Yesterday as I was carefully backing up my car into the driveway, my neighbor came by and described how much easier it would be for me if I had a car like his with a camera in the back and a large screen that provided a view behind the car. “It’s a safety issue,” he explained, knowing how I felt about automobile safety.
“I know,” I said. “But I don’t mind looking back over my shoulder. I’ve never had an accident backing up.” While what I was saying was true, it was not the entire reason why I did not want to trade in my car for a newer one with a fancy camera. I was resisting my neighbor’s advice because I generally don’t change cars until the one I’m driving wears out. I like the familiarity of my car after I have driven it for many years. I know what its quirks are and what to anticipate in bad weather. A new car with a camera would mean I would have to trust the camera to see everything that I could when I looked over my shoulder, such as someone walking toward the car or a bike approaching from the side. It would also mean learning new features that would come with my car, like doors that would automatically lock, headlights that would turn on and off by themselves, and the automatic key I could keep in my pocket rather than insert into the ignition. Clearly, each innovation comes with both advantages and drawbacks.
Later, as I pulled out of the driveway and headed to work, I pondered the exchange I had just had with my neighbor and realized that it reminded me of the topic of this editorial, which is about the implementation of health professions curriculum changes and the various barriers to and facilitators of change. I wondered whether my reaction to upgrading my car might be analogous to the reactions many faculty have to proposals to reform the curriculum at their medical school. Like me and my car, they are familiar with how the curriculum works and how its various elements fit together, and are probably worried about the unintended consequences of a major change. They do not mind minor adjustments to the curriculum—just as I do not mind buying new headlights or replacing the brakes of my car—but likely feel that a major overhaul or a new curriculum could create extra work and confusion, and could not only put at risk the good results the students are achieving with the current curriculum but could also affect the safety of patients who are cared for by the students.
The challenge of curriculum change has been the struggle between those advocating fundamental changes—with new content, methods, and structure—and those resisting the changes, since they are basically satisfied with the curriculum. The latter group may be willing to make minor adjustments and upgrades to accommodate new content but not a fresh start to the curriculum. Because the goals for medical education are typically general and vague—such as “preparation of medical students for the practice of medicine”—there is no clear way to prioritize suggested new topics or courses. Instead, decisions about what is included and what is excluded from the curriculum may be based on the effectiveness of the advocates for change, the institutional political dynamics of decision-making committees, and the culture of the medical school. While making minor curriculum adjustments is often an optional and gradual process that can be accomplished through negotiation and compromise, there are also times when there seems to be a need for fundamental, radical reform. In this issue, Borkan et al1 and Gonzalo et al2 provide differing views about the best approaches for major curriculum change.
Curriculum Change Through Development of a Track
Borkan et al1 describe the development of the Primary Care–Population Management track for 16 students per year; it includes nine courses for a master’s of science in population health that will be taken concurrently with the undergraduate medical degree program and will also include an integrated longitudinal clinical clerkship model. They note that having a track rather than a universal curriculum change has engaged students who are highly motivated, been less threatening to existing hierarchies, required fewer resources, avoided costly errors, caused less disruption, and allowed for incorporation of selective elements of the program into the curriculum for all students. Their comments are reminiscent of an innovative primary care problem-based track described by Kaufman et al3 that I participated in 30 years ago that functioned side by side with the traditional curriculum. Kaufman et al explained that
a small track would provide a protected environment where the experiment could be nurtured by a small group of committed educators and adventuresome students without wholesale impingement upon the conventional track.
They identified four barriers to curriculum change: fear of loss of control; comfort with the status quo; seeing academic promotion as more related to research and clinical services than education; and seeing educational innovation as too costly in time, money, and resources. They found that they were able to overcome those barriers by encouraging broad ownership of the innovation from the outset, finding converts by encouraging participation rather than intellectual conversation, forming new alliances to broaden support, and sharing the rewards broadly.
