canada - afmc of saskatchewan...of medicine following the release of the association of faculties of...

Dean’s Office 5D40 Health Sciences Building 107 Wiggins Road Saskatoon SK S7N 5E5 Canada Telephone: 306-966-61493 Fax: 306-966-6164 www.medicine.usask.ca

February 6, 2015 Dr. Geneviève Moineau, MD, FRCPC President and Chief Executive Officer The Association of Faculties of Medicine of Canada 265 Carling Avenue, Suite 800 Ottawa ON K1S 2E1 Dear Dr. Moineau, The University of Saskatchewan’s College of Medicine is committed to enhancing MD education to ensure today’s learners are well-prepared for the challenges of the future. The launch of the Association of Faculties of Medicine of Canada’s The Future of Medical Education in Canada (FMEC) report ushered in an era of change at the University of Saskatchewan’s College of Medicine. From the beginning of the FMEC report’s release in early 2010, our college saw the ten Recommendations and five Enabling Recommendations as presenting great opportunities; as a result, the document sparked a period of intensive self-reflection, self-evaluation, research, discussion and debate amongst our faculty, students and staff. Since the release of the FMEC report, our college has examined and discussed the ideas presented in the FMEC document within a Saskatchewan context. In order to fully explore the recommendations and examine how best to incorporate the recommendations in the Saskatchewan context, a college leader was assigned to champion each Recommendation and Enabling Recommendation. Working groups were created to help each champion examine the recommendations and offer ideas and strategies for change at the college. The intention in creating a University of Saskatchewan response was to provide a series of strategies to guide our medical education work going forward, and to demonstrate the College of Medicine’s ongoing commitment to offering medical education of the highest standard. During a period of more than eight months, the champions analyzed the FMEC Recommendations in a variety of ways, including engaging in discussions with working group members and conducting surveys, focus groups, environmental scans and literature reviews. Following many meetings, stakeholder consultations and a significant amount of research, our college responded to the FMEC recommendations with our own report, entitled MD Education at the University of Saskatchewan’s College of Medicine: Looking to the Future. The document is attached. From the beginning, it was evident our Saskatchewan approach would be shaped by four key college priorities:

1. Expansion of Distributed Medical Education in Saskatchewan 2. Development and implementation of the undergraduate medical education 2+2 curriculum 3. Focus on inter-professional education (IPE) 4. Adapting admissions procedures

Our progress on each of these four college priorities and the relationship with the FMEC recommendations is outlined below:


Expansion of Distributed Medical Education in Saskatchewan Over the past five years, the College of Medicine has focused considerable effort on developing distributed medical education (DME) across Saskatchewan. These efforts have been essential to meeting our social accountability mandate and addressing the reforms in medical education as outlined by the FMEC recommendations. Since 2011, four new rural family medicine residency training programs have been established in La Ronge, Swift Current, North Battleford and Moose Jaw. These are in addition to existing training sites in Saskatoon, Regina and Prince Albert. Together, these seven sites now welcome 40 Family Medicine PGY1s annually. With this increased postgraduate capacity, the college has gained additional capacity within each of these site for UGME learners. For example, at the Prince Albert site, a distributed JURSI (clinical clerkship) has been established and now serves to train four UGME students. Through the expansion of DME in Saskatchewan, the college has concentrated on three of the 10 recommendations outlined in the FMEC report:

1. Address individual and community needs: to serve the people of Saskatchewan, the college must first reach the people of Saskatchewan. A distributed education model is the vehicle by which we will achieve greater connectedness to the communities we seek to serve. This includes both rural and urban populations and also encompasses meaningful engagement with under-served communities.

2. Diversify Learning Contexts: This is at the heart of a distributed model. Students are increasingly

exposed to a wide range of learning contexts with the aim they will become well-rounded physicians. While training in large, tertiary care facilities is an important aspect of medical school, it cannot be the only environment students are exposed to.

3. Value Generalism: Recognizing that generalism is foundational for all physicians, MD education must focus on broadly generalist content, including comprehensive family medicine. Moreover, family physicians and other generalists must be integral participants in all stages of MD education.

Development and implementation of the undergraduate medical education 2+2 Curriculum Following three years of preparation, a redesigned “2+2” curriculum was introduced for our undergraduate medical education students in the 2014-2015 academic year. The curriculum renewal project has two main objectives:

1. To reshape the curriculum from its current 2½ years pre-clerkship and 1½ years clerkship model to a more standard 2 years pre-clerkship and 2 years clerkship model

2. To simultaneously improve the curriculum to provide the optimum learning experience for our

undergraduate medical students. Our renewed curriculum has been designed with the FMEC recommendations in mind. Specifically, the 2+2 curriculum addresses six key areas:


1. Builds on the scientific basis of medicine: by providing solid grounding in basic biomedical sciences and the frequent use of integrated case studies to link basic and clinical science learning.

2. Promotes prevention and public health: through multiple learning opportunities within the

Medicine and Society course which runs in stages during the two pre-clinical years of training. 3. Addresses the hidden curriculum: through multiple learning opportunities with the Success in

Medical School course which runs in stages during the two pre-clinical years of training. 4. Values generalism: by focusing on a generalist approach. This has been a guiding principle

throughout the curriculum renewal process. Each course development team included at least one generalist physician.

5. Adopts a competency-based approach: The educational philosophy underlying curricular

planning continues to be learner-centered, making use of increasingly complex and relevant cases within the following broad approaches: Cooperative, Active, Self-Directed and/or Experiential learning (i.e., CASE-based). Students benefit from early and frequent patient contact and the 2+2 curriculum encompass a patient-centered approach to care.

6. Fosters medical leadership: by including discussion of CanMEDS roles throughout the

curriculum and building our formal Mentoring Program into the core curriculum. Focus on Inter-Professional Education (IPE) In 2012, the college created a new position to lead IPE. The addition of this resource has provided considerable focus to our work and resulted in several advances specific to UGME. At the U of S, each health profession college has agreed the Canadian IPE core competency document should guide our priorities in curriculum development. Specifically, the College of Medicine determined our MD graduates must be effective team members demonstrating IP competencies in six domains: Inter-professional communication; patient/client/family/community-centered care; role clarification; team functioning; collaborative leadership; inter-professional conflict resolution. These IP competencies have informed 2+2 curriculum development, programming and evaluation and are integrated throughout. In addition, time is now scheduled within the curriculum and designated for IPE. Learning objectives for the Interprofessional Problem Based Learning (iPBL) modules have been developed, and evaluation around IP competencies continues to be advanced. During the 2014-2015 academic year, iPBL modules are offered in the following topics: HIV/AIDs; Student Stress and Wellness; Palliative Care; Respiratory Illness – A One Health Perspective; and First Nation Health. The module on Palliative Care included approximately 340 students (UGME, Physical Therapy, Nursing, Nutrition, Pharmacy, Social Work) and many tutors. Data for iPBL student involvement for 2014 showed 1324 students were involved in these activities including 324 UGME students. IPE Faculty development has been supported through tutor training workshops (3x/yr) led by faculty from Medicine, PT and Pharmacy/Nutrition.


Admissions Several changes to our admissions process have been implemented since 2010, with the FMEC recommendation to enhance admissions processes as a guiding principle. Specifically, our college has focused on assessing non-cognitive abilities, encouraging diversity, and fostering excellence in clinical research. For the incoming class in 2015, the college will require a four-year baccalaureate degree as the minimum university preparation for our medical school. For the incoming class in 2016, the college will introduce the Medical College Admissions Test (MCAT) as a weighted application requirement. The four-year GPA will contribute 30% to an applicant’s overall ranking score, and MCAT score will contribute 20%. Taken together, assessment of an applicant’s cognitive abilities will comprise 50% of an applicant’s rank-order admission score. Aligning the FMEC recommendations with the Saskatchewan environment has meant we continue to assess the non-cognitive abilities of our applicants. The Admissions process continues to utilize the multiple-mini-interview (MMI) as the main process for assessment of applicants’ non-cognitive ability. For the incoming class in 2016, 50% of their rank-order admission score will be based on MMI performance. To encourage diversity, 10 percent of first-year seats are reserved for persons of Canadian Aboriginal

descent (with a preference for applicants meeting the Saskatchewan residency requirement and a

maximum of five equity seats open to out-of-province applicants of Aboriginal descent. Since 2010, the

college has admitted 45 applicants of Aboriginal ancestry to the undergraduate medical education

program.

To enhance the research mandate of the College of Medicine, the College has implemented a seven-year combined MD/PhD program. Funding is available for up to three students a year to be taken into the combined program. The PhD portion begins after the two years of preclinical studies. I hope this broad overview, together with our comprehensive Looking to the Future document will provide a sense of the University of Saskatchewan College of Medicine’s commitment to continually adapting medical education to respond to society’s evolving needs. I look forward to reading AFMC’s reflective report on our collective innovations and advances in medical education. Sincerely, Preston Smith MD, MEd, CCFP, FCFP Dean, College of Medicine University of Saskatchewan

MD Education at the University of Saskatchewan’sCollege of Medicine:

Looking to the Future September 2011

This document is an implementation plan prepared by the University of Saskatchewan’s College of Medicine following the release of the Association of Faculties of Medicine of Canada’s (AFMC) report entitled The Future of Medical Education in Canada (FMEC): A Collective Vision for MD Education.

Table of Contents

Dean’s Message 2

Project Overview 3

Response to FMEC I: Address Individual and Community Needs 5

Response to FMEC II: Enhance Admissions Processes 6

Response to FMEC III: Build on the Scientific Basis of Medicine 8

Response to FMEC IV: Promote Prevention and Public Health 10

Response to FMEC V: Address the Hidden Curriculum 13

Response to FMEC VI: Diversify Learning Contexts 15

Response to FMEC VII: Value Generalism 17

Response to FMEC VIII: Advance Inter- and Intra-Professional Practice 18

Response to FMEC IX: Adopt a Competency-Based and Flexible Approach 21

Response to FMEC X: Foster Medical Leadership 23

Response to FMEC A: Realign Accreditation Standards 25

Response to FMEC B: Build Capacity for Change 26

Response to FMEC C: Increase National Collaboration 28

Response to FMEC D: Improve the Use of Technology 30

Response to FMEC E: Enhance Faculty Development 32

Next Steps 34

Appendix A: Table of Diverse Learning Opportunities 35

Appendix B: List of College of Medicine Recommendations 39

Appendix C: Common Themes in the Recommendations 41

Acknowledgements 43

References 44

2 Looking to the Future College of Medicine • University of Saskatchewan

Dean’s Message

The launch of the Association of Faculties of Medicine of Canada’s The Future of Medical Education in Canada (FMEC) report ushered in an era of change at the University of Saskatchewan’s College of Medicine. From the beginning of the report’s release in early 2010, the College saw the ten Recommendations and five Enabling Recommendations outlined in the FMEC report as presenting great opportunities; as a result, the document sparked a period of intensive self-reflection, self-evaluation, research, discussion and debate amongst our faculty, students and staff.

After months of careful consideration, we now present the College’s response to the FMEC report. This document, entitled

MD Education at the University of Saskatchewan’s College of Medicine: Looking to the Future, demonstrates our ongoing commitment to offering medical education of the highest standard. We know that as societal and student needs change and evolve over time, so too must the College of Medicine. This implementation plan provides us with a clear path on our journey toward providing the best possible undergraduate medical education to the learners of tomorrow.

Since the release of the FMEC report, our College has examined and discussed the ideas presented in the FMEC document within a Saskatchewan context. A College leader was assigned to champion each FMEC Recommendation and Enabling Recommendation, and working groups were created to help the leaders examine the recommendations and offer ideas and strategies for change at the College. We believe this implementation plan will provide the College with significant direction now and into the future.

In the fall of 2011, the College submitted an integrated planning document to the University of Saskatchewan. The College’s FMEC implementation report was a key component of the College’s integrated plan. The ideas contained in this implementation report will help our College achieve many of the important goals outlined in the integrated plan in the short-, medium- and long-term. We wanted to identify areas that needed changing and we wanted to create a blueprint for this change. In essence, it’s not always enough to know where you’re going; you often need a roadmap to get there.

Although the FMEC chapter has been written, the story is far from over. We want to continue the dialogue around the future of medical education in Canada. We want to receive feedback from our stakeholders. We want you to participate in the evolution of undergraduate medical education at the University of Saskatchewan. As U.S. President John F. Kennedy once said, “Change is the law of life. And those who look only to the past or present are certain to miss the future.”

