What Can We Learn From the Letters of Students and Residents About Improving the Medical Curriculum?

There is a long history of narratives and fiction by physicians that include information about their medical education—for example, books such as The House of God,¹Blood of Strangers,² and, most recently, When Breath Becomes Air.³ These books depict events that at times challenge values of medicine, such as professionalism, compassion, confidentiality, or patient safety, under the pressure of a demanding schedule, lack of supervision, and an overwhelmed staff. Often, a patient’s illness or injury engulfs students, residents, and patients in a chaotic struggle leading to tragic, heroic, or sometimes comic consequences. Frequently in the process of the narrative the author may make observations of trainees’ personal and professional identity crises, curricular and supervisory inadequacy, and mistreatment of trainees or patients. These books and others by physician authors offer a valuable perspective for those considering a career in medicine as well as for those seeking to improve medical education.

They also provide a window into the lives of medical students and residents that is often absent from scholarly journals such as Academic Medicine. Even though our journal welcomes submissions in all the journal’s categories from students and residents, the small number that we receive from them often do not survive the journal’s rigorous review process. Unfortunately, because of the few submissions by physicians in training in the journal, we likely miss important concerns that should be shared and discussed by our community. To address this gap, we at Academic Medicine recently sought the perspectives of students and residents by soliciting letters from them. The call went out August 28 last year with a deadline of November 1.

The response to this request was almost overwhelming: 224 letters arrived. They covered topics such as admission, testing, burnout, relationships, curriculum, assessment, diversity, empathy, learning environment, and professional identity. The authors were from 98 institutions across the United States and from 10 other countries. We were able to accept only a fraction of these letters. Some of those letters are published in this issue, in print or online, and the others will appear in several future issues in those formats. Of the 224 letters we received, the topic most frequently addressed was the curriculum, with 64 submissions. Those letters’ topics ranged from suggestions for changing or amending the required medical education curriculum to advocating students’ involvement in the curriculum development process. In this issue we have published in print five of the letters related to the topic of curriculum; others on that topic are published online and listed in this issue’s Table of Contents. In this editorial I provide some background on the recent history of curriculum reform in medical education and discuss some of the concerns raised by the letters.

Curriculum is derived from the Latin verb “currere,” to run, and originally meant the course of a race before being used to describe planned educational programs. Like the course of a race, an educational curriculum is expected to have a certain length and boundaries. As a former cross-country runner who enjoyed the freedom of an open field with various options of how to find the best route to the finish line, I was probably constitutionally inclined against a rigid and fixed curriculum. As a student I often viewed a detailed curriculum as an unnecessary restriction on my curiosity and self-directed learning. When I started medical school, I chafed at the standard approach of two years of preclinical sciences with their emphasis on lectures before exposure to clinical experience.

When I became a program director some years later, I still believed a curriculum should be flexible and responsive to each student’s needs, but I also acknowledged the value of structure and guidance that a good curriculum can provide. Part of my job was to develop a written curriculum for my residency in emergency medicine that would demonstrate how the didactic material and experiences of the residents would encompass the core content of the specialty. In the residency curriculum that I developed—which was similar to most residency curricula in my specialty at that time—there was no acknowledgment of the difference between teaching and learning or that some types of knowledge, skills, and attitudes such as professionalism might be best absorbed through the learning environment, role modeling, and the institutional culture rather than through a lecture. The achievement of competence was assumed to occur by the completion of the prescribed curriculum in the specified number of years. No specific competencies were measured beyond what was discussed informally during an annual faculty meeting prior to promotion of residents. Evaluation of medical knowledge occurred during annual in-service examinations and on the specialty certification examinations after completion of residency.

Since that time, competency-based medical education and curricula have appeared and spread throughout the medical education continuum. Carraccio et al⁴ and Batalden et al⁵ describe the transformation from a process- and time-based curriculum to a competency-based curricular format and how the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties came to consensus with other stakeholders to identify six competencies. Frank et al⁶ provide information about how the original concepts about competency-based curricula evolved and how they have been evaluated. Many of the articles Academic Medicine receives propose new competencies and describe a curriculum following the six-step approach, described by Kern et al,⁷ of problem identification, general needs assessment and specific needs assessment for targeted learners, goals and objectives, educational strategies, implementation, and evaluation and feedback.

The proliferation of competency-based curricula reflects the increasing complexity and specialization in medicine, as well as new areas of importance in health care, but raises the specter of an unmanageable number of competencies. David Leach,⁸ when asked why there are only six competencies, noted:

The ACGME resisted the opportunity to deconstruct physician competence into an almost infinite set of competencies. Six competencies could be recalled by a group of people interested in and working on the project without referring to a document, and those volunteers and employees of the ACGME who were working on the problem were not certain that would be true for seven.

My own experience validates Leach’s concerns. Most residents and faculty that I interview cannot remember even the six core competencies. I wonder how additional competencies and curricula could be accommodated into the already-crowded medical education curriculum.

As I think about the students’ letters related to curriculum and the recent history of curriculum reform, I have three reactions.

Include More Flexibility and Variety

The first reaction is reminiscent of my perspective as a student when I resisted the boundaries placed around the curriculum. I believe students should have the flexibility to guide their learning based on their interests and future directions. We should encourage their curiosity to explore emerging areas of knowledge. Not all students learn in the same way, and the long-term goals of students may differ. When medical schools do change their curricula, it is important that they include the perspectives of students, as described by Yengo-Kahn et al⁹ in this issue, to limit the anxiety that the change process will elicit among the students, to maintain open lines of communication about concerns that arise, and to make sure that all aspects of the transition go smoothly.

