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Curriculum Reform and You

HOW YOU CAN MAKE A DIFFERENCE

The New Physician October 2004
“Can you tell I’m using my administrative voice?” asks third-year Miranda McCann, lapsing for a moment from her “new” grown-up voice to the more uneven tone of a nervous student. “It goes with the dress-up clothes.”


It also goes with her new perspective. In early 2003, halfway through her second year at Northeastern Ohio Universities College of Medicine (NEOUCOM), McCann had developed concerns about her medical education. She found classes disjointed. Lecturers would come in and teach for an hour on a subject, never to be seen again. Teachers didn’t know what students were being tested on, and testers didn’t know what was being taught.


“That just seemed to be a real disconnect from the way that I understood education should be occurring,” says McCann, who, contemplating a leave of absence, took her concerns directly to a dean’s office. But instead of leaving with empty excuses, she left with a job: the Educational Excellence Fellowship, which made her the first official liaison between students and medical school administrators and gave her a strong voice in NEOUCOM’s impending curriculum overhaul.


This past July, she finished her one-year stint inside the administration. And while her position may have been unique, McCann is just one of many medical students across the country who have questioned the rationale and structure of their medical education and parlayed those criticisms into action. No two schools are alike, but all the students interviewed for this story agreed on one thing: Future physicians have more power than they think in impacting their curricula.


TOTAL RECALL


Kristofer Smith understands this well. Smith, now a fourth-year at Boston University School of Medicine (BUSM), began questioning his school’s teaching methods after his first semester. “I felt like medical school was taking a lot of really smart, kind, interesting people and just sort of abusing them with a fact-based, heavy memorization learning experience,” says Smith, whose physician-father works in an academic medical center. “Ultimately, you’re not going to be an encyclopedia of facts; you’re going to learn to apply facts in a meaningful way.”


Smith felt BUSM’s letter-grading policy for the preclinical years was an uninspired, poorly considered system that encouraged a competitive, selfish atmosphere among students and fostered a focus on extrinsic rewards instead of intrinsic learning. “We’re in medicine. We want to do good; we’re studying for altruistic reasons. So it’s kind of insulting to say that I need grades to learn the art and science of medicine,” he says.


He thought a pass/fail grading system would be a “benefit to the quality of the learning environment, to collegiality, to students helping one another, where we see each other as participating in a community with a common purpose rather than just individual actors pursuing their own academic interests.”


Upon discussing these ideas with classmates, he learned many of them agreed the grading system needed reforming. But he also discovered a fervent undercurrent of displeasure in other areas. “People were pretty tired, pretty emotionally beat up, questioning why they came to medical school in the first place.”


When Smith spoke with upperclassmen, he heard the same moping chorus. At this point, he says, “You have to ask yourself, ‘How do we move beyond just complaining? How do we actually sustain real change?’ Because it probably won’t benefit my preclinical years to fight for this, but I didn’t want the problems to repeat themselves.”


So, he and other concerned students formed the Student Committee on Medical Education and “created some power for ourselves” through the language of basic science: hard data. They used student satisfaction surveys from other schools to guide them in creating one for BUSM, eventually getting a solid 85 percent response rate from their first-year class. “And we were very open about the process. We told everybody—the dean, chairs, faculty—this is what we’re doing, so they wouldn’t feel surprised or ambushed.”


The student committee issued a 20-page report to BUSM administrators, outlining the data they’d found and explaining three areas that needed mending: the grading system, course feedback procedures and faculty development—literally teaching instructors how to be effective teachers. Then they went one step further, proposing solutions to their findings and creating leadership groups for each effort, which met regularly with faculty members until changes were made.


And they were. In the fall of 2003, by the time Smith was beginning his third year, grading for preclinical students changed to a pass/fail system. The school implemented feedback systems and in January 2004 hired a faculty development coordinator. What’s more, after the Liaison Committee on Medical Education’s review team—which evaluates schools as part of the accreditation process—saw Smith’s report in March 2003, the entire set of bylaws governing BUSM’s curriculum was retooled, streamlining the process for any future curriculum changes.


Smith says he and his fellow students were so successful because they’d built a consensus for change and used it to methodically demonstrate their reasoning to faculty.


“Students need to appreciate how much power they have. You have far more power than you’re ever going to have as a resident or as a junior faculty member,” he says. Still, students may face some consequences for their actions, so he encourages reformers to be thoughtful in their efforts.


REFORM FOR ALL SEASONS


Dr. Jess Mandel, assistant dean for student affairs and curriculum at the University of Iowa’s Carver College of Medicine, echoes Smith’s advice. “If your criticism isn’t constructive, it can be perceived as whining,” Mandel says. “But if you suggest a better way to do it or an alternative that should be considered, then people really respond to that much better.”


