2 From Curricular Goals to Instruction: Choosing Methods of Instruction Psi ATs ME FAP urricula by definition are planned educational evens, and there isa generally agreed-upon proces for this planning (1), Every accreditation body in medical education requires that writen curtcala include leaming objectives, educational methods, and eval- ‘ution pans (2-4). To assis inthe develonment ofthese components this chapter briily discusses the follwing steps in the planning process: conducting a needs assessment, articulating overall goals developing specifi leaning objetives, measuring results and nally, aluatng the curriculum itself The emphasis ofthis chapter is on fi ting specified methods of teaching, described in subsequent chapters ofthis book, with curricular goals and objectives. This chapter does ot include a complete discussion ofealation designs; this is cov eed in greater detalln another book inthe Teaching Main series, eaiership Careers in Medical Education (Si; readers can consult ‘other references fora more technical discussion ofthat topic (6. 4 Needs Assessment Goals and objectives fr a major educational intervention ideally fl low a need assessment that identifies and characterizes the health care problem that will be addressed, how itis currently being aressed, ad How it shouldbe addressed. Ata minimum, the nedsKEY POTS ‘+ Awellconstructed curiulam includes specific and mea- ‘sureabe objectives, appropriate methods of instruction to achieve those objectives, and a plan for evaluation of learners and the program. ‘+ Competeny-based lamer objectives in medal education include knowledge, attitudes, sil, and behavior objectives. ‘Methods of instruction shouldbe congruent with cutricu- lar objectives and methods of evaluation. *+ Choosing the appropriate method of instruction will require ‘knowledge of the leamers and ofthe content and the con- text in which the leaming takes place. Ths often involves ‘the additonal step of performing a needs assessment. ‘+ Many educational theories describe how adults learn; attention to the principles of adult leaning theory will limprow the efcieney and effectiveness of learning + Methods of instruction, aswell as evaluation methods can affect learning environments in beth positive and negative ways assessment puts the topic into epidemiologic perspective and informs the course director of current versus ideal lineal practice and teaching state sis related to the healthcare problem. Such information ean usualy be ‘obtained by reviewing the published Ierature and selected Internet sites (2) (or example sites of professional organizations, and by colletng rel: ‘ant informatian about one’s targeted learners and medial institution (For more limited educational activites, such a a single lecture in 3 pathophysiology course, the needs assessment may focus on the pretegui site leaming needed to master the new content to be presented (se also, ‘chapter 3 ofthis book) Examples ofthe types of needs assessment infor ‘mation that are useful in choosing the goals, objectives, content, and lean ing methods for one's curiclum inlude the following ‘+ For the health care problem: How does it affect patients, healthcare professionals, medical educators, and society? How does it aft clinical outeomes, quality of lif, work and pro- Auetvity, use and cost of healthcare and other resources, and societal function? What are the most effective management strategies? How do these compare to current practice? From Cui Gaus Istucon: Chasing Methods of nstction 17 + For leammers and thee media institution: What the devel- ‘opmental stage ofthe learners early clinical students, evly- ing clinical stadents, experienced practitioners) Is there a mix ofeamers (for example, students, residents other health pro- fessional students)? What ae ther previous and already Planned training inthis content area Is there an opportunity to build on or complement other training? Whats known, about learners! exiting pofciencies and deficiencies, about ‘thir prefered leaning syes and methods? What known, about the informal or hidden curriculum a ther insttation (6)? Who are the other stakeholders inthe curriculum (or ‘example, course directors, clerkship directors, residency ro- gam directors, accrediting bodies) and what are their needs? For educators: What are the mos efetve edaatonal approaches? How do these compare te current approaches? Who will