Understanding Medical Education

Evidence, Theory and Practice

Tim Swanwick, Tim Swanwick

• Publisher: Wiley-Blackwell
• Year: 2011
• ISBN:
  9781444348187
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Education

For the first time in a single core textbook, the Association for the Study of Medical Education presents a complete and authoritative guide to medical education. Written by leading experts in the field, Understanding Medical Education provides a comprehensive resource of the theoretical and academic bases to modern medical education practice.

This accessible and timely reference is designed to meet the needs of all those working in medical education from undergraduate education through postgraduate training to continuing professional development. As well as providing practical guidance for clinicians, teachers and researchers, Understanding Medical Education will prove an invaluable resource to those studying at certificate, diploma or masters level and a first 'port-of-call' for anyone engaged in medical education as an academic discipline.

Exploring medical education in all its diversity and containing all you need in one place, Understanding Medical Education is the ideal reference not only for medical educators, but for anyone involved in the development of healthcare professionals, in whatever discipline wherever they are in the world.

An on-line edition of the complete book, together with individual chapter downloads, are available at www.wileymedicaleducation.com

Understanding Medical Education has been brought together and edited by Professor Tim Swanwick, Director of Professional Development in the London Deanery, Visiting Fellow at the Institute of Education and Visiting Professor of Medical Education at the University of Bedfordshire.

1

Principles of curriculum design

Janet Grant

KEY MESSAGES

• The curriculum is made up of all the experiences learners have that enable them to reach their intended achievements from the course.
• A curriculum statement should enable learners, teachers and managers to know and fulfil their obligations in relation to the course. It should describe intended learner achievements, content to be covered (the syllabus), teaching, learning, supervision, feedback and assessment processes, entry requirements and course structure.
• A syllabus is simply a list of the main topics of a course of study. This is only part of the curriculum.
• The way in which a curriculum for medical education is designed depends on the designers’ views about how students learn, how medicine is practised, social responsibility and accountability, the role of the knowledge base, professional values and health service development.
• The curriculum design process should ask what is the purpose of the educational programme, how will the programme be organised, what experiences will further these purposes and how can we determine whether the purposes are being attained?
• There is no body of evidence that shows that there is one best choice for framing a curriculum as a whole or any of it parts. A curriculum should simply be fit for the purpose and context of its day.

Introduction

My bookshelves are a history of medical education. I chose some books at random to determine whether the years had produced different ideas about curriculum design. Partially they had, and partially they had not. In 1961,(1) the debate was around instructional skill based on ideas about how students learn. The curriculum was to be made up of objectives and experiences with relatively traditional divisions of content, but all based on the health needs of society, the philosophy of scientific thinking and the professional characteristics of physicians. In 1972,(2) the advice was to define aims and objectives in behavioural terms (not so different from today’s preoccupation with competences, perhaps), and also that curricula should offer what the student and community require – not what is convenient for medical school staff to offer. Teachers were advised to try to integrate their teaching more effectively and give students some choice over what they learn. By 1982(3) and 1983,(4) a systems approach to educational design was advocated, with an emphasis on teaching methods aimed at delivering the learning objectives in the knowledge that active student involvement in learning was a likely effective strategy. By 1989,(5) it seemed reasonable to devote entire books to the question of how the curriculum might be structured to facilitate learning appropriate to clinical practice.

We can see from this snapshot that ideas develop and have roots in previous thinking. Ideas of integration, a focus on students learning rather than teachers teaching, a need for teachers to learn how to do their job well, a focus on outcomes, albeit expressed as objectives, and a recognition of the responsibility of the school to respond to societal need and to prepare the student for professional practice have been current for many years. But the same ideas can give rise to different curriculum designs and to different processes of reaching that design. The design principles that we have now are based on the professional choices that curriculum designers make. Those choices are informed by the theories and social conditions of the day, and by the values and experiences of the medical profession doing its best to produce the next generation of doctors fit for its changing purpose.

Jolly and Rees(6) admit that there is a need for rational, open and accountable curriculum design processes. They eloquently describe the accompanying lack of evidential basis for how best to do this, but conclude that:

Although curriculum design is an imprecise and arbitrary rubric, such a code is needed: systematic and arbitrary is somewhat better than capricious.

Curriculum design in medical education is an arena in which many battles are fought. There are many different views and values about, for example, what medical students should learn, how they should learn it, what qualities we want them to develop, where the science base stands, where skills of communication and examination should be acquired, how long it should all take and whether we want to frame their task in terms of outcomes or competences.

