‘Discovery Learning’: An account of rapid curriculum change in response to accreditation

Abstract

Background/Aims: The purpose of this study was to explore the attitudes and experiences of leaders responsible for making rapid changes to a medical school curriculum in response to an adverse accreditation report. The new curriculum was based on the principles of problem-based learning (‘Discovery Learning’), with changes to the way that students were assessed.

Methods: We conducted semi-structured interviews with leaders responsible for education at the school two and a half years after the adoption of the new curriculum. We coded the resulting transcripts to identify major and minor themes expressed by participants.

Results: Thirty-five senior leaders, administrators and course directors were invited for the interview; 14 (40%) were interviewed. Five main themes were noted in the data: (1) organization and control of the curriculum; (2) changes in the practices of teaching and learning; (3) effects on faculty members; (4) sources of resistance and (5) attitudes to curriculum change in general.

Conclusion: This study demonstrates that major curriculum change can be achieved successfully in a short period of time. This study also illustrates some of the problems associated with making rapid changes to the medical school curriculum, and highlights the importance of attitudes to change amongst the leadership of a medical school.

Background

Curriculum change is essential to the cycle of program evaluation and improvement in a medical school, but it can often be a complex and difficult undertaking (Craig & Bandaranayake 1993; Guze 1995; Sefton 2004). The need for change may arise from within the school, as a desire to improve on current methods of teaching (Al-Gindan et al. 2000), or be driven by external forces such as accreditation (Kassebaum et al. 1997; Bernier et al. 2000; Simon & Aschenbrener 2005).

A number of medical schools around the world have described the process of curriculum change (Mennin & Krackov 1998; Watson et al. 1998; Rollins et al. 1999; Schwartz et al. 1999; Bernier et al. 2000; Uchegbu 2001; Putnam 2006; Ryder et al. 2008; MacCarrick 2009; Marinović et al. 2009). The changes described have included new methods of teaching (e.g. problem-based learning, replacing lectures with small group teaching, incorporating new technology), reorganizing teaching (e.g. system-based, interdisciplinary education, early introduction of clinical experiences, integration of clinical experience with classroom) and changing how students and faculty are assessed and evaluated. Kotter's eight-step model of change management has its origin in the business literature, but may also be relevant to the organizational change occurring in a medical school (Kotter 1996). Commonly cited reasons for failure to change include a lack of faculty understanding and support for the change, the lack of skills needed to make the change and inability to coordinate and assess the impact of the change (Rollins et al. 1999; Genn 2001; Sefton 2004). Sources of resistance to change within medical schools may include a conservative culture, defence of current practices and territorial conflicts between disciplines (Bernier et al. 2000; Lane 2007). Organizational resistance may also be caused by conflicting organizational objectives or pre-existing beliefs (Bowe et al. 2003). Accounts describe curriculum change occurring over a period of years (Des Marchais et al. 1992; Bernier et al. 2000), and caution against the hasty introduction of the change (Marinović et al. 2009). While major changes may be achieved at speed, especially if a novel approach is adopted (Bland et al. 2000b; Cottingham et al. 2008), there are few accounts of rapid adoption of major change in a medical school curriculum.

Table

Practice points

Initiating a curriculum change in response to an adverse accreditation report is an increasingly common experience for the leadership of medical schools. Successful major curriculum change can be achieved rapidly, with appropriate leadership and under the correct circumstances. When initiating major curriculum change, it is important to consider factors such as control of the curriculum, the impact on practices of teaching and learning and on individual faculty members, to anticipate and deal with resistance to change, and to consider faculty and student attitudes to change.

Change in our curriculum was driven by the April 2006 joint visit of the Liaison Committee on Medical Education and the Committee for Accreditation of Canadian Medical Schools (LCME/CACMS), which found our school to be non-compliant on several important educational standards. As a result, the school was placed on probation, and withdrawal of accredited status was threatened. The issues cited had been identified in previous accreditation reports, but few changes had been made in response (Lewis 2009). The school had for long followed a traditional curriculum, with much time in the pre-clinical years spent on didactic teaching in the lecture hall. Small group sessions were employed, using a mixture of case-based and problem-based approaches which varied from course to course.

