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Real time curriculum map for internal medicine residency Wong, Roger Y; Roberts, J M Nov 7, 2007

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ralssBioMed CentBMC Medical EducationOpen AcceResearch articleReal time curriculum map for internal medicine residencyRoger Y Wong* and J Mark RobertsAddress: Postgraduate Medical Education, Department of Medicine, University of British Columbia, Vancouver, CanadaEmail: Roger Y Wong* - rymwong@interchange.ubc.ca; J Mark Roberts - james.roberts@vch.ca* Corresponding author    AbstractBackground: To manage the voluminous formal curriculum content in a limited amount ofstructured teaching time, we describe the development and evaluation of a curriculum map foracademic half days (AHD) in a core internal medicine residency program.Methods: We created a 3-year cyclical curriculum map (an educational tool combining thecontent, methodology and timetabling of structured teaching), comprising a matrix of topics undervarious specialties/themes and corresponding AHD hours. All topics were cross-matched againstthe ACP-ASIM in-training examination, and all hours were colour coded based on the categoriesof core competencies. Residents regularly updated the map on a real time basis.Results: There were 208 topics covered in 283 AHD hours. All topics represented corecompetencies with minimal duplication (78% covered once in 3 years). Only 42 hours (15%)involved non-didactic teaching, which increased after implementation of the map (18–19 hours/yearversus baseline 5 hours/year). Most AHD hours (78%) focused on medical expert competencies.Resident satisfaction (90% response) was high throughout (range 3.64 ± 0.21, 3.84 ± 0.14 out of 4),which improved after 1 year but returned to baseline after 2 years.Conclusion: We developed and implemented an internal medicine curriculum map based on realtime resident input, with minimal topic duplication and high resident satisfaction. The map providedan opportunity to balance didactic versus non-didactic teaching, and teaching on medical versus nonmedical expert topics.BackgroundAlthough accreditation bodies in North America have out-lined well-established, multifaceted goals (overall direc-tion of the education program), objectives (educationallyuseful elements that are rotation specific) and competen-cies (important observable knowledge, skills and atti-tudes) for residency training in internal medicine, theoperational delivery of formal curriculum has been chal-lenging for many postgraduate programs. Not only isexpected to teach residents all 6 general core competenciesmandated by the Accreditation Council for GraduateMedical Education (ACGME) in the United States [1], orall 7 roles in the CanMEDS framework mandated by theRoyal College of Physicians and Surgeons (RCPSC) inCanada [2]. All of these need to be achieved within a finitetraining period [3], and without extending training hoursbeyond the resident work hour restriction guidelines [4].In some residency programs, formal curriculum is deliv-Published: 7 November 2007BMC Medical Education 2007, 7:42 doi:10.1186/1472-6920-7-42Received: 14 September 2007Accepted: 7 November 2007This article is available from: http://www.biomedcentral.com/1472-6920/7/42© 2007 Wong and Roberts; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 8(page number not for citation purposes)there a tremendous and growing amount of academiccontent to cover during residency, but programs are alsoered through structured teaching opportunities such asacademic half days (AHD) or full days. While these aca-BMC Medical Education 2007, 7:42 http://www.biomedcentral.com/1472-6920/7/42demic days may be mandatory, no standardized planningtool exists. Detailed educational planning is needed toachieve the largest possible impact, so that important top-ics are not missed and repetition is minimized. It is alsounclear if the topics taught are actually pertinent to assess-ment at public internal medicine examinations, such asthe American College of Physician – American Society ofInternal Medicine (ACP-ASIM) in-training examination.The lack of standard methodology to manage the aca-demic content within a busy curriculum, together withuncertainty if the content covered is actually relevant,present a double challenge for residency program direc-tors and