Shared Canadian Curriculum in Family Medicine (SHARC-FM)

Problem identification and general needs assessment.

The new accreditation standards and the limited faculty time at each Canadian department of family medicine were driving forces for this project. Additionally, all Canadian family medicine undergraduate directors were being given substantial mandates to expand the presence of family medicine within each school’s curriculum, usually without additional resources. While several departments of family medicine had embarked on creating educational resources to address gaps in students’ exposure to patients, progress was slow and expensive, and efforts were uncoordinated.

Outside of family medicine, the only similar project we could identify was the Computer-assisted Learning In Pediatrics Project (CLIPP) cases.⁵ Initially fostered by the Council on Medical Student Education in Pediatrics,⁶ CLIPP was a collaborative development of online cases to support medical student learning in pediatrics.⁴ It now operates in a non-profit subscription model.⁷

Targeted needs assessment.

While CUFMED members were supportive of the development of a national curriculum, many were hesitant over concerns about lack of time and financial resources. Using a deliberative inquiry⁸ approach to curriculum development, we first identified the needs of various stakeholders in our curriculum at our in-person meetings, as listed in Table 1. We then used these needs to determine the principles that would guide the development of the curriculum. These core principles were discussed, debated, and revised through in-person and online discussions over a 2-year period, leading to the final version in 2008 (Table 2).⁹

Decisions were made to deliberately use language and develop tools to counter the hidden curriculum, emphasizing a core feature of family medicine: evidence-based clinical excellence in a patient-centred model.

Our group agreed on the following vision for SHARC-FM: that it be a national curricular collaboration of family medicine undergraduate education leaders, comprising a set of key clinical scenarios and competency objectives for students in family medicine clerkships, backed up by a matrix of educational resources for learning and assessment that would be free and available to all members and the public.

Goals and objectives.

By consensus, we chose to initially focus on determining the core clinical scenarios, as this was the greatest common need of undergraduate family medicine programs. Also, by focusing on the core clinical scenarios, we believed this would be a knowledge domain that would immediately resonate and be easily understood by our external stakeholders. Finally, we anticipated that this would be less difficult than determining broader competency objectives and would enable early progress in developing the curriculum.

Over several years, we conducted surveys and held in-person meetings to create a list of key clinical scenarios. In this modified Delphi process,¹⁰ we used a total of 7 phases to refine our list to 23 core topics. We started with a rough list of potential topics comprising the top 20 postgraduate clinical topics for Canadian family medicine residency training,¹¹ the top diagnoses made by family doctors,^12,13 data on the most common concerns patients bring to family doctors,^14,15 and additional topics our primary authors thought should be part of the first iteration. We also included “red herrings”— topics that should likely not make it to the final list—to confirm the effectiveness of our process. Respondents to the surveys were blinded to the fact that there were deliberate red herrings.

This first list of 48 topics went out to CUFMED members by survey for feedback on the importance of each topic for medical students in family medicine clerkships. The survey responses, comments, and suggestions for additional topics were used to refine the list and were sent back in another survey. Two more cycles of surveys and refinement were conducted, followed by presentation of the fifth version at a gathering. After these 5 phases, we had 20 core topics. We later returned to the topic list for an additional 2 cycles of debate and refinement, leading us to our current 23 core clinical topics. None of the red herrings made it through the first 4 cycles.

An additional project is under way to determine the skills or competencies that a medical student needs (eg, “able to write a prescription”), the results of which will be reported when complete.

The complete clinical scenario list, which includes presentations (such as cough), established conditions (such as hypertension), and preventive care, is found in Box 2.

As a group that had spent 2 years refining our vision and principles and more time coming to a set of core clinical scenarios, we were impatient to get started on creating learning resources. We made a tacit assumption that a common list of topics would translate into a shared understanding of the objectives for each topic and used the topic areas alone to guide the development of educational resources. This assumption was wrong.

