curriculum & context - iapae.files. · pdf fileexisting models within the institution ......
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Curriculum & Context
Nick Ross Emeritus Professor University of Birmingham UK
A disclaimer There is no such thing as the perfect curriculum for the Physician Associate Profession.......
A disclaimer There is no such thing as the perfect curriculum for the Physician Associate Profession I cannot begin to tell you what YOUR Physician Associate curriculum should look like All I can do is point you towards some issues you need to explore, some questions you might usefully ask and some tools you might use
• In the region / country in which it is located:
• For the professional role as planned
• In the context of the educational institution
• In the context of the health care provider partnership:
• For the nature of the intake
• In the historical context
There is no single perfect curriculum... for any health profession.
Too many variables that MUST be allowed to shape the curriculum so that it is fit for purpose...
The national / regional context
the pattern of disease / health need related to demographics relate to economic development / wealth related to climate and geography
the demography of the country age profile ethnicity and related health issues immigration / emigration change as a factor in its own right
The health care system
General organisation Community and hospital care State, charitable and/or commercial providers Existing mix of health care professions National or local legislative framework
The role of the Physician Associate Fields in which role is, or may be used Scope of PA practice: e.g. prescribing Mentoring, supervision and professional accountability
The health care provider partnership
Good partnerships with providers are vital
Institutional link
Involvement in programme development / implementation
Sponsorship
Provision and supervision of student placement - criteria under which student placement is offered - roles of education and provider organisations - nature of supervision - expectations of the student PA
Internship
Employment
• Special rules apply to an emergent profession which may not be as important for an established profession. • Lack of knowledge and therefore limited trust amongst employers and public. • Professional patch protection • Overwhelming institutional scrutiny
The era in which the programme runs The evolution of the profession
• Existing models within the institution
• Human resources
• Physical resources
• Faculty skill set
• Institutional self-perception
GREENFIELD and BROWNFIELD Sites
The educational institution: I
Green field & Brown field Greenfield Site
Say NO to PAs! We don’t know what they are, but we’re SURE we won’t like them
Green field & Brown field
Ancient monuments and preservation orders
The graveyard of previous failures
Existing regulatory framework
Infrastructure that limits change
Slurry pool of Toxic Opinions
Brownfield Site
The educational institution: II Existing models within the institution To what extent is the development of a new programme constrained by institutional regulation? Are there institutional programme norms: custom and practice?
Are there norms in the institution specific to programmes for health care professionals?
Is there a school of medicine?
The educational institution: III Physical Resources: • Largely lecture based, or significant small room use? • Is there a morbid anatomy facility available? • Is there a skills centre / clinical simulation facilities? • Is there the potential for dedicated space? Virtual Learning Resources: • Is the necessary hardware for virtual learning available? • Is there a student/staff friendly virtual learning environment? • Are faculty engaged in producing materials? • Does the ‘virtual campus’ include the clinical area?
The educational institution: IV
Human Resources: • What importance is given to education in the academic model of the institution? • What is the level of engagement of academics with pedagogy as a discipline? • How much of the teaching is done by faculty and how much by honorary staff? • What skills / experience do faculty / potential faculty have? You have to start from where you are, not where you would like to be (just as with students)
Professional grand-parenting Medicine (whether we like it or not) is the senior partner. Norms for medical education determine norms for PA education as for any profession fulfilling a medical role. Differences between US and UK medical education reflected in US and UK PA programmes Institutional grand-parenting • Successful programmes we know and admire • Offers of faculty assistance • but: ‘buyer’ (and ‘seller’) beware.... ...evangelical / philanthropic or colonial / multinational
What shapes the curriculum?
Cross-professional Frameworks Statutory accreditation processes National Examinations The recommendation of others Voluntary agreements
What shapes the curriculum?
UK Competence and Curriculum Framework (PAMVRC)
Institutional Support without the continuing support of the institution, the best curriculum in the world is worth nothing. • Does the institution believe that this is something it should be doing - does it reinforce the message it wants to give to the world? •What compromises are necessary on the part of programme developers to meet institutional budgetary constraints? • What priority does the institution give to education in general and the partnership with health providers in particular?
What shapes the curriculum?
Maturity of Intake
What age are students when they enter the programme and how much life experience do they have? • A programme designed for 18 year olds would not take advantage of all that mature students have to bring. • A programme designed for mature students may fail to engage younger students who expect the pedagogic approach that they’re used to in school.
What shapes the curriculum? Intake
Prior educational experience
At what level are students taken into the programme - as school leavers; as graduates? What is the nature of prior education – • highly didactic? • valuing independent learning / development of life-long learning skills? Academic ability
How selective is the programme able to be in terms of the intake? How mixed is the ability of the cohort?
