Table of Contents Foreword Jordan J. Cohen and Daniel M. Fox The Authors Responsive Curriculum Reform: Continuing Challenges Michael E. Whitcomb Curriculum Reform, 2000: An Analysis Kenneth M. Ludmerer Baylor College of Medicine Rebecca T. Kirkland University of California, San Francisco, School of Medicine David M. Irby Case Western Reserve University School of Medicine Marcia Z. Wile and C. Kent Smith University of Connecticut School of Medicine Bruce M. Koeppen University of Florida College of Medicine Robert T. Watson and Larry Rooks Northwestern University Medical School Raymond H. Curry College of Medicine, Medical University of South Carolina Victor Del Bene Tufts University School of Medicine Mary Y. Lee University of Utah School of Medicine T. Samuel Shomaker Wake Forest University School of Medicine Cam Enarson

---

Foreword

Medical schools are justifiably sources of civic pride, in no small part because they are the wellspring of the high-quality health care enjoyed by the people whose taxes, tuition payments, and insurance premiums subsidize them. Medical schools have prospered for most of the past century because they had broad public support. And that support is needed now more than ever, as medical education attempts to adapt to significant changes in what students must learn to be good physicians in the 21st century.

This report is designed to enhance our understanding about the nature and extent of those changes. Its findings are both encouraging and unsettling. The good news is that many medical educators are implementing curricular changes that are responsive to the latest advances in biomedical science, to the social and policy sciences relevant to medical practice, to the burden of disease, to the organization and financing of health care, and to the changing demography of the American population.

The unsettling news is that most contemporary curriculum reformers have not yet been able to make necessary changes in the second two years of medical education, when students receive their first intensive education in clinical practice. In the first of two essays that introduce this report, Michael Whitcomb, a senior vice president of the Association of American Medical Colleges, writes that this "lack of innovation . . . is almost certainly due to the fact that many members of the clinical faculty do not believe that changes are needed." The author of the second introductory essay, Kenneth Ludmerer, agrees with this analysis, as do the authors of most of the case studies that follow the essays. Ludmerer, a professor of internal medicine and history at Washington University, worries that "the approaches described in the case studies are insufficient to prepare the nation's medical students properly for the practice of medicine in the 21st century."

We commend the report to persons who have formal responsibility for higher education as well as to medical educators. Members of university governing boards and leaders of the legislative and executive branches of state government should be aware of current achievements and limits of curriculum reform in medical schools and of their potential consequences for American health care.

We also hope that medical educators and persons responsible to the public for higher education will discuss the barriers to reform in the clinical curriculum. Some of these barriers are financial. Others are a result of the reward system in academic medicine. All of them are amenable to change as a result of collaboration among people within and outside medical education. Academic responsibility is the price we must pay for academic freedom.

Finally, we thank the authors of the studies, who are identified below, for drafting and redrafting them against tight deadlines and Drs. Ludmerer and Whitcomb for writing engagingly about controversial conceptual, political, and historical issues that have great practical importance.

Jordan J. Cohen
President
Association of American Medical Colleges

Daniel M. Fox
President
Milbank Memorial Fund

---

The Authors

Raymond H. Curry, M.D.
Executive Associate Dean for Education
Northwestern University Medical School
Chicago, Illinois

Victor E. Del Bene, M.D.
Professor of Medicine
Associate Dean for Students
College of Medicine
Medical University of South Carolina
Charleston, South Carolina

Cam Enarson, M.D., M.B.A.
Associate Dean for Medical Education
Wake Forest University School of Medicine
Winston-Salem, North Carolina

David M. Irby, Ph.D.
Professor of Medicine
Vice Dean for Education
School of Medicine
University of California, San Francisco

Rebecca T. Kirkland, M.D., M.P.H.
Professor of Pediatrics
Associate Dean for Curriculum
Baylor College of Medicine
Houston, Texas

Bruce M. Koeppen, M.D., Ph.D.
Dean for Academic Affairs and Education
School of Medicine
University of Connecticut Health Center
Farmington, Connecticut

Mary Y. Lee, M.D.
Associate Professor, Department of Medicine
Dean for Educational Affairs
Tufts University School of Medicine
Boston, Massachusetts

Kenneth M. Ludmerer, M.D.
Professor of Medicine, School of Medicine
Professor of History, Faculty of Arts and Sciences
Washington University
St. Louis, Missouri

Larry Rooks, M.D.
Clinical Associate Professor
Chair, Curriculum Committee
University of Florida College of Medicine
Gainesville, Florida

T. Samuel Shomaker, M.D., J.D.
Formerly: Senior Associate Dean for Academic Affairs
University of Utah School of Medicine
Salt Lake City, Utah
Currently: Vice Dean
John A. Burns School of Medicine
University of Hawaii
Honolulu, Hawaii

C. Kent Smith, M.D.
Vice Dean for Medical Education and Academic Affairs
Case Western Reserve University School of Medicine
Cleveland, Ohio

Robert T. Watson, M.D.
Senior Associate Dean for Educational Affairs
University of Florida College of Medicine
Gainesville, Florida

Michael E. Whitcomb, M.D.
Senior Vice President
Division of Medical Education
Association of American Medical Colleges
Washington, D.C.

Marcia Z. Wile, Ph.D.
Director of Curricular Evaluation
Case Western Reserve University School of Medicine
Cleveland, Ohio

---

RESPONSIVE CURRICULUM REFORM: CONTINUING CHALLENGES
Michael E. Whitcomb

The studies presented in this report describe in some detail the changes occurring in the education of medical students in ten U.S. medical schools and the dynamics of the curriculum reform process at those schools. The Association of American Medical Colleges (AAMC) has recently surveyed all medical schools to collect information about the organization and management of their education programs. It is clear from this information that the kinds of changes described in the studies are occurring in a majority of schools nationwide. As reflected in the studies, medical schools are making major changes in the structure and organization of the curriculum, adopting innovative pedagogical strategies for enhancing students' learning, improving the methods used to assess students' performance, and focusing greater attention on the professional development of faculty as teachers and educators. To support these activities, schools also are making fundamental changes in the management and financing of their education programs. Based on these observations, it is apparent that a major transformation is now under way in the education of medical students in this country.

Despite the importance of these changes, the studies presented in this report make it quite clear that the great majority of the curriculum changes that have occurred or are planned largely affect only the first two years of each school's educational program. The ten schools whose experiences are described in the report have found it difficult, and in some cases almost impossible, to make fundamental changes in the last two years of the curriculum, when most clinical education occurs. The data that the AAMC has collected about the organization and management of all schools' education programs indicate that the experiences described in the studies reflect the situation nationally. Although some schools have been able to introduce a number of structured small-group learning exercises into the final years of the curriculum, many schools, including some that have planned to do so, have not been successful in accomplishing even this relatively modest change. The lack of innovation in the last two years is almost certainly due to the fact that many members of the clinical faculty do not believe that changes are needed.

The attitude that change is not needed in the design and organization of the last two years of the curriculum ignores certain current realities. It is contradicted by published reports indicating that, at the time of graduation, medical students too often lack fundamental clinical skills that they should have acquired during their clinical education. It also fails to acknowledge that the entire curriculum––including the last two years––must change over time in response to changes in medicine and in society's expectations of medicine.

During the past two decades, important changes have occurred in medical practice that have critical implications for the content of students' clinical education. For example, concerns about the cost of medical care have led to major changes in the organization, financing, and delivery of medical care services. As a result, physicians now entering practice are expected to be able to provide high quality care in an efficient and cost-effective manner; to be skilled at accessing, managing, and using electronically stored information in clinical decision-making; and to understand the population-health dimensions of providing care to individual patients.

During the same period, society's expectations of medicine have changed. The public has come to recognize that the promises of curative medicine that dominated thinking about medical practice and medical education in the 1960s and 1970s were somewhat overstated. Americans recognize that that the emphasis placed on "biomedicine" during that period resulted in a devaluing of the humanistic dimensions of medical care, and they are dissatisfied with the impact this has had on doctors' professional behavior. People now want doctors who are able and willing to communicate more clearly with them and their families, who will respect them as persons and honor their wishes about their care, and who will continue to care for them when medical treatment is no longer indicated or desirable.

The goal of the curriculum must be to provide medical students with a general professional education that will ensure that they have opportunities to develop a strong foundation in the knowledge, skills, and attitudes required for clinical practice. To achieve this goal, the content of the curriculum must be aligned with evolving societal needs, practice patterns, and scientific developments. This alignment cannot occur if changes are made only in the first two years of the curriculum. In fact, given the nature of the issues now facing medicine, much of the new content would be better placed in the third and fourth years, when the clinical education of students is occurring. To gain a perspective on the pressing need for change in the last two years, it is useful to reflect on how little those years have changed since formal instruction in clinical medicine became an integral component of the medical school curriculum a century ago.

In the United States, the formal instruction of medical students in clinical medicine is largely a development of the 20th century. Until the late 19th century, medical schools, with few exceptions, included no formal instruction in clinical medicine in their curricula. In general, medical school graduates learned clinical medicine (such as there was to learn) on their own once they had entered independent practice or by apprenticing themselves to community practitioners. Some graduates, desiring some formal instruction in clinical medicine, would spend a period of time studying in Europe, where medical education was more advanced, or would find a "house officer" position at a hospital, where they could learn under the watchful, albeit somewhat distant, eyes of local practitioners.

Although in the mid-1800s some medical schools began to offer formal instruction in clinical medicine, the opening of the Johns Hopkins Hospital in Baltimore in 1893 is usually considered to be the signal event that established clinical instruction as a necessary and required component of the formal education of medical students. Indeed, the approach to clinical instruction that William Osler established at Johns Hopkins became the model adopted by other medical schools. Osler believed that formal instruction in clinical medicine should begin in the third year, when students would observe clinical demonstrations conducted in the clinic and amphitheater. He thought that fourth-year students should deepen their knowledge of clinical medicine by being assigned responsibility for the care of a certain number of patients on hospital wards and that every few months they should rotate from one clinical service to another, thereby gaining experience in different clinical disciplines. The fourth-year experience that Osler instituted at Hopkins became the model for the clinical clerkships that came to dominate the clinical education of medical students throughout the 20th century.

By the 1920s, the medical school curriculum had become standardized. In this "2+2 curriculum," the first two years were devoted almost entirely to the study of the sciences of medicine and the last two to the study of clinical medicine. The first two years were composed of a number of discipline-specific, departmentally administered science courses. The last two years were composed of required clinical clerkships in internal medicine, surgery, obstetrics/gynecology, pediatrics, and psychiatry and elective rotations in these and other clinical disciplines.

In the 1950s, a few changes began to be made in the organization of the educational program. For example, some schools experimented with new approaches to organizing the material taught in the first two years. Rather than teaching the sciences in individual, discipline-specific courses, they taught relevant material drawn from each of the sciences in units organized around individual body organs or organ systems. This approach was adopted as a means for integrating content across the sciences as well as for integrating basic science and clinical discipline content to at least a limited degree. In virtually all schools, clinical clerkships were moved from the fourth year (the Osler model) to the third, with the fourth year now devoted to rotations in hospital clinics and to inpatient services in clinical disciplines not represented in the clerkship experiences. Over time, more and more schools set aside much of the fourth year for electives, so that students could gain experience in clinical disciplines of particular interest to them.

