Sherbrooke University Medical School

Curriculum Management and Governance Structure ♦ In 1987, after a grand reform of the educational program, the school instituted an organ-system-structured PBL preclinical curriculum. The ongoing evolution of medical education and fundamental change in health care led the school, at the end of the 1990s, after more than ten years of experience, to “reform the reform.” ♦ A curriculum committee is in place that is chaired by the vice dean for undergraduate education. ♦ The committee is composed of student representatives from each cohort, resource and content expertise (heads of clinical departments), specific pedagogic input (consultant in education), the faculty development program director, members of the coordinating committee, and ad-hoc heads of specifically appointed subcommittees. ♦ The committee's function is to present and discuss all major changes in the content of the teaching and learning process and to assure ongoing evaluation of the curriculum in order to reflect upon and plan future changes. ♦ A coordinating committee deals with the everyday implementation of curricular policy. ♦ The coordinating committee is composed of the coordinators of the five undergraduate sectors (basic sciences, PBL, clinical skills, clinical integration, and clinical clerkship), the chair of the evaluation committee, and the chief faculty secretariat administrator, and is chaired by the vice dean for undergraduate education. ♦ The coordinating committee meets bimonthly and monitors curricular activities as well as trouble-shooting day-to-day problems in the undergraduate program. Office of Education ♦ The Office of Medical Education has been in place for more than two decades. ♦ The undergraduate program and the education office share a common conceptual framework of what to teach (medical expertise), how to teach (contextual learning with teachers as facilitators), and how students learn (the cognitive psychology of information processing for learning). ♦ Since 1997, the office has worked very closely with the undergraduate program to implement faculty training and support congruent with the pedagogic methods used by the faculty. ♦ PBL tutors are obliged to attend yearly full-day courses adapted to keep pace with changes suggested by internal and external curricular monitoring. More than 80% of teachers have participated. ♦ Other major faculty development programs currently being presented by the education office include training in clinical coaching and clinical-reasoning sessions as a continuing part of the reform in the clinical clerkship. Budget to Support Educational Programs ♦ Funding of all medical education in Quebec comes from the provincial government and from student tuition fees. ♦ A highly sophisticated local system integrating clinical practice plan funds assures that appropriate remuneration is directed towards those who are actively involved in teaching activities and educational development. ♦ Teachers and educators thus have some direct reward for their efforts. Valuing Teaching ♦ Undergraduate teaching is one of the fundamental pillars of our medical school and this is made clear in staff recruitment. ♦ Clearly much depends on individual motivation and interest, but heads of department also suggest or delegate where appropriate. ♦ Teaching activities also figure prominently in assessment for faculty promotion. ♦ Individual teaching competence is assessed through PBL-unit monitoring, and annual faculty development is obligatory before the beginning of each teaching unit. CURRICULUM RENEWAL PROCESS Learning Objectives ♦ General learning objectives have been in place since the implementation of the PBL curriculum in 1987. ♦ Terminal medical competencies, largely related to those defined by the Medical Council of Canada, are defined in relation to each clinical clerkship and for the clerkship overall. ♦ The school is in the process of emphasizing humanistic and community-oriented components of the curriculum. ♦ Terminal medical competencies for each PBL unit are currently being identified, with the aim of integrating clinical skills and clinical reasoning with the new knowledge acquired in the units in addition to the integration of public health concepts and professional values. Changes in Pedagogy ♦ Ten years into a wall-to-wall PBL curriculum, during which time our students continued to perform well at the national level, formal and informal assessments revealed the need for overhaul. ♦ Lack of communication across curricular components, relative weaknesses in isolated knowledge domains, declining motivation of students, teachers, and management, and lack of teacher standardization led us to decide to “reform the reform” of our undergraduate program. ♦ Following much internal review and reflection based on the educational literature, it was decided to propose an integrated conceptual framework based on three different recognized theories from the medical literature. The first refers to the longitudinal acquisition of medical expertise from the novice who enters medical school to the expert clinician of later years. This theory suggests that there is a need to design a different, more efficient way of acquiring knowledge, skills, attitudes, and habits of mind. For this reason, the aim is to blend learning objectives into terminal competencies integrating all of these concepts. The second refers to the learning process itself and how students learn. —To facilitate the reactivation of prior