One hundred years after Flexner’s recommendations on medical school structure, many schools are re-examining their curricula, some of which is summarized in a recent Carnegie report [1]. Many are moving toward integrated curricula, which have been implemented in parts of various schools (e.g., Harvard, UCSF) and for all students at the University of South Dakota [2-4]. In my own institution, The Ohio State University, we have been phasing in an integrated curriculum, with the first class entering “third year” this year. The surgery clerkship has been integrated with obstetrics and gynecology, and we have added anesthesiology and elements of pathology and radiology. We have 65 students for 15 weeks at a time. Their other two 15 week cycles are medicine/psych/neurology and family medicine/pediatrics. Overall it has gone well. Below are some observations about that integration that will hopefully help you as your schools (almost everyone is doing it) go through your own curriculum redesigns.

Educational Theory

The basic idea behind integration is that if students learn related elements over a longer time in a more integrated fashion (e.g., being reminded of the foundational science behind wound healing at the same time as learning how to suture and participating in the operating room) they will process the information differently, retain it longer and be able to use it more effectively throughout their careers. This is in contrast to the binge and purge tendency of students studying for a series of essentially independent exams.

Change Management

Major curriculum reform is primarily an educational “problem”, but that is followed very closely by it being a change management “problem”. Much has been written about change management, but I would encourage you to start with John Kotter’s article in Harvard Business Review [5]. Whether you use Kotter’s steps or someone else’s, it is imperative that both leaders and other implementers understand how you plan to manage the change. For example, if you are the clerkship director and are asked to describe the new curriculum spontaneously in a faculty meeting, what will you say that will help you build momentum for implementing your new ideas rather than make the faculty worried or defensive about the current structure? If you manage to make it sound really complicated without making it sound worth the trouble, you just lost ground.

Time

In integrated curriculum design, time is the biggest sticking point. Your best standing is to define the objectives that students must achieve in order to be good doctors and base your structure on that. We did that by identifying Enduring Understandings, then defining our objectives. We also defined Enduring Experiences that we felt all medical students should have (e.g., participating in a trauma resuscitation, delivering a baby, suturing). So you must make a structure that allows for those things, and then work with the intricacies of your institution (e.g., grand rounds is Thursday morning), common differences across disciplines (e.g., the best operating experience is in the morning, pathologists’ best teaching time is in the afternoon, babies come whenever they want), and political realities (e.g., if you turn a week into an “outpatient experience” where students learn a lot, some group will be upset that they have fewer students during that week on their service).

People

We have great people on our team, many of whom started around the time I did (2007), a few before and a few since. Several of us have participated in our own institution’s Faculty Teaching Scholars Program, meetings of the Association for Surgical Education and the Association of Professors of Gynecology and Obstetrics, as well as other courses. (Harvard Macy Institute, ACS Surgeons as Educators, ASE’s Surgical Education Research Fellowship) While such training is expensive, it makes a huge difference in smoothing out the changes, keeping them true to their purpose and in faculty satisfaction.

This brings me to the idea of getting the right people on the bus. The right people may be young or old, true believers or skeptics (in relationship to the proposed change), faculty with or without educational titles, faculty or staff (hint: you need both). Oh, and you need representatives from your target learners (students in this case). You need people who will express their ideas, listen thoughtfully to the ideas of others, see things from others’ points of view, and not dominate the conversation. Jim Collins summarizes some of his writing on this issue (and also on change management) in this article.

Integrating Disciplines that Really Cross All Disciplines

Think pathology and radiology. Who is going to teach the reading of chest x-rays, surgery or medicine, or both? Do students really need to be able to identify appendicitis on an abdominal CT? Are students going to leave their surgery service to learn about pathology for half a day? Ours do, and I think it’s very valuable. Can students follow a patient from pre-op through surgery and then be with the pathologist while they examine the specimen a day or two later? Sounds good, but I can’t figure out how to make that feasible for 65 students.

Why do people become doctors?

“I love science and I want to help people.” We all said it. This is another chance to prove it. Education has its own science, which you must at least start to learn to be an effective educator. And then approach your changes scientifically. We piloted our changes with 20 student volunteers two years before our full implementation. We put them on services that mostly included faculty who were already on our team or were otherwise dedicated to education, and we did everything we planned to do. We set a standard for ourselves that we would ensure throughout that we were not “harming” students. Parts of it worked well, parts didn’t (e.g., urology and anesthesia worked well as one-week rotations, cardiac surgery did not). We studied the results, we changed some things for all students the following year, and then we fully implemented it for all students this year. And we continue to study it and make changes. It is hard to watch even little things that you thought were a great idea be very unpopular with students, but you have to let it go and make changes based on the data. (Caveat: There are some things that are unpopular [think taxes and early morning rounds] that really are good and must be done.)

What Do You Change To?

So far, our structure is more of a blocked integration (e.g., 4 weeks general surgery, then 2 weeks L&D, then 1 week anesthesia, then 2 weeks cardiac surgery, then 2 weeks gynecology then 2 weeks gyn onc) than all specialties integrated across all of the weeks [6]. We start with a week of Ground School with lectures, skills sessions, orientation, scrub training, etc. and end with an Assessment Week with an OSCE and NBME shelf exams in surgery and OB/gyn. That structure was developed by our team of surgeons, obstetrician/gynecologists, anesthesiologists and urologists over about 3 years.

My last thought would be this. Curriculum change is a long process involving a lot of talking and working things out. But we want all students to know certain things about surgery, we want to recruit great students into our field, and we all need well-trained doctors. If we don’t participate, others will write the objectives and design the curriculum.

1. Cooke, M., et al., Educating physicians : a call for reform of medical school and residency. 1st ed. The preparation for the professions series. 2010, San Francisco, CA: Jossey-Bass. xvi, 304 p.
2. Ogur, B., et al., The Harvard Medical School-Cambridge integrated clerkship: an innovative model of clinical education. Academic medicine : journal of the Association of American Medical Colleges, 2007. 82(4): p. 397-404.
3. Norris, T.E., et al., Longitudinal integrated clerkships for medical students: an innovation adopted by medical schools in Australia, Canada, South Africa, and the United States. Acad Med, 2009. 84(7): p. 902-7.
4. O’Brien, B.C., et al., Students’ workplace learning in two clerkship models: a multi-site observational study. Med Educ, 2012. 46(6): p. 613-24.
5. Kotter, J.P., Leading change. 1996, Boston, Mass.: Harvard Business School Press. x, 187 p.
6. Hirsh, D.a., et al., “Continuity” as an organizing principle for clinical education reform. The New England journal of medicine, 2007. 356(8): p. 858-66.