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TWELVE TIPS
Twelve tips to designing and implementing a learner-centred curriculum: Prevention is better than cure MICHELLE MCLEAN1 & TREVOR GIBBS2 1
United Arab Emirates University, United Arab Emirates, 2Ukraine National Medical Academy of Postgraduate Education, Ukraine
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Abstract Background: Change in medical education has brought with it new perspectives on content, process, assessment and evaluation. With this change has emerged a new discourse. New words and phrases, used by many but not always fully understood, have infiltrated every aspect of our academic lives. One such term which we believe is used relatively freely but which is not well understood or implemented is ‘‘learnercentred’’ or ‘‘student-centred’’ education. Aim: These twelve tips, drawn from experience, attempt to clarify the implications of learner-centred education and provide a structure upon which to ensure that all stakeholders have the same understanding of the implications of what being learncentredness involves. Conclusions: Without a common understanding of learner-centreness, the true educational concept may not be appropriately implemented, resulting in considerable faculty and student stress. We should practice what we preach and consider the ‘‘whole’’ student.
Introduction Over the past few decades, medical education has experienced a major paradigm shift. Influences from educationalists and educational theory have revolutionised the manner in which we teach and how students are expected to learn. With this change has emerged new educational terminology. New words and phrases now describe the how, what and when of student learning. One such phrase commonly used in curriculum design is ‘student-centred learning’ or to be more politically correct, ‘learner-centred education’, with many medical schools having moved from a traditional ‘teachercentred’ curriculum to a ‘learner-centred’ programme (Harden et al. 1984; Ludmerer 2004). The focus has shifted from the teachers as the conveyers of information to the student being the focus of the learning experience. The teacher is now a facilitator rather than a content expert (Neville 1999; Spencer & Jordan 1999; Harden & Crosby 2000; Spencer 2003; Ludmerer 2004). The expectations of students in a learner-centred approach are vastly different from a traditional curriculum. Medical students can no longer expect to be passive participants. Through active engagement and experiential learning, tailored to their own needs, they are required to become independent and reflective life-long learners who are able to function in a dynamic educational and professional environment. Today’s medical students not only have to demonstrate sound clinical and medical science knowledge, but also have to be able to use evidence to inform their clinical decisions and to work as members of a team (O’Connell &
Pascoe 2004; Olckers et al. 2006). In addition, with a ‘patient-centred’ and biopsychosocial approach to health care now widely advocated and practised, students need to develop the appropriate attitudes and behaviours towards patients, establish partnerships and negotiate management strategies, taking cognisance of the ‘whole’ patient, including his/her mental and social well-being (Engel 1977). The medical education literature proudly reflects our curriculum innovations to more learner-centred approaches. Innovations such as problem- and case-based learning have ensured that students become active participants in their learning (Dolmans et al. 2005), while team-based learning approaches emphasise the socially constructed nature of learning and learner-centredness (Gibbs et al. 2007). In addition, outcome-based education has made the competencies which students must achieve more transparent (Harden et al. 1999, Jelsing et al. 2007), while the development of professionalism has been facilitated by learner-centred approaches (Goldie 2008). One of the many reasons for abandoning the traditional curriculum was the stress that it inflicted on students, due to many factors, not least the overloaded content and the preclinical/clinical divide. The ethos of learner-centred approaches was to shift the focus from the teacher to the learners, and provide them with resources and opportunities to acquire knowledge and develop skills according to their own needs and learning styles. But, have these innovations ameliorated the plight of the medical student? The literature suggests that very little may
Correspondence: Michelle McLean, Faculty of Medicine and Health Sciences, Department of Medical Education, United Arab Emirates University, PO Box 17666, Al Ain, UAE. Tel: þ973-3-7137137; fax: þ971-3-7672167; email:
[email protected] ISSN 0142–159X print/ISSN 1466–187X online/10/030225–6 ß 2010 Informa Healthcare Ltd. DOI: 10.3109/01421591003621663
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have changed, despite medical students having been given the ‘power’ to decide on how, when and sometimes what they should learn (Cleland et al. 2005). Alas! The life of today’s medical student remains stressful (Dyrbye et al. 2005; Piele & Carter 2005). The reason, we believe, is that as medical educators, we do not always practice what we preach. Just as we expect our students to be ‘patient-centred’, using the biopsychosocial model to manage patients holistically, so should the same principles apply in a ‘learner-centred’ curriculum. We need to teach and develop the ‘whole’ student. Despite great innovative strides in medical education, we are still preoccupied with the ‘bio’ component (i.e. the curriculum), often neglecting the psychosocial well-being of our learners. A useful ‘whole’ student approach would be Maslow’s (1954) hierarchy of needs model (Hutchinson 2003). For a learner to reach self-actualisation (i.e. to be all he/she can be), attention should be paid to his/her physiological needs (e.g. sufficient sleep, food), safety (e.g. free to experiment with ideas, voice opinions, personal safety guaranteed), sense of belonging (e.g. respected team member, useful roles in faculty) and self-esteem (e.g. input valued, constructive feedback). In providing these 12 tips to embracing learner-centredness as a philosophy rather than merely an approach to medical education, we hope that individual teachers and medical school leaders will take time to reflect on how they might improve the learner-centredness of their curriculum, taking cognisance of all domains of learning: cognitive, affective and psychomotor.
