National undergraduate surgical learning objectives: the NUSLO project

Summary

The Canadian Undergraduate Surgical Education Committee (CUSEC) undertook a project to address variance in undergraduate surgical learning objectives among Canada’s medical schools. Its aim was to compile a reasonable set of national undergraduate surgical learning objectives (NUSLOs) for all medical undergraduates and map them to the Medical Council of Canada (MCC) objectives. In phase 1, CUSEC invited Canada’s 10 surgical specialty societies or associations to identify discipline-specific lists of undergraduate surgical learning objectives deemed essential for all Canada’s medical students to achieve by the time of graduation. In phase 2, 8 medical students and 7 CUSEC faculty from 6 Canadian universities mapped each individual NUSLO to the corresponding MCC objectives, then to primary and secondary MCC objectives. By 2023, all 10 surgical specialty societies had derived, ratified, and submitted their discipline-specific NUSLOs, for a total of 72 major objectives, some of which had sub-objectives. All phase 1 NUSLOs were mapped to corresponding MCC objectives, with each NUSLO mapping to an average of 18 MCC objectives. Each NUSLO was then tiered to 1–2 primary MCC objectives. The NUSLOs and the NUSLO–MCC maps, now publicly posted on the CUSEC website, may serve as a foundational reference for students and teachers. They are a means by which Canada’s medical schools can customize, standardize, and revise their undergraduate surgical curricula.

The surgical learning objectives for Canadian medical students currently vary substantially across medical schools. The Canadian Undergraduate Surgical Education Committee (CUSEC) was formed more than 30 years ago, under the auspices of the Canadian Association of Surgical Chairs, to promote the study and discussion of topics related to undergraduate surgical education in Canada and to facilitate nationwide conversations, debates, shared problems, and solutions as they relate to undergraduate surgical education.¹ For decades, CUSEC has been concerned with notable variance, a lack of consistency, and possible deficiencies in the undergraduate surgical curricula of Canadian medical schools. Since the 1990s, the committee has made several attempts to derive and publish appropriate undergraduate learning objectives.^2,3

In the late 1980s and early 1990s, panels sought to align American and Canadian surgical curricula and published general learning objectives.^4,5 However, perhaps because of a lack of objective specificity or of curricular uptake and integration, there still remain perceived deficiencies in undergraduate surgical curricula among Canadian and American medical schools.^6–8

Beginning in 2011, CUSEC used a modified consensus-building approach to develop tiered surgical disease lists within surgical specialty rubrics. This approach involved iterative rounds of surveys and feedback from experts to ensure the lists were comprehensive and relevant, emphasizing that students should be able to explain basic pathophysiology, describe common clinical presentations, outline differential diagnoses, plan appropriate investigations, recommend management principles, and describe the anticipated treatment effects, prognosis, and potential complications of the listed surgical diseases. However, again, for a myriad of possible reasons, this list approach was generally not adopted by Canadian medical schools or used by students.

Canadian medical students continue to express their confusion and concern over what they need to learn about surgery as undergraduates.⁹ The limited surgical exposure and education in their preclinical years no doubt contributes to this lack of knowledge about surgery and increases their anxiety as they enter their clerkships. Surgical educators are uncertain about what students are expected to know and what they should teach, and the lack of clear surgical learning objectives poses challenges in assessing students’ surgical knowledge and skills.¹⁰

In addition, family medicine residency programs may be decreasing the number of surgical learning experiences for their learners in the face of increasing demands to incorporate other areas of learning into their 2-year postgraduate training. This shift, perhaps not fully recognized by medical schools, places the burden of surgical education primarily on classroom-based sessions in undergraduate medical school and clinical clerkship rotations as the main sources of surgical learning for Canada’s future family physicians.

However, CUSEC believes that the Canadian public, although aware that most doctors are not surgeons, nevertheless has a reasonable expectation that all medical doctors possess a certain baseline of foundational knowledge of surgical diseases and management, acquired during their medical education. For these reasons, CUSEC has continued to prioritize the establishment of a national set of surgical learning objectives for medical undergraduates. Consequently, the National Undergraduate Surgical Learning Objectives — the NUSLO project — was initiated by CUSEC in 2019. This project’s goal is to create relevant and realistic foundational undergraduate surgical learning objectives to ensure that all Canadian medical schools deliver clear and consistent learning expectations to both their students and faculty.

The project had 2 phases. Phase 1 aimed to establish a baseline set of surgical learning objectives (NUSLOs) that all Canadian medical students should achieve by graduation, regardless of their future careers. In 2020, CUSEC invited Canada’s 10 surgical specialty societies and associations to identify what their organization regarded as essential surgical knowledge for all Canadian medical graduates. The Canadian Urological Association and the Canadian Society of Otolaryngology–Head & Neck Surgery — ahead of the game — had already derived their essential undergraduate surgical learning objectives and had posted them publicly on their websites. The other 8 organizations were encouraged to look at those objectives and undertake similar compilations. The project’s intent and resources, including the Medical Council of Canada (MCC) learning objectives, were outlined in the invitations to the surgical associations. Without being prescriptive, CUSEC’s intent was to urge and encourage all the surgical specialty societies to establish and ratify their respective NUSLOs.

Some societies had existing education committees, while others formed new NUSLO project groups. Phase 1 results were presented to the Association of Faculties of Medicine of Canada (AFMC), who supported the NUSLO concept. The AFMC Council of Undergraduate Deans and the AFMC Committee of Clerkship Directors both consistently encouraged the CUSEC NUSLO project team to undertake a phase 2 to map the NUSLOs to the corresponding relevant MCC learning objectives.

