Ronald M. Harden

Competency-based medical education: theory to practice

Although competency-based medical education (CBME) has attracted renewed interest in recent years among educators and policy-makers in the health care professions, there is little agreement on many aspects of this paradigm. We convened a unique partnership – the International CBME Collaborators – to examine conceptual issues and current debates in CBME. We engaged in a multi-stage group process and held a consensus conference with the aim of reviewing the scholarly literature of competency-based medical education, identifying controversies in need of clarification, proposing definitions and concepts that could be useful to educators across many jurisdictions, and exploring future directions for this approach to preparing health professionals. In this paper, we describe the evolution of CBME from the outcomes movement in the 20th century to a renewed approach that, focused on accountability and curricular outcomes and organized around competencies, promotes greater learner-centredness and de-emphasizes time-based curricular design. In this paradigm, competence and related terms are redefined to emphasize their multi-dimensional, dynamic, developmental, and contextual nature. CBME therefore has significant implications for the planning of medical curricula and will have an important impact in reshaping the enterprise of medical education. We elaborate on this emerging CBME approach and its related concepts, and invite medical educators everywhere to enter into further dialogue about the promise and the potential perils of competency-based medical curricula for the 21st century.

Educational strategies in curriculum development: the SPICES model.

Six education strategies have been identified relating to the curriculum in a medical school. Each issue can be represented as a spectrum or continuum: student‐centred/teacher‐centred, problem‐based/information‐gathering, integrated/discipline‐based, community‐based/hospital‐based, elective/uniform and systematic/apprenticeship‐based.

What Is a Spiral Curriculum

In planning a curriculum there are many questions to be answered (Harden, 1986). Much attention has been paid to aims and objectives, the content of the curriculum, teaching methods, assessment, and educational strategies such as problem-based learning, integration and community-based learning. A relatively neglected area has been the question of the organization of the content and the overall structure of the curriculum. A traditional view of the curriculum is of a series of courses, each with its own programme and assessment.There is a growing tendency, however, to break down barriers or boundaries between courses and departments and to look at the overall aims or objectives of the curriculum. It is in this context that the concept of a spiral curriculum has particular relevance.

AMEE Guide No. 25: The assessment of learning outcomes for the competent and reflective physician

Two important features of contemporary medical education are recognized. The first is an emphasis on assessment as a tool to ensure quality in training programmes, to motivate students and to direct what they learn. The second is a move to outcome-based education where the learning outcomes are defined and decisions about the curriculum are based on these. These two trends are closely related. If teachers are to do a better job of assessing their students, they need an understanding of the assessment process, an appreciation of the learning outcomes to be assessed and a recognition of the most appropriate tools to assess each outcome. Assessment tools selected should be valid, reliable, practical and have an appropriate impact on student learning. The preferred assessment tool will vary with the outcome to be assessed. It is likely to be some form of written test, a performance test such as an OSCE in which the student’s competence can be tested in a simulated situation, and a test of the student’s behaviour over time in clinical practice, based on tutors’ reports and students’ portfolios. An assessment profile can be produced for each student which highlights the learning outcomes the student has achieved at the required standard and other outcomes where this is not the case. For educational as well as economic reasons, there should be collaboration across the continuum of education in test development as it relates to the assessment of learning outcomes and in the implementation of a competence-based approach to assessment.

BEME Guide No. 1: Best Evidence Medical Education

There is a need to move from opinion-based education to evidence-based education. Best evidence medical education (BEME) is the implementation, by teachers in their practice, of methods and approaches to education based on the best evidence available. It involves a professional judgement by the teacher about his/her teaching taking into account a number of factors-the QUESTS dimensions. The Quality of the research evidence available-how reliable is the evidence? the Utility of the evidence-can the methods be transferred and adopted without modification, the Extent of the evidence, the Strength of the evidence, the Target or outcomes measured-how valid is the evidence? and the Setting or context-how relevant is the evidence? The evidence available can be graded on each of the six dimensions. In the ideal situation the evidence is high on all six dimensions, but this is rarely found. Usually the evidence may be good in some respects, but poor in others.The teacher has to balance the different dimensions and come to a decision on a course of action based on his or her professional judgement.The QUESTS dimensions highlight a number of tensions with regard to the evidence in medical education: quality vs. relevance; quality vs. validity; and utility vs. the setting or context. The different dimensions reflect the nature of research and innovation. Best Evidence Medical Education encourages a culture or ethos in which decision making takes place in this context.

