Final LCME Report: April 2001

LCME Interim Report: May/April 2001

April 25, 2001

RE:      LCME INTERIM REPORT

Dear Drs. Stevens and Simon:

This letter contains our detailed response to those areas, for which the LCME requested follow-up after its 1999 survey of our School of Medicine.  We continue to value the close scrutiny and framework for improvement that our interaction with LCME provides.  Our responses below utilize the same numbering system contained in LCME’s letter dated June 8, 1999.

2A.    “The establishment of bylaws, as required by accreditation standards, that describe the manner in which the medical school is organized, ...The LCME’s major concern here deals with the terms of reference of standing committees, especially their functions accounting for the educational programs.”

Consistent with its tradition of faculty participation in governance, the operation of the School of Medicine is concentrated in the hands of the Dean and a strong faculty committee system, which covers all aspects of the School of Medicine.  The major committees are listed below beginning with those that impact education. A brief narrative is attached to those committees with an impact on education.

Johns Hopkins School of Medicine Committees with Oversight in Education

Advisory Board of the Medical Faculty (ABMF)

This is the chief governing body of the School of Medicine (SOM).  The Advisory Board was constituted by resolution of the Trustees (April 3, 1893) “to report to the trustees from time to time their suggestions and to prepare and to carry forward the proper arrangements for the instruction and graduation of medical students.”  The Board is composed of Department Directors and Deans of the School of Medicine, the School of Public Health and the School of Nursing, President of the Medical School Council, the Director of the Kennedy-Krieger Institute, and the President of the Johns Hopkins Hospital.  It is chaired by the President of the University or, in his absence, the Provost of the University.  The Advisory Board must also approve all appointments to the faculty, both tenured and non-tenured. 

Advisory Board Agenda Committee

The Agenda Committee meets monthly to set the agenda for meetings of the Advisory Board. It reviews materials prior to submission to the ABMF and approves all new assistant professor appointments before referring them to ABMF for final approval.  The membership includes: the Provost of the University, the Dean of the Medical Faculty, six Department Directors, the Chairperson of the Medical School Council, the Executive Vice Dean of the School, the Vice Dean for Faculty, the Vice Dean for Education, the Vice Dean for Clinical Practice and the Assistant Dean for Medicine, who serves as secretary to the Committee. 

Medical School Council

The President of the University established the Medical School Council in 1971 in order to provide a mechanism for the faculty, fellows, and students of the School of Medicine to participate more effectively in the deliberations and governance of the SOM.  It is composed of members of the full-time faculty, a medical student and two postdoctoral fellows elected by their peers.  The Council is free to deliberate any and all subjects related to the operation of the School of Medicine, its policies and procedures.

Committee on Educational Policy and Curriculum (EPC)

This Committee provides vital leadership to the SOM and ABMF on all issues affecting medical student education.  It approves all changes in curriculum and monitors the effectiveness of individual courses and clerkships.  The Vice Dean for Education chairs this committee.  The membership consists of course and clerkship directors, the Associate Dean for Student Affairs, the Registrar, and four medical students representing each year of medical school.

Committee on the MA and Ph.D. Programs

This Committee oversees graduate student education.  It is chaired by the Associate Dean for Graduate Student Affairs.  In addition to overseeing curriculum and program design for each of the graduate programs, it also approves MA and Ph.D. degree candidates for graduation. The membership consists of the graduate program directors, the Vice Dean for Education, and the Registrar.

Committee on Admission

The Committee on Admission is composed of members of the Johns Hopkins School of Medicine faculty and students and of individuals with ties to the School of Medicine (former residents or staff). Committee members assess and recruit prospective medical students to Johns Hopkins.  The Associate Dean for Admissions chairs the Committee.

 Committee on the M.D./Ph.D. Program and Medical Scientist Training Program (MSTP)

This committee directs the recruitment, admission, and course of study for M.D./Ph.D. students in the School of Medicine. Members of the committee write and manage the MSTP grant. Ex officio members of the committee include the Associate Deans for Student Affairs, Admissions, and Graduate Student Affairs.

Committee on Student Awards

This committee meets every spring to identify those students in each year, whose performance has been distinguished. The Dean chairs the committee.

