Curricular change in medical schools: how to succeed

Evaluating the impact of a blended interprofessional education course on students' attitudes towards interprofessional education: a pre-post study

BACKGROUND

Since 2011, five educational and healthcare institutions have implemented a short interprofessional education (IPE) course to bring together undergraduates from five disciplines. To meet the logistical challenges of IPE implementation, more specifically, the large number of classrooms needed to gather students together and the need for human resources to guide learning activities, a face-to-face IPE course was redesigned into a blended (online and face-to-face collaborative learning activities) IPE course. In March 2023, 183 medical, 378 nursing, 46 radiologic technology, 69 physiotherapy, and 74 occupational therapy students participated in a one-day IPE blended course to learn interprofessional team functioning and dynamics, role clarification and responsibilities of other professions, and interprofessional communication skills. This study aimed to assess students' changes in attitudes towards IPE after being involved in a large-scale interprofessional blended learning course.

METHODS

A before-after study was conducted using a French translation of the validated questionnaire "University of West of England Interprofessional Questionnaire" (UWE-IP questionnaire). Students' attitudes towards interprofessional (IP) relationships and IP learning were measured before and after the course. In March 2023, two hundred fifty-six students from five professions answered two subscales of the UWE-IP questionnaire before and after the course (response rate 34%).

RESULTS

Students' attitudes towards IP relationships improved significantly after the course. The score on this subscale (min 8; max 24) changed from 11.18 (SD 2,67) before the course to 10,38 (SD 2,55) after the course, indicating a significant improvement in attitudes towards IP relationships (p < 0,001). More specifically, students had more positive attitudes on the item "I have a good understanding of the roles of different health and social care professionals." and the item "I feel that I am respected by people from other health and social care disciplines." after the course. A positive change in students' attitudes towards IP learning was observed, but the results were not significative.

CONCLUSION

A face-to-face IPE course redesigned as a blended course helped overcome existing challenges to implementing an IPE course. The results suggest a blended IPE course improves students' attitudes towards interprofessionality.

Evaluating Competence by Design as a Large System Change Initiative: Readiness, Fidelity, and Outcomes

Program evaluation is an essential, but often neglected, activity in any transformational educational change. Competence by Design was a large-scale change initiative to implement a competency-based time-variable educational system in Canadian postgraduate medical education. A program evaluation strategy was an integral part of the build and implementation plan for CBD from the beginning, providing insights into implementation progress, challenges, unexpected outcomes, and impact. The Competence by Design program evaluation strategy was built upon a logic model and three pillars of evaluation: readiness to implement, fidelity and integrity of implementation, and outcomes of implementation. The program evaluation strategy harvested from both internally driven studies and those performed by partners and invested others. A dashboard for the program evaluation strategy was created to transparently display a real-time view of Competence by Design implementation and facilitate continuous adaptation and improvement. The findings of the program evaluation for Competence by Design drove changes to all aspects of the Competence by Design implementation, aided engagement of partners, supported change management, and deepened our understanding of the journey required for transformational educational change in a complex national postgraduate medical education system. The program evaluation strategy for Competence by Design provides a framework for program evaluation for any large-scale change in health professions education.

Building a strong foundation from the ground up: the impact of a medical student substance use disorder organization on curriculum and community

Due to the increasing rates of substance use disorders (SUDs), accidental overdoses, and associated high mortality rates, there is an urgent need for well-trained physicians who can grasp these complex issues and help struggling patients. Preparing these physicians occurs through targeted education and clinical exposure in conjunction with medical school curricula in the field of addiction medicine. Medical students can often feel overwhelmed by the medical school curriculum and changes to the curriculum take time, money, and administrative commitment to ratify. Implementing a student organization dedicated to SUD education can be a solution to provide clinical exposure, education and student autonomy in their medical school experience. At Wayne State University School of Medicine, Detroit vs. Addiction (DvA) is a student-run organization that is filling the gap in SUD education for medical students whilst providing assistance to the community. DvA not only extends clinical education for physicians in training, but it also provides the medical school with an opportunity to allow students to create a blueprint for education initiatives that can be incorporated as a mainstay in the school's technical trainings. Herein, we describe the evolution of this organization and its activities.

Continuous enhancement of educational quality - fostering a quality culture: AMEE Guide No. 147

Internal quality assurance (IQA) is one of the core support systems on which schools in the health professions rely to ensure the quality of their educational processes. Through IQA they demonstrate being in control of their educational quality to accrediting bodies and continuously improve and enhance their educational programmes. Although its need is acknowledged by all stakeholders, creating a system of quality assurance has often led to establishing a 'tick-box' exercise overly focusing on quality control while neglecting quality improvement and enhancement. This AMEE Guide uses the concept of quality culture to describe the various dimensions that need to be addressed to move beyond the tick-box exercise. Quality culture can be defined as an organisational culture which consists of a structural/managerial aspect and a cultural/psychological aspect. As such this AMEE Guide addresses tools and processes to further an educational quality culture while also addressing ways in which individual and collective awareness of and commitment to educational quality can be fostered. By using cases within health professions education of both formal and informal learning settings, examples will be provided of how the diverse dimensions of a quality culture can be addressed in practice.

A Cautionary Tale: Exploring Stakeholder Emotions During Curricular Change Using Group Concept Mapping

PhenomenonCurricular change is essential but challenging. Change efforts often struggle and some fail due to well-articulated challenges as well as other barriers less understood. The curricular change literature characterizes the organizational and operational features of successful change yet virtually ignores stakeholder emotions. A deeper understanding of these emotional responses during the change process could enhance participant and organizational well-being and support change success. Approach In 2019, data were collected at one large North American medical school using group concept mapping methodology, an asynchronous mixed methods approach. We sought to generate themes characterizing the emotional responses of faculty, administrative staff, and students across multiple stakeholder groups participating in the new and traditional (legacy) curricula 27 months after curricular change initiation. Participants brainstormed, sorted, and rated statements on emotional responses. Rating participants rated each statement using a Likert scale from 1 (does not resonate) to 4 (very strongly resonates) according to this prompt: "This emotional response resonates with my emotional experience during the curricular change." Multidimensional scaling and hierarchical cluster analyses were used to generate emotional profiles and compare them across stakeholders. Findings Of 335 stakeholders invited, 123 contributed to brainstorming (36.7%), 153 completed rating (45.7%) and 33 completed sorting (9.9%). Participants generated six themes of emotional responses to curricular change: enthusiastic, apprehensive, overwhelmed, missed opportunities, uncertain, and abandoned. The enthusiastic theme overall had the highest mean statement ratings while the abandoned theme had the lowest. Demographic subgroup analysis revealed new curriculum students (Class of 2021) were most enthusiastic while legacy curriculum students (Class of 2020) were more likely to feel abandoned. Overall, faculty and administrative staff were more enthusiastic than students whereas students rated the five other themes higher than faculty and administrative staff. InsightsCurricular change is emotionally taxing. Students in both curricula experienced greater uncertainty, apprehension, sense of missed opportunities, and feeling overwhelmed than did faculty and administrative staff. Legacy curriculum students rated statements in the abandoned cluster highest while new curriculum students rated statements in the enthusiastic cluster highest. Given the ubiquity of curricular change which often includes a legacy cohort, medical schools embarking on this journey must carefully attend to the varied emotional responses of their different stakeholder groups. The very activities recommended by organizational change models used in medical education, such as communicating wins early and often, could alienate legacy students, creating emotional polarization. These findings suggest that tailored communication strategies are necessary during change implementation to optimize success.

