CBE Guideline Development

Competency-Based Education

One Specialty’s Collaborative Approach to
Competency-Based Curriculum Development
Diane Kittredge, MD, Constance D. Baldwin, PhD, Miriam Bar-on, MD,
R. Franklin Trimm, MD, and Patricia S. Beach, MD

Abstract
The authors describe a seven-step incorporation of up-to-date information collected for the 2004 edition,
consensus development process used to from the literature and national experts, demonstrate that both editions have
create the two most recent editions of (4) responsive consultation with the been used by most residency programs
the Academic Pediatric Association’s national Pediatric Residency Review throughout the country. The authors
(APA’s) educational guidelines for Committee on the latest accreditation believe that the multifaceted approach
pediatric residency. The 1996 (printed) requirements, (5) wide distribution for to consensus development and the
and 2004 (online) editions of the prepublication review, to obtain broad customizable design of the curricular
guidelines were designed as flexible organizational buy-in and end-user tools in the APA’s guidelines are directly
tools to help residency programs meet acceptance, (6) intensive dissemination associated with their broad national
changing accreditation requirements by and faculty development through
use. These methods may help to guide
providing lists of goals and objectives multiple national workshops over several
educators in other disciplines who are
and objective-based evaluation tools. The years, and (7) careful evaluation of
interested in developing and
guidelines were developed in seven utilization and user feedback.
implementing educational products for
steps: (1) centralized national leadership Representatives of all major
national dissemination and use.
combined with coordinated, organizations involved in pediatric
disseminated authorship, (2) clear education helped to refine the Acad Med. 2009; 84:1262–1268.
definition of targeted users and repeated guidelines. User surveys conducted for
assessment of their needs, (3) the 1996 edition, and Web site user data

S ince 1983, the Academic Pediatric changing environment of clinical experiences and normal newborn
Association (APA) has engaged pediatric medicine and medical education.1–3 rotations for medical students and
educators nationwide in the collaborative Pressure to develop a better-articulated residents.8 In 1996, the APA completely
development of three successive editions and more structured approach to rewrote the 1985 edition and published
of educational guidelines for residency residency training led to revised an expanded Educational Guidelines for
training. Each edition of these guidelines accreditation standards for residencies. Residency Training in General Pediatrics.2
was shaped in purpose and scope by the In 1997, the Accreditation Council for This edition provided the first
Graduate Medical Education (ACGME) comprehensive set of learning goals and
mandated the use of written goals and objectives for the education of general
Dr. Kittredge is professor of pediatrics, Dartmouth objectives for residency curricula.4 Later, pediatricians across all three years of
Medical School, Hanover, New Hampshire. the ACGME focused on strengthening postgraduate training. Finally, in 2004,
Dr. Baldwin is professor of pediatrics, University of the evaluation of residents and required updated APA Educational Guidelines for
Rochester Medical Center, Rochester, New York. programs to certify residents’ Pediatric Residency were published on
Before 2005, she was professor, Departments of competence in six competency domains an interactive Web site.3 This edition
Pediatrics and Family Medicine, University of Texas
Medical Branch, Galveston, Texas. by the completion of their training.5–7 offers residency programs a resource
These changes challenged programs in all for building their own customized,
Dr. Bar-on is associate dean for graduate medical
education and professor of pediatrics, University of
medical disciplines to improve their competency-based curricular
Nevada School of Medicine, Reno, Nevada. Before curricula. documents, using interactive tools and a
2006, she was professor of pediatrics, Loyola comprehensive database of goals and
University Stritch School of Medicine, Maywood,
Illinois.
The APA addressed these challenges objectives.
by developing a curriculum resource
Dr. Trimm is professor of pediatrics, University of for pediatric residencies that evolved In this article, we describe the seven-step
South Alabama College of Medicine, Mobile,
Alabama. over three editions to become a national consensus development process
comprehensive and flexible set of used to create the 1996 and 2004
Dr. Beach is professor of pediatrics, University of
Texas Medical Branch, Galveston, Texas. In 2001, she tools. In 1985, the APA published the Guidelines and develop a community
joined the team that helped prepare the educational first edition of the guidelines, of Guidelines users. The Guidelines
guidelines discussed in this article. Educational Guidelines for Training in developers were influenced by a national
Correspondence should be addressed to Dr. Kittredge, General/Ambulatory Pediatrics,1 which climate of collaboration around shared
Department of Pediatrics, Dartmouth Hitchcock outlined a minimum core of pediatric curriculum development that was visible
Medical Center, 1 Medical Center Drive, Lebanon, NH
03756; telephone: (603) 653-6041; fax: (603) 653- knowledge, skills, and attitudes that in projects reported by several disciplines
6050; e-mail: (diane.kittredge@hitchcock.org). should be taught in ambulatory in the 1990s. The Society of Teachers of

