Bland CJ, Starnaman S, Wersel L, et al: Curricular change in medical schools: how to succeed. Acad Med
2000; 75:575—594
Bland CJ, Starnaman S, Harris D, et al: "No fear" curricular change: monitoring curricular change in the W. K. Kellogg Foundation's national initiative on community partnerships and health professions education. Acad Med
2000; 75:623—633
In these two articles, Bland and her colleagues report the results of a literature review on curriculum change and a specific multi-institutional curriculum change project. The literature review was based on 44 articles on curriculum change in medical school, as well as in other educational settings, and on accounts of organizational change in business and elsewhere. The authors noted, however, that the number of sources was surprisingly small.
Thirty-five features of successful curricular change were identified and grouped into three clusters: context, curriculum, and process. Six of the most often-cited features were leadership, cooperative climate, participation by organization members, evaluation, human resource development, and politics. Leaders articulated and advocated an organizational vision and controlled nearly all of the other factors essential for success. Cooperative climates were characterized by collaborative problem-solving, effective communication, skillful conflict resolution, and rewards for risk-taking.
Broad participation was fostered by human resource development to ensure that faculty understood the theoretical underpinnings of the desired innovation and had the skills necessary for its implementation. Evaluation, especially formative evaluation, provided useful feedback on the organization's progress in implementing change. Political issues included getting "buy-ins" from powerful individuals and factions, securing adequate funding for the innovation, and obtaining support from external constituents.
Bland and her colleagues conducted an evaluation of the W. K. Kellogg Foundation's Community Partnerships and Health Professions Education Program (CPHPE). The goal of this 5-year project was to increase the number of primary health care providers by modifying curricula to include multidisciplinary instruction, community-based training experiences, and oversight by community as well as institutional members. Also, they would seek necessary modifications in national and state policies to sustain these changes. Twenty-seven health-education schools at seven sites in seven different states participated and included schools of medicine, nursing, social work, public health, and dentistry.
The evaluation was organized around 12 factors that were identified, through a literature review, as being correlated with successful and enduring curricular change. These 12 factors were organized into three categories: institutional design features, institutional process features, and curriculum process features. Outcome indicators were competency levels of students participating in the revised curricula, number of new or revised primary courses offered, and number of students choosing primary-care specialties. Data sources included surveys, interviews, standardized annual reports from project directors, focus groups, and residency match data.
The evaluation results indicated that the project had met its goals to increase the amount of primary care training in community and multidisciplinary settings and that changes necessary to sustain this growth had also occurred. Furthermore, there did not appear to have been an impact on the quality of student outcomes nor on faculty research productivity. Match results indicated that the increases in the percentages of medical students from the project schools who selected primary care residencies were greater than the national percentages and that in the year after the project ended, a higher percentage of the project school graduates selected primary care than those of the national average.
Follow-up interviews with key leaders conducted 2 years after the project ended indicated that the curricular changes associated with the CPHPE initiative had been sustained. These respondents most often identified the collaborative efforts among disciplines, universities, and communities as the major long-term positive outcome from the project.
Ginsburg S, Regehr G, Hatala R, et al: Context, conflict, and resolution: a new conceptual framework for evaluating professionalism. Acad Med
2000; 75(suppl):S6—S11
Ginsburg et al. reviewed the literature on evaluating professionalism in medical education and found few studies that directly addressed this aspect of competence. Professionalism has typically been defined in terms of traits or characteristics such as altruism, accountability, excellence, duty, honor, integrity, and respect—rather abstract concepts that are difficult to concretize for assessment purposes.
Faculty ratings have been the most commonly used method for assessing professionalism. In addition to often having limited opportunities to observe medical students and residents, supervisors are often reluctant to report lapses in professional behavior. Other data sources have included patients, nurses, and peers. Patient ratings were not reliable, and those from nurses and peers reflected a general reluctance to rate one another. Self-evaluations, mostly of knowledge and skills, tended to be quite inaccurate.
The authors concluded that professional behaviors, rather than personality or character traits, need to be defined. Also, they recommend developing greater understanding of "what drives students to demonstrate occasional lapses in professional behavior, in order to develop effective teaching and remediation in this domain."
Norcini JJ, Lipner RS: The relationship between the nature of practice and
performance on a cognitive examination. Acad Med 2000; 75 (suppl):S68—S70
This study explored the relationship between scores on the recertification examination in Critical Care Medicine and data obtained from a practice survey. The subjects were the two cohorts who took the examination in 1997 (n=510) and in 1999 (n=334).
The dependent variables were scores on the Cardiovascular and Pulmonary sections of the examinations. Independent variables were scores on the initial certifying examination, amount of time spent taking care of patients with cardiovascular and pulmonary problems, complexity of those problems, and the interaction of volume and complexity.
Performance on the initial certifying examination was a significant predictor of performance on the recertification examinations. For the Cardiovascular area, volume and complexity did not significantly predict examination performance, but the volume-complexity interaction variable did in both years. For the 1977 Pulmonary disease questions, volume was related to test performance, but complexity and the interaction term were not. In 1999, complexity and volume predicted performance on the Pulmonary disease subtest, but the interaction term did not.
Norcini and Lipner concluded that, "These findings, taken together with previous work, suggest that performance on a cognitive examination is related to performance in practice." However, they also suggested that multiple-choice examinations cannot replace evaluation of practice outcomes, nor do they assess such aspects of competence as communication skills and professionalism.