There are equally as many views about how a curriculum should be developed and structured. And given that in education it is often difficult to find incontrovertible research findings on which to base decisions, there are no evidence-based approaches to curriculum design that we could meaningfully quote. This means that vogues in curriculum design ebb and flow in response to the dominant concerns of society and the professions, just as they ebb and flow in relation to teaching and learning methods, curriculum evaluation and even assessment of learning.

All these factors make a heady cocktail, which ensures that the business of curriculum design, development and review will never close. Eisner(7) talks of ‘curriculum ideologies’, which are ‘the value premises from which decisions about practical educational matters are made’. These can be very strong, so that, as Toohey (8) says, ‘Alternative views are literally “unthinkable”’. And so zealousness for a particular curriculum model develops, as she says, on beliefs that are ‘so commonly held in the discipline, that they are accepted without question’. And because curriculum theory is based largely in ideology rather than evidence, this continuing spiral of changing views will never cease.

To muddy this pool even further, the issues around curriculum design at the basic (medical school), postgraduate and continuing education levels are very different. In medical school, we have students who have everything to learn and a school that has the responsibility and opportunity to ensure that they do and the right to call on the student’s time and fill it with activities that reflect the school’s view of curriculum.

At the postgraduate level, learning occurs in the context of clinical practice. Our student now is a young doctor who still has much to learn and examinations to pass, but also has clinical duties to fulfil. Much of the learning is dependent on the clinical work that is experienced, and teachers and curriculum planners only have limited power to organise the days of a postgraduate trainee.

At the stage of continuing professional development, every doctor has become an autonomous professional, each with a unique history of experience and many with unique learning needs arising out of their professional practice. For most, there is little protected time and minimal finance for learning. At this point, the idea of a set curriculum might seem to be an unworkable irrelevance. Instead, we might simply guide senior doctors to identify their own learning needs, design their own learning and reinforce that in their own practice.(9)

Here, therefore, the principles of curriculum design are discussed only as they apply to medical school and postgraduate training. Enduring principles are presented that will stand the tests of time, changes of fashion and the many different contexts across the world in which medical curricula are applied. The principles outlined should be flexible enough to yield different types of curricula in different hands. A question not discussed here concerns whose hands they might be. We assume that a curriculum is best designed by teams that include subject specialists, clinical and non-clinical teachers, learners and teachers, educationalists, managers and, of course, patients.

What Is Curriculum? Definition and Standards

Educators and philosophers have addressed the question of what to teach and how to teach it at least since Plato wrote The Republic in about 360 _BCE. It might seem surprising, then, that it is only relatively recently, perhaps in the last 40 to 50 years, that curriculum design has become a topic of debate in its own right, although the initial concerns about the nature of curricula arose with the advent of mass schooling in the late 19th century.(10) Until that point, curricula were defined by elite and specialist groups, and a curriculum statement (whether explicit or implicit) might contain only the content to be studied, and perhaps the time to be taken and the teaching method to be used.

Nowadays, however, this will not do. For reasons discussed in the next section, a curriculum statement now would be regarded as satisfactory only if it addresses the wider experience of the learner and the context of learning as well as the content and quality control of the enterprise. The curriculum should guide the learner, the teacher and educational managers. At the same time, it should leave room in its implementation for the creative and individual professionalism of the teacher, and for the individual preferences of the learner, given that both are clear about what is to be achieved.

The specification of intended curriculum outcomes (expressed in whatever terms) is, in almost all cases, non-negotiable, not least because the curriculum is the basis for planning and developing the assessment system. If there is no agreed curriculum, how can we develop an objective, representative, valid and reliable assessment system? Simply, we cannot.

Every country has some kind of guidance in relation to curricula at all stages. But few set actual standards for how a curriculum should be stated, what its component parts should be, and how it should be developed, implemented and used. In the UK such standards are set by the General Medical Council (GMC) now incorporating the Postgraduate Medical Education and Training Board (PMETB). There are no national curricula for continuing professional development, because at this stage practitioners need to identify their own learning needs from their practice.(9)

In many countries, curricula are set by the state; in others they are set by regulatory or professional bodies. In the US, the Liaison Committee on Medical Education sets accreditation standards that contain guidance on many key aspects of curriculum, but not on how to frame the curriculum statement itself. The UK offers a similar statement at the undergraduate level and specific standards for curriculum design at the postgraduate level, which allow the development of different curriculum statements that meet those set standards. Increasingly, medical educators at all levels are comparing their own curricula and medical education and training processes with the standards set by the World Federation for Medical Education (WFME).

Definition

Although much is written about curriculum, definitions are few and far between. Accordingly, the curriculum subcommittee of PMETB reviewed curriculum theories, the context of medical ...