1262 Academic Medicine, Vol. 84, No. 9 / September 2009


Family Medicine (STFM) created a The Collaborative Development centralization of control was essential.
collaborative family medicine clerkship Process: Key Steps and Lessons The core team developed templates and
curriculum in 19909; a pediatric clerkship Learned instructions for the section editors
curriculum was published in 1995 by the The collaborative development processes and reviewed and combined all the
Council on Medical Student Education used to develop the 1996 and 2004 documents to ensure consistency in
in Pediatrics (COMSEP)10 –11; and an editions of the Guidelines were similar. format and language across all sections.
internal medicine clerkship curriculum The seven steps of this process are This was especially important for the
was published in 1995 by the Clerkship described below and summarized in complex tasks of Web site design,
Directors in Internal Medicine.12–14 Table 1. In this article, we will focus database construction, and development
Collaborative curriculum development is mainly on development of the 2004 of new curricular tools. These jobs were
a common method of the STFM, which edition, which updated the content of the most efficiently conducted by a small,
resembles the APA in its practice of 1996 edition and added subspecialty goals focused group.
networking around national projects.15–18 and objectives. This edition is built on a
Step 2: Clear definition of targeted users
Use of a highly collaborative process for large database of 334 goals with objectives
and repeated assessment of their needs
the Guidelines was appropriate because the that can be accessed dynamically on the
goal was to develop a flexible product that Web; lists of goals and objectives can be Process. Needs assessment surveys were
all residency programs could readily adapt selected for every residency experience conducted before and during the
to their own needs. Creation of a and downloaded as customizable development of both the 1996 and 2004
standardized, prescriptive curriculum documents. The Web site also includes Guidelines editions, to ensure that the
onscreen instructions, curricular tools content served the needs of a broad group
resource was not considered a useful end
such as customizable evaluation forms of potential users and to enhance end-user
point. This same strategy of flexibility was
and templates for rotation planning, acceptance.
adopted by the Clerkship Directors in
and six tutorials on how to build
Internal Medicine for their curriculum.14 Surveys of pediatric program directors
competency-based curricula that are
downloadable for local adaptation. conducted in 1993, 1996, and 1999 pointed
Carole Bland and colleagues, in an
19
out discrepancies between residency
influential article published in 2000, Step 1: Centralized, national leadership program performance and current
described 35 features of successful combined with coordinated, accreditation requirements. These data
curricular change in medical schools disseminated authorship helped the team define the utility, content,
which were drawn from a careful review and scope of the resources under
Process. All editions of the Guidelines
of the educational and business literature. development. For example, the 1999 survey
were official projects of the APA
Her process includes numerous elements on programs’ uses of the 1996 Guidelines
Education Committee. The Guidelines
that resemble our collaborative process— identified demand for a more flexible, easy-
project director for the 1996 and 2004
for instance, creation of a cooperative to-customize document that could be
editions (D.K.) was chair of the education
climate, broad participation, strong committee from 1992 to 1995. For both accessed online. Hence, the 2004 edition
communications, formative evaluation, editions, about 50 educators were divided was designed to be interactive at its point of
training support, and effective guiding into writing and review subcommittees. access, so programs could select needed
leadership— but she was not describing a Hence, the Guidelines were “owned” tools and customize them after
curriculum development process that from the start by a large group of leaders downloading. The survey also showed that
crossed institutional borders. Our project in pediatric education, who not only the previous edition was more useful for
was particularly ambitious because it contributed their expertise in the generalist than subspecialty rotations, so
was designed to serve more than 200 development and refinement process extensive subspecialty content was added.
residency programs and to address the but also were able to assist with Finally, because the survey showed that new
full scope of three years of residency dissemination of the final product. ACGME requirements were still very
training. None of the national challenging to many programs, tutorials
collaborative projects mentioned In 2000, substantial funding to produce and program planning and evaluation tools
above have described their the 2004 edition enabled formation of a were added.
national advisory board to garner the
development process in clear steps with
support of pediatric subspecialists and The core team also used workshops to
sufficient detail to help other groups
to facilitate an efficient nationwide gather continuing needs assessment data.
implement their methods.
collaborative process. The core team To guide development of the 2004 edition,
recruited 10 section editors from the APA workshops were conducted in a computer
Therefore, we wrote this article to
Education Committee to manage writing classroom, so users could try out the Web
describe a national consensus and review of content revisions. Other site interface, sample objectives in the
development method that might serve as contributors were members of the APA Guidelines database, and suggest ways to
a useful model for other disciplines. We and/or other organizations, or they were make the resource more useful.
also demonstrate wide utilization of the paid consultants on competency-based
Guidelines, and we hypothesize that the accreditation, project evaluation, and Lessons learned. Cycles of needs
systematic collaborative development of computer programming. assessment were essential to make the
this shared resource and its customizable product as responsive as possible to the
format have enhanced its acceptance, Lessons learned. While the revision needs of educators “in the trenches,”
usefulness, and broad dissemination. process was intensely collaborative, especially because they were working in