Implementing a successful targeted neonatal echocardiography service and a training program: The ten stages of change

Implementing any new service or program in the health care system is not always straightforward; a multi-stage implementation process is required most of the time. With the advancements in neonatal care and increased survival rates, there has been an increased need for ongoing assessment of hemodynamic stability. At the Children's Hospital of Eastern Ontario and the Ottawa Hospital Neonatal Intensive Care Units (NICUs), University of Ottawa, Canada, Targeted Neonatal Echocardiography service (TnEcho) was successfully established and has led to improvement in the hemodynamic evaluation and decision making in neonatal intensive care. In this article, we describe our experience establishing this program and the process of ensuring its success. This review article highlights the ten steps taken by multiple stakeholders to achieve this goal; this may help other centres implement a similar program.

Incorporation of Comprehensive Examinations for a Time-Efficient Remediation Method

BACKGROUND

Remediation in medical school should be a time-limited, and highly structured process that addresses student deficiencies and allows them to prove content competency before progressing in the curriculum. In this study, we analyze the use of a comprehensive end-of semester final examination in the remediation process for pre-clinical students at Kirk Kerkorian School of Medicine (KSOM). Faculty time utilized is analyzed and compared with the previously employed remediation process.

METHODS

Administered to all students at the end of each semester is a comprehensive examination consisting of a sufficient number of faculty-selected questions relating to each organ system covered with a 75% passing threshold. A student must also demonstrate competency of any failed system examination content to remediate successfully. The performance of those who did not exhibit competency was analyzed to identify areas of deficiency then an individualized exam would then be administered. The total remediation time spent by faculties and students was then analyzed.

RESULTS

KSOM Class of 2024 results showed that faculty were able to yield significant savings in time spent on remediation. Faculty spent 45 total remediation hours for the Class of 2024, compared to 400 hours remediating using the paper-based assignment method for the Class of 2021. With the transition to comprehensive end-of-semester final examinations, a total of 355 hours were saved. Furthermore, faculty used an average 1.07 hours/student with end-of-semester comprehensive examinations. The saved time allows faculty to work on improving the overall curriculum for all students rather than focusing on a limited number of students.

CONCLUSION

Utilizing comprehensive end-of-semester final examinations notably decreased the amount of faculty time spent per semester on remediation. Further evaluation is required to evaluate long-term effectiveness on content competency and would further be strengthened by a multi-institutional comparison.

Transforming medical education to strengthen the health professional training in Viet Nam: A case study

The competency-based undergraduate curriculum reform at the University of Medicine and Pharmacy at Ho Chi Minh City, Faculty of Medicine (UMP-FM) is detailed and reviewed in reference to the instructional and institutional reforms, and enabling actions recommended by the Lancet 2010 Commission for Health Professional Education. Key objectives are to: revise the overall 6-year curriculum to be more integrated and competency-based; reinforce students' knowledge application, problem-solving, clinical competence, self-directed learning and soft skills; develop a comprehensive and performance-based student assessment programme; and establish a comprehensive quality monitoring programme to facilitate changes and improvements. New features include early introduction to the practice of medicine, family- and community-based medicine, professionalism, interprofessional education, electives experiences, and a scholarly project. Institutional reform introduces a faculty development programme, joint planning mechanism, a "culture of critical inquiry", and a transparent faculty reward system. Lessons learnt from the curriculum reform at UMP-FM could be helpful to medical schools from low- and middle-income countries considering transitioning from a traditional to a competency-based curriculum.

FUNDING

This work receives no external funding.

Pre-clerkship National Board of Medical Examiners Subject Examinations Versus End-of-Semester Final Examinations: How Well Do They Assess Preparedness for the United States Medical Licensing Examination Step 1?

Background The ability to provide performance insights of various United States Medical Licensing Examination (USMLE) Step 1 assessments is of great importance to medical educators. Two custom pre-clerkship assessments used at the Kirk Kerkorian School of Medicine at the University of Nevada, Las Vegas (KSOM) are National Board of Medical Examiners (NBME)-derived end-of-semester final examinations and subject examinations. The authors sought to determine if performance on these custom assessments can provide feedback on a medical student's readiness to undertake the USMLE Step 1 examination. Methodology Deidentified student performance data were provided by institutional databases for the KSOM graduating class of 2023 (N = 60). Pearson correlation analyses were utilized to evaluate the strength of the correlation between USMLE Step 1 performance and NBME subject examinations versus NBME end-of-semester final examinations. Results The results indicated that the NBME end-of-semester final examinations have a statistically higher correlation to the USMLE Step 1 score than the majority of the individual NBME subject examinations. However, the mean NBME subject examination score (Semester 1: r = 0.53, p < 0.05; Semester 2: r = 0.58, p < 0.05) demonstrated significantly higher correlation to the USMLE Step 1 performance than the NBME end-of-semester final examination score for both Semesters 1 and 2 (Semester 1: r = 0.50, p < 0.05; Semester 2: r = 0.48, p < 0.05). Conclusions These results showed that the mean of the NBME subject examination score was a better metric to assess readiness for the USMLE Step 1 than the NBME end-of-semester final examinations. However, each NBME end-of-semester final examination score showed a better correlation than the majority of the NBME subject examinations.

Planetary Health Education and Capacity Building for Healthcare Professionals in a Global Context: Current Opportunities, Gaps and Future Directions

The emerging concept of planetary health needs to be discussed in a more organized and sustainable way within the global public health and healthcare disciplines. Therefore, planetary health should be considered a cardinal component of the global academic framework for healthcare professionals. The availability of related curricula and courses is crucial to equip health professionals in this relatively new discipline of planetary health. In this review article, we aimed to explore published articles and online databases of courses to summarize the available planetary health education opportunities and discussions for health professionals, to identify the gaps in resource allocation and to suggest future recommendations. We observed a visible resource inequity in the global south with the lack of a universal planetary health module for healthcare professionals. Additionally, there is minimal inclusion of allied health disciplines in this learning process. We therefore recommend a dedicated network of motivated healthcare professionals and regional hubs with an agenda to ensure a comprehensive, uniform, and inclusive planetary health education curriculum and practice.

Development of a Scientific Writing Course to Increase Fellow Scholarship

Physicians in training are often taught how to conduct original research but may lack the skills necessary to write their results in a paper for the peer-reviewed medical literature. To help our critical care fellows increase their publication rates, we implemented an 8-hour scientific writing course that provides a structured approach to writing an academic research paper. We have demonstrated an increase in publication rate during fellowship from an average of 0.7 manuscripts per fellow just before course inception to 3.7 manuscripts per fellow in the current graduating class. We highlight strategies for developing a writing course aligned with adult learning theory within three key areas: planning, pedagogy, and implementation. Planning strategies center around creating a case for change, including multiple stakeholders with diverse backgrounds, including the research mentor, and ensuring accountability among stakeholders. Pedagogical strategies focus on harnessing the power of experiential learning, considering a flipped classroom approach, and peer teaching to leverage social and cognitive congruence. Implementation strategies include breaking down the writing process into manageable tasks, organizing the writing process according to learner needs, using peer review processes to drive learning, and celebrating the accomplishments of learners within the course. These strategies represent broad initiatives that can be tailored to local training needs and instituted across a wide variety of teaching platforms.

Using the 'Twelve tips for applying change models' for undergraduate medical curriculum reform in Pakistan: Incorporating a new Trauma Evaluation and Management TEAM® course

Background: Trauma evaluation and management skills are not taught enough in medical school undergraduate curriculums worldwide. It has been recommended by trauma educators to incorporate trauma training in medical schools' curriculum as first-line management of trauma cases is usually required by junior doctors in ERs. The introduction of formal trauma training in the form of the Trauma Evaluation and Management TEAM® course is a change introduced into the curriculum. Even when introducing such a simple change, certain factors need to be considered including the stakeholders' apprehensions and involvement, the complexity of the internal and external environment, cultural context and political influences, and finally the psychological impact of change. Methods: Based primarily on the " Twelve tips for applying change models to curriculum design, development and delivery" by McKimm and Jones (2018), these 12 tips provide educators, involved in curriculum or program development, a practical example of the systematic and organized outlines to improve medical curricula. Results & Conclusions: While addressing these factors, this framework can guide educators for the successful development and implementation of a suggested change in the existing curriculum.

