Rethinking Medical Education

The ThinkerQuestions, observations, and recommendations toward reform of the process and content

Medical school curriculum - Part 2:
Designing an appropriate curriculum.* 
It is not the strongest of the species that survive, nor the most intelligent, 
but the one most responsive to change. 
Charles Darwin
(English naturalist; 1809–1882)
NOTE: In the following discussion, I’ve focussed mostly on abstract generalities, not on the specifics of how to implement the recommended educational approaches, nor on examples of these approaches in action. I introduce the implementation theme in Part 3 of this curriculum series, and I will be offering more of the specifics and examples in subsequent postings. 
At least for a while, a new medical school provides an opportunity to pursue the dream of overcoming problems inherited from the past. We must begin by acknowledging that our legacy educational designs weren’t based on evidence from educational or brain research. They weren’t even based on careful or systematic reasoning. They grew out of the intuition and impulses of those in positions of leadership. Most often, those in positions of educational leadership gained their influence from prominence in domains only marginally related to the processes of medical education. Typically, those leaders were people who were admired for their clinical and/or research achievements, aided by their inclinations to publish their writings and to seek positions of prominence. Not all of their educational design decisions have proven to be inappropriate, but many have, as I summarized in Part 1 of this curriculum series. Some of our inherited curricular problems are especially serious and are long overdue for correction.

We must begin by being “diagnostic”
The first component of an educationally defensible curriculum needs to be a set of systematic, sophisticated diagnostic steps and strategies (assuming we’ve already defined a reasonable set of general outcome goals for medical education, as I discussed in Part 1). We need to devise, test, and refine an array of tools and experiences that can provide our incoming learners and us with a reasonable array of insights into several of each learner’s relevant characteristics, strengths, and areas of current, high priority needs. The following are some examples of information we will need to learn how to gather as part of the “diagnostic workups” we should be routinely doing, partly during the candidate-selection process, to decide who has the potential for becoming the kinds of physicians we want to graduate, and partly after their admission to the program, to guide the design of the experiences we will recommend for their initial phases of learning. For all incoming students, we need to determine the extent of their:
  1. capabilities as independent learners;
  2. capacities for reflection and accurate self-assessments;
  3. openness to, and established ways of responding to, feedback;
  4. levels of curiosity about the human condition and other matters;
  5. levels of social and emotional intelligence;
  6. skills as verbal and non-verbal communicators;
  7. levels of insight into their own characteristics and behaviors, especially in identifying whatever difficulties they have as learners;
  8. levels of understanding of contemporary issues in health promotion and healthcare;
  9. commitments to, and approaches to, sustaining their own health.
As you may have already recognized, the process of undertaking this comprehensive diagnostic phase brings the secondary, important educational benefit of helping the students gain a more refined sense of their own strengths and an enhanced awareness of the learning tasks that lie ahead.

Aren't there some outcomes needed by all students? 
There certainly are some foundation outcomes we should expect of anyone who is to be considered worthy of graduating from medical school. But, those outcomes need to be conceptualized quite differently from the way they’re most commonly formulated now. Our characteristic approach to defining outcomes (if we think about them at all) has been in terms of "content,” in terms of the information that graduates are expected to possess and the procedures they are expected to be able to perform. Only recently have we begun to include some focus on outcomes in terms of the “processes” in which our students engage: the cognitive and emotional competencies new physicians are expected to develop. And, even as these  “process outcomes” have begun to be pursued, the focus has been far more on the students' cognitive competencies (the ways they think and solve problems) than on their emotional and social competencies (the ways they understand themselves and others; the ways they detect and respond to emotional signals, the ways they communicate, and more).
Even as we move toward a fuller and more appropriate sense of needed outcomes, we’ve tended to remain more rigid than is optimal. And, we’ve not typically adapted to the fact that our graduates will pursue a wide spectrum of different careers. With some exceptions, different careers need different cognitive and emotional competencies. We need to learn how to produce graduates who have those generic competencies that are needed for most or all healthcare careers. Those commonalities are found far less in the sphere of “content” than they are in the spheres of “processes.”