Academic Medicine, Vol. 84, No. 9 / September 2009 1263


Table 1
Collaborative Development of the Academic Pediatric Association’s Educational
Guidelines for Residency Training: Key Points and Lessons Learned*

Collaborative process step Purpose of step Key points and lessons learned
Step 1: Centralized national • Efficiently coordinate a nationwide • Central leadership was especially important for the
leadership combined with collaborative process complex tasks of Web site design, database construction,
coordinated, disseminated and development of new curricular tools.
authorship • Dissemination offered a range of content expertise
representing end-user groups and enhanced buy-in.
...................................................................................................................................................................................................................................................................................................................
Step 2: Clear definition of targeted • Create immediately useful product • Needs were measured before, during, and after the
users and repeated assessment of project to guide both planning and implementation.
their needs • End-user input facilitated meeting of end-user needs.
• Multiple methods of data collection, including face-to-
face feedback during pilot testing, were used.
...................................................................................................................................................................................................................................................................................................................
Step 3: Incorporation of up-to-date • Align content with latest, best evidence • National experts, as well as the literature, were used to
information from the literature and help identify latest and best evidence regarding medical
national experts content and educational process.
• Step 3 increased content validity.
...................................................................................................................................................................................................................................................................................................................
Step 4: Responsive consultation • Align curricular content with residency • Alignment with requirements of the Accreditation
with the national Pediatric program needs Council for Graduate Medical Education (ACGME) was
Residency Review Committee on critical to later use of the resource, BUT:
the latest accreditation • It was important to avoid acting as a mouthpiece of the
requirements ACGME and to serve as an advocate for faculty.
• The resource was not dated by too-close adherence to
changeable requirements.
• All semblance of prescriptiveness was avoided.
...................................................................................................................................................................................................................................................................................................................
Step 5: Wide distribution for • Tap expertise nationwide to refine product • This was a low-cost, effective way to test innovations,
prepublication review, to obtain and enhance user buy-in garner support, disseminate the product, and enlist future
broad organizational buy-in and • Develop visibility and buy-in by professional users.
end-user acceptance organizations
...................................................................................................................................................................................................................................................................................................................
Step 6: Intensive dissemination and • Enhance wide visibility and utilization • Hands-on workshops were critical for beta-testing and
faculty development through refinement of tools.
national workshops • Encourage and guide use • This was a powerful, low-cost approach to faculty
development.
...................................................................................................................................................................................................................................................................................................................
Step 7: Careful evaluation of • Refine the products • Collection of data was carried out using multiple
utilization and user feedback strategies (surveys, Web usage reports).
• Enhance user buy-in and satisfaction • Evaluation by actual users of specific product functions
was more informative to developers than global surveys.
* The table summarizes key features and lessons learned by the authors in the development of the Academic
Pediatric Association’s educational guidelines.2,3

