The problem with outcomes-based curricula in medical education: insights from educational theory

BACKGROUND: Educators across the world are charged with the responsibility of producing core learning outcomes for medical curricula. However, much educational theory exists which deliberates the value of learning outcomes in education. AIMS: This paper aims to discuss the problems surrounding outcomes-based curricula in medical education, using insights from educational theory. DISCUSSION: The paper begins with a discussion of the traditions, values and ideologies of medical curricula. It continues by analysing the issue of control within the curriculum and argues that curriculum designers and teachers control product-orientated curricula, leading to student disempowerment. The paper debates outcomes-based curricula from an ideological perspective and argues that learning outcomes cannot specify exactly what is to be achieved as a result of learning. CONCLUSIONS: The paper argues that medical schools should adopt a model for co-operative control of the curriculum, thus empowering learners. The paper also suggests that medical educators should determine the value of precise learning outcomes before blindly adopting an outcomes-based model.     

Just a spoonful of humanities makes the medicine go down: introducing literature into a family medicine clerkship

BACKGROUND: This project introduced medicine-related poetry and prose to a Year 3 family medicine clerkship with the purpose of determining students' perception of the usefulness of such materials to enhance empathy, improve patient management, and reduce stress. Although humanities are represented in the curricula of many medical schools, we need more information on how best to incorporate them during the clinical years. METHOD: In 2000, we used a needs assessment survey to identify learner perceptions of medical humanities. Using this information, in 2001-03 we developed and implemented a humanities-based curriculum consisting of readings linked to clinical vignettes, comments about humanities reading in required clinical Subjective, Objective, Assessment, Plan (SOAP) notes, and either station-specific or general poetry accompanying student end-of-clerkship objective structured clinical examinations. We collected both quantitative and qualitative data assessing student reactions and examined the data using non-parametric statistics and content analysis, respectively. RESULTS: Students showed moderate interest in incorporating humanities in medical education as a way of enhancing empathy, improving understanding and reducing frustration. Assessment of the clerkship humanities curriculum suggested a positive influence on students in terms of empathy for the patient's perspective, and a lesser, but still positive, impact on patient management. DISCUSSION: Responses from this group of learners suggest that there is receptivity toward introducing medical humanities into family medicine curricular venues and that such effort can have a generally positive effect on learner empathy, awareness and understanding toward patients and doctors.     

Integrating Eisner's Arts Education Philosophy into Culinary Arts Education

Abstract

This paper outlines the life and work of Dr. Elliot W. Eisner, a champion of American education and the inclusion of art in students' lives. Three areas of Dr. Eisner's life are explored, his early formative years, his ideas on curriculum in the United States of America, and his research on the development of arts-based education in schools. The paper recommends several ways to achieve Discipline Based Arts Education (DBAE) in the instruction of culinary arts through the examination of Eisner's educational philosophy and its application in a culinary setting.     

Analysis and prospects for curricular reform of medical schools in Southeast Europe

AIM: To analyse the curricula of 16 medical schools in 6 countries in Southeast Europe in order to establish a prevailing standard curriculum against which a prospective curriculum reform could formulate its objectives. METHODS: Curricular information was gathered from a questionnaire sent via e-mail to the respective medical schools. The data collected ranged from the numbers of enrolled students to a breakdown of courses with distribution of instruction hours for certain teaching formats. For easier comparison the courses were clustered into 5 groups: pre-clinical, clinical, public health, liberal arts and electives. RESULTS: Belgrade has the highest number of undergraduate students, while Mostar has the lowest. Novi Sad, Foca/Srbinje, Zagreb, Split, Sofia, Ljubljana and Mostar have more than 5000 instruction hours, but Sarajevo lags behind with 4005 hours. Anatomy dominates the course load in Year 1, ranging from a share of 18.4% in Sofia to 11.3% in Novi Sad. Physiology dominates Year 2, ranging from 16.8% in Rijeka to 8.9% in Split, whereas in Year 3 the dominating course is pathology, reaching a peak of 13.7% in Sarajevo. Sofia has the highest number of class hours of clinical courses. The predominant public health courses are social medicine, family medicine and medical ecology. Medical English is taught at all medical schools (as electives in Ljubljana and Rijeka). CONCLUSION: There is considerable potential for curriculum improvement in the region. Teacher training, student participation, the definition of core competencies and the introduction of new methodologies should all be implemented in the process.     