Person-centred care on the move - an interview study with programme directors in Swedish higher education

BACKGROUND

There is an increasing trend towards person-centred care (PCC) worldwide, suggesting that PCC should be mastered by future health care professionals. This study aims to explore programme directors' views on facilitators and barriers to implementing PCC in four of the largest national study programmes in Sweden training future health care professionals.

METHODS

A qualitative design was applied and interviews were conducted with 19 programme directors of Swedish national study programmes in medicine, nursing, occupational therapy and physiotherapy. The interviews were analysed using qualitative content analysis. Themes were sorted according to the Consolidated Framework for Implementation Research (CFIR) in an abductive approach. COREQ guidelines were applied.

RESULTS

The overarching theme, as interpreted from the programme directors' experiences, was 'Person-centred care is on the move at different paces.' The theme relates to the domains identified by the CFIR as outer setting, innovation, inner setting and process. PCC was understood as something familiar but yet new, and the higher education institutions were in a state of understanding and adapting PCC to their own contexts. The movement in the outer setting consists of numerous stakeholders advocating for increased patient influence, which has stirred a movement in the inner setting where the higher educational institutions are trying to accommodate these new demands. Different meanings and values are ascribed to PCC, and the concept is thus also 'on the move', being adapted to traditions at each educational setting.

CONCLUSION

Implementation of PCC in Swedish higher education is ongoing but fragmented and driven by individuals with a specific interest. There is uncertainty and ambiguity around the meaning and value of PCC and how to implement it. More knowledge is needed about the core of PCC as a subject for teaching and learning and also didactic strategies suitable to support students in becoming person-centred practitioners.

Assessing medical students' perception and educational experience during COVID-19 pandemic

INTRODUCTION

The COVID-19 pandemic has significantly impacted the traditional delivery of medical education. Medical education programmes have had to cope with limitations on face-to-face learning, and accelerate the adoption of digital learning. In addition, the pandemic has potential serious implications on the psychological well-being of medical students. We aim to assess the changes in perceptions and experiences of medical students as a consequence of this pandemic.

METHODS

Cross-sectional survey of medical students at Trinity College Dublin (TCD) between March and April 2022 was performed. The survey explored student satisfaction with the current education program, teaching delivery and the impact of COVID-19 on education and student well-being.

RESULTS

175 medical students participated in the survey. Overall, the majority of students were happy/neutral with their medical education. 93 (53.1%) felt tutorials and problem-based learning (PBL) to be the most effective method of teaching, followed by laboratory and clinical placements in 78 participants (44.6%) and hybrid-learning in 85 participants (48.6%). There was a mixed reaction to the changes in the delivery of education brought about by the pandemic. 67 participants (40.6%) felt happy with the changes, another 64 participants (38.8%) felt neutral, whilst only 34 participants (20.6%) were unhappy. However, most participants felt the pandemic negatively impacted their mental health, with 96 participants (55.8%) reporting negative responses. 58% of participants (n = 102/175) reported utilising the student support services at university campus and 49% (n = 50) were satisfied with their services.

CONCLUSION

Digital content and delivery confer the benefit of greater flexibility in learning, the ability to learn at one's own pace and in a preferred environment, however lacks the advantage of bedside teaching and hands-on training. Our findings reinforce the potential advantages of online learning.

Rivalries for attention: insights from a realist evaluation of a postgraduate competency-based medical education implementation in Canada

BACKGROUND

Implementing competency-based medical education (CBME) in post-graduate medical education (PGME) is a complex process that requires multiple systemic changes in a complex system that is simultaneously engaged in multiple initiatives. These initiatives often compete for attention during the implementation of CBME and produce unintended and unanticipated consequences. Understanding the impact of this context is necessary for evaluating the effectiveness of CBME. The purpose of the study was to identify factors, such as contexts and processes, that contribute to the implementation of CBME.

METHODS

We conducted a realist evaluation using data collected from 15 programs through focus groups with residents (2 groups, n = 16) and faculty (one group, n = 8), and semi-structured interviews with program directors (n = 18), and program administrators (n = 12) from 2018 to 2021. Data were analyzed using a template analysis based on a coding framework that was developed from a sample of transcripts, the context-mechanism-outcomes framework for realist evaluations, and the core components of CBME.

RESULTS

The findings demonstrate that simultaneous initiatives in the academic health sciences system creates a key context for CBME implementation - rivalries for attention - and specifically, the introduction of curricular management systems (CMS) concurrent to, but separate from, the implementation of CBME. This context influenced participants' participation, communication, and adaptation during CBME implementation, which led to change fatigue and unmet expectations for the collection and use of assessment data.

CONCLUSIONS

Rival initiatives, such as the concurrent implementation of a new CMS, can have an impact on how programs implement CBME and greatly affect the outcomes of CBME. Mitigating the effects of rivals for attention with flexibility, clear communication, and training can facilitate effective implementation of CBME.

Understanding the challenges related to breastfeeding education and barriers to curricular change: a systems perspective for transforming health professions education

OBJECTIVES

A majority of women and families wish that their babies be breastfed. However, too many still receive insufficient or inappropriate initial care from health professionals (HPs) who have limited breastfeeding (BF) competencies. We investigated barriers and potential solutions to improve the undergraduate training programs for various HPs.

METHODS

Focus groups were carried out in three universities in Quebec and one in Ontario (Canada), with 30 faculty and program directors from medicine, midwifery, nursing, nutrition, and pharmacy. Discussions were subjected to thematic content analysis, before being validated in a strategic planning workshop with 48 participants from the same disciplines, plus dentistry and chiropractic.

FINDINGS

Substantive improvements of undergraduate training programs for BF could be obtained by addressing challenges related to the insufficient, or lack of, (i) interactions among various HPs, (ii) opportunities for practical learning, (iii) specific standards to guide course content, (iv) real-life experience with counselling, and (v) understanding of the influence of attitudes on professional practice. Several potential solutions were proposed and validated. The re-interpretation of the results in light of various literature led to an emerging framework that takes a systems perspective for enhancing the education of HPs on BF.

CONCLUSIONS

To improve the education of HPs so as to enable them to provide relevant support for future mothers, mothers and their families, solutions need to be carried out to address challenges in the health system, the education system as well as regarding the curricular change process.

Developing a Parental Leave Policy in Undergraduate Medical Education: A Successful Student-Administration Collaboration

PROBLEM

Most medical schools lack parental leave policies, leaving medical students vulnerable to discrimination, diminished educational opportunities, delays in graduation or matching, and breaches of privacy. This report outlines the steps taken by student-leaders to advocate for such a policy and the lessons learned along the way.

APPROACH

In September 2018, leaders of the Family Support Initiative, a medical student interest group at the University of North Carolina School of Medicine, initiated the process of advocating for a clear, official parental leave policy. Certain elements proved essential in bringing about institutional change, including active involvement of a faculty advocate; well-documented student testimonials; commitment from top administrative leaders; involvement of the Title IX office and legal counsel; creating space for authentic collaboration; building clear, flexible mechanisms for making up missed time; and consideration of preclinical training and regional campuses.

OUTCOMES

The Education Committee unanimously approved the New Child Adjustment Policy in June 2019. The policy was published online; shared broadly in various formats with students, faculty, and members of the university health system; and announced at class meetings and new student orientations. Faculty advisors were trained on its content and procedures. Administrators and students report that the policy has informed their discussions around family planning and made these conversations easier to navigate.