the context of rapid change and new Lessons learned. This step is essential to team to address current and upcoming
demands. Workshops served as focus earn credibility for a curricular resource. faculty needs, even before revised RRC
groups and taught the development The amount of content to include in the requirements were published. For
team more than mailed surveys did final product was an issue that we and our example, in developing the 2004 edition,
about specific user needs and reactions targeted users debated extensively. We learning objectives from the 1996 edition
to individual Guidelines components. decided, as did the internal medicine were revised by modifying the verbs to
clerkship curriculum task force,14 that reflect performance (e.g., “analyze” and
Step 3: Incorporation of up-to-date making our resource comprehensive rather “manage” rather than “discuss” and
information from the literature and than abbreviated would facilitate local “explain”). Customizable evaluation tools
national experts adaptation, even though the large volume were developed that could be built
Process. During the 1996 Guidelines of information could be overwhelming. around a program’s selected list of
development, the editorial team learning objectives and, thus, be specific
conducted an extensive review of the Step 4: Responsive consultation with the and competency-based. Templates for
literature on curriculum content, national Pediatric Residency Review program and rotation planning were also
drawing on expert opinion about medical Committee on the latest accreditation created to help program directors
content and educational methodologies. requirements
organize their responses to new ACGME
For the 2004 edition, the core team and Process. Throughout the development requirements.3
its consultants also reviewed literature on process for both editions, members of the
educational change, competencies, national Pediatric Residency Review Lessons learned. Consultations with
evaluation processes, and faculty Committee (RRC) informed the APA and the RRC were essential to adjust the
development. Further content refinement other organizations about anticipated Guidelines to users’ needs. However, the
resulted from the extensive expert review changes in accreditation requirements. team learned that keeping some distance
process described in Step 5, below. This knowledge enabled the Guidelines from the RRC was important, given the



