**2. The past century in medical education**

Traditional medical education has been shaped by guiding principles formulated by Abraham Flexner and William Osler early in the twentieth century. In his seminal 1910 report, Flexner stated that medical schools should be university based, have minimum admission requirements, implement a rigorous curriculum with applied laboratory and clinical science content, and have faculty actively engaged in research. Osler developed a system of bedside teaching which emphasized medical students learning clinical medicine from direct encounters with patients under the guidance of faculty clinicians. The insights of Flexner and

#### **Figure 1.**

*Diagram presenting the continuum of medical education including a traditional approach to undergraduate medical education modified to provide progressive integration of basic biomedical sciences and clinical disciplines.*

Osler resulted in the establishment of a model of medical education with two key components or pillars, namely, the basic or foundational sciences and the clinical sciences [1]. The two-pillar model of medical education served as the basis for a four-year UME curriculum comprising biomedical science courses in the preclinical years and clinical clerkships in the clinical years. Over the years, thoughtful analysis has brought about modifications to promote integration of the two components (**Figure 1**). Medical schools utilizing this construct produced scientifically grounded and clinically skilled physicians as well as a subset who pursued successful careers as physician-scientists and academicians.

## **3. The new curriculum and competency-based education**

Yet, in response to criticisms of the traditional system and changes in the healthcare landscape, sweeping changes have been launched in UME and GME with the goal of producing physicians "fit for the twenty-first century" who are adept in functioning in ever changing health care delivery systems [2–4]. The post-Flexnerian UME is based on the so-called fully integrated spiral curriculum encompassing both horizontal and vertical integration across time and across disciplines (**Figure 2**) [6].

The fully integrated UME curriculum resulting from the redesign eliminates a distinct focus on the critically important pre-clinical, basic medical sciences as a foundation for the clinical clerkships. Health Systems Science encompassing diverse topics including population health and interdisciplinary care now is included as a co-equal to basic and clinical sciences. The emphasis is on developing skills in modern clinical reasoning and decision-making and on the demonstration of "competencies" rather than cognitive knowledge. The result of these initiatives has been a loss of a significant amount of time and emphasis on the basic biomedical sciences in the curriculum. The new post-Flexnerian paradigm fits the definition of disruptive innovation. Innovation is a driver of progress, but disruptive innovation is prone to risks and unintended consequences [5].

In the United States, standards for UME and GME are set by the Liaison Committee for Medical Education (LCME), and its sponsoring institutions, the *Contemporary Medical Education: Revolution versus Evolution DOI: http://dx.doi.org/10.5772/intechopen.99453*

**Figure 2.**

*Diagram presenting the concept of a fully or spirally integrated curriculum including simultaneous vertical and horizontal integration. The complexities in realizing this model are considerable, as reflected in the diagram.*

American Association of Medical Colleges (AAMC) and the American Medical Association (AMA), and the Accreditation Council for Graduate Medical Education (ACGME). Regulatory bodies in other countries have had similar roles. Curriculum reformers have used actual and perceived expectations of the LCME and ACGME to drive curriculum revision.

The movement toward outcomes and competency-based education in UME follows innovations in GME, which the Accreditation Council for Graduate Medical Education (ACGME) to implement the six competencies as key elements in residency training programs [3, 4]. These competencies relate to patient care, medical knowledge, interpersonal and communication skills, professionalism and practicebased learning and improvement. The ACGME has moved further along the path of competency-based training with the introduction of milestones as a focus of the new accreditation system (NAS). Competencies also have been linked to Entrustable Professional Activities (EPA). Other concepts under discussion include an accelerated three-year UME program and/or time variable criteria for the granting of the medical degree as well as certification in medical specialties following a period of graduate training.

### **4. Critique**

#### **4.1 Paradoxes**

The fully integrated, competency focused curriculum for UME and GME is promoted as the optimal approach to produce physicians with skills in modern

clinical reasoning and diagnostic and therapeutic decision making. Yet, the solid grounding in the basic biomedical sciences required for high level clinical reasoning and decision making has been diminished. Also, deterioration in history taking and physical examination skills of medical trainees has occurred over the last twenty years contemporaneously with the implementation of the new curriculum [7].

#### **4.2 Unintended consequences and downsides**

The paradigm shift in medical education is based on the premise that changes in the healthcare system and in medical practice in the clinic and hospital have outpaced those in the classroom, resulting in a declining relevance of the traditional curriculum [2]. The claim is that reduction and revamping of the basic science content is readily achieved by elimination of perceived redundancy in the old curriculum. But the reality is that biomedical science, both in terms of curriculum time and emphasis, has been diminished in the new curriculum. Further negative pressure on the basic sciences is coming from the initiative to incorporate Health Systems Science into the curriculum with the associated need to develop faculty with skills in teaching this material. Furthermore, transitioning from a few basic scientists lecturing entire classes from the podium to numerous small groups often tutored by clinical faculty dramatically increases the teaching demands on all faculty and especially faculty clinicians.

Implementation of the new curriculum has required trade-offs, with certain topics such as clinical decision-making, comparative effectiveness and other Health Systems Science topics given priority over the depth of basic science content presented in traditional courses. The justification given for this major revamping and truncation of basic science in the curriculum is perceived excessive and unnecessary detail of course content as well as major overlap and repetition among traditional basic science courses. While strong emphasis is placed on integrating basic science courses and providing clinical experiences early in the curriculum, the extension of basic science content into the clinical years has been a major challenge and a major shortcoming of the integrated curriculum [1].

#### **4.3 Impact on medical educators**

The reconstruction of the content of the UME curriculum as well as pedagogical methods geared to the learning styles of contemporary students requires a major increase in commitment of faculty and staff for the delivery of content in smaller groups than in a lecture format [8]. The lecturer now is being reprogrammed as a learning facilitator, creating stress for many faculty members [9].

Medical educators, including basic biomedical science educators and clinician educators, are faced with adapting to major changes in the curriculum. Many medical educators have experienced significant challenges in the implementation of the new curriculum. A curriculum heavily geared to small group teaching places considerable additional demand on faculty who have to meet multiple competing demands. A significant inverse relationship has been found between faculty members' readiness to change teaching approaches and their severity of burnout [10].

While attempting to cope with major revision of the curriculum, faculty also have special challenges in educating the current generation of medical students [8]. Certainly, faculty educators need to be cognizant of the characteristics of today's students and how they approach leading in the Information Age. However, faculty educators still need to set expectations regarding standards of performance. Pedagogical approaches can be modified to meet the learning pattern of today's medical students, for example, by blending lecture and non-lecture formats.

Nevertheless, faculty educators must continue to set standards for content and learning without compromise on the material that must be learned.
