Introduction Mount Sinai School of Medicine was established in 1968 as an alternative to traditional, university-based medical schools. It grew out of a clinical and scholarly need to better serve the communities of East and Central Harlem, and that legacy continues to this day. In the past five years, we have undertaken a major transformation of our curriculum, have increased class size (from 120 to 140 per year), have established major programs in global health and care of the uninsured, and have dramatically enhanced our research portfolio. We attract applicants with the strongest academic credentials who are committed to both science and service and see themselves as playing an important role in the social fabric of society. Our goal is to train outstanding professionals who are prepared to enter society as informed leaders, advocates, and activists, able to advance science and clinical care, and capable of promoting change. Curriculum Management and Governance Structure ♦ The committees responsible for the curriculum are illustrated in Figure 1 and includeFIGURE 1:: Curriculum Committees The main oversight committee is the Executive Curriculum Committee (ECC), which meets monthly and comprises students, faculty, and representatives from the Dean's office. The ECC assures that our curriculum complies with LCME and Middle States requirements and that our students are provided with the tools to become competent housestaff. The Curriculum Steering Committee (CSC) comprises representatives from the Office of Student Affairs and the key managers of the curriculum, including the Associate Dean for Undergraduate Medical Education, the Coordinator of Clinical Sites, the Year 1 to 4 Course and Clerkship Directors, the administrator who oversees the year 1 and 2 courses, and the Director of our Longitudinal Clinical Experience. This committee meets biweekly to address curricular, assessment, and administrative issues and facilitate communication between all committees and between the Curriculum and Student Affairs offices. The Clinical Clerkship Committee (CCC) comprises the Director of the Clinical Curriculum and Assessment and all the Clerkship Directors and meets monthly to review any issues related to clinical sites, new LCME requirements, and to review clerkship best practices, assure consistency between clerkships, and the seamless transition between clerkships and an integrated and developmental preclerkship curriculum. The Year 1 and 2 Course Directors Committee comprises the Director of Curriculum and Assessment and each course director. It meets quarterly to discuss relevant changes to the curriculum, assessment, and to review the progress of each class as the year evolves. Our curricular reform process has necessitated the establishment of several ad hoc committees/working groups including: Competency, Oversight, Curricular Reform, Assessment, and Electives. Office of Education ♦ Mount Sinai has a Department of Medical Education that oversees support and organization of student education and development of our faculty. There are currently 21 faculty with primary appointments in Medical Education and 20 faculty with secondary appointments. ♦ The Department of Medical Education is also the home for a number of major programmatic initiatives related to education. These include the Office of Medical Student Research, the Global Health Center, the East Harlem Health Outreach Partnership (EHHOP, our student-run free clinic), the Office of Curriculum Support, and the Institute for Medical Education. Financial Management of Educational Programs ♦ The School of Medicine utilizes a mission-based budgeting system, which was created to maintain transparency of the budget process and distribute resources based on effort. There are five categories of funding: Clinical, Administrative, Research, Teaching, and Strategic (CARTS). The Department of Medical Education is responsible for the tracking and allocation of all Teaching dollars. ♦ During this academic year, we added a quality metric into the distribution of Teaching (T) dollars for Course Directors. The system incorporates teaching quality and administrative excellence into the disbursement process. ♦ Our system is designed for flexibility, and our process starts from a predetermined budget for education. Teaching dollars account for the entire educational enterprise insitutionwide. Valuing Teaching ♦ Our school has had an Institute for Medical Education (IME) since 2001. The IME's function is to (1) advance the teaching skills of our faculty, (2) provide opportunities for scholarship in education, and (3) promote the professional and academic development of our faculty. In recent years, our institution reorganized the research infrastructure at Mount Sinai into an interdepartmental Institute model. In recent months, the IME was included in that paradigm, giving it equal status with all our research Institutes and allowing it to extend its missions