Curriculum Renewal (CR) Overall
As the only medical school in BC, UBC must ensure that our medical graduates are able to meet the full spectrum of current and future health care needs of society, including physicians for rural and remote areas and clinician scientists.
The principles that underpin the renewed curriculum also align with the UBC strategic vision to:
- Increase flexibility of learning;
- Embed opportunities for inter-professional education with other health profession programs; and
- Move towards a competency-based, spiraled, integrated educational approach.
Watch Executive Associate Dean, Education Dave Snadden talk about why we are undertaking curriculum renewal.
As he notes, our current curriculum is a very good curriculum. We graduate exemplary MDs year after year. Therefore, one of the questions we are frequently asked about the curriculum renewal process is “why change it?”
There have been a lot of changes to health care since we last renewed our curriculum in 1997. One of the biggest has been the advancement in our scientific knowledge. Another is in our ability to use technology. Within our province-wide distributed MD program, we have embraced technological changes and innovations and we are now able to support learners in all areas of British Columbia.
In the Association of Faculties of Medicine of Canada (AFMC)’s “Future of Medical Education” project, there were a number of recommendations about the curriculum of medical schools across Canada and how they would have to change to meet future needs. Our renewed curriculum embraces all of these recommendations, in addition to addressing previous accreditation feedback.
For more information, see the Dean’s Task Force on MD Undergraduate Curriculum Renewal Final Report (2010).
The renewed curriculum will be made up of more integrated courses that developmentally spiral content. This gives the ability to be more flexible, and will better support students in their development. The spiral-based curriculum means that concepts will be periodically revisited, reinforced, and built upon so that students can absorb information in a more meaningful way.
In addition, the programmatic approach to assessment in the renewed curriculum means we will be able to effectively ensure that students are meeting required competencies and identify students earlier who may need additional attention, while not over-assessing.
Also, part of what we're doing through CR is embedding processes for continuous quality improvement. It's much better to allow our program to continuously evolve than to go through large scale changes every 10-15 years.
The end goal of renewing the MD Undergraduate Program (MDUP) curriculum is to develop and implement a transformative curriculum that will produce Doctor of Medicine graduates who will meet both the current and future health care needs of British Columbians.
The Curriculum Renewal Project Sponsor is the Undergraduate Medical Education Executive (UMEX) formally MD Undergraduate Regional Executive Committee (MDUREX). The members of this committee also sit on the Curriculum Renewal Project Steering Committee along with the Assistant Dean, Clinical Education, Director of Assessment, Director of Project, VFMP Administrative Director, and Evaluation Studies Unit representatives. The Curriculum Renewal Project Steering Committee provides strategic leadership and direction for the Curriculum Renewal project.
For many people, the renewed curriculum will feel very similar to the current curriculum. The program remains focused on training MDs and much of the content, although structured and delivered in different ways, will remain the same.
The renewed curriculum is based on a defined set of program Exit Competencies. All aspects of the curriculum, from year-level milestones to course learning outcomes to week objectives and educational activity objectives, all drive towards the overall Exit Competencies.
Applicable content from current courses (FMED, DPaS, Clinical Skills, and Family Practice) will be integrated into larger courses that focus on a series of clinical presentations. Each clinical presentation in the Foundations of Medical Practice (MEDD 411, 412, 421) and Transition into Clinical Education (MEDD 422) courses will draw on content from systems, themes, and clinical curriculum, and spiral back periodically to reinforce learning. This is primarily a structural change in the way content is delivered.
Similarly, in the renewed Year 3 clerkship course (MEDD 431), traditional clerkship disciplines (e.g.: Pediatrics and Obstetrics and Gynecology) will be grouped into four 12-week blocks, with the goal of increasing integration among disciplines.
The Flexible Enhanced Learning courses are also new to the curriculum. They bring together some content that was previously in the DPaS courses, along with an increased focus on scholarship and flexible opportunities for students to pursue a variety of activities throughout the four years of the MDUP.
