Flexibility in primary medical programs: A scoping review


  • Anna Barrett University of Melbourne
  • Lisa Cheshire University of Melbourne
  • Robyn Woodward-Kron University of Melbourne




flexibility, medical students, curriculum, time variable, diversity, equity


Introduction: Students and universities increasingly seek flexibility in learning options, however terms such as flexible are not consistently defined in the medical education literature. This review aimed to 1) propose a definition for flexibility in medical education and 2) create a typology of contemporary examples of how flexibility has been operationalised in medical education.

Method: A systematic scoping review of papers published in English since 2009 was undertaken. The focus was on papers reporting initiatives to create flexibility in primary medical programs.

Results: Based on review of 1,641 search returns and 140 full-text articles, two interconnected concepts were identified: flexibility and individualisation. Flexibility describes mechanisms that allow students choice in how they allocate time and resources to meet the requirements of their course, including time-variable progression, acceleration, deceleration, articulated degree entry and exit options, and pedagogical approaches that reduce time required in classrooms. Individualisation describes options that enable student-driven direction, extension or expansion of medical education into special interest areas, including dual degrees, breadth subjects, curriculum tracks, elective service-learning pathways, electives and selectives.

Conclusions: Though not always clearly defined as such, international medical education literature describes a rich variety of flexibility and individualisation initiatives. While the constructs of flexibility and individualisation are interconnected, they can assist curriculum designers to differentiate between the mechanisms that enable flexibility in how students meet course requirements and the mechanisms that enable individual choice in what students study. Flexibility and individualisation initiatives target different needs, including both students’ needs and medical workforce needs; they also suggest different institutional and financial implications. Consensus on and consistent use of common terminology about flexibility and individualisation initiatives will improve the “searchability” and synthesis of research on such initiatives and their impacts and enablers, as well as encourage further research, publication and synthesis of outcomes of such initiatives.

Author Biographies

Lisa Cheshire, University of Melbourne

Department of Medical Education

Robyn Woodward-Kron, University of Melbourne

Prof in Healthcare Communication


Ackerly, D. C., Sangvai, D. G., Udayakumar, K., Shah, B. R., Kalman, N. S., Cho, A. H., Schilman, K. A.,Fulkerson, W. J., Jr., & Dzau, V. J. (2011). Training the next generation of physician-executives: An innovative residency pathway in management and leadership. Academic Medicine, 86(5), 575–579. https://doi.org/10.1097/ACM.0b013e318212e51b

Alamri, Y. (2018). Dual degrees in medicine: Options for medical students. Journal of Cancer Education, 33(1), 4–6. https://doi.org/10.1007/s13187-016-1022-5

Andrews, J. S., Bale, J. F., Jr., Soep, J. B., Long, M., Carraccio, C., Englander, R., & Powell, D. (2018). Education in Pediatrics Across the Continuum (EPAC): First steps toward realizing the dream of competency-based education. Academic Medicine, 93(3), 414–420. https://doi.org/10.1097/acm.0000000000002020

Arksey, H., & O’Malley, L. (2005). Scoping studies: Towards a methodological framework. International Journal of Social Research Methodology, 8(1), 19–32. https:///doi.org/10.1080/1364557032000119616

Arvidson, C. G., Green, W. D., Allen, R., Reznich, C., Mavis, B., Osuch, J. R., Lipscomb, W., O'Donnell, J., & Brewer, P. (2015). Investing in success: Student experiences in a structured, decelerated preclinical medical school curriculum. Medical Education Online, 20(1), Article 29297. https://doi.org/10.3402/meo.v20.29297

Australian Medical Council. (n.d). Assessment and accreditation of primary medical programs (medical schools). Retrieved July 5, 2022, from https://www.amc.org.au/accreditation-and-recognition/assessment-accreditation-primary-medical-programs/

Bellini, L. M., Kalet, A., & Englander, R. (2019). Providing compassionate off-ramps for medical students is a moral imperative. Academic Medicine, 94(5), 656–658. https://doi.org/10.1097/ACM.0000000000002568

Brass, L. F., Akabas, M. H., Burnley, L. D., Engman, D. M., Wiley, C. A., & Andersen, O. S. (2010). Are MD–PhD programs meeting their goals? An analysis of career choices made by graduates of 24 MD–PhD programs. Academic Medicine, 85(4), 692–701.

