University of Pittsburgh School of Medicine

Abstract

Curriculum Management and Governance Structure ♦ The University of Pittsburgh School of Medicine (UPSOM) has a centrally governed curriculum that features active learning, a problem-based approach, an early introduction to the patient and the community, a required scholarly project, and the integration of a rigorous foundation in basic and clinical biomedical sciences with the social and behavioral aspects of medicine. ♦ A Curriculum Committee (CC) was organized in 1991 as a standing committee of the faculty, with student representation, and was given responsibility and authority for all four years of medical student education. ♦ As the new CC began to prepare for its role as a centrally governing body, it became apparent that to govern effectively, an “effector arm” of the committee was needed to optimize central management of the curriculum. The Office of Medical Education (OMED) was founded as a component of the dean's office and was charged with implementation and management responsibilities. ♦ The central governance structure (described in Reynolds CF III, Adler S, Kanter SL, et al, Academic Medicine 1995 Aug;70(8):671–5) facilitates both the planning and the implementation of curricular innovations. Office of Education ♦ The Office of Medical Education (OMED) was founded in May 1992 to implement the new hybrid problem-based learning curriculum for medical students. ♦ OMED has grown with the curriculum and now includes academic counseling, course and clerkship evaluation services, testing services, information technology support, facilities management, advanced administrative support for special projects (e.g., community-based courses and clerkships), standardized patient programs, disaster-preparedness training, instructional support, and research in medical education. ♦ OMED's professional staff is composed of full-time associate and assistant deans for medical education and a half-time clinician overseeing the standardized patient program. They are supported by a director and 14 staff members. ♦ OMED's directors provide direct support to and leadership for new and ongoing curriculum programs and innovations. ♦ OMED facilitates connections between medical educators and other health science disciplines and acts as a conduit for information from external sources to the UPSOM community. ♦ The OMED director plays a key role in the development and implementation of interprofessional educational initiatives. ♦ The Laboratory for Educational Technology (LET) was created in 2001 to support and expand the use of instructional technologies throughout the curriculum. ♦ A physician director and eight full-time staff support operation of the online curriculum, which includes all course materials, including webcasts of all large-group sessions in the preclinical years, the clinical learning log, the student information portal (the ZONE), a just-in-time learning system triggered by log entries, and curriculum management tools. ♦ The LET is an incubator for innovative approaches to applying technology to medical education, such as development of a user-friendly virtual patient authoring system. Financial Management of Educational Programs ♦ The CC has a Resource Subcommittee that oversees the funding for all first- and second-year courses and selected third- and fourth-year activities. ♦ The Resource Subcommittee considers budget proposals and makes recommendations to the Vice Dean and Dean about funding. ♦ The source of the education budget has been a combination of hard money funds from the dean's budget, new funds, and selected resources previously allocated to departments. ♦ Generally, the sponsoring department funds discipline-based third- and fourth-year clerkships and electives. ♦ Current financial pressures have focused increased attention on optimizing the deployment of finite resources. However, existing resources have been sufficient to both amply support existing operations and to allow the development of new initiatives to proceed uninterrupted. ♦ The Educational Credit Unit initiative quantifies faculty teaching effort throughout the curriculum, including direct instructional activities, advising, researching mentoring, curriculum administration, and committee service related to the school's educational mission. This information supports management of the curriculum and provides a credible basis for distribution of funds to departments to support education efforts. Valuing Teaching ♦ Faculty leaders for the educational program are recommended for appointment to the Vice Dean and Dean by the CC's Executive Subcommittee. ♦ Faculty leaders frequently identify themselves by participating in an exemplary manner in an existing course or clerkship, by assuming administrative responsibility for a segment of a course or clerkship, by chairing an ad hoc curriculum task force, or by designing an outstanding elective experience. ♦ Faculty leaders receive a title that is descriptive of their duties (e.g., Course Director, Block Coordinator). ♦ Faculty may be recognized by students (e.g., Golden Apple Awards, Excellence in Teaching Awards) or by the Dean with advice from the CC (e.g., Dean's Master Educator Award). ♦ Documentation of teaching excellence is required for promotion both in the nontenure and tenure streams. ♦ Individuals with exceptional accomplishments at both an individual and programmatic level may be promoted primarily on the basis of teaching contributions, including promotion within the clinician educator track, with or without tenure. ♦ The Academy of Master Educators (AME) was established in 2006 to recognize outstanding educators and promote excellence and scholarship in medical education. A key feature of the AME is that it is service oriented. Academy members serve on task forces that focus on faculty development, residents as teachers, evidence-based medicine training for faculty, and dissemination of educational resources. Having a cadre of individuals with such exceptional combined expertise and energy has led to highly productive collaborations on each of these initiatives. Curriculum Renewal Process ♦ The current UPSOM curriculum is the product of a series of three major phases of self-study, planning, and implementation. ♦ An entirely new four-year curriculum was phased in, one year at a time, beginning in 1992. A key feature of this