Outcomes

Overview
“Outcomes”
in Medical Education
• What are “outcomes”?!!!!!!"#$%&'()
– What about learning objectives
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• How are they used in Scotland?
Phillip Evans
– Scottish Doctor Project
• How are they different from competences?
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Visiting Professor, MEDC Gifu
Project coordinator, Scottish Doctor Project
Curriculum Development Officer,
University of Edinburgh
This presentation will offer a definition of an outcome and how learning
objectives are developed from outcomes. I will explain the Scottish
Doctor Project, and finally, explain why outcomes are preferred to
competences
My experience with outcomes stems from
my role in developing the medical
curriculum in Edinburgh, where I
established ‘outcomes’ as the mechanism
for defining the course. I am a member of
the Scottish Doctor project, that used the
outcome model to define the Scottish
Doctor.
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Outcomes:
a philosophical basis
Bloom’s Taxonomy
Cognitive domain!VMWX
• A constructivist view of Education
(knowing)
» Evaluation
» Synthesis
» Analysis
» Application
» Understanding
» Knowledge
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In the UK, the fundamental philosophy in medical education is
‘constructivist’. This is because the discipline of medicine is
continually developing and therefore the professional characteristic of
the medical profession is one of life-long learning. Medical education
must therefore be student centred, (as life-long learning means that
doctors are perpetual students), and integrated within the clinical
context.
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Blooms taxonomy is a useful starting point for exploring outcomes.
Bloom recognised that learning activities fall into categories that are
also hierarchical, with evaluation (and therefore transfer of knowledge)
to be the highest cognitive skill of all.
(Benjamin S Bloom, ‘Taxonomy of educational objectives’ Pearson
Education 1884)
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Bloom’s Taxonomy
Affective domain
Bloom’s Taxonomy
Psychomotor domain mnopWX
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(actions)
(processing)
» Internalising
» Organising
» Valuing
» Responding
» Receiving
» Origination
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» Adaptation
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» Mechanism
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» Set (ready to go)
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» Perception
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Krathwohl and Bertram (1973) Taxonomy of Educational Objective
Handbook II - Affective domain.
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Constructivist beliefs
Constructivist beliefs
• Learning is a psychological process
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• Learning embraces all 3 domains
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• “Understanding” is the end point
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• Marton and Saljo (1976)
• Entwistle (http://www.ed.ac.uk/etl/publications.html)
– Superficial learners
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– Strategic learners
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– Deep learners
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– Deep learning, Marton & Saljo (1976)
– Entwistle (1981)
• Adults learn in a constructive way
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– Kolb, Knowles
The constructivist view is that the psychology of learning requires the
student to engage in a process that enables the individual to reach a
point of understanding. Several workers have described a number of
paradigms.
This seminal paper written in 1976 has inspired a great deal of work in
this field. Essentially, individuals express 3 main approaches to their
learning. Superficial learning- learning enough to get by. Strategic
learning, learning to pass the exam, Deep learning, learning for
understanding. The implication being that if we want doctors who
really understand medicine, then we have to adopt educaiotnal
strategies that encourage understanding and does not promote
superficial learning.
Marton and Saljo (1976) On qualitative differences in learning I.
Outcome and process British Journal of Education Psychology, 46 4-11
Kolb (1984) Learning Styles Inventory
Knowles (1990) The Adult learner- a neglected species Houston Gulf
Publishing
My colleague at Edinburgh, Noel Entwistle, now an Emeritus
Professor, has made a substantial contribution of research in this field.
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Kolb
Knowles
Individuals “engage” by:
• Concrete / experience, or
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• Reflection / observation !! !!!!!ªG«G¬'They “internalise” by:
• Abstract thought / conceptualisation!®¯d
• Action / experimentation
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Individuals pass through all four events to complete the
learning experience
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Adults learn by:
• Focusing on a problem!!!! ·¸#¹IŠ@ºG
• Being in control / ownership / planning
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• Collaborating / team work!!!!!!!!½¾¿À~
• Immediate relevance / significant!!ÁÂÃI…/
• Are Active
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Kolb’s view is that learning requires a range of experiences if learning
is occur. The implication being that medical schools have to adopt a
range of teaching and learning events (and not rely on lectures).
