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Medical Education and Societal Needs: A Planning Report for Health Professions (1983)

Chapter: 5. Innovative Models of Medical Education in the United States Today: An Overview with Implications for Curriculum and Program Evaluation

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Suggested Citation:"5. Innovative Models of Medical Education in the United States Today: An Overview with Implications for Curriculum and Program Evaluation." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"5. Innovative Models of Medical Education in the United States Today: An Overview with Implications for Curriculum and Program Evaluation." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"5. Innovative Models of Medical Education in the United States Today: An Overview with Implications for Curriculum and Program Evaluation." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 109
Suggested Citation:"5. Innovative Models of Medical Education in the United States Today: An Overview with Implications for Curriculum and Program Evaluation." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 110
Suggested Citation:"5. Innovative Models of Medical Education in the United States Today: An Overview with Implications for Curriculum and Program Evaluation." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"5. Innovative Models of Medical Education in the United States Today: An Overview with Implications for Curriculum and Program Evaluation." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 112
Suggested Citation:"5. Innovative Models of Medical Education in the United States Today: An Overview with Implications for Curriculum and Program Evaluation." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 113
Suggested Citation:"5. Innovative Models of Medical Education in the United States Today: An Overview with Implications for Curriculum and Program Evaluation." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 114
Suggested Citation:"5. Innovative Models of Medical Education in the United States Today: An Overview with Implications for Curriculum and Program Evaluation." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 115
Suggested Citation:"5. Innovative Models of Medical Education in the United States Today: An Overview with Implications for Curriculum and Program Evaluation." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 116
Suggested Citation:"5. Innovative Models of Medical Education in the United States Today: An Overview with Implications for Curriculum and Program Evaluation." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 117
Suggested Citation:"5. Innovative Models of Medical Education in the United States Today: An Overview with Implications for Curriculum and Program Evaluation." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
×
Page 118
Suggested Citation:"5. Innovative Models of Medical Education in the United States Today: An Overview with Implications for Curriculum and Program Evaluation." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 119
Suggested Citation:"5. Innovative Models of Medical Education in the United States Today: An Overview with Implications for Curriculum and Program Evaluation." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 120
Suggested Citation:"5. Innovative Models of Medical Education in the United States Today: An Overview with Implications for Curriculum and Program Evaluation." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 121
Suggested Citation:"5. Innovative Models of Medical Education in the United States Today: An Overview with Implications for Curriculum and Program Evaluation." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 122
Suggested Citation:"5. Innovative Models of Medical Education in the United States Today: An Overview with Implications for Curriculum and Program Evaluation." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 123
Suggested Citation:"5. Innovative Models of Medical Education in the United States Today: An Overview with Implications for Curriculum and Program Evaluation." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 124
Suggested Citation:"5. Innovative Models of Medical Education in the United States Today: An Overview with Implications for Curriculum and Program Evaluation." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 125
Suggested Citation:"5. Innovative Models of Medical Education in the United States Today: An Overview with Implications for Curriculum and Program Evaluation." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 126
Suggested Citation:"5. Innovative Models of Medical Education in the United States Today: An Overview with Implications for Curriculum and Program Evaluation." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 127
Suggested Citation:"5. Innovative Models of Medical Education in the United States Today: An Overview with Implications for Curriculum and Program Evaluation." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 128
Suggested Citation:"5. Innovative Models of Medical Education in the United States Today: An Overview with Implications for Curriculum and Program Evaluation." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 129
Suggested Citation:"5. Innovative Models of Medical Education in the United States Today: An Overview with Implications for Curriculum and Program Evaluation." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 130
Suggested Citation:"5. Innovative Models of Medical Education in the United States Today: An Overview with Implications for Curriculum and Program Evaluation." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 131
Suggested Citation:"5. Innovative Models of Medical Education in the United States Today: An Overview with Implications for Curriculum and Program Evaluation." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 132
Suggested Citation:"5. Innovative Models of Medical Education in the United States Today: An Overview with Implications for Curriculum and Program Evaluation." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 133
Suggested Citation:"5. Innovative Models of Medical Education in the United States Today: An Overview with Implications for Curriculum and Program Evaluation." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 134
Suggested Citation:"5. Innovative Models of Medical Education in the United States Today: An Overview with Implications for Curriculum and Program Evaluation." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 135
Suggested Citation:"5. Innovative Models of Medical Education in the United States Today: An Overview with Implications for Curriculum and Program Evaluation." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 136
Suggested Citation:"5. Innovative Models of Medical Education in the United States Today: An Overview with Implications for Curriculum and Program Evaluation." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 137
Suggested Citation:"5. Innovative Models of Medical Education in the United States Today: An Overview with Implications for Curriculum and Program Evaluation." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 138
Suggested Citation:"5. Innovative Models of Medical Education in the United States Today: An Overview with Implications for Curriculum and Program Evaluation." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 139
Suggested Citation:"5. Innovative Models of Medical Education in the United States Today: An Overview with Implications for Curriculum and Program Evaluation." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 140
Suggested Citation:"5. Innovative Models of Medical Education in the United States Today: An Overview with Implications for Curriculum and Program Evaluation." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 141
Suggested Citation:"5. Innovative Models of Medical Education in the United States Today: An Overview with Implications for Curriculum and Program Evaluation." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 142
Suggested Citation:"5. Innovative Models of Medical Education in the United States Today: An Overview with Implications for Curriculum and Program Evaluation." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"5. Innovative Models of Medical Education in the United States Today: An Overview with Implications for Curriculum and Program Evaluation." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 144
Suggested Citation:"5. Innovative Models of Medical Education in the United States Today: An Overview with Implications for Curriculum and Program Evaluation." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Page 145
Suggested Citation:"5. Innovative Models of Medical Education in the United States Today: An Overview with Implications for Curriculum and Program Evaluation." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"5. Innovative Models of Medical Education in the United States Today: An Overview with Implications for Curriculum and Program Evaluation." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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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

