policy analysis in medical education: a structured approach

Musick DW. Policy analysis in medical education:A structured approach.Med Educ Online [serial online] 1998;3,2. Availablefrom URL http://www.utmb.edu/meo/SynthesisRepresentative of the field of educationalpolicy analysis as a distinct discipline is thework of Carol Weiss. 21,22 According to Weiss,much of what passes for policy analysis and discourseis adapted from the social sciences. Conceptsfrom the social sciences, such as professionalnorms, organizational culture, social networking,and bureaucratic/political structures,are “borrowed” and applied to other (e.g. educational)realms. This, in turn, helps to disguisethe fact that: “much of what policy makers knowcomes from disparate, unorganized and inchoateexperience…social science concepts give formto this tacit knowledge and enable policy makersto manipulate and use it”.Weiss further states that policy is the productof interplay among four essential components,the “four ‘I’s” of policy analysis: institution,information, ideology, and interests. To elaborate,policy decisions are made within giveneducational institutions. The process of policyformation and implementation results from acombination of rational information-processing,ideologies of various kinds, and the interests ofself and/or others who may be affected by thepolicies. Weiss’ approach is useful in understandingcontextual factors which affect policydevelopment, but does not provide an overallframework for policy analysis.Short 24 has described an approach to policyanalysis in education which is research-oriented.He outlines ten methods of inquiry currently inuse within the field of curriculum studies, anddescribes their use in analyzing educational researchand evaluation. These ten methods are:philosophical, historical, scientific, artistic,moral, religious, interpretive, instrumental, deliberativeand action-oriented. These distinctionsare useful in terms of helping medical educatorsunderstand the various aspects of policyanalysis and how they might relate to medicaleducation policy.Humes 4 examines key questions used by educationaldecision-makers in order to understandall aspects of the policy analysis and developmentprocess. Key questions are: 1) By whatprocesses do new educational policies begin tobe formed?; 2) How are these processes influencedby ideological, political, economic, andcultural concerns?; 3) Who has the most influencein the formation of new educational policies(i.e., politicians, bureaucrats, or teaching professionalswithin education)?; 4) Where does theresponsibility lie for the success or failure ofnew educational policies (i.e., with policy makers,managers or teachers)? This author alsostresses the importance of involving parties fromboth “inside” and “outside” the formal educationalgoverning body in analyzing new educationalpolicy.Reid 23 advocates a structured approach toeducational policy analysis which is geared towardcurricular issues. He states that five crucialareas must be considered in developing educational/curricularpolicies: teachers, learners, the“educational milieu” (or environment), subjectmatter, and “curriculum-making” (i.e., educationaldecision-making processes). He lamentsthe “intrusion of interests outside the professionalworld of education” into educational policydevelopment, stating that such intrusion hasled to “approaches [which] stress top-down controland short-term goals” rather than sound educationalpolicies.Based on this review, what seems missingfrom the medical education literature is a rigorousmethodological approach to policy analysiswhich can be used within the unique context ofmedical education. In short, a “tool” is neededwhich can be used by decision-makers in medicalschools to assist them in the process of policyanalysis. Such a tool does not appear to exist atpresent.A Specific ExampleA policy issue which has been addressedwithin the field of medical education in recentyears demonstrates the need for an analytic approachto policy analysis. Debate has been evidencedon issues related to governance structureswithin medical schools. 24,25 What is often aprimary feature of such debate appears to involvea clash between two diverse views of authority,namely, professional authority and administrativeauthority. As stated by Etzioni 26 ,“the most basic principle of administrativeauthority and the most basic principle of authoritybased on knowledge (or professional authority)not only are not identical but are quite incompatible…theultimate justification for a professionalact is that it is, to the best of the professional’sknowledge, the right act. He might3