NEXT STEPS

The process model outlined here is intended to serve as a roadmap for other institutions. While student input should inform the development of parental leave policies, institutions are morally and ethically responsible for providing parental leave policies that address the key components outlined here. The authors will further study the impact of this policy on student satisfaction and academic performance. The authors urge the Liaison Committee on Medical Education and Commission on Osteopathic College Accreditation to make clear, inclusive, student-centered parental leave policies a requirement for accreditation.

Applying activity theory to undergraduate medical curriculum reform: Lessons in contradictions from multiple stakeholders' perspectives

PURPOSE

Medical school curricula require regular updating. We adopted an activity theory lens to conduct a holistic, multiple stakeholder-informed analysis of curricular reform, aiming to understand how the social relations between groups contribute to unanticipated tensions and outcomes.

METHODS

A research assistant conducted semi-structured interviews with purposively sampled (N = 19) administrative staff, faculty course leads, faculty tutors, curriculum developers, change leaders and student leaders. The team applied a framework analysis to guide within and between stakeholder comparisons.

RESULTS

Participants reported unique (N = 21) and cross-cutting (N = 17) contradictions underscoring emerging drivers of current and potential change. Unique contradictions raised by 1-2 groups represented seeds of change that had the potential to spread across all groups. By contrast, two general types of cross-cutting contradictions arose when one group had a dominant, confirming voice or two or more groups had contrasting perspectives.

CONCLUSIONS

While finding contradictions was expected, our analysis profiled their nature and some of the specific tensions they raised across and within stakeholder groups. The activity theory lens provided an accessible way to unravel curricular reform into manageable units of analysis. Systematically identifying contradictions arising from curricular reform will help stakeholders collaborate with a shared purpose toward positive, sustained change.

Using the ‘Twelve tips for applying change models’ for undergraduate medical curriculum reform in Pakistan: Incorporating a new Trauma Evaluation and Management TEAM® course

Background: Trauma evaluation and management skills are not taught enough in medical school undergraduate curriculums worldwide. It has been recommended by trauma educators to incorporate trauma training in medical schools’ curriculum as first-line management of trauma cases is usually required by junior doctors in ERs. The introduction of formal trauma training in the form of the Trauma Evaluation and Management TEAM® course is a change introduced into the curriculum. Even when introducing such a simple change, certain factors need to be considered including the stakeholders’ apprehensions and involvement, the complexity of the internal and external environment, cultural context and political influences, and finally the psychological impact of change. Methods: Based primarily on the “Twelve tips for applying change models to curriculum design, development and delivery” by McKimm and Jones (2018), these 12 tips provide educators, involved in curriculum or program development, a practical example of the systematic and organized outlines to improve medical curricula. Results & Conclusions: While addressing these factors, this framework can guide educators for the successful development and implementation of a suggested change in the existing curriculum.

A qualitative study applying Bourdieu's concept of field to uncover social mechanisms underlying major curriculum reform

PURPOSE

Planning committees play a key role in blueprinting major curriculum reform. In this qualitative study, we apply Bourdieu's sociological concept of field to the perceptions of committee members to identify the social mechanisms operating in major curriculum reform.

METHOD

A planning committee with 18 members developed a blueprint for major curriculum reform at the Charité Berlin in its transition from a discipline-based programme to a fully integrated undergraduate medical programme. Interviews with 13 members about their experiences were subjected to inductive-deductive content analysis.

RESULTS

Viewed through a Bourdieuan lens, the curriculum committee represents a social field of intense competition and conflicts. Groups of committee members struggled for and with different forms of economic, cultural and social capital to maintain and increase their power and social position in the medical programme. In our case, the major reform was accompanied by loss of power within the teaching department group, while the student group gained power.

CONCLUSION

Bourdieu's concept of field reveals that a major curriculum reform is substantially shaped by power struggles over various forms of capital and social positions related to the future curriculum. The findings may serve as a complementary guide for those navigating the complexity of major curriculum reform.

Two sides of the same coin: Quality improvement and program evaluation in health professions education

Health professions education is in constant pursuit of new ways of teaching and assessment in order to improve the training of healthcare professionals. Educators are often challenged with designing, implementing, and evaluating programs in the context of their professional practice, particularly those in response to dynamic and emerging social needs. This article explores the synergies and intersections of two approaches-quality improvement and program evaluation-and the potential utility of their combinations within our field to design, evaluate, and most importantly, improve educational programming. We argue that the inclusion of established quality improvement frameworks within program evaluation provides a proven mechanism for driving change, can optimize programming within the multi-contextual education systems, and, ultimately, that these two approaches are complementary to one another. These combinations hold great promise for optimizing programming in alignment with social missions, where it has been difficult for institutions worldwide to generate and capture evidence of social accountability.

Measuring the Uptake of Disclosure and Apology Content in the American Medical School Curriculum

Surveys were sent to deans and curriculum leaders of American medical schools regarding the teaching of disclosure and apology in the curriculum. One-hundred six medical schools responded (n = 106; 60% response rate) and results showed that disclosure and apology (also known as communication and resolution programs or CANDOR) is being taught in American medical schools but more work remains to develop consistent curriculum across all medical schools. The same survey (with slightly different wording) was sent to a commercial list of fourth year medical students; two hundred thirty students (n = 230, 17% response rate) representing 67 medical schools completed the survey. The students' data - though not statistically significant - provides a glimpse into students' feeling about this topic, including the desire to learn what happens after "sorry" and how cases can be resolved with disclosure, including the insurance, legal, and compensation aspects. Further avenues of research on this topic are suggested.

An adaptation-focused evaluation of Canada's first competency-based medical education implementation in radiology

OBJECTIVES

Systematic program evaluation of the Queen's University diagnostic radiology residency program following transition to a competency-based medical education (CBME) curriculum.

METHODS

Rapid Evaluation methodology and the Core Components Framework were utilized to measure CBME implementation. A combination of interviews and focus groups were held with program leaders (n = 6), faculty (n = 10), both CBME stream and traditional stream residents (n = 6), and program staff (n = 2). Interviews and focus groups were transcribed and analyzed abductively. Study team met with program leaders to review common themes and plan potential adaptations.

RESULTS

Strengths of CBME implementation included more frequent and timely feedback as well as the role of the Academic Advisor. However, frontline faculty felt insufficiently supported with regards to the theory and practical implementation of the new curriculum and found assessment tools unintuitive. The circumstances surrounding the curricular implementation also resulted in some negative sentiment. Additional faculty and resident education workshops were identified as areas for improvement as well as changes to assessment tools for increased clarity. Residents overall viewed the changes favorably, with traditional stream residents indicating that they also had a desire for increased feedback.

CONCLUSIONS

Rapid Evaluation is an effective method for program assessment following curricular change in diagnostic radiology. A departmental champion driving enthusiasm for change from within may be valuable. Adequate resident and faculty education is key to maximize change and smooth the transition. Advances in knowledge: This study provides insights for other radiology training programs transitioning to a CBME framework and provides a structure for programmatic assessment.

Medical educators' beliefs about learning goals, teaching, and assessment in the context of curriculum changes: a qualitative study conducted at an Iranian medical school

BACKGROUND

Achieving changing needs, advancing knowledge, and innovations in higher education require the constant changes of medical school curricula and successfully applying the new reforms requires some modifications in the medical educators' core beliefs. The purpose of this study was to describe the medical educators' beliefs about the alignment of the learning goals with teaching and assessment processes in the context of the curriculum changes.

