EDUCATION * EDUCATION
Preparing faculty to teach in a problem-based learning curriculum: the Sherbrooke experience Paul Grand'Maison, MD, MClSc, FCFP; Jacques E. Des Marchais, MD, MSc, FRCSC, FAAOS, MA Over the last 6 years Sherbrooke Medical School has undertaken a major reform of its undergraduate curriculum. A new student-centred, community-oriented curriculum was implemented in September 1987. Problem-based learning (PBL) is now the main educational method. To adequately prepare teachers for the curriculum a series of faculty development programs in pedagogy were offered: first, a 2-day introductory workshop to initiate teachers into educational principles and their application in the new program; second, a 1-year basic training program in medical pedagogy; third, a 1-day workshop on PBL; and fourth, a comprehensive 3-day training program in PBL tutoring. Over 60% of all full-time teachers attended the introductory program and 80% the tutor training program. The 1-year basic training program was completed by 33% of the faculty members. The implementation of these programs, coupled with a high participation rate, resulted in a more student-centred educational philosophy and a greater interest in medical education. This had a significant impact when the new curriculum was instituted. Lessons learned from the experience are dicussed.
Au cours des 6 dernieres annees, la Faculte de medecine de l'Universite de Sherbrooke a entrepris une reforme majeure de son programme d'etudes de premier cycle. Un nouveau programme axe sur les etudiants et oriente vers la collectivite a e mis en oeuvre en septembre 1987. L'apprentissage centre sur les problemes (ACP) constitue maintenant la principale methode d'enseignement. Afin de bien preparer les enseignants au programme, on leur a offert une serie de programmes de perfectionnement en pedagogie. Le premier volet, un atelier d'introduction de 2 jours, les initie aux principes de l'enseignement et a leur application au nouveau programme. Un programme de formation de base d'un an en enseignement de la medecine constitue le deuxieme volet. Troisibmement, un atelier d'une journee porte sur l'ACP. Un programme de formation poussee de 3 jours en direction de travaux pratiques en ACP constitue le quatrieme et dernier volet. Plus de 60 % des enseignants a plein temps ont participe au programme d'introduction et 80 %, au programme de formation en direction de travaux pratiques. Trente-trois pour cent des enseignants ont termine le programme de formation de base d'un an. Jumelee a un taux de participation 6lev6, la mise en oeuvre de ces programmes a debouche sur une philosophie de l'enseignement axee davantage sur les etudiants et a suscite un plus grand interet pour l'enseignement de la medecine, ce qui a eu d'importantes retombees lorsqu'on a mis en oeuvre le nouveau programme. On discute des lecons tirees de cette experience. Dr. Grand'Maison is professor and director, Department of Family Medicine, andfrom 1984 to 1988 was director, Office of Medical Education; Dr. Des Marchais is vice-dean, Education, and professor ofsurgery, Faculty of Medicine, University of Sherbrooke, Sherbrooke,
Que. Reprint requests to: Dr. Paul Grand'Maison, Director, Department of Family Medicine, Sherbrooke Medical School, 3001 12th Ave. N, Sherbrooke, PQ JIH 5N4 CAN MED ASSOC J 1991; 144 (5)
557
S ince 1983 Sherbrooke Medical School has undertaken a major reform of its 4-year undergraduate program curriculum",2 in an attempt to implement the recommendations of the Panel on the General Professional Education of the Physician (GPEP).3 The new student-centred, community-oriented curriculum uses problem-based learning4-6 (PBL) as the main educational method. In September 1987 the first cohort of 100 students began the new curriculum. The GPEP report recommended that faculty development programs be organized in schools planning curriculum change. The Sherbrooke Office of Medical Education offered four such programs from 1984 to 1990: first, a 2-day introductory workshop on educational principles and their application in medical education; second, a 1-year basic training program in medical pedagogy7 requiring more than 100 hours of participation; third, an introductory workshop on PBL; and fourth, a comprehensive 3-day training program in PBL tutoring followed by a 1-day-a-year refresher workshop. We describe the programs, their development, implementation and outcome, the resulting increased interest of faculty members in education and the adoption of a student-centred philosophy to underlie the new curriculum.
that demands greater educational expertise and experience. There is also the risk, which increases as more faculty members are trained, that this rapid transmission of restricted expertise and skills might not be solidly supported by the necessary theoretical background, so that program quality erodes over time. We tried to overcome this difficulty by stimulating some faculty members who had a broader background in education to become mentors in the art of faculty development and to accept the responsibility of sustaining the quality of the programs.
