Training medical students for the twenty-first century: Rationale and development of the Utrecht curriculum “CRU+”

Abstract

Aim: The aim of this report, written for the 40th anniversary issue of Medical Teacher, is to document 20 years of development of the Utrecht undergraduate medical curriculum, as both to exhibit accountability and to inform the community of the process and choices that can be made in long-term curriculum development.

Methods: We used the SPICES model, created by Medical Teacher’s Editor Ronald Harden and colleagues in 1984.

Results: The Utrecht six-year program, now called “CRU+”, has many distinct features that were introduced, most of which are well documented. A limited selection includes

•  • A new 3+3 years Bachelor-Master structure following the EU Bologna rules leading to MD registration for cohorts of about 300.

•  • Horizontally integrated classroom teaching of basic sciences with clinical disciplines predominantly in groups of 12 and limited lectures.

•  • Mandatory knowledge retention tests, retesting the clinically relevant core knowledge from block tests of semesters one through four.

•  • Vertical integration not only linking clinical experience with background knowledge, but also exemplified by a stepwise increase in health care responsibilities throughout the curriculum.

•  • A final year focussing on growth towards the level of a primary responsible physician in a 12-week sub-internship for a limited number of patients and beds, in a chosen specialty. The student is called a semi-physician in the clerkship of this transitional year to residency.

•  • Teaching skills training for all medical graduates, an elective teaching rotation and various peer-teaching arrangements throughout the curriculum.

•  • Integrated semi-longitudinal clerkships with an assessment focus on entrustment decisions for Entrustable Professional Activities.

Conclusion: UMC Utrecht has made a continuous attempt to both develop its medical curriculum and to study and report on its development in the literature, regarding new methods found and insights derived. UMC Utrecht will remain committed to developing training to meet twenty-first century demands of medical graduates.

Introduction

In 1999, at the dawn of the twenty-first century, Utrecht University introduced its—arguably—largest medical curriculum reform in history, which goes back to the early seventeenth century. Following developments in all medical schools in the Netherlands, basically from the time when Maastricht University was founded with an innovative medical school in 1976, guided by the visionary Utrecht pediatric educator Harmen Tiddens (Klijn 2016), Utrecht University created a new medical curriculum. Utrecht was late with reforms but added new innovations in the past two decades that subsequently became examples for other schools.

The 1999 curriculum showed a philosophy and a practice aligning with much of Harden’s 25-year old SPICES model (Harden et al. 1984) in a more modern dress. It became student centered, problem-oriented, integrated, slightly more community oriented with many elective possibilities, and showed more structured clinical teaching. The undergraduate program reform led to distinct curricula, starting 1999 (a completely new curriculum), 2006 (a minor revision), and 2015–16 (a major revision).

Table

Practice points

Curriculum development appears successful if guided by both external incentives and visionary power from within. The SPICES model remains a suitable framework to describe modernization of medical education. The characteristics of the twenty-first century Utrecht program are many, including vertical integration, early clerkships, integration of clinical disciplines, and the application of Entrustable Professional Activities . If summarized in one expression, the aim of the Utrecht medical program is to educate medical professionals, ready to take up responsibilities in health care.

In the latest reform, significant new and revolutionary additions were supplemented to a curriculum that is now branded as “CRU+”, an acronym that associates the curriculum Utrecht with a superb French wine, combined with the health symbol of a cross and PLUS being explained by a Program of Longitudinality for Utrecht Students.

The program, enrolls about 300 students annually into a six-year program, which has many distinct features that were introduced over the course of two decades, the most important of which will be highlighted.

Reasons, rationales, and the process of reform

Immediate reasons to improve medical education in Utrecht were two suboptimal national reviews for accreditation (1992 and 1997) and the verdict that Utrecht “did not meet contemporary standards of medical education”, leading to a major curricular reform. After this new curriculum was introduced in 1999, a subsequent reason to adapt the curriculum in 2006 was the European Bologna Agreement forcing all the Dutch programs to reorganize in 3 + 3-year undergraduate programs (bachelor and master; ten Cate, 2007b; Patricio et al. 2012). In 2011, a new national review process applauded the Utrecht program, but pointed at some conditions to be improved. The Dean issued another reform in 2015.