METHOD

A qualitative method was used to study the medical educators' beliefs through selecting the faculty participants via a purposeful sampling strategy. The study was conducted at a Medical School in Iran. For the individual interviews, we invited both the professors of the basic sciences and the clinical professors who had thought medical students for at least 5 years. Ten educators were interviewed.

RESULT

The results of the research showed that, in the professors' viewpoints, the development of competencies in the students has been abandoned and this is due to the priority of treatment to education in the clinical courses and the limited learning experiences. Moreover, the gap between the content and the context and the attendance of the students in the hospitals instead of the clinics to pass their internship courses has reduced the provision of authentic learning experiences. These conditions have affected the quality of education negatively. The non-systematic assessment has also worsened the situation.

CONCLUSION

Despite the changes in the curriculum, the compartmentalization of the curriculum and the structure of the medical education have caused the professors' beliefs to be in line with the past perspectives. Some modifications in the structure of the curriculum seem to be necessary.

Roadblocks to Integration; Faculty's perspective on transition from Traditional to Integrated Medical Curriculum

OBJECTIVE

This study was conducted to explore the faculty's opinion regarding factors impeding practical transition from traditional to integrated medical curriculum at the outset and a few years after the process.

METHODS

This qualitative exploratory study was conducted from April 2018 to October 2018 at two undergraduate medical colleges; one where integrated curriculum was at the outset and the second running it successfully. A total of 12 semi-structured interviews (six from each college) were recorded and transcribed. Thematic content analysis was carried out and faculty's perceptions about factors impeding practical transition to integrated curriculum were explored at two stages, i.e., at the outset and after its implementation.

RESULTS

Four impediments identified at the outset were deemed genuine by faculty who had gone through the experience including, faculty's resistance, lack of training, lack of incentives, and insufficient resources. Four more impediments were identified after the experience including lack of leadership, lack of attention to faculty's concerns, lack of communication and difficulties in setting appropriate assessment.

CONCLUSIONS

Several factors if ignored can result in failure of integration of curriculum in undergraduate medical colleges. Relevantly appropriate policies should be outlined by the regulatory body to ensure the control on the impediments.

Advancing quality culture in health professions education: experiences and perspectives of educational leaders

The concept of quality culture has gained increased attention in health professions education, drawing on insights that quality management processes and positive work-related attitudes of staff in synergy lead to continuous improvement. However, the directions that guide institutions from quality culture theory to educational practice have been missing so far. A prospective qualitative case study of three health professions education programmes was conducted to explore how a quality culture can be enhanced according to the experiences and perspectives of educational leaders. The data collection was structured by an appreciative inquiry approach, supported with vignette-based interviews. A total of 25 participants (a selection of course coordinators, bachelor coordinators and directors of education) reflected on quality culture themes to learn about the best of what is (Discover), envision positive future developments (Dream), identify actions to reach the desired future (Design), and determine how to support and sustain improvement actions (Destiny) within their own educational setting. The results are presented as themes subsumed under these four phases. The experiences and perspectives of educational leaders reveal that peer learning in teams and communities, attention to professional development, and embedding support- and innovation networks, are at the heart of quality culture enhancement. An emphasis on human resources, (inter)relations and contextual awareness of leaders stood out as quality culture catalysts. Educational leaders are therefore encouraged to especially fuel their networking, communication, coalition building, and reflection competencies.

Barriers and facilitators to implementing a longitudinal dementia education programme into undergraduate healthcare curricula: a qualitative study

BACKGROUND

As the numbers of people with dementia worldwide rises, there is a need for improved knowledge and awareness about the condition across the healthcare workforce. There are concerns that traditional models of healthcare education, which focus on short-term episodes of care, limit student understanding of long-term conditions. We therefore designed and delivered the Time for Dementia programme at five Universities in the UK. Through longitudinal contact with families living with dementia, healthcare students gain increased understanding about the experiences of living with dementia. However, implementing new educational models brings challenges. To enable implementation of similar programmes in other educational institutions, this study aimed to identify the common barriers and facilitators of implementing these types of longitudinal programmes at scale.

METHODS

To understand the facilitators and barriers of implementing a longitudinal dementia educational programme, a qualitative study was completed. Between October and December 2018, twelve in-depth semi-structured interviews were completed with university teaching staff (n = 6), programme administrators (n = 4), and Alzheimer's Society staff (n = 2) that had key responsibilities for implementing Time for Dementia. Interview questions explored participants experiences, the facilitators, and the challenges encountered when implementing the programme. Interviews were audio recorded, transcribed verbatim, and analysed using inductive thematic analysis.

RESULTS

The analysis identified five key themes: "Leadership characteristics", "Organisational and student buy-in", "Perceived value and motivating factors", "Team coalition and support", and "Time and fit". Implementation of the programme was enhanced by resilient leaders managing the challenges of curricular change. Their belief in the value of the programme, stakeholder buy-in, and supportive team working enabled challenges to be overcome. Workload was reduced and student buy-in increased as time progressed and as more resources became available. A flexible approach to implementation was recommended to ensure the programme fits within the established curriculum.

CONCLUSION

Curricular change is a challenging task, yet necessary, if we are to improve care for people with long term conditions such as dementia. This study highlights the common barriers and facilitators experienced when implementing a longitudinal educational programme at scale. The findings presented in this study can be used by other educational institutions to manage curricular change efforts.

Capturing the impact of cultural differences in residency

BACKGROUND

Postgraduate training is a period in which residents develop both their medical competency and their professional identity in an environment of apprenticeship. As situated learning suggests, a critical dimension of such apprenticeship is the mode through which trainees can legitimately participate in the practice before they become experts, in this case physicians. One source of barriers to participation is cultural difference between learner and the clinical environment.

OBJECTIVE

To assess the extent cultural differences create barriers for residents, particularly but not exclusively for international medical graduates (IMGs).

METHODS

In 2014-15 a questionnaire was developed with subscales assessing areas such as sense of hierarchy, individuality versus teamwork, and risk tolerance. We refined the instrument by subjecting it to a review panel of experts in postgraduate education followed by "think aloud" sessions with residents.

RESULTS

Piloting this instrument yielded a Cronbach's alpha of 0.675. When administered to a larger group of residents and faculty representing many specialties, the Impact of Cultural Differences on Residency Experiences (ICDRE) questionnaire revealed a few items for which the Canadian Medical Graduates and International Medical Graduates differed in their mean opinion. The groups were not substantially different overall, but we did observe an interesting diversity of cultural beliefs within each group.

CONCLUSIONS

We suggest that the ICDRE may be useful in identifying beliefs which may present challenges to an individual resident or in capturing trends in a resident population so that a specialty program can address the trends proactively. The instrument also provides language with which to anchor preceptors' evaluations of residents' professionalism and may serve as an interventional coaching tool.

Vertical integration in postgraduate teaching for anaesthesiology residents: A questionnaire based descriptive cross-sectional study

BACKGROUND

Medical education has observed numerous reforms in the last hundred years. While most of the reforms are applied to the undergraduate teaching, postgraduate education and training have lagged behind in keeping the pace. Anesthesiology curriculum has witnessed a few new methods inducted into practice like problem-based learning, flipped classroom etc. We introduced vertical integration with anatomy at our department and assessed its impact.

METHODS

After a five-week schedule of integrated anatomy classes, a self-structured questionnaire was circulated amongst the 41 anesthesiology residents to know their perceptions and attitudes towards the classes. Their suggestions were also sought. The responses were analyzed with descriptive statistics (percentages).

