AMEE guide No. 14: Outcome-based education: Part 2-Planning, implementing and evaluating a competency-based curriculum

Editorial Comment

Medical EducationVolume 48, Issue 5 p. 525-525 Really Good Stuff: Lessons learned through innovation in medical education Clinical sketches: teaching medical illustration to medical students Kevin T Liou, Kevin T LiouSearch for more papers by this authorPaul George, Paul GeorgeSearch for more papers by this authorJay M Baruch, Jay M BaruchSearch for more papers by this authorFrançois I Luks, Corresponding Author François I LuksCorrespondence: François I Luks, Department of Paediatric Surgery, Alpert Medical School, Brown University, 2 Dudley Street, Suite 190, Providence, Rhode Island 02905, NJ, USA. Tel: 00 1 401 228 0556; E-mail: [email protected]Search for more papers by this author Kevin T Liou, Kevin T LiouSearch for more papers by this authorPaul George, Paul GeorgeSearch for more papers by this authorJay M Baruch, Jay M BaruchSearch for more papers by this authorFrançois I Luks, Corresponding Author François I LuksCorrespondence: François I Luks, Department of Paediatric Surgery, Alpert Medical School, Brown University, 2 Dudley Street, Suite 190, Providence, Rhode Island 02905, NJ, USA. Tel: 00 1 401 228 0556; E-mail: [email protected]Search for more papers by this author First published: 09 April 2014 https://doi.org/10.1111/medu.12450Citations: 3Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article.Citing Literature Volume48, Issue5May 2014Pages 525-525 RelatedInformation

Objectives The purpose of this study was to propose evaluation criteria for assessing competency-based medical education curriculum, which are currently the main educational programs in medical schools in South Korea. The ultimate goal was to enhance the quality of medical education by establishing evaluation criteria that reflect the characteristics of competency-based medical education curriculum.
 Methods To achieve this, the study conducted a literature review to identify the characteristics of competencybased medical education curriculum and analyzed existing evaluation models and criteria used in medical education. Based on this analysis, primary evaluation criteria were identified. Subsequently, interviews were conducted with five experts to derive practical elements that should be included in the evaluation criteria, considering the current reality of medical education curriculum in South Korean medical schools. Through the literature review and expert interviews, the final evaluation criteria were developed.
 Results Through literature analysis, we have developed a framework for evaluation criteria by combining evaluation models that are commonly used in medical education. By analyzing previous studies that mentioned evaluation criteria in the field of medical education, we initially derived 8 evaluation areas, 31 evaluation items, and 73 evaluation indicators. Subsequently, incorporating the secondary evaluation criteria factors derived from expert interviews, we organized them to finalize 5 evaluation areas, 19 evaluation items, and 61 evaluation indicators.
 Conclusions This study contributes to the development of evaluation criteria and models that reflect the theoretical and practical characteristics of competency-based medical education curriculum in medical schools. Additionally, through the investigation process, it provided in-depth insights into the challenges and areas for improvement faced in implementing competency-based medical education curriculum in current medical schools.

Objective and Aim The growing emphasis on accountability, quality assurance, and outcomes-based education has intensified the demand for robust and critically appraised evidence in medical education. While the principles of evidence-based medicine have substantially shaped clinical decision-making, their direct transfer to educational contexts has proven conceptually and methodologically challenging. Objective: This systematic review aims to synthesize the literature on evidence types, critical appraisal frameworks, and methodological quality standards in medical education research, and to present an integrative appraisal matrix suitable for educational decision-making. Methods A systematic review was conducted in accordance with PRISMA 2020 guidelines (7). Searches were performed in MEDLINE (PubMed), ERIC, Scopus, and Web of Science for studies published between 2000 and 2024. Included studies addressed evidence hierarchies, critical appraisal, research quality instruments, or methodological frameworks in medical or health professions education. Data were synthesized narratively due to methodological heterogeneity. Results Eighty-four studies met inclusion criteria. Evidence in medical education was categorized into quantitative, qualitative, mixed-methods, and design-based research. Traditional biomedical hierarchies were insufficient to capture educational relevance and contextual complexity. Appraisal tools such as BEME, MERSQI, CASP, and realist review frameworks were commonly cited, yet inconsistently applied. Conclusions Critical appraisal in medical education requires a pluralistic, theory-informed, and context-sensitive approach. The proposed appraisal matrix integrates methodological rigor, educational relevance, outcomes meaningfulness, and transferability to support informed educational practice. Keywords: Medical education research; Systematic review; Critical appraisal; Evidence hierarchy; Research methodology

