Exploring the Possibility of a Common Core in Medical EducationCharles Prober | Senior Associate Dean for Medical Education at the School of Medicine, Stanford University
The medical education space is immensely challenging, and demand for medical education is consistently rising. However, from institution to institution the medical curricula can vary widely, despite the similarity in subject matter and the national examination end point facing students. In this interview, Charles Prober shares his thoughts on the value a common core curriculum could bring to the medical education space and reflects on the most significant challenges standing in the way of its adoption.
The EvoLLLution (Evo): How different would a common core medical education curriculum be from what’s currently delivered by medical schools across the United States?
Charles Prober (CP): I can’t provide a very granular answer because what each individual medical school is teaching is a little bit of a mystery to me. I obviously know what our medical school is teaching but there is a lot of variation from school to school based upon the faculty at that school, the expertise that that faculty has, and the regional expertise and demand in each area.
It’s hard to know how much variability there is because there‘s not a central repository of all curricula. I can’t tell you what the degree of variability is, though I know it exists.
Evo: Why is it beneficial for American medical schools to adopt a common curriculum?
CP: There are a few reasons why a common medical curriculum would be beneficial for American medical schools.
One is that when you have many schools coming together and discussing the foundational and core principles for medical education in North America the likelihood is that that wisdom of a crowd—as opposed to the wisdom of a single school—will get closer to what is right because it taps into the thinking of many people as opposed to a limited number of people.
The second is that the students are mobile after they finish medical school. They may go to residency somewhere else after graduating, and following that, they may choose to do a fellowship somewhere else, and then they go into an academic medical center or a practice somewhere else again. Providing students with a solid academic foundation that is transportable across all of the different places they may end up serves them better.
The third reason that a common curriculum would be beneficial is test preparation for students. We hold medical students accountable to a single test broken down into three parts. All the students need to take and pass each of those three parts and, as such, it is recognized that they rely upon a core body of knowledge to review. Unfortunately, many students don’t believe that they’re getting that core body of knowledge at their individual schools. So they rely on third-party providers and their publications to tap into that core body of knowledge. We should not be teaching to the test, but rather agreeing upon the knowledge that is core and foundational and then designing programs around the material that should be tested. Then we wouldn’t be teaching to the test; we’d be testing the teaching. We’d be testing what schools have agreed is really that core foundational knowledge.
I don’t want to create confusion by suggesting that every medical school should teach their students in the same way with that limited core foundational knowledge, because that would be a misrepresentation. I think that each school is unique and should embrace its uniqueness—students absolutely benefit from the uniqueness—but it needs to lie on top of that core foundation. First, there’s an agreed-upon idea about what every student needs to learn and needs to really be able to rely upon in their knowledge for their future practice. Then, on top of that, should be where the variability between each school comes in .
Evo: If a common core was adopted by all medical schools, how would different colleges and universities differentiate themselves to prospective medical students?
CP: There would be many ways that medical schools would differentiate themselves after the adoption of a common core. One is obviously geographic— where you end up living for those years—but that’s the least important
Each school will still have its own personality, its own set of experts, its own area of expertise and a particular passion—not a singular passion—for a certain type of medical education or medical science. For example, Stanford is appropriately recognized as a research-intensive school with some of the strongest basic science faculty on the globe who are doing some of the most important cutting edge research. As such, one of the distinguishing features of a Stanford medical education is the capacity for students to take a deep dive into some cutting edge discoveries into the basic sciences, which is part of our DNA (no pun intended!). Contrast that with a new medical school that Kaiser Permanente plans to launch in Southern California. Kaiser provides some of the best, most organized and probably cost-effective healthcare in the United States. They really are a very effective engine of delivering high-quality healthcare. Students who go to the future Kaiser medical school will probably get a large dose of the way that the healthcare system could be organized to optimize patient experiences and outcomes in a cost-effective fashion because that’s what they do. That doesn’t mean that every student at Stanford should be prepared to take a big dose of basic science or every student who goes to Kaiser should be prepared to take a big dose of healthcare reform, but it means that those environments will certainly play to students who have that particular passion. A distinguishing aspect of a medical school environment is going to be the expertise contained within that environment reflected in the faculty experts that are in that environment.
