Competency-Based Curricular Design to Encourage Significant Learning

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Competency-Based Curricular Design to Encourage Significant Learning Larry Hurtubise, MA, and Brenda Roman, MD

Most significant learning (SL) experiences produce long-lasting learning experiences that meaningfully change the learner’s thinking, feeling, and/or behavior. Most significant teaching experiences involve strong connections with the learner and recognition that the learner felt changed by the teaching effort. L. Dee Fink in Creating Significant Learning Experiences: An Integrated Approach to Designing College Course defines six kinds of learning goals: Foundational Knowledge, Application, Integration, Human Dimension, Caring, and Learning to Learn. SL occurs when learning experiences promote interaction between the different kinds of goals, for example, acquiring knowledge alone is not enough, but when paired with a learning experience, such as an effective patient experience as in Caring, then significant (and lasting) learning occurs. To promote SL, backward design principles that start with clearly defined learning goals and the context of the situation of the learner are particularly effective. Emphasis on defining

assessment methods prior to developing teaching/learning activities is the key: this ensures that assessment (where the learner should be at the end of the educational activity/ process) drives instruction and that assessment and learning/ instruction are tightly linked so that assessment measures a defined outcome (competency) of the learner. Employing backward design and the AAMC’s MedBiquitous standard vocabulary for medical education can help to ensure that curricular design and redesign efforts effectively enhance educational program quality and efficacy, leading to improved patient care. Such methods can promote successful careers in health care for learners through development of self-directed learning skills and active learning, in ways that help learners become fully committed to lifelong learning and continuous professional development.

Significant Learning

kinds of goals, for example, acquiring knowledge alone is not enough, but when paired with a learning experience, such as a patient experience as in Caring, then significant (and lasting) learning is more likely to occur. The concept of SL may seem intuitive to medical educators for two reasons. First, Fink's goals map well to the now familiar ACGME competencies (Table 1), and thus the SL construct is easily aligned with the goals of achieving competence that define the medical education process. Second, the efforts by medical educators to “identify the clinical situations in which trainees should, upon graduation, be trusted to perform competently,” clinical activities defined by Ten Cate and Scheele2 as “entrustable professional activities” (EPAs), refer to “professional activities that together constitute the mass of critical elements that operationally define a profession.” EPAs, like SL goals, are aligned and oriented to the ACGME competencies,3 and EPAs generally require multiple competencies. To illustrate the holistic nature of EPAs, the following patient care EPA can be seen to incorporate multiple competencies. “For example to manage a patient with diabetes, health care providers must have medical

ost medical educators, when asked to describe one of their most significant learning experiences, typically will refer to the one in which the learning lasted beyond the end of a specific course or experience, and one that changed their thinking, feeling, and/or behavior. Likewise, most, when asked about their most significant teaching experience, will rarely describe a lecture, but usually define a teaching experience in which there was a powerful and meaningful connection with the learner. In his book, Creating Significant Learning Experiences: An Integrated Approach to Designing College Course, Fink1 defines six kinds of learning goals: Foundational Knowledge, Application, Integration, Human Dimension, Caring, and Learning to Learn. As he defines it, significant learning (SL) best occurs when learning experiences promote interaction between different

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From the Ohio University Heritage College of Osteopathic Medicine. Curr Probl Pediatr Adolesc Health Care 2014;44:164-169 1538-5442/$ - see front matter & 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.cppeds.2014.01.005

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TABLE 1. Mapping significant learning to the ACGME competencies

Significant learning

ACGME competencies

Foundational Knowledge Application Integration Human Dimension Caring Learning to Learn

Medical knowledge Patient care Systems-based practice Interpersonal communication skills Professionalism Practice-based learning and improvement

knowledge, be able to effectively interview patients, use evidence-based resources, make a differential diagnosis, work with interprofessional colleagues to develop a treatment plan, and explain it to the patient in a way that encourages adherence.”4

Backward Design Fink also suggests a “backward” instructional design process to best insure the SL orientation and delivery. Backward design is a process, which can be counter intuitive, or “backward,” to many educators. Given an instructional assignment, many educators will first plan how they will teach, then develop assessment methods and only write learning objectives if they are required. While backward design is typically considered to be construction of a course or educational block; these principles can be usefully applied to clinical rotations, specific educational activities, and single educational encounters (such as a lecture or class). Table 2 shows the backward instructional design process and the steps in this intentional order. This approach assures that the goals of medical education are anchored to the context of the situation of the learner and also that instructional methods follow the definition of the learning goals (objectives) and identification of how the assessment methods will demonstrate that the goals are met by the learner. The emphasis on defining assessment methods prior to developing teaching/learning activities is the key: this ensures that assessment (where the learner should be at the end of the educational activity/process) drives instruction5 and that assessment and learning/instruction are tightly linked to help ensure achievement of competency by the learner.6,7