Thinking the post-colonial in medical education

Context  Western medicine and medical techniques are being exported to all corners of the world at an increasing rate. In a parallel wave of globalisation, Western medical education is also making inroads into medical schools, hospitals and clinics across the world. Despite this rapidly expanding field of activity, there is no body of literature discussing the relationship between post-colonial theory and medical education.
Discussion  Although the potential benefits of international partnerships and collaborations in education are incontrovertible, many medical educators are sometimes too unreflecting about what they are doing when they advocate the export of Western curricula, educational approaches and teaching technologies. The Western medical curriculum is steeped in a particular set of cultural attitudes that are rarely questioned. We argue that, from a critical theoretical perspective, the unconsidered enterprise of globalising the medical curriculum risks coming to represent a 'new wave' of imperialism. Using examples from Japan, India and Southeast Asia, we show how medical schools in non-Western countries struggle with the ingrained cultural assumptions of some curricular innovations such as the objective structured clinical examination, problem-based learning and the teaching of clinical skills.
Conclusions  We need to develop greater understanding of the relationship between post-colonial studies and medical education if we are to prevent a new wave of imperialism through the unreflecting dissemination of conceptual frameworks and practices which assume that 'metropolitan West is best'.     

Student perceptions of medico-legal autopsy demonstrations in a student-centred curriculum

Objectives  Teaching autopsies in undergraduate medicine, although traditionally considered valuable by both educators and students, have been marginalised in modern curricula. This study explored medical students' experiences of the medico-legal autopsy demonstrations which formed part of their training in forensic medicine.
Methods  In this phenomenological study, qualitative data obtained by interviewing 10 Year 4 medical students from various socio-cultural backgrounds were interpretively examined. One-to-one, semi-structured interviews were tape-recorded and transcribed. The data were thematically organised and then analysed using a theoretical framework of three dimensions of learning, namely, cognitive, emotional and societal.
Results  Students still perceive autopsies as essential even in the context of self-directed learning. They identified a better understanding of anatomy and traumatology as the main cognitive benefits. At an emotional level students felt they had developed a degree of clinical detachment and would be better equipped to deal with issues surrounding death. Although socialisation influenced students' feelings about the autopsy, it did not detract from their appreciation of the educational value of the experience.
Conclusions  The results support previous findings from both students, prior to curriculum reform, and medical educators who were canvassed for their opinions in relation to a modern curriculum. Besides the obvious cognitive advantages, educators should be mindful of the hidden curriculum that emanates from autopsies because it impacts on the development of professionalism and ethical behaviours of future medical practitioners.     

Country report: Australia

The last 10 years has been an interesting time for Australian medical education despite reduced funding. WORKFORCE: There are five main workforce trends: a rural/urban maldistribution, a need for more specialists, public hospital staffing difficulties, increasing female practitioners and under-representation of indigenous practitioners. ISSUES FACING THE DEANS: Lack of resources is a problem facing Deans, with pressure for clinical service in teaching hospitals. Entrepreneurial activities have been undertaken including the enrollment of overseas students. Medical schools have also responded to important government initiatives. DEVELOPMENTS IN MEDICAL EDUCATION: Australia's 11 medical schools have undergone significant reform in the last decade. There is a mix of four (graduate), five and six year courses. AUSTRALIA'S NEW MEDICAL SCHOOL: James Cook University opened the first medical school in northern Australia in 2000. The School admits students from rural, northern Australian and indigenous backgrounds. It has a strong regional mission. RURAL AND COMMUNITY-BASED EDUCATION: Government funding to address the maldistribution of the workforce has led to the establishment of rural clubs, Departments of Rural Health and community-based programs. THE FIRST TWO POSTGRADUATE YEARS: There have been recent moves to improve education in the two years following graduation. This includes the initiation of national projects in curriculum and assessment. POSTGRADUATE AND CONTINUING MEDICAL EDUCATION: Postgraduate programs in Australia are being reformed to build on the changes in undergraduate education. CME is also under review. CONCLUSION: Australian medical educators should build on the recent reforms and take on some of the new directions in medical education.     

