Family Medicine Basic Curriculum

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Deputy Minister of Public Health and Services

Directorate of Human Resource Development in Health

National Program for Family and Community Health

Project for the strengthening of the Specialization in Family Medicine.

Basic Curriculum for specialization in Family Medicine in Colombia

February 2014


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Presentation of the Basic Curriculum for Specialization inFamily Medicine

The development process for a basic curriculum aimed at opening and renovating all thespecialization programs in Family Medicine in Colombia, conforms an integral part of the projectto strengthen the postgraduate program, within the context of the National Program for Familyand Community Health that is currently being consolidated by the Ministry of Health and SocialProtection and that includes other actions related to basic and lifelong training, improvingworking conditions regarding practice and fulfilment, as well as organization and harmonizing ofthe attention and service model.

This basic curriculum was designed with the participation of Family Medicine scholars from thesix active programs in this specialization1, and other Universities that are interested inimplementing the program. The process has enjoyed the participation of the Colombian Societyof Family Medicine - -SOCMEF-, health advisor from the National Committee on Quality

Assurance in Higher Education (CONACES - from the Spanish acronym) and has socializedwith the management team from the Vice Ministry of Public Health and Services, delegates fromthe Colombian Association of Universities (ASCUN), the National Ministry of Education, some ofthe Territorial Departments of Health, health insurers (EPS) and Institutions Providing HealthServices (IPS).

According to the agreements subscribed during the process, the specialization programs inFamily Medicine will include at least 70% of this basic curriculum. In designing the basic

curriculum, the profile and professional competences of a Family Physician were taken intoaccount, the components of which were broken down into academic competences. A team ofscholars from the Universidad del Valle2carried out the systematization of the collective designwork in which the six Universities with active programs and a further 11 Higher EducationInstitutions (IES) participated.

This curriculum, from Zurubia's3 proposal, summarises the Hexagonal curricular model4 toguide collective construction.

1Universidad del Valle, Universidad Sabana, Fundacin Universitaria de Ciencias de la Salud (FUCS), Fundacin UniversitariaJuan N. Corpas, Universidad de la Javeriana2 Doctors Carlos Pineda & Liliana Arias, scholars and family doctors from the Universidad del Valle lead this systematization

process.3De Zubira-Samper, J. (1997). Los Modelos Pedaggicos. En D. Z. Julin, Tratado de Pedagoga Conceptual. Bogot D.C.:Fundacin Alberto Merani.4Ibid.


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Figure 1 Hexagonal curricular model

This model includes the following questions for orientation:

Why do we teach? It relates to the sense and objective of education, which is to sayteleological matters (PURPOSE)

What to teachSelection, character, subject hierarchy. (CONTENTS) When to teachStructure and sequence of contents. (SEQUENCE) How to teach The problem of methodology, linked to the relation and role of teacher,

student and knowledge (METHOD) What to teach with Nature and purpose of the media, aids and teaching resources.

(EDUCATIONAL RESOURCES) How are achievements evaluated? Responds to partial or total fulfilment of the

resolutions, the process diagnosis and the consequences derived from it.(EVALUATION)

CURRICULUM

Teaching

What?

Purpose

What for?

Sequence

When?

Didactics

How?

Resources

What with?

Evaluation

Achievements?


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Process of Developing the Curriculum Based on theCompetences Approach

The following elements have been taken into consideration while developing it:

1. Teleological foundation, videlicet, what type of Family Physician do we want to train, underwhat paradigm and based on what epistemological position?

The Family Physician comes about due to two realities: On the one hand, the super-specialization process, the tendency for generalization to disappear, and the super-technificationof medical practice, on the other hand, medicine is broaching new paradigms of

thought and speech, which include General System Theory, cybernetics, complex thought andthe integration of Engel's biopsychosocial model, which acknowledges the complexity of thepopulation's needs, health situation, potentialities. From this conception, training physiciansrequires a critical consideration of the different paradigms regarding the conception of humanbeings and the learning process.

2. Context evaluation, which includes:

Study relating to labour needs of Family Physicians. Analysis of the labour market: Whatkind of physician do employers require?

