Université de Montréal Faculty of Medicine

Medical Education Program Highlights About 1,300 students (including 200 at the Mauricie Regional Campus) are currently being trained in the undergraduate MD program of the Faculty of Medicine of Université de Montréal, making it one of the largest in North America. The entire education is provided in French, as we serve a population whose mother tongue is French. Social accountability of doctors as active members of society is an important value for our medical school, a value we wish to convey to students. Our faculty received the 2019 AMEE ASPIRE-to-Excellence Award in Social Accountability, underscoring this special feature. The beginning of year 1 is marked by a symposium where students are introduced to humanities and the concept of social accountability by speeches from local and international leaders who are involved with underserved populations. During clerkships, students take a 1-week required rotation in social commitment and community health, with clinical exposure to vulnerable and marginalized populations, as refugee claimants, domestic abuse victims, sex trade workers, or prisoners. Two bodies are prospectively involved in our curriculum: the Office of Clinical Ethics and Office for Patient Partnership and Collaboration. Faculty collaborators from both offices actively participate in the Program Committee. Students benefit from a diverse and strong hospital network associated with the Université de Montréal, with several institutions of highly specialized care: the new Hospital University Center inaugurated in 2018, Sainte-Justine Mother and Child University Hospital Center, Montreal Heart Institute, and National Institute of Legal Psychiatry. Ten other integrated health centers and 17 family medicine groups located in Montreal and across Quebec constitute the University Integrated Health Network. Curriculum Curriculum description See Supplemental Digital Appendix 1—Curriculum Structure and Sequencing—at https://links.lww.com/ACADMED/A961. Curriculum changes since 2010 Major changes were implemented to clerkships in 2013: The surgery, pediatrics, internal medicine, obstetrics–gynecology, and psychiatry rotations decreased from 8 to 6 weeks. Two of the original 8 weeks of the family medicine rotation were removed to create 2 new 1-week rotations in palliative care and social commitment and community health. Elective rotations were increased from four 4-week rotations to twenty 2- or 4-week rotations, including three 2-week selectives in medicine, surgery, and pediatrics. Lectures taking place during clerkship and ethics workshops were combined into 7 “campus weeks” where students reunite at their respective central or regional campus. Simulation half days are now matched to associated rotations in internal medicine, obstetrics–gynecology, psychiatry, surgery, pediatrics, and emergency medicine. All end-of-rotation written assessments were eliminated, except for internal medicine. They were replaced by integrative progress tests taken throughout clerkship. To allow for more stability in students’ rotation sites, 85 places are reserved for students wishing to remain in one institution during clerkship (centralized clerkship). For these students, 26–34 weeks of clerkship take place in a single institution. Students who are parents, elite sport students, and special accommodation students take precedence in these spots. Other changes: 2017: Improved teaching in dermatology (module), allergy (simulation center), and ethics (preclinical workshops added) 2018: Curricular change in teaching pain management, with special focus on appropriate opioid usage 2018: Entrustable Professional Activities (EPAs) introduced in clerkship. In 2019, EPAs were formalized into a course; although EPAs remain formative assessments, students must reach specific EPA goals to pass 2019: Enhancement of the curriculum in First Nations’ health and social responsibility 2019: Preparatory year curriculum was changed completely both at the Montreal Campus and at UQTR (Université du Québec à Trois-Rivières) for Mauricie students; courses were reformatted, sequencing was changed to avoid overlap, and an effort was made to standardize teaching and learning experiences at both universities 2019: Ultrasound skills added to several existing simulation scenarios at the simulation center Assessment Medical program objectives are based on the CanMEDS Framework. See Table 1—Program Objectives and Assessment Methods.Table 1: Program Objectives and Assessment MethodsPreclinical years: Each course in years 1 and 2 has a midcourse low-stakes examination (2017). Previously, students had marks attributed completing the examination. With the use of EXAMSOFT software, students take examinations online and get the exact scoring of their performance, along with a retroaction based on success rate on learning objectives. The Nephrology and Urology course, in year 2, was transformed from