Beruflich Dokumente
Kultur Dokumente
Educational strategies
Outcome-based curriculum
S. R. Smith
20
Section 3:
Educational strategies
“l”
“The only way to get somewhere, you know, is to
figure out where you’re going before you go there” 1. Effective communication
Updike 1960 2. Basic clinical skills
3. Using basic science in the practice of science
Outcome-based education defines what we expect of 4. Diagnosis, management, and prevention
our graduates and holds us accountable to provide an
5. Lifelong learning
education that achieves those endpoints. It is not only
good education, it is good public policy. 6. Professional development and personal growth
Medical schools around the world are increasingly 7. The social and community contexts of healthcare
embracing the concepts of outcome-based educa- 8. Moral reasoning and clinical ethics
tion (Liu et al 2006, Simpson et al 2002, Smith et al
9. Problem solving.
2003). National and international bodies in medical
education have espoused these principles, urging and The ‘Scottish doctor’ model has 12 outcomes, cat-
even requiring their constituents to comply (ACGME egorised into three elements (Simpson et al 2002):
2001, Schwartz & Wojtczak 2002). • What the doctor is able to do:
cc clinical skills
cc patient investigations
cc patient management
The traditional model of medical education (‘planning
cc health promotion and disease prevention
forwards’) begins with the delineation of the knowl-
cc communication
edge fundamental to medicine, teaching that knowl-
edge, then testing whether students have learned that cc medical informatics.
162 Section 3: Educational strategies
What is
“Fundamental
Knowledge”
Test fo r
Knowledge
• How the doctor approaches his or her practice: A Outcomes should be few in number, self-evident,
and easily understood
ccbasic, social and clinical sciences The US Accreditation Council on Graduate Medical
ccattitudes, ethical understanding and legal Education (ACGME 2003) lumps the outcomes into
responsibilities a smaller set of six general competencies:
cc decision-making skills and clinical reasoning.
• patient care
• The doctor as a professional:
cc the role of the doctor within the health service • medical knowledge
cc personal development. • practice-based learning and improvement
Chapter 20: Outcome-based curriculum 163
• interpersonal and communication skills Another example is drawn from the ‘Scottish
• professionalism octor’ learning outcomes:
d
• systems-based practice. Outcome 6: Communication. Good communication
underpins all aspects of the practice of medicine.
Using an already established list of outcomes has All new graduates must be able to demonstrate
the advantages of ease, simplicity, comparability and effective communication skills in all areas and in
established credibility. However, simply adopting all media, e.g. orally, in writing, electronically, by
someone else’s list has its own drawbacks. The faculty telephone, etc.
and students may not feel the same sense of owner-
ship, unique characteristics of the school may not be
Developing criteria
represented or sufficiently emphasised, and the out-
comes may be interpreted differently from what was Once the definition of the outcome is agreed upon, the
originally intended. next step is to delineate criteria. The criteria describe
If a school chooses to create its own list of out- specific tasks that students will be expected to under-
comes, it ought to maximise the amount of partici- take to demonstrate mastery. For example, procedures
pation in the process to increase the buy-in from such as taking a blood pressure, performing a urinalysis
students and staff. Since the only requirement of par- and interpreting a chest X-ray could be delineated as
ticipants is that they have an opinion on what qualities criteria under the medical procedures outcome.
they appreciate in their own doctors, everyone can be The group charged with delineating the criteria
part of the process, from PhD basic scientists to stu- should also provide examples of ways in which the
dents to clinical professors. criteria could be demonstrated. An example for the
A nominal group process technique can be used to lifelong-learning outcome might be: ‘presents find-
maximise participation and minimise the impact of ings of research to other students in problem-based
overbearing personalities. Each person in the group is learning group’. These illustrations help other teach-
allowed to add a desirable attribute of a good doctor. ers think of ways to incorporate the outcomes in their
This continues in a ‘round-robin’ fashion until no new own teaching activities.
attributes are suggested. Attributes may be grouped
together, with the permission of the persons who pro- Levelling
posed them. Participants then vote by placing a star
The competence of students grows as they progress
next to the attribute they believe is most important
through their education. Teachers’ expectations should
and ticks alongside to the three attributes they feel
also increase in parallel fashion. Tasks assigned to stu-
are next most important. The stars are counted as two
dents at the beginning of their course of study should be
points and ticks as one point. The votes are tallied and
simpler than those assigned at the end of their training.
the attributes with the highest votes are selected as
the outcomes.
“l”
“It is a highly questionable practice to label
Defining outcomes someone as having achieved a goal when you
Having chosen the outcomes, the curriculum planners don’t even know what you would take as evidence
must define each more fully. This is best accomplished of achievement”
by small writing committees comprised of individuals Mager 1962
with a particular interest in that outcome.
The definition should be relatively short, but Faculty should classify learning expectations into a
detailed enough to be clear (Harden 2002). The fol- minimum of two levels: one appropriate for the nov-
lowing is an example from the nine abilities described ice or beginning student and another that specifies the
at Brown Medical School: expectations necessary for graduation. A third level of
Ability 7– The social and community contexts of achievement higher than the minimum required for
healthcare. The competent graduate provides graduation should also be specified. Students should
healing guidance by responding to the many be allowed to differentiate themselves at this advanced
factors that influence health, disease and level, based on their individual interests and talents.
disability, besides those of a biological nature. The complexity of the challenge should increase at
These factors include sociocultural, familial, the intermediate and advanced levels. For example,
psychological, economic, environmental, legal, novice students should be expected to demonstrate
political and spiritual aspects of healthcare seekers good communication skills with patients who are rela-
and of healthcare delivery. Through sensitivity tively free of significant communication impairments,
to the interrelationships of individuals and their whereas more advanced students could be challenged
communities, the graduate responds to the with patients who are not native language speakers or
broader context of medical practice. who have hearing or speech impairments.
164 Section 3: Educational strategies
Written communication skills are easily assessed their knowledge of the underlying scientific facts and
through formal writing assignments such as hav- principles through clinical correlations (see Ch. 33).
ing students write a short opinion piece on a contro- At the Memorial University of Newfoundland, the
versy in healthcare policy. The writing sample can physiology faculty designed a three-stage paper-based
be evaluated based on its ease of readability, clarity, ‘triple-jump’ examination in which students were pre-
organisation, tone and the degree to which it is free of sented in class with a clinical situation, then asked
errors in spelling, grammar and usage. to list the topics in biomedical science necessary for
Writing skills can also be assessed in clinical set- understanding the physiological responses in such a
tings. Legibility can be assessed in students’ entries in person. Students pursued their own learning objec-
patient records. Students can be asked to draft con- tives outside of class, followed by an in-class examina-
sultation letters to assess their ability to write clearly, tion derived from the students’ own work (Hansen &
concisely and correctly. Roberts, abstract presentation, 1993).
During the clinical years, students can be assigned
Basic clinical skills to present an update on the latest scientific expla-
nations of the mechanisms of disease related to the
Bedside teaching patients they are caring for. This can be done either
Bedside teaching (see Ch. 13) represents the way in as an oral presentation to their faculty supervisor and
which clinical skills have traditionally been assessed. fellow students or as a written report as part of the
Clinical tutors observe students obtaining a history or patient record.
examining the patient or performing a clinical procedure.
Procedure logs can help ensure that this actually hap- Diagnosis, management and prevention
pens. Students are required to obtain faculty members’ Medical teachers are comfortable with assessing stu-
signatures attesting to the adequacy of specific clinical dents’ skills in diagnosis, management and preven-
skills that have been directly observed. Assigning respon- tion. Student ability is most often assessed through
sibility to students to obtain the signatures increases the oral presentations to faculty preceptors and by written
likelihood that the observations will actually be done. lists of differential diagnoses and management plans as
part of the medical record.
Videotaping OSCEs also can be used to assess these outcomes,
Given the hectic schedules of students and faculty, both during the interactions with standardised patients
videotape recordings of encounters between students and in exercises following the encounters with them.
and patients offer the advantage that they can be Examples of standardised patient cases that assess
jointly viewed at more convenient times. Videotapes these outcomes are: offering the standardised patient
are particularly useful to assess the history-taking an opinion about the nature of a headache after obtain-
skills of students. Videotapes are less ideal when used ing a history, diagnosing depression in a patient pre-
to assess physical examination skills or clinical proce- senting with somatic complaints, offering the patient
dure skills because of limitations of fields of vision. a management plan for the treatment of low back pain
and providing the patient with contraceptive options.
Standardised patients Examples of exercises without standardised patient
Standardised patients (see Ch. 29, Simulated stan- present include: interpreting a chest X-ray, electro-
dardised patients) can be used very effectively to assess cardiogram or Gram stain, and writing a prescription
physical examination skills. Standardised patients have for an antihypertensive drug in a patient newly diag-
proved particularly useful in teaching and assessing nosed with hypertension.
female breast and pelvic examination skills and male Diagnosis, management and prevention can be
genitourinary and rectal examination skills. applied to populations as well as to individuals and
families. Students can be told to undertake a commu-
Simulations nity diagnosis in which they ascertain the health sta-
tus of the population, then propose plans for better
Nonhuman simulations can be used safely and effi- management of the health problems, including pub-
ciently to assess skills in clinical procedures. Plastic lic health measures designed to prevent or minimise
manikins can be used to teach students how to per- illness and injury.
form lumbar punctures, catheterise the bladder, insert
nasogastric tubes, obtain arterial blood samples and Lifelong learning
many other common procedures.
