Curriculum & Context

Nick Ross Emeritus Professor University of Birmingham UK

A disclaimer There is no such thing as the perfect curriculum for the Physician Associate Profession.......

A disclaimer There is no such thing as the perfect curriculum for the Physician Associate Profession I cannot begin to tell you what YOUR Physician Associate curriculum should look like All I can do is point you towards some issues you need to explore, some questions you might usefully ask and some tools you might use

• In the region / country in which it is located:

• For the professional role as planned

• In the context of the educational institution

• In the context of the health care provider partnership:

• For the nature of the intake

• In the historical context

There is no single perfect curriculum... for any health profession.

Too many variables that MUST be allowed to shape the curriculum so that it is fit for purpose...

The national / regional context

the pattern of disease / health need related to demographics relate to economic development / wealth related to climate and geography

the demography of the country age profile ethnicity and related health issues immigration / emigration change as a factor in its own right

The health care system

General organisation Community and hospital care State, charitable and/or commercial providers Existing mix of health care professions National or local legislative framework

The role of the Physician Associate Fields in which role is, or may be used Scope of PA practice: e.g. prescribing Mentoring, supervision and professional accountability

The health care provider partnership

Good partnerships with providers are vital

Institutional link

Involvement in programme development / implementation

Sponsorship

Provision and supervision of student placement - criteria under which student placement is offered - roles of education and provider organisations - nature of supervision - expectations of the student PA

Internship

Employment

• Special rules apply to an emergent profession which may not be as important for an established profession. • Lack of knowledge and therefore limited trust amongst employers and public. • Professional patch protection • Overwhelming institutional scrutiny

The era in which the programme runs The evolution of the profession

• Existing models within the institution

• Human resources

• Physical resources

• Faculty skill set

• Institutional self-perception

GREENFIELD and BROWNFIELD Sites

The educational institution: I

Green field & Brown field Greenfield Site

Say NO to PAs! We don’t know what they are, but we’re SURE we won’t like them

Green field & Brown field

Ancient monuments and preservation orders

The graveyard of previous failures

Existing regulatory framework

Infrastructure that limits change

Slurry pool of Toxic Opinions

Brownfield Site

The educational institution: II Existing models within the institution To what extent is the development of a new programme constrained by institutional regulation? Are there institutional programme norms: custom and practice?

Are there norms in the institution specific to programmes for health care professionals?

Is there a school of medicine?

The educational institution: III Physical Resources: • Largely lecture based, or significant small room use? • Is there a morbid anatomy facility available? • Is there a skills centre / clinical simulation facilities? • Is there the potential for dedicated space? Virtual Learning Resources: • Is the necessary hardware for virtual learning available? • Is there a student/staff friendly virtual learning environment? • Are faculty engaged in producing materials? • Does the ‘virtual campus’ include the clinical area?

The educational institution: IV

Human Resources: • What importance is given to education in the academic model of the institution? • What is the level of engagement of academics with pedagogy as a discipline? • How much of the teaching is done by faculty and how much by honorary staff? • What skills / experience do faculty / potential faculty have? You have to start from where you are, not where you would like to be (just as with students)

Professional grand-parenting Medicine (whether we like it or not) is the senior partner. Norms for medical education determine norms for PA education as for any profession fulfilling a medical role. Differences between US and UK medical education reflected in US and UK PA programmes Institutional grand-parenting • Successful programmes we know and admire • Offers of faculty assistance • but: ‘buyer’ (and ‘seller’) beware.... ...evangelical / philanthropic or colonial / multinational

What shapes the curriculum?

Cross-professional Frameworks Statutory accreditation processes National Examinations The recommendation of others Voluntary agreements

What shapes the curriculum?

UK Competence and Curriculum Framework (PAMVRC)

Institutional Support without the continuing support of the institution, the best curriculum in the world is worth nothing. • Does the institution believe that this is something it should be doing - does it reinforce the message it wants to give to the world? •What compromises are necessary on the part of programme developers to meet institutional budgetary constraints? • What priority does the institution give to education in general and the partnership with health providers in particular?

What shapes the curriculum?

Maturity of Intake

What age are students when they enter the programme and how much life experience do they have? • A programme designed for 18 year olds would not take advantage of all that mature students have to bring. • A programme designed for mature students may fail to engage younger students who expect the pedagogic approach that they’re used to in school.

What shapes the curriculum? Intake

Prior educational experience

At what level are students taken into the programme - as school leavers; as graduates? What is the nature of prior education – • highly didactic? • valuing independent learning / development of life-long learning skills? Academic ability

How selective is the programme able to be in terms of the intake? How mixed is the ability of the cohort?