be teaching the curriculum tothe targeted leamers? ‘Are the teachers content experts? Ae hey sled in desired teaching methods? Wil faculty development be needed? Are there previously validated elation instruments that can be used to evaluate the cuviulum? ‘Context: What is an appropriate contest for learners in which to lam this content? Can more than one conte be ed to deepen the learning? [Needs assessment methods range from systematic reviews of the med- teal education literature (0) and formal saves (10) t informal interviews ith groups of lamers, faculty, or other stakeholders, The needs assess rent provides foundation for the curriculum that grounds it in beste ‘ence of efectiveness and relevance tothe learners. Tt informs eich of the subsequent steps of educational planning: writing goals and objectives, choosing appropriate instructional methods and planning lamer and po. ‘ram evaluation, The need assessment *makes the argument” forthe eu ‘culum, and prepares for needed resources to implement it A scholarly neds assessment places the curriculum in the context ofthe educational literature, defines its generaliabity, and forms the background for is Wider dissemination. © Goals Goals are generally writen in broad terms that ae easy to cormmunicate to all the stakeholders, including program directors, funding agencies, tach ers and learners, Goals provide desired overall drcton fora curiculum,18 Wetots for Tescing Meine For example, one goal of a medicine clerkship rotation for medical students may be: To lear the tial evaluation ad manayement for the ‘ast common diagnoses seen on the general internal medicine bpatient ‘goal for an inten orientation week program maybe To teach incom ‘ng interns the arpropriatepatint safety and quality procedures us etait n the Hospital Interdsipinaty Clinical Practice anual. ‘The following goa could be used for a continuing medical education rogram: To provide practicing éntomists current information and discus Sion on naw developments in eardionacular medicine. Objectives Determination of methods for instruction shoul follow from the goss and jective. If goals are broad and general objectives ae specific and meas able Objetves can be atthe eel ofthe individual learner or the program, ‘Leamer Objectives Learner objectives fous the cusculum content and informs lanes of what is to be achieved. They usually flow from the needs assessment 8s Akscrbed in the preceding section, Assuming thatthe goal af the educa. ‘ional program is to achieve competence in some area of health ear, dein: ing that competence usally inches a description of the requisite fou doe, atitdes, ad skills thatthe learner vill need to acquire. Learner objectives then are categorized into three types: cognitive (howledge, fective (tits), and psychomotor (skills or behavior), otendesribed asthe KAS" framework, These types of objective are important o note, as you wl se ltr, in choosing the methods of instruction, Within each typeof objective, there i a hierarchy of compleity and ‘achievement, This i most famously described forthe cognitive objectives with Bloom's Zaxonomy of Educational Objectives (1). looms taxonomy lists st levels of cognitive abjetves, which not only describe a level of Knowledge obtained but aso imply the steps of laming require to reach ‘hat level, This taxonomy hasbeen revised many times; one ofthe most recent versions uses the following desrintors of mental tsk to remem ber understand, app analyze evaluate, and rete (12). Foe meal eda ‘ation objectives, for instance, remembering factual knowledge anatomic ‘names forthe heart would be low-level cognitive objective, whereas ca ‘zing an elecrocariogram tracing and the underlying pathophysiology of "thm disorders woud bea higher-level objective, Course directors would wat to write the highest expected level of achievement forthe lamer ath- cise known asthe terminal objective. For each event inthe cours, the objective may describe an enabling objective for this terminal objective In the example above, a laming objective for the “Cardiowseular Black ours for medical students may be that stents wil be able to interpret tlectrcariogram tracings. A lecture objective within thie couree may be that leamers willbe able to explain the normal electrophysoloy ofthe heat. “To ensure that objectives are specific and measurable it helps to have a template structure for writing the objective. One