Project Cork:

a case study in designing and implementing an alcohol curriculum for medical education

Jean Kinney, MSW; Trevor R.P. Price, MD; Peter C. Whybrow, MD; Susan Linsey, MA
Dartmouth Medical School, Hanover NH 03755

CONTENTS

Preface

Introduction

The Opportunity

The Setting

Environmental Variable: The Alcohol Field

Strategies for Broaching Curriculum Change

A Case History

Planning Stage: Building a Mandate
Planning Stage: Defining the Content
Building an Organizational Structure
Implementation: Preclinical Teaching
Faculty Development and Community Awareness
Creative Spending
Special Projects
Implementation: Clinical Curriculum
Evaluation
Dissemination
Relationship with the Alcohol Community
Winding Down, or Death with Dignity

Epilogue

Looking Back: with 20/20 Hindsight
Process
Educational Issues
Concluding Comments

References

Appendices

A. Model Curriculum    PDF
B. Evaluation    PDF
C. Public Relations    PDF
D. Clinical Teaching    PDF

PREFACE

Project Cork was a four year grant-supported program at Dartmouth Medical School funded by Operation Cork, a program of the Kroc Foundation. Its charge was to develop a model curriculum for undergraduate medical education in alcohol and alcoholism. Initiated in 1977 it was successfully concluded in 1981.

Unlike alcohol education efforts in other medical schools, Project Cork was then unique in several respects. For one, it was a school-wide effort, which involved, in some fashion, most of the faculty of the medial school. For another, it was concerned not only with making modifications in the core curriculum, but in also understanding the obstacles to improving medial education on what was clearly a very major public health problem. In utilizing the existing faculty, many of whom had national reputations as researchers and medical educators, Cork brought into the arena of alcohol education individuals whose primary interests were elsewhere. In this way, broad and diverse talents were brought to bear on a topic which had not been in the forefront of academic medicine or medical education.

In the founding of Project Cork, there was a second charge which was to disseminate the results of the experiment to other medical educators. Accordingly, in the course of the four year project, considerable energy was devoted to the development of curriculum materials, the preparation of reference and bibliographic materials as well as presentations at national meetings. At the same time, none of these seemed to adequately convey the richness of the Cork experience. Upon receipt of request from colleagues such as "please send me all you have on Project Cork," we were often at a loss as how to respond. This compilation is an attempt to remedy that. It pulls together not only the content of the Cork curriculum and the nature of the changes initiated, but also describes the process of initiating change, the materials produced, evaluation instruments devised, the approaches used in clinical teaching, and the resource materials collected.

In chronicling the efforts of Project Cork, there is in no sense the belief that we have hit upon "the" formula. It would be our presumption that though there will be much in common between endeavors by medical educators to improve alcohol/alcoholism curricula, there will also be significant differences dictated by the nature and character of a particular institution. While unable to provide the answers, we have some confidence that we have identified the questions which others, who would be embarking upon similar efforts, might do well to consider.

Jean Kinney, MSW
Assistant Professor of Clinical Psychiatry
Executive Director, Project Cork Institute
April, 1986

INTRODUCTION

The Opportunity

In 1997, Operation Cork, a program of the Kroc Foundation, approached Dartmouth Medical School to explore the possibility of developing a model alcohol curriculum for medical education. Unlike other foundations, Operation Cork does not solicit or accept grant proposals. Rather it selects groups of individuals who can be engaged in a collaborative effort to mount its programs. Operation Cork had been established the preceding year by Mrs. Kroc with the purpose of reaching families touched by alcoholism. To accomplish this, Operation Cork had conceived of two major types of programs. One used media and public information/education campaigns to reach family members directly, informing them of the possibility of help and hope. The other programming initiative was geared to improve the professional training and education of those who could/should be in a position to identify and intervene in alcohol problems. To Operation Cork, physicians were an obvious choice. In approaching the Dartmouth Medical School, the Foundation's vision was that Dartmouth faculty would develop and implement a model curriculum which could be adapted, in whole or in part, by other institutions.

In the initial discussions with Operation Cork, Dartmouth Medical School set forth two conditions. While a reflection of its educational philosophy, these conditions also had important strategic implications. The first was that the model curriculum was to be an integrated one, with material infused throughout the existing curriculum rather than inserted in "add-on" fashion, e.g. by establishing separate course on alcohol and alcohol abuse. This in turn meant that the task would fall to existing faculty of the institution. The second condition was that the effort was to be approached as an experiment in medical education. The meant including a research/evaluation component to identify those factors which facilitated or impeded efforts at curriculum change, as well as the factors which influenced student performance.

The Setting

The Medical School as an Organizational Phenomenon. In the literature of organizational development and institutional change, very little has been written about higher education, much less the professional school. Professional schools are distinguished from traditional bureaucratic organization by particular characteristics. [Weisbord, 1975]. The medical school in not a hierarchically structured institution. It is more correctly described as a loose confederation whose members, the departments, function autonomously. The medical school administrative structure functions primarily as the mechanism for negotiating the boundaries and relationships between the component groups. From the departmental vantage point the medical school is a convenient way of securing and sharing essential support services.

The medical school is further distinguished by the multiple and divided "loyalties" of its members. Or, in organizational theory, the external environment of the organization strongly influences internal workings. Chief among the external forces that have a large impact on the function of the organization are the hospitals which serve as clinical training sites, the professional subspecialty organizations which represent peer groups, as well as other groups such as the Liaison Committee for Medical Education, the Association of American Medical Colleges, or the medical school trustees. These external groups represent potent variables which must be accounted for not only in long-term planning, but also in understanding the day-to-day medical school operation.

Finally, although the medical school is ostensibly in existence to be the vehicle for training and educating physicians, paradoxically undergraduate medical education is rarely the top priority. This is true both at the departmental level, as well as being true for individual faculty members. Not uncommonly, greater energy is expended in mounting and conducting residency training, undertaken research, and providing clinical services.

The implications of the above should not be lost on one who would attempt changing a medical school curriculum. First, it is natural to assume that one must or can achieve an institution-wide mandate to initiate change. In reality one must be prepared to deal separately with the various fiefdoms and cultivate appropriate incentives for each. One must also take into account that faculty members, in their capacity as educators, are vested by tradition with virtually autonomy. While other facets of their existence may be subject to considerable external pressure - to provide clinical care, to secure grant funding for research, to participate in administrative roles - when they step up to the lectern, at least for that moment, they are total masters in the kingdom of the lecture hall. This last sure, and perhaps sole, bastion of independence is guarded by faculty with a primitive ferocity, which must not be underestimated. With this as a given, how to broach the need for change with individual faculty members is a matter of some delicacy.

Any effort to initiate curriculum change carries, at least implicitly, the suggestion of some deficiency. Since faculty are the guardians and arbiters of content for their respective areas, since the educational process is organized along disciplinary line, who would dare to make such a charge? How does one avoid even the appearance of challenging faculty competence? It is probably not accidental that "the problem" being tackled when many curricular changes are discussed is the "lack of synthesis" or the "need for integration" or the need for "better coordination" of what is described as an "interdisciplinary concern." Through such formulations, competence of faculty is unchallenged, and the ground work is laid for collaborative efforts to address difficulties.

The above is confounded when one comes to alcohol/alcoholism curricular change. Who are authorities or experts? Whose judgments are acceptable to the faculty? To whom can the faculty comfortably defer? Unlike other efforts to change medical curricula - be it around the teaching of sexuality, death and dying, gerontology or medial ethics - changes which are spearheaded by experts located in academic medicine or at least in academia, what distinguishes the alcohol effort is that the well established alcohol field lies clearly outside the structure of academic medicine. A significant majority of practitioners are non-physicians. Often they are alcohol counselors, the most senior of whom entered the alcohol field largely on the credential of their being recovering alcoholics. The treatment field has been described as organized around "craft" rather than professional lines. In many instances the field has a strong anti-scientific and anti-physician bias [Kalb and Propper, 1976].

Environmental Variable: The Alcohol Field

If the medical school is described as having an anomalous organizational structure, "the alcohol field" can be conceived as an un-coalesced, poorly differentiated amalgam of special interest groups. Historically, one can trace along a number of dimensions - be it as a scientific issue, a medical problem, or a social and legal problem - an evolution in understanding of the phenomenon of alcoholism. The "modern" treatment era dates from the founding of Alcoholics Anonymous in 1935. This self-help group emerged on the heels of the abandoned national experiment of Prohibition. Both directly and indirectly, AA defined the system of care for alcoholism treatment which predominated through the early 1960s and which existed outside the medical and social service systems. Early members of AA, as individuals, engaged in public education and founded national voluntary organizations, e.g. the National Council on Alcoholism. These efforts eventually led to some marginal involvement in the alcohol field by established care-givers, e.g. the American Medical Association's Panel on Alcoholism.

Prior to the 1960s, the alcohol treatment field developed in large part in isolation from the medical mainstream. The backbone of alcohol treatment was what were commonly referred to as "drying-out farms." Often founded and staffed by recovering alcoholics, the "rehabilitation" program was predicated largely on introduction to AA and placement of the alcoholic in an environment in which drinking was impossible. Without medical staffs, these facilities relied upon sympathetic community practitioners. At the same time other forms of alcohol treatment were largely unavailable and alcoholics were routinely denied admission to hospitals.

