Designing a Curriculum That Serves and Reflects Your Community – Dr. Steve Riley, Dean of Medical Education at Cardiff University in Wales

Michael Carrese: Hi everybody. I'm Michael Carrese. We've been fortunate on Raise the Line to hear from clinicians and educators around the globe -- including from Israel, Uzbekistan, Singapore, and India to name a few -- but today we welcome our first guest from Wales. Professor Steve Riley is Dean of Medical Education and head of the School of Medicine at Cardiff University, where he is responsible for the design, delivery, and development of the undergraduate medicine program.

His academic interests include curriculum design, education leadership, and application of systems theory to education delivery. He's also passionate about social accountability in the higher education sector, including issues such as health inequities, DEI, and climate change. In addition, Dr. Riley is a nephrologist with a special interest in diabetes, and a fellow of the Academy of Medical Educators. Thanks very much for joining us today.

Dr. Steve Riley: Thank you.

Michael Carrese: We always start on the program with wanting to learn more about our guests, and what got them interested in medicine, and in your case, particularly, nephrology. What's the story there?

Dr. Steve Riley: Well, I'm the first in my family to go to university. I grew up in the middle of the heart of the Midlands in the middle of England. I had a neighbor who was a practicing General Practitioner, and we were very friendly, and I used to chat away to him and it was always interesting to me. He was a police surgeon, a GP, and an orthopedic surgeon. He was originally from India and came over in the late 70s, early 80s really, to practice in the UK, and he really got me started on this path of being a doctor.

I ended up setting myself up to do medicine and moved to Cardiff in Wales to start university and then never left, really. I really found the environment in which I work in Cardiff and in Wales, in general, to be in line with my way of thinking. I developed very strong friendship groups through university and settled here when I met my wife. Then I guess nephrology really came about because of a mentor of mine. I started doing nephrology clinics as a junior doctor, and I was in a clinic with a professor of nephrology called John Williams.

The subject fascinated me in terms of patient contact, and the continuity of care, and the numbers. Nephrologists are usually numbers people. It was around the numbers for me. And again, back to the system's thinking, I guess really the way in which the kidney interacts with other systems in the body and maintains homeostasis. That's how I got to where I am. In terms pf medical education, I started as a clinical academic and started doing some clinical research in the time that it was very, very challenging to get really big grant capture for that sort of work.

I was asked to do some curriculum work and to help with students and really took to it like a duck to water and enjoyed doing it. Then I worked my way around sort of a self-made apprenticeship of the various aspects of medical education, and that's how I've ended up here today.

Michael Carrese: When you were first starting out as a physician, was being a leader and getting into academic medicine part of what you had in mind, or did that happen unexpectedly?

Dr. Steve Riley: Completely unexpectedly. It never really occurred to me, to be honest. I just tend to try and just do a good job, and make sure the people around me are supported to do a good job. But as time went by, I did enjoy the aspects of the work that involve maybe lifting the bonnet and having a look underneath the bonnet and seeing how the engine works. That sort of thing started to have an impact on me. I have a very, very good privilege of working with some excellent leaders who have shown me the ropes and I've learned from each and every one of them. I've enjoyed trying to apply what they've taught me.

I've done a variety of courses that I could advertise on this -- but I'll perhaps resist from that -- that have really shown me the way in terms of how people in this specialty of medical education think, how they work. I’ve learned from some of the real big hitters I've had the privilege to talk to and listen to and I guess it's just fallen well for me.

Michael Carrese: You mentioned before that you felt at home at Cardiff, or connected to the outlook and the mission there. Tell me more about that.

Dr. Steve Riley: Wales is a very different place. All four nations have got their differences, I guess. The political philosophy is different to England. The approach of the NHS has differed significantly from England and other parts of the UK. There is a sense of citizenship and social accountability that I get in Wales. It feels as though you can make a difference in terms of trying to influence the way in which underserved parts of Wales can be helped to improve in terms of recruitment and retention of the clinical workforce.

It's multiple factors, really. Put that on top of a place that is really great to live in. We've got some really great places around for recreational time. It had all of the things that I wanted out of life, really. So that's where I settled.

Michael Carrese: We'll get back to the social accountability piece in a minute. First, can you give the audience a sense of the size and scope of the School of Medicine at Cardiff University, and also what you think the particular strengths are?

Dr. Steve Riley: We are quite a big school. We have around 1,500 undergraduate medical students and around the same postgraduate-taught students. Around 200-250 postgraduate research students. We are structured into five big divisions and centers with a fairly strong research portfolio that covers systems immunity, psychiatry, neuroscience, cancer and genetics, and population medicine. We are a big school, and we are part of a big university. Cardiff University is a Russell Group University in the UK. About 30,000 students every year come through Cardiff University. 

