Although undergraduate medical education (UME) curricula have increased in complexity over the past 25 years,1–3 the structures for administrative oversight of those curricula remain static. Scholarly consideration of the structure and authority of curriculum management has likewise been sparse over that same period. The configuration of a governance committee in any organization can aid or inhibit that organization’s function and the execution of its charge.4,5 Innovations in curriculum governance for medical schools have not kept pace with changes in curricula or institutional context. In this article, we discuss common problems with medical school curriculum committees and describe a novel structure for the faculty curriculum oversight committee (i.e., the “curriculum committee”) that was implemented in one medical school. This serves as a case study on how to more effectively manage the MD program while minimizing departmental “silos” and fostering commitment to the shared mission of the school.
Common Problems With Medical School Curriculum Committees
Integrated curricula versus dispersed authority
Several factors contribute to the increased complexity of medical school programs. Curricula are often integrated across academic disciplines and clinical departments. Common instructional settings include providers, faculty, and students from multiple health care professions.6 Assessments of students measure clinical skills and attitudes in addition to cognitive achievements.7 Additionally, the health care systems in which students train have been in flux for two decades, which compounds the complexity of delivering the UME curriculum.4,8 Despite these growing demands, a single faculty committee has continued to supervise and oversee these increasingly complicated curricula.4
The trend toward centralized, institutional-level control of the curriculum runs counter to the conventional financial structure of medical schools in which academic departments generate their own revenue and thus wield substantial control over resources, such as faculty time and educational space.9 Departments have been unwilling to contribute financially to an educational system over which they exert diminishing control.10,11 The trend to centralize curricula within the existing departmental “feudal” financial system interferes with the revenue generation power of the individual departments.9,12 This juxtaposition of curriculum management by a central authority against separate departmental financial management further complicates the task of centralized curricular governance.
The need for faculty oversight of a UME program is unquestioned and is, in fact, required for accreditation in the United States and Canada.13 As enumerated by the Liaison Committee on Medical Education (LCME), the functions of a faculty curriculum supervision committee include design, management, integration, evaluation, and enhancement of a coherent and coordinated medical education curriculum.13 This directive for effective oversight of the curriculum has grown substantially in recent years. For example, in 1989, LCME standards explicitly did not prescribe curriculum committee structure or functions.14 In 2002, the standards specified that the medical school had responsibility for three curriculum oversight tasks: design, management, and evaluation.15 Further, effective July 2015, LCME standards have added two more tasks: integration and enhancement.13 Although the existence and function of a medical school’s curriculum committee are prescribed by LCME,13 the structure of such a committee has not been ordained.
Recent literature in education reveals little scholarly consideration of how curriculum committee structure and membership can affect how it functions. In a 1993 position paper, Whalen16 described how a curriculum committee should be formed and structured; however, no additional research or follow-up commentary appeared to follow Whalen’s proposal. In that same year, Davis and White17 presented a case study of one school’s move toward centralized curriculum management, but this article did not stimulate follow-up either.
The Project Panel on the General Professional Education of the Physician18(p20) noted: “To provide coherent general professional education, interdisciplinary and interdepartmental consensus on its purpose, its content, and its resources is necessary. Curriculum committees are rarely able to achieve such a consensus.” Davis and White4 expressed a similar pessimism about curriculum committees, asserting that curricular changes should occur through an ad hoc group rather than a standing curriculum committee. Despite these pessimistic conclusions about curriculum committees, we have not found additional research, case studies, or proposals exploring how to improve the situation.