Dr. William AlbrittonDeanUniversity of Saskatchewan College of Medicine

University of Saskatchewan • College of Medicine Looking to the Future 3

Project Overview

FMEC at the University of Saskatchewan College of Medicine

The University of Saskatchewan’s College of Medicine is committed to enhancing MD education to ensure today’s learners are well-prepared for the challenges of the future.

“Implementing the recommendations contained in The Future of Medical Education in Canada (FMEC): A Collective Vision for MD Education will help us to meet the evolving needs of individuals and communities in Saskatchewan,” said Dr. William Albritton, Dean of the College of Medicine. “The FMEC recommendations have been examined within the context of our College. Following many meetings, stakeholder consultations and a significant amount of research, our College has responded to the FMEC recommendations with a series of strategies that will guide our work going forward into the future.”

The Association of Faculties of Medicine of Canada (AFMC) released the FMEC report in January 2010, following a Health Canada-funded study of undergraduate medical education. According to the AFMC, which represents Canada’s 17 faculties of medicine, the 30-month FMEC project “set out to conduct a thorough review of medical doctor (MD) education in Canada, assess current and future societal needs, and identify the changes needed to better align the two.” This resulted in the national launch of the FMEC report, which contains 10 Recommendations and five Enabling Recommendations that comprise the FMEC Collective Vision.

At the University of Saskatchewan’s College of Medicine, each recommendation was championed by a leader. Each leader was responsible for examining his or her FMEC recommendation within the context of the U of S and for putting forward ideas and strategies to attain the goals outlined in the AFMC’s report. In most cases, this involved forming College of Medicine working groups to discuss how the FMEC report’s objectives could be achieved. The College also hired an FMEC project coordinator, who assisted the working groups in examining the recommendations and in writing the College’s FMEC implementation report.

“It is vitally important that we align our training priorities beyond the ‘medical expert’ role to meet society’s changing needs and increasing expectations of the medical practitioner,” said Dr. Gary Linassi, Assistant Dean, Undergraduate Medical Education. “The FMEC visionary statement identifies key expanded roles and guides medical education in their development to ensure inclusion in undergraduate medical curricula across Canada.”

“The U of S College of Medicine has embraced the FMEC recommendations, which will enhance work that is currently underway in our College,” added Dr. Albritton. “Our commitment to distributed medical education and social accountability are positive steps in the right direction.”

At the University of Saskatchewan’s College of Medicine, a leader was assigned to each FMEC Recommendation. The 10 Recommendations and the leaders are as follows:

• RecommendationI:AddressIndividualandCommunityNeeds–Dr.TomSmith-Windsor

• RecommendationII:EnhanceAdmissionsProcesses–Dr.BarryZiola

• RecommendationIII:BuildontheScientificBasisofMedicine–Dr.NickOvsenek

• RecommendationIV:PromotePreventionandPublicHealth–Dr.NazeemMuhajarine

• RecommendationV:AddresstheHiddenCurriculum–Dr.PennyDavis


• RecommendationVI:DiversifyLearningContexts–Dr.WilliamAlbritton

• RecommendationVII:ValueGeneralism–Dr.GillWhite

• RecommendationVIII:AdvanceInter-andIntra-ProfessionalPractice–Dr.LizHarrison

• RecommendationIX:AdoptaCompetency-BasedandFlexibleApproach–Dr.GaryLinassi

• RecommendationX:FosterMedicalLeadership–Dr.AnuragSaxena

A leader was also assigned to each FMEC Enabling Recommendation. The five Enabling Recommendations and the leaders are as follows:

• EnablingRecommendationA:RealignAccreditationStandards–Dr.SheilaHarding

• EnablingRecommendationB:BuildCapacityforChange–Dr.MarcelD’Eon

• EnablingRecommendationC:IncreaseNationalCollaboration–Dr.SheilaHarding

• EnablingRecommendationD:ImprovetheUseofTechnology–Dr.GrantStoneham

• EnablingRecommendationE:EnhanceFacultyDevelopment–Dr.FemiOlatunbosun

Duringaperiodofmorethaneightmonths,theleadersanalyzedtheFMECRecommendationsinavariety of ways, including engaging in discussions with working group members and conducting surveys,focusgroups,environmentalscansandliteraturereviews.Eachsectionofthisreport–alsoreferredtoastheCollegeofMedicine’sFMECimplementationplan–addressesoneofthetenFMEC Recommendations or five Enabling Recommendations outlined in the AFMC’s FMEC report. In each section, the Recommendations are written in italics as they originally appeared in the AFMC’s FMEC report. These statements were the foundation upon which this report was written. In addition to the ground-breaking work of the AFMC, which conducted the first comprehensive review of undergraduate medical education in Canada since the influential 1910 Flexner report, this implementation plan would not have been possible without the many contributions of the College of Medicine FMEC leaders, the members of the working groups, and others who assisted in the research, writing and editing of this report.

While the College of Medicine’s FMEC report has now been published, the College’s work is not over. Rather, the implementation process must now begin. The FMEC leaders have suggested that an Undergraduate Medical Education (UGME) project coordinator be hired to assist in the implementation process, so that the recommendations are considered in their entirety and implementation efforts are coordinated throughout the institution. Some of the recommendations contained in this report contain similar themes; a project coordinator would ensure that such themes are addressed in a way that will have a far-reaching impact in the College.


FMEC Recommendation I:

Address Individual and Community Needs

Current StatuS

The College of Medicine is committed to incorporating social accountability into its education, researchandservice,andhasrecognizedtheroleofservice-learningforitsfacultyandstudents in fulfilling that commitment. The College supports a number of programs and initiatives that address community health needs, including Aboriginal health, primary health care, urban and rural underserved areas, gender and equity, eco-health, immigrant and refugee health and global health.

In 2011, the College of Medicine established the Division of Social Accountability to promote and support the College’s obligation to direct its Clinical activity, Advocacy, Research and Education (CARE model) to activities toward the priority health concerns of local, regional, national and internationalcommunities.Thedivisionhasalsolaunchedasocialaccountabilitye-zine,whichupdates College of Medicine stakeholders on what is happening in the area of social accountability.

Looking to the Future

1) Further identify individual and community health needs: The College of Medicine should actively seek relationships and liaise with regional health authorities, community health and epidemiologyorganizationsandtheSaskatchewanPhysicianRecruitmentAgencytofurtheridentifythe health needs of individuals and communities in the province. A paid project coordinator should be hired to assist in further strengthening these relationships. This individual could also assist in conducting needs assessments and in the development of research projects to address the identified health needs. Research groups should also be established in the College of Medicine’s five enhanced learning centres to assist with the needs assessments and with research design.

2) Foster stronger connections with Saskatchewan communities: The College of Medicine is working to develop distributed learning sites in more rural locations around the province, where students will receive the bulk of their clinical training. This will forge stronger connections between communities and the learning institution. Students will be encouraged to work with community-basedorganizationstoinvestigatelocalhealthissues.Facultysupportmustbeprovidedtolocalpreceptors to enable them to engage the community. Local preceptors should also be offered faculty development on conducting needs assessments. College of Medicine representatives should travel to communities throughout the province to learn more about the community residents’ health needs and to develop and strengthen relationships. A liaison should be identified in each community where there are learners to welcome the learners and provide them with the support they need to be successful.

3) Continue to support the Division of Social accountability: Strong support must continue for the Division of Social Accountability and its programs and learning opportunities, such as Making the Links and SWITCH (Student Wellness Initiative Toward Community Health). Students’ groups should be encouraged and supported. By implementing this recommendation and the two previous recommendations, new knowledge about individual, community and regional health needs will be generated. Practitioners and students will have a better understanding of the determinants of health in their communities. The ultimate goals of this working group are to see healthier individuals and communities and greater enthusiasm for the presence of learners in the communities.

Social responsibility and accountability are core values underpinning the roles of Canadian physicians and Faculties of Medicine. This commitment means that, both individually and collectively, physicians and faculties must respond to the diverse needs of individuals and communities throughout Canada, as well as meet international responsibilities to the global community.

College of Medicine Working group Leader: Dr. tom Smith-Windsor


FMEC Recommendation II:

Enhance Admissions Processes

Current StatuS

TheUniversityofSaskatchewan’sCollegeofMedicinerecognizestheimportanceofconsideringboth academic achievement and non-academic characteristics in selecting the students for its undergraduate program. As a result, in addition to examining the grade point average (GPA) of prospective students, the College replaced the traditional panel-style interview with the multiple mini interview (MMI) process in 2007.

The MMI is a series of short, structured interviews used to assess personal traits. The MMI was developed at McMaster University, where it was first assessed in parallel with the panel interview in 2003. There is a consensus building across Canada that the MMI is the process of choice for assessing various non-cognitive abilities, such as communication skills, commitment to helping others, and ethical and critical decision-making. At the U of S College of Medicine, the MMI comprises 65% of the admission rank score with the grade point average of an applicant’s best two full years of university comprising the remaining 35%.

In January and April 2011, the College of Medicine Faculty Council and the University Council, respectively, approved an enrolment increase at the College from 84 to 100 undergraduate medical students. Approval by the University Senate in October 2011 will lead to the first incoming class of 100 students in August 2012. As the province’s only medical school, the University of Saskatchewan’s College of Medicine strives to meet the needs of Saskatchewan citizens.ItisanticipatedthattheenrolmentincreasewillenhancephysicianretentioninSaskatchewan communities.

The College aims to be representative of the population it serves, and is committed to increasing the number of Aboriginal physicians in Saskatchewan and in Canada as part of the Aboriginal Equity Program. The College has been using a target of 10% of its undergraduate students to be of Canadian Aboriginal descent, with a preference for applicants meeting the Saskatchewan residency requirement. This is a modest goal that will be revisited as the College achieves greater success, as 15% of Saskatchewan residents are of Aboriginal ancestry, and substantially more are represented in the youth cohort. In July 2010, the College hired an Aboriginal Coordinator to work closely with First Nations and Metis students, Elders and Aboriginal communities. The Aboriginal Coordinator connects Aboriginal students with the medical education system and offers support to the students during their studies.


1) Continue to assess non-cognitive abilities: As the AFMC’s FMEC report notes, “selecting the most appropriate candidates is one of the greatest challenges in medical education.” The report also acknowledges that due to the changing nature of medical practice and of Canadian society, the need to assess non-academic characteristics is even more critical. As such, the U ofSCollegeofMedicinewillcontinuetoutilizetheMMIprocess,andwillcontinuetogiveitsignificant weight in the rank admissions score. Literature reviews and environmental scans

Given the broad range of attitudes, values, and skills required of physicians, Faculties of Medicine must enhance admissions processes to include the assessment of key values and personal characteristics of future physicians – such as communication, interpersonal and collaborative skills, and a range of professional interests – as well as cognitive abilities. In addition, in order to achieve the desired diversity in our physician workforce, Faculties of Medicine must recruit, select, and support a representative mix of medical students.

College of Medicine Working group Leader: Dr. Barry Ziola


FMEC Recommendation II:

Enhance Admissions Processes

will be conducted periodically to determine whether 1) the MMI remains the best tool for assessing non-cognitive characteristics; 2) whether there is another non-cognitive assessment tool that could be employed; and 3) whether the MMI and another non-cognitive assessment tool could be used together in a complementary manner.

2) Collect data on students’ backgrounds: The AFMC’s FMEC report notes that in Canada little progress has been made in attracting medical applicants from First Nations, Inuit, and Metis communities and from rural areas. The report states that other sociocultural and economic groups are also underrepresented. The U of S College of Medicine will continue its efforts to increase the number of Aboriginal students through the Aboriginal Equity Program and through the work of the Aboriginal Coordinator. In addition, beginning with the next admissions cycle, a questionnaire will be employed to collect data on the applicants’ backgrounds, with a focus on identifying students from rural and remote areas of the province. The University of Manitoba’s Faculty of Medicine’s Supplementary Application 2011-2012, which identifies rural background, is an example of a tool usedtogathersuchdata.Thedatacollectedafterthreetofouradmissionscycleswillbeanalyzedto determine whether an additional pipeline program is needed to increase the number of undergraduate medical students from rural and remote communities.

3) admit students with an interest in combining medical training and clinical research: As the AFMC’s FMEC report acknowledges, medical education must evolve as the role of the physician evolves. According to the report, “in a nimble and adaptable system, medical education can lay the foundation for physicians to be skilled clinicians, health scientists, researchers, and advocates for health system reform.” In order to lay this foundation, the report states, “the medical education system must be sufficiently flexible and supportive to adapt to the individual academic, professional, andpersonalcontextsoflearners–includingthosewishingtopursuecomplementarygraduatedegrees (e.g., MPH, MBA, PhD) or other advanced training concurrently.”