medical educators. Such challenge has beenexpressed and shared among program directors atnational and international meetings.Earlier educational studies have described the potentialvalue of creating curriculum maps, mostly in the tradi-tional K-12 school system [5]. A curriculum map is aneducational tool that combines what is taught (the aca-demic content), how it is taught (the teaching resourcesand opportunities), when it is taught (the timetable), andthe measures used to assess if teaching has successfullyoccurred [6]. Like a road map to knowledge, a curriculummap makes the formal curriculum more transparent to allstakeholders and clarifies the relationships and links [6].The process of establishing a map is, however, time andeffort intensive. In health education, curriculum mappinghas been used to help teach evidence based medicine [7],geriatrics [8], clinical nutrition [9], and computer-basedvirtual medical courses [10].Curriculum mapping is a dynamic process, requiringongoing (real time) feedback and needs assessment fromthe learners [11]. Ongoing feedback is commonly used inweb based learning [12], which can be assessed usingstructured questionnaires [13,14] or focus groups [15].We elected to have a designated group of residents fromall training years to provide feedback, as this motivatesresidents to actively participate in their own education.We recently developed a real time curriculum map specif-ically designed for internal medicine residents, mainlybecause our former scheduling method for the formal cur-riculum resulted in numerous duplications and omis-sions, and sub-optimal resident/faculty satisfaction. Ourmap allowed us to proactively manage the logistics andrelevance of formal curriculum delivery during AHD,while taking into account the specific requirements ofteaching residents the non medical expert core competen-cies as mandated by the ACGME or RCPSC. The primaryobjective of this article is to describe the development ofthis real time curriculum map. The secondary objective isMethodsSettingThe core internal medicine residency training program atthe University of British Columbia (UBC) is a 3-year pro-gram with a 3-year cyclical formal curriculum. There were72 residents in our residency program in 2003–2004 (26in post graduate year (PGY)-1, 26 in PGY-2, 20 in PGY-3),74 in 2004–2005 (26 PGY-1, 20 PGY-2, 28 PGY-3), and81 in 2005–2006 (31 PGY-1, 31 PGY-2, 19 PGY-3). Thebulk of the residency training experience involved clinicalrotations in general internal medicine (clinical teachingunits) and medical sub-specialties. Although each rota-tion had specific educational objectives, formal curricu-lum delivery was predominantly unstructured anddetermined by individual preceptors. The main structuredteaching opportunity involved a weekly AHD program,which ran for 4 hours every Wednesday afternoon andwas a mandatory component of the program. Of theweekly 4 hours, 3 hours had scheduled teaching activities(the focus of the curriculum map), with the remaining 1hour for personal independent learning. AHD was pro-tected time for residents and all services were expected torelease them from ward and patient duties.Curriculum Map DevelopmentIn October 2004, we assembled the first 3-year cycle of theAHD curriculum map. We retrospectively used the 2003–2004 curricular data as baseline (which became year 1 ofa 3-year cycle), and prospectively planned for the subse-quent 2 years (2004–2005 and 2005–2006). The map wasin the form of a matrix that comprised of 20 themes,which represented 16 specialties and 4 non medical expertthemes (biomedical ethics, evidence based medicine,quality improvement, teaching skills). One hour of sched-uled AHD time was allotted to each topic. Topics belong-ing to the same specialty/theme were grouped together inconsecutive rows, and the hours of AHD coverage in eachacademic year were plotted in consecutive columns. Alltopics covered were cross-matched against the list ofexamination objectives from each year's ACP-ASIM in-training examination. The latter information was dissem-inated to all program directors after the annual examina-tions. The topics were colour coded to indicate those thatwere covered and examined, those covered but not exam-ined, and those examined but never covered. The hourswere also colour coded to indicate the category of corecompetencies