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COMPETENCY-BASED
CURRICULUM DEVELOPMENT
IN MEDICAL EDUCATION
An Introduction
WILLIAM C. McGAGHIE
GEORGE E. MILLER
ABDUL W. SAJID
THOMAS V. TELDER
With the assistance of Laureite Lipson
Center For Educational Development
University of Illinois at the Medical Center, Chicago, IL, USA
WORLD HEALTH ORGANIZATION
GENEVA
1978
ISBN 92 4 130068 X
© World Health Organization 1978
Publications of the World Health Organization enjoy copyright protection in
accordance with the provisions of Protocol 2 of the Universal Copyright Convention.
For rights of reproduction or translation of WHO publications, in part or in toto, appli
cation should be made to the Office of Publications, World Health Organization, Geneva,
Switzerland. The World Health Organization welcomes such applications.
The designations employed and the presentation of the material in this publication do
not imply the expression of any opinion whatsoever on the part of the Secretariat of the
World Health Organization concerning the legal status of any country, territory, city or
area or of its authorities, or concerning the delimitation of its frontiers or boundaries.
The mention of specific companies or of certain manufacturers’ products does not imply
that they are endorsed or recommended by the World Health Organization in preference
to others of a similar nature that are not mentioned. Errors and omissions excepted, the
names of proprietary products are distinguished by initial capital letters.
The authors alone are responsible for the views expressed in this publication.
PRINTED IN SWITZERLAND
CONTENTS
Page
Foreword
7
Acknowledgements
9
1. Curriculum models
Subject-centered curriculum ..
Integrated curriculum
Competency-based curriculum
11
13
16
18
2. Identifying the elements of competence
General considerations in defining competence
Analysis of physicians’ activities
Self-reports
Observation
...........
Task analysis
Critical elements of behaviour
Critical incidents
Expert judgement
Health care needs
Public health statistics
Medical records
Social, economic, and political realities ....
Professional performance situation model . ...
21
21
23
24
27
29
30
31
35
39
39
40
41
43
3. Learning for mastery...........................
Programme organization: time
Programme organization: sequence ..
Programme organization: mastery ..
Specification of learning objectives
Identification of curriculum clusters
Development of instructional units
Encouragement of self-pacing . . ..
Recognition of competence levels .
Frequent assessment of learning . ..
51
51
52
55
56
56
57
58
58
60
4. Assessment of competence
Entry assessment
Formative assessment ..
Summative assessment . .
69
70
73
75
— 5 —
5. Preparation of teachers, students and institutions
New educational roles
The teacher
The student
Strategies for curriculum change
Power
Rationality
Re-education
Aids
— 6 —
80
81
81
83
85
85
86
87
89
FOREWORD
Writing a book that will be useful to all 150 Member States of the
World Health Organization is a formidable undertaking at best. When
the topic is curriculum development for the health professions, the
difficulty is compounded not only by the strong feelings associated with
educational traditions, but also by the very different needs, opportunities,
and resources among WHO Members.
We have attempted to deal with this problem by emphasizing the
process of curriculum construction rather than its content. While we are
persuaded that the most significant health problems for whose solution
young professionals must be prepared are those relating to communities
and the preservation of health, rather than to individuals and the cure of
disease, nevertheless we are not prepared to suggest that these are the only
competencies toward which medical education should be aimed. If we
have achieved the balance for which we strived then the protagonists
for neither view will be satisfied that we have given their particular concern
sufficient attention.
Our hope is that whatever their present views about the content and
emphasis required in medical education, readers will be willing to examine
the process set forth here as a point of reference against which to test the
conclusions about curriculum they may have reached through other
means. If any significant number gain new insight into what may be
required to improve curriculum design, we will be satisfied that the first
objective of this volume has been realized.
The second, however, is more difficult to achieve. Despite an effort
to be precise and concrete, not general and abstract, the translation of
principles and procedures described here into the curriculum, practices
of any school will not be easy. For the simple fact is that most medical
teachers have been trained to think or to act not as educators so much as
content experts who are charged with teaching responsibilities. The task
of helping staff members of schools for health professionals to acquire
the necessary knowledge and skills to improve the quality of education
is one to which WHO has given steadily increasing attention by
— 7 —
8
FOREWORD
able to deal with these issues and still keep the book to manageable size
Readers who feel a need for assistance in this realm may wish to consult
other WHO publications, notably in the Public Health Papers series.
While the principal focus of this volume is medical education, since
that is the discipline in which the authors have had their greatest
experience, the solution of curriculum problems in the education of other
health workers is equally important in the production ofpractitioners who
can meet the health needs of the contemporary world. Thus it is worth
noting that the principles embodied here are not limited in their
application to medical education but have general usefulness It is our
hope that representatives of these other health professions and occupa
tions will also find them helpful.
With these disclaimers we wish our readers a pleasant and projitable
journey through this volume.
w. C. McG.
G. E. M.
A. W. S.
T. V. T.
ACKNOWLEDGEMENTS
A debt of gratitude is owed to the following reviewers for their
comments on a draft of this book;
Dr Daoud S. Ali, Executive Secretary, Association of Medical
Schools in the Middle East, Beirut, Lebanon
Dr M. Lotfy Dowidar, President Emeritus and Professor of Surgery,
Alexandria University, Egypt
Dr N. Jungalwalla, Controller of Examinations, Indian Academy
of Medical Sciences, New Delhi, India
Professor G. L. Monekosso, Director, University Centre for Health
Sciences, Federal University of Cameroon, Yaounde, United Republic
of Cameroon
Professor H. G. Pauli, Director, Institute for Research in Education
and Examinations, Faculty of Medicine, University of Berne, Switzer
land
Professor P. P£ne, Director, Unite d’Enscignement et de Recherche
de Medecine et de Sante tropicales, University of Aix-Marseilles,
Marseilles, France
Professor G. Velasquez-Palau, Rockefeller Foundation, Salvador,
Bahia, Brazil
Professor T. Varagunam, Director, Medical Education Unit, Faculty
of Medicine, University of Sri Lanka, Peradeniya, Sri Lanka
Dr J. Vysohlfd, Head, Department of Postgraduate Medical Educa
tion, Institute for Postgraduate Education in Medicine and Pharmacy,
Prague, Czechoslovakia
*
*
*
A number of tables and figures in this book are reproduced from
other sources. Thanks arc due to the following for permission to use
copyright material: American Medical Association, USA (Fig. 1);
Annals of Internal Medicine. USA (Fig. 3); Association for Hospital
— 9 —
10
ACKNOWLEDGEMENTS
Medical Education, USA (Tables 9 and 10); Blackwell Scientific
Publications Ltd, United Kingdom (Table 1); Chulalongkorn Uni
versity, Thailand (Table 5); Journal of Medical Education, USA
(Fig. 4, 5, 6); Royal College of Medical Practitioners, United Kingdom
(Fig’ 12)’
CHAPTER 1
CURRICULUM MODELS
It must be evident to any objective observer that the practice of
medicine becomes increasingly complex with each passing year. Tech
nological advances and research findings leading to improved methoids
of disease prevention, diagnosis and treatment produce a constantly
changing definition of the competence a medical student must acquire.
Equally important, although less often articulated as a determinant .of
competence, is the setting in which a graduate will work. The knowledge
and skills needed to meet health service needs in a developing country
(e.g., Rwanda, where the ratio of physicians to population has been
estimated at 1:90 5001) are very different from those needed in an
industrialized country such as the United Kingdom. In the former, the
most important element of professional competence may be the physi
cian’s ability to train a team that will handle most of the direct patient
care load, and to manage a system that serves the public health. In the
latter, professional competence is usually judged by the physician’s
ability' to provide personal care for individual patients.
Given the exponential growth of medical information and clinical
skills and acknowledging that the roles and functions of the doctor will
vary according to the patient care setting, medical schools and other
institutions responsible for the education of health professionals face a
serious dilemma. On the one hand, there is a legitimate expectation
that graduates will be proficient in the latest and most advanced tech
niques for preserving health and managing disease. This expectation
is coupled with the belief that a thorough foundation in the basic and
clinical sciences is a fundamental prerequisite for achieving that goal.
On the other hand, concern for assuring academic quality in these
sciences must not divert attention from the competence required to
meet the real health needs of people. It is a rare school that has
seemed successful in resolving this dilemma. For example:
i WHO Chronicle, 30: 32 (1976).
— 11
12
COMPETENCY-BASED CURRICULUM DEVELOPMENT
“A study of general practitioners in ... shows an inverse correlation betweenjthe
frequency of disease and the emphasis given to instruction about diseases durjing
medical training.”1
“The general attitude among the staff is that university education consists of ‘the
learning, remembering, and reproducing of the information in the books or the
notes’. Such archaic views are so predominant among the older and senior staff
that one could easily believe the report that they objected to extension into the
evenings of the opening hours of the university library for the use of students as an
unnecessary move!” 2
'
“In ... the teaching of the preclinical subjects has not been organized in!an
atmosphere of research, with the result that the students’ powers of observation and of
drawing deductions from such observation are not adequately stimulated. Nor is the
practical application of the preclinical subjects brought home to the students. The
transition from preclinical to clinical studies is abrupt. The student in the period of
clinical training does not have to apply anatomy and applied physiology taught to
him by his preclinical professors. The preclinical and the clinical portions of the
course lie side by side instead of being integrated, though each with its own emphasis:
the former on scientific research and the study of the subject for its own sake rather
than for its application to the treatment of disease, and the latter on the treatment
of disease itself.”3
“Students in ... receive rigorous training in the [European] tradition including
instruction in sophisticated diagnostic and patient management techniques. However,
a district hospital, where one physician with the help of a trained nurse and a
handful of auxiliaries care for over 100 000 people, may have no X-ray, running
water, or operating theater, and medication of any variety is scarce.” 4
Such illustrations highlight the discrepancy that often exists between
medical curricula and the functional requirements of medical practice,
but give little insight into underlying causes. In many parts of the world,
but particularly in nations with a history of colonial influence, one
important reason is tradition. Not only are medical curricula commonly
based on foreign models, but also academic degree and specialty
certification requirements are often established by external agencies.
A second cause may be the isolation of many medical schools from the
clientele their graduates should be expected to serve. Predominantly
located in major urban areas, very few appear to provide significant
student contact with rural people, who have the greatest health care
needs and the fewest health care facilities. A third possibility stems from
what seems to be a primary interest of the most prominent medical
teachers: understanding human disease, rather than preserving human
1 Hodgkin, K. Towards earlier diagnosis. Edinburgh, Livingstone, 1966.
2 Zamiri, I. A personal view of recent medical and educational developments in Iran. British
journal of medical education, 5: 75 (1971).
3 Nayar, D. P. Undergraduate medical education in India. British journal of medical education,
5: 172 (1971).
4 Bryant, J. Health and the developing world. Ithaca, NY, Cornell University Press, 1969.
CURRICULUM MODELS
13
health. Certainly the infrequency of opportunities for students to
study preventive medicine or to engage in projects designed to enhance
the public health is in striking contrast to the regularity of experiences
with diagnostic and therapeutic medicine. There are probably other
explanations for the apparently low correlation between what is taught
in medical schools and what is most needed for medical practice but none
of these, taken singly or in combination, should perpetuate educational
programmes in which medical competence is defined largely by
academic proficiency with books or written tests rather than by the
practical ability to meet human needs.
While admittedly painted with a broad brush the picture sketched
thus far would provoke a sharply negative response to the question:
“Is the current medical curriculum a valid expression of optimal
professional practice?” The more important question is: “How, then,
can things be changed?”
The most common method of curriculum change has been to revise
content while preserving the subject-centred structure. Two major
alternatives also demand a wider hearing. The first is an integrated pro
gramme model where learning and teaching attempt to fuse formerly
separate medical disciplines by using, for example, organ systems or
medical problems as the organizing structure. The second arranges
learning and teaching around the functional elements of medical
practice. Because the emphasis is on learning how to practise medicine,
not on accumulating knowledge about medical practices, it is called
competency-based. But before any school can make a sound decision
about which of these three options might yield the most appropriate
curriculum plan, it is necessary to understand the reasoning that
underlies their development and use, and the assumptions each makes
about the practice of medicine and how students should be prepared
to engage in that craft.
SUBJECT-CENTRED CURRICULUM
The subject-centred curriculum is the most widespread model for
medical education. It generally includes 2-4 years of didactic instruction
in basic and preclinical science, followed by several years of instruc
tion in the clinical disciplines, including varying amounts of practical
work. Three to 6 years of additional study are commonly required if
qualification in a medical or surgical specialty is sought. This model
assumes that physicians must be scientifically oriented and that they
need an extensive introduction to the biological and physical sciences
prior to controlled clinical experience. Large doses of scientific fact
14
COMPETENCY-BASED CURRICULUM DEVELOPMENT
and theory, together with instruction in research methodology, are
provided through discrete courses that cover such classical subjects as
physics, chemistry, anatomy, physiology, and pathology, as well as
more recent additions such as immunology and biostatistics. The
emphasis is on learning the disciplines rather than their application
to the practice of medicine. Contact with patients occurs only after
proficiency in these sciences is demonstrated, usually through end-ofcourse or end-of-year written examinations.
All students study the same material, in the same setting, within the
same time frame. An implicit assumption is that given, for example,
14 weeks of classroom lectures complemented by intense study outside
class, students can become proficient in a basic science such as bio
chemistry. This is a dubious assumption for two major reasons. First,
because faculty and students rarely have a clear and explicit under
standing of what is meant by a functional proficiency in biochemistry.
Consequently, both class sessions and outside assignments are oriented
to books and tests, not functional applications. Secondly, setting a
fixed time for any course implies that all students learn in the same
manner and at the same rate, a presumption rejected long ago by
students of human learning.
The ensuing clinical experience, while separate from the classroom
and laboratory work in basic science courses, is often taught by the same
methods. The principal instructional difference is in the opportunity
students have to see patients, and occasionally to work with them.
Yet separation among the clinical disciplines is as sharp as that found
in preclinical instruction. Surgery, medicine and psychiatry, for example,
are taught as separate subjects, and not as tools for understanding the
undifferentiated problems which patients present to medical prac
titioners.
Students arc exposed to patients primarily in a teaching hospital
stocked with the best available equipment, medication and personnel.
Such hospitals are usually populated with patients suffering from
complex or unsolved medical problems. Thus clinical instruction tends
to emphasize diagnosis and management of the unusual, not the most
frequent patient complaints. Indeed, rare or unexpected disorders
seem to attract the most attention from teachers and students alike.
In the face of such experience and models it should not be unexpected
if students become indifferent to, and have limited skill in managing,
the common problems that will occupy a major portion of their later
professional lives.
This observation should not be taken to suggest that such hospitals or
the professional services they provide are undesirable. It merely
indicates that a subject-centred curriculum is an almost inevitable con
sequence when instruction is controlled by basic and clinical scientists
CURRICULUM MODELS
15
who see medicine as a series of independent disciplines which in sum
represent the modern doctor’s work. The nature of the scientist’s work
inevitably limits perspective and many are incapable of seeing the
contribution each course or clinical experience might make to the daily
requirements of medical practice outside the training sites. Caught up
in the task of dealing with difficult, frequently insoluble but always
challenging problems of disease, they have little time or energy left to
think about the preservation of human health through modifying
environmental hazards, social conditions, and human ecology in general.
The result is an educational programme in which the practice of
medicine is mortgaged to the study of medicine, a series of exercises
divorced from the realities of providing care for those most in need.
The challenge to improve health care and the corresponding need
to improve education for the health professions is beginning to high
light these limitations of the subject-centred curriculum model. In
developing nations, where the need is greatest, attempts to modernize
medicine, to improve general health standards, and to train practitioners
at all levels in a manner that relates their work to indigenous socio
cultural needs are increasingly evident. Industrialized nations, struggling
with acute shortages of competent health manpower, an uneven dis
tribution of medical practitioners, and urban decay are exerting pressure
on health science institutions to modify the education they offer to
meet these problems. The most common response has been revision
of curriculum content to reflect the latest research findings or clinical
techniques. Courses and disciplinary distinctions are preserved, while
change is seen mostly in new course syllabi, textbooks, audiovisual
materials, or time allotments. Such modifications are surely expected
of any first-rate faculty irrespective of the curriculum model being
used, but revising course offerings while maintaining a subject-centred
format produces primarily cosmetic change; only rarely does it bring
medical education closer to the work of practising physicians.
As an example. Table 1 shows the 1950-1958 and 1969—1970
distribution of instructional time at one university in the United
Kingdom. While there is a pronounced reduction in the number of hours
devoted to anatomy and more time is given to such subjects as biology,
medical physics, physiology, and mental health, the emphasis is still on
departmental offerings, despite the introduction of some integrated
instruction, topic teaching, and elective offerings that are not shown in
the table.
Whatever its scientific merit, the subject-centred curriculum model
has undesirable consequences for medical students, their future patients,
and the institutions responsible for training health care personnel. For
students, this traditional organization of medical education emphasizes
factual knowledge of independent medical disciplines, lockstep instruc-
16
COMPETENCY-BASED CURRICULUM DEVELOPMENT
TABLE 1.
APPROXIMATE DISTRIBUTION OF TIME (HOURS)
IN A MEDICAL CURRICULUM3
Subject
Biology
Chemistry
Physics and medical physics
Genetics..................................................
Statistics
Orientation course
Anatomy
Physiology
Biochemistry
Human ecology
Medical psychology
Pharmacology ......................................
Therapeutics
Pathology
Bacteriology
Public health/social medicine
Forensic medicine ........................ • • •
History and philosophy of medicine
Mental health ........................................
Dermatology
Ophthalmology
Venereal diseases
Diseases of ear, nose and throat ..
1950-1958
1969-1970
210
250
245
20
20
0
910
260
170
0
20
240
210
310
20
40
20
595
350
140
30
10
110
60
270
85
48
26
0
100
24
30
7
24
165
230
70
85
50
15
95
35
35
35
35
Increase
or decrease
+30
—40
+65
0
+20
+ 20
-315
+90
-30
+30
-10
+ 5
+40
+ 15
-37
-24
-15
+ 5
-11
- 5
-28
a Based on : MCANDREW, G. M. ET AL. The undergraduate curriculum in retrospect. British
journal of medical education, 4: 294, Table 2 (1970) (by permission).
tion, patient contact without direct responsibility for patient care,
attention to the less common clinical problems, and an implicit focus on
human disease—not health. Consumers of medical services suffer
because such a curriculum prepares health workers according to dis
ciplinary, rather than community expectations. In institutions, it pro
motes professional insularity rather than involvement with the most
pressing problems of health manpower and systems of health services.
INTEGRATED CURRICULUM
The integrated curriculum attempts to fuse independent disciplines
into a more unified whole. Development of this model was based on
the assumption that medical learning and teaching gain greater meaning
when didactic courses and clinical experience are brought together, an
assumption supported by recent research on human learning and
memory.1 This does not mean that isolated fragments of information
1 Ausubel, D. P. Educationalpsychology: a cognitive view. New York, Holt, Rinehart & Winston,
1968.
CURRICULUM MODELS
17
cannot be learned; they are learned regularly in many formal
educational programmes. However, their retention and use is another
question. In one study, where the same tests were administered to
medical students at the end of basic science courses and again 1, 2 and
3 years later, the results showed remarkably little retention of what
had been acquired. Disappointingly few students remembered enough
to pass the original courses again.1 In fact the forgetting curves were
similar to those reported in the nineteenth century for the retention of
nonsense syllables.
Integrating curriculum elements into a conceptually meaningful
structure is one way to overcome the problem of instruction presented
in the form of separate subjects. Advocates of the approach argue that
courses organized around major organ systems (e.g., cardiovascular,
gastrointestinal, genitourinary) provide a more appropriate context
for learning about medicine. Within each course students study the
biological and chemical foundations of an organ system, its structural
properties, reactions to disease and injury, and response to treatment.
If relevant experience of patient care can be provided at the same time,
educational impact is further heightened.
Such principles were the basis for the then revolutionary curriculum
instituted at Case Western Reserve University’s School of Medicine
at Cleveland, Ohio, in the early 1950s. Organ system instruction coupled
with an institutional commitment to correlate the basic sciences with
clinical experience represented a striking contrast to the subject-centred
model which then, as now, dominated medical education. Although
greeted with considerable scepticism the model has now been adopted
in whole or in part by many other medical schools.
A variation of the integrated model is the core curriculum. Here
a set of fundamental courses representing the essential foundations of
medicine in general, or a medical specialty in particular, is offered to
all students before more individualized opportunities for focused study
are presented.
One of the most exciting examples of such a curriculum is now being
offered in Mexico City at the Autonomous Metropolitan University,
Xochimilco. In January 1975, 800 students in biological sciences and
health and social sciences and humanities began their studies on this
satellite campus with a basic core programme that encompassed three
primary areas: (1) common sense and scientific method; (2) normality
and abnormality; and (3) labour and the labour force.
Upon completing this common experience the two groups separated
for additional core work more directly related to their specific areas
1 Office of Research in Medical Education. Report to the Faculty. Chicago, IL, University
of Illinois College of Medicine, 1961 (unpublished document).