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

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

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

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

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

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

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

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

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

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

o teaching students not only to understand disease processes, but also to care about patients as persons and as members of society, o providing a curriculum that facilitates integration and continuity in teaching and learning, and o encouraging self-education by the student and fostering the notion that the physician is an investigator for life. Evaluation Activities There have been numerous evaluation 1 _ studies on the impact of Case Western Reser~re's medical education program on its graduates. One such study, recently completed and prepared for The Commonwealth Fund, assesses the impact of the new curriculum on the first 10 classes of graduates (1956-1965~.16 This study was designed to facilitate comparison of results with an earlier study of Case Western Reserve medical graduates, which covered the period 1935-1945. Both studies examine physicians' careers ant career patterns and their sources of satisfaction and dissatisfaction with the ir professional lives. The recent study, released in February, 1983, is based on two types of data: survey data f rom the American Medical Association on career choice, geographic distribution, Board certification, association memberehips, medical school teaching appointments, and other such background data for all living graduates of Case Western Reserve University School of Medicine through 1972; and data gathered from an intensive f ield study of a stratified random sample of 180 of the 800 graduates of the first ten years of the new curriculum ( 19 56-1965 ~ . The f ie Id s tudy involved personal interviews; self-administered, short-answer questionnaires; and four personal) ty inventories. The stratified random sample included 20 male physicians from each of eight categories (general or family practice, internal medicine, general surgery, psychiatry, pediatrics, obstetrics and gynecology, full-time medical faculty, and full-time hospital physicians) and 20 women physicians in private practice and nonof f ice based careers e Among the findings from the -survey portion of the recent studyl6 are that (1) a higher proportion of the new curriculum graduates are in full-time research than are graduates from the 1934-1935 period (4. 5 percent as opposed to less than 1 percent), and that (2) for the more recent period, psychiatry was the second most popular specialty choice (following internal medicine), although nationwide for the same period it placed fifth. The field study, which attempted to determine the impact on graduates of the total program and of some 17 special features of the curriculum during the period 1956-1965, yielded the following findings, among others: L. Whole-hearted enthusiasm for the revised curriculum was exhibited "by all but a very small number of the interviewees, " and there was an overwhelming sentiment among graduates that they would choose the same program if they had it to do over again. 118

2. Mbre than three-fourths of all ratings (on all features of the program) across all categories sampled were favorable or positive . 3. The 1956-1965 curriculum feature that received the highest proportion of "extremely important" ratings was subject-committee teaching, followed by "caring about the patient as a person, " and the basic clerkship. While caring about the patient as a person was widely-accepted by all graduates from the 1956-1965 period, not all those interviewed attributed their concern to their medical education program; some indicated they had entered the program with this value. It is worthy of note, nonetheless, that among six of the groups of male practitioners, caring about the patient as a person was viewed as the most important of the 17 special features of the curriculum inqui red about . 4. All graduates of the new curriculum, in contrast to only the psychiatrists from among the earlier graduates, revealed a clear understanding of the nature of good doctor-patient relationships (involving open communication, trust, respect). 5. For graduates of both periods, the level of satisfaction with the profession of medicine was high; ant in both periods the intellectual and technical problem-solving capabilities that produce accurate diagnosis and successful therapy are what contribute most to professional satisfaction. Women physicians (studied only for the more recent period ~ were, on the whole, as satisf fed with the ir careers as were their male counterparts. 6. Surgeons as a group were found to be the most satisf fed with their practices, psychiatrists the leant satisfied (though psychiatry was the second most popular specialty chosen by graduates from the 1956-1965 period), and the level of satisfaction among pediatricians improved from the earlier to the later time period. 7. The mayor sources of dissatisfaction with respondents' careers derived from time pressures, interprofessionaL problems, the demands of office management and paper work, government regulations, ant worries about malpractice. B. The women physic lane were f ound to have most f requently entered psychiatry or pediatrics and to be more likely than their male counterparts to be practicing in institutions. Impact of the Cased GO He most profound impaled at Case Western Reserve in the 1950s has been its influence on other medical schools, both in the IJnited States and abroad--not so much as concerns particular curriculum features, but rather as an "inspiration," which liberated them from "the lockstep of conformity that dominated ~ United States schools] for forty years. t13 The 119

evidence that Case Western Reserve produces a "dif ferent kind of doctor, " however, is ambiguous. * The Flexible or Elective Model Origin and Purposes A great many factors and pressures both within ant outside medical schools Led to major curriculum ant program innovation and experimentation that began in the 1950e with Case Western Reserve 's pioneering introduction of its totally interdi~ci;plinary prograel.3~5~9~12,l8~20 These factors included: (1) the expansion of biomedical knowledge, which was overloading the system; (2) extension of postgraduate medical education as preparation for specialization, which raised questions about the proper scope of the medical school phase of education; (3) an increasingly wide variety of careers open to medical graduates, which challenged the uniformity of course content and curricular structure; (~) student demands for curricula tailored to their abilities, needs, and interests; and (5) social pressure for the training of physicians from more diverse geographic, racial, ant socioeconomic backgrounds. 4, 5, 10 In recent years, a survey questionnaire was sent to all 97 medical schools and the six schools of teas ic medical science in existence in the United States in 1970/71, in preparation for a Josiah Macy, Jr. Foundation conference. The survey found that all but nine of the established schools had inst ituted radical changes in their curricula during the previous f ive years, or were planning to do so. 5 Among the changes introduced into existing curricula or alternative medical education programs offered at the same institution were (1) a reduction in the number of hours devoted to required work in the basic sciences, (2 ~ an increase in interdisciplinary instruction (of ten including an organ system rather than a discipline approach) and elective course offerings, and (3) recognition that though a core curriculum in basic sciences is desirable, there are many alternate instructional routes to tranami t the requisi te knowledge . 5 Illustrative Example: Duke University School of Med icine ' s Elective i- Curriculum In addition to Duke's Elective Curriculure,4,l5 discussed below, numerous medical education programs at diverse institutions throughout the United States might be considered to exemplify this *According to Dr. Susan D. Block, member of the Institute of Medicine committee for this report . 120