knowledge, the learning objectives were mapped for the entire curriculum and made available to students and teachers. —In order to foster better organization of knowledge in memory, the students are required to provide concept mapping of knowledge learned after individual study of each PBL problem. —A program had been implemented to help students study more effectively by helping them develop better learning and motivational strategies. The third theory concerns contextualized teaching and learning. —In order to restore to teachers their importance in the teaching process, we have evolved from the passive tutor to one who is much more active. —Tutors are encouraged to contextualize the learning objectives by appropriate clinical examples and this is reflected in students' end-of-unit assessments of tutors' ability to transfer knowledge. ♦ Faculty development programs have been implemented to educate teachers in aiding students to transfer theoretical to practical knowledge, in giving constructive feedback on concept maps, and in reading and learning strategies. Thus the teacher can pass on to the apprentice the benefit of his or her acquired medical expertise. ♦ Enormous time and effort has been invested in the reform of pedagogic methods across the spectrum of the curriculum, from the technical aspects of the PBL tutorial to the broad application of teaching philosophy and current education theory. ♦ A major project is under way that will serve to export and implement this conceptual framework to undergraduate clinical teaching, postgraduate training, and continuing medical education. Application of Computer Technology ♦ Although students are not required to own computers, many do, and all have access via the medical school library ♦ All educational objectives have been collated into a database available to students and faculty through an intranet. ♦ Pilot projects are in place in some PBL units using Internet links with hypertext features, etc., to access validated resources and materials. Clinical Experiences ♦ The students have a three-week clinical exposure in the first trimester. ♦ Clinical skills learning sessions in parallel and related to PBL units begin in the second half of the first year and continue to the final-year clerkship. ♦ There is a two-week clinical community experience in the latter part of the second year. ♦ The clinical clerkship is preceded by a trimester of clinical integration and preparation. ♦ The clinical clerkship takes place over a period of 15 months of obligatory and optional clerkships, primarily in hospitals (wards, OR, and clinics), but also in primary care clinics. ♦ The goal is to expand the community clinical exposure of the undergraduate program. Curriculum Review Process ♦ The themes and goals of curricular reform have been defined in relation to the pedagogic methods used. ♦ To achieve the ultimate goal of the acquisition of medical expertise, the plan is to standardize the skills of the teachers through very active faculty development. This provides a coherent and common approach across the spectrum of clinical specialties and basic sciences. ♦ The results of systematic curricular monitoring, including formal student evaluations of teaching units, learning objectives, teachers, and modes of evaluation, are collated and analyzed for presentation and discussion at coordination and curriculum committee meetings. ♦ Subsequent changes in policy or practice distills from these discussions and the education office designs and implements faculty training in order to complete the reforms. ♦ Program coordinators produce annual lists of objectives and reports that are discussed with the vice dean and presented to the coordination and curriculum committees. ♦ Subcommittees are created to address specific needs and priorities. ♦ Practical decisions for implementation are taken there-after. ♦ The decisions of the curriculum committee are overseen by the faculty council, chaired by the dean of the medical school. Changes in Assessment ♦ Standardized patients and OSCEs are used throughout the curriculum. ♦ Faculty development in the sphere of clinical coaching is putting much emphasis on the importance of direct observation of the student performing history taking and clinical examinations. ♦ In terms of traditional evaluation methods, the students' performances on the national licensing examination have been outstanding. ♦ Competencies are more difficult to evaluate than knowledge, and we are exploring modes of evaluation based on global performance as part of our program of terminal, integrated end-of-unit competencies. ♦ The development of a comprehensive structured oral clinical examination is one of the current priorities. Future Goals ♦ Immediate challenges are the implementation of end-of-unit competencies as well as a trans-unit curriculum in public health. ♦ The efficient use of computers across the curricular spectrum is under discussion, and faculty development will soon be in place. ♦ Other considerations include reform of the admission process, the effects of the feminization of medicine, apparent devaluation of professional values, and the implantation of legal, ethical, and caring issues. ♦ Finally, budgetary constraints imposed on the universities are putting a heavy strain on the various components of medical education; maintaining and improving standards of excellence in medical education in the face of such pressures remain the perennial challenge.

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