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AV俱乐部鈥檚 Faculty of Medicine announced recently that its undergraduate medical education program had been placed on probation by its American accrediting body, the Liaison Committee on Medical Education. Having just completed the appeals process, new Dean Tom Marrie sat down with Dalnews to answer our questions and explain how the medical school is responding to the challenge.
Let鈥檚 start with the basics, especially for those who aren鈥檛 versed in the particulars of medical education. When we鈥檙e talking about accreditation, what do we mean? Who accredits our medical school and why is their assessment important?
The medical schools in North America all undergo roughly the same process. Every seven years, on average, there鈥檚 a team that will come to campus to visit and will check using 132 standards that have been arrived at 鈥� the standards keep changing, so they鈥檙e not always the same, they鈥檙e massaged from time to time 鈥� but they鈥檙e divided into areas such as curriculum, student affairs and so-forth.
In Canada, we鈥檙e different than the U.S. because we鈥檙e accredited by both the Canadian and American agencies and they both come (to campus) at the same time. The interesting thing about this is that the teams both came in early February, had the same information but came to somewhat different conclusions.
And it was the American agency, the Liaison Committee for Medical Education (LCME), that placed the school on probation.
Yes. The bottom line is that we were judged non-compliant on 17 out of 132 standards. Now, these standards are not all created equal. Some of them, for example, are relatively minor. Not having enough lockers for students, for example, was something we were cited for. It鈥檚 not unimportant, but it really doesn鈥檛 have a great impact on your educational experience. The other extreme is that the curriculum, which in 1992 was ahead of its time, hadn鈥檛 really undergone a complete review since that time.
We received the report a day before I arrived on campus. I wasn鈥檛 due to start as Dean until September, but as soon as I arrived in mid-July I got working on this before becoming Dean formally in the fall. I spent those two months getting to know the environment again 鈥� I was a faculty member here a long time ago 鈥� reviewing the accreditation report and meeting with as many stakeholders as possible.
When the news broke in July, you pledged to appeal the probation decision. What was the outcome?
We had our opportunity to appeal. We looked at this very carefully and there were a number of things we couldn鈥檛 appeal because they got it right, and you can only appeal on errors of fact. We did appeal 10 (standards) and did extremely well, in that they reversed their decision on seven. However, it wasn鈥檛 enough to get us out from under the shadow being placed on probation.
So what does 鈥減robation鈥� mean for the medical school?
What that means is that we have to tell incoming students that we鈥檙e on probation 鈥� but still fully accredited 鈥� and we have two years to fix the areas of non-compliance. But while we鈥檙e working on that, we decided that we had to start on a long-term plan 鈥� one to work towards having the best undergraduate medical education program in North America, and that鈥檚 achievable for several reasons.
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I鈥檓 sure that one of the questions many people have is a simple one: how does this happen? If accreditation is important to the ongoing operations of the medical school, and if we were aware of these standards, how is it that we鈥檙e scrambling to meet them after the fact?
It鈥檚 a good question, and one that I don鈥檛 know the full answer to because I wasn鈥檛 here. I鈥檝e taken the approach of moving forward and fixing it. I can surmise some of the reasons why it happened, but I don鈥檛 think there鈥檚 any point in me trying to discover who鈥檚 to blame.
If I had to surmise in general, I鈥檇 figure that this program was doing so well that people just didn鈥檛 get as nervous about this as they should have. There may have been this attitude, 鈥淲ell, we鈥檝e always been accredited, we鈥檙e the third oldest medical school in the country, we never had a problem with it before.鈥�
So is this unusual? Is this the sort of thing that Canadian medical schools have faced in the past, to your knowledge?
Nobody gets all 132 of these standards perfect; that鈥檚 almost unheard of. I鈥檝e led an accreditation team, I鈥檝e talked to people at other schools. You generally never get all of them, and there are always things to improve on.
When we had those seven (criteria) overturned, I thought they would give us two years to fix the rest and not put us on probation. They didn鈥檛 give me a good explanation as to why they made the probation ruling; in fact, they didn鈥檛 give me any explanation. But on November 30, three representatives are coming to visit 鈥� two people from the US, one from Canada. And the purpose of that visit is for us to submit our plan for how we鈥檙e dealing with the outstanding items moving forward, and I鈥檓 hoping that maybe I can get some more of their thinking as to their decision.
Does the medical school feel that it has been treated fairly in this process?
After we started, we decided to hold a town-hall meeting for all students, faculty and staff members and we said 鈥渢his is what鈥檚 happened to us, and this is what we鈥檙e going to do 鈥� we鈥檙e going to use it as an opportunity to make major changes.鈥� Everyone was behind it. I think the sentiment was that there is no point in whining about it 鈥� this is the way we鈥檝e been judged and let鈥檚 move on. I think that鈥檚 the overall sentiment.
