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Academic Medicine:
doi: 10.1097/ACM.0b013e3181574a62
Professionalism

From Traditional to Patient-Centered Learning: Curriculum Change as an Intervention for Changing Institutional Culture and Promoting Professionalism in Undergraduate Medical Education

Christianson, Charles E. MD, ScM; McBride, Rosanne B. PhD; Vari, Richard C. PhD; Olson, Linda EdD; Wilson, H David MD

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Author Information

Dr. Christianson is associate professor, Department of Family and Community Medicine and Office of Medical Education, University of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota.

Dr. McBride is assistant professor, Department of Family and Community Medicine and Office of Medical Education, University of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota.

Dr. Vari is professor of physiology and associate dean for medical education, University of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota.

Dr. Olson is associate professor, Department of Family and Community Medicine and Office of Medical Education, University of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota.

Dr. Wilson is dean, University of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota.

Please see the end of this article for information about the authors.

Correspondence should be addressed to Dr. Christianson, Department of Family and Community Medicine, University of North Dakota School of Medicine and Health Sciences, 501 N. Columbia Road, Box 9037, Grand Forks, ND 58202-9037; telephone: (701) 777-3240; fax: (701) 777-3849; e-mail: (cchristi@medicine.nodak.edu).

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Abstract

The authors reframe a curriculum change from a traditional lecture-based to an integrated patient-centered approach as an intervention for changing the culture and hidden curriculum of an institution in ways that promote professionalism. Within this context, the authors articulate some of the inherent process and relational factors brought about by these curricular changes that are essential elements of this intervention process. In 1998 the University of North Dakota School of Medicine and Health Sciences (UNDSMHS) introduced a new preclinical patient-centered learning (PCL) curriculum for first- and second-year medical students. Case-based, small-group learning forms the critical foundation of the PCL process, and an integrated basic and clinical science didactic component supports this process. At the student level, the case-based PCL process generates innovative opportunities for professionalism education from the explicitly articulated formal content that arises naturally from the cases, but more importantly from the implicit values inherent to the PCL small-group process itself—humanism, accountability, pursuit of excellence, and altruism. Further, the organizational changes necessary for the transformation to the PCL curriculum required process changes at student, faculty, and administrative levels that have resulted in a cultural shift toward relationship centeredness within the institution. The authors describe the evolution and structure of the PCL curriculum at UNDSMHS and how this curricular transformation has served as an intervention that promotes professionalism and institutional culture change through (1) processes at the student level that present new opportunities for professionalism education, and (2) processes at student, faculty, administrative, and institutional levels that have created an institutional culture that supports, models, and promotes relationship-centered professional values.

“A profession sets its own standards … and cherishes performance above personal rewards. A profession is directed by a code of ethics which includes the moral imperative to serve others.” Justice Louis Brandeis's words greet medical students entering the University of North Dakota School of Medicine and Health Sciences (UNDSMHS) on their first day of orientation. The first activity is a welcome from the dean, who says, “You can pass all your exams with flying colors, but if you do not act in a respectful and professional manner, you are not going to graduate from this school.”

During orientation week, each student signs a teacher–learner contract, attends an introductory lecture on professionalism that introduces its major concepts and sets forth specific expectations for behavior, and spends six hours in a group with six other students and a faculty facilitator analyzing a patient case, identifying learning objectives, and teaching fellow students. At the end of the week, students meet in a lecture hall with the actual patient in the case and the physician who provided care. Students observe that an entire floor of the medical school building is dedicated to these small groups and that a wide range of faculty members—research-oriented basic scientists, allied health professionals, and clinicians—serve as small-group facilitators. The week ends with a white coat ceremony during which a distinguished physician from the region speaks on the meaning of professionalism, students take a modified Hippocratic Oath, and are presented with a white coat.

This attention to the elements of professionalism, from the educational process (e.g., altruism and accountability in teaching fellow students, respect for other disciplines, interacting respectfully with an actual patient, institutional priority on professionalism), to the physical environment itself (e.g., a large amount of space devoted to learning in groups), supports and parallels the explicit values of professionalism we espouse in our formal course content at UNDSMHS. In this paper, we describe this patient-centered educational process and its effect on our institutional culture.

