How to cite this article: Hamui-Sutton A, Varela-Ruiz M, Ortiz-Montalvo A, Torruco-García U. Educational model to develop trustworthy professional activities. Rev Med Inst Mex Seguro Soc. 2015;53(5):616-29.
Received: November 14/11th 2014
Accepted: December 16/12th 2014
Alicia Hamui-Sutton,a Margarita Varela-Ruiz,b Armando Ortiz-Montalvo,c Uri Torruco-Garcíad
aCoordinación de Investigación Educativa, División de Estudios de Posgrado
bDepartamento de Investigación en EDUCATION Médica, Secretaría de EDUCATION Médica
cDepartamento de Evaluación y proyectos Especiales, Subdivisión de EDUCATION Continua, División de Estudios de Posgrado
dDepartamento de investigación en EDUCATION Médica, Secretaría de EDUCATION Médica
Facultad de Medicina, Universidad Nacional Autónoma de México, Distrito Federal, México
Communication with: Alicia Hamui-Sutton
Telephone: (55) 5623 7274, extensión 81062
Background: The reorganization of the national health system (SNS), enforces reflection and transformation on medical education in clinical contexts. The study presents an educational model to develop entrusted professionals activities (MEDAPROC) to train human resources in health with reliable knowledge, skills and attitudes to work in the shifting scenario of the SNS.
Methods: The paper discusses international and national documents on skills in medicine. Based on the analysis of 8 domains, 50 skills and 13 entrusted professional activities (APROC) proposed by the Association of the American Medical College (AAMC) we propose a curriculum design, with the example of the undergraduate program of Gynecology and Obstetrics, with the intention to advance to internship and residency in a continuum that marks milestones and clinical practices.
Results: The pedagogical design of MEDAPROC was developed within three areas: 1) proposal of the AAMC; 2) curricular content of programs in pre and postgraduate education 3) organization of the daily agenda with academic mechanisms to develop the competencies, cover program items and develop clinical practice in deliberate learning activities, as well as milestones.
Conclusion: The MEDAPROC offers versatility, student mobility and curricular flexibility in a system planed by academic units in diverse clinical settings.
Keywords: Medical education, Competency-based education, Faculty.
The global trend in medical education is to design and implement curriculum with a focus on skills for academic programs, mainly in the clinical setting. The Modelo Educativo para Desarrollar Actividades Profesionales Confiables (MEDAPROC) is a proposal for medicine and other health sciences that aims to develop human resources with reliable knowledge, skills, attitudes to work in the changing scene of the Sistema Nacional de Salud in Mexico (SNS), which manages approval through two processes, portability and convergence.1
The reorganization of the SNS forces us to reflect on the challenges of medical education in clinical settings. In the current curriculum, teaching incorporates few pedagogical elements, so that a new educational model inspired by the instructional proposals of world medicine seeks to address the limitations in the training of health professionals and standardize the quality of education.
The model is based on the assumption that through the iterative experience2 situated learning is achieved.3 Mediated by academic programs and teaching devices, the deliberate practice4 is encouraged in which the student participates and learns inductively while being supervised. The latter is coupled with reflective practice, on and about the clinical activities5 that, when integrated with the study of scientific knowledge of the profession, enhance learning to return to make more informed and trustworthy actions.6
The MEDAPROC proposal by competencies provides the curricular mobility and flexibility necessary to encourage a degree of autonomy in students in order to guide their academic career, built by the accreditation of educational modules that can be pursued in different sites and institutions. Several international and national institutional proposals revised are on the list of competencies (Asociación Mexicana de Facultades y Escuelas de Medicina, AMFEM; Project Tuning; Canadian Medical Education Directives for Specialists, CanMEDS), however, associations like Accreditation Council for Graduate Medical Education International7 (ACGME) and the Association of American Medical Colleges8 (AAMC) have continued the effort to translate them into Reliable Professional Activities (RPA).
