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Abstract

Objectives

Several stakeholders are formally recognised when designing undergraduate medical curricula, but past studies have failed to identify them with sufficient breadth, to explore their understanding of the system, or examine their views on curriculum composition. This qualitative study drew on elements of systems thinking to better understand the stakeholders in undergraduate medical education and their role and priorities in curriculum composition.

Methods

This study employed an exploratory qualitative methodology. Participants were initially identified from the General Medical Council's list of stakeholders and were recruited using a combination of convenience, judgmental and snowball sampling. Data were collected through semistructured interviewing. Interviews were descriptively coded and then thematically analysed.

Results

In total, 18 participants were interviewed about their perspectives on stakeholders, the purpose of the education, along with their ideal weightings for curriculum subjects. The findings suggested that the breadth of stakeholders exceeded the modest list provided by the General Medical Council. The purposes of the education were themed into: (1) safe patient care, (2) social benefit, (3) service provision, (4) student benefit and (5) provider benefit. Safe patient care emerged as a universally shared purpose, although views on the customer varied between participants. Curricula priorities were more diverse, with competing interests favouring different subjects for emphasis in the curriculum, with views on the value of scientific-learning particularly divided.

Conclusion

Undergraduate medical education likely concerns a broader range of stakeholders than are often engaged. Several stakeholders are formally recognised when designing undergraduate medical curricula but past studies have failed to identify them with sufficient breadth, to explore their understanding of the system, or to examine their views on curriculum composition. This research raised questions about engagement of vital stakeholders and how power is distributed in the system, along with the need to develop roles into the future when renewing curricula.

Keywords

UME (Undergraduate Medical Education)stakeholders curriculum

Introduction

There is a drive to streamline undergraduate medical education due to shortages of doctors, increasing cost of education, and providers’ training capacity.¹ Yet, medical, scientific and social advances create an ever-expanding body of knowledge to be imparted to students that already feel overwhelmed by the excessive amount of factual knowledge they are obliged to learn.^2,3 Subject matter breadth or conceptual difficulty is not proposed to be the limiting factor to curricula rather than sheer volume.^4,5 Despite the conflicting pressures of time, volume of facts and student capacity, undergraduate medical curricula in the United Kingdom demonstrate a fixed duration,⁶ which precludes the option of simply extending study programmes to accommodate the new material.

Student capacity presents a limitation because the volume of content is potentially almost limitless. Over 40 years ago, a UK medical course was estimated to include 100,000 facts and concepts,⁷ and Newble reported that ‘factual overload has been a consistent criticism of medical schools… for over a century’.⁸ Modern additions such as bioethics and sociology are competing with the traditional disciplines of anatomy and physiology; mandates and pressures to continuously add new content are causing the already packed curricula of medical schools to outgrow their long-established Flexnerian structures.⁹ Knowledge is both expanding exponentially¹⁰ with an ever-reducing doubling time, and new facts are almost as rapidly then becoming outdated. This half-life effect of medical knowledge further challenges medical education in the selection of suitable material for curricula.

Student suicide, mental illness and drop-out are problems at medical school. The overall prevalence of depressive symptoms and suicidal ideation among medical students is higher than in the general population,¹¹ which is attributed partly to the stress of their training.¹² Studies have reported the ‘vastness of academic curriculum/syllabus’ as a significant cause of stress among medical students.¹³

In the field of medicine, there is a challenge to ensure that medical education reflects the evolving knowledge and ideas of contemporary practice while meeting the ever-changing needs and expectations of society.¹⁴ The Institute of Medicine¹⁵ highlighted ‘overly crowded curricula and competing demands’ as a challenge to healthcare. Fulfilling these requirements must be balanced against the risks presented by a swelling curriculum that might endanger student welfare and threaten the reliable supply of trained junior doctors that society needs, with the UK medical profession under pressure due to the well-publicised shortage of qualified doctors.¹⁶

Health educational leaders work directly with and within at least two complex systems (education and healthcare) and face challenges as they engage various stakeholders with competing interests and demands.¹⁷ Accepting that curriculum renewal is essential, planning future medical education requires judicious decision making⁹ and stakeholders should be encouraged to offer input during planning. However, participation can be constrained by social and political context, along with other more practical difficulties such as deficits in technical understanding when consulting across the stakeholder base. Such emancipatory concerns justify a systems thinking approach in order to pluralistically explore a potentially diverse range of stakeholder interests. This study aimed to identify stakeholders and explore their understanding of purpose and their interests and beliefs relating to curriculum composition.

