Hall, Pippa MD, MEd; Byszewski, Anna MD, MEd; Sutherland, Stephanie PhD, MA; Stodel, Emma J. PhD, MSc
In 2005, the Royal College of Physicians and Surgeons of Canada disseminated the CanMEDS Framework,1 which describes essential physician competencies in seven roles: medical expert, communicator, collaborator, health advocate, manager, scholar, and professional.2 Demonstrating assessment of these competencies is now part of the accreditation of Canadian postgraduate medical training programs.3 An environmental scan conducted in 2008 noted that “there have been localized discussions centered on introducing the CanMEDS Framework into the undergraduate medical education (UGME) system. In fact, some undergraduate programs have proactively adopted the CanMEDS Framework, aligning curriculum learning objectives and adjusting assessment forms to reflect the seven CanMEDS roles.”4
In preparation for an approaching accreditation review, the of (uOttawa) Faculty of Medicine undertook a revision of its UGME curriculum. In 2008, it launched the revised curriculum, which is based on the seven CanMEDS roles and adds an eighth role of “person” to incorporate the dimensions of mindfulness and personal well-being. Others have also advocated the addition of such a role to physician education and assessment and have stressed the importance of encouraging personal and professional growth.5–9 (A detailed description of the educational objectives for each of the eight roles is available at http://tinyurl.com/6srmvjr.)
As the curriculum revision process was under way, different methods were explored to evaluate students’ attainment of competency in each role. In late 2007, the decision was made to develop an electronic portfolio (ePortfolio) for this purpose and to implement it as part of the new curriculum in September 2008. The mandatory ePortfolio program spans all four years of UGME and provides all students (in both the English- and French-speaking programs offered by the medical school) with a place to document their activities and personal development in areas beyond basic science knowledge and clinical skills.
In this article, we describe our evolving ePortfolio program, reflect on the challenges we have faced in its development and implementation, and share the lessons we have learned on our way to a successful and sustainable program.
Why Implement an ePortfolio?
An ePortfolio has been defined as a purposeful collection of information and digital artifacts that demonstrates development or evidences learning outcomes, skills, or competencies. The process of producing an ePortfolio (writing, typing, recording, etc.) usually requires the synthesis of ideas, reflection on achievements, self-awareness, and forward planning, with the potential for educational, developmental, or other benefits.10
All ePortfolios, including those prepared by medical students, should demonstrate reflection, evolution of thought, and professional development. Indeed, the primary purpose of many ePortfolios is reflection. Shumway and Harden11 emphasized the importance of portfolios in assessing what learners actually do rather than what they know or can demonstrate they know in written and clinical examinations.
Reflection and reflective practice are regarded as important components of professional competence. Reflection provides an explicit approach to explore one’s own beliefs, attitudes, and values in the context of integrating the theory and practice of the profession. Schön12 discussed reflection as a tool for revisiting an experience in the context of the complexity of real-world practice, to learn how to improve and grow from that experience.
A national study of UGME programs in Canada demonstrated that many were struggling to develop professionalism and ethics curricula.13 Given that aspects of students’ professionalism, such as altruism, empathy, and conscientiousness, may be eroded during medical school, it is important to consider preventive approaches.14,15 Suggestions have included improving narrative skills, participating in small-group discussion, engaging in reflection with supportive feedback,16 and having positive role models,17,18 all of which can be achieved through the use of an ePortfolio. The ePortfolio can also serve as a means for addressing the “hidden curriculum,” which includes the norms, values, and practices that are transmitted through role modeling and can have a profound effect on student learning.19 The hidden curriculum runs parallel to the formal curriculum and is a process of socialization to the complexities of physician–patient, physician–interprofessional team, and physician–community relationships.