The aim of this paper is to demonstrate the development of MEDAPROC to relate the RPA of the AAMC, domains and skills by domain, to the 2010 Curriculum and the Single Curriculum of Medical Specialties (SCMS), specifying the milestones and clinical practice, for which the program of Gynecology and Obstetrics of the fourth year of the Bachelor of Medicine, Universidad Nacional Autónoma de México (UNAM) is used as an example.
The proposal is to create blocks with educational units, estimated credits, to complete the curriculum map, where students practice and fulfill the academic plan.9 In this model, the aim is to move from the student assignment at a single site, to educational mobility where one can build one’s academic career by completing the various blocks that make up the curriculum in different sites or clinical settings.
At the Facultad de Medicina (FM) of the Universidad Nacional Autónoma de México, starting October 2012, an interdisciplinary group of researchers versed in medical education met in order to develop a model of Competency-Based Education (CBE) according to university undergraduate and graduate programs, and appropriate to the trends of the Mexican SNS. After reviewing the literature on the subject, we proceeded to develop the research protocol focusing the work on designing, in principle, the specific competencies of the program of Gynecology and Obstetrics (ob-gyn) fourth year in the Bachelor of Medicine. The plan envisages progress in the curriculum of this specialty through medical internship and from there to the residence, to establish a continuum between undergraduate and graduate, in order to modulate the milestones in academic levels. This same exercise could be replicated in all specialties and rotations considered in the study programs to transform traditional education based on behavioral objectives, into CBE.
The research protocol was approved by the Research and Ethics Committee of the Research Division of the FM and registered with the number 033-2013 in April 2013. At the beginning of the study international and national documents were analyzed, including the six ACGME competencies,7 the seven roles of medical expert in the CanMEDS framework,10 the eight domains of the proposed Reliable Professional Activities of the AAMC, the Pact of Bologna, and methodology of Project Tuning for Latin America.11,12 At the national level we considered: the skills profile of the Mexican general physician of AMFEM13 and the Curriculum 2010 of the FM of UNAM.14 Considering the above sources, a model of generic competences was formed, applicable to all doctors, and other specific skills applicable to the field of gynecology and obstetrics. Nevertheless, in May 2014 the AAMC published 13 RPA and after a thorough analysis of them, we chose to adopt this model, which is described below (Figure 1).
Figure 1 AAMC model
The aim of the AAMC in proposing the RPA was to define a common set of core behaviors expected from graduating students of the Bachelor in Medicine. The RPA are professional practice units defined as unsupervised tasks or responsibilities entrusted to students in their performance for reaching specific skills sufficient to achieve them. The RPA are done independently, are observable and measurable in both processes and results. The thirteen RPA are set forth in Table I.
|Table I Reliable professional activities of the AAMC|
|1 Perform the clinical history and physical examination|
|2. Prioritize a differential diagnosis after consultation|
|3. Indicate and interpret routine diagnostic and screening studies|
|4. Develop and discuss indications and prescriptions|
|5. Document consultation or clinical care in the patient record|
|6. Make the presentation of a clinical consultation|
|7. Formulate clinical questions and retrieve evidence to improve patient care|
|8. Give and receive information to patients to give them the responsibility for their self-care|
|9. Work as a member of an interdisciplinary team|
|10. Recognize if a patient requires urgent attention, start your evaluation and management|
|11. Obtain informed consent for testing and / or procedures|
|12. Perform general medical procedures|
|13. Identify deficiencies in the health system and contribute to a culture of safety and quality of care for the patient|
RPA incorporate the domains and the competencies of each domain, so they are not mutually exclusive, the integration of RPA and skills allow better assessment practice in the clinical setting. Competency means: those observable abilities of the healthcare professional that integrate multiple components including knowledge, skills, values and attitudes. Since competencies are observable, they can be measured and assessed to ensure their acquisition. According to the AAMC there are 8 domains with 50 competencies distributed between them (Table II).