Hendricson et al19,20 conducted two surveys of medical school curriculum leaders and found that curriculum committees were either a single committee that oversaw the whole curriculum or a set of committees (one for each year of the curriculum). In both organizational schemes, the committees and subcommittees were not structured by their functions or areas of expertise. In the second 1993 survey, Hendricson et al20 also found a groundswell of support from one-third of survey respondents for restructuring their curriculum committees to increase effectiveness. A survey of pharmacy schools found similar results.21,22
In 1998, Watson et al23 discussed the lessons learned from a five-year curriculum change process. A key factor for success of that change was to clarify and reiterate regularly to the curriculum committee members that they should act in the institution’s best interests and the faculty as a body—not as protectors of the interests of their individual departments. This finding was corroborated by a separate 2000 study.24
Bland et al25 echoed prior recommen dations that to successfully change a curriculum, the curriculum committee should be bypassed in favor of a task force devoted to the change process. Bland et al also concurred with Hendricson et al20 that curriculum committee effec tiveness can be enhanced by creating subcommittees to increase faculty involve ment and which can also enhance subcommittee members’ specialized knowledge on specific educational topics.
The philosophies of contemporary curricula and curriculum change, in conjunction with LCME accreditation standards, have made the existence of an effective, centralized curriculum committee crucial to a program’s success. In the remainder of this article, we will describe themes found in medical education literature and discuss how they were operationalized to design and implement an innovative curriculum committee structure at the Emory University School of Medicine (EUSOM).
Restructuring One Curriculum Committee: A Case Study
In 2007, EUSOM instituted a new curriculum that featured a shortened phase for courses in foundational sciences and in which courses were defined by scientific principles or human organ systems, rather than by academic disciplines or departments. The phase of required clinical clerkships was modified to increase ambulatory training in multiple specialties; biweekly educational events for the entire class were also added. Required clinical clerkships continue to be delivered in blocks that are 4 to 12 weeks long, structured according to medical specialties, and the majority is directed by clinical departments. A research phase was added, during which individual students perform research in collaboration with a faculty mentor. The last phase of the EUSOM MD program consists predominantly of elective rotations, some required clinical clerkships, and a final, preresidency “Capstone” course. The new curriculum also instituted a longitudinal course that occurs in all four years and trains students in fundamental clinical skills, ethics, population health, and other aspects of being a physician. Although all of these changes to move away from discipline-specific or departmental organization of content suggested a need for centralized management of the curriculum, minimal reorganization or redefinition of the curriculum committee was implemented to correspond with the new curriculum.
Goals for creating a new curriculum committee structure
In 2013, a task force of EUSOM faculty and administrators, including the authors, was charged to address the curriculum oversight and management issue and to propose a new curriculum committee structure. The task force’s goals were threefold: (1) to streamline decision making while expanding channels for faculty input, (2) to increase faculty participation in curriculum governance, and (3) to foster communication between faculty from various departments.
The task force first addressed how to balance increasing the number of people actively invested in curriculum management while maintaining efficient decision making within a lean, efficient group. To solve this predicament, the task force endowed final decision-making power to a small executive committee that would act on recommendations made by several task-specific subcommittees. This Executive Curriculum Committee (ECC) was granted the authority to make all curriculum decisions; the dean and the executive associate dean for education retained only veto power. The ECC was composed of the chairperson of each standing subcommittee as well as two assistant deans who serve as cochairs of the ECC. By defining the ECC membership as the chairs of the subcommittees, each subcommittee was given direct influence on key decisions. During ECC meetings, subcommittee chairs report on their subcommittees’ activities and present items to the ECC for action.
The intent was for each of the task-specific, standing subcommittees to become proficient in one aspect of the curriculum and to provide the ECC with information and proposals on issues related to that one aspect. Subcommittees were charged with identifying and investigating issues, deliberating, and then providing recommendations to the ECC for final action. All subcommittee members—including students—are empowered to steer key decisions about the curriculum.
The task force debated whether to define subcommittees by their function (e.g., course evaluation, instructional technology) or by the academic level (e.g., first year, second year).5,20 On the basis of accreditation standards and its own goals for the subcommittees, the task force settled on nine curricular aspects that needed to be addressed and established one subcommittee for each: one subcommittee for each of the four student levels, and five additional subcommittees for (1) student assessment, (2) program evaluation, (3) pedagogical development, (4) instruc tional technology and informatics, and (5) curriculum integration. Thus, the full curriculum committee body consists of the nine aforementioned subcommittees, a subcommittee composed entirely of students, and the ECC. The names and functions of all 11 subcommittees are presented in Table 1. By-laws for the new curriculum committee structure were drafted and subsequently approved by the EUSOM dean.