18
COMPETENCY-BASED CURRICULUM DEVELOPMENT
of interest. For example, the biological sciences and health group had
a core module dealing with cellular biology in which gastroenteritis
(not gastroenterology) was used as a working example around which
key anatomical, biochemical and pathological concepts were developed.
During a subsequent academic term another core module dealt with
energy and energy consumption, using nutrition as the illustrative
content area. In the second year the biological sciences and health group
further divided into health sciences, veterinary medicine and agronomy,
and biological sciences. In the ensuing year the health sciences group
subdivided into medicine, nursing, and dentistry cohorts.
It should be clear that the core in this instance is not a body of
content separately identified by academic disciplines, but a collection
of concepts, drawn from many sources, that are useful to several
professions. But even when the professional groups are more sharply
separated in the advanced stages of the programme there may still be
both core experiences and focused options as further specialization
replaces basic professional competence as the principal educational
goal.
Use of an integrated approach to medical education or endorsement
of a core curriculum appears to have several advantages over subjectcentred instruction: fusing distinct scientific and clinical disciplines
makes learning more meaningful for students; courses may be stream
lined by eliminating areas of redundancy while strengthening those
of greatest importance; and, with careful advance planning, integrated
curricula can bring the experience of medical education closer to the
work of medical practitioners.
COMPETENCY-BASED CURRICULUM
Medical education that is competency-based differs from the
subject-centred and the integrated course models in 3 fundamental
ways. First, such a curriculum is organized around functions (or com
petencies) required for the practice of medicine in a specified setting.
Secondly, it is grounded in the empirically validated principle that
students of the intellectual quality found in medical schools, when given
appropriate instruction, can all master the prescribed basic performance
objectives. Thirdly, it views education as an experiment where both
the processes of student learning and the techniques used to produce
learning are regarded as hypotheses subject to testing. The intended
output of a competency-based programme is a health professional who
can practise medicine at a defined level of proficiency, in accord with
local conditions, to meet local needs.
CURRICULUM MODELS
19
The critics of this model rarely get beyond the question: “What is
competent medical practice ?” It would be pointless to suggest that there
is a single definition. Competence includes a broad range of knowledge,
attitudes, and observable patterns behaviour which together account for
the ability to deliver a specified professional service. The competent
doctor can correctly perform numerous (but not necessarily all) clinical
tasks, many of which require knowledge of the physical and biological
sciences or comprehension of the social and cultural factors that
influence patient care and well-being. Competence in this sense also
involves adoption of a professional role that values human life,
improvement of the public health, and leadership in settings of health
care and health education. The competencies are many and multi
faceted. They may also be ambiguous and tied to local custom and
constraints of time, finance, and human resources. Nevertheless, a
competency-based curriculum in any setting assumes that the many roles
and functions involved in the doctor’s work can be defined and clearly
expressed. It does not imply that the things defined are the only elements
of competence, but rather that those which can be defined represent
the critical point of departure in curriculum development. Careful
delineation of these components of medical practice is the first and most
critical step in designing a competency-based curriculum.
When students master the medical functions that comprise an
acceptable repertoire of professional practices they are judged to be
ready to work as physicians. But what does mastery learning require and
how can a student’s mastery of the necessary medical competencies
be assured?
Technically, mastery learning means that, given adequate prepara
tion, unambiguous learning goals, sufficient learning resources, and a
flexible time schedule, students can with rare exceptions achieve the
defined competence at high levels of proficiency. The technology of
mastery learning requires: (1) knowledge of what a student brings to
a learning task, not merely what is to be taken from it; (2) that broadly
defined competencies of medicine be dismantled into smaller, cumu
lative steps, through which students may work at individual rates using
many learning resources (books, laboratory experience, teachers, and
other things) according to their own needs and rates of progress;
and (3) that student achievement be thoroughly assessed at each
learning stage in order to document the growth of competence and to
provide valuable feedback on the quality of instruction.
The principles of learning for mastery—i.e., entry-level testing,
stepwise instruction, flexible time scheduling, and frequent assess
ment—describe the operational characteristics of the competency
based curriculum model, which leads to cumulative learning along a
continuum of increasing medical sophistication. A frequent bonus in
20
COMPETENCY-BASED CURRICULUM DEVELOPMENT
such a system is that the rate of learning accelerates as the student’s
experience grows, thus reducing the time needed to achieve programme
goals. For example, when a combination of clinical problems, inde
pendent study, audiovisual materials and computer-based mastery
testing was used, Sorlie and co-workers1-2 reported that one group of
medical students was able to satisfy basic science requirements, usually
achieved after 2 years, in only 1 year.
The competency-based curriculum model also calls for new skills
on the part of teaching staff. The remainder of this monograph is
devoted to the steps they must take in constructing and implementing
such a programme.
1 Sorlie, W. E. et al. A one year program in basic medical science. Journal ofmedical education,
48: 371 (1973).
2 Sorlie, W. E. & Jones, L. A. Description of a computer-assisted testing system in an inde
pendent study program. Journal of medical education, 50: 81 (1975).
CHAPTER 2
IDENTIFYING THE ELEMENTS OF COMPETENCE
Defining professional competence is the cornerstone upon which a
competency-based programme of medical education is built. Unless
this task is approached both thoughtfully and systematically the medical
curriculum is more likely to be a reflection of faculty interests than
of student and public needs. It is to the mechanisms for developing
such a definition that this chapter is addressed.
GENERAL CONSIDERATIONS IN DEFINING COMPETENCE
The desirable attributes of a health professional, whether physician
or nurse or basic medical scientist, are determined by many influences.
Expert opinion, the practice setting, the types of patients or the health
care problems to be encountered, the nature of a discipline or a specialty,
the stage of socioeconomic development of a community or nation
(present as well as future) all deserve consideration. In reaching a
decision about the competence goals for a specific curriculum, planners
may examine all or select only a few of these essential determinants,
depending upon the type of health professional being trained, the
curiculum level, or simply the time and resources available. Whatever
sources are employed the primary consideration in planning must
always be the nature of the professional role a graduate must play,
not merely the information that faculty experts are most comfortable
in teaching.
For example, Adjou-Moumouni1 provides a portrait of the medical
competencies to which curricula in the developing nations of Africa
should be directed, noting that the physician graduate should be
able to:
1. Detect the major communicable diseases plaguing the community.
2. Treat individuals or groups affected by these diseases.
1 Adjou-Moumouni, B. On developing curriculum to train physicians according to the needs of
African countries. Chicago. IL, Center for Educational Development. University of Illinois College
of Medicine. 1972 (unpublished manuscript).
21 —
22
COMPETENCY-BASED CURRICULUM DEVELOPMENT
3. Recommend or organize measures for preventing such diseases from spreading
throughout the community.
4. Identify the social or economic significance of communicable or noncommunic
able disease prototypes and suggest appropriate social measures.
5. Diagnose and treat organic and functional disorders affecting the major body
systems.
6.
6. Analyse
Analyse the
the consequences
consequences of
of disease
disease on
on the individual’s life and family and
take the necessary action to minimize the sequelae of the disease.
7. Analyse the influence of social, economic, and environmental factors on the
health status of individuals and groups, and suggest appropriate measures for
their correction.
8. Collaborate with governmental and private organizations to provide a healthful
environment, good food, and better use of available resources to meet the
needs of the community.
9. Obtain community participation in solving health problems.
10. Lead the health team, supervising their activities, supporting their morale, and
helping to solve their problems.
11. Use record systems to supply information to upper levels.
12. Participate in national health planning.
13. Pursue his own professional education.
Except for items 1, 2, and 5 these elements of competence do not
match what is typically emphasized in medical training: diagnosis and
treatment of particular complaints in individual patients. They are not
only more comprehensive but also deal with issues of administrative
leadership, liaison with governmental bodies, social research, and
consumer education which are commonly ignored or neglected in
medical curricula.
Yet contrast the description of needs in developing Africa with those
seen in an urban medical centre of industrialized North America where
another observer comments:
“During a three-month rotation at Boston’s Beth Israel Hospital... 1 came across
a computer program that evaluates a patient’s metabolic status at least as well as the
average physician could ... a Harvard nephrologist interested in computer applications
to medicine was able to devise a program, to act as a physician’s consultant, that can
accept the relevant metabolic data, demand more if necessary, and, in milli-seconds,
provide the doctor with a list of diagnoses (in order of probability), explanation of the
physiology involved, appropriate therapies, potential problems to watch out for, and
even a list of recent references in case the doctor wants to learn more about the
condition.”1
In such an'advanced setting the doctor’s work may increasingly centre
on managing man—machine interactions, with computers performing
1 Avorn, J. The future of doctoring. Atlantic, 243 (Nov.): 71 (1974).
THE ELEMENTS OF COMPETENCE
23
much of the diagnostic work and paramedical personnel applying
therapies under the physician’s supervision. Yet these aspects of
competence may also be overlooked in the medical curriculum.
The sharp differences between these examples simply underscore
what should be obvious: the definition of medical competence is bound
to local political, social, and economic circumstances, to health needs,
to the availability of resources, and to the structure of the health care
system. Thus any effort to find a universal definition of competence
will inevitably fail. The “good physician” in one setting may be totally
incompetent in another.
But basic medical scientists may wonder how such definitions can
be helpful to them in making curriculum decisions. Here it is necessary
not only to identify but also to separate competencies that are required
in an expert in a particular discipline and those demanded of a student
whose goal is the practice of medicine. Preparation of students for a
career in teaching and research is a legitimate and desirable objective
for a basic science department, but it should be a curriculum determinant
only for those students with that career goal, not for all students. There
may be common elements of competence for the two groups for
example, making independent observations, formulating and testing
hypotheses, analysing data and drawing conclusions that are consistent
with recorded findings—but there must be a considerable difference
in the depth as well as the breadth of that competence between the two
groups of students, a difference so great that a single course of instruc
tion for both is probably inappropriate. The task of the basic scientist,
working with clinical colleagues, is to determine the elements of a
practitioner’s professional competence to which basic science may
contribute. The more common strategy of offering a basic science
course in the hope, or even the expectation, that at some future time
it may serve the physician-graduate is not satisfactory.
Acknowledging the many factors that influence the definition of
competence, curriculum planners must collect data from multiple
sources to ensure a wide sample. Many methods can be used but they
vary in usefulness as well as practicality. Ideally a medical school staff
will employ several techniques but even limited information gathered
systematically is more useful than random impressions. As an opera
tional principle it would be wise to begin with what is near at hand, using
simple procedures, before moving to more complex techniques. The
following suggestions are based on that premise.
ANALYSIS OF PHYSICIAN’S ACTIVITIES
Documentation of what physicians do can provide insight into how
their time is spent, and into the critical elements of performance that
24
COMPETENCY-BASED CURRICULUM DEVELOPMENT
provide the most effective patient care (or alternatively those that may
impede effective care). While incomplete as a curriculum determinant,
precise information on these matters will facilitate the task of curri
culum designers and make the product of their efforts more realistic,
whether they work in the USA or the United Kingdom, in Argentina
or Sri Lanka.
Data about the daily work schedule of a physician can be gathered
in several ways: (1) a personal account of activities; (2) observation
by peers or others; (3) task analysis. The selection of any one or more
of these techniques will depend on the resources available and the
readiness of individual practitioners to cooperate. Simply soliciting that
cooperation, however, is often an important first step in establishing
the better lines of communication between those who practise and those
who teach which are essential to continuing curriculum improvement.
Self-reports
Self-reports are the most direct way to collect functional data, but
may be the most difficult since they require busy practitioners to take
on yet another task that cannot contribute directly to the care of their
patients. None the less, this technique is worth considering not only for
the information it provides to curriculum designers, but also as a means
of involving physicians in the analysis of their own performance, a
critical component of meaningful continuing self-education.
The methods that can be employed are of varying sophistication and
reliability. The simplest is a daily narrative diary which allows each
physician to carry out the task in an independent and unconstrained
fashion. But this advantage in recording is a disadvantage in analysis
since the lack of standardization in terminology and content makes sum
marization virtually impossible without an immense investment of
time and effort. However, such narratives can provide enlightenment
about problems, opportunities, frustrations, and achievements that
might not otherwise be revealed to faculty members seeking information
on what their graduates do, and thus for what they should be educated.
For analytical purposes it is much easier to ask a practitioner to
complete some standard form after each encounter with a patient
(or a specified sample of those encounters) over a fixed time period.
Fig. 1 shows one such form that has been successfully used in the USA
for this purpose; Fig. 2 shows another of somewhat greater complexity.
Clearly generalizations about the nature of what practitioners do
cannot be made from the information provided by any one individual
but if, for example, it is shown that among 100 participating physicians
15°/o of patients were over 65 and that in 50% of all patient encounters
FIG. 1.
EXAMPLE OF PATIENT ENCOUNTER FORM3
Please record the information for all patients seen midnight to midnight on two successive days of full time practice. If a diagnosis or probable diagnosis cannot be made,
ignore the Inst column. If the visit is not made for nn illness {for example, immunization) specify in Reason For Visit Column. Estimate age if not known.
AVERAGE t OF VISITS
BY A PATIENT WITH
THIS DIAGNOSIS
DATES ON WHICH PATIENTS WERE SEEN:
month
WHO?
n
AGE RACE
SEX
OCCUPATION
day tfl
WHERE?
HOW LONG?
HOME, OFFICE,
HOSPITAL, OR
ELSEWHERE
RECORD LENGTH OF
ACTUAL CONTACT
WITH PATIENT
IN MINUTES
day ^2
3
WHY?
SYMPTOMATIC
REASON FOR
VISIT
DIAGNOSIS (if
established) OR
PROBABLE DIAGNOSIS
ACUTE
PATIENTS
CHRONIC
PATIENTS
Number of
visits per
illness
Number of
visits per
year
M
W
r
w
2
z
o
'Tj
o
o
s
s
8z
8
a STOREY, P. B. ET AL. Continuing medical education: a new emphasis, Chicago, IL, 1968
Medical Association).
(reproduced by permission of the American
K)
Ul
SECOND EXAMPLE OF PATIENT ENCOUNTER FORM
FIG. 2.
a
C487402
mSSUA.
C 487402
• (XlCtK
th* pu»po*«* ol
PATIENT RECORD
NATIONAL AMBULATORY MEDICAL CARE SURVEY .
1. DATE OF VISIT
PATIENT LOG
Day
Mo
01 trial on tna log below. For IM patient in
land on Lot »3. also complate the pal-ent
—1__
record to the righL
Mo / Day
PATIENT'S NAME
TIME OF
VISIT
4. COLOR OR
RACE
t
■
t
Yr
WHITE
‘ ° N»
FEMALE
• Q OTHER
MALE
.
UNKNOWN
7. HAVE YOU EVER SEEN
THIS PATIENT BEFORE?
■
■ MOST
IMPORTANT.
b. OTHER.
NO
i
t Q YES
VERY SERIOUS
i
SERIOUS
>
SLIGHTLY SERIOUS
«
NOT SERIOUS
If YES. for the problem
indicated in ITEM 5a)
.
»
YES
8. MAJOR REASON(S) FOR THIS VISIT (Uack allaejet nir<m\
=.
WELL AOULT/CHILO EXAM
m
m
FAMILY PLANNING
«
CHRONIC PROBLEM. ROUTINE
u
COUNSELING/ADVICE
H Q CHRONIC PROBLEM. FLARE-UP
n
»
IMMUNIZATION
REFERRED BY OTHER PHYS/AGENCY
n
ADMINISTRATIVE PURPOSE
PRENATAL CARE
POSTNATAL CARE
•t Q POSTOPERATIVE CARE----- j
s
H
tn
Z
n
tn
U
O
d
go
b OTHER SIGNIFICANT CURRENT DIAGNOSES
(In ort/tr of importanct)
c
d
>. Q OTHER (Specify)
p.n_
Record items 1 -12 lor this patient
(Ope'a Iire proce dure)_________________________________ 11. DISPOSITION THIS VISIT
10. TREATMENTJSERVICE ORDERED OR PROVIOEOTHIS VISIT (Check ell that apply)
(tterf all that apaly}
si
NONE ORDERED/PROVIOEO
o>
PRESCRIPTION DRUG
■
>
m
PSYCHOTHERAPY/THERAPETUIC
LISTENING
a
RETURN IF NEEDED. P.R-N.
. Q TELEPHONE FOLLOW-UP PLANNED
.
REFERRED TO OTHER
PHYSICIAN/AGENCY
«
>
RETURNED TO REFERRING
PHYSICIAN
ADMIT TO HOSPITAL
•
OTHER (Specify)
u
GENERAL HISTORY/EXAM
as
LAB PROCEDURE/TEST
«
X-RAYS
as
1NJECTI0N/IMMUNIZATI0N
•o
MEDICAL COUNSELING/ADVICE
«
OFFICE SURGICAL TREATMENT
»
OTHER (Speedy)
12. DURATION OF
THIS VISIT (Time
acually ipaet milk
phyiiciu)
.MINUTES
serviceAN0 welfabe
<tn
2tn
z
H
CONTINUE LISTING PATIENTS
department of
U
tn
r
o
NO TOLLOW-UP PLANNED
RETURN AT SPECIFIED TIME
NON-PRESCRIFTION DRUG
(Speedy)---------- —---------
OM.I »6a-S72tO«
EXPIRATION DATE «/30/75
• United States Department op Health. Educawn, and Welfare. National ambulatory care survey: 1973 survey, Washington, D.C.,
1975.
S
NO
* DIAGNOSIS ASSOCIATED WITH ITEM 5. ENTRY
o
ACUTE PROBLEM
ACUTE PROBLEM. FOLLOW-UP
m
ON NEXT PAGE
O
O
9. PHYSICIAN'S PRINCIPAL DIAGNOSIS THIS VISIT
'
m
3
6. SERIOUSNESS OF
PROBLEM IN ITEM Si
(Check one)
5. PATIENT’S PRINCIPAL PROBLEM(S)
COMPIAINT(S). OR STMPTOM(S) THIS VISIT
(It patirat'c etra werrfr)
3. SEX
•
iiisi.
Yr
2. DATE OF BIRTH
As aach patitnt arrrvet. recorfl name and time
to
Ox
THE ELEMENTS OF COMPETENCE
27
only counselling (and not more specific therapy) was given, these
findings should suggest to a teaching staff some of the competencies
toward which the educational programme should be directed.
Observation
It is obviously easier for an individual physician to have the task
of recording his activities carried out by someone else. It may also
provide more reliable data since trained observers, using an obser
vational guide and checklist, are less likely to disregard small but
potentially important bits of information that doctors may consider
trivial. Busy physicians are also subject to significant error in reporting
what they do if the recording is not made at regular and frequent
intervals. While the presence of an observer may have some influence
upon a practitioner’s behaviour, the gain in reliability of what is
described is probably worth the small potential loss in validity. If the
data are to achieve the desired degree of accuracy and completeness
the observer must not only be trained in use of the observation instru
ment, but also have some familiarity with medicine. One way in which
this has been accomplished in several studies is by employing medical
TABLE 2.
EXAMPLE OF A SIMPLE OBSERVATIONAL GUIDE8
1. Intravenous therapy: time actually spent in administering intravenous therapy to
any patient.
2. Patient and relative contact: history taking; physical examinations; procedures
(lumbar punctures and so forth) — time spent only with patient; conferences of
doctor and patient alone— doctor and his patient (not a patient of another intern)
in the presence of other personnel, such as on rounds; and conferences with
relatives of patients.
3. Communication with staff (about clinical subjects only): conferences with nurses,
superiors, colleagues, students or administrators in the patient's absence: con
ferences with any of these personnel in the presence of a patient of another intern;
and chart work and the writing of orders.
4. Ancillary services: walking ; waiting ; telephoning; form writing ; messenger and
delivery work; setting up intravenous or procedure apparatus (in the absence of
the patient); and laboratory work.
5. Personal activities: eating; toilet; recreation; reading (medicine); and con
versation.
6. Sleeping.
7. Miscellaneous.
3 PAYSON, H. E. ET AL. Time study of an internship on a university medical service. /Vew
England journal of medicine, 264: 439 (1961).
COMPETENCY-BASED CURRICULUM DEVELOPMENT
28
students as observers. This has the additional advantage of providing
such students with a new set of insights about the professional role
for which they are preparing, through intimate acquaintance with what
physicians do hour by hour, not merely what they do in the dramatic
moments of triumph over obscure illness.
In one such study of hospital practice the observer simply recorded
time spent in each of 7 categories (Table 2). In another, a far more
detailed checklist was employed (Fig. 3). Each provided significant
data about the realities of medical practice, data that demand attention
in curriculum planning. For example, observation of the work of paediaFIG. 3.
EXAMPLE OF A MORE COMPLEX OBSERVATIONAL GUIDE8
PROFESSIONAL ACTIVITIES
CODE
Continuing Education
ACTIVITY
Total time with patients (Also fill out at
tached sheet)
Examining (including laboratory work)
P-P Ct
and treating—no verbal exchange
Exchanging information with patients
P-P i
(e.g. taking history, explaining diet in
struction, explaining disease process,
counseling, etc.)
