Cathleen Morrow, MD, Geisel School of Medicine at Dartmouth

When we work to develop, implement, and revise family medicine clerkship curriculum, we are mindful of principles of active adult learning. These include but are not limited to:

• Establishing effective learning climates in which learners feel safe and comfortable expressing themselves
• Inspiring curricular ownership in learners
• Reinforcing principles of lifelong learning and engagement
• Encouraging learners to formulate their own learning objectives and plans
• Structuring curriculum that supports learners in carrying out their learning plans, which implies flexibility and adaptability to meet a given student's need.
• Team teaching, team work, and peer teaching

Implementation of curriculum rooted in such principles can be disruptive, tending to lead to disturbance in traditional lecture formats, Socratic questioning, and emphasis on exams and grades. This can contribute to both student and faculty discomfort, leaving faculty with anxiety about losing control of the classroom setting and students disturbed that they are not being fed material that directly speaks to the next exam they face.

Yet, experienced physicians know that rote memorization, reams of facts and data, and keen command of the literature alone does not make a great physician. It is in the active, deeply engaged student whose innate curiosity and drive is supported, enhanced, and pushed so that "learning that sticks" occurs. Our responsibility, in as much as it is possible, is to foster such learning environments—and sometimes get out of the way. If we believe that this is so, some further principles of student driven curriculum arise:

• Student centered versus faculty centered
• Shift of emphasis away from competitiveness and having the "right" answer
• Better mimic of real-life clinical medicine with support for team and peer teaching and learning.
• Appreciates that we may not know the questions students are struggling with and may not know the answers once questions are known.

These principles, taken together, have strongly influenced revision of the clerkship curriculum at my home institution and continue to influence ongoing consideration of both methods to teach particular material, as well as content.

Curricular examples of such a philosophy:

• Team teaching—multiple exercises in which students break into small groups to answer clinical questions and coming up with assessments and plans for simple and complex medical conditions
• Peer teaching via write-up evaluation—students do first drafts of required formal H&Ps and are paired with a colleague who critiques, asks questions, and suggests edits. Students revise their work based on colleagues' comments before final submission to faculty for evaluation
• Videoconferencing case presentations—faculty select cases based on submitted student write-ups and identify needs raised by the write-up such as organizing and prioritizing data, differential formulation, and clinical reasoning. The "expert" is the student who saw the patient, helping to push the faculty off-stage.
• Wiki: Students post unanswered questions from selected clinic days to a wiki; students share in answering one another's questions with faculty oversight; selected questions are discussed over scheduled videoconferencing.
• The BIG questions: In the final week of clerkship, after all have returned to campus, students post their unresolved questions as they reflect on their 6 weeks in family medicine. These tend toward "big issues" in family medicine and are often more focused on broad health care system issues, complexities of delivery of care, and challenges experienced by students as they struggle to absorb the implications of full-spectrum care. A single faculty facilitates the session in which all students contribute to explore answers together.

We are strongly influenced by the questions students ask and work to create teaching and learning structures that allow curricular fluidity and responsiveness. We strive to create a learning community in each block of the clerkship that fosters active engagement by all participants and places responsibility for learning outcomes on the whole group. That way faculty and students alike have "skin in the game."