R.M. Harden

A move from process to product

Callahan suggested in 1998 that ‘it is an odd fact of contemporary medicine that there is comparatively little discussion or debates on the goals of medicine.’ Over the last 15 years there has been a dramatic change, with consideration of the competencies and abilities expected of a doctor high on the agenda. Indeed, it can be argued that the move to outcome-based education has been the most significant development in medical education in the past one or two decades: more important than the changes in educational strategies such as problem-based learning, in instructional methods such as the use of new learning technologies and in approaches to assessment including the use of portfolios. All of these are important. They are, however, a means to an end: what matters are the abilities gained by the doctor as a result of the educational experience.

A vision of the type of doctor to be graduated and the associated learning outcomes are the first two of the ten questions to be answered in the development of a curriculum as described in Chapter 2. Only when these have been specified can we consider the content of the curriculum, the teaching and learning methods, the educational strategies and the approach to student assessment to be adopted (Fig. 18.1).

There has been a change in emphasis from process, where what matters is the education approach, to the product, where the abilities and attitudes of the graduates are of key importance. This is the essence of outcome-based education (OBE). The use made of simulators and e-learning, team-based and interprofessional approaches to the curriculum and assessment techniques such as the OSCE and the Mini-CEX are important and are addressed in other chapters in this book. Their contribution to the education programme, however, must be guided by the expected learning outcomes.

The trend toward OBE

OBE is now at the cutting edge of curriculum development internationally. The 2011 and 2012 AMEE Conferences saw presentations on the topic from more than 10 countries in different regions around the world. The 4th Asia Pacific Medical Education Conference (APMEC) in Singapore had OBE as its theme. The Tuning Initiative in Europe sought to standardize learning outcomes across the different countries in Europe.

The UK General Medical Council (GMC) guidelines for medical schools, ‘Tomorrow’s Doctors’, changed from an emphasis in 1993 on issues such as integration, problem-based learning and the abuse of lectures, to guidelines in 2003 and 2009 that highlighted the expected learning outcomes to be achieved on completion of the undergraduate course.

The Association of American Medical Colleges (AAMC) initiated a Medical Schools Objectives Project (MSOP) which encouraged educators to think about what was expected of medical students no matter which medical school in the United States they attended. In Canada, the CanMEDS recommendations from the Royal College of Physicians and Surgeons of Canada and in the United States, the Accreditation Council for Graduate Medical Education (ACGME) areas of competence set out the expected learning outcomes in postgraduate education.

Why the move to OBE

OBE is not some passing fad that lacks an educational underpinning. While there has been some opposition to the approach, there are sound reasons for the position OBE now has at the forefront of education thinking. Here are some of the arguments for adopting OBE.

Assessment of the learner’s progress and the continuum of education

The need for a more seamless transition between the undergraduate, postgraduate and continuing phases of education is now accepted. Implicit in this is a clear statement of the learning outcomes expected of the student or trainee, for example, the required communication skills, prescribing skills or mastery of practical procedures, at the end of each stage before they move on to the next phase of their training. Clarity is also necessary with regard to the required achievements by learners as they progress through each phase of the training programme including the 4, 5 or 6 years of the undergraduate curriculum. It is useful to chart a student’s progress towards each of the learning outcomes (Fig. 18.2).

Fig. 18.2 A representation of progress by a first-phase student in relation to each of 12 learning outcome domains. The expected progress for each outcome is indicated by the inner target for the first phase of the programme, by the middle target for the second phase of the curriculum and by the outer target for postgraduate training (with permission from Harden RM: Learning outcomes as a tool to assess progression, Medical Teacher 29:678–682, 2007.)

 Learning outcomes provide a vocabulary to support the planning of the continuum of medical education across the different phases.

The student’s progress in each of the outcome domains can be looked at from different perspectives (Harden 2007):

• Increased breadth, e.g. extension to new topics or different practice contexts

• Increased difficulty, e.g. more advanced or in-depth consideration

• Increased utility and application to medical practice, e.g. a move from theory to practice and integration of what is learned into the work of a doctor

• Increased proficiency, e.g. more efficient performance with fewer errors and less need for supervision

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