Cangiarella, J., Fancher, T., Jones, B., Dodson, L., Leong, S. L., Hunsaker, M., Pallay, R., Whyte, R., Holthouser, A. & Abramson, S. B. (2017). Three-year MD programs: Perspectives from the Consortium of Accelerated Medical Pathway Programs (CAMPP). Academic Medicine, 92(4), 483–490. https://doi.org/10.1097/ACM.0000000000001465

Chen, H. C., Wamsley, M. A., Azzam, A., Julian, K., Irby, D. M., & O'Sullivan, P. S. (2017). The health professions education pathway: Preparing students, residents, and fellows to become future educators. Teaching and Learning in Medicine, 29(2), 216–227. https://doi.org/10.1080/10401334.2016.1230500

Choi-Lundberg, D. L., Al-Aubaidy, H. A., Burgess, J. R., Clifford, C. A., Cuellar, W. A., Errey, J. A., Harper, A. J., Malley, R. C., Ross, R. M., Williams, A.-M. M., & Hays, R. (2019). Minimal effects of reduced teaching hours on undergraduate medical student learning outcomes and course evaluations. Medical Teacher, 42(1), 58–65. https://doi.org/10.1080/0142159x.2019.1652258

Desy, J. R., Reed, D. A., & Wolanskyj, A. P. (2017). Milestones and millennials: A perfect pairing—competency-based medical education and the learning preferences of Generation Y. Mayo Clinic Proceedings, 92(2), 243–250. https://doi.org/10.1016/j.mayocp.2016.10.026

Dhar, S. U., Alford, R. L., Nelson, E. A., & Potocki, L. (2012). Enhancing exposure to genetics and genomics through an innovative medical school curriculum. Genetics in Medicine, 14(1), 163–167. https://doi.org/10.1038/gim.0b013e31822dd7d4

Eaglen, R. H., Arnold, L., Girotti, J. A., Cosgrove, E. M., Green, M. M., Kollisch, D. O., McBeth, D. L., Penn, M. A., & Tracy, S. W. (2012). The scope and variety of combined baccalaureate–MD programs in the United States. Academic Medicine, 87(11), 1600–1608. https://doi.org/10.1097/ACM.0b013e31826b8498

Frenk, J., Chen, L., Bhutta, Z. A., Cohen, J., Crisp, N., Evans, T., Fineberg, H., Garcia, P., Yang, K., Kelley, P., Kistnasamy, B., Meleis, A., Naylor, D., Pablos-Mendez, A., Reddy, S., Scrimshaw, S., Sepulveda, J., Serwadda, D., & Zurayk, H. (2010). Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. The Lancet, 376(9756), 1923–1958. https://doi.org/10.1016/S0140-6736(10)61854-5

Goldfarb, S., & Morrison, G. (2013). The 3-year medical school: Change or shortchange? New England Journal of Medicine, 369(12), 1087–1089. https://doi.org/10.1056/NEJMp1306457

Green, M. M., Welty, L., Thomas, J. X., & Curry, R. H. (2016). Academic performance of students in an accelerated baccalaureate/MD program: Implications for alternative physician education pathways. Academic Medicine, 91(2), 256–261. https://doi.org/10.1097/ACM.0000000000000804

Havnaer, A. G., Chen, A. J., & Greenberg, P. B. (2017). Scholarly concentration programs and medical student research productivity: A systematic review. Perspectives on Medical Education, 6(4), 216–226. https://doi.org/10.1007/s40037-017-0328-2

Hensen, P. (2010). The “Bologna Process” in European higher education: Impact of bachelor’s and master’s degrees on German medical education. Teaching and Learning Medicine, 22(2), 142–147. https://doi.org/10.1080/10401331003656710

Hew, K. F., & Lo, C. K. (2018). Flipped classroom improves student learning in health professions education: A meta-analysis. BMC Medical Education, 18(1), Article 38. https://doi.org/10.1186/s12909-018-1144-z

Hoff, R. G., Frenkel, J., Imhof, S. M., & Ten Cate, O. (2018). Flexibility in postgraduate medical training in the Netherlands. Academic Medicine, 93(3S), S32–S36. https://doi.org/10.1097/ACM.0000000000002078

Jeffe, D. B., & Andriole, D. A. (2011). A national cohort study of MD–PhD graduates of medical schools with and without funding from the National Institute of General Medical Sciencesʼ Medical Scientist Training Program. Academic Medicine, 86(8), 953–961. https://doi.org/10.1097/acm.0b013e31822225c5

Kohl, C., McIntosh, E., Unger, S., Haddaway, N., Kecke, S., Schiemann, J., & Wilhelm, R. (2018). Online tools supporting the conduct and reporting of systematic reviews and systematic maps: A case study on CADIMA and review of existing tools. Environmental Evidence, 7(1), Article 8. https://doi.org/10.1186/s13750-018-0115-5