Comparison of the Family Medicine programs in Colombia and the world

Prospective analysis: social, economic, political, cultural and ecological mega-trends forthe 21st century

Prospective in health problems Investigative tendencies for the 21st century Medicine in the 21st century: The biotechnological convergence Trends in education General trends in medical education Analysis of the national, regional and local epidemiological figures Document review of training of human resources in health, Higher Education, medical

practice and healthcare system standards in Colombia Evaluation of the impact of the graduate

Once these elements have been consolidated, it is possible to move on to discuss moreoperational matters:

3. Definition of the professional profile of the Family Physician we will be training. Attached is a

document that we have developed during this process, with the proposal for the profile for a

Family Physician in Colombia.


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4. Training in competences. Attached is a proposal for the professional competences for a

Family Physician in Colombia.

5. Weighting, content, teaching strategies, sequencing, resources and assessment.

a. Clinical components

i. By stage and problems;

1. Child

2. Adolescent

3. Adult

4. Pregnant woman/sexual and reproductive health5. Older adult

ii. Level of attention (low, medium and high complexity) and

iii. Type of attention: Emergency, hospitalization, outpatient, house-call;

iv. Level of intervention:

1. Primary prevention and promotion of health

2. Screening

3. Complication prevention

4. Treatment

5. Physiotherapy

b. Psychosocial components;

c. Administrative components;

d. Epidemiological - investigation methodology components;

e. Pedagogical components;

f. Integration components (of all of these aspects, what a Family Physician practice

should be like).

6. Pensum: with all the previous information a micro-curriculum is developed.

7. Modalities.The differences that will exist in the dedication of academic credits for each

modality will be defined.

g. Conventional residency

h. Intern modality

i. Service training


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8. Practice scenarios for training:

j. Low, medium and high complexity IPS

k. Community spaces

l. Household -- family environment

m. Other (childcare centres, nursing homes, educational institutions, among others)

However, developing the curriculum by competences implies that the whole curricular process isbased on the professional profile and competences that have been proposed for the FamilyPhysician. The curriculum is organized by modules and evaluation is based on performance.

The methodological processto define the professional profile and competences is thus:

1. Analysis of the teleological definitions and context

2. Formulation of the competence map, incorporating elements of the different existing

programs as well as the recommendations of scholars, students and alumni; as well as

the analysis of labour demand

3. Analysis of competences that have been formulated in the past in other training

programs and organizations. Such competences are suited to the focus of the program

so that it accords with disciplinary, trans disciplinary developments, the labour and

professional environment

4. Submit the competence map to analysis, complementation and validation by a group of

experts in the professional area. This group of experts must also help perfect the

components and drafting of the competences

From July to November 2013, a labour of participative development was carried out with the IESthat impart the specialization in Family Medicine, in order to determine the Profile andProfessional Competences of the Family Physician that Colombia requires, as a platform fordeveloping the basic curricular structure. Returning to the different available input5, this proposalwas jointly developed alongside the Universities6from the group, other IES, and the Ministry ofHealth and Social Protection, with socialization and validation exercises with different

dependencies. The Profile and Professional Competences of the Family Physician were used

5Profile defined for the Latin American Confederacin Iberoamericana de Medicina Familiar and the 2010 WONCA: Arias-

Castillo L., Brand C. Freifer S., Fernndez M.A. with contributions from each of the represented Universities: Universidad delValle, F.C.U.S., Universidad Javeriana de Cali, Universidad Militar Nueva Granada, among others.6The initial group was conformed by the Institutions with active programs in higher education: Fundacin Universitaria deCiencias de la Salud (FUCS), Fundacin Universitaria Juan N. Corpas, Universidad de la Sabana, Universidad el Bosque,

Universidad Javeriana, Universidad del Valle. Other Universities which are interested in implementing the program alsoparticipated: Universidad Industrial de Santander, UDES, Universidad Tecnolgica de Pereira, CES de Medelln, UPTC deBoyac, Universidad del Tolima.