Portfolio learning encourages students to debrief challenging events that occur during the course of their learning. It provides a safe environment in which they can reflect, receive feedback, and engage in discourse around context-specific experiences.20 Portfolios allow learners to actively engage in self-assessment through reflection and feedback. Although some students find discussing emotions difficult, evidence exists that using these methods to do so improves learning outcomes.21 Whereas portfolios support individual reflection and enable the student to have a discourse with himself or herself, these conversations with the self can grow into dialogues with others,22 particularly the teacher or mentor. The increasing awareness of the role of reflection in learning in the health professions,23 and in medicine specifically,12,24–28 supported the use of an ePortfolio as a formative and summative evaluation tool that addresses all eight roles in uOttawa’s UGME program, not just a tool that focuses on the role of “clinician.”
uOttawa Faculty of Medicine’s UGME ePortfolio Program
The concept of the ePortfolio emerged from the Faculty of Medicine’s ongoing UGME curriculum renewal process. We conducted an extensive review of the general portfolio literature,29–32 as well as that specific to medical education,11,33–36 to build the knowledge base on which to ground our decisions around the development of an ePortfolio program that would meet the needs of our unique context. Our key ideas included providing a clear and thorough introduction to the program; integrating it throughout the curriculum; making it student controlled; employing a simple, systematic evaluation procedure; and supporting faculty in their role in the program.
The curriculum review process, led by the UGME Curriculum Review Committee, regularly brought together medical educators and innovators, clinical teachers, students, and administrators. Throughout 2008, this group contributed to the development of the ePortfolio within the context of the overall curriculum renewal and the transition to a more electronic-based curriculum. In addition, preparations for an upcoming accreditation review highlighted the need for reflective learning opportunities.
Development of the ePortfolio involved a diverse team composed of three clinician–educators interested in the humanities and medicine (including P.H. and A.B.), an electronic learning (eLearning) consultant/instructional designer (E.S.), and uOttawa Faculty of Medicine technical staff with diverse programming expertise. Communication with the student, faculty, and administrative members of the UGME Curriculum Review Committee was ongoing from the time the concept was proposed to the committee in fall 2007 through its launch in September 2008.
The uOttawa Faculty of Medicine’s ePortfolio program incorporates both face-to-face meetings and an online component in which students and their ePortfolio coach reflect together on the evolving roles of the physician and celebrate students’ successes in gaining competence in each of these areas. (For the ePortfolio program’s general objectives, see List 1.)
Within the separate French- and English-language programs, students are randomly divided into groups of six to eight by administrators at the start of the UGME program and are assigned a faculty member as their coach. This process results in 24 new ePortfolio groups each year (6 French, 18 English). Students remain in the same small group with the same coach for the entire four-year program.
These small groups, which were inspired by the University of Toronto’s professionalism proposal,37 provide a safe, nonjudgmental, and nonpunitive setting that fosters collegial conversations in which students share personal experiences with one another and learn to give and receive formative feedback. A coach facilitates each group’s reflections on the effects that personal and professional values and/or experiences have on individuals’ behavior and perceptions. During group meetings, with colleagues as sources of support, dialogue, and feedback, students problem-solve difficult ethical and professional experiences. The online ePortfolio component provides a space where each student can engage with his or her coach in ongoing reflective discussions and interactions that are not bound by time or space.
The ePortfolio program is a mandatory and evaluated course. Participating faculty support and nurture students’ learning and reflection, but they also must formatively and summatively evaluate each student’s progress toward achieving the competencies within each role. We chose the title “coach” rather than “mentor” because mentors tend not to evaluate. Further, a faculty–student mentorship program already existed.
Students are expected to add entries to their ePortfolios on a regular basis. Submissions can be in any media format (e.g., written narrative, drawing, podcast, video) and, by the end of the second year, should demonstrate the student’s development and learning in all of the CanMEDS roles. Submissions during the third and fourth years should demonstrate ongoing development, with evidence of achieving all objectives in each role. There is no required length or format for entries in the ePortfolio, although they should show adequate reflection and effort. The coach is expected to comment on each student post, encouraging deeper reflection and connection to the curriculum’s objectives. These student–coach dialogues offer opportunities for insights for both student and coach.
Each year, every ePortfolio group meets with its coach during two mandatory two-hour sessions. During these meetings, each student is expected to share an entry from his or her ePortfolio, to reflect on the objectives of the selected role, and to self-assess his or her competency using a rubric (Appendix 1). The student discusses related challenges and successes. If time permits, the student may choose to reflect on additional roles. The coach facilitates these sessions, while students are expected to provide feedback to their colleagues. Peer input is therefore part of the formative feedback students receive. Between meetings, the coach–student conversations continue online through the ePortfolio site. Some small groups may also choose to meet on other occasions. There are no required face-to-face meetings between individual students and their coaches.