model. These would include the medical education program at Stanford University School of Medicine.*l7,21 Description Curriculum revisions at Duke ~ begun in the 1960~, were undertaken in response to pressures for change, most notably students' demands for curricula tailored to their needs, abilities, and career goals. With support from a number of private philanthropies, Duke completely overhauled its medical education program, contrasting sharply with the traditional post-Flexnerian model. In the M.D. curriculum, all firat-year students take a tightly structured, intensive science program, to provide the science base on which an elective curriculum in the third and fourth years can be built. All students must take the core clinical clerkship program in their second year. The third and fourth years are devoted to elective courser that must be equally divided between basic science and clinical sub jects, in accordance with students' career aspirations. The purpose of requiring electives in the basic sciences is to ensure that students return to the study of the basic sciences following their experience in patient care. Goals or Ob iectives The coals of Duke's Elective Curriculum are as f allows: o to gibe students more freedom and flexibility than available in traditional curricula, o to use more fully the resources of the entire university in the medical education of its students, o to acquaint the student with a variety of disciplines from which to make career choices, o to provide multiple pathways to diverse career opportunities, or stimulate in-depth study of an appealing area, ant 0 to design electives that demand rigorous scholarly effort. Evaluation Activities In conjunction with the overhaul of its medical education program in the 1960s, Duke designed and implemented mayor longitudinal curriculum evaluation activities. As of 1975, Duke had been evaluating the impact of its program changes for some 10 years. With respect to achievement of the stated goals of the Elective Curriculum, numerous surveys (some attitudinal, some objectives and other research tools have been uset to monitor or track the implementation of curriculum changes ant to compare successive cohorts of students with each other over time and against . *Stand ord has had an all-electi~re curriculum, but at the request of the medical faculty, will return to a more structured and traditional program beginning with the class entering in 1984. 121

national norms. Patterns of elective choice, student career decision making, student success rates on standardized teats (National Boards, for example), and faculty teaching effort have been analyzed and evaluated, among others. As of 1975, analysis of student ant faculty outcomes on these indicators of achievement were viewed as highly favorable. However, since that time there has been no rigorous analysis of the data, though program administrators express conf idence that analyses would conf ire their impressionistic view that the elective program has been highly successful. For example, they note that the postgraduate training programs that Duke graduates enter are "excellent, " and that Board certification rates are "high." Additionally, the point at which career choices are made tends to be earlier for Duke students than for students at other medical schools, which may be due to Duke students' earlier exposure to clinical experiences.22 Communi ty-Based/Primary Care Model Origin and Purposes A national physician shortage in comprehensive health care, especially for rural areas and economically poor population groups, became a major concern of the federal government and medical educators al ike beginning in the L9SOs. During the post-Flexner era, the struggle to integrate science and medical education concepts and the rapid growth of medical technology hat led to emphasis on the treatment of disease through the practice of specialized medicine and to a trend away f row treating the patient as a whole person, thus de-emphasizing the investigation and management of environmental, social, and economic factors affecting heal to. Government grants and funds from philanthropies over the past three decades have encouraged various institutions, both in the U.S. and abroad, to experiment with programs that address the patient rather than the disease and attempt to find practical ways to meet the health care needs of undeserved groups and communities. 1, 8,12 ,13, 23-27 Frequently this in accomplished through basing clinical experiences in community hospitals in addition to, or in lieu of, tertiary-care facilities owned or controlled by the university. Medical education programs geared to communi ty medicine or primary care also tend to include the social sciences along with the biomedical sciences in their science baleen and to focus on skills development rather than on the transmission of specific knowledge through instruction. There are 18 communi ty-based schools of medicine in the United States today.27 The original and perhaps best known is the College of Human Medicine of Michigan State University at Lansing, established in the early 1960s; since 1974 it has had the Upper Peninsula Medical Education Program, encouraging family practice and 122

the provision of primary care in shortage areas.23 The University of New Mexico School of Medicine's Primary Care Curriculum and the University of Washington's WAMI program, discussed below, are typical of co~munity-based/primary care programs being experimented with. Additional examples include the University of North Carolina ~ UNC ~ School of Medicine General Clinic programl2 and the University of Kentucky College of Medicine's special program. 28 At Morehouse College School of Medicine,1 a Minority-Oriented Primary Care Medical Education Program has been created to develop a curriculum more applicable and responsive to the needs of persons living in underserved communities. The principal goal of the UNC interdepartmental clinic program is to produce physicians who will practice in the state of North Carolina, giving part icular at tension to social, psychological, and preventive aspects of patient care. What these and other programs like them have in common i~ a focus on underservet populations, typically in rural areas or particular regions of a -state or states, where there is a maltistribution of available physicians or where there are shortages of a particular type of physician, such as primary care o r family pract i tioners . In Europe, a Network of Community-Orientet Educational Institutions for Health Sciences25 was established trader the auspices of the World Health Organization (WHO) in 1979, bringing together representatives from some 18 medical schools with curricula or programs that departed from the current or traditional models of medical education, either in their emphasis on a community orientation (in addition to the health needs or individuals) or by their use of educational methods or processes emphasizing student problem solving. The network links these schools with each other and with other medical schools committed to an innovative approach or willing to collaborate with such sChooln.26 Both McMaster and Ben Gurion Uni~rersittes ~ discussed below, have medical schools belonging to the network. Illustrative Example: University of New Mexico (UNM) School of Medicine Primary Care Curriculum Description Supported by the W. K. Kellogg Foundat ion and the U. S. Department of Health ant Human Services, the Primary Care Curriculum (PCC) at UNH, founded in 1977, has as its main purpose the training of physicians to practice in underserved, rural areas.l,29~39 In New Mexico, physicians have tended to cluster in the ma jar metropolitan areas of Albuquerque and Santa Fe, catering largely to middle-class Anglo population groups. The state has also hat a poor retention rate for physicians trained at UNM, the state 's only medical school. Because UNM "feels a special obligation to serve the state 's unmet health needs, " the School of Medicine established the PCC as an alternative educat tonal track, parallel to 123

