• Feedback and suggestions from a broad sample of current McMaster medical students established the principle directions for renewal of the COMPASS curriculum.  
• Faculty, staff, and students sitting on the MD Program’s standing committees, particularly the Curriculum Committee, and on various working groups are significantly involved in advancing the curriculum renewal process and reviewing decisions as the renewal process progresses.  
• Teaching faculty have the opportunity to contribute ideas about specific facets of the curriculum renewal process during the curriculum retreats.  
• There are others beyond the Undergraduate Medical Education program that review large renewal projects such as the one being proposed. The Faculty of Health Sciences Education Council, the Faculty of Health Sciences Executive Committee, the McMaster University Undergraduate Council, and the McMaster University Senate all participate in reviewing and confirming changes to the MD Program curriculum.  All proposed changes must also comply with the undergraduate medicine accreditation standards established by the Committee on the Accreditation of Canadian Medical Schools (CACMS).

Several principles are central to the curriculum renewal process (further explained after the list below):

• Building upon the tenets of the current COMPASS curriculum.
• Progressively introducing greater complexity into the problems that students encounter.
• Spiraling learning content throughout the curriculum, providing students with more, intentional opportunities to revisit the same or similar concepts in a variety of contexts or levels of complexity.
• Ensuring student readiness for clerkship and other points of transition (such as the beginning of the program and the first clinical experience in the first summer of the program).
• Provide optimal, pre-programmed time off of the program.

Complexity refers, in general terms, to interrelatedness of components of a system.  Complexity increases with the “number of components in a system, number of relations between them, and uniqueness of those relations.” A complex problem then will challenge students to consider more factors, more sources of information, and subtle, differentiated relationships between these factors and information sources. 

For more on complexity, see Kannampallil, Thomas G., Guido F. Schauer, Trevor Cohen, and Vimla L. Patel. "Considering complexity in healthcare systems." Journal of Biomedical Informatics 44, no. 6 (2011): 943-947.

Spiraling refers to distributing study of a topic so that students periodically return to that topic in increasingly complicated manifestations, with the goal of increasing long-term retention.  For more on spiraling, see Son, Lisa K., and Dominic A. Simon. "Distributed learning: Data, metacognition, and educational implications." Educational Psychology Review 24, no. 3 (2012): 379-399. 

Spiraled content in the renewed curriculum will manifest itself in one of three ways:

• Creating Awareness

  A group simply notes that a concept has been discussed previously or will be discussed again

• Adding Breadth to Concept

  The problem/session/activity allows a group to learn about a previously-introduced concept as it occurs differently in the current point in the curriculum

• Adding Depth to Concept
  The problem/session/activity allows a group to build a more nuanced/comprehensive understanding of a previously-introduced concept.

Readiness for Clerkship refers to optimizing and lengthening the transition to Clerkship from MF4 onwards so that students shift smoothly into the clinical learning environment.  Opportunities for optimizing the transition may include the integration of complex cases into Clinical Skills sessions, introducing “Clerkship Orientation” concepts such as practice in interprofessional communication earlier than the week before Clerkship, and earlier introduction of essential Clerkship procedural skills.  

The proposed curricular changes build upon the tenets of the current COMPASS curriculum that was launched in 2005 for the Class of 2008. These tenets are: concept-oriented, multidisciplinary, problem-based, practice for transfer, simulations in clerkship, and streaming.  There has been minimal change to the overall philosophies or organization of the Medical Foundation curriculum during that time; although the curriculum undergoes constant amendment at the level of patient problems, objectives, and large group sessions in both content and delivery.  Significant modification of the Professional Competencies and anatomy curricula and modest modification of the Clinical Skills and Clerkship curricula have occurred over this same time.  For more details on the philosophical and organizational tenets of the COMPASS curriculum, readers can refer to the 2004 document which addresses these issues in detail: A New Curriculum for the Information Age: A concept- and practice-based approach.

• Adding two weeks to the beginning of the MD Program, thereby lengthening the current orientation from one to three weeks. This will mean a start date between August 10^th to August 16^th, depending on the timing of statutory holidays, particularly the December holiday.