frustrations felt by educators during workshops and e-mail queries facilitated users were pediatric generalists. The
those years of rapidly changing ACGME by links to online materials to review. major limitations to use of the Guidelines
requirements. We carefully disclaimed a Modern information technology has were reported to be lack of time,
prescriptive intent for the Guidelines greatly reduced the time and expense of resources, and faculty support. Although
and consistently encouraged local this activity. few considered the format (14; 8%) or
customization of the resources provided. content (2; 1%) to be a limiting factor,
Step 6: Intensive dissemination and written comments indicated that the
Step 5: Wide distribution for faculty development through national document was intimidating in volume,
prepublication review, to obtain broad workshops and many respondents suggested online
organizational buy-in and end-user publication.
Process. The 1996 and 2004 Guidelines
acceptance
have been distributed free of charge and
Process. The APA Board and the core widely publicized in 14 well-attended In October 2005, 18 months after
Guidelines team recognized the value of a national workshops. In 2000 and 2007, publication of the 2004 Guidelines,
national consensus-building effort pediatric residency programs were members of the APA, Association of
around development of the Guidelines. invited to showcase their own innovative Pediatric Program Directors (APPD), and
The 1996 edition went through three curriculum development activities that Society of Adolescent Medicine were
drafts, and at each step broad input was implemented the Guidelines. In 2003 and surveyed using a commercial Web survey
sought from APA members and other 2004, live demonstrations using a tool (SurveyMonkey; http://www.
groups, including subspecialists and portable computer laboratory gave SurveyMonkey.com; accessed May 21,
academic leaders. A prepublication draft participants the opportunity to explore 2009). Replies were received from 582
was distributed in advance to participants new Web site functions and give instant respondents, who represented 171 of 204
at a national workshop, generating feedback, and helped the core team (84%) ACGME-approved residency
valuable practical feedback. A formal recruit beta-testers for more extensive programs. The data showed that 149 of
external review by all the major pediatric explorations. training programs (73%) were aware of
organizations involved in education the Guidelines and that 106 (62%) had
took place prior to publication. The both logged onto the Web site and used
Lessons learned. Faculty development is
APA explored the need for formal the Guidelines; many said they were likely
one of the cornerstones of educational
endorsement of the document from to return at a later time for further use.
change. While users like self-directed
leadership organizations within The majority of respondents did not
online tutorials,20 interactive workshops
pediatrics, but these groups deemed report significant barriers in using the
encouraged educators to use the
formal approval to be unnecessary, Web site, but 145 (about 25%) of users
Guidelines creatively and share what they
because they had been involved in the commented on long downloaded
had learned. These low-cost workshops
development process, and because the documents and difficulty manipulating
informed potential users about the
product was intended to be a flexible tool the tables.
resource, taught them how to use it,
for local adaptation, not a prescription helped to win their acceptance, and
for curriculum change. In December 2007, we extended this
gathered their feedback so the tools could
preliminary survey by evaluating online
be optimized to meet educators’ needs.
For development of the 2004 edition, a use of the 2004 Guidelines by registered
We believe that the personal contact
similar national consensus process for users between July 2005 and December
achieved in workshops was instrumental
content review was formalized through 2007. A total of 1,747 registered Web site
in making the resource more “friendly”
the national advisory board. A new users came from 47 states and 33 foreign
to users.
challenge was developing users’ countries and represented all pediatric
acceptance of and comfort with the web- residencies approved by the ACGME in
Step 7: Careful evaluation of utilization 2008. In all, 8,754 files had been
based platform. Guidelines section editors
and user feedback downloaded by 188 of a total of 194
served as alpha-testers, and we recruited
beta-testers at annual workshops and Process. During development of the residency programs (97%). Our
computer laboratory demonstrations. 1996 and 2004 Guidelines, we surveyed companion study by Beach and
Beta-testing was conducted in cycles users repeatedly to measure their use of colleagues,20 published in this issue of
throughout two years as new functions the Guidelines and gather information Academic Medicine, provides more detail
were completed. Feedback from on satisfaction, barriers to use, and on how these users implemented the
reviewers and workshop attendees led to suggestions for improvement. The results online resources.
significant revisions of some Web site are summarized in List 1.These
components and the addition of several evaluations were approved by Dartmouth Lessons learned. Evaluation data
new tools. Medical School’s IRB. collected from users provided critical
information to help us improve the
Lessons learned. Prepublication review To prepare for the 2004 edition, Guidelines during development. An
has been included in the development of questionnaires mailed to educators at online survey tool vastly simplified the
many national curricular resources. We all 195 ACGME-approved pediatric process of gathering these data, compared
found that it was an effective way to test residency programs (in 1999) yielded 170 with mailed surveys, but data collected
innovations, garner support, and enlist responses (program response rate, 87%). directly from the Web site were far
future users. This process is relatively Among all programs, 131 (77%) reported more representative of users. Getting
inexpensive when conducted using that they had used the Guidelines; most overloaded program directors to respond



of specific Guidelines tools by those who
List 1 had used them.20
Use of the 1996 and 2004 Editions of the Academic Pediatric Association’s
Educational Guidelines for Residency, as Reported by Survey Respondents and
Site Users* Discussion