Lifelong learning comprises both skills and attitudes.
The skills involve being able to identify one’s own
Using basic science in the practice of medicine learning needs, to undertake the appropriate learn-
Students can become excited about the relevance of ing activities, and to apply what one has learned.
basic science when they are asked to demonstrate Attitudes of curiosity, a drive for excellence, a
166 Section 3: Educational strategies
willingness to honestly appraise one’s own weak- be built into the curriculum because they are unlikely
nesses and a motivation for learning fuel the quest for to happen on their own, given the other pressures on
lifelong learning. students.
Problem-based learning groups (see Ch. 22,
Problem-based learning) are an excellent venue in The social and community contexts
which to assess this ability in students. The faculty of healthcare
facilitator can observe the degree to which students
Service learning enables students to make connections
contribute to the delineation of learning issues, ade-
between what they have learned in class about the
quately investigate the learning issues and apply what
healthcare system and the reality that their patients
they have learned to the case under discussion.
actually encounter (see Ch. 15). By reflecting on their
The attitudes of lifelong learning can be observed
experiences, students can bring their own values into
in the clinical setting when students take the initiative
their analysis of what they have seen. Journals are a
themselves to learn more about their patients. This can be
particularly good way to capture these reflections.
observed when students cite sources they have explored
Faculty can assess the journal entries on the degree to
in learning more about their patients’ problems.
which they demonstrate evidence of careful observa-
Structuring the curriculum to allow students to pur-
tion, curiosity, connections, self-awareness, empathy
sue independent interests provides another excellent
and social consciousness.
opportunity to assess lifelong learning. In designing
Students’ ability to understand the nonbiological
their projects, students should be asked to explicitly
factors that influence health can be assessed by involv-
state what incident or event made them think about
ing students in discharge planning for patients with
what they needed to learn. Students should also be
complex health and social service problems. Students
asked to explicitly describe their proposed learning
can make home visits to assess the home situation and
strategies and resources. Students should suggest
the patient’s progress, accompany patients to commu-
ways in which faculty could determine whether the
nity health resources and work with other health pro-
student had successfully achieved the learning goals.
fessionals involved in the patient’s care.
This model of assessing lifelong learning in students
Community health projects initiated by students
closely parallels the model for continuing professional
reflect an advanced level of competency, demonstrat-
education for practising clinicians.
ing a commitment to public health and social justice.
Formal assessment of such initiatives can be undertaken
Professional development and in a seminar format in which the student leaders pres-
personal growth ent an overview of their efforts to a panel of faculty,
Portfolios (see Ch. 46) may be the best way to assess perhaps augmented by community representatives.
professional development and personal growth, since Assessing students in nontraditional outcomes such
self-reflection and self-awareness are such an impor- as this one requires a different approach to evaluation
tant component to this outcome. Students select the than used in more familiar areas of student perfor-
material that they wish to put into their portfolios that mance. Greater reliance must be placed on the sub-
is important and meaningful to them. For example, jective judgments of experts. Those who are selected
some students may wish to write a short reflection as evaluators must be recognised as experts in the out-
essay about their feelings after having first encoun- come being assessed by their peers and students. The
tered a cadaver or after their first interview with a judges should come from a diverse range of disciplines
patient. Ideally, students should discuss these reflec- and experiences. The assessment process must allow
tions with a trusted faculty advisor. an energetic dialogue among the evaluators to assure
that the judgments are not idiosyncratic or arbitrary
(Smith et al 2007).
A The staff in community practices are in an
excellent position to assess professionalism in
students.
Moral reasoning and clinical ethics
Students can be asked to present ethically challeng-
Faculty advisors assess students’ achievement of this ing cases to faculty supervisors. The ensuing discus-
outcome not so much on the specific content of the sion enables the faculty to assess the student’s ability
discussions as much as on the degree to which stu- to identify ethical issues in a clinical context and to
dents have thoughtfully reflected on the incidents, analyse them appropriately (see Ch. 36). OSCE sta-
honestly confronted their own feelings and values and tions can be designed with the same goals in mind.
drawn lessons that help them grow both personally The OSCE format has the advantage of being able to
and professionally. demonstrate whether students can detect an ethical
Professional development and personal growth are component and allows direct observation of the stu-
best assessed over a long period of time by the same dents’ clinical ethics skills during interactions with
faculty advisor. Specific time for these activities must patients (Smith et al 1994).
Chapter 20: Outcome-based curriculum 167
Students can also write formal papers on ethical The goal of teaching is to help students learn.
controversies. This approach is particularly useful to Therefore, we make our expectations of learning clear,
assess students’ ability to explore the moral dimen- precise and public. Since assessment drives student
sions of issues of health policy. The evaluation focuses learning, we create assessments with the primary pur-
on how well students can argue their positions on the pose of helping students learn. The assessment should
basis of moral principles rather than the particular reflect, as authentically as possible, the actual tasks
position they take. that students will be expected to perform in actual
situations.
Problem solving The course of study should present students with
Problem solving means more than calculating the cor- repeated opportunities to experience, practise, and
rect answer to a computational question in physiology. gauge their progress in the assessment tasks in var-
Problem solving as an educational outcome means ied contexts and situations, at increasing levels of
being able to get the job done in messy situations. In challenge and complexity. Faculty should repeatedly
a very real sense, problem solving is a meta-outcome, assess student performance and ask themselves how
requiring students to utilise all the other previously the learning experience might be improved to enhance
enumerated skills to assess a situation, frame the prob- student performance.
lem, devise an action plan, negotiate with multiple
players, mobilise resources, execute the plan, respond References
flexibly and creatively to unanticipated obstacles and
constantly monitor progress. Being a good problem ACGME (Accreditation Council on Graduate Medical
solver is the essence of being a professional. Education) ACGME Outcome Project 2001 Online.
The best way to assess problem solving is to put Available: http://www.acgme.org/outcome/comp/
learners into real clinical situations in which they have compFull.asp 19 Dec 2003
primary (but closely supervised) responsibility for Harden R M 2002 Learning outcomes and instructional
patient care. Clinical supervisors must restrain them- objectives: is there a difference? Medical Teacher
selves from giving too much direction, instead observ- 24:151–155
ing how students set priorities, juggle multiple tasks Liu M L, Huang Y-S, Liu K-M 2006 Assessing core
simultaneously, filter and interpret large amounts of clinical competencies required of medical graduates
data and respond agilely to changing circumstances. in Taiwan. Kaohsiung J Med Sci 22:475–483
Of course, clinical supervisors must be ready to inter-
Schwartz M R, Wojtczak A J 2002 Global minimum
vene to safeguard patient safety and assure appropri-
essential requirements: a road towards competence
ate care, but should do so only when necessary and
oriented medical education. Medical Teacher
with the least amount of intervention needed to get
24:125–129
things back on track. Ideally, this could be done by
suggesting to students that a new approach is needed Simpson J G, Furnace J, Crosby J et al 2002 The
and asking the students to come up with alternative Scottish doctor – learning outcomes for the
plans. medical undergraduate in Scotland: a foundation
for competent and reflective practitioners. Medical
Teacher 24:136–143
Summary Smith S R, Balint J A, Krause K C et al 1994
Performance-based assessment of moral reasoning
An outcome-based curriculum rests on sound, practi-
and ethical judgment among medical students.
cal, time-tested principles of good education:
Academic Medicine 69:381–386
• Define what you want students to come away
Smith S R, Dollase R H, Boss J A 2003 Assessing
with from your course. We must go beyond
students’ performance in a competency-based
simply knowing, to being able to implement what
curriculum. Academic Medicine 78:97–107
one knows.
Smith S R, Goldman R E, Dollase R H, Taylor J S
• Design assessment methods to ascertain whether 2007 Assessing medical students for non-traditional
students have achieved the learning you expected. competencies. Medical Teacher 29:711–716
Chapter
21 Section 3:
Independent learning
R. M. Harden
Educational strategies
“l”
“Self instruction may be an alternative to other
matters, irrespective of the approach adopted to teach- forms of teaching, but it can also be combined
ing and learning, is the learning achieved by the indi- with them”
vidual. In postgraduate and continuing education, and
Rowntree 1990
in traditional and innovative undergraduate education
programmes, learners spend a significant proportion of
their time learning on their own. Indeed, the formal The importance of independent learning may not be
learning in the taught part of an educational programme fully recognised – time for it is not formally scheduled
may represent only the tip of the iceberg (Fig. 21.1). in the curriculum and appropriate learning resource
material and support for students are often not pro-
vided. The closest to recognition of independent
learning as a formal part of the curriculum may be the
provision of a list of recommended textbooks. There
Formal is an increasing emphasis being placed, however, on
teaching independent learning with the acknowledgement that
learning is not something that someone else can do
for students but that it must be done by students for
themselves.
