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Perspectives

Partnered Educational Governance: Rethinking Student Agency in Undergraduate Medical Education

Bilodeau, Philippe Antoine; Liu, Xin Mei; Cummings, Beth-Ann MD, MSc

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doi: 10.1097/ACM.0000000000002777
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Abstract

Student representation has been an important part of university governance since the 1970s1,2 and is essential for undergraduate medical education (UME) programs. Ideal student representation has a profound effect on the educational experience, whereas ineffective representation can breed student disengagement and mistrust of the program. We examine the role of student government, student representation in medical education, and theories of accountability in public organizations as described in the literature to inform a new model for student representation in UME.

Role of Student Governments

Student governments act as political entities, with their own sets of rules and regulations and a significant level of policy and managerial autonomy.3 As intermediaries between students and university decision-making bodies, student governments relate to the universities, abide by their rules, and engage in their networks.3 As such, they provide expertise, legitimize policies, and exert influence over the student body.4 Concurrently, as elected governing bodies, student governments represent the interests of the students and answer to them.3,5,6 The tension between these 2 sometimes opposing roles5 is associated with 2 conceptualizations of student representation: student-as-consumer and student-as-partner.7

The framework of student-as-consumer emphasizes that learners act as data sources and provide feedback to educators about policies and curricula.8–10 Though common, this framework for student representation at the university level has been increasingly criticized as an oversimplification of the roles and accountabilities of faculty and learners.5 Student representatives may, in fact, be passive and individualistic11 and not representative at all.12 Particularly when the appointment of student representatives is by the university rather than by the student organization, student representatives may find significant personal advantage in representing their own interests rather than the interests of the student body.13,14

The framework of student-as-partner emphasizes the notion of cooperative, nonhierarchical application of knowledge.4,15–19 Influenced by the principles of democratic participation, this conceptualization of student representation empowers students as stakeholders in a policy network and recognizes the need to close the feedback loop and comply with quality assurance agencies.8 There are several challenges to this framework, including perceptions that students may not be able to ensure confidentiality of sensitive information, may have ulterior motives, and may lack sufficient understanding of issues facing the program because of transience in their role.13 Nonetheless, student representatives most frequently cite their motivations as wishing to improve university decision making and gain experience.13 The problem of transience can, in part, be overcome through the training of new student leaders.13

Student Representation in Medical Education

In medical education, there has been a call for furthering the student-as-partner approach for several decades. In 1969, speaking at the Annual Meeting of the Association of American Medical Colleges, Carl Slater, MD, a fellow at the Center for the Study of Medical Education at the University of Illinois College of Medicine, deplored the limited involvement of students in curricular development and argued that the student role should be expanded beyond curricular evaluation.2 Experience at Maastricht University in the Netherlands highlights that for students to be partners, medical educators need to keep an open attitude toward students and act on their feedback, and students must organize themselves, exchange information, and voice their concerns whenever given the opportunity.1 North American accreditation processes (Committee on Accreditation of Canadian Medical Schools element 8.5 and Liaison Committee on Medical Education standard 8.5) require that UME programs use medical student evaluations of program experiences as part of their formal program evaluation process.20,21 Although there is no explicit requirement for proactively engaging students in decision making, and the student-as-consumer framework may be considered sufficient, the spirit of medical school accreditation calls for involving students, with emphasis put on their perspective during formal institutional reviews.22

Moreover, medical student indifference poses a risk to programs if learners believe that their feedback is sought only as a formality for accreditation purposes.1,8,14 In line with accreditation requirements and in an effort to improve student involvement in UME governance, medical schools have started including student representatives on faculty committees and collaborating with them in various ways. For example, at the Johns Hopkins University School of Medicine, a Student Curriculum Review Team was created in partnership with UME leadership to review preclinical courses.23 At the University of British Columbia, a student Medical Education Committee was created to organize student representation.24 Although there are several such accounts of curricular and policy innovations, there is a paucity of published literature on student agency in UME governance and its underlying conceptual frameworks.

Vertical and Horizontal Accountability

Accountability has always been central to representation and the democratic process. Generally, accountability describes a relationship in which the behavior of an “accountor” is evaluated and judged by the “accountee” in light of possible consequences to the accountor.25 Literature on public administration and the nonprofit sector distinguishes 2 types of accountability. The most common type is upward (or vertical) accountability— that is, being accountable to whoever entrusts you with a responsibility.25–28 In a hierarchical system, such as an educational program, vertical accountability often arises instrumentally with student representatives on committees being accountable to the committee and the educational program. The less common lateral or downward (or horizontal) accountability is a less formalized form of accountability to other members of the accountor’s organization and its constituents.26,29 Horizontal accountability is predominantly driven by shared values and goals and is collaborative rather than hierarchical.30

In the face of organizational complexity, vertical accountability may have limited impact; hierarchical superiors will be naturally selective in the exercise of their attention, and democratic processes alone may be insufficient to transform constituents’ feedback into actionable changes. Conversely, strengthening horizontal accountability is associated with an ability to operationalize the feedback from relevant stakeholders.29 Although the concepts of accountability have been described in the literature on public administration and the nonprofit sector, student representation, specifically in medical education, has seldom been framed in these terms.