Using the rubric bel...Image Tools
After each mandatory small-group meeting, the coach completes a progress evaluation form for each student. Using a pass/fail system, the coach assesses whether the student has provided evidence of achieving the objectives in the role discussed and has demonstrated skills in self-assessment and giving and receiving feedback. A failure requires remedial work. Students must pass each progress evaluation in order to graduate.
At two points during the UGME program, students select ePortfolio entries for formal assessment. The entries chosen for the midpoint (submitted at the end of the second year) and final (submitted at the end of fourth year) ePortfolios must demonstrate the achievement of competence in all eight roles. After the coach reviews the selected entries and engages in a dialogue with the student to finalize the submission, the coach uses a modified version of the rubric in Appendix 1 to recommend a passing or failing grade. The midpoint ePortfolio is expected to include evidence that the student is developing competence in at least some of the objectives for each role. The final ePortfolio is expected to demonstrate the student’s competence in all the objectives for each role. The coach’s recommendation is reviewed by the director of the ePortfolio program. If a coach recommends a “fail,” the student’s submission is referred to and reviewed by the 7 to 13 members of the ePortfolio Evaluation Committee, composed of the ePortfolio Faculty Committee and volunteer coaches, who make a final decision. Students with failed submissions must do remedial work.
The ePortfolio Program’s Challenges and Successes
Our ePortfolio program is in its fourth year and has grown from 154 students and 24 coaches in the first year to more than 600 students in 91 groups with 74 coaches across the four years of study (several coaches have chosen to work with more than one group). As medical educators, our learning is guided by Schön’s12 theory of reflection-in-action and reflection-on-action. The journey to get here has been rewarding but not devoid of challenges that needed to be overcome in order to develop a sustainable and successful program. We hope that by sharing our reflections on our challenges and successes, others contemplating an ePortfolio program can learn from our experiences and travel a smoother path.
The technical development of the ePortfolio
To address our technical requirements (List 2), which are based on the goals and objectives of the UGME program and its student population, the uOttawa Faculty of Medicine’s technical team during May–July 2008 developed a bilingual, online ePortfolio system using SharePoint, a Microsoft product designed to support collaboration and file sharing. The system was tested and refined over the remainder of the summer and launched in September 2008.
Over the course of the 2008–2009 academic year, it became clear that the complexity of the system’s design made its use cumbersome and tedious. For example, on the student interface, the eight roles ran along a navigation bar at the top of the homepage. Each role had a dropdown menu with links to private, public, and coach folders; the folder to which the student uploaded the entry determined who could see it. After the student uploaded a file to the coach folder, the coach would need to download the file in order to view it. The coach would enter any comments/feedback directly in the file and then upload the revised file for the student to access. The student would then need to download the revised file to view the coach’s comments. It was decided that there would be a major revision of the ePortfolio system.
During summer 2009, a medical student was hired to help with the redesign. He proposed the use of a simple blogging platform that would allow for dynamic posting of content, in-browser viewing and editing, and commenting by others directly on the post. In the redesigned ePortfolio system (http://www.med.uottawa.ca/ePortfolio/), launched in September 2009, each student’s homepage includes links to each of the roles. When the student clicks on one of these links, he or she connects to a page that explains the role, including the objectives and suggestions for appropriate ePortfolio entries for that role, and displays all of the student’s current postings in that role.
When the student creates an ePortfolio entry (essentially a blog post) for a role, he or she identifies who has access to the post (e.g., coach, guest, midpoint or final evaluation committee). The student can attach files to posts, insert images, embed videos, or use any other form of multimedia to present his or her learning. The coach receives e-mail notifications of new posts and adds comments to the posts. The student is notified by e-mail when the coach adds a comment. This system is causing far fewer technological problems than the original system. It is proving much simpler to use and more acceptable to coaches and students.
Introduction to the ePortfolio program for students and faculty
When the ePortfolio program was first launched in September 2008, students in the class of 2012 began their first year of medical school with a 30-minute session outlining the goals and objectives of the ePortfolio program. This was followed by two hours of formal introduction to the program, including an orientation to the technology and two sessions with their coaches. Coaches attended a separate introductory session. Despite our efforts, throughout the first year of the ePortfolio program, students struggled to understand the program’s purpose and benefits. They perceived it as a tool without a specific purpose in their education, and so they questioned and criticized its usefulness. Coaches were also unclear about their new role. The non-user-friendly ePortfolio system contributed to both groups’ dissatisfaction.
