For a teenage boy growing up in a small town, the local auto mechanic can become a best friend and key to social success. I had great admiration for one in particular who would let me watch and explain what he was doing as he went about trying to resuscitate whatever antiquated pile of spare parts I was currently passing off as my “drive”. He always seemed to be able to find a way to repair whatever part was ailing, or adapt yet another spare part to replace whatever previously adapted spare part was no longer operational. But sometimes, even he would throw in the proverbial towel. “There are times”, he would say, wiping grease from his hands, “when you just need to jack up the horn and drive under a new car”.
Many times, when grappling with really difficult and highly complex problems, we are tempted to just “blow it up and start all over again”. The concept of going back to first principles and taking a new and fresh approach that sets aside all of the partial “patch work” fixes and “spare parts” that have been put in place over the years can be hugely tempting, particularly when it’s obvious that those noble and well-intentioned attempts are now resulting in a system that is unnecessarily complex and no longer addresses the initial intent.
But we don’t often get those opportunities, particularly when dealing with established and multifaceted systems like, for example, medical schools. Former United States President Calvin Coolidge is credited with remarking that “changing a college curriculum is like moving a graveyard – you never know how many friends the dead have until you try to move them.” We tend to resist change and cling to the familiar, particularly when those changes may be seen as threatening or offensive to folks who have developed or embraced them with every good intention.
All that notwithstanding, a rather courageous (and perhaps naïve) group set out to do just that at our medical school 7 years ago. There were multiple motivations. Many faculty were expressing frustration and a sense that we could do much better. Students were quite vocal in their view that the curriculum seemed out of keeping with their needs. The catalyst was provided by a recently received accreditation review that made it abundantly clear that multiple and key facets of our program required review and that no partial repair was going to address those concerns.
And so, an intrepid group was assembled and set out on what turned out to be a year long journey to “jack up the horn and drive under a new car”. The group consisted of three clinical faculty members who were established and respected medical educators and had great familiarity with our current curriculum and its history (Lindsay Davidson, Michelle Gibson, Sue Moffatt); two specialists in medical education theory and practice (Sheila Pinchin, Elaine VanMelle); a much respected clinician and teacher with longstanding interest in the development of Professionalism and the so called “non-medical expert” competencies (Ted Ashbury); a Pathologist/Immunologist who had led our basic science group in developing and delivering what was called “Phase 1” of the curriculum (Sherry Taylor); and a freshly minted and recently recruited Master of Education who was passionate about the role of generalism and the representation of Family Medicine within our curriculum and medical school (Michael Sylvester).
Despite their differences, the group gelled remarkably well. They were united by many things but, I believe, first and foremost by a shared commitment to provide the best possible educational experience for our students, summed up rather nicely in the following statement of intent:
Our graduates will have exemplary foundations in medical competencies that will prepare them for success in qualifying examinations and in post-graduate training programs and for fulfilling careers serving their patients and their communities.
A number of key decisions followed…
- We would base our curriculum on competencies as expressed by the CanMEDS framework and Family Medicine principles of practice.
- We would use the AAMC Scientific Basis of Medical Practice as a framework for our basic science teaching
- We would use the Medical Council of Canada Clinical Presentations as a basis for teaching the Medical Expert components of our curriculum
- We needed a course-based structure in order to assign competencies and clinical presentations in a logical, integrated and progressive fashion
- We would introduce more small group teaching to complement our lecture-based approach
- We would ensure students had opportunity to monitor their own learning process by introducing formative assessments into every course
- We would identify and retain aspects of our curriculum that were very successful, such as our Clinical Skills program
- We would provide more patient-centred experiences early in the curriculum in order for the students to engage their “physician” role early and to recognize the relevance of their early learning
- We would provide more opportunities for structured learning in later years by expanding our Clerkship to two years in order to develop three periods of “Core Curriculum” where the students would come back to school to learn complex issues or those that are best introduced after they’ve engaged clinical medicine.
What emerged was dubbed the “Foundations Curriculum” which had to be introduced over four years in order to ensure every class enrolled during those years received a full, albeit somewhat different, curricular experience.
The description of that new curriculum was articulated in a document entitled “Curricular Goals and Competency-Based Objectives” that was widely discussed, passed by our Curriculum Committee and endorsed by all faculty at School of Medicine Council. Because the undergraduate office happened to have a large supply of red printing paper that was used to produce a cover, the document became known as the “Red Book”.
That document has now been revised twice, based on experience with its implementation and considerable feedback from students, teaching faculty and curricular leaders. That third version, approved recently by our Curriculum Committee, has been packaged very attractively by Sheila Pinchin and her colleagues, and is being released this week. It will be made widely available in both electronic and print formats, and should serve as an articulation of the “why, how and what” we teach, and unifying focus for all the following:
- Student Learning – this document outlines what we expect our students to know, to do and to be, by the time they graduate
- Curricular Design – our course structure, sequencing and content will all be guided by this document. Each course will be assigned some subset of the Program Objectives and MCC presentations outlined.
- Teaching Events – each one of the 3,000 or so individual teaching sessions we provide over the four year curriculum will be structured with the goal of relating to one or more of the Curricular Objectives.
- Assessments – a comprehensive “blueprinting” process developed and monitored by our Student Assessment Committee will ensure that all summative assessments relate to a subset of the objectives assigned to the course or competency to which they relate.
In summary, the “Red Book” provides a basis to ensure that the key educational triad is maintained, interrelating the three pillars of any educational program – Objectives, Teaching and Assessment. It also serves to keep all of those engaged in our educational enterprise “on the same page”.
I’m very grateful to all of our educators, students, faculty and administrative staff whose dedication and commitment make our curriculum, and our school, so special – spare parts and all.