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Invited Commentaries

Applying the Hedgehog Concept to Transform Undergraduate Medical Education

Ginzburg, Samara B. MD; Willey, Joanne M. PhD; Bates, Carole MPH, MBA; Santen, Sally A. MD, PhD; Battinelli, David MD; Smith, Lawrence MD

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doi: 10.1097/ACM.0000000000002564
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Creating a new medical school offers rich opportunities for innovation. Medical schools that have opened since 2000, sometimes called “millennial” medical schools, have devised original approaches to navigate political, geographic, and financial constraints while introducing fresh approaches for distributed learning. However, these efforts have fallen short of pioneering change in the design of undergraduate and graduate medical education (UME and GME) to meet future health care workforce needs.1 Transforming medical education also requires shifting programmatic focus to align educational goals with the burgeoning societal and technological pressures shaping the future of health care delivery in the United States.

Rethinking the roles of educators, students, and physicians is necessary. Traditional physician responsibilities are shifting, and the medical profession needs to reevaluate previously held notions of what a physician does and does not do. Driving this shift are the ever-changing nature of health care delivery systems as medicine moves toward providing team-based care and emphasizes efforts to reign in unsustainable costs without reducing quality of care. Information technology is exploding, giving rise to data-driven medicine and informed patients who actively select their care and caregivers. Future physicians must learn to value the scientific principles that underpin clinical medicine and to practice in a health care environment that is increasingly interdisciplinary. Medical educators must incorporate these concepts into UME to produce competent and confident clinicians who execute appropriate, cost-conscious patient care while demonstrating the ability to lead, work in, and devise new models for health care teams with a focus on patient satisfaction. Attending to the development of these essential skills in future physicians requires a novel approach.

Applying the Hedgehog Concept to Transforming UME

In the business text Good to Great: Why Some Companies Make the Leap … And Others Don’t, Jim Collins2 introduces the “hedgehog concept.” Collins draws upon the Greek poet Archilochus, who wrote that “the fox knows many things, but the hedgehog knows one big thing.” Like the hedgehog, Collins argues, companies with a singular focus are more likely to succeed, thereby transforming from “good to great.” Collins defines three hedgehog principles: (1) the organization’s passion, (2) what the organization sees the opportunity to be the best at, and (3) the drivers of the organization’s economic and resource engine. The intersection of these three principles identifies the organization’s hedgehog concept, which is the single mission that can be used to guide the organization’s key decisions and drive its overall success (Figure 1). Application of the hedgehog concept instills organizational discipline to decline opportunities that fail to align with the concept.

Figure 1
Figure 1:
Application of the hedgehog concept to undergraduate medical education. The hedgehog concept is defined by the intersection of the three hedgehog principles, as illustrated here. Adapted with permission from Jim Collins, Good to Great: Why Some Companies Make the Leap … And Others Don’t.2

Nonprofit organizations have employed the concept,3 but the medical education community—passionate about creating innovative curricula to produce graduates prepared to excel in GME and practice—has not previously reported applying the hedgehog concept to educational transformation. We propose the adoption of a hedgehog concept to transform UME and align it with 21st-century health care delivery needs. As illustrated in Figure 1, passion should motivate the medical education community to create innovative UME curricula by challenging the status quo of existing training paradigms. To meet future challenges in health care delivery, the community should rethink how to leverage health system resources to be the best at training graduates to excel in systems-based care. Success requires aligning the institutional economic and resource engine (e.g., human and infrastructure resources, reputation building) with this passion and expertise. Only when institutional leaders support all three principles can the hedgehog concept be realized and medical education transformed.

In this Invited Commentary, we describe how we applied this hedgehog concept to unite UME program and health care delivery goals at a millennial medical school, the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell (Zucker SOM), which was founded as a partnership between Northwell Health and Hofstra University. Zucker SOM graduated its first class in 2015 and has a full complement of 100 students per year.

Hedgehog principle 1: Passion

To succeed, an organization must discover its passion. Collins2 posits that an organization goes from “good to great” by pursuing goals about which its workforce is passionate, rather than trying to create passion for what is being done. In UME, creating innovative curricular experiences to prepare learners for future health care workforce and delivery system needs demands visionary educators whose passion to innovate makes them unafraid to challenge the status quo.