Methods

The aim of the study was to explore stakeholder perspectives surrounding the purpose of undergraduate medical education. This was broken down into discrete objectives: to comprehensively identify the stakeholders involved in undergraduate medical education and consider their stakes, to examine individual stakeholders’ perspectives on the stated purpose of medical education and to explore views on curriculum composition by subject proportions.

Study Design

This study employed an exploratory qualitative methodology,¹⁸ seeking to explore the breath of stakeholder perspectives on the matter of curriculum composition. This form of study permits both the description and explanation of different perspectives from personal standpoints. While an individual's unique personal history, their position and their role would likely influence their views, this study did not interview its participants with the expectation that they would speak in a representative capacity.

Context

The study was completed in the setting of a large undergraduate medical programme in a University medical school in the west of England (although participants from two other medical schools in the United Kingdom were also interviewed). The medical school provides two courses (a five-year MB ChB, and six-year Gateway to MB ChB course). The five-year course consists of a mixture of lectures, case-based learning, cadaveric anatomy prosections and practical work. It also involves patient contact from year 1 and full-time clinical placements from year 3. It also offers students the opportunity to intercalate for a one-year BSc or MSc degree after year 3. Although the study is based exclusively in the United Kingdom, it raises a number of issues which medical educators in many countries will recognise.

Participants

Participants were initially identified from the GMC list of eight stakeholder groups.¹⁹ Literature review, consultation and early interviewing then extended this list to include more potential stakeholders. All were expected to hold unique and important connections to undergraduate medical education. Participants were recruited by a variety of methods: mainly by direct approaches and personal recommendations, but several were contacted via their public email addresses. Best practice protocols were adopted before and during interviewing concerning how to make contact, answers about the interview process and preliminary contacts.²⁰

The process of recruitment involved convenience, judgmental and one instance of snowball sampling. Judgmental (purposeful) sampling involves the selection of participants for their experiences and roles related to the research question of interest.²¹ Characteristics of interest were identified (the subject's role-related proximity to medical education) prior to sampling, and this strategy was employed whenever possible. Convenience sampling opportunistically samples the most accessible subjects for participation,²² which was judged to be appropriate for stakeholders where access was challenging.

Data Collection

Data were collected through the semistructured interviewing of eighteen participants, lasting on average 44 min, following the structure shown in Appendix A. A single stakeholder was interviewed from each group. The interviews had three main foci, mapping onto the three study objectives: stakeholders, purpose and curriculum.

Stakeholders: The GMC's list of stakeholders¹⁹ featured medical students, doctors in training, educators, employers, other health and social care professionals, and patients, families and carers. It was used as a framework for discussion, with participants asked whether any stakeholders were absent from the list or whether any did not belong on it. Some participants then offered proposals for novel stakeholders, and these became the subject of direct closed questions to future participants.

Purpose: Exploring perceptions on purpose used several approaches. Relatively open questions were asked, such as ‘what is the purpose of medical education?’ The PQR formula from Soft Systems Methodology [what should be done (P), how it should be done (Q) and why it should be done (R)]²³ was used to explore system purpose (ie what the participant deems the intellectual construct to be) with particular focus on ‘R’: the ‘why’ or overall purpose of the transformation. A partial application of Smyth and Checkland's CATWOE (Customer, Actor, Transformation, Worldview (Weltanschauung), Owner, and Environment) construction²⁴ was used, and every participant was also questioned on whom they saw as the system customer, in a closed fashion. To broaden and stimulate discussion, a series of candidate declarations of purpose were also shown to the participants (Appendix B).

Curricula: Questioning was structured around the Quality Assurance Agency benchmark standards for undergraduate medical curricula²⁵ (Appendix C). Participants were shown the list and asked whether certain subjects/topics/matters deserved emphasis in preference to others in a curriculum. An ordinal categorical scale was formed with two discrete possibilities: increased emphasis and de-emphasis.