behavioral method (1) isto structure the objective statement so that it answers the question, “Wo will do how muehsow wel af what by when?” The verbs (sil do") in the objectives describe the behaviors expected ofthe successful learner, and the nouns (what) describe te content of the educational program, Let's ay tata workshop is being developed to teach internal medicine interns the proper insertion of central venous ethers The leaner objec tives for this workshop could be: By he end o the &-hour workshop, ‘Bach inte will be able to cite the risks and complications associated with insertion of central venous catheters. (Knowledge) + Fach intern wil correctly demonstrate corret procedural steps fr insertion ofthe central venous cutter as culled ‘nthe obseraton chee) (Skil) + Bach intra wil be commited to minimizing risk for nf tion during noasive procedure. (Mite). ‘Some considerations in writing learning or learner) objectives are the folowing *+ Keep the numberof objectives manageable. Too many objec: ties overwhelm learners and instractors and may diminish the impact ofthe objectives. This may require combining sev- ral similar objectives into one. Inthe knowledge abective lve “ris and complications is somewhat general, but its presumed that several specific sks and complications will be reviewed inthe workshop and that interns wl be able to dis cuss these with patents before the procedure * When choosing the verbs for the obecties, use a8 specie a verb as possible, and one that will imply how the objective will be measured. Verbs such as “Wil know” “wil understand and “will appreciate” don't necessarily indicate how the objec- tives will be measured. Table 21 showts mote useful verbs to sein writing specific measurable objectivesTable 2-1. Verbs or Phrases for Use in Writing Objectives ‘ype of Objective Spc Verbs or Phrases Cognitive Uist, wrt, ite identify define ier exin itustrate feneat a differential dagnoss, diferentate seneate a hypothesis discriminate compare and contrast, construct anaize save Iietive rate a valle ‘ate as important rankasenjable _ recognin shaving a impact Pyehomator demonstrate show se in practice) ‘+ Not every curriculum will have all types of cbjectives. An online eursculum in preventive medicine, fr example, could have several knowledge objectives but would be unlikely to have psychomotor obectives Program Objectives ‘What are program objectives and why do we ned them? Writing program objetives provides planners with an opportunity to prospectively deine the success ofthe curriculum, Program objectives could simply be writen 38 agaregated leener objectives; for example: “All residents will achieve +8006 ona knowledge examination at theend ofthe cours." T sustain the curriculum, those developing the curiulum need to know whether the curriculum was implemented as planned. Objectives that address imple mentation issues are described as process objectives for the curriculum. amples of process objectives include: ‘Attendance: All residents weil ated the worktop forts entirety. Participation: AU residents wil participate roleplay and debrief with ther peers ‘+ Functionality: No resident il report dificult in logging on to the curriculum Web ste, + Quality: ach lecture wil be accompanied by detailed lecture nates Many course directors have more ambitious program objectives in mind. These are often termed oufeome objectives. Some may be conve nientiy measured, for example ‘+ Saisfacton: Al resents wll report that the role lay was @ useful method for leaning behavioral change counseling. + Selfassessed competence: Residents participating in the works sop wil report improved self-efficacy in matioational inter. iwing techniques. ‘+ Reported behavior change: Three months afer the workshop, particiants as compared with nonpartcipants, will be more likely to report use ofthe "As" approach to behavior counsel. {ng in their encounters with patients who smoke. ‘other program objectives, suchas changes in objectively measured sil, behaviors, or heath cae outeomes, are more dificult to measure, such as this one + Changes in documented resident behavior and health out- comes: One year afer the course, an aut of pationt panels of artic residents wil show an increase in documentation of ‘the smoking stats of patients an a delet tobacco use ‘compared with atont pana ef nonparicipant residents (1) Although sometimes posible to