Deliberative curriculum inquiry for integration in an MD curriculum: Dalhousie University's curriculum renewal process

Abstract

Background: Dalhousie University's MD Programme faced a one-year timeline for renewal of its undergraduate curriculum.

Aim: Key goals were renewed faculty engagement for ongoing quality improvement and increased collaboration across disciplines for an integrated curriculum, with the goal of preparing physicians for practice in the twenty-first century.

Methods: We engaged approximately 600 faculty members, students, staff and stakeholders external to the faculty of medicine in a process described by Harris (1993) as ‘deliberative curriculum inquiry’. Temporally overlapping and networked intraprofessional and interprofessional teams developed programme outcomes, completed environment scans of emerging content and best practices, and designed curricular units.

Results: The resulting curriculum is the product of new collaborations among faculty and exemplifies distinct forms of integration. Innovations include content and cases shared by concurrent units, foundations courses at the beginning of each year and integrative experiences at the end, and an interprofessional community health mentors programme.

Conclusion: The use of deliberative inquiry for pre-med curriculum renewal on a one-year time frame is feasible, in part through the use of technology. Ongoing structures for integration remain challenging. Although faculty collaboration fosters integration, a learner-centred lens must guide its design.

Introduction

Curricular integration is ‘the interweaving of disciplines to teach a subject from multiple perspectives’ (Muller et al. 2008). At the content level, it requires a framework shared across disciplines. At the institution level, it requires culture change: faculty must design and teach across traditional departmental and course boundaries. As Harris describes in her classic analysis, curriculum design is more than a technical task: it is an institutional process (Harris 1993). We describe here our rapid pre-clerkship curriculum renewal, which engaged a broad range of faculty members, students, staff, and stakeholders in a process described by Harris as ‘deliberative curriculum inquiry’ (Harris 1993). In the course of deliberative curriculum inquiry, multiple models of integration (Harden 2000) for the resulting curriculum emerged.

Medical schools struggle with curriculum mapping. Mapping is considered essential to curriculum planning and oversight, but by the mid-2000s, only 20% of surveyed medical schools in the United Kingdom and Canada had completed curriculum maps (Harden 2001; Willett 2008). The process of designing a curriculum via objectives is both ‘top-down’ and learner-centred, as described in Wiggins and McTighe's ‘understanding by design’ framework (2001). Educators focus on student outcomes of learning, asking: what lasting understandings do learners need to develop? Objectives and learning occasions are then ‘constructively aligned’ (Biggs 1996) to enable students to achieve specific knowledge, skills and attitudes, and integrate these for successful participation in the practice environment, while mapping assessment to objectives enables the programme to monitor learner achievement in relation to programme goals. The resulting ‘map’ of a curriculum, typically housed in a database, enables everyone involved in the curriculum to learn and teach more effectively. Curriculum planners can monitor content for its staging, and identify gaps and redundancies; individual faculty can see their contributions in relation to the whole and identify relevant skills and content students learn elsewhere in the curriculum. Students similarly have a ‘map’ of where the curriculum is taking them, and a mechanism for readily finding and relating materials via objectives. They are also introduced to the process of reflecting on their learning in relation to goals, an element of lifelong learning.

Harris (1993) describes the structural challenges that medical schools encounter when this approach, which she calls the ‘empirical analytical tradition’, meets the competing pressures of institutional life. Medical school faculty are responsible to clinical as well as research priorities; each individual may feel little ownership of the curriculum, given their small role in a complex and integrated enterprise. They may be particularly reluctant to engage in work perceived as unnecessary (Davenport et al. 2009). Mapping may be seen as a technical process of database design; the human question of aligning intraprofessional and interprofessional collaboration for common educational goals may be forgotten. As Harris describes, the institutional setting of practice, intraprofessional and interprofessional culture(s), the missions of research, patient care and policy, and departmental ownership of educational content must be negotiated and brought into ‘alignment’. Beyond the institution, the education of future physicians must prepare them to be full participants in a changing world, not only with respect to the ever-accelerating pace of scientific knowledge production, but also with respect to transformations in the physician–patient relationship fostered by the internet, calls for physician leadership within healthcare systems, the changing demographic profile and health needs of the community, rapid technological advances, and economic pressures that threaten equitable and accessible healthcare.

