Keywords
Clinical Presentation Curriculum, CP Curriculum, and Medical Education
Clinical Presentation Curriculum, CP Curriculum, and Medical Education
Sir William Osler, considered the father of modern medicine, emphasized the teacher's role in helping students to observe and reason. He recommended abolishing the traditional lecture method of instruction.1 Medical education is evolving in response to scientific advances and societal needs.2 A well-organized comprehensive knowledge domain has practical implications in clinical problem solving, and appropriate teaching and learning methods play an important role in achieving the educational goals.3
Clinical presentation (CP) is a relatively new and innovative approach to teaching medicine. CP engages medical students in their understanding of the disease process from clinical feature to diagnosis. Students begin studying abnormalities of complaints, examination, and laboratory findings; i.e., signs, symptoms, and laboratory investigations which a patient presents to the doctor with. Students then progress towards diagnosis. The underlying philosophy of the CP Curriculum is that: “The reaction of the human body to an infinite number of insults is always finite and stable over time”.4 For example, if there is any attack on the respiratory system, whether infectious, inflammatory, immunological, traumatic, or iatrogenic; the respiratory system responds through coughing, cyanosis, chest pain, difficulty breathing, noisy breathing, or hemoptysis.4 Thus, the CP Curriculum aims to help students understand the process of moving from “symptoms to diagnosis.”
The CP curriculum was first formulated in 1990 at the University of Calgary Faculty of Medicine in Canada.5 The curriculum was adopted and redesigned based on local needs at various medical schools worldwide. Patan Academy of Health Sciences (PAHS), a state-funded medical school in Nepal, has adopted several new and innovative approaches in teaching and learning medicine. The CP Curriculum is one of the several approaches adopted by PAHS.6
PAHS medical education team assumes that the CP curriculum is better than traditional lecture-based teaching. In this study we are testing the perceived effectiveness of students and faculty, and the level of knowledge among the students trained by the CP curriculum. The level of knowledge was assessed by marks scored by the students in a surprise non-routine exam without prior information. Perceived effectiveness was based on the thinking/perception of the students and faculty on the effectiveness of the CP curriculum. We assume the CP curriculum is at least not inferior to traditional lecture-based teaching.
This is a cross-sectional study that aims to evaluate the efficacy of the CP curriculum in teaching different disciplines of clinical medicine to undergraduate medical students of PAHS, which is currently the only medical school implementing the CP-curriculum in undergraduate medical education. A new Multiple-Choice Question (MCQ) based questionnaire was designed to evaluate the level of knowledge and two separate questionnaires were developed for faculty to evaluate perception about CP-curriculum.
All consenting medical students from 2016 of PAHS School of Medicine currently in clinical clerkship years and all clinical sciences faculty who had delivered at least one teaching-session with the CP curriculum to these students were included in the study. Consenting students were asked to fill the questionnaire together in class, whereas faculty were approached personally and asked to complete the questionnaires. Students and faculty who were part of the study team, those who didn’t provide consent, and those who participated in the pilot survey section of the questionnaire developed for this study were excluded. All 34 faculty completed the perception questionnaires, with zero non-response rate. Out of 49 students, 33 completed the perception questionnaires and 38 turned up to the surprise non-routine exam for assessment of knowledge retention.
This study was approved by the Institutional Review Committee (Ethical Committee) of Patan Academy of Health Sciences (PAHS), Kathmandu, Nepal (Ref No std1505911069). Written informed consent was obtained from all participants before completing the questionnaire. Students who gave verbal consent were asked to complete the questionnaire together in class. Faculty were approached personally and requested to complete the questionnaires. At the start of each questionnaire, a tick box was used for participants to indicate written consent. Participants were informed verbally and in writing that their names and identifiying information would be kept anonymous, and their data would only be used for research purposes.
Three sets of questionnaires were used. The first set of questionnaires were designed to test the perceived effectiveness of the CP curriculum from the faculty perspective. It contained seven questions on background information (age, sex, job position, highest academic degree, etc) and 13 questions on perceived effectiveness.
Similarly, the second set of questionnaires for the students included 11 questions on background information and 15 questions on perceived effectiveness. The perception questionnaire had questions about effectiveness or satisfaction in regard to different aspects of the CP curriculum. Participants had to respond with a tick mark in a Likert scale ranging from one (strongly agree) to five (strongly disagree) for each question.
The third set of questionnaires tested the students' clinical knowledge and contained 50 MCQs from different clinical medicine disciplines. Based on curriculum of the university, there were seven MCQs each from surgery, medicine, pediatrics, obstetrics and gynecology, and two questions each from orthopedics, emergency medicine, general practice, otolaryngology, anesthesiology, dermatology, dentistry, psychiatry, radiology, ophthalmology, and forensic medicine. The questions were randomly selected from the question pool of the Examination section of university. The selected questions were randomly arranged, and a surprise non-routine written exam was conducted with this questionnaire. A maximum time of one hour was provided to solve these 50 questions.