Description of the programs Introduction to Pedagogy in Medical Education
The goal of the 2-day workshop is to arouse teachers' interest in medical education and in the student-centred approach. Teachers are introduced to the four steps in systematic educational planning defined by Guilbert8 and to self-directed learning, student motivation and community-oriented education. The material and procedures used in the workshop were derived from Guilbert's Educational Handbook for Health Personnel8 and were adapted to the Sherbrooke context. To ensure the highest level of participation the instructional format includes Development of the programs individual work, small group assignments and discussions, and plenary sessions. Eleven workshops During the 6-year period the only available were given, the first directed by Guilbert and the in-house educational resources were the vice-dean of others by members of the Office of Medical Educaeducation, the director of the Office of Medical tion. Education, clinicians with training in medical educaThis introductory program is now considered tion and five to seven other faculty member clini- essential for any new faculty member. Although the cians who collaborated on a part-time basis. Because general atmosphere is relaxed the sessions are charof these limited resources a series of consecutive and acterized by hard work and the discovery of educasystematic steps, maximizing collaboration between tional concepts unfamiliar to most participants. The outside experts and local resources, was the format themes of student motivation and self-directed learnadopted for the development of each program; ac- ing initiate teachers into the new, student-centred count was taken of the fact that the experts had to approach to teaching. transfer their specific expertise to the educationally involved faculty members. Basic Training Program in Medical Pedagogy Experts in fields related to our needs were invited to develop and give the first version of a This 1-year program was developed by colprogram to some faculty members while those cho- leagues from the University of Montreal.7 The program is aimed at changing traditional sen to be future instructors observed. The second version was delivered by those who had observed in attitudes so that participants place more emphasis collaboration with the external expert, who provided on the process of learning than on that of teaching. It constructive feedback. Subsequently local educators encourages participants to learn the scientific basis repeated the program with the help of other faculty of medical education, to master the knowledge and members. The school now counts on a pool of 15 skills of teaching and learning and to apply the newly educationally trained faculty members, all full-time acquired knowledge and skills to their daily teaching activities. teaching physicians. Although offering many advantages this method There are 17 self-instructional modules,9 which does have drawbacks. Faculty members do not gain cover basic concepts and major themes in medical competence in developing original programs, a task education. Homework is assigned for each module, 558
CAN MED ASSOC J 1991; 144 (5)
and participants must apply their knowledge to a year-long project related to their teaching activities. Every 3 weeks there are half-day small group (four to six people) meetings that foster discussion on previous assignments and provide contact with the instructors, who act as group leaders and content experts. Six to ten hours of preparation is required between sessions, for a total program workload of about 100 hours throughout the year. From September 1984 to May 1985 the program was offered to 14 faculty members. The next year 4 of them were trained and supervised by the program developers to become group instructors thereafter. Since then the senior author has conducted the program yearly, assisted by 11 faculty members who have completed the program. Those involved in the implementation of the new curriculum were invited to act as instructors; this was a strategic decision taken to increase their expertise in medical education. The main impact of the program has been the development of a student-centred philosophy, which instructors see emerging during the second half of the program.
Introduction to Problem-Based Learning Methodology The third program is a 1-day workshop offering initiation into the methodology of PBL. The workshop's goals are to help teachers understand PBL, develop an interest in its adoption and acquire some skills in problem construction and tutoring in small groups. The instructional format includes theoretical explanations of PBL, small group discussion, individual reading, construction of PBL problems and experience of the PBL method with a nonmedical problem; then participants practise tutoring medical students using medical problems and receiving feedback. Teachers learn from the workshop how the new curriculum is student-centred rather than teacher-centred; constructing PBL problems and experiencing tutoring is quite revealing here. The content of the workshop was based on Schmidt's writings5"10 and also drew from the work of Barrows and Tamblyn.46 Schmidt led the first (2-day) workshop, in September 1986, and then trained the members of the Office of Medical Education to run the subsequent 10. Attendance is a prerequisite for the program in tutor training. The workshop is always well attended during visitors' week, a regular feature in our school since 1989.
Tutor Training Program This program aims at training teachers in their new role as small-group PBL tutors. Its goals are to
help them more deeply assimilate the PBL methodology, understand tutoring tasks and acquire the skills needed to perform these tasks and intervene effectively when needed. Eight tutor tasks were identified according to a competency-based model:"' managing the PBL process, ensuring the proper functioning of a small group, guiding the discovery of specific content, fostering student autonomy, fostering humanism, stimulating motivation, evaluating the learning during tutorials and participating in the administration of studies. The program is seen as a continuous process. Three weeks before the workshop, participants attend a 2-hour meeting during which they identify and discuss tutor tasks and their own learning needs. Over the following 3 weeks they observe 6 hours of tutorials. Thereafter, a 2-day workshop enhances participants' understanding of tutor tasks and helps them master related skills through a series of specific exercises and practical sessions with students. An expert in adult education from our university developed and led the program in collaboration with faculty members, including the coauthors. As of June 1990 nine programs have been given altogether. The program has taken shape gradually as we have gained insight into PBL methodology and our faculty members' needs and with the benefit of Barrows' thoughts on the tutorial process.'2 Instructors have observed that student-oriented teachers seem to benefit the most from the workshop. Those who have not yet acquired the approach fostered in the preceding program are often confused by how to interact as a PBL tutor with students. Since 1988 a 1-day refresher workshop per year has been offered to experienced tutors. Geared to participants' needs it promotes discussion of tutor tasks and PBL steps as well as new themes, such as how to become a more active tutor. All activities are geared to reinforcing the student-centred philosophy and its related specific skills.
Outcome Assessing the outcome of faculty development programs is never easy, as there are so many variables to be considered. Other than participation rate and satisfaction indexes objective measures are hard to collect.