What shapes the curriculum? Intake II
Prior learning
• What learning are students required to bring to the programme • Is the programme about the novel application of prior learning to a new context, or about fresh disciplines Character
The professional persona is of vital importance. • To what extent is this left to a process of professional ‘formation’.... • ...or is appropriate 'character' expected from outset?
What shapes the curriculum? Intake III
definition of the profession / role patterns of supervision / dependency readiness for assuming the medical role scope of practice - profession - cohort - individual
What shapes the curriculum? Output
Curriculum decisions: philosophy
process...........product leading...........following educational comfort.............educational challenge disciplines..........integration profession oriented............service oriented
None of these are categorical decisions!
Curriculum decisions: ordering
Bloom and concept of domains
Evaluation Synthesis Analysis Application Comprehension Knowledge
Bloom (1956) Cognitive taxonomy
Kratwohl (1964) Affective taxonomy
Internalise Organise/resolve Value Respond Receive
Curriculum decisions: ordering II
Dave (1970) Psychomotor taxonomy
Unconscious mastery Adapt and integrate Execute reliably Reproduce from memory Observe & replicate Steinaker & Bell (1979) Experiential taxonomy
Dissemination Internalisation Identification Participation Exposure
See one
Do one
Teach one
The dream of philosophical / educational discourse without language • fuzzy logic • discussion of concepts • keeping the big picture • not getting mired in language
Curriculum decisions: Models I
Visual Curriculum Models
Benefits of visual modelling Herman Hesse The Glass Bead Game
Shaping the curriculum: Models II
Content / product models
Tyler (Basic Principles of Curriculum and Instruction - 1949) Product focussed / content driven Owes much to Henry Ford - production line thinking
• Defining appropriate behavioural objectives
• Establishing useful learning experiences
• Organizing learning experiences for maximum cumulative effect (subject precedence +)
Focus on measurability can lead to ‘immeasurables’ being ignored
Carl Rogers (and others)
Emphasis on personal growth rather than specific outcomes: on offering and enabling experiences.
Shaping the curriculum: Models II
Personal growth
Driven by individual curiosity
Does such a model have anything to offer in professional healthcare education?
JUSTIFICATION FOR LEARNING
DEFINITION OF KNOWLEDGE
Closed (authoritative, consensual)
Open (conditional, reflexive)
Intrinsic Extrinsic
Curriculum as a portfolio of meaningful experiences
Curriculum as a map of key subjects
Curriculum as an agenda of important cultural issues
Curriculum as schedule of basic skills
Shaping the curriculum: Models III
Shaping the curriculum: Models IV
Bruner: The Spiral Curriculum Kolb in 3D
experience
reflection conceptualisation
reapplication
Shaping the curriculum: Models V
Science in Medicine
Individuals and Populations
Clinical Skills
Diagnosis and Decision Making
Professional Skills
Treatments
Lifespan
A curriculum model for medicine I
Managing the patient, sick and well
A curriculum model for medicine II
Broadening the professional base
Acquiring using clinical information
Synthesising and applying the medical knowledge base
Building the medical knowledge base
A curriculum model for medicine III
Managing the patient, sick and well
Broadening the professional base
Acquiring using clinical information
Building the medical knowledge base
Synthesising and applying the medical knowledge base
Science in Medicine
1
2
3
4
DO
MA
INS Lifespan Clinical Skills Science in
Medicine Individuals and Populations
Diagnosis & Decision Making
Professional Skills
Treatments
A curriculum model for medicine IV
C
1
2
3
4
Introduction to the basics of pharmacology: major classes of drug, their action and interaction. Principles and economics of prescribing. Influencing lifestyle decisions.
The elderly in general and specialist hospital settings, in social care and in their own homes. Social and cultural constructs of old age. Normal pregnancy and developmental milestones.
Ageing as a biological, psychological and social process. Health problems / challenges for different age groups. Immunisation vaccination, screening and health MOTs
Children, adolescents and the elderly in mental health settings. End of life issues: patient, family and clinician
Pregnancy and childbirth. The roles of community and hospital medicine. The child and their family in the hospital setting. Adolescence adulthood and sexual health.
Therapeutics: individual patients: actions reactions and side effects. Safe prescribing. Surgical management in OD and perioperative environment. Fluid management. Rehabilitation
Therapeutics in specialist environments. Effective prescribing. Radiotherapy and chemotherapy. Special considerations in palliative care. Ethics and law of treatment in mental illness
Complex and urgent treatment in the patient with a life threatening illness. Adapting treatment regimes to the context of paediatric medicine. Medicalisation of normal life events
Translating organisational skills into the NHS Trust environment. Pt. safety and quality improvement. The multi-professional team. Self-directed learning in a pt. centred environment.
