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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:
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o To gain basic information and feedback about curriculum or
program impact; to determine whether an innovation or experiment is
working and what its effects (both intended and unintended) are; or
to determine whether an innovation, experiment, or variation from
the norm accomplishes the goals or objectives it was intended to
accomplish. It will be noted in Part II that most of the evaluation
activities undertaken by the illustrative programs have been or are
being conducted expressly for this purpose.
O To track or moni tor the process and progress of curriculum or
program implementation and the process by which it does or does not
achieve its goals. Among the illustrations in Part II, the
University of Michigan Medical School's Inteflex program and Duke
University Medical School, among others, have been monitoring the
process of program impact.
o To compare the benef its and costs of alternative ways of
achieving the same goalk s), perhaps with the intention of selecting
least costly means of achieving a particular goal or Ret of goals.
To our knowledge, none of the evaluation activities noted in Part II
have been undertaken explicitly for this purpose, although the cost
of amounting innovative medical education programs has certainly been
a consideration. In the evaluation conducted for the Commonwealth
Fund on its Interface programs, for example, it was noted that on a
cost-per-student basis, these programs have been very expensive.
O To make decisions, based on evaluation findings, about the
future of a curriculum or program innovation: whether to fund or
re-fund, continue or discontinue, modify, and/or disseminate the
curriculum or program to other institutions or settings. Tong the
illustrations in Part II are several examples of evaluations that
have contributed to such decisions. For example, the Southern
Illinois University School of Medicine decision to drop its
three-year curriculum and convert to a four-year medical education
program was based on analysis of faculty and student attitudes. The
evaluation of the Commonwealth Fund ~ s Interface programs was
undertaken in part to ascertain the value and worthwhileness of its
investment in that particular type of program innovation. Decisions
to disseminate program information, presumably based in part on
evaluation findings, have been undertaken at by the University of
New Mexico (concerning the Medical School 's Primary Care
Curriculum), by Boston University (concerning its Modular Medical
Integrated Curriculum), ant by the Center for Health Sciences of Ben
Gurion University of the Negev, to name a few. The (European)
Network of Community-Oriented Educational Institutions for Health
Sciences exists for the purpose of sharing information and knowledge
gained and to provide assistance to other. interested institutions.
O To fulfill a requirement (often for continued funding), or for
reasons such as placating or pleasing an influential person or
organization.
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Requis i tes for Produc t ive Curr iculum
or Program Evaluation
The following are basic requirements that must be met if
evaluation activities are to be useful, productive, and taken
seriously:
o There must be clear specif ication of curriculum or program
goals or objectives to be examined and evaluated. In reviewing the
stated (or inferred) goals or objectives of the various medical
education curricula or programs discussed in Part II, it will be
noted that they are typically expressed in terms of one or more of
the following: (1) student outcomes--the characteristics,
qualities, or skills and/or capabilities to be developed in or
demonstrated by students while they are in the program/curriculw~ or
af ter they graduate (see, for example, the McMaster School of
Medicine program); (2) curriculum characteristics or changes (see,
for instance, the University of Hissouri (Kansas City) program or
the University of Washington WAMI--Washington, Alaska, Montana, and
Idaho--program); or (3) (health) outcomes for the larger community
~ see, for example, the School of Medicine of Ben Gurion University
Center for Health Sciences ~ . The goals, as stated, will of course
determine the focus of evaluation activities undertaken.-
o The curriculum or program goals must be specified in testable
form.
O The research (evaluation) design and methodology selected or
developed should be appropriate to the evaluation task.
O Ideally, the evaluation study design and methodology to be
used should be fully specif led prior to the initiation of the
curriculum or program innovation. Note that Duke University, the
University of Michigan, and McMaster University, among others,
appear to have designed their evaluation activities in this way.
O There must be a commitment of resources (both tine ant money)
to the evaluation effort for its duration.
O There must be a commitment to the evaluation effort on the
part of key administrators and other personnel who are in a position
to af feet the course of the curriculum or program implementation,
and a willingness and ability on their part to participate in the
evaluation where appropriate and needed.