While these reasons are of external regulatory nature; societal and educational developments guided the direction of curricular improvements from 1999 onwards. Educational developments, theories, and documents that have affected the preparatory thinking of curricular reform include cognitive apprenticeship theory (Collins et al.1989; Collins 2005), Lave and Wenger’s (1991) work on legitimate participation of learners in a community of practice and Vermunt’s insights about process-oriented education (Vermunt and Verloop 1999; ten Cate et al. 2004). Features of problem-based learning served as an inspiration for much of Utrecht’s small group teaching (Barrows and Tamblyn 1980; Schmidt 1983). The justification of the Utrecht case-based clinical reasoning approach in the early curriculum years (ten Cate 1994) has been extensively documented recently (ten Cate, Custers, et al. 2018). The introduction of competency-based medical education for postgraduate training, specifically the CanMEDS model (Frank and Jabbour 1996; Frank et al. 2015), has greatly affected Dutch postgraduate (Bleker et al. 2004) and undergraduate (Van Herwaarden et al. 2009) education and consequently the Utrecht program. More recently the curriculum developers were inspired by major calls to reform the medical education (Cooke et al. 2010; Frenk et al. 2010) and for more longitudinal integrated clinical training (Irby 2007).

The early process of curriculum reform, carried out as a systematic project was well documented in 2006, producing guidelines that were used for later innovations (Mulder and ten Cate 2006). The most recent innovations involved the following steps:

1. Year-long preparation for a National Review, including a critical self-evaluation report (2010–2011).

2. A site visit by a National Review Committee and its report, with a balanced judgment of the educational program (2011).

3. A decision by the Dean to explore the needs for a next curriculum generation by 2015 (2011).

4. A horizon-scanning report reviewing local, national, and international needs for the future of medical education (2012).

5. Establishment of a curriculum committee to create a blueprint for a new medical curriculum by 2015, retaining the strengths of the existing program and adding innovations as needed (2013).

6. First changes in the Bachelor program from year B1, including student selection for admission (2014–2015).

7. A pilot study to test the possibilities of integrated clerkships and a longitudinal patient panel program in year B3 (2015).

8. Knowledge retention tests introduced and the start of a new Master year M1 (2016).

9. Encouragement from a new national review committee to proceed with the intended innovations (2017).

10. All major changes implemented in years B1 through M2, modest changes in M3 (2018).

11. New curriculum CRU + fully implemented; the curriculum committee to complete its work (2019).

Innovations in the Utrecht undergraduate program

The multifaced innovations, evolved over almost two decades, are not easily captured in a brief paper. However, the framework of SPICES, as proposed by Harden et al. as early as 1984 (Harden et al. 1984), still proves extremely useful to categorize the most important innovations applied in the Utrecht curriculum of the twenty-first century.

Student-centeredness

In 1999, a new key vision on teaching and learning was constructivism, the philosophic and psychological conviction that individuals form or construct much of what they learn and understand themselves (Schunk 2012), rather than teachers doing that for them. Stimulating students to construct their own meaning and knowledge, a prototypical student-centered approach, led to the introduction of active small group education— of about 12 students per group and 24 parallel groups in cohorts of about 300—as the core method of preclinical education and a sharp decrease in lectures. While not all features of true problem-based learning are present, teachers were asked to understand and gear to learning processes (ten Cate et al. 2004); even in patient-based lectures (Borleffs et al. 2003). One specific student-centered feature is the application of peer teaching (Durning and ten Cate 2007; ten Cate 2017), both in mandatory and elective courses (ten Cate 2007a; Zijdenbos et al. 2010; ten Cate et al. 2012; ten Cate 2018). This, together with a very active role of students in curriculum development and curricular management led to an AMEE Aspire to Excellence Award for Student Engagement in 2015 (Aspire-to-Excellence n.d.).

Integration

Horizontal integration, with the focus on organ systems, clinical problems, or other foci with collaborative input of multiple disciplines, has been the standard approach in preclinical blocks or modules of 5 to 7 weeks since 1999. Since 2016, horizontal integration is being applied to clinical training, as all clerkships of year 3–5 (i.e. B3, M1, and M2) in the Utrecht program now have a length of 12 weeks, combine 3–5 clinical disciplines in a rotation and are preceded by a six-week block course delivered by the same disciplines (see Figure 1). These semi-longitudinal clerkships are to serve the purpose of continuity in patient care and supervision and follow the emerging insights that short rotational mono-disciplinary clerkships have serious shortcomings (Hirsh et al. 2007; Holmboe et al. 2011; Hudson et al. 2017).

Figure 1. Schematic representation of the “CRU+” curriculum.

