Abstract
Background: The introduction of competency-based curricula in institutions situated in resource-limited environments is likely to pose new challenges for the implementation process. The St. Elisabeth Hospital (SEHOS) in Curaçao, Dutch Caribbean, is affiliated to university teaching hospitals in the Netherlands. It is a teaching hospital in a resource-limited environment.
Aims: Following the revision of the curriculum of the Dutch paediatric residency training, the country's paediatric society mandated its implementation in all training institutions within Dutch sovereignty. We set out to implement the revised curriculum in SEHOS and highlight the benefits it may have in a setting like Curacao.
Method: The intended learning outcomes for the 16-week project were (1) the implementation of the core changes in the curriculum and (2) conduct an assessment of the learning environment. The strategies used included informative meetings, workshop and lecture-based trainings, questionnaire surveys, and focus group interviews.
Results: Registrars and staff were successfully trained in how to use brief clinical assessments and digital portfolios. ‘Departmental portfolio’ was introduced as an innovative method of evaluating and monitoring departmental educational activities.
Conclusions: Competency-based curricula can be successfully implemented in resource-limited environments. Educational experts in the local setting are crucial for the success of the process.
Introduction
The professional training of specialist registrars (SpRs) in the Netherlands is undergoing major reform. The country's Central College of Medical Specialists (CCMS) has recommended that the curricula of specialist training programs in the country should be revised, in order to address the growing changes in the medical profession, as well as the shifting demands for health care services in society (Framework for the Dutch Specialist Training Programs Citation2004). The rationale for this recommendation was to re-define the criteria for successful professional training; from the traditional conception that the duration of clinical exposure determines the content and quality of what learners acquire to an outcome-based training, where competencies are used to assess the amount and quality of learning that has taken place within a predefined period of time. Seven professional competencies, culled from the essential role and key competencies of specialist physicians of the Canadian Royal College of physicians and surgeons, formed the basis for this recommendation (CANMEDS Citation2005). These competencies (i.e. medical expert, communicator, collaborator, manager, health advocate, scholar and professional), were identified as mandatory requirements for the training of medical specialists in the Netherlands, and were proposed to constitute the curriculum of a new competency-oriented, training program for Dutch SpRs (Bleker et al. Citation2004). In order to facilitate this transition process, an advisory board for postgraduate curriculum development was set up to support the 27 Dutch medical societies in developing (and implementing) their respective curricula in accordance with the new guidelines. Besides their primary advisory role, the board was also responsible for disseminating best practices and new ideas among the different medical societies based on the medical educational literature and new insights from the ongoing curriculum reform process (Scheele et al. Citation2008).
In a government sponsored project (IN VIVO project 2006), the Dutch society of Paediatrics (together with the society of Obstetrics and Gynaecology) began with the formal implementation of their revised postgraduate curricula. The IN VIVO project was set up as a pilot study for the curricula reform process within the Netherlands and the aim was to gather helpful information that other medical societies could use for the successful implementation of their respective curricula.
The most notable changes in the curriculum of Dutch paediatric residency training program were the introduction of educational portfolios and new methods of evaluation that included self reflection reports, brief clinical assessments and multi-source feedback (revised curriculum for the Dutch paediatric specialist training program). The brief clinical assessment otherwise referred to as direct observation in practice (Scheele et al. Citation2008) were in training assessment methods similar to the mini-CEX described by Norcini & Burch (Citation2007). The goal of these new methods of evaluation was to ensure that the assessment and quantification of any form of learning during the SpRs’ professional training was objective and quantifiable.
Method
The St. Elisabeth hospital in Curaçao (educational context)
The St. Elisabeth Hospital (SEHOS) was established in 1855 and is the largest and oldest hospital on the Dutch Caribbean island of Curaçao. It has 430 beds and provides services in all major clinical specialties, including adult, paediatric, and neonatal intensive care. The hospital has a close professional alliance with tertiary medical institutions in the Netherlands (the universities of Groningen and Amsterdam) and provides training services for Dutch medical students and residents. The scope of its programs include accredited residency training in paediatrics and pre-residency training in, internal medicine, surgery, obstetrics and gynaecology, neurology, otolaryngology, ophthalmology, dermatology and paediatrics (Busari et al. Citation2001). The curricula of the respective training programs are catered for by the University Medical Centre Groningen (UMCG) and Academic Medical Centre Amsterdam (AMC) and implemented in line with the recommendations of the Dutch medical specialist registration body (MSRC).