Prior to opening Zucker SOM, our leadership teams traveled nationally and internationally to visit other medical schools and meet with medical education experts, thought leaders, and reformers to ensure that we understood the issues impeding and advancing innovation in medical education. This prompted insights into curricular experiments, identification of the greatest barriers to change in medical education, and thoughtful discussions to define learning experiences and high-value skills for our trainees.4

Of paramount importance was the elimination of silos and territoriality that stonewall curricular change. Our solution was to create an interdisciplinary Department of Science Education (DSE) that includes basic scientists and clinicians who design and deliver curricula together. Neither basic science departments nor individuals “own” courses or curricular time. Instead, the first two years of our curriculum consist of seven fully integrated courses that are taken one at a time.5 Faculty operate under a mandate to include only paradigmatic illnesses, relieving them of the burden of trying to cover everything and promoting a conceptual approach to learning.

Contact time with learners is limited, protecting time for self-directed learning. New curricular content is integrated into existing sessions or replaces less valuable sessions. Students prepare outside of class for faculty-led, interactive sessions in which they are held accountable for applying information. For example, we have eliminated anatomy as a course and instead provide our students with a two-year longitudinal experience. Every week, students explore a body system through patient-centered stations, examining components of anatomy, embryology, histology, pathology, interpretation of medical imaging, skills-based point-of-care ultrasonography, and physical diagnosis. This is done in small groups with faculty serving as facilitators of problem exploration. Students research learning objectives in advance of class and assess their understanding through these application exercises. Faculty who are receptive to nontraditional approaches in UME and an infrastructure that supports these approaches pave the way for inclusion of experiential learning opportunities specific to training for future workforce needs.

Hedgehog principle 2: Be the best at

An organization must also examine and understand its area of expertise.2,3 For UME, we submit that this principle requires leveraging health system resources to be the best at training graduates to excel in systems-based care. However, traditional UME models do not adequately prepare learners to deliver high-value, team-based, and cost-conscious care, most of which will occur in ambulatory settings and will include growing use of telehealth and population-based predictive data.1 New training experiences based in care models designed to deliver this type of health care are needed.

Zucker SOM’s founding dean (L.S.) and dean for medical education (D.B.) also serve as physician-in-chief and chief medical officer, respectively, for Northwell Health, the 14th largest health care system in the United States. This facilitates our access to health system resources. We provide early, community-based experiences by using Northwell Health’s Emergency Medical Services to train our learners to work effectively in health care teams as emergency medical technicians (EMTs) during their first course of medical school.6,7 Subsequently, and continuing throughout the first two years, our students participate in longitudinal, one-on-one clinical experiences with preceptors in five disciplines. Rather than shadowing, students are entrusted, as a result of their EMT certification, to engage in weekly, authentic ambulatory clinical activities.7 We reject the notion that learners should not be allowed to talk with patients prior to understanding their specific pathology and embrace learners’ early application of the three-function model during medical interviews.8 To that end, an intensive seven-week communications curriculum begins the first week of medical school and launches a four-year curricular thread. This longitudinal curriculum emphasizes the development of interpersonal skills and the physician’s role of educator and coach, as patients can increasingly access the same online medical information as their health care team. Being entrusted to interact with patients one-on-one then provides opportunities for the deliberate practice9 of clinical reasoning and skills. In addition, our hybrid case/problem-based learning program extends beyond contextualizing biomedical sciences within the drivers of changes to health care and includes training in leadership, process improvement, and teamwork.10 Communications skills, ambulatory clinical encounters, and team-based care11 are assessed quarterly the first three years via individual clinical skills exams and high-fidelity team-based simulations in Northwell Health’s Patient Safety Institute and Clinical Skills Center.

Our clerkships are designed for students to develop understanding of the high-value continuum of care, rather than for convenience for teaching. This results in clerkships that include more time in ambulatory settings as well as time in complementary services; for example, our neurology clerkship includes neurosurgery and physical medicine and rehabilitation. Learners regularly consider costs of care and patient satisfaction by working in interdisciplinary teams on accountable care units. The fourth year includes three required subinternships, wherein learners are given autonomy to function as interns responsible for patient care (with lower volume). For electives, students are counseled to select experiences that complement their chosen field to help them become more comfortable with uncertainty and delivering cost-conscious care. Learners also complete a four-year ultrasound curriculum, train in telemedicine during electives, and engage in research in cutting-edge areas such as bioelectric medicine and immunotherapy—all experiences designed to prepare them to use technologies that will define high-value care in the future.1

The combination of deliberate practice, longitudinal ambulatory experiences with direct observation, and working with technology with progressive autonomy in innovative models of care delivery readies our learners to provide care in complex systems. Medical education leaders should collaborate with health system leadership to create learning opportunities specific to their resources that allow them to advance the UME mission to train physicians for the future.