|Table II domains and skills for mastery of the AAMC|
|Domain||Competences by domain|
|1. Patient Care (PC)||PC 1. Carry out all medical, diagnostic and surgical procedures wCISh are considered essential for the practice area|
|PC 2. Collect essential and accurate information about patients and their condition through medical history, physical examination and the use of data from laboratory, imaging, and other tests|
|PC 3. Organize and prioritize responsibilities to provide safe, effective and efficient care|
|PC 4. Interpret laboratory, imaging, and other tests required for clinical studies|
|PC 5. Make informed decisions about diagnostic and therapeutic interventions based on patient preferences, scientific evidence, and clinical judgment|
|PC 6. Develop and carry out plans of management for patients|
|PC 7. Educate patients and their families to give them the possibility to participate in their care and enable shared decision making|
|PC 8. Provide appropriate referral of patients, including continuity of care during the transitions between providers or establishments and follow-up of patient progress and results|
|PC 9. Provide health care services to patients, families and communities aimed at problems prevention or health maintenance|
|PC 10. Provide models of appropriate behavior|
|PC 11. Carry out oversight responsibilities consistent with their roles, capabilities and qualifications|
|2. Knowledge for practice (KP)||KP 1. Investigate and demonstrate the analytical approach to situations clinical|
|KP 2. Apply scientific principles and biophysical fundamentals to the care of patients and populations|
|KP 3. Apply the established and emerging principles of clinical sciences in diagnostic and therapeutic decisions, clinical problem-solving, and other aspects of evidence-based health care|
|KP 4. Apply the principles of epidemiological sciences for the identification of health problems, risk factors, treatment strategies, resources and efforts of disease prevention and health promotion for patients and populations|
|KP 5. Apply the principles of social science and behavior to the provision of care, including the assessment of the psycho-social-cultural impact on health, disease, attention-seeking, care performance and attitudes toward care|
|KP 6. contribute to the creation, dissemination, application, and translation of new knowledge of care and practice|
|3. Learning based on practice improvement (LBPI)||LBPI 1. Identify strengths, weaknesses and limitations in knowledge and experience|
|LBPI 2. Combine learning and improve goals|
|LBPI 3. Identify and do learning activities that address deficiencies in
knowledge, skills or attitudes
|LBPI 4. Systematically analyze practice using quality improvement methods and implementing change|
|LBPI 5. Incorporate feedback in everyday practice|
|LBPI 6. Locate, evaluate and assimilate evidence from scientific studies related with the health problems of patients|
|LBPI 7. Use technology to optimize learning|
|LBPI 8. Participate in the education of patients, families, students, and people in training, colleagues, and other health professionals|
|LBPI 9. Obtain and use information about individual patients, populations of patients, or communities that patients come from, to improve care|
|LBPI 10. Identify, analyze, and implement new knowledge, guidelines, standards, technologies, products or services that have been shown to improve outcomes|
|4. (CIS) Communication and interpersonal skills||CIS 1. Communicate effectively with patients, families and the public, where appropriate, through a wide range of socio-economic and cultural contexts|
|CIS 2. Communicate effectively with colleagues of the same profession or specialty, other health professionals, and health institutions|
|CIS 3. Work effectively with others as a member or leader of a
health care team or other professional group
|CIS 4. Perform an advisory role for other health professionals|
|CIS 5. Keep complete, relevant, and readable medical records|
|CIS 6. Demonstrate sensitivity, honesty and compassion in difficult talks (for example, on issues such as death, end of life, adverse events, bad news, reporting of errors and other sensitive issues)|
|CIS 7. Demonstrate knowledge and understanding of emotions and human responses to develop and manage interpersonal interactions|
|5. professionalism (P)||P 1. Demonstrate compassion, integrity and respect for others|
|P 2. Demonstrate responsiveness to the needs of the patient that goes beyond self-interest|
|P 3. Demonstrate respect for the privacy and autonomy of the patient|
|P 4. Demonstrate accountability to patients, society and the profession|
|P 5. Demonstrate sensitivity and responsiveness to different populations of patients, including but not limited to the diversity of gender, race, culture, age, religion, (dis)ability and sexual orientation|
