University of Toronto Faculty of Medicine

Medical Education Program Highlights The University of Toronto Faculty of Medicine was founded as a school of medicine in 1843. It is uniquely positioned as the only medical school operating in a greater Toronto area with a diverse population of more than 6 million people. The MD program is delivered in partnership with 30+ affiliated clinical teaching sites, including 9 fully affiliated hospitals and research institutes and 4 associate affiliated hospitals. Partnered with the Faculty of Medicine, they comprise the Toronto Academic Health Science Network (TAHSN), one of the largest biomedical research, education, and clinical care networks in North America. A unique feature of the MD program is its academy system. The 4 academies—FitzGerald, Mississauga, Peters-Boyd, and Wightman-Berris—comprise clusters of affiliated hospitals. Medical students are assigned to an academy as part of the admissions process, with each academy providing students with a distinctive clinical community of learning for the program’s duration. With an annual entry class of 259 domestic students and up to 10 supernumerary international students, the MD program is the largest in Ontario and one of the largest in Canada. It has a large and highly competitive applicant pool and consistently high rate of acceptance of offers. See Table 1—Student Application Characteristics, 2011–2019.Table 1: Student Application Characteristics, 2011–2019In alignment with our commitment to better reflect the society we serve, the MD program has established the Indigenous Student Application Program (first entry in 2012) and Black Student Application Program (first entry in 2018). The goals of these application pathways are to break down some of the barriers that might impede these students from applying to medical school and to increase their representation within the program. There is also a long-standing admission pathway for the MD–PhD program, the largest of its kind in Canada. Curriculum Curriculum description The preclinical Foundations curriculum (years 1 and 2) is composed of 6 courses, 4 longitudinal components, and longitudinal themes. The weekly curriculum is organized to include the equivalent of a full day of unscheduled time, providing students with time for self-study and with early exposure to the clinical environment. See Supplemental Digital Appendix 1—Foundations Curriculum—at https://links.lww.com/ACADMED/A843. Clerkship begins with the Transition to Clerkship course, which prepares students for a series of core clinical rotations that are the focus of year 3. Students reconvene from various clerkship rotations for centralized teaching (transition education days) throughout year 3. In year 4, students have the opportunity to pursue elective experiences and complete a Transition to Residency course. See Supplemental Digital Appendix 2—Clerkship Curriculum—at https://links.lww.com/ACADMED/A843. Multiple curricular themes and a Portfolio course support longitudinal, integrated teaching in areas interwoven throughout all 4 years of the MD program. These longitudinal themes are grouped into 3 major categories related to priority population groups, specific CanMEDS roles, and specific content areas. Curriculum changes since 2010 The introduction of the Foundations curriculum over 2016–2017 (year 1) and 2017–2018 (year 2) is one of the most significant changes made to our delivery of medical education. Drawing on theories of expertise, particularly training for adaptive expertise, we implemented curricular strategies and instructional principles that align education activities with the goal of preparing learners to become adaptive physicians. Centered on 72 virtual patient cases, our spiral curriculum introduces learners to complexity and variation, which are necessary prerequisites for expertise development. Learners address this complexity through integrated instruction, productive struggle during guided discovery learning, and assessment that enhances guided learning.1,2 Learning experiences focused on career planning, and wellness/resiliency have been integrated into the core curriculum across all 4 years. This includes shadowing opportunities in Foundations, a longitudinal resiliency curriculum, and career planning learning sessions in both Foundations and year 3 transition education days. The clerkship structure underwent significant revisions over 2010–2011 and 2011–2012 to ensure that all students experience the core specialties and have opportunity to complete the same number of elective weeks before the residency ranking process. The opportunity to pursue a 2-week home school elective in May/June of year 3 was introduced in 2019–2020. Two new courses (year 3, Transition to Clerkship, and year 4, Transition to Residency) to support students at key medical education transition points were introduced in 2010–2011. A new longitudinal Portfolio course designed to facilitate students’ professional development through small-group discussions and guided reflections was introduced in 2010–2011. The initial iteration of this course spanned years 3 and 4 and expanded to years 1 and 2 concurrent with the introduction of Foundations. Assessment Over the 2017–2018 academic year, the MD program refreshed its overarching education goals to more clearly articulate the program’s aspiration to prepare graduates who are: Clinically competent and prepared for life-long learning through the phases of their career Ethical decision-makers dedicated to acting in accordance with the highest standards of professionalism Adaptive in response to the needs of patients and communities from diverse and varied populations Engaged in integrated, team-based care wherein patient needs are addressed in an equitable, individualized, and holistic manner Reflective and able to act in the face of novelty, ambiguity, and complexity Resilient and mindful of their well-being and that of their colleagues Capable of and committed to evidence-informed practices and scholarship and a culture of continuous performance improvement To support achievement of these goals, the MD program curriculum is governed by a competency framework adapted for an undergraduate medical education context from CanMEDS 2015. Our competency framework is also informed by Medical Council of Canada objectives and Association of Faculties of Medicine of Canada Entrustable Professional Activities for the transition from medical school to residency. See Supplemental Digital Appendix 3—Medical Education Program Objectives—at https://links.lww.com/ACADMED/A843. The Office of Assessment and Evaluation has expanded program evaluation measures beyond traditional measures, such as student satisfaction, to include analytics, meaningful qualitative data, and objective assessment data. These are collected and synthesized to evaluate specific courses and components as well as the program as a whole against the intended outcomes. Assessment changes since 2010 Concurrent with the development of Foundations, we adopted a programmatic assessment model that shifts the purpose of assessment from assessment of learning to assessment for learning. Foundations assessments include frequent no-stakes, formative quizzes, as well as