Carl J. Shapiro Institute for Education and Research Harvard Medical School and Beth Israel DeaconessMedical Center

The Clinical Education of Medical Students

would promote a national dialogueon the need for changein the clinical educationof medical students and assistindividual schoolsin planning and implementingreform efforts.

Severalyears ago,the faculty and staff of the Carl J. ShapiroInstitute for Education and Researchat Harvard Medical School and Beth Israel DeaconessMedical Center decidedthat the beginning of the new millennium would be an ideal time to host a working conferenceon the clinical education of medical students.The confluence of a number of circumstancesled to this conclusion: recognition of the educationalchallengesthat exist at the interface between a medical school and an academicmedical center; a senseof the financial and time pressuresfelt by clinical faculty as they dischargetheir patient care and teaching responsibilities;the publication of Kenneth Ludmerer'slandmark book, Time to Heal, that chroniclesso well the developmentof the daunting challengesfaced by academicmedical centers; and an interest in expandingthe ShapiroInstitute's activities in medical educationbeyond the local academiccommunity. At the sametime, the Associationof American Medical Colleges(AAMC) had launchedits Project on the Clinical Education of Medical Students.The project was designedto conduct a comprehensivereview of the clinical education of medical studentsand to effect changesin the designand conduct of the clinical curriculum to improve the quality of medical students' education. PhaseI of the project was intended to define the organization,structure, and content of the clinical curriculum, and to identify both issuesof concern and the educationalinnovations that might addressthose concerns.Phasen of the project was envisionedas a set of activities that

Givenboth organizations'interestin the topic, it madesenseto co-hosta national conferenceon the clinical educationof medicalstudentsin the new millennium. Wedecidedthat a worldng conference involving small teamsof medicaleducatorsand educationleadersfrom a representativegroup of medicalschoolswould generateideasfor innovations in clinical educationthat eachschool'steam could usein designingeducationalreforms that might be implementedat their institution, and that could be disseminatedwidely to stimulatereform in other institutions. Wefelt tl1atthe first Millennium Conference(April 28 to May 1, 2001)was highly successfulin achieving the goalswe had set. As a result, we decidedto co-hosta secondconference,involving teamsfrom another group of schools.Millennium Conference n (April 26 to 28,2002)was designedto allow the participating schoolsto reap the benefit of the discussionstl1atoccurred at Millennium ConferenceI by focusingthe attention of the participants on the issuesand opportunities consideredmost important by the participants at that conference. In this report, we attempt to capture much of the rich discussionand many of the thoughtful ideas that characterizedboth Millennium Conferences. We present a single summary,becausethere was significant overlap in the discussionsthat ocCUlTed at the two conferences.It is difficult to convey in a written report the senseof urgency,as well as the excitement and enthusiasmthat characterized the discussionsof educationalreform and innovation. In issuing this report, we hope that the ideas contained within will stimulate discussionsat medical schools acrossthe country about the clinical education of their medical students,and lead to meaningfulreformsof their educationalprograms.

The Clinical Education of Medical Students

In this way,the Millennium Conferenceswill have an impact on many more schoolsthan the relatively small number that were able to participate in the two conferences. In closing, we wish to expressour sincere gratitude to severalindividuals at the AAMC whose contributions, support, and participation in the conferenceswere truly invaluable-Dr. Jordan Cohen,Presidentof the AAMC; Dr. Donald Nutter, PetersdorfScholarin Residence(2000-2001)and Co-Chairof the LCME;and Ms. Brownell Anderson,SeniorAssociateVice Presidentfor Medical Education. Wealso are indebted to a number of individuals associatedwith the Shapiro Institute - Drs.CharlesHatem,Richard Schwarwtein, and Mitchell Rabkin;Jane Neill, Deputy Director of the Shapiro Institute until 2001 and now Deputy Director of the Academyat Harvard Medical School;Christine Coughlin, AssociateDirector of the Shapiro Institute; Carol Murree, OperationsCoordinator at the Shapiro Institute; Michele Cohn,AcademicCoordinator at the ShapiroInstitute until 2001and now Academic ProgramManagerof the Academyof Harvard Medical School;and DeanneNakamoto,who assistedwith preparation of this report. StevenWeinberger,M.D. Executive Director Carl J. ShapiroInstitute for Education and Research Michael Whitcomb,M.D. SeniorVice Presidentfor Medical Education Associationof American Medical Colleges

The Clinical Education of Medical Students

The first Millennium Conferenceon the Clinical Education of Medical Students(Millennium Conference I) was held from April 28 to May 1, 2001at the Center for Executive Education at Babson College,Wellesley,Massachusetts.Requestsfor applications to participate in the conferencewere sent to the deansof all North American medical schools in the fall of 2000.Forty-eight schools submitted applications.Eleven schools were selectedto attend basedin part on the scope and potential impact of a school'sproposedplans for reform of the clinical education of its students, and on a demonstratedcommitment to educational reform. In addition, a consciouseffort was madeto have diversity in the types and locations of the participating schools.The following schools participated in Millennium ConferenceI:

. . . .