Participation and attrition rates The number of teachers who participated in all programs from September 1984 to June 1990 is reported in Table 1. The participation rate seems to be higher than that usually found in faculty development programs.'3 This can be explained by the fact CAN MED ASSOC J 1991; 144 (5)
559
that curriculum revision and its implementation were seen in our school as the collegial responsibility of all faculty members and as a societal project. The introductory workshop on PBL and the tutor training program are mandatory for any faculty member who agrees to participate in PBL activities, whereas the 1-year basic training in medical pedagogy is voluntary. However, pressure has been exerted by program authorities on those faculty members directly involved in the implementation of the new curriculum. Interestingly, most of the early promoters of the curriculum revision and the early developa:ble
ers of the new PBL units have been recruited from those who had completed these programs. The participant attrition rate was very low, at less then 5% for all programs except the 1-year one, at 25%. This is explained by the short duration of the workshops and the importance placed on them by the school authorities. The attrition rate in the 1-year basic training program was higher than that reported for other schools offering the same program.7 Three factors may explain this: the greater number of faculty development programs offered by our institution, the large amount of work already
Number of participants in faculty development programs at Sherbrooke Medical Seh r( ye: ...Ya
1984-85
ntroduction fo Pedagogy
o.. participantV
Year: no. of participants1985-86 1986-87 41987-88 19 88-89 24 22 84 19 16 68
20
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.1
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$4r, hirSt row of figures for each program refers o all participants. the second to full-time teacher. te figuress prfportions of full-time teachers (out of the total .f 205) who participated in the program
a:
araule 2. Departmental affiliatioin 01: participants who were full-time teachers Department; no. of participants Basic sciences -
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Medical Education Basic Training Program in Medical
9
13
10
-Itroduction to
35
37
18
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53
28
42
23
16
59
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30
16
.11
-51
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29
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Learning Methodology Tutor Training Program
Ator Training Thdate 560
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CAN MED ASSOC J 1991; 144 (5)
D.§8
expected from teachers at the time of curriculum reform and the pressure exerted on some faculty members who were not ready to participate. Full-time members from all departments participated in the programs (Table 2). There was a higher percentage of basic science teachers participating than is usually reported in the literature.7' 13 In the last 2 years part-time faculty members were invited to join the programs in order to increase their contribution to undergraduate teaching and to prepare them for the implementation in April 1990 of the new clerkship, in which they would be involved.
Participant satisfaction Questionnaires on participant satisfaction were filled out at the end of each program. The results demonstrated the participants' high satisfaction and increased interest in pedagogy and educational development, a finding confirmed elsewhere.' For many teachers, participation in the programs was a trigger for further involvement in educational activities. Since 1986 five faculty members have enrolled in a master's degree program in education. Leaders responsible for the new curriculum implementation have repeatedly observed that the Introduction to Problem-Based Learning Methodology workshop had the most significant influence on the shift toward PBL. Combined with the Tutor Training Program it ensured that the skills necessary for implementing PBL and being an effective tutor were acquired. Without-these programs PBL would never have been implemented in our school. This was clearly confirmed in 1989 by the accreditation report of the Liaison Committee in Medical Education (LCME)/Association of Canadian Medical Colleges, which led to a full 7-year accreditation for Sherbrooke Medical School.
Lessons learned This experience in implementing comprehensive faculty development programs in pedagogy has taught us many lessons about faculty development and curriculum change. Faculty development must be tightly based on identified educational needs and must be a continuous process'4 adapted to the evolving needs of an
A major goal of our faculty development activities was attitudinal change over time in the instructor-student interaction. Without this shift toward a student-centred approach significant and sustainable educational changes would not have occurred and would most likely not have been attainable. However, this is a lengthy process. Accordingly, activities to initiate and sustain this trend were started long before any practical curriculum change was attempted. To embark on major curriculum change an institution must have a small core of faculty members interested in promoting medical education and ready to learn or deepen their basic understanding of education. The commitment and enthusiasm of these people ought to be reinforced by the school authorities. A mentor seems to be a sine qua non in the development of such a core of proponents. We have tried to avoid the pitfalls of reinventing the wheel by hiring outside experts to help us. However, these experts must receive a clear educational contract: to transfer a part of their expertise to the local faculty in order to create a core of in-house potential educators.
Conclusion Although many factors guide curriculum change, such as strong political commitment, relevant expertise, an adequate reward system and acceptance of change, faculty development in pedagogy remains a major element in the process.15 In our medical school it has been given high priority for the last 6 years, during which time a major undergraduate curriculum change has been successfully implemented. A comprehensive series of four faculty development programs in pedagogy was offered to teachers. The success of the programs was measured by a high participation rate, increased interest in medical education, modification of educational philosophy and efficient acquisition of specific skills. The programs had a significant impact on the successful shift from a traditional to a problem-based, small-group tutorial curriculum. The lessons we have learned from our 6 years' experience lead us to believe even more strongly that faculty development was and will remain a prerequisite of curriculum change in medical schools.
educational milieu and its teachers. The curriculum revision and subsequent implementation of the un- References dergraduate PBL program have given rise to a set of new and evolving educational needs in our school. 1. Des Marchais JE, Dumais B, Pigeon G: Changement majeur du cursus medical a l'Universite de Sherbrooke: raisons et The programs we have implemented since 1984 have du changement. Rev Educ Med 1988; 11 (2): 21-30 met these needs as perceived by the participants 2. etapes Idem: Changement majeur du cursus medical a l'Universite themselves, the internal proponents of educational de Sherbrooke: objets et consequences du changement. Rev change, the external consultants and the 1989 LCME Educ Med 1988; 11 (4): 9-17 3. Physicians for the Twenty-First Century: Report of the Panel accreditation surveyors. CAN MED ASSOC J 1991; 144 (5)
561
4. 5.