its traditional medical education curriculum.] To be eligible for the program, a student must be enrolled in the School of Medicine, and preference is given to students who themselves come from rural or medically underserved areas. The PCC is divided into three phases, the f irst two years being totally separate from the traditional curriculum. In the third year, however, all UNM medical students take in-hospital clerkships. A distinctive feature of the PCC is that students participate in clinical experiences from their freshman year, in order to establish primary care as their main intensive clinical experience prior to exposure to tertiary-care and clinical clerkship experiences . The f irst eight months of the freshman year are spent in clinical problem-based learning via small tutorial groups that focus on patient problems commonly found in rural New Mexico. Problems selected for study are chosen to expose the student to the ma jar content areas of the basic clinical sciences. At the conclusion of this period, students are regarded as comparable in skill level to a physician's assistant about to begin practical training. If judged adequately prepared, the student then begins a four- to six~month rural preceptorship, working under close supervision with a team of primary care physicians experienced in. problems most frequently encountered in rural New Mexico.1 The rural clerkship sites represent the cultural diversity of the state and the varieties of medical practice pat terns in use , ranging f rom a Nava JO community clinic to a group practice in an Anglo ranching community. During this period, students also continue their basic and clinical science learning (centered around the problems of patients they encounter), and study the social, political, and economic forces affecting the health of their communities; they also conduct community health assessments and develop community health projects on the basin of the needs they have identified. Medical school faculty visit each student on a biweekly basis to monitor their educational progress. At the conclusion of their rural preceptorship and for the remainder of their second year, students return to small tutorial groups for problem-based learning on a more sophisticated level. The US Primary Care Curriculum, now in its fourth year of operation, has a to Cal enrollment of 65 students spread over three medical school years. During its first year, 10 students were accepted into the program; 15 were accepted during its second year, ant 20 during its third and fourth years (with the expectation that admissions will continue at this level). Goals or Ob jectives The goals and ob jectives of the US PCC, in terms of student capabilities to be developed, are 0 to be able to identify, evaluate, and manage patient, family, and community health problems, 124

o to become a self-directed learner, o to perform constructive ~elf- and peer-evaluation, and o to function productively in a small, interdependent group.1 Evaluation Activities Evaluation of the PCC is conducted by a - team of reedical sociologists not af f iliated wi th the program. The extent and type of evaluat ion of the curriculum has not been ascertained, but some preliminary f indings have been reported. For instance, preceptors ' opinions about the program tend to be more favorable af ter they have experienced the preceptorship (based on pre- and post-preceptorship self-ratings of enthu~lasm). Similarly, " the rural experience appears to reinforce ehe desire of PCC students to practice in smaller communittes.. 1 of the 10 Students in the f test PCC class completing the preceptorship, eight said they wanted to have a rural and/or primary care practice. The medical school faculty, however, has demonstrated considerably less enthusiasm for the program. Some have been found to resent the extra teaching burden imposed by two medical education tracks. Loss of control over student learning is also an issue, some faculty being "skeptical that 'town' doctors can provide the quality of teaching offered by the university faculty. .81 Likewise, the fact that the PCC track focuses "outward toward existing community health care needs" creates "discord," because medical school faculty typically focus "inward upon institutional concerns.''] Illustrative Example: University of Washington WAMI (Washington, Alaska, Montana, Idaho ~ Program. Description In 1977 the states of Alaska, Montana, and Idaho entered an agreement wi th the state of Washington to become full partners in medical education, with the University of Washington School of Medicine (Seattle) serving as the medical education, faculty, and tertiary-care resource.33~35 Students entering the program from the four WAMI states take their first year of medical education at one of four universities without medical schools (Washington State University, the University of Alaska, Montana State University, and the University of Idaho), or at the Uni~reraity of Washington, and train at 17 community clinical units in rural and semirural areas throughout the region. The second and third years are spent at the University of Washington. During the fourth year, students have the opportunity to take structured community-baset clerkships in rural portions of the WAM1 states. Goals or Ob jectives The goals of the WAMI program are as follows: o to increase the number of students in medical school from each of the four states, 125

0 to increase the number of students trained for careers in primary care, including family medicine, pediatrics, and primary care internal medicine, 0 to place physicians in areas of need in the four states, especially in rural areas, and o to bring the resources of the medical center at the Unive rsi ty of Washington (Seattle) to the communities of the four states. Evaluation Activities The WAMI program has been internally . . . monitored and extensively evaluated since its inception, to determine whether and how well it is meeting its goals. Target goals for increasing the numbers of students enrolled in the program from each of the four states have been met, and the other outcome goals are viewed as being met or within reach, on the basis of surrogate measures. * Aside from the n''merica1 goals, three ma jar impact-evaluation activities are underway: (~) a comparative assessment of the quality of the firat-year instructional program at the participating universities (as measured by student performance levels on such standardized tests an the National Boards); (2) assessment of student and faculty attitudes toward the program; and (3) assessment and tracking of career aspirations and proposed practice locations of program graduates. A longitudinal ~ 25-year) follow-up of students (and of the regional resource networks established by this program) is also planned.35 Illustrative Example: blcMaster University Faculty of Health Sciences School of Medicine (Hamilton, Ontario, Canada) Description The McHaster program was originally developed as an educational innovation with a commitment to a particular teaching-learning style that is problem-based and involves self -directed learning . 36-40 The f irst class of students entered in 1969. Students typically complete the McMaster program in three years, with attendance for 11 months per year. However, in contrast to the typical three-year metical education program developed in the United States (and discusses later under Accelerated Models), this is not a compression of the typical four-year program; rather it represents a major rethinking of the educational experience. The ma jor innovative or experimental feature of the program ts that clinical and science knowledge and skills are developed through small-group tutorials organized around sets of problems, which, when *For instance, surreys of the intentions of graduating seniors suggest that the goal of placing physicians in areas of need is being met . Not enough s tudents have completed their training to know for sure whether the third stated goal actually will be accomplished . 126

