The difficulty of sustaining curricular reforms: a study of "drift" at one school

Curricular Hoarding

As practice evolves and scientific advancements are achieved the natural inclination for educators and administrators is to add new content to existing curricula. Often pre-existing curricula that may be outdated or no longer relevant may go un-checked leading to excessive coursework and program completion times. Faculty may also have emotional or other attachments to certain topics or content and that may serve as an additional or independent barrier to removing extraneous material. To avoid and curtail curricular hoarding of material it may be prudent to periodically engage in reviews of material assessing them for not only adherence to accreditation standards but also in terms of their on-going appropriateness and relevance to contemporary pharmacy practice. These exercises may be especially important today given the rate of information creation and dissemination in the modern digital age.

Curricular Revision and Reform: The Process, What Was Important, and Lessons Learned

Beginning in 2005, the Doctor of Veterinary Medicine program at the University of California underwent major curricular review and reform. To provide information for others that follow, we have documented our process and commented on factors that were critical to success, as well as factors we found surprising, difficult, or problematic. The review and reform were initiated by the Executive Committee, who led the process and commissioned the committees. The planning stage took 6 years and involved four faculty committees, while the implementation stage took 5 years and was led by the Curriculum Committee. We are now in year 2 of the institutionalizing stage and no longer refer to our reform as the "new curriculum." The change was driven by a desire to improve the curriculum and the learning environment of the students by aligning the delivery of information with current teaching methodologies and implementing adult learning strategies. We moved from a department- and discipline-based curriculum to a school-wide integrated block curriculum that emphasized student-centered, inquiry-based learning. A limit was placed on in-class time to allow students to apply classroom knowledge by solving problems and cases. We found the journey long and arduous, requiring tremendous commitment and effort. In the change process, we learned the importance of adequate planning, leadership, communication, and a reward structure for those doing the "heavy lifting." Specific to our curricular design, we learned the importance of the block leader role, of setting clear expectations for students, and of partnering with students on the journey.

Exploring barriers to teaching behavioural and social sciences in medical education

CONTEXT

Tomorrow's Doctors provides guidance about what is considered core knowledge for medical graduates. One core area of knowledge identified is the individual in society: graduates are required to understand the social and cultural environments in which medicine is practised in the UK. Yet, despite the presence of the behavioural and social sciences (B&SS) in medical curricula in the UK for the past 30 years, barriers to their implementation in medical education remain.

OBJECTIVE

This study sought to discover medical educators' perceptions of the barriers to the implementation of B&SS.

METHODS

Medical educationalists in all UK medical schools were asked to complete a survey identifying what they felt were the barriers they had experienced to the implementation of B&SS teaching in medical education.

RESULTS

A comparison of our findings with the literature revealed that these barriers have not changed since the implementation of B&SS in medical education. Moreover, the barriers remain similar across medical schools with differing ethos and strategies.

CONCLUSIONS

Various agendas within the hidden curricula create barriers to effective B&SS learning in medical education and thus need further exploration and attention.

Lessons from industry: one school's transformation toward "lean" curricular governance

As medical education grapples with organizational calls for centralized curricular oversight, programs may be compelled to respond by establishing highly vertical, stacked governance structures. Although these models offer discrete advantages over the horizontal, compartmentalized structures they are designed to replace, they pose new challenges to ensuring curricular quality and the educational innovations that drive the curricula. The authors describe a hybrid quality-assurance (QA) governance structure introduced in 2003 at the University of Kentucky College of Medicine (UKCOM) that ensures centralized curricular oversight of the educational product while allowing individualized creative control over the educational process. Based on a Lean production model, this approach draws on industry experiences that strategically separate institutional accountability (management) for a quality curriculum from the decision-making processes required to ensure it (production). In so doing, the authors acknowledge general similarities and key differences between overseeing the manufacture of a complex product versus the education of a physician-emphasizing the structured, sequential, and measurable nature of each process. Further, the authors briefly trace the emergence of quality approaches in manufacturing and discuss the philosophical changes that accompany transition to an institutional governance system that relies on vigorous, robust performance measures to offer continuous feedback on curricular quality.

Maximizing the value of feedback for individual facilitator and faculty development in a problem-based learning curriculum

BACKGROUND

Recruiting and retaining facilitators in problem-based learning requires considerable staff development. Providing meaningful feedback to individual facilitators should contribute to improved management of the tutorial group.