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Historical Context

It was once assumed that students competent in the biomedical sciences would learn the values of the profession through clinical experiences combined with appropriate mentoring.1–3 However, training environments have changed dramatically over the last 100 years—becoming more complex and often conveying confusing and conflicting messages about the values associated with patient care.3–6 These changes have made it increasingly more difficult and less effective to rely on mentoring and clinical experience as adequate resources for professionalism education.5–7 This problem has come into sharp focus in the last two decades, as both medical educators and the general public expressed concern about the depersonalization of medical care and the increasing commercialization of the medical profession.7–10 Medical educators have responded with a number of calls to increase our attention to professionalism,11–14 and medical schools have made a number of responses. These included experiences such as white coat ceremonies as well as additions to formal curricular content. By the beginning of this decade, most medical schools reported formal educational content addressing the humanities, ethics, and professionalism.15 There was a hope and an expectation that these changes would produce medical graduates who were more humanistic and relationship centered in their practice. Disappointingly, the research to date suggests that these formal curricular changes did not produce the desired results.1,4,10,16 Rather, medical students continued to graduate showing not only a deterioration of these desired values but also an increase in undesirable attitudes such as cynicism and a sense of entitlement.16,17

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The hidden curriculum

These outcomes highlight concerns expressed since the 1950s that there are other processes or forces at work within medical education training environments that have a more powerful influence on the formation of professional values than explicit content knowledge—the widely recognized hidden curriculum, informal curriculum, and metacurriculum.18 These terms describe a culture of medical education with unwritten rules that influence attitudes and behaviors during training and later during medical practice—“hidden” rules that may contradict the explicit messages we would like our students to embrace about humanistic values and relationship-centered medical care.4,10,17–19 Furthermore, cynicism can develop when students attempt to reconcile any perceived disconnect between the humanistic values to which they aspire and those of the actual cultural milieu of the medical training environment, further undermining the teachings of the formal curriculum.10,17,19

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Addressing the hidden curriculum

To counterbalance the erosion of humanistic and professional values, Coulehan and colleagues,10 as well as other scholars,19–23 have emphasized narrative-based professionalism that includes small-group reflection in the clinical years, faculty development in role modeling, narrative competence, and the incorporation of service learning. Wear and Castellani24 (p604) propose a reframing and broadening of “what counts as ‘knowledge’” as an important aspect of changing how medical students internalize and apply the values of medicine.

Several medical schools have described institutional interventions to address and improve the learning environment to support the development of appropriate professional values. Goldstein and colleagues25 have developed innovative methods for initiating institutional changes geared to the teaching of professionalism. They found that introducing a professionalism curriculum for preclinical students led to an awareness of the need to address professional development for faculty, residents, and staff, in order to create a “safe” institutional environment that promotes professionalism. Other medical educators19,26–28 are working toward a constructive reframing of relationship-centered care and the notion that paralleling relationship centeredness within and among administration, faculty, students, and hospital staff is essential in developing students' professional values. Haidet and Stein4 also emphasize the importance of paralleling the professional values we desire in students in the student–teacher relationship—referring to this process as an inoculation against the negative impact of the current medical cultural milieu on professional development.

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Transforming the formal curriculum as a culture change intervention

Many medical schools have been or are now engaging in curriculum renewal, and transforming the formal curriculum itself may provide another pathway or intervention for changing institutional culture in ways that promote professionalism. However, if the term curriculum renewal describes a situation in which existing content such as lectures and laboratory experiences are reorganized or integrated under different course titles, a few new lectures or courses are added to fill perceived gaps, or a few small-group learning experiences are integrated with existing lectures, then the formal curriculum changes may have a marginal impact on the culture of the institution. As Beach and Inui,26 Suchman et al,28 and Haidet and Stein4 each emphasize, with respect to professionalism education, it is important to parallel relationship-centered values within relationships at all levels of an institution: student–student, student–faculty, faculty–faculty, etc. Thus, if formal curricular transformation results in new opportunities or substrates that promote and support relationship-centered processes and values in the educational process, the assessment process, and the program evaluation and development processes (e.g., the way students relate to each other, the way students relate to faculty, the way faculty relate to each other, how students/faculty relate to the material they are learning/teaching), then the curricular transformation itself can serve as an intervention for professionalism education and transformation of the institutional culture and learning environment.

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Formal curriculum change as an intervention for culture change at UNDSMHS

Our aim is to describe a curriculum change of this kind that was implemented at the UNDSMHS, articulate how the new educational processes associated with this change provided novel ways to address professionalism education, identify the strengths of these initiatives at our institution, address areas where we continue to struggle, and describe our future directions. To provide a context for discussing institutional processes that support professionalism education, we begin by detailing the evolution and organizational structure of the case-focused, problem-based learning (PBL) component of our patient-centered learning (PCL) curriculum—the central foundation of our formal curriculum in the first two years. We follow with a description of the processes and structures required to implement the PCL curriculum, how these support professionalism education and relationship-centered values—both explicitly and implicitly—for our students and faculty, and how these changes resulted in a major shift in the culture of the institution.