In the midst of much media attention, the Dean of the Faculty convened an Accreditation Response Team to respond to the situation, and a number of changes were rapidly implemented. One key criticism of the program was the ‘lack of active learning’; the response was to reduce the amount of time spent in lectures and to increase the amount spent in small group teaching. Small group teaching in the pre-clinical years was to be delivered using a local implementation or ‘brand’ of problem-based learning (PBL) named ‘Discovery Learning’ (DL).

In November 2006, the Dean directed that this major change in curriculum be achieved at the start of the following academic year, in August 2007. The curriculum changes consisted of the following:

• Introduction of a new ‘Discovery Learning’ program based on the principles of PBL in all of the pre-clinical teaching courses in Years 1 and 2. This replaced an existing program of small group case-based education; the new program required tutors to be trained in the principles and practices of PBL; tutors were encouraged to teach on courses outside their own content expertise. Groups of 10–12 medical/dental students and one tutor met together for one to two hours thrice a week (2 + 2 + 1 hours) to discuss a DL case, covering a different theme relating to the course each week. Students were required to discuss the information presented to them, to decide their own learning issues, to research learning issues between sessions and to report their findings to the group at the next meeting. Courses lasted five to seven weeks, with tutors and student groups changing between each course.

• Reduction of the amount of time in each course allocated to lectures and laboratory work, and formal scheduling of free study time for students. The maximum allowed hours per week were set at eight hours for lectures, five hours for labs, five hours for DL and six hours for self-directed study.

• Assessment of student performance on each course using (a) tutor ratings of participation and interaction in the DL group and (b) a multiple-choice examination to assess the knowledge.

• All of the existing cases were replaced with new ‘DL case’ developed for each week of each course; cases were written by a dedicated team according to a standard template based on the principles of PBL.

• Each Department Chair was required to provide a given number of faculty members to be trained as DL tutors, according to the size of their department. All tutors were required to complete two mandatory four-hour workshops developed specifically for DL as a part of the faculty development program. The body of tutors was composed of both physicians and scientists; completion of the workshops was required prior to tutoring.

The aim of this paper was to explore the attitudes, opinions and experiences of the faculty leaders and course directors responsible for making this rapid, major change in curriculum, and to consider lessons learned for future change implementation at our school. A secondary aim of the paper was to provide a scholarly account of the events of 2006–2007, which proved to be an interesting period in the history of our medical school.

Methods

The curriculum change was implemented at the start of the 2007–2008 academic year. Data were collected on tutor recruitment and retention. In early 2010, interviews were conducted with senior leadership, administrators and course directors responsible for pre-clinical education at the school. We chose to employ an inductive approach, and developed a semi-structured interview schedule which included the following introduction and open-ended questions:

In September 2007 the undergraduate medical program implemented DL. Looking back on the last few years, please tell me how you think the medical school has changed as a result of implementing this program with respect to the curriculum.

Tell me how you think the medical school has changed in terms of implementing this program with respect to:

• the assessment of students

• faculty engagement

• faculty evaluation

• organization of the undergraduate program

• program evaluation and accreditation

Interviews lasted for 30–45 minutes and were recorded and transcribed. The identity and role of each participant was kept confidential, and were not known by the analysis team. Transcripts were analysed by the authors and a research assistant using a thematic analysis approach. This involved iterative reading and identification of themes, followed by meetings to discuss the themes observed in the data. Major and minor themes were identified. All authors agreed on the final coding scheme, themes and representative quotations. Ethical approval was obtained from the local Health Research Ethics Board.

Results

The curriculum change was implemented successfully in September 2007. ‘DL’ was adopted in all courses in Years 1 and 2 of our medical school, and continues at the time of writing. In 2007, 331 faculty members had their names put forward by Department Chairs to become tutors. Of these, 163 completed both training workshops (49%) and 56 completed one (17%). The faculty members whose names were put forward totaling 112 (34%) did not attend any training workshop. In the first year of operation, 198 tutors (60%) participated in DL sessions. Some faculty members who had taught on courses before chose not to continue, and some new tutors were recruited. In 2008, 79% of tutors agreed to return and serve as a tutor again for the second year of the curriculum change.

