Many medical schools face the challenge of curriculum renewal.1–5 Responding to diversity in patient populations, integrating new pedagogical practices, recognizing evolving health care systems, and appreciating the role technology plays in health care are all creating pressures for change. Most schools begin with developing the overarching goals and principles that will underpin and drive their change.6 Although these can be difficult to elucidate, the greater challenge is translating lofty goals into a concrete curriculum and assessment practices. In this article, we describe the development and use of an innovative tool, known as the Matrix, which was designed to help move a large-scale curriculum renewal process from high-level principles to a pragmatic, implementable curriculum. We also explore this tool’s impacts, both intended and unintended, on the University of British Columbia (UBC) Medical Doctor Undergraduate Program (MDUP).
Understanding the Complexity of the Curriculum Renewal
For any medical school contemplating curriculum renewal, the first step is to understand the complexity of the many involved elements. Bordage and Harris6 describe the medical curriculum as an entity made up of five elements: competencies or outcomes; learners; assessment; conditions and resources for learning; and socio-politico-cultural context. Given this complexity, Bordage and Harris argue, one element cannot be revised independently of the others—changes in one element may have unanticipated impacts on the others. Additionally, many attempts at curricular reform have been largely unsuccessful or unachievable because of lack of attention to local social, political, economic, and cultural contexts and realities.6
Whereas Bordage and Harris’s6 framework guides the way we describe the impact of the Matrix, for the purposes of this article, we focus on two domains: conditions and resources for learning (i.e., content and instructional methods for delivery, as well as human and socio-material resources such as faculty, staff, patients, facilities, and learning materials) and the socio-politico-cultural context (i.e., the environment created by formal, informal, and tacit values and norms established by individual faculty role models; the academic institution’s mission, governance structure, and policies; the health care practice atmosphere; and broader social, political, and economic societal forces).6
As we describe below, in addition to the intended outcomes on conditions and resources for learning, using the Matrix had unexpected system impacts, as described by Bordage and Harris,6 with respect to the socio-politico-cultural context, including the realignment of governance structures and accountability. Thus, whereas others have documented the use of curriculum maps,7,8 what is novel in this case is less the development of the innovative tool than its application and impact on both curriculum and governance structure and function.
The UBC Faculty of Medicine is constructed of 19 departments, 3 schools, and 21 research institutes/centers. It offers 18 academic programs, including the MDUP. The MDUP, which culminates in the doctor of medicine degree, is distributed among four regional campuses across British Columbia, Canada. There are nearly 1,200 students across the program’s four years and more than 7,000 clinical faculty.
In 2009, the Faculty of Medicine leadership gave the MDUP a mandate to create a renewed developmental, spiraled, integrated, and competency-based curriculum. Approaching curriculum design developmentally meant that curriculum content and context would become increasingly complex over time.9–11Spiraled meant focusing on changes that would allow content areas to be revisited at regular intervals.12 Building an integrated curriculum referred to constantly connecting basic biomedical, clinical, and social sciences so that students would concurrently acquire and apply knowledge and skills from different disciplines, consistent with real-life patient care and evidence-based practice. Finally, creating a competency-based curriculum meant the curriculum would have, at its core, an agreed-upon set of competencies or learning outcomes.
Based on the visioning recommendations for the renewed curriculum,13 the initial curriculum renewal activities (2010–2012) started with developing an overall structure with a major focus on the preclinical years. These activities included designing term-long courses in which all major educational elements were integrated into large, omnibus 14-week courses, with a smaller flexible concurrent course each term that provided students with opportunities to engage in research, community service learning, and scholarship (see Figure 1).
Goals for Developing the Matrix
In the second set of curriculum renewal activities (2013–2015), the authors co-chaired the Curriculum Coordination and Blueprinting Working Group, a subcommittee of the curriculum renewal leadership team, which was composed of foundational scientists, clinicians, educators, and administrators. This working group was tasked with developing, revising, and adapting a curriculum map to ensure that content would be aligned with the structure, themes, principles, and overarching goals set out in the visioning document.13 Without a holistic and cohesive approach to curriculum development, the risk of fragmentation (i.e., a curriculum made up of many disparate small parts) loomed large. One of us (S.J.S.) had developed a simple matrix for the Department of Surgery to blueprint the CanMEDS competencies across all surgical rotations14 and, on the basis of this early work, introduced the concept of using a more complex matrix to accomplish the task of creating a curriculum blueprint for all four years of the MDUP.
