LCME Considers Proposed Changes
in Accreditation Standards

The LCME held a hearing for public comment on October 28, on three new proposed standards and on changes to three existing standards. The period for accepting public comment was extended to December 1, 2006. The full text and rationale for each proposed change is described below. At its next meeting on February 6-8, 2007, the LCME will determine whether or not to approve the new and revised standards, after considering the comments received by the public.

The LCME and its sponsoring organizations have approved the addition of three new accreditation standards dealing with 1) the learning environment for medical students; 2) opportunities for students to participate in service-learning activities; and 3) clinical and translational research in the curriculum.

Additionally, the LCME and its sponsoring organizations have approved substantive changes to three existing standards dealing with 1) the use of educational program objectives in course design and evaluation; 2) outcome-based objectives and expected competencies; and 3) criteria for the types of patients and clinical conditions encountered by students.

The full text and rationale for each proposed change is described below. NOTE: "Must" in accreditation standards signifies an absolute requirement. "Should" is a requirement that must be met unless there is a compelling reason, acceptable to the LCME, for waiving the need to comply with the standard.

1. New Standard on the Learning Environment

New Standard
Medical schools must ensure that the learning environment for medical students promotes the development of explicit and appropriate professional attributes (attitudes, behaviors, and identity) in their medical students.

Annotation
The medical school, including faculty, staff, students, and residents, and its affiliated clinical teaching sites share responsibility for creating an appropriate learning environment. The learning environment includes formal learning activities as well as attitudes, values, and informal "lessons" conveyed by individuals with whom the student comes in contact. These mutual obligations should be reflected in agreements (for example, affiliation agreements) at the institutional or departmental levels.

It is expected that each medical school define the professional attributes it wishes students to develop in the context of the school's mission and the community in which it operates. Examples of professional attributes could come from such resources as the American Board of Internal Medicine Project Professionalism or the AAMC Medical School Objectives Project. Such attributes should also be promulgated among the faculty and staff associated with the school, with suitable mechanisms available to identify and promptly correct recurring violations of professional standards. As part of their formal training, students should learn the importance of demonstrating the attributes (attitudes, behavior, professional identity) of a professional and understand the balance of privileges and obligations that the public and the profession expect of a medical doctor.

In addition, to defining the attributes of professionalism expected of the academic community, the school and its faculty, staff, students, and residents should regularly assess the learning environment to identify positive and negative influences on the maintenance of professional standards and conduct, and develop appropriate strategies to enhance the positive and mitigate the negative influences.

Rationale
An LCME Task Force worked for almost two years to develop a standard that addresses the need for explicit attention to the environment in which learning occurs. The Task Force originally focused on the "hidden curriculum," but came to believe that the phrase "learning environment" is more accurate and descriptive. This standard presupposes that the environment in which learning occurs, including health care provider role models, has a meaningful impact on the development of professionalism, including the attitudes/values that students acquire. There are no other standards that explicitly address this issue.

2. New Standard on Service Learning

New Standard
Medical schools should make available sufficient opportunities for medical students to participate in service-learning activities and should encourage and support student participation.

Annotation
"Service-learning" is defined as a structured learning experience that combines community service with preparation and reflection. Students engaged in service-learning provide community service in response to community-identified concerns and learn about the context in which service is provided , the connection between their service and their academic coursework, and their roles as citizens and professionals.

Sufficient opportunities means that students who wish to participate in a service learning activity should have the opportunity to do so. To encourage participation, medical schools could do such things as developing opportunities in conjunction with relevant communities/partnerships, providing information about available opportunities, offering elective credit for participation, or holding presentations/public fora. Support for student participation could include offering or providing information about financial and social support for student service-learning (such as stipends, faculty preceptors, community partnerships).

Rationale
The standard establishes that students who desire to participate in service learning (as defined in the annotation) have opportunities to do so, and by doing so deepen their understanding of health care issues. Data from the 2005-2006 LCME Annual Medical School Questionnaire indicate that opportunities for service learning are widespread and, typically, voluntary. The proposed standard places this kind of activity on the same accreditation footing as a similar standard already in place (IS-14) for student participation in faculty research.