Live audio was recorded for collection, and transcription was performed using the online service trint.com and extensively verified against the audio file for accuracy. Telephone was used as a pragmatic alternative to in-person interviews, which allowed the interviewing of people who were otherwise difficult to access. Telephone calls were recorded using an Android call recorder app, with participants notified of this as part of their informed consent process.

Data Analysis

Interview analysis followed steps outlined by Berg.²⁶ Transcripts were presented in a multicolumn format and analysed without the use of computer software. First-pass coding was performed in a descriptive fashion according to protocols described by Saldana.²⁷ Following coding, themes were identified and analysis was performed using Braun and Clarke's approach.²⁸

The analysis of the responses to the myriad statements of purpose involved constructing an affinity diagram (Appendix D) to permit the reduction of ‘complex issues into smaller subject matter categories from which relationships and common themes can be analysed’.²⁹ The process continued in an iterative fashion until central and uniting themes emerged.

Reflexivity

Data were collected by APR, the lead author. The inherent subjectivity and the potential influence that the background, experiences and position of the researcher had on the recruitment, interviewing, interpretation and analysis of the finding are acknowledged.³⁰ APR was a student at the medical school at the time of data collection and was known to some participants; he was also a Systems thinking student, committed to pluralistic inquiry, and so might be prone to seek and observe a breadth of stakeholder perspectives, even if relative consensus is perhaps as likely. This background has undoubtedly shaped the study and research question. Assumptions and preconceptions were regularly examined throughout the project, which involved sharing personal perspectives and reflective sessions with an academic supervisor.

Ethical Approval

This research was conducted as part of an MSc dissertation with ethical approval granted following detailed review by an academic supervisor (with delegated authority from the Open University, UK). It was not formally reviewed by a Research Ethics Committee (REC) as it was judged to be neither particularly complex nor sensitive and did not present an identified conflict of interest. All works were conducted in line with the principles of the Declaration of Helsinki and according to the best research practice. Participant information sheets were sent to participants 24 h before the interviews, which outlined the study and explained their rights, including their anonymity and their freedom to withdraw. Signed consent forms were obtained at the time of interviewing in person or by email.

Results

Interviews were conducted with 18 participants (Table 1) who were categorised using the Office of Government Commerce's³¹ framework for stakeholders into user (consumer), provider, influencer and governance. All stakeholder groups were represented in this study, suggesting an acceptable breath was achieved and some stakeholders covered more than one group by being both provider and user of the education.

Table 1.

Study Participants, Each a Possible Stakeholder.

	Role	Category
P1	Patient	User
P2	Medical Student	User
P3	Patient Participation Group (GP Practice)	User
P4	Allied Healthcare professional (Occupational Therapist)	User
P5	Medical school Programme director	Provider
P6	Medical school Dean	Provider
P7	Surgeon: undergraduate teacher/trainer of postgraduate trainees	Provider/User
P8	Medical school Senior Tutor: student welfare	Provider
P9	Medical regulator with interest in Education	Governance
P10	UK Department of Health: National Policy advisor	Influencer
P11	Regional postgraduate Dean: public education funding body	Influencer
P12	Non-science teacher teaching medical students	Provider
P13	Sciences teacher (head of physiology school)	Provider
P14	Doctor's union: Medical Academic Staff Committee	Influencer
P15	Trust Director of education/Trust senior leadership team	Provider/User
P16	Royal College education committee member	Influencer
P17	Doctor post-Foundation year: Clinical Education Fellow	Provider
P18	Medical technology company: Manager	Provider

Abbreviations: GP = General Practitioner.

Stakeholders

Participants were asked their perspectives on who they considered to be stakeholders in undergraduate medical education. Interviews also explored an individual participant's stakes in the education. Differing perspectives were shown in the potential breath of desired stakeholders. Some codes were strongly represented, notably the inclusion of patients, families and carers who were commonly felt to be important stakeholders. Table 2 shows participant views on the GMC's stakeholders.

Table 2.

Participant Views on Stakeholders.

