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Chapter 5 INNOVATINJE MODELS OF MEDICAL EDUCAT ION IN THE [JNITED STATES TODAY: AN OVERtJIFW WITH IMPLICATIONS FOR CURRICULUM AND PROGRAM EVALUATION Jane S. Takeuchi, Nina M. Smith, and Allyn M. Mortimer Thin critical review discusses some of the more innovative approaches to medical education found in United States medical schools today, and summarizes evaluative ef forte. Some foreign medical education programs also are discussed by way of comparison. Part I focuses on problems and complexities in curriculum ant program evaluation as applied to medical education. Part II outlines the origins and broad purposes of several innovative models of medical education, and provides a capsule description of one or more exponents of the model, together with a statement of program or curriculum goals (as stated or inferred), and a brief very of evaluation activities (if any) undertaken on the Impact of the program or curriculum. Examples of similar curricula or programs at otter institutions are also noted. PART I There have been numerous attempts to evaluate the impact of speci f ic curriculum component s, the curricula t hemselves, ant even entire medical education programs, with varying degrees of success or completeness. These evaluation efforts have most typically been conducted by the institutions themselves or by their outside consultants, by the funding sources, or by knowledgeable organizations with the capability of conducting evaluation research. Some evaluations have been conducted across similar curricula or programs, but most focus on a single institution. This section reviews some of the generic issues and dilemmas of curriculum and program evaluation as applied to the medical school phase of medical education, beginning with an inventory of the purposes of evaluation research ant the requisites for useful and productive evaluation efforts, moving on to problems mose frequently encountered in actual conduct of evaluation research, and concluding with Dome remarks about opportunities and future directions for evaluation of medical education curricula and programs. Purposes of Curriculum or Program Evaluation She main purposes of curriculum or program evaluation are the f allowing: 107

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o To gain basic information and feedback about curriculum or program impact; to determine whether an innovation or experiment is working and what its effects (both intended and unintended) are; or to determine whether an innovation, experiment, or variation from the norm accomplishes the goals or objectives it was intended to accomplish. It will be noted in Part II that most of the evaluation activities undertaken by the illustrative programs have been or are being conducted expressly for this purpose. O To track or moni tor the process and progress of curriculum or program implementation and the process by which it does or does not achieve its goals. Among the illustrations in Part II, the University of Michigan Medical School's Inteflex program and Duke University Medical School, among others, have been monitoring the process of program impact. o To compare the benef its and costs of alternative ways of achieving the same goalk s), perhaps with the intention of selecting least costly means of achieving a particular goal or Ret of goals. To our knowledge, none of the evaluation activities noted in Part II have been undertaken explicitly for this purpose, although the cost of amounting innovative medical education programs has certainly been a consideration. In the evaluation conducted for the Commonwealth Fund on its Interface programs, for example, it was noted that on a cost-per-student basis, these programs have been very expensive. O To make decisions, based on evaluation findings, about the future of a curriculum or program innovation: whether to fund or re-fund, continue or discontinue, modify, and/or disseminate the curriculum or program to other institutions or settings. Tong the illustrations in Part II are several examples of evaluations that have contributed to such decisions. For example, the Southern Illinois University School of Medicine decision to drop its three-year curriculum and convert to a four-year medical education program was based on analysis of faculty and student attitudes. The evaluation of the Commonwealth Fund ~ s Interface programs was undertaken in part to ascertain the value and worthwhileness of its investment in that particular type of program innovation. Decisions to disseminate program information, presumably based in part on evaluation findings, have been undertaken at by the University of New Mexico (concerning the Medical School 's Primary Care Curriculum), by Boston University (concerning its Modular Medical Integrated Curriculum), ant by the Center for Health Sciences of Ben Gurion University of the Negev, to name a few. The (European) Network of Community-Oriented Educational Institutions for Health Sciences exists for the purpose of sharing information and knowledge gained and to provide assistance to other. interested institutions. O To fulfill a requirement (often for continued funding), or for reasons such as placating or pleasing an influential person or organization. 108

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Requis i tes for Produc t ive Curr iculum or Program Evaluation The following are basic requirements that must be met if evaluation activities are to be useful, productive, and taken seriously: o There must be clear specif ication of curriculum or program goals or objectives to be examined and evaluated. In reviewing the stated (or inferred) goals or objectives of the various medical education curricula or programs discussed in Part II, it will be noted that they are typically expressed in terms of one or more of the following: (1) student outcomes--the characteristics, qualities, or skills and/or capabilities to be developed in or demonstrated by students while they are in the program/curriculw~ or af ter they graduate (see, for example, the McMaster School of Medicine program); (2) curriculum characteristics or changes (see, for instance, the University of Hissouri (Kansas City) program or the University of Washington WAMI--Washington, Alaska, Montana, and Idaho--program); or (3) (health) outcomes for the larger community ~ see, for example, the School of Medicine of Ben Gurion University Center for Health Sciences ~ . The goals, as stated, will of course determine the focus of evaluation activities undertaken.- o The curriculum or program goals must be specified in testable form. O The research (evaluation) design and methodology selected or developed should be appropriate to the evaluation task. O Ideally, the evaluation study design and methodology to be used should be fully specif led prior to the initiation of the curriculum or program innovation. Note that Duke University, the University of Michigan, and McMaster University, among others, appear to have designed their evaluation activities in this way. O There must be a commitment of resources (both tine ant money) to the evaluation effort for its duration. O There must be a commitment to the evaluation effort on the part of key administrators and other personnel who are in a position to af feet the course of the curriculum or program implementation, and a willingness and ability on their part to participate in the evaluation where appropriate and needed. Problems in Curriculum and Program Evaluation Discussed below are some of the problems most frequently encountered in curriculum and education program evaluation research, together with some examples from the medical education literature 109

