From vision to implementation: Building a national undergraduate paediatric curriculum

Abstract

Objective

There are many challenges in ensuring medical students learn paediatrics. Medical educators must develop and maintain curricula that meet learners’ needs and accreditation requirements. Paediatricians and family physicians, practicing and teaching in busy clinical environments, require Canadian-relevant curricular guidance and resources to teach and assess learners. Students struggle with curricular cohesion, clear expectations, and resources. Recognizing these challenges and acknowledging the need to address them, the Paediatric Undergraduate Program Directors of Canada (PUPDOC) created canuc-paeds, a comprehensive competency-based undergraduate curriculum that teachers and students would actually use.

Methods

Curriculum development included the following: utilization of best practices in curriculum development, an environmental scan, development of guiding principles, Delphi surveys, in-person meetings, and quality improvement. All Canadian paediatric undergraduate educator leaders and other stakeholders were invited to participate.

Results

The curriculum, based on the RCPSC CanMEDS Framework, includes 29 clinical presentations, each with key conditions, foundational knowledge objectives, and learning resources. Essential paediatric-specific physical examination and procedural skills that graduating medical students are expected to perform are identified. Objectives specific to Intrinsic Roles of Collaborator, Communicator, Professional, Leader, Health Advocate and Scholar that can be assessed in the field of paediatrics at the undergraduate level are articulated. The national curriculum has been implemented widely at Canadian medical schools. Online, open-access clinical resources have been developed and are being used world-wide.

Conclusion

This curriculum provides overarching Canadian-specific curricular guidance and resources for students and for the paediatricians and family physicians who are responsible for teaching and assessing undergraduate learners.

There are many challenges in ensuring medical students learn paediatrics. Medical educators, often working in isolation, must develop and maintain curricula that meet learners’ needs and accreditation requirements. Paediatricians and family physicians, practicing and teaching in busy clinical environments, require Canadian-relevant curricular guidance and resources to teach and assess learners. Students struggle with curricular cohesion, clear expectations, and resources. Recognizing these challenges and acknowledging the need to address them, the Paediatric Undergraduate Program Directors of Canada (PUPDOC) created canuc-paeds, a comprehensive competency-based undergraduate curriculum that teachers and students would actually use.

The vision for the curriculum was twofold: (1) to articulate what graduating medical students, regardless of their career path, need to know and demonstrate about the care of paediatric patients and (2) to create a comprehensive paediatric undergraduate curriculum that included key clinical presentations, and addressed advocacy, vulnerable populations, social determinants of health, interdisciplinary care, and learner wellbeing.

METHODS

The curriculum was developed through five phases: (a) identification of key steps in curriculum development (b) environmental scan, (c) articulation of guiding principles, (d) objective development, and (e) quality improvement.

Steps in curriculum development

Key sources focused on curriculum development were reviewed (1,2) and employed. This provided the necessary rigor, reflection, and pedagogy to formulate a coherent and comprehensive curriculum.

Environmental scan

An environmental scan was conducted to learn from existing related curricula and stakeholders in undergraduate medical education. Two major Canadian projects had been undertaken that provided a foundation for our national work.

First, the University of Alberta (UA) had developed an undergraduate paediatric competency based curriculum (3). This process included reviewing the Evaluation objectives in Family Medicine: Topics, key features and procedural skills of the College of Family Physicians of Canada objectives (4), the Council of Medical Student Education in Pediatrics (COMSEP) curriculum (5) and the relevant objectives of the Medical Council of Canada (MCC) (6). To ensure the objectives identified were representative of clinical practice, provincial billing data was analyzed to identify the most common child health conditions presenting to family physicians, paediatricians, and emergency departments. The objectives were organized as clinical presentations and formed the basis of the Medical Expert (7) component of the UA curriculum (3).

Second, many education leaders at Canadian universities had developed local competency-based objectives for medical students. In particular, The University of Manitoba (UofM) had developed objectives specific to the paediatric undergraduate learner (8) according to the Royal College of Physicians and Surgeons of Canada (RCPSC) Intrinsic CanMEDS Roles (7). The work at these two institutions formed the foundation for the canuc-paeds objectives.