problem-based learning (PBL) to team-based learning (TBL) (2011). Students are paired for mutual feedback about their participation within the team. Teachers assess the quality of feedback given by students. A formative progress test was added for second-year students (2016). Self-assessment of progression and learning strategies has been introduced to PBL (2015) and has been added in Introduction to Clinical Medicine and Initiation to the Clinical Approach courses in years 1 and 2 (2017). Clerkship: “Learning opportunities,” direct observation of clinical competencies as “disclosure of bad news,” was introduced (2010). Direct observations were mapped into the Association of Faculties of Medicine of Canada EPAs (2017). Written examinations at the end of each clerkship rotation were removed (2013). Progress tests (PTs) in clerkship replaced them. Students perform 3 PTs in year 3 and 2 in year 4. They get a personalized retroaction classified by learning objectives. Written examinations were reintroduced in medicine (2017) and in public health and public health and community medicine (2019). An end-of-clerkship OSCE was introduced (2017). If a student fails the OSCE, the remedial is in OSLER (Objective Structured Long Case Examination Record) examination. An end-of-clerkship written exam was added (2018). Both these assessments must be passed to earn the MD degree. Preclinical and clerkship: Numeral marks were replaced by pass/fail scoring for all courses (2018). Parallel curriculum or track The University of Montreal does not offer a 3-year MD degree program. Pedagogy The following pedagogical approaches are used: Case-based learning Team-based learning Lectures Laboratory Role play/dramatization Simulation/standardized/simulated patients Clinical experience: ambulatory Clinical experience: inpatient Self-directed learning/tutorial Video/podcast Workshops Interfaculty workshops (involving pharmacy, nutrition, physiotherapy, kinesiology, nursing, dentistry, speech therapy, audiology, optometry, and social sciences students) Changes in pedagogical approaches since 2010: Workshops in clinical ethics, with one each practicing physician, resident, and patient collaborator Testimonial lectures from patient collaborators and First Nations patients Improvement in use of concept maps in PBL Podcasts in surgery Formative short-form PTs Preceptorship for clerk students who demonstrate clinical difficulties Clinical reasoning comprehensive assessment for students with difficulties during clerkship Clinical experiences Types of clinical site(s) required educational experiences: Tertiary and quaternary care hospitals Community hospitals Local community service centers Home visits Primary care physicians’ offices and family medicine groups Required longitudinal experiences Our regional campus offers an integrated longitudinal clerkship. This approach aims at providing students with an authentic practice experience and at developing professional identity early on. This apprenticeship by iteration emphasizes self-reflective practice and collaborative work with other health care professionals, while students are exposed to ambulatory care. Students also benefit from individual and group mentorship. Clinical experience first encounter Learners have their first clinical encounters with patients in the first semester of year 1, during the Introduction to Clinical Medicine course, followed in year 2 by Introduction to Clinical Approach. They spend 1 half day every week learning history taking and physical examination as well as fundamentals of physicianship. Required and elective community-based rotations Required rotations: Family medicine Public health and community medicine Social commitment and community health Palliative care Elective rotations: First Nation’s health Remote area family medicine Addiction medicine Social pediatrics Primary care psychiatry and intellectual deficiency Day care internal medicine Social and legal medicine Challenges in designing and implementing clinical experiences for medical students The challenges we face are linked to large numbers of students needing placement. These numbers also imply faculty and faculty development, faculty training, and continuous pedagogical education, for ends of teaching and fair student assessment. The new implementation of EPAs illustrates this challenge as some teachers practice in remote centers, including regional family practice. Curricular Governance See Figure 1—Curricular governance.Figure 1: Curricular governance.Decentralized curricular governance Curricular governance remains at the UME level. Budgets for teachers responsible for clerkship rotations are managed departmentally. However, the template for fair remuneration is decided by the UME director. Education Staff Academic and administrative support lies in the UME office. The academic direction counts 8 physicians in Montreal and 3 in Mauricie. There are 17 administrative management