Preclerkship weekly clinical duties.
The Hybrid Curriculum class was the first to experience clinical placements in the preclerkship phase, with weekly clinical duties. To accommodate all students, individual placements were made across a variety of clinical settings. Although the primary intent of this experience was to provide clinical context and to raise awareness of health care systems issues, the students (and many preceptors) naturally focused on clinical skills development. This, in turn, led to concerns among students about variation in clinical opportunities across these myriad settings. The addition of clinical duties also created less flexibility in the weekly schedule of first-year students.
Incorporation of more active and team-based learning modalities.
The Hybrid Curriculum class experienced pilots of the active learning formats and team-based activities that are a primary focus of the Curriculum 2.0 preclerkship experience. Faculty were developing cases and techniques and were excited to share these new tools with current students. The Hybrid Curriculum students, however, did not have sufficient repeated practice with these formats to fully overcome the burden of learning a new technique. Some students became frustrated by the sense of inefficiency that this created. Additionally, Hybrid Curriculum students served an important role in voicing to faculty the significant discomforts associated with approaches that feel foreign and that raise individual vulnerability in a group setting.
Reduction of preclerkship course work.
The Hybrid Curriculum class reduction of the preclerkship phase from 2 to 1.5 years was largely accomplished by moving an existing required research experience to the postclerkship phase, and altering break periods. Only minimal changes in content and length of the foundational science blocks were required, such that faculty efforts could focus on the significant revision planned for the subsequent Curriculum 2.0. However, any change can generate anxiety among students regarding preparation for the United States Medical Licensing Examination (USMLE) Step 1. Additionally, the Hybrid Curriculum class bore the brunt of the transition to moving core clerkships to year 2, with most of their rotations involving the presence of extra students from other classes.
Longitudinal course work in parallel with clinical rotations.
Several longitudinal curricular elements were introduced with the Hybrid Curriculum class. Courses in health systems science; research and inquiry; and medical humanities and ethics were designed to run throughout all phases of the curriculum. The Hybrid Curriculum students quickly noted redundancy as topics were revisited. Additionally, in the clerkship phase and beyond, there was a significant sense of competition between these longitudinal activities and a traditional view of student roles on clinical rotations.
Addressing the challenges.
The majority of concerns that students raised during their Hybrid Curriculum experiences had actually been identified as potential issues during the design phase by development teams (which included students). Decisions to proceed were deliberate and based on the educational rationale for such changes. The lived experience of students, however, was cumulative across all of these interventions. This led to a pervasive sense of instability that was not adequately anticipated by the administration. A laudable tradition among students at VUSM is a process of near-peer mentoring; it became apparent that some anxiety among the Hybrid Curriculum students was on behalf of subsequent classes. The Hybrid Curriculum class perceived much of the burden, but less of the cumulative benefit, that the true Curriculum 2.0 cohort would ultimately experience.
Five Student-Centric Considerations in Curricular Transition
Drawing from our experiences during this recent curricular transition, we propose five broad areas to manage when implementing student-centered curriculum change. Additionally, we describe specific ways students assisted in identifying these challenges and solutions. These considerations suggest that broad and continuous involvement by student representatives, starting from the planning stages and continuing into implementation and through maintenance of the new curriculum, is essential to curriculum transition success.
1. Communicate rationale
Through SCC-designed surveys, informal feedback, and town hall meetings, we found that the Hybrid Curriculum students’ lack of engagement with piloted Curriculum 2.0 elements largely stemmed from having insufficient background information for why these changes were taking place. Of course, the entry of a new class provides an obvious opportunity to set the stage for all subsequent learning by communicating “why” and “how” the proposed changes will benefit students in their careers. Notably, entering students had received detailed explanation of the differences and similarities across curricula. Students who enroll prior to a targeted revision pose a difficult situation because they have already practiced, and become successful, in a different learning environment and can be overlooked in the transition process5: Such was the subjective experience of students in the Hybrid Curriculum. If the rationale for change is not addressed early and often, educators may “lose” a key student population before the implementation of the curriculum has the chance to succeed. Administrators at VUSM correctly recognized this and used town hall meetings as venues to proactively educate existing students about upcoming changes. However, it was and will probably always be an uphill battle for administrators. When the University of California, San Francisco, School of Medicine’s curriculum changed, Loeser and colleagues5 write, “we found that no matter how much communicating we did, it was not enough.”
