led to increased clinical dollars and more grant awards. ♦ In addition, we have worked with the development office to seek philanthropic donations in support of innovative curricular initiatives. Valuing Teaching ♦ Education is a core value at OHSU, which is exemplified in a number of ways. ♦ Multiple faculty teaching awards are granted by students and by the Dean through peer or chair nomination. ♦ A Clinician Educator academic track was approved by the Faculty Council in 2009, which acknowledges those faculty who have primary interest in medical student or resident teaching and education scholarship. ♦ The Education and Student Affairs Office has sponsored several faculty development programs including one on how faculty can better understand and work with students from Generation Y or the Millennial Generation. ♦ An “excellence in teaching” program is also in development and is designed to enhance the instructional skills of faculty and residents. ♦ A robust leadership and mentorship program for faculty was initiated at OHSU in 2009 in an effort to model leadership skills and “grow our faculty from within.” Curriculum Renewal Process ♦ OHSU is in the process of preparing for curriculum renewal in the setting of federal and state health care reform initiatives. ♦ We will consider several key questions as we move forward with this process: What will future patients want and need? How many physicians will be needed and in what specialties? What will future physicians want in a career? How will the practice of medicine be organized? What role will technology play in daily practice? What strategies will help increase workforce diversity so that physician demographics reflect the populations they serve? ♦ Our primary goal for the curriculum renewal process is to meet the educational needs for physicians who will practice in the mid-21st century. ♦ With this goal in mind, the key objectives are to provide students with team-based, interdisciplinary, and interprofessional learning experiences; optimize the use of the six ACGME core competencies in assessment of student performance; train students to use technology for their learning in all settings; and enhance our current training in cultural awareness to prepare physicians who will work with an expanding and diverse patient population. ♦ Physicians of the future will work in team settings with other health care professionals. With this in mind, the incorporation of interprofessional educational experiences within our core curriculum will be essential. We will be examining how to build more training experiences with dentistry, nursing, pharmacy, and physician assistant graduate students in both classroom and clinical settings. Of note, OHSU medical students have designed and implemented an interprofessional elective on Health Care Reform, which has been very well received and should facilitate future educational opportunities for these students to examine health care issues from different perspectives (http://ohsuhealthreform.wordpress.com/). ♦ Technology will play an increasing role in the career of future physicians. At OHSU, simulation has played a growing role within medical education over the past decade. We have increased the use of standardized patients in student assessments. Use of computerized mannequin-based simulation (SimMan) exercises have been utilized in the basic science curriculum both in lieu of animal laboratories and as adjunctive learning experiences in basic science course work. There are ongoing curriculum enhancements with technology, including use of Sakai (a computer-based educational learning platform) and Twitter. We are also examining the use of digital technology to potentially replace traditional slide presentations in histology and pathology. Furthermore, we are developing curricular elements utilizing the Electronic Health Record. ♦ With more patients serving as active partners in their health care, it is essential for medical education to incorporate a focus on “maintenance of health” rather than simply “treatment of disease.” With this in mind, we will look at ways to enhance the preventive medicine and public health components in our curriculum. For example, it will be important to incorporate education on the influence of advances in medical genetics in combination with personalized medicine in the future practice of medicine. ♦ Physicians in the mid-21st century will also be faced with an increasingly diverse patient population. Thus, a comprehensive cultural awareness/diversity curriculum for medical students is essential. ♦ The need for an increased physician workforce is clear with the aging and retirement of physicians from the “Greatest Generation” and “Baby-Boomer” generation in combination with possible health reform initiatives at the state and federal levels. Moreover, physicians in Generation X and the Millennial Generation have been increasingly attracted to the so-called “lifestyle” specialties. Taking all of these factors together, we recognize the importance of moving forward with a curriculum renewal process that addresses these realities. ♦ Our curriculum renewal process is currently in a fact-finding and needs-assessment phase. A task force to examine the use of simulation in our curriculum has been created. Additionally, there will be a formal review of several core courses over the next year. We will also examine how the topics of “wellness” and “resilience” are covered within our curriculum as they relate to medical students, physicians, and patients. ♦ Another aspect of the curriculum renewal process is to consider the incorporation of scholarly pathways for students to gain special expertise. Global health, social medicine, primary care medicine, rural health, integrative medicine, leadership, and clinical/translational research are among the pathways under consideration. ♦ Finally, a series of retreats are also scheduled over the next year. Clinical clerkship directors have reviewed clinical assessment across the clerkship curriculum, and a similar retreat addressing assessment within the basic science curriculum is scheduled. These two retreats have been designed to facilitate the process of assessing our medical students' performance within each of the six core competencies using a variety assessment tools. We are also preparing a large-scale retreat in preparation for our upcoming LCME Self-Study in the next academic year. Learning Outcomes/Competencies ♦ The goal of the OHSU School of Medicine curriculum is to present a four-year continuum that balances emphasis on the scientific basis of medicine with early clinical experience; offers progressive patient care responsibilities for students; and permits students to individualize their educational programs to enhance their independent learning and problem-solving skills. ♦ Foundational medical sciences are presented in an interdisciplinary format focusing initially on scientific principles and ultimately progressing to disease processes and clinical management and care of patients. ♦ As we engage in our curriculum renewal efforts, our current learning objectives will be revised in order to