across all our teaching programs (MD, PhD, and master's programs). ♦ The IME has opportunities for advanced membership (Fellow and Master Educator) that require a portfolio-type application process. This portfolio has been presented to, and embraced by, our Appointments and Promotions Committee as a model for rigoroursly describing and quantifying the accomplishments of Clinician and Scientist Educators. Mount Sinai has had a formally recognized Educator track since 2003. Curriculum Renewal Process ♦ We began planning our most recent curricular transformation in 2006. The key objectives were a focus on social relevance, enhanced longitudinal clinical experiences, opportunities for scholarship, better integration across courses and disciplines, and a competency-based curriculum. ♦ Initial efforts focused on programmatic innovation. This has included a Longitudinal Clinical Experience (LCE) that spans the first two years and is required, as well as an Interclerkship Ambulatory Care Track (InterACT) for a cohort of self-selected students that spans the third year. We also developed multiple opportunities for more in-depth scholarship, including a Doris Duke Clinical Research Fellowship Program, protected time for scholarship between third and fourth year (INSPIRE), and an MD/Masters in Clinical Research track (PORTAL). ♦ The next stage has involved a great deal of conceptual work, data collection on best practices, and modeling different curricula that will best suit our patients, students, geographic location, and culture. ♦ Finally, we will tackle the question of how to make our courses and clerkships fundamentally different by making them tailored and better suited to the needs of our trainees and the communities we serve. Learning Outcomes/Competencies ♦ For the new curriculum, the following four competencies have been developed and finalized in 2009: Competency 1: Patient Care history taking physical examination procedural skills clinical reasoning medical decision making communication skills Competency 2: Scientific and Medical Knowledge organ structure and function characteristics and mechanisms of disease healing and therapeutics social and cultural dimensions of health and disease health care resources and delivery systems ethical principles of medical practice Competency 3: Learning, Scholarship, and Collaboration self-awareness and commitment to self-improvement curiosity methods of investigation, analysis, and dissemination teamwork Competency 4: Professionalism and Advocacy service accountability honesty and integrity empathy respect ♦ Our previous competencies can be found at http://www.mssm.edu/students/handbook/pdf/handbook_09.pdf (see p. 30). New Topics in the Curriculum Since 2000 ♦ Patient safety issues are addressed throughout the clinical curriculum beginning in the first-year Art and Science of Medicine course and continuing through the clerkships and subinternships. ♦ Quality improvement initiatives are introduced in the third- and fourth-year clerkships. ♦ Team-based learning modules are used in the first-year Gross Anatomy and Histology courses and continue in all the clerkships. ♦ Simulation is currently used in all four years of the curriculum. Gross Anatomy, Physiology, Pharmacology, and Renal Pathophysiology courses have multiple sessions in the simulation laboratory. The Surgery, Anesthesiology, and Emergency Medicine clerkships use the simulator laboratory as well. ♦ Approach to caring for patients with chronic illness throughout years 1–3. ♦ Longitudinal Patient Experiences in years 1 and 2. ♦ Internal Medicine rotation includes a four-week ambulatory experience that focuses on Geriatrics and Palliative Care; each student participates in home visits for one week, the palliative care inpatient consult team for one week, and two weeks of Geriatric ambulatory care in third year. ♦ Evolution from a four-week experience in Community Medicine to a Family Medicine Clerkship and then to an Ambulatory Care Clerkship. ♦ Anatomic Radiology, an integrated web-based e-learning clerkship experience, year 4. ♦ Critical Care Clerkship with a revisit of physiologic principles in year 4. ♦ Introduction to Internship in year 4. ♦ Bench to bedside: two-week immersion with exploration of a focused topic linking basic science principles to clinical medicine, end of year 1. ♦ Scholarly Leave program for research or scholarly endeavor, after years 2 and 3 or most of 4. ♦ PORTAL (Patient Oriented Research Training and Leadership): five-year MD/master's in Clinical Research offering training in clinical research methodology. ♦ MD/MPH within four years or via a fifth-year Scholarly Leave. ♦ INSPIRE (Individual Scholarly Project and Independent Research Experience), an optional 12 week intensive mentored research experience in year 4. ♦ Global health curriculum and experiences: throughout all four years. ♦ Pharma conflict of interest curriculum: a longitudinal curriculum to teach appropriate