What shapes the curriculum? Intake II

Prior learning

• What learning are students required to bring to the programme • Is the programme about the novel application of prior learning to a new context, or about fresh disciplines Character

The professional persona is of vital importance. • To what extent is this left to a process of professional ‘formation’.... • ...or is appropriate 'character' expected from outset?

What shapes the curriculum? Intake III

definition of the profession / role patterns of supervision / dependency readiness for assuming the medical role scope of practice - profession - cohort - individual

What shapes the curriculum? Output

Curriculum decisions: philosophy

process...........product leading...........following educational comfort.............educational challenge disciplines..........integration profession oriented............service oriented

None of these are categorical decisions!

Curriculum decisions: ordering

Bloom and concept of domains

Evaluation Synthesis Analysis Application Comprehension Knowledge

Bloom (1956) Cognitive taxonomy

Kratwohl (1964) Affective taxonomy

Internalise Organise/resolve Value Respond Receive

Curriculum decisions: ordering II

Dave (1970) Psychomotor taxonomy

Unconscious mastery Adapt and integrate Execute reliably Reproduce from memory Observe & replicate Steinaker & Bell (1979) Experiential taxonomy

Dissemination Internalisation Identification Participation Exposure

See one

Do one

Teach one

The dream of philosophical / educational discourse without language • fuzzy logic • discussion of concepts • keeping the big picture • not getting mired in language

Curriculum decisions: Models I

Visual Curriculum Models

Benefits of visual modelling Herman Hesse The Glass Bead Game

Shaping the curriculum: Models II

Content / product models

Tyler (Basic Principles of Curriculum and Instruction - 1949) Product focussed / content driven Owes much to Henry Ford - production line thinking

• Defining appropriate behavioural objectives

• Establishing useful learning experiences

• Organizing learning experiences for maximum cumulative effect (subject precedence +)

Focus on measurability can lead to ‘immeasurables’ being ignored

Carl Rogers (and others)

Emphasis on personal growth rather than specific outcomes: on offering and enabling experiences.

Shaping the curriculum: Models II

Personal growth

Driven by individual curiosity

Does such a model have anything to offer in professional healthcare education?

JUSTIFICATION FOR LEARNING

DEFINITION OF KNOWLEDGE

Closed (authoritative, consensual)

Open (conditional, reflexive)

Intrinsic Extrinsic

Curriculum as a portfolio of meaningful experiences

Curriculum as a map of key subjects

Curriculum as an agenda of important cultural issues

Curriculum as schedule of basic skills

Shaping the curriculum: Models III

Shaping the curriculum: Models IV

Bruner: The Spiral Curriculum Kolb in 3D

experience

reflection conceptualisation

reapplication

Shaping the curriculum: Models V

Science in Medicine

Individuals and Populations

Clinical Skills

Diagnosis and Decision Making

Professional Skills

Treatments

Lifespan

A curriculum model for medicine I

Managing the patient, sick and well

A curriculum model for medicine II

Broadening the professional base

Acquiring using clinical information

Synthesising and applying the medical knowledge base

Building the medical knowledge base

A curriculum model for medicine III

Managing the patient, sick and well

Broadening the professional base

Acquiring using clinical information

Building the medical knowledge base

Synthesising and applying the medical knowledge base

Science in Medicine

1

2

3

4

DO

MA

INS Lifespan Clinical Skills Science in

Medicine Individuals and Populations

Diagnosis & Decision Making

Professional Skills

Treatments

A curriculum model for medicine IV

C

1

2

3

4

Introduction to the basics of pharmacology: major classes of drug, their action and interaction. Principles and economics of prescribing. Influencing lifestyle decisions.

The elderly in general and specialist hospital settings, in social care and in their own homes. Social and cultural constructs of old age. Normal pregnancy and developmental milestones.

Ageing as a biological, psychological and social process. Health problems / challenges for different age groups. Immunisation vaccination, screening and health MOTs

Children, adolescents and the elderly in mental health settings. End of life issues: patient, family and clinician

Pregnancy and childbirth. The roles of community and hospital medicine. The child and their family in the hospital setting. Adolescence adulthood and sexual health.

Therapeutics: individual patients: actions reactions and side effects. Safe prescribing. Surgical management in OD and perioperative environment. Fluid management. Rehabilitation

Therapeutics in specialist environments. Effective prescribing. Radiotherapy and chemotherapy. Special considerations in palliative care. Ethics and law of treatment in mental illness

Complex and urgent treatment in the patient with a life threatening illness. Adapting treatment regimes to the context of paediatric medicine. Medicalisation of normal life events

Translating organisational skills into the NHS Trust environment. Pt. safety and quality improvement. The multi-professional team. Self-directed learning in a pt. centred environment.

