학부의학교육의 설계와 도입으로부터 얻은 교훈(University of Dundee)

학부의학교육의 설계와 도입으로부터 얻은 교훈(University of Dundee)

Planning and implementing an undergraduate medical curriculum: the lessons learned

MARGERY H. DAVIS1 & RONALD M. HARDEN2

1Centre for Medical Education, University of Dundee and 2The International Virtual Medical School (IVIMEDS), Dundee, Scotland, UK

배경

Introduction

교육과정의 여섯가지 특징

The medical school at the University of Dundee introduced a new curriculum in 1995. The curriculum combined idealism and pragmatism and six aspects were described by Harden et al. (1997): 

• the spiral curriculum; 
• a systems-based approach; 
• a core curriculum with options; 
• the educational strategies; 
• the student assessment approach; and 
• organization and management of the curriculum. 

The medical school has now had eight years’ experience of implementing the curriculum in practice. Since 1995 there have been significant changes both in the healthcare delivery system and in medical education. In this paper we look at how the curriculum has withstood the test of time and responded to change; which aspects of the curriculum are still in place; and what new approaches have been added. (...)

던디 의과대학의 학부 교육과정

The Dundee undergraduate medical curriculum

The 1995 curriculum was implemented as the result of proposals by a working group of the Dundee faculty of medicine for curriculum development (Davis, 1993). The focus for implementation was a sophisticated blend of educational strategies, which underpinned the curriculum. These included...

• a spiral curriculum with three interlocking phases; 
• a systems-based approach with themes running through the curriculum that provided a focus for the students’ learning; 
• a core curriculum with options; elements of problem-based learning (PBL); 
• community-based learning; 
• student-centred approaches to teaching and learning that encouraged students to take more responsibility for their own learning; and 
• an approach to assessment that emphasized the overall objectives of the course. 

An organizational and management structure and the allocation of resources were designed to support the educational philosophy. Since the programme was introduced, not unexpectedly, many details relating to the curriculum have changed. There have also been significant developments. In 1997, an outcome-based approach (Harden et al., 1999a, 1999b) was adopted for all five years of the curriculum, task-based learning (Harden et al., 2000) was introduced as the framework for student learning in phase 3 and the portfolio assessment process (Davis et al., 2001) was introduced as the medical students’ final examination.

교육과정 평가

Evaluation of the curriculum

The curriculum has been evaluated on evidence from a number of sources. These include both internal and external reviews and student examination data. The conclusions reached in this paper are based on this evaluation.

• (1) The internal reviews
• (2) External reviews, both formal and informal
• (3) Student examination data

교육과정

The curriculum

(1) The spiral curriculum

Lessons learned. The spiral design, with students revisiting topics in each phase, building on what they already know and adding further complexities is a robust and useful model for the undergraduate medical curriculum. One should not underestimate, however, the difficulty students may find in moving from one phase to the next, each with different approaches to teaching and learning. We found that an introduction to the overall curriculum and an interface between the phases was necessary.

(2) Outcome-based education

Lessons learned. There is a significant difference between outcome-based education and the production of a list of learning outcomes for an existing curriculum. ‘‘Outcome-based’’ suggested Spady (1993), ‘‘does not mean curriculum based with outcomes sprinkled on top. It is a transformational way of doing business in education.’’ The implementation in a curriculum of outcome-based education is not easy and requires the use of curriculum mapping. The effort is, however, worthwhile. The outcomes provide a valuable focus for student learning and direct the students’ attention towards learning outcomes that are easily ignored in the traditional curriculum. The outcomes also provide a sound basis for the student assessment process.

(3) Core curriculum with options

The core curriculum - Lessons learned. Identification of the core basic science components of the curriculum is not easy and is best done by basic scientists working in collaboration with clinicians. The specified learning outcomes play a key role in identification of what is core for all students

The options - Lessons learned. Options have proved popular with both staff and students, but providing large numbers of optional courses each attended by a few students is probably not cost effective. Staff and departments are more likely to accept a reduction of teaching time in the core if they can compensate with time in the optional part of the programme.

(4) The adaptive curriculum

Lessons learned. We learned that the adaptive curriculum approach could be employed in an undergraduate medical programme. Logistical difficulties were encountered with the implementation of the adaptive curriculum that led to changes in the number of attempts at an examination without, however, compromising the basic principles. What has been more challenging, however, is the creation of a new mindset which recognizes that curriculum time is finite and that how students may best use this time may vary from student to student.

(5) An integrated, systems-based approach

Lessons learned. System-based teaching is a key strategy in the early years of an undergraduate medical programme and is popular with both staff and students. Implementation may vary according to the preferred approach of individual teachers. Significant input from clinicians throughout the curriculum is needed to achieve both horizontal and vertical integration.

