Living on Site While Renovating; Flexible Instructional Design of Post-Graduate Medical Training

SHOW AND TELL

ABSTRACT

Background: Developing theoretical courses for post-graduate medical training that are

aligned to current workplace-based learning practices and adaptive to change in the ﬁeld

is challenging, especially in (sub) specialties where time for re-design is limited and needs

to be performed while education continues.

Approach: An instructional design method was applied based on ﬂexible co-design to

improve post-graduate theoretical courses in child and adolescent psychiatry (CAP) in the

Netherlands. In four phases over a period of three years, courses were re-designed at a

national level.

Evaluation: Once common vision and learning goals were agreed upon and the prototype

was developed (phases 1 and 2), the ﬁrst courses could be tested in daily practice (phase

3). Phase 4 reﬁned these courses in brief iterative cycles and allowed for designing

additional courses building on and adding to previous experiences in brief iterative cycles.

The resulting national theoretical courses re-allocated resources previously spent on a

local level using easily accessible online tools. This allowed trainees to align content with

their clinical rotations, personal preferences and training schedules.

Reﬂection: The development of theoretical courses for post-graduate medical training

in smaller medical (sub-)specialties with limited resources may proﬁt from a ﬂexible

instructional design method. We consider the potential merit of such a method to other

medical specialties and other (inter-)national efforts to develop theoretical teaching

courses. A longer-term implementation evaluation is needed to show to what extent the

investment made in the re-design proves to be future-proof and enables rapid adaptation

to changes in the ﬁeld.

CORRESPONDING AUTHOR:

Peter K. H. Deschamps

Child and Adolescent

Psychiatrist, Training Program

Director Psychiatry at Karakter,

Academic Centre for Child

and Adolescent Psychiatry

and Educational Researcher

Associated with the Radboud

Health Academy, Nijmegen,

The Netherlands

p.deschamps@karakter.com

TO CITE THIS ARTICLE:

Deschamps PKH, Beugels GMJ,

Dudink J, Frenkel J, Hennus

MP, Hofstra MB, Rutten AX,

van der Schaaf M. Living on

Site While Renovating; Flexible

Instructional Design of Post-

Graduate Medical Training.

Perspectives on Medical

Education. 2024; 13(1): 300–306.

DOI: https://doi.org/10.5334/

pme.1198

PETER K. H. DESCHAMPS

GEKE M. J. BEUGELS

J. DUDINK

JOOST FRENKEL

MARIJE P. HENNUS

MARIJKE B. HOFSTRA

ALEXA X. RUTTEN

MARIEKE VAN DER SCHAAF

*Author afﬁliations can be found in the back matter of this article

Living on Site While

Renovating; Flexible

Instructional Design of

Post-Graduate Medical

Training

301Deschamps et al. Perspectives on Medical Education DOI: 10.5334/pme.1198

BACKGROUND AND THE NEED FOR

INNOVATION

If building a house is a metaphor for instructional design

of education, most methods would advise aspiring

homeowners to acquire land, plan carefully with an

architect, select materials and craftsmen, and start

building a new house from scratch regardless of their

current living situation. In reality, families often ﬁnd

themselves renovating their home while still living on site

due to budget constraints. The latter scenario of gradual

co-design may very well be a metaphor for the ﬂexible

(re)design of courses as part of a postgraduate medical

training, during the ﬂow of training programs in dynamic

professional ﬁelds.

This paper reports a ﬂexible instructional (re)design

method for theoretical courses in post graduate medical

training, which we applied within the medical sub-specialty

of child and adolescent psychiatry (CAP) in the Netherlands.

Recent changes in postgraduate medical training,

including CAP [1], demand more personalized and ﬂexible

training to cultivate adaptable professionals [2, 3]. Evolving

evidence on brain development and on the importance

of mental health resilience and vulnerability for disorders

across the life span needs to be integrated into (child and

adolescent) psychiatry training. Societal workforce shifts

require accommodating part-time schedules of trainees.

Additionally, CAP trainees are encouraged to tailor their

learning, fostering a lifelong learning attitude, while

postgraduate training converges with continuous medical

education, offering, at least in the Netherlands, adjusted

tracks for general psychiatrists entering CAP later in their

careers [4]. Together, these changes in the ﬁeld and context

of CAP pose challenges to clinical educators to re-design

training in CAP, including theoretical courses.