Stakeholder (GMC)	Approval	Disapproval
Teachers from the medical school
Employers of graduates	P6
Bodies responsible for continuing training (Royal Colleges)		P7
Students	P2
Doctors in training
Educators		P13
Other health and social care professionals
Patients, families and carers	P3, P5, P6, P11, P12
Proposed further stakeholders (open Q)
External examiners	P5
UK education funding agencies	P11, P15
Department of Health (Government)	P15, P17
Pressure/single-interest groups		P1, P11
University	P15
Public Health funding bodies (NHS England, etc)	P11
Research Funders (MRC, NIHR)	P11
Voluntary sector	P10
Further stakeholders (closed Q)
Parents of students	P2, P8, P11	P3, P4, P6, P7, P16
Medical technology industry	P18	P16

Abbreviations: GMC = General Medical Council; NHS = National Health ServiceXXX; MRC = Medical Research Council; NIHRC = National Institute for Health and Care Research.

All participants (with one exception: P12) agreed that they themselves constituted a stakeholder in the education. Common answers were that the list was ‘about right’ (P10) or expression of agreement with it: ‘it seems fairly comprehensive’ (P3).

Some answers, however, challenged the status of certain stakeholders:

I'd take the Royal Colleges off it. They’ve become less and less relevant. That's their own problem. (P7)

Educators. ….. Some people find them very useful. Some people find them a pain in the neck. (P13)

It was also common that patients were considered to be stakeholders in curriculum decisions though not universal. Several participants expressed either their surprise or their contentment that patients were consulted. P12 stated that they doubted whether a ‘meaningful’ consultation was made, P11 described the difficulties involved in seeking their input and one participant stated that pushing the patient agenda had ‘almost gone too far’.

If they are involved I'd be pleasantly surprised. If they are involved meaningfully then I'd be even more pleasantly surprised. (P12)

We are so busy in some curricula pushing the patient agenda and advocating for the patients that actually we're not allowing our medical students and doctors to be assertive, it's almost gone too far…(P16)

The risk that single-issue pressure groups (eg antivaccination lobbies) might infiltrate such representation was also raised. This was viewed as potentially unhelpful or dangerous (P11).

Stakes: A stake is ‘an interest in or a share in an undertaking’³² and an interest described what a stakeholder got out of the education. A number of different stakes were described, including their own safety as a patient, their livelihood and their professional security:

I have a vested interest in doctors being trained to a high standard to give good care …… a product of how they have been trained. (P1)

I get paid. And with a bit of luck, if I become unwell in future then I'll have a group of really sensible doctors. (P8)

I enjoy it … I like imparting what knowledge I have to a new generation. (P17)

Other interests were less obvious. The interests of the senior responsible doctors (user) were described:

if you have a poorly educated team and you are responsible for the end customer(patient)..then you are potentially vulnerable. (P15)

The workforce needs of the health providers were represented, as were the financial needs of the trusts (P11,P15):

the organisation… is a business, it has an income stream and a spending stream and the business will only survive if that's reasonably matched. (P15)

Some further interests were offered including opportunity for profit, the social responsibility implicit in educating doctors from wide social backgrounds and also certain characteristics of the education.

Purpose

Freeform answers to the open question of ‘what is the purpose of medical education?’ were wide ranging and several participants offered more than one purpose. Challenges were sometimes encountered, and participants might either conflate purpose with function or misunderstand entirely (thinking the answer axiomatic). The most common and reliably recurring theme for the purpose of undergraduate medical education was to provide safe and high-quality care, which was expressed in some form by all participants. Further themes were benefits to students and doctors themselves, benefits to education providers, service provision (personnel for health service), moral obligation and social benefit.

The need for a student to gain maturity through education was frequently mentioned (P5, P6, P7, P8, P9, P11, P14, P15, P16 and P17), which was thematically linked with safety.

The purpose of the education…is to produce high quality Drs. To maintain, or possibly even raise standards of patient safety. (P9)

The need for medical school to provide a safe place to make mistakes before being exposed to patients was mentioned by P5 and P13:

Safety is first…are you going to be let loose on the patient population? (P13)

Safe patient care: it was proposed during interviewing that medical education protects patients from the danger of poorly educated future doctors, and so purposively fulfils a safety function. It does so by formalising the process of imparting knowledge, skills and attitudes to the students:

(to provide) a better chance than not of receiving something that's legitimate and evidence-based…and competent. (P1)

Customer: A wide variety of answers were received to closed questions concerning the participants’ views on the customer of the system. This was seen in the additional themes surrounding purpose, namely: benefits to students and doctors themselves (students: P2, P5 and P8), benefits to education providers (P7, P8, P11 and P13), service provision (personnel for health service and patients: P6 and P13), moral obligation and social benefit (UK public: P6).

