Pathology Course Director Perspectives of a Recent LCME Experience: Preparation in an Integrated Curriculum With the Revised Standards.

Preparation for a Liaison Committee of Medical Education (LCME) accreditation site visit is a daunting task for any medical school, particularly for medical schools that have adopted integrated curricula. The LCME accreditation is the standard that all US and Canadian allopathic medical schools must meet in order for the school to award the degree of medical doctor. The Uniformed Services University of the Health Sciences (USU) recently underwent a full-scale LCME accreditation visit that was conducted under the newly revised LCME standards and elements. The site visit occurred just 5 years after our school began implementing a totally revised, organ system-based curriculum. Preparing for a critical, high-stakes site visit shortly after transitioning to a totally revised, integrated module-based preclerkship curriculum presented an array of new challenges that required a major modification to the type of preparation, communication, and collaboration that traditionally occurs between course directors and departmental chairs. These included the need to ensure accurate, timely communication of curricular details to different levels of the academic administration, particularly as it related to the execution of self-directed learning (SDL). Preparation for our site visit, did, however, provide a novel opportunity to highlight the unique educational experiences associated with the study of pathology, as pathology traverses both clinical and basic sciences. Sharing these experiences may be useful to other programs that are either undergoing or who are preparing to undergo an accreditation visit and may also aid in a broader communication of the highlights or initiatives of educational activities.

Introduction

The Liaison Committee of Medical Education (LCME) is recognized by the US Department of Education as the governing organization that officially establishes the accreditation standard for institutions granting the degree of doctor of medicine (MD).[1,2] The LCME accreditation is not a university-level accreditation. Rather, it reflects accreditation of the educational program that leads to the award of the MD degree. The LCME is specifically focused on the training of medical students and does not confer accreditation for graduate educational programs, nursing programs, or any of the dental programs that may coexist within a given medical university. The LCME is cosponsored by the American Association of Medical Colleges (AAMC) and the American Medical Association (AMA).[3] Each of these 2 organizations designates an individual to serve as LCME cosecretary. Together these 2 cosecretaries represent the LCME Secretariat, which serves in an advisory capacity for US and Canadian medical schools. The AAMC cosecretary is based in Washington, District of Columbia, and the cosecretary from the AMA is based in Chicago, Illinois. Accreditation by the LCME committee members allows allopathic medical schools to demonstrate that they fully uphold the high level of educational standards that are needed in order to ensure that graduating students have the appropriate preparation necessary to enter the profession of a physician.[4]

Pathology plays a unique role in physician preparation, as it provides and develops a wealth of foundational knowledge that is essential for success in both basic sciences and clinical medicine. Thus, pathology departments typically shoulder a significant portion of the educational responsibilities associated with the provision of undergraduate medical education. In many contemporary integrated curricula, pathology departments no longer issue separate grades or teach pathology as a stand-alone course. Many of our curricular reform efforts followed the 2010 Carnegie Report[5] that included the following key tenets: (1) standardized outcomes with individualized processes, (2) enhancing curricular integration, (3) fostering habits of inquiry and improvement, and (4) advancing the process of (early) professional identity formation. The 2011 AAMC-HHMI[6] report described increased scientific foundation in medical school as well as movement away from independent academic courses in medical schools, but rather an interdisciplinary approach to teaching to create a scientific basis for life-long learning. Added to this complexity is the fact that the LCME standards were recently significantly revised to reflect the changing tide of curricula. Thus, the process of preparing for LCME accreditation has drastically changed in recent years, particularly as integrated curricula have become more widespread. As a result, preparatory efforts may require some focused faculty development and explicit leadership from the departmental chair. Understanding the theory underlying the LCME standards and the importance of accurate and sustained documentation of compliance with the various standards and their associated elements is especially key. This is important as effective preparation is truly a team effort, not only involving detailed coordination and communication within individual departments but also within and among the entire institution—to include multiple levels of faculty and administration.

Changes in LCME Standards

The implementation of the 2015 Standards and Elements for LCME accreditation reflects a marked change from previous versions.[7] Prior to 2015 there were 132 standards that were grouped into 5 focus areas. These included (1) institutional setting that included topics such as governance, administration, and the academic environment; (2) educational programs that included an assessment of educational objectives, structure, evaluations, curriculum management, and overall programmatic effectiveness; (3) medical students that involved a review of the admissions process, student services, and the learning environment; (4) faculty that included ensuring the presence of an adequate number and array of faculty members, along with a review of their qualifications and the policies governing faculty; and (5) educational resources that included a review of the school’s financial status, facilities, and library.

