Innovations in medical education: the Medical College of Georgia School of Medicine experience.

Picture two community-based physicians instructing seven student apprentices in two borrowed rooms in the City Hospital of Augusta, GA (http://www.mcg.edu/history/index.asp). That was the setting when the Georgia state governor signed a charter for a state medical academy in 1828. The original curriculum consisted of a 1-year lecture series. Two more physicians joined the faculty, the curriculum expanded to 2 years, and, in 1833, the first four graduates were awarded medical degrees. Two years later, the young medical school moved from the City Hospital into a separate building.

During the succeeding years, the school had several name and location changes (Fig. 1A). Its fortunes waxed and waned, and it even closed for 4 years while students and faculty served in the Civil War. After the war, it reopened and ultimately became a department and then a unit of the University System of Georgia. By its 100th anniversary, the school's curriculum had expanded to 4 years, comprising 2 years of basic sciences and 2 years of clinical sciences. By the middle of the 20th century, the school had adopted its present name, The Medical College of Georgia (MCG), and had its own teaching hospital.

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Today, 175 years after MCG's founding, the picture is different. MCG now is the health sciences university for the state of Georgia. It comprises five schools (allied health, basic sciences, dentistry, medicine, and nursing) located on an urban campus with more than 80 buildings. The nearly 600 faculty members in the five schools teach approximately 2,000 students, 720 of whom are medical students.

Although the external structure of the medical school curriculum seems similar in its emphasis on basic sciences during the first 2 years followed by 2 years of clinical training, medical education at MCG has changed dramatically. Today, education at MCG is designed to prepare students to provide health care in an era of rapidly changing technology and fiscal constraints while emphasizing state-of-the-art clinical knowledge, continued learning skills, early clinical experience, assessment of competence, and professionalism. (1) This article describes some of the recent curriculum changes and how they affect students, communities, and faculty members.

The Changing Medical Curriculum

Clinical Integration

During the 1990s, emphasis on clinical medicine during the first 2 years of medical school produced a disjointed curriculum. In 2000, MCG implemented a comprehensive, integrated Essentials of Clinical Medicine course that changed the first 2 years of the curriculum markedly. (2) Essentials of Clinical Medicine emphasizes principles underlying the art and science of medical practice. In Year 1, students study the core curriculum: family, community, and society, as well as communication skills, health promotion, disease prevention, lifelong learning, public health, and professionalism. Two contemporary elements include the county project and a disaster simulation. In the first element of the program, groups of five students are assigned to 1 of the 159 counties in Georgia and must conduct a health needs assessment, examine local demographics and resources, create a health plan to meet the county's health needs, and present their findings to a small audience. In the second element of the program, students practice basic disaster response skills of triage, handling airway obstructions, splinting and bandaging in the field, carrying patients on litters, and crisis command at a local park. Year 1 emphasizes unique, simulated, and real patient experiences. Year 2 teaches common illnesses and the impact of lifestyle decisions on health and illness using an integrated, age-based approach. Encounters with real and standardized patients help students to develop clinical skills, and discussing clinical cases in a problem-based learning format helps them hone their lifelong learning skills. The teaching and assessment methods are designed to foster professional attitudes, behaviors, and skills.

Professionalism

Professional development has been an implicit component of medical education since Hippocrates. Now it is an explicit, fundamental principle that is applied throughout the curriculum. (3,4) In preparation for the white coat ceremony, each entering class develops a class oath--a professional code of ethical conduct--with principles that the students pledge to uphold. In small-group sessions, students explore ethical decision making in a physician's life. They learn about collaborative patient-physician interaction, become aware of similarities and differences in health and health care across cultures and groups, and discuss professional and ethical issues. The student evaluation system reinforces professional behavior, knowledge, and skills throughout the 4 years of study.

