FMEC National Consultation - Edmonton May 6, 2009 Report€¦ · o add new bullets: • “Link funding of Faculties of Medicine to them meeting community health needs.” • “Faculties

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The Future of Medical Education in Canada

National Forum

Edmonton May 6, 2009

Table of Contents Background ................................................................................................. 1

Objectives ........................................................................................................... 1 Participants ......................................................................................................... 1

Part II: The Collective Vision Document: Looking Backward, Looking Forward ...................................................................................... 3

Overall Comments on Document .................................................................. 3 Recommendations: Pre‐review opinion poll ............................................... 4

Part III: Recommendations One by One ............................................... 5 Part IV: FMEC Task Force on Implementation Strategy Co‐Chairs: “What We Heard” .............................................................. 24 Appendices ................................................................................................ 26

Appendix I: Forum Agenda........................................................................... 26 Appendix II: List of Participants .................................................................. 27 Appendix III: Keypad Voting Results ........................................................ 29 Appendix IV: Chronology of Pre‐Forum Work......................................... 34

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Background The Future of Medical Education in Canada (FMEC) project is a systematic review of the Canadian undergraduate medical education system. The purpose of this Health Canada funded project is to identify strengths and potential areas for improvement. As part of this review, consultations were held with members of both the undergraduate medical education community and broader communities, and a comprehensive environmental scan was undertaken and then complemented by international consultations (see Appendix IV). This input culminated in the formulation of a series of recommendations for changes to the existing system. On May 6, 2009, key stakeholders met in Edmonton, Alberta, for the second of two national consultations hosted by the Association of Faculties of Medicine of Canada (AFMC) to review these recommendations and contribute to the development of a collective vision for undergraduate medical education in Canada. This report is a summary of their discussions. It is designed for use by AFMC staff and the Task Force Implementation Group, and is not intended for broad distribution. Objectives The objectives of the national forum were to

share information about the process and background information used to develop the FMEC Collective Vision Document,

provide forum participants with an opportunity to review and provide feedback on this document through discussions with colleagues and other stakeholders, and

continue to build a network of stakeholders committed to excellence in undergraduate medical education through the development of a shared vision for Canada.

Participants Approximately 90 people took part in this invitational forum, including representatives from the AFMC’s faculties of medicine; the FMEC Steering Committee, Task Force on Implementation Strategy, and Environmental Scan

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team; health, medical, and academic groups; government policy makers; and key stakeholders from other constituencies and health disciplines across Canada.

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Part II: The Vision Document— Looking Backward, Looking Forward

Overall Comments on Document Note: throughout this document, differences in opinion appear. Because this was a consultation, comments on all perspectives are included and will be considered by the Implementation Task Force when making decisions about a final report. Plenary discussion points:

Unlike other countries, we have eight years of post‐graduate training. Perhaps we should consider a different structure.

Some people have suggested creating an environment that gets away from the undergraduate/post‐graduate distinction.

The enabling recommendation on “national collaboration” encourages medical schools to work together; however, the same point needs to be made to other stakeholders (e.g., health planners, government).

One of the weaknesses of this methodology is that the voice of the patient/consumer is missing and needs to be incorporated. One way may be to embed it in the organizational reviews on a regional basis.

The Task Force on Implementation Strategy is looking for input on how to organize the recommendations better (e.g., community needs, prevention and public health, and learning in family medicine are all linked to community context).

The theme of lifelong learning is important in light of self assessment, regulation, and monitoring.

The link between Recommendation X and undergraduate medical education is not clear. Is the intent to ensure a new generation of leaders in medical education or to generate leaders from the undergraduate class?

The actual needs of the Faculties of Medicine are conspicuously absent. The health of the faculties is an essential educational issue.

There is only one entry point for undergraduates, yet there are multiple entry points for post‐graduates. That discrepancy needs to be addressed.

The way the recommendations are written, they have lost touch with their impact on care. We need to link them more closely to the ultimate goal of training physicians and improving the quality and safety of their work.

We need to include some guidelines at the end of the report on post‐doctoral education, or it will seem as if we are washing our hands of it.

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What is missing is a clear definition and understanding of the role of the physician and what constitutes a good physician. Without a measurable outcome, we won’t know if we have reached our goal.

The overriding theme seems to be that we are moving away from what students know and toward teaching students how to learn. That point should be more overt.

There are so many requests for additional material in the curriculum that it can become unworkable.

If we want to adapt training to the needs of communities, we have to work with them to identify those needs (e.g., the teenage health project changed completely when teens themselves were consulted). If we engage partners from the start, we’ll be ahead at the end of the day.

One size doesn’t necessarily fit all; we may not need to have a rigid four‐year program.

It is great to have the recommendation on intra‐ and inter‐professionalism in there, but it is written from a somewhat siloed perspective. When will other health colleagues be getting involved in this?

Stakeholders need to be involved in defining a “good physician”. Do regular physicians even know this initiative is going on?

What is missing is acknowledgement that we have many health care systems across Canada, and they are changing.

I am concerned about the level of support we will get for these changes in the medical community. The document is oriented almost entirely toward family medicine and ignores specialists. If we don’t mention them and indicate that they have shortages too, we could have a lot of trouble marketing this in medical schools, where 60 to 70 percent of the clinical faculty members are specialists.

The concept of clinical courage is absent. We live in and train our students in a risk‐adverse environment, and see some graduates trying to reduce their risk and uncertainty by restricting their practices.

Recommendations: Pre‐review Opinion Poll Participants were given keypads and asked to rank their level of comfort with each recommendation and their perception of how challenging each will be for stakeholders to implement. The results are provided in Appendix III.