In 2015, the LCME officially implemented a totally redesigned set of standards. Instead of having 132 individual standards, the new approach involved ensuring compliance with 12 overarching standards that are associated with a total of 95 elements (6-12 elements per standard). These new standards are listed in Table 1.

Table 1.

LCME Standards Implemented in 2015.*

Missing/Planning Leadership and Administration Academic and Learning Environment Faculty preparation, productivity and policies Educational Resources and Infrastructure Competencies/Curricular Objectives and Design Curricular Content Curricular Management and Evaluation Teaching, supervision, Assessment, Patient safety Medical Student Selection Medical Student Academic Support Medical Student Health Services

Abbreviation: LCME, Liaison Committee of Medical Education.

*This Table Summarizes the Revised LCME Standards Implemented in 2015 which can be fully Reviewed on the LCME Website: LCME Standards: lcme.org/publications.

These new standards are more broadly based and provide general descriptive guidelines of the curriculum, consistent with the newer approach to integrated educational designs. For example, the old standard, ED-11, states that “The curriculum of a medical education program must include content for the biomedical sciences that supports students’ mastery of the contemporary scientific knowledge, concepts, and methods fundamental to acquiring and applying science to the heath of individuals and populations and to the contemporary practice of medicine…” Under this old standard, pathology was specifically identified as a distinct course that must be included in all medical school curricula. On the other hand, the current set of LCME standards does not require the inclusion of any specific courses for accreditation purposes.

Similarly, the old standard ED-17 specifically stated that “educational opportunities must be available in clinical pathology…” and stipulated that students must be exposed to “…basic mechanisms of disease, disease manifestation in organs, and application of disease mechanisms to clinical practice for diagnosis and management.” These 3 core areas of pathology are no longer mentioned in the revised standards. The more generalized standards are thus interpreted to be more descriptive of what a curriculum should contain, and are less prescriptive, thereby being more consistent with the trend toward the more widespread adoption of integrated medical curricula.

Preparation for the Visit

Active preparation for the LCME accreditation visit starts about 18 months prior to the actual site visit and includes initiating work on the comprehensive data collection instrument (DCI) as shown in Figure 1.

Figure 1.

The timeline for preparation begins 18 months prior to the Liaison Committee of Medical Education (LCME) visit with the completion of the data collection instrument. This is followed by completion of the independent student survey, the executive summary, and finally the self-study. All components are completed prior to the LCME site visit. The site visit team has 6 weeks to review all of the submitted data prior to the actual site visit.

Preparing for a LCME accreditation visit involves 3 key components—(1) compilation of the DCI, (2) the independent student analysis (ISA), and (3) completion of the institutional self-study.[6] Moreover, the school must also prepare a concise summary of the DCI, with particular emphasis on identified strengths and weaknesses of the educational program. Guidance for completing the all-encompassing DCI is provided in the form of a 144-page, blank document that includes an extensive array of questions regarding all aspects of the educational program. The DCI must be completed first, as it will serve as the foundational document for the ISA and for the institutional self-study.

Once the DCI was fully populated, the school’s LCME leadership team established a series of subcommittees that were tasked with critically evaluating one or more of the 12 standards, using data in the emerging DCI. Participation on these committees allowed for the representation and active engagement of individuals from an array of departmental disciplines, which, in turn, facilitated broad data inclusion and communication. The ISA was based on an independently conducted survey of students in all 4 classes of the medical school. Unlike other surveys, it is critically important that this survey be completely designed, developed, compiled, and evaluated by the students, without any external influence, although university staff are permitted to provide administrative assistance and support if needed. We found it useful to utilize the existing student (class) leadership in completing this task. However, this was especially challenging for our third- and fourth-year students who are literally spread across the United States, from coast to coast, participating in various clinical rotations. Once completed, though, the ISA is a key element of the institutional self-study, as it provides the school with an objective evaluation of just how it is meeting its internally established goals and objectives and complying with established LCME standards.

The extent to which individual course directors need to prepare for the accreditation visit, is, in part, dependent on the extent to which they were involved in preparing the DCI and institutional self-study. Thoughtful review and evaluation of data included in the DCI are critical in order to being able to effectively articulate to the site visit team about the strengths and challenges of the school. This is particularly important, as the site visitors will have had approximately 6 weeks with which to review these data in detail. As a result, faculty preparation is very important—as not only do faculty need to be familiar with the content of the ISA, self-study, and DCI, but it may also be helpful to conduct a series of “mock” sessions, giving faculty members some insight as to the type of challenging questions that they may be asked to answer during the actual accreditation visit.