These questionnaires were compiled and discussed in the research group and reviewed by the research advisors to establish content validity. Copies of all three questionnaires can be found under Extended data.10 They were administered to randomly selected 15 students and 15 faculty in a pilot study to establish the face validity and feasibility. The students and faculty randomly selected for the pilot study were administered the questionnaires to complete. Then they were asked in detail about the questionnaire and any suggestions for revisions or editing needed. The pilot survey was not powered for statistical comparisons. Only a few grammatical corrections were made after review and feedback from the pilot study. Subsequently, the final study was conducted.
The faculty participants were also involved in the development of the CP curriculum at PAHS, hence, responder bias in favor of CP curriculum may be present in this study.
The data collected were digitalized using Epi-Info version 7 software. These raw data were exported to MS-Excel. The excel sheet is made available in the public domain for readers.10 SPSS version 13.0 was used for statistical test and analysis. Shapiro-Wilk test was used first to test the normality. Non-parametric tests (Mann-Whitney and Kruskal Wallis) was used for normal distribution. Classical ANOVA for equal variance and Welch ANOVA for unequal variance were used after testing the homogeneity of variance, and post-hoc/tukey test was used for significant classical ANOVA results.
In this study, we calculated the total score via forced Likert scale, ranging from 1 (strongly agree) to 5 (strongly disagree) for each respondent determined as the dependent variable, and compared it with other variables i.e., background information. The total score of all the Likert scale questions was calculated, and the normality test was performed, keeping “total score” as the dependent variable. The full dataset can be found under Underlying data.10
The data of the total score did not follow a normal distribution (Shapiro-Wilk Test, p < 0.05), so a non-parametric test was used to compare the dependent variable. We used Mann-Whitney and Kruskal Wallis tests for the variables containing two groups and more than two groups, respectively.
Among the 34 respondents from the faculty group, 24 (70.59%) were male, and 10 (29.41%) were female. 20 (58.82%) of the faculty respondents were lecturers, and the remaining 14 (41.18%) were senior professors, associate professors, and assistant professors. Out of the 34 respondents, 31 (91.18%) were involved in developing the CP curriculum at PAHS. However, 3 (8.82%) were involved in teaching the curriculum but not in developing the CP curriculum.
As many as 15 (44.12%) respondents favored the CP curriculum system over the traditional system, 11 (32.35%) preferred the traditional teaching system, and 8 (23.53%) preferred both. Overall, the faculty liked the CP curriculum more than the traditional system of teaching clinical medicine (Kruskal Wallis = 0.023, p-value < 0.05). The majority of faculty, 27 (79.41%), would suggest future students to join a medical school that implemented the CP curriculum system rather than the traditional system. Only 12 (35.29%) of them thought that the CP curriculum system should be the sole leading teaching and learning system in clinical medicine, meaning more faculty preferred a hybrid system of both the CP curriculum and the traditional system. However, these differences were not statistically significant (p-value > 0.05).
As shown in Table 1, a significant number of faculty (p values > 0.05) perceive the CP curriculum to be more effective than the traditional system for teaching clinical medicine to undergraduate medical students. There is no significant difference in the perception of the effectiveness of the CP curriculum among faculty based on academic rank, gender, highest academic degree, or the institution of their residency training (p-value > 0.05). The median number of faculty who perceive the CP curriculum system to be more effective and suggest future students to study medicine in this system rather than the traditional system is higher. But, the difference was not statistically significant (p > 0.05). There was no significant difference in faculty foreseeing the CP curriculum as the leading method of teaching and learning medical education in the future (p > 0.05).
The normality test shows that the total score data follows a normal distribution (Shapiro-Wilk, p > 0.05) with a mean value of 50.57 with a standard deviation of 8.17. Therefore, we used a parametric test to compare the test variable with others. We subsequently tested for homogeneity of variance: we used classical ANOVA for equal variance, and Welch ANOVA for unequal variance. Finally, if significant classical ANOVA results were obtained, we used the post-hoc/tukey test.
There were 33 respondents, among which 23 (69.70%) were males, and 10 (30.30%) were females. The age group of respondents was between 20 to 30 years. A significantly higher number (20 i.e., 60.61%) of the respondents recommended studying in a medical school implementing CP curriculum (p < 0.05). No significant differences were seen between educational or geographical backgrounds and scholarship categories (p > 0.05) as shown in Table 2.
An hourly surprise non-routine written exam was conducted to test the knowledge of the students. A copy of this exam can be found under Extended data.10 The exam included 50 MCQs from different disciplines of clinical medicine. The surprise test was conducted without prior reminders, and 38 out of 49 students participated. The findings, as outlined in Table 3, show that 24 out of 38 (65.79%) of the students scored 60% or higher. The results demonstrate that approximately two-thirds of the students passed the surprise test, indicating good test performance.
The current study shows a higher preference for the CP curriculum by undergraduate medical students and faculty at PAHS for teaching and learning clinical medicine in medical school. These findings further substantiate previous reviews on the principles of teaching methods and the acceptability of the curriculum.