Compared to the other teaching hospitals within the sovereignty of the Netherlands, the SEHOS is an example of an affiliated teaching institution in an environment where resources are limited. This is reflected by a low gross domestic product (GDP) and high perinatal mortality rate. The GDP per capita of the Netherlands Antilles is estimated at US $17.032 compared to US $36.618 in the Netherlands (IMF Citation2006). According to the World Health Organization, perinatal mortality reflects the standard of a country's obstetric and paediatric health care. (WHO Citation2006) While the perinatal mortality rate in Curaçao is slightly lower than average in the Caribbean region (23.5 vs. 31/1000), it is substantially higher when compared to countries in the North American and European regions (7 and 13/1000 respectively). Curaçao is thus a country, with a less-developed health care system. This has implications for the prioritization and distribution of its available resources (PAHO Citation2005) as well as for the successful implementation of (new) educational initiatives.
Project description
In January 2005, the UMCG initiated the implementation of the new paediatric training curriculum in all of its affiliated teaching hospitals including the SEHOS. Due to limited financial resources and the lack of an educational expert in Curaçao, the UMCG appointed an educationalist (and paediatrician) in April 2005 to coordinate the implemenation process on-site, in collaboration with the directors of the residency training programs in UMCG and SEHOS. As little was known on the constraints of implementing competency-based curriculum in resource-limited country at the time, we also investigated the feasibility of implementing the core elements of the Dutch competency-based postgraduate program in Curaçao; it being an example of an environment with limited resources.
Two central objectives formed the focus of this project. The first was to adequately implement the core changes in the curriculum of the residency program, while the second was to assess the learning environment and in particular highlight (any) additional benefits a competency-based training in an environment like Curaçao could offer. The intended outcomes that we defined for the project included:
Implementation of core changes in the Curriculum
Introduce a new process of evaluation that focuses on professional competencies of SpRs as recommended by the CCMS.
Implement a new process of evaluation using the guidelines of the Dutch pediatric society that includes the implementation of (1) Portfolios and (2) Brief clinical assessments.
Assessment of the learning environment
Highlight any additional benefits of the clinical rotation for SpRs in Curaçao compared to the Netherlands.
Identify aspects of the residency training in Curaçao that may require improvement.
Prior to commencement of the 16 week project, a number of major and specific actions were defined. These were to be applied in achieving the outcomes of the project mentioned above (see ).
Implementation of the project
The implementation process was preceded by a number of separate meetings held in the first week with different involved parties in the hospital. These included:
members of the pediatric staff;
SpRs;
director of the medical clerkship;
director of the hospital's medical services;
head of the Computer and information technology (CIT) department.
Results
Implementation of the core changes in the curriculum
At the end of the 16 week period, the department had been informed about the changes in the curriculum of the paediatric residency training, a new concept of ‘competency-based’ evaluation had been successfully introduced, and the implementation of the new methods of evaluation was initiated i.e. brief clinical assessments. A portfolio was designed based on the draft advised by the CCMS (framework for the Dutch specialist training programs). The content was modified to suit the local educational context in Curaçao and the end result was provided digitally in CD-rom format. A demonstration on how to use the CD-rom was given to both the residents and members of staff. Following the introductory meeting in the first week of the project, a second meeting was held with the SpRs in the 12th week (focus group interview). The goal was to evaluate the SpRs’ experiences with the brief clinical assessments and to address any problems they may have had with the content or use of the CD-roms for the digital portfolio. Although the SpRs were enthusiastic about the idea of the digital portfolio, they expressed dissatisfaction with the amount and frequency of the different evaluations that needed to be carried out and registered. The feedback we obtained was used to adjust the frequency of brief clinical assessments i.e. from once per month to once every two months.
Assessment of the learning environment
The results of the survey we conducted revealed that the past graduates perceived being well prepared in the 7 professional competencies through their training in Curaçao. They claimed that the training was accountable for >70% of their total professional development. The professional competency they felt best prepared in was as health advocate. The five SpRs who were currently undergoing their training in Curaçao at the time of the survey disagreed with the assertion that the training prepared them well in the 7 professional competencies. They perceived being well prepared in all, but the competencies as manager, scholar and collaborator (see ). There was no clear explanation for their disagreement from the survey although one can assume that certain external factors like the uncertainty around the continuation of the residency in Curaçao (at the time) and the perceived lack of adequate clinical supervision and educational activities e.g. grand rounds, symposia, journal clubs, were responsible for this. Still, the SpRs felt that the training accounted for about 40–50% of there professional development and that their role as medical experts was the competency best developed from the professional training. We concluded from the survey that both past en present trainees in Curaçao perceived being well prepared in the role as medical expert, however the current SpRs felt less prepared in their roles as manager, scholar, and collaborator. Based on the responses of our survey, we identified two additional competencies that required further improvement. Besides the competencies as manager, scholar and collaborator, we included the competencies health advocate and medical expert in our recommendations. These competencies were considered relevant considering the distinct nature of the educational climate in Curaçao (Busari et al. Citation2001).