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The Development and Structure of PCL at UNDSMHS

Background

One of the authors (H.D.W.) assumed the deanship at UNDSMHS in 1995 after previous experience with successful curriculum renewal at the University of Kentucky School of Medicine. In 1996, he established a faculty committee charged with reviewing the best existing curricular models at other medical schools and making recommendations for change at UNDSMHS. The committee was most impressed by a PCL model in which a case-focused, PBL component forms the backbone of the educational experience. We patterned our approach after the highly successful PCL model developed at the University of Missouri–Columbia.29 Three key factors encouraged us to adopt this approach: direct observation of the enthusiasm, motivation, and satisfaction of the students at Missouri; the sustained improvement in performance of these students on standardized examinations; and supportive narrative comments from clinical faculty concerning the improvement in students' clinical performance compared with the traditional model. Other motivating factors supporting the change were our small class size (57 students then; 62 now), strong support from UNDSMHS's dean, and the willingness of faculty to make the changes. The primary factors that lead to the success of this transition are described elsewhere.30 An office of medical education was created in 1997 to facilitate the implementation, assessment, faculty development, and program evaluation needed for the transition and beyond, and the new curriculum was introduced in 1998. Before the curricular transition in 1998, the UNDSMHS employed a traditional, lecture-based curricular model, and the first class to complete the new PCL curriculum graduated in 2002. Finally, we instituted an educator–scholar track for faculty promotion, to recognize the importance of teaching and to provide a path for those who concentrate their efforts in this activity.

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Overview of curricular organization
Case-focused, problem-based learning.

In our PCL format, first- and second-year classes are divided into groups of six to eight students who meet three times a week to analyze a clinical case, with a different case introduced each week. Each small group also includes a faculty member who, rather than instructing students about case content, facilitates the group process. Students rotate responsibility for serving as “quarterback,” the leader of the group, on a weekly basis. As details of a case are revealed during the first meeting of the week, students identify and generate group learning objectives that they feel are necessary to gain an understanding of the case. Each student takes responsibility for researching a learning objective, preparing a presentation and handout, and teaching this information to the group. At the end of the second weekly meeting, students receive a list of faculty learning objectives that they research and present at the third and final weekly meeting. The case learning objectives—both student- and faculty generated—for each week involve both basic science and patient-management issues. At the end of each week, the actual patient from the case or a patient with the same condition (often accompanied by family members) and his/her physician participate in a case wrap-up session. This forum provides students with an opportunity to ask questions specific to the patient's medical condition and to explore the patient's subjective illness experience.31 In addition, students participate in basic and clinical science lectures as well as lab and physical exam experiences that provide an integrated knowledge base centered on the PCL case.

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A focus on curricular integration.

We embrace an integrated approach structured by organ system, and there are no departmental courses. The curriculum is organized in eight-week blocks—four blocks in each of the first two years—with each block devoted to several organ systems (e.g., Block II consists of cardiovascular, respiratory, and immune systems). Chart 1 shows the basic and clinical sciences content of each block. The office of medical education administers the teaching and evaluation process in the first two years. Each block is supervised by a block director and developed and evaluated by a block design team representing the relevant basic sciences and clinical fields. The block design teams meet several months before the beginning of each block to review and renew the cases, the supporting lectures and labs, the faculty learning objectives for individual cases, and the overall block learning objectives.

Chart 1
Chart 1
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A didactic curriculum is wrapped around the case-based PCL process. The basic sciences component includes lectures and laboratory experiences. The clinical sciences are presented through lectures and small groups addressing communications skills, physical examination skills, and bioethics issues, as well as laboratory experiences teaching basic clinical procedures. Lectures are limited to nine hours a week in the basic sciences and four in the clinical; two afternoons each week between PCL sessions are kept free to give students the time necessary to research and prepare the presentation of their learning objectives. Chart 2 shows a typical weekly schedule.

Chart 2
Chart 2
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Case-Based PCL and Professionalism Education

Formal professionalism content

Professionalism issues and themes arise organically from the PCL cases that form the backbone of learning. Some case examples are:

1. A patient who is diagnosed with breast cancer and admitted to the hospital for surgery. This presents the opportunity to discuss the elements of the informed consent process, delivering bad news, and psychological elements of breast cancer treatment.