As students mature it is natural for them to adopt styles of learning that
are in keeping with their development. Adults do have a particular way
of learning and the sociology of the workplace demonstrates this well.
Adults do learn best when they are motivated by a problem that is
relevant, they collaborate with others and solve problems in an active
way .
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What are outcomes?
What are outcomes?
Outcomes are statements that clarify
what has to be learned.
• They make learning & teaching explicit
• They empower individuals
• They standardise assessment
• They are the basis for quality assurance
• They are predictive and deterministic
Outcomes are statements that clarify
what has to be learned.
Therefore outcomes may be arranged in
an orderly manner
= Constructive Alignment (Biggs 1999)
Outcomes take the guess work out of medical training. If students
know what was expected of them, they will achieve. The outcome
model provides clarity about what has to be learned.
Outcome statements may be arranged in an orderly and rational so
that the course provides a learning experience that is meaningful and
systematic . Biggs (1999) teaching for quality learning at university
SRHE open university press
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What are outcomes?
Outcomes in Medical Education?
Quality Assurance
• In Medical Education, in Scotland,
Outcomes define a student-doctor at the
point of graduation.
MBChB outcomes
Programme
Year 5
Year 4
Year 3
Year 2
Year 1
Standard setting
informs learning
Assessment
Year 5
Year 4
Year 3
Year 2
Year 1
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informs teaching
This diagram illustrated how Outcomes underpins all aspects of the
programme.
In Scotland, outcome are taken very seriously, and they have been
used to describe the attributes of a doctor at graduation.
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What are outcomes?
Application
The Scottish Doctor Project
http://www.scottishdoctor.org
• In Medical Education in Scotland,
Outcomes define a student-doctor at the
point of graduation.
• Example:!>'Íå
Take a history from a patient, relatives
or others.
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Phillip Evans
Project Co-ordinator
The Council of Deans of Scottish Medical Schools
Curriculum Group
[email protected]
They are quite straightforward, and few would disagree with them.
Collectively, they provide a significant definition of a doctor.
The five Scottish Medical Schools formed a collaborative group to
bring about a better understanding of the “Scottish Doctor”
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Scottish Doctor Group
Scottish Doctor Project
!The Five Scottish Medical Schools
Scottish Deans Medical Curriculum Group.
!Phase 1 – Learning Outcomes (1999- 2000)
Membership (~ 15) includes :
!Phase 2 – Assessment (2000-2002)
•Associate Deans for Undergraduate
Medical Education
!Phase 3 – Standard setting (2003 +)
!Phase 4 - Cross-referencing (2004 +)
•Curriculum Co-ordinators.
•Invited experts and representatives.
Composition of the group includes representatives from the five
schools.
The project has several phases, beginning with the definition of the
Outcomes.
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Location of Schools
Overview of Schools
School
Aberdeen
Glasgow
Dundee
St Andrews
Edinburgh
(London)
Aberdeen
Year
Founded
1495
Student
intake
175
5 Years MBChB
1 Year Foundation
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Dundee
1881 / 1967
154
"
Edinburgh
1583
218
"
Glasgow
1465
241
"
St Andrews
1413
112
*
*St Andrew’s.
Years 1,2 3, BSc (Medical Science) then Year 4 Honours in Medical Science, or,
transfer to another medical school for 3 Years clinical training before graduation
100km
The Geographical distribution of the schools
Comparison of the schools
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General Medical Council
Aberdeen Curriculum Overview
60% core (systems based) with Options
Phase I: Fundamentals of Medical Sciences- Year 1
Phase II: Principles of Clinical Medicine- Yr2, 2/3Yr3
Phase III: Specialist Clinical Practice- Yr 3 yr 4
Phase IV: Professional Practice- Yr 5
All five medical courses apply the recommendations of the General Medical
Council set out in the document “Tomorrow’s Doctor” (1993 and 2002)
Options include: “Complementary medicine”, “European languages”
The recommendation are not Outcomes
All Schools are licensed by the General Medical Council and therefore
conform to its recommendations. Each school interprets the
recommendations in their own way, and there is great diversity in the
curriculum structures. The key recommendations are that schools
should adopt modern approaches to teaching, learning and
assessment; that factual content should be kept to a minimum, that
programmes should be based on body systems and not subjects; that
there should be clinical integration from Year 1.
