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Nov 2004  Vol. 8   No. 3  

........   INSTITUTIONAL CHANGES  ........
Managing Change in Medical Education
Professor David Prideaux
Head, Department of Medical Education
School of Medicine, Flinders University,
Adelaide, South Australia


The late twentieth century and the early twenty-first have been marked by a world-wide process of change in medical education. New medical schools and courses have been developed and significant reforms have been undertaken in existing ones. These include changes in curriculum content, adoption of new approaches to teaching, learning and assessment or changing the length of courses and criteria for student admission. All such schools, whether creating new courses, changing existing ones or developing parallel tracks, have to pay significant attention to the management of change.

Approaches to Educational Change

In the literature two main approaches to educational change have been defined: centralised or ‘top-down’ and decentralised or ‘bottom-up’. The latter approach has been preferred because it claims to build ownership and commitment to the change (Fullan, 1992; Fullan & Hargreaves, 1992; Grant & Gale, 1989; Smyth, 1991). A decentralised approach was used at Flinders University in 1996 when the School of Medicine moved to a four-year graduate entry course with accompanying changes in teaching, learning and curriculum. The main strategy in the decentralised approach was to develop a structure of 18 committees and working parties to ensure staff participation in the change. The change has been successfully adopted but a staff survey conducted in 1999 revealed that the decision-making structure was time-consuming and that there were issues of long term sustainability. This prompted a comparative study by the author of four international medical schools, two of which were changing existing courses while the other two were developing new ones, to define factors that were important in managing the change process.

Factors Affecting the Change Process

The study revealed four major factors which had affected the change process at the schools (Figure 1). These were:

  • the external forces,
  • the nature of the change itself,
  • the nature of the pre-existing change culture,
  • the change mechanisms adopted.

Negative external forces such as threats to survival or accreditation were associated with the two schools that were changing existing courses. The two remaining schools had embraced positive external forces in creating new programmes. This brought both legitimation and resources to their endeavours.

There were similar differences in the change mechanisms adopted. Decentralised approaches to change were associated with the two schools

Figure 1. Factors affecting the change process

changing courses. These were necessary to build staff ownership and commitment to the new programmes. More centralised approaches were adopted in the two schools creating new programmes. In these cases, small teams of staff, recruited specifically for the new courses, worked in what were called ‘purpose-built’ structures.

The nature of the change was important too. Total changes required more attention than the partial parallel track undertaken at one of the schools. Not surprisingly, aspects of changes which were compatible with existing practices were the easiest to achieve. More specific and focused change strategies had been adopted where changes were incompatible with existing practices.

In all four schools the nature of the existing culture of change had to be embraced. Traditional cultures required attention to leadership models, complex organisations with multiple stakeholders required attention to communication approaches, and departments had to be engaged where there was essentially no departmental ownership of the curriculum.


The study, although small at this stage, has shown that it is no longer useful to approach the management of change as either being just centralised or decentralised. Rather change should be conceptualised as ‘dynamic, complex and open’ (Wheatley, 1999). In managing change, the mechanisms need to be sensitive to the nature of the change itself, the culture in which it is to be implemented and the external environment rather than building upon pre-conceived notions of what approaches are effective and what are not. Purpose-built structures are required to match the characteristics of each organisation.

Managing change is also a long term issue. In the approaches taken by all four schools, there were questions about the long term sustainability of the mechanisms used. Fullan (1992), one of the supporters of decentralised approaches, now argues that change must not be seen as a one-off event. If it is to be successful an ‘ongoing culture of change’ built on staff development, then teacher maintenance must be instituted. This is important for all those who contemplate and manage change.


Fullan, M. (1992). Successful School Improvement: The Implementation Perspective and Beyond. Milton Keynes: Open University Press.

Fullan, M. & Hargreaves, A. (Eds.). (1992). Teacher Development and Educational Change. London: Falmer Press.

Grant, J. & Gale, R. (1989). ‘Changing Medical Education’. Medical Education. Vol. 23, pp. 252–257.

Smyth, J. (1991). Teachers as Collaborative Learners: Challenging Dominant Forms of Supervision. Milton Keynes: Open University Press.

Wheatley, M. (1999). Leadership and the New Science: Discovering Order in a Chaotic World. (2nd edition). San Francisco, CA: Berrett-Koehler Publishers.





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