Musick DW. Policy analysis in medical education:A structured approach.Med Educ Online [serial online] 1998;3,2. Availablefrom URL http://www.utmb.edu/meo/sions? Is there a potential or actual conflictof interest?I. Historical: Does the proposed policy have ahistory within the institution? Have previousattempts been made to address the policyissue under consideration? If so, whatwas the result? What can be learned fromthese previous attempts?J. Assumptive: Are there key assumptions beingmade by the various parties involved inor affected by the policy issue? What arethe assumptions made by those on bothsides of the issue? Have these assumptionsbeen made explicit? Are these assumptionsknown and understood by all policy decision-makers?K. Legal: What legalities or legal precedentsmay be involved in or have an effect on theproposed policy? What key legislationand/or other legal requirements are likely tohave an impact on policy development?L. Logical: Are statements made in the policylogically sound? Do they avoid illogical orfaulty inferences? Can they withstand rigorousscrutiny by a “neutral” party?It is not assumed that each of the twelvecomponents of policy analysis would be of equalvalue to a given policy discussion. However, itis suggested that an examination of all twelvecomponents be considered essential to the processof developing sound educational policy.The Use of A Structured Approach to PolicyAnalysisAs an example of how to use this policyanalysis tool in a medical education context,consider a familiar issue related to the curriculumof a medical school: medical ethics education.While public interest in ethical issueswithin medicine and biomedical research seemsto be exploding, it is apparent that the time givento this subject in most medical schools has onlyrecently increased. 29 As a hypothetical policyanalysis “case”, suppose the Curriculum Committeeat the “XYZ Medical School” is presentedwith a petition signed by one-third of theschool’s students wherein a request is made toincrease the amount of medical ethics educationwithin the curriculum, including a recommendationthat a separate, identifiable course called“Medical Ethics” be offered. This request representsan opinion that decision-makers at “XYZMedical School” should reexamine and perhapschange an existing educational policy. How orby what process should members of the Committeego about considering this issue?Among the steps the Curriculum Committeeshould take, the use of the twelve policy analysisingredients as discussed previously should beincorporated into a formal process of policyanalysis and educational decision-making. So,for example, the Committee would need to ensurethat the following general types of informationwere available before a final decision ismade on whether to increase the amount of curricularcontent in medical ethics:A. Conceptual: what are the “core concepts”which should be included in an ethics educationcurriculum for medical students?What educational outcomes would be measuredto ensure that students learned theseconcepts?B. Normative: is “medical ethics” somethingthat ought to be included in the curriculum?At least some of the medical students feelstrongly that it should be; do other constituentgroups (e.g., faculty, administration, patients,former students/residents) concur?What about accreditation standards; do theyaddress the issue of ethics education? If so,how?C. Theoretical: if a core curriculum in ethics isto be