Aberdeen: Has a integrated body systems arranged in four phases of
development.
The documents are available at www.gmc-uk.org
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Dundee curriculum overview
Dundee core-systems
Dundee
Core course with 30% Options
Systems are:
•Cardiovascular
•Respiratory
•Alimentary
•Central nervous
•Locomotor
•Renal and urinary
•Growth and reproduction
•Behavioural and psychiatric
•Special senses
PRHO
knowledge
Skills
attitude
Phase 3 Years 4 & 5:
Clinical practice in clinical attachments
Phase 2 Year 2 & 3: Integrated systems
ABNORMAL structure and function
Phase 1 Year 1 Integrated systems: NORMAL
structure and function
(Subjects are integrated in body systems, and include clinically
relevant examples)
Options include: “Human Rights” , “Travel Medicine”
Dundee has three phases.
The systems are readily recognisable. Each school has its own
variations on these themes.
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The Edinburgh
Medical
Programme
Edinburgh
curriculum
overview
Glasgow curriculum overview
Core course: Problem-based learning.
Horizontal Modules
Cases based on defined list of “presenting
symptoms” for example, headache, back-pain,
(Body-systems with
clinical integration)
and Vertical Themes
20% course has a choice of special study
modules
Edinburgh has a series of modules that reflect the integrated bodysystems, but includes other key-components as ‘vertical themes’.
Glasgow has adopted an integrated approach through core cases and
problem-based learning.
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Glasgow - an integrated curriculum
St Andrews: subject-centred curriculum
Year
Year 1 Block 1 (5weeks):
Courses
1
Human
Anatomy
Human
Physiology
Cellular &
Molecular
Medicine
Behavioural
Science
First Aid
2
Human
Anatomy
Human
Physiology
Cellular &
Molecular
Medicine
Behavioural
Science
Special
Assessing
Study Module Medical
Evidence
3
Pharmacology
Medical
Microbiology
General
Pathology
Applied
Medical
Science
Behavioural
Science
Public health
4
CAL
project
seminars
Research
project
The Student and the Drunk Driver
•The hierarchy of systems : Wound healing and
scarring
•Blood vessels and blood pressure: stopping bleeding
•Blood: Consequences of infection
Information
Technology
•The Body’s defences: Alcohol
After Year 3 or 4 students go to Manchester for 3 Clinical Years
This is an example of the first block of problems about a student who is
injured in a road traffic accident.
St Andrews is now revising its course, but at the moment maintains a
traditional subject centred curriculum
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St Andrews/Manchester
Deciding on the Outcomes
Aberdeen
Glasgow
• The first phase
Dundee
St Andrews
Edinburgh
– Can we agree on common outcomes for our
undergraduates?
• “Scottish Doctor I” - 2000
Manchester
(A PBL School)
London
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100km
St Andrews does not have a clinical school and so students go to
Manchester for two years clinical work (Manchester is a PBL school)
Five different schools with different kinds of curriculum came together
to agree a common core of outcomes.
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Deciding on the Outcomes
Deciding on the Outcomes
• Began with describing all the attributes of
a doctor at the time of graduation
• Began with describing all the attributes of
a doctor at the time of graduation
– What can the doctor do?
– What does the doctor know?
– How does the doctor practice?
– What can the doctor do?
Identify all skills
– What does the doctor know?
Identify all knowledge
– How does the doctor practice?
Identify all attitudes
They began by asking 3 key questions about the nature of a doctor.
Each of the three questions were expanded
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Deciding on the Outcomes
Medical
informatics
Attitudes, ethics
and legal
Patient
management
Decision making,
clinical reasoning,
Judgment
• Began with describing all the attributes of
a doctor at the time of graduation
Patient
investigation
Clinical skills
Basic, Social &
Clinical science
– What can the doctor do?
Identify all skills
– What does the doctor know?
Identify all knowledge
– How does the doctor practice?
Identify all attitudes
Organise!