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Plenary discussion points:

Any change is challenging, no matter how small. All of the decision‐makers are in this room, and they have shown that they are committed to seeing this through.

This is a culture change, and that is tough work. We are talking about moving from a specialist‐oriented biomedical area to a community‐oriented, patient‐focused one.

There have been many cases where reports were written and only a few recommendations implemented. It is important to determine which of these recommendations are linked and should be developed in tandem. Interdependence is critical.

When it comes to implementation, it will be important to connect with young leaders. Perhaps half the spaces for the next workshop should be reserved for people 30 to 35.

Although there have been student and resident leaders involved in this initiative from the outset, we don’t know how broadly they have consulted within their communities or whether we have achieved the kind of relationship we need to achieve.

If some recommendations are out there by 2010, and faculty are educated by 2011‐12, we will still have to convince some of the doctors out there to do this. Given the length of time this could take, it is critical to see what can be done sooner rather than later.

The document should be written so that all future physicians see themselves in it and that it improves the quality of care. The educational principles need to be underscored and to be less political.

The evidence that these ideas will improve service needs to be there, otherwise this will not resonate with young people who have been educated using evidence‐based medicine practices.

When approaching schools, we should pre‐select from the “almost converted” students who are already geared for leadership.

Part III: Recommendations One by One Participants self‐divided into 10 smaller groups, each of which was asked to provide detailed feedback and suggestions on one of the recommendations in the collective vision document. To encourage a variety of perspectives in the discussions, representatives from faculty, Steering Committee/Task Force members, medical organizations, health professions, and policy were included in

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each group, and group members were asked to provide input using “sticky notes” for consideration by other groups in their discussions . The results of their plenary presentations and worksheet notes are summarized as follows. I: LINK TO COMMUNITY NEEDS Is the recommendation clear and concise? No

• add a second sentence that reads: “Recognizing our international role, the Faculties of Medicine have a responsibility to the needs of the global community.”

• local and population health needs should drive the work (curriculum, research, learning) of the faculties

• stakeholder collaboration is important • the definition of “community need” is a looming issue

Recommendations for changes to “Why”, “How”, and “Challenges” sections:

• “Why”: o add new bullet a): “Responding to health‐care needs, including

those of vulnerable populations/communities, is the basis of evidence‐based medical education.”

o delete c) o delete h)

• “How”: o a) change last part of sentence to read: “patient‐, family‐, and

community‐centred approach.” o add new bullets:

• “Link funding of Faculties of Medicine to them meeting community health needs.”

• “Faculties of Medicine consult with community stakeholders and other professions in curriculum design.”

• “Faculties of Medicine engage in health‐system planning and service delivery planning in collaboration with other professions (beyond health).”

• “Promote inter‐professional partnerships to deliver on the societal determinants of health.”

• “Link Faculties of Medicine to organizations collecting health data (e.g., Canadian Institutes of Health Research, Statistics Canada, Public Health).”

• “Challenges”: o add new bullets:

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• “Narrowing scopes of practice is a challenge if we are to meet community health needs.”

• “Accreditation guidelines that are overly restrictive/perscriptive are another barrier.”

On a scale of 1‐5, to what extent does this recommendation have the potential to significantly advance undergraduate medical education in Canada? 4

• existing work/directions of the Faculties of Medicine need to be strengthened

• “significantly” is not a measurable term Importance of enablers to supporting action on this recommendation, on a scale of 1‐5:

Additional Committee on the Accreditation of Canadian Medical Schools (CACMS) accreditation standards: 4; do not create additional standards but revise existing ones (otherwise this may challenge CACMS‐Liason Committee on Medical Education relationships)

Organizational review: 3 Increased national collaboration: 4

Additional enabling recommendations:

• targeted resources to support the recommendations Plenary discussion points:

This will all be for nothing if we don’t deal with post‐graduate education. There are some real issues around the influence of residency programs on the type of physician people become — this needs to be discussed.

What is needed are caring, competent physicians. This is an opportunity to set the stage for the physician of the future and to ensure that lifelong learning is linked to lifelong competency.

We need regular, in‐depth clinical evaluation and personal behavioural evaluation. There is a significant number of physicians who demonstrate disruptive behaviour and, if we don’t do something about it, we could lose the privilege to self‐govern.

When we struggle with the definition of community needs, we must remember that we spent a lot of money consulting people about major issues in health care. We must not forget that we have already spent time reflecting and consulting on this.

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Those of us with privilege have spent a lifetime looking at disadvantaged populations, and serious self‐reflection is also about interrogating our own privilege. So, although it is an edgy term, we need to do some thinking around it before we let it go.

We need to be more specific about what we mean by “international” and “global”.

II: ADMISSIONS PROCESSES Is the recommendation clear and concise? No

we can’t assess socioeconomic status (SES), so we should remove barriers like grade‐point average (GPA)/Medical College Admission Test (MCAT) to allow applicants into the pool so they can be measured on other skills

this wording places good emphasis on recruiting, selecting, and supporting and on the importance of factors other than academics in creating a good physician

divide the introduction into two separate concepts: move the second part up before the first, then add “while meeting the needs of the communities we serve” to the end of that sentence

Recommendations for changes to “Why”, “How”, and “Challenges” sections: • “Why”:

o delete c) o change b) to read “The applicant pool should contain a variety of

individuals…” • “How”:

o b) at the end of the last sentence, add “(e.g., lower the GPA to open the applicant pool)”.