6. 7.
8.
9.
on the General Professional Education of the Physician and College Preparation for Medicine, Association of American Medical Colleges, Washington, 1984 Barrows HD, Tamblyn RM: Problem-based Learning: an Approach to Medical Education, Springer Pub, New York, 1980 Schmidt H: Problem-based learning: rationale and description. Med Educ 1983; 17: 11-16 Barrows HS: How to Design a Problem-based Curriculum for the Preclinical Years, Springer Pub, New York, 1985 Des Marchais JE, Jean P, Delorme P: Basic Training Program in Medical Pedagogy: a 1-year program for medical faculty. Can Med Assoc J 1990; 142: 734-740 Guilbert JJ: Educational Handbook for Health Personnel (offset publ 35), WHO, Geneva, 1981 Jean P, Des Marchais JE, Delorme P: Apprendre a enseigner les sciences de la sante: Guide deformation pratique, Faculte de medecine, universites de Montreal, Sherbrooke et Ottawa, 1988
Conferences continuedfrom page 546 Apr. 22-23, 1991: Symposium on Bioequivalence and Interchangeability of Pharmaceutical Products Queen Elizabeth Hotel, Montreal Dr Jacques Gagne, Faculte de pharmacie, Universite de Montreal, CP 6128, succ. A, Montreal, QC H3C 3J7; (514) 343-2102 Apr. 25-27, 1991: Alzheimer Society of Canada 13th Annual General Meeting and Conference St. John's Alzheimer Society of Canada, 201-1320 Yonge St., Toronto, ON M4T 1X2, (416) 925-3552; or Alzheimer Association of Newfoundland, (709) 576-0608
May 2-3, 1991: Introduction of Recombinant Factor VIII to Clinical Practice: an International Symposium Montreal Canadian Hemophilia Society, 840-1450 City Councillors St., Montreal, PQ H3A 2E6; (514) 848-0503, FAX (514) 848-9661 May 18-21, 1991: National Conference on Medical Management Harbour Castle Westin, Toronto Jill Roote, American College of Physician Executives, 200-4890 W Kennedy Blvd., Tampa, FL 33609-2575; FAX (813) 287-8993 May 22-24, 1991: Centre for Health Economics and Policy Analysis 4th Annual Health Policy Conference Health Care and the Public: Roles, Expectations and Contributions Sheraton Hamilton Hotel, Hamilton, Ont. Lynda Marsh, Department of Clinical Epidemiology and Biostatistics, McMaster University, 1200 Main St. W, Hamilton, ON L8N 3Z5; (416) 525-9140, ext. 2135, FAX (416) 546-5211 562
CAN MED ASSOC J 1991; 144 (5)
10. Schmidt HG: A specific, problem-based, self-directed learning method designed to teach medical problem-solving skills, self-learning skills and enhance knowledge retention and recall. In Schmidt HG, De Volder ML (eds): Tutorials in Problem-Based Learning: a New Direction in Teaching the Health Professions, Maastrich, Van Gorcum Assen, 1984: 915 11. Davis I: Competency-based Learning Technology, Management and Design, McGraw, New York, 1973 12. Barrows HS: The Tutorial Process, Southern Illinois University School of Medicine, Springfield, Ill, 1988 13. Jason H, Westberg J: Preparation for teaching. In Teachers and Teaching in US Medical Schools, ACC, East Norwalk, Conn, 1982: 71-83 14. Bates CW: Faculty development: a continuing process [E]. J Med Educ 1988; 63: 490 15. Barrows HS, Peters MJ: How to Begin Reforming the Medical Curriculum, Southern Illinois School of Medicine, Springfield, Ill, 1984: 21-27
June 9-13, 1991: Canadian Association of Radiologists 54th Annual Scientific Meeting Hamilton Convention Centre, Hamilton, Ont. Canadian Association of Radiologists, 510-5101 Buchan St., Montreal, PQ H4P 2R9; (514) 738-31 11, FAX (514) 738-5199
June 10-14, 1991: 4th International Conference on Systems Science in Health - Social Services for the Elderly and the Disabled Barcelona Inter-Congres, 646 Gran Via de les Corts Catalanes, Barcelona 08007, Spain; telephone 011-34-3-93-3012577, FAX 011-34-3-93-301-6332
June 13-15, 1991: College of Family Physicians of Canada (Ontario and Manitoba chapters) Spring Seminar Minaki Lodge, Kenora, Ont. Ontario Chapter, College of Family Physicians of Canada, 4000 Leslie St., Willowdale, ON M2K 2R9; (416) 493-7641, FAX (416) 493-9630
June 14-15, 1991: Suicide, Sleep and School Problems in Children and Adolescents Health Sciences Centre, University of Calgary University of Calgary Health Sciences Centre, 3330 Hospital Dr. NW, Calgary, AB T2N 4N 1; (403) 220-7240
June 16-18, 1991: Canadian College of Health Service Executives Annual Conference Toronto Canadian College of Health Service Executives, 201-17 York St., Ottawa, ON KIN 5S7; (613) 235-7218, FAX (613) 235-5451
continued on page 568
Preparing faculty to teach in a problem-based learning curriculum: the Sherbrooke experience Paul Grand'Maison, MD, MClSc, FCFP; Jacques E. Des Marchais, MD, MSc, FRCSC, FAAOS, MA Over the last 6 years Sherbrooke Medical School has undertaken a major reform of its undergraduate curriculum. A new student-centred, community-oriented curriculum was implemented in September 1987. Problem-based learning (PBL) is now the main educational method. To adequately prepare teachers for the curriculum a series of faculty development programs in pedagogy were offered: first, a 2-day introductory workshop to initiate teachers into educational principles and their application in the new program; second, a 1-year basic training program in medical pedagogy; third, a 1-day workshop on PBL; and fourth, a comprehensive 3-day training program in PBL tutoring. Over 60% of all full-time teachers attended the introductory program and 80% the tutor training program. The 1-year basic training program was completed by 33% of the faculty members. The implementation of these programs, coupled with a high participation rate, resulted in a more student-centred educational philosophy and a greater interest in medical education. This had a significant impact when the new curriculum was instituted. Lessons learned from the experience are dicussed.
