Today I'm going to be talking about curriculum development, or specifically the identification and application of COCATS, the American College of Cardiology Core Cardiology Training Symposium document and curricular recommendations that come from that document. COCATS originates in the mid-90s with the first generation of the core document coming out in 1995 in the Journal of the American College of Cardiology. Since that time, there's been three subsequent revisions, COCATS 2, 3, and 4, the most recent of which was published in 2015. A number of task forces for each portion of cardiovascular disease, cardiovascular medicine, has reached 15 total in the most recent iteration. And these roughly correspond to clinical rotations or domains of cardiology with some degree of overlap. COCATS 4 is the primary consensus reference document for fellowship training in cardiology. And this quote's taken from its introductory statement and serves the purpose of defining the aims of the document, which are to delineate components of competency, define tools to assess training, establish milestones to be met as fellows progress towards independence as clinical cardiologists and competent physicians in the public domain. So as a curricular document, COCATS coexists with the Accreditation Council for Graduate Medical Education or ACGME core program requirements for cardiovascular disease and the American Board of Internal Medicine or ABIM board eligibility requirements. There's some overlap in these documents and one has to be mindful of all three of them, but COCATS is really the primary resource coming from the ACC. New focuses that are shown in COCATS 4 are the following. First is that it employs a competency-based framework, and that specifically is defined as an outcomes-based approach to design, implementation, assessment, and evaluation of an educational program. It also takes the step of defining EPAs or Entrustable Professional Activities for cardiologists. EPAs are activities that patients in the public expect all competent cardiologists to be able to perform. Lastly, it focuses on patient-centric education, taking the prior emphasis away from inpatient or critical care cardiology and building more of an emphasis on ambulatory, consultative, and longitudinal care. COCATS 4 is a guiding curricular document, but it helps to think bigger using an established framework when considering the curriculum. And from this resource in medical education entitled Making a Difference in Curriculum Reform and Decision-Making Processes from 2011, it gives three things to consider. One, consider the whole, not simply the parts. Two, ground the curriculum in theory or evidence. Three, use deliberative and leadership curriculum design processes to achieve input, buy-in, and political support. I'll go through each of these in detail with some examples to follow. First, consider the whole, not simply the parts. Each curriculum as an entity has five key elements. Those are listed over on the right in this diagram taken from the article. Learners, the assessment system, competencies and roles, conditions for learning, and context. And you can see some of the defining characteristics adjacent to each of those ovals on the screen in the diagram. Learners are clearly at the heart of the curriculum. Competence is the central mission of any training program. And lastly, assessment drives the curriculum. In other words, a large amount of time may be spent on the development of an educational curriculum while assessment can sometimes remain underdeveloped. These should really be in alignment as learners will value what is tested and assessed even if the curriculum itself disagrees. Another part of the framework is to ground the curriculum in theory or evidence. There's two examples on the left and center of the screen. Far left is the face page of the original Flexner Report in 1910. Its primary aim was to ground the medical school curriculum across the United States in the basic sciences, which it saw as a uniform, suboptimal system in its current state at the turn of the century. If we were to think about something that might apply to our current state of fellow education, we might think about a theory with some evidence such as Erickson's theory of expertise development using deliberate mixed practice or purposeful practice with feedback. Both of these are examples that focus on forms of teaching and learning, but the real challenge is to find ways to include these frameworks and their evidence in the interpretation planning and execution of your particular curriculum. Next, using deliberative and leadership curriculum design processes to achieve input, buy-in, and political support. This slide highlights a deliberative inquiry approach, which is a systematic approach where a group thinks deliberately about formulating and considering all the alternative perceptions about the problems in a specific educational situation and generates a range of solutions, recognizing that values and belief systems play central roles. So the group should really think about doing the following. They should try to include all the stakeholders and representatives from those groups, take into account the local conditions such as those listed on the prior slide with the diagram of the essential key elements of a curriculum. The group should have knowledge of effective processes of curriculum design. They should be knowledgeable about the nature of the practice. They should consider perspectives out in the national arena, and they should consider the informal or hidden curriculum that coexists with the written curriculum. From a leadership point of view, using deliberate and leadership curriculum design processes, here's two example frameworks when considering leadership curriculum design processes. One is the Cotter example of changing and succeeding under any conditions, otherwise known as Our Iceberg is Melting, if you reference his book, or the Bollman and Diehl reframing organizations model, where they break organizations into four frames, the structural frame, human resources frame, political frame, and symbolic frame. So your group can choose a framework that offers ways of thinking about and implementing curricular change and maintenance. Here's a case example. So for your annual program evaluation, your APE, the program leadership or the program evaluation committee needs to document formal, systematic evaluation of the curriculum at least annually, and it needs to monitor and track the following areas, fellow performance, fellow faculty development, graduate performance, program quality, progress on the previous year's action plan, and in the subsequent slides, I'll show you this case example highlighted in red. So if we go back to our framework and consider the whole, not simply the parts, the PEC needs to think about all available data for consideration of the program's evaluation during the APE. So they orient their approach thinking about the five key elements of the curriculum seen over on the top right. They also have to consider the EPAs, the intractable professional activities for subspecialists in cardiovascular disease derived from the COCATS 4 document, and they really should merge these two thinking about all the data from assessment systems, from end of year surveys, from fellow scholarship, from any additional metrics that take into account the five essential elements of the curriculum. They should ground the curriculum in theory or evidence. And so in this particular example, they choose to focus the program and consideration of the program on fellows' professional identity formation as they become cardiologists, and professional identity formation is a broad category, but the real description of it is below. So as trainees transition to practice by learning how to think, act, and feel like a physician, or in this case, a cardiologist, they internalize the profession's values and norms. They evolve with the melding of their new knowledge and skills and an altered sense of self and through socialization with one's professional peers. They're influenced by mentors and role models. They get exposed to the explicit curriculum, COCATS 4, and the implicit curriculum, which is the curriculum that they live and learn are exposed to each day. And finally, one key point is they learn how to live with ambiguity as they evolve over the course of constructing their professional identity as a cardiologist. Finally, to use the deliberative and leadership curriculum design processes to achieve input, buy-in, and political support, the two examples are shown here with the deliberative in red and leadership in blue. So the PEC uses a deliberative process to include all the relevant stakeholders. Their orientation includes faculty development regarding COCATS and the curricular concepts. And most importantly, they focus on the hidden curriculum and how it aligns or contradicts COCATS and the overall goals. Then the PEC thinks about leadership curriculum design processes, and they choose two frames from the Bowman and Diehl model, the structural frame where they draft a plan to better align the organizational structure of the program, in this case by creating single responsible faculty members as a liaison for each of the COCATS and clinical rotations, and consider the symbolic frame that allows them to describe a plan to reflect on their particular institution's history and achievements to think about their legacy. Who are we? What makes us unique? These are the two questions that they ponder. So in summary, COCATS exists as a curricular document, but the latest revision allows for a focus on fellow competencies and patient-centric education. But in addition to viewing it as a practical roadmap for program directors, they need to consider a broader framework, such as the three parts we discussed, consider the whole, not simply the parts, ground the curriculum in theory or evidence, and use deliberative or leadership curriculum design processes as the fellowship directors evaluate and manage their curriculum over time.

curriculum development

cardiology training

COCATS

competencies

patient-centric education