Development of guiding principles

The initial 18 months were used to identify and refine principles that would guide curriculum development. This process identified six key principles, as follows:

Curricular decision making

The curriculum would be an optional resource for paediatric undergraduate programs as curricular governance resides locally at each medical school, in accordance with accreditation requirements (9). The curriculum would be adaptable to the structure and educational needs of each medical school.

Alignment

The curriculum would be aligned with the RCPSC CanMEDS Roles (7), and the objectives of the MCC (6). The curriculum would respond to recommendations from a multi-disciplinary symposium, co-sponsored by the Canadian Paediatric Society (CPS) related to advocacy, social determinants of health, mental health, vulnerable populations and interdisciplinary care (10).

Project design

The curriculum would use the best practices in medical education. It would be competency-based, grounded in principles of curriculum development (1,2) and user-friendly to both students and educators.

Cost, profit, and access

The curriculum would be published in an open-access model and shared at no cost to educators and students.

Scope and context

The curriculum would have a Canadian context, and address core paediatric content for both pre-clerkship and clerkship years. The curriculum would emphasize generalism, focusing on what all graduating medical students, not only those pursuing a career in paediatrics, must know about the care of children and youth.

Language(s)

The curriculum would be bilingual. Original work would be completed in English and would subsequently be translated into French.

Development of objectives

The curriculum was developed using a combination of modified-Delphi surveys and in person meetings. The RCPSC CanMEDS Intrinsic Roles (7) were adapted to an undergraduate paediatric environment. The UofM work (8) served as a starting point; feedback was provided both asynchronously and during a large group meeting to refine the objectives and achieve national consensus. These objectives ensured we addressed the Symposium’s recommendations of advocacy, vulnerable populations, social determinants of health, and interdisciplinary care (10).

To develop the objectives for the Medical Expert component of the curriculum, a five-phased modified Delphi process (11,12) was carried out to determine the core clinical presentations and their respective objectives. Work from UA (3) was used as a starting point. This was followed by a series of three surveys and two in-person meetings to reach a national consensus on core content. Through this process, the original 26 clinical presentations were identified.

Curricular quality improvement

The curriculum underwent review at a national meeting after being in use for 3 years. Through consensus, some clinical presentation names were clarified and three more were added. Several key conditions were added.

RESULTS

The original curriculum comprised objectives in each of the CanMEDS Roles, with 26 clinical presentations in the Medical Expert domain. Three clinical presentations were subsequently added; the list of original and current clinical presentations appears in Table 1. The Medical Expert objectives were further elaborated with key conditions and foundational knowledge.

Table 1.

Clinical presentations of canuc-paeds

Original—2013	Current—2021
Abdominal pain	Abdominal pain and abdominal mass
Altered level of consciousness	Acutely ill child
Bruising/Bleeding	Adolescent health issues
Dehydration	Altered level of consciousness
Development and behavioural problems	Bruising/Bleeding
Diarrhea	Dehydration
Edema	Development/Behavioural/Learning problems
Fever	Diarrhea
Growth problems	Edema
Headache	Eye issues
Inadequately explained injury (child abuse)	Fever
Limp/Extremity pain	Genitourinary complaints
Lymphadenopathy	Growth problems
Murmur	Headache
Neonatal jaundice	Inadequately explained injury (child abuse)
Newborn	Limp/Extremity pain
Pallor/Anemia	Lymphadenopathy
Periodic health supervision	Mental health concerns
Rash	Murmur
Respiratory distress/Cough	Neonatal jaundice
Seizure/Paroxysmal event	Newborn
Sore ear	Pallor/Anemia
Sore throat/Sore mouth	Rash
Sore/Red eye	Respiratory distress/Cough
Urinary complaints	Seizure/Paroxysmal event
Vomiting	Sore ear
	Sore throat/Sore mouth
	Vomiting
	Well child care (newborn, infant, child)

Key conditions

For each clinical presentation, key conditions were identified, defined as those conditions essential for medical students to learn because they are either (a) unique to paediatrics, (b) common conditions, or (c) critical conditions in this patient population. For example, slipped capital femoral epiphysis, trauma (such as sprains and fractures), and septic arthritis are key conditions of the clinical presentation of Limp, representing unique, common, and critical conditions that present in paediatric patients.