Committees on Medical Student Promotion

Separate committees meet to consider promotion of students in each year of training. The Dean chairs the committees. Ex officio members include the Vice Dean for Education, the Associate Dean for Student Affairs, and the Registrar. Course or clerkship directors for the medical student year in question complete the membership of the committee.

Student Health Services Committee

A committee of faculty and students oversees the scope, quality and accessibility of student health services. The Director of Student Health Services chairs the committee.

Advisory Committee on Continuing Education

The Office of Continuing Medical Education (OCME) manages all postgraduate courses sponsored by The School of Medicine. The committee advises OCME on matters of budget, fee structure, and instructional design. The membership of the committee consists course directors (faculty) appointed by the Dean.

Grievance Committee

This committee (appointed by the Dean) addresses grievances that cannot be resolved through informal discussions. Any member of the School (faculty, fellows, residents or students) may petition the committee. The committee reviews the facts of each case and recommends action to the Dean.

Other Important Committees within the School of Medicine

• Committee on Conflict of InterestAnimal Care and Use CommitteeProfessorial Promotions Committee
• Associate Professor Promotions Committee
• Associate Professor Reappointment Review Committee
• Other Important Committees Convened Jointly By the School of Medicine and The Johns Hopkins Hospital
• Joint Committee on Clinical Investigation (Institutional Review Board)
• Joint Committee on House Staff and Postdoctoral ProgramsJoint Committee for Health, Safety and Environment

2B.    “The system for periodic evaluation of objectives, content and method of pedagogy utilized for each segment of the curriculum . . .”

The Educational Policy Committee (EPC) has adopted a new formal policy to address this goal.  EPC conducts a formal review of all medical school courses.  The goals of the review are to ensure the highest quality medical school curriculum, and to provide constructive recommendations to assist course faculty in achieving this goal.  The process is intended to be helpful and collegial and is conducted as a self-study of educational practices.  The review of 14 basic science courses and nine required clinical clerkships occurs on a three-year cycle.  The monthly EPC meetings serve as the forum for review.  A yearly EPC retreat serves as the forum for an integrated review of the entire curriculum.

The course director provides the supporting materials for the self-study report to the EPC in advance of the formal presentation.  The criteria for the course review are presented in Attachment 2B-1.  The detailed worksheet to guide course directors in the preparation of their review is given in Attachment 2B-2.

The system for monitoring redundancies and deficiencies in the curriculum is carried out at three levels. The first year, second year, and required clinical clerkship directors belong to separate subcommittees representing those portions of medical school education.  These subcommittees of the EPC meet on a regular basis to review the appropriate year curriculum.  As an example of the efforts of such committees, the first year curriculum committee decided recently to award additional time to the Anatomy course, and shortened the Molecules and Cells course.  Additional embryology teaching was added to the Developmental Biology course.  These changes were based on curricular review, including significant input from students.

The yearly retreat provides the ultimate level of review for the curriculum in order to address overarching questions and long-term objectives.  The agenda for this year’s educational retreat is attached in 2B-3.

Finally, the School uses the results of NBME shelf exams, AAMC exit surveys of our students, and our graduate surveys as additional sources of information to aid in curricular assessments.

2C.       “The evaluation of educational program effectiveness based on assessment of the extent to which specified instructional objectives/outcomes are used, in particular the assessment of Hopkins’ graduates performance during residency training...”

The School of Medicine has long employed an evaluation program to assess the performance of our graduates during residency.  The results of this evaluation program suggest that Hopkins graduates have performed exceptionally well as residents.

Based on the recommendations of the last LCME review, we have revised our instrument to allow greater specificity in the assessment of our program’s effectiveness.  Attachment 2C-1 demonstrates the revised evaluation instrument, which covers the graduates’ knowledge, skills, behaviors, and attitudes.

2D.       “The results of the process complying with accreditation standards that defines the objectives of clinical education and establishes quantified criteria for the types of patient, the level of student responsibility, and the appropriate clinical settings necessary to accomplish this goal.”

 Attachment 2D-1 presents a summary of the objectives, criteria, levels of responsibility, and clinical settings for our clerkships.

All required clinical clerkships present the objectives in both verbal and written formats on the first day of the rotation.  The types of patients and their settings vary depending on the clerkship, but in general, a wide variety of settings are used including inpatient, outpatient, and emergency department venues.