The Art of Medicine through the Humanities: an overview of a one-month humanities elective for fourth year students

BACKGROUND: The purpose of incorporating humanities teaching into medical education is to encourage students to develop into more sensitive and caring doctors who communicate well with their patients and colleagues. CONTENT: A unique 4th year student elective at the Medical College of Wisconsin incorporates reflective and writing activities. Small group sessions are facilitated by faculty with specific interest and expertise in the humanities. EVALUATION: Students keep a journal in which they record their reflections on personal issues, career planning and reactions to classroom discussions. Each student writes a poem and an essay or short story. The course is well received and oversubscribed. CONCLUSIONS: Students increase their understanding of the humanities through readings, small group discussions, journal keeping and formal writing. By incorporating humanism into their professional lives, medical students can learn to care for their patients in a more humane and thoughtful manner.     

Can the science of communication inform the art of the medical humanities?

CONTEXT There is increasing interest in establishing the medical humanities as core integrated provision in undergraduate medicine curricula, but sceptics point to the lack of evidence for their impact upon patient care. Further, the medical humanities culture has often failed to provide a convincing theoretical rationale for the inclusion of the arts and humanities in medical education. DISCUSSION Poor communication with colleagues and patients is the main factor in creating the conditions for medical error; this is grounded in a historically determined refusal of democracy within medical work. The medical humanities may play a critical role in educating for democracy in medical culture generally, and in improving communication in medical students specifically, as both demand high levels of empathy. Studies in the science of communication can provide a valuable evidence base justifying the inclusion of the medical humanities in the core curriculum. A case is made for the potential of the medical humanities – as a form of ‘adult play’– to educate for collaboration and tolerance of ambiguity or uncertainty, providing a key element of the longer‐term democratising force necessary to change medical culture and promote safer practice. CONCLUSION The arts and humanities can provide important contextual media through which the lessons learned from the science of communication in medicine can be translated and promoted as forms of medical education.     

Understanding medical students' attitudes towards and experiences with persons with disabilities and disability education

BackgroundIn the United States, approximately one quarter of individuals are living with disabilities and receiving healthcare services. The undergraduate medical school curriculum provides an opportunity to improve the attitudes and skills of physicians working with persons with disabilities (PWD).Objective/hypothesisThe purpose of this study was to gain an understanding about fourth-year medical students’ self-reported attitudes towards and experiences with PWD and disability education. We hypothesized that medical students would recall having education about disabilities, would be able to identify a pivotal disability education experience, and would report being less comfortable working with PWD than persons without disabilities.MethodsThis mixed methods observational study was conducted via an online survey distributed to medical students during Winter 2020/2021. It contained an adapted instrument and a few short answer questions.ResultsOur survey had 44 respondents, a 28% response rate. Though 98% of students reported receiving disability education during one or more courses, 80% felt their disability education during medical school has been inadequate. Additionally, 64% reported having an influential learning experience involving PWD. Despite their attitudes, education, and experiences, respondents reported feeling less comfortable obtaining a history, performing a physical exam, and establishing a differential diagnosis when working with PWD.ConclusionsThis study highlights the need for continued development of disability curricula, which likely extends beyond the studied institution. Additional educational elements could be added to humanities sessions, as well as other courses and clerkships.     

Advancing educators and education by defining the components and evidence associated with educational scholarship

OBJECTIVE: This study aimed to establish documentation standards for medical education activities, beyond educational research, for academic promotion consistent with principles of excellence and scholarship. METHODS: In 2006 a Consensus Conference on Educational Scholarship was convened by the Association of American Medical Colleges (AAMC) Group on Education Affairs (GEA) to outline a set of documentation standards for use by educators and academic promotion committees. Conference participants' work was informed by more than 15 years of literature on scholarship, educator portfolios and academic promotion standards. RESULTS: The 110 conference participants, including medical school deans, academic promotion committee members, department chairs, faculty and AAMC leaders, re-affirmed the 5 education activity categories (teaching, curriculum, advising and/or mentoring, education leadership and/or administration, and learner assessment), the contents of each category, and cross-category documentation standards. Educational excellence requires documentation of the quantity and quality of education activities. Documenting a scholarly approach requires demonstrating evidence of drawing from and building on the work of others, and documenting scholarship requires contributing work through public display, peer review and dissemination; both involve engagement with the community of educators. Implementation of these standards - quantity, quality and engagement with the education community - should occur in parallel with the development of an infrastructure to support educators, including sustained faculty development for educators, access to educational resources and journals, peer review mechanisms and consultation and support specific to each activity category. CONCLUSIONS: Educators' contributions to their institutions must be visible to be valued. The establishment of documentation standards for education activities provides the foundation for academic recognition of educators.     