Coordination and communication are key elements to the preparation, as the preparatory documents are often lengthy and very detailed. Faculty members, course directors, module directors, and chairs are all expected to be conversant in the information contained in these core documents. To accomplish this, we shared the documents electronically and met with groups of faculty and chairs to review the major components of these documents prior to our visit. In addition, a series of monthly LCME newsletters were developed and subsequently disseminated throughout the School of Medicine. These newsletters were used to apprise faculty and staff about the LCME in general and provided a more focused overview of each of the 12 standards, the key elements within that standard, and examples of how that standard was being addressed within the School of Medicine. An example of one of these bulletins is included in the supplemental material. Timely dissemination of information and in particular ensuring that key personnel are fully aware of what is currently being taught in the curriculum and how key LCME elements are being fulfilled is absolutely critical.

Some of our core components, such as Pathology Small Groups, are administered as a cumulative educational activity, with 4 sessions spread across several modules. Each of the pathology small group sessions includes an individualized, formative evaluation, followed by a summative evaluation at the end of the fourth session. Taken together, these allow faculty to more accurately assess the progress the student has made over the previous sessions. This approach was particularly challenging, as we needed to develop a way for our module directors to feel comfortable embracing the longitudinal and cumulative summative sequence of the pathology small group sessions. Doing this required setting up a series of face-to-face meetings with the various preclerkship module directors, which provided an opportunity to more effectively convey the rationale and educational merits of such an approach—to include the use of summative grading, which we felt was essential to the process. This was of particular importance when meeting with preclerkship module directors who did not have a summative pathology small group grade in their module.

Preparation for Stand-Alone Curriculum Versus Integrated Curriculum

In the past, the USU pathology department prepared for LCME reaccreditation in much the same way as how we prepare for a College of American Pathologists (CAP) inspections. The previous set of LCME standards were more prescriptive in what was expected to meet the requirements of each of those LCME standards; this is similar to the specific topics of a CAP checklist for the pathology laboratory. Historically, when preparing for prior LCME visits, our department would begin by evaluating each standard that related to our stand-alone pathology course and would compile a notebook with an example of each of these standards and how it is (was) being addressed. For example, we had a section on student grading, examples of grade sheets including all components of the course such as laboratory quizzes, Team-Based-Learning grades, pathology small group grades, pathology exam grades, the NBME Pathology Subject Examination, laboratory instructor narrative comments, pathology small group narrative comments, and a final grade. Examples of objectives, how pathology objectives related to school of medicine objectives, and how curricular coordination was accomplished between pathology and the introduction to clinical reasoning course were included. We also included examples of faculty evaluations, small group instructor evaluations, student evaluations, and described each type of instruction in the course with examples. Our preparation was very thorough in this manner, and we could readily show the LCME site visitors examples of how we met each of the standards as a course. Our experience suggested that this was an effective method of preparation and that the results were well received by the LCME site visitors.

Under the revised 2015 LCME standards and elements, the sections pertaining to pathology are more descriptive and less directive but that does not negate the need for cultivating and documenting very detailed responses. In our case, the pathology course director began preparing in a similar manner, by first reviewing the new set of standards and elements and then documenting how we coordinated and executed our educational activities as a longitudinal course of study instead of as a traditional, stand-alone course. For example, we again compiled a notebook with examples of our teaching guidelines, digital slides, course materials, pathology instructor evaluations, and end-of-module evaluations. We also gathered examples of how we tied student assessment to specific pathology session objectives. What was remarkably different this time was that communication of these activities needed to occur between and among the pathology course director, 7 pairs of preclerkship module directors from different disciplines, and all of our pathology teaching faculty. This was accomplished by a combination of in-person meetings and by developing a series of strategic e-communiques that were sent by the course director to each of the teaching faculty. This was important, particularly for schools with an integrated curriculum, as virtually anyone speaking to the LCME team could then be asked where topic “X” is taught or how “X” topic is integrated and coordinated in the curriculum. This, in turn, required a much greater degree of integrated, team-based preparation. To achieve communication across departments, a variety of methods were used that are summarized in Table 2.

Table 2.

Key Intradepartmental Communication Methods.*

✓ Broad intradepartmental inclusion in DCI subcommittees ✓ Key preparation documents shared on in Google docs ✓ In-person communication of longitudinal educational activities ✓ Summary e-mails between course directors and faculty ✓ Regular LCME newsletters to the School of Medicine faculty ✓ Mock site visit sessions

Abbreviations: DCI, data collection instrument; LCME, Liaison Committee of Medical Education.