. . . . . . .

Baylor Collegeof Medicine Duke University School of Medicine University of California, Los AngelesSchool of Medicine University of California, SanFrancisco School of Medicine Harvard Medical School University of Iowa Collegeof Medicine MCPHahnemannUniversity School of Medicine (now the Drexel University School of Medicine) Mayo Medical School Mount Sinai School of Medicine of New York University University of RochesterSchool of Medicine and Dentistry Uniformed ServicesUniversity of Health SciencesF. Edward Hebert School of Medicine

Each of the participating schools sent to the conference a team composed of four of the institution'8

educationleaders.The teamsgenerallyincludedthe ~e or vice deanfor medicaleducation,a clinical clerkshipdirector,a residencyprogramdirector, and an educationadministratorrepresentingone of the school'smajor affiliatedteachinghospitals. To set the stagefor the work of the conference participants, Dr. Jordan Cohenpresenteda keynote addressentitled ..A SecondRevolution in the Education of Physicians:Why Now?" Dr. Donald Nutter followed by presentinga talk that summarizedthe findings of PhaseI of the AAMC's Project on the Clinical Education of Medical Students.The conferenceparticipants were then informed of the three main questionsthat they would be askedto addressduring the course of the conference: 1.

What should be taught in the clinical curriculum? (What to teach?)

2.

How should the clinical curriculum be taught?(How to teach?)

3. Who should teach the clinical curriculum? (Who teaches?) To addressthose questions,the participants were divided into working groups composedof team membersfrom different schools.All of the groups addressedeach of the questions,one at each of three separateworking group sessions.A brief plenary sessionwas held before each of the three sessionsto orient the participants to the major issuesof concern related to the questionto be addressedduring the sessionand to clarify the objectivesof the session.At the completion of each working group session,the teamspresented the major points that aroseduring their discussions to the entire group of conferenceparticipants.At this conference,thesepresentations were followed by commentsfrom a group of experienced educatorswho had been invited to attend the conference. Following the three working group sessions,Dr. CharlesHatem presenteda plenary talk that focusedon the barriers to educationalreform. The

77IeClinical Education of Mediool Students

school teams then met individually to discusshow the issuesidentified in the three prior working group sessionsmight be addressedat their school, and to develop a plan for effecting refonns that were deemeddesirable.The conferenceconcluded with a presentation of each school'spreliminary plans for refonn. Millennium ConferenceII was held from April 26 to 28, 2002,again at the Center for Executive Education at BabsonCollegein Wellesley, Massachusetts.Eight schools were selectedto send teams to the conference,using a selection processsimilar to that used in selectingschools for the first conference.The following schools participated in Millennium ConferenceII:

. . . . . . . .

Dartmouth Medical School Indiana University School of Medicine Medical Collegeof GeorgiaSchool of Medicine University of Michigan Medical School University of NebraskaCollegeof Medicine New York University School of Medicine Northwestern University FeinbergSchool of Medicine State University of New York Upstate Medical University Collegeof Medicine

In addition, each school that had participated in Millennium ConferenceI sent a team representative to Millennium ConferenceU. Each of those representativespresenteda report swnmarizing the progressthat had been madein implementing the plans that had been developedat the end of Millennium ConferenceI for refonn of the clinical education of their students.The representatives also servedas resourcefaculty for the Millennium ConferenceII working groups. At Millennium Conferenceil, team memberswere againdivided into small groups,each composedof faculty from different schools,to discussthe key

questions:What to teach?How to teach?Who should teach?However,by taking advantageof the discussionsthat occurred during Millennium ConferenceI, it was possible to focus those discussionson a more specific set of ~es. Again, at the completion of the three working group sessions, eachschool'steam met to discussreform proposalsfor their school. The conferenceconcluded with a presentationof the plans developed by eachof the teams.

As noted above,the participants at the two conferenceswere divided into working groups,and eachworking group was chargedto addressissues related to the three main questionsthat servedas the organizingframework for the conferences.We summarizebelow the major points that arosein responseto those questionsduring the working group discussionsat both conferences.Each of the three sessionsis describedseparately.Before summarizingthe major discussionpoints that arose in eachsession,we outline the issuesof concern presentedin the brief plenary sessionsthat were held beforethe working group discussions.Wealso presentthe specific chargesthat were madeto the working groupsbeforethey begantheir ~ions.