is divided into the following three categories: assessment methods, instructional methods, and teaching resources, which align nicely with the backward design process. The MedBiquitous project team reviewed existing terminologies for instructional methods and assessment methods from accreditation bodies like the Liaison Committee on Medical Education (LCME) and the Accreditation Council for Graduate Medical Education (ACGME) as well as other sources, and developed a list of instructional methods and assessment methods that describe learner activities. The lexicon is intentionally general. A list of resource types may be used in conjunction with the MedBiquitous instructional and assessment methods to allow greater specificity in the nature of the activity.8

Backward Design Steps Step 1: Situational Factors Determining situational factors, and how they will be managed, is the first step in the backward design process. Situational factors include the context of the learning situation, the nature of the subject, and characteristics of the students and teachers. These three factors are essential to consider as the instructor makes the next three major decisions about the course—Steps 2–4 (Table 2).1 In 2010, the Carnegie Foundation released Educating Physicians: A Call for Reform of Medical School and Residency.5 “The huge increases in medical knowledge, technology and specialization in recent decades have interacted with a now near-chaotic system of health care delivery, magnifying the challenges facing medical education,” Cooke et al. write. “There is a need to motivate continuous learning and improvement across the whole arc of medical training.” Some of the historically fixed situational factors facing medical educators, such as the time-based structure of medical education and the pre-clinical and clinical divide, will be challenged if medical educators take the TABLE 2. Backward design

MedBiquitous and Curricular Design The AAMCs curriculum mapping project, MedBiquitous,7 has established a standardized vocabulary for medical education. The MedBiquitous vocabulary

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Step Step Step Step Step

1 2 3 4 5

Determine situational factors Develop learning goals Determine feedback and assessment methods Develop teaching/learning activities Integration

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recommendations of the authors, which include the following: (1) To standardize learning outcomes and assess competencies over time. A focus on learning outcomes and milestones could end the timebased structure of medical school and residency. (2) To strengthen connections between formal and experiential knowledge across the continuum of medical education, specifically by incorporating more clinical experiences earlier in medical school and providing more opportunities for knowledge building later in medical school and throughout residency. (3) To promote learners' ability to work collaboratively with other health professionals, such as medical assistants, nurses, pharmacists, physical therapists, and social workers. (4) To support learners' responsibility for quality of care, team performance, and their own learning while providing skilled supervision. (5) To make professional formation an explicit area of focus in medical education through strategies, such as formal instruction in ethics and reflective practice, exploration of the role of the physician–citizen, and establishment of more supportive learning environments. (6) To cultivate a spirit of inquiry and improvement in learners and in health care teams; this spirit supports both innovations in daily practice that translate into better service to patients, system improvements, and improved patient outcomes as well as the development of larger research agendas, new discoveries, and knowledge building. (7) To be more intentional about our selection, development, and support of teachers and medical educators.5

Step 2: Learning Goals After gathering and considering the information about the situational factors, the first decision for the instructor is to establish the learning goals, i.e., what the teacher wants the students to learn from the course or educational activity.1 Since the primary goals of medical education are the formation of effective practitioners of medicine and ultimately improved patient and societal health outcomes, these outcomes are ideally considered in creation of the learning goals.9,10

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In 2012 the Association of American Medical Colleges (AAMC) in partnership with the ACGME announced the AAMC's Entry Level EPAs Project. The project's charge is to “develop a clear, concise list of what graduating medical students should be entrusted to do without direct supervision on day 1 of residency.”11 In Entrustable Professional Activities in Family Medicine, Shaughnessy et al.4 suggest a “list of EPAs developed through our Delphi process can be used as a starting point for family medicine residency programs interested in moving toward a competency-based approach to resident education and assessment.” “The value of EPAs is that they identify the professional activities of daily practice and can be used to drive curriculum development as well as assessment.12,13 For example, a competent family medicine physician is expected to provide care for a child with a respiratory illness. This includes eliciting a history, performing a physical examination, arriving at a diagnosis, and implementing a plan of care that is evidence-based and takes into account the needs and values of the patient.”4,12 Effective learning goals can involve subsets of larger educational objectives or address to more comprehensive objectives. The learning goals should describe knowledge, attitudes, and/or skills and specificity (Table 3), which aid the ability to link the learning goals to assessment methods.