Problems in Curriculum and Program Evaluation
Discussed below are some of the problems most frequently
encountered in curriculum and education program evaluation research,
together with some examples from the medical education literature
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reviewed for this chapter. It should be noted that these problems
are by no means limited to the evaluation of education or medical
education curricula or programs, but more generally plague all
evaluation efforts in the social or behavioral sciences.
Evalua t ion De s ign and Re sea rch Me thodo logy
Selecting Comparison Groups To design and test properly the
ef fects of a curriculum or program innovation in terms of student
outcomes (which is the f ocus of most of the programs or curricula
discussed in Part II), it is necessary to select one or more
comparison or control groups with great care. Short of randomly
assigning students to "treatments" (i.e. ~ to one or more
experimental or innovative curricula or programs, or to the
traditional curriculum/program), there is always the possibility
that selection bias will mask the true impact (or lack of impact ~ of
the experimental program or curriculum. A question to ask in making
the selection is, To what extent do the students who select or who
are recruited into the experimental program resemble the students
who enter other or traditional programs, and what difference should
this make in the way the f inkings are and should be interpreted and
disseminated?
It Will be noted in Part II that the process of selecting
students for participation in an innovative or nontraditional
curriculum or program is never done by randomly assigning all
students admitted to the medical school to one or the other of its
medical education programs. In all cases, students select
themselves for a program (by applying for it ~ or (perhaps) are
recruited because of their particular characteristics. Thus, even
students participating in parallel program tracks at the same
medical school (as at the University of New Mexico) cannot truly be
considered comparable or equivalent to the "experimental" students
for evaluation purposes. What this means is that when graduates of
one program are compared with graduates of one or more other
programs in terms of their performance--for instance, on
standardized tests such as the National Boards--the superior or
inf erior pert ormance of one or the other group cannot be attributed
uniquely to program impact. One interesting method of trying out an
innovative program on two different types of students is the
University of Missouri (Kansas City) policy of reserving 10 percent
of its Spaces for students with more traditional premedical
education backgrounds ~ some college experience ~ than have the bulk
of the students, who are admitted directly from high school. The
college-age students thus serve as a control for the experimental
group .
Variety among students across medical education programs or
curricula also is desirable in other respects. For example,
innovative educational programs often are designed to be effective
with particular types of students, and it is precisely the
interaction between the program goals and the characteristics of the
incoming student body thee may in fact make the program work. A
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review of Part II indicates that many experimental or innovative
medical education programs were indeed designed for particular types
of student~--high achievers, low achievers, Conscience majors,
minorities, the educationally disadvantaged, mature students, and so
forth. Whether the programs would be equally successful with other
types of students, or with the same types of students at different
institutions, is a matter for empirical testing (which has generally
not been done ~ .
Short-term Versus Longitudinal Evaluation Designs Most of the
program evaluation efforts discussed in Part II involve a desire to
determine the long-term impacts of the innovative curriculum or
program on graduates and their careers, and perhaps ultimately on
the quality of health care in the communities in which they or their
successors will practice medicine. Because most of the innovative
programs and curricula have been in existence for a relatively short
time, there are not yet a sufficient number of graduates far enough
along in their postgraduate and professional careers to be able to
ascertain long-term program impact with any certainty. Thus,
evidence of program impact on s tudents, as measured by surveys of
graduates, most frequently get at career intentions rather than at
actual career paths followed (see, for instance, the programs
discussed under the Community-Baset/Primary Care model ). It is
laudable, however, that most of the schools discussed in Part II
have plans for, or express an interest in, long-term follow-up of
their graduates. It should also be noted in this connection that
longitudinal research is both costly and time-consuming, ant the
inability to demonstrate results quickly can often cause problems in
attracting needed resources to continue useful long-term evaluation
activities.
Small Ns A third issue has to do with the number of students
.
being exposed~to the innovative or nontraditional curriculum. The
evaluation of the Interface programs conducted for the Commonwealth
Fund, for example, expressed concern thee very few students had
experienced these programs. Small Ns are sometimes inevitable, but
they do cause problems in interpreting results ant in generalizing
f ram f Ending .