Session I

-What to Teach?

The clinical curriculum has two purposes. First, it must provide opportunities for students to acquire the knowledge,skills, and attitudes they will needto provide supervisedpatient care as a resident physician in the early months of their residency training. Second,it must provide opportunities for students to acquire the knowledge,skills, and attitudes neededfor a strong foundation in clinical medicine, which they can build on during residency training as they strive to becomecompetent clinicians in the specialtY of their choice.

The Clinical Education of Medical Students

Given this, the working groups were chargedto consider the following issues:

1.

2.

What content should be included in the clinical curriculum, with a particular focus on interdisciplinary clinical topics that generally fall outsidefue domainsof individualspecialties (sometimescalled "orphan topics") and on advancesin basic science knowledgerelevant to clinical medicine? What level of mastery of fundamental clinical skills should studentsbe expectedto achieve during their clinical education,to include communicationskills and other skills important for establishinga productive doctor-patientrelationship?

Four common themesemergedfrom the working group sessions.

1. Development and use of a competencybased curriculum It is critical that eachmedical school establisha set of graduationcompetenciesthat it wishes its studentsto achieve,and then desigl:tthe curriculum in a mannerthat will best allow the studentsto acquirethesecompetencies.Becausecompetencies are now being establishedfor graduatemedical education,the acquisition of competenciesshould be consideredthroughoutthe continuumof medical education,with a clear indication of the developmentally appropriate time for each competencyto be achievedduring that continuum.

Fonnative feedbackshould be provided basedon theseperfonn3I\ce assessments, 3I\d individual learning plans should be developedthat take into account 3I\Ydeficienciesin perfonn3I\ce,3I\d student-specificeducational3I\d career goals.

3.

Integration of "orphan topics"

Although there was concernabout the appropriatenessof the tenn "orphan topics," there was generalagreementabout the importance of incorporating into the medical school curriculum a relatively large number of interdisciplinary topics of contemporaryimportance.Thesetopics typically fall outside the purview of any single clinical clerkship, but rather havethreadsthat should be woven throughout the curriculum. Sometopics, such as medical ethics, are clinically relevant to each of the clinical clerkships.Others,such as bioinfonnatics, do not needto be integratedinto all of the clerkships,althoughthe topic doesneed to be coveredat somepoint during the clinical curriculum. A number of modelsfor incorporating thesetopics into curricular designwere discussed, taking into accountboth horizontal and vertical integration throughout the four years of the curriculum. Examplesof such modelsinclude: a) schedulingcoursesthroughoutthe curriculum that include appropriate coverageof thesetopics; b) schedulingof "inter-sessions"(e.g.,blocks of time interspersedat intervals throughout the clinical curriculum) during which one or more of these topics are discussed.

4. Integration of basic science and clinical medicine

2.

Performance assessment

To ensurethat studentsachievethe objectives of the clinical curriculum, competency-basedassessments must be conductedat regular intervals. Although assessmentis a component of each clinical clerkship, the acquisition of competencies,as viewed in an integrated,cross-disciplinaryfashion, should be assessedat regular intervals independentof specific clerkship assessments,e.g.,at the end of eachyear of the four-year curriculum.

Giventhe continued advancesin understandingof the basic sciencesthat are fundamentalto clinical medicine,it is important that the curriculum be designedto integratebasic scienceand clinical medicinethroughout the four years.Students developa better appreciationof the importance of basic sciencewhen they can seethe clinical applications of basic sciencelmowledge,and they becomebetter clinicians by understandingthe scientific underpinningsof clinical medicine.In

The Clinical Education of Medical Students

addition, given the importAnceof lifelong learning and the need for physiciansto understandfuture advancesin basic sciencethroughouttheir careers, it is essentialthat medical studentsdevelopa value systemthat recognizesthe importAnt link betweenbasic scienceand clinical medicine,and that they acquire a skill set that facilitates future understandingof the interface of basic science and clinical medicine.Examplesof models for integrating basic scienceand clinical medicine include developmentof intersessionsduring the clinical years,at which time studentsreturn to basic sciencetopics, or developmentof required or elective coursesduring the fourth year that link basic scienceand clinical medicine.

ambulatory sites be used in the required clerkships?What is the optimal time in the course of the four year curriculum to begin the required clerkships,and how should elective experiencesrelate to the sequencing of the required clerkships? How should the elective curriculum be designed?Shouldelectivesbe chosenbased on a student'sinterests and careerplans, or should they be chosento addressdeficiencies in a student'sperfonnanceduring the required clerkships?Shouldelectivesbe designedto foster the students'professional development,to allow integration of core content throughout the four-yearcurriculum, or both?