In this chapter we will consider:
Informal self-
directed learning • what we mean by ‘independent learning’ and
related terms such as ‘self-learning’
• why independent learning makes a key
contribution to the curriculum
Fig. 21.1 The formal learning ‘iceberg’ • some current trends in independent learning
associated with the development of new learning
techniques.
After a lecture, students master the topic by read-
ing their notes or the relevant sections in a textbook.
Students prepare for small-group work and follow What is independent learning?
up such sessions by studying on their own. In the
clinical setting, too, students need to find out more Six key principles
about the underlying problems of the patients they
The concept of independent learning means differ-
have seen, from further reading or the use of elec-
ent things to different people. It incorporates six key
tronic information sources. The intensity of inde-
principles:
pendent learning in the traditional undergraduate
curriculum usually increases before a formal examin • Students learn on their own
ation, with students attempting to revise or master • Students have a measure of control over their own
the contents of a course over a relatively short period learning. They may choose:
Chapter 21: Independent learning 169
cc where to learn a basis for students’ learning, and the freedom this
cc what to learn gives to the student.
cc how to learn
• ‘Just-for-you’ or flexible learning – emphasises the
cc when to learn.
wide range of learning opportunities offered to
Learners take responsibility for: students and flexibility in responding to individual
cc deciding the context for learning student needs and aspirations.
cc diagnosing personal learning needs
• Open learning – often used interchangeably with
cc identifying resources
flexible learning. It emphasises the provision
cc deciding time for learning and the pacing
of greater access for students to their choice of
of learning. education.
• E-learning – learning is facilitated by information
and communication technology.
A Think about the extent to which – the student
control of their learning would, in your studies, be
advantageous
• Distance learning – emphasises that students work
on their own at a distance from their teacher.
Implicit in the approach is that the teachers
• Students may be encouraged to develop their own interact with students at a distance and facilitate
personal learning plans (Challis 2000). the students’ learning.
• The different needs of individual students are • ‘Just-in-time’ learning – resources are made
recognised and appropriate response is made to available to learners when required. This facilitates
the specific needs of the individual learner – ‘just- ‘on-the-job’ learning and the integration of theory
for-you’ education. and practice.
• Student learning is supported, to a greater or The two ideas underpinning the above concepts
lesser extent, by learning resources and study are:
guides prepared for this purpose. • learners study individually on their own
• The role of the teacher changes from a lecturer • learners have charge of the learning process.
or transmitter of information to a manager of the Both features are absent in the lecture but present
learning process – a more demanding but a more in independent learning where students direct their
rewarding role (Harden & Crosby 2000). own studies to achieve the prescribed learning out-
comes (Fig. 21.2). In many education programmes,
Terms used students work on their own, e.g. reading prescribed
A number of terms have been used to describe this texts, but have little control of their learning. In other
approach to learning. These terms are often used situations, students may control their learning, as in
interchangeably although different meanings may be problem-based learning, but greater emphasis is placed
implied. on group rather than on individual work.
“l”
“Flexible learning is a generic term that covers all
these situations where learners have some say in
how, where or when learning takes place” Content
Ellington 1997
Place Pace
of of
• Independent learning – emphasises that students learning learning
work on their own to meet their own learning
needs. Choices in
• Self-managed learning, self-directed learning independent learning
or self-regulated learning – emphasises that
students have an element of control over their Time
Learning
own learning, with responsibility for diagnosis strategy of
of learning needs and identifying resources. learning
Implicit in this approach is that students have
a clear understanding of the intended learning Media
outcomes.
• Resource-based learning – emphasises the use of Fig. 21.2 Students make choices in independent
resource material in print or multimedia format as learning
170 Section 3: Educational strategies
“l”
“Web and Internet technologies are transforming
our world, presenting opportunities we could only • relevance to the needs of the practising doctor
imagine a few years ago” • individualisation to the needs of each learner
Horton 2001 (‘just-for-you’ learning)
• Self-assessment by the learner of his or her own
Developments in the new learning technologies and competence
e-learning are occurring at an astonishingly rapid • Interest in the programme and motivation of the
pace, and the implications for traditional approaches learner
to education, and indeed for medical schools as • Systematic coverage of the topic or theme for the
we know them today, are profound. The dramatic programme.
developments taking place in e-learning cannot be
A blended learning approach can be adopted where
questioned, bringing a whole new dimension to
e-learning is combined with face-to-face learning to
what is possible in independent learning (Masters &
create an integrated learning experience.
Ellaway 2008). In addition to the use of the inter-
net, personal digital assistants (PDAs), MP3 play- Active learning
ers and mobile phones can play podcasts or vodcasts
of lectures and tutorials for use by the student at a Independent learning, if planned appropriately,
time and place convenient to him or her. The poten- encourages a more active approach to learning.
tial for the new learning technologies including their Students adopt a deep rather than a superficial
support for independent learner is described in approach to learning and search for an understanding
Chapters 28, 29, 31 and 32. The development of of the subject rather than just reproducing what they
new social software that allows students to gener- have learned. Students are encouraged to think and
ate their own context and share this with their col- not just recall facts.
leagues supports a more personalised and support The traditional curriculum emphasises the views
centred view of learning. on a topic of the teacher or lecturer with whom the
student is in contact. The student may be seduced
into the notion that there is one right answer or one
A Social networking sites provide several combined
features, including instant messaging and logs and
could be used to develop personalised learning
approach to a problem. Independent learning allows
him or her to be exposed to the rich environment of
many visions and interpretations.
“l”
The modular and flexible curriculum “Uncertainty should not be hidden away as an
embarrassment”
There has been a trend to modularity and flexibility
in curriculum planning. Students, individually or in Alderson & Roberts 2000
small groups, may rotate through a series of attach-
ments. The advantages of resource material to sup-
port the students learning can help to ensure that
The needs of individual learners
different groups receive a similar education experi- Learners are not a homogeneous group – they have
ence and the time consuming and unnecessary repe- different needs and different aspirations and learn
tition of lectures by staff is avoided. Different groups in different ways. The adoption of an independent
of students may use the same resource pack and learning approach encourages these needs to be rec-
study guide, leaving the teacher free for one-to-one ognised and allows for learner choice in terms of
contact with students. In electives or special study content, learning strategy and rates of learning (Fig.
modules, where students can choose to study areas 21.3). In ‘just-for-you’ learning, the learning pro-
in more depth, independent learning has a useful role gramme is customised to the needs of the individual
to play. student or doctor.
Chapter 21: Independent learning 171
Learning outcomes
Small Distance
Yes There is a move away from a process model of curricu-
Student centred
PBL group learning
lum planning to a product one where the learning out-
comes are made more explicit and where outcomes
No Lecture Prescribed influence decisions about teaching and learning and
reading or study about assessment.
No
Working on own
Yes
A A greater emphasis on independent learning can
be seen as a response to many of the challenges
facing medical education
Fig. 21.3 Control of learning by student
“l”
“The only man who is educated is the man who
tive effect on motivation. has learned how to learn”
Rogers 1983
• The role of the lecture is changing. Lectures are abused, encouraging passive learning rather than a
used to support independent learning rather than deeper understanding and reflection. The need is now
independent learning being used as an adjunct to recognised to incorporate proven effective educa-
support the lecture. tional strategies into the instructional design for self-
• Students make increasing use of the internet as a learning.
learning resource.
“l”
“There is no right way to develop self-instructional
A planned and supported initiative materials. But there are lots of wrong ways”
Independent learning has to be carefully planned and Rowntree 1990
not left to chance. The choice is not between a planned
programme including lectures and other scheduled
activities on the one hand, and on the other, students Support for students
being left to fend for themselves and using any learn- The adoption of independent learning does not imply
ing resources they can find. that the teacher abandons the student to work on
his or her own. The role of the teacher as a facilita-
“l”
“The curriculum must motivate students and help tor in independent learning is important. This can be
them develop the skills for self-directed learning” achieved through interactions between student and
GMC 2002
teacher, face-to-face, by telephone or on the internet.
The teacher can also prepare study guides to support
the student’s learning (Harden et al 1999). This is
Planning by the teacher for independent learning discussed in Chapter 27.
includes:
• Recognising the role of independent learning in
“l”
“A study guide can be seen as a management
the curriculum, making this explicit to students tool which allows teachers to exercise their
and scheduling it in the timetable. responsibilities while at the same time giving
• Ensuring students have the necessary study skills students an important part to play in managing
with which to engage in independent learning in their own learning”
the first instance. Study skills training needed may Harden et al 1999
include:
cc how to assess needs Study guides can:
cc how to plan learning
cc how to manage time
• provide guidance for students on the
cc how to locate and use appropriate resources
management of their learning, with advice on
what they should learn, how they should learn
including electronic resources
cc how to evaluate outcomes of learning.
it and how can they assess whether they have
learned it.
• Identifying the resources to be used by students
• suggest activities for students which reinforce
in their studies, including textbooks and e-learning
their learning and relate it to clinical practice.
resources.
• provide information for students not readily
available through other sources to which they have
A wide range of resources available access.
