MILITARY MEDICINE, 180, 4:158, 2015
Academic Change Management: Leadership Lessons From Curricular Reform Col Arnyce R. Pock, USAF MC; Col Martin Ottolini, USAF MC (Ret.); COL Louis N. Pangaro, MC USA (Ret.); COL William R. Gilliland, MC USA (Ret.); Col Brian V. Reamy, USAF MC (Ret.); Col Paul A. Hemmer, USAF MC (Ret.); CAPT Mark Stephens, MC USN; Alison O’Brien, PhD; CAPT Larry Laughlin, MC USN (Ret.)
INTRODUCTION In August, 2011, the F. Edward Hebert School of Medicine extensively revised its four year curriculum, focusing on the theme of “Molecules to Military Medicine.” Since most civilian medical schools undergoing a major curricular reform typi cally allow three to seven years for full implementation, the fact that its revision was designed and implemented in two years, was itself a momentous achievement. As such, this report will describe some of the key innovations associated with the new curriculum, followed by a summary of some of the leadership lessons that may help guide other programs considering similar types of curricular revision.
BACKGROUND Despite what might have been described as an academic “blitzkrieg,” initial parameters suggest that implementation of the new Molecules to Military Medicine curriculum has been remarkably successful, as early indicators are already exceeding expectations. For not only has the clinical perfor mance of students in the new curriculum been just as strong (if not better) than students in the “old” curriculum, results of the U.S. Medical Licensing Exam (USMLE) Step 1 exam for the inaugural Class of 2015 yielded an impressive 99% first time pass rate, with a mean score that was 11 points higher than the preceding class (scores of 218 vs. 229, respec tively). An equally strong performance was evident on the more clinically oriented, USMLE Step 2 CK (clinical knowl edge) exam, in which the USU Class of 2015 achieved a mean score of 240, which exceeded the previous (baseline) class mean of 232 points.
INNOVATIONS ANS PRINCIPLES An initial six month period of “discovery,” -devoted to a review of contemporary curricular challenges and other schools’ responses to the same, was conducted in the Fall of 2009. After which, the Uniformed Services University’s
Department of Medicine, F. Edward Hebert Uniformed Services University of Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814. The views expressed are those of the authors and do not reflect the official policy or position of the Uniformed Services University of the Health Sciences, the Department of Defense, the U.S. Air Force, or the U.S. Government, doi: 10.7205/MILMED-D-15-00030
158
F. Edward Hebert School of Medicine embarked on an ambi tious, two year period of complete curricular revision, transforming its traditional, “2+2 “curriculum (2 years of classroom based study followed by 2 years of hospital/clinic based experience) into an integrated, organ-system based cur riculum. Instead of utilizing a conventional, departmentally based approach to teach the foundational sciences, in the new approach, material that had been covered in the first 24 months of medical school was re-configured and re-aligned into an 18-month, pre-clerkship curriculum that tightly inte grates basic and clinical science into a series of seven to nine week modules. As a result, students now learn the pathology and pharmacology of cardiac problems right after they study the anatomy and biochemistry of normal cardiac function, i.e., There is no longer a year-long hiatus before students are able to make the connection between the foun dational science and clinical medicine. Moreover, clinical application in the form of diagnostic reasoning seminars coupled with the practice of clinical skills with standard ized patients further strengthens this relationship between clinical and basic science. An additional benefit of the more concentrated teaching of basic sciences is that students begin transitioning from under standing to action much sooner. This