The 1996 Guidelines2: Model of collaboration
The survey and respondents The collaborative development of
the Guidelines is consistent with
• Survey mailed November and December 1999 to 195 programs, which included all APPD listed
pediatric residency programs in 1999. organizational practices first introduced
in the business world. Peters and
• 170 programs (87%) responded.
Waterman,21 in In Search of Excellence:
• 151 programs (77%) responded that they had used the guidelines. Lessons From America’s Best-Run
Sample of written comments on needs Companies, emphasize the importance
• Needs more specificity of staying close to the customer, listening
to users, and promoting intense
• Needs a functional index
communications within an
• Needs online format to allow updates organization—all principles that were
Sample of written evaluation comments reflected in our collaborative process.
They also describe the value of
• Objectives lack detail
“simultaneous loose-tight properties,”
• Too much material in objectives that is, a combination of central control
• Guidelines facilitated development of required curriculum with reasonable investment of and disseminated freedom of action,
resources which also typified our process. Day22
• For next step, please develop materials to facilitate teaching and implementation wrote that the value of a business should
• Was useful to develop ideas for grant writing be anchored in value offered to the
customer, and Kotter’s23 eight steps for
• In RRC preparation, guidelines helped us add more structure and substance to existing
the change process emphasize the
curriculum
importance of coalition building and
The 2004 Guidelines3: communication. Our goal was to build
The survey and respondents not only a set of tools and resources but
• Survey mailed October and November 2005* to 204 programs, which included all pediatric also a community of Guidelines users
residency programs on the ACGME-approved list for 2005. who initially contributed to the
• 171 programs (84%) responded. development of document content and
Web site design and who later shared
• 127 programs (62%) responded that they had used the guidelines.
ideas about how to implement the
Sample of written evaluation comments Guidelines in their programs. In our view,
• I wish the “build your own” selections were more concise to avoid excessive editing after our most effective community-building
download technique was conducting national
• Standard predesigned goals and objectives were too short, but the “build your own” tables workshops; these simultaneously
were too lengthy monitored user concerns, elicited
• It is a wonderful resource and really helped us revise goals and objectives in competency format formative feedback, and provided faculty
development.
• Exceedingly helpful in giving my subspecialists ideas for goals, objectives, and ways to redesign
their rotations with competence in mind Our collaborative process also drew on
• I could never have gotten started building competency-based evaluations without the guidelines methods used by several concurrent
site national curricular development projects.
• I greatly appreciate the tutorials for faculty Development of the national curricular
guidelines for family medicine
• Fellowship directors have taken to this site and like its ease of use
clerkships10 was funded by the Bureau of
The 2004 Guidelines: Site User Data, May 2005 Through December 2007 Health Professions (BHPr) and published
• Users of Web site from May 2005 through December 2007 were from 194 programs. in 1991. This project balanced central
• These programs represented 100% of all ACGME-approved programs for 2008. control, provided by the BHPr, with
disseminated review, facilitated by an
• Site registrants from 188 programs (97%) downloaded files from the Web site. (No written
comments are available.) advisory committee of representatives
from national organizations with an
* The survey was carried out 18 months after initial publication of the guidelines Web site in May 2004, and 6 interest in family medicine education.
months after completion of site refinements in May 2005. (Superscripted numbers 2 and 3 refer to references 2
and 3 in the reference list.) We also drew inspiration from the
COMSEP curriculum, which was also
supported by the BHPr and published in
to surveys has become increasingly collection worked best: we harvested 1995. This project employed an advisory
difficult over the past decade. We decided utilization data from the Web site, and committee, conducted two national
that a combined approach to data supplemented these data with evaluation surveys, and used an iterative process of