Thirty-five individuals with roles in senior leadership, administration and course delivery were invited for the interview; 14 (40%) attended for the interview about their attitudes and opinions on the change that had taken place. The major and minor themes observed are presented below and in Table 1 with supporting representative quotations. Five main themes were noted in the data: organization and control of the curriculum, changes in the practices of teaching and learning, effects on faculty members, sources of resistance and attitudes to curriculum change in general.

Table 1  Representative participant quotations about curriculum change

RESULTS
1. Organization and control of the curriculum
Absence of central curriculum control	Our curriculum was very decentralized and coordinators at both the clerkship and pre-clinical level had pretty much a free reign. They could do whatever they want and [the curriculum committee] had very little control.
Lack of clear learning objectives	There were objectives but they weren’t truly objectives – there was a document that kind of stated a whole bunch of things that potentially listed things students could be expected to learn but there was very loose, if any, linkage between the actual instructions that were taking place and the assessment that was taking place for those documents.
Effects of increased centralized control	Students seem to be much more comfortable having gotten used to a teaching environment throughout those two years. They see evidence from day to day of a central idea or ideology behind the way that we teach. I think that makes them much more comfortable that there is somebody in charge.
Improvement in objectives	[We have] more effective objectives that are linked to instruction and assessment … having a more consistent approach with specific objectives [has] established a better foundation for the teachers and the learners.
Increased uniformity across courses	The DL program had a huge impact – it achieved a greater degree of consistency across blocks, from year one to year two.
2. Practices of teaching and learning at the school
Perceived advantages of DL	I think there's been a movement towards more application of knowledge to clinical scenarios. Not just rote regurgitation but higher order thinking skills.
Self-direction and problem solving	DL has provided a way to show the students the importance [we] put on active learning and self-directed learning.
Assessment of student performance in small groups	Can you listen in a group to someone else's take on things, are you willing to learn from a learner of your same cohort rather than always expecting to be taught from someone more senior to you? Those are things that now we have an opportunity to assess.
3. Effects of the changes on faculty members
Enjoyment	[There are] people who are enjoying their DL facilitation experience and they are wanting to come back again and again … they enjoy it and find it a worthwhile experience.
Increase in faculty numbers	The move from didactic lectures to DL has resulted in a lot more faculty in the medical school than previously … I think as a result of that, the students, and I think the faculty as well, gets a much broader idea of the people in the faculty and what their strengths and weaknesses are.
Increased awareness	I think understanding and awareness of our undergraduate curriculum has increased as a result of including all of these people in the curriculum.
Increased engagement	Previously, I think a lot of faculty didn’t really think about the medical school at all. Seeing how the medical students think and where they are at with regard to the pre-clinical years, I think it makes a difference when you come to see those same students in the third and fourth year and even as residents because you have a better idea of the process that they have been through and what level of learning you might expect from them.
More contact with students	When I started doing more DL stuff I had a better appreciation of the students’ level of knowledge, that I wasn’t aware of when I just saw them randomly in my clinic. I didn’t really know what a year one or year two student had under their belt in terms of knowledge. By doing DL, it helped me in terms of my ability to understand where the student is coming from.
Altered expectations around teaching contributions	The most obvious thing that was brought in by [the Dean] was that … you couldn’t get into the annual report without clicking the ‘yes’ or ‘no’ as to whether you had done DL. This made it very obvious that it was a major expectation of the faculty.
4. Resistance to change
The extent of resistance	Initially, there was a large amount of push back and actually resentment on the part of faculty.
‘They had been volunteered’	There were a lot of Chairs who designated faculty to participate that were not necessarily interested. They had been volunteered and were essentially told that they would participate and this produced a lot of negative feelings on the side of faculty. I know when I participated in faculty development workshops that feeling was certainly present.
