2012; 34: e785–e793

WEB PAPER

Deliberative curriculum inquiry for integration inan MD curriculum: Dalhousie University’scurriculum renewal process

LYNETTE REID, ANNA MACLEOD, DAVID BYERS, DIANNE DELVA, TIM FEDAK, KAREN MANN,TOM MARRIE, BRENDA MERRITT & CHRISTY SIMPSON

Dalhousie University, Canada

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 stake-

holders 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 under-

standings 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 achieve-

ment 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

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.

Correspondence: L. Reid, Department of Bioethics, Dalhousie University, PO Box 15000, Halifax NS B3H 4R2, Canada. Tel: 902-494-1842; fax: 902-

494-3865; email: Lynette.Reid@dal.ca

ISSN 0142–159X print/ISSN 1466–187X online/12/O120785–9 � 2012 Informa UK Ltd. e785DOI: 10.3109/0142159X.2012.687479

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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-clerk-

ship 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 objec-

tives, 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.

Aims

Our aims for curriculum renewal included meeting the one-

year timeline for launching a distributed programme, fulfilling

accreditation standards, particularly around mapping, achiev-

ing 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 curricu-

lum 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 develop-

ment (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.

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 docu-

mented 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

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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 interprofes-

sional collaboration, including specialist and generalist physi-

cians, 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 develop-

ments 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 undergrad-

uate 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 curricu-

lum 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 recom-

mendations 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 gen-

eralist 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

Figure 1. Parallel and networked processes.

Deliberative curriculum inquiry at Dalhousie

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Competencies (ProComp) Unit for integration with the con-

current 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, repre-

senting 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 sup-

ported 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.

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 med-

ical profession. Community members indicated that our future

physicians should be able to listen well; share information in

an understandable manner; treat their patients, family mem-

bers, 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.

Figure 2. Curriculum Wiki.

L. Reid et al.

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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, withstrengthened 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 knowl-

edge 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, wher-

ever 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 andeducational 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 repre-

sents 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.

The writing group used the concept of ‘entrustable profes-

sional 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

Figure 3. Curriculum outcomes: the ‘square’.

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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 entrus-

table 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 andbiomedical 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, pharma-

cology 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 relation-

ships 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)

The development of the ProComp Unit involved establish-

ing 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 endo-

crinology 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 responsi-

bilities, and being introduced to the rights of temporary

residents and immigrants as patients – an example of

‘correlation’, or Harden’s Step 7.

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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 deliber-

ation 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 ‘integra-

tion’ 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 under-

stood. 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 educa-

tion. Facilitating contributions from stakeholders with a variety

of sets of knowledge, expertise and experience led to a richer

Figure 4. Integration model.

Deliberative curriculum inquiry at Dalhousie

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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 on contributors

DAVID BYERS, PhD, is a Professor in the Departments of Biochemistry &

Molecular Biology and Pediatrics at Dalhousie University, with research

interests in the discovery of novel antibiotics targeting microbial lipid

metabolism. His educational focus is the teaching of biochemistry to

medical and science students, and he was a co-developer and initial Unit

Head of the Foundations Unit.

DIANNE DELVA, MD, is a Professor of Family Medicine and was the

Associate Dean of Undergraduate Medical Education at the time of the

renewal. She contributed to the development of the curriculum.

TIM FEDAK, PhD, Director of Distributed Education and Assistant

Professor in the Division of Medical Education, seeks to enhance the use

of new media and education technologies for the support of medical

education.

ANNA MACLEOD, PhD, is an Assistant Professor and the Education

Specialist, Division of Medical Education and chairs the Undergraduate

Medical Education Assessment and the Objectives and Case Review

Committees. She is an educational researcher interested in medical

education curriculum and pedagogy.

KAREN MANN, PhD, is a Professor Emeritus in the Division of Medical

Education at Dalhousie University in Halifax, Canada. She is also a

Professor and holds a part-time Chair in Medical Education, Manchester

Medical School in Manchester, United Kingdom.

THOMAS J. MARRIE, MD, is Dean, Faculty of Medicine, Dalhousie

University, and past Dean, Faculty of Medicine and Dentistry, University

of Alberta. He is an Infectious Diseases Physician, with a research focus on

community acquired pneumonia and spans the spectrum from basic to

applied science.

BRENDA MERRITT, PhD, is a faculty member within the Dalhousie School

of Occupational Therapy. Her primary research interests include investi-

gating the impact that chronic health conditions have on daily life

performance and evaluating the quality of curricula within health profes-

sion programmes.

LYNETTE REID, PhD, is an Assistant Professor in the Department of

Bioethics, Dalhousie University, with a research and teaching interest in the

social dimension of professional ethics. She led, with colleagues, the

curriculum outcomes process, and is co-developer and co-Unit Head of the

Professional Competencies Unit.

CHRISTY SIMPSON, PhD, is Head and Associate Professor, Department of

Bioethics, Dalhousie University. She, with other colleagues, facilitated the

community conversations for the Faculty of Medicine.