Ten questions to ask when planning a course or curriculum

Summary. This brief practical aid to course or curriculum development cannot replace educational qualifications or experience, but it does examine ten basic questions, any of which may be all too easily neglected. These are: (1) What arc the needs in relation to the product of the training programme? (2) What are the aims and objectives? (3) What content should be included? (4) How should the content be organized? (5) What educational strategies should be adopted? (6) What teaching methods should be used? (7) How should assessment be carried out’ (8) How should details of the curriculum be communicated? (9) What educational environment or climate should be fostered? (10) How should the process be managed? Each aspen is illustrated through the analogy of car manufacturing.

Learning outcomes and instructional objectives: is there a difference?

Learning outcomes are broad statements of what is achieved and assessed at the end of a course of study. The concept of learning outcomes and outcome-based education is high on todays education agenda. The idea has features in common with the move to instructional objectives which became fashionable in the 1960s, but which never had the impact on education practice that it merited. Five important differences between learning outcomes and instructional objectives can be recognized: (1) Learning outcomes, if set out appropriately, are intuitive and user friendly. They can be used easily in curriculum planning, in teaching and learning and in assessment. (2) Learning outcomes are broad statements and are usually designed round a framework of 8-12 higher order outcomes. (3) The outcomes recognize the authentic interaction and integration in clinical practice of knowledge, skills and attitudes and the artificiality of separating these. (4) Learning outcomes represent what is achieved and assessed at the end of a course of study and not only the aspirations or what is intended to be achieved. (5) A design-down approach encourages ownership of the outcomes by teachers and students.

A framework for developing excellence as a clinical educator

The current emphasis on providing quality undergraduate and postgraduate medical education has focused attention on the educational responsibilities of all doctors. There is a greater awareness of the need to train doctors as educators and courses have been set up to satisfy this need. Some courses, such as those on how to conduct appraisal, are specific to one task facing a medical educator. Other courses take a broader view and relate educational theory to practice. In this paper we describe an outcome‐based approach in which competence in teaching is defined in terms of 12 learning outcomes. The framework provides a holistic approach to the roles of the teacher and supports the professionalism of teaching. Such a framework provides the basis for the development of a curriculum for teaching excellence. It helps to define important competences for different categories of teachers, communicate the areas to be addressed in a course, identify gaps in course provision, evaluate courses, assist in staff planning and allow individuals to assess their personal learning needs. The framework is presented to encourage wider debate.

What is an OSCE

The student is assessed at a series of stations with one or two aspects of competence being tested at each station. The examination can be described as a ‘focused’ examination with each station focusing on one or two aspects of competence. In a typical examination there may be 20 such stations and students rotate round the stations at a predetermined time interval. A 20-stations examination with 5 minutes at each station will occupy 100 minutes. One circuit of 20 stations will allow 20 students to be examined simultaneously. If the number of students is greater than 20, this can be accommodated by running parallel circuits of stations or by repeating the single circuit with another group of students. Although the concept of an examination with stations round which students rotate represents an important aspect of the OSCE, the examination is more than just a ‘multi-station’ examination.

Task-based learning: the answer to integration and problem- based learning in the clinical years

Integrated teaching and problem‐based learning (PBL) are powerful educational strategies. Difficulties arise, however, in their application in the later years of the undergraduate medical curriculum, particularly in clinical attachments. Two solutions have been proposed – the use of integrated clinical teaching teams and time allocated during the week for PBL separate from the clinical work. Both approaches have significant disadvantages. Task‐based learning (TBL) is a preferred strategy. In TBL, a range of tasks undertaken by a doctor are identified, e.g. management of a patient with abdominal pain, and these are used as the focus for learning. Students have responsibility for integrating their learning round the tasks as they move through a range of clinical attachments in different disciplines. They are assisted in this process by study guides.