Q and A with Tom Marrie

Dean of Medicine Tom Marrie. (Bruce Bottomley Photos)

Dalhousie’s 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’s start with the basics, especially for those who aren’t versed in the particulars of medical education. When we’re 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’s a team that will come to campus to visit and will check using 132 standards that have been arrived at – the standards keep changing, so they’re not always the same, they’re massaged from time to time – but they’re divided into areas such as curriculum, student affairs and so-forth.

In Canada, we’re different than the U.S. because we’re 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’s not unimportant, but it really doesn’t have a great impact on your educational experience. The other extreme is that the curriculum, which in 1992 was ahead of its time, hadn’t really undergone a complete review since that time.

We received the report a day before I arrived on campus. I wasn’t 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 – I was a faculty member here a long time ago – 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’t 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’t enough to get us out from under the shadow being placed on probation.

So what does “probation” mean for the medical school?

What that means is that we have to tell incoming students that we’re on probation – but still fully accredited – and we have two years to fix the areas of non-compliance. But while we’re working on that, we decided that we had to start on a long-term plan – one to work towards having the best undergraduate medical education program in North America, and that’s achievable for several reasons.

"It is ... 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’re not known for their speed of decision making. We just can’t afford to go at this the way we ordinary go at things – 15 committees, no one making decisions. We just have to do it." — Tom Marrie, Dean of Medicine

One is our students are second to none. We actually have quite a good infrastructure for medical education. We have a Division of Medical Education, with several PhD faculty, some of whom are internationally known. And we have people that are interested in teaching. We know we can achieve that goal.

I’m 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’re scrambling to meet them after the fact?

It’s a good question, and one that I don’t know the full answer to because I wasn’t here. I’ve taken the approach of moving forward and fixing it. I can surmise some of the reasons why it happened, but I don’t think there’s any point in me trying to discover who’s to blame.

If I had to surmise in general, I’d figure that this program was doing so well that people just didn’t get as nervous about this as they should have. There may have been this attitude, “Well, we’ve always been accredited, we’re the third oldest medical school in the country, we never had a problem with it before.”

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’s almost unheard of. I’ve led an accreditation team, I’ve 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’t give me a good explanation as to why they made the probation ruling; in fact, they didn’t give me any explanation. But on November 30, three representatives are coming to visit – two people from the US, one from Canada. And the purpose of that visit is for us to submit our plan for how we’re dealing with the outstanding items moving forward, and I’m 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 “this is what’s happened to us, and this is what we’re going to do – we’re going to use it as an opportunity to make major changes.” Everyone was behind it. I think the sentiment was that there is no point in whining about it – this is the way we’ve been judged and let’s move on. I think that’s the overall sentiment.

From my personal point of view, I was certainly surprised – 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’t know what went on at the time of the visit, don’t know what the behind the scenes thinking was, so it’s 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, “you have two years to fix it and, if you don’t, then you’ll be in trouble.” And the way everybody here is responding, I don’t think there’s any danger that it won’t be fixed – in fact, we’ve done a lot of the things right now.

Such as?

So here’s what we’re doing: we’ve got a very ambitious effort to totally renew the curriculum. We’ve 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 – 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’ve 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 – curriculum review. Should current students be concerned about the quality of education they’re receiving?

The answer is no, and I’ll tell you why. The curriculum is still a good curriculum. The learning modules – be they a lecture or a course – have been kept up to date by individual teachers; it just hasn’t been organized across the faculty. And our students continue to do extremely well in the licensing exams.

Even more importantly from the students’ point of view, if you’re 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’re 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’re 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’ve been up front with them and met with them at several occasions. They’re also involved in the curriculum renewal and have been nothing but supportive. They’ve been helping out, working on these committees and they believe in what we’re trying to do.

What about the rest of the community – what’s your impression of the response from faculty and staff to this whole scenario?

In a word – fantastic. There’s 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’s 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’t address these deficiencies to the LCMA’s satisfaction?

Well, we’ve 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’s class. And we’ll meet that.

Probably the one that will take us the longest to do is developing a curriculum map.  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’ve 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’s being tested on was covered. There’s 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’t have done. But as long as we have the curriculum done and can demonstrate progress, we’ll be okay.

All the others? We’ll 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’ll 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’t touched on is that we’ve 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’re meeting it. So that’s one of the things that’s 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’re not known for their speed of decision making. We just can’t afford to go at this the way we ordinary go at things – 15 committees, no one making decisions. We just have to do it. And we’ve 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’re not always totally in line. But it’s like a family – if someone from outside comes in and presents a threat and you circle the wagons. And we emerge stronger because of it.