Curriculum Management and Governance Structure ♦ The Bylaws of the School of Medicine at the University of Missouri School of Medicine (MU SOM) charge the Curriculum Board with the primary policy-making authority for medical student academic programs. ♦ Voting members of the curriculum board are elected from the faculty. Each medical student class elects a nonvoting representative. ♦ Dean's office representatives are ex-officio members. ♦ The Preclerkship Curriculum Steering Committee oversees the Year 1–2 curriculum; the Clinical Curriculum Steering Committee oversees Years 3 and 4. Both of these groups report to the Curriculum Board. Office of Education ♦ The University of Missouri School of Medicine Offices of Medical Education (MU OsME) provide support to the medical student education program and its mission, “to educate physicians to provide effective patient-centered care for the people of Missouri and beyond.” ♦ Leaders of the MU OsME responsible for medical student education include the Senior Associate Dean for Education and Faculty Development, the Associate Dean for Education Evaluation and Improvement, the Associate Dean for Student Programs, the Associate Dean for Curriculum, the Associate Dean for Rural Health and the Director of the Clinical Simulation Center. ♦ The current Associate Dean for Education Evaluation and Improvement has a PhD in Education Leadership and Policy Development. In addition, there are three PhD educators who support undergraduate educational programs, including one who works in the Rural Track Program. ♦ MU OsME supports faculty and students in all aspects of medical student education, including preadmission programs, medical school admissions, basic science and clinical curricula, standardized patient and other simulation experiences, rural health experiences, student assessment, education program evaluation, advising, residency selection, and graduation. Financial Management of Educational Programs ♦ In fiscal year 2009 (FY 2009), an agreement between the Missouri Governor and the leaders of Missouri's state-supported colleges and universities held state funding at 2008 levels in exchange for flat tuition rates. ♦ In fiscal year 2010 (FY 2010), a similar agreement promised to hold cuts in funding to state-supported Missouri colleges and universities to 5.4%. ♦ Currently, FY 2010 funding to MU OsME is 5% less than in FY 2009. ♦ To minimize the effect on medical student education, we have cut professional travel supported by the dean's office by 50%, discontinued food for faculty meetings, and cut costs in extracurricular student activities. ♦ Universitywide there has been a hiring freeze since late 2008, and salaries are frozen at FY 2009 levels. ♦ A separate initiative, “Caring for Missourians,” is providing temporary additional funding to state-supported health professions schools. ♦ With $5.8 million in one-time supplemental funding, MU SOM will increase its class size from 96 to 104 in 2010 and 2011. ♦ If the funding is not renewed, class size will decrease back to 96 in 2012. We will use these funds to create new problem-based learning laboratories. increase faculty resources to accommodate a larger class size. create the Mizzou Preparation for Medical School program, with the goal of helping rural, socioeconomically disadvantaged, minority, and other nontraditional students gain admission and achieve success in medical school. enhance academic support to successfully graduate enrolled medical students. develop new learning methods and training sites, with the goal of preparing students for future practice in both rural and urban settings. Valuing Teaching ♦ Medical School faculty participate in a number of voluntary medical education faculty development programs including medical education journal clubs that include faculty from the college of education, clinical scholars groups for scholarly collaboration, and project-based mentoring from seasoned medical educators. ♦ The school supports the participation of faculty medical education leaders in the Harvard Macy Institute and other external faculty development programs. ♦ The School of Medicine values teaching in two important and substantial ways: (1) through the funding model used to allocate general operating dollars to departments and (2) as a requirement for academic promotion. ♦ MU SOM has developed a mission-based management methodology that rewards participation in activities related to the mission of the school. ♦ This method uses approximately 80 individual education metrics to provide general operating funding to departments based on the amount each contributes to teaching medical and other students. ♦ Academic rank and tenure (when applicable) are awarded based on demonstrated excellence in teaching, scholarship, and other areas as appropriate. Curriculum Renewal Process ♦ In 1993, MU SOM instituted an integrated system-based problem-based learning curriculum in Years 1–2 and streamlined the core clerkships in Years 3–4. The results have been sustained improvements in academic and residency performance (Hoffman K, Hosokawa M, Blake R, Headrick LA, Johnson G. Problem-based learning outcomes: Ten years of experience at the University of Missouri–Columbia. Acad Med. 2006;81:617–625). ♦ In 2003, the “MU 2020” initiative clarified MU's medical education mission, established a set of foundation values, and put in place eight “key characteristics” for our medical school graduates (see below). Figure 1 illustrates the far-reaching effects of aligning all our medical education activities toward these goals.FIGURE 1:: Impact of MU 2020 Initiative**The authors would like acknowledge Thomas S. Inui at the Indiana University School of Medicine's Relationship Centered Care Initiative for the format of this diagram. Learning Outcomes/Competencies The eight key characteristics of MU SOM graduates are as follows: ♦ Able to deliver effective patient-centered care: Our graduates are able to deliver care that improves the health of individuals and communities. Effective patient-centered care: Respects individual perspectives, beliefs, values and cultures. Shares timely, complete, accurate and understandable information to inform health choices. Engages each person as he/she prefers, understanding that care choices belong to that individual. Partners in decision-making and the delivery of care. Our graduates are active participants in the creation of policies, programs and environments that promote care that is patient-centered, grounded in the best available evidence, and conserves limited resources. The care they provide is marked by compassion, empathy, cultural humility, and patient advocacy. ♦ Honest with high ethical standards: Our graduates' behavior reflects honesty in relationships with patients, colleagues and the broader healthcare system. In practice our graduates understand and adhere to the basic principles of medical ethics, including justice, beneficence, non-malfeasance, and respect for patient autonomy. ♦ Knowledgeable in biomedical sciences, evidence-based practice, and societal and cultural issues: Our graduates possess a fund of knowledge that reflects current understanding in basic biomedical sciences, clinical disciplines, population health, and the social and behavioral sciences that impact patient care. ♦ Critical thinker; problem solver: Problem solving and critical thinking engage three interdependent components: knowledge base, processing skills, and insight (metacognition). Building from a strong knowledge base, our graduates seek, synthesize and evaluate information through intellectual curiosity and by questioning the status quo. ♦ Able to communicate with patients and others: Our graduates effectively communicate with patients, families and health care providers in order to establish professional, caring relationships and to facilitate the delivery of high quality, compassionate patient-centered health care. ♦ Able to collaborate with patients and other members of health care team: Our graduates are skilled in the collaborative processes by which patients and interprofessional teams create and implement integrative care plans. They work together through mutual cooperation, respect, exchange of information and meaning, sharing resources, and enhancing each other's capacity for mutual benefits. ♦ Committed to improving quality and safety: Our graduates work as members of the health care team striving for excellence in the quality of patient care and safety. They assess the results of current practice, analyze the literature to determine best practice, and take action to close any gaps. Our graduates recognize their own limitations and acknowledge their responsibilities in delivering safe and effective care. They problem solve and reconcile errors and near misses. They are committed to proactive systems improvement. ♦ Committed to life-long learning and professional formation: Our graduates are aware that the profession of medicine is a lifelong endeavor. They are committed to reflection, self-assessment and self-improvement. They continually appraise and assimilate evidence to keep abreast of changes in best practice. New Topics in the Curriculum Since 2000 ♦ An emphasis on patient-centered care begins with the White Coat ceremony at the beginning of medical school and continues throughout the core longitudinal Problem-Based Learning (PBL) and Introduction to Patient Care (IPC) courses in Years 1 and 2. ♦ Patient-centered care activities also occur in Year 3 core clerkships, including a unique “Legacy Teacher” program in which students are invited to write essays about patients who have taught them lessons they feel will make them better physicians. ♦ Beginning with the Class of 2012, students must pass the Patient-Centered Care Objective Structured Clinical Examination (OSCE) at the end of Year 3 to graduate. ♦ Table 1 summarizes the curricular activities related to patient safety and quality improvement. More details are available in Headrick LA, Hall LW, Teacher's guide: Designing ways for students to learn to improve care, Chapter 11 in Fundamentals of Health Care Improvement: A Guide to Improving Your Patients' Care, Oakbrook Terrace, Ill: Joint Commission on Accreditation of Healthcare Organizations. 2008.TABLE 1: Continuum of Learning About the Improvement of Health Care♦ Clinical Simulation activities are integrated throughout the curriculum: standardized patient experiences in clinical interviewing and physical diagnosis courses in Years 1 and 2. interprofessional simulation experiences in patient safety in Year 2. skill development in basic procedures in Year 3. simulation-based elective in Year 4, Simulation Preparation for Internship, designed to increase medical students' knowledge and skill base in preparation for their first year of internship by being exposed to a variety of situations common to first-year residents through the use of simulation. Changes in Pedagogy ♦ Preclerkship Curriculum Enhanced authenticity in the PBL preclerkship curriculum: We routinely incorporate high-resolution images into the PBL cases (pathology, histology, imaging, electrocardiograms, and so on) and use video to simulate the patient encounter that provides the starting point for the PBL case. Enhanced integration between PBL and IPC: In a standardized patient encounter, medical students use the interviewing and physical examinations skills they have acquired in IPC to obtain the information needed to begin a PBL case. Communication skills: The curriculum makes extensive use of standardized patients to enhance communication skills with patients. These include breaking bad news and difficult conversations, in addition to core communication skills in obtaining the history and physical examination. Enhanced curricula in professionalism and medical ethics. Skill development in health information