Curriculum Development and Assessment in Medical Education Sultan Qaboos University College of Medicine and Health Sciences 22 April 2009 Professor Nigel Bax Academic Unit of Medical Education School of Medicine and Biomedical Sciences University of Sheffield, UK

Becoming a doctor Cost ($) ,000

How is the world making better doctors? ‘Scottish Doctor’ ‘Tomorrow’s Doctor’ CanMEDS 2000 World Federation for Medical Education ‘Good Medical Practice’ Accreditation Council for Graduate Medical Education WHO/EMRO Gulf Cooperation Council Association of American Medical Colleges Institute for International Medical Education

Questions we need to answer: What are the features of a medical professional?

Questions we need to answer: What are the features of a medical professional? How do students and doctors develop these attributes?

Questions we need to answer: What are the features of a medical professional? How do students and doctors develop these attributes? How do we know that they have them?

Questions we need to answer: What are the features of a medical professional? How do students and doctors develop these attributes? How do we know that they have them? Are we selecting the right people for admission?

Questions we need to answer: What are the features of a medical professional? How do students and doctors develop these attributes? How do we know that they have them? Are we selecting the right people for admission? Selection – Curriculum – Assessment – Work as a doctor

‘He who causes the death of a patient shall lose his hands.’ Hammurabi – about 4000 years ago

‘He who causes the death of a patient shall lose his hands.’ Hammurabi – about 4000 years ago ‘I do not want two diseases, one nature- made, one doctor-made.’ Napoleon Bonaparte, 1820

Kitab Kamil as-sin’a at-tibbiya ‘The Complete Book on the Art of Medicine’ Isagoge by Johanituis Massa’il fi’l tib by Hunayn Ibn Ishaq ‘Medical Questions’ Key books from 1000 years ago

Kitab Kamil as-sin’a at-tibbiya ‘The Complete Book on the Art of Medicine’ Isagoge by Johanituis Massa’il fi’l tib by Hunayn Ibn Ishaq ‘Medical Questions’ Key books from 1000 years ago The first book about Problem Based Learning?

Abraham Flexner (1886 – 1959)

Abraham Flexner Report in 1910 to Carnegie Foundation – Many unstandardised US medical schools – No proper curricula

Abraham Flexner Report in 1910 to Carnegie Foundation – Many unstandardised US medical schools – No proper curricula “an overproduction of uneducated and ill trained medical practitioners with no regard for public welfare or interest”

Abraham Flexner Report in 1910 to Carnegie Foundation – Many unstandardised US medical schools – No proper curricula “an overproduction of uneducated and ill trained medical practitioners with no regard for public welfare or interest” Recommendations – Pre-clinical science programme – Clinical programme

Year 1 Year 2 Year 3 Year 4 Flexnerian curriculum Pre-clinical Clinical

Post-Flexnerian trends Outcome based curricula Curriculum integration Adoption of adult learning principles – Self-directed/Problem Based Learning Student determination of learning Move to community based education Professionalism

Mortality rates and density of healthcare workers Ghanim Alsheikh WHO/EMRO, 2006

Mortality rates and density of healthcare workers

Staff per 1,000 population: European countries, USA and Australia Doctors Nurses UK Aust USA UK Aust USA

Planning for curriculum revision The SPICES model

S tudent Centred I ntegrated C ommunity Based E lectives/Options S ystematic P roblem Based Teacher Centred Didactic/ Information Gathering Discipline Based Hospital Based Structured Apprenticeship/ Opportunistic SPICES Model

S tudent Centred I ntegrated C ommunity Based E lectives/Options S ystematic P roblem Based Teacher Centred Didactic/Information Gathering Discipline Based Hospital Based Structured Apprenticeship/ Opportunistic Sheffield Present Future

S tudent Centred I ntegrated C ommunity Based E lectives/Options S ystematic P roblem Based Teacher Centred Didactic/Information Gathering Discipline Based Hospital Based Structured Apprenticeship/ Opportunistic Karolinska Institutet, Stockholm Present Future

S tudent Centred I ntegrated C ommunity Based E lectives/Options S ystematic P roblem Based Teacher Centred Didactic/ Information Gathering Discipline Based Hospital Based Structured Apprenticeship/ Opportunistic University of Wollongong, Australia Past curriculaFuture curriculum (Hospital doctors) (Community doctors)

S tudent Centred I ntegrated C ommunity Based E lectives/Options S ystematic P roblem Based Teacher Centred Didactic/ Information Gathering Discipline Based Hospital Based Structured Apprenticeship/ Opportunistic National University of Singapore

Vision Statement The University of Sheffield strives to produce excellent medical graduates. The medical curriculum will be outcome focussed where the aim is to produce graduates who are able to fulfil their role as junior doctors in the NHS and who also possess the generic skills expected of students attending a research-led university. The course will feature increased opportunities to see patients in the community; a high degree of integration; an emphasis on facilitating student learning; and an increase in student choice. The course will be organised on a body system basis with a progressive emphasis on learning around undifferentiated patient problems. The instructional approach will consist of a spine of problem, case and patient-based integrated learning activities complemented by a range of other teaching and learning activities. There will be an increase in systematic teaching of some components to ensure competence in key areas. Students will be expected to become progressively more self-directed, aided by increasing reliance on IT-based and distance learning materials and activities. Assessment, both formative and summative, will be closely matched to defined outcomes. The curriculum will be managed centrally by a multidisciplinary team, including those with a stake in the outcome of medical education. The Department of Medical Education, the Administration and an IT-based curriculum management system will provide support. A monitoring system will be established to evaluate the implementation of the curriculum and to support a process of continuous improvement.