curriculum was the organization of basic science and organ system pathophysiology courses. Integrated basic science and organ pathophysiology courses provided a logical and effective organization of content and facilitated demonstration of the relevance of foundational information to clinical medicine. ♦ Integrated clinical clerkships were introduced in 1999. These experiences provide students with the opportunity to focus on patient populations in a more logical and integrated fashion, compared to prior, traditional rotations based in a single discipline. ♦ The current curriculum was launched in 2004 after three years of planning by the CC, faculty, and six major task forces. ♦ Key features of the 2004 renewal include a longitudinal mentored scholarly project requirement, with complementary curriculum content on research and critical thinking; an intensified longitudinal clinical skills curriculum; increased flexibility through opportunities for electives in all four years, including clinical electives at any time during the third and fourth years, accompanied by individualized clinical scheduling; and shortening of the second year by two months. ♦ The curriculum was “phased in” one year at a time beginning in fall 2004. ♦ The renewal process was the result of several phases of preparation. ♦ Early in the planning process, a Curriculum Vision Task Force of senior leaders in basic and clinical sciences provided valuable input from their own perspectives and from colleagues nationwide. ♦ Deliberations among the CC and UPSOM leadership led to decision making about how to re-focus the curriculum, particularly the need for a research-intensive institution to train new generations of physician-scientists, and about the introduction of a scholarly project requirement for every student to accomplish this goal. ♦ Over two years leading up to the new curriculum launch, five curriculum task forces worked with existing course directors to clarify curriculum needs and assure optimal integration. ♦ CC efforts to refine the initial plans continued long after the launch of the curriculum to continue to improve the implementation plan. Learning Outcomes ♦ In 2008, a process was launched to re-assess the School's goals and outcomes for student learning. The schoolwide annual curriculum colloquium, attended by more than 100 faculty leaders and students, focused its efforts on reaffirming the learning outcomes of the MD curriculum. This ongoing work has led to a revised set of learning outcomes for the school in 2010. Changes in Pedagogy ♦ Features of the curriculum include active learning, an emphasis on problem solving, an early introduction to the patient and the community, and the integration of a rigorous foundation in basic and clinical biomedical sciences with the social and behavioral aspects of medicine. ♦ Scheduled instructional time in the first two years of the curriculum is apportioned approximately as one third lecture, one third small-group learning (much of which is problem-based learning; the remainder includes demonstrations, faculty-directed problem-solving exercises, skill practice sessions, and other activities), and one third “other” (which includes observation of and participation in patient care, community site visits, experience with standardized patients, laboratory exercises, and other activities). The use of standardized patients and simulation for teaching and assessment is increasing. Overall, every student spends at least 26 hours in learning activities using high-fidelity, whole-body simulators and an additional 26 hours using task trainers. There are many additional hours spent with standardized patients, virtual patients, and other simulations. Four fifths of students have additional experiences using high-fidelity simulators during their elective courses (an average of 39 additional hours per student). There has been a gradual shift to more diverse methods of small-group instruction to include not just problem-based learning, but also an increasing use of methods such as workshops; case conferences; problem-solving sessions; peer presentations; and, most recently, team-based learning. The most noteworthy marker of success of these approaches has been the increase of student investment and personal energy in these activities. UPSOM has piloted the application of asynchronous learning in a musculoskeletal medicine elective. This elective offering is a completely online course, with no classroom component. Although commonplace elsewhere in higher education, this is just beginning to take hold in medical school curricula. This approach was selected to align the teaching methods with today's students' needs and preferences. New Topics in the Curriculum Since 2000 ♦ The decade since the turn of the millennium has seen the introduction of numerous new topics and themes into the UPSOM curriculum. Examples include Public Health Preparedness, including Bioterrorism and Disaster Medicine, presented as a longitudinal curriculum theme and punctuated by major curriculum events, such as the Pandemic Influenza Hospital Simulation Exercise. Population-Based Medicine, presented as an integrated curriculum theme. Patient Safety, Quality Improvement, and Medical Informatics: These topics are focus areas within the Patient, Physician and Society block. Simulation, including human body simulation, task trainers, standardized patients, and virtual patients, is used widely throughout the curriculum. Patient Education and Counseling, with an emphasis on motivational interviewing techniques, to address obesity, tobacco cessation, and alcohol use [screening, brief intervention, referral and treatment (SBIRT)]. Research Fundamentals: Course work throughout the first two years prepares students to develop and implement their own scholarly project plan and contribute as a full partner to the larger efforts of their mentors' teams, and it adds substantially the development of essential critical thinking skills. Evidence-based medicine is integrated throughout the four-year curriculum as a basis for developing critical thinking skills in preclinical course work and clinical clerkships and as the basis for the development of diagnostic acumen. Geriatrics is taught across the curriculum as a theme, and as a one-week, third-year Clinical Focus Course. Interprofessional Education is aimed at helping all students develop the