adopted, within what theoretical and/ordisciplinary framework would this materialfit? By what educational process(es) shouldthe material be taught to medical students?Will such teaching require a separate course,as the students suggest, or can the materialbe integrated into existing courses?D. Empirical: what does the medical educationliterature reveal on this issue? Are therestudies which show the value of includingethics education in the medical school curriculum?What has been the experience ofother medical schools who have introducedan ethics component into the curriculum?Are the “facts” cited in support of or in oppositionto ethics education based on soundresearch?5

Musick DW. Policy analysis in medical education:A structured approach.Med Educ Online [serial online] 1998;3,2. Availablefrom URL http://www.utmb.edu/meo/By considering policy analysis and developmentas a formal activity, using a systematicframework which takes into account the twelveingredients of successful policy analysis, educationaldecision-makers will craft more informedpolicy decisions. It is then necessary to carry outthose well-crafted policies, or (as stated above)“to get it done”.Note: The author wishes to express appreciationto Professor Richard LaBrecque, Universityof Kentucky College of Education, for his creativeguidance and stimulating instruction in regardto the various approaches to educationalpolicy analysis.8

Musick DW. Policy analysis in medical education:A structured approach.Med Educ Online [serial online] 1998;3,2. Availablefrom URL http://www.utmb.edu/meo/References11. Harden, R.M.; Sowden, S.; Dunn, W.R.“Educational Strategies in Curriculum Development:The SPICES Model”, Medical1. American Educational Research Association(AERA). URLEducation 1984; 18: 284-97.http://www.aera.net/divisions/L/page2.html(1998). 12. Sheets, K.J.; Anderson, W.A.; Alguire,2. Cheek, J. and Gibson, T. “Policy Matters:Critical Policy Analysis and Nursing”,Journal of Advanced Nursing 1997; 25:668-72.3. Wildavsky, A. “The Once and FutureSchool of Public Policy”, Public Policy International1985; 79: 25-41.P.C. “Curriculum Development andEvaluation in Medical Education”, Journalof General Internal Medicine 1992 September-October;7 (5): 538-43.13. Stumpf, S.H. “Helping Faculty VisualizeOutcomes of a Five Year CurriculumEvaluation”, Evaluation & the Health Professions1994 September; 17 (3): 358-65.4. Humes, W.M. “Analyzing the Policy Process”,Scottish Educational Review 1997May; 29 (1): 20-29.5. Ryder, David. “The Analysis of Policy:Understanding the Process of Policy Development”,Addiction 1996 September; 91(9): 1265-70.6. Bozeman, B. and Landsbergen, D. “Truthand Credibility in Sincere Policy Analysis”,Evaluation Review 1989 August; 13(4): 355-79.7. Blumberg, P.; Deveau, E.J.; Ryan, N.C.“How to Determine the Extent to Which aProgram Achieves Its Goals: A MethodologicalConsideration”, Professions EducationReview Quarterly 1994-1995 December-January;16 (2): 2-5.8. Coles, C.R. and Grant, J.G. “CurriculumEvaluation in Medical and Health CareEducation”, Medical Education 1985; 19:405-22.9. Craig, P. and Bandaranayake, R. “Experienceswith a Method for Obtaining Feedbackon a Medical Curriculum UndergoingChange”, Medical Education 1993 January;1: 15-21.10. Friedman, C.P.; de Bliek, R.; Greer, D.S.;Mennin, S.P.; Norman, G.R.; Sheps, C.G.;Swanson, D.B.; Woodward, C.A. “Chartingthe Winds of Change: Evaluating InnovativeMedical Curricula”, AcademicMedicine 1990 January; 65 (1): 8-14.14. Harris, I.B. “Perspectives for CurriculumRenewal in Medical Education”, AcademicMedicine 1993 June; 68 (6): 484-6.15. Abrahamson, S. “When Is a School Not aSchool?”, Academic Medicine 1990 January;71 (1): 13-14.16. LaDuca, A. and Engel, J.D. “On the Neglectof Professions Theory in ProfessionsEducation”, Professions Education ResearchQuarterly 1994; 15 (4): 8-11.17. Tosteson, D.C. “New Pathways in GeneralMedical Education”, New England Journalof Medicine 1990 January 25; 322 (4):234-8.18. Clancy, T.E.; Fiks, A.G.; Gelfand, J.M.;Grayzel, D.S.; Marci, C.D.; McDonough,C.G.; Peppercorn, J.M.; Roberts, T.G.;Smith, A.L.; Winickoff, J.P. “A Call forHealth Policy Education in the MedicalSchool Curriculum”, Journal of the AmericanMedical Association 1995 October;274 (13): 1084-5.19. Parmet, W.E. and Enrich, P. “Health andEducation: A Tale of Two Crises”, Journalof Law, Medicine and Ethics 1994 Spring;22 (1): 53-62.20. Starr, P. The Social Transformation ofAmerican Medicine. New York: Harper-Collins Publishers, 1982.21. Weiss, C.H. “The Four ‘I’s of School Reform:How Interests, Ideology, Informationand Institution Affect Teachers and9