Vision Statement The University of Sheffield strives to produce excellent medical graduates. The medical curriculum will be outcome focussed where the aim is to produce graduates who are able to fulfil their role as junior doctors in the NHS and who also possess the generic skills expected of students attending a research-led university. The course will feature increased opportunities to see patients in the community; a high degree of integration; an emphasis on facilitating student learning; and an increase in student choice. The course will be organised on a body system basis with a progressive emphasis on learning around undifferentiated patient problems. The instructional approach will consist of a spine of problem, case and patient-based integrated learning activities complemented by a range of other teaching and learning activities. There will be an increase in systematic teaching of some components to ensure competence in key areas. Students will be expected to become progressively more self-directed, aided by increasing reliance on IT-based and distance learning materials and activities. Assessment, both formative and summative, will be closely matched to defined outcomes. The curriculum will be managed centrally by a multidisciplinary team, including those with a stake in the outcome of medical education. The Department of Medical Education, the Administration and an IT-based curriculum management system will provide support. A monitoring system will be established to evaluate the implementation of the curriculum and to support a process of continuous improvement. Assessment drives learning and matches outcomes Community based learning

Index of Multiple Deprivation Herringthorpe (R) Athersley (B) Manor (S) Bentley Central (D) Penistone West (B) Kiveton Park (R) Southern Parks (D) Ecclesall (S) Mean standardised death rates from CHD Per 100,000/yr Data from the Report of the Directors of Public Health in the region

Six domains of medical professionalism Ethical practice Reflection/self-awareness Responsible for actions Respect for patients Working with others Social responsibility Royal College of Physicians, London 8 December 2005

Year Assessments Academic/Clinical + Patient input

Year Assessments Academic/Clinical + Patient input Professional behaviours Multi-source appraisal

Year Assessments Academic/Clinical + Patient input Professional behaviours Mini CEX / Observed long cases Multi-source appraisal

Educational and service progression Undergraduate Independent practice

Educational and service progression Undergraduate Independent practice Use of same assessment methods throughout UG and PG periods PG assessments linked to PG curricula PG curricula linked to UG curricula Seamless development of UGs and PGs Assessments used throughout professional life – revalidation for practice

The learning pyramid Teach others Lecture Discussion group Demonstration Audiovisual Reading Practice by doing Retention % National Training Laboratories, Bethel, Maine, USA

The learning pyramid Teach others Lecture Discussion group Demonstration Audiovisual Reading Practice by doing Retention % National Training Laboratories, Bethel, Maine, USA

Medicine is increasingly Competitive Market driven Patient driven International Expensive and not state supported Running out of able teachers Responsive to stakeholders

Challenges to doctors Their expense Others able to do what they do Accountability Changing expectations of patients

What is the role of a doctor? What will they need to know and be able to do in the future? What is need is the need for doctors – now and in the future? Where are doctors most needed? Where will doctors be recruited from? Who will teach them – and assess them – and to what standards? Key questions in medical education

Sir William Osler ( ) ‘Medicine is a most difficult art to acquire. All the college can do is to teach the student principles, based on facts in science and give him good methods of work. They simply start him on the right direction, they do not make one a good practitioner – that is his own affair’.

International developments Decrease of the pre-clinical / clinical divide – integrated programmes

International developments Decrease of the pre-clinical / clinical divide – integrated programmes Increasing use of community placements for learning

International developments Decrease of the pre-clinical / clinical divide – integrated programmes Increasing use of community placements for learning Students having an active role in their learning

International developments Decrease of the pre-clinical / clinical divide – integrated programmes Increasing use of community placements for learning Students having an active role in their learning Curricula becoming institutionally led

International developments Decrease of the pre-clinical / clinical divide – integrated programmes Increasing use of community placements for learning Students having an active role in their learning Curricula becoming institutionally led Optimal learning opportunities not optimal teaching opportunities

International developments Decrease of the pre-clinical / clinical divide – integrated programmes Increasing use of community placements for learning Students having an active role in their learning Curricula becoming institutionally led Optimal learning opportunities not optimal teaching opportunities ‘Fitness to Practise’ – different from clinical ability

International developments Decrease of the pre-clinical / clinical divide – integrated programmes Increasing use of community placements for learning Students having an active role in their learning Curricula becoming institutionally led Optimal learning opportunities not optimal teaching opportunities ‘Fitness to Practise’ – different from clinical ability Medical professionalism

International developments Decrease of the pre-clinical / clinical divide – integrated programmes Increasing use of community placements for learning Students having an active role in their learning Curricula becoming institutionally led Optimal learning opportunities not optimal teaching opportunities ‘Fitness to Practise’ – different from clinical ability Medical professionalism High quality assessments including work-based assessments

International developments Decrease of the pre-clinical / clinical divide – integrated programmes Increasing use of community placements for learning Students having an active role in their learning Curricula becoming institutionally led Optimal learning opportunities not optimal teaching opportunities ‘Fitness to Practise’ – different from clinical ability Medical professionalism High quality assessments including work-based assessments Dealing with curriculum overload

International developments Decrease of the pre-clinical / clinical divide – integrated programmes Increasing use of community placements for learning Students having an active role in their learning Curricula becoming institutionally led Optimal learning opportunities not optimal teaching opportunities ‘Fitness to Practise’ – different from clinical ability Medical professionalism High quality assessments including work-based assessments Dealing with curriculum overload Lack of opportunities to work in UK, USA, Canada, Australia