Atul Butte discusses the divide between bioinformatics and the clinic

Currently one federal program funds community health centers (CHCs) to provide services in underserved communities, and a second supports development of primary care teaching programs. Teaching CHCs respond to both program's goals, but their development is hindered by restrictive regulations of the two programs and lack of information regarding cost. Spreadsheet software was used to develop a model that allocates cost components of a CHC-based residency. Productivity and staffing data from a teaching CHC program were used to estimate the cost of training and its sensitivity to selected variables. Data from 1992 through 1994 were collected from the family practice residency sponsored by the Brown University School of Medicine, the Memorial Hospital of Rhode Island, and the Blackstone Valley Community Health Center. An educational supplement of $13.21 per visit would be required for the program to be cost-neutral relative to staff. The cost of outpatient training for a resident averaged $13,935 per year. Residents would "break even" if they saw patients at 19% above the average rate recommended by the residency review committee. If staff physicians instead of residents had provided the patient care, the CHC would have saved $6,171 per resident. Additional savings from improved physician recruiting and decreased turnover would increase the value of the program to the CHC. Cost was most sensitive to resident productivity, precepting arrangements, nursing staff support, and staff turnover. Developing graduate medical education programs in CHCs can be a cost-effective way of increasing the pool of appropriately trained primary care physicians and increasing health care access for underserved populations. If teaching CHCs are to expand, provisions will need to be made for adequate reimbursement of their costs.