Year 4 will be quite similar, with a series of clinical electives followed by the Transition into Postgraduate Education and Medical Practice course (MEDD 448). MEDD 448 will also be case-based, focusing on the most complex cases and giving students ample opportunity to prepare for residency by honing their clinical reasoning and practical application skills.
In addition to these structural factors, there is also a shift from problem-based learning (PBL) to case-based learning (CBL). The purpose of this is to make the experience more developmental for students. The CBL experience in first term of Year 1 will be different than the experience in second term of Year 2, with increasing emphasis on unguided questions and clinical reasoning. For tutors who have experienced PBL, it will feel very natural to facilitate these small group sessions.
Case-based learning (CBL) is a longitudinal learning experience used to facilitate the development of clinical reasoning and decision making in students. A CBL learning session integrates foundational science concepts with the clinical curriculum, providing the students with a structured environment in which to develop their cognitive skills. As the program continues, the cases increase in complexity, allowing students the opportunity to critically think about the information presented each week and identify the key points in each case.
In June 2017 the Class of 2019 will begin the first iteration of the renewed Year 3. This year-long course (MEDD 431: Clerkship) is organized into four 12-week integrated blocks:
- Women and Children’s Health (WCH) Block
- Includes clinical experiences in Obstetrics and Gynecology and Pediatrics
- Surgical and Perioperative Care (SPC) Block
- Includes clinical experiences in Anesthesia, Orthopedics and Surgery
- Brain and Body (BB) Block
- Includes clinical experiences in Internal Medicine and Psychiatry
- Ambulatory Care (AMB) Block
- Includes clinical experiences in Outpatient Internal Medicine, Dermatology and Ophthalmology Clinics, Emergency Medicine and Family Practice
This organizational structure allows for greater integration of common clinical presentations found within blocks thereby reducing redundancy and increasing opportunities to spiral content and themes initially encountered in Years 1 and 2.
The structure of Year 3 in the renewed curriculum will not change the CaRMS application process for UBC students. Matching will continue to occur in fourth year. The renewed Year 4 has been structured to ensure that all students have 24 weeks of electives prior to CaRMS interviews, putting UBC in the lead with the greatest, number of pre-CaRMS electives of any school across Canada.
Out of the 145 clinical presentations that form the backbone of the content for our renewed curriculum, 54 were covered during the first two years. The remaining 91 clinical presentations have been assigned to different blocks in Year 3 and will be explored using a variety of teaching methods, including clinical experiences, simulation sessions, small group exercises, online modules and interactive videoconferences. As students participate in patient care and educational activities in the different blocks, they will also have the opportunity to enhance their understanding of the clinical presentations covered in Years 1 and 2.
MEDD 439 (FLEX), originally scheduled as a third-year course, is now scheduled at the end of Year 4 as MEDD 449. This was done to address a Year 3 scheduling issue where the total length of curriculum time in Year 3 was reduced from 54 to 50 weeks. This does not impact the FLEX course in any way other than moving it to the end of Year 4.
From an assessment perspective, the renewed curriculum will be assessed in a coordinated way with a defined set of assessment methods, each of which is well suited to assessing certain types of competencies. Results of all assessments will be used to make decisions on student standing, with each assessment method bringing a unique and important type of information on student performance.
In addition to the new programmatic approach to assessment, there will be two new assessment methods that haven’t been used before in the MDUP: Portfolios and Progress Tests. The Portfolio is a developmental activity where students build foundational reflective learning skills in Years 1 and 2, and apply these in clinical environments in Years 3 and 4.
The Progress Tests are comprised of MCQs that sample the complete knowledge domain expected of an MD graduate. The cumulative results over time will be used to identify students who require additional attention and provide feedback about performance across subject and competency domains to guide learning.
In addition to these new assessment methods, Workplace-based Assessments, Written Exams, and Objective Structured Clinical Examinations (OSCEs) will continue to be used in a programmatic and consistent way.