By the beginning of the 1980s, the last two years of the curriculum were generally composed of a series of required clerkships in the major clinical disciplines in the third year followed by a series of largely elective experiences in the fourth year. In virtually all cases, the educational design of the clerkship and elective experiences consisted solely of assigning students to teams composed of resident physicians and an attending physician. Even though most physicians spent the majority of their time caring for ambulatory patients, the focus of clinical education was on the care of seriously ill, hospitalized patients. This approach assumed that students could learn the skills required to provide care to ambulatory patients after entering practice––an assumption based on the belief that most ambulatory patients had either relatively minor, self-limiting conditions or were being seen in follow-up after a period of hospitalization for a life-threatening, acute disease.

The design of the clerkship experiences was largely governed by the idea that students could learn what they needed to know by observing resident and attending physicians in action in inpatient settings and by doing whatever they were asked to do. From an educational perspective, this design concept was highly flawed, because clerkship experiences (even within a single clinical discipline) were in actuality highly variable. Such variability was inevitable because of the variable nature of the clinical sites to which students were assigned over the course of any given year and the variable quality of the supervision and teaching provided by residents and attending physicians. This same conceptual flaw affected the elective experiences provided in the fourth year. The variable nature of these experiences likewise made it impossible to ensure that all students were having similar educational experiences, and neither the third nor the fourth year was designed to be a part of a coherent educational program that would ensure that all students would receive a comparable general professional education.

In the early 1980s, the AAMC impaneled a group of distinguished educators to review medical students' education and to make recommendations on changes that might be needed. The panel, which had the cumbersome title of the Panel on the General Professional Education of Physicians and College Preparation for Medicine (known as the GPEP Panel), issued its final report in 1984. That report, and a supplemental document prepared by a subgroup on clinical skills (the Working Group on Fundamental Skills), severely criticized the clinical education of medical students, specifically the clinical clerkship. The panel and subgroup concluded that clinical clerkships were often little more than unstructured apprenticeship experiences that lacked clear learning objectives and that did not contribute in a coherent manner to the general professional education of medical students.

The GPEP Panel made two major recommendations that addressed issues related to the clinical education of medical students. It recommended that a comprehensive study of clerkships be conducted so that deficiencies in those educational experiences could be better documented. The panel also recommended that medical schools provide more opportunities for medical students to be exposed to clinical medicine in ambulatory care settings. The rationale for this recommendation was based on the fact that clinical care was increasingly being provided in ambulatory settings. If students were to be exposed to the clinical problems more commonly encountered in medical practice, it was necessary to shift some of their clinical education to those sites.

The GPEP Panel's critique of the clinical clerkship was largely ignored by the medical education community, most importantly by deans and department chairs. Over the years, the chairs of the major clinical departments had become powerful forces within medical schools, and they refused to accept the notion that changes were needed in the traditional approach to clinical education. Since the clerkships that they controlled had provided generations of doctors with a sound clinical education, they saw no need for change. Absent support from clinical department chairs, no meaningful discussion occurred at the national level about undertaking a comprehensive review of the clerkship, as the GPEP Panel had recommended. As a result, no changes occurred in the experiences provided during the third and fourth years, and the organization of that portion of the curriculum remained unchanged.

In the 1990s, medical schools did begin to provide more ambulatory care–based experiences for their students. The schools developed these experiences partly in response to the recommendations of the GPEP Panel and those of other blue ribbon panels established in the late 1980s and early 1990s to review various aspects of medical education. Foundation and government grants often funded the experiences, at least in part. They primarily took the form of longitudinal preceptorships that placed students in the offices of primary care physicians for one-half day per week, generally during the first two years of the curriculum. The rationale for placing these experiences in the "preclinical" years was that they would provide clinical relevance for the basic science material that students were then studying. Additionally, educators thought that they would promote more favorable student attitudes toward primary care medicine before they entered the specialty-dominated clerkships.

In addition to the preceptorships, many schools began to set aside some of the time previously allocated for clerkships in the third and fourth years for ambulatory care–based experiences, primarily in internal medicine, pediatrics, obstetrics/gynecology, family medicine, and psychiatry. Schools often established these experiences because of hospitals' declining patient volumes––the result of the movement into ambulatory care settings of more and more of the care formerly provided in inpatient facilities. It bears emphasizing that these changes did not occur because of a recognition that the traditional clerkship experiences were somehow fundamentally flawed; the inpatient component of the traditional clerkships therefore remained unchanged.

The fourth year has remained more or less the same during the past few decades. In virtually all schools, a major portion of this year is devoted to elective experiences. Students and faculty support the current situation because it serves their mutual interests in addressing the transition that students must make from medical school to residency training. In general, students want ample elective time in the fourth year so that they can opt for rotations in the clinical disciplines that they hope to specialize in during their residencies. In fact, many students opt for multiple electives in the same discipline and arrange to take those electives at institutions where they might want to take a residency (the so-called audition electives). Students also want ample elective time so that they are relatively free to travel for residency program interviews. Relatedly, many faculty want ample elective time in the fourth year so that they have opportunities to recruit students to electives offered in their specialties, hoping that some of the students who opt for the electives will choose to train in these disciplines. Equally important, they want students who are interested in their residency programs to be able to take elective rotations (audition electives) on their services, so that they can gain some personal knowledge of students before making selections for their programs. In combination, these interests have made it difficult to make the fourth year of the curriculum part of a coherent educational program that provides a general professional education for all students.

Given the need to provide educational experiences that will allow students to acquire the knowledge, skills, and attitudes required by changes in medicine and in society's expectations, the traditional clerkship and elective experiences offered during the third and fourth years of the curriculum should be redesigned. Students cannot begin to acquire the attributes needed to care for patients in the evolving delivery system in clinical experiences that continue to emphasize the care of hospitalized patients. These experiences must be redesigned––not abandoned––so that they provide clear opportunities for students to learn how to communicate well with patients and their families; to gain an appreciation of the impact that patients' cultural beliefs, patients' home environments, and the availability of community resources can have on care; and to understand the population-health dimensions of medical practice. Some of these objectives can be achieved by using the kinds of strategies described in several of the studies.

Some may suggest that students can begin to acquire the knowledge, skills, and attitudes needed for future practice during the preceptorship experiences that have become commonplace in medical schools. If this were the case, there would be less reason to be concerned about the design of the clinical education provided in the third and fourth years. There are good reasons, however, why these experiences cannot adequately serve this purpose. Recall that the preceptorship experiences generally occur during the first two years of the curriculum, before students have acquired the background knowledge and skills to take full advantage of the learning opportunities the preceptorships might provide.

Equally important, however, is the fact that the learning opportunities provided by these experiences are quite limited. The preceptorships generally occur only one half-day per week, provide relatively brief patient care encounters, and are based in primary care practices. They therefore do not provide adequate opportunities for students to explore in any detail the complex issues involved in caring for patients with serious chronic disease. Since preceptors are busy practitioners who volunteer their services, schools cannot expect them to spend a great deal of time exploring those complex issues with their students. Moreover, first- and second-year students are unlikely to devote the time needed to acquire the necessary attributes, since advancement during the first two years is largely dependent on how well they perform on examinations that test their knowledge of the basic sciences, not on how well they perform in the preceptorships.

The experiences described in the studies make it clear that there is a great deal of resistance to making changes in the third and fourth years of the curriculum. Those who do not see the need for change fail to recognize that it is no longer appropriate to focus the clinical education of medical students on the diagnosis and management of seriously ill, hospitalized patients with acute diseases. This focus has been justified over the years by the claim that students had to be ready for the kinds of patients they would encounter as interns or first-year residents and prepared to assist in the treatment of the most seriously ill patients they would encounter on entering practice.

This argument had some merit in the 1950s and 1960s, when a good number of medical school graduates planned to enter general practice after only one additional year of formal training (the rotating internship), but since this is no longer the case the argument no longer holds. Medical students certainly must learn enough about the care of seriously ill patients to be able to meet the patient care responsibilities they will face during the initial months of their residency experiences. But, in considering this issue, it is important to recognize that the degree of supervision now provided new resident physicians is substantially greater than in past decades. At issue, then, are the kinds of changes that should be made in the last years of the curriculum so that students are provided with experiences that contribute to a general professional education while also preparing them for the challenges they will encounter during the initial months of their residencies.

The GPEP Panel had it right more than 15 years ago when it called for a comprehensive review of clinical education. In fact, since there are several good reasons for believing that the quality of clinical education has deteriorated since that time, the need for such a review is today even more compelling. Not only are the traditional clerkships inadequate for developing the knowledge, skills, and attitudes required for the care of patients with chronic diseases in the new and evolving practice environment, but changes in the clinical environments where medicine is learned have undermined the quality of the teaching that occurs in those environments. Clinical faculty and, it should be noted, resident physicians alike claim that they do not have time to teach adequately, and, as noted above, published reports indicate that students too often lack fundamental clinical skills at the time of graduation. Moreover, medical schools now use many more sites for clinical rotations, which makes it even more difficult than in the past to maintain consistency of the educational experiences.

Accordingly, the AAMC will devote considerable time and effort in the coming year to a study of the clinical education of medical students. The association will analyze data available from a variety of sources (the LCME Annual Survey, the AAMC Graduating Student Questionnaire, the AAMC Curriculum Directory, and the Curriculum Management and Information Tool) to document and characterize the organization of the third and fourth years of the curriculum in U.S. medical schools generally. AAMC staff will visit a group of schools to obtain more detailed information about the design and conduct of the educational experiences offered in those years. The schools visited will be representative of the diversity of medical schools in the United States. In advance of the visit, we will ask each school to provide information about the learning objectives for the clinical education experiences it offers, the approaches it uses for assessing students' performance during their clinical rotations, and the instruments its students use in evaluating these experiences. We will use this information to structure a series of interviews that will be held during each visit with clerkship directors, fourth-year students, and members of the dean's staff.

AAMC staff also will collect information about the attitudes that faculty who administer clinical education experiences have about medical students' education. We will hold focus-group sessions with directors of clerkships in core specialties. The focus groups will explore the degree to which the clerkship directors view the clerkships as part of the general professional education of medical students and how they believe the experiences might be modified to enhance students' learning. We will also obtain views on these subjects from others interested in medical students' education, including graduate medical education program directors.

The association will also explore a set of issues related to the teaching of clinical medicine. One often-repeated explanation for the decline in medical students' clinical skills is that clinical faculty no longer spend adequate time with students because of the pressures of clinical practice and the perception that medical school administrations do not value teaching. We will explore these issues by reviewing faculty productivity data, through focus-group sessions with clinical faculty, and through conferences devoted to the topic. If faculty are unable or unwilling to devote adequate time with students, little will be gained by reorganizing the third and fourth years.

As I have conveyed above, there are very good reasons for believing that the third and fourth years of the medical school curriculum need to be reorganized and that the clerkship and elective experiences provided in those years need to be redesigned. The ultimate purpose of any reforms that might be adopted is to ensure, to the greatest degree possible, that the third- and fourth-year experiences contribute to a coherent educational program that provides all medical students with a comparable general professional education.