A Partnered Educational Governance Model

At our institution, McGill University, UME is governed by the Program Committee (curriculum committee), which has executive power and oversight of curricula and policies. Before 2016–2017, the Program Committee and some subcommittees included student representatives elected by the student body. However, the process of appointing students to committees was usually faculty driven and lacked transparency. Although student representatives were entrusted by faculty members to represent their peers’ interests, they were neither selected by students nor required to consult with or report to students. As such, their accountability was mostly vertical, toward physician–educators on individual committees. Without horizontal accountability, representativeness of student input was difficult to achieve and was explicitly questioned at times. Student representation lacked structure; therefore, support, coherence, and unity of student feedback were absent.1 Given the perceived deficiencies in accountability and representativeness, student representation often lacked impact.

In the summer of 2016, regular meetings between a small group of elected representatives from the student council and the associate dean for UME were established to seek student input on various curricular and policy questions. These meetings planted the seed for a partnership between students and UME leadership and shed light on both the lived student experience and the quality improvement efforts of UME committees. The disconnect between the program’s true openness toward student input and the prevailing perception that it was static was striking: Although UME leaders were ready to listen, the students felt largely unheard. Students often began conversations at UME meetings with “Everyone knows that . . . ” and expressed frustration that although a problem was common knowledge, nothing had been done. In practice, this important student feedback was either not known by the program leadership (because students had stopped reporting it out of the belief that it wouldn’t be addressed) or had been prematurely dismissed by the program leadership as not representative.

From an initial seed of partnership grew an institutional partnered educational governance (PEG) culture. Here, we describe the process of, and rationale for, building a PEG model to enhance student agency in UME governance. Grounded in the student-as-partner framework, the PEG model relies on building student agency through accountability, representativeness, and proactive collaboration with UME leadership on policies and curricula.

Toward multidirectional accountability and representativeness

In a traditional student-as-consumer model, student proactivity may be limited by lack of access to discussion platforms or the risk of being perceived as overstepping. Recognizing that for the UME program to consider student input actionable, the student voice needed to be coherent, in 2016–2017, the student Medical Education (MedEd) Committee was created at McGill University to provide structure to student representation. Inspired by the structure of the student Medical Education Committee at the University of British Columbia, the McGill MedEd Committee aimed to ensure accountability and representativeness. Accountability was hardwired into the system by establishing mechanisms in the MedEd Committee for representatives to receive input from and report to the student body. Representativeness was improved by taking ownership of the nomination of students to UME committees and creating a meaningful platform for consultation and discussion among student representatives.

With approval from the Program Committee, selecting student representatives for UME committees became the responsibility of the student government rather than the committee chair. Student representatives were nominated by peers on the MedEd Committee through a transparent process and then appointed to UME committees by the UME associate dean, who vetted each nomination in good faith. Simultaneously, along with his or her UME committee mandate, each student representative became a member of the student MedEd Committee and was required to answer to its chair and fellow members. Participation at regular MedEd Committee meetings was expected, and systematic reporting mechanisms were developed, including providing regular updates at meetings, submitting end-of-year reports, and documenting ownership of tasks in meeting minutes. Instead of being accountable solely to the UME committee, student leaders became additionally accountable to their MedEd Committee colleagues and student constituents.

Moreover, the MedEd Committee became a new discussion and decision-making platform that enabled dialogue between student leaders and student constituents. Any member of the MedEd Committee could add items to the agenda. Issues such as professionalism, clinical supervision, workload, mistreatment, and course revisions were frequently discussed. Although the chair aimed to build consensus, all members had voting rights, and decisions required a simple majority. The traditional (pre-2016) model had 7 representatives on 5 UME committees. The new (post-2016) model expanded student representation to 24 members by bringing together previously independent representatives and increasing the number of UME committees with student representation to 11.

Through shared goals and values, the MedEd Committee enables multidirectional accountability. This accountability may mark a shift in student representatives’ motivations from individualistic to collectivistic, although such a shift remains to be demonstrated. Irrespective of students’ motivations, the structure allows student representatives to better grasp issues, support each other in their roles, and unify the student voice.

UME leadership–student partnership

Along with supporting the substantial changes in student representation, UME leaders initiated changes in UME structure and governance. Discussions and decisions of the Program Committee and other UME committees were made more transparent and accessible to student leaders through their participation in the MedEd Committee. A confidentiality agreement for student representatives was drafted by the associate dean and approved by the Program Committee. The agreement facilitated student inclusion in program discussions that were sensitive, controversial, or nuanced by ensuring that students would recognize and respect the confidential nature of the discussions.

In our PEG model, student representatives, entrusted by both their peers and faculty, are consulted proactively in the development of policies and curricular changes, rather than being only data sources after the fact. The partnership between students and faculty facilitates a shared understanding of educational challenges and potential solutions but does not signify that the partners have the same level, or nature, of responsibility. Rather, it implies shared values and goals while allowing diverging opinions on how best to achieve these goals, and with final authority for UME curricula and policies continuing to rest with the UME leadership. It is for this reason that we consider our PEG model to truly embody a partnership in educational governance. Although one could question which enabled the other, we argue that the willingness of UME leaders to legitimize student input and the student representation reform mutually enabled the major shift to a PEG model.