is further enhanced by the fact that students now start their traditional core clerk ships six months earlier than they had in the past. Moreover, the timing of USMLE Step 1 examination was also changed, so that it is now administered after completion of the core clerkships, in contrast to the more conventional timing, just prior to the start of the core clerkships. As part of the curricular revision, the entire grading nomen clature was changed from one based on conventional letter grades, to a strictly Honors/Pass/Fail system. Other changes included incorporating a deliberate return to advanced didac tics, in the basic sciences, during a 6 week, post-clerkship segment known as “Bench to Bedside and Beyond” (or B-3). Also included in this post-clerkship period is an opportunity for senior students to work with a dedicated faculty mentor, as they design, develop, and implement a clinical, scientific, or operational research project of their choosing—an initia tive now referred to as a Capstone Project. Needless to say, implementing a major curricular revi sion in a highly accelerated manner evoked a number of significant challenges. Although focused on academic change
MILITARY MEDICINE, Vol. 180, April Supplement 2015
Academic Change Management: Leadership Lessons From Curricular Reform
management/cuiricular revision, many of the following lessons have applicability in both academic and non-academic settings. L e ss o n # 1: S ta r t w ith th e e n d in m in d
Visualize from the start, what successful integration would look like, and provide explicit goals and objectives as this is essential for maintaining focus when distractions intervene. Even sophisticated educators require a basic nosology and framework to begin the arduous task of curricular change. Basing these goals and objectives on sound educational prin ciples may sound simple, but simplicity is often the key to success. Collectively knowing where the group is heading helps keep disparate voices on track. L e ss o n #2: E s ta b lis h a tim e lin e , b u t re c o g n iz e th a t w h a te v e r it is, it w o n ’t b e lo n g e n o u g h !
Change, particularly widespread curricular change, is never easy, but once a commitment is made, progress must be main tained on a tight, agreed-upon schedule as momentum is critical. While hastily made decisions can lead to resentment and/or operational failure, these concerns must be balanced against the risk of changing things too slowly, or allowing frequent and/or liberal extensions of an established timeline, which can delay critical decision-making and prolong main tenance of the status quo. Recognize too, that a journey of 1,000 miles begins with a single step1, and that the first few steps are often the most difficult. As such, it is essential to continue to partner with teams such as the Long Term Career Outcome Study group that provide programmatic evaluation and help ensure that the long-term goals and objectives of the curriculum are being met. L esson #3: C o m m u n ic a te s tra te g ic a lly a n d e ffe c tiv e ly
The importance of consistent, clear and effective communi cation is often under-estimated. Recognize that despite best efforts, there will always be someone who simply “didn’t’ get the message”, or who may just be overly aggressive with the delete key. Make a special effort to communicate multidirectionally, both horizontally and vertically—engaging stu dents, instructors, researchers, scientists, clinicians, professors and administrators. Be sure to use a variety of communication mechanisms, as what works for some is an anathema to others. E-mail is easy and efficient, but it doesn’t replace the impor tance of face-to-face discussions with key stakeholders, where critical ideas and opinions may be more readily conveyed. Other venues, such as Town Halls, “Pizza with the Professors sessions,” briefings, posters, flyers, You-Tube like presenta tions, etc., can all be used utilized with positive results.
