LCME Accreditation

The Liaison Committee on Medical Education (LCME) accredits all medical schools in the U.S. and Canada every eight years. It is jointly sponsored by the Association of American Medical Colleges and the Council on Medical Education of the American Medical Association.

LCME logo

Re-accreditation assures our stakeholders that our medical education program meets or exceeds nationally accepted standards of quality. As such, the Medical School aims to ensure it meets the standards of accreditation set by the LCME and to identify opportunities for program improvement. 

  • Process Overview
  • Spring - Fall 2018
  • Spring - Summer 2019
  • Spring 2020
  • Process Overview

    Prior to the Site Visit we will be undergoing an intensive Self-Study that involves representatives across the institution. These individuals will collect and review data, identify our strengths and challenges, and assist in the development of action plans to improve the educational program. The next steps are as follows:

  • Spring - Fall 2018

    Completion of a data collection instrument (DCI) and an independent student analysis (ISA)

  • Spring - Summer 2019

    Analysis of the DCI, ISA, and other information sources by an institutional self-study task force and its subcommittees, for integration into a summary report to be submitted to the LCME in fall 2019.

  • Spring 2020

    Visit by an ad hoc survey team and preparation of the survey team report for review by the LCME. This is followed by Action on Accreditation by the LCME.

FORESIGHT 2020: An LCME Newsletter

LCME Banner

This newsletter will be published monthly and showcase the "Standard of the Month" as well as other important updates as we gear up for the site visit in April 2020.

January 2020

Happy New Year and welcome to 2020, the year of our accreditation site visit. I have to admit it seemed so far away when we first notified the LCME that I would be the Faculty Accreditation Lead 2 ½ years ago. As with every new year, I have spent a great deal of time in reflection, especially as I have read and reread our Data Collection Instrument that details every aspect of our school, from soup to nuts.

One of the many areas we can be proud of is the focus of this month’s LCME Newsletter. Standard 10 is all about how we recruit, retain, advance and graduate medical students. Efforts on both the Central Campus in the Twin Cities and the Regional Campus in Duluth have resulted in impressive growth in the diversity of our matriculating classes since the last site visit. I continue to marvel at the amazing classes of students they recruit each year.

Kudos to Dimple Patel, Associate Dean for Admissions on the Central Campus, Dr. Robin Michaels, Associate Dean for Student Affairs and Academic Life who was overseeing admissions for most of the past five years on the Regional Campus, and Dr. Kendra Nordgren, Assistant Dean for Admissions, who ably has taken over the reins for Dr. Michaels. Finally, Dr. Yoji Shimizu, Director of our MD/PhD program, has overseen impressive recruitment and retention efforts for the school’s superb MD/PhD students. While I know each of them would still tell me “we have lots more work to do”, I think it is well worth taking a moment to celebrate their (and as a result of our) successes.

I also want to thank all of the members who serve on the Admissions Committees for the two campuses MD degree programs and the MD/PhD program. The commitment of time and the devotion to recruiting outstanding classes year after year is a true labor of love from the many participants.

Finally, this standard also addresses how we advance students. I want to thank the many members of the Committee on Student Scholastic Standing on the Central Campus (COSSS) and the Scholastic Standing Committee (SSC) on the Regional Campus. I sit as an ex-officio member on COSSS. I am ever impressed by the gravity of the decisions they have to make, and the commensurate seriousness and dedication of the members of the committee.

At this time of resolutions, I am more resolved than ever to continue to celebrate our successes and to find the opportunities in every challenge we face.

Cheers to a spectacular 2020...



The final few Standards of the DCI focus more specifically on students, beginning with Standard 10 that covers, “Medical Student Selection, Assignment, and Progress.”   The Elements within this Standard include topics on admissions, scholastic standing committees, and the policies that govern the selection, progression, and graduation of students. Specifically, Standard 10 states:

“A medical school establishes and publishes admission requirements for potential applicants to the medical education program, and uses effective policies and procedures for medical student selection, enrollment, and assignment.”

What are we doing well:
Both the Regional and Central Campuses, including the MD/PhD program, continue to recruit and admit the best and brightest through their robust and intensive admissions processes. These efforts have resulted in some notable achievements:

  • The UMMS ranks second in the nation for graduating Native American students. In particular, the Regional Campus in Duluth matriculated a record number of Native American students in 2019 (18.5%) and reported an overall percentage of UIM students in the class (including Native American students) at 22%.
  • Recruitment and admission of those underrepresented in medicine has increased dramatically since 2012 for all three programs (TC MD, DU MD, and MSTP). For the incoming class of 2019, 18.8% of the total class was underrepresented in medicine.
  • The Central Campus in the Twin Cities has more recently reconfigured their admissions process to include the Multi-Mini Interview (MMI) format, in addition to a traditional interview. The MMI structure challenges applicants to demonstrate skills at multiple stations rather than only talking about them during a single interview.
  • The Admissions Offices review applications for the medical school’s Essential and Desired Qualities (  throughout the entire admissions process to ensure that the students admitted are poised for success at the University of Minnesota Medical School and throughout their careers.

What are we working on:

Standard 10 did not receive any citations from the previous LCME visit in 2012 and as you can see from the above, we’ve only continued to improve in these areas during the intervening years. The staff, faculty, and offices involved in this Standard should take great pride in their efforts over the years to proactively identify and address areas for improvement. Their hard work is what has allowed the medical school to admit, progress, and graduate some of the finest physicians and physician-scientists in the country, many of whom will go on to practice in Minnesota.   