Examining, treating AND exchanging in
P-P eti
formation
Note: The remainder of the professional activities may
or may not take place when doctor is with pa
tients. If the doctor is with a patient, place a P
before code.
(Example: Physician writes notes in patient's
zhen with patient: P-P-C, Physician writes
chart wht
when not with patient: P-C)
note ini chart
c.
Checking appointment log
P-A
Banking and related activities
P-B
Writing notes on patient's chart
P-C
Talk to detail men
P-DM
Completing death certificates
P-DC
Filing
P-F
Completing and signing insurance forms
P-I
Filling out lab report forms
P-LR
Doing laboratory work
P-LW
Opening and reading mail
P-M
Talking to physicians on telephone (1) to
P-MD-t
get information about patient referred to
him, (2) to refer patient, (3) transfer
trusteeship when not on call (e g. goi:
out of town) For #2 and ^3, note
specific problems are discussed.
In person (same as above)
P-MD-p
P-O
Ordering supplies
Supervision—personnel management and
P-S
instructions
Social service—arranging for community,
P-Tel SS
heaiih services for patients (welfare,
MediCal, health department, Social Se
curity, homemaker service, etc.) Note
type of service.
P-Tel a
Talking to answering service
P-Tel h
Calling hospital to admit patient
Talking on telephone to patients
P-Tel p
Talking on telephone to patient’s family
P-Tel f
P-Tel Rx
Calling in prescriptions to pharmacy
P-Tax
Completing tax forms
P-T c
Travel by car from office to and from
hospitals, nursing homes, patient's homes.
P-T f
Travel by foot—Note destination
P-CE j
P-CE I
P-CE t
P-CE tv
P-CE c
Journals
Reading medical
i
ling lectures and seminars sponAttendin'
by hospitals, voluntary organizasored t,
(Heart Assoc., Cancer Society),
tions, (F
specialty/ groups. (Note sponsoring
agency)
Listening to audio digest tapes
Watching medical TV
Conversation on medical subjects with
colleagues (not for referrals, social or
organizational reasons.)
Medical Community Service
P-MCS mm
P-MCS mr
P-MCS t
Attending business meetings of medical
organizations and committees (Note name
of organization).
Attending meetings as representative of
medical profession or medical organiza
tion (Note name of organization).
Teaching seminars or other teaching ac
tivity (Note type).
ACTIVITIES NOT DIRECTLY RELATED
TO PROFESSION
ACTIVITY
Civic
business (other than health)
N-CB
Dictating or writing personal letters
N-Let
Ealing, drinking, restroom
N-P
Other personal business (Note type)
N-Po
Reading newspaper, nonprofessional mag
N-R
azines, etc.
Personal telephone calls
N-Tel p
Telephone calls in connection with civic
N-Tel cb
business
Talking with student observer
N-T mo
CODE
N-T c
N-T £
N-V
Travol by car to and from nonprofeasional activity (Note destination, e.g. City
Hall)
Travel by foot to and from nonprofes
sional activities
Passing time of day with friends, person
nel or visitors (Note with whom)
LOCATION
H
N
PH
O
Hospital
Nursing :Home, Convalescent Home, etc.
Patient’si Home
Office
a BRODY, B. L.'& STOKES, J. Use of professional time by internists and general practitioners in
group and solo practice. Annals of interna! medicine, 73: 741-749 (1970) (reproduced by per
mission).
THE ELEMENTS OF COMPETENCE
29
tricians in one study revealed that half their time was spent with well
children and dearly a quarter with children suffering from simple
respiratory disease.1 While such findings cannot alone dictate the
amount of curriculum time that should be given to instruction about
healthy children or those with respiratory illness, it should bring into
sharp focus some of the specific components of professional competence
which must be perfected in order to deal successfully with 75°/o of
the patient population. The same study also revealed that 15°/o of the
practitioner’s time was spent dealing with problems by telephone rather
than in direct contact with patients, yet the skill of using a telephone
effectively in managing paediatric disorders is not commonly taught
even in countries where it is a major means of communication. And
finally the study indicated that the average amount of time given to each
patient was 11 minutes, scarcely the kind of encounter that is
demonstrated in most formal programmes of medical education. In
many countries the time would be even less, suggesting the importance
of having students acquire, through planned education, the competence
to identify major problems quickly, with a high degree of accuracy, and
to decide promptly how best to deal with them.
Task analysis
The meticulous dissection and description of what a physician does
may also be drawn from the combined opinions of experts, and not
direct observation and analysis. While this has the disadvantage of
being more an intellectual than an empirical exercise, it has the
advantage of generating consensus, and is thus less subject to the
criticisms often directed at generalizations about physician behaviour
derived from observational or self-report methods. This technique
has not often been applied to the delineation of physicians’ practices
but is widely used in outlining the functions and responsibilities of
allied health professionals.
One sample of such a task analysis is shown in Table 3. It was
developed by a group of respiratory therapists who defined the
sequential steps in caring for a patient with a tracheostomy. This
arrangement allows both teachers and students to see what must be
learned first in order to gain the proficiency required to move to more
difficult tasks. Many teachers would criticize such a tabulation as too
specific and detailed for the advanced performance required of a
physician. While they may be right, it would probably be unwise to
dismiss the method without at least a trial, for many of the pitfalls in
delivering health care appear to result from failure to exhibit the kind
1 Bergman, A. B. et al. Time and motion studv of practicing pediatricians. Pediatrics, 38:
254 (1966).
30
COMPETENCY-BASED CURRICULUM DEVELOPMENT
'
TABLE 3.
RESPIRATORY THERAPY COMPETENCIES NEEDED
TO PERFORM TRACHEOSTOMY CARE3
Step 1: Procure equipment needed for tracheostomy care (not included)
Step 2: Perform tracheostomy care
saline and hydrogen
hydrogen peroxide,
peroxide,
£
if needed.
.
.
&
tracheostomy.
R Fncrea^e oxygen 'concentration being given to the patient, and, if possible,
instruct him to take deep breaths.
G. Don sterile gloves and remove catheter from sterile packet.
H. Protect the sterile catheter in palm of hand which is to remain sterile> an
pick up suction connecting tube with hand to be contaminated and attach
to suction catheter.
, .
Using the contaminated hand, apply gentle pressure on the flange of the
tracheostomy tube to prevent its being disloged (tubes with 'nn®
cannula), carefully unlock and remove inner cannula and place it in the
bowl provided for its cleaning (bowl with hydrogen peroxide).
J. Suction the tracheostomy tube.
,
K. Reapply oxygen or ventilator before cleaning inner cannula.
-L. With sterile forceps in contaminated hand, pick up enough pipe cleaners
I.
to clean lumen of inner cannula.
M. With hand which has been kept sterile for suctioning, remove inner
cannula from bowl of hydrogen peroxide.
Cr^n
Pnd
N. Advance pipe cleaner through lumen of inner cannula. Small wire and
qauze strips may be substituted for pipe cleaners to clean inner cannula.
O. Rinse inner cannula thoroughly in bowl of sterile water or saline.
P. Replace inner cannula in tracheostomy tube carefully and lock in place.
Q. Change tracheostomy dressing when it gets soiled, but at least every
R. Replace humidified oxygen or ventilator (at pre-procedure concentration)
and make the patient comfortable.
3 METROPOLITAN GROUP OF HOSPITALS AND AREA HEALTH EDUCATION SY.S™'
REGIONS° UNIVERSITY OF ILLINOIS AT THE M EDICAL CENTER. A curriculum for resptratory therapy.
Chicago, IL, Aldine, 1975.
of competence described in such a task description. One of the
limitations of task analysis as a mechanism for defining competence
is that it does not reveal things that are being omitted, only what is
being done.
CRITICAL ELEMENTS OF BEHAVIOUR
Delineation of competency would be incomplete if it dealt only
with a quantitative description of practitioners’ work. The description
must also embrace the qualitative dimensions of care in order to define
the elements of competence to which a curriculum should be addressed.
The several techniques described here have all been used successfully
in gathering such information.
THE ELEMENTS OF COMPETENCE
31
Critical incidents
One of the most sophisticated methods for collecting behavioural
data about the ingredients of professional competence is the critical
incident technique.1 Here qualified individuals are asked to describe
incidents of medical care which they have observed and judged to
reflect superior or poor performance. The judgement requested is of
the incident, not of the individual, since even outstanding professionals
occasionally falter and even tyros sometimes perform superbly. Each
description includes the setting in which the event took place, exactly
what occurred, an account of the outcome, and why it was judged to
be effective or ineffective. As the number of individually described
incidents grows larger they begin to fall into natural clusters and a
detailed description of competence begins to emerge. Ideally the
collection of incidents continues until the addition of 100 new events
fails to add more than one new category of behaviour. One of the early
applications of this technique to medicine was conducted for the
National Board of Medical Examiners in the USA to describe the
competence expected of a physician at the conclusion of an internship.2
In a more recent study, carried out by the American Board of
Orthopedic Surgery, 1761 separate incidents, contributed by nearly
1000 orthopaedic surgeons, were classified into 9 major categories
and 94 subcategories of behaviour (Table 4).3
In these studies physicians were the source of descriptions about
physician behaviour, but other sources may supply additional insights
into other elements of proficiency that also deserve consideration. For
example, in an effort to define competencies required in the practice
of child psychiatry, specialists in the field were only one of the groups
asked to provide critical incidents.4 Paediatricians, who are the principal
source of patient referrals, and judges in juvenile courts, where child
psychiatrists often serve as counsellors or expert witnesses in cases
involving delinquent children, were additional sources of information.
Nonprofessional consumers of health services may also be useful pro
viders of descriptive data. In a study on competency in family practice,
Deisher5 asked a randomly selected group of patients for incidents of
1 Flanagan, J. C. The critical incident technique. Psychological buUerin, 51: 237 (1954).
2 American Lnstiiute for Research. Classification of critical incidents: intern-resident per
formance. Pittsburgh, PA, 1960 (multilith).
3 Blum, J. M. &. FnzpATRiCK, R. Critical performance requirements for orthopedic surgery.
Chicago, IL, University of Illinois College of Medicine. 1965 (multilith).
4 Berner, E. 'Toward a definition of competency in child psychiatry. In: Report io the Faculty,
1975. Chicago, IL, Center for Educational Development, University of Illinois College of Medicine
(multilith).
5 Deisher, J. E. Defining the family physician: the patient's view. In: Report to the Faculty. 1966.
Chicago, IL, Center for Educational Development, Universirv of Illinois College of Medicine
(multilith).
cOCVV-’
ISq-bt N'l S
COMPETENCY-BASED CURRICULUM DEVELOPMENT
32
TABLE 4.
EXAMPLES OF CRITICAL PERFORMANCE REQUIREMENTS
FOR ORTHOPAEDIC SURGEONS3
Skill in gathering clinical information
I.
A. Eliciting historical information
1. Obtaining adequate information from the patient
2. Consulting other physicians
3. Checking other sources
B. Obtaining information by physical examination
1. Performing thorough general examination
2. Performing relevant orthopaedic checks
II.
Effectiveness in using special diagnostic methods
A. Obtaining and interpreting X-rays
1. Directing or ordering appropriate films
2. Obtaining unusual, additional or repeated films
3. Rendering complete and accurate interpretation
B. Obtaining additional information by other means
1. Obtaining biopsy specimen
2. Obtaining other laboratory data
III.
Competence in developing a diagnosis
A. Approaching diagnosis objectively
1. Double-checking stated or referral diagnosis
2. Persisting to establish definitive diagnosis
3. Avoiding prejudicial analysis
B. Recognizing condition
1. Recognizing primary disorder
2. Recognizing underlying or associated problem
IV. Judgement in deciding on appropriate care
A. Adapting treatment to the individual case
1. Initiating suitable treatment for condition
2. Treating with regard to special needs
3. Treating with regard to age and general health
4. Attending to contraindications
5. Applying adequate regimen for multiple disorders
6. Inventing, adopting, applying new techniques
B. Determining extent and immediacy of therapy needs
1. Choosing wisely between simple and radical approach
2. Delaying therapy until diagnosis better established
3. Testing milder treatment first
4. Undertaking immediate treatment
C. Obtaining consultation on proposed treatment
1. Asking for opinions
2. Incorporating suggestions
V.
Judgement and skill in implementing treatment
A. Planning the operation
1. Reviewing literature, X-rays, other material
2. Planning approach and procedures
B. Making necessary preparations for operating
1. Preparing and checking patient
2. Readying staff, operating room, supplies
a From BLUM & FITZPATRICK, op. cit.
THE ELEMENTS OF COMPETENCE
C. Performing the operation
1. Asking for confirmation of involved area
2. Knowing and observing anatomical principles
3. Using correct surgical procedures
4. Demonstrating dexterity or skill
5. Taking proper precautions
6. Attending to details
7. Persisting for maximum result
D. Modifying operative plans according to situation
1. Deviating from preplanned procedures
2. Improvising with implements and materials
3. Terminating operation when danger in continuing
E. Handling operative complications
1. Recognizing complications
2. Treating complications promptly and effectively
F. Instituting a non-operative therapy programme
1. Using appropriate methods and devices
2. Applying methods and devices correctly
VI. Effectiveness in treating emergency patients
A. Handling patient
1. Properly applying splints and other protective measures
2. Handling and transporting carefully
B. Performing emergency treatment
1. Determining location and extent of injuries
2. Attending immediately to lifesaving procedures
3. Treating most critical needs first
4. Obtaining and organizing help
VII. Competence in providing continuing care
A. Paying attention postoperatively
1. Administering suitable postoperative care
2. Recognizing postoperative complications
3. Adequately treating postoperative complications
B. Monitoring patient's progress
1. Checking on effectiveness of therapy
2. Reassessing, altering or repeating treatment
C. Providing long-term care
1. Arranging for rehabilitative care, socioeconomic assistance
2. Explaining and monitoring home and rehaoilitative care
VIII. Effectiveness of physician-patient relationship
A. Showing concern and consideration
1. Taking personal interest
2. Acting in discreet, tactful, dignified manner
3. Avoiding needless alarm, discomfort, or embarrassment
4. Speaking honestly to patient and family
5. Persuading patient to undertake needed care, or only needed care
33
34
COMPETENCY-BAS ED CURRICULUM DEVELOPMENT
Table 6. Continued
B. Relieving anxiety of patient and family
' 1. Reassuring, supporting or calming
2. Explaining condition, treatment, prognosis or complication
IX. Accepting responsibilities of a physician
A. Accepting responsibility for welfare of patient
1. Heeding the call for help
2. Devoting necessary time and effort
3. Meeting commitments
4. Insisting on primacy of patient welfare
5. Delegating responsibilities wisely
6. Adequately supervising residents and other staff
B. Recognizing professional capabilities and limitations
1. Doing only what experience permits
2. Asking for help, advice or consultation
3. Following instructions and advice
4. Showing conviction and decisiveness
5. Accepting responsibility for own errors
6. Referring cases to other orthopaedists and facilities
C. Relating effectively to other medical persons
1. Supporting the actions of other physicians
2. Maintaining open and honest communication
3. Helping other physicians
, 4. Relating in discreet, tactful manner
5. Respecting other physician's responsibility to his patient
D. Displaying general medical competence
1. Detecting, diagnosing, (treating) nonorthopaedic disorders
2. Obtaining appropriate referrals
3. Preventing infection in hospital patients
4. Effectively keeping and following records
E. Manifesting teaching, intellectual and scholarly attitudes
1. Lecturing effectively
2. Guiding and supporting less experienced orthopaedists
3. Encouraging and contributing to fruitful discussion
4. Contributing to medical knowledge
5. Developing own medical knowledge and skills
F. Accepting general responsibilities to profession and community
1. Serving the profession
2. Serving the community
3. Maintaining personal and intellectual integrity
effective and ineffective professional performance they had experienced
at the hands of family doctors. While these judgements cannot be
regarded as definitive if they deal with medical facts, they arc often
much more useful than information gathered from either generalists
or specialists in the realm of professional attitudes and values.
THE ELEMENTS OF COMPETENCE
35
A full critical incident study is a formidable undertaking, but a less
elaborate version of the technique can provide illuminating information
about specific behaviour worthy of consideration by any faculty in the
specification of curriculum objectives. In this limited fashion the
technique is as practicable in a rural clinic in central Africa as it might
be in a specialized hospital in central France.
Expert judgement
The judgement of experts has traditionally been the principal
mechanism for identifying the professional behaviour towards which
educational programmes are aimed. These descriptions may emerge
from authoritative statements by acknowledged medical leaders on
“what I expect my students to learn”, from carefully or casually designed
opinion polls, or from systematic surveys of the professional literature.
Yet whatever the method, the final determination of what a competent
doctor must know, the skills to be acquired, and the desired dimensions
of professional attitudes and values come chiefly from the teaching
staff. These conclusions vary in usefulness depending on the quality
of the search and the nature of the sampling. The examples that follow
illustrate some of the more successful techniques for eliciting expert
judgement upon which decisions about curriculum content may be
soundly based.
One of the issues that must first be addressed is identification of the
experts from whom judgements are sought. They may be a highly select
group, as in one effort to gain consensus about the components of
competence in paediatric cardiology.1 Here, 50 specialists were brought
together in groups of 10 and asked to draw upon their personal
experience in completing 5 judgemental tasks: (1) to define the general
areas of knowledge and skill necessary for the practice of paediatric
cardiology; (2) to rank general areas of knowledge and skill according
to their relative importance; (3) to identify specific components within
these general areas; (4) to provide an operational definition of these
components; and (5) to designate the required level of competence
which a certified paediatric cardiologist should demonstrate in each
area. Out of this work emerged a generally acceptable list of items which
embraced the principal elements of competence in that narrow field.
In attempting to achieve a similar consensus in ophthalmology,
Spivey2 used a different population of experts, since his goal was not
to achieve agreement on the competence a specialist in the field should
exhibit, but on what level of proficiency should be demonstrated by a
1 Adams, F. H. The review and revision of certification procedures in pediatric cardiology. Journal
of medical education, 47: 769 (1972).
2 Spivey, B. E. A technique to determine curriculum conrent. Journal of medical education, 46:
269 (1971). ’
36
COMPETENCY-BASED CURRICULUM DEVELOPMENT
FIG. 4.
EXPECTED COMPETENCE QUESTIONNAIRE'7
When confronted by a cooperative
patient with an ocular injury (e.g.
corneal foreign body, acid body or in
jury, corneal or lid lacerations), a
graduating medical student, as a min
imum acceptable performance,
should be able to:
1. Demonstrate immediate di
agnostic measures
2. Initiate treatment of a non
penetrating injury.
3. Outline possible complica
tions of therapy under
taken or considered.
4. Arrive at a decision within
five minutes, of his own
competence to continue in
the same course of treat
ment, begin another, or
refer the patient.
5. Demonstrate his ability to
converse with the pa
tient's family regarding:
a. The possible need for
further treatment.
b. The prognosis.
c. The time and cost in
volved in treatment and
. convalescence.
Essential
Desirable
But Not
Essential
Useful But
Should Not
Be Required
Of No
Impor
tance
I Have No
Basis for
Judgement
4
3
2
1
0
4
3
2
1
0
4
3
2
1
0
4
3
2
1
0
4
3
2
1
0
4
4
3
3
2
2
1
1
0
0
3 SPIVEY (1971), op. cit. (reproduced by permission).
medical student at the time of graduation. His population sample
included 66 directors of ophthalmology programmes, 204 medical
teachers from many disciplines, 535 practising specialists (including
but not restricted to ophthalmologists), 176 interns and residents, and
199 medical students. The study employed a structured questionnaire
instead of individual generation and group discussion of views derived
from personal experience. Each respondent was asked to judge the
importance of specifically listed knowledge and skills for a graduating
medical student faced by 7 key problems selected through earlier
discussion and literature review. A sample of the questionnaire is
shown in Fig. 4. The resulting consolidated list of generally agreed per
formance-expectations is shown in Fig. 5.
In seeking a more precise definition of the competence in patient
care which should be expected of any physician, Price et al.1 took as
their experts not only members of the health professions (physicians in
practice, nurses, medical technicians, interns and residents), but also a
1 Price, P. B. et al. Attributes of a good practicing physician. Journal of medical education, 46:
229 (1971).’
THE ELEMENTS OF COMPETENCE
FIG. 5.
37
POSSIBLE CURRICULUM CONTENT IN OPHTHALMOLOGY FOR
MEDICAL STUDENTS3
normal, glaucomatous, or nonglaucoma but
abnormal disc).
5. If given a cooperative child or an adult
1. When given a cooperative patient with an
vCdth strabismus, obtain a history of the gen
opacity of the cornea or lens (i.e., cataract) or eral hnd ocular status; examine the patient in
a retinal abnormality, utilizing external and order to diagnose the type of s’rabismus (i.e.,
funduscopic examination, elicit a history esotropia, exotropia, hypertropia); and obtain
pertinent to the general health and ocular
an estimate of the amount of deviation (small,
status and indicate verbally the location of the
moderate, large).
findings and describe the appearance.