Au cours des 6 dernieres annees, la Faculte de medecine de l'Universite de Sherbrooke a entrepris une reforme majeure de son programme d'etudes de premier cycle. Un nouveau programme axe sur les etudiants et oriente vers la collectivite a e mis en oeuvre en septembre 1987. L'apprentissage centre sur les problemes (ACP) constitue maintenant la principale methode d'enseignement. Afin de bien preparer les enseignants au programme, on leur a offert une serie de programmes de perfectionnement en pedagogie. Le premier volet, un atelier d'introduction de 2 jours, les initie aux principes de l'enseignement et a leur application au nouveau programme. Un programme de formation de base d'un an en enseignement de la medecine constitue le deuxieme volet. Troisibmement, un atelier d'une journee porte sur l'ACP. Un programme de formation poussee de 3 jours en direction de travaux pratiques en ACP constitue le quatrieme et dernier volet. Plus de 60 % des enseignants a plein temps ont participe au programme d'introduction et 80 %, au programme de formation en direction de travaux pratiques. Trente-trois pour cent des enseignants ont termine le programme de formation de base d'un an. Jumelee a un taux de participation 6lev6, la mise en oeuvre de ces programmes a debouche sur une philosophie de l'enseignement axee davantage sur les etudiants et a suscite un plus grand interet pour l'enseignement de la medecine, ce qui a eu d'importantes retombees lorsqu'on a mis en oeuvre le nouveau programme. On discute des lecons tirees de cette experience. Dr. Grand'Maison is professor and director, Department of Family Medicine, andfrom 1984 to 1988 was director, Office of Medical Education; Dr. Des Marchais is vice-dean, Education, and professor ofsurgery, Faculty of Medicine, University of Sherbrooke, Sherbrooke,
Que. Reprint requests to: Dr. Paul Grand'Maison, Director, Department of Family Medicine, Sherbrooke Medical School, 3001 12th Ave. N, Sherbrooke, PQ JIH 5N4 CAN MED ASSOC J 1991; 144 (5)
557
S ince 1983 Sherbrooke Medical School has undertaken a major reform of its 4-year undergraduate program curriculum",2 in an attempt to implement the recommendations of the Panel on the General Professional Education of the Physician (GPEP).3 The new student-centred, community-oriented curriculum uses problem-based learning4-6 (PBL) as the main educational method. In September 1987 the first cohort of 100 students began the new curriculum. The GPEP report recommended that faculty development programs be organized in schools planning curriculum change. The Sherbrooke Office of Medical Education offered four such programs from 1984 to 1990: first, a 2-day introductory workshop on educational principles and their application in medical education; second, a 1-year basic training program in medical pedagogy7 requiring more than 100 hours of participation; third, an introductory workshop on PBL; and fourth, a comprehensive 3-day training program in PBL tutoring followed by a 1-day-a-year refresher workshop. We describe the programs, their development, implementation and outcome, the resulting increased interest of faculty members in education and the adoption of a student-centred philosophy to underlie the new curriculum.
that demands greater educational expertise and experience. There is also the risk, which increases as more faculty members are trained, that this rapid transmission of restricted expertise and skills might not be solidly supported by the necessary theoretical background, so that program quality erodes over time. We tried to overcome this difficulty by stimulating some faculty members who had a broader background in education to become mentors in the art of faculty development and to accept the responsibility of sustaining the quality of the programs.