reflect the terminology of the six ACGME Core Competencies. ♦ Our current learning objectives are presented in List 1.LIST 1: Learning ObjectivesLIST 1: (Continued) New Topics and Changes in Pedagogy in the Curriculum ♦ Since 2000, we have incorporated a number of new topics and pedagogical methods within our curriculum. ♦ Simulation technology has been incorporated within the curriculum in both basic science and clinical education. Cardiovascular pathophysiology course work has been augmented through the use of a simulation exercise. There is a simulation-based elective used for diagnostic reasoning skill training. We have also incorporated the use of simulated models in our obstetrics and gynecology and surgical clerkships. ♦ Our Principles of Clinical Medicine (PCM) course curriculum, which runs over the first two years of medical school, has been enriched over the past 10 years with the incorporation of additional lectures and small-group experiences covering the topics of health care disparities, physician impairment, and diagnostic reasoning exercises through problem-based learning. ♦ During the third-year medical school curriculum we also have two weeks of “Continuity Curriculum” in which the entire third-year class comes back together for educational experiences. Topics within these two weeks include integrative medicine, palliative care, wellness, and diversity and cultural competence. During the 2009-10 academic year a “Dean's Book Club” was established with the goal of using recent books to both broaden the students' perspectives and engage in conversation over a special topic. The initial book club addressed diversity in the context of the discussion of the book The Stubborn Twig. ♦ Over the past decade we have increased use of problem-based learning opportunities across the basic science and clinical curriculum in Years 1 and 2. The majority of problem-based learning exercises have been incorporated primarily in the context of developing skills in diagnostic reasoning. ♦ Evaluation of the success of these new methods has been primarily through the examination of both the AAMC Graduation Questionnaire information and the data received from the postgraduate evaluation of interns by residency program directors. ♦ These surveys are important to the overall evaluation of our curriculum and review of the outcome of our new curriculum methods. Changes in Assessment ♦ With regard to new student assessment models since 2000, we have increased the use of NBME Shelf Examinations in our clinical clerkships. Three of the six core clerkships now use the shelf examination as one method of evaluation of our students. ♦ With the entering class of 2009 we instituted the requirement that students must pass the USMLE Step 1 examination prior to entering Year 3 of the curriculum and must pass both components of the USMLE Step 2 examination prior to receipt of the MD degree. ♦ We have also increased the use of standardized patients in the assessment of our students' clinical skills with OSCEs in Years 1 and 2 and a formative Clinical Practice Examination (CPX) at the end of Year 3. Clinical Experiences ♦ OHSU students complete clinical rotations at a variety of clinical sites. There is the OHSU Hospital, an academic health center. The Portland Veterans Affairs Medical Center is located across a sky bridge from OHSU and serves as another training site for our medical students. The Doernbecher Children's Hospital is a primary location for pediatric clinical experiences. In addition to these facilities, students may complete clinical clerkships at three community hospitals in Portland. We collaborate with two other hospitals in Bend, Oregon and Eugene, Oregon in the provision of clinical education for our third-year students. ♦ Clinical education is currently challenged by the number of learners involved in the clinical care of patients. In addition to medical students, there are nursing, pharmacy, physician assistant students, and housestaff. With this number of learners, it is a challenge for students to participate as directly in the care of individual patients. However, with challenges come opportunities—most important, the understanding of what roles other health care professionals play in the care of patients, which is an essential component of medical education. ♦ Another challenge in clinical education is that the majority of this training revolves around admitted patients in an inpatient setting who have increased severity of illness that is of an acute nature. For example, patients are often admitted with an acute exacerbation of an underlying chronic illness, which reduces students' opportunity to diagnose unknown illnesses de novo—the answer is often found on the computer screen in our electronic health record. Although there is a reduction in this aspect of patient care, students are trained to care for very sick patients with complex medical histories, which is an essential preparatory skill for residency training. ♦ Furthermore, students gain the opportunity to engage in the differential diagnosis of unknowns during rotations at local community and regional hospitals, where patients may present with less complex medical conditions. ♦ Our students have the unique opportunity to participate in a required rural rotation, which provides outpatient and inpatient experiences with rural primary care physicians. Highlights of the Program/School ♦ The School of Medicine at Oregon Health and Science University is proud of its role as a pioneer in the development of innovative medical education curricula. ♦ We have a 20-year history of offering clinical education in the first two years of medical school, upon which many other medical schools have modeled their curricula. ♦ We were early adopters of interdisciplinary basic science courses, which have incorporated large- and small-group learning experiences. ♦ We believe that our tradition of having “nontraditional” students has facilitated and enriched the caliber of discussions within the small-group sessions. ♦ Another highlight of the medical school curriculum at OHSU is the required rural rotation. This rotation allows students to learn medicine alongside a primary care physician who cares for patients and their families within a rural community. ♦ In the rural setting, students are not only exposed to a wide range of clinical cases, but also have the opportunity to reflect on what life can be like as a solo practitioner in a medically underserved area. This has proved to be a very well received rotation and one that we believe may foster interest in rural medicine. ♦ Another highlight of the OHSU curriculum is our recent increased use of the Sakai online learning platform for both basic science and clinical science curricula. We anticipate increased use of technology and simulation (broadly defined) within our medical education training curriculum over the next decade. ♦ We are uniquely positioned to assume a pioneering role in the development of interprofessional education of medical students alongside other health care professional students in preparation for their careers in medicine in the mid-21st century.