skills and behaviors necessary to function well within teams and to lead professional and interprofessional teams. Spanish language instruction is offered through a series of interactive electives and experiential opportunities. Exploratory Preclinical Electives are noncredit electives offering opportunities to pursue studies beyond the required curriculum, help students understand the connection between their basic science coursework and medical practice, and provide exposure to topics and specialties that cannot readily be included in the core curriculum. Expansion and growth of the Area of Concentration program with new experiences in Global Health, Public Health, and Neuroscience. Changes in Assessment ♦ Performance-based assessment using standardized patients (SP) and simulation has been highly successful as a method for safe, structured learning and for feedback and assessment. ♦ Specific assessments include Clinical Skills Assessment, second year, on the details of the history and physical; Advanced Physical Examination OSCE, second year, on focused histories and physicals; clerkship OSCEs in Combined Ambulatory Medicine and Pediatrics and Family Medicine clerkships, third year, as part of the summative evaluation of students; formative OSCE events during medicine, surgery and neurology, when each student's performance assessment leads to an individualized learning prescription; and the Clinical Competency Assessment, fourth year, summative performance-based assessment based on SP cases. ♦ A web-based clinical learning log provides valuable insights into more than just the quantity of patients seen, by recording information about various aspects of students' learning experiences related to the care of a patient. Clinical Experiences ♦ Clinical experiences span all four years as follows: Students begin their clinical experience by observing a faculty physician interview a patient on the first day of medical school. Beginning with the start of the Medical Anatomy course, students also begin the Medical Interviewing course, where they develop their skills with standardized patients. Also in the fall of the first year, students learn the basic examination skills in the Introduction to Physical Examination course. By the winter recess of first year, students have acquired a basic toolkit for having meaningful patient encounters. Through the remainder of the first year and all of the second year, students interview and examine standardized patients in a controlled environment and hospitalized patients on the inpatient units in the Advanced Physical Examination course. Also starting in their first year, students are exposed to the practice of medicine in a range of settings, such as ambulatory primary care, including clinics and physicians' offices; in generalist and specialized settings; and in practices that care for underserved populations in the Clinical Experiences course. The Advanced Medical Interviewing course provides late second-year students with an opportunity to revisit interviewing techniques and gain experience with more challenging encounters on the eve of starting the clinical years. At the end of the third year, students return to the classroom and simulation center for a one-week Advanced Clinical Skills course, which augments clerkship experiences across a broad range of topics in a format akin to that of continuing medical education courses. A variety of voluntary activities provide supplementary clinical experiences during the first two years, including Bridging the Gaps (a seven-week summer internship in a community clinic); Area Health Education Center (AHEC)-supported initiatives; work in shelters for the homeless and for victims of domestic violence; and others. Most students participate in one or more voluntary clinical experiences. The third and fourth years are primarily grounded in appropriately supervised clinical experiences. Sites used are largely the hospital and ambulatory sites affiliated with the School's primary affiliate, the University of Pittsburgh Medical Center, and the VA Hospital System. It is a continuing challenge to help preceptors, especially office-based preceptors, balance clinical demands and educational needs. The depth and breadth of the preceptor network continues to make this a success. Also, there is competing pressure from other health profession schools in the region and beyond the region, who seek this region's excellent clinical sites for their students. Curriculum Review Process ♦ The CC is charged with ongoing review of the medical student curriculum, which is conducted through evaluation of individual courses and clerkships, analysis of external and internal data, examination of special issues with ad hoc task forces, and appraisal of the curriculum as a whole at an annual colloquium attended by more than 100 invited faculty and students. Highlights of the School ♦ Each student learns how to think creatively and independently through completion of a required, mentored scholarly project. ♦ Students benefit from individualized opportunities through flexible scheduling, electives, a mentored scholarly project, areas of concentration, year-off opportunities, and dual degree programs. ♦ Early and ongoing emphasis on superb clinical skills. ♦ Enduring success of collaborative central governance of the curriculum. ♦ Dynamic approach to curriculum renewal with a progressive environment that promotes innovation and experimentation without the need to wait until a major curriculum change is undertaken. ♦ During the last decade, the UPSOM created the nation's first Department of Critical Care Medicine and, consistent with national trends, created departments of immunology, physical medicine and rehabilitation, and urology. ♦ Major projects in interprofessional education among our Schools of Medicine, Nursing, Pharmacy, Dental Medicine, Public Health, and Health and Rehabilitation Sciences. ♦ Innovative year-long experiences in basic science research (Physician Scientist Training Program) and clinical research (Clinical Scientist Training Program) complement the traditional MD/PhD (MSTP) program. ♦ Increased breadth and depth of strength in basic science through the creation of new departments of structural, computational, and developmental biology provide a strong foundation and important opportunities for students to begin to develop as physician-scientists.