Service Learning

Many students begin medical school with a demonstrated commitment to volunteerism. We think that our students are more likely to establish a lifelong commitment to community service if they actively contribute to the local community during medical school. (5) One example of their commitment to community-based service is the Migrant Farm Health Initiative (Fig. 1B). In 2001, MCG students applied for and received grant funding to establish a mobile health clinic that provides free health care to migrant workers. Grant funds support equipment costs. An area physician and MCG student and faculty volunteers staff the mobile clinic, which visits a different farm each Sunday during the harvest season (ie, April-June). First- and second-year students take individuals' histories and perform blood pressure and blood glucose cheeks, and third- and fourth-year students perform complete physical examinations. Everybody benefits: Students learn preventive medicine, practice their clinical skills, and learn about the need for cultural sensitivity; migrant workers have access to free health care and health education; and the community's health care costs are reduced because of fewer emergency room visits for untreated health problems. Other student-led service initiatives include leading an annual bone marrow drive and volunteering at a collaborative student-, resident-, and faculty-staffed homeless clinic at the local Salvation Army center. Local newspaper articles and television news programs have high-lighted these student service activities.

Community-based Teaching and Learning

Volunteer Community-based Faculty

Many of Georgia's community-based physicians volunteer to teach MCG students at their medical practice sites. In the 1990s, medical care shifted from the hospital to ambulatory care. Therefore, MCG expanded its network of community-based teaching sites so student education would more closely mirror medical practice. (6) The school partnered with the Georgia area health education centers (AHECs) to identify primary care practices in Georgia with community-based physicians who were interested in teaching students. Many sites are located in medically underserved regions (Fig. 2). In 2003, 57 community-based teaching sites support family medicine, internal medicine, and pediatric clerkships. AHEC preceptor coordinators are critical in identifying potential preceptors and serving as on-site administrative coordinators for clerkship directors. On-site faculty development programs are conducted regarding how to teach in a busy clinical practice, offer feedback, and evaluate students before students are assigned to the site. Student housing is provided at no cost to MCG.

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Community-based faculty members are primarily volunteers, and they are recognized by a modest faculty recognition program. The MCG community-based preceptor development programs also foster close collaboration between MCG clinical teaching faculty members and clinical preceptors. Pediatricians, internists, family practitioners, nurse practitioners, and physician assistants often attend faculty development programs together. This program has helped local AHECs recruit health care practitioners to serve in underserved areas of Georgia.

Students rate their community-based clerkship experiences highly and, in one clerkship, have performed as well as or better than students trained at MCG on standardized written examinations (CW, AT, unpublished data). They interact with a wide variety of patients with common problems and experience the practice of medicine at rural, suburban, and urban sites. On the basis of the success of the primary care sites, the obstetrics/gynecology department is developing 10 clerkship sites.

Clerkship Communication

We use the Internet to provide curriculum materials and teaching resources and as a mode of student communication to maintain consistency across clerkship sites. Students use an Internet-based program to document their clinical experiences with patients and assure the faculty that they have consistent experiences across clinical sites. Many courses use WebCT for online assignments, and one clerkship uses online written examinations. All clinical clerkships provide their course content on the Internet. Clerkships are converting all lectures to CD-ROM format so that students can view the required course conferences at any site. All students will be required to demonstrate and document competency in various clinical skills and procedures by the 2004 academic year. Students will use personal digital assistants to document their competency and experiences with patient care.

Community-based Research

Community-based physicians also can play a role in research. MCG recently received federal grant funding to develop a practice-based research network. This network will strengthen relationships between MCG and community-based faculty members and enhance MCG's educational mission. MCG will recruit physicians practicing in various settings to conduct primary care research at the point of care, permitting students and faculty members to examine clinical questions early in the patient's health care-seeking process. Student, resident, and community-based physicians can collaborate in asking clinical questions on the basis of day-to-day practice, developing research programs to answer those questions, and using the school's programs in clinical settings throughout Georgia. Rural physicians who usually are not involved in the academic environment will be able to participate.