2. Patients diagnosed with genetically determined diseases. These present the opportunity for learning objectives on ethical issues in prenatal screening and communicating results to parents.

3. A patient who is a man of color with an abnormal EKG related to his activity as an elite athlete. The actual patient is a faculty member of our university who comes to the wrap-up session; he discusses how his treatment may have been affected by the perception that he was “black” when he is, in fact, of mixed European–African descent—an identity that is important to him. He raises issues of racial/ethnic stereotyping, and whether the health care delivery system is color blind.

4. A patient with chronic renal disease secondary to diabetes who is Native American. This patient's management presents issues of cross-cultural care and health disparities.

In addition to the patient themes arising from cases such as these, an integrated clinical sciences curricular component (i.e., clinical science lectures and activities on a variety of topics relevant to the case and block objectives are integrated into each block rather than having separate block- or semester-long clinical courses) builds on these themes by addressing bioethics issues, professional conduct, communications skills, and principles of patient-centered care such as understanding the patient's perspective, getting to know the patient as a whole person, and negotiating a mutually acceptable treatment plan. For most professionalism topics, some introductory material is presented using a traditional format of lecture with assigned reading. However, for many areas of professionalism education we supplement traditional lectures with other, more experiential methods such as videotapes and films, small-group discussion of patient cases, and standardized patient interviews. Some examples include (1) bioethics teaching that involves small-group discussion of patient cases, (2) lifestyle modification teaching that uses a small-group format in which students practice interviewing techniques on standardized patients, with standardized patients and peers providing feedback about interviewing skills, and (3) end-of-life care teaching that uses videotapes followed by reflective activities, narrative techniques, and small-group case discussions. Further, by emphasizing the themes that naturally arise from PCL cases and embracing an integrated approach in our clinical and basic sciences components, we hope to directly address the tendencies of some students (and faculty) to prioritize “hard” science learning and marginalize “soft” content—a designation frequently applied to professionalism topics.

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PCL process and implicit learning about professionalism

As we gain experience with the PCL process, we increasingly appreciate its impact on institutional culture and its potential to support professional development and promote the values we espouse explicitly. One of the most powerful implicit messages this process can convey is that the patient is at the center of all learning. Basic as well as clinical science learning objectives evolve naturally out of the patient cases, and indeed students are encouraged to relate their presentations to the case whenever possible. The case wrap-up at the end of the week, where both patient and physician are present, further reinforces that caring for the patient is the focus of our work. Students value most highly the opportunity to hear from the patient about the illness experience; in fact, they are disappointed if the wrap-up physician does not allow adequate time for the patient's perspective. A second, powerful message relates to the value given to learning in groups—the sense of team—which provides a model for working within a health care team. Further, for each block, students are assigned to work with a new group of students and a new facilitator for six hours per week in formal small-group activity, providing many opportunities to work with a variety of skill levels and personalities. Moreover, students' work areas are located in their respective small-group PCL rooms, and so they spend many hours a week engaging in informal interaction and collaborative learning with their peers. In this process, we echo Parker Palmer's32 (p126) description of patient-centered learning as a “small circle of students around a patient.” He proposes that this approach draws its power from putting a “great thing,” the patient, at the center of the pedagogical circle, and that communal inquiry is more effective and motivating than individual learning.

In reflecting further on the implicit values supported by the case-based PCL process, we have been influenced by Hatem's33 work with medical residents as teachers. He observed that the teaching process parallels many of the values necessary for the practice of medicine—that “caring for the learner and caring for the patient reflect identically parallel professional skills.”33 (p710) Specifically, the peer teaching process encourages one to embrace values such as humanism (needing to “know the learner” as well as to create and maintain a safe learning environment); accountability (needing to negotiate an “educational contract” to meet shared expectations and to take responsibility for preparation and presentation of teaching materials); and striving for excellence (maintaining a shared focus on continued professional growth, including reflection and feedback about teaching successes and failures).

Our experience suggests that similar professional values are reinforced by our case-based PCL process. Students need to identify the learning needs and styles of others and create a respectful and safe learning environment, which can underscore the value of humanism. Students are accountable to their peers for the quality of their group participation and presentations, and this sense of responsibility can engender a demand for excellence as well as placing the needs of fellow learners before personal needs for leisure time (e.g., altruism). The process places a strong emphasis on communication skills not only in teaching but also in working together and negotiating group learning objectives—negotiation being a central aspect of patient-centered care. Students are from different ethnic backgrounds, calling for some cultural sensitivity. Finally, the process requires group and individual reflection on performance, introducing and formalizing a critical substrate for professional development.

