Curriculum planning and development

Introduction

Curriculum planning and development remains very much on the agenda for undergraduate, postgraduate and continuing medical education. The days are now past when the teacher produced a curriculum like a magician produced a rabbit out of a hat, when the lecturer taught whatever attracted his or her interest and when the students’ clinical training was limited to the patients who happened to present during a clinical attachment. It is now accepted that careful planning is necessary if the programme of teaching and learning is to be successful.

“Curriculum is in the air. No matter what the problem in medical education, curriculum is looked to as the solution.”

Davidoff 1996

What is a curriculum?

A curriculum is more than just a syllabus or a statement of content. A curriculum is about what should happen in a teaching programme – about the intention of the teachers and about the way they make this happen. This extended vision of a curriculum is illustrated in Figure 2.1. Curriculum planning can be considered in 10 steps (Harden 1986b). This chapter looks at these steps and the changes in emphasis since the publication of the third edition of the text.

Fig. 2.1 An extended vision of a curriculum

The 10 steps described provide a useful checklist for planning and evaluating a curriculum.

The relevance or appropriateness of educational programmes has been questioned by Frenk et al (2010), Cooke et al (2010) and others. The need has been recognized to emphasize not only sickness salvaging, organic pathology and crisis care, but also health promotion and preventative medicine. Increasing attention is being paid to the social responsibility of a medical school and the extent to which it meets and equips its graduates to meet the needs of the population it serves.

“Professional education has not kept pace with these challenges, largely because of the fragmented, outdated, and static curricula that produce ill-equipped graduates.”

Frenk et al 2010

A range of approaches can be used to identify curriculum needs (Dunn et al 1985):

• The ‘wise men’ approach. Senior teachers and senior practitioners from different specialty backgrounds reach a consensus.

• Consultation with stakeholders. The views of members of the public, patients, government and other professions are sought.

• A study of errors in practice. Areas where the curriculum is deficient are identified.

• Critical-incident studies. Individuals are asked to describe key medical incidents in their experience which represent good or bad practice.

• Task analysis. The work undertaken by a doctor is studied.

• Study of star performers. Doctors recognized as ‘star performers’ are studied to identify their special qualities or competencies.

Establishing the learning outcomes

If you leave this book with only one idea, it should be the concept of outcome-based education.

One of the big ideas in medical education over the past decade has been the move to the use of learning outcomes as the driver for curriculum planning (Harden 2007). In an outcome-based approach to education, as discussed in Chapter 18, the learning outcomes are defined and the specified outcomes inform decisions about the curriculum. This represents a move away from a process model of curriculum planning, where the teaching and learning experiences and methods matter, to a product model, where what matters are the learning outcomes and the product.

“A move from the ‘How’ and ‘When’ to the ‘What’ and ‘Whether’ ”

Spady 1994

The idea of learning outcomes is not new. Since the work of Bloom, Mager and others in the 1960s and 1970s, the value of setting out the aims and objectives of a training programme has been recognized. In practice, however, long lists of aims and objectives have proved unworkable and have been ignored in planning and implementing a curriculum. But in recent years, the move to an outcome- or competency-based approach to the curriculum with outcome frameworks has gained momentum and is increasingly dominating education thinking.

Agreeing on the content

The content of a textbook is outlined in the content pages and in the index. The content of a curriculum is found in the syllabus and in the topics covered in lectures and other learning opportunities. Traditionally, there has been an emphasis on knowledge, and this has been reflected in student assessment. Content relating to skills and attitudes is now recognized also as important. Increasing emphasis has been placed on an authentic curriculum – a curriculum where the content is more closely related to the work of the practising doctor. Basic science content, for example, is considered in the context of clinical medicine.

The content of the curriculum can be presented from a number of perspectives:

• subjects or disciplines (a traditional curriculum)

• body systems, e.g. the cardiovascular system (an integrated curriculum)

• the life cycle, e.g. childhood, adulthood, old age

• problems (a problem-based curriculum)

• clinical presentations or tasks (a scenario-based, case-based or task-based curriculum).

These are not mutually exclusive; grids can be prepared which look at the content of a curriculum from two or more of these perspectives.

No account of curriculum content would be complete without reference to ‘the hidden curriculum’. The ‘declared’ curriculum is the curriculum as set out in the institution’s documents. The ‘taught’ curriculum is what happens in practice. The ‘learned’ curriculum is what is learned by the student. The ‘hidden’ curriculum is the students’ informal learning that is different from what is taught (Fig. 2.2 and see Chapter 7).

Fig. 2.2 The hidden curriculum

Organizing the content

An assumption in a traditional medical curriculum was that students should first master the basic and then the applied medical sciences before moving on to study clinical medicine. Too often students failed to see the relevance of what was taught to their future career as doctors, and after they had passed examinations in the basic sciences, they tended to forget or ignore what they had learned.

“Early experience helps medical students socialise to their chosen profession. It helps them acquire a range of subject matter and makes their learning more real and relevant. It can influence career choices.”

Dornan et al 2006

It has been advocated that the curriculum should be turned on its head, with students starting to think like a health professional from the day they enter medical school. Students at Hofstra Medical School, New York spend their first 8 weeks working as paramedics. In a vertically integrated curriculum, students are introduced to clinical medicine alongside the basic sciences in the early years of the programme. The need for students to continue their studies of the basic sciences as applied to clinical medicine in the later years is now recognized. In a final portfolio assessment, students at Dundee Medical School, for example, are expected to interpret the clinical cases they document in the context of an understanding of the basic sciences.

A spiral curriculum (Fig. 2.3) offers a useful approach to the organization of content (Harden & Stamper 1999). In a spiral curriculum:

Fig. 2.3 A spiral curriculum

• there is iterative revisiting of topics throughout the course

• topics are revisited at different levels of difficulty

• new learning is related to previous learning

• the competence of students increases with each visit to a topic.

Deciding the educational strategy

In planning a curriculum, ask teachers to identify where they think they are at present on each continuum in the SPICES model and where they would like to go.

Much discussion and controversy in medical education has related to education strategies. The SPICES model (Fig. 2.4) offers a useful tool for planning a new curriculum or evaluating an existing one (Harden et al 1984). It represents each strategy as a continuum, avoiding the polarizing of opinion and acknowledging that schools may vary in their approach.