General recommendations for improvement of the clinical rotation in Curaçao
As is known, the competency as medical expert is central to the SpRs function as a physician (CANMEDS Citation2005). SpRs are expected to be able to integrate the entire CANMEDS roles and apply medical knowledge, clinical skills, and professional attitudes in the provision of patient-centred care. As medical experts, SpRs should be able to demonstrate the professional skills appropriate for their individual level of training in ensuring good health care for their patients. The clinical rotation in Curaçao is an ideal educational setting for developing this competency, bearing in mind the influence the cultural climate of the community may have on this process. Expanding on this, the organizational climate and culture of a community has been found to influence the way different communities coordinate their activities (Hofstede Citation1980, Citation2001). Some of the mechanisms involved in this process have been described as power-distance (i.e. extent to which the community encourages superiors to exert power), uncertainty-avoidance, individualism (i.e. emotional dependence of individual on organization or institution) and masculinity (i.e. extent to which the culture places emphasis on performance and difference in the sexes, rather than to quality of life). Applying these descriptors to Curaçao as a community, the cultural climate reflects a large power-distance, masculinity and low individualism. This is reflected by a health care delivery system that is not well-structured, a rather paternalistic doctor-patient relationship and more autonomy resting with care providers than with the individual patient. In contrast, western communities like the Netherlands exhibit highly specialized health care systems with less evident paternalistic doctor-patient relationships and active participation of patients in clinical decision-making. Hence, in a community where patient autonomy is low and the responsibility for self is often placed in the hands of health care providers, the physician is obliged to develop good managerial and advocacy skills.
As a manager, SpRs would be expected to participate in activities that contribute to the effectiveness of their health care organization. It would entail that they are able to prioritize effectively, balance their professional and personal lives efficiently, execute tasks collaboratively with other health care providers and make systematic choices when allocating scarce healthcare resources. As health advocates, the SpRs should be able to use their expertise and influence responsibly, to advance the health and well-being of the individual patient and community. Considering the socio-demographic constitution of Curaçao, it is our view that the training in SEHOS provides a rich opportunity for the SpRs to recognize their duty and ability to achieve this. For example, the health care insurance scheme in Curaçao is run by the government as well as by private organizations. However, about 40% of the population is registered as ‘pro paupertatis’ (the less privileged) under the government-run insurance scheme. In practice, it means that a large number of patients would require the assistance of SpRs to assist them in navigating the healthcare system and access the appropriate health resources in an efficient and timely manner. For this, expert advocacy skills by the latter are necessary.
The training in Curaçao also facilitates the development of good collaborative skills. As collaborators, SpRs are expected to work effectively within health care teams characterized by professionals working closely together at one site and affiliated with other teams in multiple locations with a variety of perspectives and skills. Since the health care system in Curaçao is less well-structured and the demand for good health care is high, SpRs ultimately find themselves working in partnership with others who are involved in the care of their (or other) patients. Being able to collaborate effectively with the patients, families, and other expert health professionals in providing optimal care, education and scholarship is therefore essential. Finally, as scholars SpRs should be able to demonstrate a lifelong commitment to reflective learning, as well as the conception, dissemination, application and translation of medical knowledge. By engaging in a lifelong pursuit of mastering their domain of expertise, they can develop relevant skills (clinical, cognitive, communicative skills) and cognitions required for optimal professional development (Akhund 2006). Based on the experiences from the 16-week project, a few specific recommendations adapted to the local situation, have been made to further improve the implementation process in Curaçao. An overview of these recommendations is provided in .
Conclusion
This report describes the implementation of a revised competency–based training program for paediatric SpRs in a developing nation (Curaçao). It also shows how crucial it is to have the support of an educational expert in the local setting and how this facilitates the implementation of a comprehensive training program. Digital portfolios and brief clinical assessments have been effectively implemented in the department of paediatrics in SEHOS. Both residents and members of staff have been trained in how to conduct and interpret brief clinical assessments and make use of portfolios. ‘Departmental portfolios’ have been introduced as an innovative method of evaluating and monitoring the educational activities of the various clinical departments (see ). An advisory committee comprising of the Director of medical clerkships, departmental heads of the residency training programs, a medical educationalist and a representative from the teaching hospital (UMCG) in Groningen, has been set up to monitor the progress and quality of the training program. A yearly (re-)evaluation of the competency based training process would take place, including additional trainings in relevant educational methods.
