Journal of Medicine and Life Vol. 5, Issue 1, January‐March 2012, pp.16‐20
Developing an educational scheme for undergraduate medical
Curriculum: the unit of "INFERTILITY" as a sample
Aflatoonian A*, Baghianimoghadam B*, Abdoli A*, Partovi P* Hemmati P**, Tabibnejad N*, Harasym P***
*Research and Clinical Center for Infertility, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
**Center for Disease Control, Deputy Ministry for Health Affairs, Ministry of Health and Medical Education, Tehran, Iran
***Faculty of Medicine, University of Calgary, Alberta, Canada
Correspondence to: Payman Hemmati, MD
Center for Disease Control, Deputy Ministry for Health Affairs, Ministry of Health and Medical Education, Tehran, Iran
Phone: +98-21-66707377; E-mail: email@example.com
Received: November 20th, 2011 – Accepted: January 24th, 2012
Objectives: to present our first experience in scheme development based on CPC philosophy in Iran.
Hypothesis: One of the most important reasons of an obvious gap between medical education and professional expectations
(outcomes) encountered by recent medical graduates is due to applying conventional curricula, which rely on hypothetical-deductive
reasoning model. The University of Calgary has implemented a new curriculum which is organized according to 125 ways in which
patients may present to a physician. In this study we will present our first experience in scheme development based on CPC
philosophy in Iran.
Methods: In 2007, research and clinical center for infertility (Yazd University of medical sciences, IRAN), began developing a full
module for infertility (lesson plan) with fourteen components based on the new curricular philosophy. We recruited a scheme of
infertility according to a specific way.
Results: Thus, at the first step of the module creation, a scheme was made as the most important mainstay of presentation module,
i.e. a structured scheme that includes all causative diseases of infertility.
Conclusions: Any effort in the organization of knowledge around schemes including in the domain of infertility would be valuable to
meet some of the standards of WFME. Also, development of modules, by the teams composed of experts and students, can improve
the quality of medical education.
Keywords: CPC, scheme, infertility, backward reasoning, forward reasoning
Medical education and medical systems
expectations are different, medical graduates encounter
some problems that the educational curriculums did not
supply [1–3]. One reason may be routine conventional
curricula, which rely on hypothetical-deductive reasoning
model (HDR or backward reasoning or disease-centered
medical education) [4,5]. This philosophy returns to Dr.
Abraham Flexner’s ideas, who made the difference
between the hypothetical-deductive reasoning model from
the model of reasoning in basic sciences and applied it for
medical education too . In fact, the influence and
strength of Flexner in his era made a lot of his concurrent
educators to follow his idea. Therefore, the effect of that
idea remained up to now even in modern Problem Based
Learning (PBL) curricula .
The patient did not come with a name of his
disease; the patient has not read medical books!! In fact,
he talks about his complaint (or clinical presentation for
example chest pain, cough, dysuria. etc.). The current
educational direction is from disease to manifestations.
Supporters of this type of reasoning believe that there is a
serious need for a hypothesis generated beforehand in
order to enable one to set an inquiry strategy. But, this
type of problem-solving, may not be completely
appropriate for problem solving under the constraints of
clinical setting (i.e. constraints of time, knowledge and
skills) [5,7], especially considering that this direction
practices a deliberate trial-and-error approach on a
human subject, being unethical. Barrows and Pickell
proposed a backward clinical problem solving model .
In this model and also PBL (that has borrowed its
philosophy from problem solving), the nature of traditional
educational curricula is apparent. Even in PBL that starts
from case presentation (Problem), as it name implies, in
the interim of its process, it somehow returns to disease-
centered education. Accordingly, we can see Flexner’s
view of hypothetico-deductive reasoning. But, this cannot
support the needs of clinic. However, if it comes to
developing the quality of the medical education, we must
pull out the way of reasoning that is going on in the
Journal of Medicine and Life Vol. 5, Issue 1, January‐March 2012
expert’s mind [8,9]. Actually, because of his experience,
an expert can go from clinical presentation to diseases;
and this is the way we want it to happen. In fact, an expert
has a broad picture of all suspected etiologies of clinical
presentation and discriminates them together with the key
In an attempt to advance the quality education
for medical students, the University of Calgary medical
school implemented a new curriculum in the fall of 1994.