Curriculum Reform Through Global Change
Gonzalo et al2 provide an alternative argument: They see curriculum reform as a global institutional process. They believe that some curriculum changes are so fundamental and transformative that all students need to participate in them. They also believe that health systems science (defined later) is a key pillar of medical education, like basic and clinical sciences. They believe that rather than trying to fit in the curricular changes around the existing curriculum, “We must start with our desired outcomes and goals and work backward to reimagine our classroom and experiential learning agendas.” The goal of reform is to prepare students with the basic understanding of health systems just as they have been traditionally prepared with a basic understanding of bioscientific principles. Both forms of preparation enable students to solve both clinical and care delivery problems of patients and to consider how to improve population health rather than limit their focus to providing health care.
In this issue, Stevens4 discusses the difficult choices in curriculum reform between changing how we teach the basic mechanisms of disease—which can provide a foundation for informed clinical decision making—and integrating what both Borkan et al and Gonzalo et al describe as health systems science, which includes clinical epidemiology, appraisal of clinical trials, high-value care, stewardship of costly medical technology, and shared decision making.
Alignment of Curriculum and Health Systems Goals
Lucey5 has suggested that “we sunset the target of the personally expert sovereign physician and in its place target the development of the collaboratively effective systems physician.” I believe that such a physician would be motivated to learn the material advocated by Borkan et al and Gonzalo et al, which emphasizes health systems science and how students have a critical role in using the systems to improve quality of care. However, to arrive at a consensus that health systems science is a fundamental pillar of medical student education, we need to agree on the purpose of medical education. Will a listing of agreed-upon competencies for medical students provide that consensus? Or is there something more cohesive and memorable that aligns medical education with goals of the health care system, such as better health, lower cost, better health care, and wellness of health professionals?
Sklar and Lee6 have suggested that a medical school’s curriculum could be developed by working backward from the desired outcomes of high-quality medical care, which would better align medical education and clinical care. If a medical school’s leaders could reach a consensus that the curriculum should be fundamentally changed in this way, then they would next need to decide whether Borkan et al’s approach or Gonzalo et al’s approach would be more compatible with the institutional culture of the medical school. School leaders would also have to take into consideration the other stakeholders who would be affected by the change, as well as other features of the educational and health care environment that could either nurture or impede curriculum change.
The Importance of Students in Implementing Curriculum Change
Probably the most important stakeholders for curriculum change are the students who will be affected by the new curriculum. Yengo-Kahn et al7 describe key issues that were of concern to medical students in the curriculum reform at Vanderbilt and suggest that curriculum reformers should (1) communicate the rationale, (2) acknowledge students’ anxiety, (3) adjust extracurricular leadership roles, (4) manage “the bulge” of learners in the clinical environment, and (5) foster ongoing collaboration of students and administrators. As the major stakeholders in the curriculum, the students must always be included in all phases of the planning, implementation, and evaluation of curriculum change.
Influence of the Clinical Environment on Curriculum Change
Curriculum change cannot be viewed in isolation from the clinical care environment. In this issue, Henderson et al8 describe a moral dilemma at the University of California, Davis Health (UCDH) system—which includes the University of California, Davis, School of Medicine (UCDSOM)—when the clinical practice environment changed. The authors note that
since its founding, UCDH has earned a reputation for educating primary care physicians and serving the area’s poor and disenfranchised. In recent years, however, these traditions have proved an insufficient bulwark against perceived economic realities, and in 2015 UCDH terminated its last Medi-Cal primary care contract. Despite being a nonprofit, state-designated public hospital system, UCDH no longer routinely accepts Medi-Cal patients in most of its primary care clinics…. This retreat from Medi-Cal has prompted medical student, housestaff, and faculty protests as well as public criticism.
The authors go on to describe the effects of this change on the students and on the residents, who have lost patients with whom they had established relationships and opportunities for learning. The authors note that
UCDSOM students, a third of whom come from ethnic or racial groups underrepresented in medicine, have become discouraged because their institution no longer provides primary care to patients from their communities.