Mandel should know. Iowa’s curriculum may be the most accountable model in the country, incorporating multiple avenues for feedback. One of the oldest is Caduceus, a medical student organization that for nearly two decades has addressed preclinical curriculum concerns by taking five to 10 student volunteers from each course to form a liaison committee for that course. Committee members meet with the course director before each test—generally four or five times during a semester, though sometimes as often as every other week—to discuss the progression of learning. Committee members are introduced in class so students with concerns know to whom they can turn, and Caduceus is explained to all first-years during orientation.


In addition to ensuring all the appropriate topics are being covered in the course, committee members offer suggestions about lecturers who didn’t work well and recommendations for teachers who should be emulated, says Dom Cirillo, a fifth-year M.D./Ph.D. student and a former president of Caduceus.


The system works, Cirillo says. “[The] liaison committees actually have a big impact on some courses. Just doing a course evaluation after the course is over doesn’t have as much impact as evaluating the course all the way through it,” he says.


Some of the changes Caduceus members have helped implement include tinkering with the timing of exams to ensure adequate study time for each course, refocusing a microbiology lab so important material was covered, and adding public health and service-learning courses.


Mandel says Caduceus and two other feedback mechanisms at Iowa—regular lunches that invite one-fourth of each class to discuss the course’s progress with an independent facilitator and anonymous, Web-based questionnaires that can be completed throughout the year—help reinforce the idea that students and faculty are colleagues, not combatants, in medical education.


“I think other schools have had some difficulty in respecting student insight because they sort of put all of their eggs in one basket when they have only one venue for feedback,” Mandel says. “You either take pains to have a collaborative discussion with students, or you don’t.”


WANTED: MORE KNOWLEDGE


But future physicians aren’t always interested in taking on the kind of whole reform efforts Smith undertook at Boston or those offered by Iowa’s system. Sometimes, they just want to add a subject they believe to be lacking in their curricula. But even small changes can be uphill battles.


Third-year Sarita Sonalkar has been interested in reproductive health issues since volunteering at Planned Parenthood in college. When she began her studies at the University of Medicine and Dentistry of New Jersey, New Jersey Medical School (UMDNJ-NJMS), however, she was surprised to see little instruction on abortion.


“Abortion is one of the most common surgical procedures in the country,” she says, citing a Planned Parenthood statistic claiming that nearly half of all U.S. women have an abortion by the time they reach the age of 45. “But it’s just not thought about in medical schools.”


Yet improving a microbiology lab is one thing; tackling such a controversial and divisive topic as abortion is quite another. So Sonalkar sought assistance from the UMDNJ-NJMS chapter of Medical Students for Choice. For the past three years, the group has helped organize a reproductive health lecture series at the medical school that doubled as an elective for students who attended at least six of the nine talks.


And with UMDNJ-NJMS on the cusp of a major curriculum reform effort, “We saw it as a window—an open period where the administration might be comfortable introducing [mandatory abortion education],” she says.


But after organizing a coalition of interested groups and lobbying at curriculum reform committee meetings for a dedicated course that would integrate women’s health, reproductive and sensitivity issues into a weekly class, Sonalkar and her colleagues soon found that window closing. Although faculty welcomed ideas and said they would consider adding some aspect of reproductive health to the new curriculum, “after that, it was like the curriculum was being developed behind closed doors,” she says.


Their request didn’t make it into the revised curriculum UMDNJ-NJMS began rolling out this fall. So they refocused their efforts on better publicizing the lecture series, as well as on building more hard data by tracking the peripheral mentions of reproductive health issues in existing classes.


Still, Sonalkar is not entirely discouraged. “I’ve learned it’s as important to have small goals as it is lofty ones,” she says. “I’ve found that people who have other leanings, if they’re really adamant about what they believe, it’s hard to talk to them. You have to strike a balance.”


Exactly, says McCann, who exchanges her NEOUCOM administrative suit this fall for scrubs. The third-year says she tended “to fall into the ‘faculty are our enemy’ perspective that a lot of students have: that the faculty only care about their research, that they don’t care about my education. The biggest lesson for me is that that’s just not true. The faculty love students. They want them to be phenomenal physicians. Not every decision they make is right for students, but decisions are arrived at through thoughtful processes….


“Students tend to sit in their rooms and complain. That’s great therapy,” McCann says. “But an even better idea is to go straight to faculty members and have a conversation with them, find out why something is done the way it is, and make a suggestion for improvement if you still think it’s wrong.”


Vairavan Subramanian, a fourth-year at Baylor College of Medicine, says he is lucky to be in an “innovative environment” for medical education: The faculty supported his move for a one-of-a-kind, hands-on surgical elective for third- and fourth-years, and the course is now entering its third year. But Subramanian and fellow students still had to use some elbow grease—finding funding for laparoscopic equipment and cadavers, drawing up the course syllabus and securing surgeons for classes. The upside? As a result, the future physicians had more control over what they learned.


“If you’re interested in something,” he says, “don’t be daunted by how difficult the task seems in theory. Faculty and students often have common goals. But as students, we may have a little bit more time for—and a little bit more invested in—change.”
Beth McNichol is a contributing editor with The New Physician. Direct comments about this article to tnp@amsa.org.