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reviewed for this chapter. It should be noted that these problems are by no means limited to the evaluation of education or medical education curricula or programs, but more generally plague all evaluation efforts in the social or behavioral sciences. Evalua t ion De s ign and Re sea rch Me thodo logy Selecting Comparison Groups To design and test properly the ef fects of a curriculum or program innovation in terms of student outcomes (which is the f ocus of most of the programs or curricula discussed in Part II), it is necessary to select one or more comparison or control groups with great care. Short of randomly assigning students to "treatments" (i.e. ~ to one or more experimental or innovative curricula or programs, or to the traditional curriculum/program), there is always the possibility that selection bias will mask the true impact (or lack of impact ~ of the experimental program or curriculum. A question to ask in making the selection is, To what extent do the students who select or who are recruited into the experimental program resemble the students who enter other or traditional programs, and what difference should this make in the way the f inkings are and should be interpreted and disseminated? It Will be noted in Part II that the process of selecting students for participation in an innovative or nontraditional curriculum or program is never done by randomly assigning all students admitted to the medical school to one or the other of its medical education programs. In all cases, students select themselves for a program (by applying for it ~ or (perhaps) are recruited because of their particular characteristics. Thus, even students participating in parallel program tracks at the same medical school (as at the University of New Mexico) cannot truly be considered comparable or equivalent to the "experimental" students for evaluation purposes. What this means is that when graduates of one program are compared with graduates of one or more other programs in terms of their performance--for instance, on standardized tests such as the National Boards--the superior or inf erior pert ormance of one or the other group cannot be attributed uniquely to program impact. One interesting method of trying out an innovative program on two different types of students is the University of Missouri (Kansas City) policy of reserving 10 percent of its Spaces for students with more traditional premedical education backgrounds ~ some college experience ~ than have the bulk of the students, who are admitted directly from high school. The college-age students thus serve as a control for the experimental group . Variety among students across medical education programs or curricula also is desirable in other respects. For example, innovative educational programs often are designed to be effective with particular types of students, and it is precisely the interaction between the program goals and the characteristics of the incoming student body thee may in fact make the program work. A 110

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review of Part II indicates that many experimental or innovative medical education programs were indeed designed for particular types of student~--high achievers, low achievers, Conscience majors, minorities, the educationally disadvantaged, mature students, and so forth. Whether the programs would be equally successful with other types of students, or with the same types of students at different institutions, is a matter for empirical testing (which has generally not been done ~ . Short-term Versus Longitudinal Evaluation Designs Most of the program evaluation efforts discussed in Part II involve a desire to determine the long-term impacts of the innovative curriculum or program on graduates and their careers, and perhaps ultimately on the quality of health care in the communities in which they or their successors will practice medicine. Because most of the innovative programs and curricula have been in existence for a relatively short time, there are not yet a sufficient number of graduates far enough along in their postgraduate and professional careers to be able to ascertain long-term program impact with any certainty. Thus, evidence of program impact on s tudents, as measured by surveys of graduates, most frequently get at career intentions rather than at actual career paths followed (see, for instance, the programs discussed under the Community-Baset/Primary Care model ). It is laudable, however, that most of the schools discussed in Part II have plans for, or express an interest in, long-term follow-up of their graduates. It should also be noted in this connection that longitudinal research is both costly and time-consuming, ant the inability to demonstrate results quickly can often cause problems in attracting needed resources to continue useful long-term evaluation activities. Small Ns A third issue has to do with the number of students . being exposed~to the innovative or nontraditional curriculum. The evaluation of the Interface programs conducted for the Commonwealth Fund, for example, expressed concern thee very few students had experienced these programs. Small Ns are sometimes inevitable, but they do cause problems in interpreting results ant in generalizing f ram f Ending . Measurement Instruments Yet another concern is whether the measurement instruments selected for the evaluation effort are appropriate ant reliable. As Part II shows, the evaluation activities on innovative or nontraditional programs typically involve the use of one or more of the following types of instruments: (1) standardized tests--e."., National Boards, licensure examinations-on which the performance of students or graduates of the program is compared with that of other students/graduates; (2) attitudinal and demographic surveys of students, graduates, and/or faculty members or others involved in medical training programs; and (3) ratings of student or postgraduate performance by clinical supervisors. While theme and

