Chapter 3 The challenge for the medical teacher is designing and implementing a curriculum that will achieve this aim in the limited time that is available for the undergraduate component of medical studies. A narrow focus on the knowledge content of the course will fail to instil the attitudes and skills that are essential for an effective professional. While there is a correlation between knowledge and clinical performance, the two are not identical. It is now recognized that the ability to apply knowledge appropriately is the important measure. The emphasis should be on ‘what can the student do?’ rather than ‘what does the student know?’ (Corbett & Whitcomb 2004). Following the Flexner Report in 1910, the conventional medical undergraduate curriculum had two distinct phases. In the preclinical phase the students learnt the basic science underlying medical practice and had little contact with patients. During the clinical phase, most learning took place in clinical placements or clerkships with little input from the basic sciences. Over the last 20 years there has been increasing emphasis on early clinical experience (Dornan et al 2006). The proponents of clinical teaching in the early years suggest at least three benefits from the early encounters with patients. The first is motivation of the students (von Below et al 2008). Meeting patients and clinical practitioners reinforces the students’ underlying ambition to become a doctor (Dyrbye et al 2007). This intrinsic motivation will lead to more effective learning than the extrinsic motivation that arises from the need to pass examinations in order to progress to the next stage of training (Williams et al 1999). The second benefit is the provision of a clinical context for the learning of basic science. This contextualization of knowledge is important for the future retrieval and application of that knowledge (Schmidt 1983). Vertical integration leads to deep rather than superficial learning (Dahle et al 2002). The third benefit is that early clinical experience can increase the time that is available for students to practise their clinical and communication skills. Areas that the students find challenging (such as taking a history from a patient with communication difficulties) can be revisited. Since facility with any skill is related to the amount of purposeful practice that is undertaken (Ericsson 2004), the students should graduate with a greater level of proficiency in their basic interactions with patients. In addition, clinical teaching in the early years plays an important part in the socialization of students into the medical profession (Dornan & Bundy 2004). It provides early acclimatization to a clinical setting and may avoid the problems associated with transition into the clinical years (Prince et al 2000). It may allow identification of those few students who are unsuited to clinical medicine at a much earlier stage. However, while clinical teaching in the early years appears to benefit students, it can cause stress for staff who encounter it for the first time (von Below et al 2008). The curriculum encompasses learning methods, assessment methods, resources and timetabling in addition to content. Traditionally, much effort has gone into identifying the content while the learning methods have been assumed. As the awareness of different learning approaches has grown, the temptation has been to concentrate on learning methods to the relative detriment of content. Medical schools are labelled by their predominant teaching methods, for example, as problem based, systems based, community based or traditional. However, medical education is a preparation for practice rather than a purely intellectual exercise, and it is arguable that there must be a minimum essential content. If an effective curriculum is to be created, all areas must receive careful attention (Table 3.1). Table 3.1 The scope of curriculum planning There are a number of possible solutions. Some specialties could be considered optional. There are problems with this, as some common or important conditions may fall within the province of ‘optional’ specialties. The opposite approach is to ask each specialty to identify its own core material. This gives rise to practical problems, as the core identified in this way is too large to fit into a standard undergraduate programme. An approach that has been adopted by a number of medical schools is the identification of index cases or presentations that are based on the different ways in which the population comes into contact with healthcare professionals. The core knowledge that students need within each discipline is determined by what they need to know in order to understand and manage these core clinical problems. The cases may be identified from published health statistics or may be based on consensus among experienced practitioners. The list may vary from school to school depending on the patterns of practice around that school, but there is considerable overlap among the lists, suggesting that a realistic core is being identified (Bligh 1995, Mandin et al 1995, O’Neill 1999). The core defines the scope of the curriculum. The next step is to define what it is that the student needs to learn about the core. The most effective way to do this is to define learning outcomes for the course. These clearly express what the student will be able to do at the end of the course. When an entire course of 4–6 years is being considered the outcomes will, necessarily, be very broad. As smaller and smaller components of the course are considered, the outcomes become more and more focused and specific. The detailed outcomes for each component should map on to the overall outcomes (GMC 2009, Simpson et al 2002).
The undergraduate curriculum and clinical teaching in the early years
Introduction
Curriculum planning
Content
What knowledge, skills and attitudes should the course cover? What are the learning outcomes of the course?
Delivery
How will the learning be delivered? What teaching or learning methods will be used?
Assessment
How will the students’ learning be tested?
Structure
How will the content be organized? How will learning and teaching be scheduled?
Resources
What staff, learning materials, equipment and accommodation are needed?
Evaluation
How will the organizers know that the course has been effective in delivering the learning outcomes?
Defining the content
Core material
Learning outcomes
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The curriculum needs to define the learning outcome, the setting in which it should be performed and the standard to which it should be performed.
The core curriculum should reflect the consensus views of specialists and generalists. Specialists should not be permitted to determine the core curriculum in their own discipline.