Notes1. 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

References

AAMC, HHMC (Association of American Medical Colleges & Howard

Hughes Medical Institute). 2009. Scientific Foundations for Future

Physicians: Report of the AAMC-HHMI Committee. Washington DC:

AAMC. [Accessed 27 July 2011] Available from http://www.hhmi.org/

grants/pdf/08-209_AAMC-HHMI_report.pdf

Anderson RS, Speck BW. 1998. ‘‘Oh what a difference a team makes’’:

Why team teaching makes a difference. Teach Teach Educ

14(7):671–686.

Biggs J. 1996. Enhancing teaching through constructive alignment. High

Educ 32(3):347–364.

Case R. 1994. Our crude handling of educational reforms: The case of

curricular integration. Canadian J Educ 19(1):80–93.

Collins L, Arenson CA, Jerback C, Dressel R, Kane P, Antony R, Necky J,

Oduneye A. 2009. Chronic Illness Care Education: Reflections on a

Longitudinal Interprofessional Mentorship Experience. Health Policy

Newslett 21(4):3.

Davenport NC, Spath ML, Blauvelt MJ. 2009. A step-by-step approach to

curriculum review. Nurse Educ 34(4):181–185.

Epstein RM, Hundert EM. 2002. Defining and assessing professional

competence. JAMA 287(2):226–235.

Eva KW, Neville AJ, Norman GR. 1998. Exploring the aetiology of content

specificity: Factors influencing analogic transfer and problem solving.

Acad Med 73(Suppl.):1–5.

GMC (General Medical Council). 2009. Tomorrow’s Doctors: Outcomes

and standards for undergraduate medical education. London:

General Medical Council. [Accessed 27 July 2011] Available from

http://www.gmc-uk.org/education/undergraduate/tomorrows_doctors_

2009.asp

Harden RM. 2000. The integration ladder: A tool for curriculum planning

and evaluation. Med Educ 34(7):551–557.

Harden RM. 2001. AMEE Guide No. 21: Curriculum mapping: A tool for

transparent and authentic teaching and learning. Med Teach

23(2):123–137.

Harris IB. 1991. Deliberative Inquiry: The Arts of Planning. In: Short E, editor.

Forms of curriculum inquiry. New York: SUNY Press. pp 285–308.

Harris IB. 1993. Perspectives for curriculum renewal in medical education.

Acad Med 68(6):484–486.

Kern DE. 2009. Curriculum development in medical education: A

six-step approach. 2nd ed. Baltimore, MD: Johns Hopkins University

Press.

MacLeod A. 2011. Six ways problem-based learning cases

can sabotage patient-centered medical education. Acad Med

86(7):818–825.

Muller JH, Jain S, Loeser H, Irby DM. 2008. Lessons learned about

integrating a medical school curriculum: Perceptions of students,

faculty and curriculum leaders. Med Educ 42(8):778–785.

Murata R. 2002. What does team teaching mean? A case study of

interdisciplinary teaming. J Educ Res 96(2):67–77.

Oblinger DG, Barone CA, Hawkins BL. 2001. Distributed education and its

challenges: An overview. Washington, DC: American Council on

Education and EDUCAUSE. [Accessed 20 September 2011] Available

from http://www.acenet.edu/bookstore/pdf/distributed-learning/dis-

tributed-learning-01.pdf

Prideaux D. 2003. Curriculum design. BMJ 326:268–270.

RCPSC (Royal College of Physicians and Surgeons of Canada). 2005. The

CanMEDS 2005 physician competency framework: Better standards,

better physicians, better care. Frank JR, editor. Ottawa: Royal College of

Physicians and Surgeons of Canada. [Accessed 27 July 2011] Available

from http://rcpsc.medical.org/canmeds/CanMEDS2005/CanMEDS

2005_e.pdf

Reid WA. 1978. Thinking about the curriculum: The nature and treatment of

curriculum problems. London: Routledge & Kegan Paul. p84.

L. Reid et al.

e792

Med

Tea

ch D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y 11

7.17

1.23

6.21

9 on

05/

20/1

4Fo

r pe

rson

al u

se o

nly.

Srinivasan M, Wilkes M, Stevenson F, Nguyen T, Slavin S. 2007.

Comparing problem-based learning with case-based learning:

Effects of a major curricular shift at two institutions. Acad Med

82(1):74–82.

ten Cate O, Scheele F. 2007. Competency-based postgraduate training: Can

we bridge the gap between theory and clinical practice? Acad Med

82(6):542–547.

ten Cate O, Snell L, Carraccio C. 2010. Medical competence: The interplay

between individual ability and the health care environment. Med Teach

32(8):669–675.

Wenger MS, Hornyak MJ. 1999. Team teaching for higher level learning: A

framework of professional collaboration. J Manage Educ 23(3):311.

Wiener CM, Thomas PA, Goodspeed E, Valle D, Nichols DG. 2010.

‘‘Genes to Society’’—The logic and process of the new curriculum for

the Johns Hopkins University School of Medicine. Acad Med

85:498–506.

Wiggins GP, McTighe J. 2001. Understanding by Design. Upper Saddle

River, NJ: Merrill/Prentice Hall.

Willett TG. 2008. Current status of curriculum mapping in Canada and the

UK. Med Educ 42(8):786–793.

Deliberative curriculum inquiry at Dalhousie

e793

Med

Tea

ch D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y 11

7.17

1.23

6.21

9 on

05/

20/1

4Fo

r pe

rson

al u

se o

nly.