Freshening up

Becoming a doctor at Dalhousie looks a bit different in 2022 than it did in years past.

The changes, which were evident during orientation week in August, stem from a multi-year review and refresh of the undergraduate curriculum.

Last extensively reviewed in 2009, the consistent evaluation and modification of the undergraduate curriculum is part of ensuring students receive a world-class education, and is an accreditation requirement of the Committee on Accreditation of Canadian Medical Schools (CACMS).

“We are extremely proud of the medical education we provide, and the outstanding yearly success of our graduates in licensing exams and the CaRMS match is a testament to the quality of the education our students receive,” says Dr. David Anderson, Dean of Medicine.

A responsibility to change

The new changes were motivated by several elements, some informed by the changing realities of the world, some by the practice of medicine in Canada, and others by the growing acceptance of the Medical School’s responsibility to better address equity, diversity and inclusivity in both the education of physicians, as well as the care of patients.

Through extensive internal and external consultations, nine key areas of focus were identified: equity, diversity, and inclusivity (EDI); public health; planetary health (including climate crisis); priority communities; generalism; addictions medicine; movement to competency-based learning for UGME; health systems; and student wellness. Working groups, comprised of faculty, residents, medical students, and staff were established to focus on each theme. They began their work in the summer and fall of 2020, with recommendations presented to the Undergraduate Medical Education Curriculum Committee (UMECC) in January 2021. Feedback was then sought from faculty, residents, students, staff, and the community, through town halls, one for each theme, held over a five-week period between February and March 2021.

Recommendations were compiled and presented to administration in undergraduate medical education in April 2021. Encouraged initially to, ‘dream big,’ the working groups were aspirational, and not all recommendations could be accommodated within the existing structures of the undergraduate program.

Dr. Evelyn Sutton is the associate dean of undergraduate medical education, and curriculum refresh project leader. She says the gaps that were identified have been addressed, and the new curriculum will position students to meet to the demands of a changing world.

“We've got a very strong curriculum. Our students are doing very well in in the national regulatory examinations, they're doing well in terms of matching. But there is a changing world that we have to keep responding to, and that's what the refresh is doing.”

Diversity in case-based learning

The architecture of the undergraduate curriculum has not changed, with most of the transfer of knowledge continuing through small group discussions, and case-based learning. What is changing is the quality of those cases. Medical students in their first and second year of study work through nearly 200 tutorial cases that feature fictional patients. All 200 cases will be edited to present students with a more diverse array of patients. This will more accurately represent the diversity of patients that interact with the healthcare system, and also disrupt normative assumptions about who is served and what values are upheld by health care in Canada.

To assist in this enormous task, the Curriculum Refresh Committee (CRC), a subcommittee of the UMECC, seconded Leanne Picketts from the Centre for Collaborative Clinical Learning and Research. Leanne, who has worked as a simulated patient educator for 11 years, has a master’s degree in education with a focus on curriculum development for health professions education.

“We are writing in several different dimensions of diversity for every patient – a full name, pronouns, racialized identity, sexual orientation, sex/gender identity, family structure, and socioeconomic status, to name a few,” she says. “When details about a person’s identity are omitted from a case, it suggests that their experience is unimportant or assumed.”

Working in collaboration with the Case Diversification Committee, subject matter experts, and clinicians, Leanne is ensuring patients aren’t merely presented as a disease or medical condition, but more realistically as an integral part of their healthcare experience – where they react to a diagnosis, are part of the decision-making, and may have aspects of their identity affect their health. She says from a de-colonizing and anti-oppressive perspective, the goal isn’t adding information to cases, but removing normative assumptions about the ‘standard’ patient.

Historically, medical research and medical education have studied and taught students to consider the 70 kg male who is assumed to be white, cis-gender, heterosexual, without a disability or a mental health condition, and of medium-high education and income. This does not reflect reality.

Leanne and her team have specific targets to reach. The previous case load included only four cases with Indigenous patients. That number will increase to 20 under the curriculum refresh, and a concerted effort has been made to better represent communities in Nova Scotia and New Brunswick, as well as communities that are growing nationally.

“We are also paying particular attention to language use, to avoid perpetuating stigma, bias, and harm,” she says. “We are using person-first language, eliminating pejorative terms, and aiming to make patient-centeredness a key component of every case.”

The Faculty of Medicine has been gathering ideas from students and tutors about diversifying the tutorial cases for several years, so many of the ideas for both the overall project, and the specific cases were provided before the work of editing the cases even began.

Med 1 cases have been implemented this academic year, and Med 2 cases will be ready for 2023/24.

Interest in broad-based practice

Though the most material changes to the undergraduate curriculum will be found in the updated tutorial cases, all elements of the curriculum were reviewed, and many changes have been made. Learners will see a greater focus on health systems, addictions medicine and the overdose crisis, and a growing field in health sciences, planetary health, which concentrates on the human health impacts of the earth’s natural systems. Lectures and case studies have been added on generalism, reflecting the increased need for family physicians and surgeons in this field who have core abilities characterized by a broad-based practice across a range of settings.

“One of the things we're giving more emphasis to is that patients don't come in with labels, in terms of ‘here's what's wrong with me,’ says Dr. Sutton, “They come in with a headache and the student’s job is to start developing a differential diagnosis, and how challenging and how interesting that process is.”

Focus has also been given to student wellness, and the medical school is working to ensure students are supported throughout their four years of training and have developed the skills and healthy habits to serve them through their careers.

“Training doctors is one thing, but retaining our doctors is just as important,” says Dr. Sutton.

The way forward

Students were first introduced to the changes in the curriculum during orientation week. Whereas activities in the past were focused on policies and procedures, 2022 orientation set the tone for Dalhousie’s focus on inclusivity with a 60-minute lecture on anti-oppressive practice, an opening lecture on public health, and a framing lecture on Indigenous and Black health.

Dr. Sutton is hopeful the medical school will be in a different place because of the updates, but says it isn’t going to happen in one academic cycle.

“It's going to be our medical students going through and educating their teachers and then teaching those who come behind them as well,” she says. “What I think this is going to do long term, and it's going be a process, is really change how we think about ourselves, our patients, our society, and what we have taken to be truths. And once you uncover one stone, you start looking at others and you're finding all kinds of things that require change.”

And change they will, because if one thing is certain it’s that change is constant. Going forward, the medical school will continue to ensure the undergraduate curriculum is constantly renewed to meet the needs of our future physicians and the communities they serve.

Learn more about the undergraduate curriculum refresh.