review by its future constituency.10 –11 A implementation, and evaluation. Our argue that our collaborative development
1995 clerkship curriculum for internal process was consistent with all six of process, our customizable design, and
medicine was also developed Glassick’s27 criteria for the evaluation of our scholarly approach were probably
collaboratively.12 This BHPr-funded educational scholarship. The project additional important contributors to the
development project, like ours, included team widespread use of the product.
a collaborative process, an advisory
• set clear goals for the project, carefully A causal connection between
board, and national surveys of clerkship
identifying our purpose and our collaborative development and
directors to help define curriculum
targeted end-users in advance; widespread use of the Guidelines may be
content.13–14 Although these projects, and
others published more recently,24 –25 • made adequate preparation by implied by these associations, but it
collectively included methods which we conducting needs assessments and cannot be proven by the data available at
adopted or adapted, none of them has literature reviews and consulting with this time. However, evaluation data from
published a well-articulated model to RRC members and other experts; other national collaborative projects
disseminate their approaches to other suggest similar associations. In pediatrics,
groups. • used appropriate methods for team for example, the collaborative COMSEP
building, collaborative development curriculum for medical students10 was
and review, evaluation, faculty used by 90% of all U.S. medical schools.11
Model of developmental flexibility
development, and dissemination; The Web-based CLIPP project,28 –29
The project’s emphasis on flexibility in which recruited more than 100 faculty
curriculum design reflects developmental • demonstrated significant results through
surveys, focus groups, and online data nationwide to author and peer review 31
approaches to innovation and the teaching cases for pediatric clerkships, is
evaluation of innovations that have collection;
now licensed by more than 75% of U.S.
evolved in industry during the past 20 • used effective communications, through medical schools and used by more than
years. Peters and Waterman,21 and also workshops and publications, to keep 12,000 students (Leslie H. Fall, MD,
Collins and Porras,26 advocate methods targeted users apprised of project associate professor of pediatrics,
that avoid restrictive traditions and status, new online functions, evaluation Dartmouth Medical School, personal
hierarchical power structures so that results, and implementation ideas; and communication, May 2008). Many
organizations can adapt to unexpected educators recognize the “not invented
environmental challenges and • engaged in reflective critique to examine
here” phenomenon, which typically
opportunities. The Guidelines were our work before, during, and after
limits the dissemination of educational
created in a rapidly and radically publication of the Guidelines.
innovations across institutions. That
changing world of education and clinical these three educational projects have
This process led to many enhancements
practice. We designed them to help all succeeded in overcoming this
of the Guidelines as we worked to build
residency programs deal with evolving parochialism may be attributable at least
innovative tools to meet evolving
changes by (1) developing the document in part to their collaborative
needs—inventing, testing, and refining at
by a collaborative process that engaged development.
each stage of the development process.
the intended users in a dynamic fashion,
and (2) making the document flexible Widespread usage The 1996 and 2004 editions of the
and adaptable, rather than prescriptive. Guidelines were created with generous
For the 2004 edition, technological Although our usage data are support from a large number of pediatric
innovations enabled us to create a highly impressive—188 programs (97%) have educators from within and outside the
flexible resource that surpasses many used the 2004 edition—we recognize that APA. We believe that our effort garnered
available Web-based educational tools by self-reported use of the tools via surveys national participation and enjoyed wide
offering users choices for selecting the and Web site usage data cannot measure acceptance at least in part because it was
content and the format of curriculum how programs actually applied the tools carefully planned and conducted with
documents. For example, educators can they obtained from the Guidelines. Nor extensive input from intended users and,
build a customized list of learning can these data tell us how well the therefore, met their immediate need to
objectives for a rotation and then insert Guidelines helped faculty integrate move toward competency-based
those objectives into custom-formatted competencies into their programs. To educational models with flexible tools
evaluation tools, in order to meet the address such key questions, more suitable for local adaptation. Our
requirements of competency-based comprehensive outcome studies will be collaborative model, with its emphasis
education. We believe that in today’s needed. Residents’ competence at the end on developmental flexibility and
challenging world of health professions of training and after entry into practice customizable products, attention to
education, developmental and will be the best measure of the real faculty development, and adherence to
interactive, user-driven approaches to effectiveness of our educational resource, the scholarly criteria of Glassick, may
innovation have great value to offer. the basis of an important study that is prove useful in other settings and for
beyond the scope and time frame of this other disciplines.
project.
Scholarly approach
Another factor that may have enhanced The urgent need for curricular resources Acknowledgments
dissemination and utilization of the to meet changing RRC requirements The authors of this article acknowledge the
Guidelines was our use of a systematic, probably drove the extensive use of the generous assistance of individuals representing
scholarly approach for development, 1996 and 2004 Guidelines, but we would many pediatric organizations in refining the