More generally, the faculty at different medical schools are differentiators themselves. Faculty are going to be the ones that hopefully inspire the students during their education and into their future. They define the educational experience of their respective medical schools. So the opportunity to interact with very specific individuals who are involved in the education and training is obviously specific to that environment. What I want students at Stanford to capitalize on is the rich relationships that they can build with faculty here. I don’t believe they build those rich relationships by just attending lectures. Those rich relationships are formed when both groups roll up their sleeves and rub elbows in interactive sessions meant to make the learning more powerful, deeper and more foundational.
Those are the elements that truly distinguish a school: the faculty, the particular expertise contained within that environment and then anything else that’s associated with that particular region of the country.
Evo: Internationally, how would the adoption of a medical common core curriculum impact the global distribution of qualified healthcare professionals?
CP: I don’t think that there would or should be an identical common core taught to medical students regardless of their geographic location. Take students studying medicine in Africa and compare them to students studying medicine in North America. In African countries, there should be in their common core a greater emphasis on malnutrition issues, and infectious diseases endemic to the continent. These issues are very different to what we face in North America.
One common core element that may be actually the same, that students need to know on a foundational level, is anatomy. Anatomy doesn’t vary from country to country around the world, nor does the physiology of kidney function. Much of the common core would overlap in different parts of the world, but just like the expertise of institutions will vary in the United States, critical content will vary in different parts of the world.
Evo: What are the critical steps that need to be taken to make a common core curriculum a reality in the medical education space?
CP: The first step is to see if this concept has traction amongst the wider medical education community because obviously if one doesn’t have a lot of partners in the development of a common core it won’t go anywhere.
First of all, we must agree upon the basic principle and then there has to be a convening of individuals from a broad range of schools and environments to work on what that common core should look like. We’ve done one small part of this experiment in the space of infectious diseases in the United States where, with funding from the Robert Wood Johnson Foundation, we identified a group of schools who were interested in exploring the development of a common core of microbiology (infectious diseases). We committed to bringing the experts in microbiology (infectious diseases) from our institutions together and identifying, together, what we believe to be the core of what our students, at each of our schools, should learn on the topic. We did this with five schools and that is probably going to be highest number of institutions able to participate in such a conversation, and once you have five agreeing maybe that’s sufficient. It would be best to have all 150 schools but that wouldn’t be manageable. In this exercise, we worked through identifying the topics we felt were the core of microbiology. We then committed to producing that in a sharable way, which happened to be in a video format and facilitator guide, and then we proceeded to deliver it to our students in different schools. That’s an example of a group coming together after buying into the idea that this common core makes sense, identifying what the core is and developing that core in some sharable fashion. The next step is deploying back to the schools and then scaling it if success is demonstrated at other schools until eventually you have a common core being used by the majority of 150 medical schools.
My vision is to do that with all of the different elements that make up a medical education in North America: anatomy, microbiology, physiology, etc. The parallel discussions that need to go on—and have begun in some cases—are with the national organizations that are responsible for blessing what’s going on in medical education and creating the examinations that measure knowledge acquisition.
Evo: What are the most significant roadblocks that stand in the way of a common core becoming the norm in American medical education?
CP: One roadblock is the medical schools in America—all 150 or so of us—are free standing, independently operated entities. The granularity of what is being taught at those individual schools has really been left to the discretion of the individuals at each of those schools and each of us in medical education, and medicine in general, tends to develop relatively fixed ways of thinking. I’m certainly not suggesting that there’s not a lot of commonality in what’s being taught across the schools—every medical school teaches anatomy and every medical school teaches physiology—it’s really at the granular level that there’s a lot of divergence. We need to choose what we really need to be teaching as time moves forward because obviously medicine, and biomedical science in general, is moving forward and we need to make sure we’re staying relevant. We need to be including in our curriculum emerging issues. Right now, each of us comes up with our best approximation of what’s optimal to teach in every space and we do it independently. It’s geography, it’s tradition, it’s local expertise and, to an extent, it’s us being stubborn. There’s a resistance that comes from a natural point of view that, “We’ve been doing this for a long time and we kind of know what we’re doing so we’re going to keep on doing it.”
As we have begun to learn more about the sharing economy and the wisdom of the crowd, those principles should become much more pervasive in our minds when it comes to creating unified educational content. That said, the barriers are historic and challenging to overcome.