Kost, A., Evans, D., Dobie, S., & Sanders, E. (2018). What is the impact of the Underserved Pathway program on graduates entering an underserved family medicine residency? Five-year findings from the University of Washington School of Medicine. Academic Medicine, 93(7), 1042–1047. https://doi.org/10.1097/acm.0000000000002073

Lawson, L., Lake, D., Lazorick, S., Reeder, T., Garris, J., & Baxley, E. G. (2019). Developing tomorrow's leaders: A medical student distinction track in health system transformation and leadership. Academic Medicine, 94(3), 358–363. https://doi.org/10.1097/acm.0000000000002509

Leong, S. L., Cangiarella, J., Fancher, T., Dodson, L., Grochowski, C., Harnik, V., Hustedde, C., Jones, B., Kelly, C., Macerollo, A., Reboli, A. C., Rosenfeld, K., Thompson, T., Whyte, R., & Pusic, M. (2017). Roadmap for creating an accelerated three-year medical education program. Medical Education Online, 22(1), Article 1396172. https://doi.org/10.1080/10872981.2017.1396172

Levac, D., Colquhoun, H., & O’Brien, K. (2010). Scoping studies: Advancing the methodology. Implementation Science, 5, Article 69. https://doi.org/10.1186/1748-5908-5-69

Lindberg, O. (2013). Gatekeepers of a profession? Employability as capital in the recruitment of medical interns. Journal of Education and Work, 26(4), 431–452. https://doi.org/10.1080/13639080.2012.658032

Lockyer, J. M., Violato, C., Wright, B. J., & Fidler, H. M. (2009). An analysis of long-term outcomes of the impact of curriculum: A comparison of the three- and four-year medical school curricula. Academic Medicine, 84(10), 1342–1347. https://doi.org/10.1097/ACM.0b013e3181b6c08e

McGrath, B., & McQuail, D. (2004). Decelerated medical education. Medical Teacher, 26(6), 510–513. https://doi.org/10.1080/01421590410001696407

McHugh, M. (2012). Interrater reliability: The kappa statistic. Biochemia Medica, 22(3), 276–282. https://doi.org/10.11613/BM.2012.031

Menon, A., Klein, E., Kollars, K., & Kleinhenz, A. (2020). Medical students are not essential workers: Examining institutional responsibility during the COVID-19 pandemic. Academic Medicine, 95(8), 1149–1151. https://doi.org/10.1097/ACM.0000000000003478

Murdoch‐Eaton, D., & Whittle, S. (2012). Generic skills in medical education: Developing the tools for successful lifelong learning. Medical Education, 46(1), 120–128. https://doi.org/10.1111/j.1365-2923.2011.04065.x

Newman, N., & Lattouf, O. (2020). Coalition for medical education—a call to action: A proposition to adapt clinical medical education to meet the needs of students and other healthcare learners during COVID‐19. Journal of Cardiac Surgery, 35(6), 1174–1175. https://doi.org/10.1111/jocs.14590

Ng, E., Jones, A. A., Sivapragasam, M., Nath, S., Mak, L. E., & Rosenblum, N. D. (2019). The integration of clinical and research training: How and why MD–PhD programs work. Academic Medicine, 94(5), 664–670. https://doi.org/10.1097/Acm.0000000000002467

Novak, D. A., Hallowell, R., Ben-Ari, R., & Elliott, D. (2019). A continuum of innovation: Curricular renewal strategies in undergraduate medical education, 2010–2018. Academic Medicine, 94(11S), S79–S85. https://doi.org/10.1097/acm.0000000000002909

Patel, M. S., Arora, V., Patel, M. S., Kinney, J. M., Pauly, M. V., & Asch, D. A. (2014). The role of MD and MBA training in the professional development of a physician: A survey of 30 years of graduates from the Wharton Health Care Management Program. Academic Medicine, 89(9), 1282–1286. https://doi.org/10.1097/acm.0000000000000366

Peine, A., Kabino, K., & Spreckelsen, C. (2016). Self-directed learning can outperform direct instruction in the course of a modern German medical curriculum: Results of a mixed methods trial. BMC Medical Education, 16(1), Article 158. https://doi.org/10.1186/s12909-016-0679-0

Prideaux, D. (2019). The global–local tension in medical education: Turning "think global, act local" on its head? Medical Education, 53(1), 25–31. https://doi.org/10.1111/medu.13630

Raupach, T., Brown, J., Anders, S., Hasenfuss, G., & Harendza, S. (2013). Summative assessments are more powerful drivers of student learning than resource intensive teaching formats. BMC Medicine, 11(1), Article 61. https://doi.org/10.1186/1741-7015-11-61