With the creation in 1970 of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) the alcohol field was provided real impetus. The infusion of federal dollars for treatment, research, training and education provided a mantle of professional legitimacy and changed the landscape of the alcohol field. These was an influx of professionals bringing with them disparate viewpoints. The decade of the 1970s was marked by lively, and at times strident debate, particularly over what constitutes "appropriate" treatment, and credentials for those in the field. A variety of professionals organizations also emerged (i.e. AMERSA, AMSA).

The alcohol field being sensitive to medicine's historical lack of interest in alcoholism, has adopted medical education as one of its major agenda items. At various times this has been translated to mean to teach doctors an/or to "shape up" medicine. The NIAAA for example identified the improvement of physician education as a priority. It initiated its Career Teacher Program to educate and support junior factory of medical schools in alcohol and substance abuse, and then to encourage these individuals to develop an alcohol and substance abuse curriculum within their schools. The program appears far more successful in accomplishing the former than the later.

Strategies for Broaching Curriculum Change

A careful reading of the report evaluating the Career Teacher program is instructive for those contemplating curriculum change [CONSAD, 1977]. It provides a primer, as it were, of unsuccessful strategies. The Career Teachers, generally junior faculty with little power or status, were at the outset, despite senior "sponsors," poorly positioned to influence their organizational systems. In planning the Career Teacher Program it appears that little attention was directed to the nature and dynamics of the medical school environment upon which the individuals were intended to have an impact. For the most part, they functioned in isolation within the institution, their curriculum innovations generally being restricted to courses which they themselves taught. Not unexpectedly the peer group which emerged for such individuals and was fostered by NIAAA was comprised of faculty in similar circumstances at other institutions. These peer group relationships appeared to be far stronger than the professional relationships within their institutions. Although those Career Teachers who were most successful in initiating changes within their institutions were thought to be successful for "idiosyncratic" reasons, they were actually proceeding in accordance with principles of institutional changed.

A monograph Competency Based Curriculum Development in Medical Education [McGahie et al. 1978] outlines the advantages and limitations of three principal methods through which educational changes are accomplished: power, rationality and re-education.

Power strategies require decrees by those who are invested with authority to implement changes, either after winning support of colleagues or after determining their willingness to pay the costs of proceeding despite opposition. While having the advantage of rapidly initiating change, there is a real question about how lasting such changes will be if they are not supported by the organization. Changes for which there is little support entail ongoing monitoring to assure compliance and probably will be subject to subversion at every opportunity.

Rationality as a strategy is seen as being of particular appeal to academics. It is based on data assembly, investigation of alternatives, through dispassionate reasoning, developing recommendations which are open to further modification on the basis of experimentation or experience. McGaghie comments that a plan, while to be taken seriously, cannot omit logic or reasoning, it is imperative to recognize that logic alone rarely produces or sustains significant change. Re-education as a strategy is seen as encompassing changes in attitudes, values, skills and significant relationships as well as changes in knowledge, information, and intellectual rationales. It is frequently a necessary accompaniment to the above.

The experience of Project Cork at Dartmouth Medical School described below effectively drew upon each of these three basic strategies, with one or the other playing a predominant role at various points in the evolution of curricular change. In respect to tactics, Bennis [1975] and Baldridge [1975] discuss approaches to orchestrating educational change. The tips being set out as marginalia in this monograph are supported by the "rules" and approaches outlined.

A CASE HISTORY

Planning Stage - Building a Mandate

When the Dean of Dartmouth Medical School accepted the Foundation grant that established Project Cork, he named the chair of the Department of Psychiatry as the Project Director. The selection of Psychiatry was not based on any particular theoretical view of alcoholism, i.e., that it was or was not proper to consider alcoholism within the rubric of psychiatric disorders. What alcoholism expertise existed in the school happened to be located in the Department of Psychiatry. The department had a Career Teacher and had conducted a successful alcohol counselor training program. However, there was not a stable of nationally recognized alcohol experts, the type of resources which one might usually expect in academic medicine if one has aspirations of being a national model. The most compelling reason for selection of Psychiatry was administrative.

The medical school's Executive Committee, comprised of department chairs was requested by the Medical School's Dean to attend a planning meeting to determine how the Project would be engineered and structured. The Dean also attended this session. Thus, an early step was to define the project clearly as a school-wide, not a Department of Psychiatry-based, effort.

While a "power strategy" was employed to convene those parties whose official sanction or blessing was essential to the ultimate success of the effort, the tone of the first organizational meeting was collegial. It established the tone which predominated throughout the life of the project.

The major topic of this initial meeting was generating guidelines for approaching the task: that it was being conceived as an educational experiment; that it was obviously an educational challenge, inasmuch as physicians themselves agreed that they were relatively poorly equipped to deal with a recognized major public health problem; that collectively both faculty and project administration were starting from a position of ignorance; and that the immediate task was to develop and implement a workable plan. The project's goal was presented to the medical school's Executive Committee as an attempt to address an important educational problem, not as a call to humanitarian interest nor a call to redress past sins or to right wrongs. The discussion centered largely on various individuals' views of the task as an educational problem. It was explicitly acknowledged by the Project Director that curriculum time was very tight, a constraint to be faced, and that carving out additional alcohol hours was not the objective. At the conclusion of the first meeting, the group agreed, for the time being, to consider itself a Steering Committee, and to meet again to explore further structuring of the endeavor. There was some preliminary discussion too about approaching the overall task in steps, making eventual changes to keep pace with the students who would enter in 1978, a year hence.

Planning Stage - Defining the Content

The initial members of these task groups were drawn from the Steering Committee itself as well as from nominations made by the Committee. As the task groups were convened, additional members were added, informally recruited by other members on the basis of interest or information. Thus, efforts were made to foster maximum participation of interested individuals with different personalities and abilities. Becoming involved in an ad hoc fashion was acceptable, therefore no one needed to make a long-term, open-ended commitment. In the initial three-month planning period, the blessing of the official structure was secured and the task was defined as a school-side endeavor. Further, basic ground rules were established which fostered collaboration rather than competition. Squabbles over turf were avoided by not looking specifically for new "alcohol time," by not raising the specter of an outside authority coming in to declare how content should be handled, by providing good staff support to facilitate participation, and by holding out the promise of carrots being equitably distributed on the basis of effort.

In respect to the function and findings of the task groups, there are several noteworthy observations. The Model Curriculum Committee, quickly dubbed the Blue Sky Task Force, attempted to define what a model curriculum effort would encompass. As a point of departure the group utilized the curriculum objectives which had been set forth by the AMERSA Committee on Curriculum Objectives. In the process of the Committee's deliberations these were modified - with additions, deletions, and changes of emphasis. Beyond that, to complete its work, the Model Curriculum Committee identified the logical courses within the Dartmouth curriculum in which particular material would be appropriately addressed. It prepared a bibliography, supporting each of the one hundred items in the model curriculum which had turned out to be a very detailed document. In drafting an introductory statement to its report, the Committee made explicit its vision of goals for undergraduate medical education, and thereby provided a context in which to consider the suggested alcohol material. While ostensibly concerned with defining content deliberations were not solely restricted to that. Discussion focused as well on pedagogical issues, e.g. the need for selective redundancy or the implications for suggesting a specific locus for a particular body of information. A copy of the Cork Model Curriculum is located in Appendix A. PDF

The Assessment Committee, charged with defining the medical school's alcohol-related teaching at that time, had the tedious task of contacting each of the course chairs to determine what material was then incorporated within each course. Interestingly, the Committee discovered that there were significant omissions in the alcohol-related teaching at that point. These discoveries proved useful at various points in "selling" the project to faculty. In the face of egregious omission, it was hard for anyone to dispute the need to systematically address alcohol teaching. For example, management of alcohol withdrawal syndromes was not covered in the formal curriculum! This was not because it was considered unimportant. Rather, Medicine presumed that this was covered by Psychiatry; Psychiatry assumed that it was being included in Neurology; and vice versa. Neurology made the same assumption about Psychiatry. Given other instances, one might make the generalization that when disciplines or individual faculty are forced to make judgments in isolation about topics to cover, they tend to include material which under no circumstances will be addressed elsewhere.

The Evaluation Task Force for research design (described in detail later) also developed the associated evaluation instruments. [The instruments are found in Appendix B. PDF] One of these was a paper and pencil test known as the Global Survey. It included measure of attitudes, a self-rating of clinical competence, and an extensive knowledge section. The questions for the knowledge section, authored by faculty, paralleled the knowledge domains of the model curriculum. The Project Director was then the head of the Psychiatry Section of the National Boards. Under his direction, the project replicated the process of question development, and used the question format used by the National Boards. The generation of a pool of questions, their subsequent close examination, and either adoption, re-writing or exclusion, was a very time-consuming activity. Nonetheless, the process involved many faculty, and, as it were, through shared tedium, helped to further build a sense of camaraderie.

Project Cork was represented by 11 persons, drawn from the Steering Committee and the three ad hoc task forces, plus Department of Psychiatry faculty and individuals who would be in key positions to influence teaching within the first year curriculum.

After that meeting, at which Project Cork made its presentation to the Foundation, the major focus of the Project turned to planning for Year I implementation.