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other such objective and subjective measurement devices are reasonably easy to design and administer, and in some cases relatively inexpensive to use, they may not be the most appropriate methods to determine program impact. Findings from ~elf- admini~tered questionnaires, for instance, may be quite unrelated to the actual behavior of graduates where it counts--in their professional pract ices and in the community at large . Many of the schools discussed in Part II use such measures as interim approximations of program impact and plan follow-up activities that may be more directly relevant (see, for instance, evaluation plans for the University of Washington's WAMI program) . Testing the Right Hypotheses Behind any statement of curriculum or program goals or ob jectives, there are implicit hypotheses about cause-and-ef feet relationships. Such hypotheses must be plausible, explicitly stated, and testable via the evaluation research design. A review of the medical education curricula and program innovations described in Part II suggests that program or curriculum designers oust have had a variety of hypotheses about education in mint. Some were evidently concerned with the learning process itself--how it takes place most ef fecti~rely and with what kinds of students (see the McMaster University and Ben Gurion University programs in particular), some more particularly with the relationship between the stage at which ce rtain concepts or experiences are introduced and reinforced and subsequent career choices (see, for example, all Community-Based/Primary Care programs), some with the effect of length and type of schooling on the quality and performance of the graduate, ant shill others with the relationship between early exposure to role models and subsequent behavior, and no forth. Some have sought to demonstrate that particular types of students prosper in particular types of environments. The implicit, or explicitly stated, hypotheses underlying the goals of the educational innovations discussed in Part II appear both reasonable and worthy of testing, though major results in the form of definitive findings are far from being at hand. Maintaining the Stability of the Curriculum or Program Being Evalua ted One of the most serious problems in conducting evaluation research' especially if the design is longitudinal, is that of ensuring the constancy of the curriculum or program for the duration of the evaluation. What this means from a practical standpoint is that successive classes (for instance in a baccalaureate/M.D. program) may not be--and frequently are not--exposed to the identical. curriculum (with the identical options, electives, or faculty). Similarly, the first class of students exposed to the new curriculum may encounter a rather different curriculum than that originally planned by the time they enter their third or fourth year in the new program. The reason f or this instabi li ty in new curricula or programs, of course, in that program administrators 112

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will often alter their plans as experience with the program and new information and feedback on the feasibility of their plans become available (see, for instance, Meharry Medical College or Ben Gurion University's Center for Health Sciences). While this kind of behavior~which might be dubbed learning from experienced, of course, undereeandable, it toes create problems for program evaluators, ant tends, in general, to necessitate all sorts of caveats when the evaluation findings are presented or released to the public. For this reason as well, the findings are likely to be less generalizable to other institutions that have or are considering the development of similar educational curricula or programs. Other Problems: Institutional and Political Realities The following comments, based on a recent article by Kaufman et al.,1 directly pertain to how educational innovations come to be instituted in the first place, but indirectly also concern evaluation efforts. The authors suggest that "major innovations in medical education can develop more easily in new medical schools or in satellites remote from the parent institution," citing the McMaster program, Michigan State University' ~ Upper Peninsula Program, and the Biomedical Education Program at City College of New York. However, the creation of new medical schools is unlikely because of economic realities and the high cost of establishing them, and because existing schools are already reducing their entering class size in response to projections that the number of phys icians will exceed expected overall requirements in the next few decades. Thus, "major new curricular innovations will have to arise within traditional medical school establishments in which strong vested interests and departmental prerogatives will inevitably run a collision course with those seeking overall change. in curriculum design." Particularly hart hit, according to the authors, will be curricular reforms that propose to cut across "all basic and clinical science disciplines." Referring in particular to the University of New blexico's Primary Care Curriculum, Kaufman et al. note (as discussed in Part II) that evaluation activities have shown thee the program is unpopular with the faculty, ant that to enable it to succeed, its administrators and students have forged alliances with the "external environment"--its consumer constituencies. 1 It might be observed at this Juncture that both at Stanford University and at Southern Illinois University (among others), evaluation of medical faculty views have led to the demise of program innovations. This is not to suggest that such actions are inappropriate; there may indeed have been abundant and sound justif ication for dropping such innovations. Rather, the point is to note that in any program or curriculum evaluation involving medical education, the voice of the medical faculty is likely to be present and powerful. 113