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as a reference framework for developing the academic competences, and the development of

the basic curriculum. Attached is a specific document pertaining to the Profile and ProfessionalCompetences of the Family Physician.

Additionally they will also be used as input for other basic and lifelong training processes, aswell as a benchmark to contribute to the transformation that the focus of health education andservices requires. They will be useful in developing the administrative and academicadjustments required that will allow the practice scenarios to be guaranteed, the transformationof the services, and the placement of Family Physicians in the context of multidisciplinary workgroups focussed on family and community health, considering the differential approachaccording to the needs of the region and specific groups, among other aspects.

Mapping of academic competences

1. Identify the areas of performance, general and specific activities that the professional

context demands with their criteria of excellence, with objective evidence based on

interviews with external experts from different areas of the program.

2. Analyse advances in the profession, reviewing scientific literature to determine present

and future requirements.

3. Specify activities and quality indicators of the professional context and trends of the

profession.

4. The following competences are established:

a. Global competence (performance area)

b. Specific competence (general activities)

c. Competence elements (specific activities)

1. Performance indicators

2. Essential knowledge

Cognitive dimension Actuational dimension Affective-Motivational dimension

3. Required evidence

The process of defining the competences must be as specific as possible. Following is anexample of a competence development:


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a. General activities shall be established for each performance area.

Example:

Performance area: disease prevention

General activities:

1. Detecting risk factors.

2. Prescribe prevention activities as necessary in a relevant, safe and timely fashion.

3. Educate patients, families and community groups.

4. Promote behavioural changes regarding risk factors and habits in the population.

5. Find and interpret the best scientific evidence regarding prevention activities.

b. Several specific activities are specified for each general activity.

General activity:Find and interpret the best scientific evidence regarding prevention

activities.

Specific activity:

Be competent in basic Operating System and data packages (word processor,

spreadsheet and presentations) as well as internet browsers.

Formulate clinical questions that guide the search.

Access the primary medical information search and meta-search engines.

Carry out complete, relevant, efficient, and effective searches for information.

Select reliable information, with solid scientific evidence.

Interpret the validity of the information, judging the methodology of the studies

according to epidemiological and statistical tools.

c. For each performance area, a global competence will be established which

would define a problematizing node within the curriculum.This competence


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is described with a verb that refers to a specific performance; the object of the

action is aggregated and complemented by the finality of the competence and aquality condition.

Performance area: disease prevention

Action to be carried out (verb): Prevent

Object (object or situation on which the action falls): diseases

Finality:in order to maintain the population's health and make a more efficient use of

resources.

Quality condition (general criteria to evaluate the action upon the object): in accord withthe best scientific evidence available and in a way which is safe for the patient.

Global competence: Prevent disease in order to maintain the population's health and

make a more efficient use of resources, in accord with the best scientific evidence

available and in a way that is safe for the patient.

d. Then, for each global competence, we define the competences that conform

it, which correspond with the general activities.The structure of the more

specific and concrete competences is also written using a verb, an object, a finality

and a quality condition.

Global competence: Prevent disease in order to maintain the population's health and

make a more efficient use of resources, in accord with the best scientific evidence

available and in a way that is safe for the patient.

Detect risk factors in order to intervene and lessen risk.

Prescribe prevention activities as necessary in a relevant, safe and timely fashion.

Educate patients, families and community groups on risk factors in order to lessen

risk.

Promote behavioural changes regarding risk factors and habits in the population in

order to lessen the risk.

Find and interpret the best scientific evidence regarding prevention activities.


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e. The next step is to identify competence elements in the specific

competences that make up the global competences.The competenceelements refer to specific activities that make up the general competences.

Find and interpret the best scientific evidence regarding prevention activities.

Be competent in basic Operating System and data packages (word processor,

spreadsheet and presentations) as well as internet browsers.

Formulate clinical questions that guide the search.

Access the primary medical information search and meta-search engines.

Carry out complete, relevant, efficient, and effective searches for information.

Select reliable information, with solid scientific evidence.

