Visit to University of Calgary Faculty of Medicine - October 28-29, 1996

1. The Situation

• The medical school is 23 years old; accepted the first class of 40 students in 1974, now it has 70/yr.
• There are close to 100 basic science faculty with 80% of them on 100% research grants.
• Alberta went through a restructuring of health services reducing the number of hospitals in the Calgary region and consolidating specialty services.
• The medical faculty participated in a Province - and University-wide 21% budget cut.
• The clinical faculty has full time (tenure track), major part time, and volunteer faculty ranks.
• Originally, there were no departments, only divisions. About 12 years ago, departments were established. However, the departments do not have a budget.
• Departments have neither budgets nor curricular time. Research and teaching depend on a matrix organization. Space is assigned to research groupings, usually on a systems basis.
• The educational program is controlled by the faculty (not departments) through the Faculty Council. The Council's Executive Committee serves as the Nominating Committee for CC membership. The Dean appoints the chair who currently is an internist with specialization in infectious diseases.
• The new Associate Dean for Undergraduate Medical Education, Dr. Allen Jones, (hematologist) is totally supportive of the curriculum change. He will continue urging the faculty to contribute to the enabling objectives in order to complete the database.
• All administrative appointments, including the dean, are made after a search (internal). They are for 4 year periods with possibility of one renewal after an evaluation. After eight years the incumbent is out.

2. Observations: Curriculum Development/Implementation

a. Curriculum

• Calgary has had from its inception a system-based curriculum. Implementation of the new curriculum based on clinical presentations was begun two years ago.
• Transition to a clinical presentation curriculum is considered easier when starting with a system-based curriculum than a discipline-based curriculum.
• Terminal objectives for the 120 defined clinical presentations have been completed. Work is in progress to define the enabling objectives by departments or defined content groups (e.g. Informatics).
• Curriculum change can be initiated by faculty developing enabling objectives related to a clinical presentation. This request is then presented to the Curriculum Committee.
• Engagement of basic scientists is a key element for successful development of enabling objectives and implementing fully the curriculum. Calgary has not reached that goal as described in the original publication.
• The teaching of basic sciences is considered deficient as currently done, although students do pass the licensing examination. Not to have succeeded engaging the basic science faculty in the entire process, is considered a failure. However, it is not considered necessarily a fault of the system, rather one of execution.
• In particular, biochemistry and pharmacology are participating at the margins only.
• Enabling objectives have been completed by only a few units, but most consider the planning process a worthwhile activity.
• The school is committed to the effort of defining enabling objectives although not all faculty seem to fully understand the conceptual basis of the approach.
• The effort depends on the energy and involvement of a core group of faculty.
• The schemas and enabling objectives are critical. However, the number of enabling objectives must be kept within reasonable limits.
• The database (CUBE) has the potential of becoming a powerful instrument for instructional planning, student learning, student evaluation.

b. Organization/Structure of the Medical School

• Historically, the medical school is being run by clinicians. The basic scientists were and are predominantly researchers and not teachers. There is strong clinical leadership of all courses.
• The school is undergoing two extraneously created stress periods:
  • reduction of provincial support, so far of 21%
  • restructuring (consolidation regionalization) of the health care system
• Financial support of basic science faculty by the province is minimal. Eighty percent of the faculty depend exclusively on grants for their salaries. This may explain some of the reluctance of the basic science faculty to cooperate fully in the development of enabling objectives.
• In some areas the clinical faculty feel contributions by basic scientists is unnecessary, some of the basic scientists do not agree.
• There is always a question looming what will happen when the current dean steps down and the Associate Dean for Undergraduate Education changes. Will that effort continue? The dean is confident that this will be the case.