After identifying this deficiency, administrators developed targeted online prematriculation orientation modules for subsequent incoming classes. These modules introduced incoming students to the rationale behind changes, explained innovative learning modalities featured in their first year, and prompted each student to consider the challenges that Curriculum 2.0 posed and how the student might be successful in overcoming these challenges. Surveys of students matriculating in academic year (AY) 2013–2014, the first year of Curriculum 2.0, indicated that 78% found the modules helpful in understanding expectations. Importantly, 42% of incoming students reported that the modules influenced their perspectives on education, indicating the reach of this simple intervention. The use of an online preorientation module is a simple but effective method to communicate the rationale of a curriculum change.
Another unique consideration for a transitional class is messaging during the admissions process. Although not participating in the full Curriculum 2.0, members of the Hybrid Curriculum class were expected to benefit from some of the curricular innovations, and this could be viewed as an opportunity for prospective students. In complete agreement with Loeser and colleagues’5 recommendations, we advocate the greatest possible transparency about the role of a “hybrid” class in curricular transition from recruitment through matriculation, which may include piloting some course work, benefiting from new initiatives, and contributing to innovative curricular review as a student.
2. Acknowledge the multifactorial nature of anxiety
Since the beginning of curricular evolution at our institution, a common theme in student feedback was the anxiety that accompanies the changes. Annual questionnaires conducted by administrators showed an initial decrease in the self-reported amount of “wellness” by first-year students compared with classes before the curricular change. Scores in this metric for first-year students were historically between 19.1 and 20 on a 25-point scale, and dropped to 18.0 the first year of Curriculum 2.0 (AY 2013–2014). The conclusion drawn by students and administrators alike was that change brings uncertainty, which is uncomfortable and provokes anxiety leading to decreased perceived “wellness.” The SCC was able to quickly elucidate and articulate sources of anxiety that the administration could then address.
First, one aspect of the students’ anxiety was related to mastering new learning modalities and the development of new work and study habits. Learning to succeed in these new modalities takes time, and students will be understandably inefficient at first. As mentioned previously, introducing these novel educational concepts before starting medical school better prepares students to tackle these challenges from the start. Also, administrators can confidently reassure students that this period of adjustment is normal.
Second, student anxiety stemmed from the complexity of assignments needing completion. One goal of modern medical curricula is to expose students to the clinical environment as soon and as often as possible. Educators attempt to integrate and layer learning experiences within the clinical setting. However, the course in Curriculum 2.0 tasked with organizing this initial clinical experience inadvertently micromanaged the clinical environment. For example, students were given assignments that required describing their clinical duties in highly structured online forms with situation-specific questions, rather than allowing students to abstract their clinical duties pertinent to the assignment and reflect in a freeform manner. This regimented assignment design caused students to think more about completing the assignment than participating in and reflecting on clinical care. Moreover, this stacking of responsibilities increases the cognitive load for new medical students in an unfamiliar setting and causes the assignment to detract from, rather than supplement, the clinical experience. The SCC was able to rapidly identify inefficiencies within this particular course before a formal course review. SCC members stressed that faculty combine and streamline clinical assignments and use open-ended questions that could be easily applied to the individualized learning that occurs in the clinical setting.
Third, anxiety about potential impacts of curricular change on student performance in the USMLE Step exams is understandable, given the significant influence these scores have assumed upon placement in competitive residencies. VUSM had a strong track record in this area, and improvement was not an explicit goal of Curriculum 2.0; however, all stakeholders wanted to ensure that there was “no harm done.” Although ultimately student performance on USMLE Step 1 did indeed improve, particularly among lower performers, that perceived risk was a significant stressor.
Fourth, the novel curriculum altered peer-mentoring roles and disrupted the traditional advising channels. Previously, first-year students relied heavily on the informal advising from second-year students as to how to allot their time, maintain work–life balance, study effectively, and choose extra- and intracurricular opportunities to pursue. Although more senior students were preemptively educated about the new curriculum and sought to advise junior students as much as possible, the senior students found that they were not able to speak reliably about the specific demands and best practices of Curriculum 2.0. Additionally, second-year students in the new curriculum were engaged in their first clinical rotations and lacked the flexibility in scheduling to offer extensive mentoring. Without effective peer advising, junior students felt isolated and forced to “find their way” through a new curriculum, provoking anxiety.
With the help of the many student leaders, a multifaceted solution was organized to mitigate the anxiety associated with reduced peer-to-peer mentoring. One aspect was the development of Friday afternoon “Social Rounds” where all four classes could meet in the student lounge, relax, and catch up. Additionally, key administrative figures (e.g., dean of students, senior associate dean of health sciences education) established additional outlets (e.g., office hours, “Bagels with the Dean”) for students to communicate with them directly about the anxieties and frustrations they were experiencing. Through these and other solutions, students were able to play a critical role in identifying anxiety provocations within the new curriculum and providing solutions.
3. Adjust extracurricular leadership roles and encourage participation
Extracurricular activities are a means of achieving balance in life and education during medical school. Furthermore, as residency positions become more competitive, extracurricular experiences are an expected component of a strong resume. As small-group and team-based-learning modalities requiring in-person attendance dominated the Curriculum 2.0 schedule, students had less flexibility to fit extracurricular activities around their required academic load. A decrease in schedule flexibility translated into a perceived increase in academic load for junior students. Together, this resulted in decreased engagement of junior students in extracurricular activities as students either chose or were compelled to focus on academic studies to the exclusion of extracurricular pursuits.
One major example occurred at VUSM’s student-run clinic. The clinic provides not only a formative experience for students but also essential health care for uninsured or underinsured patients in our community. Traditionally, students gain experience in the clinic throughout their first year and transition to an organizational leadership role in their second year based on their first-year experience. These leadership roles are historically highly coveted and are some of the most significant extracurricular roles a student can hold. Having completed their clinical rotations, third- and fourth-year students provide the majority of patient care, supervised by a core faculty group. During the first year of Curriculum 2.0 (AY 2013–2014), the number of junior student volunteers waned as students perceived inadequate time to participate in the clinic. Then, on the wards in their second year, students were not expected to hold significant extracurricular roles because of clinical obligations. When third year came, few students had significant experience at the clinic, and few applied for leadership roles.
The administration foresaw how the changing clinical demands in the curriculum would alter traditional leadership roles in extracurricular activities. By proactively redistributing leadership roles to senior students, extracurricular organizations were able to maintain continuity. However, the extent of diminished participation on behalf of first-year students that, two years later, reduced the pool of students expected to carry leadership roles was not foreseen. Additionally, the student-run clinic originally asked fourth-year students to take these leadership roles. We now find that with hectic residency interview schedules, fourth-year students (graduating in 2016) are not the most appropriate group to lead extracurricular organizations. A shift will encourage the third-year class (graduating in 2017) to hold extracurricular leadership roles.
We recommend that leadership of extracurricular organizations be predominantly allocated to second- or third-year students—whichever is not primarily occupied with their initial core clerkships on the wards at their respective institution. Those students are sufficiently experienced in the school’s culture, are not burdened with their initial clinical experience, and are not occupied or distracted by the demands of an oncoming residency. On the administrative side, students should be encouraged and have the flexibility built into their schedules to participate in extracurricular activities early in medical school to gain exposure to a variety of extracurricular pursuits.
4. Manage “The Bulge”
As new curricula move to a shorter preclerkship phase, a greater portion of the student body will be in the clinical environment, which places learners with varying objectives, abilities, and experience together. Furthermore, the influx of learners can be detrimental if providing adequate learning opportunities is a strain on the clinical team. Although this facet of the curricular change was recognized beforehand, students were essential in providing feedback on specific issues and solutions for “The Bulge,” the colloquial term for a sudden increase in learners on the wards.
Solutions to “The Bulge” take two forms. One solution is to rethink where students are placed and employ underused clinical teams. The administration proactively identified previously untapped clinical teams and resources that could host students. Examples include affiliated community hospitals for obstetrics–gynecology rotations, affiliated community practices for neurology, and use of additional Veterans Affairs hospital teams. Students supplemented this effort by providing feedback based on their personal experience on clinical teams such that course directors could best distribute students. For example, students identified our surgical transplant service as being able to accommodate a greater student load without sacrificing learning opportunities, while our “GI (gastrointestinal)–laparoscopic” surgical service afforded a better experience with fewer students. A second solution is to embrace the opportunity for peer mentorship such that course directors are deliberate about placing senior and junior students together rather than segregating the class years. Faculty and residents are familiar with having learners of different levels on a single service, since third- and fourth-year students have shared the clinical space for decades. Curriculum 2.0 involves a more diverse and nuanced course catalog that targets specific student-driven topics; this necessitates faculty development and empowerment of students to clarify learning priorities with their clinical teams
5. Foster ongoing collaboration between students and administrators
The transition to a new curriculum is a lengthy process with many small adjustments following the initial major change, and each subsequent adjustment is significant to students. Invariably, small changes will be necessary but can erode student confidence if not communicated well. Relying on an SCC or similar group of student leaders to discuss upcoming changes and how to present them to the student body is imperative to successful implementation of a curriculum. Furthermore, the involvement of student representatives at all levels of curricular review allows for increased student ownership of the curricular implementation.
At our institution, administrators anticipated the need for “rapid-cycle” feedback sessions (every two to three weeks) where student representatives meet with faculty leaders to discuss any issues with which students were struggling or actionable items that could rapidly improve the learner experience. For example, in the Foundations of Medical Knowledge phase (year 1) of Curriculum 2.0, there was a considerable amount of content that was delivered via new modalities such as team-based and case-based learning. We used rapid-cycle feedback to notify course directors when learning objectives were not being met, allowing for the addition of supplemental sessions or review materials to fill in gaps in knowledge.
These rapid-cycle meetings also allow faculty to present upcoming changes and receive feedback from the students on messaging these changes. An example from the Immersion Phase (years 3 and 4) of Curriculum 2.0 was the proposed addition of a problem-based learning assignment to accompany clinical months. Standing rapid-cycle feedback meetings allowed for students to voice concerns regarding the impact of the assignment on the student experience during the rotation. We were able to make adjustments to the assignment before its release to maintain its value and objectives without negatively impacting the students’ clinical experience. Holding regular standing rapid-cycle feedback meetings between students and faculty leads to a sense of trust and collaboration—an important component of smooth curricular transition.
Our recommendations for inclusion of medical students as primary facilitators in the curriculum reform process complement and extend previous authors’ work on the topic. Bernier and colleagues’6 list of eight “Barriers Encountered and Processes Used to Overcome Them at Two Medical Schools” does not include a single challenge created by student receptiveness to the new curriculum, but it does include several faculty- and administration-centered concerns. To complement this list, we would add a ninth barrier—student reception of curriculum—and our proposed solutions for optimal implementation. The difference between Bernier and colleagues’ list of barriers and our own reflects recent evolutions in change-management theory originally put forth by Kotter.13 In the 2014 update to his seminal work, Kotter emphasizes (1) continuous feedback to the change-management process, (2) recruiting “buy-in” from a broad participant base, (3) functioning flexibly within and outside of a traditional hierarchy, and (4) constantly seeking out and capitalizing on new opportunities.13 According to Kotter, an administration interested in making student-centered curriculum changes in the 21st century would benefit from a more inclusive change-management team looking to iteratively and creatively capitalize on real-time information and opportunities, such as those that percolate up from current students. Therefore, we are emboldened to advise any administrations considering student-centered curriculum change to utilize their student body’s full potential and dynamically respond to challenges as they arise.
We submit that it is critical throughout the reform process that the academic institution maintain its culture and priorities. The institution must have a clear sense of itself and what it hopes to change and, equally important, what it wishes to stay the same. In their review of McMaster University’s problem-based learning curriculum over the last four decades, Neville and Norman14 encourage us that a medical school can undergo significant change without losing sight of its core mission. While still in the process, students and faculty at VUSM have strived to maintain the culture of academic rigor and student wellness that have defined this institution.
Our five considerations are not exhaustive, and the specific examples provided may be particular to the culture and values at our single institution. Other institutions that plan to implement major curricular reform may have a different set of cultural norms and identities that they wish to maintain through this process.
Multiyear, longitudinal studies of academic performance on USMLE exams, residency matching, participation in extracurricular activities, and student-perceived wellness will be needed to fully characterize the outcomes of VUSM’s current curriculum change. This Perspective qualitatively validates the benefits of increased student participation in curriculum reform; however, it reflects the experience of a single institution with a strong history of student involvement. This Perspective would benefit from reviews and viewpoints of student involvement at other institutions undergoing similar curriculum changes.
Our experience of large-scale, student-centered curriculum change demonstrated that students themselves were a productive resource for aiding this transition. Five specific considerations when making these curricular changes are to (1) communicate the rationale, (2) acknowledge anxiety, (3) adjust extracurricular leadership roles and encourage participation, (4) manage “The Bulge” of learners in the clinical environment, and (5) foster collaboration between students and administrators. Regardless of the unique details of curricular change across institutions, the core principle of actively engaging students in all aspects of revision remains essential to success.
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