Vertical integration, briefly defined as early attention to terminal objectives, has been a hallmark of development of the Utrecht program since 1999. Early clerkships, starting in bachelor year 3 (Kamalski et al. 2007) have become an important reason for students to apply for medical training in Utrecht. Vertical integration has been visually represented as a Z-shaped curriculum (ten Cate 2007b). Increasingly, vertical integration is being represented by a deliberate developmental structure to gradually increase participation in the professional community of practice through graduated responsibilities (Lave and Wenger 1991; ten Cate et al. 2004; Wijnen-Meijer, 2012). This concords with the significant 2015 innovation of introducing Entrustable Professional Activities (EPAs) in clinical clerkships (Chen et al. 2015) and a more gradual transition to postgraduate training (Jonker et al. 2017; Wijnen-Meijer et al. 2010). This vertical integration culminates in a final year of transition to postgraduate training. Students develop towards the level of a primary responsible physician in a 12-week sub-internship for a limited number of patients and beds in a chosen specialty. The student is then no longer call ‘student’ or ‘clerk’ but ‘semi-physician’.

Community

University Medical Center Utrecht, responsible for Utrecht University medical program, is not a community health care environment. While most physicians in The Netherlands do not particularly serve in remote communities with true community-based health care, awareness of the limitations of education in a specialized care environment has affected the curriculum. Family medicine is a prominent extramural primary care specialty in The Netherlands and a shift to more prominence for public health and the family doctor was envisioned in the most recent reform, particularly to serve true longitudinal attachments with their patients. This aim has not been fully reached (Mol et al. forthcoming), but a focus on patient-centered education remains a primary goal for future development.

Electives

Modern medical curricula are characterized by elective opportunities for students. Of the 360 mandatory European credit units of CRU+, 78% cover standard educational objectives and content for all students, 22% has an elective nature, comparable with one year, and one trimester of the six-year program. During the course of the program the elective component increases, culminating a final “transitional year” to residency, most of which provides choices that can be geared toward career preference development (Van den Broek et al. 2017).

Systematic clinical training

Systematic clinical training, as opposed to opportunistic experiences with little directional guidance—the clerkship model that has long been and still is prevalent in many schools, has become typical of the Utrecht clinical program since the turn of the century. This is realized through a series of features:

• General preparation for clinical education and work through extensive training in skills and communication throughout the curriculum.

• Specific preparation of all clinical rotations through a preceding six week block course

• A framework of EPAs throughout the clinical training program from year 3 (B3) to year 6 (M3). This framework is explained in a separate journal article, published in parallel.

• A portfolio for reflection and documentation of progress; until 2016 in a physical form and since 2016 in an electronic form.

• Assessment focused on entrustment decisions related to level of supervision.

• Regular short observations with a brief report including narrative feedback.

• Assessment of professionalism in all clerkships.

• Regular case discussions, framed as entrustment-based discussions (ten Cate and Hoff 2017).

• A gradual increase of responsibility in patient care.

Single-discipline clerkships have been abandoned for years B3 through M2. The semi-longitudinal integrated clerkships force disciplines to communicate about individual student progress and collectively contribute to a final clerkship assessment.

Additional innovations

The SPICES acronym does not capture all innovations that were realized in this period. The Dutch national weighted lottery system was replaced by a local qualitative selection procedure in 2014. Education technology was boosted at University Medical Center (UMC) Utrecht by a multi-million investment from 2012 until 2017, which led to the creation of numerous web lectures, e-learning modules, electronic testing, blended learning and flip-the-classroom approaches, simulations, e-portfolios, and other technology innovations to elevate the delivery of education (Kwant et al. 2015; Bouwmeester et al. 2016; Uijl et al. 2017). While the curriculum did not intend to expand basic science teaching, the need was felt to support the students retention of this knowledge (Weggemans et al. 2017). Mandatory retention tests (so-called CRUX tests)—basically delayed tests covering clinically relevant core knowledge from previous block courses—were introduced in the bachelor program to prepare students better for clinical training. The assessment of professional behavior during clerkships (ten Cate and de Haes 2000) and remediation if needed were strengthened. Most of these innovations would benefit from a more extensive explanation, but space restrictions do now allow for this. However, one innovation deserves to be highlighted, as we expect readers may particularly be interested in the development and implementation of Entrustable Professional Activities in the Utrecht program. A separate publication, in parallel with the current article, expands on the Utrecht EPA framework (ten Cate, Graafmans, et al. 2018).