• this has the potential to advance the profession as well Importance of enablers to supporting action on this recommendation, on a scale of 1‐5:

Additional CACMS accreditation standards: 5 Organizational review: 5 Increased national collaboration: not every school has the same social accountability responsibilities; this enabler is especially important to outcome measures, which will be necessary for government funding

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Additional enabling recommendations: • funding for outreach programs • ongoing support for people who are recruited • engagement of government at all levels (develop measurement outcomes)

Presentation points:

• There are points along a person’s life where they will be excluded (e.g., disadvantaged, at‐risk groups very early on get the impression that they won’t be admitted into medical school). We need to develop programs that go back as far as grade 7, in some cases, to create a culture and belief that this is something they can do. And we need to offer programs that enable them to stay there once they are in.


Did you talk about gender? The pendulum has swung too far, and we now have 75 to 80 percent women; that is not an equitable mix, and we should be striving for one.

Many participants expressed their belief that there shouldn’t be defined admission quotas based on gender.

It is commendable to be moving away from grade‐point averages (GPAs) when it comes to applications.

There is no evidence that the many complex mechanisms used in some admissions processes actually lead to a better pool of candidates.

It is surprising that we haven’t heard more about CanMEDS, as its role is reasonably clear and it resonates. Perhaps it should be linked to the admissions process.

There need to be discussions on strategies around the “transitional year” program. We have to support people before entry and make them literate about things like the hidden curriculum, otherwise we’re setting them up for failure.

For the past 15 years, the University of Toronto has run tutoring and mentoring programs for high‐school kids who are underrepresented (e.g., aboriginal, African ancestry). Job‐shadowing is a critical component of this, so the students are exposed to a wide array of opportunities in health care, including hospital work. They are now enjoying success in post‐secondary programs in health care and medical school, and have very supportive residency programs. Although the government invests in this effort, contributions from other stakeholders also need to be sought.

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In response to the previous point, it was suggested that some of the students who have been involved in these programs could offer valuable input and insight into ways to integrate underprivileged students so they are encouraged to succeed.

III: BASIC AND CLINICAL SCIENCES

Is the recommendation clear and concise? it is clear, but it is not what we wanted to say revise the recommendation to read “That basic sciences, both human/social and biological, should be taught, learned, and assessed in a fashion that provides a relevant and immediate clinical context throughout the entire undergraduate experience.”

Recommendations for changes to “Why”, “How”, and “Challenges” sections: “Why”:

o change a) to read: “Assure that the scientific basis of medicine continues to be appropriately emphasized.”

o delete b) and change it to: “Basic science learning objectives, relevant to medical practice, need to be presented in a health‐care context.”

o in c) , add “emerging” after “integrate” and add at the end of the sentence, add “…daily practice as lifelong learners.”

“How”: o delete a) and change it to: “The design, development, and

implementation of the undergraduate curriculum and associated learning activities needs to be a collaborative effort among basic scientists, clinical faculty, and medical educators.”

o change b) to read: “Create a national forum to discuss what basic…”.

o delete c) “Challenges”:

o add d): “The reward system for basic science faculty must reflect their value as collaborative medical educators.”


promotion of collaboration among basic science, clinicians, and medical education would serve to provide a relevant and conceptualized learning experience

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Importance of enablers to supporting action on this recommendation, on a scale of 1‐5:

Additional CACMS accreditation standards: 1 Organizational review: 5 Increased national collaboration: 5


support for a “Community Academy of Scholars” around medical educators that would allow opportunities for faculty to do collaborative work and promote a sense of value for all faculty

Canadian Association for Medical Education outreach to basic scientists Plenary discussion points: The table discussion group preferred the term “medical science” to “basic science” or “biomedical science”, because “basic science” is almost pejorative in many medical schools, while medical science has an intrinsically broader scope. The term needs to be more clearly defined.

Part of “intra‐professionalism” is the work we need to do between the basic science faculty and the clinical faculty. It is about being inclusive.

There was some discussion in the small group about governance being an enabling recommendation, but the camp was split. Overall, it was felt that some form of reorganization was needed to get the clinical and medical sciences faculty more in line in terms of curriculum collaboration, but that would not require a total restructuring.

Basic science is the grammar of clinical science. The system has been abused by basic scientists who have simply taught areas of personal interest to them. We have to stop that practice, and ensure that the essential areas are being taught in a relevant and intelligible fashion.

It was suggested that the sciences be referred to as “explanatory” rather than “basic”, because what is meant is that they are explanatory to everything that goes on in the human body.

More discussion is needed about the degree to which this is also applicable at the post‐graduate level.

IV: PREVENTION AND PUBLIC HEALTH Is the recommendation clear and concise? No

change the title to “Population Health”, to be more all‐encompassing

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revise the recommendation to read: “Address as core to undergraduate medical education the social determinants of health, prevention, and promotion throughout the undergraduate curriculum, preferably in partnership with other health disciplines.”

a glossary of terms related to population health language is needed Recommendations for changes to “Why”, “How”, and “Challenges” sections:

“Why”: o to improve the health of the population (social accountability) o change a) to d) o change b) to a) o add new b): “Morbidity and mortality are related to modifiable

factors (e.g., injury prevention).” o delete d) and e) and add new d): “Teach learners how to assess the

value of allopathic, complementary, and alternative approaches to medicine.”

“How”: o change e) to a) and revise to read: “Enable all physicians and

students to understand and value the impact of social determinants of health on population health.”

o in b) change end to: “…in relation to population health, including prevention and public health.”

o in c) change “Integrating” to “Integrate” o in d) change “Involving” to “Involve” and add at end: “…teaching

(e.g., schools of public health).” o add new e) to read: “Promote a culture of scholarship innovation in

the teaching of population health, including prevention and public health that responds to each Faculty of Medicine’s context.”

