Why Change the Core Curriculum?
Undergraduate medical schools serve as the source for transformation of students into physicians. The purpose of a core curriculum is to integrate comprehension of physiological and pathological processes with the mindset of thinking like a physician. In recent years, medical school core curricula have been undergoing a fundamental shift, evolving from the traditional, teacher-based curriculum to a student-centered and active learning approach. The teacher-centric approach began as early as the 1760s with the apprenticeship-based curriculum model and has persisted despite various forms of curricular changes (Papa & Harasym, 1999). As of 2018, a total of 124 medical schools indicated that a curriculum change is being planned or has been implemented within the past three years (Association of American Medical Colleges [AAMC], 2018). Specifically, newly formed medical schools, as well as current schools, have or are transitioning to some semblance of a student-centered curriculum in the form of case-based learning (CBL), problem-based learning (PBL), and/or team-based learning (TBL) (AAMC, 2018; Haidet, Kubitz, & McCormack, 2014).
Modernization of the core curriculum shifts focus from reiteration of factual information to application of knowledge to novel, problem-solving settings. Advancements in medical research and technology have produced a greater volume of material that students need to use in patient care, much of which can be accessed quickly if not immediately known. The pedagogy of the progressive curriculum trains physicians for a role where they need to use readily available information to apply in a unique situation. With educators being accustomed to the traditional method of education, it is vital to ensure this transition is thorough and efficient.
Curricular changes have occurred due to several fundamental reasons. The essential driving force is due to the greater onus placed on students in patient care as well as the transformation of medical examinations for physician certification. There has been a growing responsibility placed on medical students during their clerkships and residents. Expectations for competency in a wide range of activities, including communication and procedures, have been rising; it is the responsibility of medical schools to prepare students for these roles (Raymond, Mee, King, Haist, & Winward, 2011). Student transition into medical clerkship has been studied extensively, with many reporting difficulties in time management due to the longer hours, faster pace and greater intensity (Surmon, Bialocerkowski, & Hu, 2016). A common concern expressed by students was their inability to contextualize and integrate their preclinical knowledge into a patient-centered, clinical experience. A significant barrier in the adaptation to clerkship was the nature by which preclinical assessments were carried out, emphasizing recall of facts rather than the understanding of concepts (Surmon et al., 2016). This is exemplified with the struggle to apply knowledge and skills to practice, as the learning in the preclinical years did not foster an approach for doing so (Surmon et al., 2016). Whereas traditional testing fosters rapid acquisition of information in order to be prepared for the next assessment, students benefit in the long term with a contextual approach that integrates learning within clinical frameworks (Surmon et al., 2016). Clerkship requires learning through patient encounters and occurs at a faster pace compared to the preclinical curriculum where learning is completed via lectures and textbooks. The nature of learning is autonomous and longitudinal, requiring reflection to identify knowledge gaps and an impetus to fill in those gaps through research. It is therefore imperative that assessment in the preclinical years models the behaviors and aligns with the methodology of learning in graduate medical education.
The curricular evolution also stems from the need to adapt to current medical practices and assessments. In order to have a proper means of student evaluation in the expanding healthcare environment, the United States Medical Licensing Examination (USMLE) underwent a transformation in 2009, updating its format to ensure practice readiness while testing the “ability to obtain, interpret, and apply scientific and clinical information” (Haist, Katsufrakis, & Dillon, 2013). Whereas the prior USMLE experienced the unintended consequence of students focusing on short-term, “binge and purge” memorization, there was a need to reflect the reality of patient care where basic sciences serve as a long-term foundation to patient care (Haist et al., 2013). In addition, analysis completed by The National Board of Medical Examiners demonstrated a lack of practice readiness in communication skills, information retrieval, evaluation, and integration (Haist et al., 2013). The new methods of assessment alter the focus from straightforward knowledge to the proficiency with which students can use and apply information (Cohen, 2013). The premise that assessment drives learning encourages undergraduate medical curricula to shift to a dynamic pedagogy of education and alter their approach to foster the development of critical thinking.
As a result of medical advancements and societal changes, this chapter will further detail the curricular changes that are occurring, how they are implemented, and why they are important for shaping the next generation of physicians.