Measurement Instruments Yet another concern is whether the
measurement instruments selected for the evaluation effort are
appropriate ant reliable. As Part II shows, the evaluation
activities on innovative or nontraditional programs typically
involve the use of one or more of the following types of
instruments: (1) standardized tests--e."., National Boards,
licensure examinations-on which the performance of students or
graduates of the program is compared with that of other
students/graduates; (2) attitudinal and demographic surveys of
students, graduates, and/or faculty members or others involved in
medical training programs; and (3) ratings of student or
postgraduate performance by clinical supervisors. While theme and
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other such objective and subjective measurement devices are
reasonably easy to design and administer, and in some cases
relatively inexpensive to use, they may not be the most appropriate
methods to determine program impact. Findings from ~elf-
admini~tered questionnaires, for instance, may be quite unrelated to
the actual behavior of graduates where it counts--in their
professional pract ices and in the community at large . Many of the
schools discussed in Part II use such measures as interim
approximations of program impact and plan follow-up activities that
may be more directly relevant (see, for instance, evaluation plans
for the University of Washington's WAMI program) .
Testing the Right Hypotheses Behind any statement of curriculum
or program goals or ob jectives, there are implicit hypotheses about
cause-and-ef feet relationships. Such hypotheses must be plausible,
explicitly stated, and testable via the evaluation research design.
A review of the medical education curricula and program innovations
described in Part II suggests that program or curriculum designers
oust have had a variety of hypotheses about education in mint. Some
were evidently concerned with the learning process itself--how it
takes place most ef fecti~rely and with what kinds of students (see
the McMaster University and Ben Gurion University programs in
particular), some more particularly with the relationship between
the stage at which ce rtain concepts or experiences are introduced
and reinforced and subsequent career choices (see, for example, all
Community-Based/Primary Care programs), some with the effect of
length and type of schooling on the quality and performance of the
graduate, ant shill others with the relationship between early
exposure to role models and subsequent behavior, and no forth. Some
have sought to demonstrate that particular types of students prosper
in particular types of environments. The implicit, or explicitly
stated, hypotheses underlying the goals of the educational
innovations discussed in Part II appear both reasonable and worthy
of testing, though major results in the form of definitive findings
are far from being at hand.
Maintaining the Stability of the Curriculum or Program Being
Evalua ted
One of the most serious problems in conducting evaluation
research' especially if the design is longitudinal, is that of
ensuring the constancy of the curriculum or program for the duration
of the evaluation. What this means from a practical standpoint is
that successive classes (for instance in a baccalaureate/M.D.
program) may not be--and frequently are not--exposed to the
identical. curriculum (with the identical options, electives, or
faculty). Similarly, the first class of students exposed to the new
curriculum may encounter a rather different curriculum than that
originally planned by the time they enter their third or fourth year
in the new program. The reason f or this instabi li ty in new
curricula or programs, of course, in that program administrators
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will often alter their plans as experience with the program and new
information and feedback on the feasibility of their plans become
available (see, for instance, Meharry Medical College or Ben Gurion
University's Center for Health Sciences). While this kind of
behavior~which might be dubbed learning from experienced, of
course, undereeandable, it toes create problems for program
evaluators, ant tends, in general, to necessitate all sorts of
caveats when the evaluation findings are presented or released to
the public. For this reason as well, the findings are likely to be
less generalizable to other institutions that have or are
considering the development of similar educational curricula or
programs.
Other Problems: Institutional and Political Realities
The following comments, based on a recent article by Kaufman
et al.,1 directly pertain to how educational innovations come to
be instituted in the first place, but indirectly also concern
evaluation efforts. The authors suggest that "major innovations in
medical education can develop more easily in new medical schools or
in satellites remote from the parent institution," citing the
McMaster program, Michigan State University' ~ Upper Peninsula
Program, and the Biomedical Education Program at City College of New
York. However, the creation of new medical schools is unlikely
because of economic realities and the high cost of establishing
them, and because existing schools are already reducing their
entering class size in response to projections that the number of
phys icians will exceed expected overall requirements in the next few
decades. Thus, "major new curricular innovations will have to arise
within traditional medical school establishments in which strong
vested interests and departmental prerogatives will inevitably run a
collision course with those seeking overall change. in curriculum
design." Particularly hart hit, according to the authors, will be
curricular reforms that propose to cut across "all basic and
clinical science disciplines."