The studies presented in this report offer evidence that trying to effect changes in the last two years of the curriculum is a formidable challenge. The design and conduct of the clinical clerkships and of many of the elective experiences are deeply rooted in the tradition and the culture of medical schools' clinical departments. Although over the years much has changed in medical education and medical practice, these departments have been steadfast in retaining their prerogative to conduct their student experiences as they see fit, and this has too often meant maintaining the status quo. This attitude must change if medical schools are to provide coherent educational programs designed to enable students to acquire the knowledge, skills, and attitudes needed for the practice of medicine in the 21st century. The curriculum reforms described in the studies in this report will not, of themselves, accomplish this goal. They have, however, set the stage for making the fundamental changes in the third and fourth years that will ensure that this goal can be achieved.

---

CURRICULUM REFORM 2000: AN ANALYSIS
Kenneth M. Ludmerer

The ten studies presented in this report illustrate that medical schools in the United States today are taking curricular reform seriously. The reports describe major changes during the past decade in both the content of the medical curriculum and the pedagogical strategies employed. Nevertheless, the approaches described in the case studies are insufficient to prepare the nation's medical students properly for the practice of medicine in the 21st century. This essay will describe in detail why the present medical curriculum is not accomplishing the desired objective.

I shall begin by discussing three educational principles that have guided medical educators throughout the 20th century. Then I shall describe the positive accomplishments achieved at the ten schools. Last, I shall examine why current curricular innovation is inadequate to meet the main educational challenges of the moment: the molecular revolution in medicine, the growing importance of chronic diseases in the United States, and, most important, the erosive effects on the learning environment that have occurred during the managed care era. Unless medical educators are able to address these issues successfully, the country faces the prospect that its physicians will be ill-prepared to meet their professional and public responsibilities.

Educational Principles

The details of medical education are always changing. Each school regularly revises the content and organization of its curriculum and introduces new methods for teaching the subject matter and evaluating students. Nevertheless, medical education in the United States has developed around three underlying educational principles that have proved remarkably constant even as the specific details and strategies of the curriculum have continually evolved. Since the late 19th century these principles have served as the ideal of what medical education should encompass, though medical schools have usually fallen short of fully realizing their educational goals.

First, American medical education is based on the premise that the most effective learning occurs when students are allowed to "learn by doing." This philosophy, which was heavily influenced by John Dewey and the school of progressive education, relegates traditional teaching devices such as lectures and textbook-reading to relatively minor roles. Instead, it emphasizes "active learning" through laboratory work in the scientific subjects and hospital work with real responsibility for patient care in the clinical years. Since the late 19th century, medical educators have believed that active learning is the key that enables students to master biological principles, develop independence, and become problem-solvers, critical thinkers, and lifelong learners (Ludmerer 1985, pp. 63–71).

Second, medical educators' most important role in facilitating active learning is not that of structuring a formal curriculum per se but that of creating a rich, student-centered "learning environment" that permits active learning to proceed. Stimulating classmates, well-equipped laboratories, and a good library are among the components of a rich learning environment. So are a knowledgeable and creative faculty and a large amount of personal contact between students and instructors. Most important is the availability of clinical learning opportunities that allow students to have sufficient time to study patients in depth. It bears noting that, even though clinical learning takes place in the "real world" of health care delivery, not just any hospital, outpatient office, or clinical preceptor is considered acceptable. Rather, medical educators have long considered it axiomatic that good clinical teaching should illustrate exemplary patient care and thereby provide students with a model of how medicine should be practiced.

Third, much of who physicians are, particularly in terms of their attitudes, values, and behavior, is shaped not by formal course work but by the so-called "hidden curriculum"––the broad social and cultural milieu in which medical education takes place. Numerous sociological studies over the past five decades have documented the profound impact of the entire institutional environment of the academic health center on the attitudes, values, beliefs, modes of thought, and behavior of medical students. These studies have found that attitude formation results from the totality of students' interactions with faculty, house officers, patients, hospital staff, and one another in laboratories, classrooms, wards, and clinics (Fox 1989, pp. 72–107). No matter how much emphasis is given to caring and compassion in the formal curriculum, students are continually exposed to implicit messages about caring that emanate from the reality of how care is actually delivered in the academic health center. These messages often run counter to what medical educators are trying to convey. The effects of a brilliant lecture on caring to an assembled medical class can easily be undone should students return to a harsh ward culture where residents routinely speak of the "GOMERS" ("Get Out of My Emergency Room!"––a derogatory term for elderly or critically ill patients in the argot of house officers) who have just been admitted.

Ten Studies

Though strategies at the sample schools vary in detail, the ten studies presented here illustrate a number of common themes. Foremost among these are the attempts to incorporate relatively new subjects into the curriculum to help prepare learners for the exigencies of contemporary practice. These subjects include biomedical ethics, evidenced-based medicine (that is, the practice of basing patient management on well-conducted clinical studies whenever possible), disease prevention, health promotion, and population health (which addresses the health needs of a defined population, such as the individuals enrolled in a specific HMO). Many of the studies are also characterized by efforts to eliminate redundancy in the curriculum and to achieve greater coordination and integration between the basic science and clinical components of medical education. Another widespread initiative is the expanded use of new educational strategies, such as standardized patients, medical informatics, and Web-based medicine. Many of the schools are also placing more emphasis on tutorials and small-group discussions to achieve greater personal interaction among students and between students and faculty.

It is noteworthy that these studies report that the majority of innovations have been implemented during the first two years of the curriculum––the years when basic science is taught––and not during the last two years, which are typically devoted to clinical instruction. This will hardly surprise those familiar with the history of medical education in the United States (Ludmerer 1985, 1999). Medical faculties have always had complete control over the scientific work; in contrast, clinical instruction has traditionally occurred at teaching hospitals and other clinical venues that have not been directly controlled by medical schools. Moreover, basic science departments are relatively isolated from the turbulence of the contemporary U.S. health care environment, whereas the sites used in clinical teaching are directly affected by those forces. Accordingly, it is hardly a surprise that medical schools should concentrate on reforming that part of the curriculum that is under their direct control rather than the part that has the most influence on what kind of doctors students ultimately become.

Throughout the 20th century, the most important curricular experiments at U.S. medical schools have been led by strong deans committed to educational reform (that is, by deans who possess both vision and a strong command of institutional resources). These innovations include the "Yale system" introduced by Milton C. Winternitz in 1925, the organ-based system pioneered at Western Reserve in 1952 by Joseph T. Wearn, and the "New Pathway" program introduced at Harvard Medical School in the 1980s by Daniel Tosteson. The importance of the dean to curricular innovation continues to be apparent in the present ten reports. At schools where the dean has exerted strong leadership, as at the Medical University of South Carolina, educational reform has been more extensive. At schools where the dean has remained relatively uninvolved, as at the University of Utah School of Medicine, curricular reform has occurred only with the greatest difficulty and has accomplished relatively little in terms of effecting meaningful change.

Throughout the 20th century, good teaching at U.S. medical schools has been handicapped by faculty and institutional value systems that have rewarded research accomplishments (and, for the past quarter-century, the generation of clinical revenue) more than educational effectiveness (Ludmerer 1999, pp. 49–51, 215–8, 307–13). In this context, events at one of the sample medical schools represented here, the University of California, San Francisco, are truly extraordinary. There, the dean created an Academy of Medical Educators, which he funded with an initial commitment of $5 million of school reserves to establish 20 endowed chairs for unusually accomplished medical teachers. Additional fundraising plans for the Academy are under way.

Though some may view the establishment of such an academy as a "baby step," this in fact represents the first time in nearly a century that an American medical school has systematically attempted to reward good teaching with institutional resources. Early in the 20th century, medical schools introduced the system of full-time faculty appointments on the theory that research would enhance faculty members' teaching. As noted above, however, medical schools in practice have mainly granted promotions and other institutional rewards for research, not teaching. Indeed, the folk wisdom of academic medicine has long held that the sure way for an instructor not to be promoted is to win an award for good teaching. In this context, the UCSF's Academy of Medical Educators will bear close watching.

For all the promise of the ten studies, one disquieting fact must be kept in mind: schools' lack of effective tools to evaluate curricular reform. No school has ever been able to document scientifically the advantage of one curricular approach over another––however strong the theoretical rationale for a change or the subjective impressions among faculty that a change is making a difference. As the report from the University of Florida College of Medicine attests, "We continue to struggle to find ways to answer the biggest question regarding the effectiveness of change, 'Are we producing better physicians?'" The issue of curricular evaluation is especially difficult because the ultimate measure of effectiveness is not the examination scores of students today but what kind of doctors they ultimately become. It is possible that a dialogue might be initiated between medical schools and residency programs regarding how well-prepared a school's graduates seem to be at the start of residency training. None of the case reports discuss this approach, however.

The Limits of Curricular Reform

Though important changes in the medical curriculum are clearly occurring, the ten studies do not address three of the most fundamental challenges that presently face medical education. Two of these challenges arise from events internal to the development of medical science and practice; the third relates to the external conditions of the health care marketplace. The failure of the case reports to meet these challenges raises serious questions about the adequacy of the education that medical schools are currently providing.

The first issue pertains to the challenges to medical teaching posed by the molecular revolution in biomedical science. For most of the 20th century, a distinctive feature of medical education in the United States was the integration of research with teaching and patient care (Ludmerer 1999, pp. 30–9, 148–51). The cohesiveness between teaching and research was possible because instructors taught students what they themselves were investigating. After 1970, however, as biomedical research became increasingly molecular in its intellectual orientation, teachers found it increasingly difficult to be cutting-edge researchers, and vice versa. Accordingly, the identification of qualified teachers, in both the scientific and clinical disciplines, became a difficult task.

Today, this difficulty is especially clear in the basic science fields, where the research interests of most faculty no longer directly relate to much of the subject matter still taught to medical students. Professors in these fields are in the awkward position of studying fundamental molecular and cellular biology, for which they are rewarded, while teaching clinically necessary subjects they do not particularly value, such as gross and microscopic anatomy, fluid and electrolyte metabolism, and classic organ physiology. In some fields, it has become difficult to find faculty who can still teach the classical subject matter. Gross anatomy is the prime example. Anatomy departments now depend heavily on surgeons, radiologists, anthropologists, and dentists for help in teaching, since the field is virtually dead as an area of active investigation among anatomy faculty (most of whom now work in cell biology). To a lesser extent, this problem affects instruction in the other basic science departments as well. At the dawn of the 21st century, officials at some schools are acknowledging the possibility that the basic science departments might be forced to split into separate research and teaching faculties.

Similar developments have occurred in the clinical departments, where the traditional cohesiveness among research, patient care, and education has substantially eroded. Until around 1970, the defining characteristic of clinical research was its focus on patients. This meant that clinical research went hand-in-hand with patient care and clinical instruction. In the molecular-biology era, patients are being bypassed. Although the results of this approach to clinical research have been gratifying in terms of medical discovery, a conspicuous separation of functions has occurred between clinical research and clinical teaching.

Clinical departments at many schools have responded by establishing two faculty tracks: a "clinician-teacher track" for faculty concentrating on education and patient care and an "academic track" for laboratory investigators. Most faculty members specializing in evidence-based medicine have opted for the clinician-teacher track because of their familiarity with the clinical literature and their expertise in delivering medical care. But such an approach merely highlights the fundamental problem it was meant to solve: the growing estrangement between teaching and research. Experts in evidence-based medicine seldom possess the clinical investigator's knowledge of the molecular mechanisms of disease and therapeutics, while today's clinical investigators are much more removed from day-to-day patient care and clinical teaching than were clinical professors of the past. In the clinical departments as in the basic science departments, no one has a good answer to the vexing question, "Who are the teachers?"

