In the midst of a rapidly changing health care environment, medical education also is evolving. Indiana University School of Medicine is among a handful of schools that have adopted a competency-based curriculum in order to graduate well-rounded physicians.
In the recent movie "Patch Adams," actor Robin Williams portrays a medical student in the 1970s who questions the philosophy behind teaching students to remain distant from patients and place more importance on knowing disease characteristics than a patient's name.
In fact, students of the '70s did not interact with patients until their third year of medical school. But since then, schools have incorporated the instruction of basic clinical skills and patient contact into the first year of study. They have emphasized a more personal approach to medicine, with students learning the importance of positive doctor-patient relationships.
Today, a competency-based curriculum is taking that concept a step further by identifying specific skills, both medical and interpersonal, that every student should master before graduating.
"The goal of a competency-based curriculum is to ensure that students learn not only basic sciences and clinical skills, but also skills that make a well-rounded physician," explains Joseph Chu, MD, associate dean of student and curricular affairs. "Our current curriculum doesn't measure things like communication skills, professionalism and ethical reasoning, yet we expect our graduates to perform well in these areas."
Curriculum revision is a long process. At IUSM the design process began in 1992 when Dean Emeritus Walter Daly, MD '55, created a task force chaired by Stephen Bogdewic, PhD, assistant dean for primary care education. The task force's recommendations became a blueprint for the new curriculum. Today, the plan is being implemented by the Curriculum Council, chaired by Philip Breitfeld, MD.
Certain parts of the new curriculum were introduced during the 1998-99 academic year. The next major step will take place next fall, but some estimate the complete revision may take up to five years.
Based on the Brown University School of Medicine model, IUSM's new curriculum is divided into nine competency areas. (See list on page 16.) Each competency represents a skill or behavior that medical school graduates should possess. Three levels of mastery permit a student's performance and improvement to be measured throughout medical school. In order to graduate, students will be expected to master level two of six competencies and level three of three competencies. Upon graduation, students will receive two transcripts - one noting grades and one noting competency mastery.
"Together the areas of competency represent a common skill set that all physicians should have," says Dr. Breitfeld, who is professor of pediatrics and director of pediatric hematology/oncology. "In this case," he explains, "competency implies excellence."
Nine competency directors are responsible for the integration and evaluation of the competencies. Patricia Keener, MD '68, describes the four-year "score sheet" for achievement in the various competencies as equal in importance to the existing course evaluations and to the requirement for passing scores on parts I and II of the United States Medical Licensing Exam.
Graduation will depend on success in all three areas. Dr. Keener and the other competency directors are responsible for coordinating the integration of competency content into the current curriculum, creating a workable plan to track competency achievement, and providing opportunities for students needing remediation.
Preparation for the new curriculum has included restructuring the basic science courses students take during their first two years of medical school. Some courses are now designed by topic rather than by department and use a team teaching approach.
For example, the first-year course "Concepts of Health and Disease" is team-taught by professors from the Departments of Biochemistry and Molecular Biology, Physiology and Biophysics, Microbiology and Immunology, and the clinical specialties. Students work in small groups, using case studies to learn basic science and clinical concepts through a problem-based learning format. The course assesses four competencies: effective communication; lifelong learning; problem solving; and using science to guide diagnosis, management, therapeutics and prevention. Lesson plans will be structured so students learn related material at the same time in different courses.
"Our hope for this type of restructuring is to better utilize students' time by better organizing the material," says Curricu-lum Council member Robert Harris, PhD, chairman of the Department of Biochemistry and previous director of the first-year curriculum. "The challenge is to coordinate course directors and professors from each department. It's a lot of people and a lot of information to bring together," adds Dr. Harris.
Clinical faculty face an equally daunting task. Physiciansand residents will have to become familiar with the competency areas in order to train and assess students. Stephen Leapman, MD, chairman of the clinical assessment advisory group, is piloting an evaluation tool known as an objective structured clinical exam (OSCE).
Last August, 253 third-year students rotated through four stations in the University Hospital Surgery Outpatient Clinic where standardized patients (actors) simulated four clinical scenarios. Three scenarios tested students' clinical skills and the fourth tested their communication and sensitivity when delivering bad news to a family member. Standardized patients are trained to prompt and evaluate specific skills and behaviors of students. They were given a checklist to assess students' performance.
According to Dr. Leapman, the OSCE ran smoothly and IUSM students tested very well. The same students will be re-tested at the end of their third year to assess improvement. "Our objective for this first experience was to see if we could actually manage the logistics of the OSCE successfully," says Dr. Leapman, professor of surgery. The OSCE involved thirty-five standardized patients and a cadre of staff and faculty who served as orientation and debriefing facilitators, couriers, audio-visual technicians to tape each scenario, proctors, and doctors to write the scenarios. "Now that we know it's do-able, we can concentrate more on assessing areas where our students are deficient and creating mechanisms for improving the educational process."
Part of improving the process will be to provide opportunities for students to master specific skills described in the competencies. For example, one of the expectations for competency in social and community context of health care is that graduates act as advocates for the health of the community.
"We want students to appreciate the diverse cultural, economic and social factors that influence the utilization of health services and, as a result, impact the health status of specific populations," explains Dr. Keener, who also is vice chairman of pediatrics and director of general and community pediatrics. "An excellent way to sensitize students to the importance of seeing patients in context to their communities is to provide neighborhood-based opportunities for student involvement."
Everyone involved in the curriculum revision agrees that the challenges ahead include educating faculty, residents and volunteer faculty to teach and evaluate students using the competency-based curriculum. "Many of our teaching faculty already train and assess our students in several of the competency areas, but not in a formal or recognized way," says Dr. Breitfeld. "We have to design a process that will ensure education in all areas, especially the non-scientific areas, in a way that can be fairly evaluated."
Core Competencies
Effective communication
Basic clinical skills
Using science in medicine
Lifelong learning
Self-awareness
Social & community
contexts of health care
Moral & ethical reasoning
Problem solving
Professionalism