In 2009–2010, Dalhousie University's Faculty of Medicine faced the task of rapid renewal of a two-year case-oriented problem-stimulated problem-based learning (PBL) pre-clerkship curriculum that had not been significantly revised since its implementation 16 years earlier. The timeline was determined by accreditation results, and by plans for a distant campus. We benefited from the experience of our institution's School of Occupational Therapy in their design of a new MSc-level curriculum on an outcomes-oriented model. Their example of defining and aligning shared outcome-based learning objectives, values and beliefs to develop a framework for individual course objectives and design, and for creating an appropriate learning environment supported the model of deliberative curriculum inquiry. The School of Occupational Therapy enjoys a small, cohesive faculty and benefited from faculty release time; the Faculty of Medicine is a large, diverse community with competing priorities, and faced its task with no teaching release, though with some funding to facilitate retreats, team meetings and engagement of educational specialists.

Table

Practice points

Deliberative curriculum inquiry is feasible for forging a shared curriculum vision. Deliberative inquiry facilitates the development of an integrated curriculum. Deliberative curriculum inquiry is feasible for rapid curriculum renewal. Content integration is facilitated by faculty collaboration, but its implementation must remain student-centred. Appropriate supports must be in place for technologies, like wikis that can facilitate curriculum renewal.

Aims

Our aims for curriculum renewal included meeting the one-year timeline for launching a distributed programme, fulfilling accreditation standards, particularly around mapping, achieving better integration of basic, clinical and social/humanistic sciences, and re-engaging faculty for ongoing curriculum collaboration and quality improvement. Given that we were both clarifying responsibilities for oversight of the programme, and fostering more interprofessional and intraprofessional collaboration in the resulting integrated units, a central challenge was to be broadly inclusive while avoiding chaos.

Methods

Drawing on Schwab's work at the University of Chicago in the 1970s, Harris recommends deliberative curriculum inquiry to address such institutional challenges. In deliberative curriculum inquiry, members of purposefully constituted groups reach curriculum decisions through processes of deliberation. Deliberative inquiry has several strengths that foster effective curriculum development (Prideaux 2003). It enables a broad group to bring diverse perspectives to consider curriculum needs and how they can best be addressed, providing justification for decisions and fostering the commitment of participants. It provides a structure within which integration can be accomplished across disciplinary and professional boundaries. It allows for the explicit inclusion of the values, resources, goals and context. It can enhance the effectiveness of more linear, stepped approaches to curriculum development (e.g., Kern et al. 2009). Perhaps most significantly, it reflects the complex environment of medical education (Harris 1993).

Such a complex process also brings challenges. Diverse groups with different perspectives may need time (a rare commodity) to reach common understanding of curriculum needs. Distributed ownership of curriculum can also challenge the development of integrated curricula. Differences of approaches to methods of teaching and learning, appropriate learning environments and understanding of curriculum goals can create confusion for faculty and learners.

Our process of deliberative curriculum inquiry largely involved re-prioritization of existing resources, with the exception of an education specialist hired to support faculty in translating their commitment to outcomes-oriented design into practice. We engaged in four parallel and networked processes of overall curriculum planning (Figure 1) during the fall of 2009 and a subsequent unit design process in the winter/spring of 2010. Approximately 600 faculty, students and stakeholders participated in the renewal efforts, broadly transforming institutional culture and preparing educators to collaborate for integration. Technology was essential to facilitating collaboration and enabling rapid connection with stakeholders.

Figure 1. Parallel and networked processes.

To design programme outcomes, we held a retreat of 100 faculty members, researchers and community stakeholders who deliberated on the local context and national and international competency profiles (RCPSC 2005; GMC 2009). A small group synthesized the results of the retreat. The process of designing programme-level outcomes was documented and shared on a blog, which served as a conduit for rapid stakeholder input. The results of this process served as a touchstone for subsequent decisions.1

In a second parallel process, 20 curriculum scan groups (comprising approximately 220 members; some served on more than one group) searched the literature and networked nationally and internationally to present best practices for both content and educational approaches in important areas.2 Each group was deliberatively constructed, with a focus on integrating the necessary faculty expertise and interprofessional collaboration, including specialist and generalist physicians, other health professionals, scientists, education specialists and students.