A second issue not adequately addressed by the ten studies is the preparation of students for the management of patients with chronic diseases. Medical educators created the hospital clerkship, the mainstay of clinical education, in the late 19th century, when Americans' life expectancy was barely 40 years and when the treatment of acute illnesses (infections, injuries, and acute manifestations of chronic diseases) dominated medical practice. Today, as a result of the success of public health and modern medicine, life expectancy in the United States is approaching 80 years, and chronic and degenerative diseases dominate the practices of most physicians.

The diagnosis and management of chronic diseases, unlike that of many acute illnesses, is largely an outpatient activity. Over the past two decades, there have been many calls for medical schools to provide more and better ambulatory experiences so that students might obtain greater exposure to patients with chronic illnesses. (The Association of American Medical College's GPEP Report in 1984 was the most prominent of these calls.) The ten studies presented here report some movement in this direction, particularly through the establishment of preceptorships with community physicians during the second year of medical school. Nevertheless, on balance, the schools represented here continue to rely on inpatient hospital clerkships for the lion's share of clinical instruction. Conspicuously absent from these reports is any discussion of how students are to acquire the knowledge, skills, and attitudes required for the care of patients with chronic diseases. It remains to be shown that today's students will be fully prepared for the most important challenge they are likely to face when they begin the practice of medicine.

The third––and most important––omission from the case studies is the recognition that present-day market forces are rapidly destroying the learning environment of clinical education. Throughout the 20th century, American medical schools had two "homes": one in the university, the other in the health care delivery system. Of the two, the ties to the university have traditionally been far stronger. Since the passage of the original Medicare and Medicaid legislation in 1965, the patient care activities of medical faculties have grown enormously and medical schools' ties to the health care delivery system have correspondingly increased. These developments have resulted both from the financial incentives of the marketplace and from faculty members' enjoyment of the much higher salaries and benefits they have received in the Medicare era (Ludmerer 1999, pp. 3–348).

As a result of these forces, academic health centers today operate in the "real world" of health care delivery. Driven by intense, market-oriented competition, they are under great pressure to see as many patients (both inpatients and outpatients) as possible (Ludmerer 1999, pp. 349–99). This state of affairs has had deleterious effects on the ability of students to acquire the fundamental skills of clinical care and to learn caring attitudes and behaviors. Herein lies the overarching threat to the education of the country's physicians at the present moment.

The market's erosive effects on medical education are exerted in many ways. For instance, one consequence of the current situation is that fewer and fewer clinical faculty are available to serve as teachers and mentors. Instead, today's faculty are under intense pressure to be "clinically productive"––that is, to see as many paying patients as possible so that they can help keep the medical center financially afloat. (The common definition of "clinical productivity" at medical schools refers to the amount of professional fees generated, not to the quantity or quality of care. Delivering ordinary care to paying patients is considered clinically productive; delivering outstanding care to charity patients is not.) This writer has heard the chairman of internal medicine at a prestigious medical school tell his faculty, "If you want to teach, do so at lunch––and keep your lunches short." Because of such pressures, many clinical faculty presently have little time to teach, advise, serve as mentors, or conduct research. In addition, medical students' opportunities to observe faculty doctoring in a teacherly, caring way are dwindling (Ludmerer 1999, pp. 373–5).

These conditions have not escaped the attention of faculty. Instructors at many medical schools are troubled by being unable to teach medicine, engage in research, and take care of patients in a way that fulfills their criteria of clinical and moral excellence. In particular, they have bemoaned the new rules of faculty practice that insist on maximum clinical productivity because those rules interfere with their educational duties. In the words of a pediatrics professor at the University of Texas Medical School at Galveston, because of the pressure to maximize clinical earnings, "We don't see how we can be educators" (Mangan 1996). If there was one tenet of medical education that helped to ensure medicine's place as a university discipline in the 20th century, it was the importance of conducting medical education in a scholarly environment. This principle is being violated by the shift in emphasis from teaching and research to patient care and by the conversion of a scholarly faculty to an exclusively clinical faculty.

Though teachers are important to the learning environment, the opportunity for students to spend ample time with patients is even more critical. In this respect, the marketplace has again been extremely injurious to clinical learning. Through the mid-1980s, the average length of stay at teaching hospitals was 10 to 12 days. Now, it is three to four days. In part this change reflects technological advances in medical care, such as the growing use of minimally invasive surgery. However, it largely represents the attempt by third-party payers to reduce hospital costs. Short hospital stays have forced medical schools to conduct clinical education in an atmosphere in which speed is the principal mandate for patient care. As a result, students are being converted from active learners to passive observers, with deleterious consequences for their ability to acquire fundamental knowledge and skills.

Among the present clinical environment's negative effects on the education of students is its impact on the acquisition of cognitive skills. It is much harder for learners to develop problem-solving abilities when patients are admitted with their diagnoses known and treatment plans already determined. Clinical clerks in surgery, meeting patients under the drapes of the operating table, can still learn about removing a gall bladder, but such encounters do not teach students to recognize the patients who might actually need the procedure or to distinguish such patients from those who do not. Once admitted, patients are often discharged before a diagnosis has been made or the effects of therapy observed––or even before an attending physician has had the chance to confirm a physical finding. These circumstances deprive students of the opportunity to follow the course of disease and treatment.

Of equal concern are this hurried environment's negative implications for the all-important latent learning of the "hidden curriculum." Habits of thoroughness, attentiveness to detail, questioning, and listening are difficult to instill when learning occurs in a clinical environment more strongly committed to patient "throughput" than to patient satisfaction. In addition, it is hard to imagine how it can be good for the development of caring attitudes to conduct medical education in a commercial atmosphere in which a good visit is a short visit, patients are "consumers," and institutional officials more often speak of the financial balance sheet than of the relief of suffering. Many of the ten case reports discuss the schools' attempts to develop professionalism through "white coat" ceremonies. None of the reports, however, addresses the issue of how such efforts can succeed if the internal culture of the academic health center no longer readily reinforces the values and principles that faculty wish to impart.

Conclusion

For the past century, the strength of clinical education in the United States has grown mainly from the exceptional learning opportunities available to students in the wards and clinics of teaching hospitals. A diverse array of patients was present, faculty were well qualified, and students actively participated in their care. There was time enough for teaching and for learning. Students could observe firsthand the natural history of disease and the course of therapeutics, learn the nuances of clinical medicine, and explore in-depth issues of particular interest.

In this context, the erosion of the learning environment at academic health centers represents the greatest threat to the education of physicians in the United States. The intellectual challenges to teaching posed by the molecular revolution are very real, as is the need to prepare students more fully in the area of chronic diseases. These challenges, however, are less pressing than that of maintaining a nurturing learning environment where teachers have enough time to teach, learners have enough time to learn, and institutional leaders care more about service to patients than cash flow or market share. If the medical profession and society do not address this problem, medical students will not be adequately prepared to practice.

Going forward, medical education's greatest need is to modify the internal culture of the academic health center so that it once again facilitates active learning and better reinforces the values and attitudes that medical educators wish to impart. Medical educators have spent much time in recent years discussing how they can accommodate education to inpatient and outpatient settings without slowing down the flow of patients. They will now need the courage to do just that––slow down the patient-flow in teaching settings––so that educational objectives can be better met. Of course, preserving the learning environment is no small task, since academic health centers have become far more commercial––and far less friendly to patients and students––than they were even a few years ago. Faculty and administrators might have to make personal financial concessions for the sake of preserving the quality of medical education and patient care at their institutions.

All who might ever be sick should hope that these steps will be taken. Until professional and public leaders succeed at making the internal culture of academic health centers less commercial, our efforts to produce competent and caring physicians will continue to be undermined.

References

Fox, Renée C. 1989. The Sociology of Medicine: A Participant-Observer's View. Englewood Cliffs, N.J.: Prentice-Hall.

Ludmerer, Kenneth M. 1985. Learning to Heal: The Development of American Medical Education. New York: Basic Books.

Ludmerer, Kenneth M. 1999. Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care New York: Oxford University Press.

Mangan, Katherine S. 1996. Medical Schools Are Reining in the Salaries of Faculty Members. Chronicle of Higher Education , July 26, p. A18.

---

Baylor College of Medicine
Rebecca T. Kirkland

Executive Summary

Students entering Baylor College of Medicine today will have a very different educational experience even from that of students who entered less than a decade ago. In response to societal needs, calls for change from numerous national organizations, and an internal recognition of growth opportunities, the medical school has made many important and far-reaching changes to the governance, organization, and teaching format of its curriculum and has implemented innovative programs to develop, recognize, and reward its faculty. These changes have produced a more active, meaningful, and responsive learning climate.

What Are the Innovations?

Baylor faculty and students today have a greater awareness of the health needs of the populations we serve. This awareness, coupled with our desire to serve, have compelled the faculty to strive to incorporate into the curriculum contemporary topics such as pain management and palliative care, nutrition, genetics, child and adult abuse, cultural differences and spirituality, and alternative and complementary medicine. Clinical and community experiences now occur early in the medical school curriculum in order to relate the science to the care of patients. Later, in the fourth year, students revisit basic science in relation to disease topics. And to support active, lifelong learning, we have woven small-group problem solving, case-based learning, and problem-based learning sessions into the curriculum. We emphasize ethics, humane and professional behavior, and altruism throughout. We have implemented the Master Teacher Fellows Program, the Committee on Education Development (CED), and Medical Education Seminar Series (MESS) to improve teaching skills and demonstrate that we value teaching.

What Are the Innovations Expected to Accomplish?

Baylor's educational goal is to prepare skillful, productive, ethical physicians who will advance scientific discovery and who will apply technological innovation to the health needs of patients, families, and the greater society in a humane and professional fashion. We are developing innovations that enable our students to grasp new scientific knowledge in the context of patients' health needs, to communicate with their patients about health issues of concern to them, and to respond to societal concerns. The innovations encourage our students to become active, lifelong learners so that they will more naturally use and incorporate new knowledge into their medical practice. The innovations enable Baylor College of Medicine to offer pedagogical training to its faculty and to demonstrate to faculty members that teaching is valued by rewarding them for improvements in teaching.

What Are the Known Effects of the Innovations?

We know that students are more knowledgeable about the services available to patients in the community as a result of their exposure to these services. We know they are more involved in reaching out to the community through a student-run homeless clinic with faculty supervision. From student responses to the 1999 Medical School Graduation Questionnaire, we know that we are teaching more about contemporary issues in medicine than we had before. And we know that, immediately after its implementation, 80 percent of matriculants said they chose Baylor because of the new curriculum. In addition, the Master Teacher Fellows Program, the CED, and the MESS have enabled us to identify additional faculty with a renewed interest in education.

Introduction

Baylor College of Medicine in Houston is the only private medical school in the greater southwestern United States. Since its founding in 1900, the school has gained international respect for excellence in education, research, and patient care. Of the 126 medical schools in the United States, Baylor ranks among the top 15 in research funding.