We created the Matrix to address the complexities in renewing the MDUP curriculum, including the geographically distributed contexts, numerous organizational structures, and pedagogical goals. The starting point for the Matrix was the visioning document.13 The six goals of organizing curricular information in the Matrix included:
- facilitating the process of mapping the curriculum to ensure that all necessary elements were included;
- translating high-level design principles into practical implementation guidelines;
- creating a strong relational connection between a complex set of curricular components representing a large number of contributing experts across a vast geographical area;
- providing the curriculum renewal leadership team a way to map content to the overarching principles to aid in decision making, communication, and monitoring;
- developing a common framework and shared language for curriculum development; and
- enabling a visual representation of the curriculum blueprint for all 130 weeks of the MDUP.
Description of the Matrix
The Matrix was initially created in Microsoft Excel (version 14, Microsoft Corp., Redmond, Washington). It is organized by rows and columns resulting in cell-level information. Partial illustrations of the Matrix are provided in Figure 2 and Supplemental Digital Appendix 1 at http://links.lww.com/ACADMED/A565.
Columns consist of the three foundational curriculum components—systems, themes, and clinical experiences—that were chosen through a process of working groups and task force activities. The systems component includes all major biological systems; a working group was convened to identify and define each of those subcategories (e.g., cardiovascular, respiratory) and to align them with nationally defined objectives. For the themes component, a broad group of stakeholders was tasked with identifying the areas to be blueprinted into the four years of the curriculum; these theme clusters include medical sciences, diagnostic science, treatment, care of patients, populations, diversity and equity, and scholarship. In the preclinical years, the clinical experiences component includes simulated sessions and family practice visits. As the curriculum progresses into the clinical years, clerkships and clinical electives form the entire clinical experiences component.
Rows represent a week in the program and include specific topic(s) or patient presentation(s) (e.g., hypertension, breast mass, pregnancy). In the preclinical years, one topic is assigned per week, whereas in the clinical years, multiple topics are assigned per week. Separate rows are clustered to make up a course or clerkship.
Cells (i.e., the intersection of a row and column) indicate which systems and themes are the focus of teaching and learning for a specific topic. For example, the heart murmur week (week 9) includes two systems, many themes, and clinical experiences (both simulated clinical skills sessions and family practice office visits). Initially, integrated learning objectives representing desired learning outcomes for a given topic were accessed from each cell via a hyperlink. For example, an integrated objective of the hypertension topic (week 14) is “Describe the general approaches to the management of congenital heart disease, including the role for parental counseling, decisions re: pregnancy termination, and end-of-life care.” As more detail was developed, technological limitations made it impossible to include hyperlinks to all the cell-level details beyond the week-level objectives. Therefore, a virtual course book was created for each course to provide outlines for each week, including an overview, learning objectives, clinical case(s), and so forth. (The outline for week 9 is provided as an example in Chart 1.) The virtual course books were created in Microsoft Word (version 14, Microsoft Corp., Redmond, Washington).
The process of populating the cells was conducted by the Curriculum Coordination and Blueprinting Working Group using an iterative, consensus-based approach based on learning outcomes (program and national). This allowed the group to draft initial versions of the Matrix that would be further refined through a series of larger engagement meetings with stakeholders across the UBC MDUP throughout the development and implementation of the renewed curriculum. Through a series of working group meetings, all curricular components were blueprinted into the Matrix. This underpinned the launch of the renewed curriculum, which was slated for September 2014 but was delayed a year because of unrelated circumstances. The curriculum officially launched in September 2015.
Impact of the Matrix
Both intended outcomes of the Matrix (i.e., the impact on the conditions and resources for learning) and originally unintended outcomes (i.e., the impact on the socio-politico-cultural context) were realized. To deconstruct the initial intended positive effects of the Matrix, we outline below the transition from high-level goals and principles to a pragmatic, implementable curriculum. We then consider the unintended effects on the MDUP’s governance approach.