prescribing practices and critical appraisal of the literature including pharmaceutical information and ads. ♦ EHHOP and advocacy: student-run free clinic (every Saturday) and part of the planned pilot program (2010-11) for a primary care alternative experience during year 3. ♦ Student as teacher: elective course in year 4. ♦ Business of medicine course: elective for years 1 and 2. Changes in Pedagogy ♦ Team-based learning and assessment: Gross Anatomy, Histology and Art and Science of Medicine courses. ♦ Online self-directed learning throughout all four years. ♦ Enhanced case-based formats in all four years. ♦ Simulation (see above). ♦ Clinical skills week and intersession: one week each, with large selection of experiences, workshops, and selectives. ♦ Online, honor-code examination system: Students decide when and where they will take their unproctored examinations over a window of time (usually 48 hours); this has allowed us to save curricular time, decrease student anxiety about taking examinations, and allow students to make their own decision about when they are prepared to take an examination. ♦ Student portfolio: Students have the opportunity to participate in courses, extracurricular activities, service, and leadership, which they self-report in an electronic portfolio summarizing the experience, the student's role, and the time commitment, all promoting self-directed learning. This information is transposed into the MSPE as part of the narrative transcript of the overall educational experience. Changes in Assessment ♦ Students do self and peer evaluations in their Gross Anatomy and Art and Science of Medicine Courses in years 1 and 2. ♦ High stakes six-station standardized patient clinical skills examination that includes assessment of a student's knowledge, understanding and application of ethical principles, and evidence-based medicine. ♦ Summary statement for MSPE: numerical scoring system that takes into consideration the USMLE Step I score, Gold Humanism Honor Society, performance on the comprehensive clinical assessments with standardized patients, clerkship grades, research publications, school leadership, teaching, and community service. ♦ Critical incident reports: narrative reports submitted by course/clerkship directors and administrative leaders that document behaviors that are both positive and negative. ♦ Overall assessment: paradigm shift in that the Promotions Committee oversees all aspects of the students' experience, including basic science, clinical, and professional achievements. The Disciplinary Tribunal no longer exists, and the assessment of professionalism issues is via the Promotions Committee. Clinical Experiences ♦ Sites Mount Sinai Medical Center Elmhurst Hospital Veterans Administration hospital in the Bronx Englewood Hospital Morristown Hospital Overlook Hospital Various primary care physicians' offices throughout three boroughs and New Jersey Mount Sinai of Queens Queens Hospital Center Saint Joseph's Hospital, New Jersey Jersey City Hospital Patients' Homes ♦ Challenges and the unanticipated outcomes of our students' clinical education Patients with complex medical problems and short length of stay Faculty preceptors who have less time to teach and supervise Resident work–duty hours restrictions, which fragment the supervision of students Foreign medical students who utilize clinical sites, patients, and preceptors, making fewer available for our students Highlights of the Program/School ♦ There are three features of our school that define who we are and distinguish us in important ways from other schools: Our mission: our focus on service and advocacy is just as intense as our focus on research and scholarship. This synergy has strong historical precedents at Mount Sinai and has been recognized nationally, most recently by the AAMC's Spencer Foreman Award for Community Service. Our communities: our school sits on the “fault line” between the wealthiest (and healthiest) community and the poorest (and sickest) community in New York City. We also serve a community in Queens that is the most ethnically diverse community in the United States according to the U.S. Census Bureau. These contrasts allow our students to have what is arguably the most diverse clinical experience available anywhere in the country. More importantly, it allows them to develop a healthy appreciation and perspective on the health needs of society. Our culture: we believe in creating a supportive, compassionate, and respectful environment for our students. We do not subscribe to the idea that medical school needs to be more stressful or more aggressively competitive than it already is. Our explicit rationale for this is that medical students who are treated with respect and compassion during their training will go on to treat colleagues and peers in that way and, most importantly, will have a deeper reserve of respect and compassion for their patients in the most trying times.