Referring in particular to the University of New blexico's
Primary Care Curriculum, Kaufman et al. note (as discussed in Part
II) that evaluation activities have shown thee the program is
unpopular with the faculty, ant that to enable it to succeed, its
administrators and students have forged alliances with the "external
environment"--its consumer constituencies. 1 It might be observed
at this Juncture that both at Stanford University and at Southern
Illinois University (among others), evaluation of medical faculty
views have led to the demise of program innovations. This is not to
suggest that such actions are inappropriate; there may indeed have
been abundant and sound justif ication for dropping such innovations.
Rather, the point is to note that in any program or curriculum
evaluation involving medical education, the voice of the medical
faculty is likely to be present and powerful.
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Some Opportunities and Possible Future Directions
for Education Evaluation Activities
As the foregoing discussion indicates, ant as Part II will
demonstrate, program and curriculum evaluation results for
nontraditional medical education programs are far from definitive.
Most evaluation activities in progress are in their nascent stages
and, because of the length of time required for the impact of a
program or curriculum to be felt, cannot be expected to yield
decisive results that would be universally accepted in the near
f uture. Thus, there in as yet no proven, single, best way to
provide medical education for any particular set of goals or
ob jectives, or for any particular type of student . In the absence
of def initive information, what would be a useful course to pursue
with respect to innovations in medical education and their
e~ralua tlon?
It seems clear that there are a number of interesting ant
promising models of medical education and individual curricula or
programs in existence today that are worthy of continued attention.
The absence of clear-cut evidence as to what works might be viewed
as making it all the more important to try to ensure that research
on medical education programs and curricula is high-quality, well
designed, and comprehensive . Concurrently, given rapid changes in
medical education and the lack of precise cause-and-effect tata, it
would seem useful (1) to keep all options ant variants open rather
than to reach premature judgment, (2) to study and evaluate the
impact of the variants and innovations that presently exist, and
(3) to encourage diversity of program and curriculum offerings on
general principle . The very existence of the variants may, in fact,
convey important messages to prospective physicians about what is
valued in the medical community and by the community at large .2
A further suggestion is that more attention in medical education
program evaluation be directed toward developing and specifying
methods to evaluate . program impact on distant, societal goals
(meeting the health care needs of the population, for example).
While the intermediate (and perhaps more easily measurable ) goals,
such as producing graduates with particular characteristics or
developing a curriculum of a certain type ~ may be connected causally
to the remote societal goals, more ef fort in elucidating these
interrelationships would appear to be useful.
AcIditlonally, it is important to note that the medical education
evaluation activities that have come to the attention of the
Institute of Medicine Committee to Plan a Review of Medical
Education in the United States have been conducted almost
exclusively on undergraduate programs. Evaluation efforts should
also be undertaken on graduate medical training programs.
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PART I I
The models* of medical education discussed here include (1 ) the
traditional (post-Flexnerian) model; (2) the organ system approach
developed at Western Reserve University School of Medicine; (3) the
flexible or elective model originally developed in the 1950~ in
response to the traditional model; (4) the community-based or
primary care model; and (5) accelerated medical education programs,
including (a) three-year M.D. curricula' (b) baccalaureate~M.D.
programs, and (c) H.D.-Ph.D. programs. Orate medical education
program that serves the needs of a particular population group is
also discussed. In contrast to the other models, the traditional
model is simply described and its origins are briefly cited, as it
constitutes the base model from which the other models originally
developed as innovations or experiments.