The LCME process is a huge undertaking for a medical school, involving thousands of hours of effort and hundreds of people over several years.  It’s also at times not the easiest to understand or see its impact.  We invite members of the medical school community to submit a question they may have about the accreditation process.  We will select a representative sample and provide the responses in the next newsletter. Our hope is this will help answer any questions YOU have and ensure we are meeting YOUR needs during this important time. Submit Questions Here

Ask Joe Question of the Month

Question: “How are clerkship directors evaluated to determine if they are meeting course goals?”

Response: Clerkship Directors are evaluated to ensure they are meeting course goals primarily through the annual clerkship review process. This review encompasses student evaluations, duty hour compliance, USMLE Step 2CK performance in the specialty and students' reports on the learning environment. The Clinical Education Committee, a curriculum sub-committee, reviews the clerkship performance during the annual review. The performance is also reviewed by the Education Council, the curriculum oversight committee, in the annual State of Undergraduate Medical Education report.

**Joe Oppedisano is the Director of Accreditation and Continuous Quality Improvement within the Office of Undergraduate Medical Education. Joe was brought into the medical school in late 2017 to oversee the LCME Self-Study process with a focus on shaping a continuous quality improvement program that will continue beyond the Site Visit in April 2020. Previously, Joe spent 16 years as the Director of Student Affairs and Dual MD/Masters Degree Programs for the New York University School of Medicine and participated in three LCME accreditation visits. 

December 2019

We are now less than 5 months to our site visit, and as last week was Thanksgiving the theme of my letter will be gratitude. I hope you all had a wonderful holiday. 

First, I am grateful for the more than 250 people who have participated in our Self-Study process, bringing us ever closer to readiness for the submission of our Data Collection Instrument and its Executive Summary (likely to end up around 600 pages with >2,000 pages of supporting documentation) and our Independent Student Analysis, presented at the Education Council two weeks ago. 

I am also grateful to the Medical School community writ large. As we have gone through this process, I am both proud of the many things we are doing well and ever impressed with the willingness of our faculty, staff and students to face our challenges head-on and work towards continuous improvement.

Finally, as this is the month that we discuss Standards 8 and 9, focused on curriculum, teaching, and assessment, I am grateful for the true village it takes to make a doctor-the amazing UME staff that I have the joy of working with every day, the course and clerkship directors and their discipline leads and site directors, the faculty who teach on the front lines every day, and the students who contribute by giving feedback and then using that feedback to help us design and implement change. 

With gratitude,



This month we look at Standards 8 and 9. Standard 8 reviews “Curricular Management, Evaluation, and Enhancement” while Standard 9 covers “Teaching, Supervision, Assessment, and Student and Patient Safety.” The primary focus of these Standards includes the structure, monitoring, and assessment of the curriculum.

Specifically, Standard 8 states:

“The faculty of a medical school engage in curricular revision and program evaluation activities to ensure that medical education program quality is maintained and enhanced and that medical students achieve all medical education program objectives and participate in required clinical experiences.”

Standard 9 states:

“A medical school ensures that its medical education program includes a comprehensive, fair, and uniform system of formative and summative medical student assessment and protects medical students’ and patients’ safety by ensuring that all persons who teach, supervise, and/or assess medical students are adequately prepared for those responsibilities.”

What are we doing well:

Element 9.5 on Narrative Assessment requires medical schools to “ensure that a narrative description of a student’s performance, including his or her non-cognitive achievement, is included as a component of the assessment in each required course and clerkship of the medical education program whenever teacher-student interaction permits this form of assessment.” 

In the previous LCME Site Visit, the medical school was cited as being in Non-Compliance with this Element.  Specifically, the Site Visit Team found that, “Only one course out of the entire first and second years at the Twin Cities campus has any narrative description included as a component of the assessment.”  This finding was primarily focused on the Twin Cities Campus, as the Duluth Campus already utilized narrative assessment in a more substantial way.

Since that time, the medical school has engaged in a number of initiatives to rectify this finding.  These include:

Revising the Course and Clerkship Feedback, Years 1-4 policy to clarify that each course and clerkship must assess and provide formal mid-course/clerkship feedback to every student, early enough to allow sufficient time for remediation. This feedback is provided through online assessments that includes space for faculty to leave narrative descriptions of student performance. 

Creating a new series of faculty development workshops in 2017-2018 in the Twin Cities provided to small group facilitators from two classes (Foundations of Clinical Thinking and Essentials of Clinical Medicine). These workshops, of which there were three, prepared faculty to provide verbal and written formative assessments.  

Beginning in 2017-2018, each student in Foundations of Clinical Thinking (FCT) receives two written mid-course formative assessments and feedback on two written assignments during each academic year.

In addition to the specific efforts outlined above, an annual survey of students regarding the availability and usefulness of narrative feedback has consistently shown high levels of satisfaction, with those rates increasing each year since the initial citation.  As a result, while this citation is still being monitored by the LCME (but no longer in Non-Compliance), it is expected that this positive trend will continue and the LCME will see this as a strength.

What are we working on:
Element 8.8 focuses on how the medical school monitors and manages the time students spend in required clinical activities.  This includes opportunities students have for independent learning or personal time (including medical appointments) outside of those required activities.  

In 2018, as part of the school’s major focus on improving mental health, a Task Force, consisting of administration, Course Directors, Course Coordinators, a resident, and several students, was convened to review the medical school’s Duty Hours Policy. Factors taken into account in revising the policy included: 
  • the need for rest and recuperation during clinical courses to optimize learning 
  • the need to consider requirements for exams during the clerkships and the resultant necessary study time
  • career development needs to prepare for the Match and residency  
Given the nature of clinical learning experiences, the Task Force determined that a specific, standardized number of hours per week was not practical. Rather, the decision was made to increase the amount of time off by requiring an additional day off every two weeks (consecutive with another day off) and to institute one half-day off every two weeks for Independent Learning Time (ILT) to be used at the student’s discretion.  Further, clarity was added to the medical school’s Excused Absence Policy around the ability of students to be accommodated for medical appointments.