Students may also get support from their col-
“l”
the resources available is often not paralleled by their “A peer support website can broaden student
educational sophistication. Many lack the basic prin- interest in learning independently and is especially
ciples of educational design such as the incorporation pertinent to the needs of less confident students
of meaningful interactivity and feedback. seeking to improve their academic performance”
Too often computers have been used merely as Baker & Dillon 1999
mechanical page-turners and the internet has been
Chapter 21: Independent learning 173
22 Section 3:
Problem-based learning
A. E. Sefton
Educational strategies
“l”
“A particular goal of this student-centred, problem- structured to match the students’ growing knowledge
based approach is to develop physicians who and confidence, and to include a range of age-groups,
practice ‘science in action’ rather than attempting occupations and geographic locations.
to apply learned formulas to clinical situations”
“l”
Tosteson, Adelstein & Carver 1994 “The key for problem-based learning is… to use a
problem to drive the learning activities on a need-
to-know basis”
For nearly 40 years, PBL programmes have been suc-
Woods 1994
cessfully implemented (e.g. Henry et al 1997, Des
Marchais 2001) and graduates perform effectively
in practice (Dean et al 2003, Katinka et al 2005, An effective PBL group offers a safe, supportive envi-
Schmidt et al 2006). Originally designed as an inte- ronment for discussing and sharing existing knowl-
grated ‘whole of programme’ approach, PBL has been edge while generating ideas and testing possibilities
adapted successfully for dental, health and biological (Visschers-Pleijers et al 2006). Students practise using
science programmes (Schwartz et al 2001, Dangerfield and applying the language of science and medicine,
et al 2007). Evidence has accumulated over many evaluate ideas critically and receive feedback from
years to demonstrate that, graduates from PBL peers and tutor. Each week, members comment on the
Chapter 22: Problem-based learning 175
Effective training of staff ensures that the neces- • What additional learning activities are provided?
sary background, goals and local strategies are consid- What resources are available (IT, museums,
ered, together with information on assessment and library, notes, formal classes including practicals
evaluation. Specific issues of institutional emphasis and clinical work)?
(e.g. evidence-based medicine or information technol- • How do students in difficulties access support?
ogy) require explanation, practice and ongoing sup-
• How are students assessed? Do tutors contribute
port. Tutors need skills in monitoring the process and
to summative assessment?
giving feedback.
To summarise, tutors in a training session will: At your first tutorial, introduce yourself and allow
time for each student to do the same. New tutors gen-
• Review the goals and expectations
erally find it easiest to start with an established group.
• Understand the tutor’s role Helping students to form a new group requires par-
• Clarify local practices and requirements ticular skills; some tutors prefer that role.
• Acknowledge and share concerns, finding solutions
• Identify helpful resources and support
• Practise new strategies A An effective tutor
• is well-prepared, understanding the goals and
the process
• Share experiences • maintains a friendly and open atmosphere
• Meet fellow tutors • recognises the characteristics of the individual
• Participate enthusiastically! students
• avoids instructing
In addition to materials supplied to students, tutors • knows when to intervene
are usually issued with handbooks or on-line informa- • handles difficulties with tact and sensitivity
tion, highlighting issues for each problem. Guides for
tutors may also contain essential information to be
revealed progressively as the problem unfolds.
One important source of continuing support is The PBL tutor’s role
engagement with other tutors. A useful strategy is Good tutors support appropriate interaction by main-
to meet and discuss progress in the current problem taining an open and trusting environment. They reflect
and review the next problem, ideally with case writ- on their own performance and encourage students to
ers and/or subject experts present. Issues of content do likewise. PBL teachers enjoy facilitating learning
and process are discussed, while difficulties or confu- and enhancing reasoning skills.
sions are resolved; experiences shared and strategies Does subject expertise matter? With training,
reviewed. Such meetings encourage tutors to contrib- senior undergraduates, research students and staff
ute to the quality control of the programme. at all levels of appointment have become effective
tutors. Successful tutors are drawn from diverse dis-
Starting as a PBL tutor ciplines but the majority are most comfortable tutor-
ing in areas related to their own expertise. Some
prior knowledge or experience may allow tutors to
A To become a confident tutor:
• first observe a class
• access staff training and development (may be
enhance a group’s effectiveness providing that they
facilitate and do not dictate. Relevant experience
mandatory) leading to a sense of comfort may come from a back-
• review the sequence of problems ground of teaching, research, or clinical practice in an
• study tutor guides, web-sites and relevant area, or from previous tutoring on the same problems
literature (Wilkerson 1994).
• understand assessment requirements Individuals with broad backgrounds – educational,
scientific, health professional or humanities – have
Before the first session, tutors need information: been effective medical PBL tutors. Staff who direct
• Are the students beginners or ‘old hands’? the group, deliver mini-lectures or interrupt the free
What do they know already? What are their flow of discussion are inappropriate since they cir-
expectations? cumvent the essential exploration and interaction that
underpin the success of PBL.
• What model of PBL is used? How many tutorials?
Effective tutors encourage behaviours that enhance
What are the reasoning steps?
the sessions, ensuring general participation. They need
• Are guides, handbooks or on-line information to know if they are expected formally to assess individ-
supplied to tutors/students? ual students. Tutors help set expectations and provide
• What is the tutor’s role in guiding the breadth and thoughtful insights to the group, but some teachers who
depth of learning? are expert in an area find it difficult to facilitate rather
178 Section 3: Educational strategies
than dictate. That shift in role requires an understand- Suggest that the group exchanges information
ing of the goals of PBL, flexibility and an awareness of beforehand by e-mail, paper summaries or in a
students’ learning needs. prior meeting, and help members to structure
At the end of the session, tutors encourage the their reporting back.
group to review its performance. Effective tutors
reflect on their own contribution:
• Are we achieving the faculty’s and the group’s goals? A If difficulties arise, deal with them promptly, don’t
let them fester:
• Tactfully suggest a new direction
• Were there aspects I should have handled better?
What were the high or low points? • Seek support/solutions from the group
• Offer practical assistance where possible
• Did I intervene too much or too little? • Deal with personal issues in private
• Was the time well balanced? • Identify local resources for assisting students
• Did everyone participate effectively? If not, how • Don’t be tempted to undertake a counselling
can I best encourage or restrain? role
• Should I have a word with student…?
What is the tutor’s role
in assessment?
“l”
“I thought the group I sat in with was doing really
well for second year students – their collective
knowledge and understanding was impressive. Tutors must be familiar with local assessment policies.
Then I found out that they were actually only a few Individual students and/or groups may be assessed
months into first year!” summatively (determining progression) or formatively
Visitor from UK to Medical Program, University of (for feedback).
Sydney
The group
At the end of each problem, groups review their pro-
Group dynamics cesses and progress, to encourage self-reflection and
Encourage the group to articulate concerns, make sug- enhance their collective performance. Some students,
gestions and own the solutions. Problem-based learning however, are uncomfortable with self-assessment and
by Schwartz et al 2001 is a useful resource. personal discussion. Differences reflect national char-
Examples of difficulties and solutions are: acteristics, cultural backgrounds, fluency in the local
language, confidence and personality. Overall, the
• A dominant student, confident and perhaps wrong
comfort of students with PBL and the level of trust
Encourage the group to examine all statements in the tutor and fellow members will affect their
critically, and maybe have a quiet word with the willingness to engage in meaningful revelation and
student outside the tutorial. reflection.
• Silent students – personality, or failure to keep up? The skills of a tutor are tested when the group is
Sensitise the group to the needs of the shyer or unwilling to take responsibility for the process or to
less confident; make ‘space’ for contributions, participate effectively. Trust is essential and must be
suggest particular roles to ensure inclusion. established early; students who fear a penalty or nega-
• Uncooperative, disruptive students tive outcome are unlikely to commit themselves hon-
estly and openly. Facilitative strategies include posing
Encourage group discussion and solutions; open-ended questions or inviting comments on par-
interview the student privately; in extreme cases ticular situations.
consult the course director. Useful questions to discuss include:
• Students who persistently seek information from the
• How did we go as a group? What went well?
tutor
• What could I have done better as a tutor?
Respond with open questions; encourage others to
contribute. • Were there difficult situations? What helped to
• A group that fails to ‘gel’, or in which personality resolve them?
clashes develop • What have you found to be particularly helpful?
Raise the issues; elicit suggestions for diagnosing Formative assessment of groups can occur when
the problem(s) and invite students to share in tutors change groups for one problem in order to pro-
developing solutions. vide independent feedback to the group and to the
• A group that bogs down, reporting detailed regular tutor. If substantial difficulties are apparent,
information retrieved rather than advancing more formal reviews require expert observation or the
discussion of the problem (common) use of group assessment instruments.
Chapter 22: Problem-based learning 179
of an effective discussion during the reporting phase functioning and student achievement in problem-
in problem-based learning. Medical Education based learning. Medical Education 40:730–736
40:924–931 MacMaster University Medical Website. Online.