AIM

To ascertain the value ascribed by facilitators to feedback they received (based on student input) regarding their performance in the small group tutorial in a new problem-based learning curriculum.

METHODS

Thirty-seven facilitators from a purposive sample, selected for their facilitation experience during the 2001-2003 period, completed a comprehensive survey regarding their experiences. The aspect currently being reported deals with the perceived usefulness of the feedback they received from students and from Faculty following the evaluation of their participation in the small group tutorial. Data are reported for medically qualified and non-medically qualified facilitators.

RESULTS

Both clinical (50%) but more notably the non-clinical (70%) facilitators found the feedback (individual facilitator and general report) useful. Facilitators generally preferred the qualitative comments provided by students in the open-ended section of the evaluation to the Likert scale items. Student comments were valued for the specific direction they offered facilitators to reflect and improve on their management of the small group. For this feedback to be more useful, however, facilitators believed that it needed to be completed by more students who took time to critically engage with the criteria and reflect more honestly on their experiences. In addition, facilitators requested for feedback reports to be made available sooner such that they could improve their facilitation skills for the next group of students.

CONCLUSIONS

Both qualitative and quantitative feedback are important for facilitator development and training. While quantitative feedback is important for summative purposes (e.g. quality assurance and promotion), individual student comments provide more formative feedback, allowing facilitators to reflect on and improve their management of the small group. In order for the feedback to be valid, the majority of students had to participate. Facilitators should receive feedback in time to allow them to modify their activities for the new group.

Twelve tips for recruiting and retaining facilitators in a problem-based learning programme

Successful curriculum reform requires considerable staff development. It is imperative for management to ensure that its academic staff members are committed to the change. This requires planning and negotiation. As facilitators form the 'teaching' backbone of a problem-based learning programme, faculty management must ensure mechanisms are in place to recruit facilitators, and that once recruited, the experience is sufficiently rewarding personally for their enthusiasm to be sustained. This article offers several solutions to difficulties which many medical schools encounter during the early years of an undergraduate PBL programme which replaces a traditional curriculum. The advice offered ranges from recruiting facilitators from the private sector to encouraging staff to become involved in other areas of curriculum development. Most importantly, however, is the reward and incentive system, which must be well advertised in advance of any programme implementation. The suggestions presented in this article will be useful to faculties planning to implement problem-based learning as well as those who already have a programme in place.

Faculty development for problem-based learning

Changing to a problem-based learning (PBL) curriculum represents a substantial challenge because many faculty members are unfamiliar with the process. Faculty development is a crucial component of successful curriculum change to PBL. This paper describes a logical process for designing and implementing a comprehensive faculty development programme at three main stages of change: curriculum transition, curriculum implementation and curriculum advancement. The components of each stage are discussed with reference to the literature and practice. Future advances in faculty development include harnessing the potential of complex adaptive systems theory in understanding and facilitating the change process, and incorporating the results of research, which illuminates the relationships of the PBL tutorial process to student achievement. There is a continuing need for rigorous outcome-based research and programme evaluation to define the best components and strategies for faculty development.

Learning from the problems of problem-based learning

BACKGROUND

The last decade has witnessed a rapid expansion of biomedical knowledge. Despite this, fashions in medical education over the same period have shifted away from factual (didactic) teaching and towards contextual, or problem-based, learning (PBL). This paradigm shift has been justified by studies showing that PBL improves reasoning and communication while being associated with few if any detectable knowledge deficits.

DISCUSSION

Analysis of the literature indicates that the recent rapid rise of PBL has closely paralleled the timing of the information explosion. The growing dominance of PBL could thus worsen the problems of information management in medical education via several mechanisms: first, by creating the impression that a defined spectrum of core factual knowledge suffices for clinical competence despite ongoing knowledge expansion (quality cost); second, by dissuading teachers from refining the educational utility of didactic modalities (improvement cost); and third, by reducing faculty time for developing reusable resources to impart factual knowledge more efficiently (opportunity cost).

SUMMARY

These costs of PBL imply a need for strengthening the knowledge base of 21st-century medical graduates. New initiatives towards this end could include the development of more integrated cognitive techniques for facilitating the comprehension of complex data; the design of differentiated medical curricula for producing graduates with defined high-priority skill sets; and the encouragement of more cost-effective faculty teaching activities focused on the prototyping and testing of innovative commercializable educational tools.