As clinician educators in CAP hold clinical responsibilities

in an already overwhelmed mental health care system,

they have little time and resources for teaching and

re-design of their theoretical courses. Most traditional

instructional design (ID) models include ﬁve or six steps

of design activities that overlap with the overarching

acronym ADDIE [5], referring to: analyze, design, develop,

implement and evaluate. A common example can be

found in Kern et al.’s [6] model for ID including: 1. Problem

identiﬁcation and general needs assessment; 2. Targeted

needs assessment; 3. Goals and Objectives; 4. Educational

Strategies; 5. Implementation; 6. Evaluation and Feedback.

Such an approach provides a structured process for

developing comprehensive curricula in medical education,

focusing on achieving speciﬁc learning objectives through

systematic planning and implementation. However, these

redesign methods do not always ﬁt clinician educator’s

practice. Other ID models are more ﬂexible, iterative,

based on co-design with stakeholders and increasingly

embedding technology. Such is Salmon et al’s [7, 8] Carpe

Diem instructional design model, which emphasizes active

learning, technology integration, ﬂexibility, collaboration,

and continuous feedback. Carpe Diem emphasizes seizing

the moment and allows a straightforward and efﬁcient

approach for re-design that can be weaved into ongoing

training programs.

GOAL OF INNOVATION

The dual goal of the innovation was to align the content

and form of theoretical courses with the changing needs in

the ﬁeld of CAP and workplace within the limits of feasibility

in the Netherlands.

PHASES TAKEN FOR DEVELOPMENT AND

IMPLEMENTATION OF INNOVATION

THE STAKEHOLDERS PANEL

According to the Carpe Diem method, a small panel

of stakeholders, representing the four regions of the

Netherlands where CAP theoretical training was offered

(n = 10), was brought together, consisting of training program

directors/teachers, trainees, an administrative support

assistant and an educational specialist. Throughout the re-

design process, the panel communicated every phase with

the national assembly of CAP training program directors to

assure co-construction with a larger stakeholder’s group.

CARPE DIEM DESIGN METHOD

This contribution shows a ﬂexible instructional design

procedure based on the Carpe Diem method [7] that applies

principles of ﬂexibility, technology and co-design [9].

Typically, in one rather concise session a common ground

of vision (step 1) and learning goals (step 2) are agreed

upon by all stakeholders and prototypes are designed that

can readily be integrated into daily practice (step 3). The

last three steps reﬁne the prototypes in brief iterative cycles

with evaluation (step 4), adaptation (step 5) and further

implementation (step 6) merging daily practice with re-

design. The current project applied these steps in 4 phases

as depicted in Figure 1.

FIRST PHASE: AGREEMENT ON LEARNING

OBJECTIVES BASED ON A COMMON VISION

A request for information was sent out to CAP training

institutes in the Netherlands requesting their current CAP

learning objectives and training practices. Responses

302Deschamps et al. Perspectives on Medical Education DOI: 10.5334/pme.1198

were combined in an inventory of learning objectives by

a CAP trainee and training program director. The recently

updated European Curriculum Framework [10, 11] was

used as an additional source to add objectives to the

inventory. During a ﬁrst meeting, the stakeholders panel

formulated a common vision for future CAP training around

the central question: What does a child and adolescent

psychiatrist need during training to best prepare them to

deliver optimal care for children and their families in the

future? With this common vision in mind, items from the

inventory of learning objectives were retained, removed,

reﬁned, complemented, and ordered using a storyboard.

At the end of this session, which lasted approximately six

hours, a learning goals inventory was ready to send out

to all training program directors in the Netherlands for

comments and broader agreement.

SECOND PHASE: DEVELOPING A PROTOTYPE OF

COURSES FOR CAP TRAINING

An inventory of teaching methods preferences was

made, combining written evaluation forms ﬁlled in by

trainees and teachers after regional theoretical courses

in the prior 2 years with in-depth interviews with 10

CAP trainees (representatives of all four regions). These

forms and interviews enquired about the most inspiring

and least helpful experiences. During a meeting with the

stakeholders panel, based on these teaching methods

preferences and the common vision, several guiding

principles were deﬁned for the prototypes of course

modules (phase 2a). Combined with the learning goals

from step 1, a modular program of theoretical courses

was proposed (phase 2b). At the end of this session, which

lasted approximately four hours, the results were sent out

to all training program directors in the Netherlands for

comments and agreement.

THIRD PHASE: PILOTS OF COURSES

A system with online media walls was introduced as a

tool to help organize the development of teaching courses

and facilitate student and teacher engagement [12].