2

Session 11- How to Teach? The designand conduct of the clinical curriculum has changedvery little during the past half century despite major changesin the clinical environments in which medicine is practiced and taught, and in society'sexpectationsof medicine. Now, as in the past, studentsrotating tltrough required clinical clerkships (generallyyear-threeof the curriculum) are simply assignedto a clinical team, and their learning is largely determinedby the scopeof the team'spatient care activities.Although many medical schoolshave learning objectives for those clerkships,the teachingfaculty are generally unawareof the objectives,and do not teach or assessstudents'performancesbasedon those objectives.It is also clear that there is insufficient attention paid to the fonnative assessmentof students' sldlls during the required clerkship experiences.Furthermore,since at most medical schools the fourth year of the curriculum is devotedlargely to electiveexperiences,monitoring of students' progressto ensurethey are achievingthe level of clinical skills expectedat the time of graduationis not adequate. Given this, the working groups were chargedto considerthe following issues: 1

How should the required clerkship be designed?Is the current set of specialtyspecific clerkships still valid? How should

3. How should the clinical curriculum be designedto provide better integration of core contentacrossthe entirecuniculum,to include both advancesin scientific lmowledgerelevant to clinical medicineand contemporaryissues importantto medicine,such as end-of-lifecare, population health, cultural competence,ere?

4.

5.

How should non-traditional educational methodologies,such as computer-based programs,standardizedpatients, simUlation experiences,and others, be incorporated into the clinical curriculum? How should the curriculum be structured to focus on the developmentof the student as a future physician?How should the roles of clinical faculty be defined to ensureappropriate faculty supervisionand role modelingfor students?How should the curriculum be structured to encouragestudentsto develop personalstandardsof excellenceand a commitment to lifelong learning?

Sevencommonthemesemergedfrom the working group sessions.

1.

Centralization of curricular oversight

TheClinicalEducation ofMedical Studmlt." .

There was generalagreementon the need for centralized designand oversight of the clinical curriculum, thus allowing better coordination of the educationalprogram acrossdifferent clerkships. At present, responsibility for the developmentand implementation of clinical clerkships often resides at the level of clinical departments,rather than with the central administration of the medical schooLAs a result, interdepartmentalbarriers often inhibit educationalinnovation and the ability to incorporate into the curriculum topics that are multidisciplinary and cross departmentallines.

of basic scienceand a progressiveincreasein the amountof clinical medicineas the studentproceeds through the four years of medical school. Another approachwould be to interspersediscrete periods of basic scienceexposurethroughout the clinical years,serving as basic science"intersessions"that enrich clinical exposure.A third model would involve a more aggressiveintegration of basic sciencecoveragewithin each clinical clerkship, through commitment of facultYand course directors to focus on the basic scienceaspectsof clinical issuesencounteredby the student.

2. Design of the clinical experience:

Integration of "orphan topics" throughout the curriculum was also felt to be an important goal of curricular refonn. Development of a matrix that shows when and how the orphan topics are mCOlpOnltedmto the clinical clerkships is one way to assure appropriate coverage of these mterdisciplinary topics. A model of "immersion and retreat," the latter allowing time for reflection and synthesis of knowledge and experiences, was felt to be a valuable one. The medical student experience should be made more distinct from the graduate medical education model that generally does not allow for periods of retreat, reflection, and consolidation.

curricular integration The designof the clinical experienceproved to be one of the most fruitful topics of discussion.Most participants felt that significant innovation and reform was needed.Therewas a generalconsensus surroundingthe needfor better integration betweenthe first two years (typically considered preclinical years) and the last two years (typically consideredclinical years)of medicalschool Clinical exposureshould begin during tile preclinical curriculum, with the recognition that tile particular type of exposureand assignedresponsibilities should be consistentwitil a student'sexperience and level of training. At a number of schoolsstudents begin tile required clinical clerkships in tile spring of year-twoof tile curriculum. One benefit to this approach,noted by a school whose students begin clinical rotations in April, is that firstyear residentsare relatively experiencedat that point, and hencebetter able to supervisenovice studentsthan is tile casein July when botil tile students and the first-year residentsare new. At the sametime, the thread of basicscienceshould be woven more clearly throughout the clinical curriculum. As one model, the distinction between preclinical and clinical years could be removed, and the four years of medical school could be considered as a continuum, during which studentsare simultaneouslydealingwith basic scienceand clinical medicine.Usingthis approach,there would be a progressivedecreasein the relative proportion