It became apparent that we had different ideas about what content should be taught or tested. As a result, we reconvened several times from June 2011 to June 2012, working in small and large groups to develop common objectives for each topic using an approach based on key features¹⁶ by ensuring that we captured issues where medical students in family medicine clerkships are most likely to go wrong and critical “cannot miss” issues. We used another modified Delphi process (series of surveys and meetings) to reach unanimous agreement on the objectives for each of the clinical scenarios. The objectives for ischemic heart disease are outlined in Box 3 as an example. The full objective set is available at www.sharcfm.ca.

Educational strategies.

We have developed a series of materials to support student learning and assessment around our curriculum topics, including the following.

Point-of-care, hand-held learning resources (Canadian Family Medicine Clinical Cards): These clinical cards provide handy information that assists in clinical reasoning and management, including recognition of red flags and adapting care to patients’ contexts. An example is the exercise prescription clinical card, which is shown in Figure 1.¹⁷ Clinical cards are made available for electronic downloading and distribution, and some schools choose to print hard copies for their students and preceptors.

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Figure 1.

Example Canadian Family Medicine Clinical Card

Reproduced from Wickenheiser et al.¹⁷

Paper cases: The CUFMED members have contributed paper cases that are aligned with the topics and objectives within SHARC-FM. These cases can be used by schools to assist with delivering small group learning sessions.

Virtual patients: Led by David Topps of the University of Calgary in Alberta, a series of virtual patient cases have been developed. These are online simulations of patient encounters in which learners work through a case making decisions on patient assessment and examination, interpretation of findings, diagnosis, and management.

Multiple-choice questions: These are for summative assessment of student knowledge and are available to family medicine clerkship committees in Canada who wish to use them to augment their own examination banks. The questions are blueprinted to the clinical scenario objectives. (These questions are held securely at the CFPC headquarters and are couriered to interested schools on encrypted media.)

Other resources: We have also curated key articles that are aligned with each of the objectives. These background learning materials serve as self-learning resources for students and are also available at www.sharcfm.ca.

Implementation.

This project has been exciting and challenging, with numerous implementation issues to explore and overcome.

Support: The CFPC provides ongoing funding for administrative and operating costs of SHARC-FM, and strategic guidance through its Undergraduate Education Committee. This support was critical during the early formative stages. Departments of family medicine and undergraduate medical education offices across the country have provided additional financial support and e-learning technology expertise, which have been also critical to maintaining momentum.

Peer review: New educational objects and resources developed through SHARC-FM are subjected to blinded peer review that is coordinated by the lead members for each type of resource. Reviewers assess the quality of material design and the accuracy of medical content, and ensure the absence of third-party material for which permission has not been granted and that there is no identifying patient information. Authors of materials must address reviewer comments to the satisfaction of the resource type lead before being formally published as a SHARC-FM resource. Multiple-choice questions are subjected to non-blinded peer review during question-writing workshops.

Dissemination: The learning resources within SHARC-FM have been made available to the public through www.sharcfm.ca. Upon reviewing our foundational research and peer-review process, MedEdPORTAL,¹⁸ the online publishing arm of the American Association of Medical Colleges, granted our initiative Special Collection Reviewed status, which has further streamlined the ability for resources developed under SHARC-FM to be broadly disseminated. MedEdPORTAL now houses SHARC-FM materials within the iCollaborative section of its website.

Local implementation: A key guiding principle of SHARC-FM has been that the implementation of its materials at local schools was optional. As a result, the local implementation of SHARC-FM at each Canadian medical school has varied, with some schools replacing their previous ED-2 criterion scenarios¹ (ie, the clinical experiences students are required to have for the purposes of program accreditation) with those within SHARC-FM, and others using the resources to supplement the learning resources they provide to students. With the recent completion of the SHARC-FM clinical scenario objectives, many schools have replaced or refined their current relevant objectives to align with these new national objectives. Many schools direct medical students to SHARC-FM resources, and 8 schools have borne the cost of printing hard copies of the point-of-care clinical card handbooks for their clinical clerks. Some schools have decided to distribute them additionally to residents and preceptors, who have informally reported that they are welcome and useful resources for their teaching and as a support for their own clinical care.