We addressed these issues for the 2009–2010 academic year by reorganizing the introductory sessions for the class of 2013. One 30-minute session introduced the first-year students to the technological aspects of the ePortfolio. An additional 1.5-hour session, attended by both coaches and students, introduced the program objectives and process, reviewed the expectations for both coaches and students, and allowed time for questions and discussion. This was followed by a 30-minute, small-group session that allowed students and coaches to meet and to review the confidentiality agreement. The introductory sessions have continued to use this format and have been much more effective for orienting both students and coaches.
Student input and buy-in
Inviting and respecting student input into the ongoing modification of the ePortfolio program has proved effective in gaining student buy-in. Students now serve as official advisors to the ePortfolio Faculty Committee, providing feedback and facilitating student–faculty communication. Their insights into student experiences and attitudes about the program have helped us improve the clarity of our message about the ePortfolio’s purpose and benefits for both coaches and students. As the formative and summative evaluation strategy emphasizes the importance that the UGME dean, associate dean, and Undergraduate Curriculum Committee place on reflective learning, students have remained engaged with the program and recognize their important stakeholder role. The coaches also have found the evaluation framework to bring clarity to their role.
Faculty support, development, and recognition
Faculty buy-in was low initially, and recruiting coaches proved challenging. Although we circulated recruitment notices with information about the new program through the faculty listserv and to personal connections of the UGME office staff and ePortfolio Faculty Committee, our efforts to communicate the program’s goals and the coach’s role were not highly successful. We were able to recruit only the minimum number of required coaches. The coaches had varying approaches to nurturing student growth, which led to inconsistencies in their expectations of students. They were also frustrated with the first ePortfolio system, which was just one component of the massive curricular reform facing the faculty.
As awareness of the ePortfolio has increased—along with recognition that it is a mandatory element of the UGME curriculum—faculty support and interest have become stronger. Faculty are more knowledgeable about the program and appreciate its worth in terms of student learning. Now, even with 74 coaches participating, we have a waiting list of faculty who want to be coaches.
The role of the ePortfolio coach is important and challenging; there is no defined curriculum to teach or evaluate. To serve as coaches, faculty require broad experience that includes knowledge of the Canadian health care system, the eight roles in uOttawa’s UGME curriculum, and reflection/reflective practice, as well as skills in providing timely feedback, evaluating performance, facilitating collegial discussions, creating nonjudgmental environments, and writing. A benefit for the coaches is that as they engage with students in discussions about the eight physician roles, they have the opportunity to increase their own understanding of and competence within these roles. As the program has evolved, developing coach competencies in each role (Table 1) has become an essential component of faculty development.
Faculty development has been critical to the success of the ePortfolio program.38 Each coach is expected to attend two of the three annual faculty development sessions for coaches. These sessions provide a forum to network, to share successes and challenges, and to review the program’s technology, goals, and objectives as well as the competencies necessary to be a successful coach. The faculty development sessions have resulted in more consistency among coaches and less confusion for the students.
In addition, coaches need to be recognized for their efforts. Initially, coaches received an hourly rate for each mandatory session. Given the online coaching activities and required faculty development sessions, the associate dean approved a token annual honorarium of $1,000 in recognition of the estimated 10–20 hours per year it takes to fulfill a coach’s commitment and responsibilities. To further celebrate the coaches’ work, a letter of recognition signed by the associate dean and members of the ePortfolio Faculty Committee is sent on a yearly basis, and a special, student-nominated award for excellence in coaching is being developed.
Faculty of Medicine support for the ePortfolio program
The members of the uOttawa Faculty of Medicine’s executive committee, led by the associate dean of UGME, have been unwavering in their support for the ePortfolio program. This has allowed the program to evolve organically and overcome rocky moments.
In the early stages of the ePortfolio program, limited administrative staff support was available. This made it challenging to plan and coordinate ongoing implementation activities (e.g., scheduling group sessions and ePortfolio Faculty Committee meetings, distributing materials and information to coaches and students).
Increasing administrative staff support for the ePortfolio since 2008 has facilitated the organization and management of the program and bridged departmental communication silos. The UGME administrative staff is now aware of the ePortfolio program and well positioned to discuss any questions related to the program at departmental meetings.
The technology services staff provide support to the ePortfolio program, assisting both students and coaches with technical challenges. They have continued to work closely with the ePortfolio Faculty Committee to make ongoing improvements to the ePortfolio system.