• Changing the sequence of content in the pre-clinical portion of the program and making corresponding changes to the length of each Medical Foundation:
  • Medical Foundation (MF) 1: 8 weeks; Cardiac & Respiratory
  • MF2: 8 weeks; Renal & Hematology
  • MF3: 12 weeks; Gastroenterology, Endocrinology, & Reproduction
  • MF4: 12 weeks; Musculoskeletal, Neurology, & Brain and Behaviour

• Replacing the current MF5 with an Integration Foundation that will:
  • Allow for repetition and practice of key concepts introduced in the first year of the curriculum;
  • Provide an opportunity for students to be introduced to more complex (especially multi-system) and chronic illnesses, and to introduce more complex and integrated clinical skills;
  • Provide a longer transition period to prepare students for the clinical clerkship.
• Adding a one week break in March of first year between the new MF3 and MF4, and adding two break weeks during the national residency interview period in students’ third year.
• Accelerate work that was already occurring to increase problem complexity, to enhance and highlight connections between medical concepts, and to improve the cohesion and sequencing between the different facets of students’ medical education (Medical Foundations, Professional Competencies, Clinical Skills, and Clerkship).

Many students accepted into the UGME program have little or no experience with small group or problem-based learning (PBL).  A sustained orientation to PBL reaffirms the Michael G. DeGroote School of Medicine’s commitment to a pedagogy of PBL, deliberately introduces students to the rationale behind and process of PBL, and transitions learners into the PBL environment on a more equal footing, with the skills to benefit more fully from the advantages of a PBL curriculum.  Likewise, an introduction to the MD Program graduating competencies prepares students for the breadth that their professional role will encompass.

Students are disadvantaged by the current ordering of the organ-based Medical Foundations (MF) units in that three major foci of generalist medical practice are not introduced until after their summer clinical elective period: musculoskeletal, neurological, and behavioural (and psychiatric) medicine. Most students participate in generalist electives or electives focused on these fields of medical practice and are therefore missing knowledge and skills that are essential to having an optimal clinical learning experience. Students have indicated a strong preference to learn about all major organ systems before entering the summer elective that is scheduled at the end of their first year.  A rearrangement of the MF units to learn about all major organ systems benefits all students as they head into the summer elective and creates an opportunity for integration towards the end of pre-clerkship.

Healthcare in high-resource health systems is focusing increasingly on the care of patients living with chronic diseases that tend to concurrently involve multiple organ systems and result in complex social and health considerations.  Medical curricula, including McMaster’s, tend to focus on acute disease presentations to the neglect of chronic and complex disease or health conditions.  The introduction of an Integration Foundation will enable better coverage of complex and chronic health conditions, support students’ integration of multiple aspects of medical practice in preparation for clerkship and provide a structural mechanism for repetition of key concepts.  Students and faculty interviewed in focus groups identified a separation between blocks of instruction as a reason that students did not think about medical issues more comprehensively.  By concluding pre-clerkship with a unit that addresses complex and chronic care, students are impelled to review the major organ systems, which both consolidates medical concepts and skills while simultaneously preparing students for clerkship.

Mental health and well-being has been receiving increased focus in medicine for many years. McMaster’s UGME Program stands out as one of only two three-​year medical degree programs in North America.  To meet CACMS accreditation standards requiring a minimum of 130 weeks of training, McMaster medical students only get one week of vacation in the first summer, two weeks in the second summer, and two weeks over the Christmas holiday period in each year.  During Pre-Clerkship, students deliberately accelerate their own learning to create breaks in between curriculum blocks.  McMaster University has the sole medical school in Canada that does not provide clerkship students three full weeks off from studies to coincide with the national residency interview period.  Currently, McMaster clerkship students only receive one week off, resulting in many counter-productive behaviours during a particularly stressful time including taking a two-week elective in place of their two-week summer holiday in order to “bank” the time forward into the interview period.  The introduction of break weeks during Pre-Clerkship and Clerkship can easily be accommodated by the weeks introduced for an extended orientation, and these break weeks meet students’ need to have pauses in learning and to focus on their residency interviews and clerkship rotations sequentially rather than concurrently.