Questioning the "big assumptions". Part I: addressing personal contradictions that impede professional development

BACKGROUND

The ultimate success of recent medical curriculum reforms is, in large part, dependent upon the faculty's ability to adopt and sustain new attitudes and behaviors. However, like many New Year's resolutions, sincere intent to change may be short lived and followed by a discouraging return to old behaviors. Failure to sustain the initial resolve to change can be misinterpreted as a lack of commitment to one's original goals and eventually lead to greater effort expended in rationalizing the status quo rather than changing it.

OBJECTIVE

The present article outlines how a transformative process that has proven to be effective in managing personal change, Questioning the Big Assumptions, was successfully used in an international faculty development program for medical educators to enhance individual personal satisfaction and professional effectiveness. This process systematically encouraged participants to explore and proactively address currently operative mechanisms that could stall their attempts to change at the professional level.

CONCLUSIONS

The applications of the Big Assumptions process in faculty development helped individuals to recognize and subsequently utilize unchallenged and deep rooted personal beliefs to overcome unconscious resistance to change. This approach systematically led participants away from circular griping about what was not right in their current situation to identifying the actions that they needed to take to realize their individual goals. By thoughtful testing of personal Big Assumptions, participants designed behavioral changes that could be broadly supported and, most importantly, sustained.

Questioning the "big assumptions". Part II: recognizing organizational contradictions that impede institutional change

BACKGROUND

Well-designed medical curriculum reforms can fall short of their primary objectives during implementation when unanticipated or unaddressed organizational resistance surfaces. This typically occurs if the agents for change ignore faculty concerns during the planning stage or when the provision of essential institutional safeguards to support new behaviors are neglected. Disappointing outcomes in curriculum reforms then result in the perpetuation of or reversion to the status quo despite the loftiest of goals. Institutional resistance to change, much like that observed during personal development, does not necessarily indicate a communal lack of commitment to the organization's newly stated goals. It may reflect the existence of competing organizational objectives that must be addressed before substantive advances in a new direction can be accomplished.

OBJECTIVE

The authors describe how the Big Assumptions process (see previous article) was adapted and applied at the institutional level during a school of medicine's curriculum reform. Reform leaders encouraged faculty participants to articulate their reservations about considered changes to provided insights into the organization's competing commitments. The line of discussion provided an opportunity for faculty to appreciate the gridlock that existed until appropriate test of the school's long held Big Assumptions could be conducted.

CONCLUSIONS

The Big Assumptions process proved useful in moving faculty groups to recognize and questions the validity of unchallenged institutional beliefs that were likely to undermine efforts toward change. The process also allowed the organization to put essential institutional safeguards in place that ultimately insured that substantive reforms could be sustained.

Reflective critique and collaborative practice in evaluation: promoting change in medical education

The School of Medicine at the University of Tasmania has recently begun to implement a process of curriculum evaluation,which aims to reflect contemporary best practice in evaluation in tertiary pedagogy and medical education. Best practice must accommodate a broadening interest in cooperative and collaborative evaluation strategies among stakeholders, advances in applied qualitative educational research and recognition that critical reflection on practice is the cornerstone of professional education. This paper reports a recent evaluation strategy in a specific year-long unit in the second year of a six-year undergraduate medical degree. The paper begins by presenting the context; it then discusses and rationalises the evaluation strategy and presents findings. The paper concludes by arguing that curriculum evaluation as best practice must be reflective, informed by the scholarship of medical education, and internalized as a dynamic process that can promote sustainable change and improvement in medical curricula. Such an approach will contribute to an undergraduate medical curriculum that prepares students for the demands and complexities of medical practice.

Changing face of medical curricula

The changing role of medicine in society and the growing expectations patients have of their doctors means that the content and delivery of medical curricula also have to change. The focus of health care has shifted from episodic care of individuals in hospitals to promotion of health in the community, and from paternalism and anecdotal care to negotiated management based on evidence of effectiveness and safety. Medical training is becoming more student centred, with an emphasis on active learning rather than on the passive acquisition of knowledge, and on the assessment of clinical competence rather than on the ability to retain and recall unrelated facts. Rigid educational programmes are giving way to more adaptable and flexible ones, in which student feedback and patient participation have increasingly important roles. The implementation of sustained innovation in medical education continues to present challenges, especially in terms of providing institutional and individual incentives. However, a continuously evolving, high quality medical education system is needed to assure the continued delivery of high quality medicine.