6. When confronted by a cooperative pa
2. When given a typically cooperative pa tient with an ocular injury (e.g., corneal foreign
tient (ranging from a child of three years to a body, acid body or injury, corneal or lid
normal or illiterate adult, with “normal” or lacerations), demonstrate immediate diag
abnormal vision), obtain a history of the nostic measures; initiate treatment of a non
visual complaint; and measure and record the penetrating injury; outline possible compli
cations of therapy undertaken or considered;
distan'ce and near visual acuity.
arrive at a decision within five minutes of his
3. When given any individual (newborn to
own competence to continue in the same course
elderly) with unilaterally or bilaterally red of treatment, begin another, or refer the pa
eyes, obtain a contributory history if possible; tient; and demonstrate his ability to converse
examine the patient and his eyes in a manner with the patient’s family regarding the possible
adequate to provide a decision about diag
nostic possibilities and therapy; include in the need for further treatment.
7. When given a cooperative patient with a
decision a statement regarding etiology (i.e.,
injury, inflammation, glaucoma, infection, or neurological or neuro-ophthalmological prob
degeneration); and take a culture if indicated lem, demonstrate his ability to distinguish
abnormality from apparent normality in a
by the examination.
neuro-ophthalmological examination by in
4. When confronted by any cooperative
adult patient, measure the patient’s intraocular cluding examination of the retina and nerve
pressure with a Schiotz tonometer; and evalu head, plus ocular motility and pupillary reac
ate the nervehead (making a decision of tions.
As a minimum acceptable performance, a
graduating medical student should be able to:
a SPIVEY (1971), op. cit. (reproduced by permission).
group of health service consumers (college students, members of
minority groups, special ethnic groups). Like the ophthalmology study,
this investigation also used a questionnaire. Each participant was asked
to judge the relative importance of 116 performance qualities identified
in an earlier inquiry which had tapped the views of a large number of
health care providers and consumers. Samples of behaviours thatemerged as most highly valued and those that were regarded most
negatively are set forth in Fig. 6. The investigators found interesting
differences among the respondent groups, but were impressed by the
overall similarity in judgements. The most significant finding foi
purposes of educational programme review is the frequency with
which things valued in physicians by ••'expert” providers or consumers,
things which might be learned, are omitted from most medical curricula.
In planning instructional programmes teachers need to consider the
inclusion of these components of competence as well as the more
conventional academic subjects.
38
COMPETENCY-BASF.D CURRICULUM DEVELOPMENT
FIG. 6.
RANKING OF IMPORTANCE OF DIFFERENT PERFORMANCE
QUALITIES IN A PHYSICIAN a
A Ranking of 87 Positive Physician Qualities Based on the Ratings of 1,604 Respondents
(Qualities are ranked from most important to least important)
1. Has good clinical judgment (the ability to
reach appropriate decisions regarding the care of
patients)
2. Has thorough up-to-date knowledge of his
own field of medicine
3. Has knowledge and ability to study patients
thoroughly, and reach sound conclusions regard
ing diagnosis, treatment, and related problems
4. Readily refers patients when it is to their
advantage 19 do so
5. Habitually makes as thorough an examina
tion of each patient as may be required for ac
curate diagnosis and proper treatment
6. Is wise, thoughtful; is able to get at the
heart of a problem; is able to separate important
points from details
7. Is strict about honoring confidences; avoids
and discourages gossip
8. Is adaptable; is able to adjust to new knowl
edge and changing conditions
9. Provides treatment appropriate to the condi
tion of each of his patients, with (in general)
satisfactory immediate and long-range results
10. Is able to convert acquired information
into working knowledge
11. Inspires confidence in his patients
12. Has intellectual honesty (incompatible
with bluffing, cheating, assuming poses for ulterior
purposes, trickery, claiming undue credit, assum
ing knowledge not really possessed, transferring
blame unfairly, etc.) and forthrightness
13. Keeps completely honest records
14. Is alert, observant
15. Is able to be his own teacher; to learn from
books and journals, from meetings and informal
discussions, from experience and his own mis
takes, etc., thus adding continually to his own
education
16. Keeps full and accurate clinical records
17. Is emotionally stable
18. Has sustained genuine concern for pa
tients during their illness and convalescence
19. Has awareness of emotional and psycho
somatic factors in dealing with patients and
their diseases
20. Is decisive; is able without undue delay to
reach conclusions and act upon them
21. Is a stable, calming influence in critical or
stormy situations
22. Is conscientious; strives for perfection in
his work
23. Is equipped with an orderly mind; mentally
efficient; logical
24. Is willing to take needed time to listen to
patients’ problems sympathetically and helpfully
25. Establishes good doctor-patient relation
ships
etc.
A Ranking of 29 Negative Physician Qualities Based on the Ratings of 1,604 Respondents
(Qualities are ranked from most undesirable to least undesirable)
1. Is negligent in handling of patients; uses
slipshod methods (c.g., frequently makes diagnosis
and prescribes antibiotics customarily without
definitive diagnosis or sensitivity tests; examines
patients in a cursory incomplete manner; excessive
number of “exploratory” operations without care
ful prcopcrativc diagnosis; etc.)
2. Is summoned frequently before monitoring
committees for such things as malpractice, un
necessary surgery, excessive infection, morbidity
or mortality rates, exorbitant fees, negligence of
patients, etc.
3. Is devious, dishonest, deceptive
4. Is a chronic alcoholic
5. Is a narcotic addict
6. Is prone to jump to conclusions; to generalize
from meager information; to make snap diagnoses
7. Exhibits unprofessional, unethical conduct
(any behavior that would bring the medical
profession into disrepute)
8. Is immodest in handling of female patients
9. Has not kept abreast of advances in medical
knowledge
10. Holds on to patients to undue degree;
disinclined to suggest or seek consultation; apt to
be offended if patients request consultations or a
transfer to another doctor
11. Is rude, discourteous; inconsiderate of
others
12. Is unavailable except during specified
business hours, even for emergencies
13. Is critical of other physicians behind their
backs (whether for personal or professional
reasons)
14. Is lazy
15. Is not interested in, and does not want to be
bothered with, patients’ subjective difficulties and
problems
16. Is indecisive, unsure of self, basically an
insecure person
17. Is inefficient, disorganized
etc.
sPRICE, P. B. ETAL op. cit. (reproduced by permission).
THE ELEMENTS OF COMPETENCE
39
HEALTH CARE NEEDS
In the end it is the health care needs of the community, and the
resources available to meet those needs, that should provide the prin
cipal directional signals in building a curriculum. No matter what the
interests of teachers, the hopes of patients, or the aspirations of a society,
medical education should first address the realities that exist, or can
reasonably be expected to develop during the professional lifetime of
a graduate. It is wrong to train physicians to a high level of competence in
dealing with problems they will rarely encounter while neglecting the
acquisition of deep concern for and skill in managing problems that will
be met with great frequency. Yet it seems to happen regularly in all parts
of the world. It is equally wrong to educate physicians in such a way
that they are satisfied only with a level of care that cannot be supported
by the society in which they must work. But this also appears to occur
with disheartening frequency. In determining competency goals for a
programme of medical education the teaching staff must first examine
carefully and thoughtfully the conditions that graduates must face, and
arrange an educational programme which prepares them for that role.
Public health statistics
Public health statistics represent one major clue to the knowledge
and skills medical graduates must acquire. In virtually all developed
nations, as well as in a steadily growing number of those still developing,
mortality and morbidity data are available and periodically updated.
Even in countries that have not yet established a systematic process of
monitoring public health, the experience of health personnel may be
drawn upon to establish crude estimates of the major problems they
encounter. Tb whatever extent this information can be assembled,
it should influence the delineation of curriculum content and the pro
fessional competence toward which instruction is aimed. If, for example,
malnutrition and diarrhoeal disease produce the highest morbidity
and mortality, then proficiency in managing these problems must be
of the highest priority even at the expense of other topics that may
be a greater intellectual challenge to the teaching faculty.
In the absence of detailed morbidity and mortality statistics, even
such simple information as age distribution of the population can serve
as a guide to curriculum content. Since some 41% of the population
of the less developed countries is aged under 15 years and only 4% is
over 65, whereas the corresponding proportions in the more developed
countries are 27% under 15 and 10% over 65 (1970 figures),1 it would
be reasonable to expect that education of medical students in developing
1 United Nations. World population prospects as assessed in 1973, New York. 1977 (Population
Studies No. 60).
40
COMPETENCY-BAS ED CURRICULUM DEVELOPMENT
nations would be heavily weighted toward the health problems of
infancy and childhood, while that in the industrialized countries would
be dominated by the problems of aging. Yet neither emphasis is
found with any regularity. There are, of course, those who would say that
education directed toward the practical matter of dealing with what is
currently pfominent overlooks the importance of preparing students for
solving health problems not yet clearly understood, in a future that can
be perceived only dimly. It is true that such a risk exists, but it can be
minimized by methods of instruction (described in chapter 3) designed
to prepare students for continuing their own independent learning
rather than to anticipate during the period of university medical
education all their educational needs for a professional lifetime.
Medical records
Medical records from hospitals, health centres, or individual physi
cian practices represent another potential source of information about
needs that can guide curriculum developers. Regrettably, careful and
systematic record-keeping is not uniformly carried out. Even when kept,
records may be in a form that is virtually useless for analysis aimed
at documenting the nature of health problems seen. While deploring this
situation, many thoughtful practitioners take the position that proper
record-keeping is so time-consuming that it cannot be carried out in
the face of more urgent demands in patient care. This view may be
accurate. It may also represent rationalization of a disinclination to
keep detailed records, or simple rejection of the record-keeping
methods learned in medical school, which may have seemed an academic
formality rather than vital documentation of health care. This is not the
place to debate that issue, but it may be the place to urge the adoption
of simple record-keeping methods that do not require a large investment
of time or effort, and that could provide important data for educational
programme planning, not to mention the contribution those records
would make to health care.
And it can be done. In a rural hospital in Nigeria, a modest punch
card system was employed to record such standard items as individual
patient identification, diagnosis, length of hospital confinement (if any),
and therapeutic procedures for obstetrical cases. Simple statistical
analysis of these data was carried out easily and provided such helpful
information as:
“In the six years 1957-1962 there were 6,848 confinements. Of these, 422 were
twin confinements, an incidence of 1:16. Of the 6,426 singleton confinements 307 were
delivered by Caesarean section (4°/o of primigravidae, 5.1°/o of multigravidac). One
hundred and seventy-one patients were delivered by forceps (2.7%), 9 patients underwent
symphisiotomy, and in 28 patients a destructive operation was required. It is rare to
41
THE ELEMENTS OF COMPETENCE
find heart disease, thrombophlebitis, embolism or varicose veins in pregnancy, and we
have never had a case of diabetes”.1
A comparable record-keeping system at 29 rural health centres in
Thailand provided the information shown in Table 5.
TABLE 5.
MOST FREQUENT DIAGNOSES AT 29 RURAL HEALTH CENTRES
IN THAILAND DURING 19693
Diagnosis
Common cold and influenza
Gastroenteritis and colitis (diarrhoea and dysenteries)
.
Common skin diseases (dermatophytosis, scabies, pediculosis)
Malaria
Inflammation of eyes (conjunctivitis and trachoma)
Accidents, poisoning and violence .............................................
Beri-beri ........................................................................................
Tuberculosis .,
Nutritional disorders
Complication of pregnancy and labour
Simplegoitre ...............................................................................
% of cases
13.60
10.11
9.76
6.26
5.80
2.14
2.11
0.19
0.85
0.28
0.28
a SUWANWELA, C. Pattern of diseases in Thailand. Chulalongkorn medical journal, 15:
1 (1970) (reproduced by permission).
Unless curriculum planners have access to such data they may be
forced to depend on information gathered from experience in urban
settings where .most medical teachers work. This will almost certainly
provide an unreliable picture of national health care needs. For example,
in one country where the cause of death is regularly recorded only in
the capital city of each state, no deaths from smallpox were reported
in 1970; but 1771 cases, many fatal, were identified by surveillance
methods in the country at large. 2
Medical records can be kept even in busy, ill-equipped rural settings
if those in responsible positions recognize that there is a more important
reason for doing so than merely fulfilling a bureaucratic demand. One
of those reasons is to provide more realistic information on which to
build a description of the professional competencies that physicians
must acquire in the course of a medical education.
Social, economic, and political realities
Medical education and medical practice exist as a part of the social
system, not apart from it. Medical teachers may wish this were not so,
and often organize educational programmes for which the}7 are
responsible as though it were not so. They may even be proud that
1 Cannon, D. S.'H. & Hartfleld, V. J. Obstetrics in a developing country. Journal of obstetrics
and gynaecology of the British Commonwealth, 71: 940 (1964).
2 Koch-Wieser, D. et al. An introduction to internanonal health. I. World-wide overview of health
and disease. Washington, DC, Association of American Medical Colleges. 1975 (tnu’.tilith draft).
42
COMPETENCY-BAS ED CURRICULUM DEVELOPMENT
graduates satisfy some external criterion of quality (e.g., a high grade
in the Educational Council for Foreign Medical Graduates examination
in the USA). But such an effort to meet an ill-defined international
standard of excellence will usually be at the expense of meeting a clearly
evident national standard of health service need. Educational quality
should be judged by the success with which it meets needs, not by the
success with which its graduates practise in another setting. The social
and economic realities of any nation must be reflected in the pro
gramme through which its physicians are educated.
The competence which a physician must acquire to be successful
in a nation with only one doctor for every 29 000 people (and one nurse
for 43 000), and which can afford only about US $1 per capita for
health services, is obviously very different from that required where
there is one physician for every 960 persons (and one nurse for each
200), and the per capita health services investment is US $88.00.1
This stark fact should not deter the former country from striving to
achieve what the latter already has, but such dramatic changes are rarely
swift, and in the meantime physicians must live and work with what is,
not with what might be. A medical school which feels this responsibility
will manifest that feeling by rejecting competency goals that are
inappropriate for the setting, rather than fostering them in the hope
that things may change.
Medical educators do not function alone in making these decisions.
They may be encouraged by political policies to strive for a level of
medical education, and an array of competencies in their graduates,
that serve national pride rather than national need. Or they may be
encouraged by political decisions to abandon pride, and adopt a system
of health personnel education and health services delivery addressed
to the desperate needs that lie all about them, even though it may not
match poorly defined but none the less pervasive concepts of inter
national standards.
It might be noted, for example, that in one country, the People’s
Republic of China, the leaders, in an attempt to improve the quality of
health care, looked first at what resources were then available.2 They
found mostly herb doctors, many of whom were barely literate, but at
least they were there and the people both trusted and accepted them.
These indigenous health workers were given a rudimentary education
in medicine for 3 months, were taught how to take a blood pressure,
count a pulse, read a thermometer, and recognize obvious symptoms
of disease.' As time passed they were taught to use a few basic drugs, but
1 See, for instance: Bryant, J. Health and the developing world. Ithaca, NY, Cornell University
Press, 1969, p. 56.
2 Wen, C. P. & Hays, C. W. Medical education in China in the post Cultural Revolution era.
New England journal of medicine, 292: 998 (1975).
THE ELEMENTS OF COMPETENCE
43
most importantly to recognize their own limitations and when faced
by problems beyond their own competence to pass the patient on to
the next level of the health service system.
Such an approach does not mean that the standard of competence
for every medical practitioner in China has been reduced to this level;
it means only that the health personnel education system has adapted to
social and economic needs as reflected in political decisions about
national priorities. Neither does it suggest that any nation should
adopt what has been found useful elsewhere. It merely emphasizes
that each medical school, wherever located, needs to take the realities of
national life into consideration when identifying the competencies to
which the educational programme is to be directed.
The illustrations need not be multiplied, for the point must by now
be very evident: there is no single set of competencies that characterizes
all physicians. Any medical school that aims at such a target is pursuing
an illusion. The hard work medical teachers must undertake, before
beginning what is ordinarily thought of as teaching, is to define the
specific competencies their students must acquire to meet the real needs
of the constituency they are being prepared to serve.
PROFESSIONAL PERFORMANCE SITUATION MODEL
The argument has now been fully developed that professional per
formance does not occur within a vacuum; it takes place within the
context of a reality defined by variables such as those explored in this
chapter. Recognizing this inescapable fact, a special study group at the
University of Illinois Center for Educational Development has created
a new conceptual model for defining competency objectives1-2. This
concluding section is largely derived from its work, which has dealt
with 2 allied health professions: occupational therapy and dietetics.
In summary, proficient professional performance in this model is
defined by a three-dimensional universe (Fig. 7) in which each
dimension identifies one essential feature: the client, the problem, the
setting. Three-way intersections within the cube represent discrete
situations which a competent practitioner must be prepared to manage
in an appropriate fashion. Each of the 3 variables has been further
elaborated in order to account for the fullest range of possibilities from
which a profession may then identify educational priorities in terms of
situations, not of content alone.
1 LaDuca. A. et al. Professional performance situation model for health professions education:
occupational therapy. Chicago, Center for Educational Development. University of Illinois College
of Medicine. 1975 (multilith).
2 LaDuca, A. et al. Toward a definition of competence in dietetics. Chicago, Center for Edu
cational Development. University of Illinois College of Medicine. 1975 (multilith).
44
COMPETENCY-BASED CURRICULUM DEVELOPMENT
For example, in occupational therapy in the USA these components
of a professional competence situation universe have emerged :
1. Patientlclient
A. Age and sex
B. Ethnic group/religion
C. Socioeconomic class
D. Occupation
E. Marital status
F. Education
G. Other significant persons in life setting
2. Clinical problems
A. Developmental
B. Physical
C. ■ Psychosocial
3. Setting
A. Acute hospital
B. Nursing home
C. Rehabilitation centre
D. Outpatient clinic
E. Psychiatric unit
F. Community agency
Etc.
Approximately 200 clinical problems with which occupational
therapists deal have been identified in 4 major patient age categories
FIG. 7.
PROFESSIONAL COMPETENCE SITUATION UNIVERSE3
SITUATION
I
»
i
i
CLIENT
I
I
i 1
CLINICAL
PROBLEM
3 LADUCA A ET AL. Professional performance situation model for health professions education.
ocZ^onal therapy, Chicago”Center for Ed
—-e! n^nmAnr
Educational
Development, Un.vers.tv
University of lll.no.s
Illinois
College of Medicine, 1975 (multilith).
45
THE ELEMENTS OF COMPETENCE
by a special task force of occupational therapists in the USA (a selection
of these problems is given in Table 6 as an illustration); specific dys
functions were also specified and associated with these clinical problems
(Table 7). While the full inventories described in this manner are
important in defining the universe of professional competence, they
are generally too cumbersome to be operationally useful. Therefore,
it is necessary to select from the universe those situations that have
the highest priority, in order to preclude instruction or testing on rarely
encountered problem situations, and to avoid unnecessary duplication
(for example, in terms of the tasks an occupational therapist must
perform, to determine whether cerebral palsy in a child is significantly
different from the same disorder in an adult). The resulting “critical
mass” of situations identifies the array of problems with which an
occupational therapist must be prepared to deal.
A final requirement is elucidation of the professional performance
elements that must be employed in all situations. For occupational
therapy, 5 consistent performance roles were specified: (1) evaluation;
(2) programme planning; (3) programme implementation; (4) reevaluation ; and (5) discontinuation. Each of these roles has been further
elaborated (Fig. 8) to guide both teachers and students toward the
TABLE 6.
SELECTED CLINICAL PROBLEMS ACCORDING TO PATIENT AGE
AND DISABILITY3
Principal disability
Age
category
Physical
Psychosocial
Child
«12)
Autism
School phobia
Pica
Leukaemia
Sickle cell anaemia
Burns
Spina bifida
Blindness
Muscular dystrophy
Adolescent
(13-17)
Schizophrenia
Drug dependence
Infectious hepatitis
Diabetes
Spinal cord injury
Haemophilia
Cerebral palsy
Adult
(18-64)
Alcoholism
Psychosis
Sexual deviance
Ulcer
Nephritis, nephrosis
Diabetes
Multiple sclerosis
Cerebrovascular accident
Neoplasms
Aged
>65)
Senile dementia
Neurosis
Diabetes
Arthritis
Parkinson's disease
Arteriosclerosis
Emphysema
Cerebrovascular accident
8 LADUCA, A. ET AL. Professional performance situation model for health professions
education: occupational therapy, op. cit.
COMPETENCY-BASED CURRICULUM DEVELOPMENT
46
TABLE 7. OCCURRENCE OF SPECIFIC DYSFUNCTIONS IN
SELECTED CLINICAL PROBLEMS ENCOUNTERED BY
OCCUPATIONAL THERAPISTS3
Illustrative clinical problem
Specific dysfunction
Schizo- Alcophrenia holism
Psychosocial
Apathy ....................
Depression
Ego problems
Hallucinations
Inappropriate use of
defence
mechanisms
Situational fears ...
Withdrawal
Physical
Athetosis
Contractures
Incoordination ....
Joint limitation ....
Muscle weakness ..