Wilkerson L A 1994 The next best thing to an answer Available: http://fhs.mcmaster.ca/facdev/tutorPBL.
about tutor’s content expertise in PBL. Academic pdf 13 February 2009
Medicine 69:646–648 van Mook W N K A, de Grave W S, Huijssen-Huisman E
Woods D 1994 Problem-based learning: how to gain the et al 2007 Factors inhibiting assessment of students’
most from PBL. Donald R. Woods, Hamilton, Ontario professional behaviour in the tutorial group during
problem-based learning. Medical Education
Further reading 41:849–856
Integrated learning
D. Prideaux
23
Section 3:
Educational strategies
“l”
education. Integration through dedicated approaches “Information in isolation is inert and unhelpful”
or integration through specific contexts. In the first of Regehr & Norman 1996
these the programme is deliberately structured to organ-
ise or facilitate learning across the disciplines around key
Regehr and Norman (1996) also refer to the concept
concepts, themes or problems. There are two common
of ‘context specificity’. The ability to retrieve an item
approaches in medical education. These are:
from memory depends on the similarity between the
• horizontal integration condition or context in which it was originally learned
• vertical integration. and the context in which it is retrieved.
182 Section 3: Educational strategies
Transdisciplinary
• cardiovascular
• respiratory
Interdisciplinary • renal
• gastrointestinal
Multidisciplinary • endocrine/reproductive
• musculoskeletal.
Complementary
Within these blocks students learn the basic sciences
of anatomy, physiology and biochemistry together
Correlation
with social and behavioural sciences and clinical sci-
ences as applied to normal and abnormal structures
Sharing and functions within the systems (Fig. 23.2).
Horizontally integrated courses are becoming more
Temporal coordination popular as increasing numbers of medical schools
around the world adopt problem-based or case-based
Nesting learning approaches. In these approaches, specifically
constructed cases become the focus for a week or
Harmonisation 2 weeks of study. The cases may be organised by sys-
tem blocks but each case in itself is also integrated.
Awareness
They are designed so that students must draw on
knowledge, ideas and concepts from across the disci-
plines in order to generate and pursue learning goals.
Isolation
Problem-based learning, in particular, emphasises elab-
oration of learning as students generate learning goals
Fig. 23.1 The integration ladder and discuss them in small groups calling on all relevant
knowledge across the disciplines.
Vertical integration
A Context specificity – what is learned in one context
is more readily retrieved in another context. In vertically integrated courses the disciplines are
organised into themes or domains which run through-
There are at least three ways to address context speci- out all years of the course. Many medical courses
ficity. One is to promote the elaboration of knowledge are now organised around four main themes which,
in ‘richer’ and ‘wider’ contexts. Horizontally integrated while given different names, generally deal with the
system or case-based curricula can provide such elabo- following:
ration. Repeated opportunities to use information in • clinical and communication skills
different contexts can also reduce the effects of con- • basic and clinical sciences
text specificity. Such opportunities can be found in
vertically integrated courses where there is revisiting • social, community and population health
of knowledge in different situations and in different • personal and professional development.
combinations of disciplines. A common way of organising a vertically inte-
An additional way of reducing the effect of con- grated curriculum through the themes is to use a spi-
text is to make the learning contexts as close as pos- ral approach. Within each of the themes there may
sible to the context in which the information is to be be sub-themes or blocks which provide the basis for
retrieved. This provides an argument for integrated integration across the years of the medical course. For
learning within integrated clinical contexts such as in example there may be a sub-theme such as life cycle
primary care, family medicine or general practice.
Anatomy
Approaches to integration Biochemistry Physiology
In the rationale for integrated learning set out here it A symbiotic relationship can be achieved by enabling
is argued that one way to achieve such learning is to students to have longer placements in clinical services
ensure that the learning context is itself integrated. and by providing guidelines and support for students
With medical practice becoming more specialised, par- to direct their own learning from patients rather than
ticularly in large teaching hospitals, this is becoming expecting them to be constantly directly ‘taught’ by
increasingly difficult to achieve. This is one of the rea- busy clinical staff. In a recent paper Bleakley and Bligh
sons underlying the calls for more clinical experiences (2006), of the Peninsula Medical School in the south
for students in general practice, family medicine or west of England, have advocated a shift from the
184 Section 3: Educational strategies
‘primacy’ of the doctor–student relationship to the then to draw the content from across the disciplines
relationship between student and patient. In patient- that will contribute to the understanding of the con-
centred approaches students can have extended place- cept. There then can be a selection of the linked con-
ments across clinical services with opportunities for tent to provide the material for study in the medical
integrated learning facilitated by study guides or learn- course. Maps can also be used as a double-check on
ing logs. At Peninsula a model of ‘pathways of care’ the curriculum. Those responsible for the disciplines
is used where students follow patient-centred pro- can draw up their own maps of essential concepts and
grammes across the different services accessed by content to be covered. This can be matched against
patients for various conditions. the material covered in the integrated approach to
identify omissions or overlapping content.
Searchable computer databases provide an effec-
Achieving integration in medical tive way of determining the coverage of content in
education programmes integrated courses and are increasingly employed in
medical schools across the world. Course content can
It is regarded as paradoxical by some medical educa- be logged onto the computer and can be subject to
tors that integrated curricula require a greater degree searches according to a number of criteria, including
of structuring than those based around traditional discipline, key concepts, common presentations or
disciplines. In a course based on separate disciplines, illnesses and system complexes. Students can have
concepts and key ideas can be defined by the well- access to the data bases as a guide for their own learning
structured approaches existing in the disciplines. In and preparation for assessment. They can match what
an integrated curriculum, concepts and key ideas from they learn in their integrated programmes to what is
several disciplines must be combined together in some expected in the course as a whole, by careful exami-
logical way. Hence there has been increasing interest nation and searching of the database. This gives them
in medical education on approaches to the organisation responsibility for their own learning. Databases can
and articulation of curriculum and curriculum content. be linked to electronic resources to support student
There is much contemporary interest in medical learning. In this way students can access ‘reusable
education in outcomes-based approaches to curricu- learning objects’ which may be shared by different
lum design and development (Harden et al 1999). In medical schools.
an outcomes approach those responsible for the course All these approaches require a greater degree of
define broad and significant outcomes that students central rather than departmental control of the cur-
must attain on graduation. There is then a process riculum. Indeed, they require the breaking down of
of ‘designing down’ so that learning and assessment so-called departmental ‘silos’. In most medical schools
systems match the outcomes. More recently the out- the responsibility for curriculum content and organisa-
comes approach has been incorporated into a dynamic tion now lies in a central committee or decision-mak-
model of curriculum design which is well suited to the ing body representative of the disciplines and groups
construction of integrated curricula (Prideaux 2007). in the course. It is this body which oversees curricu-
In a similar manner, integrated curricula can be defined lum content and the contribution of the disciplines.
by key concepts or ideas that transcend disciplines. For
example, ‘homeostasis’ can be used as a key concept
to integrate content from biochemistry and physiol- Learner integration
ogy. Clinical studies can be integrated by examining the
An important distinction made by curriculum writers
effects and outcomes of disordered homeostasis. The key
is that between the ‘intended’ curriculum and the ‘real’
is to define a set of concepts that will effectively integrate
curriculum as it is experienced by students. There may
all the content required in the course (Fig. 23.4)
well be a difference between the curriculum as it is
Curriculum maps can be employed effectively in
intended and written down by its designers and how it
this process. One way of designing maps is to place
is actually received by the students who experience it.
the key concept or idea in the middle of a diagram and
Thus the real measure of the degree of integration
of a curriculum is not what is written down in plans,
Biochemistry Physiology
statements and booklets but rather how much integra-
tion takes place in student learning.
Homeostasis
“l”
“A number of empirical studies have shown,
Normal
however, that effective competence-based
Disordered learning is not achieved by offering students
structure homeostasis
and function separate building blocks because this does not
facilitate transfer of what students have learned”
Fig. 23.4 Homeostasis is an example of a key learning
concept Janssen-Noordman et al 2006
Chapter 23: Integrated learning 185
“l”
“The point of education is to improve the quality of example of this. Students from different health disci-
meanings we construct” plines work together in the authentic tasks of actually
Newman et al 1996 running an interprofessional patient care service.
The frequently quoted adage in medical education
that ‘assessment drives learning’ must not be ignored.
Newman and colleagues (1996) have provided a cri-
If integrated learning is to be achieved it must be driven
tique of constructivist approaches where student
by integrated assessment. As in the process of struc-
engagement has become an ‘end in itself’ rather
turing the curriculum, integration must be deliberately
than the pursuit of quality learning and ‘intellectual’
incorporated into the assessment process. The most
outcomes for students. They use the term ‘authen-
important step is to ensure that integrated learning
tic learning’ which they argue has three central
is represented in assessment blueprints. This requires
components. These are:
a central process of test and examination construc-
• the construction of knowledge tion, with responsibility for assessment residing with
• disciplined inquiry the medical school overall rather than with individual
• ‘value beyond’ the school or educational context departments, similar to the design of the curriculum as
in which the learning takes place. indicated earlier.