|P 6. Demonstrate a commitment to etCISal principles relating to the provision of care, confidentiality, informed consent and commercial practices including compliance with laws, policies and regulations|
|6. Systems-based practice
|SBP 1. Work effectively in diverse contexts and systems of health care in a clinical specialty|
|SBP 2. Coordinate care within the health system|
|SBP 3. Incorporate awareness of costs and risk-benefit analysis in patients and/or care based in the population|
|SBP 4. Advocate for the quality of care for the patient and optimal care systems|
|SBP 5. Participate in the identification of errors in the system and the implementation of potential solutions|
|SBP 6. Carry out administrative and management responsibilities consistent with one’s role, skills and qualifications|
|7. Professional collaboration
|PC 1. Work with other health professionals to establish and maintain a climate of respect, dignity, diversity, etCISal integrity and mutual trust|
|PC 2. Use the knowledge of their own role and those of other professions to adequately assess and meet the health needs of patients and populations|
|PC 3. Communicate with other health care professionals with a rapidity and responsibility that supports the health and disease treatment in individual patients and in populations|
|PC 4. Participate in different roles of the team to establish, develop and continually improve inter-professional teams to provide care focused on the patient and the population that is safe, timely, efficient, effective and equitable|
and professional development (PPD)
|PPD 1. Develop the ability to use self-awareness of knowledge, abilities and emotional limitations to engage in appropriate behaviors that seek help|
|PPD 2. Demonstrate healthy coping mechanisms in response to stress|
|PPD 3. Manage conflicts between personal and professional responsibilities|
|PPD 4. Practice flexibility and maturity to adapt to change with the ability to alter behavior|
|PPD 5. Demonstrate confidence that make colleagues feel safe when one is responsible for the care of patients|
|PPD 6. Provide leadership skills that will improve the operation of the team, the environment of learning, or the health care system|
|PPD 7. Demonstrate self-confidence that gives comfort to patients, the families and members of the health care team|
|PPD 8. Recognize that ambiguity is part of clinical care and respond using the resources to deal with uncertainty|
Table III shows the relationship between RPA (work units), domains, and skills by domain (skills of individuals) according to the proposal from the AAMC.
|Table III distribution of domains and competencies in the RPA|
|Domains and competencies by domain|
|1. Patient care (PC)|
|2. Knowledge for practice (KP)|
|3. Learning based on practice and improvement (LBPI)|
|4. Communication and interpersonal skills (CIS)|
|5. Professionalism (P)|
|6. System based practice (SBP)|
|7. Professional Collaboration (PC)|
|8. Personal and professional development (PPD)|
The domains correspond to the broad and abstract skills described in several models of medical education, and they resemble the six of the ACGME, the difference is that the AAMC disaggregates the domain of communication (at 4 and 7) and adds one (8) on personal and professional development. One of the positive features of this classification is that each domain is well-defined, facilitating the discrimination and division of skills in a single category. The skills by domain are timelier and relate to personal, relational, and institutional arrangements in medical practice. One RPA may have more than one domain and multiple skills. Each competency specifies the milestone or desired level to determine whether the activity is considered reliable or pre-reliable. A milestone is a narrative descriptor of student behavior that indicates a level of performance in a given competency. The AAMC prepared at least two milestones per competency, the first corresponding to activities considered pre-reliable (requires supervision) and the second to reliable (does not require supervision). A good example of how the milestones are set forth in each specialty is in the Milestone Project at the ACGME.9
Based on the RPA and considering the domains and competencies, we analyzed the contents of the ob-gyn program of the eighth semester of the Curriculum 2010,15 and the Single Curriculum of Medical Specialties of the División de Estudios de Posgrado corresponding to ob-gyn revised in 2009,16 In tables IV and V the undergraduate and graduate programs are shown respectively, including the thematic content descriptions and university curricula, which in turn should reflect national epidemiological reality in the field.