The first medical humanities programme in Turkey

THE MEDICAL HUMANITIES: The arts and humanities have been considered a recreational activity related to the interests and talents of the doctor, rather than to their practice of medicine. GOOD MEDICAL PRACTICE COURSE: At Hacettepe University, the 'good medical practice course' was added to the curriculum in September 2004. The goals of this course are to help the students achieve the skills and attitudes of a good doctor and to become competent in caring for and communicating with patients. IMPLEMENTATION: As a part of the programme, in the first 3 years students prepared 526 projects concerned with medical humanities in the broad areas of 'medicine and art', 'medicine and history' and 'man and medicine'. They presented 72 of the projects as short communications at the Medical Humanities Congress and the remaining projects as posters. Each project was also to be prepared as a portfolio. PROGRAMME EVALUATION: At the end of the programme, a questionnaire was given to both the students and the tutors to evaluate the course. The part of the programme rated most difficult was the medical humanities section, according to 67.1% of the students. They commented that it took a great deal of time to research and prepare the projects. PROPOSED CHANGES: The new concept and the extra workload, in addition to new medical knowledge, confused all the students. We have made some changes to the programme and have decided to develop a number of new activities. CONCLUSION: 'Medical humanities' is a new concept for almost all the students and the faculty; it needs to be well defined.     

Anatomy 1999–2000: the curriculum,who teaches it and how?

AIM: To review the impact of Tomorrow's Doctors on anatomical teaching in the UK and Ireland. To establish in particular whether a consensus has emerged on: (a) the duration and format of teaching, and (b) the impact on staffing and on the four main anatomical disciplines of gross anatomy, histology, embryology and neuroanatomy. METHOD AND RESULTS: A postal survey of 28 anatomy departments was carried out. This yielded a response rate of 75%. Twelve departments used systems-based curricula, five used problem-based curricula, and four used a traditional regional format. There were variable levels of integration between the anatomical disciplines and subjects outside anatomy. Dissection taught over the first 2 years was retained in 76% of the courses, frequently supplemented with demonstrations, with an average of 2 hours of practical work for every hour of lecture. Staff/student ratios varied with the type of curriculum: dissection room teaching and problem-based curricula were associated with higher numbers of either full or part-time clinically qualified teachers. Teaching was supported by a high proportion of part-time clinically qualified staff, giving an overall average staff/student ratio of 19.8 in a dissection class. CONCLUSIONS: There is considerable variation in duration and staffing of anatomy teaching, according to the type of curriculum. This suggests there may well be substantial variation in the level, content and depth of anatomical curricula across the country, and that this should be quantified.     

Information Management and Technology (IM&T): training provision in postgraduate medical education

Information Management and Technology (IM&T) is assuming a greater role within the modern NHS and there is an increasing need for members of the medical, and other health care, professions to receive appropriate training and education in these areas. Over half the Postgraduate Deans, Regional Advisers in General Practice and the Medical Royal Colleges have made a conscious decision to supply training in IM&T-related areas. These courses are open to a wide range of health care professionals. However, the number of reported places is not adequate for the large number of people who require the training. Less than half the organizations employed staff with a remit to provide training but over half provided courses in collaboration with educational establishments. As the medical undergraduate curriculum changes and incorporates training in computer skills, the links between the postgraduate institutions and medical schools must be fostered and developed. This will lead to increasing opportunities for health professionals both in the range of subjects and the number of places available.     