dissenting opinions. Take time to elicit, listen and understand their concerns, and find ways to engage them in the planning process, for example, by placing them on key subcommittees. Make a special effort to seek out “quiet” faculty and elicit their insights as well. In any case, it’s important to provide an explicit mechanism for dissenting opinions to be heard and considered. Doing so will enhance the process and strengthen the final product. L e s s o n #5; S e le c t a n d s u p p o rt g o o d p e o p le a n d g o o d th in g s w ill h a p p e n
Caring, committed, and motivated stakeholders are vital assets. Estimates vary, but most experts believe that a supportive core of 20-30% represents the critical mass needed to implement a major organizational change. Note the advice of author Jim Collins who wrote that: “... leaders of companies that go from good to great.. .start by getting the right people on the bus, the wrong people off the bus, and the right people in the right seats. And they stick with that discipline—first the people, then the direction—no matter how dire the circumstances.”3 Note that tangible support-in the form of protected time or a salary supplement, can also be very important. L e ss o n #6: G ive p e o p le a u th o rity c o m m e n s u ra te w ith th e ir le v e l o f re s p o n s ib ility
Responsibility without authority can promote stagnation, whereas authority without responsibility can lead to mis management and/or mission failure. Balancing authority and responsibility allows for real change and rapid operation alization. It also promotes ownership and critical ‘buy-in.’ Likewise, Deans and Institutional leaders should resist any tendency to second guess faculty decisions about what to achieve and how to achieve it. L e ss o n #7: O w n e rs h ip m a tte rs
This lesson is closely related to Lesson #6, but getting buy-in from a variety of different stakeholders makes the entire process easier to manage. Recognize too, that as curricular change evolves, competition for “ownership" of student con tact hours will likely escalate. Allocation of contact hours can be guided by several key principles, to include consider ation of the complexity of the materials, whether the con dition being conveyed is both, common and serious, serious but rare, or common but not serious, etc. An additional factor can involve an assessment of the relative priority (high or low) of the content. L ess o n #8; A d u lt le a rn e rs s o m e tim e s a r e n ’t
L e ss o n M : E m b ra c e , r a th e r th a n avo id , d is s e n tin g o p in io n s
As Stephen Covey (author of 7 Habits of Highly Effective People) frequently espoused, “seek first to understand.”2 Actively seek out and engage those with highly vocal and/or
MILITARY MEDICINE, Vol. 180, April Supplement 2015
Explicit pedagogy is sometimes necessary, particularly for high stakes elements. This may be especially important during the early phases of implementation, when a diverse student body is acclimating to a demanding curriculum and develop ing and/or refining more mature study habits.
159
Academic Change Management: Leadership Lessons From Curricular Reform
Lesson #9: Don’t lose sight of the fact that assessment drives learning It’s not what you expect— it’s what you inspect! Assessments can lead to desirable or undesirable behaviors. Focus on what you want students to learn, and what you want them to be able to do, and align assessments with those goals. Consider changing grading policies to a Pass/Fail system as new cur ricular elements are implemented. Lesson #10: Recognize and reward those who lead and actively engage in curricular change /integration Decide in advance, how to recognize and reward those who engage in and embrace the desired change. Celebrate and share successes with the entire educational community, while pro viding quiet, but positive reinforcement to those who encoun ter resistance or other challenges. Rewards can certainly include monetary bonuses, but public recognition at small ceremonies or in campus newsletters may also suffice. Efforts such as these strengthen faculty commitment and will help sustain the process through the inevitable challenges.
willingness to negotiate and collaborate. Changes in the amount of student contact time tend to elicit the greatest amount of faculty stress; as such, it’s something that needs to be anticipated and proactively addressed. Lesson #12: Recognize that the process of curricular integration never ends Prioritize goals and available resources. Be willing to con sider constructive feedback from all sources and embrace an ongoing cycle of continuous quality improvement. CONCLUSION Implementing change is rarely easy, and restructuring an entire curriculum is no exception. Nonetheless, efforts that focus on inclusivity, and incorporate deliberate planning, frequent multi-directional communication and positive rein forcement for early adopters are excellent ways to begin a successful journey of 1,000 miles. REFERENCES
Lesson #11: “Contact Time” is the most basic, but fundamental “currency” of curricular integration Reducing and/or integrating the number of contact hours that had previously “belonged” to a particular department, requires a genuine commitment to change, strong leadership, and a
160
1. Lao Tzu Quotes: Journey of 1,000 miles. Available at http://www .quotationspage.com/quote/24004.html; accessed April 30, 2012. 2. Covey SR: The 7 Habits of Highly Effective People: Restoring the Char acter Ethic. New York, Simon and Schuster, 1990. 3. Jim Collins: Good to Great. Available at http://www.jimcollins.com/ article_topics/articles/good-to-great.html; accessed December 5, 2014.
