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Letters to the Editor

The Perils of Curricular Change

Weissman, Sidney H. MD

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doi: 10.1097/ACM.0000000000002684
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To the Editor:

The October 2018 issue of Academic Medicine contains an editorial and three articles that deal with medical school curricular change. Although I respect each perspective about how best to execute curricular change, I disagree with the authors’ suggestions.

Stevens1 argues for caution in proposing change, but he places the responsibility for precluding preclinical curricular change on residency program directors. He writes that “the impetus for making change must come from the USMLE’s [United States Medical Licensing Examination’s] key customers—residency program directors.”1 Residency program directors use the USMLE scores in assessing medical students because they are the only objective measure of a student’s medical school performance. Additionally, most program directors have learned that students who have done well on Step 1 will do well in residency. They do not determine the content of Step 1 or the preclinical medical school curricula. The USMLE mirrors curriculum determined by the schools but does not drive it.

Borkan and colleagues2 and Gonzalo and colleagues,3 although they disagree on how to best implement curricular change, both argue for a curriculum that stresses health systems science (HSS) in medical school. Borkan and colleagues2 define HSS as the “principles, methods, and practice of improving quality, outcomes and cost of health care delivery for patients and populations within systems of medical care.” I agree that the health care system in the United States must focus on the parameters of HSS. Although medical students, like all of us, must become familiar with the U.S. health care system, the question is when and how? As medical students, residents, or in practice?

Borkan and colleagues2 and Gonzalo and colleagues3 argue for a critical role of HSS in the medical school curriculum. They do not address the motivation or learning agenda of students or the need for the contemporary physician to be well schooled in the workings of the human body. Students want to be able to effectively diagnose and treat individual patients and to fully use and understand new and emerging therapeutics. They enter medical school with varied knowledge of biologic systems. Students learn in the first two years how the human body works and in the second two how to provide clinical care. Adequate time must be spent on the evolving science of the human body and its relationship to health and disease, which does not allow the focus on HSS in medical school. Our primary concern when each of us seeks health care is our physician’s medical and surgical knowledge and skill—not his or her knowledge of HSS.

Sidney H. Weissman, MD
Clinical professor of psychiatry and behavioral science, Northwestern University Feinberg School of Medicine, Chicago, Illinois;


1. Stevens CD. Repeal and replace? A note of caution for medical school curriculum reformers. Acad Med. 2018;93:14251427.
2. Borkan JM, George P, Tunkel AR. Curricular transformation: The case against global change. Acad Med. 2018;93:14281430.
3. Gonzalo JD, Wolpaw T, Wolpaw D. Curricular transformation in health systems science: The need for global change. Acad Med. 2018;93:14311433.
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