Pain
Prosthesis
Sensory loss
Spasticity
X
X
X
X
X
Senile
Leu
de
kaemia
mentia
X
X
X
X
X
X
X
X
X
X
X
X
Burns
X
X
Spinal
MulAr
cord
tiple
thritis
injury sclerosis
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
aAdapted from: LADUCA, A. ET AL. Professional performance situation model for health
professions education: occupational therapy, op. cit.
competency goals of education in this profession. A sampling derived
from a master grid of patient situations is set forth in Fig. 9.
A comparable delineation of professional competence has also een
accomplished in dietetics,1 where 5 client categories have been specified
(infant, child, adolescent, adult, aged); 5 dietary interventions in
over 200 clinical problems identified (physical composition of food,
meal frequency, overall food intake, specific nutrient intake and no
dietary modification); 14 settings established (university hospital,
community hospital, clinic, home, etc.); and 4 roles elaborated (assess
ment, planning, implementation, evaluation).
No comparable work has yet been done in medicine. Growing
interest in determining more precisely the services best provided by
auxiliaries, generalists and specialists, in primary health centres, district
clinics, regional hospitals and university medical centres, suggests t a
i LaDuca, A. et al. Toward a definition of competence in dietetics. op. cit.
THE ELEMENTS OF COMPETENCE
FIG. 8.
ROLE
EVALUATION OF
ASSETS &
DEFICITS
II.
PROGRAM
PLANNING
47
OCCUPATIONAL THERAPY (OT) CLIENT MANAGEMENT
PERFORMANCE MODEL3
PROBLEMS
FUNGI IONS
A. Preliminary assessment
- What are the client's probable problem areas?
B. Selection of appropriate
Instruments and/or
techniques
- What evaluative Information is needed?
- How should it be obtained?
- What factors influence administration?
C. Administration of
selected instruments
- What is client's performance in relevant
components?
;erpretat1on of
D. Intt
llected data
coll
- What is level of client's performance in
relevant components?
- What are deficits in performance levels?
E. Utilization of other
information sources, e.g.
chart, other consultation
- What additional information is needed?
- How should it be obtained?
F. Communicating (recording
and reporting)
- What should be recorded, reported, for what
purpose?
-In what form?
- To whom?
A. Specification of program
(treatment) goals
- What are relationships among client's com
ponent performance levels?
- What are client's needs?
- What needs can be met by O.T.?
- What are client's priorities?
- What are long-r;
■ange goals?
- What other treai
itments are being
administered?
B. Identification of
treatment methods and
sequence
- What interventions are needed, i.e.
restoration, adaptation, prevention of
deterioration, maintenance of functioning?
- What activities comprising interventions
accomplish restoration, et. al.?
- What is optimal sequence of goals and
activities?
- How is treatment in concert with rest cf
treatment prcgran?
C. Identification of
personal and institutional
facilitation and
cons trai nts
- What characteristics of client influence
program implementation?
- What external factors influence program
implementation? (treatment, institutional,
social)
D. Modification of selected
treatment methods
- How are selected treatment methods
individualized?
E. Recording and reporting
- What should be recorded, reported?
- In what form?
-To whom?
a LaDUCA, A. ET AL. Professional performance situation mode! for health professions edu
cation : occupational therapy, op. cit.
COMPETENCY-BASED CURRICULUM DEVELOPMENT
48
Continued
Fig. 8.
ROLE
III. IMPLEMENTATION
IV.
RE-EVALUATION
FUNCTIONS
PROBLEMS
A. Preparation of treatment
materials and/or environ
ment
- What materials and/or environment are
needed?
B. Motivation of client and/
or others
- What techniques are needed to develop
and/or maintain cooperation of family,
etc.?
C. Instruction of client
and/or others
- What are proper processes, techniques
for particular treatment modality?
- What modifications are needed for
particular client?
- What "others" need to be instructed?
How accomplish?
D. Manipulation of
therapeutic relationship
- What kind of interaction should be
developed in order to accomplish goals
(both client-therapist and client-other
relationships)?
Supervision of client
activities
- What type of supervision 1s needed?
F. Adjustment of treatment
approach in light of
emergent factors
- What change;•s are needed in light of
G. Recording and reporting
- What should be recorded, reported?
- In what form?
- To whom?
A. Identification of changes
in client performance
and/or circumstances
■rformance at this
- What Is client's per
point in treatment?’ (Improvement, same.
deterioration)
- What other circumstances have changed
to influence client's status?
- How do changes in perirfonnance and
circumstances relatei to goals?
B. Revision of program plan
- How have needs of client changed?
- What goals need to be changed?
informationi gained during interaction
with client?
- What performance should be reevaluated
and when?
- How should program be revised in light
of changes identified (activities,
schedule)?
- How should locus of treatment be
changed (outpatient, home)?
V. DISCONTINUATION
C. Recording and reporting
- What should be recorded, reported?
-In what form?
- To whom?
A. Specification of
discharge or follow-up
plan
- What is present status of patient in
regard to previously stated needs and
goals?
- What cannot be accomplished under
present program?
- Who can meet any remaining needs?
B. Recording and reporting
- What should be recorded, reported?
- In what form?
- To whom?
FIG. 9.
PATIENT
CLINICAL CLINICAL
AGE
SITU CATEGORY PROBLEM SETTING SEX/AGE
ATION No.
Acute
hospital,
M/6 yr
Burn
Child
5
burns
unit
6
8
13
9
Child
Cerebral
palsy
Community
agency
Out
patient,
i Rheumaoccu
Adolescent' toid
arthritis pational
therapy
clinic
State
Drug
paychi.
Adolescent depenhoapltal
dence
Adult
Radical
mastec
tomy
Acute
hospital
F/10 yr
SAMPLE FROM MASTER GRID3
SOCIO
SIGNIFI
ECONOMIC HOUSING
CANT
STATUS
OTHERS
2 Parents,
Inner-city
Lower4 siblings,
apartment
class
1 grand
parent
1 Parent,
2 siblings
Lover
middle
class
Suburban
row
house
F/13 yr
1 Parent,
4 siblings,
1 aunt
Lowermiddle
class
Urban
garden
apartment
(6 steps
down)
M/lS yr
1 Stop
parent,
3 siblings
Lowerclass
Correctnl
insti
tution
Married,
2 siblings
Middle
class
Suburban
house
i'7/,0 yr
7
Aging
Chronic
brain
syndrome
Nursing
home
F/72 yr
Widow,
2 children
(married)
Lowerclass
Urban
house
15
Aging
Halnu-
Hom®
M/70 yr
Widower,
no child
Lowerclass
Urban
apartment
(3rd-floor
walk-up)
j trition
a Adapted from: LADUCA ET AL. op. cit.
SPECIFIC DYSFUNCTION
Reduction of selected function; trauma; isolation;
pain; susceptibility to infection; possible body
imago distortion; possible joint limitation;
lowered sensory input; probability of contracture.
Retardation; athetoid movements; facial grimacing,
associated movements; poor eye-hand coordination;
redual asymmetrical tonic neck reflex; muscle
tone and range of motion normal; socially and
emotionally immature; nervous, fear of failure;
poor peer relationships.
____________ ______
Limited range of motion in shoulders, elbows, wrists,
hands and lower extremity joints; diminished muscle
strength; pain in shoulders, elbows, wrists, knees
and ankles; anaemia, poor appetite; mood swings,
depressed, uncommunicative; negative attitude;
easily discouraged.
Suicide attempts, without remorse; depression; ~
hopelessness; poor impulse control; anger; overriding
guilt; delinquency; glue sniffing.___________________
Muscle strength: fair in shoulder to 45’; others
normal; range of motion: limited in shoulder (active
and passive), some limitation, (active and passive)
of elbow due to swelling of arm; pain at surgery and
donor site; reduced endurance; fearful of moving arm;
self-conscious; anxious about appearance, progress,
relationship to husband.
______________
Impairment of memory, orientation, and intellect;
irresponsibility; situational foar; denial of
condition/hostility toward children and nursing
hone staff; diabetes, associated blurring vision.
aw
M
W
i$
o
►ri
O
O
S
ag
2:
o
PI
TB ; secondary malnutrition; severe weight loss;
low endurance; periods of disorientation.
VUO 71C22
'O
50
COMPETENCY-BAS ED CURRICULUM DEVELOPMENT
the time to attempt this task has come. Unless the situational variable
is systematically incorporated in the specification of competencies
towards which educational programmes are directed, medical school
teachers will probably be inclined to continue in the future, as they
have been in the past, to see the world of medicine, and thus of medical
education, from the limited perspective of their own work setting.
- CHAPTER 3
LEARNING FOR MASTERY
If achieving professional competence represents the goal of an
educational programme, and a curriculum provides the mechanism
through which such competence is to be acquired, it is important to
ask what principles are used to determine the nature and organization
of student learning experiences. Three themes stand out in current
debates about instructional strategies: time; sequence; and mastery
learning.
PROGRAMME ORGANIZATION: TIME
Learning to become a physician is bound to take time, but the
question of how much time has never been answered with any high
degree of confidence. In most of Europe the modal duration of a
university course in medicine is 6 years, although the period may be one
year longer or shorter depending on the country in which the course is
taken. In the USA a comparable programme (in college and medical
school) usually occupies 8 years, although a few special programmes
may be completed in 6 years or less. Within the autonomous schools
of a single country the range of time given to instruction in individual
disciplines may be equally wide. For example, a 1961 study of United
States and Canadian medical schools1 revealed that “the scheduled
hours of instruction in biochemistry extend from a low of 144 to a high
of 338; pathology ranges from 108 hours in one school to 462 hours in
another; one institution reports 1135 scheduled hours in surgery, while
another reports 195; psychiatry claims 560 hours in one and 40 in
another”. And 13 years later the information derived from a random
sample of 30 American medical schools2 still revealed an instructional
range in anatomy from 105 hours to 395 and in physiology from 27 to
1 Miller, G. E. An inquiry into medical teaching. Journal of medical education, 37:185 (1962).
2 Association of American Medical Colleges. 1973-2 974 AAMC curriculum directory.
Washington, DC, 1973.
— 51 —
/
I
IX
52
COMPETENCY-BASED CURRICULUM DEVELOPMENT
240, with an equal spread in most other subjects. The time required for
postgraduate training of a generalist or specialist shows an even wider
range, since the objectives for that phase of education and the legal
requirements for registration are neither consistent nor universal.
Since educational programmes are planned by educators, although
often under the influence of legislators, it can only be concluded that
those responsible for these programmes must believe that the time
required by a department, an institution or a nation is proper, but there is
very little evidence to support those individual conclusions. In fact, the
most widespread cry among medical educators everywhere appears to
be that they have insufficient time to teach their subject, whatever the
amount of time available to them.
To bring some sense of perspective into the chaotic arguments about
time and learning, Shulman1 has written:
“Consider the analogy of a race. Imagine the mile run if it began with the firing
of a gun and ended at the end of four minutes when another gun went off and everyone
had to stop wherever they were. It would be even more ludicrous if about five minutes
later another gun went off for the next race and everyone began the next race at the
point from which they had ended the previous one. We would find it rather laughable,
and yet we run our educational programmes in precisely this manner. Ostensibly,
our purposes in education, especially in medical education, are to see to it that a
certain minimal level of competence is established for each learner. Therefore, we
should logically set levels of achievement as constants and let time act as a variable.
Instead, we do exactly the opposite. We set time as a constant and have students run
until their time is up. The grades we give reflect how far they have gotten in the race
within the time span we have allotted.”
Since there is no discernible evidence that time is the significant
variable when learning for mastery of defined professional competence
represents the educational goal, curriculum committees around the
world should be able to end the regular battles about time allocation that
seem to dominate their deliberations. The time saved might then be
devoted to fruitful discussion of other variables. One of these is
sequence. '
PROGRAMME ORGANIZATION: SEQUENCE
The presentation of subjects in a particular order implies that
completion of those given early in the curriculum is required for success
in later subjects. Successful advancement through a programme is
equated with accumulating professional competence, and such com
petence is in turn assumed to reflect an appropriate ordering of the
learning experiences.
1 Shulman, L. S. Cognitive learning and the educational process. Journal of medical education,
45 (Nov. suppl.): 90 (1970).
LEARNING FOR MASTERY
53
Despite the wide range of difference in time and specific content
of courses of instruction, there is a general similarity of sequence in
all parrs of the world. The curriculum usually begins with the basic
sciences (such as mathematics and chemistry, physics and biology),
moves to the preclinical sciences (such as anatomy, physiology, micro
biology and pharmocology), and ends with the clinical disciplines
(always including medicine, surgery and paediatrics, with variable
incorporation of other general and specialized subjects). Within each
of these segments, however, there is the widest possible vaiiation in
sequence: gross anatomy may precede or be offered simultaneously with
histology; it may precede or follow physiology and biochemistry; micro
biology is sometimes given early and at other times late in the preclinical
course. The sequence in the initial basic phase and the ultimate clinical
science portions of the programme is even more varied from country to
country and institution to institution.
Such observations, in the absence of other data, can only lead to
the conclusion that a particular sequence is more the product of local
custom than a manifestation of some generally accepted educational
principle. Certainly a search of the health professions literature provides
no data from which an investigator of curriculum organization might
conclude that there is any optimal sequence. At best that literature
seems to offer impassioned arguments indicating how individuals or
groups believe the sequence of courses should be arranged, and there is
little agreement among them.
Nor is there much evidence to support the view that what comes first
in existing curricula is required to succeed in what comes later. The
rapid decay of unused knowledge has already been noted and merely
needs reemphasis here through reference to another study in which
retained learning of “prerequisite” physics and chemistry was tested
at the beginning of a medical course in physiology.1 Not only was it
found that few students recalled enough to achieve again a passing
grade in those subjects 6-16 months after completing the original
course, but also that “good” students performed only marginally better
than “poor” students. Although this was not specifically stated, the
reader was left with the inference that whatever the level of performance
in those subjects it had little influence upon later peformance in
physiology.
If the present sequence is more often a reflection of educational
custom than of learning principle, and there is limited evidence to
suggest that what is customarily offered early will significantly influence
achievement in what comes later, then a teaching staff might reasonably
1 Blizard, P. J. ET AL. Medical sruder.u retention of knowledge of physics and chemistry on
entry to a course in physiology. Biiils!: journa: or medic.-, education, 9: 249 (1975).
54
COMPETENCY-BASED CURRICULUM DEVELOPMENT
ask what difference it makes how the curriculum is organized. And if
there were no better way, the discussion (and this volume) might end
here. However, data on learning, as well as the experience of teachers
(not to mention that of learners), suggest that there may be a more
efficacious organization. In a paper contributed to the Third World
Conference on Medical Education (New Delhi, 1966), Ramalinga
swami1 wrote:
“In this regard it is illuminating to peruse a page from a diary of the rural health
center attached to the All-India Institute of Medical Sciences. On the morning of
October 13,1966, the intern, under supervision, had to tackle the following problems
in the health center.
“1. An eighteen-year-old person with chronic ulcer of the foot of seven years’
duration complicated by a discharging sinus. In this case the intern debated the
possibility of chronic osteomyelitis or a fungal infection and ordered an X-ray.
“2. A boy with a toothache.
“3. A two-year-old child with diarrhea and vomiting.
“4. An elderly woman with a low back pain.
“5. A three-year-old child with fever, toxic signs, marasmus, and loose motions,
who had been treated earlier unsuccessfully by a Hakim, a practitioner of an
indigenous system of medicine. The intern felt that he needed laboratory aids in this
case to arrive at a diagnosis.
“6. A thirty-five-year-old man with clinical features of pulmonary tuberculosis.
“7. T wo children with mild upper respiratory tract infection.
“8. A child with recurring boils on the forearms.
“9. A full-term expectant mother, markedly anemic. The intern was faced with
the problem of raising the woman’s hemoglobin rapidly before she went to term.
“10. A child with florid kwashiorkor. The mother was expecting another child.
“11. Late in the evening of the same day, an individual who had been bitten by a
snake, along with hordes of relatives and friends, and the dead snake! Rather than
losing himself in the drama of the situation, the intern’s first move was to look at the
snake to decide whether or not it was poisonous.
“Here is a tangled mixture of trivialities and serious ailments, of acute emergencies
and chronic indolent illnesses of community medicine. In such a setting, the young
intern must act. He must make decisions with inadequate data, with too many
variables. He cannot refer all or most of the patients to the big hospital, for he
would soon be left with none! He must make tentative clinical diagnoses based on
intelligent guesswork. Therefore, the focus of the educational process should be on
problem-solving, decision-making, and judgemen t.”
This suggestion that education in medicine be built around the
processes of problem-solving, decision-making, and judgement would
be supported by learning theorists, who have long recognized that
knowledge must be put to use if it is to acquire meaning and to be
remembered. It is this organizing principle that has led to such problem
based curricula as that developed at the University of Illinois College
1 Ramalingaswami, V. Factors influencing the development of the medical curriculum. Journal
of medical education, 43: 212 (1968).
LEARNING FOR MASTERY
55
of Medicine’s School of Basic Medical Sciences at Urbana/Champaign,
where basic sciences are learned in the context of a defined set of
clinical problems rather than through organized disciplinary instruction.
The initial results of this programme1 indicate not only that students
gain a real appreciation for the role of basic sciences in medical care,
but also that thje learning process is accelerated. An even more extensive
illustration of this orientation is found in the curriculum of the McMaster
Faculty of Medicine in Canada,2 where the entire curriculum is organ
ized around problems whose solution requires the integration of basic
and clinical sciences, and which lead to a steadily expanding reper
toire of clinical competencies. For here the goal is not to complete a
series of discrete disciplinary courses but to master the elements of
professional competence derived from many disciplines.
The key word, then, is mastery.
PROGRAMME ORGANIZATION: MASTERY
Mastery means nothing more or less than achieving the degree of
competence identified as the educational objective. It makes no
reference to the time that will be given to, or required for, such
achievement; neither does it determine the sequence in which this
learning will be accomplished. Mastery learning demands only that the
goal be reached. Philosophically and operationally it is very different
from the traditional approach to education. As one author3 has
described it: '
“Mastery learning... offers a powerful new approach to student learning
which can provide almost all students with the successful and rewarding learning
experiences now allowed to only a few. It proposes that all or almost all students
can master what they are taught. Further it suggests procedures whereby each
student’s instruction and learning can be so managed within the context of ordinary
group-based classroom instruction, as to promote his fullest development. Mastery
learning enables 75 to 90°/o of the students to achieve the same high level as the
top 25% learning under typical group based instructional methods. It also makes
student learning more efficient than conventional approaches. Students learn more
material in less time. Finally mastery learning produces markedly greater student
interest in and attitude toward the subject learned than usual classroom methods.”
Implementation of such a system demands substantial redefinition of
faculty and student roles and responsibilities. In the usual organization
of education instructors are in full control, prescribing how students shall
1 Sorlie, W. E. et al. A one year program in basic medical science. Journal of medical education,
48: 371 (1973).
- Neufeld, V. & Barrows, H. The McMaster philosophy—as seen in 1973. Hamilton, Ontario,
McMaster University Faculty of Medicine, 1973 (multilith).
3 In : Block, J. H., ed. Mastery learning: theory and practice. New York. NY, Holt, Rinehart &
Winston, 1971.
56
COMPETENCY-BASED CURRICULUM DEVELOPMENT
learn (usually by listening to teachers); in what setting they will learn
(usually a classroom, laboratory, ward or clinic); and for what period
of time they will be taught (a course of hours, days, weeks). At the end,
they judge the extent to which faculty expectations have been met, their
assessment usually being communicated by letter grade—A, B, C,
D or E; a number—90,83,65; or words—high honours, honours, pass,
fail. In a mastery system teachers must relinquish a substantial measure
of that control. They generate objectives, but by using the sources
outlined in Chapter 2 rather than independently. They then help
students to discover the meaning of those objectives and the array of
learning resources that may be used independently, at a pace and in a
sequence most productive for each individual. And with students (rather
than for them), teachers attempt at regular intervals to assess progress
toward the objectives, so that in the end the only judgement rendered is
“mastery achieved” or “not yet achieved.” Teachers and students arc
linked in a partnership in which their behaviour is governed by a shared
effort to fulfil unambiguous competency expectations, not those derived
from a calendar, a clock, or the special interests of individual instructors
or departments. These new roles will be dealt with at length in Chapter 5.
Here the logical steps in designing, implementing, and operating a
mastery programme of education for the health professions will be
outlined.
Specification of learning objectives
When competence is the goal of an educational programme, the
first step in programme design must be a clear and precise listing of
the components of that competence. This may be done for an entire
programme, if the staff has sufficient time, energy and commitment,
or for segments alone, if that is the only realistic way in which a start
can be made. But if the latter option is chosen it should be recognized
as only a first step toward the more comprehensive effort. The sources
of objectives and the mechanisms for establishing priorities have already
been dealt with in the preceding chapter, and need only be under
scored here.
Identification of curriculum clusters
No small part of the task of creating a competency-based curri
culum with a mastery goal lies in the identification of related pieces
which may be drawn from several discrete biomedical disciplines but
which fall naturally together in some logical pattern. For example,
57
LEARNING FOR MASTERY
in a recently developed curriculum for respiratory therapy (which,
while designed for training technicians, can also serve other professional
groups), the total programme emerged as 18 major clusters of com
petency, each of which had multiple subunits.1 While a sequential
path through the programme was suggested, a considerable degree
of flexibility was also built in, as the chart in Fig. 10 suggests.