Building an Organizational Structure

Originally the administrative structure of Project Cork had rested upon the Steering Committee; but over time a different structure evolved. An Executive Committee was formed of individuals who were charged with coordinating efforts in each of the different functional areas: evaluation, Year I implementation, extra-curricular initiatives and electives. With the Project barely organized, the Steering Committee put itself on ice and delegated the work to the Cork Executive Committee.

Fortunately at this juncture in the Project's life, an "information specialist" who was looking for part-time work in the Medical Center approached the Project Director. Trained as a reference librarian, she had been involved previously in establishing personalized information services in both corporate and higher education settings.

In respect to other staff, the Project had a full-time Associate Director, a social worker on the faculty of the Department of Psychiatry with experience in the alcohol field, and a full-time Administrative Assistant. Other part-time personnel were added at various points to assist with special projects. To compensate department for the effort of those faculty who were coordinating the areas of project effort noted above, the Project provided modest underpinnings for salary, in the range of 20% per faculty. In addition, block awards were made to the departments to underpin the departmental teaching effort.

Implementation: Pre-clinical Teaching

At the time Project Cork was initiated, Dartmouth Medical School had a three-year program leading to the MD degree. The curriculum was comprised of three phases. For each of the two preclinical phases, Project Cork designated a Coordinator to meet with each faculty member teaching within that Phase. The Coordinator, prior to meeting with each of the faculty reviewed the material assembled by the Cork Task Forces, in order to be familiar with what was currently being taught in each course and what material the Model Curriculum Committee had suggested might be covered in the course. The Coordinator was thereby prepared to discuss additions, and offer the services of the Resource Center to supply relevant articles and materials.

The response of the faculty during the first year was generally positive, but the process needed "fine tuning." In addition to being familiar with the model curriculum and current teaching, the Coordinator needed to be knowledgeable about the faculty member's discipline - good will or enthusiasm alone did not suffice. Contact between the Coordinator and faculty during the second year and Phase II were far more successful.

Beyond being more conversant with the faculty's discipline, the Phase II Coordinator also reviewed course syllabi, and actual lecture outlines prior to meeting with the faculty. Thus, upon meeting, the Coordinator and faculty member together made a detailed assessment of what alcohol-related material was being taught and what was not. The Coordinator attempted to identify the reason for the latter - generally an issue of benign neglect or lack of awareness of important alcohol-related topics, as well as incomplete knowledge of what was or was not being covered elsewhere. The Coordinator solicited the faculty member's view of what additions, modifications, or changes might be appropriate and desirable. With these on the table, the Coordinator offered ( and the faculty member generally eagerly accepted) current, relevant literature focused on the identified areas of curriculum deficiency. The Coordinator in turn provided the Resource Center with a personalized "shopping list" for each individual faculty member. The Resource Center staff, using its computerized information service, saw to it that the requested material was on the faculty member's desk within 24 hours.

The Resource Center's Information Specialist maintained an on-going relationship with faculty members, whom the Project had contacted. The Resource Center routinely and automatically forwarded new materials on topics known to be of special interest. It provided assistance in locating teaching aids such as special slides. The Resource Center's services were extended to student's as well. For example, in a special first year integrative elective in physiology alcohol was selected as the "theme," with students choosing different body systems or function for their reports. The faculty believed that use of the information services vastly improved the quality of the seminar. The students' presentation were better organized, more focused and more adequately covered the topic. Students, like faculty, have a finite amount of time to devote to any single effort. With the Resource Center providing easy access to the literature, more time was available to students to synthesize and master the material, thus facilitating and enhancing the learning process.

Faculty Development and Community Awareness: aka public relations

Among the early concerns of the Project was building and maintaining interest and achieving some visibility for its efforts. The administrative offices of the Project were housed in the medical school in space located between the Department of Psychiatry and Neurology, and strategically located right next to the elevators. As a first step, for physical visibility, the Project invested in orange paint and transformed the gunmetal gray-brown office doors, making them stand out dramatically from their neighbors along the drab, tiled corridor.

Another successful device was a ten-week Cork Contest, modeled after the "X-ray of the week" contest popular in many radiology departments. [See Appendix C. PDF] People could compete in one of two divisions, one for house officers and one for medical students. Questions related to alcohol and alcoholism were written by the senior faculty form the Department of Medicine and prominently posted outside the hospital cafeteria, probably the most frequented spot in the medical center. The person in each division who had accumulated the most points at the end of the ten weeks was awarded a seventy-five dollar gift certificate from the medical school book store. And that was 1980 dollars.

Beyond being a blatant public relations "gimmick," the Contest provided an indirect route for faculty development. The Resource Center assembled packets of articles for the faculty members authoring the contest questions. Thus the Project could "update" or "re-educate" a segment of the faculty to whom it otherwise would not have had easy access.

Another P.R. devise was the development of an in-house newsletter. Under the masthead "the erratically regular newsletter," complete with cartoons, it served to keep everyone posted on various Project activities.

In respect to the strategies for curricular change noted earlier, the Project beyond the outset, did not rely upon power strategies. There are limitations inherent to power strategies. It must be recognized, too, that the formal structure has only so much power to expend. It is unlikely that a dean or department chair will be either inclined, or for that matter, well advised, to spend too many "chits" on promoting any single endeavor. Thus, much of the effort directed toward public relations was essentially efforts at re-education.

The Project also gave attention to sustaining the loose network of affiliated faculty. Every effort was made to provide, efficient, quality staff support. Secretarial support was offered by the Project so as not to tax other systems. Telephone calls were returned promptly, feedback provided, and general effort made to recognize faculty contributions. There was the belief that, in part, persons were attracted by the competence, expertise, and challenge set forth as well as by the stimulating, congenial environment which developed.

Creative Spending

From the outset it was explicit that no new faculty were to be hired for the Project. This decision was based on several factors. An educational model intended to be applicable to a variety of settings, would be severely limited if it is predicated upon the hiring of new personnel. To achieve the Project's goal of integrating alcohol teaching into the existing course structure, it was imperative that current faculty be trained/influenced/recruited to do the job. It was also presumed that the changes introduced by existing faculty would have more staying power because they would not be tied to, nor dependent upon, the presence of one or two people. The other implication of this approach was that the grant available to underpin teaching, by going to existing faculty, were essentially budget relieving. The monies available from the Project budget to support faculty represented roughly 1.5 F.T.E. (Full Time Equivalent.) This money was seen s providing some salary support for those faculty filling major coordinating functions, as well as underpinning the broad efforts of faculty throughout the institution. Sine the Project's objective was to involve each department in the teaching efforts, it was decided to award "mini block-grants" to each department to support its involvement. In these instances, financial support was not tied to specific activities. Each department block grant was controlled by the respective chair and represented discretionary funds. Each Chair could expend the funds in a way which provided the greatest incentive to his faculty, for example, be it to cover faculty travel to meetings, or to purchase library books. The Project expected no special accounting for these awards, thus from the Project's perspective there was no point at which department had clearly expended its capital, and no more could be requested. It should be noted that Dartmouth Medical School faculty are on a "full-time system"; therefore the possibility or need to compensate individuals directly was not an issue

In the second year, (then "Phase II) the bulk of the teaching with the Dartmouth curriculum is organized into a single course: The Scientific Basis of Medicine (S.B.M.), This is taught in subsections by basic science and clinical faculty teams. Interestingly, the course director for S.B.M. refused a grant to assist in developing the alcohol teaching for this course. A man of strong beliefs and an educational purist, he saw the mini-grants as "buying the curriculum." He believed that curricular changes should be initiated on the basis of their merits. He stated that his course budget was already adequate given the support services available through the Project. In addition it is suspected that he did not want to jeopardize the future of his own course budget, by getting into business of using "soft" money. From time to time he suggested books the Project might purchase for the library; all such suggestions were promptly acted upon.

Implementation: Pre-clinical Teaching

Although the Project was required to submit fiscal reports to the Foundation in accordance with college practice, it enjoyed broad discretion in the use of funds. It was this freedom which allowed block grants to departments. The Project was also able to provide small amenities, which promoted its efforts, e.g. free coffee in the Project office which encouraged faculty to stop in, to chat, to browse in the Resource Center/Library. When finding a meeting time for the Executive Committee was difficult, due to scheduling conflicts, a 7:30 A.M. hour was seized upon with breakfast provided through the cafeteria. Such perks consumed very little of the budget and provided considerable good will.

Special Projects

While the main thrust of the Project was interjecting alcohol material into the core curriculum, opportunities also were needed to field test ideas and explore educational methodologies. The first special project was a "bridge" experience for incoming students prior to their entering medical school. A model for it already existed at Dartmouth. Several years previously an elective on physical diagnosis for first year students was offered, led by two of the most senior and respected faculty, during the month prior to their entering medical school.

Interest in an alcohol Bridge Program was sparked by two Department of Psychiatry faculty. They had taught an elective on death an dying and had been struck by the students' ability and need to struggle with issues related to clinical care. Thus they proposed placing students in alcohol treatment settings for a four-week work-study program. A twice-weekly evening companion seminar was planned to accompany the work-study experience. The idea was attractive to others as an opportunity to introduce students to issues involved in clinical care. It was also hypothesized that the early exposure to alcohol problems might sensitize students and increase their receptivity to alcohol education throughout their training. [See Appendix D PDF.]

completing the basic science curriculum. In the face of this opposition, the Project opted to bypass the formal curricular structure, not request formal recognition of the work week program as an elective, but simply to offer it as a work-study experience prior to matriculation. An unanticipated dividend was that by sending out an announcement and application for this work-study program to all incoming students, the Project received broad visibility with the incoming medical school class. This program, which proved quite successful, had the effect of creating within each class a cadre of students who were knowledgeable and interested in the topic. As advocates for the Project throughout their medical student careers, they were informal experts/consultants to their peers and functioned as a low-key lobby with faculty.