These allowed multiple people to work on a project and

to share teaching materials easily for redesign as well as

for daily teaching practice. Pilots were conducted with

three teaching courses, constructed at a national level

by a core group including a coordinator, around seven

trainers/teachers and one or two trainees. Feedback

collected each time a course was provided in a region was

used to re-design the next iteration. Ethical approval was

Figure 1 The redesign process: once common vision and learning goals are agreed upon and the prototype is developed (phases 1 and 2),

the ﬁrst courses can be tested in daily practice (phase 3). Phase 4 reﬁnes these courses in brief iterative cycles and allows for designing

additional courses building on and adding to previous experiences in brief iterative cycles.

303Deschamps et al. Perspectives on Medical Education DOI: 10.5334/pme.1198

not applicable as the evaluations were collected in light

of standard practice quality assurance of courses in CAP

training in the Netherlands.

FOURTH PHASE: EVALUATION, REDESIGN, AND

FURTHER IMPLEMENTATION

Feedback from the ﬁrst three courses was used to start up

new core groups for consecutive courses. This led to full

coverage of learning goals in a total of 16 courses. When

a course was offered in a region, evaluation was used for

further redesign at a national level. This facilitated the

implementation and the start of a full cycle across regions

with national coordination.

OUTCOMES OF THE INNOVATION

FIRST PHASE: AGREEMENT ON LEARNING

OBJECTIVES BASED ON A COMMON VISION

The vision included two central notions: a developmental

mindset in the assessment and treatment of mental health

problems in children; and a systems approach, including

circular effects of the environment on child mental health,

societal and cultural effects. A list of learning objectives was

build based on this vision. The summary is listed in Table 1.

SECOND PHASE: DEVELOPING A PROTOTYPE OF

COURSES FOR CAP TRAINING

The vision was translated into guiding principles that

could be used for theoretical course development (see

Table 1, phase 2a). Next, a decision was made to develop a

program of courses covering the list of learning objectives

(see Table 1 for titles and content, phase 2b) at a national

level and to organize them at a regional level with access

for all. Overall teaching time of these 16 modules was

about 30% less compared to previous theoretical courses

to allow time for more personal projects towards the end

of training.

THIRD PHASE: PILOTS OF COURSES

A core group led by a course-coordinator set out to develop

a course prototype. They started with a preliminary

online wall based on the learning goals from phase 1 and

teaching methods guided by principles from phase 2. It

contained sections with previously used materials, learning

objectives, a preliminary program for the new module and

literature, assignments, presentations, video lectures, and

podcasts.

This ﬁrst version was provided to a regional group of

trainees within their regular training course program. Most

core group members participated actively in the teaching,

PHASE 1: AGREEMENT ON LEARNING OBJECTIVES BASED ON A COMMON VISION

Category Example of learning goal

General etiology Knowledge on development of vulnerability and resilience in children

General assessment Knowledge on stages of typical and abnormal child development.

General treatment Speciﬁc CAP treatment skills, including creating working alliance with children and parents/care givers.

Speciﬁc conditions Knowledge and skills to assess and treat speciﬁc child psychiatric conditions.

Financial, legal, and societal

aspects

Knowledge of speciﬁc CAP related aspects of ﬁnancial, legal and organization of social and educational

system.

Attitudes Attitudes related to vulnerability of children and parents, safeguarding and stigma.

Phase 2a: Developing a prototype of courses for CAP training: guiding principles

Workplace learning the content of cursory education is in line with practice and workplace learning as much as possible

In-depth learning the curriculum allows for gradually more specialization within CAP with more abstract and overarching

themes

Group learning balance between exchange and cross-pollination between trainees within and between different

training groups and regions with an eye for emotional safety and group formation

Faculty development involvement of teachers and experts in the development of modules at a national level to assure

sufﬁcient level of expertise; increase the exchange of teaching methods and content between teachers

Embrace regional and local diversity deﬁne national chalk lines so that every psychiatrist registering as CAP has the same basis; leave

enough room for autonomy of regions and teachers (balance around 80/20)

Active and blended learning trainees prepare themselves to use principles of problem-based learning before following the modules;

modules contain as many active learning methods as possible; they can be followed on site as well as

online

(Contd.)

304Deschamps et al. Perspectives on Medical Education DOI: 10.5334/pme.1198

even when it was provided in another region, making use of

blended methods (e.g., pre-recorded videos or live sessions

with online teachers). The input from these trainers was

used for evaluation purposes. Experiences from trainees

(around n = 10 each time a course was provided) and

trainers about the strengths and weaknesses of the course

were collected at the end of the course by the course-

coordinator. The online walls were open source for trainees

and teachers allowing a consecutive number of pilots with

direct feedback from all stakeholders and simultaneous

use for teaching.