The previous systems-based curriculum was reorganized
according to 120 clinical presentations (CPs) or problem
domains. The CP model has been described in detail
elsewhere . A clinical presentation is defined as a
common and important way in which patients present to a
physician. Examples of clinical presentations include
headache, abdominal pain, sore throat, and hypertension.
Another unique feature of the CP curriculum is the
introduction of 'scheme' to students contained in the
terminal objectives of each clinical presentation.
Regarding the problems arisen by conventional
curricula and defined by Haeri, Hemmati, and Yaman ,
we decided to develop the first module according to the
last curricular model in the North America, i.e. Clinical
Presentation Curriculum (CPC). The aim of this study was
to present the first experience in scheme development,
based on CPC philosophy in Iran.
Infertility is defined as the inability of a couple to
conceive after 12 months of regular, unprotected
intercourse. Infertility is a popular presentation in the
gynecology and urology field. Due to the complexity of its
causes female infertility has a very complicated diagnosis.
However, a GP as the first line in diagnosis and
management must be capable of categorizing the causes
of this presentation.
The University of Calgary has implemented a
new curriculum, which is organized according to 120 ways
in which patients may present to a physician.
Each module will contain 14 components: the
logical development of a scheme, an expert’s scheme,
matrix, terminal objectives, enabling objectives, basic
science content list, schedule, teaching materials (i.e.
PowerPoint slides), learning materials (i.e. reading
assignments), PBL cases, process worksheet for tutors to
guide small group PBL scheme-inductive sessions,
formative evaluations, summative evaluations, and
In 2007, the research and clinical center for
infertility (Yazd University of medical sciences, IRAN),
began developing a full module for infertility (lesson plan)
with fourteen components based on clinical presentation
curricular philosophy. This program was as a part of
making 10 packages ordered by the Ministry of Health
and medical education jointed by WHO.
At first, we recruited a research team, combined
of four medical students chosen among talented
researchers, a professor (clinical expert) in infertility and
medical educationalist. During the study phase we have
also benefited from consultations from the other members
of Gynecology and Infertility Department, Faculty of
Medicine at Yazd University of Medical Sciences.
During the study phase of generating the
material of curriculum, we received guidelines. In the first
step, our medical educationalist gave us three structured
series of questions. With the aim of those questions, we
gathered detailed information about the presentation and
the prototypical diseases that our expert chose, those that
are the most important diseases that a GP must know and
can manage completely.
So, we had to look for the most popular definition
of infertility. Fortunately, all the textbooks have a common
and comprehensive definition mentioned above.
We started from a watchful study on basic
physiology and anatomy of female reproductive tracts.
Then, we searched for all diseases that can cause
infertility and we tried to extract the mechanism of the
disease in creating the infertility. According to similarities
in the anatomic and/or physiologic aspects of causative
diseases of infertility, we made a primary classification of
all possible disorders. We gathered all diseases with the
same mechanism into one “disease class”. This was the
bottom of our scheme. Then based on a mechanism we
tried to select a meaningful name for this group of
diseases, as the smallest unit of our classification (this
smallest units at the bottom of the schemes are called
“disease class” in CP curriculum). Then, based on
similarities, we tried to compile a few disease classes into
one subcategory (or sub subcategory) and continuing this
strategy we made greater sets of assembles until
achieving the main categories in the first layer of the
scheme (ovulation dysfunction, fecundation pathway and
implantation disorders), then to clinical presentation itself
(infertility) (a bottom – up scheme construction). (See
Fig.1 in the Results section).
All the process of this study was evaluated by
experts and a medical educationalist of our group every
weekend!! At any session, we got our expert comment on
our scheme and he compared our plan with the road map
in his mind (that was our aim to pull it out of his mind) and
checked every entity (category/subcategory/disease
class/disease differentials) for the existence of diagnostic
key predictors. If a key predictor/s exists he approved the
entity. The study group reported their studies in Power
Point Presentations in every meeting. In fact, the above
scheme was the fruit of studying around the first series of
Thus, the clinician has identified the differentials
of the clinical presentations (CP) in one’s field of
expertise. For each CP he/she has organized the
differentials based on common attributes (i.e., anatomy,
and physiology) into categories, subcategories, disease
Journal of Medicine and Life Vol. 5, Issue 1, January‐March 2012
classes and short lists of cohort differentials in each class.