Programmatic assessment is a more integrated, programmatic view of how a student is assessed across the four years of medical school. It ensures that assessment is built based on competencies and is developmental as a student progresses over time. Finally, it ensures that assessment is balanced across the curriculum and seeks to avoid redundancy, or, “over-assessment” of students.
The decision to make changes in assessment sits within the wider context of the key findings and recommendation made by the Dean's Task Force on MD Undergraduate Curriculum Renewal in their 2010 report. A high level recommendation was that ‘the Faculty develop a comprehensive integrated student assessment system that aligns with both the curriculum and the outcomes’, and within that change:
- The assessment system should be integrated across years and disciplines with explicit reference to exit competencies.
- The system should include both formative and summative assessments using a variety of quantitative and qualitative tools, including new assessment methods that are consistent with curriculum competencies, continuity of care and supervision, and the development of critical and integrated thinking.
- In redesigning the assessment system the burden of assessment on students and faculty must not be increased, and ideally should be reduced.
Overall, the goal of programmatic assessment is to approach assessment of students in an integrated and developmental manner. The approach to assessment in the renewed curriculum is designed to support the goals of programmatic assessment.
Programmatic assessment should:
- Ensure that all graduates have achieved the required competencies.
- Be integrative across years and disciplines.
- Be developmental; specifically testing competencies to the standard expected of students at different stages of the program.
- Be programmatic; competencies progress and build over time with linkages being made throughout the curriculum to avoid redundancy.
- Support effective decision-making by triangulating (using more than one approach) assessments over time.
- Provide regular, appropriate, and, timely feedback to students and faculty.
- Foster a culture that encourages learners to seek continuous improvements in their own and their peers’ performance toward achieving better health outcomes for patients and populations.
All four programmatic assessment components are used in Year 3 (MEDD 431):
- Written Exams (including Progress Tests)
- Workplace-based Assessment
A promotion decision will be held at the end of Year 3 and will be based on assessment results collected throughout the year. To pass Year 3, a student must pass each assessment component and supplemental exams (if applicable).
Assessment – Written Exams
There will be an integrated written exam at the end of each 12-week block. Each exam will consist of 180 questions. The ratio of questions will reflect the time spent in rotations within the block.
Each Progress Test question is developed based on the 150 clinical presentation cases seen through Years 1 to 4 of the renewed curriculum. Students can expect to see a developmental progression, each year, as they sit for the exams. These tests will also be used for early detection of students lagging behind (or excelling beyond) classmates in cognitive competencies, allowing students to understand how they compare to the class average. Finally, the test is also intended to motivate student learning, give students insight into the academic target at the end of the program, and provide practice for the Medical Council of Canada Qualifying Examination Part 1.
The Progress Test will not change in Year 3. In line with Years 1 & 2, there will be two Progress Tests, the first in August and the second in January.
Assessment – Workplace-based Assessments (WBA)
Currently, Years 1 and 2 have a multitude of both non-clinical and clinical work environments that include assessments which can be conceived as “Workplace-based Assessment”. For example, the Problem Based Learning (PBL) program includes assessment of the performance of each student in the group setting which closely parallels an End-of-Clerkship assessment. The students also receive preceptor generated assessment during the Family Practice continuum, and of course during Clinical Skills.
Consideration of the current curriculum and WBA demonstrates the directions that we need to consider as we proceed into the renewed curriculum. The WBA tools are fragmented across the four years. The variety is quite substantial and leads to difficulties with comparing results on the assessments from one year to the next or even between courses within a given year. Finally, the current WBA tools are not clearly aligned with the milestones and Exit Competencies.
Hence, the new WBA form will be used to ensure that these work-place environments are assessed in a standard and programmatic manner, across the four years of the program.
Workplace-based Assessments will be found in Case-based Learning (CBL), Clinical Skills, and Family Practice sessions in Years 1 & 2. In Years 3 & 4, WBAs will be used throughout clerkship and elective placements.