The U of S College of Medicine is committed to fostering excellence in clinical research. To bolster clinical research within the College, efforts are underway to initiate a robust process to admit students wishing to undertake combined MD/PhD training. Admitting students with completed MSc degrees or PhDs who also are interested in doing clinical research is concurrently being pursued.


FMEC Recommendation III:

Build on the Scientific Basis of Medicine

Current StatuS

The basic sciences are the foundation of medical education, and the College of Medicine is engaged in a number of initiatives aimed at fostering knowledge of and interest in the scientific basis of medicine. Currently, 50 undergraduate students take part in the Dean’s Summer Projects each year. For 12 weeks, undergraduate medical students participate in a research project under the supervision of a College of Medicine researcher. As a result, students gain firsthand experience in conducting research and presenting research findings. Another initiative, the student-driven Journal Club, encourages students to explore medical and scientific literature, to critically evaluate special topics and to more closely examine the topics that are of interest tothemthroughself-directedlearning.ThebasicsciencesareparticularlyemphasizedinYears 1 and 2 in several ways; examples include critical appraisal in Community Health and Epidemiology, the Form and Function Course, and integrative cases.


1) enhance basic science content in the undergraduate curricula: Members of the FMEC Recommendation III working group should work in conjunction with the College of Medicine’s curriculum committee to ensure the basic sciences are vertically integrated throughout all four years of medical school. Integrated cases should become a keystone of the renewed curriculum, and basic science content should be embedded within these cases. By teaching key physiological principles throughout the four years of medical school, and by building upon these concepts in clinical contexts, students will retain more information and graduate with a stronger scientific framework. For example, basic sciences “refresher” lectures in systems could be offered to students in Phases B and C, so that students are reminded of various scientific principles and how they can be used to solve clinical problems. The most relevant biomedical sciences content should be identified, and this should be taught to students within a contextual framework.

2) More fully develop and promote the MD-PhD Program: The current MD-PhD program should be more fully developed and promoted. Spots could be allocated within the newly expandedclasssizetothoseenrollingintheprogram.Additionalfundingcouldbeprovided to the MD-PhD students to cover the increased costs associated with studying in the combined program. Increasing the number of students enrolled in the program will ultimately lead to an increase in the amount of clinical and translational research occurring within the College of Medicine.

3) improve communication between basic science and clinical faculty: Focus groups should be facilitated with basic science and clinical instructors in an effort to examine how various courses and their content can become more complementary in nature. Researchers and clinicians could present on the same topics during an ongoing seminar series in an effort to highlight the connections between scientific concepts and clinical practice. The principles of basic sciences should be incorporated into every clinical presentation, so that clinicians and researchers are not envisioned as working within separate silos.

Given that medicine is rooted in fundamental scientific principles, both human and biological sciences must be learned in relevant and immediate clinical contexts throughout the MD education experience. In addition, as scientific inquiry provides the basis for advancing health care, research interests and skills must be developed to foster a new generation of health researchers.

College of Medicine Working group Leader: Dr. nick ovsenek


FMEC Recommendation III:

Build on the Scientific Basis of Medicine

4) enhance support of student activities: Funding for the Dean’s Summer Projects should be maintained and/or strengthened, and every student should be encouraged to participate. Faculty should support the student-driven Journal Club sessions, which are held monthly, by offering to participate in the sessions or by making presentations to the students and answering their questions. An annual research day could be developed that would involve every JURSI student working on a small research project throughout the academic year, and then presenting his or her research findings to all students and faculty in the College of Medicine at the end of the year.


FMEC Recommendation IV:

Promote Prevention and Public Health

Current StatuS

Currently, University of Saskatchewan medical students are introduced to the foundations of public health and prevention in the first year, or Phase A, covering the three separate areas of health determinants, basic epidemiology, and critical appraisal. The determinants are further examined in Phase B, focusing on the relation of health care to health inequity and the influence of specific determinants within subpopulations. Phase C provides instruction in occupational/environmental health, population health and Canada’s health system, and clinical epidemiology/preventive medicine; the principles of prevention and public health are also specifically taught in relation to infectious disease. Phase D’s exposures to prevention and public health are most clearly outlined within the six-week family medicine rotation, although social and preventive aspects of clinical care are noted to varying degrees in other rotations and may be present in less-specified formats.

Several related community-based learning opportunities, both required and optional, are present for students. Compulsory experiences include sixty hours of community agency service (Community Service Learning Program) or a two-week community exposure while in Phase A, additional community service learning as part of the Community Health and Epidemiology courses in Phases B (16 hours) and C (6 hours), and a worksite visit, also occurring in Phase C. Community factors are considered in primary care settings during the mandatory well-child and family medicine pre-clerkship experiences of Phase B and again as part of community pediatrics (3-12 hours) and family medicine (two weeks urban, four weeks rural) during Phase D. Several optional community experiences are also available as part of Phase A (Family Care Experience, KinderKare inner-city school proposal, Longitudinal Elderly Person Shadowing, immigrant health shadowing, Making the Links/Global Health Certificate), but proportionately fewer exist for PhasesB,C,andD(PREPexternship,JURSIZimbabweelective,SWITCH).Severalhealthscienceinterest groups and a student-run journal club offer additional related learning opportunities.

Looking to the Future:

1) ensure prevention and public health is integrated into the curriculum: Recurrent in the AFMC’s Best Practices in Public Health report series is the indication that medical students often find public health both uninteresting and removed from real medicine. Therefore, it is necessary to maximally integrate prevention and public health into the curriculum, specifically aiming for both multi-phase continuity and intersubject integration. According to the report series, overarching principles of this inclusion will include a commitment to quality teaching, theutilizationofclinical-populationteachingframeworks,anemphasisonreal-world/clinicalsituations, and rigorous ongoing evaluation. Manifesting these ideals, public health instruction willbewell-organized,enthusiastic,andknowledgeable,employingwell-structured,well-delivered lectures, case-based learning, community visits, guest speakers, many clinical-community examples, guided reflection, and ongoing innovation.

Inthespecificcontextofclinicalinstruction,recognizedtoolsandopportunitiesforpopulationhealthteachingwillbeutilized.Clinical-populationframeworkssuchastheUniversityofSydney’s Eight Essential CDT Questions and Stone’s integrated teaching matrix will ideally bring not only well-rounded community and preventive perspectives to the disease under study but

Promoting a healthy Canadian population requires a multifaceted approach that engages the full continuum of health and health care. Faculties of Medicine have a critical role to play in enabling this requirement and must therefore enhance the integration of prevention and public health competencies to a greater extent in the MD education curriculum.

College of Medicine Working group Leader: Dr. nazeem Muhajarine


FMEC Recommendation IV:

Promote Prevention and Public Health

will also provide students with an inclusive mental approach for future clinical situations. Public health objectives will be clearly delineated in both the clinical course syllabi and their individual lectures; reflecting this inclusion, public health content will be integrated into the evaluation of students’ learning with substantial weight. Prevention will also be integrated into clinical skill development,emphasizingprimaryprevention/healthdeterminantsinhistorytaking,secondaryprevention during physical examination practice, and tertiary prevention in patient discharge planning/follow-up.

Generating continuity across Years One and Two of the new 2 by 2 curriculum, specific public health learning objectives will be presented in a continuous, parallel community health course. Content will ideally be taught by community medicine specialists, again with excellence in teaching, connection to current clinical topics, and a strong emphasis of relevance to future clinical practice. The AFMC’s newly developed public health primer will be used to guide content and presentation as this electronic resource has been developed to meet the Medical Council of Canada’s public health learning objectives.

Additionalimportantelementswillincludequalityevaluation,arecognizedkeyfactorinpublichealth teaching renewal, and overall coordination. Evaluation will include both short-term assessment based on student/instructor feedback and student performance, as well as long-term assessment of practicing physician attitudes and behaviors. As noted in the University of Sherbrooke’s integration experience, integration is a significant undertaking and benefits from a designated coordinator throughout the process.

2) Make experiential learning opportunities a priority: Ongoing development, evaluation, and support of relevant, high quality, community-service learning opportunities should be a priority. These must be more evenly distributed throughout the curriculum, both as essential and optional experiences. Given the administrative demands around such opportunities, coupled with the community burden of similar requests from other colleges, the appointment of an inter-professional coordinator is necessary. As Phase D has no designated public health exposure, a mandatory, four-week, project-driven public health experience is proposed, similar to the University of Rochester. This rotation will focus on the development and hands-on implementation of a public health intervention to address a student-identified issue within a specific population.

3) appreciate and facilitate public health scholarship: Increasing prevention and health promotion education in the clinical teaching context should be consistent with a larger climate of increased overall academic appreciation and facilitation of public health scholarship. Firstly, prevention research requires engagement with communities, often in non-traditional forms of academic activity; as such, all scholarly efforts, including those less typical, must be validated and rewarded in terms of tenure, promotion and other forms of recognition. Faculty development enhancing personal capability to undertake such engagement should also be increased. These suggestions are based on an unprecedented and new consortium of several Canadian universities (including the University of Saskatchewan) involved in a current initiative supporting the advancement and recognition of community engaged scholarship in the academy. Secondly, the College of Medicine must continue to make community engagement itself a priority in order to facilitate the research that underpins public health teaching. An upcoming opportunity, the launch of the university’s Community-Engagement Hub, will present further potential partners from the community for engaged research in public health/prevention.


4) implement the following specific points of application: In an effort to ensure the enhancement of prevention and public health integration into the MD curriculum, the working group examining FMEC Recommendation IV suggests considering the following specific points of application:

• Differentmodalitiesofinstructioninpublichealth/preventionshouldbedeveloped,progressingfrom didactic and Internet formats for basic concepts to problem-based cases within clinical courses and related experience-based learning.

• Afoundationalcontentmixoflectures,small-group,andonlineinstructionshouldbeevaluatedfor effectiveness.

• Publichealth/communitymedicinefacultyshouldshareinclinicalteaching.

• Twoclinicalcoursesshouldbeidentifiedtopilottheintroductionofproblem-basedscenariosand to evaluate the delivery of prevention content within these scenarios.

• Afour-weekPhaseDmandatorypublichealthexperienceshouldbedeveloped.

• Asystematicevaluationoffactorsrelatedtobelow-averageLicentiateoftheMedicalCouncilofCanada (LMCC) examination performance in population health during recent years should be undertaken and used to further inform the above recommendations.

• Apublichealthintegration/inter-professionalcommunity-servicelearningcoordinatorshouldbe hired to facilitate these recommendations.


FMEC Recommendation V:

Address the Hidden Curriculum

Current StatuS

Working group members reviewed the literature available on the hidden curriculum in medicine, and during a series of meetings based on this review discussed aspects of the hidden curriculum that affected their roles within the College of Medicine. The working group was comprised of students, residents, practising physicians, faculty and a representative from the College of Physicians and Surgeons of Saskatchewan.

In June 2011, based on the discussions of the working group, a College-wide survey focusing on the hidden curriculum was distributed to stakeholders, including undergraduate students, postgraduate medical residents, graduate students, associate/assistant deans, full-time faculty members, community-based faculty members, staff members and program directors. A total of 116 people responded to the online survey (n=116). The majority (68.4 %) indicated that they have observed evidence of the hidden curriculum at the College of Medicine. The 80 respondents (n=80) that indicated they have observed evidence of the hidden curriculum at the College described how prevalent it is in the following ways: Extremely prevalent (10%); very prevalent (32.5%); prevalent (28.8%); somewhat prevalent (23.8%) and not very prevalent (5%).

Of the 116 survey respondents, the majority (69.9%) indicated the hidden curriculum is a high priority that must be addressed by Canada’s Faculties of Medicine. The majority (66.4%) also indicated that the hidden curriculum has negative effects on undergraduate medical education and student learning.

The “hidden curriculum” can be difficult to define, and the definition may vary from person to person. A total of 87 survey respondents (n=87) provided their definitions of the hidden curriculum, including the following definitions:

• AttitudesandbeliefswhichareimplicitlycommunicatedamongmembersoftheCollegeofMedicine via interactions and example-setting.

• Asetoflong-standing,unofficialrulesornormsinthemedicalprofessionthatarelearnedinformally and are often in stark contrast to the actual goals of medical education and patient-centred care.

• Unofficialbutprevalentattitudesaboutthecultureofmedicine,ethics,attitudes,andsocietal roles of being a physician.

• Thehiddencurriculumistheinformallessonsstudentsarelearningfromtheirpreceptorsand peers that the students may or may not be aware they’re learning, and preceptors and peers may not be aware they are teaching.