The Traditional (Post-Flexnerian) Model
During the half century between 1910, when the Flexner reports
was published, and 1960, medical education in the United States was
standardized4~10 to the extent that "students could transfer from
one medical school to another and hardly know they had moved."5
Though there was variation from school to school in instructional
methods used, the f irst two years were devoted to instruction in the
preclinical basic sciences, organized by discipline, and the third
and f ourth years to student rotation through a series of clinical
experiences "that left no medical or surgical specialty
untouched."5 This meant that "the experience in each discipline,
basic and clinical, was necessarily superficial and in most Schools
there was limited opportunity to study in depth any subjection area
of special interest."5 The aim, quite appropriate at the time,
was to provide the student, over the four-year time period, with
suf ficient knowledge to support 35 years of clinical practice .4
At that time, a one-year internship was common, but subsequent
specialization during two to five years of residency was not assumed
to follow inevitably.
The virtues of this approach at the time that it was instituted
widely--i.e., following publication of the Flexner reports and
with the Johns Hopkins University School of Medicine serving as
prototype--were that the emphasis on basic science transformed
medical schools that were "entirely vocational" ant reputedly of
uneven ant in many cases very poor quality, into institutions that
*Titles of models ant the exemplars selected to represent them are
somewhat arbitrary, and leave room for honest disagreement. The
models have been designated and the illustrations selected more in
the spirit `~f Or I..,llal clarity ant simplicity than as a true
reflection of the complex and diverse state of af fairs in American
medical schools.
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were scientif ically oriented and "worthy of their membership in
universities." Since the majority of students was to enter general
practice af te r one year of internship, a broad background ant at
least minimal competence in all fields of medicine were considered
essential. 5
The ma jori ty of medical schools in existence in the United
States today adhere to this two-plus-two format as their basic
four-year curriculum, though interdisciplinary courses and/or
elective opportunities typically are available as well.* In
general, all students at a given level must take the same group of
core courser and examinations, in some cases including the National
Board of Medical Examiners ~ Parts I and II. Courses tend to be
discipline-centered, though instructional innovations may in some
cases modify this orientation. 10
Organ System Model
Origin ant Purposes
An integrated organ system approach to medical education was
pioneered by Case Western Reserve University School of Medicine in
1952, in a series of curriculum innovations that evolved over a
ten-year period under special circu~stances--the leadership of a new
dean, many new department heads, and generous grants from The
Commonweal eh Fund . The overall purpose of these innovations, which
were f urther ref. ined in the 1960s, was to create an environment that
fostered integration and continuity in student learning, encouraged
the student to take initiative and responsibility for his or her own
education, and treated the student as an individual, colleague, and
developing physician. To accomplish this broad purpose, the
traditional departmentally organized, vertically structured,
disciplinary approach to learning was abandoned in favor of a
horizontal, crosscutting, task-oriented, and interdisciplinary
approach, in which the curriculum was viewed as the responsibility
of the faculty as a whole rather than of individual
departments. 11-16
,
*The extent to which the traditional model has been and is the
specific focus of evaluation efforts was not explicitly addressed in
preparing this chapter. Without doubt, the introduction of
curriculum and program innovations and modifications at many
institutions was an least in part based on objective evaluation of
the strengths and weaknesses of the traditional motel.
Additionally, when innovative or experimental medical education
curricula or programs are evaluated today, the traditional model is
often used as the standard for comparisons (whether of student
performance or other outputs).
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while 18 United States medical schools use some variant of the
integrated organ system model originally developed by Case Western
Reserve,15 it is estimated that as many as one-third of all IJ. S.
medical schools have adopted one or more of the innovations
pioneered at Case Western Reserve .16
I ~ t'ts ~ ra tive Example: Case Western Reserve University School of
M-licine*
Descriptionl1~15~17 In contrast to the traditional curriculum
in which the basic sciences are taught simultaneously ant separately
at the beginning of medical school ant the student is introduced to
clinical experiences later in the program, the basic sciences are
conceptualized, in the new integrated curriculum, in terms of their
relationships to each other ant their interactions as manifest in
human systems. Both the basic science and the clinical curricula
are viewed as the responsibility of the faculty as a whole, and the
faculty organize and plan their teaching through interdisciplinary
subject committees (this is known as "sub ject-committee teaching' ).
Other current features of the program include multidisciplinary
teaching laboratories, early and ongoing clinical experiences f or
students (including experience in a family clinic), free time for
self-development, flexibility in scheduling, ant pass/fail grading.