To undertake phase 2 of the NUSLO Project, CUSEC engaged 8 students from 4 Canadian medical schools, along with 7 CUSEC faculty from 6 Canadian medical schools, to map the NUSLOs to the MCC learning objectives. A mapping strategy meeting was held, and the students were then assigned the various specialty-based NUSLO sets to map them to MCC learning objectives. Their instructions were to map each NUSLO expansively but reasonably to the MCC objectives as they are listed on the MCC website. These mappings were then discussed, edited, and refined via biweekly Zoom meetings over a span of 3 months. After this mapping process, a similar process of student assignments and consultative meetings then defined tiers of primary and secondary MCC mappings for each NUSLO, whereby the 1–2 MCC objectives that aligned best were defined as the primary MCC objective for that NUSLO, with the rest defined as secondary MCC objectives.

In phase 1, complete NUSLO sets were ratified by each of the 10 Canadian surgical specialty societies and sent to the CUSEC NUSLO team by the summer of 2023. Major learning objectives were established for vascular surgery (n = 4), urology (n = 12), thoracic surgery (n = 8), plastics (n = 5), pediatric surgery (n = 7), orthopedic and musculoskeletal surgery (n = 8), neurosurgery (n = 3), cardiac surgery (n = 5), general surgery (n = 16), and otolaryngology (n = 4), for a total of 72 major NUSLO headings (mean 7.2 and median 6 objectives per specialty). These major NUSLO headings contained sublearning objectives. Among the specialty-specific NUSLO sets, there were differences in formatting and explanatory preambles. Some sets of specialty-specific objectives were simple lists of surgical conditions named by diagnosis, while other specialties provided suggested readings, and symptoms, management, and complications. Seven of the 10 specialty NUSLO listings used Bloom’s taxonomy, as CUSEC had suggested.

After the undergraduate medical students had mapped the NUSLO objectives to the MCC objectives, followed by revisions from surgeons in various specialties during the Zoom meetings, each NUSLO objective was then assigned primary and secondary MCC objectives. On average, each NUSLO objective mapped with 18 MCC objectives (range 0–95 MCC objectives per NUSLO objective, median 13).

A notable challenge in mapping was that the NUSLOs were based on pathophysiology and the MCC objectives were primarily based on clinical presentation. Mapping to the MCC seemed less appropriate when the NUSLO objectives emphasized practical and observational history and physical examination components (e.g., “Demonstrate the ability to take a history and physical exam on a patient who presents with venous related limb complaints,” “Perform an effective neurologic history and neurologic exam [i.e., orientation, cranial nerve exam, motor exam, sensory exam, cerebellar testing] to screen for neurologic pathology”). These were not mappable to MCC objectives.

In another instance, the MCC objectives did not fit well with the NUSLO objectives of diagnostic modalities and surgical management. For instance, 1 NUSLO objective for vascular surgery stated, “Outline the role of diagnostic modalities for carotid disease (duplex ultrasonography, computed tomography, angiography) and the role of symptomatic status and degree of stenosis in guiding therapeutic decisions,” which did not align with the presentation-based MCC objectives. This issue reappeared in orthopedic surgery as the MCC objectives focused on the symptoms and outcomes of a disease, whereas some NUSLO objectives also referred to management and prevention. For example, for the NUSLO objective pertaining to the principles of musculoskeletal imaging, only the MCC objectives related to joint pain and trauma aligned.

However, despite the NUSLOs being mostly based on disease or pathophysiology and the MCC objectives being mostly on presentation, most NUSLOs and MCC objectives were mappable to each other.

The full list of NUSLOs and their corresponding MCC mappings may be found at https://www.cusec-ccecp.com/nuslo/.

In conclusion, the NUSLOs may now serve as a firm foundation for standardized, high-quality undergraduate surgical education in Canada. As a living document, modifiable as medicine progresses, the list can provide a flexible and customizable baseline, allowing institutions to use the NUSLOs and the NUSLO–MCC objective mappings to refine their undergraduate surgical curricula. This would address existing variance and gaps in undergraduate surgical education evident among Canada’s medical schools, ensuring national consistency and effectiveness.

If medical schools implement the NUSLOs to define and refine their undergraduate surgical curricula, then they can facilitate consistent student assessment criteria, helping both surgical teachers and medical students to navigate their clinical evaluations of medical students. This ensures that all medical students are assessed on essential competencies, promoting fairness and transparency while enhancing instruction quality. For both students and their teachers, the NUSLOs should reduce the uncertainty regarding what they should learn or teach, respectively.

One medical school in Canada has already begun to use the NUSLOs to revise their undergraduate surgical curriculum by asking surgical undergraduate divisional representatives to review their specialty’s NUSLOs in the context of their division’s existing learning objectives. Apart from minor edits, the NUSLO compilations have been wholly accepted as reasonable and comprehensive.

Given that the NUSLOs are mostly based on pathophysiology or disease and the MCC medical expert learning objectives are mostly focused on clinical presentations, the 2 sets of learning objectives — now mapped to each other — are pedagogically complementary. With these specific learning objectives, students can focus on acquiring necessary competencies with less bewilderment, understanding more assuredly what they are expected to know. In our view, this cannot help but lead to better educational outcomes, better physicians, and even better patient outcomes.

Looking forward, the NUSLO project results may be applied to medical education at large. These objectives can be accessed and used in family medicine residency programs for their postgraduate curriculum planning, as evidenced by the College of Family Physicians of Canada’s recent interest in the NUSLO project.

Finally, the NUSLOs are the first step in the creation of undergraduate learning tools and resources. Indeed, they have already acted as a springboard to encourage Canadian surgical specialty societies and associations to compose and release undergraduate learning material and modules, which should be encouraged. The NUSLOs can also serve as a template for developing national undergraduate learning objectives in other medical disciplines, promoting national consistency and quality across medical education.