The theory of planned behaviour in medical education: a model for integrating professionalism training

Context  Teaching and evaluating professionalism remain important issues in medical education. However, two factors hinder attempts to integrate curricular elements addressing professionalism into medical school training: there is no common definition of medical professionalism used across medical education, and there is no commonly accepted theoretical model upon which to integrate professionalism into the curriculum.
Objectives  This paper proposes a definition of professionalism, examines this definition in the context of some of the previous definitions of professionalism and connects this definition to the attitudinal roots of professionalism. The problems described above bring uncertainty about the best content and methods with which to teach professionalism in medical education. Although various aspects of professionalism have been incorporated into medical school curricula, content, teaching and evaluation remain controversial. We suggest that intervening variables, which may augment or interfere with medical students' implementation of professionalism knowledge, skills and, therefore, attitudes, may go unaddressed.
Discussion  We offer a model based on the theory of planned behaviour (TPB), which describes the relationships of attitudes, social norms and perceived behavioural control with behaviour. It has been used to predict a wide range of behaviours, including doctor professional behaviours. Therefore, we propose an educational model that expands the TPB as an organisational framework that can integrate professionalism training into medical education. We conclude with a discussion about the implications of using this model to transform medical school curricula to develop positive professionalism attitudes, alter the professionalism social norms of the medical school and increase students' perceived control over their behaviours.     

Responding to the implications of the genetics revolution for the education and training of doctors: a medical humanities approach

BACKGROUND: Rapid advances in the field of genetics continue to present medical educators with significant challenges. Whilst there is undoubtedly a pressing need to educate doctors about genetic disorders, research and therapies, there is a parallel need to provide a context for all of these. CONTENT: An interdisciplinary, arts and humanities based approach, responding to this need, is described. This teaching has been successfully delivered both as optional and core undergraduate teaching, and as part of continuing professional development. THE HUMAN PERSPECTIVE: STORIES NOT HISTORIES: Understanding of the patient's perspective can be significantly improved by drawing on both written and oral stories of illness. THE HISTORICAL PERSPECTIVE: LEARNING FROM THE PATIENT: Experiential learning provides insights into the social history of developments in genetics, thereby placing the current concern and debate about the new genetics in context. THE ROLE OF THE MEDIA: THE POWER TO PERSUADE: Critical reading skills can be developed and the power of the popular press to influence the reader acknowledged by analysing and employing the skills of the journalist when reporting developments in biotechnology. LEARNER ASSESSMENT AND EVALUATION: Assessment, both formative and summative, demonstrates sophisticated insights and perspectives into the lived experience of genetic illness. Learner evaluation of the teaching is high. CONCLUSION: Medical humanities offers a powerful way to convey an understanding of how genetic disorders impact on the lives of patients and families, and to set this against the background of a history rich in the uses, and abuses, of knowledge of heredity.     

Does problem‐based learning lead to deficiencies in basic science knowledge? An empirical case on anatomy

INTRODUCTION: Problem-based learning (PBL) is supposed to enhance the integration of basic and clinical sciences. In a non-integrative curriculum, these disciplines are generally taught in separate courses. Problem-based learning students perceive deficiencies in their knowledge of basic sciences, particularly in important areas such as anatomy. Outcome studies on PBL show controversial results, sometimes indicating that medical students at PBL schools have less knowledge of basic sciences than do their colleagues at more traditional medical schools. We aimed to identify differences between PBL and non-PBL students in perceived and actual levels of knowledge of anatomy. METHODS: Samples of Year 4 students in all eight medical schools in the Netherlands completed a questionnaire on perceived knowledge and took part in a computerised anatomy test consisting of both clinically contextualised items and items without context. RESULTS: Problem-based learning students were found to have the same perceived level of anatomy knowledge as students at other medical schools. Differences in actual levels of knowledge were found between schools. No significant effects on knowledge levels were found for PBL schools versus non-PBL schools. CONCLUSION: The results of this study show that PBL does not result in a lower level of anatomy knowledge than more traditional educational approaches. It remains to be ascertained whether the levels students attain are adequate. Subjects for further study are the desired level of anatomy knowledge at the end of undergraduate medical education and the effectiveness of basic science learning within a clinical context and with repetition over the course of the curriculum.     

A proposal to address the curriculum for the M-4 medical student

The unstructured and elective nature of the fourth-year medical student (M4) medical school curriculum has been recognized by medical educators as an area of concern. Few accepted guidelines exist for the M4 curriculum, and students exercise significant discretion over their experience. The Family Medicine Curriculum Resource Project post-clerkship resource was developed by the Society of Teachers of Family Medicine under contract from the Health Resources and Service Agency to support medical educators in the development of curricula and assessment of student needs for the M4 year of medical school. The post-clerkship resource defines competencies for graduation and contains educational resources as well as recommendations for faculty development and student evaluation in the M4 year.