Ongoing efforts will continue to ensure faculty, students and staff are aware of the new Duty Hours expectations to ensure compliance. In addition, the Education Council, through the Clinical Education Committee, monitors the number of hours students spend per week in clinical care through clerkship evaluation forms. Based on results from the evaluations, any concerns about duty hour policy can be brought to the attention of the Clerkship Director.   Data from annual Clerkships Reviews and the national AAMC Graduation Questionnaire (GQ), which is completed by graduating students in the spring of Year 4), will also provide feedback on the effectiveness of the new policy.

For more information about the Duty Hours Policy, visit the Medical Student Policies webpage at: 

New Column: ASK JOE!

The LCME process is a huge undertaking for a medical school, involving thousands of hours of effort and hundreds of people over several years.  It’s also not the easiest to understand or see its impact. Beginning this month we are starting a new segment to the Newsletter: Ask Joe**.  We invite members of the medical school community to submit a question they may have about the accreditation process, either directly or indirectly.  We will select a representative sample and provide the responses in the next newsletter. Our hope is this will help answer any questions YOU have and ensure we are meeting YOUR needs during this important time.

Submit Questions

**Joe Oppedisano is the Director of Accreditation and Continuous Quality Improvement within the Office of Undergraduate Medical Education. Joe was brought into the medical school in late 2017 to oversee the LCME Self-Study process with a focus on shaping a continuous quality improvement program that will continue beyond the Site Visit in April 2020. Previously, Joe spent 16 years as the Director of Student Affairs and Dual MD/Masters Degree Programs for the New York University School of Medicine and participated in three LCME accreditation visits.


October 2019

This month in our LCME update, as we are now only a little over a half a year to our site visit, we review standards 6 and 7, focused on our desired outcomes and the curriculum to get us there. As I have gotten to know the curriculum better, both through this accreditation process and through my additional time here, I am in awe of the amount of work it takes to make a doctor. Although we have many opportunities to improve, I am confident in the impressive efforts of our faculty, staff and students to make this a great and ever better curriculum. I am also impressed that we are all driven by the right intentions to prepare exceptional physicians to improve the health and well being of Minnesota and beyond.

I am so appreciative of the flexibility and innovation of our community as we have worked to improve our curriculum. Only through curricular reform can we strive for our educational strategic plan guiding principles of promoting evidence-based education, standardizing the outcomes and individualizing the learning pathways, and empowering students (at least in part by engaging them in all aspects of curriculum design and implementation).

We will continue to work to ensure that each year is better than its predecessor. While we do so, please know that I am grateful to be part of a community-driven to improve the lives of our patients through the education and training of our students, residents, fellows and faculty

With gratitude,


Standard 6 & 7

What's the Theme?

This month brings us to the halfway point as we review Standards 6 and 7 of 12. In Standard 6 we look at “Competencies, Curricular Objectives, and Curricular Design” and in Standard 7 “Curricular Content”. These focus on ensuring students receive the necessary curriculum and opportunities in basic sciences, clinical care, research, service-learning, etc. to become good physicians. 

Specifically, Standard 6 states:

“The faculty of a medical school define the competencies to be achieved by its medical students through medical education program objectives and is responsible for the detailed design and implementation of the components of a medical curriculum that enable its medical students to achieve those competencies and objectives. Medical education program objectives are statements of the knowledge, skills, behaviors, and attitudes that medical students are expected to exhibit as evidence of their achievement by completion of the program.”

Standard 7 states:

“The faculty of a medical school ensure that the medical curriculum provides content of sufficient breadth and depth to prepare medical students for entry into any residency program and for the subsequent contemporary practice of medicine.”

What are we doing well?

  1. As evidenced by the Independent Student Survey (ISA)* distributed last January, students are quite satisfied with the 2-3rd year curricula on the TC Campus and both years on the DU campus. Specifically, the Duluth campus deserves a shout out in the area of overall satisfaction and satisfaction with the curriculum. 98% percent of DU first years and 95% of second years reported they were satisfied or very satisfied with the first-year experience, and 88% of second years reported they were satisfied or very satisfied with year 2. On the TC campus, 92% of second years were satisfied or very satisfied with year 2, and 88-90% of students from years 3-4 also were satisfied or very satisfied with their second-year experience. Regarding the 3rd year, 93% of 3rd year students and 95% of 4th year students were satisfied or very satisfied with the quality of the clinical clerkships.
  2. Also as evidenced by the results of the ISA, students are overall satisfied with the availability of service-learning and community service opportunities across both campuses (89%-93% of students report being satisfied or very satisfied with the availability of service-learning).  The combination of service-learning experiences integrated into the formal curriculum coupled with the breadth of community service opportunities available through student organizations and administrative offices is a strength within the UMMS. Some key highlights of service-learning and community service are provided below.

Service Learning
Twin Cities students are required to complete service learning projects over the course of several semesters in their required Essentials of Clinical Medicine (ECM) course. Students are able to select an area in which they would like to complete their service-learning project: community service; public health and health policy; or quality improvement & patient safety. 
Duluth students participate in community health needs assessment projects as part of the Rural Medical Scholars Program (RMSP).  The project is conducted within the rural community in which they are participating for the clinically-related portion of their pre-clerkship experience. Throughout the two-year program, students write multiple reflection papers and participate in the Brain Awareness Program, where they teach sessions on brain function and development in public schools.

Community Service
In addition to the required experiences, students have access to a variety of community service opportunities. 