FIG. 10.
STUDENT PROGRESS THROUGH THE RESPIRATORY THERAPY
CURRICULUM
'ENTER
MEDICAL GAS
DELIVERY SYSTEMS
NORMAL AND ’
ABNORMAL LUNG
FUNCTIONS
I
.[decontamination
___ PATIENT
CARE SKILLS
[AND STERILIZATION
.
I
OXYGEN
THERAPY
|
I
AIRWAY
CARE
CRITICAL *
DECISION
MAKING
CHEST ANATOMY
AND PHYSIOTHERAPY
HUMIDITY
AEROSOL THERAPY
I
___
\
INTERMITTENT)
—
STANDARDS FOR •
DEPARTMENTAL
OPERATION
POSITIVE
PRESSURE
BREATHING
-------
PULMONARY
FUNCTION
TESTING
r
H
EMERGENCY
ENDOTRACHEAL ------INTUBATION
ARTERIAL
BLOOD
GASES
f
I
GAS
4 MIXTURE
[ THERAPY
I
1(
HYPERBARIC
OXYGENATION
LONG-TERM
VENTILATION
REHABILITATION OF THE
PULMONARY PATIENT
WTfO 78031
* These clusters can be completed at any time during the program
EXIT
Development of instructional units
Each unit within each cluster is essentially self-contained. It includes
an explicit listing of objectives to be achieved, suggestions about instruc
tional sources that might be employed (such as excerpts from textbooks,
journal articles, laboratory or clinical experiences,
simulation exercises, audio and video materials
COUGHING AS
designed specifically to serve the objective), and
THE REMOVAL OF
SECRETIONS
self-tests which allow each student individually and
privately to determine whether the learning objec
ARTIFICIAL
tives are being achieved.
An example of the detail that might be incor
OF
porated in the outline for each unit is set forth
VIA
RESUSCITATION
in Fig. 11 on “Coughing as an aid in the removal
of secretions”, which is taken from the cluster on
etc.
airway care illustrated here.
Airway care
AN AID
IN
AIRWAYS
VENTILATION
PATIENT
BAG
1 Metropolitan Group of Hospitals and Areas Health Education System, Illinois Region 2,
University of Illinois at the Medical Center. .4 curriculum for respiratory therapy, Chicago, IL,
Aldine, 1975.
58
COMPETENCY-BASED CURRICULUM DEVELOPMENT
The question that will occur immediately to any reader is whether
every instructional unit must be so detailed, for if this is required the
task of creating a competency-based, mastery-oriented curnc^alum for
medical education is formidable. The answer must be that the greater
the specificity the higher the probability of success, but with the usually intelligent and independent students who are admitted to
medical schools such detail is probably less important than m pro
grammes aimed at a less select student population. The most important
element is the effort invested by the teaching staff in making explicit
what they want students to learn, and communicating those expectations
through a written document that serves as a constant reference fo
both teachers and learners.
Encouragement of self-pacing
Many teachers accept the theory of mastery learning yet resist its
requirement that students should be allowed to pace themselves through
the programme. They may acknowledge the importance of defining
objectives, organizing a programme into discrete u”\s’
an orderly sequence of learning experiences, establishing mastery
standards, and creating an evaluation mechanism to ensure that virtually
all students achieve those goals. Any major disagreement is not con
ceptual, but at the practical level of anticipating potential chaos when
limited numbers of staff must oversee the work of a large student body
in which each individual may be at a different place m theurs. of
study. This is a legitimate point that cannot be evaded, but it can b
answered realistically only when teachers accept a ro1^ dlffer“
that they now play, a role of instructional manager rather i
m^ionXurce. If they are unwilling to adopt the principle that studen s
may learn without being “taught” (in the conventional sense), or if
they are unable to provide the resources required to allow such
independent and self-paced learning, it would be unwise to attemp
this major break with a traditional curriculum structure. Sucfi a decis o
should only be made, however, after recognizing that the evidence
strongly supports the view that a competency-based, mastery-oriented
programme’ean in the long term be more efficient, more effective, and
more economical. 1>2
Recognition of competence levels
A significant problem in any programme of professional education
and one that is exaggerated in a programme with mastery as an explicit
ed. Schools, society and mastery learning. New York, NY, Hou, nine
LEARNING FOR MASTERY
59
goal, is the definition of what mastery means. Many medical teachers
have unrealistic expectations. Their instruction aims at an advanced
level of mastery rather than something simpler—as though students
would never again have an opportunity to learn what they want to
teach. The continuum of medical education does provide opportunity
for elementary, intermediate and advanced levels of learning. A com
petency-based curriculum can exploit that opportunity by explicit
definition of steadily more complete and sophisticated performance
as students move through the educational programme. For example,
the following levels of competence in examination of the cardiovascular
system might be identified as end-points for several segments of the
basic curriculum and postgraduate training period:
A. At the end of an introductory course in physical diagnosis a student will be able to
recognize the presence of gross abnormality in pulse rate or rhythm
— recognize the presence of grade III cardiac murmurs
— if the pulse rate is below 90, and cardiac rhythm is regular, determine
whether a murmur is in systole or diastole
— detect through palpation of the apex impulse or percussion of the cardiac
outline any gross enlargement of the heart (i.e., more than 3 cm eyon
normal limits)
— etc.
B. At the time of graduation from medical school a student will be able to
— identify with 60% accuracy the following abnormalities of pulse rate or
rhythm: tachycardia, bradycardia, auricular fibrillation, premature ventri
cular contractions
detect, through palpation or percussion of cardiac outline, moderate enlarge
ment or significant displacement of the heart
— recognize the presence and describe the timing and character of grade II
cardiac murmurs and list the major anatomical lesions that might produce
such abnormal sounds
— identify abnormality in cardiac configuration on posteroantenor and lateral
chest X-ray films, and list major forms of cardiac pathology that migh
produce such changes
— identify the presence of abnormality in rhythm and in cardiac axis from
standard limb lead electrocardiograph
— etc.
C. Upon completion of internship a physician will be able to
— identify with 80% accuracy the above-noted abnormalities of pulse rate and
rhythm; describe character of pulse and recognize implications of pulsus
parvus et tardus, shallow pulse of shock, bounding pulse of thyrotoxicosis, etc.
— detect, through palpation or percussion of cardiac outline, minimal enlarge
ment or displacement of the heart
— recognize the presence and describe the timing and character of Grade I
cardiac murmurs
60
COMPETENCY-BASED CURRICULUM DEVELOPMENT
identify abnormalities in cardiac configuration revealed by posteroantenor,
lateral and oblique chest X-ray films and through fluoroscopy; list major
forms or cardiac pathology that might produce such changes
identify nature of abnormality of cardiac rhythm, and presence of acute
myocardial damage on standard 4-lead electrocardiogram.
— etc.
Frequent assessment of learning
If either interim levels of learning or mastery of the ultimate com
petence objectives of a curriculum are to be achieved, frequent
assessment is an essential component of programme organization.
Examinations are most commonly used to determine educational
achievement in medical schools, or professional status following grad
uation. Regrettably, such examinations are often seen by both teachers
and students as a mechanism for eliminating those who cannot show
a high level of academic achievement, although this measurement may
have little demonstrable relationship with qualification for delivering
health care. In a competency-oriented curriculum which is based upon
objectives derived in the manner described in Chapter 2, and which
uses the procedures outlined here to assure mastery of required learning,
it is expected that virtually all students will succeed. Examinations are
used chiefly as tools along an individual learning path to identify the
deficiencies that can be corrected by further study, and only at the end
to certify that the competence objectives have in fact been mastered.
Thus interim as well as terminal examinations that address the com
ponents of competence, rather than the informational elements of
learning alone, must occupy a central position in the curriculum.
61
LEARNING FOR MASTERY
FIG. 11. EXAMPLE OF INSTRUCTIONAL UNIT ON "COUGHING AS AN AID IN
THE REMOVAL OF SECRETIONS"
GOAL
To enable the student to teach and assist patients in the technique
of secretion removal by cough.
COGNITIVE OBJECTIVES
I.
State in a paragraph or less, the definition of a cough, and
the reason for its importance. (Cherniack, et. al., 168)
II.
Briefly explain in a paragraph the mechanism of nervous stimulation
lead.ing to a cough. (Cherniack, et. al., 168-169)
III.
IV.
V.
VI.
A.
Irritation of nerve endings
B.
Impulses transmitted to a “cough center" in the medulla
C.
Cough center" sends impulses to muscles of chest and larynx
Describe the location of various nerve endings participating in
cough stimulation. (Cherniack, et. al., 168)
A.
Sensory endings of vagus nerve in larynx, trachea, and
bronchi
B.
Nerve endings located in mucous membrane of pharynx,
esophagus, pleural surfaces, and external auditory canal
List four ways in which a cough may normally be stimulated.
(Cherniack, et., al., 169)
A.
Inflammatory stimulation
B.
Chemical stimulation
C.
Thermal stimulation
D.
Mechanical stimulation
List and explain the four phases of a cough.
169)
A.
Irri tati on
B.
Deep inspiration
C.
Compression
0.
Expulsion
(Cherniack, et. al.,
Describe briefly, the role cf tne ciachracr. in » cough,
et. al . , 170)
A.
During initial deep inspiration
B.
During expulsion
(Cherniack,
62
COMPETENCY-BAS ED CURRICULUM DEVELOPMENT
Fig. 11. Continued
VII .
Write five common faults of voluntary coughing.
Outline, 80)
A.
(Hammond's Review
Apical instead of diaphragmatic filling -- usually due to too
rapid inspiration
B.
Forced, high pitched throaty noise (slows flowrate)
C.
Holding breath and making a noise followed by expiration
Putting the tongue out in the expiratory phase
E.
VIII.
IX.
X.
Compressing lips during expiration
List three ways in which coughs may be produced manually,
(Petty, 108-109; Sykes, 87-91)
A.
Using Ambu bag, chest physical therapy, and manual thoraco
abdominal compression
B.
Tracheal tickling (Depression above the supramanubrial notch)
C.
Pharyngeal suction
D.
Respiratory stimulants (to be performed only by a physician)
E.
Cricothyroid cannulation (to be performed only by a physician)
Describe the manner in which an incorrectly performed cough may
produce an episode of acute air trapping in a patient with chronic
obstructive lung disease. (Bryan and Taylor, 116)
A.
Increase in intrathoracic pressure during cough
B.
Collapse of weak bronchioles
Describe in writing the reason assistance with coughing is needed
in the following type of patients. (Bryan and Taylor, 115-116)
A.
Post-operative or post-traumatic pulmonary restriction patients
Patients exhibiting post-ventilator weakness
C.
XI.
Patients with chronic obstructive lung disease
State briefly the difference in coughing techniques that should
be used for the types of patients mentioned in objective X.
(Bryan and Taylor, 115-116)
IMPORTANT WORDS AND CONCEPTS
Abdominal viscera
Acute air trapping
Compression
Diaphragm
Expulsion
Glossopharyngeal nerve
Glottis
Inspiratory capacity
Intrathoracic pressure
Lateral costal margins
Supramanubrial notch
Transtracheal injections
Vagus nerve
learning for mastery
63
REQUIRED STUDY AND RESOURCES
Bryan, Clifford and Taylor, Joan P. Manual
Manual of
of Respiratory
Respiratory Therapy
Therapy,.
it. Louis: C. V. Mosby Company, Inc., 1973.
Cherniack, Rueben M., Cherniack, Louis, and Naimark, Arnold. ?
'
■
In, Health and Dnsease. 2nd ed. Philadelphia: W. B. SauFRespiration
ders Co.;
Hammond
rteraoy
2nd ed.
2nd ‘d-
Pettyi!es',ir,tnry
Safar,^Peter,^M.D.,^ed.^Respiratory Therapy.
Sykes, M. K., et. al. Respiratory Failure.
Scientific Publications.----------------
2nd ed.
3rd ed.
Philadelphia:
Oxford:
Blackwell
PERFORMANCE SKILL OBJECTIVES
nnc?nHrattthe c?“9hing technique that should be used for a
DO*?!.
“OnprAfivn n
a 1 a r *•
__
post-operative
patient.
(Bryan and Taylor, 115-116)
A.
II.
HI.
IV.
Support patient's lower thorax bilaterally with hands
B.
Instruct patient to inspire slowly and fully
C.
When patient's inspiration is at its peak, exert a slight
pressure with hands to begin the cough
0.
Continue compression to Increase force and velocity of exhaled
air
Demonstrate methods by which to splint the surgical wound
of a
post-operative patient. (M.D.s and therapists)
A.
Place a pillow over the area of wound and exert slight pressure
B.
Hold the wound together by exerting slight pressure inward on
both sides of sutures
Demonstrate the coughing technique that should be used
for a
post-venfi 1ator patient.
(Bryan and Taylor, 115-116)
A.
Instruct patient to inspire slowly and begin his cough from
the mid-inspiratory position
8.
Instruct patient to exhale from the
fc„ above position in
a
rapid series of short sharp coughs
Demonstrate the coughing technique tl.aL
that ^i.uuld
should be used for a
ent with chronic obstructive lung disease.
JI--- - (Bryan and Taylor,
115-116)
A.
Instruct patient to inspire slowly and begin his cough from
the mid-inspiratory position
B.
Instruct patient to exhale from
f
above position in a rapid
series of short sharp coughs
64
COMPETENCY-BASED CURRICULUM DEVELOPMENT
Fig. 11. Continued
V.
VI,
Demonstrate the method used to relieve an episode of acute air
trapping. (Bryan and Taylor, 115-116)
A.
Immediately place both hands or arms over the lateral costal
margins of the patient
B.
Exert a series of strong, short compressions to facilitate
completion of expiration
Demonstrate techniques of producing a cough.
Sykes, 87)
(Safar, 229-230;
A.
Depression of supramanubrial notch
B.
Using chest physical therapy, Ambu bag, and manual thoraco
abdominal compression
C.
Pharyngeal suctioning
D.
Transtracheal injection
SUGGESTED LEARNING ACTIVITIES
I.
Complete required readings
II.
Seif-tests
III.
Observe and assist the Instructor during coughing of patients
having different therapeutic needs
IV.
Practice coughing techniques on other students
V.
Inspect splints on the surgical wounds of post-operative patients
VI.
Practice communication techniques
VII.
Discussion with the instructor, other health care personnel,
and students
VIII.
Videotape:
Postural Drainage
IX.
Videotape:
Instruct Patient in Breathing Techniques
X.
Videotape:
Coughing as an Aid in the Removal of Secretions
LEARNING FOR MASTERY
COGMTIVE EXAMINATION FOR COUGHING AS AN
AID IN THE REMOVAL OF SECRETIONS
1.
Briefly state the definition of a cough and indicate the reason
for its importance.
2.
Briefly explain the mechanism of nervous stimulation leading to
a cough.
3.
Briefly describe the location of various nerve endings participating
in cough stimulation.
4.
List four ways in which a cough may normally be stimulated.
1.
2.
3,
4.
5.
List the four phases of a cough and in a sentence or less explain
each phase.
Phase
1.
2.
3. ’
4.
Explanation
65
66
COMPETENCY-BASED CURRICULUM DEVELOPMENT
Fig. 11. Continued
6.
Briefly describe the role of the diaphragm in a cough.
7.
Indicate five common faults of voluntary coughing.
1.
2.
3.
4.
5.
8.
List three ways in which coughs may be produced manually.
1.
2.
3.
9.
-Briefly describe how an incorrectly performed cough may produce
" Patient “1th Chr°",‘
LEARNING FOR MASTERY
10.
Briefly describe the reason assistance with coughing is needed
in each of the following types of patients.
Patient(s) TYPE
11.
1.
Post-operative or
post-traumatic
pulmonary
resection patients
2.
Patients exhibiting
post-ventilator
weakness
3.
Patients with
chronic obstructive
lung disease
REASON FOR ASSISTANCE
WITH COUGHING
Briefly indicate the difference in coughing techniques used for
the following types of patients
Patient(s) TYPE
1.
Post-oceravvs cr
post-crauratic
'pulmonary
resection patients
2.
Patients exhibiting
post-ventilator
weakness
3.
Patients with
chronic obstructive
lung disease
I
ZZ.SrlXS TECr’CZr.’-S
61
68
COMPETENCY-BASED CURRICULUM DEVELOPMENT
Fig. 11. Continued
PERFORMANCE EXAMINATION FOR COUGHING
AS AN AID IN THE REMOVAL OF SECRETIONS
I.
The student will demonstrate the following coughing techniques
used for a post-operative patient.
A.
B.
.C.
0.
II.
III.
IV.
V.
VI.
Support patient's lower thorax bilaterally with hands
Instruct patient to inspire slowly and fully
When patient's inspiration is at its peak, exert a slight
, pressure with hands to begin the cough
Continue compression to increase force and velocity of exhaled
air.
The student will demonstrate the following methods to splint the
surgical wound of a post-operative patient.
A.
Place a pillow over the area of wound and exert slight pressure
B.
Hold the wound together by exerting slight pressure inward
on both sides of sutures
The student will demonstrate the following coughing techniques
that should be used for a post-ventilator patient.
A.
Instruct patient to inspire slowly and begin his cough from
the mid-inspiratory position
B.
Instruct patient to exhale from the above position in a rapid
series of short sharp coughs
The student will demonstrate the following coughing techniques that
should be used for a patient with chronic obstructive lung disease.
A.
Instruct patient to inspire slowly and begin his cough from
the mid-inspiratory position
B.
Instruct patient to exhale from above position in a rapid
series of short sharp coughs
The student will demonstrate the following method used to
relieve an episode of acute air trapping.
A.
Immediately place both hands or arms over thq lateral
costal margins of the patient
B.
Exert a series of strong, short compressions to facilitate
completion of expiration
The student will demonstrate the following techniques of
producing a cough. (Safar, 229-230; Sykes, 87)
A.
Depression of supramanubrial notch
B.
Using chest physical therapy, Ambu bag, and manual
thoracoabdominal compression
C.
Pharyngeal suctioning
D.
Transtracheal injection
CHAPTER 4
ASSESSMENT OF COMPETENCE
Assessment is usually equated with examinations, and about these
devices Bryant1 has said:
“Examinations are among the least understood and most misused tools of edu
cation. They are used mainly to certify that the student has learned an acceptable
amount of what he has been taught and to provide a grade representing that
attainment. While the announced objectives of the institution may be to develop
the knowledge, skills, and attitudes necessary to being a good physician or nurse, the
examinations seldom measure more than the simple recall of isolated pieces of
information. The student’s grade is usually determined by comparing his performance
with the class as a whole, that is ‘grading on the curve’, rather than grading according
to standards carefully developed by the faculty... The examination system is a
dominant force in the setting for learning.”
Such a powerful force deserves careful attention in any educational
programme, but its harnessing is particularly important in one which has
competence as the goal, uses mastery as the method, eliminates time
as a programme constant, and encourages the employment of varied
resources for learning. For in such a programme the end-point comes
only when assessment indicates that the competence goal has been
achieved (summative assessment). The speed of that achievement is
determined in part by the effectiveness of a diagnostic examination
system (formative assessment) used to identify student strengths and
weaknesses in the course of study so that deficiencies may be promptly
corrected rather than allowing further study to do no more than refine
what has already been learned. The pace at which the competency goal
is attained is also influenced by where each student starts and thus
entry assessment is essential if wasteful repetition is to be avoided.
Each of these elements will be taken up in turn.
-.^BrJANT’ J‘
pp. 209-210.
anti the developing world. Ithaca, NY, Cornell Univershv Press. 1969.
— 69 —
70
COMPETENCY-BAS ED CURRICULUM DEVELOPMENT
ENTRY ASSESSMENT
The effectiveness of an educational programme depends to a great
degree on the learning students bring with them to the classroom,
clinic, or laboratory. This influence on the cumulative effect of schooling
is so strong that Ausubel1 has asserted: “If I had to reduce all of
educational psychology to just one principle, I would say this: the most
important single factor influencing learning is what the learner already
knows. Ascertain this and teach him accordingly.”
Although never explicitly defended in those terms, the almost
universal establishment of academic achievement prerequisites for
admission to medical school is intended as an assessment of readiness
for further study. In some countries this level is set politically, so that
all graduates of a secondary school, for example, are eligible for
admission to any university faculty. In other countries the criteria are
determined by teaching staff who may rule that only those whose
prior achievement is, for example, in the top 20% of a secondary-school
leaving examination will be considered for admission. In still other
countries not only past academic achievement, but present academic
aptitude, as measured by standardized tests, may be considered in
determining readiness for the study of medicine. And in at least one
country the judgement of peers in a community work setting has
replaced the usual academic criteria for admission to medical school.