completed by each student, cover the broad spectrum of human health problems. The emphasis is on developing capabilities and characteristics rather than on instilling particular knowledge; in addition, there is a focus not only on ill-health (disease), but also on the impact of biology, environment ~ and life-style on health. Students are exposed very early in the program to pat tents and their problems, in settings ranging from community health care practices to specialized hospital services (i.e., primary-, secondary-, and tertiary-care settings) ~ and a professional teamwork approach to patient care is used. Students may choose from a variety of clinical, educational, research, or community elective experiences; and they are jointly responsible with their advisers for planning their electives. To encourage graduates to practice in underserved areas, clinical experiences in rural or remote areas are of fered. Another innovative feature of the McMaster approach is to evaluate faculty on the basis of their performance as educators (in addition to service and research). The program is structured to meet the needs of interdisciplinary instruction as well as those of tradi tional department s . To qualify for admission, students customarily must have completed three years of university (college), but some mature appl icants wi th no previous college experience are admitted . The selection process allows admission of students from a variety of academic backgrounds, requires demonstration of only motest academic achievement (a higher proportion of students entering with a B than an A average), and has no specific courses as prerequisites. Almost half the admitted students have undergraduate ma jors in fields other than the biological sciences, and about one-third of each class is composed of students who lack any extensive exposure to science at the university level . From among the qualif fed applicant pool, those selected for admission are the ones judged to be most likely to meet the student outcome goals of the program (see below) and who demonstrate capability to "thrive in a relatively unstructured environment." The admissions process thus involves assessment of noncognitive as well an cognitive factors. Some 100 students per year are admitted to the School of Medicine. Women applicants have tended to be admitted in higher proportions than men. Goals or Ob jectives As of July 1973, the program development goals of the McHaster School of Medicine program were 0 to develop new approaches for the education of health personnel in. association with the provision of better health services in the communi ty, o to provide early and varied clinical experience for students in the town community ~ in teaching hospitals, community practices or other settings), and 127

0 to organize an integrated program of self-directed learning. When specif fed in terms of student outcomes (capabilities, characteristics), the goals of the McMaster program are to provide students with the capacity o to identify health problems and search for information to resolve or manage these problems; o to examine the underlying physical or behavioral mechanisms of the identif fed heal th problems; o to recognize, maintain, and develop personal characteristics and attitudes required for professional life; o to develop the clinical skills and learn the methods required to define and manage health problems of patients, including physical, emotional, and social aspects; o to become a self-directed learner, recognizing personal educat tonal needs, selecting appropriate learning resources, and evaluating progress; o to critically assess professional activity related to patient care, health delivery, and medical research; o to function as a productive member of a small group, engages in learning, research, or health care; and o to be aware of and to be able to work in a variety of health care set t ings . 37 Evaluation Activities Evaluation of student progress (called - formative or diagnostic evaluations, in that they are fed back to the student) are frequent, and are conducted principally by the students themselves, though tutors (faculty) and peers are also involved. Faculty members are also assesses, by their peers and by students. Specif ications for evaluating program impact (as opposed to formative evaluation of students or faculty) were developed from questions pa set to the f acuity . Data-gathering activities underway and funded internally include: ~ 1 ~ basic demographic information on students from admission through practice; (2) surveys of students, upon entry and exit from the program' concerning career goals and attitudes and opinions about the McHaster medical education program; ~ 3 ~ annual updating of the locat ion, f unction, and specialty choice of graduates of the program; (4 ~ information on the performance of students on licensing examinations; and (5) specialty certification pass rates. Additionally, two evaluation pro jects have received external funding: ( 1 ) analysis of the career choices ant career 128

development of the f irse six graduating classes; and (2) analysts of the extent to which, in the opinion of clinical supervisors during graduate internships, graduates meet the ob jectives of the curriculum. Another area of study concerns the relationship between licensure examination results and internship performance. In 197S, a s tudy to assess the quality of care provided by McMaster graduates who have entered general or family practice in Ontario was designet.39 Some findings from analyses of collected data follow. As of 1981, graduates, their postgraduate supervisors, and the certifying bodies they encounter "do not f ind that a three-year curriculum produces leas able physicians. "38 AS of 1981, also, more than 80 pe rcent of the members of the f irat six graduated classes, surveyed two to five years out of the McMaster program, indicated they would choose the three-year curriculum if they had it to do over again; 86 percent of those surveyed said they were "satief ted" or "very satisf let" with the sequence and type of graduate medical training they had. Additionally, clinical supervisor ratings and comparisons of McHaster's interns with interns having graduated from other Canadian medical schools suggest that McMaster graduates "perform very well."38 As of 197B, performance of McHaster students on the national licensure examination was "in the.mid-range" for Canadian medical schools; and the f irst-time pass rate on specialty board examinations (94- percent for McMaster graduates) was higher than for graduates of most other Canadian medical schools. Additionally, close to 50 percent of the first five graduating classes chose general or family practice (the remainder having chosen specialty practice ), and 64 percent of graduates were f ound to have remained in Ontario.39 On the basis of its latest internal evaluation, McMaster has renewed its commitment to its three-year medical education program. The program now, however, permits up to 10 percent of each 100-stutent class to spend six to 12 months at another site (for instance, in a laboratory), studying one or more areas in depth. Because of the lockstep nature of llcHaster 's program, however, this arrangement has caused scheduling problems for the students involved. Their time away from McHaster puts them out of sequence when they return. To accommodate these students, more f legibility in scheduling is presently being developed .41 Impact of the McMaster Program Information about McMaster's medical education program has been widely disseminated in the United States ant elsewhere. Several new medical schools' including the medical school founded in Maastricht, Holland, in 1974 and the Suez Canal University in Egypt, have based their medical education programs on the McMaster program. The medical education program at Ben Gurion IJniversity 's medical school, discussed below, was also heavily influenced by McMaster. McMaster is also a member of the network of Community Oriented Educational Institutions for Health Sciences . 41 129