The hidden curriculum is a “set of influences that function at the level of organizational structure and culture,” affecting the nature of learning, professional interactions, and clinical practice. Faculties of Medicine must therefore ensure that the hidden curriculum is regularly identified and addressed by students, educators, and faculty throughout all stages of learning.

College of Medicine Working group Leader: Dr. Penny Davis



1) Provide clear and concise descriptions of the College’s declared goals, mission and vision to all members of the College community: A concern identified by the FMEC V working group is the entrenchment of negative attitudes among students, faculty and staff. There must be an explicit description of the negative and positive aspects of the hidden curriculum as experienced in the College, possibly following research conducted by a hidden curriculum task force. Clear and concise descriptions of the College’s mission and vision should be circulated to the College community at large, and comparisons between the descriptions of the hidden curriculum and the College’s declared goals must be made. Resources should be allocated to support the creation and the work of a hidden curriculum task force, and skilled staff should be asked to help identify issues and suggest ways to resolve them.

2) Develop compulsory faculty education: The FMEC V working group also identified as a concern the concentration of faculty education on teaching skills and imparting knowledge at the expense of mentoring skills. There must be development of compulsory faculty education to assist faculty in identifying knowledge and performance gaps in this area and to teach skills in changing behaviour and attitudes. Faculty must be held accountable for poor performance in this area as well as in the clinicalsphere.AwardsshouldbecreatedtorecognizethosewhoexemplifytheCollege’sdeclaredideals and goals. Increased financial and promotional rewards for longitudinal behavioural and ethical teaching should be implemented.

3) Develop a longitudinal plan to address the hidden curriculum: The working group observed that “soft” skills education seems to be concentrated in the first year of medicine, as if to suggest these skills are something to be dealt with before the “real” teaching begins. There must be a longitudinal plan to address the positive and negative aspects of the hidden curriculum at all stages of student development. The role students can play in bringing forward examples of the hidden curriculum must be respected, encouraged and supported by the College of Medicine.


FMEC Recommendation VI:

Diversify Learning Contexts

Current StatuS

A variety of diverse learning experiences are currently available to undergraduate students at the University of Saskatchewan’s College of Medicine. These learning opportunities focus on a number of different areas and themes, including inter-professionalism, urban underserved populations, rural and northern locations, global and immigrant health issues, community health, pediatrics, geriatrics and primary care. Some of the opportunities offer placements/observerships to students, and some are longitudinal in nature. Various opportunities are available throughout all four years of medical school. While the majority of the learning experiences are mandatory, many are optional and can be selected based on student interests.


1) Complete a review of available learning opportunities: The FMEC VI working group, led by Dr. Albritton, identified more than 25 diverse learning opportunities currently available to MD learners at the College of Medicine. An administrative review of these opportunities should now occur, with the intention of answering the following questions: Do the present learning opportunities and resources meet the needs of students? Are there an adequate number of opportunities, both mandatory and optional, currently available to undergraduate students throughout all four years of their medical education? Are additional learning opportunities needed and, if so, in what areas? The administrative review should be conducted by a project coordinator, in conjunction with the FMEC VI working committee and with the assistance of the Undergraduate Medical Education (UGME) office and the UGME Curriculum Committee.

2) Formalize a process for creating and implementing new learning opportunities: If theadministrativereviewidentifiesgapsinspecificareas,aprocesswillneedtobeformalizedto create and implement new diverse learning opportunities at the College. The process should be multi-phased, beginning with needs identification and ending with program evaluation and a formal decision on whether to continue with the program. The Undergraduate Curriculum Committee, Educational Support and Development (ES&D), the Department of Community Health and Epidemiology (CH&E) and the College of Medicine Budget Planning and Priorities Committee (BPP) are entities that could be involved in this process. Inter-professional learning opportunities could be identified and developed through the Council of Health Science Deans, and through collaboration with the Division of Social Accountability, the FMEC VI working group, the FMEC VIII working group examining inter-professional practice and the UGME Curriculum Committee.

3) ensure College administrative structures can support a range of diverse learning opportunities: While new and innovative ideas are always welcome at the College of Medicine, as the AFMC’s FMEC report acknowledges, diverse learning contexts come with both benefits and “inherent challenges.” The report cites distributed and community-based education models as examples, since they “must be accompanied by appropriate faculty development supports and the identification of willing preceptors.” In addition, the report notes that when the number of diverse learning contexts is expanded, “the need to achieve learning objectives and assure quality of education must not be forgotten.” The College must ensure it is offering high-quality learning opportunities to all undergraduate medical students that focus on a wide variety of

Canadian physicians practise in a wide range of institutional and community settings while providing the continuum of medical care. In order to prepare physicians for these realities, Faculties of Medicine must provide learning experiences throughout MD education for all students in a variety of settings, ranging from small rural communities to complex tertiary health care centres.

College of Medicine Working group Leader: Dr. William albritton


areas of interest. The College must ensure adequate administrative resources are in place to support these programs, so students can participate in the best learning opportunities possible, and faculty and preceptors can have access to the resources they need to guide and enhance student learning.

4) explore interdisciplinary learning opportunities with other Colleges and Divisions: While “learning contexts” often refers to geographical locations, the University of Saskatchewan’s College of Medicine has taken a broader view of the term. Diversifying students’ learning contexts can also mean offering innovative, unique educational content that diversifies teaching and learning styles. As a result, the College of Medicine should pursue mutually beneficial partnerships and learning opportunities with other Colleges and Divisions on the University of Saskatchewan campus. While the other health sciences disciplines, including Pharmacy, Nursing, Physical Therapy, Dentistry and Veterinary Medicine, have more obvious inter-professional linkages to and relationships with the College of Medicine, broader relationships should also be pursued on campus. For example, preliminary discussions have occurred regarding possible partnerships between the College of Medicine and the Division of Fine Arts and Humanities.

It has been observed that many undergraduate medical students have a keen interest in the fine arts, particularly music, and this interest should be nurtured throughout the course of their MD education. This interest in the arts can be seen in the success of the College of Medicine’s first-year art show each year. As such, possible connections between the Division and the College should be explored. Examplesofmutuallybeneficialprojectsmayinclude,butshouldnotbelimitedto,utilizingactorsand their dramatic skills in the training of doctor-patient communication scenarios; encouraging painting with various brushes to enhance surgical skills; and further examining the innovative history of health care in Saskatchewan with the assistance of a medical historian.


FMEC Recommendation VII:

Value Generalism

Current StatuS

TheCollegeofMedicinerecognizestheimportanceofgeneralismandiscommittedtoenhancingthepresence of generalists and generalist content in its undergraduate curricula. The generalism working group has discussed a number of approaches that could help achieve these goals. For the purposes of this working group, the generalist specialties include Family Medicine, General Pediatrics, General Internal Medicine and Emergency Medicine.


1) Further involve generalists in undergraduate curriculum development: Generalists should sit on the curriculum committee and on all subcommittees, as well as on the Course Development Teams. Curricular map reviews should take place to ensure the domains of the generalist areas are identified and generalists are sought out to teach undergraduate students.

2) Further involve generalists in undergraduate teaching activities: Case studies focusing on generalist content should be developed with the participation of generalists and should be taught by generalists. The number of integrated case studies developed by generalists should be expanded (for example, chronic diseases, chronic disease management and developmental system topics should be areas of focus). As well, generalists should coordinate and teach undergraduate communications skills in areas such as: Doctor-patient relationships, role of uncertainty and breaking bad news.

3) increase undergraduate student exposure to generalism: Generalism guidelines should be developed in relation to admission policies at the College of Medicine. A mentorship program should be developed for first- and second-year undergraduate medical students so they have the opportunity to spend more time within generalist areas, including office situations, outpatient clinics and small group teaching activities. A two-week generalist clerkship rotation should be offered to all undergraduate medical students in areas such as palliative care, chronic disease clinics, chronic pain clinics, women’s health clinics, inner-city clinics and addictions.

4) enhance faculty development in relation to generalism: Enhanced faculty development opportunities should be offered to generalists, with teaching topic areas and mentoring high priorities.Standardsforgeneraliststoberecognizedforteachingforfurtherpromotionand/ortenureshould be developed.

5) implement a formal generalist structure in the College of Medicine: An Assistant Dean Generalism position should be created to ensure the above goals are met. Administrative assistance would also need to be provided. Generalist champions should be identified within the College of Medicine, and an oversight generalism committee or subcommittee should work on an ongoing basis with the curriculum committee to ensure generalist content is included and enhanced.

6) Develop a generalism communications strategy: A communications strategy should be developed to inform students, faculty, departments and administrators about the increased focus on generalism. The strategy should include ideas for further engaging teachers and students and should assist in addressing the following questions: What needs to be taught? How should it be taught? When should it be taught? How can faculty become engaged and participate in the initiatives described in this report?

Recognizing that generalism is foundational for all physicians, MD education must focus on broadly based generalist content, including comprehensive family medicine. Moreover, family physicians and other generalists must be integral participants in all stages of MD education.

College of Medicine Working group Leader: Dr. gill White


FMEC Recommendation VIII:

Advance Inter- and Intra-Professional Practice

Current StatuS

Health-care providers who are good collaborative practitioners understand the importance of working together with colleagues and the patient/family to achieve the best health outcomes.

To examine the above national recommendation within the context of the University of Saskatchewan’sCollegeofMedicine,aworkinggroupledbyDr.LizHarrisonwascreated.

The FMEC VIII working group included College of Medicine students, faculty and senior administrators representing interests in education, research, clinical practice, administration, community engagement and professional development. The recommendations on the next page focus on medical education with the knowledge that we must work with others to make any meaningful progress in inter-professional education (IPE).

In the process of developing the recommendations below, national and local reports were reviewed. A survey focusing on inter- and intra-professional practice was developed and sent out to all members of the College of Medicine in April 2011. Interviews with key individuals were carried out in May 2011. Faculty, students and administrators participated in the survey (n=68) and follow-up interviews (n=13).

The majority of respondents were not aware of two recent national documents defining IP competencies and IP accreditation standards. Although there were some comments related to the culture of hierarchy as a barrier to IPE, this theme was not as prevalent in the findings as one might have expected based on the AFMC’s FMEC report. There was also significant recognition of collaborative practice contributing to better patient care and health-provider satisfaction.

An inventory of IPE experiences was developed by the FMEC VIII working group based on survey information and other reports available to the committee, such as a Diverse Learning Opportunities Grid prepared by the working group examining FMEC Recommendation VI. A small number of mandatory IPE experiences currently exist in the program; however, there are also a range of elective or informal IPE activities. Student events were frequently mentioned as the primary consistent IP experiences in the College. The majority of individuals (faculty and students) commented on the very positive experiences to date with IPE. There was significant support for developing IP curriculum with patient-centred/case-based approaches frequently notedasappropriate.InbuildingIPcompetencies,itwasrecognizedthatthecompetenciesneedto be formally evaluated to ensure appropriate attention and value within the curriculum.

There was overwhelming support for the need to significantly advance IPE in the College of Medicine. Many opportunities exist that can contribute to the development of IP competencies. Although there is a need to build IPE capacity through faculty development, it was also noted that a small number of faculty members with significant expertise in IPE (teaching, research, practice) should be consulted through the next stages of curricular development to implement best practices and evidence related to IPE.

To improve collaborative, patient-centred care, MD education must reflect ongoing changes in scopes of practice and health care delivery. Faculties of Medicine must equip MD education learners with the competencies that will enable them to function effectively as part of inter- and intra-professional teams.

College of Medicine Working group Leader: Dr. Liz harrison


FMEC Recommendation VIII:

Advance Inter- and Intra-Professional Practice


1) Focus on iP competencies: All graduates of the University of Saskatchewan College of Medicine must be effective team members demonstrating IP competencies in six domains:

a. Inter-professional communication

b. Patient/client/family/community-centred care

c. Role clarification

d. Team functioning

e. Collaborative leadership

f. Inter-professional conflict resolution

These core competencies will be developed through an inter-professional curriculum with a patient-centred focus which should be integrated into the new 2+2 medical curriculum. An IPE medical lead should be appointed to work with the medical curriculum committee and other health professional programs to develop the IPE curriculum.

2) establish appropriate mechanisms and structures to support iPe: The College of Medicine must establish appropriate mechanisms within the College governance structures to ensure faculty, staff and student representation and engagement in IPE work on campus and throughout the province and country. The College of Medicine must establish appropriate College administrative structures and resources to support IPE within the program considering the work of faculty, staff and students.

Although the FMEC VIII working group is committed to continuing on as an advisory group on the implementationoftheFMECrecommendations,itisemphasizedthatthereistheneedforanewacademic IPE position (lead) to be established in the College of Medicine. The individual in this position would be responsible for IPE facilitation, communication and teaching. The committee envisions the establishment of an IPE lead for the College of Medicine as an important first step in moving ahead.