Another special project, undertaken in collaboration with experts in systems dynamics at Dartmouth's Thayer School of Engineering, centered on developing a computer simulation model of alcohol use and alcoholism. While successful in producing a model, this para-curricular effort did not pay equivalent dividends in prompting organizational development. It never "tickled the fancy" of faculty or students, nor became a vehicle to work together. In considering why this project failed to produce such payoffs, several possibilities came to mind.

Implementation: Clinical Curriculum

The discussion thus far has centered on the Project's efforts at changing the preclinical curriculum. When the Project turned its attentions to changes in clinical teaching, a different set of problems appeared. Clinical teaching inevitably involves multiple institutions, issues of patient care and clinical services, and a much larger group of faculty, many of whom have a marginal identification with the medical school. The Project, in electing to initiate curricular changes in a rolling, step-wise manner, effectively delayed having to assault the clinical teaching arena for two years. This allowed a cohesive working group to develop and build a consciousness of its presence in the academic medical center. The earlier official sanction which the Project had received from the Medical School Dean's Office did not extend into the new arena of clinical teaching sites. The school's power had to be exercised to secure the sanction of new key actors, e.g. the directors of clinical services and chairs of clinical departments.

The Project Director, who at this time had been appointed Executive Dean of the Medical School, became more involved in the Project's day-to-day functioning. He and the Associate Director met with hospital administrators, medical directors, and the chairman of medicine. These discussions were generally considered informational, to let people know what was going on, to ask for suggestions, to ally any apprehensions and to assure them that the Project would respect their domains and would endeavor not to disrupt their operations. These conversations were friendly, often leading to discussion of how alcoholism has been a neglected problem, and they elicited a general blessing for the Project's work.

When it came to actual planning for clinical teaching, there were no volunteers from the faculty to serve as the Coordinator for Clinical Training. To fill this void, the Project formed a Clinical Teaching Task Force with representatives from each of the clinical departments. At this point, the Project had to deal head on with the lack of specific alcoholism treatment expertise among the physicians and within the medical school as a whole.

Previously, faculty saw themselves and each other as competent within their disciplines. They were able to amass and assimilate the relevant alcohol material easily. But alcoholism treatment and clinical expertise were perceived to be outside of everyone's area of specialization and also as having a certain mystiques. For this reason no one was willing to assume the mantle of Coordinator for the clinical teaching year. Parenthetically, the Career Teacher who might have been the logical person for this position, has just assumed a position in an affiliated, though physically distant institution was little involved in the Project at this time.

Finally, a member of the Department of Medicine volunteered to chair the Clinical Teaching Task Force. This individual was a widely respected clinical teacher who also conducted an active research program. If the Project were to continue its original plan of integrating teaching in the clinical curriculums it had in the preclinical teaching, the Department of Medicine was a critical ally. As the Task Force Chairman, however, he was primarily task oriented, eager to specify what needed to be done an where it could be done, and to distribute the plan as if that were the end of the task. He was not inclined to consider the political nuances or negotiation process required to assure that any proposal put down on paper was implemented. There these process issues had to be raised by other Task Force members, usually by the Project Director, who was an active group member.

The Project Cork Co-Director (the Associate Director had been "promoted") though a non-physician, had considerable clinical experience in alcoholism. She played an active, if behind-the-scenes, role, meeting with members individually, developing ideas to be considered by the Task Force, setting the Task Force agenda and preparing the summaries of its meetings. The Co-Director used the latter to crystallize ideas which were in fact not fully formed, thereby guiding the planning process.

After several meetings the Task Force, having to abandon the "easy" solutions such as hiring an alcoholism clinician or creating an additional clerkship, began drafting a document entitled Towards a Perturbation of the Clinical Curriculum which specified discrete alcohol-related clinical skills to be taught. [This document is included in Appendix A PDF]. The Task Force also proposed a faculty development workshop for themselves and other clinical faculty to prepare them to teach this material, since by then it had become clear that if they didn't teach the materials, nobody else would.

The absence of an "expert," to whom everyone could defer to do the job, in retrospect is seen as fortunate. In an institutional setting with an alcohol expert on board, it is suspected that other faculty would be inclined to dissociate themselves. By default, the Dartmouth clinical faculty was forced to remain involved, to grapple with the issues and to assume responsibility for becoming more knowledgeable. (The challenge for an expert in this situation is to function as a consultant and a resource person

The Project Director presented the proposal for the workshop to the clinical departmental chairs, asking each to designate five faculty and five house officers to attend. This proposal was not received enthusiastically by the chairmen. For the most part they seemed to expect great resistance to the idea. It had not occurred to them that faculty might be interest in the prospect. In spite of these reservations they complied with the request.

While the mechanics of planning the workshop were left to the Project Cork staff, the task force identified course content and criteria for recruiting workshop faculty. For faculty the Committee wanted persons engaged primarily in alcoholism teaching. In respect to content, three items were specified: natural history of alcoholism and recovery; the clinical management of alcohol problems; and issues for clinical teaching. The workshop, eventually attended by participants from four department, was a failure as a teaching exercise and a success from the perspective of organizational development.

The faculty were unimpressed by the presentations; they felt that they had learned little that was new, that the special techniques of alcoholism treatment had not been well articulated, and that their own skills as clinical teachers were unrecognized. Because they had come with some commitment to clinical teaching on alcohol issues, the disappointment in the workshop translated itself, paradoxically, into more, rather than less, motivation. "We can do better than that," someone said. The shared experience, even a negative one, helped build a sense of cohesiveness and purpose.

Although the Task Force on Clinical Teaching had spent considerable time developing the goals for clinical curriculum and specifying component tasks, its work had never been intended as a grand design or binding document. Its importance lay in the discussion it evoked, and its preparation served as the organizing vehicle. In meeting with the respective clinical departments, it served as a calling card. It was clear from the initial discussions with clinical clerkship directors, that the Project's focus had to be on alcohol topics as these related specifically to each of those clinical settings. One of the apparent, although never fully articulated, concerns of clinical faculty was that they were being asked to teach very important but from the point of view of their discipline, and their time constraints, somewhat extraneous material. This concern was at one point voiced as "Are we trying to turn the students into alcohol counselors?:" In light of this, the broad schema, as developed by the Clinical Teaching Task Force, was further refined focusing on the presentation of alcohol problems in the different clinical settings and the management issues which these presented in that setting.

The next task for the Project was to work with each department individually and to develop a plan for clinical teaching. The Project Co-Director assumed the responsibility for this. Because these meetings with the directors of undergraduate training, directors of the clerkships, and other influential clinicians were a very time consuming effort. A priority was placed on the Medicine, Family Medicine, and Psychiatry, and clerkships. The Project had specifically disavowed any interest in altering clinical services. As awareness of alcoholism increased, however, attention was inevitably drawn to the inadequacy of clinical services. Of the two major teaching hospitals, the private hospital had no alcoholism treatment service. The other a Veterans Administration Hospital, had an alcohol rehabilitation services, although it had never had a full-time medical director. Interestingly, just at the point of the implementation of the clinical curriculum, a Medical Director was recruited for that service. This occurred partially in response to the fact that the Project created attention to the need and helped legitimize the position request. This individual recruited as Medical Director has worked closely with the Project and has contributed a needed expertise in alcohol and substance abuse.

The changes in formal clinical curriculum included additional lectures within the various clerkship's seminar series, and an interviewing tutorial during the Family Medicine-Primary Care clerkship. The hiring of an alcohol counselor on the Department of Psychiatry's consultation service also added clinical personnel. Subsequent to the initial tackling of the clinical teaching programs, there have been further additions and refinements to the clinical teaching efforts.

Evaluation

Recall that the total project was conceived and designed as n experiment in medical education. The central questions to be examined were: What effect did the curriculum have upon students' alcohol-related knowledge, attitudes, and clinical skills?

And, what impact did the Project have upon the curriculum? The evaluation design is schematically presented in Figure 1. The evaluation employed a quasi-experimental design with non-equivalent controls. Changes in the alcohol curriculum at Dartmouth were introduced with the class that entered in 1978. Several control groups were used. To measure differences between pre- and post-Cork initiated curricular changes, one control group was Dartmouth Medical School students in the class preceding the Cork group. Other control groups were established to enable comparison of Dartmouth medical students to persons trained at other medical schools. These controls included a sample of under-graduates from Dartmouth College who entered other medical schools, and also graduates of other medical schools who came to the Dartmouth-Hitchcock Medical Center for post-graduate training.