Communication
skills
Personal
Development
Role of the Dr within
the Health Service
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Level 1
Level 2
Practical
procedures
Health promotion
disease prevention
The final set of outcomes were arranged in a hierarchy
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Phase 1: The Learning
Outcomes
Application
Phase 1: The Learning
Outcomes
Outcomes
Learning Outcomes.
Arranged in three main levels:
Level 1 (first order)
!Level 1 – Three main divisions
#What the Doctor is able to do
!Level 2 – 12 domains
#How the Doctor approaches their practice
!Level 3 – varying number
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!(Level 4 – interpretation at the School level)
The last level in the hierarchy, that was common, was level 3. Level 4
(and 5) were variations that were specific to each school.
Level 1 = 3 categories that are commonly used as starting points in
outcomes modelling
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Outcomes
Phase 1: The Learning
Outcomes
Outcomes
#Clinical skills
Outcomes
#Practical procedures
at Level 2
#Patient investigation
#Patient manage
#Health promotion and disease prevention
#Communication
#Medical informatics
#Basic, social and clinical sciences
#Attitudes, ethics, legal responsibilities
#Decisions making skills, clinical reasoning & judgement
#The role of the Doctor within the Health Service
#Personal development
Level 3 (third order)
For example: Patient investigation (level 2)
#General principles of patient investigation
#Laboratory-based investigations
#Radiological investigations
#Clinical investigations
Level 2 - 12 outcomes
Level 3 - a large number of outcomes further categorized into level 4
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Outcomes
Phase 1: The Learning
Outcomes
Outcomes
Example 1
Example 2
Level 3 Clinical investigations:
Level 3 Pain Control :
Level 4
Level 4
The graduate should know about and may have
observed, but not routinely perform:
Ability to select and initiate appropriate anaelgesic
using local protocols
Exercise tolerance test, Pleural tap/biopsy, Upper and
lower GI endoscopy, EEG, Lumber puncture, Cytopsy,
Colposcopy, Skin biopsy, Joint aspiration, Fine needle
aspiration, Laryngoscopy, Nasal endoscopy,
Specific knowledge of pharmacological, physical and
psychological interventions
Understanding the role of the pain management specialist and
demonstrating an ability to interact with pain management
teams
Level 4 outcomes were present in all schools, but not to the same
degree or level of significance, and this was the point where natural
variation of emphasis is established.
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Published Outcomes
Outcomes & Assessment
The first report
The second report
March 2000
May 2002
Available at www.scottishdoctor.org
The outcomes were published in a document, which is available at
www.scottishdoctor.org
The outcomes were revised and a review of the assessment tools in
the Scottish Schools were published in 2002.
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Phase Conformity
1: The Learning Outcomes
and
variance
Learning objectives
All schools conform to the same generic
outcome statements ( level 3)
• Outcomes define what a doctor can do at the
point of graduation.
• Learning objectives are the detailed subcomponents of outcomes (level 4 or 5)
• LO’s are used in modules, teaching
sessions, or by students, and accumulate to
build up the final outcome
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But each school is free to use its own
specific examples (level 4, 5 and beyond)
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Whilst all schools follow the GMC recommendations and subscribe to
the Scottish Doctor outcomes, the schools are not ‘clones’, but have
courses that have their own distinct identities.
Outcomes are normally big units, and require breaking down into more
manageable units. These are translated into learning and teaching
activities that are defined as ‘learning objectives’. Learning objectives
are ‘behavioural’, and should be written with a verb at the start of the
sentence. A good reference for this is Biggs “Solo Taxonomy”
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Learning objectives
Learning objectives
Outcomes
(Cellular mechanisms)
• Level 2: Outcomes for basic, social and
clinical sciences
• Level 3: Normal structure and function of the
individual as an intact organism and each of
its major organ systems
• Level 4: Cellular mechanisms
• Learning Objective:
Describe, using annotated diagrams, the
structure and function of the cell.
Learning objectives
(describe the structure and function of the cell)
Published in Study Guides
Teachers
Plan teaching
Useful terms are describe, calculate, explain. Terms such as
“understand” are best avoided when writing objectives.
Students
Plan learning
Assessment
Basis of questions
Learning objectives are the ‘working currency’ of the course. They are
listed in the study guides and unite the teaching, learning and
assessment.