There are now established methods for assessing
These three components bring together some of integrated clinical learning once it has been repre-
the earlier discussions presented here. As indicated sented in the blueprints. The objective structured clin-
above, a major task for curriculum designers will be to ical examination (OSCE) format is ideal for assessing
design learning tasks that enable students to construct integrated clinical learning. Similarly, portfolio-based
their learning in integrated ways. This can be facili- assessment and the mini-CEX can promote this form
tated through the use of: of testing. Written assessments too can be focused on
• study guides integrated learning. Many medical schools using prob-
• learning logs and portfolios lem-based formats have adopted case-based assess-
ment methods which attempt to evaluate the processes
• online materials
of problem-based learning as well as the integration of
• independent projects. student knowledge. Multiple-choice and short-answer
This construction of knowledge should be under- questions which are are focused on the assessment of
pinned by a process of rigorous inquiry. The central application, analysis, synthesis and evaluation rather
elements of the process of inquiry as set out by Newman than recall do provide opportunities for students to
and colleagues are: demonstrate that they can integrate and apply their
learning and knowledge base. There is growing inter-
• building on a prior knowledge base
est in progress testing where students are regularly
• providing for in-depth learning assessed through integrated exit level items with
• providing for elaborated learning. student achievement documented and recorded.
These match the central elements of problem-based
learning. Thus problem or case-based approaches will
provide a strong foundation for authentic integrated
A Assessment items that test higher-order cognitive
skills allow students to demonstrate integrated
learning
learning.
186 Section 3: Educational strategies
Interprofessional education
H. Barr
24
Section 3:
Educational strategies
“l”
• decompartmentalise curricula “The days when courses are designed exclusively
• integrate new skills and areas of knowledge for doctors, or exclusively for nurses, should be
behind us”
• ease interprofessional communication
Sir Ian Kennedy 2001
• generate new roles
• promote interprofessional research
• improve understanding and cooperation between What do you mean by IPE?
educational and research institutions
IPE takes many forms in many fields. It is known by
• permit collective consideration of resource
many other names, such as multiprofessional educa-
allocation according to need
tion or interdisciplinary studies. ‘Interprofessional
• ensure consistency in curriculum design education’ now enjoys the widest currency and is
(WHO 1988, pp 16 –17) most often defined as:
188 Section 3: Educational strategies
“l”
“The question is how best to prepare current and
future professionals for practice, recognising that of the working day, to compare their practice learning
health and social care is complex and that ‘one experiences.
size’ in IPE does not fit all” Postgraduate IPE typically includes practising pro-
fessionals who need to work closely together in a
Madeline Schmitt
particular setting, e.g. primary care teams, with a par-
Professor Emeritus in Nursing and
ticular group, e.g. people with HIV/AIDS, or applying
Interprofessional Education
University of Rochester, NY
a particular treatment model, e.g. in mental health.
The entire programme may well be shared.
Chapter 24: Interprofessional education 189
“l”
“All health professionals should be educated to
deliver patient-centered care as members of an
in ways that contribute to and enhance service
interdisciplinary team” provision
• provides a co-mentoring role to peers of own
Institute of Medicine 2003
and other professions, in order to enhance
service provision and personal and professional
What about the content? development.
Competence or capability based outcomes help
Many writers recommend topics for IPE. Ross and
in setting interim objectives for pre-licensure IPE –
Southgate (2000) compiled the following after con-
preparedness for interprofessional practice – to be
sulting teachers in the United Kingdom: epidemiol-
followed up in a collaborative environment including
ogy; health promotion; ethics; critical appraisal skills;
work-based learning between professions.
clinical skills; decision making; and care planning. Lists
such as theirs clarify thinking, but may omit topics that
“l”
focus directly on collaborative practice. Of these, the “For me the key to all of the issues surrounding
one most often added is ‘communications’, but this is IPE is what does it do for patients and the public?
a complex and difficult topic open to interpretations How does it improve patient care?”
that may have little or nothing to do with collaborative Sir Kenneth Calman
practice. Headings alone may imply more common- Chancellor, University of Glasgow, UK
ality of learning needs than closer scrutiny confirms.
The same subject may need to be taught at greater
depth for one profession than for another and applied
differentially to their practice.
What about the learning
Outcome-led formulation of IPE curricula has methods?
gained popularity. Numerous formulations have ite-
mised collaborative competences (Barr 1998) and Most interprofessional learning methods have been
proved helpful in aligning professional and interprofes- adopted and adapted from one or more fields of pro-
sional objectives where the professional programmes fessional education. Problem-based learning (PBL), for
are also competency-based. But IPE, like the profes- example, has been introduced into IPE from medical
sional education in which it is implanted, may then education where it is well established in many schools,
fall prey to the same criticisms that competences are prompting some medical educators to see it, if not as
behaviourist and mechanistic, addressing readiness for the only interprofessional learning method, at least as
immediate practice at the expense of longer-term pro- the first choice. The potency of PBL in professional
fessional development. and interprofessional learning is well testified, but rely-
Alive to these reservations, teachers in Sheffield ing on any one method is needlessly restrictive and may
developed a capability framework (CUILU 2006, inadvertently devalue those drawn from other fields of
www.sheffield.ac.uk/cuilu) derived from bench- education. Depending on the topic, experienced teach-
marking statements for undergraduate professional ers vary the educational methods used in response to
programmes in medicine, nursing, allied health pro- students’ learning needs ensuring interest.
fessions and social work (for medicine see QAA 2002) The following classification is derived from learn-
covering: knowledge in practice; ethical practice, ing methods frequently used in IPE (Barr et al 2005).
interprofessional working; and reflection. It may be advantageous to use different methods in
The interprofessional team member (CUILU combination. Practice-based and e-learning may be
2006): treated either as methods, or as context within which
• is able to lead and participate in the to introduce methods. Given the importance accorded
interprofessional team and wider inter-agency to interaction and exchange, received learning tends
work, to ensure a responsive and integrated to be used sparingly.
approach to care/service management that is • Exchange-based learning, e.g. debates and case
focused on the needs of the patient/client studies
• implements an integrated assessment and plan of • Action-based learning, e.g. problem based
care/service in partnership with the patient/client, learning, collaborative enquiry and continuous
remaining responsive to the dynamics of care/ quality improvement (CQI)
service requirements • Observation-based learning, e.g. joint visits to a
• consistently communicates sensitively in a patient by students from different professions,
responsive and responsible manner, demonstrating shadowing another profession
effective interpersonal skills in the context of • Simulation-based learning, e.g. role-play, games,
patient/client focused care skills labs, and experiential groups
190 Section 3: Educational strategies
“l”
and create an environment for effective interprofes- “The key to success lies in ensuring that future
sional education’. He or she facilitates learning which programmes are grounded in best practice based
is ‘accommodative and transformative’ rather than on the evidence”
‘cumulative and assimilative’ (Howkins & Bray 2007,
Gerard Majoor
pp 22, 35). The effective facilitator is committed to Chairman, The Network: Towards Unity for Health,
collaborative learning and to the learners as the most 2005
important resource, calls upon the experience of other
professions, and respects and welcomes differences in
all people and professions. No longer is the teacher How can I get up to speed?
the font of all wisdom.
There is no substitute for reading, but be warned! The
interprofessional literature is voluminous but uneven.
“l”
“Learning is facilitated when faculty function as
a ‘guide by the side’ rather than ‘a sage on the Begin, may I suggest, with relevant journals. At risk
stage’ ” of special pleading, let me commend the Journal of
Interprofessional Care as the only one wholly dedi-
DeWitt C. Baldwin Jr
cated to collaborative education, practice and research
Scholar-in-Residence, The American Medical
Association, 2007
worldwide: www.informahealthcare.com. Numerous
professional journals also carry helpful interprofessional
Chapter 24: Interprofessional education 191
papers. They include Education for Health, Learning in be more appreciated. So too may those brought by
Health and Social Care, the Journal of Allied Health, teachers from other professions. Co-teaching will be
the Journal of Integrated Health, Medical Education stimulating. Make time to get to know each other
and Medical Teacher. Scanning indexes for these jour- beforehand and be prepared to resolve misunder-
nals may well be rewarding. standings when they surface. Join one or more of the
Interprofessional occasional papers with interna- associations where you will meet other interprofes-
tional application are accessible electronically and with- sional exponents with diverse perspectives to com-
out charge from the UK Higher Education Academy pare. Welcome to the interprofessional community of
(www.healthheacademy.ac.uk) and definitive texts practice.
included in the Blackwell/CAIPE series (see Meads &
Ashcroft 2005, Barr et al 2005, Freeth et al 2005 with
others forthcoming) – www.blackwellpublishing.com. References
National and regional interprofessional associations
Baldwin D C 2007 Interviewed by Linda D’Avray. Journal
have been established in Australia (website in prepa-
of Interprofessional Care 22 (Supplement 1):10–11
ration), Canada: www.cihc.ca/; the Nordic Countries:
www.nipnet.com; the UK: www.caipe.org.uk and Barr H 1998 Competent to collaborate: towards a
throughout Europe: www.eipen.org – each running its competency-based model for interprofessional education.