|Table IV Topics of the Ob-Gyn undergraduate program(2014)|
|1. Basic obstetric morphophysiology||9. Advanced cardiovascular resuscitation|
|2. Care of normal labour
a. identify abnormalities
|10. Neonatal resuscitation|
|2. Care of normal labour
a. identify abnormalities
|3. Prenatal care
a screening of complications (gestational diabetes,
|13. Family planning / Sexology
a application of contraceptive methods
|4. Identify obstetric emergencies|
|5. Triage||14. Diagnosis and treatment of sexually transmitted infections|
|6. Examination and interpretation of the FCF||15. Timely detection of neoplasms|
|7. Gynecological, including pelvic exam||16. Control of climacteric|
|8. Practices with simulators for skills development.
(Births, triage, exfoliatica cytology, breast exam)
|Table V Thematic contents of the Ob-Gun graduate program (2014)|
|1. Specialized obstetric morphophysiology||9. gynecological surgery|
|2. abnormal pregnancy||10. gynecological diseases|
|a. high-risk pregnancy management||a Breast|
|b. bleeding||b. ovaries and annexes|
|3. abnormal labour||c. uterus|
|4. identify obstetric emergencies||d. vagina|
|a caesarean section||e pelvis|
|b. tears and lacerations||f urological|
|c. curettage||11 Oncological Gynecology|
|d. OTB||a breast|
|e hysterectomy||b. ovary and annexes|
|f ectopic pregnancy||c. uterus|
|5 puerperium||d. vagina|
|a complicated lactation||e pelvis|
|6. complementary studies||f urological|
|a cardiotocography record||12 reproductive biology|
|b. obstetric USG||13 psychology and psychiatry|
|7. obstetric intensive therapy|
|8. obstetric anaesthesia|
Once the documents were prepared, a focus group was conducted with five expert gynecologists, undergraduate and graduate specialty professors at FM of UNAM. At that meeting, which took place on August 20, 2013 in the División de Estudios de Posgrado, which lasted about two hours, MEDAPROC was unveiled and they discussed the skills and programs in contrast with their teaching experiences in clinical practice. The observations of the gynecologists were about the appropriateness of the proposal for the hospital structure, the need to consider the guards, the issues to be emphasized and those that should be minimized depending on academic level, the educational processes during residency, and opportunities to practice rotations at sites and sub-sites, among other issues.
As a result of this exercise, the pedagogy of MEDAPROC was designed. Figure 2 shows the structure of the model in three areas: first the above described AAMC proposal appears including the 13 RPA, the 8 domains and the 50 competencies per domain. The second area relates to the content of the programs of the UNAM FM in undergraduate and graduate, and are organized into blocks that correspond to the subjects or content planned by grade. In turn, the blocks are broken down into units where the topics of academic programs are incorporated. The third area relates to the application and consists of two parts, the narrative description of milestones and planning of the day’s agenda that includes educational devices to develop the skills, cover the topics of the agenda, and develop clinical practice in deliberate activities favoring theoretical / practical learning.
Figure 2 MEDAPROC model
The axis of the model is the block, in which competencies are developed in a specific subject area at a certain level of the Curriculum with a specific duration. In table VI the blocks considered for the graduate specialty residency in ob-gyn are exemplified.