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Some Opportunities and Possible Future Directions for Education Evaluation Activities As the foregoing discussion indicates, ant as Part II will demonstrate, program and curriculum evaluation results for nontraditional medical education programs are far from definitive. Most evaluation activities in progress are in their nascent stages and, because of the length of time required for the impact of a program or curriculum to be felt, cannot be expected to yield decisive results that would be universally accepted in the near f uture. Thus, there in as yet no proven, single, best way to provide medical education for any particular set of goals or ob jectives, or for any particular type of student . In the absence of def initive information, what would be a useful course to pursue with respect to innovations in medical education and their e~ralua tlon? It seems clear that there are a number of interesting ant promising models of medical education and individual curricula or programs in existence today that are worthy of continued attention. The absence of clear-cut evidence as to what works might be viewed as making it all the more important to try to ensure that research on medical education programs and curricula is high-quality, well designed, and comprehensive . Concurrently, given rapid changes in medical education and the lack of precise cause-and-effect tata, it would seem useful (1) to keep all options ant variants open rather than to reach premature judgment, (2) to study and evaluate the impact of the variants and innovations that presently exist, and (3) to encourage diversity of program and curriculum offerings on general principle . The very existence of the variants may, in fact, convey important messages to prospective physicians about what is valued in the medical community and by the community at large .2 A further suggestion is that more attention in medical education program evaluation be directed toward developing and specifying methods to evaluate . program impact on distant, societal goals (meeting the health care needs of the population, for example). While the intermediate (and perhaps more easily measurable ) goals, such as producing graduates with particular characteristics or developing a curriculum of a certain type ~ may be connected causally to the remote societal goals, more ef fort in elucidating these interrelationships would appear to be useful. AcIditlonally, it is important to note that the medical education evaluation activities that have come to the attention of the Institute of Medicine Committee to Plan a Review of Medical Education in the United States have been conducted almost exclusively on undergraduate programs. Evaluation efforts should also be undertaken on graduate medical training programs. 114

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PART I I The models* of medical education discussed here include (1 ) the traditional (post-Flexnerian) model; (2) the organ system approach developed at Western Reserve University School of Medicine; (3) the flexible or elective model originally developed in the 1950~ in response to the traditional model; (4) the community-based or primary care model; and (5) accelerated medical education programs, including (a) three-year M.D. curricula' (b) baccalaureate~M.D. programs, and (c) H.D.-Ph.D. programs. Orate medical education program that serves the needs of a particular population group is also discussed. In contrast to the other models, the traditional model is simply described and its origins are briefly cited, as it constitutes the base model from which the other models originally developed as innovations or experiments. The Traditional (Post-Flexnerian) Model During the half century between 1910, when the Flexner reports was published, and 1960, medical education in the United States was standardized4~10 to the extent that "students could transfer from one medical school to another and hardly know they had moved."5 Though there was variation from school to school in instructional methods used, the f irst two years were devoted to instruction in the preclinical basic sciences, organized by discipline, and the third and f ourth years to student rotation through a series of clinical experiences "that left no medical or surgical specialty untouched."5 This meant that "the experience in each discipline, basic and clinical, was necessarily superficial and in most Schools there was limited opportunity to study in depth any subjection area of special interest."5 The aim, quite appropriate at the time, was to provide the student, over the four-year time period, with suf ficient knowledge to support 35 years of clinical practice .4 At that time, a one-year internship was common, but subsequent specialization during two to five years of residency was not assumed to follow inevitably. The virtues of this approach at the time that it was instituted widely--i.e., following publication of the Flexner reports and with the Johns Hopkins University School of Medicine serving as prototype--were that the emphasis on basic science transformed medical schools that were "entirely vocational" ant reputedly of uneven ant in many cases very poor quality, into institutions that *Titles of models ant the exemplars selected to represent them are somewhat arbitrary, and leave room for honest disagreement. The models have been designated and the illustrations selected more in the spirit `~f Or I..,llal clarity ant simplicity than as a true reflection of the complex and diverse state of af fairs in American medical schools. 115

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were scientif ically oriented and "worthy of their membership in universities." Since the majority of students was to enter general practice af te r one year of internship, a broad background ant at least minimal competence in all fields of medicine were considered essential. 5 The ma jori ty of medical schools in existence in the United States today adhere to this two-plus-two format as their basic four-year curriculum, though interdisciplinary courses and/or elective opportunities typically are available as well.* In general, all students at a given level must take the same group of core courser and examinations, in some cases including the National Board of Medical Examiners ~ Parts I and II. Courses tend to be discipline-centered, though instructional innovations may in some cases modify this orientation. 10 Organ System Model Origin ant Purposes An integrated organ system approach to medical education was pioneered by Case Western Reserve University School of Medicine in 1952, in a series of curriculum innovations that evolved over a ten-year period under special circu~stances--the leadership of a new dean, many new department heads, and generous grants from The Commonweal eh Fund . The overall purpose of these innovations, which were f urther ref. ined in the 1960s, was to create an environment that fostered integration and continuity in student learning, encouraged the student to take initiative and responsibility for his or her own education, and treated the student as an individual, colleague, and developing physician. To accomplish this broad purpose, the traditional departmentally organized, vertically structured, disciplinary approach to learning was abandoned in favor of a horizontal, crosscutting, task-oriented, and interdisciplinary approach, in which the curriculum was viewed as the responsibility of the faculty as a whole rather than of individual departments. 11-16 , *The extent to which the traditional model has been and is the specific focus of evaluation efforts was not explicitly addressed in preparing this chapter. Without doubt, the introduction of curriculum and program innovations and modifications at many institutions was an least in part based on objective evaluation of the strengths and weaknesses of the traditional motel. Additionally, when innovative or experimental medical education curricula or programs are evaluated today, the traditional model is often used as the standard for comparisons (whether of student performance or other outputs). 116