(6) Multiprofessional learning

Lessons learned. Multiprofessional education offers advantages and has attractions as a tool for enabling students to understand and respect the role of other healthcare professions. The true role of multiprofessional teaching and learning in medical education, however, is not clear. Unless there is a strong proponent or standard-bearer for the approach, significant change is unlikely. Multiprofessional education has to be institutionalized if it is to survive and contribute to the curriculum.

(7) Problem-based learning

Lessons learned. Implementation of an educational approach such as PBL may run into difficulties unless it is enthusiastically endorsed by the medical school. Task-based learning provides an option to PBL that is, in many ways, more attractive to staff, particularly in the clinical years. Task-based learning has been one of the curriculum’s successes. It is a valuable strategy for introducing an integrated and problem-based approach in the clinical years of an undergraduate medical curriculum. The tasks, matched with the appropriate learning outcomes, provide a framework or grid for identification of the core curriculum

Teaching and learning: student support

(1) Study guides

Lessons learned. The introduction of study guides clarifies what has to be taught and learned and has proved to be one of the most important innovations of the new curriculum. The costs of study guide production are substantial and need to be addressed. Both electronic and printed study guides have a role to play.

(2) Student-support scheme

Lessons learned. Student support is a taxing process that needs, to ensure its ongoing success, personal commitment from a large number of staff, secretarial resource to administer the system and a dedicated member of staff to provide the required leadership.

(3) Curriculum mapping

Lessons learned. Planned learning throughout a curriculum needs to be made explicit to both staff and students. Curriculum mapping aids this process. The complexities require an electronic learning environment.

(4) P-2-P learning

Lessons learned. P-2-P learning has an important part to play in supporting students

Teaching and learning: educational facilities

(1) Computer learning suite

(2) Educational resource area

(3) Integrated learning area

(4) Clinical skills centre

Lessons learned. The computer learning suite, the clinical skills centre and the integrated learning area are essential resources in a medical school. They support an integrated student-centred curriculum and help students to achieve the learning outcomes. Institutionalization of the educational facilities is essential for their successful and continued use. The clinical skills centre provides an important focus for clinical teaching, particularly in the early years of the curriculum. Unpaid volunteers have successfully provided a bank of simulated patients who are able to meet most needs of undergraduate medical student teaching in the centre. In the UK context, payment of simulated patients is not necessary and may make the extensive use of simulated patients unaffordable.

Assessment

(1) Twenty principles of assessment

Lessons learned. Principles of assessment are a useful tool to guide the development of an integrated assessment system. The principles need to be customized for the individual medical school context and kept up to date.

(2) Self-assessment

Lessons learned. One of the first principles of assessment is that the purpose of the assessment should be clear. Confusion between self-marking of summative assessment and self-assessment for formative reasons caused anxiety in some students. While self-marking of examination papers has potential for provision of rapid feedback to students, the purpose of the self-marking has to be clearly communicated to the students. The introduction of the process has to be carefully managed.

(3) Assessment to a standard

Lessons learned. The assessment-to-a-standard approach has been successful in supporting slower learners through the provision of supplemental instruction.

(4) Integrated assessment

Lessons learned. Integration of assessment is important to support curriculum integration. Integrated assessment may result in an academic staff ‘stand off’ from the assessment process related to lack of ownership.

(5) External examiners

Lessons learned. External examiners have an important contribution to make in ensuring that standards are set and maintained at an appropriate level.

(6) SSC(student selected components) assessment

Lessons learned. Relating SSC assessment to the learning outcomes facilitates standardization across SSCs. Standardizing student effort and marking criteria across disparate SSCs is challenging but achievable.

(7) Formative assessment

Lessons learned. The logistical implications of integrated assessment are considerable and had a deleterious effect on the provision of formative assessment opportunities for students.

(8) Progress test

Lessons learned. A progress test can provide useful feedback to staff and students. Student assessment needs to be adequately resourced in terms of academic staff, professional assessment advice, time and money.

(9) Portfolio assessment

Lessons learned. Portfolio assessment provided a framework within which student performance across a range of outcomes could be assessed. The portfolios identified student problems that the medical school did not have the processes to deal with; for example, a fitness to practice committee had to be set up for the undergraduates. The portfolio process is a major logistical exercise for the medical school, but it is considered to be worth the effort.

Organization and management: committee structures

(1) UMEC

(2) UMEC working group

(3) The three phase sub-committees of UMEC and the SSC committee

(4) The theme committee

(5) The faculty assessment committee

(6) The academic standards committee

(7) The computer committee

Lessons learned. The education committee structure and membership should reflect the needs of the curriculum. As a curriculum becomes established there is a tendency for the committee structure and membership to change, reflecting a more administrative and maintenance role rather than a forward-planning education role.