Step 3: Feedback and Assessment Using the principle of backward design, the next step is to define feedback and assessment measures. The basic question is, what will students do to demonstrate they have achieved the learning goals set for the course or educational activity? In terms of knowledge acquisition, this often involves multiple-choice question (MCQ) tests, but when done best accomplishment of learning goals should include other assessments and feedback activities as well.1 In evaluation of attitudes TABLE 3. Specific learning objectives related to “care for a child with a respiratory illness”

1. Elicit a focused history addressing the chief complaint 2. Perform a focused physical examination related to the chief compliant 3. Generate a differential diagnosis with information supporting the proposed diagnosis 4. Construct (and in clinical setting implement) an appropriate plan of care that is evidence based and takes into account the needs and values of the patient

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and skills, the full array of assessment techniques can be quite useful. The MedBiquitous standard vocabulary includes the following multiple assessment methods: (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11)

Computer-based/written exam Documentation review Multisource assessment Narrative assessment Objective standardized clinical evaluation (OSCE) Oral patient presentation Portfolio-based assessment Practical (Lab) Research or project assessment Self-assessment Stimulated recall

In The Next GME Accreditation System—Rationale and Benefits, Nasca et al.14 state that “A key element of the Next Accreditation System (NAS) is the measurement and reporting of outcomes through the educational milestones, which is a natural progression of the work on the six (ACGME) competencies. The aim is to create a logical trajectory of professional development in essential elements of competency and meet criteria for effective assessment, including feasibility, demonstration of beneficial effect on learning, and acceptability in the community. The milestones are based on the published literature on these competencies and were developed by an expert panel with representation from the specialties in the early phase for use in milestone development. This process moves the competencies ‘out of the realm of the abstract and grounds them in a way that makes them meaningful to both learners and faculty.’ Over time, it is anticipated that the milestones will reach into undergraduate medical education to follow the adoption of the competencies by many medical schools. This will contribute to a more seamless transition across the medical-education continuum.”5,6 The idea that milestones “create a logical trajectory of professional development”12–14 suggests the importance of formative and summative assessment and feedback for the learners. It is only through accurate assessment and effective coaching that learners can know that progress is as expected, performance can be improved, and further skill acquired. Assessment methods can contribute to learner engagement and satisfaction. Reflective portfolio assignments, research projects, OSCEs, and practice quizzes are teaching methods in

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medical education that can promote active learning. In active learning the learner has a role in defining his or her own learning outcomes and/or those of his or her peers.15 Thus, the feedback provided during formative assessments can encourage students to define or refine their own learning objectives and strategies, much in the manner in which informed and accurate feedback improves goal setting and ultimately performance in the process known as deliberate practice. The pursuit of deliberate practice to achieve mastery characterizes many disparate disciplines, including medicine.16

Step 4: Teaching/Learning Activities Finally, the appropriate and necessary teaching/ learning activities need to be formulated. If there are significant learning goals and effective assessment procedures, the teaching/learning activities become defined means to the end (outcome). Teaching and learning methods that incorporate active learning principles will be most effective in accomplishing the learning goals.1 The MedBiquitous standard vocabulary includes the following instructional methods: (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) (23) (24) (25) (26)

Case-based instruction/learning Clinical experience Discussion, large and small group Independent learning Journal club Laboratory Patient presentation Peer teaching Problem-based learning (PBL) Reflection Research Self-directed learning Service learning activity Simulation Team-based learning (TBL)

While all of the instructional methods listed above incorporate some aspects of active learning, PBL, by definition, is the best example of an active learning instructional method as defined by the LCME. Students identify the issues in the case, decide how they wish to learn about those issues, and then teach one another as they work through the case. Clinical learning is generally considered as active learning, as students identify the problems

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that characterizes the patient presentation, then research those problems—again taking the responsibility for their learning. The impact of active learning for an individual learner is highly depended on the learner's motivation, preferences, learning style, and past experiences. Prober and Khan17 recently argued for more widespread adoption of the “flipped-classroom model” in medical education. In this model, students access brief (  10 min) online videos to learn new concepts on their own time. The content could be viewed by the students as many times as necessary to master the knowledge in preparation for classroom time facilitated by expert faculty leading dynamic, interactive sessions where students can apply their newly mastered knowledge.18 Case-based instruction, clinical experience, patient presentation, and simulation can all be leveraged during “dynamic interactive sessions.” These can be particularly effective when, as noted by Cooke et al.,5 they “strengthen connections between formal and experiential knowledge across the continuum of medical education, incorporate experiences, and promote learners' ability to work collaboratively with other health professionals.” An instructional method in medical education that leverages the flipped-classroom model is team-based learning (TBL).19 Before the term “flipping the classroom” was coined in the late 1990s as the internet was beginning to be used for educational institutions, Dr. Larry Michaelsen developed team-based learning in late 1970s. In TBL, students are assigned independent learning, the MedBiquitous term for “instructor-/or mentor-guided learning activities to be performed by the learner outside of formal educational settings.”3 At the start of the face-to-face session, they gave an individual readiness assessment test (IRAT). After a group discussion, groups complete the same readiness assessment test in a group, or group readiness assessment test (GRAT). After a brief review, “classroom time is facilitated by expert faculty leading dynamic, interactive sessions where students can apply their newly mastered knowledge.” TBL methods are well researched and have been found to be effective in medical education.20 While TBL may not meet the full definition of active learning, as objectives are generated by faculty, students do take responsibility of analyzing problems in the application process while learning the importance of communication and teamwork.

