Lessons learned from a student-driven initiative to design and implement an Organ and Tissue Donation course across Canadian medical schools

The competencies required of the well-trained physician are constantly evolving, and medical education must adapt accordingly. In response, a growing number of influential medical education licensing and accreditation bodies have proposed frameworks that outline society’s expectations of physician competencies. In Canada, undergraduate and graduate curricula have undergone major changes to meet the specifications of the CanMEDS framework, and similar efforts are underway internationally. Nonetheless, ensuring the values enshrined within such frameworks become integral to a physician’s identity remains challenging. We believe that student-led curricular initiatives represent a novel way of approaching this shifting medical education landscape. In this article, we reflect on lessons we learned as medical students spearheading an initiative to change how organ and tissue donation is taught in Canadian medical schools. Citing relevant medical education literature where applicable, we include a detailed description of our approach as a roadmap for students contemplating their own curricular innovations. By outlining the factors influencing this project’s implementation, as well as the benefits and limitations of student participation in curriculum reform, we offer educators a fresh perspective on optimizing the student role in this important process. Ultimately, the authors argue that not only can student participation render curricular content more accessible to learners, but that the responsibilities students take on in this role naturally lead to the development of CanMEDs-based competencies such as advocacy, scholarship, and inter-professionalism. Electronic supplementary material The online version of this article (10.1007/s40037-018-0454-5) contains supplementary material, which is available to authorized users.


Introduction to Organ and Tissue Donation
Course Description: This introductory course on organ and tissue donation is based on classroom lectures and small group learning, and aims at raising knowledge of and support for donation among future physicians. Topics covered include context of organ and tissue donation, organ and tissue donation procedure -identification of potential organ and tissue donor, referral to organ and tissue procurement centres and communication with families -and bioethical issues in organ and tissue donation.

RATIONALE
Through transplantation, organ and tissue donation is responsible for saving thousands of lives every year worldwide. "In all countries in which deceased organ donation has been initiated, the therapeutic potential of deceased organ donation and transplantation should be maximized." (9) Unfortunately, a discrepancy between the demand for organs and tissues and the availability of donors exists, in Canada and internationally. Success in organ and tissue donation relies highly on the knowledge of health care professionals. (1) Given this fundamental role physicians play in the identification and referral of potential donors, it comes as no surprise that the evidence supports enhanced undergraduate medical education as a powerful method to improve organ and tissue donation rates. (2) Despite this overwhelming evidence, a gap still exists in the way that organ and tissue donation is currently being taught in the medical curriculum. (3) Our objective is to implement an evidence-based, expertsupported course on organ and tissue donation into the Quebec medical curricula in order to raise knowledge of and support for donation among future physicians. If this course is adopted, we expect to ultimately improve organ donation rates in the province and we expect to quantify this change.
In addition to the inherent importance of organ donation, the topic is also part of the Medical Council of Canada (MCC) objectives, an additional reason to include it at the undergraduate medical level.
The present introductory course described in this proposal, available during the preclinical years in the forms of theory-based classroom lectures, cultivates medical students' interests early in their education in the absence of barriers to learning such as lack of time and false sense of competency and encourages them to pursue a profession in donation and transplantation or a related field. (2) We believe that the implementation of this course will be very feasible and will create a unique educational experience for medical students, who will be key players in shaping the organ and tissue donation system of tomorrow.

Rationale
While most head trauma is mild and not associated with long-term sequelae, clinical examination may fail to detect serious intracranial injuries that are evident on radiological imaging. Therefore, it is imperative to recognize head injured patients that require additional diagnostic imaging. When brain death has occurred, organ transplantation should be considered.

Key Objectives
Given a patient with a head/brain injury, the candidate will diagnose the cause, severity and complications. In particular, the candidate will, based on the mechanism of injury and the clinical findings, determine the appropriate management plan and select appropriate imaging and ongoing surveillance. In cases where brain death has occurred, discuss organ donation with the next of kin.

Enabling Objectives
Given a patient with a head/brain injury, the candidate will 1. list and interpret critical clinical findings, including those derived from a. a history aimed at determining if the head injury was severe, or associated with complication (e.g., mechanism of injury, loss of consciousness); b. a physical examination aimed at determining if the head injury was severe, or associated with complication (e.g., ecchymosis behind ear);

LEARNING OBJECTIVES
This course will help medical students to • foster an interest in and awareness of organ and tissue donation; • be acquainted with the context of organ and tissue donation; • have a general understanding of the organ and tissue donation procedure; • understand major bioethical issues in organ and tissue donation.

COURSE OUTLINE
Teaching items in italics are optional. These items are considered supplemental materials. • Know the characteristics for identifying organ donors, including neurological determination of death (NDD) and donation after cardiac death (DCD) • Understand donation referral of potential organ donors • Appreciate families' attitudes, fundamental strategies for obtaining donation consent and barriers to family approach • Understand an overview of the procedure for procurement • Acknowledge the barriers to donation availability and physicians' responsibilities Case summary: An unconscious 37-year-old woman suffered from severe intracranial hemorrhage following a motor vehicle accident and is in critical condition in ICU. Over the past two days, she is surrounded by her family, who is visibly worried about her prognosis. Although the patient is ventilated and that her heart is beating, brain death is suspected based on neurological exam.

Guiding questions:
• What is the clinical definition of brain death? Describe the ancillary tests used to confirm the diagnosis of brain death. • What are the physiological mechanisms of brain death? What are the clinical scenarios that most commonly lead to brain death (and organ donation)? • What are the clinical criteria to be considered a potential organ donor? What additional information will Transplant Quebec verify about the patient? • Once NDD has been established, how will you approach the family, and how will you describe brain death to them? • How do you bring up the topic of donation? How would you respond to hesitations from the family? What should you do in the case of a refusal? • Once the patient has been consented for organ donation, what is the protocol between consent and the operating room? • Describe your understanding of DCD. How does the procedure of DCD differ from NDD?
• What do you consider to be the main barriers to improving organ donation rates? Discuss potential strategies to overcome these barriers.

Alternative teaching methods
Small group teaching sessions have gained popularity in medical education as they encourage selfdirected learning, increase student interest and enhance retention of knowledge and skills (7). Several general themes presented in the lectures may be suitable for the small group teaching format, either as a replacement of the lecture or as a reinforcement of the content taught during the lecture. Such themes include but are not limited to: organ and tissue donation procedures, communication with donor's family and bioethical issues in organ and tissue donation.
Other teaching methods, such as mandatory online modules and simulation-based learning, could also replace conventional didactic lecture teaching format to address the learning objectives above.

STUDENT EVALUATION
Knowledge acquired during lectures will be evaluated during written examinations according to faculty regulations.

COURSE EVALUATION
Students are encouraged to provide feedbacks and suggestions to this course through formal surveys, and data collected will be used only for research purposes.

REQUIRED TEXT
PowerPoint and PDF materials are provided to students.

TEACHING RESOURCES
Lecturers may be appointed by the faculty itself. Recommended areas of expertise can be found in the Course Outline section.

IMPACT ON THE MEDICAL CURRICULUM
The content of this course complements well with the neurology unit during pre-clinical years, especially following the lecture on neurological determination of death. There should not be any conflicts with other courses.

COURSE IMPLEMENTATION AND FUTURE PROSPECTIVE
This course should be implemented prior to July 2018. As new research is being done and best practices are being shared among participating faculties, revisions to this course will be expected.