1. 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 n.d.s.bax@sheffield.ac.uk

8. Becoming a doctor Cost ($) 1829 800 2009 600,000

9. 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

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

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

12. 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?

13. 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?

14. 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

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

18. ‘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

27. 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

28. 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?

29. Abraham Flexner (1886 – 1959)

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

31. 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”

32. 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

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

34. 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

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

36. Mortality rates and density of healthcare workers

41. 5 4 3 2 1 0 15 10 5 0 Staff per 1,000 population: European countries, USA and Australia Doctors Nurses UK Aust USA UK Aust USA

42. Planning for curriculum revision The SPICES model

43. 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

44. 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

45. 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

46. 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)

47. 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

48. 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.

49. 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

52. 50 0 100 150 200 Index of Multiple Deprivation 0 10 20 30 40 50 60 70 80 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

53. 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

54. Year 1234512345 Assessments Academic/Clinical + Patient input

55. Year 1234512345 Assessments Academic/Clinical + Patient input Professional behaviours Multi-source appraisal

56. Year 1234512345 Assessments Academic/Clinical + Patient input Professional behaviours Mini CEX / Observed long cases Multi-source appraisal

57. Educational and service progression Undergraduate Independent practice

58. 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

59. The learning pyramid Teach others Lecture Discussion group Demonstration Audiovisual Reading Practice by doing 5 10 20 30 50 75 80 Retention % National Training Laboratories, Bethel, Maine, USA

60. The learning pyramid Teach others Lecture Discussion group Demonstration Audiovisual Reading Practice by doing 5 10 20 30 50 75 80 Retention % National Training Laboratories, Bethel, Maine, USA

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

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

63. 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

64. Sir William Osler (1849-1919) ‘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’.

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

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

68. 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

69. 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

70. 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

71. 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

72. 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

73. 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

74. 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

75. 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