From principles to pragmatics
As described above, the early visioning document13 outlined four major pedagogical principles for the curriculum renewal: an integrated, developmental, spiraled, and competency-based program. These principles fell largely within the conditions and resources for learning domain of Bordage and Harris’s6 framework; one principle, competency based, could also fit within the outcomes domain. The Matrix supported the incorporation of each of these principles into a concrete, actionable plan that allowed for monitoring decision making across all four regional campuses.
The Matrix enabled integration of curricular components (systems, themes, and clinical experiences) across and within courses on a program level. This allowed course coordinators and content experts to see where their contributions fit within the curriculum, which aided the development and implementation processes. The Matrix also enabled visualization of the impact of changes made in one area on another area, which helped with drift monitoring (i.e., being able to see the big picture to know how smaller decisions in one area might affect other areas in possibly unintended ways). Integration of content and context within a given week and within a given educational activity was achieved variably, depending on the individual developer’s interpretation of what “integration” meant.15,16 Ongoing integration at the program, year, course, week, and session levels will continue to improve with subsequent iterations of the curriculum, as each year of the MDUP unfolds.
Because the Matrix provided a blueprint of all 130 weeks of the MDUP curriculum, it enabled educational leaders, curriculum developers, and educators to compare if and when foundational concepts were being covered, as well as to see how the sequence went from basic to complex over time and how each topic built developmentally on the last. Year-by-year developmental milestones representing a progression from foundational to more advanced concepts were generated for each component (system, theme, and clinical experience). Learning objectives for each week were derived from, and tagged to, these milestones. Therefore, with the Matrix, one could follow the developmental progression of any system, theme, or clinical experience from foundational to more advanced content and context. As an example, the cardiovascular system was taught developmentally, as follows: In the first weeks of the program, students began by learning about normal heart anatomy and function. Later on, throughout the first and second years, cardiovascular topics were revisited for students to learn more complex conditions or presentations (e.g., multiorgan systems issues). This revisiting would continue into the clinical clerkships, moving from simple case presentations to more complex ones, as students learned to manage patients with cardiovascular conditions.
The Matrix provided a blueprint of how the curriculum was spiraled; in other words, it showed places where curricular material was deliberately revisited. The columns gave a graphical representation of the timing and delivery of objectives and milestones for the systems, themes, and clinical experiences. That visual representation made it much simpler to see how information was being—and how it could be—deliberately revisited in any given area over the four-year program. For example, the team responsible for integration and delivery of content for a certain theme, such as medical ethics, could easily visualize where each instance of their theme was integrated into the curriculum. This allowed the team to understand where they could revisit topics, reinforce concepts, and continue to build upon learning outcomes related to their theme.
Moving toward a competency-based curriculum meant that curriculum designers needed to deconstruct global exit (i.e., graduation-level) competencies into year-level milestones, course outcomes, week-level objectives, and individual session objectives. The Matrix formed the “midlevel” (i.e., week-level-objective) scaffold. As described above, in the Matrix, week-level objectives were mapped to year-level milestones and were also further deconstructed in the virtual course books, which included individual session objectives. Being able to map each level was important to demonstrate how to move from a principle of being competency based to a pragmatic approach for relating each individual learning activity to the MDUP’s intended outcomes. Although not all of this information could be contained within the Matrix because of technological limitations, the Matrix facilitated the process of nesting and mapping objectives from the emerging curriculum (and associated programmatic assessment). For example, cells were linked to week-level and session-level learning objectives (via the virtual course books), which were tagged to specific systems and themes. Further details—such as itemized schedules for each week, individual session objectives, curriculum delivery format (e.g., lectures, labs, seminars), timing (e.g., sequence of activities, relational connections between activities), and faculty responsible (including location) for delivering the session—were contained within the virtual course books.
Socio-politico-cultural context changes
Returning to Bordage and Harris’s6 framework, the curricular changes aided by the Matrix had a significant unintended impact on the MDUP’s socio-politico-cultural context (e.g., implicit values, institutional structures, program policies, governance structures). Although the complexities of distributed medical education, governance, change management, and curriculum reform make it challenging to unpack the nuances of what changes did and did not occur as a result of the Matrix, we highlight below some examples of change across various organizational levels.