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while 18 United States medical schools use some variant of the integrated organ system model originally developed by Case Western Reserve,15 it is estimated that as many as one-third of all IJ. S. medical schools have adopted one or more of the innovations pioneered at Case Western Reserve .16 I ~ t'ts ~ ra tive Example: Case Western Reserve University School of M-licine* Descriptionl1~15~17 In contrast to the traditional curriculum in which the basic sciences are taught simultaneously ant separately at the beginning of medical school ant the student is introduced to clinical experiences later in the program, the basic sciences are conceptualized, in the new integrated curriculum, in terms of their relationships to each other ant their interactions as manifest in human systems. Both the basic science and the clinical curricula are viewed as the responsibility of the faculty as a whole, and the faculty organize and plan their teaching through interdisciplinary subject committees (this is known as "sub ject-committee teaching' ). Other current features of the program include multidisciplinary teaching laboratories, early and ongoing clinical experiences f or students (including experience in a family clinic), free time for self-development, flexibility in scheduling, ant pass/fail grading. The curriculum at Case Western Reserve undergoes frequent revision, as information on the success or lack of success of various innovations is fed back and responded to by faculty and students, and as goals evolve. While there have been various changes in the curriculum over the years, and a "new" new curriculum was introduced in 196B, the medical education program at Case Western Reserve has remained relatively stable for almost 30 years. When the new curriculum was developed, the faculty came together to define educational objectives through a Committee on Medical Education, by which they court "express ~ themselves ~ directly in mat ters of educational policy and curriculum. The faculty not only defined their goals with care, but . . . used their own statement of ob Jectives as a guide to their later decisions. "l3 There was great excitement and enthusiasm among the faculty for this innovation, ant a tradition developed whereby the results of each curriculum change initiated were reported on to the faculty, allowing for discussion and a scientific approach to the process of medical education, as well as a commitment to institute needed changes. Goals or Objectives The goals of the Case Western Reserve program include *A portion of this material was supplied by Ore Susan D. Block, member of the Institute of Medicine committee for this report. 117

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course selection so as not to jeopardize grade point averages ~ and those accruing to the institutions involved, in particular to the undergraduate faculties of liberal arts and sciences and to the medical schools and their faculties. At the baccalaureate level, for instance, "science courses have been improved, new interdisciplinary of ferings in science, social science, and humanities have been created, and for the most part these have been open to all" (i.e., to students not necessarily planning medical careers).48 Additionally, student counseling has improved. As for the medical schools and their faculties, the evaluation concluded that resources were expended to enhance the quality of the basic science course offerings and to increase medical faculty involvement in undergraduate courses. These and other benefits accrued are judged as good, appropriate, money well invested, and so forth. The study also noted some serious limitations in the Interface programs, which, in its view, should be remedied. Among these are that (1) no serious effort has been made to explore what premedical education should consist of--"not only in the sciences but in the humanities and social sciences as well," and (2) such a small number of students has been selected to participate in Interface programs (a total of 95 students at seven institutions entering in 1979/80) that on a per-student basis the programs are very costly. Small numbers, furthermore, create an additional problem of making it virtually impossible to "draw any conclusions" as to program impact.4d With respect to the medical schools involved, the study also notes that the universities have failed to challenge medical school admissions policies, which continue to require a high grade point average , high grades in premedical science courses, and satisfactory to good performance on the Medical College Aptitude Tests.48 Illustrative Example: University of Michigan Medical School Integrated Premedical-Medical (Inteflex) Program program: Description and Goals Begun in 1972, the six-year Inteflex program, like the Interface programs described above, is a combined baccalaureate-M.D. program involving the Medical School and the University's College of Literature, Science, and the Arts. A special feature of this program is that students join their counterparts in the traditional track at the Medical School at the conclusion of their third year in the Inteflex program, becoming sophomore medical students.l8,53,54 Two motivations, or goals, underlie the development of this o to introduce educational innovation into both the premedical (college) and medical school education programs, and 0 to produce a dif ferent type of graduate--especially one "compassionate in dealings with others.''l8~54 137