Adapting learning skills for the challenge of medicine Skills of self management, team work and working within an organisation. Principles of Ethics and Law in Medicine

Breaking bad news. Interpersonal skills in difficult / conflicted situations. Competence, consent and vulnerable adults. Responsibilities to patient, organisation and profession.

Professional responsibility and the clinical team. Moving from the student to the employed doctor role. Competence and confidence. Meeting the requirements of the New Doctor

Understanding process of diagnostic reasoning. Developing a differential diagnosis for presentation to supervisor. Roles of doctor and patient in clinical management decisions.

Developing the critical, analytical and reflective skills that underpin effective decision making. Observing and exploring the clinical decision making of others

Developing a differential diagnosis in specialist settings. Treatment decision making. EBM Referral, multi-disciplinary teamwork and decision making in difficult circumstances

Decision making in the acute environment. Decision making in the management of life threatening illness. Coping with uncertainty, wrong decisions and error.

Developing competence in taking a comprehensive patient history and physical examination. Development of procedural skills as mapped in the Passport.

Developing initial skills in history taking and examination as well as common non-invasive procedural skills that can be learnt / practiced in community-based medicine

Application of patient history taking, physical examination skills in specialist settings. Psychiatric assessment Development of procedural skills as mapped in Passport.

Sexual and obstetric history taking. Integrating physical examination with info. from monitoring etc. in the acutely ill patient. Developing and refining consultation skills.

The psychological effect of hospitalisation on the individual. Recognising mental health issues in a general health setting. The health of the hospital population.

Introducing students to behavioural sciences, public health, promotion and prevention, disability-both physical and mental. Individual choice, social pressure and the role of the doctor

The individual in society. Social construction of the meaning of ‘normal’. Life style choices and health. Serious illness and self perception. Addiction. Grieving. Mental illness. Stigmatising conditions.

The social context of community medicine. Individuals, families and populations in continuing relation to the practice. Pregnancy, parenthood and childhood .

Additional basic science to support developing physical examination skills. Basic concepts of clinical sciences and application to diagnosis and management.

Setting the basic science foundation, using system based approach which integrate the disciplines, but using a matrix assessment to ensure no discipline is ignored.

Additional basic science and clinical science in the context of specialist medicine, orthopaedic and general surgery and organic mental illness

Basic science for critical care. Understanding and supporting failing systems. Physics and biochemistry re: the ventilated patient.

DO

MA

INS Lifespan Clinical Skills Science in

Medicine Individuals and Populations

Diagnosis & Decision Making

Professional Skills

Treatments

advantages of stability for the institution for health care provider partners for faculty for students disadvantages gradual loss of relevance slow deterioration.....

Stability & Fluidity in the Curriculum I

The stable curriculum WILL reach a point where it is no longer fit for purpose. • The circumstances that shaped it • The faculty who made it work • The health care environment into which it feeds

When it ceases to function, revolutionary change is the only answer ...but it is notoriously difficult to get right

Stability & Fluidity in the Curriculum II

Stability & Fluidity in the Curriculum III

...even when it may sometimes be necessary ...and there will be blood

Institution: - cost of planning - cost of change / disruption Faculty: - principled disagreement with change - wedded to particular content being lost - wedded to an approach to the subject) - personal investment in the way things are change as personal attack - 'over my dead body' Students: - the rump............... - the guinea pigs......

faculty aren’t interested faculty don’t know what they are doing

Nothing lasts forever

Stability & Fluidity in the Curriculum IV

The Carnegie Foundation 1910 Flexner Report

2010 Cooke, Irby, O’Brien Educating Physicians A Call for Reform of Medical School and Residency

investing in fluidity

content fluidity

....ought to be relatively natural for a research / practice driven profession where development is a constant.

....but cutting edge research may be the wrong driver ....loss of clinical relevance may go unrecognised ....disciplines may not be valued

Stability & Fluidity in the Curriculum V

Genomics / proteomics Rheumatic Fever Communication studies

structure / process fluidity (curriculum and classroom practice)

requires a recognition of / engagement with educational process and a capacity for abstract thinking which is not always present amongst discipline specialists or clinicians

Developing a culture of continuing innovation requires...

The encouragement and support of the institution The engagement and education of faculty The involvement of health care partners The affirming of students as partners in the process

Stability & Fluidity in the Curriculum VI

Thank You!