Interweaving and communication
The committee structure is unique in how committee membership was constituted. Communication amongst curriculum leaders and faculty members is vital and cannot be achieved without an organizational structure to explicitly facilitate it.20 The task force was concerned that so many subcommittees might result in miscommunication across groups, and so the task force instigated an “interwoven” pattern of membership wherein each curriculum committee member was appointed to two different subcommittees. Thus, each subcommittee member also sat on another subcommittee and could facilitate information sharing between those two subcommittees.
The interweaving was realized by grouping all 11 subcommittees into three sets, as shown in Figure 1. One set was made up of the four subcommittees that were defined by the student levels. The second set was the four subcommittees that were defined by curriculum tasks. The third set was the three “wraparound” committees—Students; Transitions and Integration; and the ECC—whose scope encompassed the whole curriculum. Figure 1 illustrates the interweaving of the subcommittees and the inclusiveness of the wrap-around committees.
Each of the subcommittees has 9 members: 6 regular members, as well as 1 student, 1 member from the Transitions and Integration subcommittee, and 1 chair who is also on the ECC. The Student subcommittee has 10 members: 8 regular members and 2 cochairs. Each student sits on two committees, one of the subcommittees plus the Student subcommittee, as a voting member. One of the student cochairs sits on the Transitions and Integration subcommittee, while the other student cochair sits on the ECC.
Selection of committee members
Recruitment and appointment of faculty members to the 41 positions on the curriculum committee was conducted in two steps. In consideration of the aforementioned conflicts in faculty members’ loyalty to their departments or to the school as a whole,9,11,16 the task force carefully managed the nomination and appointment process to ensure broad representation of stakeholders. The first step was to impanel the ECC by recruiting and appointing the nine chairs of subcommittees. Selection was based on educational leadership experience and willingness to collaborate, but the task force also factored in diversity of personal and educational background and academic department. The second step was to notify all EUSOM faculty members about the new committee structure and solicit self-nominations for positions on the committee. This yielded over 100 nominations for the 32 remaining positions. All nominees submitted a CV that emphasized their experience in education, and then subcommittee chairs were asked to indicate the individuals whom they would like to have on their own subcommittee. The dean then officially appointed the selected candidates their positions on two subcommittees. Following the appointments, subcommittee chairs and ex officio members were trained by senior education leaders about their role as chair and the scope of each subcommittee. Then, at each subcommittee’s initial meeting, information about the subcommittee and individual member responsibilities was conveyed to the subcommittee members by the subcommittee chair.
A related aspect of the task force’s philosophy in selecting faculty members as candidates for curriculum committee positions was to minimize “feudal” interdepartmental disputes by assigning members to positions where they did not have a direct interest. For example, only one or two clerkship directors were appointed to the Required Clerkships committee—rather than constituting the committee entirely of clerkship directors. The task force used this approach to encourage subcommittees to make their decisions based on evidence and reasoned judgment and to reduce the influence of self-interest that could have existed if members held an oversight position related to their own curricular component.
The final people added to the subcommittees were ex officio members and support staff. Ex officio members were associate or assistant deans, or specialized professional staff. Ex officio members were not given voting rights on any of the subcommittees or the ECC. Staff members were assigned to schedule and prepare for meetings, take minutes, and assist the chair with other organizational tasks.
Medical students in the interwoven curriculum committee
The responsibility of students in the new curriculum committee was dramatically expanded by increasing the number of students directly involved in the curriculum committee from 3 to 10 and creating an independent Student subcommittee. Students and administrators agreed that students would have full membership and voting rights on each subcommittee and that those student members would be selected by school administrators from self-nominations.