|Table VI Considered blocks for the Ob-Gyn graduate residence|
|Competencies||Abnormal pregnancy 1||abnormal pregnancy 2||abnormal pregnancy 3||abnormal pregnancy 4|
|Gynecological surgery 1||Gynecological surgery 2||Gynecological surgery 3||Gynecological surgery 4|
|Obstetric surgery 1||Obstetric surgery 2||Obstetric surgery 3||Obstetric surgery 4|
|Gynecological pathology 1||Gynecological pathology 2||Gynecological pathology 3||Gynecological pathology 4|
|Puerperium||Pathological puerperium||Original research||Integration to not lose competency|
|Gynecological HC||MBE||Advanced technology 1||Advanced technology 2|
|Childbirth care||Ob-Gyn Endocrinology||Reproductive biology|
|Neonatology||Management of the critical patient||Intensive obstetric therapy
|Prenatal consultation, medium risk||Genetics|
|The blocks that are designated by consecutive numbers refer to increasing degrees of complexity; e.g.: gynecological surgery 1-4. MBE: Medicine based on evidence. HC: History clinic. GO: Gynecology-obstetrics. Advanced technology 1 and 2 refer to the use of paraclinical studies used by the gynecologist: ultrasound, colposcope, hysteroscope, etc.|
A block is divided into units, where clinical practices are developed according to the contents and milestones. Domains and competencies are specified per unit and the topics relate to clinical practice. For example, in the program of the eighth semester of ob-gyn, it takes eight weeks to cover the theoretical / practical requirements of the course, this will have three units, one General, one Obstetrics and another Gynecology (Table VII). For each day it specifies the clinical practice to be achieved, the clinical scenario where the student will rotate, and the theme according to the academic program.
|Table VII block of gynecology and obstetrics for eighth semester of undergraduate|
|General information||1||Clinical stage||Classroom||Imaging||Operating room||Imaging||Operating room|
|Clinical practice and reflection||Introduction||Internal genitalia||Internal genitalia||Breast||Breast|
|Theme||Bioethics 1||General information 1||General information 2||General information 3||General information 4|
|Obstetrics||2||Clinical stage||Operating room||Imaging||EC||EC||EC, H, LU and E|
|Clinical practice and reflection||External genitalia and pelvic floor||Fetal development||Changes in pregnancy
|Changes in pregnancy 2nd and 3rd trimester||Obstetric medical history|
|Theme||General information 5||Pregnancy 1||Pregnancy 2||Pregnancy 3||Pregnancy 4|
|3||Clinical stage||EC||Classroom||EC, H and E||EC, LU and E||EC|
|Clinical practice and reflection||Prenatal care||Selected subjects||IVU and cervicovagintis||Obstetric bleeding||Hypertensive disease|
|Theme||Pregnancy 5||Causes of mortality and morbidity and obstetric complications 1||Causes of mortality and morbidity and obstetric complications 2||Causes of mortality and morbidity and obstetric complications 3||Causes of mortality and morbidity and obstetric complications 4|
|4||Clinical stage||EC, H and E||EC and H||H||LU, E and CECAM|
|Clinical practice and reflection||Hypertensive disease||Diabetes||Threat of preterm delivery||Periods, mechanisms of labor and Friedman curve|
|Theme||Causes of mortality and morbidity and obstetric complications 5||Causes of mortality and morbidity and obstetric complications 6||Causes of mortality and morbidity and obstetric complications 7||Childbirth 1A||Childbirth 1B|
|5||Clinical stage||LU||EC, H and LU||H and LU||EC, H and E||EC|
|Clinical practice and reflection||Use of drugs and
management of birth chart
|Caesarea dystocia, fetal suffering, prolonged delivery||Immediate postnatal period||Mediate and late postpartum||Contraceptive methods|
|Theme||Delivery 2||Abnormal labor||Puerperium 1||Puerperium 2||Family planning|
|Gynecology||6||Clinical stage||EC, H and E||CE and H||LU and EC||LU and EC||EC|
|Clinical practice and reflection||Semiology and exploratory technique||Clinical history and gynecological examination||Diagnosis||Treatment||Pathologies|
|Theme||Semiology and exploratory technique in Gynecology 1||Semiology and exploratory technique in Gynecology 2||Uterine bleeding 1||Uterine hemorrhage 2||Sexually transmitted infections 1|
|Clinical practice and reflection||Pathologies||Scrutiny||Pathologies||Pathologies||Pathologies|
|Theme||2 sexually transmitted infections||Benign Neoplasms of the female genital system and breasts 1||Benign Neoplasms of the female genital system and breasts 2||Malignant neoplasms of the female genital system and breasts 1||Malignant neoplasms of the female genital system and breasts 2|
|8||Clinical stage||EC||EC||Classroom||Final evaluation|
|Clinical practice and reflection||Climacteric||Sexology||Sexual and reproductive rights of women in ob-gyn|
|USG: Ultrasound; STI: sexually transmitted infections; UTI: Urinary tract infection; EC: External consultation, H: hospitalization, LU: labor unit, E: emergency.|
For each day specified in the unit, the MEDAPROC items are denominated that reveal the educational model of deliberate practice and reflective practice focused on student learning. The items specify the clinical practice, milestones or desired levels for an activity to be considered reliable, the theme and agenda of the day to assist learning and facilitate evaluation.17 Another article develops the educational process followed in developing the items.