3. Refocusing the clinical experience At present,the inpatient model for many disciplines is the "team" model, in which the team of attendingphysician, housestaff, and studentsprovides the central focus for clinical care and educational activities. The student "fits" into the team, as doesthe group of patients who are cared for by membersof the team. Alternative models make the patient the focus, emphasizingthe importance of the clinical encounteras part of the longitudinal care of the patient, or make the student the focus, recognizingthat the primary goal of medical school is the education of the student and the developmentof his/her skills as a clinician. The "patient-centered"focus requiresmore integration of inpatient and outpatient care, as well as more integration acrossdisciplines- the student follows the patient through all aspectsof the patient's care and acrossall disciplines providing care for the

The Clinical Education of Medical Students

patient Implementingsuch a model would require interdisciplinary teams of clinicians who are responsiblefor supervisionand educationof students. The "student-centeredmodel" designseducational experiencesthat are appropriate for a student's level of development.Theseexperiencesmay need to be customized,dependingupon tlle student's previous clinical experienceand areasof deficient clinical exposure.Closementorship and supervision would becomea fundamentalcomponentof this model, ensuringtlle student'sgrowth as a skillful and knowledgeableclinician.

4. Optimizing the use of the fourth year The objectivesof the fou1tJ\year of medicalschool needto be better defined.Innovative approaches needto be developedtl1atlink the experiencesof the fou1tJ\year to its defined goals,as weDas to the overall goalsof the four years of medical education. Fou1tJ\-year coursesshould have objectives and thoughtfuUyproduced curricula, rather than beingsimply "tag-aiong"inpatient team experiences. Innovativeadvancedexperiencesneedto be createdthat: (a) build on the scientific and clinical foundationsbegunin the earlier years of medical school; (b) integrateinterdisciplinary topics, especiallyorphan topics; and (c) provide guided elective experiencesof particular value for the individual studentbasedon his/herfuture goalsand careerplans.Appropriate faculty guidancethat allows eachstudent to developa curricular plan is particularly important for optimizing the experience,and oversightis necessaryso tl1atstudents do not take multiple, and essentiallyrepetitive, "audition electives"in the samediscipline. 5.

Thansition experiences

Innovative coursesor experiencesshould be developedfor critical junctures within a student's education.Theseinclude the transition from preclinical to clinical years,and the transition from medical school to housestaff training (graduate medical education).The transition from preclinical to clinical years would introduce the student

to the clinical environment,to the culture of the inpatient setting, and to those skills of particular value when entering the h~ital environment The transition from medical school to ~uate training might include topics rangingfrom managementof common emergenciesto development of teachingskills. 6.

Use of multiple venuesfor clinical edncation

Whereasthe inpatient serviceshave beenthe traditional focus of clinical education,increasing emphasisis now being placed upon ambulatory education.Opportunities are also availablefor educationalexperiencesin such settingsas chronic care, urgent care, and emergencyfacilities. Utilizing these different venues,a curriculum could be designedthat is centeredaround four basic types of patients - the emergentlyill patient (e.g.,in the emergencyroom), the acutely ill patient (in the inpatient setting), the chronically ill patient (in the outpatient setting, especiallyin specialty practices), and the healthy patient (in the primary care setting). Such an organizational approachwould contribute to breaking down traditional departmentalbarriers that limit integration of content acrossdjsciplines. 7.

Use of computer-based technology

Although computer-based educationaltoo~ clearly havea role in medicaleducationat the begiImingof the 21stcentury,they cannot and should not replaceclinical experienceswith patients.Rather, educationaltechnologyshould be usedto till gaps and enhancethe clinical experiencesof a student. In this way,educationalteclmologycan be customizedto meetparticular needsbasedon a student'sclinical experiences.In addition, computerbasededucationusingvirtual patientscan allow the longitudinaltrdcking of a patient'scourseand the natural history of diseasethat may not be available to a studentin the real-life clinical setting.

Session III

- Who Teaches?

The roles and responsibilities of the clinical facul ty of medical schoolshave changeddramatically

The Clin~

in the past few decades,primarily becauseof the increasedinvolvement of full time faculty in the provision of clinical services.In responseto financial pressuresnow being experiencedby academic medical centers,the clinical faculty is increasingly expectedto meet certain clinical care productivity goals.As a result, many membersof the clinical faculty find it difficult to devotetime and effort to the teaching of medical students. Given this, the working groups were chargedto consider the following issues: Shouldthere be a core group of faculty responsiblefor the teaching of medical students,and if so, how shoUldthis group be selectedand supportedby the medical school? 2.

3.