3) ensure iP duties are assigned and expectations related to iPe are clearly outlined: The Faculty Council of the College of Medicine must ensure that IPE assignment of duties, performance andscholarshipbyfacultyandstaffareclearlyidentified,rewardedandrecognizedwithinthevarious College/Department structures, including standards for promotion/tenure. The College should establish two new faculty positions to support research and scholarship related to IPE and/or collaborative practice.


4) ensure iPe resources are easily accessible to the College faculty: College of Medicine faculty must have easy access to current IPE resources (IP competencies, online resources for IPE) to support faculty development. The national documents will be used to direct and guide activities.

The FMEC VIII working group will assist with College-wide communication, evaluation and education around IPE and will monitor the progress on the recommendations contained in this report. The working group will also represent the College in activities related to IPE strategic planning with CHSD as required. As noted previously, it is important that the College of Medicine appoints an IP lead who can work with the various groups and individuals in moving ahead on the implementation of these recommendations.


FMEC Recommendation IX:

Adopt a Competency-Based and Flexible Approach

Current StatuS

As the expectations of medical professionals evolve over time, so too must medical education. The CanMEDS initiative of The Royal College of Physicians and Surgeons of Canada can be viewed as a response to changing expectations of physicians around issues of accountability and societal responsiveness. Frank and Danoff (2007) describe CanMEDS as “a national, needs-based, outcome-oriented, competency framework” that centres around seven clearly-defined physician roles: Medical Expert, Communicator, Collaborator, Manager, Health Advocate, Scholar and Professional. As Frank and Danoff write, “The CanMEDS initiative defined a framework of competencies designed to address the roles physicians have in meeting societal needs.” They posit that such frameworks “are an effective method for achieving outcomes-based education.”

The University of Saskatchewan’s College of Medicine has adopted the CanMEDS roles in its delivery of undergraduate medical education. This competency-based approach to assessing students can be seen in use in major courses such as Professional Skills I, II and III. To successfully pass Professional Skills I, for example, MD students must be proficient in the seven CanMEDS roles.Competency-basedassessmenttoolswithdescriptiveanchorsandorganizedbyCanMEDS roles have been developed for Pediatrics, Emergency Medicine and Family Medicine in Professional Skills II as well as Female Reproductive and Physical Medicine and Rehabilitation rotations in Professional Skills III. End-of-rotation assessments for mandatory clerkship rotations have been drafted and are in the approval process. The evaluation continuum for these roles includes ratings of Below Expectations, Meets Expectations, and Exceeds Expectations.


1) align course objectives with competencies: In the case of undergraduate medical education courses that will focus on a competency-based approach, the course objectives should be reexamined and rewritten to reflect the required competencies. Students must have a clear understanding of the main principles and skills upon which they will be evaluated. As Leung (2002) writes, in competency-based medical training “assessments are based on a set of clearly defined outcomes so that all parties concerned, including assessors and trainees, can make reasonably objective judgments about whether or not each trainee has achieved them.” This means the course objectives should align with the core competencies.

2) Continue to evaluate CanMeDS roles: While the CanMEDS roles have been accepted across the country, some debate continues at the University of Saskatchewan about the use of the term “Medical Expert.” According to the CanMEDS 2005 Framework, this role is defined in the following way: “As Medical Experts, physicians integrate all of the CanMEDS roles, applying medical knowledge, clinical skills, and professional attitudes in their provision of patient-centred care. Medical Expert is the central physician Role in the CanMEDS framework” (Frank and Danoff 2007).

Physicians must be able to put knowledge, skills, and professional values into practice. Therefore, in this first phase of the medical education curriculum, MD education must be based primarily on the development of core foundational competencies and complementary broad experiential learning. In addition to pre-defined curriculum requirements, MD Education must provide flexible opportunities for students to pursue individual scholarly interests in medicine.

College of Medicine Leader: Dr. gary Linassi


In recognition of the importance of generalism in medical education and practice, and in recognition of the fact that physicians benefit from ongoing continuing professional learning opportunities throughout their careers and from the values and skills brought to health-care delivery by other health sciences professionals, the term “Medical Expert” should be re-examined. Consideration should be given to replacing the term “Medical Expert” with another term, such as “Clinical Learner.”

3) Support independent learning: Undergraduate medical students should be provided with ample time to explore topics and issues of particular interest to them. Information should be provided to students about a wide variety of self-directed learning opportunities, and this independent student learning time should be valued and protected.

4) Develop a peer evaluation strategy: Physicians must work effectively to deliver health-care services within inter- and intra-professional teams. Demonstrating a high level of professionalism at all times and learning to respect others’ opinions is of crucial importance. As a result, an initiative that would see peers evaluate their counterparts on all of the CanMEDS roles, with the exception of Medical Expert, would be beneficial.


FMEC Recommendation X:

Foster Medical Leadership

Current StatuS

Leadership literature often makes a distinction between “formal” and “informal” leaders. While theformalleadersatmedicalcollegesareeasilyidentifiable–forexample,theDean,Assistant/AssociateDeans,DepartmentHeadsandhigh-leveladministrators–informalleadershipisalsoanimportantaspectoforganizationalbehaviour.Asinformalleadership,theinformalleadership role must be identified and nurtured in all students, faculty and staff. C. Dean Pielstick (2000) indicates that both formal and informal leaders develop shared visions, and this is the “touchstone theme of authentic leadership.” Pielstick states that “an important role oftheauthenticleaderistoarticulatethesharedvision,values,andbeliefsoftheorganizationrepeatedly.” This can be done by those in formal roles at the College of Medicine as well as by those occupying informal roles.

The Leaders for Life website (www.leadersforlife.ca) acknowledges the Canadian medical system is facing a variety of challenges, and “these stresses are making it clear that we must introduce significantchangesinhowhealthservicesareorganizedanddelivered.”LeadersforLifestatesthere is a “significant” number of formal leaders in the Canadian health-care system, pegging “a conservative estimate” at more than 80,000 individuals occupying formal health management roles throughout the country. However, because the demographics of these leaders are consistent with the demographics of the population at large, more potential leaders must be identified in the health professions; as Leaders for Life states in describing the health system’s leadership challenges, “little has been done to develop succession plans to effectively fill the gap.” The website also notes that “this only speaks to formal leaders,” and “if you consider that employees of all kinds may wish to play a role in leading the change, then the need for effective leadership in healthcare is very great indeed.”

Leadership will be required to transform undergraduate medical education. Leadership will be needed to ensure the FMEC recommendations are implemented. As the FMEC report notes, it is up to Faculties of Medicine to foster a variety of leadership skills in the physicians of tomorrow. This can mean preparing physicians for roles “beyond direct medical care,” such as administrative and managerial positions and involvement in “system-level advocacy for social change.”


1) Create a leadership and management development program: All undergraduate students and residents at the University of Saskatchewan’s College of Medicine should have access to a leadership and management development program. A three-tiered approach to complement students’ interests and passion is recommended. For instance, an introductory courseonleadershipshouldbeofferedtoallstudents.ThiscoursewouldutilizetheLeadersforLife LEADS Framework and would also be based on the five practices of leadership identified byBarryZ.PosnerandJamesM.Kouzes(1988):Challengingtheprocess,inspiringasharedvision, enabling others to act, modelling the way and encouraging the heart. As Leaders for Life posits, leadership is an activity, not a position: “Anyone can act as leader, regardless of the positional authority they hold. To do so they need to exercise the LEADS in a Caring Environment capabilities–thatis,fromafoundationofcaring,leadthemselves,engageothers,achieveresults, develop coalitions, and transform systems. Positive change will occur.”

Medical leadership is essential to both patient care and the broader health system. Faculties of Medicine must foster medical leadership in faculty and students, including how to manage, navigate, and help transform medical practice and the health care system in collaboration with others.

College of Medicine Working group Leader: Dr. anurag Saxena


Following the introductory course, students would have the opportunity to learn through an intermediate-level course. This course would involve personal projects, reflective essays and leadership opportunities in formal and informal roles leading to a certificate or a diploma program in the College of Medicine. For those students who are passionate about this area of study, and envision it as a personal or professional pursuit, a formal degree program offered at the University of Saskatchewan or another post-secondary institution should be offered and/or encouraged.

2) integrate leadership into the undergraduate medical curriculum: Leadership development should be formally and strategically integrated into the new 2+2 MD curriculum. Any new leadership courses that are developed should be based upon the two frameworks identified above: LEADS and PosnerandKouzes’fivepracticesofleadership.Allstudentleadershipprojectsshouldbelinkedtothe Medical Expert (ME) competency and other CanMEDS roles, such as Communicator, Collaborator, Manager, Health Advocate, Scholar and Professional. Students’ leadership competencies, including knowledge, attitudes, skills and behaviours, should be assessed by using appropriate tools. Inter-professionallearningopportunitiesshouldbeutilizedsothatleadershipisdevelopedinateamsetting to reflect the changing paradigms of health-care delivery.

3) Model leadership throughout the College: Faculty should be actively engaged in modelling leadership to other faculty members, staff and students. To help develop leadership skills amongst faculty members, leadership workshops should be offered regularly throughout the academic year to all those who are interested in attending. Students should be provided with opportunities to shadow leaders and develop mentor-mentee relationships, and they should be encouraged to play formal and informal roles in health care, medical education and community-based leadership. To ensure that the learning around leadership in the early undergraduate years (years 1 and 2) is not lost in the later undergraduate years (years 3 and 4), opportunities for leadership work and learning should continue to be provided in the later undergraduate years as well as in the post-graduate years. Student and resident leadership awards should be developed and distributed at high-profile College events,sothatleadershipisformallyrecognizedandcelebratedwithintheinstitution.


FMEC Enabling Recommendation A:

Realign Accreditation Standards

Current StatuS

The Association of Faculties of Medicine of Canada (AFMC) is the national voice of Canada’s faculties of medicine. The AFMC “manages a rigorous system of accreditation at the undergraduate levels for all 17 faculties of medicine in Canada” (www.afmc.ca). Since 1979, accreditation of undergraduate medical education in Canada has been a joint undertaking between the Committee on Accreditation of Canadian Medical Schools (CACMS), working with the Liaison Committee on Medical Education (LCME) in the U.S. This accreditation process “ensures that Canadian medical faculties’ MD programs meet the quality expected when producing tomorrow’s doctors. Medical schools demonstrating compliance are afforded accreditation, a necessary condition for a program’s graduates to be licensed as physicians” (www.afmc.ca).

In the summer of 2011, the AFMC issued a request for proposals for a medical education consultant/team. The RFP document states that the AFMC’s board of directors “seeks to critically and broadly examine the potential for the development of a Canadian accreditation process for Undergraduate Medical Education (UGME) and to create a strategic development plan, inclusive of a recommendation regarding next steps. A Canadian accreditation process would be alignedwiththeCanadianmedicalschoolcontext,andwouldallowinclusionoftheFMEC–MDrecommendations” (www.merx.com).

As a result, proposals were invited from medical education consultants/teams “who are interested in undertaking the task of both conducting the qualitative research required to determine feasibility and create the strategic business plan to be considered by AFMC. The work of the consultant must be completed by January 31, 2012” (www.merx.com).


1) Continue to monitor compliance with current accreditation standards within the context of the u of S and address any associated issues: The University of Saskatchewan College of Medicine continually strives for excellence in undergraduate medical education. Recent staff positions that have been advertised and filled at the College, including a Director of Mentorship, an Accreditation Coordinator (Phase D) and a Coordinator of Student and Resident Affairs, will further strengthen the medical school’s program and help the College to better ensure full compliance with current standards.

2) actively participate in accreditation processes with national counterparts: Several faculty members in the College of Medicine engage actively in ongoing accreditation processes throughout Canada, including participation in development activities for accreditation site survey team members. As plans and processes unfold for a made-in-Canada approach to accreditation, Dr. Sheila Harding, Associate Dean, Medical Education, will act as the liaison for the College of Medicine at the University of Saskatchewan.

Recognizing that accreditation is a powerful lever, Canadian medical leaders must review and realign existing standards of the Committee on Accreditation of Canadian Medical Schools and the Liaison Committee on Medical Education and develop new ones, as necessary, to respond to the recommendations in this report. This may involve the alignment of undergraduate and postgraduate accreditation standards.

