META-CURRICULUM IN MEDICAL EDUCATION, THE

Medicine and Health Rhode Island, Aug 2004 by Smith, Stephen R

The curriculum can be conceptualized as three intersecting rings (Figures 1 and 2). The planned curriculum consists of the written lessons plans, the syllabus, and the ideas that the instructor has about what to teach. The planned curriculum also includes the plans that a school has promulgated for its overall program of instruction.

As the old saying goes about the best laid plans, things don't always go according to plan. Every teacher and student knows of classroom discussions that go off on a tangent, often leading to very stimulating and productive learning. This is the taught curriculum.

The learned curriculum represents the third circle. Students will frequently learn beyond that which is planned and taught. Teachers hope that instruction will pique students' curiosity. While this may result in learning that supplements that which teachers expect, students may also focus their learning activities on their own interests while giving scant attention to the areas that don't interest them.

Figure 1 represents a situation in which a large disconnect exists between the planned, taught, and learned curricula. Figure 2, on the other hand, reflects a situation of greater synergy among the three components.

Hafferty and Franks suggest that a fourth type of curriculum exists, the hidden curriculum) This learning occurs outside the classroom or formal teaching rounds and happens in corridor conversations, late-night chats in the on-call room, or in the car pool to and from the hospital. Students pick up values, attitudes, and "conventional wisdom" through the hidden curriculum, some of which might be quite inimical to what the faculty hope to convey through the planned and taught curriculum. I'll leave that hidden in my two figures, but readers should know it's there.

I believe that another level of the curriculum exists that 1 call the metacurriculum. The meta-curriculum reflects the ways that we structure the teaching, learning, and assessment apart from the actual content or skills being taught. For example, the faculty committee that developed the broad outlines of the curriculum for Brown Medical School specified that 25% of time during the four years of medical school be elective and available for course work in any area of the university. The committee, chaired by Jacquelyn Mattfeld, Associate Provost and Dean of Academic Affairs, further recommended that the curriculum be so arranged that students in their clinical years could set aside a whole semester free of clinical obligations for study, research, or formal course work in any area of their choosing.2 This became known as the Eighth Semester Program and still exists today.

In making these recommendations, which were adopted by the general faculty on February 6, 1973, the faculty hoped to create a learning environment that would nurture and sustain a "new" kind of physician (at least for 1973) who was broadly and liberally educated. Indeed, this notion became ensconced in the mission statement of Brown Medical School: "The medical program at Brown University has two major goals for its graduates: that they be broadly and liberally educated men and women, and that they view medicine as a socially responsible human service profession."

The meta-curriculum can be imagined as the frame around Figures 1 and 2. The meta-curriculum always exists, but can be created either consciously and deliberately with the goal of enhancing the three other curriculum circles, much like a well-chosen frame enhances its picture; or unconsciously, in which case it may detract from the other curriculum components, as an ugly frame detracts from its picture.

Like a picture frame, the meta-curriculum defines the boundaries of the object it frames. Deciding that medical school is four years in length rather than three or five sets certain limits, as does setting the semester at 13 weeks, scheduling 25 hours of in-class time per week, and not scheduling courses during the summer after the first year. These boundary decisions are not predetermined by some immutable formula consisting of universally agreed-upon constants. Rather, they reflect underlying values and principles, competing interests, and practical limitations, all within a malleable reality of what it really takes to train a physician.

Thus, the decisions about the meta-curriculum have an aesthetic quality like that involved in selecting just the right picture frame for your masterpiece. just as the sensitive and knowledgeable buyer wouldn't pick any old frame to go with her Renoir, curriculum planners should be thoughtful and deliberate in making decisions about the meta-curriculum. The goal should be a harmonious synergy between the frame, the picture, and the message to be conveyed by both. In the rest of this article, I describe some of the features of the meta-curriculum at Brown Medical School, focusing on where that harmonious synergy exists already, and where further attention may be needed.

GENERAL CONSIDERATIONS

Brown Medical School distinguishes itself among American medical schools for its greater flexibility, enabling students to chart their own course for learning. Throughout its 30-year history as an MD-degree-granting institution, the school has been loyal to the tenets enunciated in the Mattfeld committee report mentioned above. Though some erosion has occurred around the edges, the medical school curriculum remains essentially one-quarter elective. As a consequence, Brown medical students are more than twice as likely as their national compatriots in other medical schools to undertake an independent study (76% vs. 36%). This meta-curriculum decision reflects the value that the faculty places on self-directed learning.