Michael Carrese: I would say, yeah. Let's return to the social accountability issue which is quite important to you, and something that you pursue at the School of Medicine. Help us understand how that manifests itself and how you try to engage the students in thinking about that?

Dr. Steve Riley: I guess many medical students, when they come into university, have already got a lot of what we talk about in terms of social accountability because we read about it when we look at their personal statements. They talk to us in interviews about how they want to help people and communities, and very often students will come in having already done significant community work or volunteer work. For me, it's a way of enhancing that.

I mentioned before, I've had the great privilege of talking to some of the people who really espouse social accountability. For instance, David Hirsh up in Boston there. I've had some great conversations with him about this. Paul Worley from Australia, Roger Strasser, formerly of Northern Ontario…these are people that I've listened to and understood their philosophy and wanted to recreate some of the things that they've achieved in their own part of the world really.

For me, it's about trying to structure a course that recognizes the needs of the local population and seeing how a school of medicine or our curriculum or a bunch of students can contribute back to make things better for the population. It's about getting students to go back into schools to teach health literacy. It's about trying to raise the expectation of students at school who might want to then come in to do a health-related education degree. It's about looking at social and health inequalities and trying to align research strengths with how that might impact on local populations. 

Wales does have a high proportion of its population who do struggle with social and health inequalities, nd to me, it's finding ways in which we can influence that and make a difference to people.

Michael Carrese: In the United States, as I'm sure you're probably aware, COVID has really shone a light on the issue of health disparities. These are long-standing problems. It was not news to the people who were on the ground helping these communities. But it really has hit people just how we almost have two health care systems. Was it the same in Wales, or were you folks pretty much aware of the inequality issue?

Dr. Steve Riley: I think there is an awareness there. There's certainly an awareness from the Welsh government, and also from health care communities. I think that the challenge is making a difference to that. The geography of Wales is such that there are large parts that have got smaller populations in more rural and hard-to-reach communities -- not by any standards of the United States or Canada, for instance, where you are talking about hundreds of miles by road to reach some of the more distant communities. 

Still, even in the UK, the infrastructure does provide challenges to get to places, and trying to work on ways in which you can entice people to put down roots in those communities, and then work in those communities following graduation is one of those things that I think is really important because we do have to recognize we've got a legacy to leave in terms of that population group.

Michael Carrese: Do you have any sense yet about whether there has been an improvement through the course of the pandemic?

Dr. Steve Riley: Improve? I think this has been a detriment, actually. I think the pandemic has shone a light in the UK on the frailty of the health care system because we have such a lot of ground to make up now in terms of those patients who have been on waiting lists to get operations or to get treatment. There's no doubt that there are probably undiagnosed conditions out there at the moment that we need to pick up, and I know a lot of the work is ongoing for them. Our General Practitioners are working really hard. They are hard-pressed at the moment to be able to see patients as demand increases.

Then, the system itself is struggling to cope with all the referrals that are going through the system, and our waiting lists have grown significantly. In my mind, there's no doubt that will impact most on those people at the intersections of social and health diversity -- those groups that we know are underrepresented and struggle to engage with health care.

Michael Carrese: It's a similar story here for sure. I noted at the beginning that you have an interest in curriculum design. Are there particular curricular innovations in place at your school that you want to talk to us about?

Dr. Steve Riley: There are innovations for us, I guess, but other people have been doing them for a long time, really. We started on a new curriculum that we termed C-21 back in 2013. At that time, we focused very much on modernizing our curriculum…contextual learning, trying to take out those aspects of basic science that weren't needed to make room for those new areas of science that we need to enable the students to learn. Early clinical experience was important to us and trying to embed educational continuity, which I'm not sure we were completely successful with in that curriculum.

As we've learned as a group going through, I think we are better able to understand what educational continuity means. We were able to introduce a longitudinal integrated clerkship model for a proportion of our students three or four years ago now, and that was with the help of Roger, Paul, and David. It does seem to be strengthening what we can offer. Our first group of students graduated this year. We are trying to evaluate the impact of it, but that, again, is something that we need to wait for more numbers to come through the system.

We then entered into a collaboration with one of our sister universities, including Bangor University in North Wales, to start a smaller C-21 curriculum and try to embed students for the entirety of their medical education in North Wales as a means by which to demonstrate, potentially, that we could entice students to stay and work in that environment post-graduation. Our first students will graduate from that next year, I think. Again, that's more evidence for us to try and affirm what's happened in Northern Ontario and other places around the world. That's pretty much where we're at with our curriculum design.