Figure 1. Longitudinal Evaluation Design

In assessing the impact of the curriculum changes, the Project was interested in three domains: attitudes, knowledge, and clinical performance. The instruments to measure these are described below:

Global Survey. This instrument was administered to the Cork-trained students and the respective controls at three points: upon entrance into medical school, at the completion of the preclinical training, and at graduation. The Global Survey included the 40-item Marcus Attitude Scale [Marcus, 1980] and a series of knowledge questions developed by Dartmouth Medical School faculty. The knowledge section included items on the following topics: alcoholism, natural history, diagnosis and treatment; alcohol withdrawal and intoxication; biochemistry and pharmacology; and medical complications associated with chronic excessive alcohol use. The two later administrations of the Global Survey also included: a 20 item self-rating scale of "comfort in performing alcohol-related clinical tasks," demographic information, anticipated practice specialty and presence of alcohol or drug problems among family, friends, or peers.

• Students' improvement in the five knowledge domains from matriculation to graduation was roughly equivalent. However, while initial knowledge levels were quite different, residual gain scores did not differ substantially.
  
  
• Changes in attitude (or beliefs about alcoholism) within the group as a whole from matriculation to graduation occurred on three subscales. There was significantly more agreement with items for the "Alcoholics can never drink again" and "Alcoholics can't control their drinking" subscales, and there was significantly less agreement with items for the "Alcoholism has an emotional basis subscale."
  
  
• Overall, there was substantially more inter-scale correlation among attitude scales at graduation than at matriculation. (This change reflects in part the education and socialization of students into the community of practitioners with a more uniform belief system than the population at large. For example, the scales "Alcoholism reflects a moral weakness" and "Alcoholism is not a disorder" were uncorrelated at matriculation but highly correlated at graduation. Group scores on the scales themselves did not change, but reflecting the integration of two initially independent domains of moral choice and somatic illness into a single polarized pair among the student group as a whole.)
  
  
• Beliefs and attitudes at matriculation were generally not helpful in predicting ultimate attainment of knowledge about alcoholism at graduation.

Clinical Performance. In view of the well-recognized lack of correlation of clinical performance with either knowledge attitudes, several measures were developed to assess performance, each oriented to a different aspect of clinical activity.

Ability to diagnose alcoholism. A detection study was conducted during the medicine and primary care clerkships. It entailed comparing the results of an alcoholism screening test administered to the patients seen by the medical students with students' diagnoses as determined by chart reviews. The screening test (SHORT MAST) was embedded in a Health Habits Survey, administered by a research assistant who also conducted the chart reviews. Charts were reviewed for explicit alcoholism diagnosis as well as the presence of signs and symptoms set forth in the NCA criteria.

Prevalence rates were within the range reported in similar settings by other studies. 16.4% of patients were "positive identification" and 32.8% were highly suggestive by the Short MAST; 33.6% were positive for alcoholism using the NCA criteria. Only 2.8% of patients were formally assigned a diagnosis of alcoholism by the students, whose ratings were essentially equivalent to their teachers. When "diagnosis" was construed to include detection of non-normative drinking as evidenced by explicit references in the chart such as "heavy drinker" and "problem drinker," students and staff together reported 22.3% Thus, the students as a group were found to detect an alcohol problem: but they rarely made the formal diagnosis.

Ability to manage alcohol problems. A series of Patient Management Problems was developed, modeled after Part III of the National Board's examination, to examine students' abilities to manage patients with alcoholism or alcohol problems. The cases ranged from an acutely intoxicated person in the emergency room, to a child presenting to a school physician because of school behavioral problems, to a chronic alcoholics admitted to the hospital for pneumonia.

Interviewing Skills. To examine students' skills in interviewing and the ability to establish a therapeutic relationship with a patient, simulated patient interviews were conducted during the Community and Family Medicine-Primary Care Clerkship. These staged encounters, with the scenario of the student seeing, in a presumed ambulatory setting, a patient suspected to have an alcohol problem. A recovering alcoholic assumed the role of the simulated patient. These sessions were videotaped. Following the interview, the faculty present along with the simulated patient reviewed the tape with the student. This is described in detail in Appendix D PDF.

The Project was quite successful in achieving a good response rate from the students. The first administration of the Global Survey was sent to students at their homes prior to their arrival at medical school and yielded virtually a100% return. [The Project staff received several note's from parents! These were to explain that the student-to-be was on vacation but that it would be brought to his or her attention upon returning home.) Subsequent administrations required more follow-up and ingenuity. For the second and third administrations, the project paid a modest subject fee (a 10 dollar gift certificate for he medical school bookstore) for each completed survey, and to capitalize upon peer pressure, give $150 to the class for a party, when an 85%response rate was achieved.

Beyond interest in the impact of the Cork curriculum upon the students, there was also an interest in examining in a systematic fashion the nature of the curriculum changes themselves. At the outset, a survey was developed, administered both to faculty and students to assess their perceptions of the materials related to alcohol and alcoholism covered in each course. Administration to first class of Cork students indicated there was substantial agreement between faculty and students as to what was taught. However, as constructed, the questionnaire categories were so broad as to be of little use in detailing the actual curriculum changes. Consequently, faculty associated with the project examined the course lecture notes for each session of each course and met with the individual faculty to establish exactly what alcohol-related material had been covered previously and to discuss what changes were anticipated.

The evaluation and research effort had instrumental value in other ways. Involvement of faculty in designing research instruments, drafting questions for the knowledge survey, participation in question review sessions, and preparing patient management problems provided one more vehicle for faculty development.

It must be noted that the research and evaluation component of the Project was also the locus of the biggest problems encountered by the Project. While the rest of the project ran fairly smoothly and was well served by the involvement of many persons in a part-time capacity, that was not true in this area. A succession of Evaluation Directors and various research assistants caused a lack of continuity which impeded work and created strains. A tension developed between the views that the evaluation/research was primarily a "pure" research effort to answer ultimate questions regarding the impact of curriculum changes versus the view that it should be serving the organizational and developmental needs of the Project. For example, the Project Co-Director wished to be able to report back to faculty periodically, giving data as feedback on the teaching efforts. This wish met resistance from those who believed that this would contaminate the efforts and compromise future data collected.

Dissemination

As part of the original charge to the Dartmouth Medical School, the model curriculum was intended to be developed in such a way that it could be adapted in whole or in part to other institutions. To facilitate this and to provide a group of consultants to Dartmouth, at the outset a National Advisory Group to the Project was formed at the request of the Foundation, drawing upon national figures in medical education. Although Advisory Committee members met twice during the first year with members of the Project and Foundation staff, the group never coalesced as a functioning entity. Initially this group was formed to monitor and oversee the project, because medical education was a new venture for the foundation. Quickly however, the Foundation, the medical school administration, and the Project's representatives developed close working relationships and personal ties. The Advisory Group became superfluous. The Project was never able (or possibly never motivated) to redefine a charge for this group, and it faded away. From this point on, the Project called upon outside consultants with expertise in specific areas, e.g. evaluation or curriculum development, on an ad hoc basis.

Approximately a year and a half into the Project, a conference was organized by the Foundation to which the deans and faculty representatives of five other medical schools were invited. The purpose of this conference was to provide the Project with a forum to examine critically ideas, strategies, and plans. The schools invited by Dartmouth were selected somewhat arbitrarily, but with an eye to achieving a cross-section of institutions in terms of size, geographic location, public-private sector, old and new. Also in attendance was the Director of NIAAA.

The response to Dartmouth's activities was extremely positive, and from that enthusiasm, there came an unexpected development which introduced a new dimension into the Project's life. Federal money was being made available in the next fiscal year to support under-graduate medical education around alcohol. It was the understanding that if the Foundation awarded seed grants to the schools present, and if the schools began the process of curriculum change, drawing on Dartmouth's experience, presumably these schools would be in a favorable position to compete for the new federal monies. Thus, a consortium of medical schools was formed, funded by Foundation seed grants.

The formation of the Cork Consortium provided greater visibility to the Project at Dartmouth and therefore gave it added stature. It also increased the visibility of the Project nationally. The major problem was that attention directed to the Consortium sapped considerable staff and administrative effort. This was compounded by the absence of a clear directive from the Foundation as to what Dartmouth Project Cork's responsibilities were for administering and monitoring the Consortium effort. Paradoxically, the project recognized that the value of the seed grants to the schools was in large measure due to their unrestricted nature. Therefore, "monitoring" per se was inappropriate. The Dartmouth group gradually came to see the Consortium's primary benefit as an effort to "field test" the Project's approaches, materials, and services to ascertain their utility in an eventual dissemination effort.

Within the first year of its formation, the Consortium held two further meetings. While on the whole productive, providing a forum for the exchange of ideas and discussion of problems, there were several areas of tensions. One arose form the ambiguity and lack of clarity about the group's raison d'etre and the nature of its interrelationships. For example, several schools were interested in developing a common Consortium-wide evaluation format, to allow eventual comparisons between the six schools different approaches to curriculum change. Others did not want to devote that much attention and resources to such an endeavor. Another tension arose between individuals, those who identified themselves as alcohol "specialists" and those whose primary self-identification was with medical education. (This tension has arisen on other occasions and in other settings and will be amplified later.) And not unexpectedly, the issue of money, sources of future fiscal support, created a tension. This increased when the anticipated Federal money became available. It was awarded but under guidelines which placed Consortium schools as a definite disadvantage. Alcohol monies were yoked to monies to establish Departments of Family Medicine. Therefore, schools with either established Family Medicine departments or those with an existing alcohol curriculum were not competitive. Only one of the Consortium schools received these federal funds.