Baylor College of Medicine's mission is to promote health for all people through education, research, and public service. The college pursues this mission in several ways––sustaining excellence in educating students, physicians, and scientists by advancing basic and clinical biomedical research; fostering public awareness of disease prevention and other health issues; and promoting the highest standards of patient care.

Background

In 1903, Baylor College of Medicine began an affiliation with Baylor University that lasted until 1969, when the medical school became an independent institution. In 1943, the college moved from Dallas to Houston, becoming the cornerstone of the Texas Medical Center. Since 1969, Baylor has received state funding under a legislative partnership that provides physician training for Texas residents.

In the 1999–2000 academic year, Baylor had 713 medical students, 341 graduate students, 357 postdoctoral fellows, 124 allied health students, and 954 resident physicians. A majority of the medical students were Texas residents; nearly 20 percent were underrepresented minority students; and more than 33 percent were Asian-American. The college has 10 Ph.D. programs, 3 interdisciplinary programs in the biomedical sciences, 1 combined M.D./Ph.D. program, 4 allied health programs, and residency programs for resident/fellow training in 21 medical specialties. Baylor has affiliations with Rice University, the University of Houston, the University of Texas Health Science Center at Houston, and Texas A&M University. These institutions allow Baylor medical and graduate students to receive credit for approved coursework, thus offering wide choices in the physical and life sciences. The Baylor/Rice Program in Health Sciences Management consists of a dual-degree (M.D./Ph.D. and M.B.A.) program with a focus on health care. In addition, Baylor has relationships with the University of Texas–Pan-American Premedical Honors College, the University of Houston Premedical Academy, and Rice University to prepare committed undergraduates for a career in medicine.

Baylor College of Medicine's patient care services extend to 18 institutions in Houston, reaching more than 135,000 inpatients and 1.7 million outpatients annually. Baylor has affiliations with six area hospitals, including the Methodist Hospital, Texas Children's Hospital, the Institute for Rehabilitation and Research, St. Luke's Episcopal Hospital, the Houston Veterans Affairs Medical Center, and the Harris County Hospital District's Ben Taub General Hospital. These affiliated hospitals provide a wide variety of patient experiences, including inpatient acute and chronic care, outpatient experiences, and primary care opportunities. Full-time Baylor faculty serve as the attendings in these hospital settings. The college also provides medical services for six of the Harris County Hospital District's community health centers and for the Thomas Street AIDS Clinic.

Baylor College of Medicine, with total research support of $207.9 million, operates more than 50 research and patient-care centers. These centers include the nation's only Acute Viral Respiratory Disease Unit, the national Children's Nutrition Research Center, the DeBakey Heart Center, a Human Genome Research Center, the Shell Center for Gene Therapy (a unit of the Howard Hughes Medical Institute), a Child Health Research Center, the Huffington Center on Aging, a Center for AIDS Research, and the Breast Care Center.

Baylor's research facilities are outstanding. The college is one of only three U.S. institutions to house two National Institutes of Health Heart, Lung and Blood Special Centers of Research, one devoted to the study of arteriosclerosis and the other to heart failure. It is also the site of the Matsunaga-Conte Prostate Cancer Research Center, one of only two specialized programs of research excellence for prostate cancer in the nation.

Baylor's faculty includes 1,569 full-time, 147 part-time, and 1,577 voluntary faculty. The basic science faculty includes 344 full-time members and the clinical faculty 1,225 full-time members.

Curriculum Prior to Change

For more than 20 years before implementing a new curriculum in 1995, Baylor College of Medicine had a relatively traditional medical curriculum in which a lecture-oriented, discipline-based preclinical experience was followed by clinical rotations. Somewhat unusual, however, was that for almost 30 years the basic sciences portion of this curriculum occurred over one and a half years followed by two and a half clinical years.

The one and a half years of basic sciences included 16 individual courses taught from 8 A.M. to 5 P.M. daily, five days a week; 14 of these courses were under individual departments' auspices, and there was limited communication between departments or between departmental faculty and their clinical colleagues. Only two courses were interdepartmental. The courses placed emphasis on exquisite detail rather than basic concepts, and the curriculum was heavily dependent on lectures, with few opportunities for active learning or reflection. There was no horizontal integration of courses (that is, the integration of content that occurs concurrently within a block). Moreover, efforts at vertical integration––the progression in learning that builds on what has been taught previously and prepares the student for what is to come––were minimal. These unsatisfactory conditions, which already made learning difficult, were intensified by a "parade of stars" approach: multiple lecturers who were unaware of what their students had been taught before or would be taught after their own courses. A lack of communication among course directors regarding course goals and objectives made matters worse. The Curriculum Committee exerted very little influence over the organization and content of courses and rotations, and the Office of Curriculum/Education did not exist.

The absence of communication and the lack of centralized oversight led to serious omissions in the curriculum. We did not cover preventive medicine, public health issues, epidemiology, geriatrics, and women's health issues. Ethics and nutrition appeared only as electives in the basic science years. The curriculum did not emphasize professionalism and communication skills. Although we made some effort to introduce patients into the curriculum through clinical correlations during the first 18 months, the connection between basic sciences and clinical experiences remained weak.

The remaining two and a half years of medical school consisted of supervised clinical experiences in (required) clerkships and electives. The clinical curriculum included 16 core clinical rotations (a total of 68 weeks), each of which was organized by the appropriate department. The major rotations were 6 to 12 weeks in duration. The remainder were rotations of one to two weeks and were principally surgical subspecialties. The inclusion of so many required short subspecialty rotations set Baylor apart from other institutions nationally. For the most part, the sites for these required clinical rotations were the inpatient units and some outpatient units of the teaching hospitals affiliated with Baylor College of Medicine. The curriculum provided little opportunity for ambulatory experiences. Fifty-six elective credits, of which 32 were clinical elective credits, were required. The fact that teaching and evaluation by attendings were minimal on some rotations concerned us greatly (residents assumed much of the responsibility for the teaching and supervision).

Nevertheless, Baylor's combination of compressed coursework in basic sciences and longer clinical exposures was a successful format and enabled recruitment of high-quality students. Students viewed Baylor's comparatively long exposure to clinics as a major strength of the school's curriculum, particularly helpful in preparing for internships and determining ultimate career choices.

Rationale for Curriculum Change

Several forces led to the curriculum revision effort at Baylor:

1. Awareness of the national movement for reform in medical education, acknowledgment of pressures to become more responsive to societal needs, and the explosion of information and technology
2. The Liaison Committee on Medical Education (LCME) site visit in 1991
3. Internal curriculum reviews at Baylor

Each of these factors is discussed in detail below.

National Movement for Reform in Medical Education

The discussion leading to revision of Baylor's curriculum began with efforts to educate the faculty and leaders of the college about the national movement to improve medical education. We introduced the key issues through retreats, visits by educators from top schools, and questionnaires.

Traditional medical education in the United States has been successful in educating specialist physicians with strong backgrounds in biomedical and clinical sciences. While the need to improve the professional education of physicians had been discussed for many years, real efforts toward reform in medical education began with the 1984 publication of a report entitled Physicians for the 21st Century: Report of the Project Panel on the General Professional Education of the Physician and College Preparation for Medicine (Muller 1984). Two additional studies in the 1980s reinforced the GPEP Report's recommendations (Friedman, and Purcell, 1983; and Josiah H. Macy, Jr. Foundation 1988). The ACME-TRI survey, a follow-up to the GPEP Report, was conducted to determine whether any of the recommendations of the 1980s had been implemented and to discover what barriers were continuing to prevent schools from making the changes that leaders in academic medicine acknowledged should be undertaken (Swanson and Anderson 1993). While schools had implemented some recommendations, resistance to change continued to be evident at the school level. In the late 1980s, the education of medical students was for the "most part, little changed from that in the 1920's" (Swanson and Anderson 1993).

By the early 1990s, many leaders in medical education had become increasingly vocal and explicit about the inappropriateness of the ways in which medical students were taught and expected to learn:

Grossly overloaded curriculums, rote learning, the inclusion of topics with little obvious relevance to medical practice, and inappropriate teaching methods having been blamed for stifling enthusiasm, inhibiting students' abilities to benefit from post graduate and continuum training, and even contributing to stress and depression in junior doctors. (Lowry 1993)

Eli Ginzberg, director of the Eisenhower Center for the Conservation of Human Resources at Columbia University, summarized the rationale for reform in this way:

The pressures for reform come from a number of sources. From the complaints of students who object to being stuffed like turkeys during their first two years of medical school: they are taught about the most recent advances in the basic sciences which they cannot possibly absorb and much of which they will forget after they enter clinical training. . . . A growing current of criticism is also being voiced by members of the public, who complain that the physicians they need to care for them are not available or if they are, they cannot communicate effectively and thus cannot provide the counsel and help their patient needs. In addition to that, the payers for health care––both government and employers––are making the point that the out-of-control trend in medical care expenditures appears to be closely related to the faulty preparation that medical students (and residents) have received during their long periods of training. (Ginzberg 1993)

The movement to remodel the health care system led to calls for even more extensive reforms in medical education. The health needs of the population indicated that different competencies and skills would likely be required for future medical practice (Shugar, O'Neil, and Bader, eds. 1991; O'Neil 1993a; and Marston and Jones 1992). A recent survey by the Pew Health Professions Commission had found that only 19 percent of physicians who had graduated from medical school in 1960 or later believed that their schools had prepared them adequately to work in managed care settings (O'Neil 1993b), and the commission urged health professional schools to produce practitioners for the year 2005 who would possess an expanded set of competencies.

The Association of American Medical Colleges (AAMC) and the Association for the Study of Medical Education (ASME) established an agenda for change that urged medical schools to produce "physicians with the attributes that society is seeking for its next generation of physicians and beyond" (Community-bespoke Doctoring 1994).

Some medical schools (e.g., Brown University), responding to external pressures, had already redefined their curricula based on the competencies desired of their graduates. Other top schools (e.g., Harvard, Johns Hopkins) had begun a revision process including newer techniques such as problem-based learning and small-group sessions. That these respected schools had taken such action was another factor stimulating revision of the curriculum at Baylor.

Liaison Committee on Medical Education Site Visit

The Liaison Committee on Medical Education (LCME), a joint committee of the American Medical Association and the AAMC, is the major accrediting body for U.S. medical schools. The LCME's action following the accreditation visit to Baylor College of Medicine in February 1991 was a further stimulus to change. At the recommendation of the LCME, Baylor adopted an Educational Goals Statement later that year:

The goal of the educational program at Baylor College of Medicine is to provide the highest quality educational experience in the art and science of medicine and to foster the drive for excellence among all students. The College is committed to educate young men and women to become compassionate physicians with high ethical standards and technical competence and a dedication to deliver the highest quality care to all people. The program should inspire student physicians to become leaders in their fields, to help provide the knowledge base for new treatment strategies, and to develop new approaches to the delivery of health services, disease prevention, and health maintenance.

To achieve these goals, the program should be structured so that basic concepts are taught; it should be sufficiently flexible to allow students to develop and pursue their own interest in great depth. It should encourage students to seek additional training in the basic or clinical sciences, to participate in advanced degree programs such as the M.D./Ph.D. program, to conduct research, and to enroll in predoctoral fellowship programs. Graduates should be prepared to pursue careers as primary care physicians, specialists, research scientists, academic physicians, and physicians involved in public health policy.

