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Education of Medical Students: Ten Stories of Curriculum Change

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Education of Medical Students: Ten Stories of Curriculum Change The Education of Medical Students: Ten Stories of Curriculum Change September 2000 (To request a bound copy of this report, click here. To see a complete list of Milbank reports, click here. When ordering, be sure to specify which report you want, your name, mailing address, and phone number.) Table of Contents Foreword Jordan J. Cohen and Daniel M. Fox The Authors Responsive Curriculum Reform: Continuing Challenges Michael E. Whitcomb Curriculum Reform, 2000: An Analysis Kenneth M. Ludmerer Baylor College of Medicine Rebecca T. Kirkland University of California, San Francisco, School of Medicine David M. Irby Case Western Reserve University School of Medicine Marcia Z. Wile and C. Kent Smith University of Connecticut School of Medicine Bruce M. Koeppen University of Florida College of Medicine Robert T. Watson and Larry Rooks Northwestern University Medical School Raymond H. Curry College of Medicine, Medical University of South Carolina Victor Del Bene Tufts University School of Medicine Mary Y. Lee University of Utah School of Medicine T. Samuel Shomaker Wake Forest University School of Medicine Cam Enarson Foreword Medical schools are justifiably sources of civic pride, in no small part because they are the wellspring of the high-quality health care enjoyed by the people whose taxes, tuition payments, and insurance premiums subsidize them. Medical schools have prospered for most of the past century because they had broad public support. And that support is needed now more than ever, as medical education attempts to adapt to significant changes in what students must learn to be good physicians in the 21st century. This report is designed to enhance our understanding about the nature and extent of those changes. Its findings are both encouraging and unsettling. The good news is that many medical educators are implementing curricular changes that are responsive to the latest advances in biomedical science, to the social and policy sciences relevant to medical practice, to the burden of disease, to the organization and financing of health care, and to the changing demography of the American population. The unsettling news is that most contemporary curriculum reformers have not yet been able to make necessary changes in the second two years of medical education, when students receive their first intensive education in clinical practice. In the first of two essays that introduce this report, Michael Whitcomb, a senior vice president of the Association of American Medical Colleges, writes that this "lack of innovation . is almost certainly due to the fact that many members of the clinical faculty do not believe that changes are needed." The author of the second introductory essay, Kenneth Ludmerer, agrees with this analysis, as do the authors of most of the case studies that follow the essays. Ludmerer, a professor of internal medicine and history at Washington University, worries that "the approaches described in the case studies are insufficient to prepare the nation's medical students properly for the practice of medicine in the 21st century." We commend the report to persons who have formal responsibility for higher education as well as to medical educators. Members of university governing boards and leaders of the legislative and executive branches of state government should be aware of current achievements and limits of curriculum reform in medical schools and of their potential consequences for American health care. We also hope that medical educators and persons responsible to the public for higher education will discuss the barriers to reform in the clinical curriculum. Some of these barriers are financial. Others are a result of the reward system in academic medicine. All of them are amenable to change as a result of collaboration among people within and outside medical education. Academic responsibility is the price we must pay for academic freedom. Finally, we thank the authors of the studies, who are identified below, for drafting and redrafting them against tight deadlines and Drs. Ludmerer and Whitcomb for writing engagingly about controversial conceptual, political, and historical issues that have great practical importance. Jordan J. Cohen President Association of American Medical Colleges Daniel M. Fox President Milbank Memorial Fund The Authors Raymond H. Curry, M.D. Executive Associate Dean for Education Northwestern University Medical School Chicago, Illinois Victor E. Del Bene, M.D. Professor of Medicine Associate Dean for Students College of Medicine Medical University of South Carolina Charleston, South Carolina Cam Enarson, M.D., M.B.A. Associate Dean for Medical Education Wake Forest University School of Medicine Winston-Salem, North Carolina David M. Irby, Ph.D. Professor of Medicine Vice Dean for Education School of Medicine University of California, San Francisco Rebecca T. Kirkland, M.D., M.P.H. Professor of Pediatrics Associate Dean for Curriculum Baylor College of Medicine Houston, Texas Bruce M. Koeppen, M.D., Ph.D. Dean for Academic Affairs and Education School of Medicine University of Connecticut Health Center Farmington, Connecticut Mary Y. Lee, M.D. Associate Professor, Department of Medicine Dean for Educational Affairs Tufts University School of Medicine Boston, Massachusetts Kenneth M. Ludmerer, M.D. Professor of Medicine, School of Medicine Professor of History, Faculty of Arts and Sciences Washington University St. Louis, Missouri Larry Rooks, M.D. Clinical Associate Professor Chair, Curriculum Committee University of Florida College of Medicine Gainesville, Florida T. Samuel Shomaker, M.D., J.D. Formerly: Senior Associate Dean for Academic Affairs University of Utah School of Medicine Salt Lake City, Utah Currently: Vice Dean John A. Burns School of Medicine University of Hawaii Honolulu, Hawaii C. Kent Smith, M.D. Vice Dean for Medical Education and Academic Affairs Case Western Reserve University School of Medicine Cleveland, Ohio Robert T. Watson, M.D. Senior Associate Dean for Educational Affairs University of Florida College of Medicine Gainesville, Florida Michael E. Whitcomb, M.D. Senior Vice President Division of Medical Education Association of American Medical Colleges Washington, D.C. Marcia Z. Wile, Ph.D. Director of Curricular Evaluation Case Western Reserve University School of Medicine Cleveland, Ohio RESPONSIVE CURRICULUM REFORM: CONTINUING CHALLENGES Michael E. Whitcomb The studies presented in this report describe in some detail the changes occurring in the education of medical students in ten U.S. medical schools and the dynamics of the curriculum reform process at those schools. The Association of American Medical Colleges (AAMC) has recently surveyed all medical schools to collect information about the organization and management of their education programs. It is clear from this information that the kinds of changes described in the studies are occurring in a majority of schools nationwide. As reflected in the studies, medical schools are making major changes in the structure and organization of the curriculum, adopting innovative pedagogical strategies for enhancing students' learning, improving the methods used to assess students' performance, and focusing greater attention on the professional development of faculty as teachers and educators. To support these activities, schools also are making fundamental changes in the management and financing of their education programs. Based on these observations, it is apparent that a major transformation is now under way in the education of medical students in this country. Despite the importance of these changes, the studies presented in this report make it quite clear that the great majority of the curriculum changes that have occurred or are planned largely affect only the first two years of each school's educational program. The ten schools whose experiences are described in the report have found it difficult, and in some cases almost impossible, to make fundamental changes in the last two years of the curriculum, when most clinical education occurs. The data that the AAMC has collected about the organization and management of all schools' education programs indicate that the experiences described in the studies reflect the situation nationally. Although some schools have been able to introduce a number of structured small-group learning exercises into the final years of the curriculum, many schools, including some that have planned to do so, have not been successful in accomplishing even this relatively modest change. The lack of innovation in the last two years is almost certainly due to the fact that many members of the clinical faculty do not believe that changes are needed. The attitude that change is not needed in the design and organization of the last two years of the curriculum ignores certain current realities. It is contradicted by published reports indicating that, at the time of graduation, medical students too often lack fundamental clinical skills that they should have acquired during their clinical education. It also fails to acknowledge that the entire curriculum––including the last two years–– must change over time in response to changes in medicine and in society's expectations of medicine. During the past two decades, important changes have occurred in medical practice that have critical implications for the content of students' clinical education. For example, concerns about the cost of medical care have led to major changes in the organization, financing, and delivery of medical care services.
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