Description of the programs Introduction to Pedagogy in Medical Education
The goal of the 2-day workshop is to arouse teachers' interest in medical education and in the student-centred approach. Teachers are introduced to the four steps in systematic educational planning defined by Guilbert8 and to self-directed learning, student motivation and community-oriented education. The material and procedures used in the workshop were derived from Guilbert's Educational Handbook for Health Personnel8 and were adapted to the Sherbrooke context. To ensure the highest level of participation the instructional format includes Development of the programs individual work, small group assignments and discussions, and plenary sessions. Eleven workshops During the 6-year period the only available were given, the first directed by Guilbert and the in-house educational resources were the vice-dean of others by members of the Office of Medical Educaeducation, the director of the Office of Medical tion. Education, clinicians with training in medical educaThis introductory program is now considered tion and five to seven other faculty member clini- essential for any new faculty member. Although the cians who collaborated on a part-time basis. Because general atmosphere is relaxed the sessions are charof these limited resources a series of consecutive and acterized by hard work and the discovery of educasystematic steps, maximizing collaboration between tional concepts unfamiliar to most participants. The outside experts and local resources, was the format themes of student motivation and self-directed learnadopted for the development of each program; ac- ing initiate teachers into the new, student-centred count was taken of the fact that the experts had to approach to teaching. transfer their specific expertise to the educationally involved faculty members. Basic Training Program in Medical Pedagogy Experts in fields related to our needs were invited to develop and give the first version of a This 1-year program was developed by colprogram to some faculty members while those cho- leagues from the University of Montreal.7 The program is aimed at changing traditional sen to be future instructors observed. The second version was delivered by those who had observed in attitudes so that participants place more emphasis collaboration with the external expert, who provided on the process of learning than on that of teaching. It constructive feedback. Subsequently local educators encourages participants to learn the scientific basis repeated the program with the help of other faculty of medical education, to master the knowledge and members. The school now counts on a pool of 15 skills of teaching and learning and to apply the newly educationally trained faculty members, all full-time acquired knowledge and skills to their daily teaching activities. teaching physicians. Although offering many advantages this method There are 17 self-instructional modules,9 which does have drawbacks. Faculty members do not gain cover basic concepts and major themes in medical competence in developing original programs, a task education. Homework is assigned for each module, 558
CAN MED ASSOC J 1991; 144 (5)
and participants must apply their knowledge to a year-long project related to their teaching activities. Every 3 weeks there are half-day small group (four to six people) meetings that foster discussion on previous assignments and provide contact with the instructors, who act as group leaders and content experts. Six to ten hours of preparation is required between sessions, for a total program workload of about 100 hours throughout the year. From September 1984 to May 1985 the program was offered to 14 faculty members. The next year 4 of them were trained and supervised by the program developers to become group instructors thereafter. Since then the senior author has conducted the program yearly, assisted by 11 faculty members who have completed the program. Those involved in the implementation of the new curriculum were invited to act as instructors; this was a strategic decision taken to increase their expertise in medical education. The main impact of the program has been the development of a student-centred philosophy, which instructors see emerging during the second half of the program.
Introduction to Problem-Based Learning Methodology The third program is a 1-day workshop offering initiation into the methodology of PBL. The workshop's goals are to help teachers understand PBL, develop an interest in its adoption and acquire some skills in problem construction and tutoring in small groups. The instructional format includes theoretical explanations of PBL, small group discussion, individual reading, construction of PBL problems and experience of the PBL method with a nonmedical problem; then participants practise tutoring medical students using medical problems and receiving feedback. Teachers learn from the workshop how the new curriculum is student-centred rather than teacher-centred; constructing PBL problems and experiencing tutoring is quite revealing here. The content of the workshop was based on Schmidt's writings5"10 and also drew from the work of Barrows and Tamblyn.46 Schmidt led the first (2-day) workshop, in September 1986, and then trained the members of the Office of Medical Education to run the subsequent 10. Attendance is a prerequisite for the program in tutor training. The workshop is always well attended during visitors' week, a regular feature in our school since 1989.
Tutor Training Program This program aims at training teachers in their new role as small-group PBL tutors. Its goals are to
help them more deeply assimilate the PBL methodology, understand tutoring tasks and acquire the skills needed to perform these tasks and intervene effectively when needed. Eight tutor tasks were identified according to a competency-based model:"' managing the PBL process, ensuring the proper functioning of a small group, guiding the discovery of specific content, fostering student autonomy, fostering humanism, stimulating motivation, evaluating the learning during tutorials and participating in the administration of studies. The program is seen as a continuous process. Three weeks before the workshop, participants attend a 2-hour meeting during which they identify and discuss tutor tasks and their own learning needs. Over the following 3 weeks they observe 6 hours of tutorials. Thereafter, a 2-day workshop enhances participants' understanding of tutor tasks and helps them master related skills through a series of specific exercises and practical sessions with students. An expert in adult education from our university developed and led the program in collaboration with faculty members, including the coauthors. As of June 1990 nine programs have been given altogether. The program has taken shape gradually as we have gained insight into PBL methodology and our faculty members' needs and with the benefit of Barrows' thoughts on the tutorial process.'2 Instructors have observed that student-oriented teachers seem to benefit the most from the workshop. Those who have not yet acquired the approach fostered in the preceding program are often confused by how to interact as a PBL tutor with students. Since 1988 a 1-day refresher workshop per year has been offered to experienced tutors. Geared to participants' needs it promotes discussion of tutor tasks and PBL steps as well as new themes, such as how to become a more active tutor. All activities are geared to reinforcing the student-centred philosophy and its related specific skills.