The LCME had requested that the "status of curricular evaluation, planning and implementation to achieve a coordinated and coherent program of education" be addressed. The committee specifically mentioned the need to control unnecessary redundancy and to ensure that sufficient prominence was given to medical humanities, health promotion/disease prevention, and community medicine. The LCME requested information on development of an Office of Education or its equivalent as a "focus of information and research on methods of teaching and evaluation, and as a resource supporting and enhancing the educational stewardship of the Curriculum Committee and faculty." This was seen as an essential step toward developing accountability for curriculum content and educational goals and objectives.

Internal Curriculum Reviews

Baylor's curriculum was reviewed internally four separate times during the decade prior to the initiation of reform. The occasions of these reviews were as follows.

• Medical Education Task Force––Executive Faculty Retreat, February 1985
• Curriculum Self-Study, June 1990
• Medical Education 2001 Task Force, 1990–1991
• Medical Education 2001 Task Force––Executive Faculty Retreat, April 1992

These reviews made a number of recurring recommendations for change: to promote students' independent learning and analytical skills; to reward faculty teaching; to evaluate faculty in supervision of medical students (i.e., to improve methods of medical student evaluation and evaluation of courses and curriculum); to teach nutrition, preventive medicine, computer skills, ethics, geriatrics, and public health; to reevaluate the then-current requirement that students rotate through each of the surgical specialties; to allow greater participation of students in curriculum design and implementation; and to change governance of the curriculum and empower the Curriculum Committee, appoint the associate dean, and establish resources. Steps toward planning for implementation were, however, stalled until governance issues were addressed by the Executive Faculty in 1992.

Foremost among the Medical Education 2001 Task Force's recommendations was the need to redesign and empower the Curriculum Committee. At the April 1992 Executive Faculty Retreat, the Curriculum Committee was empowered to formulate, implement, direct, and evaluate the college's medical education curriculum. The number serving on the Curriculum Committee, which had previously had 44 members (including 2 students), was reduced to approximately 16, who would include 13 faculty and 3 students; 2 administrative liaisons would serve as ex officio members. In addition, the task force recommended creation of an associate dean position to administer the college's medical education curriculum. In October 1992, a new Curriculum Committee was formed following interviews by the president and dean; appointments to the committee were based on faculty interests in education rather than departmental affiliations.

In summary, the message for the faculty was that change was needed. Students needed to be more effectively prepared to practice medicine in the changing health care environment of the 21st century, to meet the expectations of a diverse society, and to become lifelong learners.

Characteristics of Curriculum Change

A first important change was the initiation of the effort to move from the traditional curriculum, with its sharp demarcation between the basic science of the first 18 months and the clinical curriculum of the following two and a half years to a graduated curriculum in which basic science and clinical experiences are represented throughout the four years (see figure 1). The first step of this process involved instituting two new courses: Patient, Physician, and Society (PPS), which would introduce the student to clinical experiences from the outset, and Mechanisms and Management of Disease (MMD), which would carry basic science education through the fourth year.

The second step was to increase students' ambulatory experiences significantly by placing them in community practices with preceptors in the first and third years as well as providing additional outpatient experiences in the clinical core courses.

A third step was to emphasize small-group experiences, including problem-based learning and case-based learning. To accommodate small groups, the college remodeled its teaching facilities to provide 21 small-group rooms as well as computer space for computer skills and medical information management training.

Fourth was a move to a modular format for some courses in the second half of the first year and the first half of the second year. The modular format improved both vertical and horizontal integration.

Fifth, evaluation of teachers and courses led to more consistent assessment, giving the Curriculum Committee the ability to identify curriculum issues to which it should respond. The modular format and formalized evaluation process required building an administrative infrastructure to support the effort to integrate courses and evaluate them.

We identified faculty development as a need very early in the process. The sixth step was to develop the Master Teacher Fellows Program, making it the cornerstone of the faculty training and education program. A curriculum office providing infrastructure such as course administration and secretarial and evaluation support was also established, and a medical educator was hired to oversee the faculty development and evaluation process.

Seventh, the Curriculum Committee identified five themes that should be incorporated into the four-year program: genetics, pain management and palliative care, evidence-based medicine and critical appraisal, managed care/cost containment, and gender issues (with emphasis on women's health issues).

Both before and since the reform process was begun, we have asked students who matriculate at Baylor why they chose the school. Before the reform, there was no single dominant reason. Following the curriculum change, 80 percent of matriculating students have said that the new curriculum was a major reason for their having chosen Baylor.

Dynamics

The reconstituted Curriculum Committee met for the first time in October 1992. At this meeting, the committee prepared a mission statement and articulated the revised program's fundamental tenets. These tenets are as follows:

• The curriculum at Baylor College of Medicine should prepare students to function as medical professionals in the social and technological environment of the 21st century.
• The curriculum should be designed to foster self-directed learning and lifelong learning skills.
• The curriculum at Baylor College of Medicine should undergo evaluation that will guide its improvement.
• The Curriculum Committee should promote excellence in teaching.

The committee also crafted a statement of the reform's ultimate purpose (adopted April 1993; revised March 2000): "To prepare skillful, productive, ethical physicians who advance and apply, in a humane and professional fashion, scientific discovery and technological innovation to the health care needs of individual patients, their families, and to larger societal groups." Among the new Curriculum Committee's first agenda items was to consider the specific recommendations that had emerged from the earlier task forces. These included the following:

• Decreasing unplanned redundancy
• Considering the appropriateness of the short rotations
• Examining the quality of behavioral sciences courses
• Introducing contemporary topics in geriatrics, nutrition, ethics, women's health, cultural diversity, etc.
• Using contemporary teaching methods, including informatics, problem-solving, concept-learning, and lifelong-learning skills
• Enhancing ambulatory care experiences
• Preparing the generalist physician
• Rewarding teaching faculty

Faculty Initiatives

Given the Curriculum Committee's directive to implement and direct the undergraduate curriculum, it was important that the committee listen to the faculty's opinions about the strengths and weaknesses in the current curriculum as well as the barriers to and opportunities for change. Through a series of meetings and questionnaires with teaching faculty in 25 academic departments, a number of familiar themes emerged: the need to recognize and reward teaching excellence, the need to improve communication between basic sciences and clinical sciences, and the need to pursue ongoing training and improvement of faculty skills.

Curriculum change at Baylor College of Medicine formally began in the fall of 1992. Phase I was a grass-roots effort carried forward by a group of creative, dedicated faculty advocating for change. We spent considerable energy on informing the general faculty of national directions and bringing them up to speed on movements occurring around the country. A group of faculty made visits to other institutions to learn about new teaching techniques (such as problem-based learning) as well as the content and format of curricula at other colleges. Baylor was extremely fortunate to have had outstanding faculty who stepped forward to lead specific efforts. Eleven task forces were appointed to capture the ideas of as many faculty as possible. During this phase, we queried all medical students in all four years about the curriculum through a questionnaire, and each of the task forces considered their responses.

We held a mini-retreat in June 1993 to discuss the result of Phase I. During this meeting, we discussed the strengths and weaknesses of the curriculum. The faculty and student body reiterated the following major strengths and weaknesses:

Strengths

• Bright students
• Talented faculty
• One and a half years of basic sciences and two and a half years of clinics
• Exposure to diverse patient population
• Excellent clinical facilities in both the private and the public sectors
• Flexible scheduling
• Extensive clinical elective opportunities

Weaknesses

• Teaching often done by residents
• Accountability for curriculum content not evident
• Perceived low priority of medical education by senior administration
• Coordination and integration between basic and clinical sciences not evident
• Overemphasis on surgery and surgical subspecialties with an excessive number of required short rotations
• Didactic courses occur from 8:00 A.M. to 5:00 P.M.
• Newer important topics (i.e., nutrition, epidemiology) not taught
• Recognized weakness in some courses
• Some basic science courses provide too much factual detail
• Outstanding faculty inefficiently utilized

Resistance to Change

Early in the process, an "if it ain't broke, don't fix it" group was quite vocal in arguing against change. The basic arguments against reforming the curriculum were that Baylor students did well on standardized tests and performed well in residencies. Other negative comments included the following:

• "We have done this before––20 years ago."
• "We have done this before. It won't work."
• "We have done this before, and there's nothing new here. What goes around, comes around."
• "My course will lose its identity."
• "It's too labor intensive, and we're too busy doing research and generating clinical revenue."
• "We don't get paid to do that."
• "My chair doesn't recognize teaching as important."

This vocal minority eventually faded, however, as the "change train" left the station and gained momentum. Various strategies used to persuade the naysayers included these:

• Enroll and engage creative thinkers and innovators among the faculty
• "Agree to agree" on basic tenets and principles
• Find out what matters to the faculty and ensure that the entire faculty discusses and buys into the general directions of change
• Rely on leadership by the deans
• Emphasize external pressures for change (LCME direction and mandate; granting agencies' preferences and requirements; other schools' curriculum reforms and their usefulness as benchmarks to determine "best practice") and use them to indicate the urgency of reform and to engender the desire and will to achieve change
• Ensure that institutional funding will continue to support and maintain ongoing efforts to change

The administration's support enabling the design and remodeling of teaching space to create the 21 small-group rooms also had a very positive effect.

In the Curriculum Committee chair's visits to departments, in task force meetings, and in other discussions, faculty indicated that they would participate in the revision process but that the school needed to provide a system of recognition and reward for excellence in teaching. One of the first high-visibility programs to be instituted was the Master Teacher Fellows Program. The program identified 12 to 20 teaching faculty who received an 18-month program of didactic theoretical and practical experiences culminating in a fellow project. We formed a Faculty Training and Education (FTE) Committee, and it developed a prototype Educator Portfolio, but this was not implemented because the Faculty Appointments and Promotions Committee was not prepared to embrace this tool as part of the promotion and tenure process. With an influx of graduates of the Master Teacher Fellowship Program and the arrival of the director of the Office of Curriculum, the FTE Committee evolved to become the Committee on Educator Development (CED). The CED was charged with the general responsibility of creating a pro-teaching environment. Drawing support from a diverse group of faculty, the CED sponsored workshops to improve teaching skills, introduce new techniques, and provide orientation to teaching opportunities at Baylor. The CED developed an awards program to reward excellence in teaching and to acknowledge contributions in education (the Presidential Educator Award and the Distinguished Educator Award) as well as a peer-review program. The college identified funding for the Presidential Educator Award, which it implemented as the Barbara and Corbin J. Robertson, Jr. Presidential Teaching Award. The CED developed a Web site to permit easy access for the faculty to the teaching opportunities (http://www.bcm.tmc.edu/fac-ed/). The Web site provides an orientation to types of teaching at Baylor College of Medicine and to workshops, lectures, and seminars on teaching techniques and methods. The committee created a Medical Education Seminar Series was to provide a forum for discussion of contemporary issues in medical education.

The efforts to create opportunities for faculty to improve their teaching skills have been substantial. We developed and implemented a system of measuring teaching quality, including student and resident assessment of lecturers and clinical attendings. Nevertheless, the faculty continue to express dissatisfaction that their department chairs do not recognize the importance of their teaching contributions and that there are increasing pressures to spend more time with revenue-producing activities (i.e., performing research, grant writing, and patient care) at the expense of teaching. Faculty participation in multidisciplinary courses where departments do not own the course has been particularly problematic.