Hedgehog principle 3: The economic and resource engine

The drivers of an organization’s economic and resource engine2,3 enable the organization to support its mission—in the case of UME, establishing a health-care-delivery-based training environment that produces learners ready to excel in GME and practice. Collins3 argues that in the social sector, the resource engine is composed of time, money, and brand. Reconceptualizing the economic and resource engine can enable UME programs to train learners for future health care workforce needs. To better align the UME mission with health care delivery needs, medical education institutions must reconsider how they frame their organizational infrastructure. At Zucker SOM, we frame our economic and resource engine in terms of faculty time, financial and infrastructure support from our two sponsoring institutions, and reputation building.

Faculty time.

The deliberate practice of clinical reasoning and skills requires frequent direct observation and coaching by experts,9 which is often difficult to adequately achieve because of competing faculty demands. As Northwell Health is a large health care system with hundreds of potential faculty members, we wrote faculty appointment and promotion guidelines tailored to Zucker SOM’s educational mission. Faculty appointments are made with the stipulation that any faculty member can be called on to contribute up to 100 hours per year to UME and/or GME without compensation specific to these efforts. We appoint community-based clinician volunteers to serve as preceptors for our early ambulatory experiences and as facilitators for small-group learning in communications, physical diagnosis, clinical reasoning, and clinical rounds. These volunteer efforts are distributed over time and occur in continuity relationships with learners, which helps sustain continued participation of clinicians engaged in full-time practice.

Financial and infrastructure support.

The success of any medical school rests on its ability to navigate the competing interests of its health care and academic homes. We created a UME program that benefits both Northwell Health and Hofstra University, which provide our financial, human, and infrastructure resources. Northwell Health, a large sponsor of GME programs, has seen an improvement in the quality of applicants to its residency programs since the founding of Zucker SOM. Hofstra University’s support of Zucker SOM reflects the university’s educational mission to expand its presence in the science, technology, engineering, and math (STEM) educational landscape. Hofstra has likewise seen increased enrollment of highly accomplished STEM undergraduates. In addition, the establishment of Zucker SOM has generated philanthropy, and our medical school continues to grow with the help of our donors and the recent naming gift. Further, our DSE fully supports 30.5 full-time equivalents as medical educators (both MDs and PhDs) who contribute across the four-year curriculum. This support eliminates the competing demands of grant writing and clinical productivity, enabling DSE faculty members to focus exclusively on UME delivery and scholarship. Finally, our access to well-established clinical sites and research enterprises within Northwell Health and Hofstra University enables unencumbered dedication of resources to our educational mission.

Reputation building.

We recognize the aspirational quality of cultivating a health-care-delivery-based learning environment to produce graduates who become outstanding residents. To evaluate our progress in meeting this goal and building our reputation, we consider an array of outcomes, including United States Medical Licensing Examination Step exam scores and our students’ responses to the Association of American Medical Colleges’ Medical School Graduation Questionnaire (see Table 1). We view the analysis of results from each data source as an opportunity to identify strengths and develop strategies for our ongoing process of improvement. The final metric of success must be graduating physicians who are effective in achieving patient-centered improvements in health in practice.

Table 1
Table 1:
Application of the Hedgehog Concept2: Tracking Zucker SOM Outcomes as of November 2018


The hedgehog concept2,3 provides a practical framework for UME transformation. We define our UME hedgehog concept as a passion to challenge the educational status quo and develop innovative curricula that leverage integrated health system resources to train medical students who are ready to excel in systems-based care and are prepared for GME and the future practice of medicine. Aligning educational and health care delivery goals demands that UME educators be instrumental in bringing programmatic changes to fruition. Applying this hedgehog concept can guide medical educators committed to transforming medical education.

Acknowledgments: The authors would like to thank Seetha Monrad, MD, John Young, MD, PhD, and David Hirsh, MD, for carefully reading the manuscript and providing invaluable advice; Elizabeth Armstrong, PhD, and the Harvard Macy Institute for their instrumental role in cultivating the concept for this paper; and Saori Wendy Herman, MLIS, AHIP, for helping with literature searches and citations.


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References cited in Table 1 only

12. U.S. News & World Report. U.S. News best hospitals rankings and ratings, 2017–2018. Accessed September 29, 2017. [Updated version available.]
    13. Association of American Medical Colleges. Medical School Graduation Questionnaire: Individual School Report, 2017: Donald and Barbara Zucker School of Medicine at Hofstra/Northwell. 2017.Washington, DC: Association of American Medical Colleges.
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