A Rapid-Response Curricular Approach to Teaching Politically Charged Topics

Medical residency training programs must prepare residents to navigate the complexities of laws and proceedings that impede evidence-based health care. There are limited medical education resources that offer guidelines for designing and implementing curricula that broach potentially polarizing topics introduced through legislative changes.¹  To prepare residents to provide quality care in a dynamic political and legal environment, educators must be able to rapidly develop and continually adapt curricula.

Recent restrictions on reproductive and gender-affirming health care (R/GAHC) create challenges for medical education in the US residency programs in states with restrictive laws, where residents face difficulties in providing comprehensive training due to limitations on R/GAHC services. In less-restrictive states, residency programs must adapt to changing regulations to ensure their curricula remain relevant and comprehensive. Without concerted support from residency programs, there is a growing concern that fewer clinicians will be adequately trained in abortion-related and gender-affirming care. This concern is underscored by a 2022-2023 decline in obstetrics and gynecology (OB/GYN) residency applications in states with abortion bans, and other primary care residency programs may also be similarly affected.^2,3  The educational challenge lies in tailoring residency curricula to meet the evolving socio-political climate and policy changes, ensuring that future clinicians are prepared to provide evidence-based, equitable care.

We aim to demonstrate the results of a 6-step curriculum development process conducted in 2022 and applied in a constrained timeframe. We discuss the curriculum’s feasibility and acceptability by stakeholders, including preliminary learning outcomes achieved by trainees.

We used Kern’s 6-step approach for curriculum design⁴  to incorporate new content into an existing women and gender health (WGH) curriculum (Table 1). Though these steps are presented sequentially, in practice they require an iterative approach.⁴  Due to the urgency of our curriculum revision, the first 3 steps were consolidated. Fortunately, a WGH curriculum retreat earlier in the year anticipated potential legal changes affecting R/GAHC, laying the groundwork for rapid curriculum revision once the changes actually occurred.

The revised curriculum was planned and implemented in the Department of Internal Medicine (DIM) at a large, Northeast US academic medical center. Curriculum planning occurred between July and September 2022, and the revised curriculum was implemented from September to December 2022. The curriculum was designed for the 175 internal medicine (IM) residents in 3 DIM training programs (traditional, primary care, and medicine/pediatrics). The module was taught by 9 WGH curriculum faculty from IM, OB/GYN, and surgery, in consultation with a reproductive health law expert. Presented as an academic half-day, the same module was offered 8 times to small groups of residents. Minor modifications, such as adjusting the content within sessions, were made during implementation. Details about methods used to conduct the 6-step curriculum development and implementation process are explained in Table 1 and the online supplementary data. Methods for evaluating the curriculum are explained below, supplemented by Table 1.

Evaluation methods illustrated a rapid approach to evaluating the curriculum in the short 5-month planning and implementation timeframe.

Feasibility was assessed in several ways. To determine whether it was feasible for the curriculum to produce desired learning outcomes, we tailored an existing evaluation form using 5-point, Likert-scale items to measure residents’ self-assessment of readiness to apply R/GAHC knowledge and essential tasks (online supplementary data). Data were analyzed by a statistically trained investigator (K.A.G.) using descriptive statistics. Feasibility was also assessed by documenting faculty time involved with planning and implementation, and costs for administering the curriculum. Faculty person time was determined by multiplying time allotted by the number of faculty members attending each planning and training session.

Acceptability was assessed by using the same evaluation form as above to gather resident responses to 2 open-ended questions about the module’s effectiveness and needed improvements. Qualitative data were analyzed by the first author (J.B.H.) for themes, which were then reviewed for consensus, accuracy, and evaluator bias by other investigators (L.V., C.F.M., J.E.). For both the quantitative and qualitative portions of the resident evaluation, anonymous responses were collected online via Qualtrics (Qualtrics). This portion of the evaluation received an exemption from full review by the university’s institutional review board. Faculty and administrative acceptability were also assessed (Table 1).