The School of Medicine has not required a uniform standard for quantification of patients seen.  Some clerkships require students to maintain a patient log.  Others utilize the student’s evaluation to capture data on the types of patients seen.  Those clerkships, which have avoided the patient log format, fear it would burden students who must see patients in multiple locations (e.g., operating room, clinic, inpatient ward, emergency department) during a single day.

The level of student responsibility in most clerkships requires the student to develop the primary contact with the patient.  Thereafter, students generally have the opportunity to present their findings during attending and resident rounds.  Presentations are usually supplemented with case write-ups for the medical record.  The inpatient clerkships require night call. 

For the majority of the clerkships, the system for monitoring achievement includes the triad of resident and faculty evaluations, written examination, and student evaluation of the clerkship.  Some courses include self-assessment tools, oral exams, USMLE shelf exams, graded case presentations, and graded log entries, among other items.

2E.       “Steps taken to establish consistent evaluation by direct observation of student’s clinical skills and behaviors across clerkships, including sufficiently early formative assessment to enable a student to make improvement before the end of the rotation.”

Early and timely assessment is a stated objective of all clinical teaching at the School of Medicine.  The ability and methods to achieve this goal vary depending on the length of the clerkship, which ranges from 4½ days to 9 weeks.  Clerkship directors encourage faculty and residents to provide students with timely, indeed concurrent, feedback on their performance.  In those instances, where student performance is perceived to be unsatisfactory, clerkship directors are to be notified immediately by concerned faculty or residents.  Conversely, students are instructed at the time of orientation to contact the clerkship director, if they perceive difficulties with the clerkship or with their performance.

Many clerkships attempt to provide a consistent faculty preceptor so that the evaluation can be based on more than one encounter.  This allows not only timely feedback, but also a stepwise mastery of the essential objectives of the clerkship guided by the same faculty member.  This objective reaches its highest expression in the assignment of a so-called “teaching attending”, whose sole responsibility is to mentor students during the entire clerkship.

Some clerkships have evolved specialized methods for timely evaluations.  In the ambulatory medicine clerkship, standardized patient assessments are used and students receive a videotape of their performance, including an evaluation within two weeks of the session.  In the neurology rotation, students have faculty or residents sign off on a checklist, as certain patient types are examined and presented. 

EPC assesses the timeliness of the final evaluation for all clinical clerkships on a yearly basis.  The most recent assessment suggested that feedback from students was not occurring within a sufficiently timely fashion for some rotations.  Therefore, a resolution has been passed by EPC mandating return of the final evaluation to the Registrar’s Office within six weeks of completion of the clerkship.

2F.       “Progress establishing greater coherence and continuity of care in the core primary care education experience of all students.”

All students are exposed to a core curriculum in primary care in required clerkships in the Departments of Pediatrics and Medicine, in which time is dedicated to ambulatory primary care office practice.

A.     The clinical clerkships in the Department of Pediatrics offer medical students the opportunity to provide and observe continuity of care.  The core clerkship includes a three-week ambulatory rotation, where students provide health maintenance exams for children.  Over the course of this session, students are often involved in caring for a patient with an acute illness over many follow-up visits.  Additional electives (of four weeks duration) are also offered in the following disciplines relating to primary care.

1. Adolescent Medicine
2. Intensive Primary Care - primary care services for HIV infected children
3. ub-internships in pediatric primary care - this can be based at the University medical center or private physician's office
4. Developmental and Behavioral Pediatrics

All pediatric subspecialty rotations expose students to the “continuum of care,” as clerks are able to evaluate children in clinics, follow patients during their inpatient stay, and then participate in the post-discharge follow-up.

B.      The Department of Medicine has provided some combined degree (M.D.-Ph.D. or M.D.-M.P.H.) students with a longitudinal experience.  These students attend a one-half day session per week and follow the same group of patients over their years of training.