Discussion

Overseeing these developments, two questions may raise: Are we more satisfied with our graduates? and Are our teachers more satisfied with their role and the program? As we aim to ground our training as much as feasible with validity support and publish about developments, as an attempt to serve public accountability, we investigated effects on our graduates and among faculty members.

Vertical integration was found to enhance the transition to postgraduate training (Wijnen-Meijer et al. 2009, 2010) and indications were found that graduates from a vertically integrated curriculum tended to outperform those from a non-vertically integrated program in working independently, solving medical problems, managing unfamiliar medical situations, prioritizing tasks, collaborating with other people, estimating when they need to consult their supervisors, and reflecting on their activities in the eyes of clinical supervisors in a questionnaire (Wijnen-Meijer et al. 2013), but a more objective assessment was less conclusive (Wijnen-Meijer et al. 2015).

To assess UMC Utrecht teacher motivation and work engagement we found that teachers show relatively favorable work engagement, particularly when the they experience autonomy, receive feedback, and are acknowledged for their teaching tasks, teach small groups, work with motivated students, and have adequate supporting facilities (van den Berg et al. 2013). While we do know how these feelings were before 1999, we did find a roughly similar pattern five years later (Chen 2016)

We cannot say these that these findings lead to the conclusion that the CRU+ is an end stage of development. In the first place, such conclusion would be too early. Graduates from CRU+ will enter residency at the earliest in 2019. Next, close monitoring of the curriculum will undoubtedly reveal weaknesses that must be attended to. Finally, new challenges will force faculty to stay alert. In 2018, the school set new strategic goals under the heading of “Fit for the Future”, that include policies to face student burn-out and depression, a phenomenon that becomes more prevalent among medical trainees (Mata et al. 2015; Rotenstein et al. 2016), interprofessional education, patient-centered education, diversity and international outlook, teaching of science, life-long learning, and enhanced academic career options based on excellence in teaching. UMC Utrecht will not stop setting new goals for educational development.

Notes on contributors

Olle ten Cate, PhD, is a Professor of Medical Education, Scientific Director of Education, and Senior Scientist at the Center for Research and Development of Education at University Medical Center, Utrecht, The Netherlands and was the Program Director for 1999–2003 and is the Vice-chairman of the CRU + Curriculum Committee.

Jan Borleffs, MD PhD, was the Program Director and Chair of the Curriculum Committee “CRU2006” 2003–2008 at University Medical Center, Utrecht and is the Dean of Education at University Medical Center Groningen, The Netherlands until 2018.

Marijke van Dijk, MD PhD, was the Program Director 2008–2017 and Chairman of the CRU + Curriculum Committee until 2017 at University Medical Center, Utrecht, The Netherlands.

Tineke Westerveld, MD PhD is the Program Director and Chair of the CRU + Curriculum Committee at University Medical Center, Utrecht, the Netherlands since 2017.

Acknowledgments

All four authors have subsequently served as a program director of Utrecht undergraduate medical education, in this order, from 1999 to 2017.

The authors wish to acknowledge numerous faculty members and students involved in the subsequent Utrecht curricular reforms. Space restrictions preclude us from naming all, but the following collaborators deserve to be named: Thomas Assink, Vera Batenburg, Hans Bijlsma, Ronald Bleys, Edith ter Braak, Sjoukje van den Broek, Carla Bruynzeel-Koomen, Joop Buddingh’, Jaap Buis, Gerda Croiset, Marco D’Agata, Hans van der Donk, Vivian Eijzenbach, Rik Endeman, Tom Fick, Samuel Fidder, Tanja Frakking, Joost Frenkel, Sibyl Geelen, Frans Grosfeld, Hein Gooszen, Timon van Haeften, Karlijn Hofstraat, Els de Jonge, Habo Jongsma, Bastiaan van der Klis, Kirsten Korte, Jan Koudstaal, Marjan Kromkamp, Marijke Kuyvenhoven, Margriet Leenen, Floor van Leeuwen, Sanne van den Munckhof, Hanneke Mulder, Marja Nieuwhof, Boris Peltenburg, Berent Prakken, Martien Quaak, Guy Rutten, Lieke Sanders, Patricia Schothorst, Anke Steerneman, Isabel Thunnissen, Suzanne van der Velden, Theo Voorn, Lisanne Welink, Margot Weggemans, Foppe Wiersma, Dick de Wildt, and Dorien Zwart.

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.