obtain, asin the preceding example, ‘seh outeome measurement i frequently not feasible, Nevertheless, the inclusion of sme behavioral or health care outcome objectives emphasizes the ultimate sims ofa curriculum and should influence the choice of cur riculr content and educational methods 4 Methods of Instruction Table 2-2 ists the most common methods used in teaching medicine, and sulsequent chapters inthis book describe several ofthese methods in more depth This table highlights the type of objective (and domain) for which ‘ach method is best suited, and, foreach method its advantages, stim ‘ations, and the resources required As noted earlier, the objectives identi fied through the needs assessment should inform the course director about ‘the most effective metho to achieve the goals ofthe course, but there are"22 Mead ortecting Medicine | Table 2-2. Common Instructional Methods Used in Teaching Medicine™ inset Reding ‘Objective or Domain * Knowledge Aectve Ivinages + Exily vale + Provides the necessary groundwork in ew content fr nvie lamers + Wellorganize an exidence tase __* Can be acces at optimal tie for ames tations Fase + Teachercentere, sine teacher has chasen the mater | * fot regulated, may overload eres ‘+ May not be used by leamers | * Learning may be super, wth students eying on shorter * Ute to aft long-term knowledge or afc unless aired with _" another api seth Field Lame Resoures Need 4 Minimal faculty resources * Online aces posible with eaming management software or through rstttonal bray etn reser + Need ovatchcoyight sues, special in distance-based kaming 1 Protrammed earning requires development amples ‘Textbooks + Jurals erature for afectve objects) Noliatons Tht Enkance Aste Leasing and Laurer Cnerednes + Programmed leaning esmers are inert queried about wht was jut presented nd receive fedock (eg AOPSIRSAP) rscoaa Mth Lire | ‘veto Dm | * Knowledge | + Afetive From Camel Gelso astracon: Chasing Methods a srcton 29 Table 2-2. Common Instructional Methods Used in Teaching “Medicine” (continued) vantages *+ vides the groundwork in new content for novice learners + Presentation software widely available + Will organized and evidence-based + Can be videotaped and reviewed ata ater time imitations *Pasive ‘Teachercentered ‘= Danger of too much information (., “engitive vero Limited by attention span of learners + Learning can be superficial unes paired with another application sctiy fi cal and Learner Resouces Needed ‘Presentation skill development amples * Medicine grand rounds + House staff noon conference + Metical student lecture, “Approach to Diabetes Me “Modifcations Tat Enhance Active Learning and Leame-Centeredness insert activity every 10-15 minutes (eg, question, disussion with neighbor (30) i Instructional Method: Discusion Groups Objetve or Dorin * Knowledge and higher cognitive objectives + Mective ‘Aantages “= Partcpatory + Develops social sls Limitations ‘+ Learners often need preparatory understanding of content (eg, reading or prior learning) + Need time and acitation to ensure al earners are engaged. 1 Learners may be rstrated if not skill faiitated-24 Medes for Teaching Medicine Table 2-2. Common instructional Methods Used in Teaching Medicine" (continued) Faulty and Learmer Resources Needed ‘+ Preparation of materials and fcitaton of earners + Skills of aiaton, such that discussion meets the objectives om Cala Gast Iran: Choong Matos of nstuction 28 Table 2-2. Common Instructional Methods Used in Teaching Medicine™ (continued) Faculty and Learner Resources Needed instructor must posses medical expertise to teach ‘Instructor fciltation ad bedside teaching sills should not ke + More cls time requited of earners sao IRIS aa * More fcilitators require: increased facullearer ratio + Learner time: coupled with work round, for instance, can imi + Ifusing case-based discussions, may need development of cases and ‘the worlow forthe tram instructors! guides to ensue equivalent experiences Across froUps + Paper or virtual cases require development - Bramples amples * Problem sts in a pharmacology course (3) + Problem-based learning about nutrition in cinicl curriculum (31) Journal clubs Noifistion That Enhance Active eaming and Learner Cnkeredness + Problem-hase learning (22) Tea-ased learning (4) Instructional Method: Case Discs Objective o Dorin * Knowledge + Alective Sk ___* Higher-order objectives of erica thinking