Organization and management: administrative support

Lessons learned. Administrative expertise residing at departmental level can be lost with the move to centralized administration of the curriculum. High-quality/senior administrative support is necessary for a successful shift to a centrally administered integrated curriculum. Separation of educational and administrative functions is needed as medical education staff can easily be regarded as administrators if academic staff are not aware of their areas of expertise. The assessment expertise residing within departments can be lost with the move to a centrally administered assessment system.

Conclusions

(1) The importance of initial planning

The 1995 curriculum was introduced as a result of a significant curriculum review. The review group was headed by the Dean and comprised 10 individuals with key roles in the curriculum and two students. They met regularly in the evenings for two to three hours at two weekly intervals over a six-month period. Attendance at the meetings was almost 100%. A careful analysis of the problems of the existing curriculum was carried out. Future needs were also considered. A key feature of the review was the wide consultation with a range of stakeholders, including recent graduates, general practitioners, current teachers and students. These stakeholders were invited to attend a meeting of, and discuss their views with, the review group. Other medical schools were surveyed for information regarding how they addressed a range of educational issues. The group issued a draft report for consultation and following this the final recommendations were produced and approved by UMEC and the faculty board. Communication of the finalized curriculum revision plans took place at a well-attended staff meeting and through circulation of the working group report.

(2) The need for a big picture

An overall structure and clearly enunciated educational principles provided a framework to inform ongoing discussions regarding curriculum implementation and guide change. The identification of the core clinical problems as the basis of task-based learning, integrated systems-based teaching and learning, outcome-based education with identification of 12 exit learning outcomes, the spiral curriculum, the core and options model and the 20 principles of assessment provided this structure and guidance.

(3) Facilitation of student learning

A range of approaches is needed to support student learning. Student study guides, introductory courses, educational facilities such as a clinical skills centre, computing suite and integrated learning area, P-2-P or collaborative learning, curriculum mapping, the student assessment system and a student support scheme are all important in facilitation of student learning.

(4) The student assessment system

The student assessment system needs to be integrated with the teaching and learning and be capable of supporting student learning. This is part of the paradigm shift from testing to assessment. If the curriculum is integrated in terms of disciplines and specialities, then the assessment system must also be integrated or the curriculum integration will be lost. The assessment-to-a-standard approach recognized the needs of different students and supported slower learners through the curriculum, even though the underlying concepts and shift in thinking involved in the approach had difficulty gaining general acceptance.

(5) Committee and administrative structure

The committee and administrative structure needs to support the curriculum. Changes in this structure may be necessary for different stages in the life of the curriculum: planning, implementation and maintenance. Implementation of an integrated curriculum where the responsibilities lie centrally in a school and where staff are located within departments does cause difficulties that need to be addressed. A matrix management system within a medical school may resolve the tensions between departmental and central control of the curriculum.

(6) Professionalism in medical education

There is a need for the commitment of all staff to the curriculum process. Different levels of educational expertise, however, are required. A critical mass of staff need to have an understanding of the underpinning educational principles and concepts and the educational vocabulary to discuss educational developments and to take part in the decision-making processes. Medical staff with educational expertise are needed for educational facilities such as the clinical skills centre. Professionalism in medical education is needed to support the curriculum, the assessment and the staff in their teaching activities. Research into medical education is necessary and professional medical educators can provide a focus for research activities. They can also engage students in the teaching and learning process and involve them in educational research.

(7) Leadership

Leadership is intimately associated with change and its sustainability. Leadership by the dean and other senior staff was needed for the curriculum revision and for the institutionalization of change. It is needed for the endorsement of change by curriculum committees. When leadership for the multiprofessional initiatives was lost, most failed.

(8) Flexibility

Built-in flexibility is important for sustainability. A curriculum is a living entity where ongoing change is almost certainly needed. When major changes such as outcome-based education, task-based learning and portfolio learning and assessment were introduced, the curriculum could adapt and cope.

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Med Teach. 2003 Nov;25(6):596-608.

Planning and implementing an undergraduate medical curriculum: the lessons learned.

Davis MH1, Harden RM.

Author information

Abstract

In 1995 Dundee medical school introduced an integrated, systems-based spiral curriculum with a number of innovative features. The medical school has now had eight years' experience of the curriculum. This paper describes the changes that have taken place in the curriculum over the eight years. Evidence from internal and external reviews and student examination data are used to identify the lessons learned from implementing the curriculum. The Dundee experience, the approaches to the curriculum described and the conclusions reached are relevant to all with an interest in medical education.

Comment in

• Competency-based assessment: making it a reality. [Med Teach. 2003]