3. New Standard on Clinical and Translational Research

New Standard
The curriculum must introduce students to the basic principles of clinical and translational research, including how such research is conducted, evaluated, explained to patients, and applied to patient care.

Annotation
The faculty should specify learning objectives (knowledge, skills and attitudes) that will, at a minimum, equip graduates to understand the basic principles and ethics of translational and clinical research, and how such research is conducted, evaluated, and applied to the care of patients. One example of relevant objectives is contained in Report IV of the AAMC's Medical School Objectives Project (Contemporary Issues in Medicine: Basic Science and Clinical Research). In addition, medical schools are expected to include experiences in the curriculum that introduce students to translational and clinical research and to document the extent to which their objectives are being achieved.

Rationale
The AAMC Task Force on Clinical Research made the following recommendations to the LCME:

1. Every future physician should receive a thorough education in the basic principles of translational and clinical research, both in medical school and during residency training.
2. The Liaison Committee on Medical Education (LCME) should add education in translational and clinical research to the requirements for medical school accreditation.…

The proposed standard establishes that students learn the basic principles of clinical and translational research in the course of their training, not necessarily to conduct or participate in such research.

4. Change to Standard on the Use of Educational Program Objectives in Course Design and Evaluation

Original Standard
ED-1. The medical school faculty must define the objectives of its educational program.

Original Annotation to ED-1
Educational objectives are statements of the items of knowledge, skills, behaviors, and attitudes that students are expected to exhibit as evidence of their achievement. They are not statements of mission or broad institutional purpose, such as education, research, health care, or community service. Educational objectives state what students are expected to learn, not what is to be taught.

Student achievement of these objectives must be documented by specific and measurable outcomes (e.g., measures of basic science grounding in the clinical years, USMLE results, performance of graduates in residency training, performance on licensing examinations, etc.). National norms should be used for comparison whenever available.

It is expected that the objectives of the educational program will be used by faculty members in designing their courses and clerkships and in developing plans for the evaluation of students. The curriculum committee, working in conjunction with the chief academic officer, should review the stated objectives of individual courses and clerkships, as well as methods of pedagogy and student evaluation, to assure congruence with institutional educational objectives.

Revised Standard ED-1
The medical school faculty must define the objectives of its educational program. The objectives must serve as guides for establishing curriculum content and provide the basis for evaluating the effectiveness of the educational program.

Revised Annotation to ED-1
Objectives for the educational program as a whole serve as statements of what students are expected to learn or accomplish during the course of their medical education program.

It is expected that the objectives of the educational program will be formally adopted by the curriculum governance process and the faculty (as a whole or through its recognized representatives). Among those who should also exhibit familiarity with the overall objectives for the education of medical students are the dean and the academic leadership of clinical affiliates who share in the responsibility for delivering the educational program.

Rationale for the Change
The expectation that the educational program objectives be used in the design of courses and the evaluation of the educational program is contained in the annotation for the existing standard but not in the standard itself. Survey teams have often cited schools for not using the educational program objectives in curriculum design and evaluation. The revision makes the expectation clear.

5. Change to Standard on Outcome-Based Objectives and Expected Competencies

Original Standard ED-1-A
The objectives and their associated outcomes must address the extent to which students have progressed in developing the competencies that the profession and the public expect of a physician.

Original Annotation to Standard ED-1-A
There are several widely recognized definitions of the characteristics appropriate for a competent physician, including the physician attributes described in the AAMC's Medical School Objectives Projects, the general competencies of physicians resulting from the collaborative efforts of the ACGME and ABMS, and the physician roles summarized in the CanMEDS 2000 report of the Royal College of Physicians and Surgeons of Canada. To comply with this standard, a school should be able to demonstrate how its institutional learning objectives facilitate the development of such general attributes of physicians. A school may establish other objectives appropriate to its particular missions and context.