Valuing and Rewarding Teaching

Valuing the Teachers. Traditionally, medical school faculty think that education is not valued as highly as research and clinical care in institutional rewards systems. MCG, however, embraces education as a core value and has made two changes to enhance the recognition of teaching. First, educators' portfolios, which demonstrate and support their teaching contributions, are important in the promotion and tenure process. Second, a broader definition of scholarship has enabled education-related products to be accepted as a legitimate form of scholarship. (7)

Educator's Portfolios

Since 1995, MCG has required all teaching faculty members to keep an educator's portfolio that documents their educational activities and becomes part of their promotion and tenure packet. The vice-dean for academic affairs offers frequent workshops for faculty members on developing portfolios and preparing for promotion and tenure review. The definition of educational scholarship now extends beyond traditional research to include integration and application of existing knowledge as well as discovery. Newly developed instruction materials and evaluation tools, educational leadership, and teaching itself all qualify as educational scholarship as long as the products meet the specific criteria of peer review for quality and public dissemination. Educators' portfolios demonstrating educational scholarship have helped several full-time faculty members achieve promotion recently.

Enhancing Teaching Skills

MCG's faculty members are its most valuable resource. Career development is essential for their and the school's success. The Career Development and Education Center, established in 2002, focuses on two areas of faculty development. The first is helping junior faculty develop their careers, and the second is offering workshops on teaching and educational research skills for all interested faculty members. The Career Development and Education Center workshops help faculty to develop their skills so that they will be successful in teaching and in advancing their academic careers. Topics include teaching effectively in various settings, using technology in teaching, helping students with problems, and scientific writing. A new initiative, the First Six Program, helps new junior faculty assimilate into the academic environment and develop plans for their academic careers. The name of the initiative refers to the first 6 years as an MCG faculty member, indicating that the program will continue to support faculty members as their careers develop.

Student Evaluations Foster Teaching

Students submit their course and clerkship evaluations through the Internet, which allows for easier administration, data management, and data reporting. Students can access this system and enter their evaluations of faculty and courses from anywhere within Georgia. Faculty members can use these data to improve their teaching and can compile summary data in their educators' portfolios. The electronic system can be used to create comprehensive evaluation reports that span a faculty member's tenure at MCG.

Conclusion

Educating physicians has been a priority for MCG for 175 years. Today, learning has moved beyond the lecture hall into the community. Students learn clinical skills and interact with patients during their first months of training. They learn required knowledge and how to continue learning throughout their careers to keep up with rapidly changing medical information. They rely on technology for learning and patient care. Regardless of how the education process has changed, however, service to the citizens of Georgia remains fundamental among MCG graduates.

References

(1.) Wallace AG. Educating tomorrow's doctors: The thing that really matters is that we care. Acad Med 1997;72:253-258.

(2.) Fincher RM. A longitudinal approach to teaching and assessing professional attitudes and behaviors in medical school. Acad Med 2001:76:505-506.

(3.) Cruess RL, Cruess SR. Teaching medicine as a profession in the service of healing. Acad Med 1997:72:941-952.

(4.) Coller BS, Klotman P, Smith LG. Professing and living the oath: Teaching medicine as a profession. Am J Med 2002;112:744-748.

(5.) ABIM Foundation. American Board of Internal Medicine; ACP-ASIM Foundation. American College of Physicians-American Society of Internal Medicine; European Federation of Internal Medicine. Medical professionalism in the new millennium: A physician charter. Ann Intern Med 2002;136:243-246.

(6.) Fincher RM, Case SM, Ripkey DR, et al. Comparison of ambulatory knowledge of third-year students who learned in ambulatory settings with that of students who learned in inpatient settings. Acad Med 1997;72(10 Suppl 1):S130-S132.

(7.) Fincher RM, Simpson DE, Mennin SP, et al. Scholarship in teaching: An imperative for the 21st century. Acad Med 2000;75:887-894.

From the Career Development and Education Center, The Medical College of Georgia School of Medicine, Augusta, GA.

Reprint requests to Janis A. Work, PhD, Career Development and Education Center, Medical College of Georgia School of Medicine, AF-1037, Pavilion II, CB1839, 1465 Laney Walker Blvd., Augusta, GA 30912. Email: [e-mail]

Accepted June 9, 2003.

Copyright [c] 2003 by The Southern Medical Association

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