technology, including introduction to medical record documentation during the first weeks of medical school. ♦ Clerkship-Based Curriculum Development of a required Patient-Centered Care OSCE in the third year. Development and/or incorporation of Web-based learning modules to supplement patient-based clinical material. Examples include Pediatrics CLIPP cases and Internal Medicine Acute Care of the Elderly cases. Patient-Centered Care Reflective exercise as part of the Surgery Clerkship. Patient-Centered Rounds experience in Child Health Clerkship. Community Integration Program during the Rural Track Clerkship Program, in which students voluntarily engage in community-based service learning projects. Integration of video teleconferencing technology into rural track clerkship program for delivering “Essential Seminars” curriculum. ♦ Evaluation of the success of each of these changes includes measuring: Student satisfaction in end-of-course evaluations, annual surveys, and the AAMC graduation questionnaire. Patient log data that monitor the depth and breadth of patient care experiences. Performance on subject examinations. Faculty comment. Residency program directors' perceptions of our graduates. Changes in Assessment Pre-clerkship curriculum ♦ Development of standardized tool to assess student performance as part of a PBL group. tool to elicit student perceptions of the quality of teaching across all courses, lectures, and small-group facilitators in the preclerkship curriculum. process of reviewing student feedback and developing action plans to continuously enhance the curriculum. web-based system to provide feedback to faculty on their contribution to the preclerkship curriculum. ♦ Enhancing authenticity of student assessments through extensive use of high-resolution images. use of standardized patients and simulations. Clerkship-based curriculum ♦ Development of standardized tool to assess students' clinical performance across all seven core clerkships. tool to elicit student perceptions of the quality of teaching across all clerkships in the clinical curriculum. web-based system to track patient encounters across all clerkships. Across the four years of medical school ♦ There is an electronic learning and assessment portfolio for each medical student. ♦ Students have 24/7 access to assessment information, board scores, faculty feedback, comments on performance, contributions to research projects, special projects, and so on. ♦ Students reflect and provide narrative on their acquisition of the key characteristics at the end of each year. Reflections are available for students to review as they progress through medical school. ♦ Students submit artifacts as evidence that they are achieving the key characteristics during their clinical years. ♦ We have delineated assessment methods for each of the 15 curricular goal statements in support of the MU 2020 key characteristics. ♦ MU OsME routinely monitors MU SOM outcome measures with periodic reporting to faculty governance. Clinical Experiences ♦ Most clinical training (inpatient and outpatient) occurs in Columbia, Missouri at University of Missouri Health Care (MUHC) facilities and the Harry S. Truman Memorial Veterans Hospital. ♦ Almost one third of MU SOM students complete up to half their core Year 3 clerkships in one of seven rural “hub” and 26 “spoke” training sites in Missouri. ♦ MU SOM and MUHC share a commitment to high-quality patient-centered care. Clinical units strive for outstanding results for both patients and learners. This requires close collaboration between clinical and education leaders. Highlights of the Program/School ♦ Clear goals and vision for the future of medical education at MU SOM: With these, we align medical education activities from before admission through graduation. ♦ Comprehensive electronic portfolio for medical student learning and assessment: The key characteristics describe the type of doctors students at MU SOM will become. The portfolio tells them where they are on the journey. ♦ MU's program in health professions education for improving the quality and safety of health care (summarized as of academic year 2009-10 in Table 1): This program received praised from the LCME as “a model for the implementation and integration of learning and assessment in the area of quality improvement and patient safety throughout the four years of medical school.” ♦ Our goal is to have learners train in an environment where improving care is a routine part of providing care. ♦ Comprehensive rural track program: Our rural track program was another area singled out for praise by the LCME: “The Rural Track program provides students with excellent opportunities for education in rural communities. It is a highly sought after experience for students that has enhanced the collaboration between the school and rural communities, AHEC, and local health care providers. In addition to offering unique learning experiences, it is designed to help address the state's physician workforce needs in rural areas.” ♦ New to the rural track is the Community Integration Program, which gives third-year medical students the opportunity to participate in service learning in the host community. ♦ Continuous quality improvement in medical education: By applying continuous improvement principles to our work as educators, we not only enhance our educational programs, but also model our own commitment to improving quality and safety (Hoffman K, Brown R, Gay J, Headrick L. How an educational improvement project improved the summative evaluation of medical students. Qual Saf Health Care. 2009;18:283–287; Hoffman K, Griggs M, Kerber C, Wakefield M, Garrett B, Kersten C, et al. An educational improvement project to track patient encounters: Toward a more complete understanding of third-year medical students' experiences. Qual Saf Health Care. 2009;18: 278–282).

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