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Program administrators have been especially interested in issues surrounding selection criteria and are convinced, through analysis of student performance data, that traditional methods of screening prospective students (primarily on the basis of college grades) are unnecessary. The Inteflex program is also especially concerned with women, particularly the program's impact on female students and graduates. Evaluation Activities Since its inception, extensive program monitoring and evaluation activities have been under way. These include a deliberate examination of program goals, measures (including measurement issues), and the mechanisms by which the effects of the Intef lex program are achieved . In fact, the university is viewed as having one of the largest data-gathering (and analysis) operations on medical students in the country.53 Among the types of evaluations that have been and are being carried out are comparisons of Inteflex students' performance and attitudes with those of regular premedical students at the University of Michigan, examination and analysis of selection criteria, and (as indicated above) analysis of the effects of the Inteflex program on female students and graduates. A longitudinal follow-up of program graduates is also planned. Illustrative Example: University of Missouri (Kansas City) School of Medicine In contrast to the other baccalaureate-M. D. programs discussed thus far, the University of Missouri (Kansas City) six-year combined degree program admits students directly from high school, ra ther than during their early college years . Northwestern University's Honors Program in Medical Education similarly admits students directly from high school. In other ways, however, the UMKC baccalaureate-M.D. program differs in focus (as will be evident) and might more appropriately be categorized as an exemplar of the Community-Based/Primary Care model. Description The year-round six-year baccalaureate-M.D. curriculum at UMKC was begun in 1971 and seeks to integrate u. .ly the college and medical school years, with the ultimate purpose of providing a pool of graduates that can meet the health care needs of Missouri residents.l5~55 Students spend 75 percent of their first two years in the program on baccalaureate studies and 25 percent on clinical studies. Years three through six are devoted to medicine. The baccalaureate degree is taken in sciences, humanities, or social sciences plus an optional minor in humanities, and additionally requires 30 hours of medicine. A public, state-supported School of Medicine, UMKC primarily accepts Missouri residents into its medical degree programs. While most of the students in the baccalaureate- M.D. program are recruited from high school, some ten percent of the spaces are reserved for older (college) students who have had a more 138

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traditional premedical education and will obtain their M.D. degree at the conclusion of a total of eight years of training. (The latter students serve as a comparison group to the six-year students.) Goals or Objectives The goals or objectives of the UMKC baccalaurea se-M. D . program are to provide o a curriculum that integrates the liberal arts and humanities, the basic sciences, and clinical medicine, using the existing resource'; of the College of Arts and Sciences; 0 a community-based program, using community hospitals and private practice physicians for training; o student-community contact from the outset of the program, via clinical training experiences with physicians, other health professionals, patients, and families, in the context of a community hospital; o a docent system that forms the basis of patient care teams, in which small groups of students are assigned for years three through six to a full-time faculty member who serves as a role model, teacher, and friend; and o explicit concern with minority and women students and graduates. Evaluation Activities Student monitoring and performance evaluation are both continuous and extensive. For example, multiple choice examinations are given every three months, and students are required to pass Parts I and II of the National Boards by graduation date. Student performance is regularly evaluated during clinical rotations. However, the most important indicator of program success, in the opinion of program administrators, is the clinical performance of its graduates during their graduate medical education years. Both objective and subjective (attitudinal) assessment instruments are used, and comparisons with traditional eight-year students are made. Particular attention has been devoted to the program's impact on minority and female students. M.D.-Ph.D. Programs Origin and Purposes There are two basic types of programs: the Ph.D.-to-M.D. program and . the combined M. D. -Ph. D . program. Ph. D. -to-M. D. programs were -instituted typically in response to the shortage of physicians in the late 1960s, with the intention of diverting Ph.D. scientists into clinical practice. A second rationale was to enrich the theory 139

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and practice of medicine via tapping the perspectives of accomplished scientists from various disciplines.56 Combined M. D. -Ph. D. programs provide scientific and medical training to highly motivated and capable students who show evidence of outstanding research and academic potential. Some 94 medical schools in the United States offer M.D.-Ph.D. programs. Illustrative Example: University of Miami School of Medicine The University of Miami School of Medicine of fers both types of programs, each constituting an alternative to its traditional f our-year medical educat ion program. 5 6 Description, Ph.D.-to-}I.D. Program Begun in 1971, the Ph.D.-to-M.D. program was developed to be completely new and separate from the traditional curriculum, enabling accomplished doctorates in the natural, physical, or engineering sciences (and now mathematics) to attain an M.D. degree within two full years of entry into the medical school. Some 38 students are admitted to the program per year, and there are no required prerequisite courses f or admission. Description, Combined M. D.-Ph. D. Curriculum The combined M.l).-Ph.D. program, begun in 1979, accepts outstanding baccalaureate candidates with majors in natural, physical, or engineering science s, who will complete a program that awards the Ph. D. in f ive years and the M. D. a t the end of six . Students enrolled in the combined M.D.-Ph.D. curriculum normally spend their first year studying biomedical sciences, the second year taking graduate courses and doing research, and the third year studying medicine. Part I of the National Boards must be passed at the conclusion of the third year. The fourth and fif th years are devoted to research and preparation of the doctoral dissertation, coupled with the core clerkships. The sixth year consists of core clerkships and elective cl inical clerkships, at the conclusion of which Part II of the National Boards must be passed. Evaluation Activities, Ph. D.-to-M.D. Program Student grades, faculty assessments, and National Board scores have been used to evaluate the success of this curriculum. Comparisons of student scores with those obtained by students in traditional programs have been judged as favorable. As of October 1979, 140 students in six cohorts had completed the Ph.D.-to-M.D. program. At that time, most were still in house-staff training programs. Of those who had completed their training, approximately half were in academic careers. "Whether or not they will make unique contributions to academic medicine is not yet known," according to evaluators, who concluded that the University of Miami School of Medicine had demonstrated that an accelerated and intensive course could medically qualify a "select group of talented scientists. 56 More definitive findings on the impact of this program are expected to be available soon. 140