MILITARY MEDICINE, Vol. 180, April Supplement 2015
Copyright of Military Medicine is the property of AMSUS and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Academic Change Management: Leadership Lessons From Curricular Reform Col Arnyce R. Pock, USAF MC; Col Martin Ottolini, USAF MC (Ret.); COL Louis N. Pangaro, MC USA (Ret.); COL William R. Gilliland, MC USA (Ret.); Col Brian V. Reamy, USAF MC (Ret.); Col Paul A. Hemmer, USAF MC (Ret.); CAPT Mark Stephens, MC USN; Alison O’Brien, PhD; CAPT Larry Laughlin, MC USN (Ret.)
INTRODUCTION In August, 2011, the F. Edward Hebert School of Medicine extensively revised its four year curriculum, focusing on the theme of “Molecules to Military Medicine.” Since most civilian medical schools undergoing a major curricular reform typi cally allow three to seven years for full implementation, the fact that its revision was designed and implemented in two years, was itself a momentous achievement. As such, this report will describe some of the key innovations associated with the new curriculum, followed by a summary of some of the leadership lessons that may help guide other programs considering similar types of curricular revision.
BACKGROUND Despite what might have been described as an academic “blitzkrieg,” initial parameters suggest that implementation of the new Molecules to Military Medicine curriculum has been remarkably successful, as early indicators are already exceeding expectations. For not only has the clinical perfor mance of students in the new curriculum been just as strong (if not better) than students in the “old” curriculum, results of the U.S. Medical Licensing Exam (USMLE) Step 1 exam for the inaugural Class of 2015 yielded an impressive 99% first time pass rate, with a mean score that was 11 points higher than the preceding class (scores of 218 vs. 229, respec tively). An equally strong performance was evident on the more clinically oriented, USMLE Step 2 CK (clinical knowl edge) exam, in which the USU Class of 2015 achieved a mean score of 240, which exceeded the previous (baseline) class mean of 232 points.
INNOVATIONS ANS PRINCIPLES An initial six month period of “discovery,” -devoted to a review of contemporary curricular challenges and other schools’ responses to the same, was conducted in the Fall of 2009. After which, the Uniformed Services University’s
Department of Medicine, F. Edward Hebert Uniformed Services University of Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814. The views expressed are those of the authors and do not reflect the official policy or position of the Uniformed Services University of the Health Sciences, the Department of Defense, the U.S. Air Force, or the U.S. Government, doi: 10.7205/MILMED-D-15-00030
158
F. Edward Hebert School of Medicine embarked on an ambi tious, two year period of complete curricular revision, transforming its traditional, “2+2 “curriculum (2 years of classroom based study followed by 2 years of hospital/clinic based experience) into an integrated, organ-system based cur riculum. Instead of utilizing a conventional, departmentally based approach to teach the foundational sciences, in the new approach, material that had been covered in the first 24 months of medical school was re-configured and re-aligned into an 18-month, pre-clerkship curriculum that tightly inte grates basic and clinical science into a series of seven to nine week modules. As a result, students now learn the pathology and pharmacology of cardiac problems right after they study the anatomy and biochemistry of normal cardiac function, i.e., There is no longer a year-long hiatus before students are able to make the connection between the foun dational science and clinical medicine. Moreover, clinical application in the form of diagnostic reasoning seminars coupled with the practice of clinical skills with standard ized patients further strengthens this relationship between clinical and basic science. An additional benefit of the more concentrated teaching of basic sciences is that students begin