Future implementation steps: Translation of all of our objectives into French has occurred, while translation of our clinical cards is under way. We plan to launch the French site, www.cccmf.ca (Curriculum canadien commun de stages en médecine familiale), in the summer of 2017. At that time, we will also be launching online formative testing modules.

Evaluation and lessons learned.

The vision for SHARC-FM—to be a national collaboration of shared objectives and learning resources to support student learning in family medicine—is being delivered. While the curriculum is still growing and maturing, Canadian family medicine clerkships now have this national consensus on topics, objectives, and other resources to draw upon. Getting to this point has not been easy, and we have learned lessons that will help others develop their own collaborative curricula, as follows.

Guiding principles: Clarifying and understanding all of our principles at the beginning of this project proved to have been a crucial step in guiding our handling of ongoing challenges and opportunities. We encountered numerous decisions that we were able to negotiate because we had already established our principles, such as whether to collaborate with a fee-for-access curriculum in another country (we did not). Regularly articulating our principles and adhering to them also enabled us to maintain momentum even though the membership of CUFMED was in constant flux; new members were immediately able to understand the role of SHARC-FM and how our decisions were guided.

Objectives: As described above, we erred in assuming each member of our group would have the same understanding of what should be learned for each of the clinical scenarios. This led to confusion and a derailing of our momentum. Having recognized this error, we were stimulated to develop and follow a rigorous process for developing our objectives. As a result, we have a strong set of objectives that are specific to each of the topics and that have been useful for schools to adopt for local curriculum development.

Structure¹⁹: Having an overall lead editor, as well as leaders for resource types and curriculum topics, has been important. In addition, the explicit support of our project leaders’ department heads has led to vital protected academic time to work on our initiative. The project was initially run in a shared-leadership model in which members were invited to contribute in their own way. This model failed, with members not being sure how best to focus their efforts.

We openly discussed this challenge, and our members unanimously agreed that they wanted firm direction during the early phases of the curriculum’s development. We empowered leaders to direct roles and jobs, such as assignment of objective-development tasks, while maintaining the ability of individuals to contribute meaningfully to content. With this new type of direction, the project gained momentum. As the curriculum matured, we have moved to an editorial board model of policy and process decision making, with membership including undergraduate family medicine leaders and a student chosen by the CFPC Section of Medical Students.

Increasing from annual to biannual meetings increased progress and momentum by providing protected time isolated from the day-to-day work at members’ home institutions. Departments of family medicine largely took a leap of faith on this project by funding their delegates’ repeated travel, thus enabling dynamic and productive meetings.

Buy-in from stakeholders: Rather than advising deans of what they “must do,” SHARC-FM offered collaboratively developed material for their schools’ use, at no cost, if they or their family medicine programs deemed it useful. This approach was key to the successful uptake of our material by most medical schools in Canada. Getting broad participation from all schools has further strengthened our community of educators, stimulating further collaborations.

Parallel curricular development: Not long after CUFMED began discussing and debating the guiding principles for SHARC-FM, the Paediatric Undergraduate Program Directors of Canada group started working on its own national collaborative curriculum called canucpaeds (Canadian Undergraduate Curriculum in Paediatrics).²⁰ The leads for both SHARC-FM and canucpaeds regularly shared progress updates, specifically sharing challenges each initiative encountered. This parallel development built momentum for both curricula, as we learned from each other’s struggles and successes, and avoided each other’s traps.

Scholarship: This project has led to new scholarly work in undergraduate family medicine education, delivering on a key purpose of SHARC-FM. Scholarship includes modified Delphi work to determine the core clinical scenarios and competency objectives, and the development of a new process to identify the best background resources for student learning on these topics.²¹ Additionally, through our peer-review process and our Special Collection Reviewed status with MedEdPORTAL, our members have been able to get their learning resources recognized as peer-reviewed publications. Finally, this project has led to the development of a medical education elective²² for medical students and a number of national and international workshops on how to lead multi-institutional curriculum collaborations.