  • Recurring community service projects, such as providing free laundry services and reading to children at a local laundromat. This is a monthly activity organized by the Gold Humanism Honor Society (GHHS)
  • Educational events for children (eg a Science Museum of Minnesota volunteer program arranged through the GHHS). Twice weekly, students volunteer at the museum to answer questions about medically related content and to get children excited about science careers
  • Ad hoc opportunities with other student groups including the Student Wellbeing Committee and Women in Medicine Group
  • Students enrolled in the Rural Academy of Leadership (RAL) on the Duluth Campus volunteer time at the student-run HOPE Clinic, participate in a longitudinal community service project, and complete two self-reflection papers about their experiences throughout the duration of the course. 
  • Another student-run clinic is the Phillips Neighborhood Clinic (PNC) on the Twin Cities Campus.  The PNC is an interprofessional clinic governed by a student board. 100 students from the MS1 and MS2 classes participate in this opportunity annually.
  • Students enrolled in the Medical Education Through Diversity and Service course on the Duluth Campus write research papers on major health concerns and issues within a global region of their choosing. 


What are we working on?

In the area of curriculum, one major area for improvement is the overall quality of the first year in the TC. MS 2 students from the TC were only 68% satisfied or very satisfied with their year 1 experience. On the bright side, the MS 1s in the middle of the year were 91% satisfied or very satisfied with their first year experience, suggesting significant improvement from the many changes to the first year we have instituted in the past two years in response to student feedback.
While there is still work being done, a few notable examples of changes already implemented are included below.  

  • Increased clinical correlations have been incorporated into the Year 1 Neuroscience course, thanks to the amazing partnership of Matt Chafee and Jamie Starks. 
  • A new clinical infectious disease specialist was hired to introduce clinical correlations in the Year 1 Microbiology and Immunology Course. 
  • The Foundations of Clinical Thinking (FCT) course, which had previously been co-curricular, was moved into the formal curriculum. 
  • The fall semester was shortened by three weeks both to make it more humane (from 19 weeks to 16 weeks) and for regulatory compliance.
  • Major changes and improvements were made to the Gross Anatomy course based on student feedback thanks to the hard work of Tony Weinhaus and his staff.

* The ISA Committee is currently finalizing the ISA Executive Summary, which includes survey results.  The Committee will make the Summary available to the medical school community once it is finalized.

With Gratitude:

Self-Study processes include the establishment of a Self-Study Task Force composed of key representatives of faculty, students, administration, and leadership who serve as the executive committee for the accreditation process.  This Task Force assists with the creation and oversight of the LCME Sub-Committees, reviews and provides feedback on the Data Collection Instrument, provides direction on action plans, reviews the Independent Student Analysis, and supports the creation of the Executive Summary.   

Some of the members from this group will continue to be engaged as part of a newly created Continuous Quality Improvement (CQI) Committee.  This new committee will allow the medical school to continue to monitor on-going LCME-related action plans and identify areas for continuous improvement.  

We would like to show our gratitude to those members of the Task Force who have, for the past year, given their time and expertise to serve and support the accreditation process. 

Jakub Tolar, MD, Medical School Dean
Paula Termuhlen, MD, Regional Campus Dean
Robert Englander, MD, MPH, Associate Dean for UME and Faculty Accreditation Lead

Felix Ankel, MD
David Bernlohr, PhD
Austin Calhoun, PhD
Kevin Diebel, PhD
Christine Kiel
Michael Kim, MD
Badrinath Konety, MD, MPH
Robin Michaels, PhD
Peter Mitsch, CPA
Dimple Patel, MS
Anne Pereira, MD, MPH
Mark Rosenberg, MD
Timothy Schacker, MD
Yoji Shimizu, PhD
Amanda Termuhlen, MD
Ezgi Teryaki, MD
Claudio Violato, PhD
Meghan Walsh, MD, MPH
Chloe Hedberg, Twin Cities medical student
Lindsay Johnson, Duluth medical student
Sarah Kemp, Twin Cities medical student


Our last site visit was in 2012. Oscar award winners from that year:

  • Actor in a Leading Role: Jean Dujardin, The Artist
  • Actress in a Supporting Role: Octavia Spencer, The Help
  • Cinematography: Hugo, Robert Richardson
  • Documentary (Feature): Undefeated, TJ Martin, Dan Lindsay, Rich Middlemas
  • Best Picture: The Artist, Thomas Langmann, Producer

September 2019

Dear Students, Staff, and Faculty:

First and foremost, welcome to the Class of 2023! We are delighted to have you join us and anxious for your input to help on our road to continuous improvement.

We are now closing in on a little over seven months until our site visit. In this month’s LCME newsletter, we highlight the fifth standard. This standard explores medical school’s resources, such as facilities, finances, technology, etc. to ensure a high-quality education. As you will see, we have had some challenges, particularly in the area of facilities, but are working across both campuses to make improvements. 

The more I get into this process, the more grateful I am for the enormous human and other resources we have at this medical school.  It only serves to bolster my desire to improve so that we may meet our educational vision:

“A community, learning together to prepare exceptional physicians to improve the health and well being of Minnesota and beyond.”

As always, please let me know if you have any questions. (

With gratitude,

With Gratitude:

It goes without saying that a medical school wouldn’t be much of one without its students. Nowhere has that been more evident than through the ways students have been, and continue to be, engaged in the accreditation Self-Study.  Over the last year, students have been involved with every aspect of the process. Most notably, the Independent Student Analysis (ISA) Committee has worked hard to create, distribute, and tabulate the ISA Survey, which garnered input from approximately 84% of the student body. Currently, the Committee is working hard to compile this data into a Summary Report that will serve as part of the medical school’s self-study package it submits to the LCME.  