RESULTS

Thirty-six responses were received leading to a response rate of 87.8%. Fourteen residents (38.9%) believed that the integrated classes would be very helpful in their clinical practice, 20 (55.5%) residents believed them to be helpful while two (5.5%) residents believed that the classes would be little helpful in clinical practice. Hundred percent of the residents recommended the classes to be continued for the future batches. Half of the residents wanted the classes to be conducted twice in the three-year tenure (in the first and last semester) while 11 (30.5%) residents wanted the classes to be conducted every year. Seven (19.4%) residents thought that it's enough to conduct the classes once during the three-year tenure. Resident's suggested that they would like to have integrated classes with other departments like physiology, radiology, emergency medicine etc.

CONCLUSION

The integrated classes with anatomy were well perceived by the anesthesiology residents. Vertically integrated curriculum should be introduced in postgraduate training of various specialties for better education and hence, better patient care.

Change is never easy: How management theories can help operationalise change in medical education

CONTEXT

Medical education is neither simple nor stable, and is highly contextualised. Hence, ways of perceiving multiple connections and complexity are fundamental when seeking to describe, understand and address concerns and questions related to change.

PROPOSAL

In response to calls in the literature, we introduce three examples of contemporary organisational theory which can be used to understand and operationalise change within medical education. These theories, institutional logics, paradox theory and complexity leadership theory, respectively, are relatively unknown in medical education. However, they provide a way of making sense of the complexity of change creatively. Specifically, they cross-cut different levels of analysis and allow us to 'zoom in' to micro levels, as well as to 'zoom out' and connect what is happening at the individual level (the micro level) to what happens at a wider institutional and even national or international level (the macro level), thereby providing a means of understanding the interactions among individuals, teams, organisations and systems. We highlight the potential value of these theories, provide a brief discussion of the few studies that have used them in medical education, and then briefly critique each theory.

CONCLUSIONS

We hope that by drawing the attention of readers to the potential of these management theories, we can unlock some of the complexity of change in medical education, support new ways of thinking and open new avenues for research.

Shaping a Culture for Continuous Quality Improvement in Undergraduate Medical Education

PURPOSE

This study sought to identify key features of an organizational quality culture and explore how these features contribute to continuous quality improvement of undergraduate medical education.

METHOD

Between July and December 2018, researchers from Maastricht University in the Netherlands conducted a multicenter focus group study among 6 education quality advisory committees. Participants were 22 faculty and 18 student representatives affiliated with 6 medical schools in the Netherlands. The group interviews focused on quality culture characteristics in relation to optimizing educational development, implementation, evaluation, and (further) improvement. Template analysis, a stepwise type of thematic analysis, was applied to analyze the data.

RESULTS

Five main themes resembling quality culture constituents to continuous educational improvement were identified: (1) fostering an open systems perspective, (2) involving stakeholders in educational (re)design, (3) valuing teaching and learning, (4) navigating between ownership and accountability, and (5) building on integrative leadership to overcome tensions inherent in the first 4 themes. A supportive communication climate (which can be fueled by the organization's leaders) contributes to and is integrated within the first 4 themes.

CONCLUSIONS

The results call for a shift away from static quality management approaches with an emphasis on control and accountability toward more flexible, development-oriented approaches focusing on the 5 themes of a culture for continuous quality improvement. The study provides new insights in the link between theory and practice of continuous quality improvement. Specifically, in addition to quality management systems and structures, faculty's professional autonomy, collaboration with peers and students, and the valuing of teaching and learning need to be amplified.

Special Pathology in the course content of Third Year MBBS: Views of students and teachers

Objective:

The students and teachers are major stakeholders whenever there is a change in the curriculum. Objective of the study was to assess the views of Third Year MBBS students and college teachers involved in teaching Third Year MBBS class regarding the inclusion of special pathology to the already cumbersome course content.

Methods:

It was a cross-sectional descriptive study carried out over a period of eight months from April, 2019 to December, 2019. An online questionnaire was used to collect the data from 110 third year MBBS students and 35 medical college teachers involved in teaching the third year MBBS class at HBS Medical & Dental College, Islamabad, Pakistan. The questionnaire contained open ended questions along with a short questionnaire based on 3-point Likert scale for a semi-quantitative analysis. The open ended responses in the interviews were assessed using Mayring’s qualitative context analysis. The similar comments were bundled up as the comments were sequentially processed and the replicates were grouped. The responses were then ranked by the number of times they were selected using Microsoft Excel 2013 and SPSS 21.

Results:

A total of 105 medical students and 32 medical teachers participated in the study. n=94 (89.5%) of the students agreed that the content taught was incoherent and n= 92 (88%)agreed that the time allocation for the various modules was inappropriate. The important reservation of the students was that the assessment strategies of the past continued to prevail and they were not aligned with the change in the curriculum. They suggested to spread Pathology over four years of MBBS so that true integration can be done. The top ranked reason amongst the students who were in favor of this system was that they could easily leave microbiology on choice and study selectively to pass the exam as the extensive course inhibited the examiners to assess every aspect of Pathology comprehensively especially Microbiology and general Pathology being compromised upon. As far as the teachers are concerned n=28 (88%) agreed that the course content is inappropriate and the students are being bombarded with selective knowledge in a shorter period of time. Important reservation of the faculty members was that they were not trained to deliver the content according to this sudden change which has seriously affected the student’s results.

Conclusions:

Although curriculum change is a dynamic process and leads to refinement of the existing content but it should be implemented after proper planning, training and validation so that the students and the teachers can cope with and derive maximum benefit.

The road taken - changing one's professional focus at a large research university

The scientific endeavor has many facets, extending well beyond the experimental research bench. However, in most fields, especially in the biomedical sciences, the traditional career pathway for scientists is first joining and later leading an experimental research laboratory or program. As a result, scientific education is often focused on training new bench researchers. My own journey from a traditional bench scientist to that of an educator and educational researcher will be discussed in the context of a large research university environment. Being a scientist with an educational focus at such an institution poses significant challenges, but also opens new opportunities. In my opinion, these two professional pathways are not exclusive or alternative choices, but rather are complementary, both representing important and essential elements of scientific progress.

What Physicians Wished They Would Have Learned in Medical School: a Survey

PURPOSE

Medical students must be provided the basic science knowledge appropriate and applicable for preparing them for best-practice medicine. To date, there have been no documented studies in the USA that have directly surveyed practicing physicians on their perspectives of their basic science/preclinical medical school education and how it could be modified to help them deliver best patient care. This study was the first to examine this information.

METHOD

A survey was administered to the alumni of Touro College of Osteopathic Medicine, Harlem, NY (2011-2018), with questions on examining perspectives on basic science disciplines, the need for a basic science refresher course, and other educational topics. In addition, questions relating to demographics and type of medical practice were also asked. Statistical analysis was performed using SPSS.

RESULTS

(1) Gender (N = 122): 55% male and 44% female; (2) medical specialty (N = 107): 51.40% Primary Care physicians (Family medicine, Internal medicine, Pediatrics), 48.60% Other Specialties; (3) top Disciplines that "should have more": Physiology (41.1%), Pharmacology (39.3%), and Preventative Medicine/Public Health (39.3%); Top disciplines that "should have less": Histology Laboratory (38.32%), Embryology (35.51%), Histology (didactic) (28.30%) (N = 107); (4) top topics "most important" to be included in curriculum: Analysis of Journal Articles (70.10%), Clinical Cases (70.1%), and Early Patient Exposure (64.5%) (N = 107); (5) presentation of a clinically relevant Basic Science refresher course had a positive response (84.4%) (N = 107).

CONCLUSIONS

Pharmacology, Physiology, Clinical Cases, Journal Article Analysis, and Early Patient exposure were among topics requiring "more" in preclinical education. A clinically relevant basic science course was deemed useful. The perspectives of practicing physicians should be included when designing future medical school curriculums.

