Section B

Implementation of the New General Pediatrics Core Curriculum: Possible Barriers and Strategies to Overcome Them

Ardis L. Olson, M.D.

New curricula have great risk of becoming another reference book on the shelf. Implementing a new curriculum is a complex process which can involve changes in multiple aspects of the clerkship. During the development of the general pediatric curriculum careful consideration has been given to potential barriers affecting its implementation. Although each institution has its own climate and issues, we have considered some common barriers and potential strategies to use when choosing to use the new general pediatrics curriculum.

1) Overwhelmed by length or detail of the curriculum

This curriculum states clearly, as objectives, material that has been part of an implied curriculum in many schools. It seeks to provide coverage of basic general pediatric issues that may have been assumed to be taught, but needed more focus. As a result it may at first seem too much to teach. Each program will decide how they will use the curriculum. Individual programs have the option to implement some areas of the curriculum before others. Some programs may choose to make some objectives honors level and others required by all students.

One possible systematic approach is given here for the clerkship director who is considering how to use this new curriculum. It will help clerkship directors determine how best to use current resources and develop new methods to teach under represented areas.

• The clerkship director needs to read carefully the curriculum.
  
  As a first step take some time to read it carefully and compare it to your current curriculum. The clerkship director will be the department member who has most thoroughly read the curriculum. Use this curriculum as a tool to assess what is currently taught and where the major and minor areas of change might occur.
  
  
• Involve your department chair early and obtain support to review the teaching program.
  
  Despite conflicting demands, most chairpersons want a student program that is strong and thus generates interest in pediatrics. In addition, the clerkship director can make the chair aware of some other advantages of their program when using a new curriculum. Some aspects to be considered are:
• The LCME now requires that clear objectives be in place for clerkships.
• Preparation for USMLE2 exams is easier with a problem approach.
• More effective student evaluation can be developed if it is clear to students what to expect.
• Development of an approach using common problems and self-directed learning experiences to support it have increased the NBME pediatric shelf exam scores.
• This curriculum can be customized to emphasize or add certain topics that convey your school's uniqueness.
• Students and teachers frequently ask what it is that the program wants covered. A specific curriculum can reduce both teacher concerns and student anxiety.
  
  
• Review the curriculum and your assessment with a core faculty group.
  
  It is important that the clerkship director has support for curriculum change from a group of faculty closely involved with student education. Broadening faculty support is then possible after this group does the ground work. Do not embark on this process alone. This group will also have its ideas about the areas where change needs to occur. One needs to consider that implementing a new curriculum may require a variety of changes to effectively teach a topic. It may involve changing the content or teaching process or site. The core faculty group can choose what areas to examine more carefully in a needs assessment.
  
  
• Explore other possible educational resources at your institution.
  
  Nearly half of American medical schools have an office of medical education. Their resources are often not utilized by clerkship directors. Sometimes another department has employed an educator who may consult with your department. Some clerkship directors have developed strong collaborations with their university departments of education. An educator can provide help in conducting needs assessment, designing educational components, developing teaching skills in faculty or evaluation of your program.
  
  
• Examine how your department teaches attitudes and skills as well as knowledge
  
  Often the curriculum is assumed to be only the didactic content. The clerkship teaching environment is a complex learning environment (see Section D," Teaching and Learning in the Pediatric Clerkship Setting"). How skills and attitude are taught deserve active consideration. This curriculum helps by defining professional conduct, attitudes and skills. The section on teaching strategies provides the clerkship director with an approach to the teaching of attitudes, skills and knowledge.
  
  
• Consider the use of different faculty to teach.
  
  The specific objectives in the new curriculum let the director clearly convey to others what they will teach. A specific teaching session can use teachers outside of traditional faculty. Some of these potential educators would like future physicians to better understand their role in health care. It also conveys to students that one can learn from other members of the health team. A few examples include:
• the chief resident conducting a session on fluids and electrolytes.
• an emeritus faculty member teaching the evaluation of common physical findings
• a community faculty member leading a discussion of patients presenting with sore throat or other common problems.
• a pharmacist teaching a session on selected aspects of therapeutics.
• a community child abuse team member conducting a seminar on child abuse.
• an early intervention team professional educating about selected development objectives.
• a nutritionist providing teaching about certain nutrition objectives.
• a parent of a child with chronic disease or disability discussing with students their family's experiences.



• Consider teaching with a variety of methods.
  