The first 5 of the 6 steps in the curriculum development process produced distinct results that are described in Table 1. Curriculum evaluation results are presented below.

Of 175 eligible residents, 164 (94%) attended the module (some were excused due to extenuating and logistical circumstances). Of those who attended, 121 of 164 (74%) completed the post-module survey. The majority of residents agreed they felt equipped with the knowledge and skills required to deliver vital aspects of R/GAHC. For example, they agreed they could describe the steps of gender-affirming therapy (115 of 121, 95%), recommend contraception (114 of 121, 94%), and describe the steps of medication abortion (112 of 121, 93%) (Figure 1).

Considering faculty time dedicated to planning and implementation, we estimated a total of 55 person hours for planning, and 152 person hours for delivering the curriculum 8 times, for an estimated total of 207 person hours. Though future implementation of the module after this inaugural year should take less planning time, 152 person hours will likely continue to be needed if 8 repetitions of the module per year are maintained.

The WGH curriculum did not underwrite faculty salaries for service provided. Since faculty came from 3 academic departments, each was required to negotiate teaching time with their respective departments. In most cases, this entailed integrating time dedicated to the WGH curriculum with other departmental teaching responsibilities. Beyond administrative support for the WGH curriculum director (J.B.H.), the only other cost was less than $200 for information-technology support. Therefore, while investment of faculty resources was considerable, additional costs were minimal.

Acceptability results indicated support from all stakeholders. Faculty meeting and training session attendance showed that all 9 faculty remained engaged from planning through the final half-day session, and all committed to continue teaching in the module after the inaugural year. Department administrative support remained constant throughout with intent to continue the curriculum.

Residents valued the curriculum’s timeliness, diversity, practical applications, and interactive formats. Recommendations for improvement included shorter sessions or more breaks during sessions, and more detail on legal topics.

The curriculum module was effective in preparing residents to provide R/GAHC in light of legal changes. Residents provided positive feedback, suggesting only minor logistical and content adjustments. Faculty engagement was strong throughout, with ongoing administrative support.

The 6-step approach proved valuable for organizing and implementing the curriculum; consolidating the initial steps in a shorter timeframe was beneficial. The module was delivered as planned, with full faculty participation and most residents attending; those who did not had valid personal or career-related exemptions. Key to implementation was the module’s integration into an existing interdisciplinary WGH curriculum with established resources and knowledgeable faculty, factors that minimized costs. The flexibility of this curricular approach will allow us to respond quickly to ongoing legal challenges to R/GAHC and can be adapted by other institutions. A main barrier to implementation may be constraints on teaching curriculum content by state-specific political climate and laws.

Resident feedback indicated their acceptance of the curriculum and self-reported readiness to implement aspects of training; however, we do not have outcome data on post-curriculum resident behavior and patient outcomes, measures we are incorporating into current ongoing R/GAHC modules.

Based on our experience, we recommend the following:

• Conduct an organizational capacity assessment before curriculum revision. We were fortunate to have faculty and administrative commitment, but such crucial engagement is not always guaranteed and needed faculty time may be substantial.

• Remain flexible with Kern’s 6-step model; eg, revisiting literature and adjusting learning objectives iteratively.

• Develop an evaluation strategy concurrently with curriculum content to ensure essential data collection. Also, though the most robust outcome assessment may not be possible in the pilot stages, determine to build in robustness once the curriculum proves viable, a step we are now taking.

We demonstrated a generalizable approach for expeditiously tailoring curricula to prepare residents to navigate changing laws affecting health care provision.

The online supplementary data contains the curriculum development discussion guide and the survey used in the study.

Funding: The authors report no external funding source for this study.

Conflict of interest: The authors declare they have no competing interests.

Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US Government.

A poster describing the curriculum module reported in the manuscript was presented at the Society of General Internal Medicine Annual National Meeting, May 13, 2023, Aurora Colorado, USA, and Medical Education Day at Yale, May 31-June 7, 2023, New Haven, Connecticut, USA.