c. Administration of the Teaching Program

• The course chairs are selected/appointed by the CC. They in turn select chairs of course units/sections and teaching faculty. The sections are specified by the clinical presentations brought together under a system.
• Principles of Medicine is an introductory course. It is based on five clinical presentations: soar throat, fever, weight gain, the well patient, genetic disorder. In the four weeks large numbers of topics are touched upon that include all basic sciences (e.g., biochemistry, anatomy, histology, infections diseases, nutrition, pathology, pharmacology, genetic, neuroscience, physiology [homeostasis, temperature regulations]).
• A major objective is "to get the student into the right frame of mind." During this course the students requested tutorial sessions in anatomy and pharmacology.
• The reproduction course is chaired by a major part-time faculty member. She was just ready to do it for the first time. She had taken preparatory courses and provided instruction in PBL tutoring to the course faculty. As compensation for chairing the four week course she receives $500 per month.
• The RES course which includes hematology and immunology is taught by seasoned faculty. They were the first to submit the enabling objectives and had to make relatively few changes to adapt to the new organization. The students liked the course. The immunology part is taught by a basic scientist while clinicians teach all of hematology.
• The chair of the GI course, a general surgeon, postponed initiation of the clinical presentation-based curriculum for one year, as it was felt that the clinical faculty was totally distracted by the health services restructuring. Now, after the first go around he thinks they are teaching somewhat less basic sciences than before.
• The physiologist who contributes heavily to the GI course explained the lesser basic science involvement by the fact that most of them are 100% funded on research grants.
• The medical skills course, chaired by a general surgeon, is conducted for 100 each hours during the first and the second years and extends into the third year. The course chair is a general surgeon. The course consists of weekly and biweekly four hour sessions in the first year and biweekly four hour sessions in the second year. There is extensive use of small group teaching, and of standardized and real patients with chronic conditions.
• Within this course there are several units (or sections) each with its own chair. Unit topics are: being a physician; stress; physician-patient boundaries; communication; culture, health and illness; informatics; the well physician; physical examination; all taught in parallel with the major ongoing courses.
• At the end of the first and second years, the integrative courses (or units) serve as means to integrate topics presented by the various courses and promote independent learning, professional behavior and other attributes of the physician (the unit chair also is a general surgeon).

d. Evaluations

• Evaluations are planned and conducted as two independent activities: (1) student evaluations, and (2) course and curriculum evaluation. Each activity has a professional leader (educational psychologist for one and psychometrician for the other) and an advisory committee.
• The program evaluation revealed that the students perceive to obtain less breadth and less depth in the new curriculum.
• The program evaluation committee provides feedback to the Curriculum Committee and the course chairs. The CC reports to the departments.
• A significant number of faculty felt a drastic change of the curriculum was not indicated as they had just completed a "flawless" LCME reaccreditation.
• Pharmacology seems short-changed; it is addressing predominantly therapeutics rather than pharmacology. The clinicians teach pharmacology (sounds like our 4th year pharmacology course).
• The new program did not capture the basic scientists as it intended to. Some explanations were given as follows:
  • The basic scientists contributing enabling objectives to the GI course is 100% on research funds. He indicates that there is not sufficient time to teach all enabling objectives so far developed.
  • The changes from the system-based to a clinical presentation-based curriculum did not change the fact of clinical leadership. In his opinion, the students do not receive a solid basic science education, because there are not enough basic scientists to teach. However, the approach to curriculum development provides the means for integration.
  • Basic scientists do not take advantage of the opportunity for contributing to curriculum development.
  • The student evaluation system assesses the students' learning gains. The instruments are designed to provide feedback to students and faculty. The evaluation planning group is independent of the faculty teaching the courses. The chair of the planning group identifies representative objectives to be evaluated and the committee develops the questions. The questions are entered into a question data bank of greater than 10,000 questions. For each exam, 20% of the total questions are to be newly generated questions. The objectives drive the exam questions and format. The group also defines the minimal performance level (satisfactory performance) not the minimal pass level (failing performance) . They are beginning to experiment with the use of adaptive testing.
  • One quarter to one third of students do not come to classes and on the average do better in the exams. Question: are they independent learners or are the learning resources that good?