interpreting and analais vantages ‘+ Embeds learning in the real context of. patient + Objectives can be austed “on the fy" hy the faculy discussant * Leamercentered learners are allowed to set objectives (i, queny theme * Including patent perspective faitats atitunal an professon- _alism objets Limitations eeu a * Not always available relying on availabe exss for learn may lit breath of earning * Goo for auditory learners; may be a problem for ater leaming ‘Team members may have disparate experience and knowledge ‘+ Aitending teaching rounds in a meine clerkship (35) «Attending rounds ona consultation serie (es, CDIM SIMPLE es) i “Modifcations That Enhance Active Learning and LeamerCenteradnes| ‘Use “ioroskils of einicl teaching (38) + Set objectives ofthe discussion by querying learners + Summarize the dscusion when closing i, and negotiate “next, steps" in learning Instructional Method: Demonstration (Modeling) Otjective or Domain ail vantages Melina skill can incorporate other “hidden” objectives such as patent centeredness,proesionlism (37), imitations + Pasive #Teachercentered + Requires that teaching material be available cally apd Learner Resources Neded “Teacher must possess the silt be demonstrated Examples ‘Bedside cardotscula examination * Bedside medial interview ‘Teaching knee arthrocentesisTable 2-2. Common instructional Methods Used in Teaching Medicine" (continued) aston Tat Banc Active Leaing ad Learner Centrtnes * Set upthe demonstration by ariing with learners wat should ‘robeered + Summarize the demonstration by asking leaner to elton whit —wasobserved esos Met Rl Py ‘Objet or Domain * Afetire _* sil ania * ative + Paticptory + Co flectve, uses eames asthe “simulators” * Leavers an npeiteifleret perpen whe porting Tinton * Lamers maybe stant ey ft tno This oes el __* Ths time o set up the oe lay and deve fete Foal and Learer Resources Needed “Fac fiation kl Sale environment tha lw lamers to take rks and eect "honey on the experience ales * Smoking cessation curriculum, to resides role ly a physician using motivational intervieving techniques 3), Moiiatos Tat Eohance Active Leng and Lenner eles Lerner can be ited to stan cect forthe ole psy (4 particular kl he or she would ike tot) * Cane video recorded freien + Use “Time Out techni to get edhck fom group members + Summarize kaming points nda for commitments to change behaviors " Flom Catia Goals telson: Choosing Mattos nstcton 27 Table 2-2. Common Instructional Methods Used in Teaching Medicine" (continued) Instruina Method: Sandrine Patent Objective or Domain Skil Mective avantages Active participatory + Standardized patients canbe trained to give feethack tations * Teachercentered in thatthe objectives and environment have been crated by the teacher + Learmers may be resistant (es "Thate acting” or “This doesn't fel ral") + Standardized patient cases must e developed with checklists, and Standardized patients must be trained + Can be costly requires standardized patient raining time aswell ___ portrayal time Faculty and Learner Resources Needed Trained standardized patients * Development of standardized patient cases, ith validated checklits (38) amples * Medical students lear clinical reasoning with the medical interview + Practitioners practice motivational interiewng techniques ina smoking esstion workshop (4) Molifcations That Enhance Active Leaning and Learner Centeredness * Can be videotaped for review by learner or with faculty facilitator + Incorporating self assessment can facilitate skill development of selfassessment. nsrctiona Method: Simulators Objective or Domain ‘+ Knovledge SkTable 22 Common Instructional Methods Usdin Teaching Medicine (continued) Mantges ‘ete Pastry * conta + Sal arog emonment roves any of casa patent tren arg il + Sk canbe ati ih adc ations Notas avable + Can rel n neve ning nt cell doped Foal nd Lear Resour Nee * High ech str can be gece * acl may need ining ose efetey “strates ato us hie __+Devdopment ofsiultoreercses wth ad ek ended ae Haneda simalstor $i aethesi Snulator __ Pat esmolol aces) A) “Modifications That Enhance Active Learning ard Learner-Centeredness * Using sal oun at ae can torpor eam and __communication skills as well as psychomotor skills (42) stn! Mati: Wing jective Dorin * Knowle 2 ace + igheondr dil of tian ani, creaty ‘antes acne Paar + can liste habits of reection * nba and deepens ring Tio ener mayest writin and efeton