The Sydney University Medical Program: highlights and lessons

In 2008, we reported our review of the Sydney University graduate medical program.1,2 When the program was introduced 11 years previously, it was innovative, with emphasis on helping students to solve problems and to think critically about what they were learning rather than to memorise lists of facts. In 2005, the Australian Medical Council (AMC) reviewed the program and awarded the maximum 10-year accreditation. However, the AMC also suggested a number of actions, including reviewing the role of problem-based learning (PBL) in the final 2 years of the course, reviewing some areas of assessment, providing a renewal process that allowed for flexibility and innovation within the defined outcomes, and reviewing the complex system of committee structures.

We made 730 recommendations in our 2007 review, incorporating the AMC’s suggestions and covering the provision of an initial scaffolding on which students could build knowledge, increased anatomy teaching and the creation of clear learning objectives. We now report on the impact of that review. The major changes implemented after the review are shown in Box 1.

Eighty-five per cent of the recommendations have been implemented. Another 5% are currently being implemented; 2% are no longer relevant; and 8% have not been implemented (Box 2). The implementation of 85% of the changes was due to three main factors: the inclusive nature of the review process; the commitment of the dean; and the team chosen to implement the changes through a newly created Office of Medical Education.

The first 9 weeks of the course became a foundation block that provides a scaffolding of basic facts and concepts on which students can build future knowledge. The foundation block provides learning activities and additional tutorial groups specifically for students from non-science backgrounds who initially find the course difficult.

An additional Chair of Anatomy with specific responsibility for teaching was created, and the amount of anatomy teaching in the first 2 years of the course was increased from 50 to 170 hours. An additional appointment of an academic surgeon jointly for Surgery and Anatomy has enabled the return of whole-body dissection as a student elective.3 These new appointments have ensured that anatomy is now taught throughout the course.

Students now have electronic access to detailed learning objectives and a core curriculum with clear links to the teaching program for each week. They engage more with medical librarians, critically evaluating information sources, developing and refining search strategies and learning database construction. A student guide provides a direct link for quick location of key databases and basic science resource materials.

While PBL remains a core component of the medical program, clinical reasoning sessions, which have more clinical emphasis than the traditional PBL tutorial,4 have replaced PBL tutorials in the final 2 years. The artificial distinction that existed between the two clinical years has been removed so they have become fully integrated.

The amount and sophistication of assessment has been increased. In formative assessments, students are able to see their progress in relation to that of other students. Grading, which was not in the original graduate program, now occurs in the last 2 years. The criteria for awarding honours on graduation have become more rigorous, with a higher standard and an increased emphasis on academic supervision. Students interested in pursuing a career in research may also do a concurrent Master of Philosophy degree, which requires intensive immersion in research during holidays and the elective term.

Heads of disciplines have become more involved in curriculum matters. Academic staff from disciplines that were previously not well integrated into the curriculum now meet regularly, contribute more to teaching and have become more collegiate. This has re-engaged clinicians and reinvigorated some disciplines that previously had less involvement in the curriculum.

The introduction of new material has depended on the leadership given by champions who have taken on these new areas. This was particularly applicable with regard to helping students to understand and critically review complementary and alternative medicine, to develop an awareness of the spiritual dimensions of health for some patients and to better understand the problems of people with a disability. Medical humanities has been strengthened; and the creation of the position of Associate Dean, International Health increased students’ exposure to a range of global health issues.

Recommendations regarding the importance of Indigenous health throughout the course have resulted in some Aboriginal health care delivery concepts being incorporated into the teaching of communication skills. Students are now encouraged to become more involved with Aboriginal medical services.

Student numbers are increasing (Box 3). The total number of students increased from 261 in 2007, to 299 in 2011, with international fee-paying students increasing from 34 to 66. Federal government funding arrangements have created the need for medical schools to take more international fee-paying students. However, a balance has to be struck between this need and the essential requirement to provide a high-quality program with good support and tutorial groups of an effective size. A medical curriculum cannot guarantee effective student learning and satisfaction if numbers increase without a commensurate increase in academic staff, support staff and upgraded facilities on campus and in clinical schools. This issue is not unique to Sydney Medical School. Medical student teaching is intensive, with emphasis on small group tutorials, one-to-one teaching and role modelling. Teaching cannot be separated from research, as research informs much of the teaching. However, adequate resources must be put into teaching so that it is supported just as research is supported.

Areas in which changes to the University of Sydney graduate medical program still need to be made are shown in Box 4.

Leadership is essential for creating and sustaining changes. Academic leadership has been a key factor in the implementation of the majority of changes recommended in this curriculum review. The leadership of the dean, the academic course coordinators and the associate deans of the clinical schools has been crucial in implementing the changes so far. The dean should be clearly in charge of the curriculum and the curriculum should be one of his or her obvious priorities. While day-to-day curriculum management is delegated, regular meetings between the dean and academic course coordinators to discuss key issues, rather than curriculum detail, are important.

Where innovative recommendations have been implemented, there has been a clearly designated and committed leader for the new area. In some cases these leaders were recognised in advance, while in other cases leadership arose spontaneously. In contrast, recommendations that were not successfully implemented did not have a champion identified.

Before introducing change to a medical curriculum, there should be wide consultation with students, faculty members, other teachers, professional bodies and community groups.5 In our experience, wide consultation with faculty members, listening to and incorporating their suggestions and giving them some responsibility for implementation effectively re-engaged them and were the crucial factors in successfully changing the curriculum.

While the importance of factors such as leadership and wide consultation may seem obvious, we need to acknowledge their essential contribution to effective, sustained change. Attempts to change a medical curriculum without leadership at the highest level, identification of leaders for specific roles and wide, regular and frequent consultation are likely to be doomed to failure.

It became clear when reviewing the curriculum in 2007 that 11 years is too long to wait. A medical curriculum is dynamic and needs to respond to changes in medicine, health regulations, educational thinking and society. More frequent review would ensure that the curriculum remains relevant and plays an integral part in shaping the future leaders in medical care. Medical education and health care delivery are not static, which is why curriculum revision must be a continuous process of renewal and response to change.