This curriculum was chosen in part because of confidence in the comprehensiveness of the knowledge it encompasses. Equally important was the organization of medical knowledge that this curriculum engenders: each clinical presentation is organized according to a variable number of causal diagnostic categories. Each of these categories is identified by a prototype. Exhaustive lists of diagnoses belonging to a given category are avoided. As students' clinical experiences increase and they encounter more diagnoses, the students can add them to the appropriate causal categories stored in their memories. How the diagnostic prototypes are presented allows students to identify the discriminating features within and between each. The process by which students can compare and contrast the distinctive features of each disease is facilitated. It is so because the CP curriculum is well organized and comprehensive.3,7 Since the CP curriculum is simple to follow and to organize the learning content, students in the CP curriculum also reported less stress due to the volume and complexity of study materials and examinations.7
Prior studies at the University of Calgary demonstrated a substantial effect size on students’ retention of basic science knowledge while participating in the CP curriculum.8 Our study conducted on clinical clerkship year participants showed that two-thirds of students achieved 60% (passing scores) or more in the surprise non-routine exam, signifying a high retention of clinical discipline knowledge. Findings from the current study expand on the effectiveness of the curriculum across medical school years with respect to knowledge retention.
A study done among medical students utilizing the CP curriculum showed a favorable response to the use of schema in the CP curriculum.9 In our study, we could not evaluate the use the schemas of CP to perform clinical assessment in order to reach the appropriate diagnosis. We recommend further studies in this respect. Additionally, long-term knowledge retention was not tested in our study, which could be another important area of investigation.
This study has several other limitations as well. The study was conducted at a single institution, thereby potentially reducing the overall generalizability of the findings. The faculty members recruited as participants for assessing the perceived effectiveness of the curriculum were also involved in the adaptation and development of curriculum at PAHS, hence, potentially increasing responder’s bias in the study by some degree. The cross-sectional nature of the study provides only a limited understanding of the effects of the curriculum over the long term.
Based on this study, we can conclude that both faculty and students perceive the CP curriculum system as an effective teaching and learning method in medicine, irrespective of their demographic and positional characteristics. The findings suggest higher knowledge retention in knowledge by implementing the CP curriculum during clinical clerkship years. Since the 1990s, CP Curriculum has been established as a multidimensional teaching-learning method in many medical school systems. In the evolving medical education world with rapid digitization, massive turnover of medical and education data, and increased use of remote learning methods, a deeper understanding of influencing variables will help effectively utilize this highly valued curriculum.
Figshare: CP Curriculum Raw data updated in Excel and PDF. https://doi.org/10.6084/m9.figshare.18666410.v110
This project contains the following underlying data:
This project contains the following extended data:
- CP Questionnaire for Faculties.pdf
- CP Questionnaire for students.pdf
- CP Surprise exam Questionnaire.pdf
Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).
SAY, SKJ, AA, and BD conceptualized and designed the study. All 9 authors; SAY, SJ, SP, SG, SB, AA, BD, NB, and SY contributed to data analysis and interpretation. SAY and SP wrote the first draft of the article. All 9 authors, SAY, SP, SG, SJ, SB, AA, BD, NB, and SY critically revised the manuscript and approved the final version of manuscript for publication.
We thank Prof. Dr. Kedar Prasad Baral and Prof. (Associate) Shital Bhandary for their immense help during this research. We thank all respondent faculty and medical students of PAHS for participating in the study.
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Is the work clearly and accurately presented and does it cite the current literature?
Yes
Is the study design appropriate and is the work technically sound?
Yes
Are sufficient details of methods and analysis provided to allow replication by others?
Partly
If applicable, is the statistical analysis and its interpretation appropriate?
Yes
Are all the source data underlying the results available to ensure full reproducibility?
Yes
Are the conclusions drawn adequately supported by the results?
Yes
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Global health, gerontology, cancer
Is the work clearly and accurately presented and does it cite the current literature?
Yes
Is the study design appropriate and is the work technically sound?
Yes
Are sufficient details of methods and analysis provided to allow replication by others?
Partly
If applicable, is the statistical analysis and its interpretation appropriate?
Partly
Are all the source data underlying the results available to ensure full reproducibility?
Yes
Are the conclusions drawn adequately supported by the results?
Partly
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Epidemiology, Biostatistics, Medical education, Public health
Is the work clearly and accurately presented and does it cite the current literature?
Yes
Is the study design appropriate and is the work technically sound?
Yes
Are sufficient details of methods and analysis provided to allow replication by others?
Yes
If applicable, is the statistical analysis and its interpretation appropriate?
I cannot comment. A qualified statistician is required.
Are all the source data underlying the results available to ensure full reproducibility?
Yes
Are the conclusions drawn adequately supported by the results?
Yes
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Endocrine disorders, Heart conditions, Medications, COVID-19, Obstetric conditions, Epilepsy, HIV, etc.
Alongside their report, reviewers assign a status to the article:
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Version 1 10 Feb 22 |
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Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. Consider the following examples, but note that this is not an exhaustive list:
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