Illustrative Example: School of Medicine of Ben Gurion University of the Negev Center for Health Sciences (Beer She va, Israeli . * Description The medical school of Ben Gurion University was established in 1974 in Beer Sheva, the principal city in Israel ' s southernmost Negev region. Its purpose is not to increase the numbers of physicians in Israel ~ there is already a high doctor-patient ratio) but rather to educate a new kind of phys ician--one that is an agent for change and concerned primarily with improving the quality of health and meeting community health care needs in the Negev region. 2 5, 42 As wi th the McMas ter University medical school, Ben Gurion University's program emphasizes skills development, self-learning, self-teaching, and self-evaluation, rather than the acquisition of concrete body of knowledge. The curriculum ant the objectives for each course are coupe tency-based, and provide the f ramework f or the content of instruction, methodology, ant student evaluation. The program features a great deal of interdepartmental cooper. tion. The nontraditional curriculum at the medical school progresses as a "spiral," at each successive stage incorporating and applying knowledge f tom the teas ic sciences to solve clinical and public health problems encountered in community settings in a Fore sophisticated manner. The seven-year curriculum (following completion of high school and military service ~ features clinical instruction from the very outset. It includes subjects normally taught in the las t two years of baccaiaurea te programs in the U. S . and the basic science and clinical disciplines taught in U. S. medical schools. There is an emphasis on social studies, the behavioral sciences, and public health aspects of medicine, including the social, socioeconomic, ethnic, and cultural facets of health and disease. The focus is on the natural history of disease ~ rather than on acute phases ), and clinical teaching takes place not only on the wards, but also in a wide range of ambulatory health facilities throughout the Negev region, including hospital outpatient clinics, occupational health units, rehabilitation facilities, and public health stations. From the first through the seventh years, clinical science ins truct ion increaser and basic science instruction decreases. The medical school also values and stresses the ability to read and evaluate scientif ic literature; and prior to graduation each student must complete a research project in public health and epidemiology in Beer She va or in outlying communities. - *This discus~ion i~ based largely on a visit to Ben Gurion university in Decembe r 1982, by Elena 0. Night ingale, Vice-Chair of the IOM Committee to Plan a Review of Medical Education in the United States (see Appendix D) and on a recent conference on communi ty-oriented pr ima ry ca re . 2 5 130

A unique feature of this program concerns its selection of students. Students typically enter Ben Gurion University School of Medicine at age 21, after graduation from high school and completion of three years of military service. (Military service is viewed as enhancing the development of a mature, focused student who is able to relate to the needs of the community by virtue of his or her real~orld experience. ~ There is a two-stage screening process for admission. To be eligible, applicants must meet a basic intelligence and achievement level, but beyond this, admission decisions are based on a variety of personal quali~ies--integrity, empathy, ~elf-identity, tolerance for ambiguity, decisiveness, insight, intellectual level, ant evidence of a community orientation and sense of social responsibility. Ability to pay is unrelated to admissions, an the costs of the medical education program are pan' by the government and the labor unions' sick f und. Goals or Objectives The goals of Ben Gurion University School of Medicine are, through emphasis on training of physicians in community-oriented primary care, to train medical students and produce medical gradua tes who will o improve the quality of health care in the Negev region, o provide appropriate preventive and therapeutic health care services to the ~ Negev) community' 0 integrate and provide continuity of care through the various phases of illness, o participate in outreach programs to serve the broader health needs of the population, 0 be lif e-long learners, self-teache rs, and self-evaluators, and o be humane, considerate, and respectful toward patients while providi ng services . Evaluation Activities Assessment of the Ben Gurion medical education program is carried out by both students and faculty. While only two classes have been graduated (as of December 1982), there is some evidence that students intend to enter primary care: roughly half of the f irst and one-third of the second graduating classed opted to enroll in a prlm~ry care, internship-type experience. Whether these students will continue in a primary care track of a residency program (several of which are being developed) is as yet unknown. Short-term formative evaluations are conducted to adapt the curriculum to changing needs as they are perceived. In addition, evaluation of the impact of background characteristics of students (e.g., personality, family history, socioeconomic status) on student outcomes is planned. 131