covered, which paralleled those mandatedby the national accreditation bodies. The map wasupdated monthly by the residency program secretary onan ongoing basis. A sample portion of the curriculummap is illustrated in the Appendix. We received approvalfrom the UBC residency training committee to developand implement the curriculum map and disseminate ourPage 2 of 8(page number not for citation purposes)to assess the impact of implementing the map on formalcurriculum planning and resident satisfaction.experience.BMC Medical Education 2007, 7:42 http://www.biomedcentral.com/1472-6920/7/42Prior to the development of a curriculum map (baseline),AHD topics and speakers were determined by 2 of the 4chief medical residents, without cross reference to whatwas previously taught and when it was taught. Afterimplementation of the map, we assessed teaching needson an ongoing basis. The topic, format (didactic and/orinteractive) and speaker selection at AHD were deter-mined by the AHD organizing committee, which com-prised of 17 members (4 chief medical residents, 2 classrepresentatives from each of the 3 years, and an additional2 representatives from each class who expressed specialinterest in medical education, and chaired by the associateprogram director). The committee met every 4–6 weeksfor about 90 minutes, during which members used thecurriculum map to formulate a list of topics that fit into aseries of predetermined AHD block themes. Members sug-gested potential speakers for these topics, with considera-tion of adequate and balanced representation based ongeography (teaching or community hospitals) and exper-tise (clinical or research), and then extended personalinvitations to the speakers. The information was collatedby the chief medical residents and approved by the asso-ciate program director. On an ongoing basis, AHD topicswere entered into the curriculum map by the program sec-retary.Curriculum Map EvaluationEvaluation of the AHD curriculum map was conductedfrom 2 perspectives: formal curriculum planning and res-ident satisfaction. The impact of the map on formal cur-riculum planning was assessed by the percentage of AHDcoverage that represented core competencies in internalmedicine, the extent of topic duplication, the amount ofdidactic versus non-didactic teaching sessions, and theamount of teaching on non medical expert competenciesas mandated by the national accreditation bodies. Resi-dent satisfaction was evaluated using a structured, 5-itemsurvey administered after each AHD for the period July 1,2003 to June 30, 2006, which provided baseline data(2003–2004), and evaluation data in the first (2004–2005) and second (2005–2006) years after implementa-tion of the curriculum map. Residents were asked to rateeach survey item on a Likert scale from 1 (minimum sat-isfaction) to 4 (maximum satisfaction), with highernumeric scores representing better satisfaction.Descriptive statistics (cumulative frequencies and relativepercentages) were used to describe the content of the cur-riculum map. All scores from the satisfaction surveys werereported as mean ± SD. Post-implementation satisfactionscores were compared with baseline using 2-tailed,unpaired t tests, and differences were considered signifi-cant when p value < 0.05. All analyses were performedResultsThe inaugural 3-year cycle of the AHD curriculum mapincluded 283 scheduled hours. A total of 208 topics werecovered, all of which (100%) represented core competen-cies in internal medicine.Duplication of topics was minimal: most topics (163 or78%) were covered once during the 3-year cycle. Therewere 30 topics (14%) that were covered twice in 3 years(e.g. general discussion on biomedical ethics, endocrineemergencies, thrombophilic conditions, HIV workshops,breast cancer, pulmonary function, etc.), and 11 topics(5%) were covered 3 times (e.g. acute coronary syndrome,diabetes mellitus, gastrointestinal bleeds, physical exami-nation workshops, electrocardiography workshops, acidbase disorder workshops, etc.) Two topics were covered 4times in this formal curriculum cycle: sepsis/septic shockmanagement, and the dermatologic manifestations of sys-temic disease. The topic on the principles of evidencebased medicine was covered 5 times in 3 years.The format of most AHD hours (241 or 85%) involveddidactic activities, with the remaining 42 hours (15%)involved non-didactic teaching (such as physical exami-nation workshops, case-based sessions, etc.). The latterincreased substantially after implementation of the curric-ulum map, from 5 hours in 2003–2004, to 19 and 18hours in 2004–2005 and 2005–2006 respectively.The number of structured teaching hours in each of the 7roles (core competencies) mandated by accreditation issummarized in Table 1. Of the scheduled AHD hours,most (220 hours or 78%) focused on competenciesrelated to medical expertise (Table 1). The remaininghours covered non medical expert competencies in schol-arly activities (16%), management skills (4%) and profes-sional skills (2%). Of note, there was no specific AHDcoverage of competencies on collaboration, communica-tion and health advocacy in this formal curriculum cycle(Table 1). The proportion of AHD hours spent on nonmedical expert competencies increased over time: 19/90(21%) in 2003–2004, 19/96 (20%) in 2004–2005, 23/97(24%) in 2005–2006.Among the 283 scheduled AHD hours, 83 hours (29%) ofwhich involved topics that were tested in the annual ACP-ASIM in-training examination. The percentage of AHDhours covering topics that were examined did not varymuch: 28/90 (31%) in 2003–2004, 29/96 (30%) in2004–2005, 23/97 (24%) in 2005–2006. The specialties/themes with the highest proportion of AHD hours cov-ered and examined were geriatrics (75%), medical oncol-ogy (67%), gastroenterology (63%), and respiratoryPage 3 of 8(page number not for citation purposes)using SPSS 11.0 statistical software package (SPSS Inc.Chicago, IL).(50%) respectively (Table 2). There were 530 topics iden-tified as examined but never covered at AHD, notably inBMC Medical Education 2007, 7:42 http://www.biomedcentral.com/1472-6920/7/42Page 4 of 8(page number not for citation purposes)Table 1: Coverage of medical expert and non medical expert categories during academic half day classified by specialty/theme in a 3-year cycle of the formal curriculum map (2003 to 2006).Specialty Medical Expert Collaborator Communicator Professional Advocate Scholar ManagerAllergy and Immunology 5Biomedical Ethics 5Cardiology 22 6Critical Care 12Dermatology 8Endocrinology 21 3Evidence Based Medicine 18Gastroenterology 17 2General Internal Medicine 8 2 3 4Geriatrics 7 1Hematology 20Infectious Diseases 17 2Maternal Fetal Medicine 9Medical Oncology 9Nephrology 18 2Neurology 15 1Quality Improvement 6Respiratory 17 1Rheumatology 15 3Teaching Skills 4All specialties combined 220 0 0 7 0 46 10The numbers represent hours of coverage in the formal curriculum. The 7 roles (core competencies) are based on accreditation requirements defined by the Royal College of Physicians and Surgeons of Canada (2).Table 2: Specialty topic/theme coverage during academic half day in a 3-year cycle of curriculum map (2003 to 2006).Specialty Hours (%) of topics covered and examined within specialtyHours (%) of topics covered but not examined within specialtyTotal hours (%) of topics covered across all specialtiesNumber of topics examined but not covered within specialtyAllergy and Immunology 1 (20) 4 (80) 5 (2) 1Biomedical Ethics 0 (0) 5 (100) 5 (2) 1Cardiology 8 (29) 20 (71) 28 (10) 38Critical Care 0 (0) 12 (100) 12 (4) 5Dermatology 0 (0) 8 (100) 8 (3) 11Endocrinology 9 (38) 15 (62) 24 (9) 27Evidence Based Medicine 0 (0) 18 (100) 18 (6) 0Gastroenterology 12 (63) 7 (37) 19 (7) 38General Internal Medicine 4 (24) 13 (76) 17 (6) 85Geriatrics 6 (75) 2 (25) 8 (3) 23Hematology 4 (20) 16 (80) 20 (7) 53Infectious Diseases 8 (42) 11 (58) 19 (7) 73Maternal Fetal Medicine 0 (0) 9 (100) 9 (3) 2Medical Oncology 6 (67) 3 (33) 9 (3) 22Nephrology 9 (45) 11 (55) 20 (7) 31Neurology 4 (25) 12 (75) 16 (6) 27Quality Improvement 1 (17) 5 (83) 6 (2) 0Respiratory 9 (50) 9 (50) 18 (6) 45Rheumatology 2 (11) 16 (89) 18 (6) 48Teaching Skills 0 (0) 4 (100) 4 (1) 0All specialties combined 83 (29) 200 (71) 283 (100) 530Examination refers to the ACP-ASIM in-training examination in the respective years.BMC Medical Education 2007, 7:42 http://www.biomedcentral.com/1472-6920/7/42general internal medicine (85 topics or 16%), infectiousdiseases (73 topics or 14%), hematology (53 topics or10%) and rheumatology (48 topics or 9%).While we mainly focussed on evaluating the process ofcreating a curriculum map, we also reviewed resident sat-isfaction surveys that were received for 255 of