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There are other instructional methods, which encourage students to take a greater role in deciding what they need to learn, or essentially generate their own learning objectives. For example, in a case discussion, students in small groups could be asked to generate 3–5 learning objectives after reading a case. If done online, the groups could post or submit those learning objectives prior to receiving more information about the case; or if in a classroom setting, then the faculty facilitators could post the objectives, according to themes generated. Likewise, at the beginning of the application exercise in a TBL exercise, students in their TBL groups could be asked to generate their learning objectives.

Step 5: Integration The last step is to evaluate the course design for integration to make sure all the components are in alignment and support each other. Are the learning activities consistent with all the learning goals? Are the feedback and assessment activities consistent with the learning goals and the learning activities?1 Integration in medical education is facilitated by robust teaching and learning systems. For, in order to “standardize learning outcomes and assess competencies over time while incorporating more clinical experiences earlier in medical school and providing more opportunities for knowledge building later in medical school and throughout residency,” as Cooke et al.5 recommend, academic medical institutions will need to build and utilize complex learning management systems. MedBiquitous members have been creating a technology blueprint for advancing the health professions. Based on XML and Web services standards, this blueprint will weave together the many activities, organizations, and resources that support the ongoing education. Ultimately, systems support the learner in ways that will improve patient outcomes and simplify the administrative work associated with lifelong learning and continuous improvement.21

Conclusion The goal of significant learning curricular redesign efforts is to enhance educational program quality and efficiency in a way that leads to improved patient care. Successful medical education requires the coordination

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of educational systems, including UME and GME. Medical educators will need to incorporate new, competency-based learning goals as the framework, with formative and summative assessment methods that provide milestones for the learners, to promote best development of students and trainees. Increased emphasis on interprofessional education can also provide more relevant learning opportunities. To be successful in a career in health care, teaching methods and learning systems need to promote self-directed learning and active learning, in order for students to be fully committed to lifelong learning and continuous professional development.

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8. MedBiqitous Curriculum Vocabularies. 〈http://medbiq.org/ curriculum/vocabularies.pdf〉; Accessed 14.09.13. 9. Alexandraki I, Mooradian AD. Redesigning medical education to improve health care delivery and outcomes. Health Care Manag 2013;32:37–42. 10. McGaghie WC. Medical education research as translational science. Sci Transl Med 2010;2:1–3. 11. Aschenbrener CA, Englander R. Entrustable Professional Activities (EPAs) for entering residency: spring meetings project update. Presented at the AAMC Central Group on Educational Affairs 2013 Meeting. 12. Hauer KE, Sonj K, Cornett P, et al. Developing entrustable professional activities as the basis for assessment of competence in an internal medicine residency: a feasibility study. J Gen Intern Med 2013;28:1104–14. 13. Carraccio C, Burke AE. Beyond competencies and milestones: adding meaning through context. J Grad Med Educ 2010;2: 419–22. 14. Nasca TJ, Philibert I, Brigham T, Flynn TC. The next GME accreditation system—rationale and benefits. N Engl J Med 2012;366(11):1051–6. 15. Liaison Committee on Medical Education Glossary. 〈http:// www.lcme.org/〉; Accessed 14.09.13. 16. Ericsson KA. Deliberate practice in the acquisition and maintenance of expert performance in medicine and related domains. Acad Med 2004;79(suppl 10):70–81. 17. Prober CG, Khan S. Medical education reimagined: a call to action. Acad Med 2013;88:1407–10. 18. Prober CG, Heath C. Lecture halls without lectures—a proposal for medical education. N Engl J Med 2012;366: 1657–9. 19. Michaelson LK, Sweet M. The essential elements of team based learning. New Directions Teach Learn 2008;116:7–27. 20. Thompson BM, Schneider VF, Haidet P, et al. Team-based learning at ten medical schools: two years later. Med Educ 2007;41:250–7. 21. MedBiqitous Mission and Scope. 〈http://www.medbiq.org/ about_us/mission/index.html〉; Accessed 14.09.13.

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