It is worth mentioning that the design developed for the fourth year undergraduate ob-gyn course does not necessarily look identical in later grades. At this level, the incorporation of thematic knowledge of the core curriculum and clinical observation are considered relevant skills, which is underlined in the items. In the medical internship it will be necessary to identify the core competencies and to design the blocks and units according to the clinical practice and milestones. The same in different years of medical residency when the accumulated knowledge and clinical experience reaches higher thresholds that modify expectations.
No doubt there is still much to do to develop the MEDAPROC, whose educational, technological and academic-administrative potential is great. The intent of this article was to show how MEDAPROC articulated the educational model by skills of the AAMC with clinical practice defined as milestones in a particular academic program. One limitation of the study is that so far it has developed only the eighth semester of the ob-gyn Bachelor of Medicine at FM UNAM including student and professor guide to carry out the proposal. It has not yet been tested in real clinical settings, although the team has social service intern students who do exercises similar to those proposed in the items. It is expected that each academic cycle requires different pedagogical designs based on the skills and milestones, which is a challenge that we must face as the development of the units advances along with the development of educational activities in clinical practice.
Some of the concerns of Norman, Norcini and Bordage18 are relevant to MEDAPROC and have to be considered in the future development of the project, such as the psychometric aspect of summative assessments to ensure its validity and reliability, proper exposure time in clinical settings to achieve reliable activities considering the different RPA to develop simultaneously, which can have different rhythms and depths, as well as its implications for the duration of educational plans, other outstanding issues related to the necessary resources to spread the model, and the development of strategies for teacher education.
Much progress has been made in the construction of theoretical and reference frameworks to give viability to skills in medical education; what is presented here is a concerted effort to combine categorical provisions of the CBE with specific curricula, which represents a modest contribution in that regard.
The present study reports a collective effort to rethink medical education under the CBE paradigm with the understanding that the pedagogical transformation is consistent with trends of restructuring towards the SNS standardization. MEDAPROC offers versatility, student mobility and curriculum flexibility in a block system and not by allegiance to a site. The preceding paragraphs outlined the basis of the educational model as an exercise in curriculum development. Much remains to be done, as there are unresolved issues in epistemology, pedagogy, operations, administration, diffusion, and institutional, which require time, dedication, and talent.
We appreciate the feedback and experience for the construction of the project to the following social service medical interns: Mirlene Barrientos Jimenez, Sahira Eunice Garcia Tellez, Veronica Daniela Duran Perez, Alan Giovanni Leon, Karina Robles Rivera, Carlos A. Soto Aguilera, and Alan I. Vicenteño Leon, as well as students of the Masters of Health Sciences Education, the Masters and Doctorate Programs of Medicine Dentistry and Health, UNAM: Adriano Garduño and Oliver R. Gijon. A special mention to Dr. Jose Antonio Carrasco Rojas for his invaluable support.
Conflict of interest statement: The authors have completed and submitted the form translated into Spanish for the declaration of potential conflicts of interest of the International Committee of Medical Journal Editors, and none were reported in relation to this article.