Around the time of the Consortium's formation, the Project had reached the conclusion that the best method of influencing other schools' curricula would come form several activities: developing quality curriculum aids and materials, conducting a competent research/evaluation effort, and preparing scholarly articles, and presenting at meetings. Project Cork, in its start-up period had been struck by the number of "complete packages" which were available and went unused. While many "packages" may have been of poor quality, that seemingly was not the root of the problem. The basic reason these were ignored stems from the fact that most faculty to do not wish to merely deliver someone else's material. Faculty do appreciate materials for handouts, or slides, or other materials which can be used in preparation for their own lectures. This impression was clearly validated by the subsequent interactions with the Consortium schools. Therefore, the Project, in collaboration with the Foundation, began developing three different types of curriculum materials: an eight unit slide series, to serve as a resource for preclinical teaching; a series of clinical teaching films which depict the natural history of alcoholism and the clinical skills of interviewing and intervention; and a monograph series appropriate for student handouts.

Another route for dissemination was presentation of papers at professional meetings, hosting visits by medical educators from other institutions, and participation in workshops. Not infrequently, the Project was approached by medical educators for information about the Project, advice and consultation. The Project was always in a quandary as how to adequately communicate the breadth and richness of the program. To address this dilemma, the Project, along with the Foundation, co-sponsored a workshop for medical educators held at the Foundation conference center. Invitations were extended to more than 60 medical schools which had had some contact with the Project. Participation was limited to 16 schools, with each school sending two faculty. Enrollment was on a "first come-first served" basis. The Workshop faculty were comprised of Dartmouth Project and two colleagues from the University of Washington, an institution involved in the Consortium. The University of Washington has placed emphasis on tackling curriculum revisions through the Department of Family Medicine.

The workshop went beyond the usual format of presentations and discussion. For one, each of the participating schools was provided with a four-inch thick notebook of resource materials. Also, the Resource Center had an extensive display of audio-visual materials, pertinent books and articles. Each institution had completed "homework" assignments to identify within their own institutions pressure points for change as well as obstacles to curriculum development. During the workshop sessions these were considered in a quasi- case study format, using the Dartmouth and consortium school experiences.

Another important resource in dissemination efforts was the considerable efforts on the Project's behalf, extended by the Foundation's public relations firm, Holin and Harris. This firm's services were more personalized and extensive than the services which were/could have been provided by the College's own news service.

Relationship with the Alcohol Community

As alluded to earlier, at points the Project encountered friction between itself and alcohol professionals. This was evidenced at the first National Advisory Group meeting. It surfaced within the Consortium, at national meetings which involved Career Teachers and the professional association which they forged, [AMERSA (Association of Medical Educators and Researchers in Substance Abuse], around grant contract awards, and in the Project's relationship with NIAAA (National Association of Alcohol Abuse and Alcoholism). An example of the later was the "pink sheet" elaborating reviewers' comments for an unsuccessful contract proposal to develop a set of alcohol curriculum materials noted the following weakness. It stated - "Personnel had no prior work history in alcohol or alcohol abuse." The alcohol professional community in the past has been a rather closed fraternity, functioning for the most part on the sidelines of academic medicine. Alcoholism professionals located in academic medicine found their major professional support coming not from colleagues within their own institutions, but from peers at other schools. The nucleus of those working in substance abuse/alcoholism in academic medicine was formed through the Career Teacher Program, a faculty development effort undertaken by the National Institute on Alcohol Abuse and Alcoholism and the National Institute on Drug Abuse. This group was the major voice in respect to medical education on alcohol. A fledgling professional association emerged (AMERSA),formed by alumni of the Career Teacher Program. AMERSA had a close, quasi-official connection with the Career Teacher programs until 1982, when the Career Teacher Program was terminated. AMERSA's annual meeting coincided with the Career Teacher meeting and was indirectly supported by NIAAA.

Ironically, the very qualities promoting the success of the venture internally at Dartmouth - that is was being undertaken as an experiment in medical education, by experienced faculty, though novices to the alcohol field - made it highly suspect to those who devoted their professional lives to substance abuse education. These individuals considered themselves professionals in the field and well beyond the point at which "experiments" were required. Also, the model adopted at Dartmouth was at odds with what heretofore had been the "traditional" approach; structured through the Career Teachers Program, alcohol and substance abuse education were organized under the aegis of and taught by an alcoholism "specialist."

In subtle and not-so-subtle ways, the Project found itself being alternately challenged and seduced. The Project's efforts to organize displays of audiovisual materials of other aids at national meetings were rebuffed. Although the Project Information Specialist had as much or more experience in working closely with faculty than anyone else, her expertise was ignored in factor of the conventional wisdom, "everyone knows that...". On other occasions, the Foundation or the Project was approached by national groups for program suggestions as, as an afterthought, possibility of financial support.

Another distinct "alcohol community" is composed of those physicians, for the most part trained a generation earlier and primarily outside of academia, who are clinicians, directing alcohol treatment programs. This latter group tended to be less critical and generally more supportive of the Cork effort than the former who were primarily medical school based.

A major problem this presented to the project was how to avoid becoming caught up in the politics of the alcohol field. An eternal temptation is to become involved in "the politics," in the hope of better positioning oneself for future grant support or ongoing funding. However, the project was at a distinct disadvantage in terms of competing for federal funds, because the physicians involved in the Dartmouth effort were not primarily working in the alcohol field. At the same time, inasmuch as the mandate was to influence the mainstream of medical education and given the fact that the alcohol field was to some extent on the outside looking in, the success of the efforts appeared to rely little on whether they were enthusiastically, moderately, or not at all supported and embraced by the alcohol field.

Winding Down, or Death with Dignity

Project Cork had been established as a four-year program with a timetable well known to all those involved. Nonetheless, as it moved into its final year, attention began to turn to "what next?" Faculty associated with Project Cork had, in the course of the Project, developed scholarly and academic interests in various alcohol related topics which they wished to pursue. Also, a strong sense of cohesiveness had emerged, which those involved wished to maintain. While the successful completion of Project Cork could be seen on the horizon, thee was an interest in continuing the work which the Project had sparked. How this might be funded was obviously the big question. Was there foundation interest in continued funding for alcohol and medical educational programs? What resources might the medical school itself commit to maintain the educational and administrative support systems for the Project? These questions were central not only to those wishing to maintain the Cork identity and programs; they were also relevant to other components of the medical school. The normal planning process provoked these questions as well; alternative fiscal support was needed for several of the faculty assigned part-time to the program, and space - the ever rare commodity - was up for re-assignment.

The prime moving force of any organization is said to be survival and maintaining its own existence. This seems to be true regardless of the nature of the original charge or whether the original premises justify continuation. This curriculum project was no exception. Many good and sufficient reasons surfaced which seemed - at least to those intimately involved - to justify continuing: (1) the growing recognition being accorded the project by medical educators; (2) the academic imperative to continue with fruitful lines of work; and (3) the realization that work in progress would not be completed if the Project were terminated. A major frustration was the inability to complete the evaluation/research effort on schedule as intended. This was the result of several confounding factors, that seemed to be working together and, at that point, against the Project. While much energy had been placed at the outset on the development of a research design and instruments, similar attention had not been paid to developing a corresponding detailed plan for data analysis.

The problems introduced by this failure were compounded by a succession evaluation-research directors, supplying a succession of views as to the appropriate methods for statistical analysis and differing stances as to what constituted minimal rigor. Inasmuch as Dartmouth is a small medical school, with limited academic support services, there was no office of education research which could provide technical assistance. In retrospect the fatal blow to the evaluation/research effort's being completed on schedule had been struck by the emergence of the Cork Consortium. It adopted Dartmouth's instruments as a common data base for all six schools. Project Cork assumed responsibility, without additional foundation funding, to provide instruments, to clean and enter data, and to provide modest statistical analysis. The research team therefore went from being concerned with several data sets of approximately 65 persons each, to a total group of over 1400 individuals. At the point that Dartmouth entered into this agreement with the other schools, the expectation had been that those schools would be receiving federal monies which could be used to contract with Project Cork for data management and analysis. When these monies did not materialize, while possibly having been well advised to drop the efforts and "cut the losses," Cork continued to manage the larger data analysis.

The final year of the Project was one of uncertainty and stress. With potentially diminished funding, various components of the Project began to see themselves in competition for limited resources, for example the evaluation effort, the Resource Center and pilot demonstration efforts. And, just at the point at which its efforts were receiving national recognition, its stock at Dartmouth seemed to be plummeting. The question arose as to the extent to which the Project continued to enjoy previous medical school institutional support. Were the interest of the Project still congruent with those of the larger institution? Clearly, the larger institution wished to maintain its relationship with the Foundation.

The Project was aware that the medical school administration might believe its institutional goals could possibly be better fostered by other joint endeavors and establishing new and/or additional ties. The Project Directors, having become the acting dean of the medical school, was seen as properly having to attend to larger issues: he could no longer be presumed to be an advocate or spokesman for the narrow interests of the Project. Whether explicit or implied, the message being conveyed to the Project was that it had been established as a time-limited program and should "go gracefully." The incoming dean unfamiliar with the history of the Project, did not see the medical school as supporting it as an on-going enterprise, either by providing space or financial support.

The temptation in such circumstances, is to personalize lack of support or to attribute it to stigma by association, in this case that alcoholism is not a respected area of medicine. In point of fact, it is more accurate to see such lack of support as representing the state of affairs in medical education generally. The value placed on being a "national center" for education on any topic is probably directly proportional to the financial resources that such a reputation attracts. Such efforts need not only to be self-supporting, but also need to contribute to the support of the institution through indirect costs which accompany grants and contracts.