Outcome Assessing the outcome of faculty development programs is never easy, as there are so many variables to be considered. Other than participation rate and satisfaction indexes objective measures are hard to collect.
Participation and attrition rates The number of teachers who participated in all programs from September 1984 to June 1990 is reported in Table 1. The participation rate seems to be higher than that usually found in faculty development programs.'3 This can be explained by the fact CAN MED ASSOC J 1991; 144 (5)
559
that curriculum revision and its implementation were seen in our school as the collegial responsibility of all faculty members and as a societal project. The introductory workshop on PBL and the tutor training program are mandatory for any faculty member who agrees to participate in PBL activities, whereas the 1-year basic training in medical pedagogy is voluntary. However, pressure has been exerted by program authorities on those faculty members directly involved in the implementation of the new curriculum. Interestingly, most of the early promoters of the curriculum revision and the early developa:ble
ers of the new PBL units have been recruited from those who had completed these programs. The participant attrition rate was very low, at less then 5% for all programs except the 1-year one, at 25%. This is explained by the short duration of the workshops and the importance placed on them by the school authorities. The attrition rate in the 1-year basic training program was higher than that reported for other schools offering the same program.7 Three factors may explain this: the greater number of faculty development programs offered by our institution, the large amount of work already
Number of participants in faculty development programs at Sherbrooke Medical Seh r( ye: ...Ya
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-51
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CAN MED ASSOC J 1991; 144 (5)
D.§8
expected from teachers at the time of curriculum reform and the pressure exerted on some faculty members who were not ready to participate. Full-time members from all departments participated in the programs (Table 2). There was a higher percentage of basic science teachers participating than is usually reported in the literature.7' 13 In the last 2 years part-time faculty members were invited to join the programs in order to increase their contribution to undergraduate teaching and to prepare them for the implementation in April 1990 of the new clerkship, in which they would be involved.
Participant satisfaction Questionnaires on participant satisfaction were filled out at the end of each program. The results demonstrated the participants' high satisfaction and increased interest in pedagogy and educational development, a finding confirmed elsewhere.' For many teachers, participation in the programs was a trigger for further involvement in educational activities. Since 1986 five faculty members have enrolled in a master's degree program in education. Leaders responsible for the new curriculum implementation have repeatedly observed that the Introduction to Problem-Based Learning Methodology workshop had the most significant influence on the shift toward PBL. Combined with the Tutor Training Program it ensured that the skills necessary for implementing PBL and being an effective tutor were acquired. Without-these programs PBL would never have been implemented in our school. This was clearly confirmed in 1989 by the accreditation report of the Liaison Committee in Medical Education (LCME)/Association of Canadian Medical Colleges, which led to a full 7-year accreditation for Sherbrooke Medical School.
Lessons learned This experience in implementing comprehensive faculty development programs in pedagogy has taught us many lessons about faculty development and curriculum change. Faculty development must be tightly based on identified educational needs and must be a continuous process'4 adapted to the evolving needs of an
A major goal of our faculty development activities was attitudinal change over time in the instructor-student interaction. Without this shift toward a student-centred approach significant and sustainable educational changes would not have occurred and would most likely not have been attainable. However, this is a lengthy process. Accordingly, activities to initiate and sustain this trend were started long before any practical curriculum change was attempted. To embark on major curriculum change an institution must have a small core of faculty members interested in promoting medical education and ready to learn or deepen their basic understanding of education. The commitment and enthusiasm of these people ought to be reinforced by the school authorities. A mentor seems to be a sine qua non in the development of such a core of proponents. We have tried to avoid the pitfalls of reinventing the wheel by hiring outside experts to help us. However, these experts must receive a clear educational contract: to transfer a part of their expertise to the local faculty in order to create a core of in-house potential educators.
Conclusion Although many factors guide curriculum change, such as strong political commitment, relevant expertise, an adequate reward system and acceptance of change, faculty development in pedagogy remains a major element in the process.15 In our medical school it has been given high priority for the last 6 years, during which time a major undergraduate curriculum change has been successfully implemented. A comprehensive series of four faculty development programs in pedagogy was offered to teachers. The success of the programs was measured by a high participation rate, increased interest in medical education, modification of educational philosophy and efficient acquisition of specific skills. The programs had a significant impact on the successful shift from a traditional to a problem-based, small-group tutorial curriculum. The lessons we have learned from our 6 years' experience lead us to believe even more strongly that faculty development was and will remain a prerequisite of curriculum change in medical schools.
educational milieu and its teachers. The curriculum revision and subsequent implementation of the un- References dergraduate PBL program have given rise to a set of new and evolving educational needs in our school. 1. Des Marchais JE, Dumais B, Pigeon G: Changement majeur du cursus medical a l'Universite de Sherbrooke: raisons et The programs we have implemented since 1984 have du changement. Rev Educ Med 1988; 11 (2): 21-30 met these needs as perceived by the participants 2. etapes Idem: Changement majeur du cursus medical a l'Universite themselves, the internal proponents of educational de Sherbrooke: objets et consequences du changement. Rev change, the external consultants and the 1989 LCME Educ Med 1988; 11 (4): 9-17 3. Physicians for the Twenty-First Century: Report of the Panel accreditation surveyors. CAN MED ASSOC J 1991; 144 (5)
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4. 5.