Impact of the Den Gurion Univernity Program Ben Gurion' ~ medical education program is having a significant impact on medical education, according to its administrators. Not only has this innovative program attracted many international visitors, but in 1973 it was nominated as a World Health Organization (WHO) Collaborating Center.24 That designation has been extended twice, and the school has been called by WHO the 'most promising experiment in medical education." The medical school is a founding member of the Network of Community-Oriented Educational Institutions for Health Sciences ~ establishes in 1979 under the auspices of the WHO, and is the only non-European member of the Association for Medical Education in Europe BAAS ~ . The program has also been instrumental in the creation (in January 1982) by Ben Gurion University of a Center for Medical Education, which will study teaching methods, teacher training, curriculum development and program evaluation, student selection, prediction of performance and career choice, professionalization of medical and paramedical students, and other issues relevant to medical and health professions education. Accelerated Models Three variants of accelerated programs are discussed here: three-year M.D. programs, baccalaureate-M.I). programs (two subtypes), and M.D.-Ph.D. programs (two subtypes). The underlying rationale of such accelerated programs is to provide earlier entrance into the medical program (abbreviate the premedical training period), earlier exit from the program (abbreviate the Medical school curriculum itself ), or some combination of these . In general, shortening the process has been accomplished by reducing in length or eliminating certain courses from ache usual sequence in the traditional motel, using special instructional devices (such as computer-assisted modules), and/or offering specially designed shortened curricula (of ten for certain types of students) in place of, or concurrently withy a more traditional program offered at the same institution. 0 Three-Year M. D. Programs Origin and Purposes Fueled by the f inancial incentives of the 1971 federal health legislation to meet a physician shortage by increasing the product ion of physicians, many Medical schools increased their medical school enrollments and shortened the length of time needed to complete the medical education program, without substantively changing the curriculum. Other reasons for adoption of a three-year curriculum included perceived savings in expenses for students and more efficient use of time through installation of a year-round curriculum. 10, 1B, 43-45 132

By 1975, some 19 medical schools offered a three-year curriculum as their standard educational program, and 59 others offered a four-year curriculum as the standard program with an option to graduate in less than f our years. However, by the fall of 1981, all 19 Schools that hat offered the three-year program as standard had abandoned it or were in the process of converting back to a f our-year curriculum, and only two three-year programs ~ both in Canada*) remained in North Amerlca.45 Illus trative Example: Southern Illloois University School of Medicine . Description and Goals Southern Illinois University began its three-year medical education program in 1973, simultaneously with the opening of its medical sChool.46 She three-year curriculum attempted to accomplish a traditional program in 36 months. Basic science content was covered over 67 weeks, there were 48 clerkship weeks, and 18 weeks of electives. The three-year curriculum was standard until 1981, when all students entering the School of Medicine embarked on a four-year curriculum. The decision to phase out the three-year curriculum was made in 1976 on the basis of an internal evaluation (see below). The f our-year curriculum adds 10 months to the three-year program, including an additional 11 weeks of basic sciences, 2 more weeks f or clerkships, and 14 more weeks devoted to electives . Two years of basic science are f allowed by a clerkship in the third year and electives in the fourth year. The four-year curriculum now in effect uses an organ system approach to teaching the basic sciences. Evaluation Activities45 The success of Southern Illinois University's three-year M.~. program in achieving its goals has been measured in terms of (1 ) the degree to which i ts graduates succeeded in receiving one of their top three choices in the National Resident Ma tching Program (as of 1981, baset on six cohorts of gradua tea f rom the program, more than 80 percent had succeeded on this measure), ~ 2 ~ residency supervisor ratings of three-year ~ tudents in comparison with their four-year counterparts, which indicate no differences, and (3) career choice Stability over dime. Despite these generally favorable findings, a decision was made in 1976 to "disimpact" the program by replacing it with a four-year curriculum. This decision was based primarily on the results of an in-house faculty survey, which revealed dissatisfaction with the fast pace (particularly in the basic sciences) ant the program's rigidity (especially troublesome for students having dif f iculty) . Additionally, both students ant faculty desires more time for electives and more free time, ant students felt they were forces to specialize bef ore they had sampled all the ma jor clinical _ *One of these is the blcHaster University Faculty of Health Sciences program, discussed above . 133

disciplines. Apparently the sequencing, organization, and administration of the program were at issue, in addition to the compressed time frame itself. Other Evaluation Act ivities The Association of American Medical Colleges (AAMC) conducted an evaluation study of three-year medical curricula in existence in the United States between 1970 and 1976, the results of which were published in 1978.43 This study, a good example of evaluation research on an educational innovation, attempted to describe the effects of the three-year curricula on the institutions involved and the process of medical education. The AAMC study analyzed data* on (1 ) each school's decision to adopt a three-year medical curriculum; (2) the process of program adoption and implementation; (3 ~ the attitudes and perceptions of administrators, department chairmen, faculty, and students; (4) appraisals by a sample of graduates; (5) curriculum characteristics; and (6) financial, admissions, student, ant other institutional variable!. as compared with those of four-year programs. Major factors in the demise of the three-year curricula were faculty opposition to them, the disappearance of the financial incentives that ha~i encouraged adoption of the programs in the f irst place, and the views of clinical program directore.43,45 Subjective factors (as opposed to objective analysis3 both propelled insti cutions i nto adopting three-year programs and considerably af fected their decisions to return to a four-year curriculum. Baccalaureate-M. D. Programs Baccalaureate-M. ~ . programs are found in two ~rarietie-~, depending on whether the student enters the program during his or her college years or directly af ter high school. (As of 1980/81, 12 U. S. medical schools offered the latter option. ~ Typically they are year-round, six-year programs for students judged to be highly capable and mature, and who have decided early to pursue careers in medicine . Many medical schools of fer one or more baccalaureate-M. D. programs in addition to their more traditional programs. An exception is the University of Missouri (Kansas City) School of Medicine, whose only medical education offering is a six-year baccalaureate - .13. program. At present there are 18 six-year baccalaureate-M. D. programs available in United States medical schools. 15 Northwestern University was the f irk to of fer such a program, in 1961. Among other institutions whose medical schools have such programs are Boston University, Brown University, the University of Chicago, *Data were obtained from four sources: the institutions themselves, institutional profiles on record at the AAblC, survey instruments designed for this evaluation study, and site visits to 16 of the institutions involved. 134