Tip 1. Implications of a ‘learner-centred’ education Ensure that all stakeholders have the same understanding of ‘learner-centredness’ It is imperative that teachers, students, patients and accreditation bodies are all ‘singing from the same hymn sheet’ in terms of what is embodied in learner-centredness. To have a clear definition of learner-centred education and a shared appreciation of its implications are essential for students and faculty alike. We believe that the use of Brandes and Ginnes’ (1986) six principles of student-centred learning would be an excellent starting point as they bring together all domains of learning, including personal development (Box 1). Another useful resource is the American Psychological Association’s (1997) ‘Learner-centred Psychological Approaches: A Framework for School Reform and Redesign’, in which 14 Box 1. Six principles of student-centred learning (Brandes & Ginnes 1986). 1. The learner takes full responsibility for his/her learning. 2. Involvement and participation by the student are necessary for learning. 3. The relationship between learners is more equal, promoting growth and development. 4. The teacher becomes a facilitator and resource person. 5. The learner experiences confluence in his/her education (i.e. affective and cognitive domains are integrated). 6. The learner sees himself/herself differently as a result of the learning experience (i.e. develops a higher conception of learning).
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principles of learner-centred instruction, which include metacognitive and cognitive, motivational and affective, developmental and social factors as well as individual difference factors, are described. Learner-centred does not mean leaving students to their own devices in the lecture theatre, laboratories, clinical area or dissection hall. Although it may entail allowing them to discover new information for themselves, a tutor or supervisor should always be on hand to support and guide their learning, taking cognisance of individual student needs (see Tip 4). The literature suggests that not only do students generally adapt more easily to becoming active learners than do many faculty members have in relinquishing their authority and expertise (Sivan et al. 2000), but they are also fundamental in bringing about educational change (Steel & Hudson 2001). Thus, in order for all stakeholders to share the same understanding of ‘self-direction’ and ‘learner-centred’, both students and staff require orientation in terms of their now very different roles and responsibilities. Staff development programmes ( preferably involving students) are essential when the curriculum becomes more learner-focussed. Evaluation of the reform may reveal that regular training and updates are required, particularly if students originate from schooling systems which are content-driven and didactic and when faculty members are from the ‘old guard’.
Tip 2. Students and the curriculum Include students at all levels of curriculum design, implementation and evaluation As ‘clients’, students need to be part of the process of developing a learner-centred curriculum. While the overarching outcome of medical education cannot be disputed (a competent and empathetic professional), there are many ways of reaching this endpoint. Learners are at the coalface of learning. Through their experiences, they can provide valuable insight into how programme outcomes may be achieved. They can also identify omissions. Students are therefore in the best position to provide feedback on the curriculum-in-action and the hidden curriculum, which may be very different from the curriculum on paper (Coles & Grant 1985). ‘Empowerment through involvement’ is the key activity that enables the students to gain insight into their curriculum and understand the reasoning behind the new and varied educational processes they are subjected to and involved in. A good example of this is seen at Liverpool Medical School, UK, where the Student Parliament plays a leading role in curriculum evaluation (Liverpool 2009). Evaluation of teachers, courses and the programme (which should be acted upon, if appropriate) and student representation on curriculum committees are the ways in which learners can add value. Koc et al. (2008) have reported on the successful integration of students on the admission panel and the value they assign to this experience. Student representation on faculty selection committees would be another way in which the student ‘voice’ can be heard.
Twelve tips: Learner-centred education
Embedded in such a participatory view is the understanding of students as self-motivated, adult learners who accept responsibility for their learning and personal development (Knowles 1973; Brookfield 2004). Forging partnerships and relationships between faculty and students will go a long way to developing a mutually agreed upon set of rules by which students learn and faculty recognise their enhanced worth as facilitators, mentors and role models rather than mere discipline experts.