These results fed into a Curriculum Symposium organized by a third group, where several hundred participants discussed the scan groups reports and learned about recent developments in learning theory and in the organization of clerkship. On the basis of the Curriculum Symposium, the scan group reports and ongoing appraisal of the literature, the undergraduate associate dean and educational specialists proposed the following principles as guidance: (1) a patient-centred focus that (2) supports life-long learning and (3) is learner-centred, offering (4) integrated learning experiences, (5) clearly linked to objectives/outcomes and with a (6) menu of learning formats, with (7) assessment tied to student outcomes. These guiding principles informed our unit design process and served as a checkpoint in reviewing proposed unit plans and curricular materials.

This first phase of the process ended in a smaller, deliberative curriculum retreat consisting of the core curriculum committee and a group of teaching faculty, students and stakeholders. This group of 30 participants weighed and prioritized the resulting recommendations, in light of the guiding principles and the educational outcomes, reaching agreement on core strategic decisions and prioritized recommendations by voting.3

Networking parallel processes enabled us to compress the first stage of renewal into 4 months: the retreat in early September, scan group reports completed by mid-November, the Symposium in late November and the final deliberative retreat in mid-December. This process might easily have stretched over two years or more if completed sequentially by a single group (Wiener et al. 2010). Horizontal communication between these processes and engagement of participants across multiple working groups ensured that emerging results from each process informed the other.

The shortened timeline challenged our efforts to obtain formal, systematic public input. The CanMEDS competency framework results from broad, inclusive consultation and lent legitimacy via its inclusion. Nonetheless, we wanted to build relationships with stakeholders and our local community. We engaged the public in two ways: via print and radio media, the dean solicited on-line input on the question, ‘what makes a good doctor?’. Meanwhile, we carried out a series of Community Conversations across the Maritime provinces. These served as a stakeholder check as results were emerging from our working groups.

New, topic-specific unit design teams were formed in January 2010, with approximately 100 members. These were again deliberatively formulated, including specialist and generalist physicians, clinicians and basic scientists, specialists in medical education and link persons for crosscutting subjects (anatomy, pathology, physiology and pharmacology). Some participants had already taken part in earlier stages of renewal; some were new at this point. Each unit had at least one interprofessional collaborator and a link to the Professional Competencies (ProComp) Unit for integration with the concurrent longitudinal unit in social and behavioural sciences, ethics, law and health policy. Mapping to the four programme-level educational outcomes, the groups developed learning objectives at three levels: unit (highest-level, to be attained upon completion of the unit), component (mid-level, representing the major aspects of the unit) and learning occasion levels (lectures, laboratories and tutorials). In reality, this process is iterative and ongoing, with objectives refined and clarified as learning and assessment activities are designed and revised.

The ability of the teams simultaneously to develop an integrated curriculum on a compressed timeline was supported by the ‘Curriculum Renewal Wiki’ that everyone in the institution could access and edit (Figure 2). The wiki housed planning space for each unit design team, as well as general resources, guidance and faculty development resources for all teams. During the renewal process, the written content of the wiki, which included images, schedules and videos, provided a current, live, searchable, representation of every team's content and a centralized authoritative location for the developing curriculum plans. The wiki was launched on 19 January 2010, and usage data demonstrates punctuated periods of high activity until late March, at which point there were 200 wiki viewers/editors. This highly active period was followed by a decrease in additions/edits in later months, but an increase in the number of viewers once the wiki was being utilized as a centralized resource for curriculum development.

Figure 2. Curriculum Wiki.

The Unit development process culminated in a one-day retreat in March of unit heads with clerkship directors and curriculum committee members, and the renewal process then gave way to a newly designed review cycle of the standing curriculum committees that had been implemented over the course of the year.

Results

The three strongest common themes that emerged from the community consultation process were the need for attentive communication, collaboration and humility within the medical profession. Community members indicated that our future physicians should be able to listen well; share information in an understandable manner; treat their patients, family members, staff and colleagues with respect; work effectively with others; accept and be able to admit when they do not know something or have made a mistake. Community members could see much of what they expressed reflected in the visual representation of our objectives, despite different wording. Ultimately, our community members challenged us to ensure that we continue to ‘personalize the profession of medicine’ throughout and beyond our curriculum renewal process.