Adapting learning skills for the challenge of medicine Skills of self management, team work and working within an organisation. Principles of Ethics and Law in Medicine
Breaking bad news. Interpersonal skills in difficult / conflicted situations. Competence, consent and vulnerable adults. Responsibilities to patient, organisation and profession.
Professional responsibility and the clinical team. Moving from the student to the employed doctor role. Competence and confidence. Meeting the requirements of the New Doctor
Understanding process of diagnostic reasoning. Developing a differential diagnosis for presentation to supervisor. Roles of doctor and patient in clinical management decisions.
Developing the critical, analytical and reflective skills that underpin effective decision making. Observing and exploring the clinical decision making of others
Developing a differential diagnosis in specialist settings. Treatment decision making. EBM Referral, multi-disciplinary teamwork and decision making in difficult circumstances
Decision making in the acute environment. Decision making in the management of life threatening illness. Coping with uncertainty, wrong decisions and error.
Developing competence in taking a comprehensive patient history and physical examination. Development of procedural skills as mapped in the Passport.
Developing initial skills in history taking and examination as well as common non-invasive procedural skills that can be learnt / practiced in community-based medicine
Application of patient history taking, physical examination skills in specialist settings. Psychiatric assessment Development of procedural skills as mapped in Passport.
Sexual and obstetric history taking. Integrating physical examination with info. from monitoring etc. in the acutely ill patient. Developing and refining consultation skills.
The psychological effect of hospitalisation on the individual. Recognising mental health issues in a general health setting. The health of the hospital population.
Introducing students to behavioural sciences, public health, promotion and prevention, disability-both physical and mental. Individual choice, social pressure and the role of the doctor
The individual in society. Social construction of the meaning of ‘normal’. Life style choices and health. Serious illness and self perception. Addiction. Grieving. Mental illness. Stigmatising conditions.
The social context of community medicine. Individuals, families and populations in continuing relation to the practice. Pregnancy, parenthood and childhood .
Additional basic science to support developing physical examination skills. Basic concepts of clinical sciences and application to diagnosis and management.
Setting the basic science foundation, using system based approach which integrate the disciplines, but using a matrix assessment to ensure no discipline is ignored.
Additional basic science and clinical science in the context of specialist medicine, orthopaedic and general surgery and organic mental illness
Basic science for critical care. Understanding and supporting failing systems. Physics and biochemistry re: the ventilated patient.
DO
MA
INS Lifespan Clinical Skills Science in
Medicine Individuals and Populations
Diagnosis & Decision Making
Professional Skills
Treatments
advantages of stability for the institution for health care provider partners for faculty for students disadvantages gradual loss of relevance slow deterioration.....
Stability & Fluidity in the Curriculum I
The stable curriculum WILL reach a point where it is no longer fit for purpose. • The circumstances that shaped it • The faculty who made it work • The health care environment into which it feeds
When it ceases to function, revolutionary change is the only answer ...but it is notoriously difficult to get right
Stability & Fluidity in the Curriculum II
Stability & Fluidity in the Curriculum III
...even when it may sometimes be necessary ...and there will be blood
Institution: - cost of planning - cost of change / disruption Faculty: - principled disagreement with change - wedded to particular content being lost - wedded to an approach to the subject) - personal investment in the way things are change as personal attack - 'over my dead body' Students: - the rump............... - the guinea pigs......
faculty aren’t interested faculty don’t know what they are doing
Nothing lasts forever
Stability & Fluidity in the Curriculum IV
The Carnegie Foundation 1910 Flexner Report
2010 Cooke, Irby, O’Brien Educating Physicians A Call for Reform of Medical School and Residency
investing in fluidity
content fluidity
....ought to be relatively natural for a research / practice driven profession where development is a constant.
....but cutting edge research may be the wrong driver ....loss of clinical relevance may go unrecognised ....disciplines may not be valued
Stability & Fluidity in the Curriculum V
Genomics / proteomics Rheumatic Fever Communication studies
structure / process fluidity (curriculum and classroom practice)
requires a recognition of / engagement with educational process and a capacity for abstract thinking which is not always present amongst discipline specialists or clinicians
Developing a culture of continuing innovation requires...
The encouragement and support of the institution The engagement and education of faculty The involvement of health care partners The affirming of students as partners in the process
Stability & Fluidity in the Curriculum VI
Thank You!