Tip 3. Student selection
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Develop a clear admission policy (with appropriate support structures) The admission process is to select those learners who will mature into our future competent and caring health care providers. Using frameworks such as the multiple miniinterview have allowed selection for non-cognitive attributes and abilities beyond academic excellence (Eva et al. 2004; Lemay et al. 2007). In developing future professionals, medical education needs to guide students to become independent, self-directed learners who use initiative to solve the problems that they are likely to face during their medical studies and in professional practice. An assumption that medical teachers and educators mistakenly make is that all students are capable of self-directed learning (Barzansky et al. 1999). Accumulating evidence suggests that some learners require a more directed learning environment (Dornan et al. 2005). In our selection process, we thus need to develop strategies and practices that allow us to identify students who have these capabilities or, with nurturing and support, have the potential to become self-directed problem solvers. If we admit students with ‘potential’, as may be the case with widening access policies (Holmes 2002), appropriate resources (e.g. language tuition) and support structures (e.g. counsellors, mentors) should be provided to allow these learners to reach self-actualisation (Maslow 1954), recognising that self-direction has to ‘grow’ with each student. Recognising the individuality of students is discussed in Tip 4.
Tip 4. Students as individuals Embrace student diversity and individual learning needs Having admitted students to a medical programme, the onus of monitoring and guiding them through their studies rests squarely with the faculty. School leavers who enter medical school directly from secondary school are probably very different in many domains when compared with their colleagues who already have a tertiary degree. Graduates or ‘mature’ students from other disciplines may not have the necessary scientific background and require additional tuition, such as the Access to Medicine course described by Holmes (2002). Acknowledging that each learner has unique requirements has resource implications. In addition, if we expect students to identify deficiencies in their knowledge or skills, provision
must be made to fill these gaps. As a minimum, learners need to have relatively unrestricted access to faculty members to assist them to identify who they are as learners, including their learning styles. They also require access to technology, resources and patients to ensure customised extensions of ‘just for me’ and ‘just in time’ learning (Harden 2005).
Tip 5. Students’ psychosocial well-being Support the psychological and social aspects of student diversity With the internationalisation of medical education, most medical faculties now admit fee-paying students from across the globe. Our learners are therefore very diverse, culturally, religiously, educationally and in terms of their language and communication skills. Cognisance needs to be taken of their different life experiences and levels of emotional maturity. Some may require pastoral or counselling support arising from their social or financial circumstances. School leavers, some of whom could be as young as 17 or 18, may need guidance in adjusting to the new social and educational environment. Accepting ‘mature’ students raises other issues (e.g. spouses, maternity leave and children) for administrators (Harth et al. 1990; Woodall & Pickard 1997). The key is to know your students, but large classes militate against this. While it would be impossible to offer a personalised service to each student with class sizes often in excess of 200, access to professional services is an imperative and should be well advertised at the outset of their studies For some students, support may involve language tuition, while for others, counselling may be required to help them through, for example, their first experience with a dying patient. Cognisance, however, needs to be taken of cultural perspectives of ‘support’. To this end, the concept of counselling and the hierarchical position of a senior tutor are likely to vary across different cultures. There is increasing awareness of the need to include emotion and communication skills training in the medical curriculum. Detecting, understanding and managing emotions in oneself and others may contribute to physician well-being and satisfaction as well as improved patient outcomes (Satterfield & Hughes 2007). Beginning such training early in the medical curriculum may assist learners to deal with the reported stress during medical studies (Dyrbye et al. 2005; Piele & Carter 2005). While much has been written about the need for a conducive learning environment, research has focused primarily on the academic (cognitive) environment (Spencer & Jordan 1999; Gordon et al. 2001). In a truly learner-centred view, this environment should include all aspects of a learner’s being, including the physiological, psychological and the social factors. The curriculum should thus offer time for students to pursue hobbies and to socialise within and outside the faculty. In order to foster an atmosphere of trust and mutual co-operation, the faculty should schedule social activities that allow students and staff to interact informally, but professionally.
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Tip 6. Skills development Develop students’ self-learning skills
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Unlike medical training a few decades ago, when the emphasis was on knowledge acquisition, medical educators now recognise broader competencies for graduating students. These competencies would include the ability to access and utilise information, make informed decisions about its validity and then use it appropriately in future professional practice. Critical thinking, problem solving, reflection and selfassessment are also expected competencies. These skills are not always innate and expecting students entering directly from a didactically-driven school background to immediately slot into a learner-centred curriculum is neither feasible nor fair (Barzansky et al. 1999). A period of educational orientation, specific for the schools’ learning process would be a wise investment.
Tip 7. Explicit learning outcomes and assessment Develop clear, transparent outcomes and assessment procedures From the outset, learners need to know the rules of the game – the why, what, how and when of programme outcomes and the expected competencies. Students need to have clearly defined outcomes and they need to be informed about how they achieve the expected competencies. It must also be transparent how these outcomes or competencies will be assessed or measured (Harden et al. 1999; