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Curricular Transformation

The Case Against Global Change

Borkan, Jeffrey M., MD, PhD; George, Paul, MD, MPHE; Tunkel, Allan R., MD, PhD

doi: 10.1097/ACM.0000000000002147
Invited Commentaries

In this Commentary, the authors make the case for medical schools to pursue more circumscribed solutions to curricular redesign for undergraduate medical education rather than whole system changes—at least as first steps and perhaps as ultimate solutions. Although they focus primarily on the experience at the Warren Alpert Medical School of Brown University (AMS), they believe that the insights gleaned from their experiences are generalizable to other innovations and other medical schools. The authors describe the implementation of the Primary Care–Population Medicine track at AMS as a working example of implementing circumscribed rather than global change, and they discuss the advantages and disadvantages of such an approach to curriculum transformation.

J.M. Borkan is assistant dean for primary care–population medicine and chair of family medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island; ORCID: https://orcid.org/0000-0003-1385-4737.

P. George is assistant dean for medical education, director of clinical curriculum, and associate professor of family medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island; ORCID: http://orcid.org/0000-0001-7433-9099.

A.R. Tunkel is associate dean for medical education and professor of medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island.

Funding/Support: Part of the funding for the Primary Care–Population Medicine program comes from the American Medical Association and the Rhode Island Foundation, both of which have provided financial and creative support.

Editor’s Note: An Invited Commentary on this article by J.D. Gonzalo, T. Wolpaw, and D. Wolpaw appears on pages 1431–1433.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Correspondence should be addressed to Jeffrey Borkan, Department of Family Medicine, MHRI, 111 Brewster St., Pawtucket, RI 02860; telephone: (401) 729-2238; e-mail: Jeffrey_Borkan@brown.edu.

Although transforming medical school curricula is a formidable task, it may be optimally achieved through pilots, initiatives, or the development of specific tracks for a portion of the medical school class rather than globally for all students. In this Commentary, we make the case for medical schools to pursue more circumscribed solutions to curricular redesign for undergraduate medical education (UME) rather than whole system changes—at least as first steps and perhaps as ultimate solutions. Although we will focus primarily on the experience at the Warren Alpert Medical School of Brown University (AMS), we believe that the insights gleaned from our experiences are generalizable to other innovations and other medical schools.

Achieving curricular transformation on an institutional scale is dependent on successfully navigating several key steps including (1) developing “big” or novel ideas for curricular transformation; (2) successfully managing the politics of change, which are often rooted in and deeply affected by the culture of the local community; and (3) attending carefully to each stage of the transformation process—from planning to implementation to evaluation. These three steps are also necessary for undertaking pilot initiatives, but many of the obstacles and challenges encountered for such limited changes are more manageable and more palatable compared with those associated with global change.

Examples of circumscribed pilot curricular initiatives or tracks abound. One is Duke University School of Medicine’s primary care leadership track. The track was introduced to enable students to pursue community-based research and participate in leadership training, with the end goal of matching into primary care residency programs.1 At the University of California, Los Angeles, the PRIME program offers students the opportunity both (1) to pursue a master’s degree in addition to a medical degree (MD) (in five years), and (2) to learn about health care research and delivery.2 The scholarly concentrations (SC) program at AMS, one of the first in the United States, serves as another example of introducing a curricular offering to only self-selected, interested students.3

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Implementing Health Systems Science at U.S. Medical Schools

Medical school curricula are often evolving, and implementing change is an ongoing concern; however, transformation is especially relevant now as medical schools begin to offer courses in Health Systems Science (HSS), which Skochelak and colleagues4 have defined as “the principles, methods, and practice of improving quality, outcomes and costs of health care delivery for patients and populations within systems of medical care.” HSS, the “third science” of medical education (complementing the basic and clinical sciences), is an amalgamation of related topics, such as health care financing, teamwork, information technology, the social determinants of health, and population health management—knowledge of which is increasingly required for trainees and graduates to function successfully in contemporary health care systems. We believe that HSS represents one of the most significant innovative contributions of the Accelerating Change in Medical Education initiative, an effort of the American Medical Association (AMA) through which a consortium of 32 U.S. medical schools are working together to create the medical school of the future.5

Incorporating HSS into medical curricula is necessary and innovative; however, global implementation has been challenging for some schools. Requiring substantial HSS content for all students likely requires major curricular overhauls, including the reallocation of focus and time, the redirection of resources, and significant faculty development. Efforts to incorporate HSS globally at some of the lead consortium schools have been met with variable, but pervasive, degrees of resistance. Gonzalo and colleagues6 have recently published some of the concerns about integrating HSS into medical education for all students. These concerns range from “If medical education isn’t broke, don’t fix it” to “There is limited space in an already packed curriculum” to “Few faculty have the knowledge and skills to teach Health Systems Science.”7 Other medical school faculties, which are not part of the AMA consortium and have not been exposed to the development and evolution of HSS, may experience even more resistance with the formal incorporation of this new science into their curricula.

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Curriculum Reforms at The Warren Alpert Medical School of Brown University

A more attractive and viable alternative may be to initially introduce reforms, such as the implementation of HSS, into UME as a pilot or track rather than globally at the institutional level for all students. To illustrate, we describe here how medical education leaders introduced the Primary Care–Population Medicine (PC-PM) track to AMS medical students in 2015. The PC-PM track allows students who apply and are selected to focus on HSS and complete a master’s of science (ScM) in population medicine (a unique graduate degree program developed at AMS) while also meeting the requirements for an MD.8 The program, which integrates medical and population medicine science, requires students to take nine courses over the four years of their UME training, concurrently with their medical school classes. PC-PM students also complete a longitudinal integrated clerkship (LIC); that is, they take all of their clinical clerkships together as an integrated whole, rather than sequentially in a more traditional block model.

Medical education leaders at AMS realized early that the program would radically change how medical students were educated, that it would require additional resources, and that it would shift the focus of the medical school by significantly integrating new HSS content and implementing the LIC (with which most faculty at the time were unfamiliar). They decided, therefore, that a circumscribed approach to implementing the content—as a track—would be the most viable path forward. They were concerned that buy-in from stakeholders might be difficult to achieve if they attempted to overhaul the curriculum for all students. To help ensure the PC-PM track’s success, AMS leaders used Kotter’s framework for the development of new initiatives and offerings (see Table 1).9 The PC-PM track launched in the fall of 2015, and the first cohort of 16 students is expected to graduate with a dual MD/ScM in 2019.

Table 1

Table 1

Specific tracks and programs can spread innovations, thereby influencing the entire medical school. One unintended, but positive, consequence of the development of the PC-PM track has been the realization that at least part of the content, including an entire course on the social determinants of health and health disparities, as well as the longitudinal patient care experiences made possible by the LIC, should ideally be offered to all students, not just those in the PC-PM track. As a result, all AMS students now take the first course in the master’s sequence, entitled Health Systems Science I, which was originally intended for just the students in the PC-PM track. AMS is also actively exploring opportunities to create longitudinal experiences as a pilot for selected non–PC-PM students during their clinical clerkships. Given the successful implementation of such longitudinal patient care experiences at the micro (track) level, the need to convince key stakeholders of the importance of this integration has decreased markedly.

At AMS, we have also successfully used the method of implementing change on a limited basis in other endeavors. One such success is the SC program, through which students have the opportunity to take additional didactic classes and enjoy research experiences in a subject area related to medicine, but not typically included in any depth within the curriculum (such as global health, medical education, or biomedical informatics).3 As with the PC-PM track, some elements may ultimately be incorporated into the core medical curriculum, but interested students and their mentors benefit from deeper exposure to a subject area of interest, and participating students have the opportunity to pursue scholarly activities (e.g., publishing) as part of their concentration. This approach to SC differs from that of other medical schools which require scholarship (e.g., Duke, Yale, and Stanford), and it is consistent with the educational philosophy at Brown University which emphasizes individual student freedom and initiative.

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Advantages and Disadvantages of Piloting Curriculum Change

Implementing partial, rather than global, curriculum transformation has multiple advantages, many of which we have learned through our experiences with either the PC-PM track or the SC program. For example, piloting particular curricular elements, especially those with high degrees of innovation and experimentation, can occur with much less disruption to the education of the entire medical school class and with greater ease of later modification. By taking a more circumscribed approach rather than a global approach to curriculum transformation—as in the PC-PM track and SC program—AMS has saved resources (financial, faculty, leadership, etc.) for other endeavors, avoided costly errors, and facilitated participation of the “right” students. Circumscribed curriculum changes, implemented as tracks or voluntary programs, can engage students who are highly motivated and more tolerant of ambiguity and change. In addition, pilots, by their nature and scope, are much less threatening to the existing hierarchy and status quo. The pilot approach also introduces “dosing” possibilities. For example, all AMS students receive some HSS content; those who desire more (a self-selected audience) can apply for admission to the PC-PM track as part of their application to medical school. Finally, pilots that work and for which evaluations are positive can be rolled out to the greater student body with increased assurance that they will succeed.

Of course, the pilot or track approach has disadvantages as well. For those who desire quick curricular innovation and change, this model is slow and perhaps clunky. It does not allow for rapid implementation of content that may be important for all medical students. In addition, tracks and similar programs have the potential to produce factions or discord among the student body; nonparticipating students may be resentful that they are not getting the same content as their peers (although, conversely, the movement toward individualization is growing). Finally, developing multiple pilots or tracks increases the cost of medical education; program directors could easily argue that the most cost-effective medical education format is a one-size-fits-all model—not one including specialized tracks and programs.

The pilot or track approach may not be right for all medical schools or for all innovations. As noted by Bland and colleagues,10 smaller medical schools and those with more narrow goals may find undertaking these types of approaches unnecessary, and their finite resources may also limit their scope of action. These approaches may also not be appropriate at medical schools where the faculty is not engaged and has a limited role in curricular innovation. Finally, pilots or tracks may not be advisable in situations where medical schools lag far behind widely incorporated medical school norms and are playing curricular “catch-up.” Such was the case at AMS regarding the Doctoring Program which was incorporated for the entire school in the early 2000s, long after such innovations had been introduced at nearly all neighboring schools and across the United States.

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In Sum

Curricular transformation in UME is critical if medical educators are to successfully train the physician workforce to meet the present and future needs of the population and to work effectively in the health care system. The stakes are high, and the way forward is unclear. As medical educators strive to create the medical school of the 21st century and beyond, global change may appear attractive, but circumscribed changes may be more palatable, prudent, achievable, adaptable, and sustainable.

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Acknowledgments:

The authors thank the leaders, staff, and members of the American Medical Association Accelerating Change in Medical Education Consortium and the many university leaders, deans, faculty, staff, and students at The Warren Alpert Medical School of Brown University who have contributed to the Primary Care–Population Medicine program and other curricular innovations at Brown.

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References

1. Duke University School of Medicine. Primary care leadership track. https://medschool.duke.edu/education/degree-programs-and-admissions/primary-care-leadership-track. Published 2017. Accessed January 26, 2018.
2. University of California, Los Angeles David Geffen School of Medicine. UCLA PRIME. http://medschool.ucla.edu/prime. Accessed January 26, 2018.
3. George P, Green EP, Park YS, Gruppuso PA. A 5-year experience with an elective scholarly concentrations program. Med Educ Online. 2015;20:29278.
4. Skochelak SE, Hawkins RE, Lawson LE, Starr SR, Borkan JM, Gonzalo JD. Health Systems Science. AMA Education Consortium. 2016.Philadelphia, PA: Elsevier;
5. American Medical Association. Creating the medical school of the future. https://www.ama-assn.org/education/creating-medical-school-future. Accessed January 26, 2018.
6. Gonzalo JD, Caverzagie KJ, Hawkins RE, Lawson L, Wolpaw DR, Chang A. Concerns and responses for integrating health systems science into medical education. Acad Med. 2018;93:843–849.
7. American Medical Association. Health systems science and value-added roles for medical students. https://www.ama-assn.org/sites/default/files/media-browser/public/aps/i16-aps-gonzalo-presentation.pdf. Published 2016. Accessed January 26, 2018.
8. Alpert Brown Medical School. Primary care–population medicine program. https://www.brown.edu/academics/medical/education/other-programs/primary-care-population-medicine/. Accessed January 26, 2018.
9. Kotter International. 8-step process. https://www.kotterinternational.com/8-steps-process-for-leading-change/. Published 2017. Accessed January 9, 2018.
10. Bland CJ, Starnaman S, Wersal L, Moorehead-Rosenberg L, Zonia S, Henry R. Curricular change in medical schools: How to succeed. Acad Med. 2000;75:575–594.
© 2018 by the Association of American Medical Colleges