Foundational knowledge

A key curricular element was the articulation of Foundational knowledge, defined as the knowledge, often related to basic sciences, that a learner requires in order to approach a given clinical presentation. For example, to approach the clinical presentation of Murmur, students need to be able to describe the anatomy of the cardiovascular system, explain the basic physiology of cardiac function, and be able to relate the anatomy and physiology to the cardiac physical exam findings. The goal was to better inform the preclinical years as to what core knowledge was required to ensure students were set up for success to approach core paediatric presentations in the clinical environment. An example of a clinical presentation, key conditions and foundational knowledge is shown in Table 2.

Table 2.

Example of key conditions and foundational knowledge associated with the clinical presentation of vomiting

Vomiting	Key conditions	Foundational knowledge
	• Gastroeosphageal reflux/Gastroeosphageal reflux disease • Intestinal atresia • Intussusception • Malrotation/volvulus • Pyloric stenosis	• Describe the physiology of gastrointestinal tone and motility • Describe the basic embryogenesis of the intestinal tract and how alterations in normal embryogenesis lead to the development of obstructive lesions of the intestinal tract with particular focus on malrotation and atresias • Relate bilious vomiting to the anatomy of the gastrointestinal tract • Identify non-gastrointestinal causes of vomiting • Describe metabolic and electrolyte alterations that occur with vomiting • Apply basic principles of pharmacology and indications for drugs used in the management of vomiting

Curricular resources

PUPDOC members accessed existing learning resources, reviewed them, and curated those that were best aligned with the curriculum’s objectives. Each identified resource was classified by type: (a) topic overview and foundational knowledge, (b) clinical resources for patient care; or (c) virtual patients or clinical cases. A two-phase review process (Supplementary Appendix 1) was used to identify and critique resources. In Phase I, resources were evaluated on four criteria: French or English; alignment with the curriculum; evidence-based or meeting the current best practice standards; and open access or available at no cost through a university library. Those resources meeting all four criteria underwent a second review. In Phase II resources were evaluated based on the quality of visuals, linkage to basic science or pathophysiology, use of International System of Units (SI Units), and ‘user-friendliness’. Resources were selected based on how well they met these criteria. Ultimately, a broad collection of resources was identified that aligned with the clinical presentations and key conditions.

The chosen resources came from a variety of sources including review articles, clinical practice guidelines, position statements, online videos, podcasts, pictures, and radiographs. Many of the resources are bilingual. Using this comprehensive list of resources, gaps have been identified. These gaps have guided resource development.

Two resources in particular have been developed in alignment with the curriculum to address knowledge gaps and promote clinical reasoning. The first is Cards—an online open-access peer-reviewed collection of short clinical cases—covering 23 clinical presentations with diagnosis, investigations, and management questions (13). Cards has generated over 350,000 cases (13). The second resource is PedsCases (14)—a series of podcasts and cases developed by students and faculty across Canada. There have been over 4.4 million downloads of the podcasts. Both have a strong national and international audience.

Unique curricular components

One of the unique aspects of this curriculum is the explicit articulation of objectives beyond medical content. While most students focus on learning about medical conditions and disease processes, PUPDOC positioned the Intrinsic CanMEDS Roles as an integral part of the curriculum. In particular, paediatric clinical experiences provide unique opportunities for the Health Advocate Role, including addressing social determinants of health and the unique needs of vulnerable populations. Supplementary Appendix 2 lists some exemplar objectives that articulate what medical students can, and are expected to, do in these important Roles. Using the two-phase criteria discussed above, resources have been identified that align with these Intrinsic CanMEDS Roles to support and guide learners and educators. These resources are posted on the curriculum website (15).