College of Medicine Leader: Dr. Sheila harding


FMEC Enabling Recommendation B:

Build Capacity for Change

Current StatuS

Enabling change may have various meanings. It may relate to examining the formal structures of anorganization,suchascommittees,decision-makingprocessesandinternalcommunicationsstrategies, as well as looking at how to foster stronger working relationships and how to further engage stakeholders. A small working group, led by Dr. Marcel D’Eon, was created to examine what change should occur at the College of Medicine, and how such change should be facilitated.

The committee met five times during the course of its work. Three public focus groups were also held for about one hour each. A total of 15 people attended and participated in a “silent brainstorming” session. The data generated by the silent brainstorming sessions, as well as information from Harvard Business Publishing and the expertise stemming from the committee members’ backgrounds, was instrumental in crafting the recommendations below.


1) enhance communication throughout the College: A communications strategy is needed so that clear, concise and accurate information can flow within the College, as well as to external stakeholders, in a timely fashion. Internally, there needs to be improved communication and transparency of decisions, followed by the delegation of the individuals responsible for implementation. For example, the College’s Curriculum Committee has created a policy manualwheredecisionsandmotionsareorganizedbytopicareaandarelinkedbacktospecificmeetings to allow for ease of searching. Better communication and coordination between the College and members of clinical departments, faculty, staff, students and residents must occur, so that stakeholders become better informed and thus more engaged with the institution. Trust isimportanttothehealthofanorganization,andpeopleshouldbeencouragedtosharetheirknowledge, thoughts and opinions. For example, no-agenda meetings, town halls, social events and courageous conversations can help facilitate trust and improve communication.

2) review processes to strengthen leadership: Administrative processes at the College should be reviewed. For example, meetings of administrative leaders often deal with substantive issues, and time must also be allocated at such meetings to deal with processes or leadership issues; in essence, “the how” in decision-making. As well, all leaders of various capacities need to engage in sustained and effective leadership and management development activities. This could include online courses, institutes, local workshops, and regular individual and group reflection on practices. Topics for discussion could include change management, decision-making,theinformalorganization,motivationandemotionalintelligence.

3) engage and empower faculty, staff and students: As Harvard Business School Publishing has noted, change is often envisioned as something that is “done” to people, rather than something people do to themselves to become more productive; thus, stakeholder engagement in the change process is essential. Change should not be done just for the sake of changing; rather, change initiatives need to be evidence-informed and decisions should be based upon

Each Faculty of Medicine should carry out a review of its organizational systems, processes, and structures to determine and build capacity, where required, to support a constructive response to these recommendations.

College of Medicine Working group Leader: Dr. Marcel D’eon


FMEC Enabling Recommendation B:

Build Capacity for Change

good-quality data. Within the College, enhanced orientation and mentoring needs to be put in place so that new employees can become more productive and better engaged sooner in their careers. Everyindividual,inhisorherroleintheCollege,mustthinkaboutthewell-beingoftheorganizationasawhole.Aswell,thereneedstobemechanismsinplaceforpeopletobeheard–thisincludesthose who are initiating changes, those who will be affected by change and those who will live in, or implement, the changes; they may have good insights to offer.

4) hire a change management specialist to review College structures and processes: The College should consider hiring a change management specialist or human resources consultant to examineandanalyzethecurrentprocesses,proceduresandadministrativestructuresinplaceatthe institution. This individual would be responsible for producing a report and recommendations for change to ensure communication is enhanced, leadership is strengthened and faculty, staff and students are engaged and empowered at the College.


FMEC Enabling Recommendation C:

Increase National Collaboration

Current StatuS

The University of Saskatchewan’s College of Medicine is committed to sharing information and forming mutually beneficial relationships with the Association of Faculties of Medicine of Canada (AFMC) and Canada’s 16 other medical schools. The development of the AFMC’s Future of Medical Education in Canada (FMEC) project is a significant step forward in enhancing national collaboration amongst the various faculties of medicine. As the FMEC report states, “The AFMC is committed to the FMEC Collective Vision. The recommendations are crafted to be interpreted and implemented as a whole. However, each of the 17 Canadian Faculties of Medicine will embrace the recommendations in this report in its own unique way. Partnerships and collaborations among faculties with similar interests and priorities will be encouraged and facilitated as this work moves ahead.” The U of S College of Medicine will seek and participate in such collaborative relationships with its national counterparts.


1) hire a project coordinator to develop a strategic implementation plan: Since the national launch of the AFMC’s FMEC report in early 2010, the U of S College of Medicine has allocated significant resources to examining the 10 Recommendations and five Enabling Recommendations outlined in the FMEC Collective Vision. College leaders were identified to champion each of the Recommendations and Enabling Recommendations, and committees were created to assist the leaders in crafting strategic responses to the ideas described in the FMEC report. In early 2011, a project coordinator was hired to assist the FMEC leaders with administrative, project and planning support. The project leader was also responsible for producing this report, entitled MD Education at the University of Saskatchewan’s College of Medicine: Looking to the Future.

The U of S College of Medicine FMEC leaders have requested that a project coordinator be hired to assist the leaders and their committees with the important next stage of the project: formally implementing the ideas contained in this report in a strategic way in the College. The hiring of a project coordinator would help to ensure the implementation is coordinated and done within designated time frames; as well, the project coordinator would assist in enhancing national collaboration by facilitating information-sharing between the U of S College of Medicine and its counterparts across the country.

2) Continue to discuss the FMeC project with other faculties of medicine: As mentioned above, the U of S College of Medicine is committed to continuing a dialogue about its FMEC work with other medical schools. To assist in this ongoing conversation, a copy of MD Education at the University of Saskatchewan’s College of Medicine: Looking to the Future will be provided to the AFMC and to each faculty of medicine across Canada. The report will be posted on the U of S College of Medicine external website, where it can be downloaded and viewed by local, national and international audiences. FMEC leaders will continue to discuss the implementation of this report with their colleagues when they attend conferences and other events throughout the country.

Canadian Faculties of Medicine are continually innovating and have much to offer each other. Increased collaboration among schools is needed, including the sharing of teaching and learning resources, evaluation frameworks, tools for common curriculum development, innovations, and information technologies.

College of Medicine Leader: Dr. Sheila harding


FMEC Enabling Recommendation C:

Increase National Collaboration

Aswell,theUofSCollegeofMedicinewillmakethisreport–andtheshorter,individualreportsthatcompriseit–availableontheCanadianHealthcareEducationCommons(CHEC)website.AnAFCMinitiative, the CHEC’s mission “is to provide an online environment and associated commons to share education materials, designs and practices associated with healthcare education in whatever form across the continuum and between professions in Canada” (AFMC 2011).

3) Continue to celebrate u of S College of Medicine innovations and successes: The College will continue to explore partnerships and learning opportunities with its national counterparts, and will share information about learning resources, curriculum development, evaluation frameworks and other innovations on an ongoing basis. The College will also seek similar information from the 16 other faculties of medicine in an effort to increase national collaboration and cross-site learning.


FMEC Enabling Recommendation D:

Improve the Use of Technology

Current StatuS

The College of Medicine’s Information Technology Unit (ITU) was established to manage the technological needs of medical education. The ITU addresses the research, learning and teaching needs of the College of Medicine. It includes the College website, management of A/V services and videoconferencing, desktop support and administrative computing needs (databases and applications).

Two significant changes taking place at the College are expected to further increase the need for technology-related expertise and resources. The first is the increase in undergraduate enrolment from 84 to 100 students; the second is the College’s move toward creating a provincial campus through a distributed medical education (DME) model. DME is an approach that has medical students study and train in a variety of different environments, such as smaller rural facilities, as opposed to studying only at the large tertiary institutions. One key way to ensure ongoing communication, teaching and learning occurs between the distributed sites is to better utilizetechnology.


1) Provide seamless access to the internet: Seamless access to the Internet is extremely importantastheCollegemovestowardamodelofdistributedmedicaleducation.Standardizedprovincial access must be available at all of the educational sites that learners attend. While improved access to the Internet is important for undergraduate students, post-graduate students and faculty must have seamless access as well. Technologies must be applicable to all locations, and particularly adaptable to rural areas. The University of Saskatchewan network should be accessible in every health region, and every student and faculty member should have access to University resources anywhere that learning takes place.

2) Create infrastructure to support the appropriate use of technology: It is time to move the undergraduate curriculum further into the digital world. Investment in human, capital and technological resources will be needed to support this paradigm shift. Faculty development will also be a key factor in the success of this initiative. College faculty and students should be further prepared for distributed medical education through increased use of videoconferencing, social media and other distance learning tools such as Elluminate. Faculty and students at distributed learning sites may feel isolated, but tools such as Twitter study groups and journal clubs have been found to improve that experience. As well, community-based and distributed faculty members who participate in Elluminate sessions report feeling more prepared for teaching. Current technologies, such as Blackboard and One45, should continue to be examined and improved to enhance learning and teaching at the College of Medicine.

3) recognize the electronic medical record as an important tool for clinical education: There should be increased use and integration of clinical information systems, including early exposure to and the use of an electronic medical record (eMR). The eMR is the cornerstone of medical practice, and access to and the integration of the eMR should be a high priority for the College.

Based on rapid and evolving technological changes related to the way people communicate and learn, there must be increased understanding and use of technology on the part of both faculty and learners at all MD education sites.

College of Medicine Working group Leader: Dr. grant Stoneham


4) Develop policies and standards that govern the use of technology: Specific guidelines must becreatedattheCollegeastechnologicequipmentisstandardizedacrossthevarioussitesandmultiple teaching venues. There must be adequate support provided to train students, faculty and staff on the use of the technology and to develop, update and maintain technological resources.

5) improve the use of simulation for educational purposes: The College should improve and support the use of simulation for educational purposes. Simulation helps to enhance the safety and quality of medical education by providing students with a hands-on learning experience. As a result, simulation can be an important educational tool in today’s evolving learning environment. In recognition of the changing environment, the College should allocate resources to allow for some degree of experimentation with different types of technology in an effort to examine how various technologies can be applied to different educational situations and settings.

6) ensure linkages between students at various sites: As the College of Medicine continues to move toward a distributed medical education model, information technology at the College may face additional challenges and resources will be stretched. A plan should be developed that will ensure all medical students, particularly those situated at rural and remote sites, can connect with each other through the use of technology. In an effort to promote a greater degree of inter-professionalisminmedicaleducation,technologyshouldalsobeutilizedtoconnectMD learners with students in other health sciences professions. In addition, the College must ensure it can regularly connect with Saskatchewan’s Regional Health Authorities not only on patient care, but for educational issues and sessions.


FMEC Enabling Recommendation E:

Enhance Faculty Development

Current StatuS

The Faculty Affairs Office, located in the College of Medicine Dean’s Office, plays a leadership role in facilitating faculty development for university and community-based faculty at the College. The Faculty Affairs Office provides services such as assistance and guidance of appointments, promotion, tenure, leaves and salary matters; the coordination of faculty awards; and the organizationofandparticipationinfacultycareerdevelopmentplanning.

A variety of resources are currently available to faculty, including workshops and individual coaching and consultations on teaching through Educational Support and Development (ES&D); the Community Faculty Website for medical faculty who teach in clinics and hospitals in Saskatchewan; and the Medical Education Wiki, a self-directed, online course about a wide variety of medical education topics for both classroom and clinical teachers. As well, undergraduate students are introduced to the concepts of teaching as part of the professional skills course and residents participate in a two-day workshop focusing on teaching improvement project systems.

In addition to ES&D, individual departments offer faculty development sessions to their own faculty (e.g., Emergency Medicine; Family Medicine). Another resource is the faculty development provided by Continuing Professional Learning (CPL). Along with the resources on its website, CPLorganizesworkshopsonavarietyoftopics.Facultydevelopmentcoursesandworkshopsoffered by the University through the Gwenna Moss Centre for Teaching Effectiveness also serve as resources.

It should also be acknowledged that faculty development occurs informally (e.g. course instructors’ meetings). This informal faculty development can also occur while revising exam questions or developing new content (such as the Form & Function course); reading material included in Instructor packages (such as the Systems course); and while working on projects withincurriculumcommittees.Manyfacultymembersseekandutilizefacultydevelopmentresources available through other medical schools and universities and regularly participate in workshops offered as part of the conferences they attend.


1) Develop administrative infrastructure to support faculty development: A Faculty Development Office should be created that is separate from the Faculty Affairs Office to focus specifically on enhancing faculty development and offering a variety of resources that support the teaching of medical education. Under this model, the Faculty Affairs Office would be restructured and administrative infrastructure would be expanded to support and enhance facultydevelopmentattheCollegeofMedicine.Thiswouldincludethecreationofaformalizedfaculty development administrative structure, including an Assistant or Associate Dean of Faculty Development, a Director of Faculty Development and additional administrative support. Such aformalizedstructureisparticularlyimportantastheCollegefocusesondistributedmedicaleducation; due to geographical diversity, the College must ensure that faculty in rural and urban areas have access to the teaching tools they need, and are continually updated on the College’s programs, policies and resources.