“Challenges”: o in a) change end to “…relative to population health”. o in c) change to read: “There are diverse understandings…”. o in e) change to read: “There are often limitations in terms…”.


advances the health of the population and, as such, falls under social accountability

has the potential to significantly impact the undergraduate curriculum

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Additional CACMS accreditation standards: 3; revise rather than add, and also disseminate

Organizational review: 5; culture change is very difficult Increased national collaboration: 5; needs continued support; public health teachers are scarce


develop and engage partnerships with key stakeholders at national, provincial/territorial, and local levels


Prevention and population health is taught as a segregated, separate entity. It should be integrated into core curriculums, so the emphasis placed on it is the same as that placed on the biomedical aspects of health.

V: THE HIDDEN CURRICULUM Is the recommendation clear and concise? No

this recommendation should possibly precede all of the others reword the recommendation to read: “Recognizing the power of the hidden curriculum, ensure that learners and teachers understand the nature of professional, institutional, and learning environment cultures and their influence on learning, professional interactions, and future clinical practice.”

it is important to acknowledge the learning continuum, as post‐graduate trainees are also integral to the hidden curriculum

there were a couple of suggestions — not supported through a show of hands by a majority of participants — made by individual group members for a new title, including “The Unintended Curriculum” and “Harnessing the Culture of Learning Environments for Good”


“Why”: o in c), change start to “Educate learners and teachers…” o add new e): “Failure to recognize the hidden curriculum is

detrimental to patient care, learner wellness, and professional interactions.”

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o one group participant handed in a separate suggestion, noting that “Preferred learning environments will demonstrate an integrated, collaborative approach to patient care among family physicians, general and other consulting specialties, and other health professionals.”

“How”: o in b), change start to “Create ways to identify the hidden

curriculum and make it relevant to the mission and the formal curriculum.”

o add new h): “Institutions regularly evaluate their informal and hidden curricula to ensure that they supports the school’s mission and values as much as possible.”

o add new i): “Create a safe environment.” o add new j): “Recognize the positive aspects of the hidden

curriculum.” “Challenges”:

o definitions o hospital cultures o other people who work in hospitals/clinics o how to assure accountability o how to value and nurture others in an overwhelmed health care

system On a scale of 1‐5, to what extent does this recommendation have the potential to significantly advance undergraduate medical education in Canada? 5 Importance of enablers to supporting action on this recommendation, on a scale of 1‐5:

Additional CACMS accreditation standards: 1; we need to set our own bar within the current accreditation standard, not create new ones

Organizational review: 5; a true review of the organization will affect health care

Increased national collaboration: 5; should focus on process Additional enabling recommendations:

faculty development

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This recommendation has the most potential to be revolutionary, and if we back away from that opportunity we waste the potential to improve the lives of both medical‐school teachers and learners. The hidden curriculum is evident in many forms, from racism to sexism, and the final document must address it unapologetically.

If we fix this, we fix our problems with professionalism, the concept of generalist versus specialist, and almost everything else. A great curriculum is important, but it’s the non‐verbal cues that have the greatest influence. We all do it, and we have to name it, recognize it, and scold people who are the worst offenders. It is time to put our money where our mouths are and to empower people to blow the whistle when they see it.

There was some discussion about the phrase “hidden curriculum”, and whether “institutional culture” or some other term would be preferable. Many participants, however, liked “hidden curriculum” because that is how it is framed in the literature and because it is commonly used.

There are huge advantages to talking about the formal, informal, and hidden curriculum, because they provide a structured approach to a difficult issue. It is also valuable to use these words as they were originally introduced into medicine.

This document isn’t for us alone; there are many people out there who don’t know what “hidden curriculum” means. We need simple language that people who are not in this room can understand.

We need to create a safe environment for the hidden curriculum to come out in the open. Right now it is not safe or wise to talk about this kind of thing in many situations.

The informal and hidden curricula have to be recognized as powerful learning tools and addressed clearly and explicitly. It will be important to address both in the recommendation and to include common definitions.

VI: LEARNING IN COMMUNITY CONTEXTS Is the recommendation clear and concise? No

“exposure” may be superficial and doesn’t necessarily lead to deeper learning

reword the recommendation to read: “That there be experience and sufficient learning experiences in a variety of community settings in each year of undergraduate medicine in order for students to fully understand the ecology of care.”

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include a definition/explanation of ecology of care the definition of “community setting” should be defined by each faculty alternate definition proposed: “Medical schools build their curricula to incorporate educational environments representing a range of communities from metropolitan tertiary to small rural/remote where all these communities are considered part of the academic enterprise and the medical school campus.”


“Why”: o move d) to the top of the list o in g) change to “Provide transformative exposure to diversity (e.g.,

socio‐cultural, geographic) in order to learn about social determinants of health in context.”

o delete h) o add new i): “Provide students with the ability to approach/care for

patients with undifferentiated problems, recognizing that there may be a greater level of ambiguity in patient presentations in community settings.”

“How”: o in b) add “and community settings” to the end of the sentence o in c) add “at all levels of education” to the end of the sentence o in d) add “(provide context)” to the end of the sentence o add new bullet: “Intra‐professional care and communication to

demonstrate connectiveness between health‐care professionals and also sites.”

“Challenges”: o add new bullets:

“Faculty development and resources in the community (e.g., training to provide appropriate role models/mentors)”.

“Shifting culture/way of thinking in terms of providing a good ground in family medicine/generalist.”

