The Next Step in Undergraduate Medical Education: Domains of Excellence

Dr. David Guzick, M.D., Ph.D.

August 03, 2007

The URMC mission statement, "Using education, technology and science to improve health," places education at the core of all that we do. Faculty members in the School of Medicine and Dentistry conduct educational programs that train 400 medical students, 565 graduate students, 653 medical residents in 71 different specialties, as well as 55 dental residents in 7 different dental specialties.

In undergraduate medical education, we have had a long and proud history of innovation. The biopsychosocial model of medical education and practice, developed at SMD during the 1970s, is now a centerpiece of medical education nationally. The much-emulated Double-Helix Curriculum (DHC), developed at SMD during the 1990's, entwines basic science and clinical work throughout all four years of medical school in a complementary manner, much like the two strands of DNA. (Thank you, Drag Anders, Professor of Pharmacology and Physiology, for suggesting this name!)

The DHC was first proposed by a faculty task force in the mid 1990's, and was subsequently shaped by faculty, students and staff under the energetic and visionary leadership of Edward Hundert, MD, then Senior Associate Dean for Medical Education. The goal of the DHC is for students to learn, both in medical school and throughout their professional careers, how to weave together cutting-edge, evidenced-based medical science and the relationship-centered art of clinical medical practice.

The DHC was launched during the 1999-2000 academic year. During our 2000 site visit by the Liaison Committee for Medical Accreditation (LCME), SMD received a "perfect score," with no citations and a full 7-year accreditation cycle. Since the initiation of the DHC, we have continually analyzed feedback from students and faculty in each component of the curriculum, and have made revisions accordingly, ever mindful of its core philosophy and goals. By now, every curricular element in the DHC has been touched by this continual improvement process, with improved assessments by students and faculty. Of course, more refinement is needed, and the process will continue.

Going one step further, as part of the current self-study process in preparation for the LCME survey that will occur in October, 2007, we asked ourselves the question: "What is the next step in the evolution of our curriculum for medical students that can take best advantage of contemporary thinking in medical education while building upon our tradition of biopsychosocial medicine and the double helix model?" The Domains of Excellence initiative, described below, is our work-in-progress answer to this question. The goal is to provide systematic medical student education in the areas of health systems, evidence-based medicine and informatics, professionalism, and communication, in addition to the traditional focus on scientific knowledge and patient care skills. Domains of Excellence will be our major educational initiative for medical students over the next five years, and will complement work that is ongoing in graduate medical education.

As part of the evolution in the Rochester curriculum for medical students, the Domains of Excellence initiative represents an extension of a focus on professional competencies developed and implemented by the Accreditation Council for Graduate Medical Education. The ACGME concept of core competencies begins with the recognition that excellence in clinical practice requires not only competency in patient care and medical knowledge, but also in communication, professionalism, practice-based learning and improvement, and systems-based practice. Currently, throughout the U.S., medical residents in all fields are expected to demonstrate their competency in all of these areas of skill and knowledge prior to graduation.

A "competent physician" is one who possesses more than traditional knowledge and technical skills. He or she will critically analyze the medical literature, confidently practice evidence-based medicine, effectively communicate to patients and members of the health care team in a multicultural society, continuously assess the quality of care provided, and understand complex health care systems to improve patient care safety and quality.

Cognizant of its role as a stakeholder in graduate medical education, and of the view that medical education is a continuum across one's professional life, the American Board of Medical Specialties (ABMS) has recently endorsed the practice of evaluating the six general competencies during initial board certification and reassessing them at regular intervals. Practicing physicians will be required to demonstrate continued competence in these areas to maintain board certification.

About 6 months ago, Diane Hartmann, MD, Associate Dean for Graduate Medical Education, posed the following provocative question: if GME trainees and faculty are being asked to acquire competence in the six domains, shouldn't the educational process begin with medical students? An affirmative answer to this question has led to a renaming of the ACGME "core competencies" as "domains of excellence" for medical students. (My informal survey indicated that "competence" was equated with adequacy rather than excellence, and was uninspiring.) These domains have never been applied in a systematic fashion to medical student education across a four-year curriculum. A grouped listing and description, as applied to medical students, is shown in the chart below:

Core Double-Helix Curriculum

SCIENTIFIC AND MEDICAL KNOWLEDGE Students must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences, and the application of this knowledge to patient care.
PATIENT CARE Students must learn to provide patient care that is compassionate, appropriate, and effective for the treatment of medical problems and the promotion of health.

Biopsychosocial model

INTERPERSONAL AND COMMUNICATION SKILLS Students must be able to demonstrate effective interpersonal and communication skills with patients, families and professional colleagues.
PROFESSIONALISM Students must demonstrate a commitment to carrying out their professional responsibilities with utmost integrity, and with sensitivity to a diverse patient population.

New Focus

PRACTICE-BASED LEARNING AND IMPROVEMENT Students must be able to appraise and assimilate scientific evidence, and to evaluate and improve their own patient care practices.
SYSTEMS-BASED PRACTICE Students must demonstrate an awareness of and responsiveness to the larger context and system of health care. They must function as effective members of a health care team that can call on system resources to provide optimal patient care.

The first two domains are the two strands of the DHC--scientific knowledge and patient care. This has been the foundation of medical education since the Flexner report, and the DHC entwines them early and in a novel way. The next two domains of excellence are professionalism and communication skills. We have always been leaders in this area, as these domains are at the core of our Rochester biopsychosocial model. The final two domains of excellence, however, have not been emphasized at this medical school or any other. Yet they are at the heart of contemporary medical practice--how best to use information technology, integrated systems of care, team approaches, and a sophisticated interpretation of data in the literature to deliver high quality, safe, and efficient medical care. We will sustain and refine our work on the first 4 domains of excellence, and add the last two domains to the DHC.

In a very real sense, beginning with Flexner and continuing through the Double Helix Curriculum, the first two domains--scientific knowledge and clinical practice--subsume all of the other domains. A balanced medical education has always emphasized the importance of incorporating professionalism, communication, life-long learning from literature and practice, and health care systems, into the acquisition of medical knowledge and patient-care skills. We now propose to incorporate the other four domains as integral yet distinct elements in the overall Rochester undergraduate medical education in order to highlight their importance. In particular, we want explicitly to ensure that each domain receives its appropriate attention, throughout the four years and across all disciplines, in a balanced manner.

Over the next academic year, this work will proceed in three phases. First, we will collect baseline data: where is material on each of the six domains presented throughout the curriculum? For example, at a recent retreat, the instruction committees of the medical school assessed where these domains appeared in the areas of cancer and women's health, and where the "systems" domain as a whole occurred throughout the curriculum. Imagining each domain as a column in the data base, and each discipline/field (e.g., cancer) as a row, each resulting cell will represent a domain-discipline combination for which there is a specified presence and distribution over the four years. Second, once the data base is complete, the Curriculum Steering Committee and Instruction Committees will assess whether there is an appropriate relative weighting of material across the domains and disciplines, and make recommendations for re-weightings as needed. Finally, we will modify our courses and clerkships to ensure that the content of the curriculum reflects these recommendations.

We look forward to feedback from the entire SMD community about these ideas, and to working with students and faculty and staff to implement this next phase of our educational evolution.

Meliora,

David S. Guzick, MD, PhD
Dean, School of Medicine and Dentistry
University of Rochester

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