Such a knowledge structure is called a scheme. And with
its demonstration, medical students would get to a more
organized knowledge structure in a shorter period.
After developing the matrix of infertility, we
continued to gather all information about prototypical
diseases, according to the second and third series of
structured questions, to complete the learning material
component of a CP module.
The scheme created by the study group is
offered in Fig. 1.
In our experience in developing infertility
package based on CPC model, as mentioned in materials
and methods, we have made a scheme about female
infertility that included all diseases causing this CP. We
divided female infertility into three main causes
(category): ovulation dysfunction, fecundation pathway
and implantation disorders (uterine). The fecundation
pathway is a new term that we devised to make the first
line of our scheme at the same level with the other two
main categories. The fecundation pathway represents the
way that sperm must transfer from external genitalia to
ovum and fecundate. Ovulation dysfunction is divided to
four sub categories: hypothalamopituitary axis disorders,
thyroid disorders, hyper prolactinemia and ovarian
disorders. Ovarian disorders divided into polycystic
ovarian syndrome, premature ovarian failure and
decreased ovarian reserve. The fecundation pathway is
divided into anatomical pathway defects, female
genitalia/mucosal secretion defects, cellular fecundation
and peritoneal factors. The implantation disorders do not
have a sub category.
Making this scheme took a long time, as our first
experience, because the generation of every surface of
scheme was like a workshop for us. The generation of
schemes needed a careful definition of CP because all
the diseases that must be included in scheme, in first
step, must have our definition specification. And then, we
needed that part of the disease that makes our CP. For
example, TB as an infectious disease makes a large
variety of presentations with multiple organ involvement.
In fact, only genital TB is important for us; other types of
TB with theirs specifications do not include our scheme.
Up to now all the medical education curricula
were based on a hypothetical-deductive reasoning model.
Now, mankind experience in education,
benefiting from cognitive sciences, has helped to develop
a new curriculum that is concomitant with the nature of
disease. Each disease starts from a disturbance in a
normal state of the body. Then, a pathology that leads to
a specific sign or a symptom in a patient appeared and
made the Clinical Presentation (CP)! A Patient talks about
this CP not the name of his disease!! In the diagnosis of
the disease an expert does not use the hypothetical
deductive reasoning; in fact, after a long time of
experiences we learnt to reorganize his knowledge (that
primarily learnt based on hypothetical deductive
Fig. 1 Infertility scheme finalized in research and clinical center for infertility, Yazd, Iran
Journal of Medicine and Life Vol. 5, Issue 1, January‐March 2012
reasoning) around the natural state, that a patient comes
with (clinical presentation).
The new curriculum, designed and implemented
in the University of Calgary, is based on this natural
necessity of clinical setting. Moreover, we tried to develop
the first samples of CP modules in this curriculum, in Iran.
The development in the quality of the medical education
implemented with each new curriculum birth. Each new
model used other older curriculum positive aspects and
tried to decrease their weaknesses. CPC (clinical
presentation curriculum) is the latest invention in the
curriculum development that gives a new implementation
with scheme, CP matrix and learning objectives.
With these discussions, CPC does not render
other previous curricula such as Problem Based Learning
(PBL) and Organ System Based Curriculum (OSBC). In
fact, in this curriculum, the philosophy of education based
on presentation (the main trait of PBL) and also the
structure of system by system education (the main trait of
OSBC) is saved, but this curriculum tries to solve the
inadequacies in other curriculums and make a physician
with empowerment in differential diagnosis and making a
correct diagnosis in shortest time.
Schemes have three major advantages:
1- They make students capable to categorize their
information in mind because in this method we
prune all unnecessary information that may
interfere the processing of information in mind.
2- The schemes develop a scaffold in students’
mind, which help them to connect all relevant
information especially basic science issues. In
our experience, we used an innovative method
to integrate the infertility scheme with the basic
science concepts that help student to deeply
understand the puzzle (our scheme) and
memorize the scheme more scientifically as well
as their previously learnt information in basic
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organization of infertility package is valuable because
module development by various teams and experts can
improve quality of medical education. Also development
of modules by the teams composed of experts and
students can improve quality of medical education.
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