FOURTH PHASE: EVALUATION, REDESIGN, AND

FURTHER IMPLEMENTATION

Every three months, national CAP trainers convened to

update and engage additional teaching staff, aligning

with their interests to motivate participation and time

reallocation. When a course was provided in one of the

regions, feedback was collected via the online media wall,

facilitating iterative cycles and alignment with common

training goals.

Considering the actual start of a full cycle at a national

level in the Netherlands, the day of the week teaching was

provided needed to be aligned. Although this may seem

mundane, it required substantial changes in local hospitals

and training centers. In line with what has been described in

the Carpe Diem methodology, alignment of common goals

and learning objectives helped reallocate and re-organize

regional resources in favor of cooperation at a national level.

The online media-walls for all modules were continuously

and simultaneously available for all teachers and trainees

at a national level throughout the process. Thus, courses

were accessible for online participants and experts could

participate as guest-speakers across regions. Teacher

and trainee online feedback on the media-wall helped

to improve courses in the short term and throughout the

next iterative cycles. An exception to blended learning

was made for the 6 day-long national modules that were

organized at a central location for all trainees to allow for

group formation and networking.

All in all, this cyclical national program integrated

knowledge from national experts in the ﬁeld of CAP into

theoretical courses, offered personalized training schedules

and allowed general psychiatrists to sub-specialize in

CAP aligned with their continuous medical educational

learning needs.

CRITICAL REFLECTION

The four phases of the ﬂexible instructional design method

took place in a ﬂexible manner ‘while living on site’, together

PHASE 2B: DEVELOPING A PROTOTYPE OF COURSES FOR CAP TRAINING: LAY-OUT OF MODULES

Module characteristics Module title example and covered DSM-classiﬁcation(s)

Speciﬁc conditions

10 modules

16 hours (4 half days) each

Blended learning.

Organized at regional level.

Online participation of trainees from

other regions allows alignment

with workplace learning, ﬂexible

personal schedules.

Online participation of experts from

other regions.

Controlling behavior and focusing attention (Attention deﬁcit and hyperactivity disorders)

A healthy mind in a healthy body (Sleeping disorders, eating disorders, neurological conditions)

Too much of a good thing (Addiction and substance abuse disorders)

General skills

6 modules

8 hours (1 day) each

In person learning.

Organized at national level.

Live participation allows for group

building and network activities for

future CAP workforce.

Interaction with national experts

serves professional development.

Roles of CAP in specialist mental health care and advocacy

Laws, regulations, and social aspects of CAP

Genetics of CAP conditions and phenotypical traits

Neurobiology and new treatments

Cooperation in networks with other professionals

Lifelong learning and development and teaching as a CAP

Table 1 Summary of results from phase 1 Agreement on learning objectives based on a common vision and phase 2 Developing a prototype

of courses for CAP training.

305Deschamps et al. Perspectives on Medical Education DOI: 10.5334/pme.1198

with a wide stakeholder’s group, supported by technology,

and within the reality of CAP as a smaller medical sub-

specialty with limited resources. Once common vision and

learning goals were aligned with changes in the ﬁeld of

CAP and the prototype was developed (phases 1 and 2),

the ﬁrst courses could be tested in daily practice (phase

3). Phase 4 reﬁned these courses in brief iterative cycles

and allowed for designing additional courses building on

and adding to previous experiences in brief iterative cycles.

Although other methods of educational re-design – with

some adjustment – could also provide ﬂexible re-design,

the lessons learned with the application of the Carpe Diem

method are worth reﬂecting on to provide insight to others

hoping to adopt a similar process.

1. Starting with a common vision and learning objectives

in line with new insights in the ﬁeld of a medical

specialty within a broad stakeholder’s group creates

common trust that allows testing prototypes in brief

iterative cycles.

2. Working with online open-source media-walls helps

to support a balanced blended learning approach and

resolves logistical challenges to ﬁt theoretical modules

with personal training and education schedules.

3. Re-designing courses at a national level requires an

initial investment from clinician-educators but when

weaved into daily practice readily saves them time.

4. Setting up a ﬂexible re-design method pays back in the

short term and holds promise to easily adapt courses

to future changes in the ﬁeld.

5. Speciﬁcally for CAP, the ﬂexible growth mindset and

collaborative approach of the Carpe Diem method

resonates well with developmental and systems

notions that are key.