The curriculum at Case Western Reserve undergoes frequent
revision, as information on the success or lack of success of
various innovations is fed back and responded to by faculty and
students, and as goals evolve. While there have been various
changes in the curriculum over the years, and a "new" new curriculum
was introduced in 196B, the medical education program at Case
Western Reserve has remained relatively stable for almost 30 years.
When the new curriculum was developed, the faculty came together
to define educational objectives through a Committee on Medical
Education, by which they court "express ~ themselves ~ directly in
mat ters of educational policy and curriculum. The faculty not only
defined their goals with care, but . . . used their own statement of
ob Jectives as a guide to their later decisions. "l3 There was
great excitement and enthusiasm among the faculty for this
innovation, ant a tradition developed whereby the results of each
curriculum change initiated were reported on to the faculty,
allowing for discussion and a scientific approach to the process of
medical education, as well as a commitment to institute needed
changes.
Goals or Objectives The goals of the Case Western Reserve
program include
*A portion of this material was supplied by Ore Susan D. Block,
member of the Institute of Medicine committee for this report.
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course selection so as not to jeopardize grade point averages ~ and
those accruing to the institutions involved, in particular to the
undergraduate faculties of liberal arts and sciences and to the
medical schools and their faculties. At the baccalaureate level,
for instance, "science courses have been improved, new
interdisciplinary of ferings in science, social science, and
humanities have been created, and for the most part these have been
open to all" (i.e., to students not necessarily planning medical
careers).48 Additionally, student counseling has improved.
As for the medical schools and their faculties, the evaluation
concluded that resources were expended to enhance the quality of the
basic science course offerings and to increase medical faculty
involvement in undergraduate courses. These and other benefits
accrued are judged as good, appropriate, money well invested, and so
forth.
The study also noted some serious limitations in the Interface
programs, which, in its view, should be remedied. Among these are
that (1) no serious effort has been made to explore what premedical
education should consist of--"not only in the sciences but in the
humanities and social sciences as well," and (2) such a small number
of students has been selected to participate in Interface programs
(a total of 95 students at seven institutions entering in 1979/80)
that on a per-student basis the programs are very costly. Small
numbers, furthermore, create an additional problem of making it
virtually impossible to "draw any conclusions" as to program
impact.4d With respect to the medical schools involved, the study
also notes that the universities have failed to challenge medical
school admissions policies, which continue to require a high grade
point average , high grades in premedical science courses, and
satisfactory to good performance on the Medical College Aptitude
Tests.48
Illustrative Example: University of Michigan Medical School
Integrated Premedical-Medical (Inteflex) Program
program:
Description and Goals Begun in 1972, the six-year Inteflex
program, like the Interface programs described above, is a combined
baccalaureate-M.D. program involving the Medical School and the
University's College of Literature, Science, and the Arts. A
special feature of this program is that students join their
counterparts in the traditional track at the Medical School at the
conclusion of their third year in the Inteflex program, becoming
sophomore medical students.l8,53,54
Two motivations, or goals, underlie the development of this
o to introduce educational innovation into both the premedical
(college) and medical school education programs, and
0 to produce a dif ferent type of graduate--especially one
"compassionate in dealings with others.''l8~54
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Program administrators have been especially interested in issues
surrounding selection criteria and are convinced, through analysis
of student performance data, that traditional methods of screening
prospective students (primarily on the basis of college grades) are
unnecessary. The Inteflex program is also especially concerned with
women, particularly the program's impact on female students and
graduates.
Evaluation Activities Since its inception, extensive program
monitoring and evaluation activities have been under way. These
include a deliberate examination of program goals, measures
(including measurement issues), and the mechanisms by which the
effects of the Intef lex program are achieved . In fact, the
university is viewed as having one of the largest data-gathering
(and analysis) operations on medical students in the country.53
Among the types of evaluations that have been and are being carried
out are comparisons of Inteflex students' performance and attitudes
with those of regular premedical students at the University of
Michigan, examination and analysis of selection criteria, and (as
indicated above) analysis of the effects of the Inteflex program on
female students and graduates. A longitudinal follow-up of program
graduates is also planned.