1996 and 2004 editions of the Guidelines. 6 Carraccio C, Wolfsthal SD, Englander R, cfm?event c.beginBrowseD&clear
These include the American Academy of Ferentz K, Martin C. Shifting paradigms: Selections 1&criteria curriculum%
Pediatrics, APA, APPD, American Board From Flexner to competencies. Acad Med. 20resources%20project#156). Accessed May
of Pediatrics, Association of Medical School 2002;27:361–367. 21, 2009.
Pediatric Department Chairs, COMSEP, the 7 Sectish TC, Zalneraitis EL, Carraccio C, 18 STFM Group on Faculty Development.
Federation of Pediatric Organizations, Pediatric Behrman RE. The state of pediatrics residency Faculty Development Resources. 2nd ed.
RRC, Society of Adolescent Medicine, and training: A period of transformation of Available at: (http://www.fmdrl.org/index.
Society for Developmental and Behavioral graduate medical education. Pediatrics. 2004; cfm?event c.beginBrowseD&clearSelections
Pediatrics. The authors also wish to thank the 114:832– 841. 1&criteria faculty%20development#2263).
8 Sahler OJZ, Lysaught JP, Greenberg LW, Accessed October 27, 2008.
hard-working chapter editors of the 1996
Siegel BS, Caplan SE, Nelson KG. A survey of 19 Bland CJ, Starnaman S, Wersal L, Moorhead-
Guidelines as well as the many contributors and
undergraduate pediatric education: Progress Rosenberg L, Zonia S, Henry R. Curricular
reviewers. Special thanks are offered to our in the 1980s? Am J Dis Child. 1988;142:519 –
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9 National curricular guidelines for third-year
provided guidance throughout development of 20 Beach PS, Bar-on M, Baldwin CD, Kittredge
family medicine clerkships. The Society of
this edition, under the able leadership of Kenneth Teachers of Family Medicine (STFM) D, Trimm RF, Henry R. Evaluation of the use
Roberts; and the loyal and indispensable section Working Committee to Develop Curricular of an interactive, online resource for
editors for the 2004 Guidelines. Guidelines for a Third-Year Family Medicine competency-based curriculum development.
Clerkship. Acad Med. 1991;66:534 –539. Acad Med. 2009;84:1269 –1275.
10 Ambulatory Pediatric Association; Council 21 Peters TJ, Waterman RH. In Search of
The projects described in this article were
on Medical Student Education in Pediatrics. Excellence: Lessons From America’s Best-Run
supported by the Academic Pediatric Association
General Pediatric Clerkship Curriculum and Companies. New York, NY: Harper and Row,
(1992–2007); the DHHS, Bureau of Health
Resource Manual. McLean, Va: Ambulatory Publishers, Inc.; 1982.
Professions, Contract 103HR940857 (1994 –1995); 22 Day GS. Market Driven Strategy: Processes
Pediatric Association; 1995.
the American Board of Pediatrics Foundation for Creating Value. New York, NY: The Free
11 Olson AL, Woodhead J, Berkow R, Kaufman
(1996); the Pfizer Foundation (2000 –2001); and NM, Marshall SG. A national general Press; 1999.
the Josiah Macy Jr. Foundation (2002–2004). pediatric clerkship curriculum: The process 23 Kotter JP. Leading Change. Boston, Mass:
of development and implementation. Harvard Business School Press; 1996.
Pediatrics. 2000;106(1 pt 2):216 –222. 24 Carroll RG. Design and evaluation of a
12 CDIM-SGIM Core Medicine Clerkship national set of learning objectives: The
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