Along with a patient-centred approach, the renewed pre-clerkship curriculum is case-based, with a high degree of integration among the relevant biomedical, clinical and social/humanistic sciences. The major systems-based units range from a half to a full semester in length and occupy three half-days of classroom (lecture, laboratory and tutorial) time per week. These occur alongside two longitudinal 2-year Units, Clinical Skills and ProComp, which focus respectively on clinical and communication skills and the social, behavioural, ethical, legal and organizational aspects of medicine, each occupying roughly a half-day per week. The remainder of the schedule is reserved for electives and other self-directed learning.4

Case-based and patient-centred learning, with strengthened integration

Muller et al. argue that, ‘an integrated approach to education may have important benefits for learning and retention because it facilitates contextual and applied learning, and can promote the development of the well-organized knowledge structures that underlie effective clinical reasoning’ (Muller et al. 2008). The PBL of our previous curriculum was intended as a high-level approach to integration, described by Harden's integration ladder model as the ‘top rung’ (Harden 2000): ideally, the paper patient's presenting problem frames learning in the context of an authentic practice challenge for students, who draw on any and all disciplines needed to reason to diagnosis and to propose management options. In our experience, however, the ‘PBL detective game’ detracted from attempts at patient-centredness in cases (Macleod 2011). Furthermore, PBL is known to limit transfer of knowledge because of its focus on single index cases (Eva et al. 1998). Curriculum redesign included a shift from a traditional PBL approach to case-based learning (CBL; Srinivasan et al. 2007). While CBL and PBL are informed by the same principles of discovery learning, learners in CBL have access to case narratives and learning objectives in advance of the tutorial; in tutorial, they integrate new and existing knowledge and engage in discussion to co-construct knowledge and learn deeply. They may be exposed in some weeks to multiple vignettes in a given area. A deliberate focus on the patient within a bio-psychosocial framework is achieved by cases that are detailed and authentic, in terms of content, educational resources and social perspectives, and by addressing, wherever possible, the same or closely related cases in the concurrent biomedical and the longitudinal ProComp units.

Other innovations included adding overlooked topics such as oral health, nutrition, sports and occupational medicine. Integration is supported by the ‘Foundations’ units at the beginning of each year, and integrative experiences (a Rural Week community placement in year 1 and an Integration Unit including geriatrics, oncology, and palliative care in year 2) at the end. To provide an early interprofessional experience, we implemented a community-based health mentors programme in year 1, based on the model of the Jefferson mentors (Collins et al. 2009). Interprofessional student teams interview patients in the community and learn about the experience of chronic disease and its management from the patient's perspective.

We describe below in more detail three results that demonstrate the strengths of deliberative curriculum inquiry to create shared frameworks and foster collaboration: the programme-level framework and educational approach, and two specific integrative units, the Foundations Unit, which remediates background basic science understanding and prepares students for integrated learning of basic and clinical sciences, and the longitudinal ProComp Unit, which introduces students to challenges in the practice of medicine for which we integrate ethics, law, population health, evidence-based practice, health policy, practice organization and quality improvement in the spirit of reflective practice and lifelong learning.

Programme-level educational outcomes and educational approach

The Educational Outcomes group produced a concept map diagram (Figure 3) representing programme outcomes. Consistent with Epstein and Hundert's (2002) vision of professional competence as integrative, our diagram represents the integration for professional practice of knowledge, technical skills, cognitive/reflective skills and attitudes. Visually, our concept map depicts four domains around the outside of a square: the ‘roles’ of professional, community contributor, life-long learner, and skilled clinician. Within the square are the knowledge (four overlapping scientific domains: biomedical, humanistic; epidemiological and social), skills (communication, collaboration, problem-solving, critical thinking and advocacy) and attitudinal attributes (compassionate, conscientious, reflective, curious, innovative, accountable, ethical, socially responsible and collegial) to be ‘habitually and judiciously used’ for the benefit of the patient, who stands at the centre of the diagram. The idea of the ‘square’ and its ‘sides’ quickly became a touchstone in planning.

Figure 3. Curriculum outcomes: the ‘square’.