own conferences and workshops. The International Journal of Interprofessional Care 12(2):181–188
Association for Interprofessional Education and Barr H, Koppel I, Reeves S et al 2005 Effective
Collaborative Practice (InterEd) – www.interedhealth. interprofessional education: argument, assumption
org – runs biennial conferences under the slogan of and evidence. Blackwell Science, Oxford
All Together Better Health and currently has a Study Calman K 2007 Foreword In: Barr H et al
Group conducting a review of IPE for the WHO (Yan Interprofessional education in the United Kingdom,
et al 2007). The Association for Medical Education 1966 to 1997. London: Higher Education Academy,
in Europe (AMEE) – www.amee.dundee.ac.uk – is Health Sciences and Practice, London www.health.
a worldwide organisation which regularly includes heacademy.ac.uk
sessions about IPE in its annual conferences. The CUILU 2006 Combined Universities Interprofessional
Network: Toward Unity for Health – www.the-net- Learning Unit: Final report. Sheffield Hallam
worktufh.org – is increasingly active in IPE, notably in University with the University of Sheffield, Sheffield
developing countries, to complement its commitment Freeth D, Hammick M, Barr H et al 2005 Effective
to the implementation of community-based medical interprofessional education: development, delivery
education with problem based learning. IPE invariably and evaluation. Blackwell Science, Oxford
features in the programme for its annual international
Hammick M, Freeth D, Koppel I et al 2007 A best
conference complemented by its interprofessional
evidence systematic review of interprofessional
special interest group.
education. Medical Teacher 29(8):735–841
Harden R 1999 Effective multiprofessional education: a
“l”
“Now is an exciting time of progress for three dimensional perspective. AMEE Guide No. 12
interprofessional education and collaborative Dundee
practice. Working together for better health is
Howkins E, Bray J 2007 Preparing for interprofessional
more important than ever”
teaching: theory and practice. Radcliffe Medical
Jean Yan Press, Oxford
Chief Scientist for Nursing and Midwifery,
Institute of Medicine Committee on Quality of Health
WHO, 2007
Care in America 2001 Crossing the quality chasm:
a new health system for the twenty-first century.
National Academy Press, Washington DC
Summary Kennedy I 2001 Final report: Bristol Royal Infirmary
Inquiry. HMSO, London
Much that you bring from medical education will be
readily transferable to interprofessional education, but Majoor G 2005 Foreword. In: Barr H et al Effective
teaching a class drawn from a range of professions is interprofessional education: argument, assumption
challenging. Assumptions, perceptions, expectations and evidence. Blackwell Science, Oxford
and experiences differ. Tensions played out may at Meads G, Ashcroft J with Barr H, Scott R, Wild A 2005
first seem intrusive, but on reflection may be seen as The case for collaboration among health and social
opportunities to facilitate mutual understanding. Turn care professions. Blackwell, Oxford
your classes into microcosms of interprofessional rela- QAA 2002 Subject benchmarking statements for
tionships in the working world. Go easy on lectures! medicine. Quality Assurance Agency for Higher
Other learning methods that you bring with you may Education, Gloucester
192 Section 3: Educational strategies
Ross F, Southgate L 2000 Shared learning in medical WHO 1988 Learning together to work together for
and nursing undergraduate education. Medical health. World Health Organization, Geneva
Education 34:739–743 Yan J, Gilbert J, Hoffman S 2007 World Health
Schmitt M 2005 Foreword. In: Barr H et al Effective Organization Study Group on Interprofessional
interprofessional education: argument, assumption Education and Collaborative Practice. Journal of
and evidence. Blackwell Science, Oxford Interprofessional Care 21(6): 588–599
Chapter
“l”
“The burden we place on the medical student is
far too heavy, and it takes some doing to keep it this educational strategy can be further developed
from breaking his intellectual back. A system of to enable both existing and new educational imper-
medical education that is actually calculated to atives to be adressed and realised.
obstruct the acquisition of sound knowledge and Public expectation and demand are now the
to heavily favour the crammer and the grinder is a principal drivers for modernisation. People increas-
disgrace” ingly want to make informed choices about how
Thomas Huxley 1876 to be treated, where and by whom. To meet such
public demand, health professionals need to put
Taking the start of the pre-registration year (equiv- their patients at the centre of all they do, com-
alent to the intern year in the USA) as a reference municating effectively with them and their carers,
point, and framing objectives in terms of the essen- recognising and respecting their rights and beliefs,
tial knowledge, skills and attitudes, all UK medi- and responding to the diversity of the population.
cal schools were urged to define a ‘core curriculum’ While recognising that pre-registration/prelicens-
that must be satisfied before a newly qualified doctor ing education continues to provide the basis for
could assume the responsibilities of a pre-registration professional competency, in the future it must
house officer/intern. In addition to this ‘core’ experi- do more than this. New health professionals need
ence, schools were urged to provide opportunities for to be adaptable, self-reliant, resilient, and able to
student-selected study in depth in areas of particular learn and work flexibly in interprofessional teams
interest to them. The broad purpose of these student- across traditional professional boundaries. They
selected components was to supply an experience for must be prepared to contribute to continuous ser-
students which: vice improvement through critical and creative
reflection on their own practice and competent to
. . . provides them with insights into scientific
evaluate the services they deliver.
method and the discipline of research and that
In most countries, programmes of basic medi-
engenders an approach to medicine that is
cal education are prescribed under broad statutory
constantly questioning and self-critical.
frameworks promoted by bodies such as the General
Almost a decade later the second edition of Medical Council in the UK and the Association of
Tomorrow’s doctors (GMC 2003) continued to American Medical Colleges in the USA. In addi-
recommend this educational strategy and by that tion, in the UK pre-registration medical programmes
time the majority of UK medical schools had made are, like all other higher education programmes,
significant progress towards identifying the core required to adhere to subject benchmark statements
194 Section 3: Educational strategies
have defined a Core Medicine Clerkship Curriculum • drawing up a profile of desired competencies
Guide (CDIM/SGIM 2006). More recently a Family • identifying a core index of clinical situations,
Medicine Clerkship Curriculum was developed based conditions, problems, cases or presentations
on the Accreditation Council for Graduate Medical
• identifying a set of experiences enabling objectives
Education CGME defined competencies (O’Brien-
to be met, e.g. a community-orientated programme
Gonzales et al 2007).
Although the process which results in the defini- • developing core content around longitudinal
tion of a core curriculum of this nature often takes themes, e.g. life cycle
into account guidelines of the national regulatory • deriving core from the learning outcomes (although
body, generally it has not been sanctioned. this presupposes the adoption of a rational method
There are also examples of individuals taking it upon for defining the learning outcomes!).
themselves to define a core curriculum within a partic-
Whatever ‘wrap’ is chosen, the basic aim is to use
ular subject area (e.g. medical statistics, paediatrics).
competencies, clinical situations or experiences as
A word of caution should be given here for institu-
triggers for defining the knowledge base, the perfor-
tional curriculum planners. Such externally defined
mance base and the attitudinal/behavioural agenda.
‘core curricula’ often emanate from individuals or pro-
The choice of approach to the way in which the
fessional associations with the vested interest of promot-
curriculum will be delivered can go some way to
ing and preserving their own subject area or discipline
determining the ‘wrap’ adopted for defining the core.
and its identity. One of the major uses of such initiatives
For example problem-based learning courses tend to
is to support the argument by subject specialists for the
define the core curriculum by a series of clinical prob-
maintenance of, or an increase in, curriculum time allo-
lems or index cases.
cated to their specialty. This is directly contrary to the
There is little research which relates curriculum
original purpose of identifying a core curriculum, i.e. to
content to educational outcome. As such, opinion-
reduce the overburdening of the curriculum.
based processes tend to dominate when curriculum
For basic medical education, it is often better that
content is defined. A corollary to this is that the
such inputs from specialties and disciplines be decided
result will depend upon those stakeholders consulted
at an institutional level, and incorporated into an inte-
and included in the process; for example a curricu-
grated core curriculum in relation to the learning out-
lum structured around a list of core clinical cases will
come ‘map’.
depend upon the range and background of stakeholders
who contributed to its development. That said, there is
A Exercise caution when presented with core
curricula defined for a specialty/discipline
general agreement that the involvement of as broad a
range of local stakeholders as possible is essential.
• The input of teachers, such as faculty staff
Methodologies (academic and clinical academic), general
For an individual school, the first step is to determine practitioners, consultants and healthcare
a rational basis for identifying the core. In practice the professionals, is crucial to facilitating ‘institutional’
commonest approach is to link determination of core ownership, as these are the people who will have
to definition of content. to deliver the curriculum.
• The input of trainers responsible for post-
“l”
“The core curriculum must be the responsibility graduation training can provide useful insights into
of clinicians, basic scientists and medical
what will be expected of the graduate in the next
educationalists working together to integrate their
stage of their medical education.
contributions and achieve a common purpose”
• The input of consumer groups, including senior
GMC 2003
students, interns, patients and employers, has
much to offer;
“l”
“The core provides the essential knowledge,
understanding, clinical skills and professional • Input of recent product – junior doctors (post-
attitudes which are required by any medical registration trainees) are a useful group in bringing
graduate in order that s/he may practise as a a sense of modern practice, the real world of
PRHO and commence post graduate training” work, and the level of skills required.