Students also served on each of our LCME Sub-Committees, working closely with faculty and administration over the course of the spring 2019 term to critically analyze every aspect of the medical education program. Students will also be integral participants during the Site Visit scheduled in April 2020. These efforts are all above and beyond what students do every day through their participation in Student Council, curriculum committees, and other forums where student voices contribute to the shape of the medical school experience.

The medical school is deeply grateful for the dedication and commitment students demonstrate every day to improve the student experience, patient outcomes, and the medical school in general.   

Standard 5

Standard of the Month: Standard 5 (of 12): Educational Resources and Infrastructure

What's the Theme?

This month we move to Standard 5 of 12. In this Standard we look at “Educational Resources and Infrastructure.” Its focus is on ensuring that the medical school has the structural and functional components necessary to meet it’s educational and strategic goals.

Specifically, Standard 5 states:

“A medical school has sufficient personnel, financial resources, physical facilities, equipment, and clinical, instructional, informational, technological, and other resources readily available and accessible across all locations to meet its needs and to achieve its goals.”

What are we working on?

For this month, what we’re working on and what we’re doing well are combined, since they cover the same topic, educational facilities.

In 2012, Element 5.11 (Study/Lounge/Storage Space/Call Rooms) was found to be “In Compliance with a Need for Monitoring.” At the time, the LCME Site Team noted low levels of satisfaction among students on study space and relaxation space on the AAMC Graduation Questionnaire (GQ).  In addition, the team noted that students were aware of the existence of problems with these spaces, but acknowledged that efforts were being made to make improvements.

The medical school was able to resolve this citation in 2015 as a result of several efforts including renovations to the surrounding common areas and student spaces (such as the Adytum).  Most notably, however, was the medical school’s successful effort to secure funding for the new Health Science Education Center, slated to open in 2020.

The Health Sciences Education Center (HSEC), which will accommodate more than 3000 academic health professions students and faculty, is a state-of-the-art education building that will provide space for teamwork and learning across health professions' schools.  The Center will include active learning spaces, large classrooms and meeting spaces, the Simulation Center, Library, and student service spaces.  In addition, current efforts are underway to add several health-related services, such as mental health, in an effort to improve access to, and awareness of, these services.  For more information about the HSEC visit: 

Constructing a new building takes time. The HSEC will help the medical school’s Twin Cities campus address many facilities-related issues.  But there is still much work to be done to provide students with the facilities they need for an optimal learning environment and to improve student satisfaction.  For example, on the most recent GQ for the Class of 2019, students reported the lowest level of satisfaction with study and relaxation space yet.  Further, the Independent Student Analysis (ISA) distributed to all students last January, show low levels of satisfaction across all years, including students on the Regional Campus in Duluth.  While the HSEC will address many needs, it will not help our students in Duluth or our students rotating outside of the University of Minnesota campus. The medical school is currently working to review and address the availability of study space, relaxation space, and secure storage at its clinical placement sites in an effort to ensure that students off-site have access to spaces that continue to provide for their educational needs.

On the Regional Campus in Duluth, efforts are currently underway to add dedicated study space that includes the renovation of a lockable room with space for approximately 10 study carrels, and the addition of more study carrels in the Student Affairs hallway.  Other spaces are also being assessed to supplement needed study space. Major classroom renovations are also planned for Summer 2020 that will increase seating and improve the overall environment.

Our last site visit was in 2012. Grammy Award Winners from that year:

  • Song of the Year: We Are Young, Fun
  • Album of the Year: Babel, Mumford & Sons
  • Best Pop Solo Performance: Set Fire To The Rain, Adele
  • Best Rock Album: El Camino, The Black Keys
  • Best Country Album: Uncaged, Zac Brown Band

August 2019

Dear Students, Staff, and Faculty:

We are now closing in on a little over eight months until our site visit.  In this month’s LCME newsletter, we highlight the fourth standard. This standard explores a medical school’s faculty, seeking to ensure that the faculty have a rich environment to carry out the school’s mission and that the students have ample access to an accomplished faculty.  I think this is one of the areas in which our school shines, and am proud to be a member of the University of Minnesota faculty. 

Additionally, over the last month so many of you put in countless hours to update our Data Collection Instrument (DCI) and to draft the student response to the Independent Student Survey (ISA).  We are so grateful for all of this work.  Through this process we have been able to really understand our strengths so that we might further exploit them, and identify the areas that we need to work on in our efforts to continually improve our medical school. 

This process has underscored one of my favorite quotes from a great mentor and a University of Minnesota Medical School Graduate, Paul Batalden, who said of health professionals, “we must come to work every day with two jobs: the job of doing our job, and the job of improving our job.”

I am honored to continue to both do and improve with all of you. As always, please let us know if you have any questions. (

With gratitude,

With Gratitude:

Compiling information across the entire spectrum of the educational program into a single source has been a great way to see areas of contribution to medical education by specific groups and/or individuals. One such group are Residents.  We would be remiss in not mentioning the immense value that residents provide our medical students in their mentoring and teaching roles.  Residents not only serve as role models to our medical students but they also offer students the chance to learn about the next stage of their professional training.  In fact, 100% of our medical students will work with residents on at least one required clerkship (for most, it’s more than one). 

In addition, residents serve as an integral part of the formal educational team responsible for supervising medical students, ensuring that learning objectives are being met, and providing direct feedback to students on their clinical skills. 

Each year, the medical school recognizes residents through its inclusion in the Distinguished Teaching Awards.  Below are the recipients of these awards for the previous three years.  However, each and every resident deserves our gratitude for their significant contribution to the success of our medical students and educational mission.