transitioning from under standing to action much sooner. This is further enhanced by the fact that students now start their traditional core clerk ships six months earlier than they had in the past. Moreover, the timing of USMLE Step 1 examination was also changed, so that it is now administered after completion of the core clerkships, in contrast to the more conventional timing, just prior to the start of the core clerkships. As part of the curricular revision, the entire grading nomen clature was changed from one based on conventional letter grades, to a strictly Honors/Pass/Fail system. Other changes included incorporating a deliberate return to advanced didac tics, in the basic sciences, during a 6 week, post-clerkship segment known as “Bench to Bedside and Beyond” (or B-3). Also included in this post-clerkship period is an opportunity for senior students to work with a dedicated faculty mentor, as they design, develop, and implement a clinical, scientific, or operational research project of their choosing—an initia tive now referred to as a Capstone Project. Needless to say, implementing a major curricular revi sion in a highly accelerated manner evoked a number of significant challenges. Although focused on academic change
MILITARY MEDICINE, Vol. 180, April Supplement 2015
Academic Change Management: Leadership Lessons From Curricular Reform
management/cuiricular revision, many of the following lessons have applicability in both academic and non-academic settings. L e ss o n # 1: S ta r t w ith th e e n d in m in d
Visualize from the start, what successful integration would look like, and provide explicit goals and objectives as this is essential for maintaining focus when distractions intervene. Even sophisticated educators require a basic nosology and framework to begin the arduous task of curricular change. Basing these goals and objectives on sound educational prin ciples may sound simple, but simplicity is often the key to success. Collectively knowing where the group is heading helps keep disparate voices on track. L e ss o n #2: E s ta b lis h a tim e lin e , b u t re c o g n iz e th a t w h a te v e r it is, it w o n ’t b e lo n g e n o u g h !
Change, particularly widespread curricular change, is never easy, but once a commitment is made, progress must be main tained on a tight, agreed-upon schedule as momentum is critical. While hastily made decisions can lead to resentment and/or operational failure, these concerns must be balanced against the risk of changing things too slowly, or allowing frequent and/or liberal extensions of an established timeline, which can delay critical decision-making and prolong main tenance of the status quo. Recognize too, that a journey of 1,000 miles begins with a single step1, and that the first few steps are often the most difficult. As such, it is essential to continue to partner with teams such as the Long Term Career Outcome Study group that provide programmatic evaluation and help ensure that the long-term goals and objectives of the curriculum are being met. L esson #3: C o m m u n ic a te s tra te g ic a lly a n d e ffe c tiv e ly
The importance of consistent, clear and effective communi cation is often under-estimated. Recognize that despite best efforts, there will always be someone who simply “didn’t’ get the message”, or who may just be overly aggressive with the delete key. Make a special effort to communicate multidirectionally, both horizontally and vertically—engaging stu dents, instructors, researchers, scientists, clinicians, professors and administrators. Be sure to use a variety of communication mechanisms, as what works for some is an anathema to others. E-mail is easy and efficient, but it doesn’t replace the impor tance of face-to-face discussions with key stakeholders, where critical ideas and opinions may be more readily conveyed. Other venues, such as Town Halls, “Pizza with the Professors sessions,” briefings, posters, flyers, You-Tube like presenta tions, etc., can all be used utilized with positive results.