Early on, actually, we moved our final assessments. We tried to make all of their major assessments at the end of year four. We've got a five-year program in the UK. So that final year was all about preparation for practice and learning to work in the environment in which they're training. It was very much a case of getting the students hands-on experience to give them more confidence when they came to work in the post-graduation environment. I think that's worked very, very well. Again, we need to look at in it a bit more detail, I think. But as an innovation, it's worked pretty well.

Michael Carrese: Obviously, COVID was extremely disruptive to all of higher education, but medical education in particular, I think, because of the clinical placements that are required and so forth. What do you think are going to be the lasting changes as a result of COVID to medical education?

Dr. Steve Riley: I think that one of the things that we have seen is the need to educate our students in a non-face-to-face consultation environment -- so either video consultation or telephone consultation. I know that curriculum probably did that pre-COVID, but it certainly raised the stakes in terms of how we train our students to be able to make themselves more accessible to patients. I know in my own clinic, we've got virtual clinics, we've got telephone clinics, we've got occasional video clinics, and other people around Wales and the UK are doing very similar things. For me, that's one of the COVID hangovers that will stay with us, I think, and we've set up our clinical skills program to ensure that our students do get experience in that environment. I think one thing we learned was that those students who survived the best in the first wave of COVID were those students who were in general practice because the general practitioners -- because of educational continuity, probably -- recognized the benefit of having a student there in terms of delivery of care.

Whereas in secondary care, it was more about "Well, hold on, let's clear the decks because we don't quite know what's coming. Let's get all the students out because they're of no use to us." And actually, that was probably the wrong way around it. When we did look at our final year students going into the clinical environment to support the junior doctors and deliver care in an environment that was frightening for everybody, they excelled. So, it's trying to work out now how our students become more integrated into the delivery of care and are seen as an asset rather than as a job that they need to be taught.

Michael Carrese: Interesting. As you may know, we're a teaching company and we love to fill knowledge gaps. We always like to ask our guests if there's something that they're particularly concerned about or interested in as a gap, and would say, “Osmosis, if you could make a video about that, that would be terrific.” What would that be?

Dr. Steve Riley: I think the thing that challenges me the most is how to navigate the ever-increasing world of evidence and data that is being put forward. Students struggle with looking at the depth of what they need to learn. We can be quite good at demonstrating breadth. We can say you need to learn about cardiology, nephrology, obstetrics, gynecology. What we're not very good at is saying how much you need to know about those subjects. The problem is that more and more that gets piled on in terms of the exponential publication rate, it makes it even harder for busy clinicians and students to make headway. I know there are tools that do that for us. There's UpToDate, and there are other groups that will assimilate that information for you. I still think it's a challenge for us in terms of being able to navigate that data. 

The other thing that I discovered a few weeks ago was that when evidence is published, it can take up to thirteen years for it to get embedded into standard practice. That implementation science is something that we could look at a bit more strongly in curricula and in how we train people.

Michael Carrese: As we wrap up here, we have a lot of students and early career professionals in our audience. You're obviously somebody who's providing advice to students all the time. What is it that you tell your own students about meeting the challenges of this moment, this pandemic, and just generally approaching a career in healthcare?

Dr. Steve Riley: I try and tell them to enjoy themselves, if I'm honest. And I know that's a challenge with what we've all been through. I think COVID has piled on the pressure in terms of expectation of what we deliver as individuals and what health services can deliver as an organization. I think it's very easy to start feeling that pressure yourself. I think it's important to have people around you that you can decompress with, you can understand, and you can support because there are times when we're at a low point because not seeing family, or it's the pressures of work that come in.

For me, it is about support for each other in terms of how we get through things. I think that friendship circle that you develop at medical school is something that I try and get our students to nurture themselves. I'm still friends with a few of my very close friends from university, and they will always be my source of support in terms of understanding where I'm at and what I'm doing.

For me, it should be enjoyable, really. You should enjoy doing your job and you should have the people around you to commiserate with and celebrate with when you've got those things that are challenging you. I'm lucky enough to have those people around me. I think as leaders, we should try and nurture those circles, but it is very hard because we're getting bigger and bigger and bigger as organizations.

Michael Carrese: That's really excellent advice, and a great note to end on. I really want to thank you for spending a few minutes with us and giving us a view into what's happening in medical education in Wales, Professor Riley.

Dr. Steve Riley: Thank you very much. A pleasure to speak to you.

Michael Carrese: I'm Michael Carrese. Thanks for checking out today's show. And remember to do your part to flatten the curve and raise the line. We're all in this together.