What roles should specialistsand generalists, ambulatory-basedand hospital-basedfaculty, and residentsplay in the teaching of medical students? What mechanisms should be used for evaluating and improving the quality of teaching?

4. What mechanismsshould be employedfor rewarding faculty, both academicallyand financially, for teaching medical students? Eight common themes emergedfrom the working group sessions. 1,

Composition of teaching faculty

There was generalagreementthat all clinical faculty membersinterestedin teaching should be given the opportunity to do so, recognizingthat each faculty member'steachinginterests and abilities will differ. Somemay be best matchedto attending duties, others to problem-basedlearning or smallgroup tutoring, and others to preceptingin practice sites. In general,many felt that all faculty should teach in somevenue,whether in the classroom, the clinical environment,or the laboratory.

Education of Medical Student.s

Teachersof medical studentsshould include both generalistsand specialists.Whetheror not a generalist or a specialistis the appropriateteacher should be determinedby the educationalobjectives of the learning experience.Becausestudents developtheir career goalsand plans during medical school, it is important for studentsto have a balancedexposureto generalistsand specialists. Although generalprinciples of care are often learned on more generalservices,it was acknowledgedthat theseprinciples also can be learned on specializedservices,as long as learning objectives are clearly defined and guidethe designof the educationalexperience.

2. House staff as teachers For a number of reasons,residentsmust continue to teach students,but perhapsnot to the present extent. Havingso recently beenstudentsthemselves,residentshave realistic expectationsof medical studentsand excellent insight about students' needs.They are also the main professional colleaguesof the students- the onesto whom they can relate best, and the onesto whom they feel comfortable asldngquestions.Residentsare important teachersof studentsin part because they are there when the action happens,and they are the "how-to-do"experts. However,residentstoday are busier,more stressedby clinical demands,and less able to perform well clinically when they also haveheavy teachingresponsibilities.The serviceresponsibilities of residentsmay needto be adjustedto allow them to teach. Faculty developmentfor residents is very important. Theseefforts should focus both on teachingskills and on clarifying the roles of the housestaff in the school'scUlTiculum.A number of schoolshave initiated "resident as teacher" programsdesignedto developteachingskills specific to the role residentsassumevis-a-visstudents. Another model is to offer senior residentsthe opportunity to focus on medical educationduring elective months. For example,the Departmentof Medicine at Beth Israel DeaconessMedical Center offers a three-month"Medical Education Area of

The Clinical Education of Medical Students

Concentration"for senior residents.Residents should also be rewarded somehowfor their teaching, e.g.,through resident teaching awards. A number of ideas emergedfor improving the role of residentsas teachers:

. .

. . 3.

Strengthenthe role of chief and senior residentsin particular as primary teachersof students Teachresidentshow to capture the real-time "teachablemoment," since residents havethe most consistentreal-timeworking relationship with studentsin the course of patient care Better define the goals and responsibilities of residentsas teachers Developa structure as part of the housestaff curriculum for ongoing developmentand improvementof housestaffas teachers Attributes and expectations of teaching faculty

Studentslearn from faculty through role modeling, through guidedreflection on ilieir clinical experiences,through syniliesis of ilie information iliey gailier, and through ilie interactions they have wiili membersof the entire healthcareteam. Therefore,it is important to define ilie attributes that make faculty most effective in each of those facets of their work with students. ~ and foremost,clinical teachersmust be knowledgeable,sldlled clinicians who iliemselves are curious and inquisitivelife-long learners.They must be excellentcommunicatorsand role models of professionalism.The medical professionitself is characterizedas embodyingspecializedknowledge, curiosity and inquisitiveness,ilie courageto challengeexistingparadigms,altruism (putting ilie patient first), and commitmentto life-long learning. Theseare qualitiesiliat teachersshould embody. Additionally, all faculty involved in teaching students must be committed to developingthe skills

necessaryto be excellent teachers,including the ability to assessthe rangeof learners' needsand to take the level of eachlearner into perspective. Faculty also must developa practice of providing timely, constructive,and effective feedbackto learners.On inpatient services,teachersmust take studentsto the bedside.All teachersmust be willing to make the time to designeducationalactivities, and all teachersmust be provided adequate time to prepare for teachingand to carry out their teachingresponsibilities. 4.

A "core faculty"

A core faculty of dedicated clinician-educatom should be developed and s1Nained It was argued that since there are elite researchem,there aJso should be elite teachem as well. One reason that teaching is not appropriately valued at present is that it is not seen as an activity requiring special skills. Members of a core faculty should be those whose primary contribution to the academicmission is basedon teaching,as opposedto either research or patient care.Their contributions to the missions of their institutions neednot be limited to education, but their primary academicrole should be in the domainsof teachingand education.

