Strategies for Instruction from the 1995 and 2002 COMSEP Curricula
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.
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
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.
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.
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
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
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
- 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
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
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
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
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:
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:
Recognizing the clerkship director as a departmental leader in educational change.
- 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.
- 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
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
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
Design ambulatory clinical experiences with
the expectation of clearly defined independent projects or readings to
complement hands on experience.
- 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.
- 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.
- One pediatrician in a multiple member private practice functions as the main preceptor for students. The role can be rotated between pediatricians.
- A student selects one subspecialty experience for a week instead of having five single day experiences.
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
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
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
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.
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.