Recipients of the Distinguished Teaching Awards:

Margot Zarin-Pass, MD

Kelsey Gelhaus, MD 
Annie Jacobsen, MD

Salma M. Shaker, MD

Standard 4

Standard of the Month: Standard 4 (of 12): Faculty Preparation, Productivity, Participation, and Policies

What's the Theme?

This month we move to Standard 4 of 12.  In this Standard we look at “Faculty Preparation, Productivity, Participation, and Policies.”   It focuses on areas designed to ensure faculty have access to opportunities that contribute to the medical school’s mission and from which medical students can benefit.

Specifically, Standard 2 states:

“The faculty members of a medical school are qualified through their education, training, experience, and continuing professional development and provide the leadership and support necessary to attain the institution's educational, research, and service goals.”

What are we doing well?

Standard 4 provides us with the opportunity to highlight our exceptional and engaged faculty, each of whom contributes to the success of the medical education program every day. Some of the information we have compiled for this Standard may not be commonly known by members of our community.  So below are just a few facts you may not know: 

  • The medical school has more than 1900 full-time clinical faculty
  • The medical school has more than 200 full-time basic science faculty
  • Our faculty numbers place us close to the 80th percentile when compared to all other medical schools (90th percentile compared to other public medical schools)
  • The medical school has more than 1400 adjunct basic science and clinical faculty comprising 26 basic science and clinical departments across both campuses
  • Faculty contributions to scholarly activity have been consistently increasing each year, with close to 2000 articles published in peer-reviewed journals and 461 faculty members serving as co-investigators or PIs on extramural grants as of 2018 data.

What are we working on?

Element 4.1 ask the medical school to evaluate that it has a sufficient number of faculty, with appropriate qualifications and time needed to deliver the curriculum and to fulfill other needs or responsibilities.

The medical school was cited during our last site visit in this area.  Specifically, the Site Team found that while the faculty on the Duluth campus is adequate to meet the current needs, retirements or other unexpected attrition could be a risk to meeting the educational needs of students in Duluth.  In 2015 we were able to have this citation removed by reporting on our recruitment efforts that increased the total number of faculty in Duluth and included increased faculty development efforts to improve retention and satisfaction. Ongoing monitoring of this Element is important, however, to minimize the chances of another citation in this area. 
To date, eight basic science faculty have been hired in Duluth, all of whom contribute to teaching the curriculum with two more being added shortly to address specific areas of shortage. Four clinical faculty have also been added in Duluth, including a new department head for Family Medicine and Biobehavioral Health. Additionally, five social scientists have been hired to contribute to the teaching mission on the regional campus.  Finally, efforts are underway between leadership on both campuses to enhance procedures for identifying and remedying unexpected and expected attrition, including ways the Twin Cities can support the teaching needs in Duluth.  

Our last site visit was in 2012. Fun space facts from that year include:

  • In January, NASA announced that its Kepler telescope had discovered 11 new planetary systems with 26 confirmed alien planets. The "exoplanets" range in size -- from 1.5 times the radius of Earth to larger than Jupiter.
  • The Curiosity Rover was launched from Cape Canaveral on November 26, 2011, and landed on Aeolis Palus inside Gale on Mars on August 6, 2012.
  • In September, the Hubble Space Telescope captured the farthest-ever view into the universe with a photo that reveals thousands of galaxies billions of light-years away.
  • In October, NASA's Storm Probe satellites captured radio waves caused by the Van Allen belts and rendered them into an audio recording.

July 2019

Dear Students, Staff, and Faculty:

We are now closing a little over nine months until our site visit. In this month’s LCME newsletter, we highlight the third standard. This standard at first glance seems a hodge-podge of expectations but perhaps can be summed into a central theme: the learning environment. We are working on a lot of fronts to optimize the learning environment-from our efforts to build diversity, to increasing student reporting when things do not go well (see below), to clinical learning environment rounds where we observe students in their authentic settings and help sites make improvements. We have visited four sites over the last year, including a recent trip to Duluth to visit the Essentia system and St. Luke’s Hospital. I am always inspired by the number of faculty and staff I meet across our state who are sincerely dedicated to ever-improving the student experience, and by the gratitude of the students even as they offer constructive criticisms in the spirit of improvement.

As always, please let us know if you have any questions. (

With gratitude,


With Gratitude:

The next couple of months will see final work being done on the Data Collection Instrument (DCI) in preparation for it to be formatted, reviewed, and collated for submission to the LCME in December. For the people who worked on the initial draft, this means going back into the DCI to provide revisions, corrections, and in some cases, significant re-writes resulting from sub-committee recommendations, new or changing program structures, or data reflecting the upcoming 19-20 academic year.

As a result, the amount of time and effort that has gone into the DCI by individuals across the medical school, including our affiliated sites, cannot be overstated. By our last estimate, more than 200 people have been engaged in providing content for the Self-Study. A couple of quotes help to highlight this effort:

“I would love to acknowledge the hard work of providing the correct data for the DCI and participating in reviewing responses and participating in workgroups that our Duluth Campus administrative team has done. Dr Robin Michaels, Dr Kevin Diebel and our former campus administrator, Jim Keith provided the majority of our Duluth Campus information while incorporating the extra work into their regular heavy load of teaching and administration.”
Paula M. Termuhlen, MD, Regional Campus Dean

“The Clerkship Directors and Coordinators have played an integral part in collecting data, reviewing information, and answering the 10,000 LCME-related surveys sent.”
Jess Blum, PhD, Director of Integrated Education - Clinical Sciences

“The Course Directors, 1Health Team, and Jamie Larson have significantly contributed to collecting data and reviewing responses to questions in the DCI. They have been willing to help, no matter the ask, at every step of the way and we truly appreciate this substantial effort; one that is in addition to their daily responsibilities. Working with this group of educators has truly made this difficult and complex process a team effort, and for that, we thank them.”
Kelaine Haas, PhD, Director of Integrated Education - Foundational Science

Chances are, if you engage with someone in medical education administration, they have played an integral part deserving of our gratitude and we thank each and every one of them.