Early this year, one of the authors (R.B.M.) initiated research that examined empirically what professional values students learn through participation in the case-based PCL process. Students were asked to reflect on their case-focused, small-group teaching and learning experiences and to identify the professional values they think they are learning from these processes. The purpose of this research is to uncover what students are now learning implicitly about the values of medicine by participation in the case-focused PCL process. Preliminary data suggest that students are able to identify the presence (or absence) of values such as humanism, accountability, altruism, and the pursuit of excellence in their actions and in those of classmates in the case-based PCL process.34 We also found that the act of asking these questions served to make implicit processes explicit, and findings suggest that this may further support the development of desired professional values.

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The Assessment Process and Professionalism Education at UNDSMHS

Our changes at the curricular level have resulted in process changes in our student assessment protocols and procedures that place a strong emphasis on professionalism issues including modeling communication skills; faculty–student, student–student, and faculty–faculty collaboration; providing and receiving feedback; and self-reflection. Specifically, at the end of each week, students, facilitators, and the block director evaluate that week's overall performance: students assesses their small-group performance and plan ways to improve group function; “quarterbacks” representing each PCL group meet with the block director to discuss issues with the case or other aspects of the learning process; and PCL group facilitators meet with the block director to discuss issues about the case content or learning objectives and to provide reflective feedback about individual PCL group performance or process. These weekly meetings require a process of self- and group reflection as well as collaborative communication and feedback, activities that are important in modeling professional values and relationship centeredness at student, faculty, and administrative levels.

Next, students are evaluated individually at midblock and again at the end of the block in the areas of knowledge acquisition and integration, peer teaching and communication skills, and professionalism. Students are required to reflect on their learning experience and compose a written narrative about strengths and learning needs in each domain, and facilitators also generate written narratives of students' performance in each domain. Suggested areas for self-reflection pertaining to professionalism include timeliness, adequacy of preparation and participation in groups, respect for others, and carrying out responsibilities. Students then meet individually with their respective facilitator to discuss the narratives,35 which provides a unique opportunity to develop trusting, collaborative student–teacher relationships that are conducive to self-reflection and mutual exchange of feedback.

Finally, end-of-block examinations consist of multiple-choice, lab, clinical skills, and case exam components—the latter requiring students to write short, narrative essays in the style of a case discussion that address professionalism issues such as bioethics, end-of-life, and patient-communication topics in addition to basic science topics and physical diagnoses skills. Further, in addition to evaluating the content and quality of the history and physical, the clinical skills component of the block exam includes an evaluation of medical interviewing skills, professional behavior, and communication. This evaluation format conveys a clear message to students that professionalism issues are important to patient care and highly valued by our institution.

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Student Outcomes

We did not adopt this curriculum so that students would memorize more facts, but, as with students' performance at Missouri–Columbia, our students' mean scores on Step 1 of the United States Medical Licensing Examination (USMLE) have remained stable since the transition (Figure 1). Step 2 scores have increased substantially, from below the national average to above it (Figure 2). More important, our clinical preceptors, even those who were initially skeptical of the new curriculum, are now enthusiastic about the results: they find our students more able to “think like doctors,” meaning they are able to integrate their knowledge base with the patient's findings in the course of clinical care. Furthermore, they report on formal clerkship evaluations that the students now relate better with patients and staff and function more effectively in health care teams.

Figure 1
Figure 1
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Figure 2
Figure 2
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As described previously, our preliminary data from the examination of our case-based learning format suggest that this process encourages the values and behaviors of professionalism and that students are able to identify instances in which these occur individually and in the context of their small-group learning environment.

Finally, results of survey data also indicate that the PCL curriculum has had an impact on student goals and objectives related to professionalism. At the end of their fourth year, all medical students are surveyed concerning 30 overall learning outcomes outlined in UNDSMHS's curriculum goals and objectives. They are asked to indicate the level to which they think the medical school curriculum and educational experiences have prepared them in each area, and the level of confidence they have in their ability to demonstrate the curricular learning outcomes. Benchmark data were collected in 2001 from senior students graduating from the previous traditional curriculum and subsequently compared with data from students who have studied under the PCL curriculum. Means for students' aggregated scores in 10 professionalism areas included in both the 2001 and 2007 surveys are presented in Figure 3. The 10 professionalism domains were