“Need to acknowledge and reward community teachers (physicians and non‐physicians) in meaningful ways.”

“Resources.”


however, it is difficult to shift thinking/culture

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Additional CACMS accreditation standards: 5; CACMS accreditation is a good lever to present/aid change in education at the faculty level

Organizational review: 5 Increased national collaboration: 5; national collaboration would aid Postgraduate Medical Education in knowing what to expect


involve registration bodies and/or admissions to promote standard of “generalist” education; this may remove some preconceived notions

Presentation points:

Learning around the social determinants of health in context can be extremely powerful and can happen in a thoughtful way in community settings.

Intra‐professional care may be played out differently in community settings than in a tertiary care hospital.

Recommendations VI and VII are related, but they need separate exposure in the document.

The concept of a borderless community experience for students from various medical schools was proposed for discussion (e.g., no restrictions on medical students experiencing schools outside their territory).


This is all about appropriate settings and ensuring that we have broad input into these areas. I understand why they are separate, but is there no creative way of bringing them together, yet broadening them?

It is a significant cultural change to be talking about moving students out of tertiary care and into the community setting.

We need to stop thinking of students as going “out” into the community and coming back to hospitals. There are many environments in which our students learn, and we have to provide them in order for them to meet their competencies and learning objectives. It’s not a matter of one being better than the other.

In terms of the differences between them, Recommendation VI is about context and VII is about the promotion of family medicine and generalist specialties.

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If we roll up family medicine into the other generalist specialties, we lose the distinction between the generalism of a consulting specialist and the generalism of providing continuing care to patients over time. The primary care distinction is what separates family medicine from the other disciplines, and it needs to be made and valued as a piece of the generalist spectrum.

The context of the document must be applicable across the spectrum of teaching practitioners, some of whom are specialists. Given that part of our problem is teacher recruitment, we need to be very cautious about the language we use. Both VI and VII are aimed at generalists and might be seen as excluding some subsets of teachers.

We are going to have to make some very difficult choices in writing the final document. At the end of the day, what we’re trying to say is that medical students should learn in a context where care is given through close cooperation between practitioners who are longitudinally responsible for patients and those who offer support and consultative services. We’re trying to find a way to integrate all levels of care, and this document doesn’t express that very clearly.

VII: LEARNING IN FAMILY MEDICINE AND GENERALIST CONTEXTS Is the recommendation clear and concise? No

there is concern about the terms “generalist” and “family medicine” and whether they should be in the title or not, as they may foster the hidden curriculum and lead non‐generalists to skip over the recommendation because they don’t think it applies to them

there is significant overlap and lack of clarity with regard to the difference between recommendations VI and VII

focusing on context alone does not go far enough to promote generalists suggest using the British term “complex medical generalist”


“Why”: o existing “whys” are political and weak and have nothing to do with

improving patient care o delete a) and replace with “Clinical reasoning skills are best

developed in a generalist context with undifferentiated patients.” o delete b) and replace with “Patients do better when treated in the

context of their own environment.”

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o in e), change start of sentence to read: “Emphasize continuity of care throughout the patient’s life and other illnesses (involve all health professionals) as a guiding principle to address…”

“How”: o change a) to read “Identify and address the hidden curriculum

issues.” o in c), add at end “…of illness, together with generalists.” o add new bullet: “Generalists of all types sharing teaching and

communications skills being part of every evaluation.” o link the infrastructure that is currently in place with alternative

educational locations “Challenges”:

o in c) at the end of the sentence, add “(address this by co‐teaching and emphasizing generalists).”


influence is dependent on clarity and implementation Importance of enablers to supporting action on this recommendation, on a scale of 1‐5:

Additional CACMS accreditation standards: 5; this is a long arduous procedure, so a Canadian qualifier is likely necessary

Organizational review: 2; the timing is not right; we need to identify the organizational challenges that exist in particular schools before undertaking a review

Increased national collaboration: 5; encourage collaboration among schools, as this is lacking on all levels; this is much too narrow


identify what is needed to transfer some of the educational components into the community (e.g., multiple stakeholders, money, infrastructure) and reward those who are doing it well

engage governments at all levels in this process Plenary discussion points:

The way the recommendation is worded, almost every medical school could argue that it’s meeting the standard. It doesn’t say enough.

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This is a very important recommendation. There are many school programs to recruit people to family medicine, but with so many teachers being specialists, this component is lacking in the hidden curriculum. If there were more family physicians involved in the curriculum, and it was based more on training students to fulfill that role, the underlying message would change.

Challenge b) talks about ”community faculty development” and the “academic generalist faculty”, which implies that the community is not academic. If we want the community engaged, the academics either have to decide that everyone is the same or find a new word. This is a major value judgement and it’s not okay.

It was noted that a number of the small‐group discussion thought the word “holistic” should not be used because it causes a visceral reaction.

Some of this feedback has to do more with political correctness. We should be looking at the richness of educational experiences that can occur in these environments and not just focus on career goals. At the undergraduate level, we want to provide the best educational experiences and opportunities to develop a sound knowledge base, skills, and attitudes. If this results in more family physicians, that’s fine, but to use it simply to create more of them diminishes the other opportunities.

