Curriculum, Course, and Faculty Development for Case-Based Clinical Reasoning

Abstract

This chapter introduces the reader with general concepts of curriculum, curriculum development, and faculty development. Then these concepts are applied to CBCR. Seven components of curriculum development for CBCR are derived from Kern’s six-step approach, and four components of faculty development for CBCR courses are recommended.

The chapter concludes with a case study of implementing CBCR at Tbilisi State Medical University in the period 2011–2014 and lessons learned from this project.

These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

The current chapter gives a brief overview of the conditions for developing a modern curriculum for medical education to include CBCR and about faculty development for CBCR teachers. The introduction of CBCR is only one element of a full curriculum; yet, just as a complete curriculum, it requires careful planning.

A Brief Introduction to Curriculum Development

“Curriculum ,” sometimes simply defined as “a planned educational experience” (Thomas et al. 2016), has evolved as a concept to be applied to several levels of education: a macrolevel (requirements defined by a government for an accredited or subsidized course), a meso-level (a plan for a school with university rules and methods of teaching and assessment), and a microlevel (an instrument to guide a classroom teacher in determining content and methods to be used in individual lessons). While this is informative, it still is very general. Janet Grant proposed that a curriculum is “a statement of the intended aims and objectives , content, experiences, outcomes and processes of an educational program, including a description of the training structure and of the expected methods of learning, teaching, feedback and supervision” (Grant 2010). To be even more practical, Mulder and ten Cate, based on extensive experience with curriculum development, constructed a ten-element definition that can guide educators embarking on major curriculum innovation projects (Mulder and ten Cate 2006). A full curriculum description , in this approach, includes a mission statement , objectives , a description of intended learners, an educational philosophy, a general curriculum framework , descriptions of individual units or courses, methods of assessment with rules on student progress and examinations, an organizational and management structure, clear conditions for teaching personnel, finances and facilities , and a quality assurance structure. All of these deserve a much wider elaboration, but for the purpose of this book, we will confine the description to Table 9.1.

Table 9.1 Ten elements that constitute a curriculum description

These elements comply with international standards for medical curricula (Lindgren 2012). However, it should be realized that a curriculum is a living thing that is only effective in the way it is delivered by teachers and received by students. Authors have distinguished the planned curriculum (as exemplified above), the delivered curriculum (as understood and carried out by teachers), the experienced curriculum (as perceived by students), and even a hidden curriculum (not reflected in formal rules and intentions but conveyed implicitly by the unwritten rules and observed behaviors) (Prideaux 2003; Hafferty and Franks 1994). We cannot and should not avoid differences between these “curricula” but must be aware of them and cautious that pathways students follow, even if not designed by curriculum developers, are effective in their learning toward common goals of medical education. There are many “pathways to Rome,” and, around the world, there are many routes to the medical degree (Wijnen-Meijer et al. 2013). There is not one “best” curriculum, and the success of a curriculum is very dependent on the students who follow it and the local and national context. Students’ motivation to become a doctor can make them just do anything that seems appropriate to get the degree, no matter what curriculum or even in which country or jurisdiction. This individual intrinsic motivation should be valued and stimulated, even with their deviations from a planned path, as long as student creativity is constructive for their own career development (ten Cate et al. 2011).

The Process of Curriculum Development

The curriculum development process for medical education is originally well described by Kern and colleagues from Johns Hopkins University School of Medicine, now revised by Thomas et al (2016). In elaborate and widely used guidelines, the authors recommend to committees embarking on a curriculum development process, to follow “Kern six steps” (slightly adapted):

• 1. Problem identification and general needs assessment: Why is change necessary? What health problems in society have priority in a new curriculum?

• 2. Needs assessment of targeted learners: Curricula will work best if students feel motivated to spend effort in learning, so identify them and query them.

• 3. Goals and objectives : Specific and measurable learner objectives, behaviorally formulated, will help to monitor progress of students.

• 4. Educational strategies: Objectives should lead to the choice of suitable methods of teaching to attain these objectives.

• 5. Implementation: Starting a new curriculum involves identifying resources; obtaining support, administrative structures, and communication strategy; anticipating barriers to change, and piloting before full implementation.

• 6. Evaluation and feedback: This includes the identification of users, resources, and issues that circulate, to design procedures and questions, choose or construct measurement instruments, collect and analyze data, and efficiently report results, feeding into a new cycle of quality assurance .

This summary combines a process that may take years to prepare and execute, but all steps are important. Two decades ago Gale and Grant compiled an AMEE Guide that is still extremely helpful in change management for medical curricula (Gale and Grant 1997).

Course Development for CBCR

Introducing just CBCR on top of a medical curriculum that already exists is possible and does not require a major organizational change in infrastructure and a long timeline to fundamentally reform a full undergraduate program. In fact, the introduction of a CBCR course following the format presented in this book can be relatively simple. However, a case-based clinical reasoning course as described in earlier chapters exemplifies many of the characteristic of what has been called a “modern” medical curriculum, since an acronym for that (SPICES ) was introduced in the 1980s (Harden et al. 1984): Student centered (particularly through the peer teaching approach), Problem based (clinical problems are the focus), Integrated (its differential diagnostic approach crosses the boundaries of clinical specialties, and applied basic science can be incorporated), Community based (depending on the cases used, this can be a focus), elective (the course is usually mandatory but can be elective), and Systematic (CBCR is an example of a very systematic approach to clinical education). Introducing CBCR in an existing traditional curriculum, as has been done in several Eastern-European countries, can be a first step to a school acquainted with modern approaches to medical education.

In Table 9.2 steps for course development are suggested, with reference to both Kern’s six-step approach and the definition of a curriculum given earlier. As CBCR is only a course, the development is simplified.