In this final period, the Project was in effect attempting to reach two incompatible goals - to complete its efforts and close down, and not only to continue, but to expand its activities. In attempting to optimize each of these goals, the central issue, was how many resources could justifiably be siphoned off, in the hopes of providing for the future, without compromising the ability to complete the original charge and bring closure to the Project.

In attempting to balanced these two items, the Project found itself having to factor in an additional unknown which was introduced by the informal structure of the Foundation. In contrast to federal grants and contracts, the rules of the game were less clearly spelled out; the Foundation does not solicit proposals and has no mechanism for review. The Project was uncertain about the interest of the Foundation in any continuation. A proposal was nonetheless submitted to the Foundation for further elaboration of the Project effort. It focused on the Project's functioning as a resource to the wider academic community. While the Foundation expressed interests in portions of the proposal it was not interested in it in its entirety. The level of future Foundation support, if any, was unclear.

At this juncture, some of the forces which had earlier been assets for the Project - the school-wide identification, and not being exclusively yoked to a single department - became liabilities. As the uncertainty continued, the Project was in danger of being dissipated by fruitless speculation and/or random activity. For example, at that time alcohol treatment seemed to be a major "growth" industry. There was a proliferation of for-profit treatment chains, a proliferation of consulting groups and education programs. A fleeting illusion of Project Cork was that there might be a market for academically based, quality education programs. While this may be true, after trying to mount several educational workshops to generate revenue, the Project realized its strength was not in its entrepreneurial skills.

To provide some direction and refocus efforts, the essential task was to disentangle the mutually exclusive goals which had emerged. In some respects this was achieved by redefinition of goals and objectives.

For one, it was important to recognize that the efforts within the medical school in respect to education on alcohol did not need to be synonymous with Project Cork. Consequently one could complete "the Project" and simultaneously continue efforts and plan for the future. The Project faculty and staff began to re-identify with the their Departments, which for an essential core was the Department of Psychiatry, and to move toward establishing it as the base for future operations within the medical school.

EPILOGUE

Project Cork, as a pilot demonstration effort to develop a model undergraduate curriculum in medical education, was successfully concluded in December, 1981. However, largely as a result of the commitment and interest which had developed among the involved faculty, the Project "could not" or "would not" fold. Thus, Project Cork thought no longer having a school-wide mandate continued, self-appointed, to coordinate and foster efforts of those interested in medical education on alcohol. Faculty expressed interest in maintaining the project identity, having it as a vehicle for planning and as a forum for information exchange among persons who would have had no other occasion to come together. The bi-weekly 7:30 AM breakfast meetings continued.

Maintaining the Cork effort in this fashion was possible because continuing faculty involvement was solely dependent upon interest; and not contingent upon continued funding. Faculty associated with the Project, with the exception of the Project Co-Director, had received either no, or at best modest salary support from the grant monies. Consequently, as they had had primary service or teaching responsibilities elsewhere in the medical center, there was not an exodus of faculty from the institution due to the loss of primary funding source.

While able to maintain the status quo which had emerged, the Project was however unable to commandeer access to the amount of faculty time needed to mount new teaching initiatives, or develop new programs. Nor was it able to provide the level of academic support services extended earlier, e.g. research assistance, secretarial support, or the Resource Center's information services.

With the Project formally concluded, a major difficulty was funding support to maintain the Resource Center which had been seen as critical to earlier efforts. There were some discussion of meshing the Resource Center with the medical school library. The Project was reluctant to that step as there wouldn't have been additional funds for the library to maintain its information service functions or database which were the heart of the Center's operation. The value of the collection came from the materials being current. Furthermore, recognizing that library and/or other education support services often go unappreciated, the Project was very reluctant to close down the Resource Center in the hope that it could be revived in the future. If funds couldn't be identified to continue an existing service, the chances seemed close to zero that future monies would materialize to resurrect a discontinued service. It was continuing small, ad hoc award from Operation Cork which provided central to keeping the Resource Center function.

As it continues by what might be best described as a "string and baling wire" approach, the Project did become involved in several new programs. Faculty associated with Project assisted in the planning and development of a new alcohol treatment program conducted by the Department of Psychiatry in collaboration with a neighboring community hospital. An unexpected result of Project Cork had been, that in heightening institutional awareness of alcohol problems, the absence of a treatment capacity in one of the major clinical sites became a glaring and embarrassing gap in services. However, the hoped for earmarking for alcohol education of some of the alcohol clinical income from this new service, which in part motivated the involvement of Project Cork, did not occur. (The moral of that story is "get it in writing!")

Also, the Project, through a contract with the State of New Hampshire developed and began to conduct an intensive weekend education and assessment program for persons convicted of DWI. [This is described in detail in Appendix D PDF]. Modest start-up funds for this were provided by the Department of Psychiatry and a small award from Operation Cork. The Program was modeled after one developed at Wright State University Medical School. The Weekend Program proved to be an excellent site for clinical teaching. The Resource Center began publication of Alcohol Clinical Update, a bimonthly subscription newsletter of highlights from the alcohol literature, and prepared annotated lists of resource materials. The Project and Resource Center continued to extend services and function as a resource to those beyond Dartmouth.

In September 1984, the Joan B Kroc Foundation made a major gift to Project Cork and Dartmouth Medical School to transform Project Cork into the Project Cork Institute. This gift provided a quasi-endowment which assured the continuation of the educational efforts by providing support for the Project's basic administration and by providing seed monies to develop new initiatives.

Looking back: with 20/20 hindsight

In looking back and considering what was most critical to the success of the Cork experiment we would focus on two separate domains: Those which deal with process and those which deal with content and educational issues.

However, first some comment on what remains now , four to six years, since the curriculum changes were introduced. In some respect the basic question is "What evidence remains of Cork's footprints?" A follow-up survey of the course directors indicates that the curriculum changes which had been implemented have largely been maintained.

Erosion which has occurred is attributable to two factors. Ironically one of these reflects upon the very success of the Cork efforts. In several courses alcohol topics had been adopted as the vehicle for presenting major themes. An example is "Introduction to Health Care," a first year course which explores the health care delivery system, through visits to a range of healthcare providers and follow-up small group discussion. With the advent of Project Cork, alcoholism and alcohol problems, had been adopted as the disease/medical condition through which students considered health care delivery. Alcohol issues were well suited to this. They. represent a significant public health problem, include both behavioral and physiological aspects, impact significantly upon the family and community, and require a range of interventions from prevention to identification of high risk individuals, to early diagnosis and treatment by an interdisciplinary team. But on the heels of Project Cork's having achieved such visibility, other successful "lobbies" emerged, advocating use of other topics as themes for the course, namely geriatric medicine and hypertension.

Erosion also developed from the inevitable departure of faculty who had been involved in introducing particular changes, the replacements whom had not been indoctrinated by nor exposed to the 'Cork experiment.' It might be reiterated that in some in-stances the "challenges" alluded to are not of the magnitude of entire lectures devoted to alcohol/alcoholism. Rather they typically represent incorporation of alcohol material which might have been ten to twenty minute segments within a larger lecture.

The Project had not established formal mechanisms to monitor the Curriculum once put in place. At the conclusion of the Project with efforts being continued on a "skeleton crew" basis, the thought simply did not occur to place limited resources into initiating this. The manpower available within the administrative structure was limited. Nor was it a task for which a faculty member eagerly volunteers to undertake. In retrospect, it would have been worth the effort to keep track of who was "going and coming," arranging to meeting briefly with any new course director, to review material introduced into that course and the underlying rationale.

Nonetheless, despite the absence of close monitoring and/or "policing," a survey conducted in 1985 has shown that not only have the changes introduced had staying power, and not vanished at completion of the formal initial effort, there were also significant, subsequent additions.

Process

An integrated approach seems to be superior to a "block" or segregated approach. For one, it follows the manner in which the bulk of medical undergraduate teaching occurs. One must presume that there is wisdom to that organization of material for teaching. It assures that content is handled by appropriate experts from their perspective vantage points, rather than by the generalist who is less familiar with the details. It allows for the needed repetitions, and reinforcement.

The Resource Center and other educational support services immeasurably eased the task of faculty cooperation and involvement.

The engagement of faculty as peers, rather than as a repository of ignorance or bad attitudes, was critical. The resistances to becoming involved in alcohol education reported by others simply did not surface. It was acceptable within the Cork project for faculty to incorporate alcohol material because of its utility as a paradigm, or vehicle to illustrate other concepts. It never became an issue that the material must be incorporated in the curriculum because to do so was a moral imperative.

Educational Issues

Project Cork rapidly moved beyond dealing only with alcoholism; Its attention increasingly wad devoted to "alcohol use." Not infrequently, alcohol curriculum is presumed to be synonymous with teaching alcohol/alcoholism. Within Project Cork, probably as a result of our own education, we have gradually broadened the focus to medical aspects of alcohol use, with ample reminders that alcohol is among the most potent self-prescribed medication, and that the disagree and use pattern which is non-problematic will vary from individual to individual and for an individual will vary throughout the life cycle.

Similarly we have arrived at the perspective that much of the value of focusing alcoholism is that it provides an exceedingly useful model for the treatment of chronic disease in general.