the total283 hours (90% response rate) in the 3-year formal curric-ulum cycle (Table 3). The baseline satisfaction ratingsprior to implementation of the curriculum map werehigh, ranging from 3.64 ± 0.21 to 3.78 ± 0.16 out of 4.After the first year of implementing the map, satisfactionratings improved in all 5 survey items, and reached statis-tical significance for the items on evidence-based nature,preparedness of the speaker, presentation skills, and ques-tions/discussion raised (Table 3). Interestingly, after thesecond year of implementation, satisfaction ratingstrended back towards baseline values. Of note, the magni-tude of changes over time remained small.DiscussionWe developed and implemented a cyclical curriculummap for our internal medicine residency program basedon real time resident input. The map provided easy visu-alization of structured teaching activities that occurred atAHD, as well as an opportunity to continuously reviewthe format (didactic versus non-didactic) and nature ofteaching (medical versus non medical expert competen-cies). In the first 3-year cycle, all topics covered were rele-vant and represented core competencies, with minimumtopic duplication. The curriculum map allowed any dupli-cation to be reviewed and/or rationalized. Resident satis-faction remained high after implementing the map. Thesefindings appear promising.A curriculum map can identify potential gaps so thatappropriate action can be taken [16]. For instance, only29% of the scheduled hours covered topics that were actu-ally tested in past ACP-ASIM examinations. While we rec-ognized that our AHD should not merely covercompetencies that were tested in the past, and not all com-petencies were testable in a multiple-choice format, wediscovered a substantial number of topics that were exam-ined but never formally covered at AHD, especially in gen-eral internal medicine, infectious diseases, hematologyand rheumatology. These mirrored the same content areaswhere our resident performance in the ACP-ASIM exami-nation was lower. The curriculum map may help to high-light deficiencies in topic coverage within these specialtiesfor future educational planning.Teaching gaps arise within the context of curricularchanges, and the real time nature of the curriculum mappermits ready incorporation of dynamic changes. Forexample, there was no specific AHD coverage of compe-tencies on collaboration, communication and healthadvocacy in the first 3-year formal curriculum cycle,although we were mandated to teach these competenciesby the accreditation bodies. These were relatively newareas in the formal curriculum, which required innovativeand conscientious efforts to teach well. A curriculum mapcan help to unmask competencies that may have becomehidden otherwise [17]. In the new cycle of curriculummap, we have now introduced new theme blocks to focuson competencies of collaboration, communication,health advocacy, as well as other medical content areas ofpalliative care and peri-operative medicine. Anotherexample of change involved the introduction of morenon-didactic, interactive sessions. The majority of ourAHD activities involved didactic teaching using the classi-cal pedagogic method of lectures, which is common ininternal medicine [18]. The curriculum map made it logis-tically easier to track the gradual increase in non-didacticsessions. During the study period, non-didactic hoursincreased substantially after implementation of the curric-ulum map. Adult learners generally learn better with inter-action, and it would be interesting to see this if theinteractive, non-didactic sessions proved to be better ratedthan the didactic ones. Future studies with a larger samplesize are warranted.We realized that AHD could not be the only structuredteaching opportunity to deliver a large internal medicineformal curriculum, and other venues such as noon-hourTable 3: Resident evaluation of academic half day before, during and after formal curriculum changes introduced based on curriculum map.Evaluation Domains Baseline (7/1/2003 – 6/30/2004) n = 79 hoursYear 1 post curriculum map (7/1/2004 – 6/30/2005) n = 89 hoursp value for difference between Year 1 and BaselineYear 2 post curriculum map (7/1/2005 – 6/30/2006) n = 87 hoursp value for difference between Year 2 and BaselineTopic 3.78 ± 0.16 3.82 ± 0.17 0.17 3.70 ± 0.22 0.01Evidence-based 