Communication between subcommittees
The interweaving ensured that on each subcommittee, there would be a member who is also a member of the related subcommittees. In this way, a subcommittee does not have to rely on ad hoc communications or experience delays waiting for a response to an inquiry. This structure has increased the volume and speed of communication between subcommittees whose functions regularly overlap. For example, the Program Evaluation subcommittee was charged with revising the system for evaluating courses and faculty in the preclinical phase of the curriculum. Two members of the Program Evaluation subcommittee also sit on the Foundations subcommittee. These members exchange firsthand information between the two committees about deliberations and decisions and answer questions about one subcommittee to the other subcommittee.
Impact of the New Curriculum Structure and Limitations
Comparison to the previous curriculum committee structure
Six years after a major curriculum change at EUSOM, a task force restructured the curriculum committee into the interwoven pattern described above. The new committee structure treated all members as equal participants in leading the program, rather than as representatives of departments who perceived their responsibility as protecting departmental interests. The new curriculum committee structure addressed five out of the six essential categories for successful curricular change as reported by Bland et al25: negotiating the politics, cultivating a cooperative climate, enhancing participation by members, evaluating objectively, and building leadership. Only the “human resource development” category was not directly addressed by EUSOM’s new curriculum committee structure.
Prior to implementing the interwoven curriculum committee, a single committee composed of faculty who represented specific curricular units, such as courses and clerkships, governed the EUSOM curriculum. The large committee size stifled discussion at meetings. Because of the ineffectiveness of that committee structure, de facto governance of the curriculum rested with the associate and assistant deans. That structure included subcommittees, but their scope of authority was not clear, no reporting structure between subcommittees and the main committee was defined, and subcommittees had little accountability for innovation or problem solving.
The interwoven structure was tailored to address the specific problems experienced by the previous committee—problems that also were not unique to EUSOM. The interwoven structure has greatly improved the communication and accountability of the subcommittees and the overall authority of the ECC to manage the curriculum.
Evaluation of the new structure and applicability to other schools
Of particular note in evaluating the new structure of the curriculum committee is its compatibility with the integrated, longitudinal curriculum; the committee structure corresponds to the goals of the curriculum itself. Previously, committee members represented a department or curriculum component. In the new structure, members are expected to serve the program as a whole and to improve overall student outcomes. In the new structure, subcommittees oversee one aspect of the curriculum but decisions are made by the ECC, which operates with a holistic view of the curriculum. In short, the criteria for ECC decisions are the improvement of student outcomes rather than protection of individual departments or constituents that members represent.
Each of the subcommittees meets monthly. Because each member participates on two subcommittees, this means members have two meetings every month. Despite the time commitment, attendance has been robust and discussions have been lively. Many members seem pleased to have the opportunity to be part of the educational leadership process, and several have informally reported that they enjoy the in-depth learning about the curriculum and the education enterprise. The cost of participation on the curriculum committee is borne by both the faculty member and her or his department. Despite initial trepidation about the increased time commitment, curriculum committee members have not requested additional financial support and have not backed away from their new responsibilities.
This interwoven structure is not a panacea for all organizational and curriculum management problems within a medical school. Additional evaluation of this structure is needed, and some caveats to generalizing this to other medical schools are already apparent. The interwoven structure is complicated and effort-intensive. It may be amenable to most medical schools; however, because of the high level of commitment required, it is likely not worth the effort at a school that employs a departmental or discipline/specialty-based curriculum. The interwoven committee is designed to provide leadership for an integrated curriculum and might not be an efficient use of resources in other contexts.
Although the people involved in this process at EUSOM believe that the interwoven committee structure has encouraged centralized curriculum management and has facilitated the maintenance of our recent curriculum change, independent analysis and verification are still needed.
Acknowledgments: The authors wish to thank the members of the Emory University School of Medicine Curriculum Committee Re-structuring Task Force for their advice and support: Kathryn Garber, PhD; Emily Hulkower, BA; Michael M. Johns, MD; Mary Jo Lechowicz, MD; J. Richard Pittman, MD; David A. Schulman, MD; and Julia A. Yeager, MHA.
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