Lack of ‘buy-in’	It's led to some negative reaction on the part of the faculty. Although they are engaged in the process, they may not be engaged in believing in the process. They don’t feel that this is necessarily the best way to deliver their curriculum and they also do not like the idea that they are out of their own specialty area. They would rather be an instructor than a facilitator. The feedback that they have had from some students, is that the students also would like them to be content experts. So although they may participate, a lot of them don’t believe in the process.
Tutor training as a specific source of resistance	Many people were offended that they were being asked to participate in training seminars. Once DL came into place, they were effectively told: ‘you need to go through all of this training’ which many of them took as a slight. [They said] ‘If I need to be trained how to teach after 20 years, then you are basically telling me that for the last 20 years, I haven’t been doing anything correct’.
Countering resistance	Whenever you introduce something new I think it's normal to expect a little bit of resistance. It was maybe a kind of testing ground for the leadership and the organizational kind of structure of our faculty to prove itself and say ‘They look this is something we think is important. We’re going to establish a subcommittee to put this together to kind of make it happen.’
Downgrading of other teaching	DL is given special status amongst the activities that we do. People who don’t participate in it are getting the message that their other activities are less important. [People who will not do DL] have been effectively marginalized because they now can’t do any kind of organized undergraduate teaching that's evaluated.
5. Attitudes to curriculum change in general.
Changing to satisfy the accreditors	The whole shift towards DL was driven not by educational principles internal to the organization – it was all external. DL was implemented so that we could say we were doing it – so that we could show the accreditors that it was happening. But I don’t think that there was really anybody who truly was of the belief that that was the best for educational learning objectives. You kind of were jumping through the hoops because you were told to do it.
Forced into change	It was only crash-instituted because we were put on probation. Despite there being prior accreditations saying we need to have more self-learning, it wasn’t instituted by the faculty. The accreditation procedure forced the faculty into this faster than they might have done it.
A positive effect	Maybe it was a classic example of ‘you don’t know what you don’t know’. The accreditors were right – you have to swallow your pride and say ‘they were right and we were wrong’, and it's a good thing that we switched.
Change bringing insight	We have a long ways to go, but at least we have some insight into how we understand where we are weak.
Change bringing improvement	When we had a repeat visit in 2008, [active learning] was no longer even an issue for the accreditors – they saw the significant improvement that we had undertaken.
Change bringing people together	There's an understanding that undergraduate teaching is an important part of the role of the professorship here. By involving large numbers of people with students whose names they get to know, whose face they recognize, they run into them in the hallways. What you’ve done is you’ve vastly increased the visibility of undergraduate education to the faculty as a whole. You can no longer be forgotten and I think it enriches the life of the faculty, makes them excited about the enthusiasm of the students that they encounter.
Change at speed	I think it's been a really hard transition to DL because it was done so quickly. People were forced into participating, both on the side of the students and the faculty. There were some facilitators who didn’t really get the tutor support they needed. There are some tutors who I think fell through the cracks and as a result of that won’t be back.
Dramatic change	Our response had to be dramatic – it had to be a big change to get any change to happen at all. It had to be done in the sense of the price, and a big change had to happen. If we had tried to do it in a step-wise fashion, I think we would have got nowhere.
Constant change	We should never think of any curricular initiative as being perfect or a one-time thing. Going forward on a more regular basis [we will have] more review of course materials, examinations, faculty development and DL cases. I think that is very important. I don’t think you can wait for an accreditation to come around before you recognize what the issues, the problems with the components.
Plans for future changes	I suspect that ‘pure DL’ may not be as prominent a part of our curriculum three years from now as it is. I think we will look for other ways to do small group learning and small group teaching. I think there are other things that [we should] look to explore. [There are] a lot of things we could be doing differently … but that will take time.