This is a case where even with a curriculum that emphasizes health equity, the clinical reality of denial of access to care for a class of patients will undercut what is taught in the classroom. What happens in the clinical environment must reinforce what is taught in the curriculum or the students will become confused and may abandon what they previously learned. The authors recommend the development of innovative models of primary care to go along with UCDH’s unique tertiary care programs. They conclude with the following warning:
Ultimately, the failure to tackle issues of access and quality for the most vulnerable may represent the biggest risk of all—abandoning our moral compass and the values on which medicine was founded.
A similar challenge has been noted in the area of interprofessional education (IPE). Paradis and Whitehead9 in this issue note that
young graduates who participate in prelicensure IPE often come to expect collaborative practice, but the workplace can be radically different. Without structures to support collaborative care delivery, students cannot become the collaborative clinicians they hoped to be.
Brandt et al,10 also in this issue, describe hopeful signs of interprofessional collaboration that they believe will overcome cultural differences that have resisted progress in IPE and practice. Bodenheimer et al11 in this issue describe visits to primary care IPE and clinical care practices from across the country, where IPE and practice programs appear to be working successfully. They conclude:
More is required than didactic lectures or intermittent consultations; repeated longitudinal collaborative care of patients is needed.
Recommendations for Implementing Curriculum Change
Based on what I have learned, I have three suggestions about implementing curriculum reform.
- Curriculum reform can be categorized either as fundamental to the training of all medical students or as an optional addition to the educational program that can be chosen by students based on specific interests and career goals. When the reform appears to be a fundamental curriculum change, it may be addressed either at a comprehensive institutional level with support from leadership, or it may be introduced as an alternative track that can operate in parallel with the traditional track, with the possibility that the two tracks may eventually be merged. The choice of approach will depend on institutional culture and resources, and either approach can be successful.
- Minor curriculum adjustments and optional tracks and programs provide flexibility for students and can often be implemented without threatening institutional hierarchies or values. At some medical schools, the review of the allotment of curriculum time has resulted in a reduction of the required time for basic sciences, providing new opportunities to offer tracks that emphasize areas that may correspond with future career aspirations of students, such as clinical research, global health, administration, health policy, public health, humanities, or medical informatics.
- Curricular change cannot be viewed in isolation from the clinical care environment. What is taught in the classroom must be consistent with what is practiced in the hospital and clinic. The alignment of clinical and educational goals and values should be part of the implementation of curriculum change, to reinforce the importance of new learning in clinical practice.
Implementation of curriculum change can be difficult because, in addition to the basic intrinsically human resistance to change, there are other substantial barriers. These include the standardized examinations, which increasingly determine whether students will be selected for an interview for the specialty of choice; the hidden curriculum; and assessment frameworks that may reward those competencies that are most easily measured rather than those that are most important for patients and communities. Students will spend much of their time using learning resources that they believe will most efficiently prepare them to succeed on National Board of Medical Examiners tests regardless of what is included in the explicit curriculum. After the preclinical curriculum, they will respond to the messages they receive from the hidden curriculum of observed clinical behaviors and to advice about how to succeed on clinical rotations. And they will focus much of their time during clinical clerkships on demonstrating their medical knowledge on multiple-choice specialty exams, knowing that performance on exams is often considered a more valid and objective measure of performance than the opinions of the residents who observe them in their daily clinical setting.
As we consider implementing curriculum change, we must engage those who design assessment tools and programs so that they are consistent with the goals and values of our curricula. Our implementation of curriculum change must go hand in hand with our implementation of assessment change, and both must be aligned with the goals and values of our care delivery system. In addition, if we say that we value health equity and teach that to our students, we must demonstrate that we are serious by how we design our clinical care systems to provide equitable care. If we provide experiences of IPE and expect our medical students to trust and learn from their colleagues in nursing and pharmacy, we must demonstrate how interprofessional care improves our patients’ outcomes.
Implementation of curriculum change can be exciting and frightening, but I encourage our community to move curricula forward in the many ways that have proved to be successful so that our students are prepared for the health systems of the future.
David P. Sklar, MD