Figure 3
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* creating a supportive environment conducive to effective communication between doctor, patient, and other professionals;

* effectively communicating with patient, family, and health care team;

* treating patients with empathy, compassion, and respect;

* eliciting and addressing the patient's understanding, concerns, and fears about his/her illness;

* behaving in an ethical, responsible, reliable, respectful manner;

* working effectively with the health care team to facilitate patient care;

* projecting a professional image in interpersonal relationships, manner, and dress that is consistent with the medical profession;

* identifying areas of deficiency in own performance;

* recognizing and proposing solutions for important moral, ethical, and legal problems of medical practice; and

* having and awareness of the impact of financial issues on medical practice.

Whereas the results illustrate considerable correlation between self-reported educational preparation and confidence in abilities relative to curricular goals and objectives, they also provide a visual representation of the continuum on which students perceive themselves relative to intended professional development curricular outcomes. For the 10 professionalism items, students' responses for proficiency increased in 2007 for all items. For one objective, eliciting and addressing patients' understanding, concerns, and fears about their illness, the increase was statistically significant (P < .025 by ANOVA). For confidence, three items increased and seven remained the same when comparing 2007 with 2001. There seems to be a substantial positive shift up and to the right in student perceptions of proficiency and confidence related to professionalism goals and objectives.

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The PCL Curriculum at the Institutional Level

Institutional decisions implicitly convey important values to students as well as faculty and administrators. Our change to a PCL curriculum necessitated changes in the physical environment of the medical school as well as the adoption of new processes for faculty to work with students and with each other. We believe that this change conveys important and powerful implicit messages to the entire medical school community concerning the values of the institution. In particular, it emphasizes the degree of importance and value UNDSMHS places on relationship centeredness in education and practice. For example, our institution devotes substantial resources, space, and faculty time to the small-group process. Even with our relatively small class size, we have 17 PCL rooms, each equipped with computers and audiovisual equipment. The office of medical education has an annual budget of almost $1 million, and the small-group process requires at least 8,000 hours a year of faculty time. Facilitating at least one block a year is considered part of the mandatory teaching activity of every faculty member; there are 51 basic science and 14 clinical or general educator faculty that participate in this activity. This investment of resources sends an implicit message that demonstrates our commitment to the qualities inherent to our small-group process—that health care is patient focused, that it occurs within the context of a group or team, and that relationships are important in learning as well as in practice.

Next, we pursue an integrated approach to learning that is paralleled in our assessment process, supporting the notion that the basic sciences do not stand alone, but that the clinical and basic sciences—the “art” and “science” of medicine—must come together to produce excellent patient care. As detailed below, we continue to struggle with this issue at student and faculty levels. On the other hand, by the very nature of embracing this approach to learning, we convey an implicit message at an institutional level that has far-reaching implications for professionalism education. Namely, in our efforts to “equalize” the importance of basic and clinical sciences, we also demonstrate a willingness to tolerate the uncertainty and critical self-reflection that accompanies working through a change process. We feel that this willingness models some of the most important aspects of good patient care and relationship centeredness at individual and institutional levels, which leads us to our final point.

To support this curriculum, we were required to develop unique processes and resources for communication at an institutional level—processes necessary for working through the challenges involved in institutional and philosophical change to find more humanistic, integrated ways of thinking about patients, relationships, and education. Specifically, our educational planning and program evaluation processes rely heavily on relationships and communication, providing a model for and emphasizing professionalism and relationship-centered values at an institutional level. Even in the first years of the PCL curriculum, the block design teams, comprising basic scientists and clinicians, spent many hours planning the objectives and content of each block and writing and refining cases. In many instances, the enthusiasm of basic scientists for their content areas was tempered by the perspective of clinicians as to what is relevant for the practice of medicine. This work required extensive communication and led to the development of new relationships across departmental lines.