Curriculum Management and Governance Structure ♦ The Committee on Curriculum and Academic Policy (CCAP) is a standing committee of the School of Medicine Faculty Senate and is chaired by the Associate Dean for Medical Education. ♦ CCAP develops or recommends policies concerning the curriculum for the MD degree program, including the structure of the curriculum and requirements for graduation, design and evaluation of courses and clerkships, adherence to Liaison Committee on Medical Education (LCME) guidelines, and evaluation of program effectiveness. ♦ CCAP oversees the assessment of medical student academic performance in required courses, clerkships, and scholarly concentrations. ♦ CCAP advises and recommends to the Faculty Senate changes in academic policy that affect performance assessment and advising and also reviews and advises the Dean's Office on the format and content of the Medical Student Performance Evaluation (MSPE). ♦ CCAP also reviews and approves requests for new required courses and clerkships (core and selective). ♦ The standing committees of CCAP that provide advice and input to CCAP on curriculum management and policy issues are as follows: Pre-Clerkship Course Directors Clerkship Directors Clerkship Evaluation Committee Office of Education ♦ The Office of Medical Education (OME) has primary responsibility for the MD program. ♦ The office is led by the Associate Dean for Medical Education, who has direct responsibility for the curriculum and its core faculty leaders, and the Assistant Dean for Medical Education, who manages the staff, finances, and operations and assists with curriculum management (Figure 1).FIGURE 1:: Office of Medical Education♦ The Office of Medical Education reports to the Senior Associate Dean for Education, who has a broader leadership role within the School of Medicine that includes undergraduate medical education, graduate medical education, and continuing medical education. ♦ In addition to the Associate Dean for Medical Education, eight faculty provide leadership, on a part-time basis, for core educational programs within the MD program, including the Preclerkship Curriculum; Clerkship Program; Educators-4-CARE; Scholarly Concentrations; Standardized Patient Program; and the Research, Reflections and Advances in Patient Care Curriculum. ♦ In addition to the Assistant Dean for Medical Education, there are nine full-time staff and one part-time staff who support the MD educational programs as listed previously. In addition, two full-time staff direct and support the Division of Evaluation, which oversees the evaluation of required courses and clerkships. Financial Management of Educational Programs ♦ During the current financial crisis, emphasis has been placed on reducing nonessential operational costs in order to retain the FTE necessary to continue delivery and improvement of the curriculum. Another goal has been to retain sufficient operational funds in order to maintain the quality of education for students. Nonessential travel and food/entertainment expenditures have been among the key areas for cost reduction. Valuing Teaching ♦ In 2008, Stanford established the “Educators-4-CARE” (E4C) program. E4C is a program in which we carefully select 15 faculty recognized for compassion, humanism, and excellence in teaching to serve as small group teachers and mentors for six students each, beginning at matriculation and lasting until graduation. ♦ The program embodies a commitment to Compassion, Advocacy, Responsibility, and Empathy. Although beyond this there is currently no formal academy/institute at Stanford for educators, an effort is currently under way to review how the promotion and tenure process could be adjusted to more directly value teaching. ♦ The Teaching Excellence Task Force was created in 2009 and is currently at work on addressing these issues, including evaluation of teaching, award/recognition of excellence in teaching, and optimal allocation of education funding to best support teaching. ♦ Excellence in teaching is currently recognized through a variety of teaching awards, the recipients of which are selected by students. In addition, key education leaders and nominees for teaching awards are annually acknowledged for their contributions. ♦ New and enhanced faculty development initiatives are currently in development. Curriculum Renewal Process ♦ Curriculum renewal began in 2002, with the following goals: early and substantive instruction in clinical skills integration streamlined content and optimized course sequence melding basic science and clinical concepts blocks of unscheduled time for study, electives, research option of a fifth or sixth year of study, dual degrees scholarly concentrations mentored opportunity for scholarly work in selection of thematic areas Learning Outcomes/Competencies ♦ A reexamination and update of competencies will be launched in 2010. ♦ Current competencies are listed on the following website: http://med.stanford.edu/md/competencies.html. New Topics in the Curriculum Since 2000 ♦ Patient safety: introduced in 2010 (preclerkship curriculum) ♦ Quality improvement: introduced in 2010 (preclerkship curriculum) ♦ Team-based learning: introduced in 2007 (preclerkship curriculum) ♦ Simulations/training in new surgical techniques: introduced in 2004 (preclerkship curriculum and selected clerkships) Changes in Pedagogy ♦ Stanford launched a new preclerkship curriculum in 2003. Themes of this curriculum include experiential, small-group learning; early clinical exposure (through the Practice of Medicine course); integration of clinical and basic sciences (through the Human Health and Disease course); and scholarship and discovery. ♦ We are beginning to analyze data from the initial cohorts through our new curriculum, looking at performance on USMLE exams, residency performance, and AAMC GQ measures, among others. ♦ Longitudinal mentorship was introduced in 2009, with the Educators-4-CARE (E4C) program. ♦ As noted earlier, beginning in 2008, each incoming medical student has been matched with an E4C faculty member, who serves as a teacher, mentor, and colleague for the duration of the student's time in the School of Medicine. ♦ E4C faculty play a key role in the development of students' clinical skills, serving as instructors in the Practice of Medicine course, and maintain contact with clerkship students through Doctoring with CARE small-group reflection sessions during the clinical years. Evaluation to measure the impact of this new program is under way (see http://med.stanford.edu/e4c/). Changes in Assessment ♦ The Criterion-Based Evaluation Initiative: Prior to July 2010, all courses and clerkships have been graded on a Pass/Fail basis. ♦ The Pass/Fail system will continue within the preclerkship curriculum. However, beginning in July 2010, students will have the opportunity to be recognized for exceptional performance (“Pass with Distinction”) in each required clerkship. ♦ Evaluation of performance will be criterion-based. All students whose performance meets established criteria will be recognized for exceptional performance, independently of how other students perform. ♦ This approach is in contrast to a curved or norm-based system, where only a certain proportion of students are eligible to earn the top descriptor of performance. Clinical Experiences ♦ The primary training site for the MD program is located in Palo Alto, California: Stanford Hospital and Clinics and Lucile Packard Children's Hospital. ♦ Additional major clerkship training sites include Kaiser Permanente Medical Center in Santa Clara, California; the Veterans Administration Medical Center in Palo Alto, California; and Santa Clara Valley Medical Center in San Jose, California. ♦ Preclerkship and clerkship training also takes place at a number of smaller ambulatory sites, both public and private. ♦ The most significant challenge to clerkship programs is limited capacity. During some clerkship periods, there are an inadequate number of student slots in certain clerkships, necessitating creative ways of scheduling students and alternate experiences to meet educational objectives. ♦ Efforts are currently under way to develop new sites and to develop new clerkship models that would relieve capacity issues while enhancing educational quality. Highlights of the Program/School ♦ Educators-4-CARE: see previous description. ♦ Scholarly Concentrations: The Scholarly Concentrations (SC) program is a required, structured program of study within the MD curriculum that promotes in-depth learning and scholarship. ♦ The SCs provide medical students with faculty-mentored scholarly experiences in areas of individual interest combined with structured coursework. ♦ Of note, students enroll in courses both within the School of Medicine and on the main Stanford University campus to support this scholarship (see http://med.stanford.edu/md/curriculum/scholarly_concentrations/). ♦ Reflections, Research and Advances in Patient Care: This curriculum is designed to provide structured time to “step back” from clerkships to promote reflection on and reinforcement for learning in the clinical environment. Goals include to reflect upon critical experiences in clerkships; to expose students to recent advances in medical discoveries, with emphasis on the perspective of patients; and to continue to develop research and critical thinking skills in areas related to the Scholarly Concentrations.