QAA 2002
Careful consideration of the core content is required A When attempting to define the core, involve as
broad a range of local stakeholders as possible
to guarantee complete mastery of essential competen-
cies. A variety of approaches have been used to enable Curriculum planners must never lose sight of the
institutions to identify the core elements upon which need to constrain the content burden of the curricu-
their current medical course is based. These include: lum, and the downside of involving a comprehensive
Chapter 25: Core curriculum and student-selected components 197
range of stakeholders is that it can easily add to that If such a three-level model is appropriate to local
burden! At programme level it is essential that the specification, then defining a core list of presentations
school has a robust curriculum governance structure will reinforce the patient-centred nature of the pro-
in place, including a small, empowered group of gen- gramme. Defining core conditions will help determine
eralists who act as the final arbiters of content. This the core knowledge and skills, while defining core
is essential if a balanced curriculum is to be produced cases will in turn help focus both students’ learning
and useful in resolving conflicts (which mostly arise and the integration of the programme such that the
from the subject/specialty level). case list will provide a corpus of illustrative material
for use in all stages and strands of the course.
1 2 3
Definition of ‘core’ content Low Medium High
3 Core cases Asthma Fig. 25.3 Matrix approach for deciding whether or not
to include a presentation, condition or case in the core
Fig. 25.2 Definition of ‘core’ content curriculum
198 Section 3: Educational strategies
“l”
“Student-selected study provides opportunities
of a relatively small number of experiences out of for study in depth and may extend beyond the
a large menu of available options. Conversely, posi- traditional medical disciplines”
tive selection implies by necessity an opting out from
many others. If a student can opt out of an experi- QAA 2002
ence that is considered essential to meet the outcomes
overall, then by definition such an experience must be
included in the core. Teaching, learning and assessment
Tomorrow’s doctors (2003) recommends that ‘at Given that range of subject areas, and therefore
least two-thirds of each student’s student-selected choice, are key features of this part of the curriculum,
components must be in subjects related to medicine’. some unifying elements must be introduced into the
In order to safeguard against deviating from this guid- student-selected components to ensure that the core
ance, but also to ensure that students do not limit their learning outcomes can be achieved and appropriately
portfolio of experience to a narrow field, it may be assessed. A variety of learning activities/tasks can be
necessary to categorise the individual student-selected provided to enable students to achieve such defined
components on offer. Successful approaches include outcomes (Stark et al 2005). Taking the possible out-
defining student-selected components as clinical or comes listed above, some examples of learning activi-
non-clinical, hospital, community or laboratory-based, ties which may be used in this way include:
and science or non-science. • Communication skills – opportunities for verbal
and written communication.
Outcomes
• Information technology skills – supervised
Curriculum planners must establish which core learning training sessions to develop information skills and
outcomes can be met by all students irrespective of the proficiency in the use of communications and
content of their selected components. Given the rela- information technology.
tively low emphasis placed on the content of the student
• Insight into research and scientific method –
selected components, it is the acquisition of skills and
opportunities to undertake a research project.
the development of appropriate attitudes and behaviour
that are most likely to be achieved through this part • Critical thinking – opportunities for evaluation
of the programme (Murdoch-Eaton et al 2004). and interpretation of information from a variety
Examples of core learning outcomes which may be of sources.
achieved through student-selected components are: • Reflection – use of portfolio or logbook to
• Communication skills: ‘. . . clearly present provide a structured approach to learning through
information verbally, visually or in writing and reflection on experiences and performance.
communicate ideas and arguments effectively’. • Self-management – opportunities to manage and
• Information technology skills: ‘. . . demonstrate prioritise stages of project.
competence in using library and other information If student-selected components are to be used to
systems to access information’. enable students to achieve core learning outcomes, then
• Insight into research and scientific method: it is essential that reliable and valid assessment method-
‘. . . demonstrate ability to apply appropriate ologies are developed and utilised. This will serve not
method of enquiry’. only to reinforce the importance of this part of the cur-
• Critical thinking: ‘. . . demonstrate ability to riculum to the student body, but also to reassure those
critically evaluate and interpret information’. teachers involved in the delivery of student-selected
components of the perceived worth by the school of
• Reflection: ‘. . . identify one’s own strengths and their contribution to the curriculum. Some examples of
weaknesses’. methodologies which have been used to assess achieve-
• Self-management: ‘. . . effectively manage time and ment of the learning outcomes defined above include:
prioritise tasks’. • Communication skills – assessment of an oral
presentation for effective communication of ideas
“l”
“Student-selected study has the aim of stimulating and arguments.
critical thought and developing further generic • Information technology skills – assessment of a
graduate skills and intellectual attributes
poster for use of information technology skills in
underpinning enquiry and critical thinking; it should
ensuring clarity of presentation.
allow students to acquire research methods
and enhance their skills in collection, evaluation, • Insight into research and scientific method –
synthesis and presentation of evidence” assessment of ‘methods’ section of a written
report for clarity and appropriate use of
QAA 2002
methodology.
200 Section 3: Educational strategies
• Critical thinking – assessment of literature review are changing rapidly, the advent of ‘new’ sciences and
for adequate and appropriate critical appraisal of technologies are having profound effects upon practice
current literature. and public understanding of disease and disability has
• Reflection – assessment of a piece of reflective increased dramatically. Consequently expectations of
writing. what can and should be achieved through basic medical
education are continuing to grow. The changing needs
• Self-management – assessment of achievement of
and demands of a wide range of legitimate stakehold-
a previously agreed set of learning outcomes.
ers must be taken into account in identifying outcomes
and content, and in curricular planning. It must be rec-
Research experience ognised that curriculum development is an ‘organic’,
It is widely recognised and accepted that academic continuing process – the curriculum is never finished!
medicine in the UK is under threat as evidenced by In many respects the original concepts of ‘core cur-
difficulties in recruitment and retention of clinical riculum’ and ‘student-selected components’ are out-
academics, and a reduction in funding for academic moded. While they focused attention on the pressing
posts. In such a climate it is essential that students need to unburden medical programmes of unnecessary
have a positive experience of research if they are to be factual information, the ‘curriculum’ must be consid-
attracted to careers in academic medicine. ered now as a whole, built around a ‘core’ set of learn-
Although some students gain research experience ing outcomes, which for all practical purposes embody
by undertaking a period of intercalation, for the major- the ‘standards’ of any single course of study.
ity of students in the UK this part of the curriculum is Nevertheless the provision of a motivational con-
an optional opportunity, the uptake of which is depen- text, a well-structured framework for learning, oppor-
dent upon several factors including financial means. In tunity for choice and the promotion of the active
contrast, student-selected components are undertaken involvement of students in their own education, are
by all students and therefore provide the curriculum all desirable factors identified as enhancing attainment
planner with opportunities to enable all students to and ensuring that basic medical education remains a
‘learn about and begin to develop and use research rewarding experience.
skills’, as recommended in Tomorrow’s doctors (2003),
in the motivational context of a subject/specialty/edu-
cational environment which each student has chosen. References
It is clear that student-selected components can be
AAMC Core Curriculum Working Group 2000
used as a means of ensuring and assuring the acqui-
Graduate medical education core curriculum
sition of learning outcomes relating to ‘insight into
(AAMC). Association of American Medical
research and scientific method’ as considered above,
Colleges, Washington, DC
however the introduction of the Research Governance
Framework by the UK Department of Health has British Association of Dermatologists. Online. Available:
been shown to have a negative impact on medical stu- http://www.bad.org.uk/healthcare/students/
dents’ opportunities to engage in research projects in undergraduate_education/
a number of UK schools (Robinson et al 2007). The British Pharmacological Society 2002 Core curriculum
perceived unwieldy requirements, especially for gain- for medicine. Online. Available: http://www.bps.
ing ethical approval, appear to have resulted not only ac.uk/education
in a change in the type of projects offered, including Clerkship Directors in Internal Medicine (CDIM) –
an increased availability of audit and literature-based Society of General Internal Medicine (SGIM) Core
projects at the expense of focused systematic enquiries Medicine Clerkship Curriculum Guide Version
involving patients and healthy volunteers, but also in 3.0. Online. Available:http://www.im.org/CDIM/
the withdrawal of some staff as student-selected com- CurriculumGuide/OnlineCDIMCurriculum.pdf
ponent supervisors. Whilst the exposure of students GMC 1993 Tomorrow’s doctors: recommendations on
to the ethical approval process is clearly an impor- undergraduate medical education. General Medical
tant aspect of research training, the development of a Council, London
shortened, simplified process for this purpose would
GMC 2003 Tomorrow’s doctors: recommendations on
open up the opportunities for medical teachers to pro-
undergraduate medical education. General Medical
vide all students with genuine research experience.
Council, London
GMC 2006 Student Selected Components in Graduate
Summary Entry Programmes. General Medical Council,
London Higher education in the learning society,
There has been a shift in balance between hospital-based Report of National Committee of Inquiry into
services and the delivery of care in the community, the Higher Education, 1997 Online. Available: http://
demography and cultural composition of populations www.leeds.ac.uk/educol/ncihe
Chapter 25: Core curriculum and student-selected components 201