Practical Application of Assessment Principles in the Development of an Innovative Clinical Performance Evaluation in the Entrustable Professional Activity Era

Educators have been challenged to create assessments that are competency-based and grounded in accepted standards such as the entrustable professional activities (EPAs). The clinical performance evaluation (CPE) is a commonly utilized assessment modality, which allows multiple evaluators to provide feedback on a learner's performance in the clinical workplace. In this paper, we describe the relevant principles that served as a guide as we developed a new CPE for medical students that fully incorporate EPAs. This may help ease the transition for other institutions looking to introduce a new student CPE.

Student participation in undergraduate medical education: a continuous collective endeavour

None

A Five Year Longitudinal Study of the Educational Environment in a Newly Integrated Medical Curriculum

Objectives

The College of Medicine at Gulf Medical University (GMU), Ajman, United Arab Emirates, was subjected to a curricular reform, which shifted the institution from a traditional curriculum to a hybrid, student-centred, integrated curriculum. There are no previous studies analysing the consequences of such a curricular modification on the educational environment (EE). Therefore, this study aimed to analyse the EE of a pioneer cohort of the innovative curriculum over their five-year course of study.

Methods

This prospective longitudinal study was conducted between September 2009 and September 2013 at the College of Medicine. The Dundee Ready Education Environment Measure questionnaire was completed by a pioneer cohort of students at the start of each academic session for five consecutive years. The mean overall, subscale and individual statement scores were evaluated using the Kruskal-Wallis and Wilcoxon-rank sum tests.

Results

A total of 178 responses were collected (response rate: 90.4%). The mean overall score throughout the five years of study was 130/200. A significant difference in the scores (P <0.05) was observed as the students proceeded through the course. The overall and subscale scores were significantly higher in the first and final years of study. Analysis of the statements recognised the medical knowledge of the teachers’ and students’ awareness of empathy and social interactions as persistent strengths of the college over the entire course of study. A curricular overload, a want for support systems for stressed students, students’ waning interest levels and assessment strategies emerged as areas that warranted further attention.

Conclusion

The pioneer cohort of the new curriculum rated their EE as positive throughout their five years of study at GMU. An examination of individual statements revealed the programme’s strengths and areas for improvement for the institution.

Minimal effects of reduced teaching hours on undergraduate medical student learning outcomes and course evaluations

Introduction: Various pressures exist for curricular change, including economic forces, burgeoning knowledge, broadening learning outcomes, and improving quality and outcomes of learning experiences. In an Australian 5-year undergraduate medical course, staff were asked to reduce teaching hours by 20% to alleviate perceived overcrowded preclinical curriculum, achieve operating efficiencies and liberate time for students' self-directed learning.Methods: A case study design with mixed methods was used to evaluate outcomes.Results: Teaching hours were reduced by 198 hours (14%) overall, lectures by 153 hours (19%) and other learning activities by 45 hours (7%). Summative assessment scores did not change significantly after the reductions: 0.4% increase, 1.5% decrease and 1.7% increase in Years 1, 2 and 3, respectively. The percentage of students successfully completing their academic year did not change significantly: 94.4% before and 93.3% after the reductions. Student evaluations from eVALUate surveys changed little, except workload was perceived to be more reasonable.Conclusions: Teaching hours, particularly lectures, can be moderately reduced with little impact on student learning outcomes or satisfaction with an undergraduate medical course.

A Medical School Dean's Guide to Orienting Educational Leaders on Roles, Responsibilities, and Resources

Continuing professional development of physicians often revolves around clinical activities. Accordingly, there is a lack of intentional development and support of medical education leaders despite such individuals having critical influence over key organizational functions. Unequivocally, educational leaders have complex and dynamic jobs that require clear delineation of roles, responsibilities, and resources available to successfully train the next generation of health professionals. Although there is guidance on how to longitudinally onboard medical education leaders, there is little information on how to effectively orient such leaders on the functional nature of their jobs. Baylor College of Medicine's medical school dean developed and delivered a 2-day orientation program to educational leaders to clarify roles, responsibilities, and resources. Postevaluation surveys aimed to identify key session content that would be frequently used by educational leaders to oversee key aspects of medical education. The purpose of this article is to outline the structure and content of an orientation program designed for medical education leaders, and share postevaluation data to identify which sessions were most used in practice. Other deans are encouraged to take ownership over the professional development of their educational leaders and delivering similar programming.

Dynamic Tensions Following New Pedagogy in Undergraduate Medical Education

The authors draw on their many decades of combined experience with medical students, observing their maturation into practice in widely differing contexts, to reaffirm some of the essential goals of medical education. They briefly review curricular changes in medical education over the past 100 years, then focus on the dynamic tension in undergraduate medical education (UME) resulting from new pedagogy. Specifically, these tensions arise from the differing trajectories and directions of the 3 traditional pillars of academic medicine: clinical excellence, state-of-the-art education, and cutting-edge research. The authors highlight the role of generalism as an essential foundation of UME, as well as the dilemma of a shrinking cadre of medical students choosing a generalist career path. To address challenges stemming from pedagogical changes, the authors offer 4 observations. First, a more condensed approach to faculty development may be to ensure that bringing teachers up to speed on the new curriculum is not excessively burdensome. Second would be a more gradual introduction of the proposed changes. Third, some discussion about medical education pedagogy and curricular development ought to have a place in UME to prepare the next generation of physicians for ongoing changes in accreditation and in approaches to education. Finally, more appropriate funding of medical education would alleviate some of the burden and anxiety by acknowledging its nonmaterial value.

Student participation in the development of interprofessional education courses: Perceptions and experiences of faculty members and the students

Introduction: Student participation has shown positive effects on the curriculum development process for a single health profession. This qualitative study explores faculty members' and students' perceptions and experiences regarding student participation in interprofessional course development.Methods: Interprofessional courses were developed and implemented by interprofessional teams of faculty members and students. Two focus group discussions were carried out: one with faculty members and one with students.Results: Students contributed to both the process and the results of interprofessional course development in a complementary manner. Student participation was facilitated via motivation for and through work on interprofessional education, a balance between clarity on tasks and students' autonomy, and a low-hierarchy team atmosphere. Students developed professionally, and faculty members saw them as future ambassadors for interprofessional collaboration.Conclusions: This study provides multiple qualitative evidence for a positive, complementary role of student participation in interprofessional course development. A number of factors were identified that should be nurtured to facilitate this effect. Our findings may stimulate and guide other schools to actively involve students in the development of interprofessional education.

HannibaL - the model curriculum at Hannover Medical School: targets, implementation and experiences

Aim: The model curriculum known as HannibaL is an integrated, professionally-based adaptive curriculum that began at the Hannover Medical School (MHH) during the 2005/06 academic year. HannibaL turns medical students into competent physicians through its patient-based interdisciplinary instruction. This paper provides an overview of the curriculum's creation, educational content and philosophy and reflects on the experience that has been gathered. Also described are organizational and quality assurance measures which were also employed to implement the model curriculum. Method: The central ideas and processes are reported in a primarily narrative manner in an attempt to present the information coherently. The aspects discussed are setting up the model curriculum, central features of teaching and exams with their underlying educational premises; organization and evaluation are also covered in the context of the research literature on curriculum and faculty development. Developing the teaching and learning culture of the model curriculum is also explored. Results: The basic objectives were realized, including the design of learning spirals and intensifying the inclusion of patients and practical elements at the beginning of study. However, plans to allow students more freedom to pursue their own learning and research interests have not yet been satisfactorily implemented. Key areas to support teaching have been expanded (teacher training for instructors, student advising, course evaluations). Conclusion: The model curriculum and its aims are widely recognized and supported not only by medical students and instructors, but also external committees and experts. As a consequence, HannibaL will be developed further in upcoming years to implement the objectives which have not yet been met and to master new challenges faced by medical education.