Musick DW. Policy analysis in medical education:A structured approach.Med Educ Online [serial online] 1998;3,2. Availablefrom URL http://www.utmb.edu/meo/Principals”, Harvard Educational Review1995 Winter; 65 (4): 571-92.22. Weiss, C.H. “Ideology, Interests and Information:The Basis of Policy Positions”.In Callahan, D. (ed), Ethics, The SocialSciences and Policy Analysis. New York.Plenum Press, 1983: 213-45.23. Reid, W.A. “The Institutional Context ofCurriculum Deliberation”, Journal of Curriculumand Supervision 1988 Fall; 4 (1):3-16.24. Short, E.C. Ten Inquiry Methods Used inCurriculum Studies. Paper presented at thePennsylvania State University Seminar onCurriculum Research, University Park, PA.1990 May 27: 1-53.25. Hendricson, W.D.; Payer, A.F.; Rogers,L.P.; Markus, J.F. “The Medical SchoolCurriculum Committee Revisited”, AcademicMedicine 1993 March; 68 (3): 183-9.26. Etzioni, A. “Administrative and ProfessionalAuthority”. In Peterson, M.W. (ed),Administration and Governance in HigherEducation. Needham Heights, MA. Simonand Schuster Co., 1991: 441-8.Academic Medicine 1994 October (Supp);69 (10): S95-S101.32. Baldridge, J.V.; Curtis, D.V.; Ecker, G.P.;Riley, G.L. “Alternative Models of Governancein Higher Education”. In Peterson,M.W. (ed), Organization and Governancein Higher Education. Needham Heights,MA.: Simon and Schuster Co., 1991: 30-45.33. Powell, R.D. “Disseminated IntracurricularFragmentation”, Pharos of AlphaOmega Alpha 1984 Winter; 47 (1): 35-36.34. Reynolds, C.F.; Adler, S.; Kanter, S.L.;Horn, J.P.; Harvey, J.; Bernier, G.M. “TheUndergraduate Medical Curriculum: Centralizedvs. Departmentalized”, AcademicMedicine 1995 August; 70 (8): 671-5.35. Brunsson, N. The Irrational Organization.New York: John Wiley Publishing, 1985.Dr. Musick, is an Assistant Professor and InterimAdministrator for the Department ofPhysical Medicine & Rehabilitation and an AssistantProfessor in the Department of Anesthesiology,University of Kentucky College of Medicine.He can be reached via e-mail atdwmusi00@pop.uky.edu27. Their, S.O. “Academic Medicine’sChoices in an Era of Reform”, AcademicMedicine 1994 March; 69 (3): 185-9.28. Elam, C.L.; Wilson, H.D.; Wilson, E.A.;Schwartz, R. “Physicians for the 21st Century:Implications for Medical Practice,Undergraduate Preparation and MedicalEducation”, Kentucky Medical AssociationJournal 1995 June; 93: 247-49.29. Miles, S.A.; Lane, L.W.; Bickel, J.;Walker, R.M.; Cassel, C.K. “Medical EthicsEducation: Coming of Age”, AcademicMedicine 1989 December; 64 (12): 705-14.30. Huppatz, C. “The Essential Role of theStudent in Curriculum Planning”, MedicalEducation 1996 January; 30 (1): 9-13.31. Lomas, J. “Medicine in Context: A NeglectedPerspective in Medical Education”,10

Musick DW. Policy analysis in medical education:A structured approach.Med Educ Online [serial online] 1998;3,2. Availablefrom URL http://www.utmb.edu/meo/Table 1Prominent Policy Issues in Medical EducationNumber ofCitations Author(s) Year Topic3 Ayanian et al 1994 Reform of graduate medical educationIglehart 1994Krol 19942 Kendall 1995 Health care for veteransFisher & Welch 19953 Cohen et al 1994 Educational innovation in medical school curriculaBernstein et al 1994Friedman et al 19905 Vernon & Blake 1993 Problem-based learning in medical educationAlbanese & Mitchell 1993Norman & Schmidt 1992Berkson 1993Schmidt 19933 Smith 1983 Present/future role of foreign medical graduates in US health care systemSutnick et al 1994Conn 19865 Dorsey & Colliver 1995 Educational program evaluation with subtopicsDimitroff & Davis 1996Sheets et al 1992Coles & Grant 1985Grum et al 19962 Nolan & Cooper 1995 Physician workforce policy/"generalists vs. specialists" issuesCohen & Todd 19944 Hendricson et al 1988 Governance structures in medical educationReynolds et al 1995Bryan 1994Huppatz 19962 Nora 1996 Gender equity/sexual harrassment issuesLenhart & Evans 19913 Miles et al 1989 Ethical/legal issues in medical educationBickel 1991Culver et al 19853 Toscani & Patterson 1995 Patient education issuesSouba 199611