Each o'f these methods serves a purpose, but not necessarily the
purpose of identifying which students are best prepared to embark on
a programme with defined professional competency goals. The open
admission technique ensures a broad opportunity for social advance
ment through education, but it says little about readiness for advanced
learning. Countries that employ the method generally have high student
failure rates in the early years of university education. The past achieve
ment and present aptitude procedures ensure a high level of success in
further academic study, but there is virtually no evidence that this
readiness for traditional course work has any significant correlation with
the quality of later medical practice.2-4 The community choice method
ensures admission of those with socially desirable attitudes toward the
responsibilities for health care which a professional should possess,
but whether this indicates a readiness to acquire the professional
1 Ausubel, D. P. Educational psychology: a cognitive view. New York, NY, Holt, Rinehart
& Winston, 1968.
2 Peterson, O. L. et al. An analytical study of North Carolina general practice. Journal ofmedical
education, 31 (Dec. suppl.): 61 (1956).
3 Price, P. B. et al. Measurement and predictors ofphysician performance. Salt Lake City, UT,
LLR Press, 1963.
4 Clute, K. F. The general practitioner. Toronto, University of Toronto Press, 1963.
ASSESSMENT OF COMPETENCE
71
competence that must accompany those attitudes remains to be
demonstrated.,
The problem with all these techniques is quite simply that they are
based upon the assumption that past achievement in an academic or
work setting is a suitable predictor of ability to acquire a professional
competence that has not been precisely defined. There is no question
that past performance is the best predictor of future performance of
the same kind of task, but if that future task must be different, then
such assessments of readiness to learn may be misleading—or even
wrong. Yet some technique must be employed to select from a large
pool of candidates those who will be admitted to medical school. As
preliminary screening procedures, and with the reservations noted,
these techniques can certainly be employed, for it is clear that they serve
social as well as educational purposes.
A more focused use of entry assessment is intended to facilitate the
design and implementation of individualized learning opportunities
for those selected. Although not often used, the technique for doing
so is conceptually simple and direct: administration of terminal
assessment at the beginning of a programme, allowing the results to
determine the subsequent course of study. Tn some instances entry
testing may cover an entire year of instruction. Those students who
are successful may then begin work at the next year’s level. In other
instances it may cover only the competencies of a single course, and
if their achievement can be demonstrated before enrolment then that
course may be omitted. Or to use the respiratory therapy curriculum
cited in the preceding chapter as an illustration, each unit might begin
with the final examination of knowledge and skills so that further
repetitious study would not be devoted to objectives that had already
been achieved.
Entry assessment of this kind is particularly important if there is
to be real opportunity for professional mobility unimpeded by rigid
academic requirements. For example, Table 8 shows the conventional
specifications for education of health personnel. It emphasizes the
site in which learning should be acquired, and the time that must be given
to formal schooling in order to qualify for each rank. However, if the
purpose of education is to assure achievement of a defined level of
competence, then rationality dictates that assessment of competence
rather than time and place of training should determine the placement
of an individual in the hierarchy of rank and responsibility. If, through
field work and independent study, a graded dresser has gained the
competence that characterizes a medical assistant, promotion to that
rank would seem logical whether the specified years of secondary
education have been completed or not. Or a medical assistant may
be able to demonstrate, through entry assessment, proficiency in a
72
COMPETENCY-BASED CURRICULUM DEVELOPMENT
TABLE 8. AN EDUCATIONAL AND PROFESSIONAL CONTINUUM
FOR TWO HEALTH PROFESSIONS®
Status
Education
Form of
schooling
Professional
Specialist
Medical
officer
Quasi
professional
Paramedical
Middle
14
Secondary
education—
international
status
12
Secondary
education
Junior
Labourer
Unskilled
Years of
schooling
University
education—
international
status
Senior
Auxiliary
Health professions
Grade
Primary
education or
none at all
Medicine
Specialist
physician
Administration
Hospital
superintendent
Medical
officer
10-12
Clinical
assistant
Assistant
superintendent
8-10
Medical or
hospital
assistant
Storeman and
clerk
6-8
Graded
dresser
0-6
Ungraded
dresser
Cleaner
0 Adapted from : King, M., ed. Medical care in developing countries, section 7:2, Table 2,
Nairobi, Oxford University Press, 1966.
significant number of the competencies required for a clinical assistant’s
post. Under such circumstances an educational programme designed
to complete the required repertoire .of competencies rather than one
to fulfil conventional time and place requirements for that education
would seem reasonable, as well as more economical.
Finally, entry assessment is more than a useful placement device
for students. It can also be a chastening experience for teachers who
are generally inclined to assume that if students demonstrate required
competency at the end of a course it reflects the quality of instruction
received. When entry assessment is made many teachers may have the
kind of painful but illuminating discovery experienced in one depart
ment of medicine1 where “one-third of the students who entered the
medical clerkship. .. achieved on the pre-test a passing grade when
judged by standards used in previous years..And further: “ .. .the
pre-test scores of many students were substantially higher than the
post-test scores of some of their classmates”. What an appalling waste
1 Ceni-er for Educational Development. A study of the junior clerkship in medicine. In: Report
to the Faculty, 1963-64, University of Illinois College of Medicine, 1964 (multilith).
ASSESSMENT OF COMPETENCE
73
of time, effort, and money to demand continued exposure of students
to routine instruction when they have already achieved the objectives!
But unless teachers know this—and act upon it—such demands will
continue. A competency-based curriculum, using entry assessment, is
designed among other things to prevent that waste.
FORMATIVE ASSESSMENT
When education aims at mastery of specifically identified profes
sional competencies the process cannot be allowed to proceed blindly
if it is to be efficient and economical as well as effective. In the last
quarter of the twentieth century it would be unthinkable to attempt a
long journey by car without map or road signs, using merely a compass
as a guide. And it would be madness to attempt a journey to the moon
without an elaborate and secure guidance system. Yet in schools for
the health professions throughout the world students travel a complex
educational path with very few, and often ambiguous, guideposts. They
usually learn only at the time of final examinations if they have missed
the goal. Formative assessment—a system of non-judgemental guidance
examinations—is a powerful tool that may be used to forestall such
tragic outcomes.
Like the entry assessment that precedes it, and the summative
assessment that follows, formative assessment takes as the point of
reference competencies that have been defined as educational goals of
the programme. And like the other two components of an overall
evaluation scheme, formative assessment must employ many testing
methods. The major difference among these stages lies in the use of the
data gathered. In entry testing the major purpose is to ensure that
students are placed at a level compatible with learning already achieved,
and to facilitate planning for further study directed towards compe
tencies not yet achieved. Summative assessment is simply a terminal
judgement of whether overall mastery has or has not been accomplished.
Formative assessment serves the student directly, providing personal
and private information on what has been learned and what has yet
to be learned. Incidentally, it may also allow teachers to identify areas
where many students are encountering difficulty, and thus need
perceptive help from staff if those difficulties are to be resolved and
the learning objectives are to be achieved by all. Formative assessment
is wholly non-judgemental; it is for guidance only. But if this guidance
purpose is to be fulfilled, one potential problem must be dealt with
directly upon institution of such a system, and reinforced regularly by the
teacher’s behaviour. This is the issue of trust.
74
COMPETENCY-BASED CURRICULUM DEVELOPMENT
Students have been thoroughly conditioned by past experience
to believe that tests are used to judge and to grade them. For many
it may be inconceivable that teachers would give tests that “don’t
count”. Yet it is precisely this spirit that must dominate a system of
diagnostic examinations. It may take time as well as considerable effort
to convince students that such tests are truly given to facilitate their
learning directly, or indirectly by helping faculty to identify ways in
which that learning can be enhanced. The system will fail unless students
come to believe this. They must fully accept as fact any policy statement
that data from diagnostic examinations are used solely for educational
purposes and not surreptitiously entered into some permanent record
that is used for grading. And nothing will precipitate failure more rapidly
than violation of trust once it has been established. It is a fragile and
precious thing.
Once the principle of formative assessment has been accepted, and
the trust issue dealt with, the practical question arises: how often
should such diagnostic, non-judgemental examinations be given? At
the end of each lecture, clinic or laboratory session ? Each unit of related
instructional experiences? Each year of an extended educational pro
gramme ? Or with some arbitrary frequency such as every week ? There
is no final answer, except in the most general terms. Diagnostic
assessment should be carried out with sufficient frequency and regularity
to enable results to guide further study of things not yet learned, but
not with such frequency as to exhaust either the student body or the
teachers. If diagnostic examinations are given infrequently, irregularly,
or only at the end of large instructional blocks, deficiencies may be
identified but the opportunity to correct them is frequently lost.
The reader may have concluded from these words that teachers
alone will determine when diagnostic examinations will be given.
Teaching staff must certainly play an important part in this decision,
but to leave the responsibility with them alone will defeat one of the
important .elements of a competency-based curriculum which uses
mastery as an instructional strategy: the opportunity for individual
pacing. If this is to be provided then the instruments for formative
assessment must be available when individual students are ready to
use them, not merely when teachers are prepared to administer
diagnostic examinations to an entire group. Thus emerges the concept
of self-testing, in which students have access to diagnostic examinations
in much the same way that they have access to books and journals, to
be used at their convenience, to serve their purposes, and without any
requirement of supervision by teachers.
A library of books is now such a familiar resource for independent
learning that no institution that claims to offer higher or professional
education can exist without one. During the last decade library
ASSESSMENT OF COMPETENCE
15
collections have been expanded in many parts of the world to include
nonprint material—audio and video devices that supplement and
complement printed works as aids to learning. An institution that adopts
mastery learning aimed at competency objectives needs a further
expansion of its library collection to include an array of self-testing
devices which is as rich and varied as the collection of textbooks,
reference works, and professional journals.
The key words here are “rich and varied”. A collection of tests which
probe only the “simple recall of isolated pieces of information” decried
by Bryant will impede rather than foster the curriculum’s formative
assessment needs by diverting attention from the professional tasks
of problem-solving and technical skills of patient management to the
academic game of absorbing information without perceived purpose.
This does not mean that conventional devices such as multiple-choice
tests are inappropriate; it merely means that they must be designed
to explore what has been defined in the competency objectives, not
simply the information that underlies those goals.
For example, respiratory illnesses represent the commonest group
of disorders for which patients in most of the developed world consult
a physician. The competency objectives for dealing with these disorders,
as outlined by the Royal College of General Practitioners in the United
Kingdom,1 include the ability to distinguish between the transient and
the life-threatening disorders of the respiratory tract, and to treat all the
common disorders except pulmonary tuberculosis and those requiring
surgery (a list of these conditions is set forth in Fig. 12). If achievement
of these goals is to be assessed in formative self-tests it will not be
enough to ask students to list the signs and symptoms of the diseases
(which they could then check against a master listing), or to select
appropriate treatment strategies in an objective examination (which
could then be compared with an answer key). An accurate formative
assessment would require a series of problem-solving tests that probed
the ability to discriminate among the diseases as they might be mani
fested in ambulatory patients, and to deal with the clinical problems
as they evolved under whatever management was selected. This is not
the place to describe such test procedures, but merely to indicate that
many testing methods must be included in a library of formative assess
ment devices designed to assist students in identifying what they still
have to learn.
SUMMATIVE ASSESSMENT
If a formative examination system is wisely used only the rare student
will arrive at the stage of summative assessment—that final judgement
1 Royal College of General Practitioners The furure general practitioner. London, 1972.
76
COMPETENCY-BASED CURRICULUM DEVELOPMENT
FIG. 12.
PULMONARY DISORDERS, EXCEPT PULMONARY TUBERCULOSIS
AND DISORDERS REQUIRING SURGERY, AS LISTED BY THE
ROYAL COLLEGE OF GENERAL PRACTITIONERS
460-519 GROUP VIII. DISEASES OF THE RESPIRATORY SYSTEM
This is the commonest group of disorders. It accounts for 650 patients
consulting in an average practice population per year.
Common occurrence is its first claim on the teacher’s attention. A
second is that a small number of possible symptoms, notably cough,
may in different people at diflerent times represent a wide range of severity
of disorder; transient infections, or recurrent and chronic disorders like
bronchitis, or conditions like pulmonary tuberculosis and carcinoma of the
lung which, if they are not to threaten life, need to be detected at an early
stage, before they have produced physical signs. The group is therefore an
excellent example for teaching the need and methods for distinguishing
serious from trivial disorders. A third claim is that the chronic diseases,
asthma and bronchitis (especially the former), are good examples of the
need to assess carefully each individual sufferer, if treatnrent is to be effec
tive.
Acute respiratory diseases threatening life
Laryngitis in children; bronchiolitis in children; influenzal pneumonia
(the rare overwhelming infection); bronchopneumonia; acute on chronic
bronchitis; asthma. (Pulmonary tuberculosis is listed under infective,
bronchial carcinoma under neoplastic disorders in the appropriate
sections).
Diseases which may be aborted, or of which the complications may be
reduced through early detection
Recurrent bronchitis, pneumococcal pneumonia, bronchiectasis.
A condition not otherwise dangerous which has dangerous complications
Influenza.
The common disorders in the group arc:—
460 Acute nasopharyngitis (common cold)
461
Acute sinusitis
462 Acute pharyngitis
463
Acute tonsillitis
464 Acute laryngitis and tracheitis
466 Acute bronchitis and bronchiolitis
470 Influenza
471-2 Influenza with pneumonia or other respiratory complication
473
Influenza with digestive manifestations
480 Viral pneumonia
481
Pneumococcal pneumonia
482 Other bacterial pneumoniae
485 Bronchopneumonia
490 Bronchitis
491
Chronic bronchitis
492 Emphysema
493 Asthma
500
Hypertrophy of tonsils and adenoids
501
Peritonsillar abscess
503 Chronic sinusitis
505 Nasal polyposis
507 Hay fever
511
Pleurisy
512 Spontaneous pneumothorax
518
Bronchiectasis
Bornholm disease appears among the infective disorders.
Chronic conditions requiring continuing care
Asthma, chronic bronchitis and emphysema, hay fever, bronchiectasis.
3royal College of General Practitioners. The future general practitioner.
London, 1972 (reproduced by permission).
77
ASSESSMENT OF COMPETENCE
of whether the competency objectives have been achieved—and be
unable to succeed. Failure of any significant number will reflect as
much on the quality of the programme as on the quality of individual
learning. But if students fail in their ability to demonstrate the required
professional competence there must be no hesitation in making that
harsh judgement, for this is the quality-control point, the means by
which an institution asserts that a graduate is qualified to render a
defined professional service. Students may have started from different
points, and have spent varying periods of time in study, but all who are
successful in meeting the requirements of summative assessment must
have achieved that defined level of competence.
With this in mind it must be clear that the common normative
procedure for determining success will not do. Such a method identifies
TABLE 9.
OBJECTIVES OF A MEDICINE RESIDENCY3
Definitions:
1. Concepts: deal primarily with disease entities or syndromes; knowledge of a
concept implies ability to diagnose, treat, and understand the basic mechanisms of
the disease or syndrome under consideration, and to be familiar with its pre
ventative, medicolegal, disability and public health aspects.
2. Skills: relate to ability to properly order, perform and interpret certain specific
technical procedures.
3. Attitudes: include behavioral characteristics, value judgments and doctor-patient
relationships.
Degree of Expertise - Classification:
Concept
Skill
Category I
Is able to carry out all medical
phases of diagnosis and manage
ment withoutconsul:at;on in 90°2
of cases. Consultation for tech
nical procedures .-nay be neces
sary'.
Is able to recognize need for,
perform, and interpret procedure
without consultation in 90% of
cases.
Category II
Usually needs consultation (other
than for technical procedures) at
some point in managing the
patient with this disease, but is
able to maintain primary respon
sibility for the patient in 90% of
cases.
In 90% of cases is able to recog
nize the need for and order the
procedure, but must obtain con
sultation to have it performed
and/or interpreted.
Category III
In 90% of cases is able to recog
nize the possibility that this
disease exists, but does not main
tain primary responsibility for
this disease and refers the patient
for both diagnosis and manage
ment.
Aware of the procedure's exist
ence and genera! characteristics,
but needs consultation to deter
mine the need for, perform and
interpret the procedure.
a HISS, R. G. & Vanselow, N. a. Objectives of a residency in internal medicine. Journal of
the Association for Hospital Medical Education, 4: 11 0971) (reprint permission from the
Managing Editor, Association for Hospital Medical Education).
78
COMPETENCY-BASED CURRICULUM DEVELOPMENT
TABLE 10.
GASTROENTEROLOGY3
CONCEPTS
Category I:
1. Achalasia
2. Carcinoma of the colon
3. Carcinoma of the pancreas
4. Carcinoma of the stomach
5. Cholangitis
6. Cholecystitis, cholelithiasis
7. Cirrhosis
8. Cyst of pancreas
9. Diarrhoea, psychophysiologic
10. Diverticulosis and diverticulitis
11. Duodenal ulcer
12. Dysentery, bacterial
13. Gastric ulcer
14. Gastritis
15. Gastroenteritis, viral
16. Haemorrhoids
17. Hepatic coma
18. Hepatitis (SH, IH)
19. Hepatotoxins and toxic hepatitis
20. Hiatal hernia
21. Jaundice, differential diagnosis of
22. Liver, fatty
23. Malnutrition
24. Pancreatitis
25. Peptic oesophagitis
26. Polyps, colonic
27. Polyps, gastric
28. Enteritis, regional
29. Ulcerative colitis, chronic
Category II:
1. Carcinoma of the oesophagus
2. Carcinoma of the small bowel
3. Oesophageal diverticula
4. Oesophageal varices
5. Evaluation of acute abdomen
6. Gastrointestinal enzyme deficiency states
7. Gastrointestinal bleeding, massive
8.
° Malabsorption, primary and secondary
9. Mesenteric arterial insufficiency
10. Post-operative alimentary complication, delayed (dumping, etc.)
11. Stricture of oesophagus
Category III:
1. Gastrointestinal malformations
2. Other gastrointestinal neoplasms
SKILLS
Category I:
1. Gastric analysis
2. Liver biopsy, percutaneous
3. Paracentesis
4. Sigmoidoscopy with selective biopsy
5. Use of Blakemore-Sengstaken tube
ASSESSMENT OF COMPETENCE
79
Category H:
1. Barium enema study
2. Cholecystography
3. Oesophagoscopy
4. Gastroscopy
5. Liver scan
6. Pancreatic function tests
7. Selective arteriography
8. Upper gastrointestinal and small bowel series, hypotonic duodenography
Category 111:
1. Malabsorption studies
2. Motility studies
3. Peritoneoscopy
4. Small bowel biopsy
a HISS, R. G. & VANSELOW, N. A. op cit. (reprint permission from the Managing Editor, Asso
ciation for Hospital Medical Education).
the successful candidate by reference to the performance of others who
have taken th$ same test or a similar one. The acceptable performance
standard may be set in many arbitrary ways, such as not more than
2 standard deviations below the mean of all who have taken the test,
or the top 80°/o of those tested, or all except the lowest 20 in the test
group. Whatever the technique, judgement of success is based solely
upon the relationship of each individual’s performance to that of others,
not to some absolute standard.
It is the absolute standard (technically, reference to a criterion) that
is required in a competency-based curriculum. If the objectives are
categorized, as they have been, for example, in one outline of a training
programme in internal medicine (Table 9), then the trainee who can
manage without consultation only 60°/o of the problems in category I,
or is unfamiliar with the procedures in category III (Table 10) will
fail no matter what the mean score of the group being tested, whether
that individual is alone in tliis deficiency or shares it with half those in the
test group. Competence is not a matter of comparison with what others
do, it is by definition either achieved or not achieved.
But it is important to point out again that the level of expected
competence in dealing with common problems will differ among groups
of health personnel who may encounter them, or be responsible in
varying degree for their management. For example summative judge
ments for a midwife and an obstetrician may cover many of the same
performance categories, but will require clearly different levels of
mastery. In each instance, however, the final judgement in terms of
the established criterion would be either mastery achieved or not
achieved. There is no middle ground.
CHAPTER 5
PREPARATION OF TEACHERS, STUDENTS
AND INSTITUTIONS
Those who endorse the assumptions and purposes of competency
based education must also recognize that implementation will alter
the usual modes of institutional operation. Educational activities,
record-keeping systems, and time schedules may all have to change,
but the most significant modifications will be those of faculty and
student attitudes and practices, which must shift in a manner that
emphasizes learning rather than teaching. Such changes are not easy
to bring about. One prominent student of organizational development
has said that “trying to reorganize a university is like trying to reorganize
a graveyard”.1 Tyler has noted that even those curriculum changes
that show great intitial promise are often abandoned after a few years,
largely because of “the institution’s failure to make those changes in
its structure and functioning that will support and promote, rather than
oppose, a dynamic process of curriculum development”.2
If it is to be lasting, educational change must be regarded as a
continuous process of institutional and professional renewal. It has
no discernible end-point. It grants tentative acceptance to today’s
innovations while being committed to improvement tomorrow. It is
experimental in the true sense, regarding approaches to learning and
teaching, even those that have won long acceptance, as hypotheses
worthy of testing rather than as empirical laws. For these reasons two
issues will be considered in this final chapter: (.1) what new roles for
teachers and students are required if a competency-based and masteryoriented curriculum is undertaken; and (2) what strategies and tactics
can an institution employ to reduce barriers and facilitate the adoption
of such a plan ?