The PEG model is self-perpetuating. As true representativeness becomes more apparent to UME leadership through the unified student voice, student input becomes more credible to UME leadership and, by extension, more effective. As the impact grows, the representatives’ accountability becomes more apparent to their vertical accountee: the students at large. Students in turn become more likely to entrust their feedback to their representatives. Thus, student accountability potentiates representativeness, and vice versa. It is now the norm in our UME program to consistently and meaningfully consult with student representatives. For example, UME leaders frequently discuss with student representatives before communicating key topics to the student body to ensure clarity of the message. Similarly, student leaders consult with UME leaders on challenging dossiers and are open to hearing the program perspective.

Impacts of an accountable and representative system

There are already examples of successes enabled by the PEG model. A recent curriculum reform increased much-needed teaching about public health. However, students perceived redundancies and structural challenges and made suggestions for ongoing improvement. To bring these issues to light in a constructive manner, the MedEd Committee produced a report detailing suggested areas for improvement and evidence-informed solutions. Although it was neither the goal nor the expectation of the MedEd Committee to have all of its recommendations adopted, the report directed the UME leadership toward concerns most important to students. Before the implementation of the PEG model, using a student-driven report in a collaborative way would have been impossible. The UME leaders might have dismissed such student feedback as a critique by a group of disgruntled students or have resented being ordered by students to adapt the curriculum to their liking. The students might have had difficulty drafting a report that was representative of a unified student view and have resented the UME leadership if all of the recommendations were not implemented. However, since the establishment of the PEG model, the UME leaders were able to receive student input as legitimate, and the students were able to accept the UME leaders’ decisions and rationale regarding which recommendations were, and were not, adopted.

Similarly, before the creation of the MedEd Committee, in one instance, a student representative shared feedback on a research course with a UME committee. However, the committee questioned whether her views adequately represented the general student voice. When the MedEd Committee was established, she found a platform for consolidating student feedback, which increased the legitimacy of her recommendations. This platform enabled her to work with UME committee members to redesign the course, and the changes were approved by the Program Committee in time for the following academic year.

In addition to curricular improvements, the PEG model has had a positive impact on UME policy development and implementation. In 2018, representatives collaborated with medical educators to design a proactive and innovative new absences and leaves policy. Its approval by the Program Committee was preceded by several months of discussions with student representatives, who gathered feedback from their respective classes, discussed problems that were identified, and proposed possible solutions.

These rapid changes in student and UME governance coincided with an accreditation follow-up visit for our school. The PEG model provided the UME leadership with additional sources of reliable feedback and student-centered solutions. This feedback allowed UME leaders to become aware of issues that were likely to arise from the surveys, gain qualitative insight into the roots of some of the data that otherwise would have remained purely quantitative, and initiate appropriate changes.

The advantages of the PEG model have manifested through mutual understanding, respect, and trust between student representatives and the UME leadership, as well as through new communication channels. Additionally, the PEG model has provided educators with a window into the world of the learner while ensuring that the student perspective is a representative one. Overall, the PEG model has institutionalized a culture where expertise sharing between student representatives and UME leadership serves to improve the educational experience of students and the UME program itself.

Limitations and Future Perspectives

Rapid student turnover, lack of medical education expertise, and insufficient perspective regarding the broader goals of curricula and policies are common criticisms of the student-as-partner framework. Means to overcome these shortcomings were built into our PEG model. For example, many key UME committees now have both a junior student and senior student representative with overlapping 2-year mandates. This structure facilitates institutional memory and attenuates the impact of student transience. It also eases concerns about lack of expertise of student representatives by building a mentorship dynamic whereby junior representatives benefit from the experience of senior representatives. Engagement in leadership also provides members with much-needed perspective on the complexity of medical curricula and policies. Likewise, presentations on hot topics such as competency-based medical education and attendance at national medical education conferences allow for capacity building and new leadership opportunities. These learning opportunities also address some of the concerns about lack of expertise and enable students to bring fresh perspectives and ideas about medical education.

Despite the early successes of our PEG model, continuous improvements remain necessary. The greater number and expanded role of student representatives increased the complexity of the MedEd Committee. Efficiency and productivity could easily be threatened by this new administrative burden unless student leaders have a sufficient grasp of the managerial aspects of such a growing structure. Moreover, despite the establishment of a junior/senior structure, student transience and a lack of knowledge in medical education intricacies remain important challenges—and interesting avenues for further development and study.

In summary, the creation of the student MedEd Committee and consequent new accountability channels facilitated a transition from a student-as-consumer to a student-as-partner framework. Further, our PEG model demonstrates how accountability and representativeness are mutually potentiating. Reproducibility of such a model requires 2 initial elements: a student government determined to build a centralized and representative structure to interact with UME leadership, and medical educators who are enthusiastic to engage with student representatives and value their unique input. These 2 catalyzing conditions are necessary and synergistic in creating a PEG model that is accountable, is representative, and, most important, has a meaningful and significant impact on the educational experience of students and on the program itself.

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