Interpret the validity of the information, judging the methodology of the studies

according to epidemiological and statistical tools.

f. Training is oriented using a base of three components which are established for

each competence element: performance indicators (quality indications for the

element in question), essential knowledge (knowledge, procedures and attitudes

required for carrying out the task) and required evidence (specific work a student

must produce to prove they are fluent in the competence element).

Competence element: Carry out complete, relevant, efficient, and effective

searches for information

Performance indicators

o Is able to hand in a report pertaining to searches related to a clinical

question in one day.

o Is able to access the most important and up-to-date articles about the

subject matter.

Essential knowledge:

o Cognitive Dimension

o Actuational Dimension


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o Affective-Motivational Dimension

Required Evidence

o Evidence of knowledge: not required

To reinforce this proposal, the experience of developing the practice of Family Medicine inColombia and the rest of the world, has shown the importance of precisely defining the type ofactivities that a Family Doctor can and cannot carry out. For example:

1. Can a Family Physician (FP) perform medium complexity emergency care?2. Can a FP handle a patient with decompensated CHF without ICU hospitalization

criteria?

3. Can a FP suture traumatic wounds?

4. Can a FP assist in a childbirth without complications?

5. Can a FP carry out prenatal controls for high-risk obstetric patients?

6. Can a FP carry out a lumbar puncture?

7. Can a FP carry out endoscopic procedures?

8. Can a FP carry out a crises intervention?9. Can a FP carry out family therapy?

10. Can a FP develop the ASIS in territorial entities and IPSs?

11. Can a FP plan and carry out training activities?

12. Can a FP diagnose and plan treatment for patients with resistant hypertension?

13. Can a FP manage a healthcare institution?

All these questions assume that the FP would carry out these activities without any

further training.

Glossary

Basic curricular axes: Clearly differentiated major areas of performance of the FamilyPhysician. They do not define specific performances, rather they include them. Even though, inpractice, the Family Physician can simultaneously carry out activities related to several axes,they will be described separately in the curriculum:


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Foundations of Family Medicine

Clinical (biopsychosocial attention)

Investigation and education

Work with communities

Management

The National Ministry of Education (MEN) as expertise in context defines general andspecific competences Specific competences. However, beyond this definition, we mustconsider that the concept of competence is imbued with a certain pedagogical model where therelationship among students, professors and knowledge is configured in a certain way. Abroader conceptualization defines competence as "... the capacity all human beings need inorder to effectively and autonomously resolve life situations. They are based on a profound

knowledge, not just knowing what and how, but knowing how to be a person in a complex,competitive and changing world"7.

Developing the competences is based on the following principles:

Identify the performance areas and the general and specific activities the professionalcontext demands as well as the pertinent excellence criteria. The specific activities theycarry out during their work are recognise within the framework of the curricular axis, andaccording to professional experience, analysis of the labour market and the realities andtrends in the practice of the profession.

These activities are written as an observable and provable action-behaviour. Forexample: "Takes action to prevent disease in order to maintain the population's health

and make a more efficient use of resources, in accord with the best scientific evidenceavailable and in a way which is safe for the patient".

Competences can be classified as:

Basic: independent of the profession, they are for life, but they help develop othercompetences. We find competences that will not be defined in this project: informationprocessing (interpretative, argumentative and proactive), ethical life-project planning,teamwork, time management, leadership, communication skills, mathematics, foreignlanguages, etc. In general, it is not standard practice to include any of thesecompetences in a postgraduate program, as it is considered a given that they have been

acquired already. Generic competences: more general processes related to the fundamental capacities of

a Family Physician, such as, for example, their capacity to fulfil a diagnostic process inan A&E setting or a community diagnosis or coordinating a chronic patient attentionprogram.

7Universidad del Valle. Program in Family Medicine.


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Specific competences: more specific capacities, which are reflected in a specific action

or intervention on behalf of the Family Physician, framed within a general competence.For example, the use and interpretation of instruments in Family Medicine.

Each one of the specific competences has a dimension of knowledge. These dimensions areaccepted in several documents, such as ASCOFAME8, ProyectoTuning9, among others.