It became clear that the process of blueprinting curriculum components in the Matrix also required emphasizing the alignment between accountability and responsibility and creating transparent lines of communication and decision making. In other words, it was critical to know who had the authority to make decisions when substantive structural changes were considered. At times, the absence of a clear understanding that the governance structure needed to change along with the curriculum resulted in a strong gravitational pull back toward the status quo. For example, the existing curriculum had multiple small blocks or modules organized by specialty or discipline (e.g., the Department of Dermatology ran the integument block, Obstetrics and Gynecology headed the reproduction block, Family Practice led the family medicine course, and departments each ran separate clerkship rotations). It was organizationally demanding to integrate all of these educational components into the renewed curriculum because the departments and clinical specialties historically had full authority and ownership over their smaller blocks or courses, which meant that there was little need for cross-collaboration or communication. With the renewed curriculum newly organized into larger integrated courses of educational elements, the existing governance structure had challenges adapting to these changes.
At the systems level, the Matrix provided a simple representation of a complex curriculum change, and it was used to engage senior leadership at each distributed site and across all UBC Faculty of Medicine departments. The Matrix helped the curriculum renewal leadership team communicate with senior leadership across the UBC MDUP about what changes were being contemplated and how those changes would affect the overall program design, development, and implementation. For example, the Matrix illustrated how the curriculum renewal leadership team translated the principles of the Faculty of Medicine senior leadership’s high-level vision (e.g., competency based) into all components of the program (e.g., session- and week-level objectives) by providing an overall view of all four years of the curriculum parsed out into various spiraled components (i.e., themes, systems, and clinical experiences). The Matrix also provided a clearer understanding of where broader leadership decisions needed to be made and provided a means to communicate these changes.
The process of blueprinting the renewed curriculum using the Matrix also uncovered the need to make fundamental changes to the governance structure that could guide program delivery. The Matrix highlighted the need to define a new middle-management governance model based on the emergence of new curricular structures. For example, themes, systems, and clinical experiences as longitudinal parts of the broader curriculum did not initially have leaders. Questions began to arise about who would lead those components and what their decision-making authority would be. Similarly, building large, integrated, spiraled courses created a course leadership issue, disrupting the prior departmental and site-based governance of smaller system-focused blocks. Through use of the Matrix, the middle-level governance structure was changed to appoint and empower theme, system, and clinical experience leads at all the distributed sites and to incorporate a course co-coordinator model for the preclerkship courses that paired a foundational scientist and clinician to provide diverse perspectives.
Finally, as mentioned above, the Matrix provided clear insight into what content was added, kept, deleted, moved, and so forth. (This was determined by comparing iterative versions of the Matrix.) The renewed curriculum was not developed entirely de novo. That is, in many instances, existing governance structures, institutional values, and curricular elements were incorporated into the renewed curriculum. Moreover, existing structures and the organizational culture were well entrenched, making change difficult for individuals and groups. Within the organizational culture, there was implicit value placed on expertise within subspecialties, which in some ways was counter to integration and holism. This provided a clear need to continue to revisit accountability and responsibility questions—Who makes what decisions, and how are those communicated? Sometimes the focus on small details in blueprinting the renewed curriculum created reactive decision making, such as attempts to integrate additional content post hoc or to shoehorn more content into already-packed course schedules.
Implicit to the change process, but never fully explored, were the diverse tacit values of individuals involved in the curriculum renewal process and those individuals’ different levels of comfort with, and understanding of the need for, change. The Matrix made these visible in two ways. First, the Matrix provided a tangible object that became the catalyst for discussions about the values of individuals. Second, the process of populating the Matrix facilitated conversations between individuals and groups regarding values, beliefs, and assumptions. In addition to change itself, taking the first step into the theoretical space between high-level, principle-based design and pragmatic implementation was unsettling. Accepting that the first iteration of the renewed curriculum would be a “straw dog” rather than the final curriculum required a leap of faith. Further, deciding which step to take first—for example, choosing the case that would drive the themes, systems, and clinical experiences or choosing the themes, systems, and clinical experiences that would define the case—was a conundrum. There were pros and cons associated with a top-down approach (i.e., starting with graduation-level competencies and progressively deconstructing) and with a bottom-up approach (i.e., starting with session-level objectives and progressively constructing) to making complex changes. Using the Matrix enabled individuals to focus on week- and course-level (i.e., midlevel) objectives, which helped resolve this issue both by defining the more detailed work that needed to be completed (e.g., daily learning activities) and identifying how the program was addressing its high-level goals (e.g., year-level milestones, graduation-level competencies). In this way, the Matrix acted as a tool to orient and reorient the more-detailed discussions by coming back to the big picture, which aided in curriculum decision making and direction. The inherent complexity and interdependence of the curriculum renewal process resulted in some inertia as some individuals had difficulty committing to a first iteration. Changing expectations from viewing the Matrix as a final and static product to accepting it as fluid, iterative, and adaptable for continuous improvement was essential to overcome this inertia.