*This table summarizes the key methods of communication between departments that were used to inform faculty during the preparation for our LCME site visit.

The Site Visit

During the actual site visit, it is critically important that the faculty and chairs who meet with the site visitors are completely familiar with the information that was included in the DCI as well as with the data and analysis that emerged from the ISA and the institutional self-study. What was surprising to our department was that the LCME team did not ask to meet with each of the various course directors. Instead, they met with a diverse array of individuals representing various facets of the curriculum. As such, it was even more essential to ensure that individuals who did meet with the site visitors were completely familiar with all aspects of the pathology curriculum and how it was presented.

From our perspective, it almost seemed as if the site visitors had a more in-depth understanding of the school and all of its components than some of our faculty members! The LCME team arrived with advance knowledge of our strengths and challenges, and it was quite evident, by the precise and/or probing nature of their questions, that they expected detailed and factual responses to address perceived gaps. In fact, the site visitors tended to direct specific questions to individual faculty members, as opposed to the more historical approach of “throwing” questions out to the entire group. As an acting departmental chair, my colleagues and I arrived at our designated session fully expecting to answer questions that were more administrative in nature. However, our session began with a series of directed questions focused on clarifying what topics were taught by which department(s) and in which segment of the medical school curriculum (eg, the preclerkship, clerkship, or postclerkship time period). This approach further underscored the need for faculty members who are scheduled to meet with LCME site visitors to be broadly prepared to answer inquiries relating to both administrative and curricular details.

Challenges

One challenge is that the school and the LCME team site visitors will determine which elements they would like to discuss and with which groups of faculty they would like to meet to discuss those elements in the short time of the site visit. During our visit, one of the prescribed meetings involved having the LCME team meet with our cadre of 14 preclerkship module directors. This represented a notable change from prior years, as a separate meeting with the various course directors did not take place. As a result, it was critically important to ensure that course directors who were not module directors were fully conversant with regard to the details of the pathology curriculum and related educational activities. At USU, our pathology curriculum utilizes a combination of large- and medium-sized lectures, laboratory sessions, small group discussions, team-based learning as well as formative and summative assessments, with narrative comments. An example of the latter is depicted in Figure 2. Clear and frequent bidirectional communication is needed in order to ensure that the intent of each of these components is effectively conveyed to the module directors, faculty, chairs, and administrators, especially since some of these activities are cumulative over several multiple modules. Communication should also include those who teach selective components, for unlike most of the other basic science departments, many pathology departments have pathology residents who assist in teaching as well. In fact, pathology residents can often be highly effective teachers, given their ability to more easily relate to the challenges experienced by contemporary medical students with whom they are essentially senior peers. This leads to a continuous bidirectional circle of communication (Figure 3) of what and who is teaching between all the stake holders of the curriculum, as the preparation and execution of the educational activities is a team effort that crosses multiple modules.

Figure 2.

Communication of pathology course components often includes multiple educational activities such as lectures, small group activities, laboratory, team-based learning, assessments, and narrative comments.

Figure 3.

Communication within an institution with an integrated curriculum is multidirectional between faculty, course directors, module directors, chairs, and administrators.

Another challenge was the level of detail needed to fully respond to questions posed by the LCME team. One particular example that stood out for us related to the emphasis placed on describing our self-directed learning activities. In this regard, it is important to note that self-directed learning is far more than simply allowing time for individualized self-study. Self-directed learning is addressed in LCME Standard 6, Element, 6.3,[4] which specifically states that self-directed learning includes 4 key components that must be undertaken in a complete and unified sequence. These key components are listed in Table 3.

Table 3.

Key Elements of a Self-Directed Learning Exercise.*

Identifying, analyzing, and synthesizing information relevant to their learning needs Assessing the credibility of information sources Sharing the information with their peers and supervisors Receiving feedback on their information-seeking skills

*This table summarizes the key components needed for a self-directed learning (SDL) exercise.