Illustrative Example: University of Missouri (Kansas City) School
of Medicine
In contrast to the other baccalaureate-M. D. programs discussed
thus far, the University of Missouri (Kansas City) six-year
combined degree program admits students directly from high school,
ra ther than during their early college years . Northwestern
University's Honors Program in Medical Education similarly admits
students directly from high school. In other ways, however, the
UMKC baccalaureate-M.D. program differs in focus (as will be
evident) and might more appropriately be categorized as an exemplar
of the Community-Based/Primary Care model.
Description The year-round six-year baccalaureate-M.D.
curriculum at UMKC was begun in 1971 and seeks to integrate u. .ly
the college and medical school years, with the ultimate purpose of
providing a pool of graduates that can meet the health care needs of
Missouri residents.l5~55 Students spend 75 percent of their first
two years in the program on baccalaureate studies and 25 percent on
clinical studies. Years three through six are devoted to medicine.
The baccalaureate degree is taken in sciences, humanities, or social
sciences plus an optional minor in humanities, and additionally
requires 30 hours of medicine. A public, state-supported School of
Medicine, UMKC primarily accepts Missouri residents into its medical
degree programs. While most of the students in the baccalaureate-
M.D. program are recruited from high school, some ten percent of the
spaces are reserved for older (college) students who have had a more
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traditional premedical education and will obtain their M.D. degree
at the conclusion of a total of eight years of training. (The
latter students serve as a comparison group to the six-year
students.)
Goals or Objectives The goals or objectives of the UMKC
baccalaurea se-M. D . program are to provide
o a curriculum that integrates the liberal arts and humanities,
the basic sciences, and clinical medicine, using the existing
resource'; of the College of Arts and Sciences;
0 a community-based program, using community hospitals and
private practice physicians for training;
o student-community contact from the outset of the program, via
clinical training experiences with physicians, other health
professionals, patients, and families, in the context of a community
hospital;
o a docent system that forms the basis of patient care teams, in
which small groups of students are assigned for years three through
six to a full-time faculty member who serves as a role model,
teacher, and friend; and
o explicit concern with minority and women students and
graduates.
Evaluation Activities Student monitoring and performance
evaluation are both continuous and extensive. For example, multiple
choice examinations are given every three months, and students are
required to pass Parts I and II of the National Boards by graduation
date. Student performance is regularly evaluated during clinical
rotations. However, the most important indicator of program
success, in the opinion of program administrators, is the clinical
performance of its graduates during their graduate medical education
years. Both objective and subjective (attitudinal) assessment
instruments are used, and comparisons with traditional eight-year
students are made. Particular attention has been devoted to the
program's impact on minority and female students.
M.D.-Ph.D. Programs
Origin and Purposes
There are two basic types of programs: the Ph.D.-to-M.D.
program and . the combined M. D. -Ph. D . program. Ph. D. -to-M. D. programs
were -instituted typically in response to the shortage of physicians
in the late 1960s, with the intention of diverting Ph.D. scientists
into clinical practice. A second rationale was to enrich the theory
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and practice of medicine via tapping the perspectives of
accomplished scientists from various disciplines.56 Combined
M. D. -Ph. D. programs provide scientific and medical training to
highly motivated and capable students who show evidence of
outstanding research and academic potential. Some 94 medical
schools in the United States offer M.D.-Ph.D. programs.
Illustrative Example: University of Miami School of Medicine
The University of Miami School of Medicine of fers both types of
programs, each constituting an alternative to its traditional
f our-year medical educat ion program. 5 6
Description, Ph.D.-to-}I.D. Program Begun in 1971, the
Ph.D.-to-M.D. program was developed to be completely new and
separate from the traditional curriculum, enabling accomplished
doctorates in the natural, physical, or engineering sciences (and
now mathematics) to attain an M.D. degree within two full years of
entry into the medical school. Some 38 students are admitted to the
program per year, and there are no required prerequisite courses f or
admission.