To assess and evaluate the value of our process for other

post-graduate training settings, a commentary perspective

was collected from international CAP educational

specialists and from pediatric post-graduate scholars from

the Netherlands. After implementation, the project was

presented to an international group of 24 educational

experts in CAP. One of the pilot courses was translated

into English using an automatic online translation tool

and presented. The international experts were positive

about the open-source method as it avoids scattering of

materials in folders and e-mails and it is simultaneous

availability for teachers and trainees. The methods were

judged as valuable and with slight adaptions useful in

other (inter-) national settings. Appreciation was expressed

for the interactive and collaborative way of development.

It was expected that trainees would gain from a better ﬁt

with challenging personal schedules and teachers from

workload reduction and inspiration. Points of concern

regarding implementation of the method in their home

countries included safe-guarding intellectual property

rights and reimbursement for module coordinators,

trainees’ privacy, and IT back-ups. Respecting cultural

differences, countries would prefer to copy the module and

modify it for their own country or region.

Three post-graduate experts in pediatrics as a related

medical post-graduate training program expected that

pediatric subspecialties (e.g., pediatric intensive care,

neonatology, neonatal neurology, …) are coping with

similar challenges. Aspects of the presented redesign

deemed relevant included a central and attractive digital

access point, accommodation of highly individualized

learning tracks, and agreement on and adherence to a

national curriculum as a basis for joint theoretical course

development. As challenges, they noted ﬁnding a balance

between transferable curriculum items while recognizing

the importance of local context in teaching courses.

CONCLUSIONS

The development of high-quality teaching modules

is feasible, even for (sub-) specialties with relatively

small numbers of trainees and trainers. In other words,

it is possible to rebuild the house while living on site.

Using a ﬂexible iterative re-design model, facilitated by

technology offers additional advantages to the specialty

at a national and international level without an increased

need for additional resources and time. A longer-term

implementation evaluation is needed to show to what

extent the investment made in the re-design proves to be

future-proof and helps adjust to future changes in the ﬁeld.

COMPETING INTERESTS

The authors have no competing interests to declare.

AUTHOR AFFILIATIONS

Peter K. H. Deschamps orcid.org/0000-0001-5127-2354

Child and Adolescent Psychiatrist, Training Program Director

Psychiatry at Karakter, Academic Centre for Child and Adolescent

Psychiatry and Educational Researcher Associated with the

Radboud Health Academy, Nijmegen, The Netherlands

Geke M. J. Beugels

Mental Health Professionals Education Manager at Karakter,

Academic Centre for Child and Adolescent Psychiatry, Ede, the

Netherlands

J. Dudink orcid.org/0000-0003-0446-3646

Neonatologist and Associate Professor Teaching at the

306Deschamps et al. Perspectives on Medical Education DOI: 10.5334/pme.1198

TO CITE THIS ARTICLE:

Deschamps PKH, Beugels GMJ, Dudink J, Frenkel J, Hennus MP, Hofstra MB, Rutten AX, van der Schaaf M. Living on Site While Renovating;

Flexible Instructional Design of Post-Graduate Medical Training. Perspectives on Medical Education. Perspectives on Medical Education.

2024; 13(1): 300–306. DOI: https://doi.org/10.5334/pme.1198

Submitted: 17 October 2023 Accepted: 11 April 2024 Published: 13 May 2024

License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source

are credited. See http://creativecommons.org/licenses/by/4.0/.

Perspectives on Medical Education is a peer-reviewed open access journal published by Ubiquity Press.

Wilhelmina Children’s Hospital, University Medical Center Utrecht,

Utrecht, the Netherlands

Joost Frenkel orcid.org/0000-0002-0200-5425

Professor of Pediatrics at the Wilhelmina Children’s Hospital,

University Medical Center Utrecht, Utrecht, the Netherlands

Marije P. Hennus orcid.org/0000-0003-1508-0456

Pediatric Intensivist and Associate Professor Teaching at the

Wilhelmina Children’s Hospital, University Medical Center Utrecht,

Utrecht, the Netherlands

Marijke B. Hofstra

Child and Adolescent Psychiatrist and Training Program Director

in Child and Adolescent Psychiatry at Sophia Children’s Hospital,

Erasmus Medical Center, Rotterdam, the Netherlands

Alexa X. Rutten orcid.org/0000-0003-0874-5755

Child and Adolescent Psychiatrist at GGzE, Centre for Child and

Adolescent Psychiatry, Eindhoven, the Netherlands

Marieke van der Schaaf orcid.org/0000-0001-6555-5320

Professor in and Director of Utrecht Center for Research and

Development of Health Professions Education, University Medical

Center Utrecht, The Netherlands

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