A paper written at the conclusion of Project Cork, by several faculty involved in the effort from its inception, described obstacles to medical education on alcohol/alcoholism. The impediments are seen as related to the structure of academic medicine with its emphasis on disease states and pathophysiology; sophisticated and technologically complex diagnostic and treatment modalities; and an acute illness cure-oriented focus rather than a chronic illness, adaptational approach to illness. The second constellation of impediments relates to the alcohol field's failure to identify with other issues in medicine that similarly challenges the Flexnerian curriculum: the lack of a conceptual basis for defining the physician-alcoholism specialists in relation to other medical disciplines; the clinical treatment field's competing craft and professional orientations; and the absence of a scientific vocabulary suited to the existing biopsychosocial paradigms.

Project Cork did not encounter among our students the "bad" attitudes as they are commonly described in the literature on medical education and alcoholism. The issue is, we believe, more complex. To the extent negative attitudes exist, they seem to be directed not to the alcoholic patient per se, but to the care of the chronically ill. Specifically, there is a devaluation of the skills which are central to managing patients with chronic disease. This is in conflict with a physician identify based upon the technological aspects of medicine. Therefore, a major conclusion drawn by Cork faculty is that efforts to improve physician education in respect to alcohol problems seem to be inevitably yoked to the larger issue of assisting students to become more comfortable and skilled in managing patients with chronic illness. If this be the case, those concerned about alcohol education may find that there are more allies available to them than they had anticipated. At the same time, there is a potential for the alcohol field to provide leadership to an area of medical education receiving increasing attention. This opportunity has been recognized by others [Clare, 1984]

Another dilemma is that within neither academic medicine nor the alcohol treatment field is there a clear consensus as to the core clinical competencies for the physician in respect to management of alcohol problems. It is the position of Project Cork that the focus of teaching should be upon three major tasks: routine screening, identification of suspected alcohol problems; and referral for either differential diagnosis and/or treatment. These are presumed to be basic skills which one might reasonably expect of any physician providing clinical care.

In light of the results of Project Cork's detection study, focusing upon these skills would build upon students' strengths. Students demonstrate a reasonable level of competence in detecting non-normative alcohol use. If one applies the model that an objective in undergraduate medical education is for the student to recognize the aberrant and effect a consultation/referral for differential diagnosis and treatment planning, then the thrust of alcohol efforts becomes clear. The educational deficiency to be addressed is in the "follow-through," the referral for further evaluation and in providing support for any forthcoming recommendations.

There are two major difficulties in making the above tasks the primary focus of clinical teaching. One results from the relative absence of alcohol consultation services in academic medical centers. For the most part, the alcohol treatment community continues to be organized apart from academic medicine and represents a separate care system. So, there is a Catch-22. To utilize treatment personnel means in effect to move a patient into a different care system, which requires that the differential diagnosis not only be made, but be communicated to and accepted by the patient and family. The second difficulty is related to the sites most commonly employed in clinical teaching around alcohol. Such teaching is most frequently conducted in an alcohol rehabilitation and/or treatment center. Unless there is an associated consultation-liaison clinical service, (or the student is involved at intakes) there is relatively little exposure to the tasks associated with the identification of al alcohol problem and referral for diagnosis and treatment. Ironically, alcohol rotations may provide little opportunity to hone those skills which would be most useful to the general physician.

A motive for Project Cork to become involved in the Weekend Program was to address these problems. Presently all students during their psychiatry rotation participate in the Weekend Program. They conduct the medical screening, which includes a medical history, a history of alcohol use, and conduct a physical examination. They also participate in the entire 48 hour program: attending lectures, participating in small groups and individual exit interviews with clients and their family members. This offers a unique opportunity to see persons prior to the onset of a clearly established disease process. It provides an opportunity to be involved in the differential diagnosis between frank alcoholism, alcohol problems, and situations which do not the meet the diagnostic criteria for either. In addition there is the opportunity to view techniques for dealing with client resistance, to work with non-physicians, and be in a clinical role in which the ask is not to be the leader but to support and reinforce non-physicians members of the therapeutic team.

The involvement of non-physician alcohol clinicians in teaching programs is essential. Beyond the fact that they are the clinicians who will be the backbone of the alcohol clinical services to which one wishes physicians to refer, there is also the practical point that clinical teaching is labor intensive. For these clinicians to be successfully incorporated, it is imperative that they be adequately screened, oriented, supported, and otherwise helped to provide effective clinical supervision. However, there is an important caveat. Physicians must be clearly present and in effect modeling interactions with the non-physician team members.

An important component of clinical teaching is providing ample opportunity for students to reflect upon not only the content but the process. Opportunities too must be provided for students to reflect upon the frustrations which the alcohol patient may provoke. A hypothesis emerged from the experiences of the Cork faculty who were involved in the "bridge program," that placed students in a work-study program in alcohol treatment centers prior to their entering medical school. In brief the hypothesis is that there is a developmental process attendant to medical education and acquisition of the physician role. Therefore, it is to be anticipated that a significant portion of students will be particularly challenged by alcoholic patients. Alcoholics do not readily comply with the expected patient role; they are perceived as "manipulative" and deceitful:; their disease is without a known definitive cause or cure; and they repeatedly force the physician to confront the nature of the physician's role, its limitations and to cope with that outside on one's control. Alcoholic patients force students, whether they are developmentally ready or not, to grapple with basic questions: the limitations of the physician's role, a perspective of illness that extends beyond the horizon of physiological abnormality, and medical care as encompassing more than technical procedures. How students fare in this clinical encounter may be highly dependent upon the supports available to them from mentors and clinical faculty.

One should anticipate as well that a significant number of students will come from a family with alcoholism, that a significant minority will be concerned about their own alcohol or drug use, and that a more sizable portion will have a close acquaintance with an alcohol problem. Responses by Dartmouth Medical School classes '81 and '82 and their respective controls, to the following questions on the Global Survey are instructive.

"Have you, any member of your family, other relative, or close friend had an alcohol/chemical dependency problem?"*

* extracted from form VII Operation Cork Medical School Consortium Study in Alcohol Information, 1981 and 1982.

Faculty and staff, particularly those involved in clinical teaching should be not surprised if this personal history influences a students' response to alcohol issues.

Concluding Comments

While Project Cork may have been unique at its inception, that is no longer the case. Many institutions have embarked upon similar systematic efforts, such as Morehouse School of Medicine, through the Cork Institute on Black Alcohol and Drug Abuse, Johns Hopkins at the undergraduate medical education level funded by the Pew Foundation, and the Commonwealth Harvard Research and Teaching Program (CHARRT) for post-graduate training in general internal medicine. Other institutions have made significant innovations in teaching formats, such as Wright State University School of Medicine's Weekend Intervention Program. Within medical education, alcohol/substance abuse training is being systematically addressed from a number of vantage points. It is no longer a novelty, nor it is seen solely as an elective offering.

Substance abuse education is receiving attention by professional associations. The Society for the Teachers of Family Medicine developed a model postgraduate alcohol curriculum in Family Medicine. NIDA and NIAAA have recently award contracts to the American Psychiatric Association, the Society for Research ad Education in Primary Care Internal Medicine, Ambulatory Pediatric Association, the Society for Research and Education in Primary Care Internal Medicine, and the Society of Teachers of Family Medicine to develop model curricula from undergraduate training through continuing education. The Annals of Internal Medicine recently published a position paper, prepared by the American College of Physician's Health Policy Committee, on the physician's responsibilities in respect to chemical dependency. (1985)

As alcohol problems and alcoholism receive increased attention, we anticipate that much described here will have become commonplace, and indeed some of it may appear primitive.

As alcohol education efforts expand, our collective challenge becomes communicating with one another. We anticipate that the ongoing legacy of Project Cork may prove to be the Resource Center described so often here as a major contributor to the work with Dartmouth Medical School. Its resources are available to researchers nationally. The most immediately accessible means is via Cork Online, a public database drawn from the Resource Center's collection. Trial use is welcome and arranged upon request. One of the strengths of the Resource Center collection is the inclusion of the "fugitive literature" and materials. The Resource Center welcomes copies of articles, protocols, and special reports, to be shared with colleagues.

References

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Baldridge VJ. Rules for a Machiavellian change agent: Transforming the entrenched professional organization. IN: Baldridge VJ and Deal TC, eds. Managing Change in Educational Organizations: Sociological Perspective, Strategies and Case Studies. McCutchon: Berkeley, 1975. pp 378-388.

Clare AW. Alcohol education and the medical student. Alcohol and Alcoholism. 19(4): 291-296, 1984

CONSAD Research Corporation. Career Teacher Program Evaluation. Final Report Vol III: Executive Summary. Prepared for NIAAA and NIDA. Pittsburgh PA: CONSAD Research.

Health and Policy Committee, American College of Physicians. Chemical Dependency. Annals of Internal Medicine. 102: 405, 1985.

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MacGaghie W; Sajid AW; Miller GE; Telder TV. Competency Based Curriculum Development in Medical Education. An introduction. Public Health Paper #68. Geneva: World Health Organization, 1978.

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Weisbord M. A mixed model for medical centers: Changing structure and behavior. IN: Adams JD, ed. New Technologies in Organizational Development. LaJolla CA: University Associates, 1975. pp 211-254