Raymond, R. M., Madden, M. M., Ferretti, S. M., Ferretti, J. M., & Ortoski, R. A. (2014). Preliminary outcomes of the Lake Erie College of Osteopathic Medicine's 3-year primary care scholar pathway in osteopathic predoctoral education. The Journal of the American Osteopathic Association, 114(4), 238–241. https://doi.org/10.7556/jaoa.2014.048

Reeve, C., Woolley, T., Ross, S. J., Mohammadi, L., Halili, S. B., Jr., Cristobal, F., Siega-Sur, J. L. J., & Neusy, A.-J. (2017). The impact of socially-accountable health professional education: A systematic review of the literature. Medical Teacher, 39(1), 67–73. https://doi.org/10.1080/0142159X.2016.1231914

Schmidt, H. G., Cohen-Schotanus, J., van der Molen, H. T., Splinter, T. A. W., Bulte, J., Holdrinet, R., & van Rossum, H. J. M. (2009). Learning more by being taught less: A “time-for-self-study” theory explaining curricular effects on graduation rate and study duration. Higher Education, 60(3), 287–300. https://doi.org/10.1007/s10734-009-9300-3

Schwartz, C. C., Ajjarapu, A. S., Stamy, C. D., & Schwinn, D. A. (2018). Comprehensive history of 3-year and accelerated US medical school programs: A century in review. Medical Education Online, 23(1), Article 1530557. https://doi.org/10.1080/10872981.2018.1530557

Schwinn, D., Cooper, C., & Robillard, J. (2019). Putting students at the center: Moving beyond time-variable one-size-fits-all medical education to true individualization. Advances in Medical Education and Practice, 10, 109–112. https://doi.org/10.2147/AMEP.S187946

Scott, K. M., Baur, L., & Barrett, J. (2017). Evidence-based principles for using technology-enhanced learning in the continuing professional development of health professionals. Journal of Continuing Education in the Health Professions, 37(1), 61–66. https://doi.org/10.1097/ceh.0000000000000146

Slavin, S. J., Schindler, D. L., & Chibnall, J. T. (2014). Medical student mental health 3.0: Improving student wellness through curricular changes. Academic Medicine, 89(4), 573–577. https://doi.org/10.1097/ACM.0000000000000166

Stamy, C. D., Schwartz, C. C., Phillips, D. A., Ajjarapu, A. S., Ferguson, K. J., & Schwinn, D. A. (2018). Time-variable medical education innovation in context. Advances in Medical Education and Practice, 9, 469–481. https://doi.org/10.2147/amep.S163984

Sullivan, W. M., DeVolder, J., Bhutiani, M., Neal, K. W., & Miller, B. M. (2017). The MD–MEd joint-degree program at Vanderbilt University: Training future expert medical educators. Academic Medicine, 92(8), 1124–1127. https://doi.org/10.1097/acm.0000000000001497

Thomas, A., Lubarsky, S., Durning, S., & Young, M. (2017). Knowledge syntheses in medical education: Demystifying scoping reviews. Academic Medicine, 92(2), 161–166. https://doi.org/10.1097/ACM.0000000000001452

The University of Edinburgh. (2021). HCP-Med: About the programme. Retrieved September 10, 2021, from https://www.ed.ac.uk/medicine-vet-medicine/edinburgh-medical-school/mbchb-for-healthcare-professionals/about-the-hcp-mbchb

Wackett, A., Daroowalla, F., Lu, W. H., & Chandran, L. (2016). Reforming the 4th-year curriculum as a springboard to graduate medical training: One school's experiences and lessons learned. Teaching and Learning Medicine, 28(2), 192–201. https://doi.org/10.1080/10401334.2016.1146610

Whelan, A., Prescott, J., Young, G., Catanese, V., & McKinney, R. (2020). Guidance on medical students’ participation in direct patient contact activities. https://www.aamc.org/system/files/2020-04/meded-April-14-Guidance-on-Medical-Students-Participation-in-Direct-Patient-Contact-Activities.pdf

Williams, B. C., Mullan, P. B., Haig, A. J., Malani, P. N., Perry, J. S., Riba, M., Williams, J., Kolars, J. C., & Mangrulkar, R. S. (2014). Developing a professional pathway in health equity to facilitate curricular transformation at the University of Michigan Medical School. Academic Medicine, 89(8), 1153–1156. https://doi.org/10.1097/acm.0000000000000286




How to Cite

Barrett, A., Cheshire, L., & Woodward-Kron, R. (2022). Flexibility in primary medical programs: A scoping review. Focus on Health Professional Education: A Multi-Professional Journal, 23(4), 16–34. https://doi.org/10.11157/fohpe.v23i4.579