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Course structure
outcomes
Year 5
Modules
Year 5
L. Objectives
“The double wedge”
The distribution of outcomes in an MBChB
programme based on integrated, body systems,
with early clinical experience
Year 5
Assessment
Year 4
Year 4
Year 4
Modules
L. Objectives
Assessment
Year 3
Modules
Year 3
L.Objectives
Year 3
Assessment
Year 2
Modules
Year 2
L.Objectives
Year 2
Assessment
Year 1
Modules
Year 1
L.objectives
Year 1
Assessment
Clinical outcomes
Science outcomes
Personal and professional development
`The simplistic model is to begin with the learning objectives and
arrange them in a sensible order [sequence and progression] that has
continuity. Then transcribe the outcomes into more specific learning
objectives. These are then published in course-handbooks (study
guides). The learning objectives form the basis of teaching events,
learning activities and assessments.
The GMC ask for early clinical integration, and most schools adopt “the
double wedge” with increased clinical contact and decreased
biomedical science, as the course progresses. Programmes that
develop the individual (personal and professional development0
continue as a parallel factor throughout the programme.
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Competences: a definition.
Relationship with Competences
• Competences have been adopted for
use by the European Union, and are
the preferred model in the ‘Tuningproject’
• Why are outcomes preferred?
• A “Competent” person is so desirable
• How about a pilot?
Competences have been adopted by the European Union.
Competences have arisen from industrial models of technical
instruction, where individuals learn to complete pre-determined
actions. (Driving a car, for example)
The notion that a professional person is competent is attractive. But
just what does ‘competent’ mean?
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Definition of Competence
Why Competence is not enough!
• Competence is about knowing what
has to be done, and to a specified
standard
• Competence via capability
• Chomsky (1965)
Linguistic competence: knows rules and
structure necessary to produce speech.
Linguistic performance
(capability):knows how speech functions
in reality.
• How to take-off
• How to fly from A - B
• How to land
Being competent means knowing what has to be done, to a specified
standard.
However, in some professions, being competent is not quite enough.
Chomsky explains that a person who is a competent linguist knows the
rules necessary to construct speech. However, performance
demonstrates how speech really functions. In medicine, this attribute
is describe as capability. A medical student may show competence in
an examination, but in the real world are they capable of making
clinical judgments?
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Competence = operational !
Competence via capability
• Competences cover a range of high-order
skills.
• Assessment of competence is an
observation that a task has been completed
successfully.
• However, the task has to be pre-determined
and is mechanistic (Pavlovian)
• It is not a considered response.
• A competent person can demonstrate they
can take off and land a plane, in a given set
of conditions. (Pavlovian)
Competences may be akin to Pavlovian responses. The response it
automatic and does not require any consideration or judgment.
Outcomes lead to understanding and demonstration of judgment, as
they are not geared to responses that are a predetermined set of
procedures or protocols.
• However, suppose an unforeseen event
occurs? If the individual is only competent,
then there will be a problem.
• A truly capable pilot will understand what to
do and fly the plane safely
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Competence via outcomes
Summary
• Competences are deterministic, and
generally appropriate for technical training.
•
•
•
•
•
• Outcomes are constructivist, and enable
action from understanding and considered
decision. They develop and test judgment,
and so are appropriate for professional
training.
Competences are ‘closed’ deterministic events yielding technician - like
responses. Outcomes are ‘open’ constructivist and enable action form
understanding. Professional judgment.
Outcomes define the ‘doctor’
Guide what is taught
Signposts for student learning
Foundation of assessment
Framework for quality assurance
In summary, the outcomes model defines what a doctor is at the point
of graduation, and encourages judgment and actions that follow
reflection. In the curriculum, they are arranged in some logical order
that unite students, teacher and examiners.
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Thank you
This is the entrance to the Chancellors Building in the Medical School,
Edinburgh. The wall tapestry was a special commission, from the
artist, Allan Davey. This new building is famous for its art collection,
which was arranged by Professor Henry Walton (founder, and life
president of AMEE), and is one of the finest art collections in Scotland.
I’ll be happy to receive enquiries: [email protected]
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