Others who are embarking on curriculum development or curriculum renewal could adapt the Matrix for local use to create a visual representation of an emerging curriculum blueprint; to translate high-level goals into a concrete, implementable curriculum; and to appreciate relationships between a complex set of curriculum components. Further, the Matrix could be used as a tool to explore the socio-politico-cultural context and to realign governance with the functionality required to implement a renewed curriculum.
Implementation and delivery of the MDUP renewed curriculum are under way at the time of writing in 2018. Our future plans include adding a program evaluation component. For example, ongoing data could be collated to streamline themes and provide examples of where collaborative approaches and increased integration could help support student learning.
We also plan to continue to use a more technologically advanced version of the Matrix as a blueprinting and communication tool. Although the Matrix created in Microsoft Excel served as a powerful visual representation of a complex curriculum, because of technological constraints there was a limit to the amount of information the spreadsheet could contain. As we described above, granular session-level objectives and comprehensive year-level milestones were both linked to information in the Matrix’s cells (i.e., week-level objectives) but had to be accessed via separate platforms (e.g., Microsoft Word for the virtual course books). Since late 2015, we have used more sophisticated technology (Entrada, Queen’s University, Kingston, Ontario, Canada) to build upon the curriculum blueprint created in the Matrix. This has allowed further advances in our mapping of systems, themes, clinical experiences, educational activities, and their associated objectives with linkages to higher-order learning outcomes. This has enabled mapping the renewed curriculum in greater detail, at the level of session-by-session learning activities, and could facilitate greater integration (e.g., clustering objectives to enable integrated sessions co-led by a specialist, such as a cardiologist, and a generalist, such as a family physician). It has also allowed the collection of quantitative and qualitative information about curriculum content and education activity modalities.
In addition, continuous monitoring and reblueprinting of what curriculum content has been (and will be) delivered will make both intended and unintended drift explicit. As with any curriculum renewal, the processes of implementation and delivery will affect development plans for future iterations of the program.
To translate curriculum renewal principles into a pragmatic, implementable curriculum, we developed the Matrix as a tool to manage the complex organization of content. It was initially meant to operationalize high-level principles, such as integrated and spiraled, by promoting communication and collaboration across sites and departments. However, application of the Matrix made explicit the interrelatedness of curricular elements as suggested by Bordage and Harris6—in this case, conditions and resources for learning and the socio-politico-cultural context. The Matrix highlighted areas with entrenched governance structures for further inquiry; it also illuminated the constant tension that exists between strategy (e.g., pedagogy and principle) and the socio-politico-cultural context (e.g., status quo, institutional culture, organizational inertia). In addition, the Matrix made visible and enabled discussion of individuals’ previously hidden assumptions, beliefs, and values.
The Matrix facilitated the curriculum renewal leadership team’s decision making, communication, and monitoring of the curriculum development process via provision of a common framework that allowed all stakeholders to visualize the location of their contributions. It thus highlighted the relationship of content to people and affected the emerging middle-management governance model. As the curriculum’s structure and content changed, a need arose to also realign governance. New roles had to be created; in some cases, roles had to change.
The Matrix also created a foundation for curriculum mapping, which has continued to guide ongoing implementation of the renewed curriculum and continuous quality improvement. It is a living and evolving approach that has transitioned from the curriculum development and renewal phase into a useful implementation framework.
The authors would like to acknowledge the contribution of all the members of the Curriculum Coordination and Blueprinting Working Group who populated the Matrix and guided the initial development of the curriculum blueprint. The authors would also like to thank Dr. Ian Scott and Ms. Katherine Wisener for their helpful review and feedback of early manuscript drafts.