1 Bennjs, W. G. The leaning ivory tower. San Francisco, CA, Jossey-Bass, 1969.
2Tylrr, R. W. Curriculum improvement in the university. Journal of medical education,
45 (Nov. suppl.): 42 (1970).
— 80 —
PREPARATION OF TEACHERS, STUDENTS AND INSTITUTIONS
81
NEW EDUCATIONAL ROLES
The teacher
Tf we look back at the educational process described in earlier
chapters, three new roles for teachers can be identified. The first is that
of planner, probably the most difficult and time-consuming of the
functions which must be embraced if a competency-based curriculum
is to be successful. Teachers have always been expected to plan their
instruction, and often spend long hours doing so. It is not the quantity
but the character of the effort which must change.
In a conventional programme the principal focus of planning is on:
(1) content—what will be presented to students in lectures, laboratory
work, or clinical experience; and (2) time—how much can be won to
convey the subject and how shall that time be divided among several
different kinds of instruction. In a programme directed at mastery of
defmed competencies, time becomes a variable that will be determined
by individual progress toward the goals; and content, in the sense of
subject matter courses, must be replaced by a system of organization
that focuses on professional problems whose solution depends on know
ledge and skills derived from many disciplines.
The most important of the planning tasks is to define the compe
tencies to which the curriculum must be directed. The next is to plan
instructional units that must build systematically and sequentially
toward those goals. Methods that might be used in carrying out those
functions have been outlined in earlier chapters.
The second new role is that of manager of instructional resources.
The usual course outlines, which identify lecture topics, reading assign
ments, laboratory exercises or clinical experience for all students, are
incomplete in a competency-based programme. In such a curriculum
it is essential to list the specific competency objectives, to indicate the
alternative learning resources that are available to assist students toward
those objectives, and to define the assessment procedures that can be
used to determine individual progress. There must also be an indication
of specific time periods when teachers are available to assist individual
students or groups in surmounting whatever learning problems they
may encounter. In these meetings the teachers task is to encourage
and not to dominate, to guide rather than to tell, to suggest sources
rather than to provide directly all the knowledge students must acquire.
The third role is that of evaluator. The skill with which this function
is carried out will probably be a major determinant of programme
success. If students find teachers using examinations primarily to
enforce lecture attendance or the completion of specific reading assign
ments by testing recall of obscure references in the former or fine
82
COMPETENCY-BASED CURRICULUM DEVELOPMENT
print in the latter, then conformity with a predetermined faculty plan
is both encouraged and rewarded. If they find teachers genuinely
concerned with helping them to assess their own progress toward
defined competency goals, no matter what learning path is chosen,
and without communicating judgement but merely identifying the
nature of that progress, independence and personal responsibility for
learning, without which a mastery-based system cannot succeed, will
be nurtured.
These new roles are not easy for teachers to adopt when they have
themselves been educated in a more conventional way and have
developed a style of teaching that is comfortable, as well as consistent
with a personal perception of professional responsibility. Yet such
personal perceptions are rarely uniform within any medical school.
One investigation of the sociology of higher education has identified
4 faculty subcultures:1
1. The teacher who is committed to students and their welfare, spends many hours
teaching, and is impatient with colleagues who devote themselves largely to
research or to professional service. This is the individual who is usually popular
with students and wins their praise, but who is often regarded by other members
of the teaching staff as lacking depth, being unfamiliar with current advances
in his discipline, and having more concern for pleasing students than with
educating them.
2. The scholar-researcher is committed to pure, disinterested study, and regards
the pursuit of new knowledge as the unique goal of a university. The teaching
function is acknowledged to be significant, but primarily as a means of sharing
with students the latest developments in a discipline, the horizons still being
explored, and the excitement of an intellectual life. Whether what is communi
cated to students is immediately relevant to their interests or needs is regarded
as relatively unimportant, since it is the process of gaining new understanding
rather than immediate application that should be of greatest academic concern.
3. The demonstrator has a teaching appointment but basically identifies with the
local practitioner community, devoting a major portion of time to the direct
delivery of professional services and a lesser amount to more academic pursuits.
Such an individual has little opportunity for or inclination towards research,
although willing to apply the products of research in practice. Teaching is
conducted largely as an exercise in showing apprentices how a master works,
and encouraging (or requiring) students to adopt that behaviour without signi
ficant question or challenge.
4. The consultant is also interested in the application of knowledge, but is more
concerned with applications at the conceptual than at the personal delivery
level. This is the professional who has achieved a national or international reputa
tion on the basis of prior work, who spends a substantial amount of time in
travel, attending or addressing meetings principally made up of others with
similar orientation, and who shares these experiences with students in an episodic
fashion rather than in continuity.
1 Feldman, K. A. & Newcomb, T. M. The impact of college on students. San Francisco, CA,
Jossey-Bass, 1969.
PREPARATION OF TEACHERS, STUDENTS AND INSTITUTIONS
83
These subcultures rarely exist in pure form but rather represent
persuasions or orientations of individual teachers. Each represents a
view that may meet some part of the university mission, but none is fully
compatible with the requirements of a competency-based curriculum.
The mechanism for bringing such teachers to the point of accepting new
roles will be dealt with in a later section of this chapter, but first it is
necessary to look also at the modifications of student role that such a
curriculum will demand.
The student
There appears to be widespread agreement that university students
today are more demanding than those of earlier generations. Student
militancy, once limited to only a few countries, is now widespread. While
the causes may vary from place to place and from time to time a few
themes regularly recur whenever students debate the merits and short
comings of educational programmes.
One has to do with curriculum content. There seem to be few places
in the world where learners do not protest against the amount and the
irrelevance of the material they are taught. While these criticisms are
directed most forcefully at the basic and preclinical sciences, there is
also discontent with the growing number of clinical subspecialties in
which instruction is given. And there is some reason to believe that
instructional content has become so large not because of any evidence
that all students will need it in the professional lives for which they are
preparing but to satisfy teachers that all have been exposed to the
things that are academically important and may at some time be useful.
Yet when given the opportunity to choose, as they are in an increasing
number of schools with substantial elective programme offerings,
students do not regularly select what might better prepare them to
serve the society of which they arc a part. Instead they often select
experiences that will make them more like the teachers who are con
cerned with serving only a small segment of that society.
Another general complaint relates to the quality of instruction. Since
lectures are still the most widespread instructional method in medical
education, the feeling prob ably indicates a major dissatisfaction with this
technique, at least as it is current!} used. But it also reflects a general
sense of alienation between students and teachers, a longing for the
personal concern through which the best teachers have always helped
students to find their way through the educational maze towards a
professional career they discern only dimly. As class sizes increase—a
phenomenon that is worldwide—the occasions for these interactions
seem to be diminishing steadily. Yet when opportunities are provided
teachers are often discouraged by the infrequency with which students
84
COMPETENCY-BASED CURRICULUM DEVELOPMENT
use them. One explanation of this behaviour is that learners have
found it safer to go unrecognized, to remain anonymous, for individual
exposure may lead to judgement that they are unworthy instead of
to the constructive help that will make them more competent.
This highlights a third target for complaint: examinations and
grading. The fairness of academic testing is challenged by students in
many countries who feel that most tests do not provide an opportunity to
demonstrate what they know, and certainly not enough to allow the
judgement embodied in a grade. In countries that use only terminal
examinations (whether oral, objective, or in essay form), students
press for more frequent assessment, while in those with many interim
tests the plea is for a reduced number so that time can be spent on
meaningful learning rather than preparation for examinations.
These observations might suggest that students would find a
competency-based and mastery-oriented curriculum very appealing.
It addresses the issue of content and relevance, provides opportunity
for independent pacing and alternative sequence, incorporates a variety
of learning experiences designed to serve clearly defined competency
objectives, employs an assessment system aimed at maximizing the
opportunity for all to succeed rather than assigning a grade, and
envisages greater commitment by teachers to the facilitation of indi
vidual student learning. But what is conceptually appealing is not
always operationally comfortable. If this kind of curriculum plan is
to succeed, students too must adopt new roles.
One necessary change is abandonment of an adversary position and
acceptance of a willingness to join with teachers in thoughtful discus
sion about learning objectives and instructional strategies. Just as the
teaching staff must use new sources to determine educational goals that
are consistent with community needs, so must students learn that their
personal opinions must be replaced by systematic delineation of the
competencies to be acquired. Demands for a stronger voice in planning
will probably produce a favourable response from teachers only when
students show willingness to engage in a disciplined examination of
alternatives, not merely emotional espousal of beliefs.
A second change will require students to accept the personal
responsibility for learning that is a central component of the
competency-based system. Although they may complain about inflexi
bility, students have been so conditioned to fixed class schedules, and to
accumulating lecture notes from which to study for final examinations
on which they will be graded, that being faced with options instead of
schedules, making choices rather than following directions, and
revealing ignorance in order to learn rather than concealing it in order
to get a high grade will all create anxieties that may initially be even
greater than those they now feel.
PREPARATION OF TEACHERS, STUDENTS AND INSTITUTIONS
85
If these arc Tthe role changes that a competency-based curriculum
requires, how can they be brought about?
STRATEGIES FOR CURRICULUM CHANGE
Behavioural scientists have identified 3 principal methods through
which educational changes are accomplished, either by design or by
accident: power, rationality and re-education.
Power
Strategics based on power are the most common, and most rapid,
means of producing any alteration in educational programmes. A vicechancellor or a dean may in some institutions identify a programme goal,
mobilize the resources that such a position controls, and in relatively
short order institute something new. More commonly this power is
vested not in a single individual but in a group of department heads who
negotiate with one another like leaders of sovereign states. Within
their empires, individual decisions about programme policies and
procedures are absolute. Teachers and students may have reservations
about the modifications proposed by such authorities and may even
vcnce their concern, but in the end it is the power figures who make
the decision after winning the support of colleagues or having decided
to proceed despite opposition.
While this method is effective there is a real question as to whether
it is efficient or lasting. The following illustration is taken from public
education in a developing country where sleeping sickness was
endemic:1
Field surveys showed that in some areas up to 40% of the inhabitants had the
disease. Tests revealed that the disease could be controlled by cutting the brush along
the streams in which the tsetse fly, the carrier of the disease, bred^The people disbeheved that sleeping sickness was carried by the fly. Moreover, thev resarded certain
patches of brush along the stream as sacred and inhabited by spirits who would be
angry if their abodes were disturbed. The clearing of the brush was successfully carried
out only when pressure was applied by.., officials throush the traditional framework
of native authority. While the disease was virtually eliminated, the ... people never
associated this fact with the cutting of the brush. This was a measure imposed upon
them by force from higher authority. Inasmuch as this practice was not incorporated
in their cultural system, there were strong indications that this activity would dis
continue after the withdrawal of [official enforcement].”
86
COMPETENCY-BASED CURRICULUM DEVELOPMENT
If a change in educational programming is to be real and lasting it
must, like preventive medicine, be worked by more than the power
of leaders. They may be able to establish the appearance of change, but
the teachers who control classrooms ultimately determine the spirit of
what goe£ on there. Without their full understanding and support, what
looks admirably different in form may prove in substance to be no
more than old wine in new flasks.
Rationality
Empiric al-ration al methods for educational programme change
should be particularly appealing to an academic community of scholars,
for they embody the principles that presumably undergird the whole
structure of higher education. Certainly they have flourished in the
contemporary world of university research. The proponents of this
strategy can be expected to assemble supporting data, investigate alter
natives, and through dispassionate reasoning produce a recommenda
tion that is itself open to further modification on the basis of experience
or experimentation. This orientation led a planning group in one medical
school attempting to establish the basic objectives for a competency
based curriculum to seek the opinion of many individuals before culling
the findings and making a rational appeal to colleagues:1
“The subcommittee majority forwarding this document has no expectation that it
will be acceptable to all. The members are agreed that the objectives outlined here
require further discussion, extension, elaboration, and even excision of some items
by a larger sample of the faculty. They can only note that what is included represents
more than the personal views of eight people—it is the distillation of ideas contributed
by nearly 300 faculty members, 50 practitioners in various settings, some 40 senior
students, and others who have recorded opinions or information in the literature of
medicine. While they believe that the general content of objectives is both appropriate
and substantively sound, they are neither willing nor prepared to defend each item;
but they do insist that the kind of specificity illustrated here is essential if the final
document is to be more than a collection of appealing generalities”.
The proposal that accompanied this recommendation, like so many
others that have focused attention on the basic competencies required
in those who will render much needed primary care, encountered attack
almost immediately. Although it could not on rational grounds be
assailed as inappropriate, it was rejected by those with special interests
as being incomplete. The document was concerned with the issue of
identifying a minimal competence expected of all students, and it gave
little attention to things required beyond that minimum. Those who at
1 AbraAam Lincoln School of Medicine Subcommittee on Objectives. Report to the Committee
on Instruction. Chicago, University of Illinois College of Medicine, 1970 (multilith).
PREPARATION OF TEACHERS, STUDENTS AND INSTITUTIONS
87
heart rejected the rational premise upon which it was built found in this
omission a reason for withholding their endorsement.
While any proposal that omits logic and reason is suspect, it is
essential to remember that logic alone rarely produces significant
change: the psychological needs of the teachers and students whose
support is required must also be dealt with. The third strategy attempts
to encompass both.
Re-education
The position taken by advocates of this strategy is captured in these
words:1
“Change in a pattern of practice or action ... will occur only as the persons
involved are brought to change their... orientations to old patterns and develop
commitments to new ones... [These] involve changes in attitudes, values, skills,
and significant relationships, not just changes in knowledge, information or
intellectual rationales for action and practice”.
It is no small task to work such change; and, before beginning,
those who undertake it should recognize the ingredients essential to
success. They fall into two major categories: things that hinder and those
that nurture the learning that will lead to new educational patterns.
Many scholarly volumes and practical guidebooks have already been
written on these topics; this monograph can do no more than identify
the issues that must be considered.
Among the barriers to re-education of teaching staff and students,
4 are particularly prominent:
(1) Inertia. The physical law that describes “the tendency of a body
when at rest to remain at rest, and when in motion to remain in motion
until acted upon by some outside force” is equally applicable to formal
education. It is much easier to go on “teaching” than to learn how to
become a “planner”, “manager”, or “evaluator”, and teachers are
remarkably skilful in finding persuasive reasons for avoiding even
intellectually desirable things that are emotionally unappealing.
The frustration such passive resistance generates in reformers
sometimes leads them to attempt to achieve change through the exercise
of power. But the most powerful stimulant to sustained change is one of
helping learners (whether they are teachers or students) to discover
that change to a new pattern of behaviour will serve them better than
1 Chin, R. & Benne, K. D. General strategies for effecting changes in human systems. In: Bennis,
W. G. et al., ed. The planning of change, New York. NY. Holt, Rinehart & Winston, 1969.
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COMPETENCY-BASED CURRICULUM DEVELOPMENT
preservation of the old. Since both teachers and students are invariably
dissatisfied in some way with the educational programmes m which
they are participants, the skilful agent of change will use these dissatisfactions as the point of entry for joint determination of how things
might be modified. Once their attention has been captured it is easier
to guide them towards new data, or to authoritative sources that can
provide a suitable rationale for change.
(2) But if this is to be accomplished, leaders must scrupulously
avoid the barrier that is created by aggressive action. Change agents
often become their own worst enemies by exhibiting impatience with
the slow pace of progress toward a new plan. One perceptive observer
has pointed out:1
“
we should not strive too much for speed in mental activities. To get speed we
have to keep the same patterns of thought; and if wc keep the same unchanging
patterns of thought we renounce all possibUity of being original and creative ... e
should not feel stupid if we cannot understand—let alone accept—a new idea or
theory. It takes time to disconnect our habitual nerve cell patterns and reconnect
them in a different order”.
Internalization of a new idea to the point of modifying behaviour
cannot be hurried by pressure or coercion. An astute leader will instead
highlight even small gains while encouraging the more difficult steps
that remain to be taken.
But the facilitator must also show personal willingness to change
course if open discussion and exploration of alternatives identify a better
path. To behave like a zealot, demanding unswerving adherence to a
single view, will arouse hostility and resistance instead of fostering the
spirit of cooperation that is essential to successful implementation of a
competency-based programme.
(3) There will inevitably be barriers created by priority conflicts.
Teaching staff in many medical schools point out that personal progress
in an academic career depends first on productive scholarship (by which
they usually mean publication), and secondly on developing some
unique skill in delivering direct patient care. Thus it should come as
no surprise if these activities take priority over learning how to become
the educational “planners”, “managers”, or “evaluators” who are
required to establish a competency-based curriculum. Those who press
teachers to accept these new educational tasks as a high priority must
somehow deal with what those staff members may perceive as a dif
ferent reality.
1 Bois, J. S. Art of awareness, 2nd ed., Dubuque, IA, Wm. C. Brown, 1973.
PREPARATION OF TEACHERS, STUDENTS AND INSTITUTIONS
89
(4) But the most important barrier is probably territoriality. Medical
schools in most countries have developed as a collection of virtually
independent units called departments or institutes. Faculty' organization
is loose and administrative responsibility is commonly assigned to a
dean who has little authority, is a temporary occupant of the post, and
is seen as a presiding officer rather than a decisive leader. Without a
more effective system of checks and balances governing departmental
autonomy than, now exists in all but a handful of institutions, intro
duction of any school-wide curriculum change is nearly impossible
since each component unit has what amounts to veto power. Asking
department heads to relinquish some of that authority is unlikely to
produce anything more than resistance. Thus an early part of any
re-education strategy must be directed toward the dominant figures,
who may see only an erosion of their power in a competency-based
curriculum. Winning the support of at least a significant segment of
that leadership group is essential if educational programme change is
to be substantive, not merely cosmetic.
Many readers may wonder why limited resources have not been
cited as an important barrier to change. The reason can be simply
stated: the greatest impediments are found in the heart, not in the
purse. In this volume illustrations from developing countries have been
used not only as a means of keeping the focus on the sites of greatest
need, but also to show that where there is a will a way can be found, no
matter how limited the resources. It is unquestionably true that some
kinds of change may demand funding or personnel beyond the reach of
some nations, and others would be easier if additional resources were
available. But it is also true that even the richest countries have exper
ienced difficulty in establishing educational programmes in medicine
that are directed at national health service needs rather than the
traditional production of conventional health personnel. External
constraints, of which inadequate resources are one, cannot be ignored.
But, as someone once said, "even in a strait-jacket, there is room for
some movement”.
Aids
What, then, of the obverse, the methods available to facilitate new
kinds of programme development?
(1) Anyone trying to understand why teachers behave as they do,
or attempting to change that behaviour, would be wise to look first at the
reward system. If a, staff member is recognized for contributions to
patient care, then this work is likely to claim the greatest attention; if for
90
COMPETENCY-BASED CURRICULUM DEVELOPMENT
research productivity, this is where effort wiU first be invested. And to
judge from the tales told in all parts of the world, creative work in
medical education is the function least likely to bring ^^emi
recognition or reward. Changing this order of things will be difficult
but a beginning must be made if such innovations as competency-based
cmriculum organization and mastery-learning methods are ever to
become an integral part of the fabric of modern medical schools^
The responsibility for producing this change lies squareiy ori th
shoulders of medical school leaders. They themselves may notcarry out
the work, but without their encouragement and suppor.itw 11 never be
done—at least not in a way that has lasting impac.on a school .Cert y
individual teachers or individual department heads here and there^have
brought about substantial changes in the educational programmes for
which they are directly responsible, but without general endorsement
by the power structure these changes remain isolated isiands injan
educational sea that is very different in character. In he face of facuky
apathy, as well as the student hostility that eventually focuses on deviant
programme methods, the probability is high that such change will
vanish, or at the very least will fail to thrive.
(2) For competency-based curriculum efforts there is a growing
extraLtitutional force that may facilitate the development of a
supportive institutional value system. This is the force describe
beginning of this volume-a steadily mounting demand from those who
provide le funds for medical education, and those who depend on
the services delivered by its graduates, to make the educational process
mmecZuentwithcoL
institutions that respond to these expectations, and institutional policy
makers reward departments and individual teachers who. work towa
bringing about the necessary programme changes a process will be set, m
motion that cannot fail to gain momentum. The danger t that
.
momentum may become a blind force, directed toward the imposition
of a new educational orthodoxy and not the continuing renewal of a
data base for perpetual programme review and refinement.
(3) This ever-present danger, as well as the pull of reason, leads
directly to the final facilitating factor—research in education A medical
school staff must learn how to study the process of medica! educat ,
to examine its efficiency and its effectiveness, its costs andbenefits,
and to use the findings for further programme improvement. Faith
unsupported opinions and limited personal experience as a basis for
generalization are insufficient in medical education just as they are m
health care. Continuous and systematic self-scrutiny is uncon’forta^’
but it is a method that has brought great strength to medical science.
PREPARATION OF TEACHERS, STUDENTS AND INSTITUTIONS
91
As one of the cornerstones for competency-based curriculum develop
ment it can lend equal strength to medical education. It is surely the
most promising tool now at hand for bringing about a better match
between education for the health professions and national health
service needs.
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