Standard 3

Standard of the Month: Standard 3 (of 12): Academic and Learning Environments

What's the Theme?

This month we move to Standard 3 of 12.  In this Standard the topics address broader institutional efforts around scholarly work, appreciation for, and programs to facilitate diversity, and methods for community members to address circumstances that might interfere with the successful achievement of those goals.

Specifically, Standard 3 states:

“A medical school ensures that its medical education program occurs in professional, respectful, and intellectually stimulating academic and clinical environments, recognizes the benefits of diversity, and promotes students’ attainment of competencies required of future physicians.”

What are we doing well?

The LCME understands the value and importance of having students interact with residents during their medical education program. Element 3.1 looks specifically at the instances of student-resident interaction during the clinical years.  Interactions with residents provides students with an opportunity to see, first hand, what the next stage of their training will encompass.  With over 900 residents and fellows across our sites, we know that every one of our medical students will interact with residents on at least one of their clinical rotations. Resident engagement enhances the learning environment and provides students with critical information they can use as they weigh their own options for residency selection. In addition, student evaluations of residents who supervise them are consistently quite high. 

What are we working on?

Element 3.6 addresses the ways a medical school minimizes incidents of student mistreatment and how it handles those incidents when and if they do arise.  Responses by graduating students on the AAMC Graduation Questionnaire around experiences of mistreatment have generally been better than the national average with the exception of responses about inappropriate remarks (language of a sexist, LGBT-specific, or generally demeaning nature). These responses are in contrast to the number of mistreatment complaints submitted by students to school officials. In addition, the Independent Student Analysis (ISA) distributed last January showed that clinical students were less satisfied with the procedures for handling mistreatment than we would like to see.

Efforts are being made to increase awareness of mistreatment: what constitutes mistreatment; how to report it; and reducing the fear of reporting.  

These include:

  • Adding or increasing topics on mistreatment during new student orientation and clinical transition activities  
  • Developing a new, more comprehensive Mistreatment Policy
  • Increasing the number and visibility of links on the medical school web pages for reporting alleged violations
  • Providing additional means for clinical students to report harassment and mistreatment in a real-time, immediate, and anonymous manner, through mobile apps and other technology
  • Adding topics on mistreatment and harassment to all clerkship orientations 
  • Developing questions on student evaluations of faculty and residents that more specifically address topics on the learning environment

Our last site visit was in 2012. Fun tech facts from that year include:

  • Apple released its mapping service in iOS, replacing Google Maps as the default mapping service
  • T-Mobile acquired MetroPCS
  • Facebook acquired Instagram for $1 billion

June 2019

Dear Students, Staff, and Faculty:

We are now closing in on ten months until our site visit.  In this month’s LCME newsletter, we highlight the second standard. This is particularly rewarding as we see a standard that resulted in a citation in 2012 and has now become a real strength.  We hope to have lots more of these successes based on everyone’s hard work for this self-study cycle.

Speaking of hard work, we want to express our gratitude for the incredible work you all are doing to make this site visit a success.  Today we begin a column entitled “With Gratitude” to do just that.  We will highlight a group of participants each month.

As always, please let us know if you have any questions. ( 

With gratitude,

With Gratitude:

When reflecting on the work that’s been done in preparation for our Site Visit in April 2020, it’s amazing to see how many people and areas are involved in supporting the Self-Study process. Whether through participation on committees, writing sections of the Self-Study materials, or providing essential information, many people across the medical school and its affiliate partners have gone above and beyond to ensure that the school is successful. Throughout the remainder of the Self-Study, this newsletter will highlight groups and individuals to express gratitude for their commitment.

This month’s expression of gratitude goes to the more than 75 faculty, staff, and students who comprise the five Self-Study Sub-Committees. Take a moment to review the committee lists and, for those you may know, thank them for their service.

These committees were charged with critically analyzing specific questions posed by the LCME and writing summary reports to form the basis for an Executive Summary. The committees have been meeting since January and are now wrapping up their work. They have provided exceptional analyses, identifying what we’re doing well and key opportunities for improvement. Their hard work is one of the cornerstones of our accreditation work and it is with extreme gratitude that we thank them.

Standard 2

Standard of the Month: Standard 2 (of 12): Leadership and Administration

What's the Theme?

We move from the institutional strategic plan (Standard 1) and overall governance structure to the role faculty play in achieving the components in that strategic plan and in overall governance. Standard 2 covers such topics as faculty appointment policies and procedures, access and authority of the Dean, sufficiency of administrative staff and integration of faculty into Standing Committees.

Specifically, Standard 2 states:

"A medical school has a sufficient number of faculty in leadership roles and of senior administrative staff with the skills, time, and administrative support necessary to achieve the goals of the medical education program and to ensure the functional integration of all programmatic components.”

What are we doing well?

One outcome from our previous LCME accreditation in 2012 was a citation of Non-Compliance with the sufficiency of key leadership positions. This was due to a significant amount of turnover and/or vacancies in leadership positions within the Dean’s Office and other key organizational units.

A number of efforts have been put into place to resolve this citation including:

  • 2013: successfully recruiting and filling the positions of Vice Dean for Medical Education, Associate Dean for Admissions in the Twin Cities, and an Associate Dean for Student Affairs & Admissions in Duluth
  • 2014: Approval to create an Assistant Dean for Student Affairs position on the Twin Cities Campus and increases to the number of faculty advisors to meet student needs
  • 2015: Increased collaborative efforts between Student Affairs on the Twin Cities and Duluth campuses to better address student needs across campuses
  • 2014-present: Over the past five years, we have surveyed our students on both campuses regarding their levels of satisfaction with support from Student Affairs, and have shown year-over-year improvement. On our most recent survey (spring 2018) response rates were all above the 95th percentile on satisfaction for all classes and across both campuses. This is a remarkable accomplishment!