In the first major theme, participants discussed ‘organization and control of the curriculum’. Participants commented on status of the curriculum prior to 2006, and identified several problematic areas: an absence of central control of the curriculum resulting in variability between courses, inconsistent teacher preparation for small-group learning and a lack of clear learning objectives. Participants acknowledged they had been aware of these issues for some time, but that prior to the accreditation visit there was no perceived need for change:

[Before the accreditation visit] I think many people felt that just because our exam results were good at the [national licensing examination] that things were going well.

Participants described the failure of previous efforts to implement central control of the curriculum:

There had been several documents presented to the curriculum committee about more organized, central program evaluation that had not been implemented.

Participants described the curriculum changes implemented as successful at increasing centralized control of the curriculum, at reducing variability between the teaching in different courses and at improving the objectives used in each course. Course organizers described the impact of having an increased awareness of the activities occurring in other courses:

I try to figure out what's being done in other blocks and refer back to other things that I have done before and build on it. Definitely you have to think more carefully about each topic and what the best way to teach it is.

The second major theme related to changes in participants had observed in the ‘practices of teaching and learning at the school’. Successful implementation of the curriculum change was noted to have led to a reduction in the hours devoted to didactic lectures, and an increase in the time available for self-directed study. Participants also described the perceived advantages of DL, in terms of increased problem-solving and self-direction, and the observation of student performance in small groups.

Instead of asking them to find a term, we’re posing clinical problems that students can be allowed on their own to come to the right conclusion, using different methods. That's a reflection of the more student-centered and free approach that you get from DL.

In the third major theme, participants discussed the ‘effects of the changes on faculty members’. Participants described about themselves and also of others’ enjoyment of participation in DL:

[There are] people who are enjoying their DL facilitation experience and they are wanting to come back again and again … they enjoy it and find it a worthwhile experience.

Participants described an increased number of faculty members who had become more involved in teaching through DL, increased awareness of undergraduate education, and increased engagement and interaction between faculty and students:

I think that the faculty members have a much better idea of what's involved in undergraduate medical education.

[DL isn’t the same as] just having a lecture and never having any follow up. It's much more fun and they’re not just faceless people out there in the lecture hall. I like the interactive part of it, it's more interesting for the faculty.

Participants also described a clear change in the Dean's expectations relating to teaching, with required reporting by each faculty member on the annual academic report whether or not he/she was participating in DL.

The fourth major theme identified related to ‘resistance to change’. Participants described the initial widespread resistance to change among faculty and course directors. Some students also resisted the curriculum change:

This change to DL was not well embraced by the students. It was as much imposed upon them as it was on faculty members and students in some cases resented this. They had had a lecture based curriculum and were expecting a lecture based curriculum.

There were accounts of colleagues who did not ‘buy-in’ to the change and of others who had been ‘volunteered’ for tutor-training against their will. Some faculty members also described faculty members’ discomfort with being required to adopt a new teaching method:

It's led to some negative reaction on the part of the faculty. Although they are engaged in the process, they may not be engaged in believing in the process. They don’t feel that this is necessarily the best way to deliver their curriculum and they also do not like the idea that they are out of their own specialty area. They would rather be an instructor than a facilitator. The feedback that they have had from some students is that the students also would like them to be content experts.

There were accounts of faculty members who did not engage due to the lack of interest in teaching, scheduling conflicts or other commitments. Participants described the need for tutor training as a specific source of resistance. Some faculty members thought that standardization of teaching was inappropriate, or did not see the need to re-train; some members perceived the requirement for re-training as a personal insult. Some faculty members felt that the adoption of DL had denigrated and under-valued other contributions to teaching.

The ways that the leaders in charge of the change dealt with such resistance was described. In some cases, resistance was overcome by those in the authority ‘pushing it through’:

[The curriculum committee] supported that and pushed it through and made it happen and dealt with resistance. It was a program that [the curriculum committee] used as a way to show that it was in control of the curriculum.

Other accounts described dealing with resistance by addressing faculty members’ fears and concerns:

We’ve tried to downplay that a little bit and to let them know that it's not about your ability to be a good teacher but because the process is different. It's no different than acquiring any other new skill. Some of the anger has died down a little bit, although at the beginning there was quite a backlash.

The final theme identified was ‘attitudes to curriculum change in general’. Some participants expressed the opinion that the curriculum change had been implemented mainly to satisfy the external forces of accreditation, and questioned the perceived need for change. Other stated that some of the changes made would have happened eventually, but that the accreditation visit had simply speeded up the process. There were accounts of individual faculty members who may have been adversely affected because of the speed and extent of the curriculum change.

I know in my own course there were a couple of tutors that I wish I could have provided more support to but I couldn’t provide that support and when I asked for it, it wasn’t available and that was too bad. It's not right to let certain members who are faculty sink, just because we are trying to hold the rest of the ship up.