For example, in our current block design team meetings, basic scientists and clinicians from a variety of disciplines continue to come together to address the educational needs of the students; these meetings provide an ongoing opportunity to air and continue to resolve the familiar differences in perspective between basic scientists and clinicians. Ideally, conflicts are resolved by reference to what knowledge and skills our students need to provide patient care in the future, again placing the patient at the center of our deliberations and again demonstrating relationship-building processes such as “finding common ground” at the faculty level. Further, as mentioned earlier, each week the facilitators meet with the block director to review the case and discuss any learning issues that have arisen. At the end of the academic year, the block directors and office of medical education administrators meet in a two-day retreat to review the successes and challenges of the past year and to make improvements for the next. Finally, in the quarterback meetings, students and faculty work together to identify problems in the case and other educational activities of the week—brainstorming solutions and resolving conflicts. Students know that their concerns are valued and have been heard by the faculty, and visa versa. Although we have sometimes questioned whether the content covered in our quarterback, facilitator, and block design meetings justifies the time spent, we have come to realize that the existence of these meetings creates an opportunity for relationship building, and thus further reinforces an important message about the value our institution places on relationships and communication. These experiences at student and faculty levels send a much different message about the values of the institution pertaining to relationships and collaboration than a traditional curriculum, where most ongoing communication occurs intradepartmentally and there is little continuity of communication between faculty and students or between basic scientists and clinicians.

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New Directions

Small-group reflection in the clinical setting

We are working to extend the values supported by the PCL process into the clinical years (i.e., years three and four). As noted earlier, others have pointed to the importance of reflection in the development of professional values as perhaps an “inoculation” against the more harmful aspects of the informal curriculum in the clinical setting.4,20,22,36 One of the authors (C.E.C.) has developed a group process on our local campus that merges our PCL process with the group process described by Branch and others.22,36 Monthly, a faculty facilitator meets with third-year students for 1 to 1.5 hours at the end of the regular clinical day. As they did in their preclinical, case-based PCL groups, the students rotate responsibility for selecting a topic from their recent experience and preparing a discussion that is often combined with assigned readings from the medical literature. Any topic not related to specific medical management is considered appropriate. Typical topics include end-of-life care issues, student-witnessed conflictual interactions among physicians or between physicians and staff, patients with unhealthy lifestyles or drug-seeking behaviors, and specific student issues such as being introduced as a physician, female students being mistaken for a nurse, and the relation of students to drug company representatives. There is an explicit agreement of confidentiality and time is set aside at the beginning of the session for catching up on what is happening in their lives and at the end for discussion of other student issues and experiences. This process embraces many of the characteristics and values deemed important to the student–teacher relationship such as trust, mutual respect, the creation of a safe learning environment, and a focus on reflection. End-of-year assessments indicate that students have found this a valuable experience that fosters their professional development.

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Interprofessional health care education course

We recognize that physicians do not work alone, but function as part of a team with other health professionals. The UNDSMHS has provided leadership within the larger university community for the development of an interprofessional health care education course. A planning committee composed of representatives from most of the health professions programs of the university began to meet in 2004, and the course was offered for the first time in January 2006. It is now taught four times a year to about 80 students per session.

Students from seven health professions (medicine, nursing, physical and occupational therapy, speech and language pathology, physician assistants, clinical laboratory sciences, and social work) meet in small groups modeled after the case-based PCL process described earlier. The objectives are to learn the contribution and skills of each others' professions and learn some basics of team function to reduce medical error. Faculty who have primarily taught medical students are also learning that many of these other professions have their own robust statements of professional values and educational experiences directed toward their development. Thus, university faculty are modeling interdisciplinary practice at a different level and strengthening professional ties across health disciplines—again, faculty modeling and paralleling the types of relationships we hope for in our students.

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Community faculty development

UNDSMHS is developing a unique collaboration with the North Dakota Medical Association (NDMA) around professional development. The NDMA has its own concerns about professionalism issues relating to practicing physicians. Noteworthy is the fact that more than 900 of the approximately 1,400 practicing physicians in North Dakota are on the clinical faculty of UNDSMHS and involved in teaching our students and residents. We are working with the NDMA to develop further training for physicians in the state to support professional development of our learners, through methods such as facilitating a third-year reflective professional development group.

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Empirical investigation of the training environments

Finally, in addition to continuing our investigation into the values imparted to our students by the PCL process, we are developing collaborative research with the University of North Dakota Department of Sociology to conduct an ethnographic study of the social environment at the UNDSMHS as well as at some of our community-based training sites. We plan during the 2007–2008 academic year to begin to uncover through direct observation some of the implicit messages conveyed by our learning environments so that we can address these messages explicitly at institutional, curricular, and interpersonal levels.