  Students differ in what is their optimal learning method. Providing students with different learning options beyond the traditional lecture is helpful. Following are examples of different teaching methods which involve the student as an active participant in the learning process; use of student presentations to their peers, faculty as a facilitator of student problem-solving, self-directed learning, learning from community experiences, computer-assisted learning, and sessions to demonstrate clinical findings at the bedside. For other teaching ideas directed to the different areas of the curriculum see Section E, "Recommendations for Teaching Strategies with a Core Curriculum in Pediatrics".
  
  
• Introduce small changes in teaching methods.
  
  The clerkship director can work with faculty to focus clinical teaching in small steps. The development by faculty of a few key teaching points for students rotating through a clinical experience has been successfully used to focus faculty teaching. Using the curriculum as a guide, the clerkship director can work with faculty subgroups to develop a few realistic objectives and a teaching plan for their setting. Workshop materials for enhancing subspecialty ambulatory teaching are available through the COMSEP Resource Clearinghouse. For community practice experiences the AAP guidelines," Pediatric Education in Community-Based Pediatric Offices" are also helpful.
  
  
• Consider alternate ways to teach skills or demonstrate clinical competency that provide consistency and do not leave all the responsibility with the busy clinical preceptor.
  
  This curriculum asks students to demonstrate clinical competencies. In responding to that challenge clerkship directors can consider utilizing other evaluators. For example, a parent could perform a simulated patient role to teach students how to Council about a health supervision issue. Many clinic nurses and staff are also parents and could evaluate and provide feedback regarding a student's skills at giving advice within health supervision issues. Adolescents have been used as simulated patients to teach the skills of adolescent history taking. Recruitment of adolescents has been successful from a high school drama club. Role play can also be used in a conference setting where students evaluate each other in Counciling competencies. Preceptors could assign a student in advance the role of advising about a particular common issue in a visit rather than only observing. Using a deck of "skill cards" in the ambulatory setting offers a "game" where each day a new card focuses on a different skill. This technique could provide specific skills teaching throughout a variety of clinical encounters. Once the departmental education group starts thinking about new ways to teach the content, many more options will be available.

2) The curriculum requires student-directed learning

One of the major goals in clinical education is to develop in students the life-long skills of self-directed learning. Self-directed learning is more than giving students the curriculum to read and learn on their own. This curriculum can help the student prioritize what to study in the short time on the pediatric clerkship. The director can select specific areas that are appropriate for self-directed learning. A more detailed discussion of the issues in student directed-learning is provided within the "Teaching Strategies" section.

3) Lack of time and resources

The problem of inadequate time will always be with us. As clinical pressures mount along with efforts to contain costs, student education is affected. The following are initial suggestions for clerkship directors considering change within a resource-limited environment.

• The clerkship director and chairperson need to work together closely.
  
  Most clerkships can not expect to change rapidly. The process of change is a gradual one which requires short-term and longer term goals. After assessing ways the program needs to change and generating possible new approaches, a plan should be developed that sets priorities about what to change first. This planning step sets goals and priorities for clerkship change. It is crucial that the chairperson share in this process with the core educational group. Plans for changing specific clerkship components can then be developed.
  
  
• Establish a departmental budget.
  
  In order to plan effectively the chair and clerkship director need to operate with a budget, even if it a modest one. The planning of creative teaching requires some flexible funds that can be used for new materials, simulated patients, etc. A budget allows one to consider the relative costs for different aspects of the clerkship. The costs for teaching in ambulatory settings should be included as well. Within the budget process it is important to identify the administrative needs of the student teaching program and separate them from administrative support provided to the clerkship director for other clinical or research activities. Budgeting allows the director to phase in gradually the costs of new teaching methods or technologies (e.g. computers, videotaping).
  
  
• Chairperson support can mobilize internal resources.
  
  If department chairs support the planning process, they can be helpful in enhancing faculty participation and skill development. Some specific ways the chair- person can contribute to the process include, but are not limited to, the following:
• Require widespread faculty involvement in teaching students in a variety of formats. The clerkship director needs to review with the chair the amount and type of student teaching provided by the faculty.
• Develop incentives and awards for student teaching by faculty and residents.
• Promote the development of teaching skills as a valid academic topic by including it in grand rounds, conferences, and workshops.
• Emphasize education as a core activity considered in promotion.
• Support the development and inclusion of appropriate outpatient ambulatory settings for teaching students, as well as providing appropriate generalist role models.
• Support the clerkship director's further development as an educator by:
1. Recognizing the clerkship director as a departmental leader in educational change.
2. Providing opportunities for the clerkship director to develop teaching, educational administration, and educational research skills. Supporting the director's attendance at faculty development courses, and national educational conferences enhances his/her skills and allows them to develop into local resources who can help improve other faculty.
3. Using the educational portfolio method to evaluate the efforts and track the progress of the clerkship director. This allows better evaluation of their effectiveness as an educator and leader than traditional methods.