Baylor's participation in the AAMC's Medical School Objectives Project has been particularly helpful in providing continuing exposure to new ideas; in developing instruments to measure professionalism, altruism, and dutifulness; and in enabling the school to share approaches to curriculum problems and issues, benchmarking, and "best practices."

Impact of Curriculum Change

The process of change that began with Phase I, assessment and review of curriculum, continued with Phase II, design of new templates; Phase III, development and further refinement of content and the piloting of a new course; Phase IV, a plan for implementation and additional pilots; Phase V, evaluation and revision; and Phase VI, ongoing "thematic" reform and continuous improvement. Important results of the implemented changes were these:

• We created an Office of Curriculum and hired an educator to direct its activities.
• We improved ongoing evaluation of courses, teachers, and curriculum.
• We eliminated unplanned redundancy.
• We incorporated opportunities for horizontal and vertical integration into the program.
• We introduced modular format (integrated) courses, such as The Nervous System and Infectious Diseases, in the second half of the first year.
• We now permit students three afternoons per week for independent study.
• We implemented the Longitudinal Ambulatory Clinical Experiences (LACE) program, including six months in community preceptors' offices and six months in community agencies in the third year (see below).
• We made nutrition, Evidence-based Medicine and Critical Appraisal, Radiology, and Ethics required courses in the second year. (Students leave the clinical rotations or electives for the "clinical half-day" each week.)
• The Patient, Physician, and Society (PPS) course emphasizes professional values, communication skills, and physical examination skills from the first week of the first year.
• Students and their faculty mentors conduct a "white coat ceremony" to emphasize professionalism.
• Integrated Problem Solving (IPS) promotes small-group participation, assessment of technology skills, use of technology, and lifelong independent learning.
• Students have more required ambulatory experiences. These experiences increased to 10 percent in the first 18 months; an additional 10 percent in the third year; and as much as 30 percent in clinical core rotations, such as the surgery rotation.
• Mechanism and Management of Disease (MMD) fosters integration of clinical and basic sciences in a modular format in the fourth year.
• Integrated Clinical Experiences (ICE), taught as an elective in the fourth year, prepares students for their internship experience. ICE includes advanced cardiac life support training as well as stress-management skills and role-play to help students learn how to counsel dying patients.
• The program puts additional focus on genetics, pain management, gender issues, cultural issues, and complementary and alternative medicine.
• Students develop improved teamwork, listening, and communication skills.
• We use a universal evaluation form, including an item to assess dutifulness in students, for clinical cores.
• Surgery is reduced to 12 weeks from 19 weeks and includes 4 weeks of ambulatory subspecialty experiences.

The community agency portion of the LACE course consists of modules on topics such as child abuse, elder abuse, alternative and complementary medicine, cultural differences and spirituality, hospice care/end-of-life issues, and geriatrics. Each module presents students with specific goals and objectives. We place students at specific agency sites in the community during each module, and, as part of the evaluation, the students must complete a "passport" regarding their experiences.

Both formal and informal assessment pointed to the revised curriculum's success. The medical school faculty indicated that, although the newer teaching efforts were more labor intensive, they enjoyed teaching more. Students also responded favorably, as can be seen from the fact that, immediately following implementation, 80 percent of the students in the matriculating classes stated that they came to Baylor because of the new curriculum. This indicated that student members of the Admissions Committee and student tour guides had communicated a positive view of the changes to applicants, since the matriculants had no prior experience with the curriculum. Following the changes, many clinical attendings on the core rotations made comments (both spontaneous and solicited) to the effect that students were less hesitant to participate in the team and were more comfortable communicating and working with patients. Several attendings volunteered that the students on their teams were actually able to serve as resources for discharge planning because of the knowledge they had gained about social services and community agencies through the LACE program. Preceptors in the fourth-year Integrated Clinical Experiences course indicated that students who had been through the curriculum provided better feedback on evaluations and performed better in role-play.

The college's president, Dr. Ralph Feigin, and state government liaison representative, Tom Kleinworth, used the specifics of the curriculum changes to lobby the legislature for state support of medical school funding. This effort was successful. The medical school curriculum reform subsequently stimulated the graduate school and physician assistant program to undertake revisions of their own curricula.

Baylor students do very well on the United States Medical Licensing Examination Steps 1 and 2. Following the curriculum revision, Baylor students' mean scores on Steps 1 and 2 continued to be significantly above the national mean. In addition, the 1997 LCME site visit was very different in tone from the earlier one and was a positive reflection on the progress Baylor had made and on the school's commitment to build on initial reforms with continuous and ongoing improvement.

Student responses to the AAMC's Medical School Graduation Questionnaire in 1999 provided an additional measure of the success of Baylor's efforts to improve coverage in certain content areas. With a 91 percent response rate, the questionnaire showed improvement over the previous year in the following areas (based on 5 percent difference in "Appropriate" ratings): teamwork with other health professionals, clinical decision making, nutrition, geriatrics, pain management, public health and community medicine, community health and social service agencies, health promotion and disease prevention, clinical epidemiology, biostatistics, medical socioeconomics, medical care cost control, cost-effective medical practice, quality assurance in medicine, managed care, law and medicine, behavioral sciences, medical ethics, genetics counseling, and alternative medicine. In response to all questions on information technology, Baylor students ranked their level of knowledge and skills as equal to or higher than that of students from all other schools (based on 5 percent difference in "agree" or "strongly agree" ratings).

The Master Teacher Fellows program has been successful in identifying faculty members who become resources for curriculum activities requiring faculty input and guidance, such as developing skill-building workshops, the peer-review program, and the merit-based educator recognition program.

Plans for the Future

From 1992 on, the process of change at Baylor has been so challenging and intensive that we decided to promote continuous improvement––using evaluations, focus groups, and other tools for gathering feedback––rather than resorting to intermittent wholesale reforms of the curriculum.

Three task forces were appointed to evaluate our next steps. The Basics Committee worked for more than a year to identify trends and directions, eventually reaching consensus that Baylor needs to proceed in the direction of interactive, interdisciplinary labs and the greater use of technology in teaching. Some of the committee's recommendations have been implemented, but others are long-range goals and require the modernization of facilities. A second task force reexamined Fall I in an effort to further integration of courses. A third group, the Educational Facilities Committee, made recommendations for remodeling Baylor's medical education facilities to accommodate technology and make space more flexible. Committee members made visits to other medical schools to examine their curriculum and facilities. The college charged an Information Technology Strategic Planning Committee with examining methods for incorporating technology in education across the college's entire educational enterprise, including allied health, graduate school, and graduate medical education as well as undergraduate premedical education and continuing medical education.

Some changes have not met expectations or served the immediate purpose of advancing the curriculum:

1. Lectures still account for more than 60 percent of teaching time during the first year. Strategies are being developed to move toward fuller integration of first-year courses.
2. The curriculum database still does not capture the desired level of detail or reflect the integration of theme areas in patient cases or clinical cores. It does, however, broadly identify who is teaching what and the time generally spent on larger topics.
3. We still have not incorporated theme areas into all four years in a comprehensive way, which indicates that we must find additional ways to address clinical teaching needs. We are developing strategies to identify clinical core content, to discover where emphasis should be placed, and to correct any omissions or unplanned redundancies.
4. We have not successfully resolved some governance issues. Identifying protected time (time set aside for and dedicated to teaching) for teachers and course directors remains an imperative. A coordinator must be appointed for the portion of the curriculum that occurs prior to clinical cores (the preclinical courses), and another must be appointed for the clinical-core years and given at least 50 percent protected time. Similarly, there needs to be improved accountability for the clinical curriculum. These steps would enable oversight of the entire curriculum to ensure that goals and objectives are consistently evaluated and met.
5. Space and infrastructure support remains inadequate. As more courses become integrated and centralized, individual departments cannot provide the required support, and coordinators and staff require space.
6. Demands on faculty to produce more research dollars per square foot of research space and to generate more clinical income by seeing more patients continue to interfere with educational goals and objectives. Furthermore, the implementation of Health Care Finance Administration (HCFA) compliance guidelines in ambulatory and inpatient documentation has eroded the amount of time faculty spend teaching in clinical venues. In response, we would like to implement mission-based budgeting. To move us in this direction, we have developed a relative value scale for education (RVSE) to enable the institution to document, recognize, and "compensate" faculty contributions to education. The proposed RVSE contains a comprehensive set of educational services (from lecturing to attending to committee participation), each with an assigned relative "value" of time-based credits. Each year, department, program, and course administrators will report individual faculty contributions to these services (e.g., number of lectures or months attending). By multiplying the number of reported contributions to each service by the value assigned it and then summing these calculations across all services, we will calculate a total RVSE value for each faculty member. Our intent is to create a single scale to apply to all faculty for all teaching endeavors.

   The following actions would help efforts to encourage faculty and residents to see themselves as educators and to foster a pro-teaching environment:

7. Faculty should be awarded incentive grants for innovation in education.
8. Funding should be provided to enable implementation of faculty peer-review and merit-based educator recognition programs.
9. The school must make additional efforts to improve residents' teaching, to help residents become role models, and to gather feedback on residents' teaching performance.
10. Effort is also needed to bring the cognitive and performance evaluation of students into line with the revised curriculum. "Students do not respect what you expect; they respect what you inspect," said AAMC president Jordan Cohen at an AAMC meeting in November 1994. The evaluation and assessment process needs to reflect the goals and objectives of each portion of the curriculum. Examination questions and other evaluation tools should reflect the integrated teaching approach. Performance-based examinations can be important measures of progress. Information technology would facilitate feedback and evaluation both of faculty by students and of students by faculty and residents.
11. The use of information technology to support active learning and to facilitate lifelong, independent learning needs to become pervasive across the curriculum. A task force is addressing and prioritizing information technology issues in education, including the use of hand-held computing devices, the use of simulation, the balancing of didactic lectures and information technology-based cases, the posting of course information on the Web, and the use of Web-based technology for gathering evaluations and feedback from a variety of off-site locations. Interactive, computer-based programs can provide an additional tool to support active learning so that students have the opportunity to use the information that they learn. We have a better chance of changing behaviors if information is owned and practiced rather than merely passively acquired.
12. The current health care environment no longer allows students with a faculty member to spend a comfortable hour and a half with a new patient or 30 to 45 minutes on a follow-up visit. Nor is inpatient service organized such that a student can follow a patient's progress from admission to discharge. Shortened hospital stays and the focus on "through-put" mean that students do not receive firsthand understanding of the stages of disease or extended exposure to experienced clinicians. Medical schools, including Baylor, need to examine medical students' clinical experiences and adapt them to the realities of today's clinical environment. We need to ensure that ambulatory experiences receive the same oversight and quality expectations as any other student activity.

Baylor College of Medicine has embarked on a three-month planning phase, called Vision 2005, to develop tactical plans in areas relating to its research, clinical care, and education missions. The Education Strategic Plan is addressing the need to create a fully integrated curriculum from preclinical through clinical years; to decrease didactic lecture time and increase active learning through small-group teaching; to diversify small-group learning venues; to support faculty development in technology and theme issues; and to integrate into the entire four-year program themes such as pain management and palliative care, health-related gender issues, cultural sensitivity, managed care and the health care environment, cost-effective health care, population health, medical informatics, communication skills and spirituality, and altruism and dutifulness. Baylor will provide opportunities to enable students with special interests to earn a certificate in topics such as research, international medicine, or medical informatics.