“Producing” highly competent learners
A central challenge we face in redesigning medical education is learning how to prepare graduates who can all be trusted to be constantly seeking to learn and improve throughout their careers. For that, they will need to be effective at continuously monitoring their current limits and learning needs. The issue isn’t what they know and can do medically at the time of graduation. The issue is ensuring that they will have what it takes to keep learning and changing. They will need to be continually evolving, acquiring what they need to know and need to be able to do as required by the particular circumstances that exist at any given time. We must stop thinking of “content competencies” as static. It isn’t safe to assume that a reasonable command of the content needed at one point in time predicts the level of content mastery a person will have at another point in time, when the circumstances will be quite different. 

Am I suggesting that what we know is unimportant? 
Definitely not. When learning to think and problem solve, we need something to be thinking about. Medical students' learning experiences, as they work to enhance their capabilities as thinkers and problem solvers, need to happen around medically relevant topics and issues. So, we must define those contexts that present the students with the sorts of challenges that require them to be continuously thinking and problem solving. But the information they acquire while engaging in these processes needs to be accepted as being a secondary consideration, not as primary, as it now often is. The information that will be relevant to the issues they will face in the future will likely be quite different from the information they use at this time. The information itself should not be seen as the central basis for our teaching or for our assessments of learning, as most typically happens now.

Toward defining a 21st century medical curriculum 
We can confidently anticipate that the demands of careers in medicine at the height of our current students' working lives will be significantly different from current demands. Of course, we can't now forecast what those demands will be, nor how they might continue to evolve during our students' lifetimes. So, our central challenge is figuring out how to prepare young people to be optimally equipped for continuously adapting to a changing future. To accomplish that goal, we need to create educational programs that prepare medical graduates who are:
  1. highly accomplished learners;
  2. highly competent searchers for and interpreters of information needed while engaged in problem-solving and decision-making;
  3. deeply devoted to, and skilled at, monitoring their own adequacy for the tasks they need to do and the problems they need to manage;
  4. fully open to being carefully assessed on their performance at intervals throughout their careers; 
  5. willing, even eager, to receive guidance from appropriate coaches; and
  6. highly refined and effective in their interpersonal relationships, whether with colleagues, subordinates, students, patients, or the general public.

Attending to these obligations mustn’t be mere embellishments on a conventional curriculum. These must be central imperatives in all parts of the educational program. The curriculum needs to be sufficiently focused and consistent to ensure that all graduates are dependably competent in all these areas. These competencies must be seen as far more than the surface behavior that shrewd test-takers know to exhibit when they are being observed, but can relinquish when on their own, as is now found to happen with too many students in relation to some medical school goals during and following formal assessments. The six competencies listed above need to become core values that are “owned” by each learner and sustained throughout their careers. Too many medical curricula now fall far short as producers of this sort of graduate. 
   Each medical school should be attending to the task of defining what they consider the minimally acceptable levels of accomplishment in each of these six areas, as a guide to their student-selection process. All schools, it seems to me, then have the task of helping all of their students grow as far as they can beyond the levels at which they began their medical education. Creating and sustaining such a program will require many changes from the currently dominant pattern in the world's medical schools. At the center of these changes will be our need for highly accomplished, deep-thinking educators as both the teachers and the administrators of our educational programs. I seek to clarify and expand on these and other requirements for creating and maintaining a thoroughly professional medical curriculum in subsequent parts of this series.

NEXT: Part 3. Implementing an appropriate curriculum. (coming soon)
   Hill Jason
Hilliard Jason, MD, EdD
First posted: 1/24/12
Revised: 1/28/12
* NOTE-1: As with all entries on this blog, your constructive critiques, recommendations and reflections are warmly encouraged. Please add your Comments below, or, to convey your reactions privately,  please send an email to: Many thanks.
* NOTE-2: I’m currently part of a small group that is conceptualizing a possible new kind of medical school for Europe, so, many elements of educational design are very much on my mind at this time. Inescapably, curriculum is a central consideration. My reflections for our deliberations have helped spawn this and other blog postings.


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