Open Journal Systems

EDUCATION

Received: November 14/11^th 2014

Accepted: December 16/12^th 2014

Educational model to develop trustworthy professional activities

Alicia Hamui-Sutton,^a Margarita Varela-Ruiz,^b Armando Ortiz-Montalvo,^c Uri Torruco-García^d

^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

Email: lizhamui@gmail.com

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.

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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.

Method

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).

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.

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 III shows the relationship between RPA (work units), domains, and skills by domain (skills of individuals) according to the proposal from the AAMC.

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.  

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.

Results

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.

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.

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.

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.

Discussion

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.

Conclusions

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.

Acknowledgements

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.

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