dissenting opinions. Take time to elicit, listen and understand their concerns, and find ways to engage them in the planning process, for example, by placing them on key subcommittees. Make a special effort to seek out “quiet” faculty and elicit their insights as well. In any case, it’s important to provide an explicit mechanism for dissenting opinions to be heard and considered. Doing so will enhance the process and strengthen the final product. L e s s o n #5; S e le c t a n d s u p p o rt g o o d p e o p le a n d g o o d th in g s w ill h a p p e n
Caring, committed, and motivated stakeholders are vital assets. Estimates vary, but most experts believe that a supportive core of 20-30% represents the critical mass needed to implement a major organizational change. Note the advice of author Jim Collins who wrote that: “... leaders of companies that go from good to great.. .start by getting the right people on the bus, the wrong people off the bus, and the right people in the right seats. And they stick with that discipline—first the people, then the direction—no matter how dire the circumstances.”3 Note that tangible support-in the form of protected time or a salary supplement, can also be very important. L e ss o n #6: G ive p e o p le a u th o rity c o m m e n s u ra te w ith th e ir le v e l o f re s p o n s ib ility
Responsibility without authority can promote stagnation, whereas authority without responsibility can lead to mis management and/or mission failure. Balancing authority and responsibility allows for real change and rapid operation alization. It also promotes ownership and critical ‘buy-in.’ Likewise, Deans and Institutional leaders should resist any tendency to second guess faculty decisions about what to achieve and how to achieve it. L e ss o n #7: O w n e rs h ip m a tte rs
This lesson is closely related to Lesson #6, but getting buy-in from a variety of different stakeholders makes the entire process easier to manage. Recognize too, that as curricular change evolves, competition for “ownership" of student con tact hours will likely escalate. Allocation of contact hours can be guided by several key principles, to include consider ation of the complexity of the materials, whether the con dition being conveyed is both, common and serious, serious but rare, or common but not serious, etc. An additional factor can involve an assessment of the relative priority (high or low) of the content. L ess o n #8; A d u lt le a rn e rs s o m e tim e s a r e n ’t
L e ss o n M : E m b ra c e , r a th e r th a n avo id , d is s e n tin g o p in io n s
As Stephen Covey (author of 7 Habits of Highly Effective People) frequently espoused, “seek first to understand.”2 Actively seek out and engage those with highly vocal and/or
MILITARY MEDICINE, Vol. 180, April Supplement 2015
Explicit pedagogy is sometimes necessary, particularly for high stakes elements. This may be especially important during the early phases of implementation, when a diverse student body is acclimating to a demanding curriculum and develop ing and/or refining more mature study habits.
159
Academic Change Management: Leadership Lessons From Curricular Reform
Lesson #9: Don’t lose sight of the fact that assessment drives learning It’s not what you expect— it’s what you inspect! Assessments can lead to desirable or undesirable behaviors. Focus on what you want students to learn, and what you want them to be able to do, and align assessments with those goals. Consider changing grading policies to a Pass/Fail system as new cur ricular elements are implemented. Lesson #10: Recognize and reward those who lead and actively engage in curricular change /integration Decide in advance, how to recognize and reward those who engage in and embrace the desired change. Celebrate and share successes with the entire educational community, while pro viding quiet, but positive reinforcement to those who encoun ter resistance or other challenges. Rewards can certainly include monetary bonuses, but public recognition at small ceremonies or in campus newsletters may also suffice. Efforts such as these strengthen faculty commitment and will help sustain the process through the inevitable challenges.
willingness to negotiate and collaborate. Changes in the amount of student contact time tend to elicit the greatest amount of faculty stress; as such, it’s something that needs to be anticipated and proactively addressed. Lesson #12: Recognize that the process of curricular integration never ends Prioritize goals and available resources. Be willing to con sider constructive feedback from all sources and embrace an ongoing cycle of continuous quality improvement. CONCLUSION Implementing change is rarely easy, and restructuring an entire curriculum is no exception. Nonetheless, efforts that focus on inclusivity, and incorporate deliberate planning, frequent multi-directional communication and positive rein forcement for early adopters are excellent ways to begin a successful journey of 1,000 miles. REFERENCES
Lesson #11: “Contact Time” is the most basic, but fundamental “currency” of curricular integration Reducing and/or integrating the number of contact hours that had previously “belonged” to a particular department, requires a genuine commitment to change, strong leadership, and a
160
1. Lao Tzu Quotes: Journey of 1,000 miles. Available at http://www .quotationspage.com/quote/24004.html; accessed April 30, 2012. 2. Covey SR: The 7 Habits of Highly Effective People: Restoring the Char acter Ethic. New York, Simon and Schuster, 1990. 3. Jim Collins: Good to Great. Available at http://www.jimcollins.com/ article_topics/articles/good-to-great.html; accessed December 5, 2014.
MILITARY MEDICINE, Vol. 180, April Supplement 2015
Copyright of Military Medicine is the property of AMSUS and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