Many participants reflected more positively on the curriculum change which took place. There was agreement that the deficits identified in the accreditation report were real, and that the ‘wake up call’ provided by LCME/CACMS was timely:

I’d say the “accreditation wake up” was certainly good for the U of A.

Some expressed the view that making ‘big changes quickly’ had been essential to success in the context of this school, and that less dramatic change would not have been effective. The process of change was described as ‘painful’ and ‘horrible’, but eventually worthwhile:

At the end of the day, I think the program is better for this horrible accreditation process. Now that most of the pain is through, all of the blocks have been looked at by a curriculum committee, I think the organization structure is better now and it's more uniform – that's probably the most important thing I can think can come out of all this.

Participants also described how the change process had brought faculty members and students together and increased the value and importance of undergraduate education at the school. The change was described as successful in addressing many, but not all, of the perceived problems in undergraduate education:

I think accreditation has moved us forward but we are not all the way there.

Participants described the need for ongoing vigilance, and for the adoption of continuing cycle of curriculum review and renewal. Many participants described their hope for further change, and discussed plans for ‘the next big curriculum change’:

I think one of the greatest gifts we were given by the previous Dean … [was] to make further changes in the curriculum. Different students need different ways to be engaged and this is just one of many ways to be engaged. Now that the changes have happened, I think we can move ahead and have refinements to the whole process. I think there is an opportunity to grow with it and to use it in different avenues and different ways.

Discussion

This paper demonstrates that, under the right circumstances, major curriculum change can be successfully achieved in a short period of time. The study also illustrates some of the factors that affect rapid change, and highlights the importance of attitudes to change among the leadership of a medical school.

We observed a number of factors affecting change, which have been previously noted in the literature, and there was also evidence of several of Kotter's eight steps of change management (Kotter 1996). We had a clear rationale for a change based on educational goals (Guze 1995), and there was an obvious impetus for urgent change (#1) (Cohen et al. 1994). The Dean took ownership for managing the ‘curriculum crisis’, providing strong leadership and the resources required (Watson et al. 1998). Together with the Dean, those in charge of the curriculum formed a powerful coalition (#2) and created a clear vision for change (#3) (Watson et al. 1998). This vision was communicated to all Departments and all Chairs (#4), who gave their explicit support (Guze 1995; Skochelak et al. 2001). The urgent nature of the crisis allowed faculty members to agree on the goals of change and to participate in the change required (Guze 1995; Genn 2001). The culture of the school is likely to have been an important factor (Cohen et al. 1994). The scope of the change was defined (Bland et al. 2000a), and obstacles were removed (#5): faculty development was provided to train the teachers for their new roles as tutors (Mennin & Krackov 1998). All departments were required to provide their share of members for training (Skochelak et al. 2001), and communication with faculty was frequent (Dannefer et al. 1998). The change was implemented according to a clear timeline, and the results of change were evaluated in studies such as this one (Dannefer et al. 1998; Loeser et al. 2007).

The speed at which the changes were made did not appear to be a major factor for participants; we hypothesize this was because the sense of urgency surrounding the ‘accreditation crisis’ was perceived as requiring a rapid response. While it is likely that some faculty members were ‘left behind’ by the pace of change, participants expressed the belief that a slower change would not have succeeded in the context of our school. It appears that a third of faculty members did not accept the need for rapid change: 34% of faculty members ‘volunteered’ by their Department Chair never became a tutor. Moving more slowly may have garnered support of more faculty members, but in the end we gained the support that was needed to make the changes which were required.

Our findings on the topic of resistance to change are in keeping with those observed in other studies. As predicted by the literature, the changes which took place in our curriculum caused repercussions at many levels (Bernier et al. 2000). Faculty members described concerns about a loss of control and recognition of their own teaching. We observed skepticism about the need for change, and some defence of existing educational practices, although there was little evidence of ‘turf protection’ (Lane 2007). We hypothesize this was because pre-clinical education was not perceived as belonging to any one Department in particular, and because all Departments were required to contribute equally to the tutor training. During the process of change, we appear to have been successful in communicating and building relationships with the faculty, and in providing them with the skills needed for them to change the way they teach; these factors have been identified as being of critical importance and are demonstrated by the high rates of workshop participation, course participation and retention of tutors (Rollins et al. 1999; Christianson et al. 2007).