Revised Standard ED-1-A
The objectives of the educational program must be stated in outcome-based terms that allow assessment of student progress in developing the competencies that the profession and the public expect of a physician.

Revised Annotation to ED-1-A
Educational objectives state what students are expected to learn. Such objectives are statements of the items of knowledge, skills, behaviors, and attitudes that students are expected to exhibit as evidence of their achievement. The educational objectives should relate to the competencies that the profession and the public expect of a physician.

The educational objectives established by the school, along with their associated outcome measures, should reflect whether and how well graduates are developing these competencies as a basis for the next stage of their training.

Student achievement of educational program objectives should be documented by specific and measurable outcome-based performance measures of knowledge, skills, and attitudes, and values (for example, measures of basic science grounding in the clinical years, USMLE results, performance of graduates in residency training, performance on licensing examinations). National norms should be used for comparison whenever available.

There are several widely recognized definitions of the knowledge, skills, and attitudinal attributes appropriate for a physician, including those described in the AAMC's Medical School Objectives Projects, the general competencies of physicians resulting from the collaborative efforts of the ACGME and ABMS, and the physician roles summarized in the CanMEDS 2000 report of the Royal College of Physicians and Surgeons of Canada.

Rationale for the Change
The revision to the standard clarifies the expectation that objectives need to be stated in outcome-based terms and should relate to expected competencies that the school has developed or adopted from external sources. The annotation has been expanded to comprehensively define what objectives are and how they relate to competencies.

6. Change to Standard on the Criteria for the Types of Patients and Clinical Conditions Encountered by Students

Original Standard ED-2
The objectives for clinical education must include quantified criteria for the types of patients (real or simulated), the level of student responsibility, and the appropriate clinical settings needed for the objectives to be met.

Original Annotation to Standard ED-2
Each course or clerkship that requires interaction with real or simulated patients should specify the numbers and kinds of patients that students must see in order to achieve the objectives of the learning experience. It is not sufficient simply to supply the number of patients students will work up in the inpatient and outpatient setting. The school should specify, for those courses and clerkships the major disease states/conditions that students are all expected to encounter. They should also specify the extent of student interaction with patients and the venue(s) in which the interactions will occur. A corollary requirement of this standard is that courses and clerkships will monitor and verify, by appropriate means, the number and variety of patient encounters in which students participate, so that adjustments can be made to ensure that all students have the desired clinical experiences.

Revised Standard ED-2
There must be a system with central oversight to assure that the faculty define the types of patients and clinical conditions that students must encounter, the appropriate clinical setting for the educational experiences, and the expected level of student responsibility. The faculty must monitor student experience and modify it as necessary to ensure that the objectives of the clinical education program will be met.

Revised Annotation to Standard ED-2
This standard requires that a system be established to specify the types of patients or clinical conditions that students must encounter and to monitor and verify the students' experiences with patients so as to remedy any identified gaps. The system, whether managed at the individual clerkship level or centrally, must ensure that all students have the required experiences. For example, if a student does not encounter patients with a particular clinical condition (e.g. because it is seasonal), the student should be able to remedy the gap by a simulated experience (such as standardized patient experiences, online or paper cases, etc.), or in another clerkship.

For each course or clerkship that requires student interaction with patients, the faculty must specify the types of patients or clinical conditions that students must see and the other patient-based experiences students must have (for example, surgical procedures), in order to achieve the objectives of the learning experience. The faculty must also specify the extent of student interaction with these patients and the venue(s) in which the interactions will occur.

Rationale for the Change
This has been one of the standards most frequently cited for noncompliance, in part reflecting difficulty medical schools have had in quantifying criteria for patient experiences when there is often little empirical evidence to justify a particular numerical threshold . The revision removes the requirement for "quantified" criteria and formalizes the expectation, previously found in the annotation, that student experiences be monitored and that gaps in student experiences be remedied. It also includes an expectation for central oversight of the system but leaves the nature of that oversight to the institution.