What are we working on?

While there is always room for improvement, Standard 2 does not currently have any notable action plans associated with it.

Our last site visit was in 2012. Fun sports facts from that year include:

  • Serena Williams won her first Olympic singles title and did not lose a set in the Olympic tournament.
  • Texas A&M Freshman quarterback, Johnny Manziel, was the first freshman to win the Heisman Trophy.
  • The U.S. women's gymnastics team, coined the "Fierce Five," won Olympic gold for the first time since 1996.
  • Mike Trout became the AL Rookie of the Year and MVP runner-up with the Los Angeles Angels.

May 2019

Welcome to your first edition of our LCME update.  We are now less than a year away from our site visit!

As your Faculty Accreditation Lead (FAL) I want to thank all of you who have been a part of the enormous amount of work to get us where we are today.  We have completed the first draft and its revisions of the Data Collection Instrument (DCI) and the Independent Student Analysis (ISA) that together provide the data for us to be able to answer the questions in our Self Study Guide to address our areas of strength and weakness.  We are laser focused on our two major goals for this visit:

  1. No surprises--we want to identify all of the potential areas for concern so that we can be actively addressing them when the site visitors arrive.
  2. An eight-year accreditation decision!

Towards the first goal, each month we will share with you one of the 12 standards and identify a few of the areas of strength and areas for improvement.  We want this to be a transparent and learning process for the organization.

I appreciate in advance all of the hard work that is upcoming in this next twelve months, and am confident we are well on the way to reaching the educational vision for the University of Minnesota Medical School:

A community, learning together to prepare exceptional physicians to improve the health and well being of Minnesota and beyond.

With gratitude,

Standard of the Month: Standard 1 (of 12): Mission, Planning, Organization, and Integrity

What's the Theme?

The 12 Standards are organized to flow from the level of the institution to the level of the student. So, it's not surprising that the first Standard covers topics such as the medical school's Strategic Plan, the Constitution and Bylaws, the overall structure of governance, including faculty participation in such governance, and our agreements with affiliate partners.

Specifically, Standard 1 states:

"A medical school has a written statement of mission and goals for the medical education program, conducts ongoing planning, and has written bylaws that describe an effective organizational structure and governance processes. In the conduct of all internal and external activities, the medical school demonstrates integrity through its consistent and documented adherence to fair, impartial, and effective processes, policies, and practices."

What are we doing well?

UMMS has a strategic plan originating in 2014 to create a culture of excellence in education, patient care, and research. An area we sought to grow and foster through this strategic plan is relationships with affiliate partners and community stakeholders. One of the many ways we have pursued that goal has been by increasing our longitudinal integrated clerkships by expanding to three of our major partners: The Veterans Administration Hospital, Health Partners, and HCMC. This meets our institutional strategic goal to provide education advancing all aspects of medicine through innovative teaching and learning practices that set national trends.

As an extension of the institutional Strategic Plan, a major initiative to develop an Undergraduate Medical Education Strategic Plan was completed in 2018. The development of this UME strategic plan engaged over 500 students, faculty, health system leaders, alumni, and staff. The UME Strategic Plan defines seven principles and their respective goals to guide the medical school into the future of medical education. We are almost through our first year objectives and many of us from across all of our sites and both campuses are working on the 2019-2020 Academic year objectives now.

What are we working on?

As is the case with any effective strategic planning, on-going revision and renewal is essential. A process is being developed to review the Institutional Strategic Plan in order to clarify progress on established objectives and revise aspects as needed to reflect current priorities.

Finally, a substantial effort is being undertaken to review and revise the medical school's constitution and bylaws to ensure they accurately represent the structure, roles, and responsibilities of the school and its members.

Our last site visit was in 2012. Fun facts from that year include:

  • Before 2012 the largest buyer of kale in the US was Pizza Hut, and they only used it as garnish around their salad bar.
  • The Hunger Games and The Avengers were released.
  • The average cost of a gallon of gas was $3.60.
  • Snapchat and Instagram were launched in the Android Store.

April 2019

A Message from Dean Tolar

To be, or not to be. There is no question. That is the importance of the Liaison Committee on Medical Education (LCME) accreditation.

Today marks the beginning of our one-year countdown to the LCME Accreditation Site Visit.


I would like to thank all of you—faculty, staff, and students—who have already contributed to and are hard at work preparing parts of the institutional self-study. This is a tremendous effort, and greatly appreciated.

In the year to come, we will all be asked to participate in this effort in one way or another. Our challenge is to capture the excellence of this Medical School and to address the areas we will be working to improve (whether identified by student survey or through the critical analysis of our education program already conducted). It is a challenge that I know you will meet with the commitment you show in your daily work.

Bearing in mind the importance of accreditation, I would like to ask everyone to please engage when asked. We will need timely responses to requests for information, active membership in committees, and willing participation in the site visit itself.

To keep you informed of the progress of the work, to ensure transparency, and to generate discussion, we will post updates on our LCME landing page.

I know that you support the efforts of the Medical School in many ways and that this is added on top of your already significant workload. I hope you know that your work and time are valued, respected, and critically important.

Please join me as we start this year of reaffirming our commitment to excellence, improvement, and the drive to meet the needs of our changing world.

For more information:

Joseph Oppedisano, D.Ac.
Director of Accreditation
(612) 625-4114