Recognizing that teaching, research, and leadership are core roles for physicians, priority must be given to faculty development, support, and recognition in order to enable teachers and learners to respond effectively to the recommendations in this report.

College of Medicine Working group Leader: Dr. Femi olatunbosun


FMEC Enabling Recommendation E:

Enhance Faculty Development

2) allocate resources for instructional technologies and utilize internal communications to support faculty development: There is a need for the College to allocate appropriate resources to support faculty to adopt novel instructional technologies. Concommitantly, internal communications strategies must be developed and implemented to ensure all faculty members are aware of important College information and are informed about where and how to access the faculty development resources they need, and are continually updated on the College’s programs, policies and resources. The expanded administrative infrastructure would enhance faculty development related to activities such as enhanced orientation of new faculty, ongoing mentoring and creation of opportunities for academic advancement and academic leadership training and development. Technologyshouldalsobemorefullyutilizedtosupportfacultydevelopment;forexample,webinarsaddressing medical education topics should be made available via the Internet so that all faculty members can access them, regardless of where they are physically located in Saskatchewan. Mobile device accessibility is also important to ensure effective communication between distributed sites.

3) Foster interest in faculty development early in physicians’ careers: New and potential future faculty should be supported early in their careers to deepen their understanding of the academic mission and to help them develop successful scholarly careers. Undergraduate medical students and residents should be introduced to best practices in teaching and critical and creative thinking, and should be offered the opportunity to explore the concept of leadership within the context of medical education early in their careers. To facilitate learning at this stage, faculty development resourcesthatareindividualizedandflexibleshouldbemadereadilyavailabletoallnewfaculty,residents and undergraduates. This may include workshops aimed specifically at engaging clinical clerks and residents; interactive, online courses that can be accessed anywhere there is an Internet connection;andformalizedmentorshiprelationshipsbetweenstudents,residentsandfacultymembers. It is vitally important for faculty to have protected time for faculty development activities and be provided with incentive and recognition packages for continuing participation in faculty development programs.


The College of Medicine FMEC Project:

Next Steps

Examining the ten Recommendations and five Enabling Recommendations contained in the AFMC’s FMEC report was a significant undertaking at the University of Saskatchewan’s College of Medicine. Many people, who are acknowledged by name later in this document, contributed their time, knowledge and expertise to this project. The College wishes to sincerely thank those individuals; without their efforts, this report would not have been possible.

This report will inform much of the activity that will take place during the College’s third integrated planning cycle from 2012-2016 and beyond. The ideas contained in this report will be examined again during the third planning cycle, and decisions around resource allocation will be made through the usual collegial processes.

Many of the committee members who worked with the College’s 14 FMEC leaders on this project have expressed interest in continuing their work to enhance undergraduate medical education at the University of Saskatchewan. As such, the working groups will not be dissolved, but rather themembers’knowledgeandskillswillcontinuetobeutilizedasthereport’srecommendationsbegin to be implemented at the College. The FMEC leaders have also requested that a full-time project coordinator be hired by the College to assist the leaders and the working group members with the implementation plans. This Undergraduate Medical Education (UGME) project coordinator could also work with the members of the College’s Advancement team to communicate information about the College’s FMEC progress to students, faculty, staff, alumni and other stakeholders.

The College does not intend for this report to sit on a shelf and collect dust; rather, this document will help guide the College during the third integrated planning cycle and in the years to come.Thepublicationofthisreportisanimportantfirststepinrealizinganewvisionforundergraduate medical education at the College of Medicine.


APPENDIX A: LIST OF DIVERSE LEARNING OPPORTUNITIESUNIVerSItY OF SASKAtCHeWAN COLLeGe OF meDICINe

Program Description Category Program Phase Type

SWitCh and SearCh–AninterdisciplinaryprograminSaskatoon and Regina that extends the hours of a downtown core community health centre, offering clinical services as well as support programs for people with complex health needs

Urban Underserved

Inter-professional

Community Health

All phases of medicine with defined scopes of practice for each phase

Optional

the Family Care experience–Matchespatientsandfamilies with children with special needs with first-year medical students

Pediatric Phase A

May become longitudinal

Optional

kinderkare Proposal –First-yearmedicalstudentsvisitaninner-city classroom and to help screen and perform physical exams on kindergarten children (under supervision)

Pediatric

Primary Care

Phase A

Currently a proposal only; has funding; research design being developed

Optional

immigrant health Shadowing Project–First-yearmedicalstudents partner with newcomers to Canada to learn about the health-care system together (through a partnership with the Open Door Society)

Immigrant Health Phase A

Potentially longitudinal (if this program is expanded –2010-2011marksthefirst year this program was offered)

Optional

Making the Links Certificate in global health–Thiscertificate is modelled after the current Making the Links program, and offers a combination of classroom and experiential learning opportunities, supplemented with foreign language training and local and international practicum experiences in northern Saskatchewan, an urban underserved community at SWITCH in Saskatoon, and internationallyinMozambiqueorNicaragua

Global Health

Urban Underserved

Rural/Northern

Phase A Optional

inter-professional Community Service Learning Program (CSLP): Medicine and Pharmacy–Thisplacementopportunity gives health sciences students the opportunity to learn together about community health needs through providingservicewithcommunityorganizationsthatworkwith individuals and families for improved health. First-year students from Medicine and Pharmacy will be placed in pairs or in small teams to provide service with community organizations.Studentswillhavetheopportunitytolearntogether by providing volunteer service together and meeting periodically to reflect on what they are learning.

Interprofessional

Community Health

Placement/Observership

Primary Care

Phase A Mandatory

(Unless student selects community experience; first year course requirement under pro skills)


APPENDIX A: LIST OF DIVERSE LEARNING OPPORTUNITIES


Longitudinal elderly Person Shadowing Project (LePS)–The purpose of LEPS is for small groups of inter-professional students to get to know an older adult and learn about his/her health concerns

Geriatric

Longitudinal

Inter-professional

Phase A Optional

(Nursing also offers LEPS)

Clinical Mentoring (Professional Skills Course, Self-Directed Learning Module)–Clinicalmentorsmeettwiceper year with a group of six to eight first-year students to lead a discussion in which students reflect on what they are learning and answer questions about clinical practice (includes physicians and other health professionals)

Mentoring

Inter-professional

Phase A Mandatory

Community experience (Professional Skills Course)–Students complete a two-week observership in a rural area, a northern community or an underserved urban area. Students shadow physicians as they carry out their clinical practice. Students also have the opportunity to observe other health-care providers.


Mentoring

Rural/Remote Health

Urban Underserved

Inter-professional

Phase A Mandatory

(Unless student has opted to do the longitudinal CSLP)

Surface anatomy (Small group Sessions)–Multi-disciplinary clinicians provide clinical context to surface anatomy instruction using professional skills techniques (IPPA). These tutors come from various health-care professions–theymaybedentists,physiotherapists,etc.

Inter-professional Phase A Mandatory

Brief Clinical observerships–Studentsinfirstyearneedtocomplete a minimum number of hours observing clinicians, both physicians and non-MDs, in practice. The student arranges to shadow a clinician as he or she goes about his or her usual clinical activities. Other health professionals are also shadowed.


Primary Care

Inter-professional

Phase A and expanding into Phase B/C for the fall of 2011

Mandatory

(with minimum number of hours)

integrative Cases–Studentsdiscussaseriesofcasesdesigned to integrate what they are learning in their Systems, Clinical Sciences, and other courses, and to help students develop an approach to undifferentiated symptoms from the generalist’s perspective and to integrate the basic sciences and pathophysiology into patient care. These could easily be adapted to inter-professional discussions.

Mentorship

Inter-professional (potentially)

Phase A and B/C Mandatory

Dean’s Summer research Projects Research Phases A and B Optional

geriatric Skills Day: The Geriatric Skills Day began with a one-day skills fair. ES&D helped with the evaluation. Non-MD professionals helped teach and the students came from several different health science programs

Inter-professional Phases A, B/C Optional




inter-professional Problem-based Learning (iPBL) Modules –AlliPBLgroupsarecomprisedofstudentsfromdifferenthealthprofessional programs, working together in small groups of 9-11 students to solve a ‘case’ and facilitated by a trained tutor from one of a variety health professions. The three modules contain learning objectives pertaining to: HIV/AIDS, Palliative Care and Aboriginal Culture, Health and Healing, with each module consisting of 4-6 hours of inter-professional small group learning.

Inter-professional Phases A, B and C Mandatory

Communications Course: This is an example where other professionals teach medical students; often an MD and a non-MD are paired, with the content driven according to pre-set objectives.

Inter-professional Phases A and B/C Mandatory

Well-Child Primary Care Clinical Learning–Second-yearstudents go to a doctor’s office to practice their pediatric history-taking and physical exam skills. This offers an opportunity for students to see children with their families in a community setting, and to explore some of the factors that affect the mental and physical health of children and their families.

Pediatric

Primary Care

Phase B

Currently takes place in Saskatoon for entire academic year; will begin in Regina in January 2012

Mandatory

MeD 204.3 Community health and epidemiology–Medicalstudentspartnerwithcommunity-basedorganizations(eighthours from January to March).

Community Health

Phase B Mandatory

Proposal for restructuring of the Clinical Sciences Courses (Professional Skills ii) for fall 2011–ThecoursewillberenamedProfessional Skills II (formerly named Clinical Sciences). In clinical scenario learning sessions, students will interview and examine a volunteer patient trained to present with a non-specific problem, then will discuss potential differential diagnoses and (when relevant) management with clinician preceptors. Preceptors can be from any discipline.

Inter-professional

Mentoring

Phase B Mandatory

(To begin in fall 2011)

Family Medicine Pre-clerkship Longitudinal Clinical experience –Startinginthe2011-2012academicyear,second-yearstudents will have the opportunity to go to a clinician’s office for a half-day several times throughout the year. The goals are to help students refine their history taking and physical exam skills, to start practicing diagnostic and management skills, to see a variety of patients in a community practice and to see how patients’ communities affect their health care.


Longitudinal

Mentoring

Phase B Mandatory

(To begin in fall 2011)

PreP externship–ThePhysicianRecruitmentAgencyofSaskatchewan (PRAS) Rural Externship Program (PREP) is a collaborative initiative between the PRAS, the Saskatchewan Medical Association and the College of Medicine. Students complete a four- to twelve-week observership in a rural area or a northern community. Students shadow physicians and also have the opportunity to observe other health-care providers. One of the main goals of PREP is to be a continuation of the Community Experience, which would give an opportunity to build strong connections among the students/physicians/communities.


Mentoring

Rural/Remote Health

Inter-professional

Phase B Optional




MeD 301.3: Community health & epidemiology–Thiscoursecovers three major subject areas: Occupational Health and Environmental Health, Population Health and Canada’s Health Care System, and Clinical Epidemiology and Preventive Medicine. A variety of teaching methods are employed, including lectures, web-based material, seminars, debates and community visits.

Community Health

Phase C Mandatory

MeD 304.1 Clinical Sciences –Thiscourseallowsstudentsto refine their basic clinical skills and to become increasingly proficient at establishing diagnoses and planning therapeutic intervention. Because of the degree of student/patient interaction during this course, the values and attitudes pertaining to the physician/patient relationship will also be stressed.


Mentoring

Phase C Mandatory

Program in Zimbabwe–SeveraloftheJURSIstudentsandFamily Medicine residents have been going to Howard Hospital inZimbabwe.Thisprogramhasnotyetbeenformalized,butthatprocess is underway.

Global Health Phases C and D Optional

JurSi rotation–Clinicalclerks(JURSIs)completeamandatorytwo-week rotation in Family Medicine in an urban/regional centre (Regina, Saskatoon, Moose Jaw or Prince Albert) and a four-week rotation in a rural centre.

Rural/Northern

Urban Placement/Observership

Mentoring

Phase D Mandatory

JurSi academic half-Day–JURSIsattendanacademichalf-daylecture/seminar series on Tuesday mornings. A range of different people present on various topics.

Inter-professional Phase D Mandatory

health training in French–TheHealthTraininginFrenchcommittee (HTiF), or Formation Sante en Francais (FSeF), aims to promote better access to health services to the minority official language community in Saskatchewan. The FSeF (HTiF) is based in the Department of Community Health and Epidemiology.