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Evaluation Activities, Combined M.D.-Ph.D. Program Evaluation of this program is in progress, but results are not yet available as the program was initiated very recently. Special Needs: A Medical Education Program for Minority Students Illustrative Example: Meharry Medical College School of Medicine* Established in 1876, Meharry Medical College School of Medicine is one of four predominantly black medical colleges that address the special needs of black medical students and the black community in the United States. (The three others are Howard University College of Medicine, the School of Medicine at Morehouse College, and Charles R. Drew Postgraduate Medical School/UCLA Medical Program.) As evidence of its role in meeting these special needs, Meharry indicates that it has trained 40 percent of the black physicians and dentists in the United States and that 46 percent of the black faculty members in United States medical schools are Meharry graduates.57 Meharry's curriculum is neither unusual nor particularly innovative, although it is constantly being revised; in essence it is a modified version of the two-plus-two traditional model.44 An uncommon feature of the clinical phase (second two years) is an emphasis on special types of health care delivery through several outreach programs and facilities in the community. In the pant, faculty research has not been emphasized, and faculty were not recruited on the basis of their research capabilities, but more emphasis is placed on research at Mtharry today. What is unique about Heharry is its special purpose: to educate poor, minority, "high risk" students in the practice of medicine--particularly to prepare them for practice in medically underserved rural and urban areas, or to stimulate them to pursue careers in health research or biomedical science. Meharry accepts some students who, on the basis of their educational and socioeconomic backgrounds and Medical College Admissions Test scores, would be unlikely to be admitted elsewhere, 17 offers some of the most disadvantaged students remedial help through its Special Medical Program, and produces competent physicians (as judged by their ability to meet state licensing requirements), some of whom it considers outstanding. *This discussion is based in part on a visit to Meharry Medical College by Institute of Medicine star f and selected members of the IOM Committee to Plan a Review of Medical Education in the United States , at the invitation of its President, David Satcher, also a member of the IOM Committee (see Appendix D). 141

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While hard evaluative evidence is lacking, Meharry administrators consider the school 's medical education programs to be successful in compensating for the equational and socioeconomic disadvantages of some of its incoming students, and in adequately preparing them for careers in medicine. In their view, some of the initially least-promising students are among those whose postgraduate performance seems best. In terms of achieving program goals or objectives (apart from student achievement), administrators note that, over the past ten years, some 75 percent of Meharry graduates have located their practices in medically underserved areas (inner cities and rural areas).57 Funding uncertainties for students, however, have been affecting and are likely to continue even more forcefully to affect the nature of the student body and subsequent career decisions of students. 142

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13. Lee, P. V. Experimentation in medical education: the student, the patient, and the university. Ann. N.Y. Acad. Sci. 128: 532-543, 1965. 14. Ham, T. H. Medical education at Western Reserve University: a progress report for the sixteen years, 1946-1962. New England Journal of Medicine 267: 868-874, 1962. 15. Association of American Medical Colleges. General and Professional Education of the Physician and College Preparation for Medicine. Third Meeting of the Working Group on Essential Knowledge . Washington, D. C.: AAMC, 1983 . 16. Mawardi, B. H. 1956-1965 Career Study Report. Cleveland: Case Western Reserve University-School of Medicine, 1983. 17. Medical School Admission Requirements 1982-83, United States and Canada. Washington, D.C.: Association of American Medical Colleges, 1981. 18. Proceedings of a Symposium: Issues and Challenges, A Decade of Experience with Cost-Effective Models for Medical Education, April 3-4, 1981. Kansas City, Mo.: University of Missouri. 19. Ebert, R. H. Medical education in the United States. Daedalus Winter 1977, 171-184. 20. Lewin, L. S. and Derzon, R. A. Health professions education: State responsibili ties under the new federalism. Health Affairs 1: 69-85, 1982. 21. Steward, J., and Rich, C. The elective curriculum at Stanford University: Report on the first three graduating classes. In Purcell, E. F., ed. Recent Trends in Medical Education, Report of a Macy Conf erence . New York, N. Y.: Josiah Macy, Jr . Foundation, 1976. 22. Personal communication, Arthur Christakos, M.D., Dean of the School of Medicine, Duke University. 23. Institute of Medicine. Community Oriented Primary Care: New Directions Nor Bealth 9~ECte~Ja~ Connor, E. and Mullan, F., eds. Washington, D.C.: National Academy Press, 1982e 24. Prywes, M. Community medicine. The "firat-born" of a marriage between medical education and medical care. Health Policy and Education 1: 291-300, 1980. 25. Segall, A., Margolis, C., and Prywes, M. The Beershe~ra experience in COPC . In Ref erence #23 . 26. Creep, J. M. Training for COPC in the Netherlands and around the world. In Reference #23. 144