With current literature indicating disproportionately high levels of depression, anxiety and burnout among medical trainees (16,17), it was critical to explicitly include personal wellbeing within the core competencies of the curriculum in alignment with the RCPSC CanMEDS Professional Role. Objectives pertaining to self-care, seeking help, and time management are articulated (Supplementary Appendix 2).

Implementation

The curriculum is named canuc-paeds for Canadian undergraduate curriculum in Paediatrics. A bilingual website has been developed, www.canuc-paeds.ca (15), that has had over 74,000 unique page views by people around the world (including Canada, USA, United Kingdom, Philippines, India, Brazil, China, Japan, and United Arab Emirates).

Reflecting on our group’s experience as Canadian undergraduate paediatric educators, we note evidence of success through widespread adoption across the country. Students from all 17 Canadian medical schools have used the learning resources. At many institutions, canuc-paeds has been used in a variety of ways to inform and improve the paediatric curriculum. Educators have referenced canuc-paeds to map the pre-clerkship and clerkship curricula and clinical experiences to detect and address redundancies and gaps. As well, they have used this curriculum to organize paediatric teaching in the pre-clerkship and clerkship years, and to create and blueprint summative and formative exams. The curriculum has been distributed via pocket cards to students, residents, and faculty to guide learning and assessment.

Discussion

After the curriculum had been developed and was in use, the Future of Medical Education in Canada (FMEC) report (18) was released, which charged Canadian medical educators to improve undergraduate medical education; specific recommendations were to develop collaborative education projects, to emphasize generalism and basic science, to promote prevention and public health, to diversify learning contexts, and to adopt a competency-based and flexible approach. A subsequent FMEC report (19) emphasized the need for physicians to be responsive to their patients and community’s needs, to learn from all members of the health care team, and to be lifelong learners. These reports provide external validation for the strategy followed for the development of canuc-paeds as these themes were part of the curricular philosophy from the outset.

During curriculum development, feedback was received from paediatric and education organizations including CPS, RCPSC, COMSEP, Children’s Healthcare Canada, Pediatric Chairs of Canada and the Canadian Undergraduate Deans. All have supported the project, the process taken, and future directions.

In reflecting on this project, the following aspects helped ensure success. Articulating guiding principles and goals at the beginning of the project, while initially time-consuming, assisted curricular decision-making and fostered efficiency. Employing key principles in curriculum design (1,2) provided rigour and structure as well as stakeholder buy-in. Commitment to bilingual implementation was key to engaging all Canadian medical schools.

Collaboration among members of PUPDOC was critical for a successful outcome, ensuring acceptance and contribution from individual schools. Together, individual expertise and background research were shared, enabling national consensus.

Evaluating other group collaborations, such as those of COMSEP and the Canadian Undergraduate Family Medicine Education Directors’ (CUFMED) (20) was valuable. CUFMED developed LearnFM/ApprenezMF, the shared Canadian curriculum in family medicine. PUPDOC and CUFMED learned from each other’s processes, successes, challenges and curricular products, and both curricula were strengthened by this relationship. When COMSEP undertook a curricular revision, they looked at canuc-paeds and consulted PUPDOC; this assisted with the articulation of guiding principles for their work.

Maintaining momentum was a challenge at the beginning of the process due to short annual meetings and member turnover as leaders transitioned in and out of roles. Strategically increasing meeting frequency and duration was critical to progress and resulted in the ability to maintain enthusiasm and ensure that all were actively involved. Creation of an editorial board to oversee the curriculum has helped keep the curriculum dynamic and relevant through quality improvement cycles. Opportunities exist to increase the depth of the curriculum through ongoing review, developing additional resources and assessment tools, and evaluating how well it meets the needs of teachers and students.

CONCLUSION

The wide adoption and implementation of canuc-paeds across Canadian medical schools and the high use of its curricular resources in Canada and beyond are evidence that it is filling a need. Paediatricians and family physicians, who face multiple demands in their busy clinical environments, can access the curricula and its resources to teach, support, and assess learners.