Dartmouth College, Duke University, Johns Hopkins University, and the University of Rochester (all of which have Interface programs, discussed below). Other examples are the University of Michigan (whose Inteflex program is highlighted below), and the University of Missouri (Kansas City), also discussed below. Two baccalaureate-M. D. programs more recently developed are those at the University of California ~ San Diego ~ and the Sophie Davis School of Biomedical Education at the City College of New York. Origin and Purposes As with other nontraditional models of medical education, the baccalaureate-M. D. programs were introduced, beginning in the 1960s, in reaction to the lockstep curriculum requirements of the traditional two-plus-two model, which were viewed as being no longer appropriate, and in recognition that optimum learning may take place under very different circumstances: when there is less concern with the pressures of getting into medical school and more freedom to explore relevant courses and fields outside the narrow spectrum to which the more traditional programs and their premedical preparation exposed the student.44,47 To reduce the overall time and expense involved in acquiring an M.D. degree (usually eight years from college entry) also has been a motivating factor. Combining baccalaureate and medical education also may help eliminate redundancies and discontinuities in course work, permit more clinical training time during the medical education phase, and make better use of facilities and human resources, according to proponents of such combined degree programs. Interface programs were established in 1975 at the seven institutions cited above, with assistance from the Commonwealth Fund, to (1) "improve the quality of science and liberal arts education offered to students preparing for careers in the health professions" through development of an interface between the premedical (college) and medical curricula in the natural and behavioral sciences and clinical disciplines, (2) eliminate the tensions surrounding the medical school application process, and (3) permit students to achieve a dual degree.48 Illustrative Example: Interface programs, including Boston Universi ty' s Modular Medical Integrated Curriculum (MMEDEC) Program Description Begun in 1977, Boston University's MMEDEC program is one of three pathways established by the university for achieving a combined baccalaureate-M.D. degree.49~52 Since its inception, five cohorts of students have been proceeding through the program, with two cohorts having completed the baccalaureate portion plus one year of medical 135

school as of 1982. Each cohort consists of 15 students selected after their sophomore year at Boston University, from an applicant pool of some 70 Boston University undergraduates. The faculties of the College of Liberal Arts and the School of Medicine jointly plan, implement, and share administrative responsibility for integrating the premedical and preclinical educational curriculum. Goals or Objectives The following are the explicit coals of the MMEDEC program: o to encourage enrichment of the usual premedical and medical curriculum; o to decrease preoccupation with grades for medical school acceptance and complementarily, through restructuring and interfacing the college and medical school curricula, to encourage students to take a broader range of courses or modules of instruction; o through the use of electives to provide a positive introduction to medicine and promote personal growth and humanistic attitudes; 0 to provide less redundancy, better sequencing, and more comprehensiveness of college and medical school curricula; and o to change student attitudes toward their remaining undergraduate (collegiate) experience. Evaluation Activities Findings from its own self-evaluation efforts are viewed internally as so favorable that its proponents recommend the MMEDEC program as a model for other schools of medicine.49 For instance, the first two cohorts of students admitted to the program took a larger proportion of conscience courses during their last two years of college than did a "similar group of premedical students who were still concerned with admission to medical school. " This f inding is cited as evidence of changed student attitudes--a program goal.49 The Commonwealth Fund recently commissioned an evaluation of its Interface programs (individually and as a group) to determine their current status and long-range potential.48 The evaluation concluded that as a group the Interface programs were by and large achieving their own goals and Commonwealth's purposes in establishing the programs-~ainly to focus attention on the role of the university in undergraduate education and on medical education as part of it. Among the benefits cited in the evaluation study are those accruing to the students themselves (e.g., alleviation of the premedical syndrome--anxiety and preoccupation with grades and 136

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

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

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

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

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

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

REFERENCES 1. Kaufman, A., et al. Undergraduate education for rural, primary care: Strategies for institutional change at New Mexico and Morehouse. Family Medicine 15:20-24, 1983. 2. Personal communication, Robert E. Tranquada, M.D., Chancellor/Dean, University of Massachusetts Medical School, University of Masachusetts Medical Center, Worcester, Massachusetts and Rosemary A. Stevens, Ph.D., Professor of History and Sociology of Science, Department of History and Sociology of Science, University of Pennsylvania, Philadelphia, Pennsylvania. 3. Flexner, A. The Flexner Report on Medical Education in the United States and Canada. A Report to the Carnegie Foundation f or the Advancement of Teaching. Washington, D.C.: Science and Health Publications, Reproduced in 1960, Original printing, 1910. 4. Gifford, J. F., ed. Undergraduate Medical Education and the Elective System: Experience with the Duke Curriculum, 1966-75. Durham, N. C.: Duke University Press, 1978. 5. Lippard, 11. W., and Purcell, E., eds. The Changing Medical Curriculum: Report of a Macy Conference. New York: Josiah Macy, Jr. Foundation, 1972. 6. Norwood, W. F. The mainstream of American medical education, 1765-1965. Ann. N. Y. Acad. Sci . 128: 463-472, 1965. I. Surgeon General's Consultant Group on Medical Education. Physicians for a Growing America. U.S. Department of Health, . Education, and Welfare, 1959 Public Health Service Publication No. 709) 8. Richmond, J. B. Currents in American Medicine: A Developmenta View of Medical Care and Education. Cambridge, Mass.: Harvard University Press, 1969. 9. Deitrick, J. E., and Berson, R. C. Medical Schools in the United States at Mid-Century. New York: McGraw-Hill, 1953. 10. Ison-Franklin, E. L. Accelerated and extended programs. In Cadbury, W. E. and C. M., eds. Medical Education: Responses to a Challenge, pp. 323-341. Mount Disco, N.Y.: Futura Publishing, 1979. 11. Williams, G. Western Reserve's Experiment in Medical Education and Its Outcome. New York: Oxford University Press, 1980. . 12. Lee, P. V. Medical Schools and the Changing Times: Nine Case Reports on Experimentation in Medical Education, 1950-1960. Evanston, Ill.: Association of American Medical Colleges, 1962. 143

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

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

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

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

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