3.65 ± 0.25 3.76 ± 0.18 0.001 3.65 ± 0.26 0.99Preparedness 3.77 ± 0.15 3.84 ± 0.14 0.002 3.73 ± 0.23 0.16Presentation skills 3.72 ± 0.20 3.80 ± 0.16 0.005 3.68 ± 0.26 0.29Questions/discussion 3.64 ± 0.21 3.75 ± 0.20 0.001 3.66 ± 0.28 0.73All satisfaction scores are reported as mean ± SD. Possible score range 1 (minimum satisfaction) to 4 (maximum satisfaction), with higher numeric Page 5 of 8(page number not for citation purposes)score representing better satisfaction.BMC Medical Education 2007, 7:42 http://www.biomedcentral.com/1472-6920/7/42Table 4: A sample portion (General Internal Medicine) of the UBC Department of Medicine Postgraduate Education Curriculum Map.Speciality and Topics 2003–2004 2004–2005 2005–2006General Internal MedicineTopics covered in Academic Half Day:Eating Disorders 1 (ME)Errors as a Learning Opportunity 1 (P)Ethics of Symptom Management 1 (P)Evidence Based Medicine: General Internal Medicine 1 (S)Fever in the Returning Traveller 1 (ME)Hypertension (including Isolated Systolic Hypertension) 1 (ME)Insurance and Introduction to Practice Management 1 (M)Optimization of Drug Therapy in Patients with Liver Disease 1 (ME)Palm Project in Medicine 2 (S)Peri-operative Medicine 1 (ME)Principles of Drug Therapy 1 (ME)Pros and Cons of Being a Community Internist 1 (M)Secondary Hypertension, Laboratory Investigations of 1 (ME)Things They Didn't Teach You in Medical School 1 (M) 1 (M)Toxicology 1 (ME)Topics not covered in Academic Half Day:Anti-obesity drugsAchilles tendonitis – from fluoroquinolone antibioticsAtrophic vaginitisBotulismBrain deathCalculate incidenceCandida albicans InfectionCase control studyCellulitisChlamydia trachomatis infectionChronic catheter-assisted urinary drainageChronic recurrent sinusitisChronic venous insufficiencyComplement cascadeCompression of the lateral femoral cutaneous nerveContact dermatitisDog biteDown's syndrome (risk for atlanto-axial instability)Dupytren's contractureEnd-of-life issuesEpidural abscessEpistaxisErythema multiformeFat-soluble vitaminsGarlic, ginseng and gingko bilobaGenetic DiseasesGlaucomaHeat strokeHereditary angioedemaHidradenitis suppurativaHyperthermiaHypophosphatemiaHypothermiaInnocent cardiac flow murmurIschemic encephalopathyIsopropyl alcohol ingestionKlinefelter's syndromeLactose intoleranceLateral epicondylitisLikelihood ratiosLow back painPage 6 of 8(page number not for citation purposes)LSDMale adolescent with gynecomastiaBMC Medical Education 2007, 7:42 http://www.biomedcentral.com/1472-6920/7/42PalpitationsPatient controlled analgesiaPost-test probabilityPost-traumatic stress disorderPrevalencePreventive medicineProstrate diseasePsoriasisRenal stonesRestless legs syndromeRhabdomyolysisRhinocerebral mucormycosisRisk reduction, absolute – number needed to treatRotator cuff tendonitisScurvySecondary syphilisSerotonin syndromeSerum alkaline phosphatase elevationSexually active homosexual manSinusitis as a cause of halitosisSubconjunctival HemorrhageSplenectomy and medical issuesSymptomatic carotid artery stenosisSymptomatic urinary tract infectionsSystolic heart failureTension headacheTinea pedis and lower extremity cellulitisTravellerUlnar neuropathyUncomplicated low back painTopics are listed in consecutive rows, with the corresponding hours of academic half day (AHD) coverage in columns. All topics are cross-matched against examination objectives from each year's ACP-ASIM in-training examination. The topics are colour coded to indicate those covered and examined (bolded black font), those covered but not examined (non-bolded black font), and those examined but never covered (red font in the original map). The AHD hours are also colour coded to indicate the category of core competencies covered under the CanMEDS 2005 framework, including medical expert (ME, or white boxes in the original map), manager (M, or gold boxes), scholar (S, or rose boxes), and professional skills (P, or grey boxes). In this particular sample map, core competencies in health advocacy (green boxes), communication (yellow boxes) and collaboration skills (orange boxes) have not been covered in the formal curriculum cycle.rounds and special retreats could be deployed to teachsome competencies. We recognize omitting other educa-tional experiences would affect the selection or distribu-tion of topics in the AHD part of the