assessments to evaluate mastery every 2–3 weeks. An e-portfolio (“Learner Chart”) provides students with access to all of their assessment data. Foundations students meet regularly with an academic coach, with the focus on performance improvement, guided by personalized learning plans to address their challenges and strengths.1 Our Foundations assessment model includes early identification of students who might need additional guidance as well as provision of resources and coaching to enhance self-regulated learning, study strategies, and forms of support tailored to their needs. The Foundations assessment items were (and continue to be) developed to test an integrated understanding of foundational and clinical knowledge. Evidence-informed practices in assessment writing and standard setting have been put into practice on an ongoing basis. Progress testing has been introduced to longitudinally track student and cohort performance against program objectives. Pedagogy Independent learning: In Foundations, students are provided with readings, videos, e-learning modules, and other resources they are expected to engage with. Similar independent learning takes place in many core clinical rotations. Large-group lectures: Lectures are used in both Foundations and for centralized clerkship learning experiences. These lectures are video-conferenced between our St. George and Mississauga campuses. Some, but not all, of these lectures are recorded for future viewing. Small-group learning/discussions (tutorials, workshops, or seminars): In Foundations, tutorials support case-based learning as well as specific curriculum components and longitudinal experiences (e.g., health in the community, integrated clinical skills, portfolio, health science research). Clinical skills development is supported through skill-based and clinical decision-making workshops in both Foundations and core clinical rotations. Seminars provide an opportunity in both forums for discussion of longitudinal themes (e.g., ethics, interprofessional education, medical psychiatry, pharmacology) and rotation-specific content. Experiential learning: Interactions with standardized patients and real patients, community site visits, role play, and/or simulations have been integrated into our Foundations curriculum. Anatomy labs: Scheduled throughout Foundations, students prepare for anatomy labs using digital anatomy apps and videos and attend in-person to explore dissections, prosections, and anatomical models. Clinical experiences (ambulatory and inpatient): Each clerkship rotation includes substantial time spent learning in the context of providing care to patients, often as part of a multidisciplinary team, in a variety of settings including ambulatory clinics, hospital wards, emergency departments, operating rooms, labor and delivery suites, and so forth. Simulations and standardized patients are also incorporated into our core rotations where appropriate. Changes in pedagogy since 2010 To enable and support productive struggle, active learning, and cognitive integration, the curriculum evolved from its previous course-based organizational structure to a series of spiraled blocks that build upon each other conceptually, with each block comprised of a sequence of scaffolded cases with progressive introduction of complexity. This evolution involved a shift from lecture-heavy learning to case-based learning, with each case (virtual patient) acting as the core for the week’s learning. These virtual patient cases enable students to contextualize their learning and integrate foundational knowledge within the structures of the curriculum.1 Clinical experiences Clinical experiences are provided in our 30+ affiliated clinical teaching sites. In year 2, students are exposed to generalist care through the Family Medicine Longitudinal Experience. Each student is matched with a family physician with whom they spend 6 half days at a community-based clinical site. In year 3, students complete a series of core clinical rotations of varying lengths. Core family and community medicine, internal medicine, and pediatrics rotations include significant ambulatory experiences. All clinical teaching sites used by our family and community medicine rotation have identified one or more vulnerable populations as priorities for their practice in the local community. Students assigned to those sites interact with those vulnerable populations as part of required clinical learning activities. In year 4, all students are required to complete at least 1 of 3 selective rotations in a community setting. Curricular Governance The MD Program Curriculum Committee is the single, centralized governing body that has overall responsibility for the MD program curriculum. Curricular governance is supported by standing subcommittees that report to the Curriculum Committee. See Figure 1—Curricular governance.Figure 1: Curricular governance.Education Staff Oversight of the administrative, governance, and leadership structures that support the planning, implementation, delivery, and evaluation of the MD program curriculum is located within the Office of the Vice Dean. The following 6 units support MD program operations: Enrollment Services, Curriculum, Student Assessment and Program Evaluation, Integrated Physician Scientist Program, the Mississauga Academy of Medicine, and the Office of Health Professions Student Affairs. See Figure 2—Medical education leadership.Figure 2: Medical education leadership.Faculty Development and Support in Education The MD program has a dedicated director of faculty development responsible for managing development and delivery of a wide range of faculty development events and resources designed specifically to support the various teaching roles across the curriculum. Faculty development is delivered at the clinical sites to make it as feasible and accessible as possible for distributed faculty. Regional Medical Campuses Formed in partnership with the Faculty of Medicine, the University of Toronto Mississauga, and Trillium Health Partners, the Mississauga Academy of Medicine (MAM) officially opened its doors in August 2011. In conjunction with the opening of MAM, the entering class size of the MD program increased by 9 seats in 2011 to our current entry target of 259 domestic students. Educational experiences across sites A consistent educational experience across sites is assured through the MD program’s centralized and integrated curricular governance. Initiatives in Progress Development of an integrated, longitudinal career advising and preparation curriculum that spans all 4 years focused on providing relevant and developmentally appropriate education and skills development. Shift to competency-based assessment in clerkship, specifically through the introduction of workplace-based assessments informed by programmatic assessment principles. Clerkship reorganization to provide students with greater scheduling flexibility (including to support wellness), enhanced opportunity for ambulatory clinics, integrated simulation opportunities, and longitudinal patient experiences. Revisions to our 2 transitions courses to more effectively support students at key transition points.

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