Cognitive Dimension (Knowing): They are related to cognitive aspects. Knowledge thestudent must be able to use in their mental processes, related to the use and mastery ofconcepts. In this case, we find, for example, knowledge of statistical concepts in order to beable to critically read scientific articles, or knowledge of the anatomy of the abdomen in order tocarry out a paracentesis, or knowledge of the stages in the life cycle of the individual andErickson crises in order to intervene when necessary.

Aptitude Dimension (Knowing how): They are related to procedural aspects. Skills thestudent presents with specific and measurable behaviour patterns. In our case, these skillscould be, for example: establishing an adequate doctor-patient relationship, carrying out athoracentesis, organizing a community talk.

Attitude Dimension (Knowing how to be): This dimension describes aspects related toattitude, including emotional aspects and values. Among them, we find motivation, respect andcompassion. They are complex traits to measure, but they become patent when observingbehaviour. Respect implies arriving on time; the way patients and colleagues are treated.Commitment can be measured in conduct such as finding help for a patient personally bymobilizing support networks, organizing activities that benefit patients in their free time, among

others.

Evaluation criteria:An evaluation rubric will be drawn up, containing the specific aspects to beevaluated in each dimension of knowledge, their consideration and the criteria for marking themas deficient, acceptable or excellent.

Clinical Training scenarios

Low, medium and high complexity IPS

Type of attention: Emergency, hospitalization, outpatient, operating theatre

Services: internal medicine, paediatrics, urology, ICU, etc.

In the community

Formal: schools, childcare centres, community action, nursing homes

8Seehttp://www.ascofamevirtual.org/index.php/component/content/article?id=89

9Seehttp://www.tuningal.org/es/competencias
http://www.ascofamevirtual.org/index.php/component/content/article?id=89http://www.ascofamevirtual.org/index.php/component/content/article?id=89http://www.ascofamevirtual.org/index.php/component/content/article?id=89http://www.tuningal.org/es/competenciashttp://www.tuningal.org/es/competenciashttp://www.tuningal.org/es/competenciashttp://www.tuningal.org/es/competenciashttp://www.ascofamevirtual.org/index.php/component/content/article?id=89


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Non-formal: home, youth groups, old-age groups.

Teaching - learning & evaluation activities

Didactic strategies that are used for each competence and dimension.

Master-class

Resident presentation

Participative workshop with reading preparation

Clinical case

Problem Based Learning tutoring session

Simulation models (simulated patient, mannequins, software)

Hands-on practice with patients

Virtual platform

Credits

Credit calculation is proposed in concordance with the latest resolution from the Universidad delValle:

Article 3. According to Decree 2376 from 2010 by the Ministry for Social Protection, the totalnumber of on-site hours should not exceed 66 hours per week; this includes theory as well asguided practice and supervised practice.

Paragraph 1. The timetable of on-site activities (theory and practice) should not be over 12hours in a row.

Paragraph 2. Taking into account that shift programming (nocturnal and weekend activity) isvariable and not all weeks are programmed in the same way or with the same shifts; a weeklyaverage will be calculated, in accordance with the number of hours a student caries out in allshifts during the month.Paragraph 3. Since the student that carries out a night shift has the right to compensatoryimmediately they finish the shift, in order to guarantee their physical and mental rest andrecovery, this time must be subtracted from the total number of on-site hours.

Article 4 The total number of independent study hours pertaining to theory activities is 2 hours

for every one on-site hour.

Article 5 The total number of independent study hours pertaining to practical activities iscalculated by dividing the number of on-site hours by 4.

Article 6 The total number of credits is calculated by multiplying the total number of weeklyhours (on-site theory, supervised practice, guided practice, independent study) by the number ofweeks on rotation, and then dividing the total number of hours from the academic period by 48.


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Total weekly hours = # theory activities hours + # supervised practice activities (day and night)

hours + # guided practice (day and night) hours + # independent study (for both theory andpractice activities) hours - # hours compensatory hours

Total hours for the academic period = # total weekly hours * # number of weeks on rotation

Credits = # total hours for the academic period / 48

Family Medicine Basic Curriculum

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