Outcome-based education, a performance-based approach at the cutting edge of curriculum development, offers a powerful and appealing way of reforming and managing medical education.The emphasis is on the product-what sort of doctor will be produced-rather than on the educational process. In outcome-based education the educational outcomes are clearly and unambiguously specified. These determine the curriculum content and its organisation, the teaching methods and strategies, the courses offered, the assessment process, the educational environment and the curriculum timetable.They also provide a framework for curriculum evaluation. A doctor is a unique combination of different kinds of abilities. A three-circle model can be used to present the learning outcomes in medical education, with the tasks to be performed by the doctor in the inner core, the approaches to the performance of the tasks in the middle area, and the growth of the individual and his or her role in the practice of medicine in the outer area. Medical schools need to prepare young doctors to practise in an increasingly complex healthcare scene with changing patient and public expectations, and increasing demands from employing authorities. Outcome-based education offers many advantages as a way of achieving this. It emphasises relevance in the curriculum and accountability, and can provide a clear and unambiguous framework for curriculum planning which has an intuitive appeal. It encourages the teacher and the student to share responsibility for learning and it can guide student assessment and course evaluation. What sort of outcomes should be covered in a curriculum, how should they be assessed and how should outcome-based education be implemented are issues that need to be addressed.

A healthy lifestyle is fundamental for the prevention and treatment of cardiovascular disease and other noncommunicable diseases (NCDs). Investment in primary prevention, including modification of health risk behaviors, could result in a 4-fold improvement in health outcomes compared with secondary prevention based on pharmacological treatment. The American Heart Association (AHA) emphasized the importance of lifestyle in its 2020 goals for cardiovascular health promotion and disease reduction. In addition to defining “cardiovascular health” based on criteria for blood pressure and biochemical markers (lipids and glycemia), the AHA Strategic Planning Committee further identified lifestyle characteristics of central importance: nutrition, physical activity, smoking, and maintenance of a healthy body weight.1 The World Health Organization estimated that ≈80% of NCDs could be prevented if 4 key lifestyle practices were followed: a healthy diet, being physically active, avoidance of tobacco, and alcohol intake in moderation.2 To support healthy lifestyle initiatives, major changes are necessary at the societal level to improve population health. Numerous strategies might help to create a culture that promotes and facilitates healthy behaviors, including creating laws and regulations, mounting large-scale public awareness and education campaigns, implementing local community programs, and providing individual counseling.3 Physicians are uniquely positioned to encourage individuals to adopt healthy lifestyle behaviors: Approximately 80% of Americans visit their primary care physician at least once a year. Physicians directly communicate with their patients during clinical encounters across numerous settings, and research indicates that patients highly value recommendations provided by their physicians.4,5 However, data further indicate that lifestyle counseling does not routinely occur in physicians’ offices, thereby representing a lost opportunity. Physicians report that they perform lifestyle counseling during ≈34% of clinic visits.4 Patients, in turn, report an even lower frequency of physician lifestyle counseling. For example, obese patients reported receiving physical activity and …

Brown University School of Medicine, Providence, Rhode Island Correspondence: Donald R. Coustan, MD, Women and Infants' Hospital of Rhode Island, 101 Dudley Street, Providence, RI 02905-2401.

PRELIMINARY but promising results of a phase 2 trial of a therapy for sepsis were reported at the 32nd annual Interscience Conference on Antimicrobial Agents and Chemotherapy, held in Anaheim, Calif. Although the nonblinded study involved a small number of patients, the researchers are encouraged by the strong dose response seen and are looking forward to analyzing the results of a larger, multicenter phase 3 trial just completed. At the conference, which was sponsored by the American Society for Microbiology, Steven M. Opal, MD, associate professor of medicine, Brown University School of Medicine, Providence, RI, reported the results of the phase 2 trial of a recombinant interleukin 1 receptor antagonist (IL-1ra). The nonblinded, prospective trial involved 99 patients with severe sepsis or septic shock who were randomly divided into a placebo group and three treatment groups, each with approximately 25 patients. The day before he presented his data at the

Outcome 14 to 18 years after percutaneous transluminal coronary angioplasty

Center for Surgical Research, Brown University School of Medicine, and Rhode Island Hospital, 593 Eddy Street, Providence, RI, 02903 USA

Perinatal Consultant, Perinatal Productions, Staff Nurse Midwife, Women and Infants' Hospital of Rhode Island, Clinical Teaching Associate, Brown University School of Medicine, Providence, Rhode Island, Adjunct Assistant Clinical Professor, University of Rhode Island College of Nursing, Kingston, Rhode Island

Near-fatal skin picking from delusional body dysmorphic disorder responsive to fluvoxamine.