Several respondents were quite definite in their response to this question, for example, P2 (student) stated ‘we are, definitely….’

It was then discussed whether the students’ customer status entitles them to near-automatic graduation with a medical degree, and whether this threatens the integrity of the education's protective function:

The expectations of students has moved on with the application of student fees. (P8)

We can't force someone out unless they do something grossly unprofessional, or they fail. (P8)

The culture in medical schools to get everyone through, whatever…I'm not sure that they have selected out students who are unable to progress as a doctor….I don't think there's an acceptance…that that's their responsibility. (P11)

Curriculum

Views on curriculum composition were found to vary relatively widely. Participants provided a range of views on subjects for emphasis and de-emphasis, with the sciences (A, B and D) and learning principles showing particularly opposing preferences. Meanwhile, the society-population health/disease-based subjects (C, E, F and K) and ethics/law (P) showed nearly a third of participants favouring them for emphasis and no detractors. Taking a systems thinking approach, discussion then naturally led to consideration of matters surrounding influence, feedback and power distribution within the system.

Following interviews, it was frequently necessary to interpret participant's answers before recording whether a subject deserved particular emphasis or de-emphasis (at the expense of others). It was important to determine the relationships between the data points rather than their absolute value. If a participant used a superlative term to describe a subject's importance, then it would be considered to deserve increased emphasis.

I think this is very important (C). I think this is less so (D). I think I think this is relatively.. (E). (P15) – interpreted as only C for increased emphasis

Molecular biochemical cellular mechanisms…yeah, important to a degree…. I think most of it is balanced right.(P6) – interpreted as D not worthy of emphasis.

The value of rote-learning of scientific knowledge in a curriculum was disputed. Some questioned learning facts in favour of learning how to readily access the information using technology (P1, P8 and P13) and some questioned the value of the science itself (P7 and P10). Others supported the need for science (P14 and P16):

You need the overall science, you need the absolute bedrock of certainty. I think we've done too much of the listening to the patient's agenda…We're so [busy] trying to be empathetic and listen to people and do the communication skills right that we've almost forgotten what to communicate. (P16)

The present role of doctors as ‘handlers of uncertainty and ambiguity’ was a view strongly supported by eight participants, but views on whether this warrants the learning of science were equivocal.

Influence in curriculum allocation: Consideration of interests in curriculum composition highlighted the substantial autonomy held by the medical schools (explicitly stated by P5). Concerning oversight, the regulator said:

We don't actually look a great deal into curricula but just use very generic overview standards’…’We basically blindly accept it if the students aren't complaining about it or the teachers aren't complaining. (P9)

Participant 16 (Royal College) described how they petition the medical schools:

The difficult bit is that everyone thinks their bit's really important and tries to get it squeezed in…whereas obviously ours is THE most important thing (laughing). (P16)

On the matter of curricula proffered by the Royal Colleges, P5 stated they were too extensive to all be included. P6 agreed with this, providing insight into power allocation:

So get all 30 specialties to give us a curricula to put in our undergraduate? Yeah, yeah, yeah…Let them knock on the door. (P6)

I don't know how much power we have in the College, we produce curriculums but we don't really change anything. (P16)

The central funders also had minimal input into the content:

Undergraduate curricula, we'd have very little input on that all really, whether we should have input in it…Yes, probably we should. (P11)

Tension: The effect of unequal power distribution and vested interests on curriculum decisions was highlighted in some of the interviews conducted:

I always felt quite peripheral to the overall…course curriculum. We just…I felt like we kind of came in, did our bit and got out. (P12) a tutor in sociology, communicating his concern about a reduction in future sociology content (an expression of interest).