• 2016-2017 Academic Year – Medical Foundations curriculum and Clerkship curriculum formally reviewed
• 2017 Autumn – Curriculum Committee receives renewal recommendations and curriculum leaders identify the central principles and objectives of the curriculum renewal process
• 2018 Winter – Faculty, students, and curriculum leaders meet to identify opportunities for stronger integration, particularly in the Medical Foundations curriculum, and Clinical Skills and Professional Competencies leaders begin to identify opportunities for stronger integration
• 2018 Spring – MD Executive Committee confirms, with the input of other committees, changes to the MD Program’s three-year calendar
• 2018 Summer – Medical Foundations Directors confirm opportunities for integration between tutorial problems

The changes comprising the renewed curriculum are coming into effect for the Class of 2022, which arrives in August 2019.

The UGME has hired a Project Officer to help with operationalizing the steps towards deploying the renewed curriculum and has hired a Project Coordinator to assist with the transition between the current and renewed curricula, including updating most of the curriculum content on medportal and in the curriculum database.  

The complete three-year renewed curriculum will be mapped by January 2019.  Faculty and facilitators will have an opportunity to give final feedback on the renewed curriculum and on the developmental structures made available to help ensure faculty and facilitators are delivering the renewed curriculum as intended by the designers.  Feedback and suggestions about the results of the renewed curriculum will also be brought to the faculty, staff, and students sitting on the MD Program’s standing committees as part of the routine annual review of the MD program’s curriculum.   

Differences in students’ engagement with PBL, in students’ clinical transfer of concepts introduced in the pre-clinical curriculum, in student readiness for clerkship, and in student performance on high stakes summative examinations such as the Medical Council of Canada Qualifying Examination Part 1 are all areas where the effects of the renewed curriculum can be assessed.  Aggregate information about student wellness can also be a marker of effects, and students’ self-efficacy can also be assessed during the CaRMS interview period.  Feedback will also be collected from faculty, facilitators, and Clerkship preceptors to examine differences in student performance and operational impact.  

In the renewed curriculum, students will approach their first tutorial problems with a stronger grounding in PBL and the group processes by which students develop their foundation for medical expertise.  As they progress through their first year, students will encounter more clearly articulated moments where medical knowledge is re-visited in a new or more nuanced context.  Students will notice cohesion and continuity that extends across the five Foundations blocks.

In the renewed curriculum, students will approach their first Professional Competencies discussion with a stronger grounding in the professional expectations of a physician.  As they progress through their first year, students will notice congruency between the theoretical discussions that that are having in Professional Competencies groups and the simulated practice they undertake in Clinical Skills labs.

In the renewed curriculum, students will learn about all major organ systems before entering the summer elective that is scheduled at the end of their first year; consequently, students will enter both their electives and the Integration Foundation with a more complete grounding in the knowledge that will be required upon entering Clerkship.  By concluding pre-clerkship with a unit that addresses complex and chronic care, students will be impelled to review the major organ systems, which will consolidate both medical concepts and skills as well as the social and humanistic aptitudes required of physicians in the clinical setting.

Because of the changes to the pre-clinical portion of the renewed curriculum, students will be better positioned to call upon and consolidate knowledge and skills during their clinical rotations.  During the national residency interview period, students will be able to focus on interviews and clinical responsibilities consecutively rather than concurrently.

The transition period between the current and renewed curriculum offer unique opportunities for the Classes of 2021 and 2022 to come together.  Senior student involvement and leadership during orientation to the MD program for the Classes of 2022  and 2023 will offer a longer period for supportive relationships to develop with the Class of 2021.  Over the course of the transition, students will also be able to share differences in experience of the current and new curriculum with faculty leaders. 

Finally, with regards to learning partnerships, no learning objectives are being removed in the renewed curriculum, so students from different years will still be able to talk about the problems and concepts discussed in different areas of the curriculum.”