The writing group used the concept of ‘entrustable professional activities’ (EPA) to link programme outcomes to concrete and readily grasped activities. An EPA is ‘a critical part of professional work that can be identified as a unit to be entrusted to a trainee once sufficient competence has been reached’ (ten Cate & Scheele 2007). We asked the question: ‘What should a program director be able to trust that a graduate of our program will be able to do on entering postgraduate training?’ (ten Cate et al. 2010). In our view, EPAs extend beyond narrow, delegated clinical skills, such as ‘perform an accurate history and physical’, to broad entrustable activities, such as ‘demonstrate appropriate professional attitudes and ethical commitments’. Students develop their professional behaviours as they progress through medical school, and are assessed on their behaviours as outlined in the objectives. Students must remediate breaches of professional behaviour, just as they must remediate inability to perform an accurate history. The EPAs are commitments to programme directors and patients that our graduates are ready to assume these responsibilities.

Integration: Foundations for integrating clinical and biomedical sciences

The renewed curriculum integrates the basic and clinical sciences from the beginning. This involves the longitudinal nesting or ‘infusion’ (Harden's step 4 integration) of basic sciences content (anatomy, pathology, microbiology, pharmacology and therapeutics) that was previously the focus of discipline-based units. Physicians require a strong foundation of basic science knowledge to support scientific reasoning in clinical practice, and as a framework for the assimilation of new discoveries (AAMC & HHMC 2009). One of our goals is to nurture our students’ interest and capacity to participate actively in research.

Despite recommendations that incoming students should be more evenly prepared to study medicine, Dalhousie has no course pre-requisites for admission. The 6-week Foundations Unit at the beginning of year 1 prepares students for the integration of clinical and basic science learning in the curriculum, and provides support for students to achieve core pre-medical science competencies. This unit focuses on cell and molecular biology, through lectures, case-based tutorials and electronic and self-directed learning resources to facilitate and help integrate student understanding of key concepts and principles in genomes and gene expression, proteins and enzymes, cell structure and dynamics, signal transduction and cellular fate. This is framed to prepare students for more advanced concepts in the longitudinally integrated basic science themes, providing them with an introduction to the language and central concepts of these traditional biomedical disciplines, and resources. It provides a ‘roadmap’ of how they will assimilate knowledge in the various systems units across the curriculum and prepares students for developments that are coming at an astounding pace, with an ever-increasing impact on medical practice.

Concurrently, evidence-based practice is introduced to assist students to begin to frame questions, search the literature, critically appraise retrieved information and apply their findings to patient care in conjunction with patient values and wishes. This thread continues throughout the ProComp Unit. Challenges in the evidence base, regulatory processes and resource allocation (e.g. as exemplified by the real world issues of cox-2 inhibitors, public attitudes towards vaccines, the controversy over screening mammography and the role of PSA testing for the detection of prostate cancer) are the subject of cases integrating epidemiology, ethics and health systems, in the context of physicians’ interprofessional collaboration in clinical practice.

Integration: The ProComp Unit

Ethics, law, population health and evidence-based practice had been added to the former curriculum as medical practice changed and expectations for social accountability evolved. Through the processes of deliberative curriculum inquiry, academic and clinical faculty forged new working relationships to integrate their disciplines from a practice perspective. In our systems-based biomedical units, students learn the various biomedical sciences together towards the goals of identifying and managing clinical conditions, while preparing for life-long learning and future scientific developments. Equally, we reasoned, students should approach the ethical, social, epidemiological and behavioural sciences together in the service of meeting patient needs in social context, while preparing students for life-long learning in the changing landscape of practice challenges, such as patient safety, health technology assessment, chronic disease management and end of life care. (Figure 4)

Figure 4. Integration model.

The development of the ProComp Unit involved establishing many new interdisciplinary collaborative relationships for case-writing, as well as new practices of collaboration in tutoring. Each student group has co-tutors, a physician and someone from another healthcare profession, or a non-clinical faculty member with expertise in epidemiology, population health, ethics or law. Higher education literature supports the potential of co-teaching/team-teaching in small group and other settings (Murata 2002): it provides opportunities for professional development and the establishment of a sense of community (Murata 2002), addresses higher order learning objectives (Wenger & Hornyak 1999), supports a constructivist learning environment (Anderson & Speck 1998) and allows faculty to role model collaborative relationships.

