What Can We Learn From the Letters of Students and Residents About Improving the Medical Curriculum?

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There is a long history of narratives and fiction by physicians that include information about their medical education—for example, books such as The House of God,1Blood of Strangers,2 and, most recently, When Breath Becomes Air.3 These books depict events that at times challenge values of medicine, such as professionalism, compassion, confidentiality, or patient safety, under the pressure of a demanding schedule, lack of supervision, and an overwhelmed staff. Often, a patient’s illness or injury engulfs students, residents, and patients in a chaotic struggle leading to tragic, heroic, or sometimes comic consequences. Frequently in the process of the narrative the author may make observations of trainees’ personal and professional identity crises, curricular and supervisory inadequacy, and mistreatment of trainees or patients. These books and others by physician authors offer a valuable perspective for those considering a career in medicine as well as for those seeking to improve medical education.They also provide a window into the lives of medical students and residents that is often absent from scholarly journals such as Academic Medicine. Even though our journal welcomes submissions in all the journal’s categories from students and residents, the small number that we receive from them often do not survive the journal’s rigorous review process. Unfortunately, because of the few submissions by physicians in training in the journal, we likely miss important concerns that should be shared and discussed by our community. To address this gap, we at Academic Medicine recently sought the perspectives of students and residents by soliciting letters from them. The call went out August 28 last year with a deadline of November 1.The response to this request was almost overwhelming: 224 letters arrived. They covered topics such as admission, testing, burnout, relationships, curriculum, assessment, diversity, empathy, learning environment, and professional identity. The authors were from 98 institutions across the United States and from 10 other countries. We were able to accept only a fraction of these letters. Some of those letters are published in this issue, in print or online, and the others will appear in several future issues in those formats. Of the 224 letters we received, the topic most frequently addressed was the curriculum, with 64 submissions. Those letters’ topics ranged from suggestions for changing or amending the required medical education curriculum to advocating students’ involvement in the curriculum development process. In this issue we have published in print five of the letters related to the topic of curriculum; others on that topic are published online and listed in this issue’s Table of Contents. In this editorial I provide some background on the recent history of curriculum reform in medical education and discuss some of the concerns raised by the letters.Curriculum is derived from the Latin verb “currere,” to run, and originally meant the course of a race before being used to describe planned educational programs. Like the course of a race, an educational curriculum is expected to have a certain length and boundaries. As a former cross-country runner who enjoyed the freedom of an open field with various options of how to find the best route to the finish line, I was probably constitutionally inclined against a rigid and fixed curriculum. As a student I often viewed a detailed curriculum as an unnecessary restriction on my curiosity and self-directed learning. When I started medical school, I chafed at the standard approach of two years of preclinical sciences with their emphasis on lectures before exposure to clinical experience.

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