We hypothesize that the ultimate source of resistance to the changes which took place was an unresolved disagreement in our faculty about the real reason that change was required. Some maintained that change was required to address actual problems in our curriculum, while others maintained it was driven purely by external unreasonable forces of accreditation. While the majority of participants in this study held that change was a good thing and that changing courses and training tutors would improve our teaching, some believed that changing the curriculum was at best unnecessary, and at worst harmful to students and insulting to the faculty. Ultimately, both sides appear to have agreed that regardless of the reason, change had to take place if the school was to survive. The persistence of these differing curricular perspectives may have implications for future attempts at change, especially in the absence of a future accreditation crisis.

This study is limited by the highly specific context in which it was carried out: our school's response to an accreditation crisis in 2006–2007. Also, data were included only from the 40% of the school's leaders who agreed to be interviewed. In addition, we did not consider whether our response to accreditation had any effect on student learning. Accreditation is now a routine part of the life of medical school, and responding to an adverse report is an increasingly common experience for school leaders. We encourage other medical schools to examine our findings about curriculum change and resistance, and consider their applicability in their own context.

Our school regained its accreditation status in 2010. Looking back from 2012, what reasons for success can we identify that might be useful to others in a similar position?

• It seems that we were probably ‘a school overdue for change’; the accreditation report of 2006 gave us the push we needed to make the change happen.

• The LCME/CACMS report provided us with ‘a clear problem to address’, and our Dean gave us ‘clear mandate and agenda for change’; these factors allowed the faculty a rare opportunity to pull in the same direction.

• Decisions were taken rapidly, and ‘a bold course of action’ was chosen.

• The extent of the change planned was large, but course directors were provided with ‘support’ to change their teaching materials and teachers were provided with ‘training’ in new techniques.

• ‘Resistance’ was acknowledged and addressed.

• The change resulted in ‘a clear, visible change’ in the way we teach. The curriculum became more organized and consistent, and there were apparent benefits in teaching and assessment, with increased ‘engagement’ of a larger number of faculty members, and more ‘connection’ between faculty and students.

• The process also resulted in ‘an enhanced recognition of the role of education’ within our faculty: education is now ‘important to us’ as a faculty in a way that it was not before.

Although many effects of the LCME/CACMS report of 2006 were indeed ‘painful’, we agree with others that accreditation is necessary to provide continuous improvement and to drive innovation in education (Kassebaum et al. 1998; Simon & Aschenbrener 2005).

In the aftermath of major change, it is tempting to relax and slip back into old habits. Now that our accreditation status has been regained, the spotlight has moved away and our faculty's focus has turned to other matters. However, many of the leaders interviewed in this study described an attitude open to ongoing curriculum review, and a readiness for future change which does not appear to have been widely present prior to 2006. It remains to be seen if we can achieve the final steps of Kotter's model of change management: ‘Build on the Change’ and ‘Anchor the Changes in Corporate Culture’ (Kotter 1996). We believe that curriculum change should not be a ‘one-off’ and that ongoing monitoring, evaluation and re-adjustment of the curriculum is essential to the continued success of our medical school (Watson et al. 1998; Ryder et al. 2008).

Conclusions

We believe that ‘Discovery Learning’ was well-named: in addition to changing our practices of teaching and learning, DL allowed us to ‘discover’ much about ourselves as a school, and to see that we were in fact capable of changing. The process of curriculum change revealed much about the attitudes and beliefs by which we shape our curriculum. Having experienced major rapid curricular change, we hope that future changes in our school will be achieved through adopting a culture of innovation and change, and a cycle of ongoing curricular review and renewal.

Acknowledgments

The authors wish to acknowledge the support of the Teaching and Learning Enhancement Fund of the University of Alberta, and also the assistance of the late Dr David Cook and Ms Joanna Czupryn with study design and data collection.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.