Finally, additional emphasis must be placed on patient–physician communication and professionalism throughout the four years. As the 1993 outcomes statement was revised in 2000, so should the Educational Goals Statement of 1991 be reevaluated to reflect patients' and families' desire for doctors who will enter into trusting, respectful relationships with them. Goals and objectives for each of the curriculum segments should reflect not only knowledge of scientifically based medicine and medical skills but also a heightened understanding of patients' familial, cultural, and spiritual circumstances. To achieve the desired professional behaviors, we need to focus on inclusion of literature in the humanities, on listening to patients' stories, on reflecting on what patients are really saying, and on identifying effective role models who can provide students with feedback regarding their professional behavior. Some of these issues were raised earlier in the decade, but they have recently been given a higher priority. The erosion of clinical skills and the lack of role models discussed by Kenneth Ludmerer (1999) are effects of the current cost-containment environment on teachers' ability to provide the quality educational experience their students need.

In summary, Baylor has made much progress over the last decade as we have moved from lecture-oriented, discipline-based courses toward integrated, interdisciplinary teaching; toward providing students with patient experiences earlier in their careers; and toward increasing students' ambulatory and active-learning experiences. We understand that we need to continue to break down the departmental silos and to integrate theme topics throughout the four years. We have strengthened our Curriculum Committee's oversight of content, developed an effective evaluation process, initiated a faculty development program to improve teaching skills and reward excellence in education, hired a medical educator to oversee the activities of a new Office of Curriculum, and gotten students more deeply involved in curriculum oversight and evaluation.

We have become more aware of what patients need and want from their physicians and the health care system. We understand that the educational program's content should reflect contemporary issues as well as the growth of scientific knowledge. We know that professionalism, in all its aspects, should be modeled from the outset so that the desired practice of the art of medicine is consistently demonstrated. And we recognize that we need to teach students about health care delivery systems in a way that emphasizes that these systems are dynamic, not static.

The good news is that the medical school of 2000 is not the extended college experience or the apprenticeship of past decades. Today, we have a much greater awareness of the populations we serve and, with this, an expanded desire to understand and meet their needs.

References

Community-bespoke Doctoring. 1994. The Lancet, 343:613–4.

Friedman, C.P., and E.F. Purcell, eds. 1983. The New Biology and Medical Education: Merging the Biological, Information and Computer Sciences. New York: Josiah H. Macy, Jr. Foundation.

Ginzberg, E. 1993. The Reform of Medical Education: An Outsider's Reflection. Academic Physicians and Sciences (September).

Josiah H. Macy, Jr. Foundation. 1988. Adapting Clinical Medical Education to the Needs of Today and Tomorrow. New York.

Lowry, S. 1993. Medical Education. London: BMJ Publishing.

Ludmerer, K. 1999. Time to Heal. New York: Oxford University Press.

Marston, R.Q., and R.M. Jones, eds. 1992. Commission on Medical Education: The Sciences of Medical Practice. Medical Education in Transition. Princeton, N.J.: Robert Wood Johnson Foundation.

Muller, S. (chair). 1984. Physicians for the Twenty-first Century: Report of the Project Panel on the General Professional Education of the Physician and College Preparation for Medicine. Journal of Medical Education, 59 (part 2).

O'Neil, E.H. 1993a. Health Professions Education for the Future: Schools in Service to the Nation San Francisco: Pew Health Professions Commission.

O'Neil, E.H. 1993b. Point of View. The Chronicle of Higher Education (September 8).

Shugar, D.A., E.H. O'Neil, and J.D. Bader, eds. 1991. Healthy America: Practitioners for 2005, An Agenda for Action for U.S. Health Professional Schools. Durham, N.C.: Pew Health Professions Commission.

Swanson, A.G., and M.B. Anderson. 1993. Educating Medical Students: Assessing Change in Medical Education––The Road to Implementation. ACME-TRI Report. Academic Medicine 68:58.

---

University of California, San Francisco, School of Medicine
David M. Irby

Executive Summary

The University of California, San Francisco, School of Medicine was founded in 1864 and in the 1970s developed into one of the top ten research-intensive medical schools in the United States. Excellence in clinical programs followed. Beginning in 1998, the school has sought to match its stellar research and clinical programs with a world-class medical education program.

In the 30 years preceding 1998, the school instituted a series of changes in the curriculum in response to developments in medical science and changes in the practice of medicine. These curricular changes included creating a new second-year organ-system curriculum, introducing new content and courses, reducing lecture hours, and increasing small-group instruction.

Both external and internal forces prompted the 1998 reexamination of the curriculum. In 1993, the California State Assembly had mandated that 50 percent of University of California medical school graduates enter primary-care specialties, and in 1995 the University of California Board of Regents had banned affirmative action. These actions required changes in admissions and curriculum. In 1996, the Liaison Committee on Medical Education (LCME) accreditation team cited the school for lack of curriculum oversight. Then in 1997 the University of California Commission on the Future of Medical Education published a report calling for significant changes in curriculum. Internally, a mandate from the dean, new educational leadership, and the establishment of a planning process that brought interest in improving the curriculum to the surface motivated curriculum reform. This process engaged many faculty members, encouraged them to reexamine their assumptions about medical education, and offered them a new opportunity to address areas of concern in the existing curriculum.

The rationale and vision for change were anchored in several important concepts. These included the importance of creating an integrated and case-based curriculum, using instructional technology to enhance collaborative and self-directed learning, improving student communication and clinical exam skills, creating a supportive learning environment, strengthening support for the teaching faculty, and providing stronger curricular oversight.

Planning has occurred in three phases. The first phase (January–June 1998) established a foundation for change. This included a comprehensive evaluation of the curriculum, development of an educational mission statement and outcome objectives, and creation of planning guidelines. The second phase (September 1998–January 1999) explored alternative visions for the future of the curriculum. One task group, known as Greener Pastures, recommended incremental changes. A second task group, known as Blue Sky, envisioned a radically new curriculum. At a school leadership retreat in January 1999, most of the recommendations of Blue Sky were endorsed. The third planning phase (January 1999–September 2001) involves design of the new curriculum.

The new curriculum will be integrated, case-based, and Web-supported. During the first two years, termed the Essential Core, new interdisciplinary block courses will be offered. Each course will weave together strands of basic, clinical, and social sciences in an integrated manner. Clinical cases will be used throughout to motivate learning, increase information retention, and facilitate transfer of learning. All courses will use Web courseware to promote collaborative and self-directed learning. In the third year, known as the Clinical Core, clerkships will be clustered into six eight-week blocks separated by four one-week intersessions. Intersessions bring all students back to the classroom for integrative, thematic sessions related to topics such as ethics, pain, and abuse. The fourth year, or Advanced Studies, provides opportunities for subinternships, electives, an anatomy selective, scholarship, and preparation for internship. A new clinical skills and simulation laboratory will be constructed to support the integrated development of clinical and communication skills. The new Clinical Core curriculum began in July 2000 and the new first-year curriculum will begin in September 2001.

Curriculum reform also resulted in the creation of an entirely new organizational structure known as the Academy of Medical Educators. This school-wide organization's purpose is to support faculty members who teach medical students and to promote teaching excellence. Only the very best teachers will be eligible for membership. Those who become members will receive protected time for teaching through endowed chairs, advocacy for promotion, faculty development, and instructional improvement grants. In return, Academy members will be expected to take leadership roles in teaching and mentoring junior faculty members in the art and practice of teaching. Over the next five years, 30 endowed chairs will be established in the academy.

Responding to changes in science, technology, and practice, UCSF is transforming the way it educates students for practice in the 21st century.

Vision

"I want the educational programs of the School of Medicine to match the world-class quality of the research and clinical programs of UCSF," stated Dean Haile Debas in 1997. As the newly hired vice dean for education, I found this challenge both exhilarating and daunting. While the medical school curriculum at UCSF had changed constantly over the preceding decades, the overall structure looked remarkably as it had 30 years before, when the last major curriculum reform took place. Could a school that prided itself on innovation in research and health care do the same in education?

Responding to this challenge, I initiated a series of conversations with key faculty leaders. Together, we envisioned creating an exceptional academic program that would attract the best students, be taught by distinguished faculty members, be designed around innovative curricula, be supported by instructional technology, and be guided by educational research. We hoped to create a learner-centered, case-based, integrated curriculum that would utilize the latest instructional technology, foster a supportive learning environment, and strengthen teaching. In short, we visualized a whole new approach to medical education that would transform the learning environment. This vision arose in the context of the unique institutional history of UCSF, prior changes in the curriculum, and the need to respond to both external and internal pressures.

Background

The UCSF School of Medicine is one of the oldest medical schools in the West. Founded in 1864 as Toland Medical College, it became affiliated with the University of California in 1873. After the San Francisco earthquake of 1906, the basic-science faculty and medical students in the preclinical curriculum moved to University of California, Berkeley. In the 1950s, the basic sciences returned to UCSF, and in the 1960s and 1970s the school became a nationally recognized leader in medical research. Today, UCSF ranks as one of the top ten medical schools in the nation, and it ranks third in research dollars awarded by the National Institutes of Health. It has approximately 1,300 full-time faculty, 1,400 residents and clinical fellows, 500 research fellows, 400 graduate students, and 600 medical students.

Current Program

Students may enter the M.D. program at UCSF (141 in the entering class) or at UC Berkeley in the Joint Medical Program (12 students). The latter program takes three years for the preclinical curriculum. In the process, students earn a master's degree from the School of Public Health. They join UCSF students for the clinical curriculum in the last two years. Six students each year are also accepted into the M.D./Ph.D. program.

Primary clinical training sites for UCSF include the UCSF Medical Center hospitals (Moffitt-Long, Mount Zion, Langley Porter Psychiatric Institute) as well as San Francisco General Hospital, San Francisco VA Medical Center, and a multisite Fresno Medical Education Program. Both students and residents receive training at additional affiliated community-based hospitals in San Francisco (California Pacific Medical Center, Kaiser), Santa Rosa, and Salinas. In 1996, the UCSF medical school leadership was heavily involved in the creation of a joint venture with Stanford University, leading to the creation of UCSF Stanford Health Care in October 1997. After two and a half years of operation and large financial losses, the merger was dissolved in April 2000.

At the same time that planning commenced for UCSF Stanford Health Care, planning began for a second UCSF campus at Mission Bay. This 43-acre basic science research and teaching facility––a 20-minute drive from the existing campus—will be completed over the next two decades. Managing these two herculean tasks (Mission Bay and UCSF Stanford Health Care) plus curriculum reform stretched the capacities of the school's leadership and faculty.

Responsive Curriculum Change in Recent Decades (1969–1997)

Although the last major curriculum change occurred in 1969, since then there have been continuous, evolutionary revisions to the curriculum. The 1969 changes involved development of an organ-system curriculum, inclusion of the teaching of communication skills in the first year, and the creation of Introduction to Clinical Medicine in the second year. New courses in the social aspects of health and disease and in epidemiology were also added. A slight reduction in the clinical core clerkship curriculum was accomplished. The fourth-year curriculum was built around major pathways that provided guidance for students' choices of clerkship electives.

Over the ensuing three decades, incre