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Strategies to continue transformation of institutional culture

Nearly a decade ago, UNDSMHS adopted a patient-centered approach to preclinical education largely to address the needs of adult learners and develop a pattern of lifelong learning in our students. Making the change from a traditional to a patient-centered curriculum was not easy, and required the active support of a critical mass of faculty as well as that of the dean and other key leaders. Having made the change successfully has in itself created an institutional culture that is more self-reflective and open to change. First, the resulting curricular planning/development and evaluation processes, which include students and interdisciplinary faculty teams, provides flexibility in modifying curricular content and ensures ongoing communication about curriculum decisions. These processes offer the opportunity to model communication, respect, continuity, and ongoing relationships among faculty, administration, and students. In continuing our development of professionalism education in this context, our plans now will focus on making these substrates for professional development and relationship centeredness (e.g., our curricular planning/development and evaluation processes in which faculty from all disciplines come together) more “visible” and explicit to our faculty. In this way, we hope to increase awareness of the implicit learning about relationships and professionalism that can occur in these situations and why the process itself is important to our students' professional development. Next, the case-based component of the PCL process offers an opportunity to model respect, compassion, integrity, accountability, excellence, and lifelong learning, as well as to develop a critical relationship-centered substrate within student–student and teacher–student relationships. In the future, we plan to make these values explicit to the students and relate the parallel between caring for the learner and caring for patients. In this way, we hope to increase the generalization of the values learned in the PCL process to the care of patients. Lastly, the ethnographic examination of our institutional processes will help illuminate the degree to which these processes support our values.

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Continuing Challenges

We have articulated many of the positive and potentially transformative aspects of our curriculum, but we also want to reflect on some areas where we continue to be challenged. Although our integrated curriculum sets the stage for “equalizing” the importance of basic and clinical science, we continue to encounter a marginalization of “soft” material such as ethics and communications and relationship skills—a problem often noted in medical education—and our students still tend to emphasize basic sciences over clinical in their studying. Perhaps this is attributable, as Wear and Castellani24 argue, to the domination of the scientific method in the first two years of medical school as the primary path to knowledge. Although we emphasize basic and clinical faculty communication in our curriculum planning processes and feel very optimistic about the ongoing communication process, we continue to encounter territorial disputes at the planning level that undoubtedly trickle down to student–teacher interactions and the implicit messages about what constitutes real knowledge. This continuing conflict underlines the need for further faculty development and dialogue around educational issues as well as further investigation into the conflicts themselves and how to create a safe space for airing concerns and finding common ground—a process that again conveys a very positive message about valuing relationships and communication. In addition to these potential internal sources contributing to the marginalization of clinical sciences, students' attitudes are strongly shaped by external forces such as the accepted requirements for admission to medical school and the emphasis of the testing process through which they must pass for licensure. We question whether a medical school can overcome the tendency of students to marginalize some clinical material through purely internal approaches without some change, for example, in the generally accepted requirements for admission to medical school and the structure and content of Step 1 of the USMLE.

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Conclusions

Our change from a traditional lecture-based to a patient-centered curriculum has served as an intervention for professionalism education and a culture change at an institutional level—a culture change that supports professionalism not only in its formal content and organization, but more importantly in the institutional and relational processes required to support these changes. In addition to the formal professionalism content of our curriculum, we now strive to articulate and emphasize professional behavior from day one, and to support that emphasis through parallel institutional processes that model and value relationships and professionalism. Specifically, we are gaining empirical support that the “backbone” of our curriculum—our case-based, small-group PCL process—implicitly conveys important attitudes and behaviors about professionalism. Next, our assessment process emphasizes communication, feedback, the creation of a safe learning environment, and a message that the softer sciences do count as knowledge. Third, our curricular planning/ development and evaluation processes model and parallel many of the characteristics important to professional development and relationship-centered values such as effective communication skills and respect for differences in perspective among faculty of many disciplines and between faculty and students. Faculty who once encountered students only in the lecture hall and interacted mainly with colleagues within their department now engage students in small groups and work extensively with colleagues from other disciplines. Finally, many feel that self-reflection and a tolerance of uncertainty are important characteristics of professional development for training and practice as well as for developing ongoing, trusting relationships. Thus, in addition to the ways in which our curriculum can promote relationship centeredness and professional development through the institutional changes required to support it, we believe we now have a curricular model in place that promotes the ongoing practice of self-reflection among students and faculty. Further, the evolution of the new curricular model necessitates openness to change and a tolerance for the uncertainty that accompanies change. We hope to continue our ongoing participation in and commitment to these at student, faculty, and institutional levels such that we can continue to transform our educational processes in ways that promote professionalism. The processes we describe have already demonstrated numerous benefits for professionalism training and hold much potential for continuing a journey toward educating the kind of humanistic physicians we want for society and ourselves.

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© 2007 Association of American Medical Colleges

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