and office staff in Montreal and 3 in Mauricie. The Program Committee is central for planning, implementing, evaluating, and overseeing the curriculum. Subcommittees that report to the Program Committee are: Clerkship Committee Pedagogical and Competency Apprenticeship Committee Clerkship Competencies Development Committee Committee of the Centre for Learning of Physician Abilities and Behaviors (simulation) To help manage these tasks, a pedagogical assistant and faculty member are appointed to follow-up of development of competencies. Regional Mauricie campus directors—the assistant dean, clerkship director, and preclinical director—are involved in decisions for planning and implementation. They share responsibilities of curricular oversight and maintenance of tools to support curriculum delivery and monitoring. For the development and maintenance of tools supporting curriculum delivery, monitoring, and management, the Medical Studies Management Committee meets weekly in videoconference with Mauricie campus directors and administrative assistants of each campus. Decisions about curriculum delivery and application of academic rules for individual student situations are discussed by that committee. The Evaluation Office has professional persons who collate results of written examinations, OSCE, and rotations assessments. They also prepare aggregated assessments of teachers, courses, and rotations, then diffuse these evaluations to the appropriate persons (students, direction, department heads, etc.). Teacher assessments are given only to individual teachers and their department head. Medical education leadership The associate deans who oversee UME are: UME associate dean and an assistant for the Mauricie campus Associate dean for faculty affairs and pedagogical and professional development, responsible for the Office of Medical Education (CPASS [Centre de pédagogie appliquée aux sciences de la santé]) Associate dean for student life, responsible for students affairs (BAER) Executive associate dean, clinical sciences and network, responsible for the Evaluation Office and relationships with clinical teaching sites in the clinical network Department of Medical Education The office is responsible for pre-UME and UME. Student Affairs is a distinct and confidential service. Faculty Development and Support in Education Professional development for faculty as educators Professional development is under the associate dean for faculty affairs and pedagogical and professional development. The office is called CPASS. Role of teaching in promotion and tenure There are 4 aspects considered for promotion and tenure decisions: teaching, research, contribution to the institution, and academic visibility. Teaching and excellence in teaching include clinical teaching to clerks and residents in hospitals or clinics, lectures, and teaching in simulation or PBL, etc. Scholarship and research in medical education are considered in the research aspect. Academic administrative involvement is considered as contribution to the institution. Invited speaker activities and teaching awards are considered academic visibility. CPASS provides continuous education for faculty members of the whole Faculté de Médecine. This includes pregraduate and postgraduate Medicine, Rehabilitation School, Speech Therapy and Audiology School, Nutrition School, and Kinesiology and Movement Science School. CPASS has pedagogical leaders, educators from several disciplines. They are trained to teach faculty and residents and develop material for that end. Support from 2 educational technologists involved in development of interactive self-learning modules is provided to them. Regional Medical Campus There is one regional campus, in Trois-Rivières, in the Mauricie region. It hosts 44 students from years 1–4. An integrated longitudinal clerkship experience is offered for 12 clerks. Educational experiences across sites All curricular aspects are coordinated at the direction level. Teachers or administrators of the Mauricie campus sit in every governance committee. The Medical Studies Management Committee meets weekly, using videoconference for the Mauricie directors. Administrative assistants for each campus are present. All lectures from the Montreal campus are presented in videoconference in Mauricie. Sometimes lectures occur in Mauricie, transmitted by videoconference to Montreal. This helps students from both campuses understand videoconferencing best practices and behaviors, for example, asking questions at microphones so students from both campuses have identical learning experiences. For PBL, Montreal and Trois-Rivières videoconference before every morning session, to ensure that teachers stress identical points and that their questions are answered. Scenarios for the simulation center teaching are identical at both campuses. Faculty development sessions are also given in Trois-Rivières.

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