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27. Lewis, I. J., and Sheps, C. G. The Sick Citadel. The American Academic Medical Center and the Public Interest, pp. 149-53. Cambridge, Mass.: Oelgeschlager, Gunn, and Hain, 1983. 28. Burke, W. M., Eckhert, N. L., flays, C. W., Mansell, E., Deuschle, K. W., and Fulmer, H. S. An evaluation of the undergraduate medical curriculum: The Kentucky experiment in community medicine . J. AMA 241: 2726-2730, 1979. 29. Alpert, J. J. New directions in medical education: Primary care. In Purcell, E. F., ed. Recent Trends in Medical Education, Report of a Macy Conference. New York, N.Y.: Josiah Macy, Jr. Foundation, 1976. 30. Kaufman, A., Obenshain, S. S ., Voorhees, J. D., Burola, N. J., Christy J., Jackson, R., and Mennin, S. The New Mexico plan: Primary care curriculum. Public Health Reports 95: 38-40, 1980 . 31. The University of New Mexico News Release, February 1983. 32. Obenshain, S. S. New Mexico's primary care curriculum. In Reference #23. 33. Schwartz, M. R. Regional medical education: The WAMI program. In Purcell, E. F., ed. Recent Trends in Medical Education, Report of a Macy Conference New York, N.Y.: Josiah Macj, Jr. Foundat ion, 19 7 6 . 34. Schwarz, M. R. The WAMI program: A progress report. Western Journal of Medicine 130: 384-90. 1979. i 5. Cullen, T. J. et al. Evaluating decentralized basic science medical education: A Model. Evaluation and the Health Prof essions 4: 407-17, 1981. 36. McMaster University Faculty of Health Sciences. Information Handbook. Hamilton, Ontario (Canada): McHaster University, 1 9 80 e q7. Neufeld, V. R. and Barrows, H. S. The "McMaster philosophy": An approach to medical education. Journal of Medical Education 49: 1040-1050, 1974. 38. Woodward, C. A. Perspective. McMaster University, p. 282. In Proceedings of the Twentieth Annual Conference on Research in Medical Education. Sponsored by the AAMC Division of . Educational Measurement and Research in conjunction with the 92nd Annual Meeting, November 1980. 39. Woodward, C. A. The Perspective from McMaster University, pp. 452-54. In Proceedings of the Seventeenth Annual Conference on Research in Medical Educatione Sponsored by the AAMC Division of Educational Measurement and Research in conjunction with the 89th Annual Meeting, October 1978. 145

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40. Bowers, J. Z. and Purcell, E. F., eds. New Medical Schools at Home and Abroad. Report of a Macy Conference, p. 459. New York: Josiah Macy, Jr. Foundation, 1978. 41. Personal communication, Dr. Robert Maudsley, Associate Dean of Education, McMaster School of Medicine. 42. Segall, A. Evaluation at the Ben Gurion University of the Negev School of Medicine, pp. 457-59. In Proceedings of the Seventeenth Annual Conference on Research in Medical Education. Sponsored by the AAMC Division of Educational Measurement and Research in conjunction with the 89th Annual Meeting, October 1978. 43. Beran, R. L. and Kriner, R. E. A Study of Three-Year Curricula in IJ. S. Medical Schools. Washington, D. C.: Association of American Medical Colleges, 1978. 44. 1981-82 AAMC Curriculum Directory. Washington, D.C.: Association of American Medical Colleges, 1981. 45. Symposium: The rise and fall of three year medical curricula. In Proceedings of the Twentieth Annual Conference on Research in Medical Education, pp. 277-284. Sponsored by the AAMC Division of Educational Measurement and Research in conjunction with the 92nd Annual Meeting, November 1981. 46. May, R. H. School of Medicine: Southern Illinois University, pp. 419-50. In Reference #40. 47. Daubney, J. H., Wagner, E. E., and Rogers, W. A. Six-year B. S. /M.D. programs: a literature review. Journal of Medical Education 56:497-503, 1981. 48. Gellhorn, A. An Evaluative Report of the Interface Programs Supported by the Commonwealth Fund. Prepared for the Commonwealth Fund, April 1980. 49. Culbert, A. J., Blaustein, H., Sandson, J. I. Special Report. The modular medical integrated curriculum. An innovation in medical education. New England Journal of Medicine 306:1502-1504, 1982. 50. Sullivan, R. Training doctors early with the liberal arts. New York Times, November 14, 1982. 51. McLaughlin, L. BU medical program suggested as model for others. Boston Globe, June 17, 1982. 52. Blaustein, E. H. and Wayne, H. L. Boston University and accelerated medical education: The first five cohorts. Journal of Medical Education 55:202-204, 1980. 53. Research News ~ University of Michigan, 1982, pp.15-17. 146

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54. Campbell, C., and DeMuth, G. R. The University of Michigan integrated premedical~medical program. Journal of Medical Education 51: 290-295, 1976. 55. Jonas, H. S. A decade of experience with a cost-effective model of medical education fully integrating college and medical school years. University of Missouri-Kannas City School of Medicine, 1982. 56. Awad, W. M., Jr., Barrington, W. J., and Papper, E. M. The Ph.D. to M.D. program: The seven-year mark. New England Journal of Medicine 301: 863-867, 1979. 57. Personal con nunication, Dr. David Etcher, President, Meharry Medical College (see Appendix D). 147