In their letters, student authors Gamlin¹⁰ and Huynh¹¹ each make the point that there are ample resources available on the Internet to address many of the content requirements of medical education and that faculty efforts in the curriculum should focus on those skills like communications, assessment, and integration of knowledge that students cannot easily learn on their own. It is also worth considering whether the curriculum for a student who wishes to become a physician scientist should be the same as the curriculum for a student who is intending a career as a rural primary care doctor. Müller and Solberg¹² in their letter describe the Norwegian medical education program, in which 10% of students take on active research responsibilities during medical school, and tout the benefits of such a large commitment to research for the individual student and the field of medicine. From a completely different perspective, Cangiarella et al,¹³ in an article in this issue, describe three-year medical school options that can provide continuity between medical school and residency education and may be particularly useful for those committed to primary care training. Perhaps we are reaching the point where multiple tracks within an overall medical education framework and the use of new learning tools might address the expanding knowledge base and the desire of students to differentiate at an early stage into a variety of specialties, some of which require several years of training beyond medical school. In this way the educational program might be made more efficient and less costly.

Give Students a Roadmap

My second reaction is that we need to give our students a roadmap so that they can understand the destination(s) of their education. The roadmap should reflect core values and concepts as well as be aligned with the priorities of our health system. While the Liaison Committee on Medical Education, which accredits medical schools, provides some subject matter guidance for the medical school curriculum, and the Association of American Medical Colleges–Howard Hughes Medical Institute report¹⁴ describes key basic science concepts needed for a physician’s education, there has not been a clear statement of expectations for either the basic science or clinical curriculum beyond what is needed to succeed on the National Board of Medical Education examinations. Englander et al¹⁵ have suggested that the list of 13 entrustable professional activities developed by a task force at the Association of American Medical Colleges could provide the basis for a medical school clinical curriculum. However, there may be other issues beyond the basic sciences and clinical skills that are also important to include in the curriculum for future physicians. Gonzalo et al¹⁶ in this issue suggest that the topic of health systems sciences should be included in the medical student curriculum and describe examples from two medical schools that illustrate how health systems and medical schools can be brought together to provide students with authentic workplace roles, which could add value to health systems and make medical education more of an asset than a burden. Malak,¹⁷ a student from Canada, suggests in a letter that quality improvement could be an integrative theme woven through the curriculum to prepare students to improve the quality of health care.

These proposed additions to the current curriculum make good sense. Unfortunately, the curriculum cannot expand to include new subjects and increase attention to the complexity of current topics and still maintain a four-year structure. Yet, as noted earlier, there are examples of three-year curricula at some medical schools. How are we to make sense of this apparent contradiction? Is it possible that the need for memorization of facts has become less important as physicians learn how to use technology to access information and can concentrate on interpersonal communication, compassion, and other ways to help patients? If so, will the tests that guide the selection of students to residencies reflect these changes in priorities? It seems incumbent upon the undergraduate medical education community to define a manageable core curriculum that will provide the foundation for graduate medical education, include priorities of our health system, and work with the accrediting and the testing organizations to make sure there is alignment with the expectations for national testing and the curriculum. For graduate medical education, Hockberger et al¹⁸ have demonstrated how core content, key skills, and context variables can be developed in a matrix framework to provide a roadmap for residents and be used for curriculum, assessment, certification, and continuing education in one specialty. Why couldn’t such an approach be generalized for all specialties and for undergraduate medical education? Without a clear destination of medical education and a roadmap, there will be constant conflict over which content to add or subtract, which key skills should be taught, and how they should be assessed, all adding to the stress of students and their teachers.

Recognize the Learning Environment

Finally, I realized that so far in this editorial I have been referring to the formal curriculum that is presented in documents for review by students, faculty, and accrediting bodies. Hafferty¹⁹ has described other learning experiences that occur outside of the formal curriculum, such as an informal curriculum of ad hoc learning and role modeling, and a hidden curriculum created by structural factors such as customs and rituals and understandings. Hafferty suggests that curriculum reform efforts will not be effective if planners do not recognize that “medical training is at its root a process of moral enculturation and that medical schools function as moral communities.” By emphasizing the importance of the learning environment, as Hafferty suggests, we move away from a focus on didactic materials and individual learning and toward authentic participation in teams, the assumption of responsibility, and the development of professional identity. This approach is consistent with social learning theory and depends on the creation of learning environments, including institutional cultures, that promote the values and behaviors that would lead to better health, better health care, and lower cost of care for the population. If the learning environment is rife with waste, poor quality, medical error, and depressed and burned-out faculty and residents, no curricular reforms will overcome what students will learn from this hidden and informal curriculum. A competency-based medical education curriculum will only be as good as the learning environment in which it takes place.

Our students and our residents are sensitive to the learning environment, and their voices, as shown in many of their letters the journal has received, are loud and clear in their critiques of the current learning environment. Whether through their narratives, their letters, or their responses to surveys about burnout and wellness, we must hear their voices and pay attention to what they are telling us as we build the medical curriculum for the future. We ignore them at our own peril and the peril of our patients.

David P. Sklar, MD