VIII: EXPOSURE TO INTER‐ AND INTRA‐PROFESSIONALISM Is the recommendation clear and concise? No

need to indicate the purpose of the recommendation, rather than the skills involved

there are lots of triggers around the phrase “exposure to”; suggest rewriting it to say “capacity building and skill development in …”

there is concern that we might be creating inter‐ and intra‐professional spaces that reproduce the very things we think are collapsing

we should focus on the issue of “professionalism” rather than inter‐ or intra‐professionalism

the intent of the recommendation is excellent, but the philosophy and specifics need work

the word “preserved” raised some concerns the same way “cultural competency” has evolved into “cultural safety”, we should talk about “safety” instead of “competency”

the document needs to be restructured in terms of admissions, patient safety, etc.

ten recommendations are far too many

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there is a disconnect between the “whys” and “hows” under “How”, add the notions of

o team‐based reflection o learning in community spaces o the examination of medical education policies to ensure support for

inter‐professional learning


if modified, the recommendation has great potential Additional enabling recommendations:

introduce framing of quality/safe care through the recommendations/document


This subject came up as a common theme in about half a dozen of the other small group discussions, so it is cross‐cutting.

A lot of discussion in this group focused on quality care and patient safety in terms of an inter‐ and intra‐professional learning environment.

IX: TOWARD A COMPETENCY‐BASED APPROACH Is the recommendation clear and concise? No

this may be the most important, most poorly written, and hardest to implement of all the recommendations

change the title to “Toward the Integration of a Competency‐Based Approach”

in the first sentence of the recommendation, change “not merely on” to “in addition to”; in the second sentence, delete “more” before “flexible” and change “beyond” to “in addition to”

there is a certain amount of socialization and experiential learning that goes on as you go through medical school; if you cut it down to 18 months or two years, that won’t happen.


“Why”:

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o in c), change the word “beyond” to “in addition to” o in e), change “portability” to “accessibility”

“How”: o there is concern about using the word “portfolio” because it is

perceived as being too cumbersome and difficult o delete d)

“Challenges”: o these don’t match with the whys or hows o delete d) to reduce the time‐based emphasis

On a scale of 1‐5, to what extent does this recommendation have the potential to significantly advance undergraduate medical education in Canada? 5 Plenary discussion points:

This is the most revolutionary of the recommendations because it means a change in the way we do business.

Would the term “development portfolio” as a means for the learner to keep track of and guide his/her development be more acceptable than the term “assessment portfolio”?

The reason this group had a problem with the word “portfolio” is that it brings to mind a fat folder of disjointed information that one person with 200 students would need to look through to make all decisions. Until a workable, effective system has been put in place, we would like to steer clear of that term.

As the recommendation was phrased, there are two completely different ideas: competency in the first sentence and flexibility in the second. In our slight rewording, by adding “in addition to” we felt that we had moved the two concepts closer together. So the second phrase now reads “flexible opportunities … in addition to curriculum requirements”. That way, if someone meets the competency requirements sooner, he would have the option of pursuing his own area of interest in the remaining weeks (i.e., without shortening the length of the rotation).

The idea of moving away from the concept of an education portfolio makes me worry that we have said “no” to that forever as an option for self‐assessment, self‐reflection, and self‐modification.

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X: BUILD A GENERATION OF MEDICAL LEADERS Is the recommendation clear and concise? No

reword the recommendation as: “That Canada build a generation of medical leaders representing the medical profession as a vital resource in clinical care, education and research, management, and public policy.”


“How”: o change b) to read: “Develop national/international leadership…” o add e): “Mentoring and role‐modeling.”

“Challenges”: o change b) to “Absence of expertise and capacity within the medical

profession and system.” o add new bullet: “A major cultural challenge is the need to

recognize and value leaders.” On a scale of 1‐5, to what extent does this recommendation have the potential to significantly advance undergraduate medical education in Canada? 5

none of the other recommendations will see progress without leadership Importance of enablers to supporting action on this recommendation, on a scale of 1‐5:

Additional CACMS accreditation standards: 3 Organizational review: 5 Increased national collaboration: 4; should this be national/international?


Although none of the proposed recommendations can move forward without leadership, this was the shortest of the 10 recommendations and the last one listed. That is telling.

There is a connection between this recommendation and the one about the hidden curriculum. The fact that we send our own students off somewhere else signals that this is not important work.

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Part IV: FMEC Task Force on Implementation Strategy Co‐Chairs: “What We Heard”

The three co‐chairs thanked participants for their focus and input, and promised to take all of their suggestions into further consideration. They noted that some of what they heard was consistent with the previous forum but that there were also many new ideas. They then summarized what they considered to be the main themes of the meeting’s discussions:

There is a struggle with the balance of a lot of concepts in the document: who our teachers are; the types of students we admit; the need to be inclusive.

Words are important and have nuances and subtle meanings in this report. We have to be cognizant of the terms we use and ensure that we reflect the appropriate balance we want looking forward.

People felt that almost every recommendation was cross‐cutting and linked to everything else. We will have to think of how we group the recommendations and put them into a meaningful matrix or visual that recognizes those links.

It may be helpful to consider lumping the recommendations into themes rather than presenting them separately.

The document should be tailored toward improving future physicians and providing better care to Canadians. We may need more dialogue about the role of physicians in the future health care system.

There wasn’t a lot of feedback on the collective aspect of medical schools working together. We have to think about a strategy for getting the 17 faculties across Canada working together.

The predominant theme is the continuum of medical education and the importance of including post‐graduates in the ultimate product. The next phase of this project will involve a substantial look at post‐graduate training. We need to break down silos.

There is a lot of confusion about definitions: hidden curriculum, generalist, equitable, public health. We need to be sure we are clear enough in the document for it to be meaningful to both us and the broader community.

We need community consultation now that the document is reasonably well formulated.

We need to define the product we’re trying to produce.

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We need to be a bit more specific in the preamble and at the same time to work on defining what the 21st century doctor will be.