"My right-hand man" versus "We barely make use of them": change leaders talking about educational scientists in curriculum change processes-a Membership Categorization Analysis

Health professions education scholarship units (HPESUs) are increasingly becoming a standard for medical schools worldwide without having much information about their value and role in actual educational practices, particularly of those who work in these units, the educational scientists. We conducted a linguistic analysis, called Membership Categorization Analysis, of interviews with leaders of recent curriculum changes to explore how they talk about educational scientists in relation to these processes. The analysis was conducted on previously collected interview data with nine change leaders of major undergraduate medical curriculum change processes in the Netherlands. We analyzed how change leaders categorize HPESUs and educational scientists (use of category terms) and what they say about them (predicates). We noticed two ways of categorizing educational scientists, with observable different predicates. Educational scientists categorized by their first name were suggested to be closer to the change process, more involved in decisional practices and positively described, whereas those described in more generic terms were represented in terms of relatively passive and unspecified activities, were less explicit referenced for their knowledge and expertise and were predominantly factually or negatively described. This study shows an ambiguous portrayal of educational scientists by leaders of major curriculum change processes. Medical schools are challenged to establish medical curricula in consultation with a large, diverse and interdisciplinary stakeholder group. We suggest that it is important to invest in interpersonal relationships to strengthen the internal collaborations and make sure people are aware of each other's existence and roles in the process of curriculum development.

Health Systems Science: The "Broccoli" of Undergraduate Medical Education

Health system leaders are calling for reform of medical education programs to meet evolving needs of health systems. U.S. medical schools have initiated innovative curricula related to health systems science (HSS), which includes competencies in value-based care, population health, system improvement, interprofessional collaboration, and systems thinking. Successful implementation of HSS curricula is challenging because of the necessity for new curricular methods, assessments, and educators and for resource allocation. Perhaps most notable of these challenges, however, is students' mixed receptivity. Although many students are fully engaged, others are dissatisfied with curricular time dedicated to competencies not perceived as high yield. HSS learning can be viewed as "broccoli"-students may realize it is good for them in the long term, but it may not be palatable in the moment. Further analysis is necessary for accelerating change both locally and nationally.With over 11 years of experience in global HSS curricular reform in 2 medical schools and informed by the curricular implementation "performance gap," the authors explore student receptivity challenges, including marginalization of HSS coursework, infancy of the HSS field, relative nascence of curricula and educators, heterogeneity of pedagogies, tensions in students' perceptions of their professional role, and culture of HSS integration. The authors call for the reexamination of 5 issues influencing HSS receptivity: student recruitment processes, faculty development, building an HSS academic "home," evaluation metrics, and transparent collaboration between medical schools. To fulfill the social obligation of meeting patients' needs, educators must seek a shared understanding of underlying challenges of HSS innovations.

Fulfilling a new obligation: Teaching and learning of sustainable healthcare in the medical education curriculum

Aims: Leading the growing international recognition of the need for sustainability in healthcare delivery, the UK medical regulator has mandated that newly qualified doctors must be able to apply the principles of sustainable healthcare to medical practice. This original research investigates how best to incorporate this new learning into the medical curriculum. Methods: Data from multiple sources were triangulated to generate themes through grounded theory. Meetings were held with representatives of key stakeholder organizations, relevant documents were reviewed and semi-structured interviews were conducted with diverse medical educators who teach sustainable healthcare. Results: There is continual pressure on space in the curriculum, and faculty lack the knowledge to teach this emerging subject, which is also difficult to examine. Students increasingly demand that sustainability be addressed in their education and future careers. Many sources of support and learning resources are available. Conclusions: Practical recommendations for implementation in any medical school include: teaching sustainability as a cross-cutting theme rather than a topic, clinicians and students learning from each other in this developing field, and embedding into assessment the wider determinants of disease. Sustainable healthcare emphasizes prevention rather than late intervention, with benefits to the environment on which health depends, healthcare systems and patients.

Who owns responsibility? An administrator's take on implementing time-variable medical training in teaching hospitals

Introduction: Developments in outcome-based medical education led to the introduction of time-variable medical training (TVMT). Although this idea of training may be a consequence of competency-based training that calls for individualized learning, its implementation has posed significant challenges. As a new paradigm it is likely to have repercussions on the organization of teaching hospitals. The purpose of this study is therefore to explore how hospital administrators cope with this implementation process. Methods: We conducted an exploratory qualitative study for which we interviewed administrators of hospitals who were actively implementing TVMT in their postgraduate programs. Results: Several problems of implementation were identified: existing governance structures proved unfit to cope with the financial and organizational implications of TVMT. Administrators responded to these problems by delegating responsibilities to departments, reallocating tasks, learning from other hospitals and scaling up their teaching facilities. Conclusions: Hospital administrators perceived the implementation of TVMT as challenging. TVMT affects the existing equilibrium between education and clinical service. Administrators' initial attempts to regain control, using steering strategies that were based on known concepts and general outcomes, including cutting departmental budgets did not work, nor did their subsequent wait-and-see approach of leaving the implementation to the individual departments.

A Cost-Benefit Analysis of Teaching and Learning Technology in a Faculty of Pharmaceutical Sciences

Objective. To conduct a cost-benefit analysis (CBA) of investment in teaching and learning technology (TLT) by a college of pharmacy in a large, research-intensive university in Canada. Methods. Document analysis was used to determine the goals and objectives of the university and college for TLT use. Semi-structured interviews were conducted with faculty members to understand their perspectives on the value of technology for teaching and learning, their metrics to assess value, and an estimate of social value using a willingness to pay (WTP) exercise. A CBA was used to compare the social value against the cost of the investment in TLT. Results. Twenty-one faculty members participated in semi-structured interviews. National, university, and college goals for TLT were diffuse and nonspecific in terms of the intended use or the metrics by which implementation and impacts on the quality of teaching could be assessed. The mean WTP for this technology was Can$4.38M and the cost of investment was Can$4.25M. The primary analysis showed a small positive net benefit of the investment (Can$134,456), although this difference was not significant. All dollar figures are given in Canadian dollars (CAD). Conclusion. The college's monetary investment in TLT was approximately equal to the social value placed on TLT by faculty users. Conducting a CBA on technology can bring greater understanding among faculty members of the college's curriculum and pedagogical practices as well as financial decision-making. Greater clarity about the goals and objectives for TLT could help to maximize the value of investment in this area.

Learning Theory and Educational Intervention: Producing Meaningful Evidence of Impact Through Layered Analysis

Like evidence-based medicine, evidence-based education seeks to produce sound evidence of impact that can be used to intervene successfully in the future. The function of educational innovations, however, is much less well understood than the physical mechanisms of action of medical treatments. This makes production, interpretation, and use of educational impact evidence difficult. Critiques of medical education experiments highlight a need for such studies to do a better job of deepening understanding of learning in context; conclusions that "it worked" often precede scrutiny of what "it" was. The authors unpack the problem of representing educational innovation in a conceptually meaningful way. The more fundamental questions of "What is the intended intervention?" and "Did that intervention, in fact, occur?" are proposed as an alternative to the ubiquitous evaluative question of "Did it work?" The authors excavate the layers of intervention-techniques at the surface, principle in the middle, and philosophy at the core-and propose layered analysis as a way of examining an innovation's intended function in context. The authors then use problem-based learning to illustrate how layered analysis can promote meaningful understanding of impact through specification of what was tried, under what circumstances, and what happened as a result. Layered analysis should support innovation design and evaluation by illuminating what principled adaptation of educational technique to local context could look like. It also promotes theory development by enabling more precise description of the learning conditions at work in a given implementation and how they may evolve with broader adoption.