Integration of curricular content depends in part on the degree of collaboration in professional practice, and this varies between practice areas. Accordingly, in the ProComp Unit, the model of integration varies from case to case, as the following examples illustrate. ProComp focuses on diabetes in a chronic disease management framework, while the concurrent endocrinology component of the Metabolism 1 Unit focuses on acute care episodes – an example of ‘temporal coordination’, or Harden's Step 5. During an HIV/AIDS case in the Host Defense Unit, in which a university student develops AIDS while in Canada on a student visa, students learn in the block Unit about immunology and infectious disease, and in ProComp about global health and the concept of burden of disease, while revisiting and applying public health responsibilities, and being introduced to the rights of temporary residents and immigrants as patients – an example of ‘correlation’, or Harden's Step 7.

Discussion

Curriculum renewal, particularly when undertaken in an expedited manner, is necessarily iterative and complex. Engaging deliberatively in this complexity in order to renew undergraduate education led to a strong programme; however, related challenges must not be overlooked.

Our deliberative curriculum inquiry approach allowed for a multitude of stakeholders to directly participate by surfacing issues and areas of concern. Nonetheless, Reid (1978), Harris (1991, 1993) and others have argued that curriculum deliberation occurs within a context of organizational relations, and ultimately will be influenced by the relative power and experience of the deliberators.

With diffusion of ownership in a systems-based curriculum comes diffusion of responsibility, and for some basic science colleagues (anatomy, pathology and pharmacology), the challenges of collaborating across two years of systems-based units to ensure appropriate integration of objectives remains a work in progress. Integration proved easier across the two-year ProComp Unit. The small number of weekly curriculum hours this course occupied made it feasible to have one set of unit heads for design, and so its component disciplines (e.g. law, ethics) had one unit structure within which to collaborate for integration. Basic science content in need of integration faced and continues to face the challenge of keeping abreast with nine unit teams across two years of curriculum.

Our process of renewal was heavily focused on ‘integration’ with respect to basic sciences and ProComp; yet, the concept of integration is one that has received significant attention in the broader field of education. Case (1994) noted, ‘the integrative merits of any given connection depend upon the reasons for integrating’. Counterproductive or inauthentic attempts at integration are likely when the goals, assumptions and tensions underlying an innovation are not well understood. Consistent with Harris's conception of the relationship between educational engagement and institutional settings, the degree and kind of integration planned for cases depended in part on perceptions of symbolism and hierarchy, and in part on existing clinical and research collaborations. The first iteration of the Foundations Unit, for example, was crowded with claims from every science to be considered ‘foundational’ to medical practice and therefore included in these six weeks. This aim contradicted the student-centred goal of preparing students unaccustomed to integration for learning in this way. In the next iteration, we focused on cellular and molecular biology and evidence-based practice. For the ProComp Unit, existing collaborations in practice and research supported complex and integrative cases involving law, ethics, policy, sociology and evidence-based practice for topics that appear early in the curriculum, such as infectious disease, while students were not yet prepared to juggle so many new disciplines at once. From a student-centred perspective, these cases needed simplification and focus in their second iteration.

Although the use of a wiki and related technologies facilitated our renewal, the use of new technologies can lead to increased complexity (Oblinger et al. 2001), particularly when combined with the multiple perspectives characteristic of a deliberative approach. These complexities include the ongoing development and renewal of viable organizational strategies, appropriate definitions of intellectual property, suitable technological support and development, and meaningful social/professional interaction, among others.

Conclusion

Despite the challenges described above, the renewed and integrated undergraduate medical education programme at Dalhousie University, while a work in progress, has been a success. We began delivering the curriculum in September of 2010 and initial feedback from learners indicates that they are appreciating the focus on integration. Yet, in order to attain the depth of integration we originally conceptualized, it became clear that working in isolation, from a purely backwards design approach, would not allow us to address the range of issues involved with the delivery of undergraduate medical education. Facilitating contributions from stakeholders with a variety of sets of knowledge, expertise and experience led to a richer and more integrated approach. Refinement of our integration models and team approaches, and research into their effectiveness, are ongoing.

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

Notes

Notes

1. Curriculum goals and outcomes available online at: http://undergraduate.medicine.dal.ca/curriculum/goals.htm

2. Topics and reports are available online at: http://curriculum.medicine.dal.ca/practices.htm

3. Reported at http://news.medicine.dal.ca/CMTretreat.htm and http://news.medicine.dal.ca/CMTTodolist.htm

4. Diagrams representing the units and schedule are available at http://undergraduate.medicine.dal.ca/curriculum/med1.htm and http://undergraduate.medicine.dal.ca/curriculum/med2.htm