Professionalism may be an overarching item that needs to have more emphasis placed on it.

Also highlighted was one interesting comment or question the co‐chairs heard about each of the 10 recommendations, which are listed in order below:

1. Local and national health‐care needs should drive the education process. 2. Should CanMEDS role be linked in some way to admissions, and should

gender balance be a consideration? 3. What are the basic sciences? 4. We need to integrate population health into the curriculum. 5. A safe learning and health‐care environment is needed to empower

people to tackle the hidden curriculum, which could be the theme for next year’s meeting in St. John’s.

6. The word “exposure” raises red flags. 7. Should recommendations 6 and 7 be lumped together or stand separately,

the former focused on context and the latter on role‐modeling? 8. Professionalism needs to be broadened to better meet the health‐care

needs of Canadians. 9. This is a paradigm shift, so we need to get this recommendation right. 10. This recommendation should be more comprehensive: we can only

advance if there are people willing to step up as leaders. As a final point, it was recognized that it will be essential not only to make changes but also to look at how to integrate this work into the post‐graduate environment in order to build on the good work done on this project.

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Appendices

Appendix I: Agenda Wednesday, May 6, 2009 Saskatchewan / Manitoba room 8:00 am Workshop Opening Welcome: Co‐chairs, FMEC Task Force on Implementation Strategy

• Dr. Nick Busing • Dr. Jay Rosenfield • Dr. Jim Rourke

8:05 am Part I: Presentation: “The Collective Vision Document: A Process in Progress”; Dr. Nick Busing, President and CEO, AFMC 8:50 am Part II: Forum Process: Dorothy Strachan, Facilitator

• Purpose, Objectives, Agenda • Introductions, Process parameters • Background Documents

9:20 am Q and A 9:35 am Recommendations: Pre‐review opinion poll 10:30 am Part III: Recommendations One by One Small group discussions on recommendations 12:00 pm Lunch 12:45 pm Results of small group work 2:00 pm The Document as a Whole: Plenary discussion 2:30 pm Break 2:50 pm Recommendations: Post‐review opinion poll 3:45 pm Part IV: FMEC Task Force on Implementation Strategy Co‐Chairs: “What We Heard”

• Dr. Nick Busing • Dr. Jay Rosenfield • Dr. Jim Rourke

3:55 pm Feedback on the Workshop 4:00 pm Closing

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Appendix II: List of Participants William Albritton University of Saskatchewan Diana Alli University of Toronto Linlea Armstrong University of British Columbia Saeed Awan University of Saskatchewan Sandra Banner Canadian Resident Matching Service Joanna Bates Centre for Health Education Scholarship Mary Bell University of Toronto Ian Bowmer Medical Council of Canada Keyna Bracken McMaster University Nick Busing Association of Faculties of Medicine of Canada Oscar Casiro University of British Columbia Claudette Chase Kevin Chin McGill University Diane Clavet Université de Sherbroke David Cook University of Alberta Sylvia Cruess Center for Medical Education, McGill University Richard Cruess McGill University Deborah Danoff Canadian Medical Protective Association Sarah Dobson UBC Centre for Health Education Scholarship Denise Donovan Université de Sherbroke Tami Everding McMaster University Gerard Farrell Memorial University of Newfoundland Bruce Fleming University of British Columbia Blye Frank Dalhousie University Pierre Gagné Université de Montréal ‐ Mauricie Campus David Gass College of Family Physicians of Canada Irving Gold Association of Faculties of Medicine of Canada Tania Gottschalk Neil John Maclean Health Sciences Library Calvin Gutkin The College of Family Physicians of Canada Mark Hanson University of Toronto Sheila Harding University of Saskatchewan Marg Harrington Council of Ontario Universities Kenneth Harris Royal College of Physicians & Surgeons of Canada Anne Harvey Université de Sherbrooke Carol Herbert University of Western Ontario Cheryl Holmes University of British Columbia Dorothy Anna Jarvis University of Toronto Allan Jones University of British Columbia Jill Konkin University of Alberta Sarah Kredentser The College of Family Physicians of Canada Joel Lanphear Northern Ontario School of Medicine David Loewen Alberta Health and Wellness Cathy MacLean University of Calgary

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Anne‐Marie MacLellan Collège des médecins du Québec Deb Marcellus McMaster University Bruce Martin University of Manitoba Susan Maskill Association of Faculties of Medicine of Canada Marie Matte Northern Ontario School of Medicine Karen McCarthy Royal College of Physicians and Surgeons of Canada Pat McCullough University of Manitoba Meredith McKague University of Saskatchewan David McKnight University of Toronto Geneviève Moineau University of Ottawa Beryl Moore McMaster University Cathy Morris McMaster University Leslie Nickell Sunnybrook Health Sciences Centre Carol Anne Northcott University of Manitoba Margo Paterson Queenʹs University Tara Petrychko University of Manitoba Kalyani Premkumar University of Saskatchewan Anita Rachlis University of Toronto Malathi Raghavan University of Manitoba Jay Rosenfield University of Toronto Shelley Ross University of Alberta James Rourke Memorial University of Newfoundland Joan Sargeant Dalhousie University Inge Schabort MacMaster University Aurel Schofield Centre de formation médicale du N.‐B/U. Sherbrooke Martin Schreiber University of Toronto Steve Slade AFMC / CAPER Preston Smith Dalhousie University David Snadden UNBC/UBC Beth Sneyd Canadian Association of Internes & Residents Kent Stobart University of Alberta Roger Strasser Northern Ontario School of Medicine Shamim Tejpar University of Western Ontario Sarah Thomas Professional Association of Residents of Alberta John Thomson Alberta Health and Wellness David Topps Northern Ontario School of Medicine Maureen Topps Northern Ontario School of Medicine Angela Towle University of British Columbia Tom Ward Fraser Health Authority Jonathan White University of Alberta CONSULTANTS AND STAFF Claire de Lucovich Association of Faculties of Medicine of Canada Leslie Ebbs Leslie Ebbs Communications Chris Lovato University of British Columbia Catherine Moffatt Association of Faculties of Medicine of Canada Dorothy Strachan Strachan‐Tomlinson