4) Current teaching practices may not be optimal to implement the new curriculum

• As faculty teach they serve as role models for students in their career selection.
  
  Many departments provide excellent subspecialty role models who encourage students to follow in their path during their teaching encounters. Departments may need to make a conscious effort to offer students contact with new role models. The experience of family medicine has shown that primary care role models in key roles are necessary for students to consider primary care as a career option. General pediatricians from the medical center and community need to be visible teachers and mentors in the teaching program. Students need to have considerable exposure to these generalists during the clerkship experience.
  
  
• Students and faculty are both happier teaching and learning in settings where they make a personal connection to each other.
  
  Only a few programs have focused on structuring the learning setting to maximize the faculty-student connection. Faculty willingness to teach in busy settings is much greater when the personal connection is present. Many pediatric practice experiences, in fact, owe their success to a preceptor taking a personal interest in the student. On the inpatient service, the resident/attending team often provides this mentoring for students. However, in the ambulatory setting student contact with faculty can become very fragmented. Clerkship directors can structure a student's experience to optimize faculty contact with one student. The following are examples where the opportunities for personal connection increases but teaching time does not need to change substantially:
1. A community faculty member works with one student every afternoon for two weeks during a few rotations of the year instead of having different students come to the office for single days during all rotations.
2. An ambulatory clinic faculty member precepts the student over three days and has the student read on topics between sessions instead of having a different student each clinic session.
3. One pediatrician in a multiple member private practice functions as the main preceptor for students. The role can be rotated between pediatricians.
4. A student selects one subspecialty experience for a week instead of having five single day experiences.
   
   
• Design ambulatory clinical experiences with the expectation of clearly defined independent projects or readings to complement hands on experience.
  
  If expectations for student learning are clear, students need not see every patient the faculty preceptor sees. Community visits, school and home visits as well as more in- depth reading on an ambulatory topic are all possible. If students are not involved in direct patient care at all times, faculty can be more efficient as well as more willing to teach.
  
  
• Look for realistic ways to increase observation of student skills on a regular basis.
  
  The clerkship director will need to make the development of clinical skills a priority of the clerkship and help faculty to understand the need to emphasize these skills. At graduation from medical school, Stillman has documented that most students have been observed only a few times while performing a history and physical by an attending physician. Providing consistent observation of a student's history and physical is not easy. It can not be assumed to be part of the student's experience. Each program has different resources. Therefore, it is the clerkship director's role to develop consistent observation opportunities during the clerkship experience.
  
  
• Provide faculty development activities directed at enhancing one on one teaching skills and ability to provide feedback.
  
  Currently there are a limited range of ambulatory teaching techniques known to most preceptors, often based on their own learning experiences. Effective but efficient teaching methods that intertwine teaching and observation need to be emphasized. A few possible techniques to introduce are: focusing the student before the encounter on a particular aspect to observe, completing different parts of the exam with different patients under the observation of the preceptor, and combining joint and independent interviewing. Preceptors can extend the learning beyond the encounter with a variety of techniques; providing guidance for student reading, picking a theme of the day to discuss in different encounters, during patient care, help the student develop a learning list of issues to return to later. Techniques to use in giving feedback are helpful for faculty as well. The options for developing a program for faculty teaching skills are discussed further in Section I, "Developing a Program to Improve the Teaching Skills of Faculty and Residents".

5) Conflict between service/ teaching

Financial pressures will continue to be a major issue. However, at the same time the goal exists to produce more pediatricians to meet the health care needs of the nation. Departmental chairs will need to be key players in continuing to keep the importance of student teaching emphasized in negotiations with Health Management Organizations as well as with their faculty. The traditional expectations that one either teaches or provides clinical care will need to change. Clearly clinicians have been teaching students for years in the primary care practice setting and have continued to earn an income. Community practitioners often recognize the importance of community role models to encourage students to enter primary care pediatrics. Preceptors committed to their role have been willing to put in extra time to discuss patients with students. In turn, preceptors have emphasized how involvement with students energizes them. Student and preceptor expectations that are clearly defined provide a better experience for both. The clerkship director and the chairperson can form important linkages to the state academy of pediatrics and practice groups that emphasize their joint goals not the competitive aspects.

Implementing the new general pediatrics core clerkship curriculum offers the clerkship director opportunities to link content more closely to teaching and evaluation methods. Without clear expectations it often has been difficult for both teacher and learner to assess progress in meeting educational goals. This curriculum serves as a blueprint to begin the change process. Well-structured effective pediatric clerkship programs can more clearly provide a strong general pediatrics experience during the clerkship.