Tension can also arise from the relationship between trusts and medical school (both providers). Doctors hold status and clinical authority in the trust but hold less power in educational matters:

I'm the end of the chain when it comes to my department, but I'm certainly not when it comes to the university..I think that tension is difficult to manage. (P8)

Meanwhile, the nested presence of a medical school in a university is advantageous to them:

I think it is a cash cow…not for the wider benefit for the medical profession or patients but it's because it's going to earn a lot of money. (P7)

it's of value to have a medical school in a university…it brings prestige there's no doubt. It's often said if you want to be a Russell Group University then you have to have a medical school. (P13)

Curriculum decisions: The consideration of stakeholder input into curriculum led to discussions surrounding power and feedback. The participants were asked about how they were judged in their role and how and whether feedback was actively used in the system. The most influential source of feedback identified was from students P12 (principally in the National Student Survey, P5). Some participants expressed that this was not ideal (P5, P6, P10 and P8):

it's not until you start working as a Dr you don't really appreciate what were the really important things for you. (P5)

….they don't put the [right] kind of feedback…the students don't realise how good it could be. (P16)

Significantly, one of the two principal customers, namely patients, appear to be largely absent when feedback is considered:

Multisource, 360 feedback of course [is needed]…not just from the one person that you deliver the training to, but to whom the training was then dispensed. (P10)

God forbid we actually speak to patients! (P8)

Figure 1 shows the key influences going into the structure and content of the curriculum and it demonstrates strong influential links between the students and the curriculum. This was evidenced when the prominence of the National Student Survey was described and how student input was reported to be the dominant feedback used to shape the curriculum. Regulator input stops at the medical school boundary and does not reach curriculum-level matters. Other factors and external examiner influence is shown to be significant, but the majority of the other influences are weaker (dashed lines represent missing/suboptimal influence that might be desirable in an effective learning system). Patient feedback, and their involvement in curriculum decisions, was frequently felt to be absent or limited.

Figure 1.

Influence and Feedback in Medical School Curriculum Composition.

Discussion

Stakeholders

This study showed that the regulator's preferred stakeholders were widely approved of, although evidence of their wide and effective engagement was unconvincing. Further possible candidate stakeholders were also suggested, though little critical analysis is offered on individual claims for inclusion.

Schiller³³ highlighted a gap in the literature when deciding who the ‘relevant people’ are during curricula reviews, and this research seeks to address that gap albeit imperfectly. In reviewing their own curriculum, Davis and Harden³⁴ described a broad attempt at diverse representation but still reported committees weighted heavily in favour of educationists, with minorities including hospital trust representatives, students and support staff. Equivalent difficulties in pursuing diverse representation were illustrated in our study, with reasons offered as to why patient engagement was particularly challenging (technical difficulty). Reported barriers to cross-stakeholder involvement in the past have been teacher resistance,³⁵ territoriality,³⁶ ivory tower phenomena³⁷ and a ‘‘turf-protecting’’ consciousness.³⁸ While some of these were undoubtedly described in this study, further boundary considerations were also uncovered, including matters of control, limits to technical knowledge and issues of legitimacy.

Purpose

This research demonstrated that views on purpose(s) ostensibly show relatively little divergence as all participants expressed a belief that the system existed to provide patient care and safety. This might suggest a strong commonality of purpose; yet, in practice, this questioning was often problematic. Wider purposes were also described with the emergence of certain parallel themes (benefit to provider, social benefit, etc). So, instead this was more suggestive of a diversity of perspectives on purpose across the stakeholder base.

A simple premise may be that all educational institutions’ core purpose is to promote learning and teaching. In Tyler's curriculum model, he suggests that the most crucial word is ‘purposes’³⁹ because educational objectives become the criteria by which materials are selected and that everything is aligned to accomplishing these educational purposes. The literature shows that consideration of purpose is not uncommon in medical education, with perspectives ranging from the relatively narrow: preparing students for their careers;⁴⁰ to far broader sociological, economical, ecological, and system perspectives.⁴¹ This latter breadth was generally supported by the present study.

Curriculum

Certain emergent themes were notable: particularly the disputed importance of scientific knowledge and the need of a curriculum to reflect the future role of doctors. The need for doctors to be able to handle uncertainty was suggested by a number of participants, but whether this warranted learning science or whether it instead mandated student maturity (conceivably justifying a graduate-only entry) were again matters that divided participants. The necessity for maturity in the students, and the role of the education in providing a safe time and space for them to reach that maturity, was a recurring theme identified in the study which merits further research.