Description, Combined M. D.-Ph. D. Curriculum The combined
M.l).-Ph.D. program, begun in 1979, accepts outstanding baccalaureate
candidates with majors in natural, physical, or engineering
science s, who will complete a program that awards the Ph. D. in f ive
years and the M. D. a t the end of six . Students enrolled in the
combined M.D.-Ph.D. curriculum normally spend their first year
studying biomedical sciences, the second year taking graduate
courses and doing research, and the third year studying medicine.
Part I of the National Boards must be passed at the conclusion of
the third year. The fourth and fif th years are devoted to research
and preparation of the doctoral dissertation, coupled with the core
clerkships. The sixth year consists of core clerkships and elective
cl inical clerkships, at the conclusion of which Part II of the
National Boards must be passed.
Evaluation Activities, Ph. D.-to-M.D. Program Student grades,
faculty assessments, and National Board scores have been used to
evaluate the success of this curriculum. Comparisons of student
scores with those obtained by students in traditional programs have
been judged as favorable. As of October 1979, 140 students in six
cohorts had completed the Ph.D.-to-M.D. program. At that time, most
were still in house-staff training programs. Of those who had
completed their training, approximately half were in academic
careers. "Whether or not they will make unique contributions to
academic medicine is not yet known," according to evaluators, who
concluded that the University of Miami School of Medicine had
demonstrated that an accelerated and intensive course could
medically qualify a "select group of talented scientists. 56 More
definitive findings on the impact of this program are expected to be
available soon.
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Evaluation Activities, Combined M.D.-Ph.D. Program Evaluation
of this program is in progress, but results are not yet available as
the program was initiated very recently.
Special Needs: A Medical Education Program
for Minority Students
Illustrative Example: Meharry Medical College School of Medicine*
Established in 1876, Meharry Medical College School of Medicine
is one of four predominantly black medical colleges that address the
special needs of black medical students and the black community in
the United States. (The three others are Howard University College
of Medicine, the School of Medicine at Morehouse College, and
Charles R. Drew Postgraduate Medical School/UCLA Medical Program.)
As evidence of its role in meeting these special needs, Meharry
indicates that it has trained 40 percent of the black physicians and
dentists in the United States and that 46 percent of the black
faculty members in United States medical schools are Meharry
graduates.57
Meharry's curriculum is neither unusual nor particularly
innovative, although it is constantly being revised; in essence it
is a modified version of the two-plus-two traditional model.44 An
uncommon feature of the clinical phase (second two years) is an
emphasis on special types of health care delivery through several
outreach programs and facilities in the community. In the pant,
faculty research has not been emphasized, and faculty were not
recruited on the basis of their research capabilities, but more
emphasis is placed on research at Mtharry today.
What is unique about Heharry is its special purpose: to educate
poor, minority, "high risk" students in the practice of
medicine--particularly to prepare them for practice in medically
underserved rural and urban areas, or to stimulate them to pursue
careers in health research or biomedical science. Meharry accepts
some students who, on the basis of their educational and
socioeconomic backgrounds and Medical College Admissions Test
scores, would be unlikely to be admitted elsewhere, 17 offers some
of the most disadvantaged students remedial help through its Special
Medical Program, and produces competent physicians (as judged by
their ability to meet state licensing requirements), some of whom it
considers outstanding.
*This discussion is based in part on a visit to Meharry Medical
College by Institute of Medicine star f and selected members of the
IOM Committee to Plan a Review of Medical Education in the United
States , at the invitation of its President, David Satcher, also a
member of the IOM Committee (see Appendix D).
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While hard evaluative evidence is lacking, Meharry
administrators consider the school 's medical education programs to
be successful in compensating for the equational and socioeconomic
disadvantages of some of its incoming students, and in adequately
preparing them for careers in medicine. In their view, some of the
initially least-promising students are among those whose
postgraduate performance seems best. In terms of achieving program
goals or objectives (apart from student achievement), administrators
note that, over the past ten years, some 75 percent of Meharry
graduates have located their practices in medically underserved
areas (inner cities and rural areas).57 Funding uncertainties for
students, however, have been affecting and are likely to continue
even more forcefully to affect the nature of the student body and
subsequent career decisions of students.
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147
Representative terms from entire chapter:
medical schools