Membersof the core faculty should havea strong commitmentto supportingthe learningobjectives of the educationalprogram;participatein meaningful ways in curriculum plam\ing,educationalscholarship,and monitoring of the generallearningand teachingexperience;mentoringof students;and assessmentof students'performance. To establisha core faculty of teachers,medical schoolsshould establisha special careerpatl\ for medical educators.In doing so, schools should establishstandardsfor medical educationtraining and provide for interestedfaculty, career development opportunities that would include mentoring relationshipsand supportfor scholarship.Oversight of the core faculty should be centralizedto whatever extent possible.

The Clinical Education of Medical Students

In establishinga core faculty, it is imperative that other faculty who teach not be alienated.There are many other individuals who do essentialteaching, but who would not be consideredcore faculty:

. . . 5.

Full-time and volunteer faculty who teach in the course of providing patient care Residents Fourth-yearmedical studentswho might serveas teachingassistants Assessing and rerming the quality of teaching

Therewas a strong consensusthat quality teaching is not adequatelyrecognized.An organizedeffort to measurecontinuously faculty effort and contributions to education (more than teachingalone) is a crucial elementin facilitating the equitable reward of faculty, and in demonstratingthat the schoolattachesimportanceto educationalactivities. In this context, standardsshould be developedfor assessingthe quality of teaching.Recommendations for evaluatingthe quality of teachinginclude:

.

. .

Use of standardizedfonns for tile objective reporting of student evaluationsof teaching, already in use in most schools,tilough not necessarilyin all courses Increaseduse of peer review (e.g.,by course and clerkship directors, chairs, deans,etc.) A centralizedfaculty teaching evaluation board

Regardingthe useof standardized fonnsfor objective evaluationof teaching,there must be mechanismsin place to ensurethat faculty receive feedbackon their teachingthat is objective and constructive, and programsmust be in place to help faculty improve their teachingskills.

medical educationand with the standardsthat define excellencein both teachingand educational scholarship.This understandingwill enable them to evaluatefaculty members'academicproductivity relating to educationalscholarship,as well as teachingportfolios and other contributions, such as developmentof enduring educational materials,local, regional and national presentations, and consulting on educationalreform at other medical schools. More funding, both external and internal, is needed for the support of scholarshipin medical education. Many schoolsprovide educationseed grants to support small researchprojects or educational initiatives. hUormationabout these and other external funding opportunities should be posted and sharedwidely with faculty. Funding to support researchin medical educationis not plentiful. A national program for funding medical education researchis needed. Faculty should be encouragedto publish the results of their work. The results of researchstudies and descriptivepiecesabout curricular innovations, faculty developmentprograms,organizational changes,and assessmenttools should be submitted for publication in peer-reviewedjournals. They should also presenttheir work at local, regional, and national meetings.Schoolsmight form educationalresearchgroupsthat allow faculty to shareideas,experiences,and expertise. 7.

Faculty development

All faculty who teach should participate in faculty developmentprograms.1ime away from clinical activity is required to developteachingskills. The pace of patient care should not be allowed to limit faculty participation in faculty development programs. Those aspiring to be membersof the core faculty

6. Scholarship in medical education Departmentchairs and promotions committees also must becomefamiliar with the scholarship of

should be encouragedto participate in a formal program, such as a medical educationfellowship or faculty developmentprogram,which has a curriculum designedto enhancetheir contributions

The Clinical Education of Medical Students

to educationalscholarship.Seminarsshould be developedand madeavailableto all faculty, and faculty should be given time to attend theseseminars,just as there is an expectation that faculty in academicmedical centers will attend grand roun~. Somemedical schools compensate departmentsfor the time that membersof their faculty spend attending seminars,or they provide stipendsto faculty who are enrolled in medical education fellowships. 8.

A number of schools,such as Baylor,Mayo, UCSF, and Harvard,are establishing"academy"organizatiOM to support excellencein teachingand curricular innovation,to serveas advocacyorganizations for teachersand medicaleducation,and to engage in raising funds to support medical education. Somemedical schoolsand organizationswithin medical schools,such as the ShapiroInstitute and the academiesmentionedabove,provide seed grants to faculty to initiate innovativemedical education projects.

Rewarding quality teaching

Standardsfor excellencein teachingmust be developed,codified, and incorporatedinto the processof evaluatingfaculty for promotion. Departmentchairs and promotion committees must becomefamiliar with the standardsof excellence for teaching,medical educationresearch, curricular innovation and developmentof curricular materials,and other important contributions madeby faculty wh~ academicf~ is teaching and medical education.There must be institutional support for peer review of teachingthat is rigorous and objective,and systemsfor peer review must be established.