e. Office of Medical Education

• The school has an established, well functioning Office of Medical Education with multiple projects supporting the curriculum, research, faculty development and training, etc. About twenty faculty members of academic departments are assigned part-time members of OME (as considered for COMEC).
• Faculty development is under the Offices of Medical Education. A general surgeon chairs the activity (the same person chairing the integrative course).

f. Student Perceptions

• The students expressed enthusiasm about the new curriculum. Three of the five students with whom we met said the curriculum was a major attraction to accept Calgary as their choice. The pass/fail evaluation system (which Calgary always had) reportedly reduces--if not completely removes--the fierce competition usually found in medical schools. Students do not feel unduly stressed.
• There is a "hidden" curriculum: upon request by students, basic science faculty offer supplementary tutorials, e.g., anatomy, during study time. This can add up to 8-12 hours during a four week course.

3. Reflections and Suggestions

After studying the Calgary Curriculum, we would like to offer the following reflections and suggestions for proceeding:

a. The Calgary Curriculum is based on a method to plan the content of the curriculum. The learning (enabling objectives) are derived from statements of what the graduate is expected to be able to do (deal competently with the clinical presentation). The assumption is that there is a finite, definable number of skills (cognitive, psychomotor, and attitudinal) that characterize a novice physician entering PGY-1. This seems contrary so far to what medical education has been doing namely the presentation of almost randomly selected skills that ultimately come together to result in competent behavior.

• Suggestion: The Curriculum Committee to clarify the role and extent of content planning. Is it desirable and/or possible?

b. The Committee's decision to strive for a competency-based curriculum and evaluation implies that learning at any level should be guided by the defined skills (cognitive, psychomotor, and attitudinal) that are essential for a particular competency. Instruction, therefore should present packets defined by the skills requirement of a particular competency. Over the four years, a large number of these skills packets accumulating contribute collectively to what is competency or proficiency of the graduate.

Click here to see attached diagram

• Suggestion: The Curriculum Committee to discuss validity and pros and cons of these two design approaches and decide whether it favors one over the other. This decision is critical for the choice of planning and evaluation methodologies. It is important that the committee be aware of the implications of this decision. (This has nothing to do with time assignment).

c. The competencies and clinical presentations provide a logical framework for developing focused teaching and learning plans by faculty and students, respectively, for either teacher-directed instruction or self-directed learning.

• Suggestion: The Curriculum Committee to designate an ad hoc group for designing a model of curriculum Clinical Presentation Reorientation (CPR) by identifying diagnostic alternatives and corresponding enabling objectives (competency packets) for one or two clinical presentations.

d. The clinical presentations can serve as reference for the validity of curricular content. Objectives guiding course development must relate to clinical presentations to have meaning for medical students.

• Suggestion: The Curriculum Committee to carry out a pilot study with one basic science course by coding the explicitly and implicitly embedded objectives against diagnostic alternatives of appropriate clinical presentations. This will be a start on developing an objectives database.

e. Clinical presentations and the enabling objectives database derived from them can serve as a framework for vertical integration. Instructional units or courses can be assembled from any groupings of clinical presentations appearing most compatible to the interdisciplinary teaching teams.

• Suggestion: That the Curriculum Committee to select clinical presentations and their database to revise instructional units with the goal of achieving vertical integration.

f. To achieve an effective balance of basic science and clinical skills emphasis of the curriculum, the engagement of all teachers, basic science and clinicaL, in interdisciplinary teams is essential.

• Suggestion: The Curriculum Committee in collaboration with the Faculty Development Advisory Committee to develop a plan of faculty training in interdisciplinary course development.

g. "According to Small" evaluations drive learning.

Suggestion: The Evaluation Subcommittee to encourage the development of an evaluation system based on clinical presentations and corresponding enabling objectives identified by the interdisciplinary groups.  Updated: December 11, 1996