The experience as described in this report shows that it is possible and also feasible to implement a competency-based program in an environment where resources are limited. As it turned out to be, the paediatric department in SEHOS was the first centre to achieve significant results in the implementation of The revised Dutch Paediatric Training Program (2008) (Muskiet et al. Citation2006), and demonstrated that careful and pragmatic approaches are necessary when implementing competency-based curricula in a setting like Curaçao. The process was also dependent on adequate information and approval of all concerned parties and with the support of an educationalist on-site. It is our view that the experience from this exercise can be helpful for other limited-resource countries that are dealing with the new trend of competency-based training.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.
Additional information
Notes on contributors
Jamiu O. Busari
JAMIU BUSARI, Paediatrician, Atrium Medical Center, Heerlen and Assistant Professor in Medical Education, Maastricht University, the Netherlands.
Eduard A. A. Verhagen
EDUARD VERHAGEN, Paediatrician and Chief-attending physician, Beatrix Kinderkliniek, University Medical Center Groningen, the Netherlands.
Fred D. Muskiet
FRED MUSKIET, Paediatrician and Director, Paediatric residency training program, St. Elisabeth Hospital, Curacao, Netherlands Antilles.
Ashley J. Duits
ASHLEY DUITS, Director, Institute of Medical Education, St. Elisabeth Hospital, Curacao and Professor in Medical Education, University of Groningen, the Netherlands.
References
- Akhund S, Masood Kadir M. Do community medicine residency trainees learn through journal club? An experience from a developing country. BMC Med Educ 2006; 6: 43
- Bleker OP, Ten Cate Th J, Holdrinet RSG. General competencies of the future medical specialist [in Dutch]. Dutch J Med Educ 2004; 23: 4–14
- Busari JO, Vervoort M, Hermans SM, Blom JR. Medical education in the new millennium–a Caribbean perspective. Med Educ 2001; 35(7)703–706
- http://rcpsc.medical.org/canmeds/bestpractices/framework_e.pdf, CANMEDS. 2005. Framework. Available at:. Accessed 10 January 2008
- http://www.medischevervolgopleidingen.nl//content/documenten/documentatie/kaderbesluiten/kaderbesluit_ccms.pdf, Framework for the Dutch Specialist Training Programs; Kaderbesluit Centraal College medische specialismen (Dutch). Available at:. Accessed 10 January 2008
- Hofstede G. Culture's Consequences: International Differences in Work-Related Values. Sage, London 1980
- Hofstede G. Culture's Consequences, Comparing Values Behaviours, Institutions, and Organisations across Nations. Sage, Thousand Oaks, CA 2001
- IMF (International Monetary Fund). Kingdom of the Netherlands-Netherlands Antilles: Staff Report for the 2005 Article IV Consultation. 2006, Available at: http://www.imf.org/external/pubs/ft/scr/2006/cr06116.pdf. Accessed 06 July 2008
- http://www.medischevervolgopleidingen.nl/pages/content/s2/10010000000006-10010000000073/invivo.aspx, IN VIVO project: the implementation of the revised postgraduate curriculum of Paediatrics and Obstetrics and Gynaecology (Dutch). Available at:. Accessed 04 July 2008
- Muskiet FD, Busari JO, Verhagen E. A fast metamorphosis: The paediatric department of SEHOS implements competency-based assessments (Dutch) Kinderafdeling Curaçao's ziekenhuis voert competentiegericht toetsen in. Med Contact 2006; 61(26)1071–1073
- Norcini J, Burch V. Workplace-based assessment as an educational tool: AMEE Guide No. 31. Med Teach 2007; 29(9)855–871
- PAHO (Pan American Health Organization- Area of Health Analysis & Information Systems). Health Situation in the Americas: Basic Indicators 2005. Pan American Health Organization, Washington, DC 2005
- http://www.medischevervolgopleidingen.nl//content/documenten/invivo/nvk%20goed%20boekje%20definitief.pdf, Revised curriculum for the Dutch paediatric specialist training program. Available at:. Accessed 10 January 2008
- Scheele F, Teunissen P, Luijk van S, Heineman E, Fluit L, Mulder H, Meninger A, Wijnen-Meijer M, Glas G, Sluiter H, Hummel T. Introducing competency-based postgraduate medical education in the Netherlands. Med Teach 2008; 30(3)248–253
- WHO (World Health Organization). Neonatal and Perinatal Mortality: Country, Regional and Global Estimates. World Health Organization, Geneva 2006