Mission-~

budgetingis one mechanismbeing usedby many medical schoolsto ensurethat funds are eannarkedfor tlle teaching~on and channeledto support those faculty who are the primary teachersof both medical studentsand housestaff. Someschoolsare establishingcore faculty structures to support faculty who have a seriousinterest in medical education,the requisite skills for becomingan outstandingteacher,and tlle willingnessto make a significant commitmentof tin1eand effort to teachingand to otller education-related activities. Allocation of teachingfunds for salary support of theseindividuals allows them to assumededicatedteachingroles. Core faculty membersalso are required to participate in forn1al professionaldevelopmentprogramsthat botll developtlle skills necessaryfor excellent teaching (e.g.,teachingon rounds and at tlle bedside,teaching in ambulatorysettings,giving effective feedback) and also provide valuablecredentials.

Promotion policies must be changedto reward the contributions that faculty memberswhose academic focus is on medical educationmake to the academicmission.Endowmentsto support the educationalmission of medicalschoolsshould be a seriousfocus of the fun~ goalsof medical schools.Currently,endowedchairs are almost exclusivelyawardedto faculty whose focus is research.Endowedchairs to recognizesenior faculty teachersshould be establishedas well.

The Clinical Education of Medical Students

Summary As noted in the introduction, it is difficult to convey in a written documentthe excitementand enthusiasmthat characterizedthe discussionsof the issues that the conferenceparticipantswere chargedto considerduring the working group sessions.The brief summariespresentedabovemakeit clear that the participantsbelievedthat medicalschoolsmust implementa numberof changesif they wish to improvethe clinical educationof their students.The summariesdo not reflect the senseof urgencythat characterizedthe participants'recommendations for change. Certainly,all of the major themesswnmarizedin the previoussectionare important,and all deservethe attention of medicalschool deansand faculties.For that reason,no effort was madeto prioritize the nineteenthemesthat emergedduring the three working group sessions.Nonetheless,it seemed clear that certain of the themesgeneratedmore discussionduring the courseof the two conferences. Indeed,somegenerateddiscussionin more than one of the three focused,working group sessions. The pUIposeof noting thoseis not to suggestthat they are more important than the others,but to highlightthe fact that real innovationis neededto addresssomeof the concernsthat exist about the quality of the clinical educationof medicalstudents. For example, the need to integrate, within the clinical C\n1iculum,core content related to advancesin biomedical science and to contemporary ~es in medicine is extremely important, and it is clear that schools will need to ~ innovative approachesto accomplish this. Some schools have started to implement approachesfor accomplishing this, but it is clear that more models need to be developed before it will be ~ble to judge how the required content can best be integrated into students' clinical experiences.

The needto redesignthe clerkship experiencesto accommodatethe integrationof core content generated a great deal of discussionabout the continued validity of the traditional clinical clerkship experi-

ence.A generalconsensusdevelopedduring ilie courseof iliose discussiollSthat simply ~gning studentsto teamscomposedof residentsand an attendingphysicianwas not an adequatestrategy for achievingwell-definededucationalobjectives. Therewas a strongsensethat innovativeclinical rotationsthat were truly patient-centeredwould be more effectivelearningexperiencesfor students, and would accommodatemore readily ilie integration of core content.To date,only a few schools haveimplementedexperiencesof tl1isldnd. A great deal of innovationwill be requiredbefore it will be possibleto makejudgmentsabout effectivemodels. And finally, there was a strong sense among the conference participants that given the realities of modem academic medical centers, schools must re-think how they define the roles and responsibilities of faculty, and how they support and reward those who are most committed to the institutions' medical education mission. The conference participants were attracted to the concept that designation of a core faculty composed of highly skilled teachers and edu~rs would be an effective means for improving the clinical education of students. Once again, a great deal of innovation is required before it will be possible to identify models that are most effective.

ill closing,it is important to emphasizeonceagain the tone and spirit that dominatedthe discussions in both the working groupand generalsessions. The conferenceparticipants,all of whom were involvedon a daily basisin the clinical educationof medicalstudents,felt stronglythat reforms are neededin the designand conductof the clinical educationof medicalstudents.ill addition,they felt that for reformsto be effective,they neededto be highly innovativeand far- reaching.Thoughthere are undoubtedlychallengesthat will needto be overcomein implementingreforms,the conference participantsembracedthe conceptthat substantive reform of the clinical educationof medicalstudents presentsa genuineopportunityto improvethe ways that physiciansare beentIained for medicalpractice in the 21stcentury.