We initially answered a question relating to self-directed learning with a broad explanation that we thought included all 4 components of the stated element. Our initial response involved highlighting the conduct of pathology case discussions/small group sessions, noting that:Our team of LCME site visitors did not view this initial response as a suitable demonstration of a coordinated self-directed learning component. Namely, conformation that the small group activity fulfilled the requirement of including all 4 components of SDL, in a unified sequence. We were able to address this perceived deficiency with a more detailed description of our SDL as depicted in the following narrative:In the second description of the pathology small group activities, much more detail was provided on each of the steps of self-directed learning outlined in Element 6.3, and each step was specifically annotated. Of particular importance was the need to specify that students are held responsible—not only for assessing the credibility of the sources of information used to research each case but also for how the cases are presented and for discussing how available resources support (or refute) a student’s clinical reasoning, and for providing meaningful feedback to their peers. The importance of being able to provide detailed responses—and at a more granular level than originally expected—based on prior accreditation visits was a key learning point and helped guide some of our other responses as well.

Students independently analyze a presented (paper) case, analyze a list of possible differential diagnoses, independently research various diagnoses and consider the evidence supporting or refuting each possibility. Students then generate a differential diagnosis, based on their research and present their findings and the supporting rationale to a group of peers and a faculty preceptor. Students then receive oral (faculty and peers) and written feedback (from faculty) on their research, analytical skills, and clinical logic.

During the Pathology Case Discussions/Small Group Sessions, students are given three paper cases at least two weeks ahead of a small group session to independently research. In this analysis, students are asked to analyze pertinent positive and negative points of the history and laboratory findings. Individual students then write a one-page report for each case, focusing on the top three items in their differential diagnosis, each of which must be supported both clinically and pathophysiologically. (Step 1 of SDL). To do this, students use various resources of their choosing and verify the credibility of the source that supports their independent analysis (Step 2 of SDL). During the sessions, a pre-designated student presents one of the three cases as if they were presenting an actual patient on the wards. Students then discuss their differential diagnosis, and compare and contrast their conclusions with those of other members of the group (8 students and 1 facilitator). Discussion includes a review of which items were used to formulate the differential diagnosis and what resources were used to find salient information (Step 3 SDL). Students and the faculty facilitator provide real-time verbal feedback to the presenting students, and all students receive individual written feedback on each of their written cases, as well as on their presentation and ability to appropriately research and analyze each case, from the faculty facilitator (Step 4 SDL).

Opportunities

Although LCME preparation and inspection presents many challenges, these visits also provide opportunities for internal inspection, reflection, analysis, and improvement—similar to what occurs during the lead-up to a laboratory CAP inspection. One such opportunity led to the development of a more sustained level of cross-communication involving faculty, departmental chairs, administrators, and preclerkship module directors. This, in turn, fostered a better understanding—and appreciation, of the unique aspects of our pathology curriculum—specifically, what we do and how we do it, and how pathology integrates into the entire curriculum. Preparation for the LCME allowed us to better articulate our strengths and unique teaching modalities. It also created an opportunity for many of our faculty to become more actively involved in developing and discussing specific components of the curriculum. An additional benefit was that it provided opportunities for faculty to participate in committees that were external to a given department and, where appropriate, to inform and/or advocate for pathology-related instructional activities. The Pathology Competencies on the Association of Pathology Chairs[8] website can easily be adapted to any curriculum and support integration of learning objectives to meet the LCME standards. Opportunities for improvement are summarized in Table 4. Although external evaluations can be stressful, they should be recognized as “golden moments” for exploring improvements, conducting critical, but reflective, self-evaluations, and most of all, for promoting further integration and innovation.

Table 4.

Opportunities for Improvement Identified Through LMCE Preparation.*

▹ Develop sustained cross-communication of educational elements between course directors and module directors and individual teaching faculty ▹ Broaden appreciation of integrated curricula ▹ Articulate strengths of individual teaching venues ▹ Create opportunities for interdepartmental faculty to work together

Abbreviation: LCME, Liaison Committee of Medical Education.

*This table summarizes several key opportunities for improvement realized through the preparation for an LCME accreditation visit.

Conclusion

The LCME accreditation is a critical process for all US and Canadian medical schools. The revised standards and elements implemented in 2015 are more descriptive and less detailed and directive than the standards of the past, and based on our experience, institutions undergoing similar surveys need to be prepared to provide detailed descriptions of many of their educational activities in order to effectively convey full compliance with the LCME standards. Gone are the days of silo thinking and separate, “stand-alone” courses, each with their own, distinct curriculum, aimed at complying with more proscriptive LCME standards. Although there are new challenges with integrated curriculums that were not present in the era of stand-alone pathology courses, these too provide new opportunities to highlight the strengths of our educational program and to promote interdisciplinary discussion, innovation, and support. As a result, the accreditation process should be viewed as providing a myriad of opportunities that promote advanced curricular integration and other educational enhancements that will ultimately benefit our students for many years to come.