Community Health

Optional

narrative Medicine Seminars–Theseseminarsaimtomakestudents aware of the patients’ perspectives in two ways: by familiarizingstudentswithpatients’storiesoftheirexperiences,and by students reflecting on, and writing down short accounts of, their own experiences with health issues. Each seminar begins with the presentation of a selected patient story, or a presentation by invited patients, with a small group discussion. In the second half of each seminar, the students create and share short accounts of personal experiences in their own health-care practice or lives.

Inter-professional Optional


APPENDIX B: LIST OF COLLEGE OF MEDICINE RECOMMENDATIONSUNIVerSItY OF SASKAtCHeWAN COLLeGe OF meDICINe

FMeC i: address individual and Community needs1) Further identify individual and community health needs2) Foster stronger connections with Saskatchewan communities3) Continue to support the Division of Social Accountability

FMeC ii: enhance admissions Processes1) Continue to assess non-cognitive abilities2) Collect data on students’ backgrounds3) Admit students with an interest in combining medical training and clinical research

FMeC iii: Build on the Scientific Basis of Medicine1) Enhance basic science content in the undergraduate curricula2) More fully develop and promote the MD-PhD program3) Improve communication between basic science and clinical faculty4) Enhance support of student activities

FMeC iV: Promote Prevention and Public health1) Ensure prevention and public health is integrated into the curriculum2) Make experiential learning opportunities a priority3) Appreciate and facilitate public health scholarship4) Implement specific points of application

FMeC V: address the hidden Curriculum1) Provide clear and concise descriptions of the College’s declared goals, mission and vision to all members of the College community2) Develop compulsory faculty education3) Develop a longitudinal plan to address the hidden curriculum

FMeC Vi: Diversify Learning Contexts1) Complete a review of available learning opportunities2) Formalizeaprocessforcreatingandimplementingnewlearningopportunities3) Ensure College administrative structures can support a range of diverse learning opportunities4) Explore interdisciplinary learning opportunities with other Colleges and Divisions

FMeC Vii: Value generalism1) Further involve generalists in undergraduate curriculum development2) Further involve generalists in undergraduate teaching activities3) Increase undergraduate student exposure to generalism4) Enhance faculty development in relation to generalism5) Implement a formal generalist structure in the College of Medicine6) Develop a generalism communications strategy

FMeC Viii: advance inter- and intra-Professional Practice1) Focus on IP competencies2) Establish appropriate mechanisms and structures to support IPE3) Ensure IP duties are assigned and expectations related to IPE are clearly outlined4) Ensure IPE resources are easily accessible to the College faculty


APPENDIX B: LIST OF COLLEGE OF MEDICINE RECOMMENDATIONS

FMeC iX: adopt a Competency-Based and Flexible approach1) Align course objectives with competencies2) Continue to evaluate CanMEDS roles3) Support independent learning4) Develop a peer evaluation strategy

FMeC X: Foster Medical Leadership1) Create a leadership and management development program2) Integrate leadership into the undergraduate medical curriculum3) Model leadership throughout the College

enabling a: realign accreditation Standards1) Continue to monitor compliance with current accreditation standards within the context of the U of S and address any associated issues2) Actively participate in accreditation processes with national counterparts

enabling B: Build Capacity for Change1) Enhance communication throughout the College2) Review processes to strengthen leadership3) Engage and empower faculty, staff and students4) Hire a change management specialist to review College structures and processes

enabling C: increase national Collaboration1) Hire a project coordinator to develop a strategic implementation plan2) Continue to discuss the FMEC project with other faculties of medicine3) Continue to celebrate U of S College of Medicine innovations and successes

enabling D: improve the use of technology1) Provide seamless access to the Internet2) Create infrastructure to support the appropriate use of technology3) Recognizetheelectronicmedicalrecordasanimportanttoolforclinicaleducation4) Develop policies and standards that govern the use of technology5) Improve the use of simulation for educational purposes6) Ensure linkages between students at various sites

enabling e: enhance Faculty Development1) Develop administrative infrastructure to support faculty development2) Allocateresourcesforinstructionaltechnologiesandutilizeinternalcommunications to support faculty development3) Foster interest in faculty development early in physicians’ careers


APPENDIX C: RECURRING THEMES IN THE COLLEGE OF MEDICINE REPORTUNIVerSItY OF SASKAtCHeWAN COLLeGe OF meDICINe

The College of Medicine’s FMEC document was created with the intention of improving undergraduate medical education at the University of Saskatchewan, enhancing the student experience and better meetingtheneedsofMDlearners.Alloftherecommendationsinthisreportaremeanttobeanalyzedand considered in their entirety. However, it can be noted that at least six recurring themes emerge throughout the document. These are: Enhancing communication; hiring a project coordinator to assist withimplementation;exploringthepotentialforinter-professionalopportunities;recognizingtheneedforfurtherfacultydevelopment/facultyeducation;recognizingtheneedtoexamineadministrativestructuresand to develop standards and policies; and developing ways to support students and enhance the student experience.

These recurring themes, and their linkages to specific College of Medicine recommendations, are outlined below.

theMe 1: enhanCe CoMMuniCation• FMECIII:Improvecommunicationbetweenbasicscienceandclinicalfaculty• FMECV:ProvideclearandconcisedescriptionsoftheCollege’sdeclaredgoals,missionandvisiontoall members of the College community• FMECVII:Developageneralismcommunicationsstrategy• FMECB:EnhancecommunicationthroughouttheCollege• FMECE:Allocateresourcesforinstructionaltechnologiesandutilizeinternalcommunicationsto support faculty development

theMe 2: hire a ProJeCt CoorDinator• FMECI:Furtheridentifyindividualandcommunityhealthneeds• FMECIV:Implementthefollowingspecificpointsofapplication(inparticular,thesection’sfinalpoint: A public health integration/inter-professional community-service learning coordinator should be hired to facilitate these recommendations)• FMECVI:Completeareviewofavailablelearningopportunities• FMECC:Hireaprojectcoordinatortodevelopastrategicimplementationplan

theMe 3: SuPPort inter-ProFeSSionaL oPPortunitieS• FMECIV:Makeexperientiallearningopportunitiesapriority• FMECIV:Implementthefollowingspecificpointsofapplication(inparticular,thesection’sfinalpoint: A public health integration/inter-professional community-service learning coordinator should be hired to facilitate these recommendations)• FMECVI:ExploreinterdisciplinarylearningopportunitieswithotherCollegesandDivisions• FMECVIII:FocusonIPcompetencies• FMECVIII:EstablishappropriatemechanismsandstructurestosupportIPE• FMECVIII:EnsureIPdutiesareassignedandexpectationsrelatedtoIPEareclearlyoutlined• FMECVIII:EnsureIPEresourcesareeasilyaccessibletotheCollegefaculty


APPENDIX C: RECURRING THEMES IN THE COLLEGE OF MEDICINE REPORT

theMe 4: SuPPort FaCuLtY DeVeLoPMent & eDuCation• FMECV:Developcompulsoryfacultyeducation• FMECVII:Enhancefacultydevelopmentinrelationtogeneralism• FMECX:Createaleadershipandmanagementdevelopmentprogram• FMECE:Developadministrativeinfrastructuretosupportfacultydevelopment• FMECE:Allocateresourcesforinstructionaltechnologiesandutilizeinternal communications to support faculty development• FMECE:Fosterinterestinfacultydevelopmentearlyinphysicians’careers

theMe 5: eXaMine aDMiniStratiVe StruCtureS & PoLiCieS• FMECVI:Formalizeaprocessforcreatingandimplementingnewlearningopportunities• FMECVI:EnsureCollegeadministrativestructurescansupportarangeofdiverse learning opportunities• FMECVIII:EstablishappropriatemechanismsandstructurestosupportIPE• FMECB:Reviewprocessestostrengthenleadership• FMECB:HireachangemanagementspecialisttoreviewCollegestructuresandprocesses• FMECD:Developpoliciesandstandardsthatgoverntheuseoftechnology• FMECE:Developadministrativeinfrastructuretosupportfacultydevelopment

theMe 6: SuPPort StuDentS & enhanCe the StuDent eXPerienCe• FMECI:FosterstrongerconnectionswithSaskatchewancommunities• FMECIII:Enhancesupportofstudentactivities• FMECIX:Supportindependentlearning• FMECB:Engageandempowerfaculty,staffandstudents• FMECD:Ensurelinkagesbetweenstudentsatvarioussites


ACKNOWLEDGEMENTSUNIVerSItY OF SASKAtCHeWAN COLLeGe OF meDICINe

The creation of this document would not have been possible without the work of all of the stakeholders who contributed ideas and information to the report. In particular, the FMEC leaders would like to thank the following working group members and contributors for providing their time, knowledge and expertise to this project. The working groups in which the individuals below were involved are indicated in parentheses following each name.

Abbas, Maryam (III)

Arden, Leonard (VI)

Bayles, Bob (B)

Bi, Dr. Henry (III)

Billington, Dr. Rob (V)

Boklaschuk, Shannon (FMEC Project Coordinator)

Bollinger, Megan (I, VI)

Bonnycastle, Deirdre (D, E)

Bourner, Rae (B)

Brownbridge, Dr. Brian (D)

Brusky, Dr. Janna (VII)

Bryce, Dr. Rhonda (IV)

Bueckert, Sherrill (II)

Burbridge, Dr. Brent (D)

Butt, Dr. Peter (II, IV)

Campbell, Dr. David (V)

Card, Dr. Sharon (VII)

Carson, Dr. George (V)

Chandler, Dr. Chris (I)

Costa, John (D)

Courteau, Alanna (X)

Cowie, Dr. Neil (D)

Davis, Dr. Penny (V, VIII, E)

DeCoteau, Dr. John (III)

D’Eon, Dr. Marcel (VII, B)

Derdall, Dr. Kirstin (V)

Dosman, Dr. James (IV)

Druvtej, Ambati (V)

Fernuck, Lindsey

Findlater, Dr. Ross (IV)

Fink, Dr. Milo (X)

Gordon, Dr. John (III)

Gustak, Dr. Roman (X)

Harding, Dr. Sheila (A, C)

Harrison,Dr.Liz(VIII)

Hubenig, Lindsay (VIII)

Irving, Dr. Bob (I)

Jeffrey, Dr. Jodie (VIII)

Johnson, Shelley (X)

Kapusta, Dr. Peter (I, VII, D)

Karras, Dr. Bev (VI)

Kendel, Dr. Dennis (X)

Klonarakis, Dr. Jim (X)

Knox, Dr. Katherine (VIII)

Koshinsky, Dr. Justina (X)

Kuzmicz,Dr.Jennifer(E)

Linassi, Dr. Gary (IX)

Mahood, Dr. Sally (V)

Mainprize,Dr.Tom(B)

Malin, Dr. Greg (III)

McEwen, Heather (VIII)

McKague, Dr. Meredith (VI)

McKee, Dr. Nora (VIII)

McKinney, Dr. Veronica (I, VI)

McKinnon, Dr. Moira (IV)

Mehtar, Dr. Maryam (VI)

Meili, Dr. Ryan (I, IV, VIII, X, E)

Mezo-Kricsfalusy,Dr.Gabriella(VI)

Mitchell, Cheryl (IV)

Morris, Dr. Gary (D)

Muhajarine,Dr.Nazeem(IV,VI)

Mulligan, Kelly (III)

Neudorf, Dr. Cory (IV)

Olatunbosun, Dr. Femi (E)

Oleniuk, Ashley (E)

Ovsenek, Dr. Nick (III)

Paton, Gillian (VI)

Pearen, Larry (I)

Poulin, Dr. David (X)

Premkumar, Dr. Kalyani (IV, E)

Proctor, Peggy (VIII)

Qualtiere, Dr. Lou (III)

Reeder, Dr. Bruce (IV, X, B)

Reid, Dr. Dave (X)

Rye, Peter (II)

Saxena, Dr. Anurag (X, D)

Scharf, Dr. Murray (B)

Senecal, Darryl (II)

Shaw, Dr. Karen (V)

Shaw, Dr. Susan (X)

Smith, Alistair (E)

Smith, Dr. Colum (VIII)

Smith-Windsor, Dr. Tom (I, II, VI, D)

Spilchuk, Vincent (VII)

Spooner, Dr. Jim (V)

Sridhar, G. (X)

Stauffer, Dr. Ardelle (X)

Stempien, Dr. James (VII)

Stoneham, Dr. Grant (D)

Student Competencies and Assessment Sub-Committee of the Curriculum Committee

Tootoosis, Dr. Janet (E)

Ward, Dr. Heather (V, VIII)

White, Dr. Gill (VII, VIII, X, D)

Xia, Lei (X, D)

Zimmer,Roland(II)

Ziola,Dr.Barry(II)


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