From my personal point of view, I was certainly surprised 鈥� not by the initial decision, but that we still got stuck with probation when we did so well on the appeal. Part of the problem is that I don鈥檛 know what went on at the time of the visit, don鈥檛 know what the behind the scenes thinking was, so it鈥檚 hard to say whether it was unfair. A better approach is that I believe these organizations could have accomplished the same thing without the probationary status. They could have said, 鈥測ou have two years to fix it and, if you don鈥檛, then you鈥檒l be in trouble.鈥� And the way everybody here is responding, I don鈥檛 think there鈥檚 any danger that it won鈥檛 be fixed 鈥� in fact, we鈥檝e done a lot of the things right now.
Such as?
So here鈥檚 what we鈥檙e doing: we鈥檝e got a very ambitious effort to totally renew the curriculum. We鈥檝e got 20 groups with well over 200 faculty members, students and some members of the community working on 20 different topics. One group, for example, is looking at the scientific basis of the practice of medicine in Nova Scotia, another one examining is the art of doctoring 鈥� empathy, how you relate to people when sick, that sort of thing. These groups are working now with their reports done at the middle of this month. We鈥檝e then got a symposium planned for two days at the end of November with guest speakers. That will set the groundwork for two days in December to start to rearrange this curriculum.
That was obviously one of the more troubling concerns that the LCME exposed 鈥� curriculum review. Should current students be concerned about the quality of education they鈥檙e receiving?
The answer is no, and I鈥檒l tell you why. The curriculum is still a good curriculum. The learning modules 鈥� be they a lecture or a course 鈥� have been kept up to date by individual teachers; it just hasn鈥檛 been organized across the faculty. And our students continue to do extremely well in the licensing exams.
Even more importantly from the students鈥� point of view, if you鈥檙e going for a residency position, we have the highest rate of matching to first career choice in the country. The reason for that is that our students, when they鈥檙e finished here, are very good clinically. They know how to look after sick people, which is not always the case in many medical schools. They鈥檙e looked upon as being very good residents, and the people who have gone before them have paved the way for the current crop.
Interestingly, the students know all this. We鈥檝e been up front with them and met with them at several occasions. They鈥檙e also involved in the curriculum renewal and have been nothing but supportive. They鈥檝e been helping out, working on these committees and they believe in what we鈥檙e trying to do.
What about the rest of the community 鈥� what鈥檚 your impression of the response from faculty and staff to this whole scenario?
In a word 鈥� fantastic. There鈥檚 a lot of work to be done, but everybody has come together around this external threat, and that in and of itself is quite an experience.
What are the next big milestones? At what point do you think the school will be able to crawl out from under this label?
That鈥檚 part of the discussion (with the representatives) on November 30. From there, at some point next year a team will come back and will look, in depth, at all the remaining deficiencies and scrutinize them very thoroughly. That will be a big milestone. My understanding is that the earliest we could drop the probation designation is probably 18 to 24 months.
Is failure an option? What happens if the school doesn鈥檛 address these deficiencies to the LCMA鈥檚 satisfaction?
Well, we鈥檝e dealt with most of the concerns already. Restructuring the curriculum is big, certainly, but we have to have done by the end of July for next year鈥檚 class. And we鈥檒l meet that.
Probably the one that will take us the longest to do is developing a curriculum map.聽 If you look at the four years that we offer, and pick a topic like, say, cancer of the lung, we should be able to demonstrate where you pick up the pieces on that topic: you get something in first year anatomy, some in surgery, some in oncology. The virtue is that it makes sure you鈥檝e covered all the key items and avoids unnecessary duplication. And when you get to the exams, you should be able to make sure that the material that鈥檚 being tested on was covered. There鈥檚 no simple piece of software to build such a tool, so building that sort of database digitally piece-by-piece takes time. So that one we probably won鈥檛 have done. But as long as we have the curriculum done and can demonstrate progress, we鈥檒l be okay.
All the others? We鈥檒l have them done. No question.
Your tenure as Dean seems destined to be defined by this probation status. When you look ahead three, five years, what does medical education at Dal look like?
There is no doubt that we鈥檒l have a better program; no doubt about that whatsoever. We will also have set in place a process where this will never happen again. One of the things that we haven鈥檛 touched on is that we鈥檝e created a position in the faculty called an Accreditation Officer. And that person, 50 per cent of his or her time will be to set up a program so that every year we are looking at the 132 standards ourselves and ensure that we鈥檙e meeting it. So that鈥檚 one of the things that鈥檚 come out of this.
I think the key message from me is that even though this is a dreadful thing in terms of our reputation, it is also probably, from my standpoint, the single best opportunity that we have to really change. Something like this allows you to make the kinds of changes that in a university can take forever. Universities are fantastic in many respects but boy, they鈥檙e not known for their speed of decision making. We just can鈥檛 afford to go at this the way we ordinary go at things 鈥� 15 committees, no one making decisions. We just have to do it. And we鈥檝e already been able to do more in a couple of months than has been done in a long, long time.
An external threat does something to you. We have a large faculty and in any large group, maybe they鈥檙e not always totally in line. But it鈥檚 like a family 鈥� if someone from outside comes in and presents a threat and you circle the wagons. And we emerge stronger because of it.