CURRICULUM CHANGE IN UNDERGRADUATE MEDICAL EDUCATION MOVING THAT GRAVEYARD ALONG!

Moving a (college) curriculum is like moving a graveyard: you never know how many friends the dead have, until you try to move them. (Calvin Coolidge/Woodrow Wilson)

Impetus for Curricular Change 1)SOCIAL ACCOUNTABILITY: society’s changing needs – new knowledge 2)Introduction of PBL – innovations in education 3)Early clinical exposure 4)Community-based clinical placements 5)Internal or External Review 6)Adoption of more valid and reliable assessment 7)Accreditation issues

Large Scale Initiatives  Physicians for the Twenty-First Century GPEP – AAMC 1984  Educating Medical Students ACME-TRI Report AAMC 1992  Tomorrow’s Doctors General Medical Council (UK) updated Jan  Educating Future Physicians for Ontario

How to move that graveyard? Successful curricular change occurs only through the dedicated efforts of effective change agents. (Bland et al., 2000)

Step 1: Decide on the “Over-Arching” Curricular Goal egEducating Future Physicians in Palliative and End-of-Life Care

Step 2: Define the Expected Competencies 1. What is the rationale for including this competency? 2. What exactly do you expect the students to be able to do? 3. Pre-Clerkship or Graduation competency levels?

Step 3: Objectives Competencies Each Competency may have several “Enabling Objectives” Classification of Enabling Objectives: eg. Biological – behavioural – population perspectives Or eg. Knowledge – skills – attitudes (behaviours)

Step 4: OUTCOMES Express “Objectives” in a way that implies an Outcome that can be measured. Must be able to Assess: Has the student achieved the objective? Is the level of competency appropriate for level of training?

Step 5: Curriculum Delivery Format 1) Didactic presentation 2) PBL small group tutorial 3) e-Learning resources 4) Clinical Placement 5) Interprofessional clinical practicum

Step 6: Educational Resources 1) What resources (human, learning) are available to facilitate student learning? 2) Where will the learning objectives of the “new” material “fit” into the rest of the curriculum? 3) Are there natural “cross-references” to competencies/objectives already in the curriculum that need to be highlighted? 4) How are you going to evaluate the achievement of the desired competencies?

Conditions for Successful Curricular Change You have developed a new curriculum! What are the factors that will determine if all Canadian Medical Schools embrace EFPPEC?

Curricular Change CONTEXT – characteristics of the school that can facilitate change – eg. Mission and Goals CURRICULUM – characteristics pertinent to the curriculum itself PROCESS – planning, initiation, implementation, institutionalization

Context  Mission and Goals  History of Change in the Organisation  Politics (internal networking, resource allocation, etc.)  Organisational (school) structure

Curriculum  Need for change  Scope and complexity of the innovation

Process  Cooperative climate  Participation by organisation (school) members  Communication  Human Resource Development (faculty development)  Evaluation  Performance Dip  Leadership And the greatest of these is LEADERSHIP

Context 1) For an institution, history of previous effective change increases likelihood of further innovation 2) Schools with well-focused goals more readily implement change 3) Informal networks are often the preferred means of negotiating power issues 4) Planned change requires at least ONE STRONG ADVOCATE who exerts influence 5) Students are allies in eliciting faculty support for change 6) Integrated structures are more amendable to institution-wise change than departmental structures

Curriculum 1) To sustain curricular change, relative advantages of implementation must seem to outweigh the costs. 2) The new curriculum must appear relevant to its potential users. 3) Increased chance of success if the innovation is “central” to the core mission of the school. 4) Pros and Cons of pilot projects.

Process 1 Collaboration creative, supportive tension sense of collective ownership questioning the “big assumptions” Communication provide a safe environment for people to voice dissent; dissenters can become advocates during institutionalisation, need to maintain energy through forums, to exchange ideas School must be attentive to needs of its faculty members as the change process of “innovating “ curriculum proceeds Ensure faculty understand the theoretical underpinnings of the innovative curriculum

Process 2: Evaluation Status of an innovation elevated in the eyes of the participants if formative evaluation strategies are put in place to monitor progress Value of focus groups

Process 3: Leadership 1) Leadership always cited as a major force in curricular change 2) Leader must be visible throughout the innovation process 3) More effective curricular change if leadership behaviour reflects “assertive and participative, and culture/value-influencing, rather than rank/power behaviour” 4) Qualities include – visionary, risk-taker, credible, energetic, enthusiastic, conflict manager, focused, effective communicator 5) Ability to view any given situation through different lenses

9 Lessons from Schools who Innovated New Curricula 1) Keep vision broad; use evolutionary planning 2) Give faculty time to learn about the innovation 3) Be inclusive, encouraging sense of ownership 4) Promote open communication with both proponents and opponents 5) Develop strong leadership, publicly stating and re-stating the goals of the innovation 6) Develop organisational structures to sustain the innovation 7) Ensure process guided by valid and reliable evaluation 8) Maintain financial support 9) Expect successful change to take longer than expected