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Appendix III: Keypad Voting Results

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Appendix IV: FMEC Fact Sheet 2007‐2009 • July – September 2008 ‐ Project Begins o The Project Secretariat is established, and the Project Manager and Assistant are hired. After the draft Terms of Reference are developed, the Steering Committee is established. A Work Plan is drafted as well. • October ‐ December, 2008 – Steering Committee meetings o The Steering Committee members meet via teleconference and in person with the Environmental Scan research team, composed of a bilingual team from the Wilson Centre for Research in Education, University of Toronto and Centre de pédagogie appliquée aux sciences de la santé, Université de Montréal. Upcoming meetings and the hiring of an Evaluation consultant are also discussed. • March 17‐18, 2008 – Data Needs and Access Group (DNAG) meeting o Stakeholders convene to identify and prioritize medical education information needs. A wide range of perspectives is shared at the meeting, including those of faculty of medicine deans, undergraduate, postgraduate and research deans, residents and medical students. • March 19‐20, 2008 – Young Leaders’ Forum (YLF) meeting o Representing a broad range of sectors including faculty members, residents, medical students, researchers and leaders of health professional organizations, participants are invited to discuss their vision of what Canadaʹs health care system would look like in 25 years. • April 2008 – International Comparison – United Kingdom o Steering Committee members, Drs. Jay Rosenfield and Angela Towle, visit the General Medical Council and three faculties of medicine in order to assess what types of innovations in medical education are happening in the United Kingdom. • April 17‐18, 2008 – Blue Ribbon Panel meeting o This first meeting of the Blue Ribbon Panel, along with the Steering Committee. Panel members are charged with several responsibilities, including: 1. Representing a community perspective; 2. Reviewing draft reports from various project panels and activities; 3. Providing input into key issues in medical education, and 4. Assisting with the development of draft principles for change in medical education in Canada.

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• May 2008 – International Comparison – United States o Steering Committee members, Drs. Jay Rosenfield and Angela Towle, hold videoconferences with the Liaison Committee on Medical Education (LCME), Association of American Medical Colleges (AAMC), American Medical Association (AMA) and The Carnegie Foundation for the Advancement of Teaching in order to assess what types of innovations in medical education are happening. • June 12, 2008 – Environmental Scan Retreat o The retreat is planned for the mid‐point of the Environmental Scan to consider data from the two components of the report, the interviews and the literature reviews. A preliminary coding structure summarizing major key emerging themes is developed and data is organized in a way that is more conceptual than before. • August 2008 – International Comparisons – Australia and New Zealand o Steering Committee member Dr. Deborah Danoff holds a videoconference with the Medical Council of New Zealand. At the Association for Medical Education in Europe (AMEE) conference, Dr. Danoff and Dr. Anne‐Marie MacLellan meet with the President of Medical Deans Australia and New Zealand and with the head of medical education at Flinders University. • September 12, 2008 – Deans and Blue Ribbon Panel Retreat o This meeting brings together the Deans of Medicine with the Blue Ribbon Panel to engage in a high‐level discussion around a series of draft principles for change to Canada’s undergraduate medical education system that are emerging from the process. • October 2008 – International Comparison – United States o Steering Committee members, Drs. Jay Rosenfield and Angela Towle, visit the Cleveland Clinic Lerner College of Medicine, Harvard Medical School, niversity of California at San Francisco, Stanford University and the University of Minnesota in order to assess what types of innovations in medical education are happening in the United States. • October 3, 2008 – Environmental Scan Working Retreat o The Environmental Scan research team and members of the Steering Committee work together to define major priorities for medical education in Canada based on the interviews and literature reviews.

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• October – December 2008 – Regional Undergraduate Deans Consultations o Steering Committee members participate in meetings in Halifax, Montréal, Moose Jaw and Toronto with Undergraduate Deans and members of the medical education community. • November 21, 2008 – International Comparison – the Netherlands o Steering Committee member, Dr. Jay Rosenfield, visits Maastricht University in order to assess what types of innovations in medical education are happening in the Netherlands. • December 15, 2008 – Final Environmental Scan submitted o The final version of the Environmental Scan report is submitted, consisting of National Key Informant Interviews, National Literature Reviews and Analyses. The Literature Reviews is made available on the project website www.afmc.ca/fmec • January 12, 2009 – Steering Committee meeting o The Steering Committee meet to review the ten priority areas as submitted by the Environmental Scan research team. Draft recommendations for change are developed. • January 29, 2009 – Task Force on Implementation Strategy meet o Task Force members meet for the first time to review draft recommendations for change. A newly revised “Collective Vision Document” is developed. • March 23‐ 24 – Data Needs and Access Group (DNAG) meeting o The second meeting of this group includes a representative from each faculty to identify and prioritize medical education information needs. • April 6‐7, 2009 – National Forum o Stakeholders are brought together to consult on the “Collective Vision Document”. • May 6, 2009 – Post‐CCME Workshop o Stakeholders are brought together to consult on the “Collective Vision Document”.