curriculum. In thenew formal curriculum cycle, we have expanded the cur-riculum map to include teaching at these venues. To helpkeep things simple and user friendly, we elected not toinclude topics covered during clinical rotations, althoughthe latter was attempted in a recent study [19].Resident satisfaction was high before and after imple-menting the curriculum map. The satisfaction ratingsimproved modestly after the initial year, suggesting resi-dents viewed positively the changes in AHD as driven bythe curriculum map. It is unclear why the same ratingsreturned to baseline 2 years later. Perhaps by year 2, someof the new residents were never exposed to the baselineAHD experience and therefore had no comparison. Otherpossible explanations include higher resident expecta-tions after the initial changes imposed by the map, or theMalignant external otitisMarked obesityMeniere's diseaseMeningitisMethanol ingestionMorton's neuromaMyoclonusNeurofibromatosisNumber needed to treatObstructive sleep apneaTable 4: A sample portion (General Internal Medicine) of the UBC Department of Medicine Postgraduate Education Curriculum Map. Page 7 of 8(page number not for citation purposes)BMC Medical Education 2007, 7:42 http://www.biomedcentral.com/1472-6920/7/42need for further acceptance and/or fine-tuning for thenewly introduced non medical expert topics. Our observa-tion can also be explained by the Hawthorne effect and/orregression to the mean.Besides satisfaction scores, there are other interesting out-comes as we evaluate the impact of the curriculum maplongitudinally. For instance, the score averages from pub-lic certification examinations can reflect clinical knowl-edge from our residents, although such confidentialinformation is not readily accessible for the residency pro-gram. Future practice choices and career trajectories arealso of interest.Our study findings have some limitations. This is a singlesite formal curriculum and may not be generalizable toother institutions. We reported data from 1 formal curric-ulum cycle, and are therefore uncertain as to whether thesame conclusions noted can be applied to future cycles.The changes in resident satisfaction ratings over time weresmall, probably due to the ceiling effect of the unvalidatedsurvey. Future efforts to validate the survey will be helpful.ConclusionIn summary, we developed and implemented an internalmedicine curriculum map based on real time residentinput. Initial evaluation of this educational tool is prom-ising. This has potential for broader implementation byresidency programs as it highlights the spatial organiza-tion and interconnections between what is taught in theformal curriculum, how it is taught, and when it is taught,all within the context of teaching accreditation require-ments in a finite period of training duration. The curricu-lum map requires ongoing needs assessment, and createsan opportunity of engaging residents to actively partici-pate in their own education.Competing interestsThe author(s) declare that they have no competing inter-ests.Authors' contributionsRYW was the principal investigator of the study, devel-oped and delivered the curriculum map, supervised thedata collection and analysis, and was the principal authorfor the paper. JMR collaborated during the developmentof the curriculum map, reviewed and improved thispaper. All authors read and approved the final manu-script.AppendixAcknowledgementsWe would like to thank Hazel Wilcox, Andrea Toker, and Nicole Stewart for their assistance and the members of the UBC academic half day organ-References1. ACGME outcome project general competencies   [http://www.acgme.org/outcome]. July 21, 20072. Frank JR, ed: The CanMEDS 2005 physicians competencyframework. Better standards. Better physicians.  In Better careOttawa: The Royal College of physicians and Surgeons of Canada;2005. 3. ACGME Program Requirements for Residency Education inInternal Medicine   [http://www.acgme.org/acWebsite/downloads/RRC_progReq/140_im_07012007.pdf]. August 8, 20074. Gopal R, Glasheen JJ, Miyoshi TJ, Prochazka AV: Burnout and inter-nal medicine resident work-hour restrictions.  Arch Intern Med2005, 165:2595-600.5. Koppang A: Curriculum mapping: building collaboration andcommunication.  Intervention in School and Clinic 2004,39(3):154-61.6. 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