Musick DW. Policy analysis in medical education:A structured approach.Med Educ Online [serial online] 1998;3,2. Availablefrom URL http://www.utmb.edu/meo/McCann & Weinman 19965 Thier 1994 Managed care systems/impact on medical educationHalperin et al 1995Rivo et al 1995Blumenthal & Thier 1996Veloski et al 199640 Total - All Citations*Resulting from Health Professions Education Literature Search using Selected Key Terms, 1982-1996Table 1 ReferencesAlbanese, M.A. and Mitchell, S. “Problem-Based Learning: A Review of Literature on Its Outcomes andImplementation Issues”, Academic Medicine 1993 January; 68 (1): 52-81.Ayanian, J.Z.; Cassell, E.J.; Altman, D.; Cohen, J.; Arnstein, S.R.; Haspel, L.U. “The Prospect of SweepingReform in Graduate Medical Education”, Milbank Quarterly 1994 Winter; 72 (4): 705-33.Berkson, L. “Problem-Based Learning: Have the Expectations Been Met?”, Academic Medicine 1993October (Supp); 68 (10): S79-S88.Bernstein, E.; Goldfrank, L.R.; Kellerman, A.L.; Hargarten, S.W.; Jui, J.; Fish, S.S.; Herbert, B.H.; Flores,C.; Caravati, M.E.; Krishel, S. “A Public Health Approach to Emergency Medicine: Preparing for the 21stCentury”, Academic Emergency Medicine 1994 May-June; 1 (3): 277-86.Bickel, J.L. “Medical Students’ Professional Ethics: Defining the Problems and Developing Resources”,Academic Medicine 1991 December; 66 (12): 726-9.Blumenthal, D. and Thier, S.O. “Managed Care and Medical Education”, Journal of the American MedicalAssociation 1996 4 September; 276 (9): 725-7.Bryan, G.T. “The Role and Responsibility of the Dean in Promoting Curricular Innovation”, Teaching andLearning in Medicine 1994; 6 (3): 221-3.Cohen, J.; Dannefer, E.F.; Seidel, H.M.; Weisman, C.S.; Wexler, P.; Brown, T.M.; Brieger, G.H.; Margolis,S.; Ross, L.R.; Kunitz, S.J. “Medical Education Change: A Detailed Study of Six Medical Schools”,Medical Education 1994 September; 28 (5): 350-60.Cohen, J.J. and Todd, J.S. “AAMC and AMA Joint Statement on Physician Workforce Planning and GMEReform Policies”, Journal of the American Medical Association 7 September 1994; 272 (9): 712.Coles, C.R. and Grant, J.G. “Curriculum Evaluation in Medical and Health Care Education”, MedicalEducation 1985; 19: 405-22.Conn, H.L. “Assessing the Clinical Skills of Foreign Medical Graduates”, Journal of Medical Education1986 November; 61 (11): 863-71.12

Musick DW. Policy analysis in medical education:A structured approach.Med Educ Online [serial online] 1998;3,2. Availablefrom URL http://www.utmb.edu/meo/Culver, C.M.; Clouser, K.D.; Gert, B.; Brody, H.; Fletcher, J.; Jonsen, A.; Kapelman, L.; Lynn, J.; Siegler,M.; Wikler, D. “Basic Curricular Goals in Medical Ethics”, New England Journal of Medicine 1985 January24; 312 (4): 253-6.Dimitroff, A. and Davis, W.K. “Content Analysis of Research in Undergraduate Medical Education”,Academic Medicine 1996 January; 71 (1): 60-67.Dorsey, J.K. and Colliver, J.A. “Effect of Anonymous Test Grading on Passing Rates as Related to Genderand Race”, Academic Medicine 1995 April; 70 (4): 321-3.Fisher, E.S. and Welch, H.G. “The Future of the Department of Veterans Affairs Health Care System”,Military Medicine 1995 October; 160 (10): 651-5.Friedman, C.P.; de Bliek, R.; Greer, D.S.; Mennin, S.P.; Norman, G.R.; Sheps, C.G.; Swanson, D.B.;Woodward, C.A. “Charting the Winds of Change: Evaluating Innovative Medical Curricula”, AcademicMedicine 1990 January; 65 (1): 8-14.Grum, C.M.; Richard, P.J.; Woolliscroft, J.O. “Consequences of Shifting Medical Student Education tothe