C.      The Basic Clerkship in Ambulatory Medicine is a required 4½ week clerkship, in which students are assigned to community-based office practices for their clinical experience.  Although sponsored by the Department of Medicine, there are currently four active family practitioner preceptors for this clerkship.  The majority of preceptors are general internists.  Student preferences for family practice or internal medicine preceptors are elicited prior to assignment.  With rare exceptions, students work in one office setting during this rotation, and have opportunities to observe continuity of care provided by their preceptors. Students are informed that the learning objectives for this clerkship consist of core generalist competencies, including care of the healthy patient, care of acute adult illness and chronic care.  Analysis of patient logs submitted by students indicates that the clinical experiences match these objectives:

Analysis of Quarter I Clerkship Logs, October 2000:

As with the Department of Pediatrics, the Department of Medicine offers a 4^th year longitudinal elective in general internal medicine with a faculty general internist in the Johns Hopkins Outpatient Center.  Students attend a one-half day session per week, and often assume primary provider role for a small panel of patients.

Continued work in progress:

The Educational Planning Committee has discussed a restructuring of the core clinical curriculum to facilitate continuity experiences and earlier exposure to primary care clerkships.  The majority opinion of the student body, however, was that flexibility in the timing of clinical clerkships was most desirable and facilitated residency selection.  It should be noted that a minority of students express an interest in primary care careers at the time of matriculation. (1998 AAMC Matriculation Questionnaire).

Progress in providing further primary care experiences will be limited by availability of community-based teachers, who are voluntary faculty for JHUSOM.  As with other university systems, these teachers are under increasing productivity constraints, which limit their opportunities to teach students in the office.  Three initiatives are currently in progress in this area:

With the support of the Vice Dean for Education, the Johns Hopkins Community Based Physicians have established a “relative value unit” system for the teaching of medical students, which relieves office based practitioners of some RVU productivity constraints when teaching. This physician group currently provides two thirds of the preceptors for the Basic Clerkship in Ambulatory Medicine.

The Department of Medicine has sent three teams to the APM Generalist Faculty Development Program in 1999-2000, and has formalized plans for recruitment, faculty development for office-based teaching, and rewards for community-based faculty.

The clerkship director has conferred with representatives of the Maryland Academy of Family Physicians to identify additional family practitioners to serve as preceptors for the clerkship and longitudinal experience. 

2G.    “Progress expanding facilities for study and small group conferences.”

The School of Medicine recognizes that the space for all three missions of the School is constrained. This includes teaching space. Two new buildings are planned, one of which is under construction. When these facilities come on line in 2004 and 2007, there will be a modest improvement in small group teaching facilities.  Additional progress would require construction of an entirely new medical education building. The options for redesign of the campus to meet educational needs are a major topic of a current campus redesign master plan project. 

2H.     “Copies of current agreements for clinical care facilities...”

The School of Medicine has executed agreements with all affiliated teaching hospitals and clinical care facilities.  These agreements are contained in Attachment 2H-1.

2I.     “Status of the program to recruit underrepresented minority students...”

Diversity in the student body and faculty is a stated goal of the School of Medicine.  Since the last LCME report, the School has added a section on the Admission’s website targeted specifically to minority students (www.med.jhu.edu/admissions/minstudents).  In addition, we joined AMCAS, which had the additional benefit of increasing the pool of underrepresented minority applicants to the School by 167%.  Our Admission’s staff visits colleges and universities with large minority populations on a regular basis, or invites students from those institutions to visit Hopkins.  Every year, the first meeting of the Admission Committee includes an address by the Dean, which among other things, highlights the importance of diversity to the School.  Finally, the School enjoys a close relationship with the Student National Medical Association (SNMA) chapter on campus.  Minority students are represented on the Admissions Committee as voting members.  Interviewees meet with an SNMA member during their visit to the campus.  All those candidates who are accepted at Hopkins are invited back for an annual “welcome back weekend” program.  The goal of the program is to allow underrepresented minority students an opportunity to spend several days at the School of Medicine before making a final determination on medical school attendance.  This program has proved highly successful.  Last year’s class consisted of 12% underrepresented minorities. 

We thank LCME for the opportunity to submit this report.

Sincerely,

Edward D. Miller, M.D.                           David G. Nichols, M.D.
Dean/CEO                                           Vice Dean for Education
Johns Hopkins Medicine                         Johns Hopkins Medicine

EDM/DGN/cnh

Attachments 

cc:       
William R. Brody, M.D., Ph.D.
President, Johns Hopkins University