Mcleod and Steinert⁴² stated that health sciences curricula ‘should be perpetually responsive to change’ and advocate frequent reviewing to ensure appropriate content and sequencing in the curriculum. The value of feedback in education is also emphasised by Thornton et al⁴³ when they stressed the need to align feedback with learning goals. Secondary research indicated that stakeholder engagement is vital in this process; and highlighted the need to balance workforce and funders’ demands when tailoring curricula, while prioritising patient safety and not ignoring the perspectives of the students. The primary research reported in this study showed that perspectives on ideal curricula covered considerable breadth. It also supported Lau's claim⁴⁴ that curriculum planners hold the most power by both completing the technical work of writing the curriculum, as well as making the political decisions concerning what knowledge goes into the curriculum. This study presents an ungoverned space, with little input from the regulator and limited multisource feedback involved in making adjustments in future iterations.

Strengths and Limitations

A strength to this study was the breath of stakeholders engaged, with good access achieved across the base. The study has benefited from a pluralistic application of a systems thinking approach and has reported a diverse range of unique perspectives concerning undergraduate medical education.

A significant limitation in this study is the narrowness in breadth of the study team, and the resulting bias this may have imparted to the study findings. Accepting that no research is free of the biases, assumptions and personality of the researcher – the lone researcher's own role as a medical student has potentially biased the collection and analysis of the data.

Internal generalisability: it was never the intention to expect study participants to speak on behalf of their stakeholder group and they were expressly not interviewed in their capacity as representatives. A single stakeholder was interviewed from each group so, while they therefore might not be expected to provide a representative view, they may yet collectively demonstrate a breadth of views. It was expected that their unique insights may be a product of their position, additional to their own experience, personal histories and individual values.

The external generalisability of the findings is measured, as the research was conducted in the United Kingdom with input from members of only three different medical schools. The comparatively recent introduction of fees to United Kingdom undergraduate medical education and the role of student as customer was highlighted in this study. This may have generalisability to systems where funding models are subject to change. Also, the unequal power distribution depicted in the study, further complicated by the roles of healthcare providers, regulators and university governance, may also have wider relevance to medical education in other countries with similar models.

Conclusions

This study has revealed a considerable breath in perspectives surrounding the stakeholder community involved in undergraduate education, a broader range than is often considered or planned for. Stakeholder interests and perspectives conferred a variety of views on curriculum composition. Acknowledging that medical schools are social institutions embedded in complex educational systems, this research raised questions about engagement of vital stakeholders and how both power is wielded and accessibility are distributed in the system. It also highlights the need for ongoing stakeholder engagement when developing undergraduate medical education into the future in an evolving multidisciplinary and technological landscape.

Supplemental Material

sj-docx-1-mde-10.1177_23821205251329750 - Supplemental material for Stakeholder Perspectives on Undergraduate Medical Education: Using a Systems Thinking Approach to Explore Interests in Curriculum Composition

Supplemental material, sj-docx-1-mde-10.1177_23821205251329750 for Stakeholder Perspectives on Undergraduate Medical Education: Using a Systems Thinking Approach to Explore Interests in Curriculum Composition by Alexander P Royston in Journal of Medical Education and Curricular Development

Footnotes

Acknowledgments

The author thanks all participants involved in data collection and Dr Rupesh Shah of the Open University for his excellent academic supervision of the MSc dissertation, of which this article is part.

Author's note

The author is also affiliated with Bristol Medical School, University of Bristol, First Floor, 5 Tyndall Avenue, Bristol, BS8 1UD.

ORCID iD

Alexander P Royston

Ethical Considerations

The study protocol was approved by the Open University.

Informed Consent

informed consent was obtained from all participants.

Author Contributions

The idea for this study was conceived by APR, and it evolved following drafting and discussion with an academic supervisor provided by the Open University. APR conducted the data collection, coding, analysis and preparation of the manuscript. The academic supervisor contributed methodological expertise along with other helpful criticism. The author read and approved the final article for submission.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The datasets generated and analysed during the current study are available in the Open Science Framework repository, DOI 10.17605/OSF.IO/BEH6W

Additional Files

The additional files for this article can be found as follows: Appendix A-D. DOI: 10.17605/OSF.IO/BEH6W

Supplemental Material

Supplemental material for this article is available online.

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