6. 7.
8.
9.
on the General Professional Education of the Physician and College Preparation for Medicine, Association of American Medical Colleges, Washington, 1984 Barrows HD, Tamblyn RM: Problem-based Learning: an Approach to Medical Education, Springer Pub, New York, 1980 Schmidt H: Problem-based learning: rationale and description. Med Educ 1983; 17: 11-16 Barrows HS: How to Design a Problem-based Curriculum for the Preclinical Years, Springer Pub, New York, 1985 Des Marchais JE, Jean P, Delorme P: Basic Training Program in Medical Pedagogy: a 1-year program for medical faculty. Can Med Assoc J 1990; 142: 734-740 Guilbert JJ: Educational Handbook for Health Personnel (offset publ 35), WHO, Geneva, 1981 Jean P, Des Marchais JE, Delorme P: Apprendre a enseigner les sciences de la sante: Guide deformation pratique, Faculte de medecine, universites de Montreal, Sherbrooke et Ottawa, 1988
Conferences continuedfrom page 546 Apr. 22-23, 1991: Symposium on Bioequivalence and Interchangeability of Pharmaceutical Products Queen Elizabeth Hotel, Montreal Dr Jacques Gagne, Faculte de pharmacie, Universite de Montreal, CP 6128, succ. A, Montreal, QC H3C 3J7; (514) 343-2102 Apr. 25-27, 1991: Alzheimer Society of Canada 13th Annual General Meeting and Conference St. John's Alzheimer Society of Canada, 201-1320 Yonge St., Toronto, ON M4T 1X2, (416) 925-3552; or Alzheimer Association of Newfoundland, (709) 576-0608
May 2-3, 1991: Introduction of Recombinant Factor VIII to Clinical Practice: an International Symposium Montreal Canadian Hemophilia Society, 840-1450 City Councillors St., Montreal, PQ H3A 2E6; (514) 848-0503, FAX (514) 848-9661 May 18-21, 1991: National Conference on Medical Management Harbour Castle Westin, Toronto Jill Roote, American College of Physician Executives, 200-4890 W Kennedy Blvd., Tampa, FL 33609-2575; FAX (813) 287-8993 May 22-24, 1991: Centre for Health Economics and Policy Analysis 4th Annual Health Policy Conference Health Care and the Public: Roles, Expectations and Contributions Sheraton Hamilton Hotel, Hamilton, Ont. Lynda Marsh, Department of Clinical Epidemiology and Biostatistics, McMaster University, 1200 Main St. W, Hamilton, ON L8N 3Z5; (416) 525-9140, ext. 2135, FAX (416) 546-5211 562
CAN MED ASSOC J 1991; 144 (5)
10. Schmidt HG: A specific, problem-based, self-directed learning method designed to teach medical problem-solving skills, self-learning skills and enhance knowledge retention and recall. In Schmidt HG, De Volder ML (eds): Tutorials in Problem-Based Learning: a New Direction in Teaching the Health Professions, Maastrich, Van Gorcum Assen, 1984: 915 11. Davis I: Competency-based Learning Technology, Management and Design, McGraw, New York, 1973 12. Barrows HS: The Tutorial Process, Southern Illinois University School of Medicine, Springfield, Ill, 1988 13. Jason H, Westberg J: Preparation for teaching. In Teachers and Teaching in US Medical Schools, ACC, East Norwalk, Conn, 1982: 71-83 14. Bates CW: Faculty development: a continuing process [E]. J Med Educ 1988; 63: 490 15. Barrows HS, Peters MJ: How to Begin Reforming the Medical Curriculum, Southern Illinois School of Medicine, Springfield, Ill, 1984: 21-27
June 9-13, 1991: Canadian Association of Radiologists 54th Annual Scientific Meeting Hamilton Convention Centre, Hamilton, Ont. Canadian Association of Radiologists, 510-5101 Buchan St., Montreal, PQ H4P 2R9; (514) 738-31 11, FAX (514) 738-5199
June 10-14, 1991: 4th International Conference on Systems Science in Health - Social Services for the Elderly and the Disabled Barcelona Inter-Congres, 646 Gran Via de les Corts Catalanes, Barcelona 08007, Spain; telephone 011-34-3-93-3012577, FAX 011-34-3-93-301-6332
June 13-15, 1991: College of Family Physicians of Canada (Ontario and Manitoba chapters) Spring Seminar Minaki Lodge, Kenora, Ont. Ontario Chapter, College of Family Physicians of Canada, 4000 Leslie St., Willowdale, ON M2K 2R9; (416) 493-7641, FAX (416) 493-9630
June 14-15, 1991: Suicide, Sleep and School Problems in Children and Adolescents Health Sciences Centre, University of Calgary University of Calgary Health Sciences Centre, 3330 Hospital Dr. NW, Calgary, AB T2N 4N 1; (403) 220-7240
June 16-18, 1991: Canadian College of Health Service Executives Annual Conference Toronto Canadian College of Health Service Executives, 201-17 York St., Ottawa, ON KIN 5S7; (613) 235-7218, FAX (613) 235-5451
continued on page 568