Outpatient Setting: Effects on Performances and Experiences”, Academic Medicine 1996 January(Supp); 71 (1): 995-1015.Halperin, E.C.; Byyny, R.L.; Moore, S.; Morahan, P.S. “What Medical Schools and Universities CanLearn from One Another”, Academic Medicine 1995 October; 70 (10): 879-83.Hendricson, W.D.; Katz, M.S.; Hoy, L.J. “Survey on Curriculum Committees at US and Canadian MedicalSchools”, Journal of Medical Education 1988 October; 63: 762-74.Huppatz, C. “The Essential Role of the Student in Curriculum Planning”, Medical Education 1996 January;30 (1): 9-13.Iglehart, J.K. “Health Care Reform and Graduate Medical Education”, New England Journal of Medicine1994 April 21; 330 (16): 1167-71.Kendall, J.W. “The Evolution of American Medical Association Policies Concerning Health Care of Veterans”,Military Medicine October 1995; 160 (10): 518-21.Krol, D. “The Numerology of Graduate Medical Education Reform”, Journal of the American MedicalAssociation 1994 May 4; 271 (17): 1369-70.Lenhart, S.A. and Evans, C.H. “Sexual Harassment and Gender Discrimination: A Primer for WomenPhysicians”, Journal of the American Medical Women’s Association 1991; 46 (3): 77-82.McCann, S. and Weinman, J. “Empowering the Patient in Consultation: A Pilot Study”, Patient Educationand Counseling 1996 April; 27 (3): 227-34.Miles, S.A.; Lane, L.W.; Bickel, J.; Walker, R.M.; Cassel, C.K. “Medical Ethics Education: Coming ofAge”, Academic Medicine 1989 December; 64 (12): 705-14.Nolan, J. and Cooper, R.A. “Should the Government Require US Medical Schools to Produce More PrimaryHealth Care Providers?”, CQ Researcher 1995 17 March; 5 (10): 233.Nora, L.M. “Sexual Harassment in Medical Education: A Review of the Literature with Comments fromthe Law”, Academic Medicine 1996 January (Supp); 71 (1): S113-S118.13

Musick DW. Policy analysis in medical education:A structured approach.Med Educ Online [serial online] 1998;3,2. Availablefrom URL http://www.utmb.edu/meo/Norman, G.R. and Schmidt, H.G. “The Psychological Basis of Problem-Based Learning: A Review of theEvidence”, Academic Medicine 1992 September; 67 (9): 557-65.Reynolds, C.F.; Adler, S.; Kanter, S.L.; Horn, J.P.; Harvey, J.; Bernier, G.M. “The Undergraduate MedicalCurriculum: Centralized vs. Departmentalized”, Academic Medicine 1995 August; 70 (8): 671-5.Rivo, M.L.; Mays, H.L.; Katzoff, J.; Kindig, D.A. “Managed Health Care: Implications for the PhysicianWorkforce and Medical Education”, Journal of the American Medical Association, 1995 September 6; 274(9): 712-15.Schmidt, H.G. “Foundations of Problem-Based Learning: Some Explanatory Notes”, Medical Education1993 (27): 422-32.Sheets, K.J.; Anderson, W.A.; Alguire, P.C. “Curriculum Development and Evaluation in Medical Education”,Journal of General Internal Medicine 1992 September-October; 7 (5): 538-43.Smith, E.G. “Study of Functioning and Location of US Citizen Foreign Medical Graduates Within the USMedical Care System”, Final Report (Volumes I and II), Health Resources Administration; 1983: 1-226.Souba, W.W. “Professionalism, Responsibility and Service in Academic Medicine”, Surgery 1996 January;119 (1): 1-8.Sutnick, A.I.; Stillman, P.L.; Norcini, J.J.; Friedman, M.; Williams, R.G.; Trace, D.A.; Schwartz, M.A.;Wang, Y.; Wilson, M.P. “Pilot Study of the Use of the ECFMG Clinical Competence Assessment to ProvideProfiles of Clinical Competencies of Graduates of Foreign Medical Schools for Residency Directors”,Academic Medicine 1994 January; 69 (1): 65-67.Their, S.O. “Academic Medicine’s Choices in an Era of Reform”, Academic Medicine 1994 March; 69(3): 185-9.Toscani, M.R. and Patterson, R. “Evaluating and Creating Effective Patient Education Programs”, DrugBenefit Trends 1995; 7 (9): 36-9, 44.Veloski, J.; Barzansky, B.; Nash, D.B.; Bastacky, S.; Stevens, D.P. “Medical Student Education in ManagedCare Settings”, Journal of the American Medical Association 1996 September 4; 276 (9): 667-71.Vernon, D.T. and Blake, R.L. “Does Problem-Based Learning Work? A Meta-Analysis of EvaluativeResearch”, Academic Medicine 1993 July; 68 (7): 550-63.14