Table 9.2 Elements of CBCR course development and implementation

The implementation of a new CBCR course should be planned well ahead. Particularly the writing of high-quality cases can take much more time than one would initially think or hope. Some clinicians are excellent, naturally born case writers; others need a lot of assistance and editing support. Given the fact that many will do this in spare hours, the planning ahead of a new CBCR course should take at least one full year before the real start.

The Aim of Faculty Development

Most faculty members of medical schools and medical universities have been trained to be adequate clinicians or scientists or both. Only a minority, although growing, has been trained to be a teacher, and it is odd to realize that as education gets more sophisticated – from grade school to university – fewer requirements apply for teaching skills.

If teaching would remain identical over the years, teachers could learn the tricks of the trade from their colleagues and remember how they themselves received education. But in a rapidly changing world, education has become quite different by the time students are faculty members themselves and must start teaching students.

Medical educators around the world begin to agree that faculty must be trained before they should be allowed to teach, just as students cannot treat patients if not properly trained. In practice this is too strict a rule, but universities have started requiring new faculty to obtain a basic teaching certificate and an advanced certification for teachers in leadership positions. Table 9.3 shows the model that exists at the University Medical Center Utrecht as an example.

Table 9.3 UMC Utrecht’s model of teaching certificates for faculty

An elaborate framework of teaching competencies for medical educators is provided by Molenaar et al. (2009) and establishes an excellent grounding for faculty development . It distinguishes teaching domains (development, organization, execution, coaching, assessment, and program evaluation) and levels of responsibility (leadership, coordination, and actual teaching – macro-meso-micro), resulting in many detailed teaching competencies that deserve attention in trainings.

Faculty Development for CBCR

Faculty development just for a CBCR course is limited but necessary, and we recommend that it exists of the four components mentioned in Table 9.4.

Table 9.4 Components of faculty development for CBCR

The following section describes a case study of the introduction of CBCR in a Post-Soviet country. This curriculum and faculty development initiative was part of the EU-Tempus project Modernizing Undergraduate Medical Education in the Eastern Neighboring Area (MUMEENA) of the EU, carried out in the years 2011–2014.

Case Study: Introducing CBCR at Tbilisi State Medical University, Georgia

As part of a project to modernize medical education in Eastern Europe, in 2011 a 3-year EU-funded project included the introduction of CBCR at six universities in three countries, one of which was Georgia. The following steps were taken:

• 1. Introduction of the CBCR rationale and concepts

  In January 2012, a workshop conducted by educators from UMC Utrecht, The Netherlands, was held at Tbilisi State Medical University (TSMU) to have faculty learn for the first time about this method and its significance for curriculum innovation. Previous evaluations of existing teaching methods had shown that graduates experience serious difficulties in clinical decision-making during residency. The workshop resulted in a proposal to select ten common medical conditions for elaboration in CBCR cases (swollen legs, cough, breathlessness, abdominal pain, loss of consciousness, arthralgia, urine incontinence, jaundice, tiredness, chest pain). It was also decided to introduce an extracurricular pilot CBCR course for third year students – at the so-called “preclinical” stage.

• 2. Training in case writing and demonstration of CBCR

  In March 2012, 10 active and enthusiastic faculty members, all of them clinicians and considered as prospective CBCR teachers (consultants), were trained during 1 week in CBCR methodology at the University Medical Center Utrecht, The Netherlands. The training focused on case writing and a demonstration of CBCR in practice by Utrecht medical students was given.

• 3. Pilot introduction of CBCR and evaluation

  Preceded by 5 months piloting of 10 CBCR sessions in and following a decision of the TSMU Academic Council, CBCR was included in 2012–2013 for 10 groups (135 students) in the third year of the undergraduate medical curriculum for 2 ECTS credits. The duration of each session, delivered once a week, was 3 h. By the end of each session, questionnaires were provided to all CBCR consultants and students. This showed that 96 % of all consultants valued CBCR as a useful course for learning clinical thinking and helpful to improve students’ ability to resolve clinical problems. About 84 % of the students rated the CBCR course as an excellent teaching tool, teaching them the approach and attitude toward patient problems and the methodology of differential diagnosis , and in addition improved their communication and leadership skills.

• 4. Formal decision to introduce CBCR

  Based on this positive feedback, the TSMU Academic Council decided to consider CBCR as a compulsory course for all third year TSMU students from the 2013–2014 academic year, i.e., for 500 Georgian and 250 international third year students.

• 5. Spread in other universities

  Following the successful implementation of CBCR at TSMU, the course was also introduced in partner medical schools in Azerbaijan and Ukraine, likewise supported by workshops in Kiev and Baku.

• 6. Lessons learned

  The introduction of CBCR took 2 years of preparation, negotiation, and faculty development but was clearly successful. With respect to the teaching method, feedback from students revealed, next to general satisfaction, the following points for improvement or attention:

  • During CBCR sessions the mere presence of senior clinician consultants can suppress student activity, in particular, communication initiative of peer teachers, clearly a further issue for teacher training.

  • Not rarely, consultants tried to unduly interfere with case discussions in the group – another issue for training.

  • There were sessions when students were less active, while peer teachers tried to recall previously memorized texts from their written materials − student instruction must stress their roles.

  • Due to a yet limited number of CBCR case scenarios , it was not always possible to avoid disclosure of correct answers (i.e., diagnoses) to other students’ groups if their session was scheduled at different times; it reveals the anxiety students feel to not know the “right” answer. Students must learn to understand that the reasoning process is just as important as the right answer.

  • Several students have suggested to become involved in the CBCR case writing process themselves.

In sum, faculty development is important, but, as this example shows, it can be very successful.