The ePortfolio Faculty Committee remains available to coaches and students to address issues as they arise, offers ongoing support and advice to the coaches, and organizes faculty development sessions. The early years of the ePortfolio program were a struggle for ePortfolio Faculty Committee members. The encouragement we received from peers to weather the difficult times kept everyone committed and enabled us to achieve our vision.
As this article shows, the ePortfolio program has evolved since it was introduced in September 2008. Although we tried to follow the wisdom shared in the extant portfolio literature, we have still learned many lessons from our experience. Identifying ways to simplify and clarify aspects of the program has been key to turning our challenges into successes. Our program has remained flexible, and we have continually clarified directions and expectations for students and coaches. Although we had support to modify and adapt the ePortfolio system and program, we did not have the luxury of time to permit piloting prior to launch; doing so might have prevented some of the initial challenges. We have begun to see encouraging outcomes that need to be properly evaluated.
In our own work as coaches and in discussions with other coaches at the faculty development sessions, we have seen that issues relevant to the hidden curriculum19 are being made explicit by the students via the ePortfolio program. Through their posts and small-group meetings, students are engaging in reflection and discussion around the increasing challenges they face in their preclinical and clinical worlds, in all eight roles, not just that of clinician. Through dialogue and facilitation by coaches, the covert is being made overt. The UGME program has addressed several issues identified through the ePortfolio process, including bullying, some inappropriate competitive attitudes, and some challenging ethical situations students encountered in both clinical and preclinical experiences. Outcomes of the ePortfolio program, such as these, will be a future focus for our research.
Several courses have started to use the ePortfolio as an opportunity for reflective student assignments (e.g., health advocacy reports/essays, reflection on clinical experiences). Students in the clerkship phase are now posting rich examples and reflections from their clinical experiences.
In the work shared by the student–coach dyads, we have observed development of the coaches’ own understanding of the CanMEDS roles and the reflection process—a transformation of not just the learners but also the teachers. Coaches have expressed interest in having their own ePortfolios.
Students’ posts have demonstrated reflection and personal growth. Students have used all types of media for their posts, some of which have been extremely creative and have received special recognition by the Faculty of Medicine and national medical education conferences. Of the two classes of students who have submitted midpoint ePortfolios, only one student has received a failing grade from the coach, requiring review by the committee and remedial work by the student.
The next steps for the program include improving the sample ePortfolio by incorporating examples of our students’ excellent work. Technical improvements, as identified by students and coaches, are ongoing. Administrative support is strengthening. Through a systematic analysis of the midpoint and final submissions, we must determine whether and how the hidden curriculum is being addressed and if students are attaining the CanMEDS competencies in practice. There is also growing interest in applying the ePortfolio to residency programs as well as using it for faculty professional development.
Portfolios have traditionally been used as a vehicle for charting professionalism. Our ePortfolio expands their application to a wider range of physician roles. Although electronic learning is quickly gaining momentum in medical education, many portfolios across a range of professions remain paper based. Our bilingual (English and French) ePortfolio program allows students to create online, portable, multimedia ePortfolios and provides a means by which students and faculty can engage in ongoing reflection and communication.
Our ePortfolio is an innovative approach to medical education that supports student-centered learning, is responsive to the changing world and society’s expectations, and should prepare future physicians to be responsive to the needs of the health care system as well as the patients for whom they will care.
Acknowledgments: The authors wish to thank all the students and coaches who have helped improve the ePortfolio; Dr. Geneviève Moineau and Dr. Ian McDowell, who have been unwavering in their support for the program; and Daniel Trottier, Olivier Heimrath, and Mladen Dekić for their creativity and technical expertise.
Funding/Support: University of Ottawa Faculty of Medicine Undergraduate Medical Education Program and the Academy for Innovation in Medical Education (AIME) at the University of Ottawa.
Other disclosures: None.
Ethical approval: Not applicable.
Previous presentations: Portions of this work have been presented at AIME Annual Education Day, Ottawa, Ontario, Canada, May 2010; the Canadian Conference on Medical Education, St. John’s, Newfoundland, Canada, May 2010; and the Association of American Medical Colleges Annual Meeting, Washington, DC, November 2010.
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Appendix 1 Rubric for Medical Student Self-Assessment of Competency Demonstrated via the ePortfolio, University of Ottawa Faculty of Medicine
Assessing Your ePortfolio