Each Workplace-based Assessments is low stakes. It is the accumulation of WBAs that will indicate the student’s grade. This makes it challenging to have many students failing as there are frequent opportunities to obtain formative feedback and many summative moments that count toward the overall score.
Due to the iterative nature of WBAs, the frequency of formative moments, and the immediate feedback after each WBA, remediation is in a sense, already built-into this kind of assessment. In fact, there may be more opportunity for students to receive feedback and improve on performance with WBAs in the renewed curriculum.
WBA grading is based on learning outcomes organized by the CanMEDS framework and yearly milestones. WBA recommendation for promotion or failure will be made by expert panels which are sub-groups of the Regional Student Promotion Sub-Committee (RSPS) based on the review of aggregated WBAs across the course.
The new WBA framework will lead to:
- more frequent feedback to students during Clerkships.
- more opportunities to document direct observation of students.
- early support and monitoring of students who are struggling.
- decisions for progress and promotion being based on robust longitudinal qualitative data.
Assessment – Objective Structured Clinical Examination (OSCE)
In the renewed Year 1, in addition to a summative Year 1 OSCE, a formative OSCE will be introduced at the end of Term 1. The formative OSCE will be an opportunity for students to participate in formative assessment and obtain feedback on performance before the summative OSCE at the end of Year 1. In Year 2, a summative OSCE is held towards the end of the year.
The mini-OSCE in the current curriculum is a practice OSCE with one station. The formative OSCE will contain four stations and will include immediate feedback from the examiner.
OSCE cases will be linked to the milestones such that student encounter OSCE stations in a developmental manner across the four year program.
There will be two OSCEs, one formative OSCE held part-way through Year 3 and one summative OSCE held at the end of Year 3. The OSCE will be programmatic, with OSCE stations that will assess a student’s ability to perform a variety of clinical tasks.
Assessment – Portfolio
Portfolios are growing in importance with the Royal College and Post Graduate programs looking to use them to facilitate and document the process of lifelong learning as part of the achievement and maintenance of licences. As an MD undergraduate program we have a duty to provide students with these core skills and suitable experiences to prepare them for residency.
Core foundational skills and habits developed in the Learning Portfolio have a direct relationship to patient safety and lifelong learning, including:
- Looking beyond knowledge growth,
- Practicing self-assessment, and
- Incorporating peer and societal feedback.
In Years 1 & 2, Portfolios occur within the Foundation of Medical Practice (FOMP) courses. In Year 1 this will be in MEDD 411 and 412; in Year 2, in MEDD 421 and 422. Portfolio as an assessment modality is also used in the FLEX courses.
As an active learning process, Portfolio uses formative assessment to drive student reflection and growth. The method is used to drive improvement in student performance connected to the acquisition of transferable abilities of life-long learning, using key concepts from within the 'care of patient' and 'populations, diversity and equity' domains to motivate their inquiry. Across the FOMP Courses in years 1 and 2, individual and group reflective dialogue are used as assessable moments for the coach to provide frequent, immediate, discriminating and caring feedback on the student’s ability to analyse, synthesise and evaluate their learning. These are key competencies in helping them to effectively integrate and make meaning of their learning, as a medical student, resident and practicing physician.
Each Portfolio session prompts students to generate ideas, either from existing curricular activities or through discovery during clinical experiences. As an active learning process it enhances the student’s learning by prompting the student to capture learning and connect these to foundational knowledge, their own values and developing identity. The role of the Coach is to gently antagonise their reflective dialogue individually and in groups, based on these ‘feedback moments’, as evidence to be formatively assessed to drive student inquiry and development of foundational abilities.
Portfolios in Year 3 will continue to provide formative assessment that utilizes and teaches self-reflective learning in small group sessions. These will occur once per block, and will continue to be facilitated by Portfolio Coaches. Continuity of student groups will be maintained in Year 3, as far as possible.
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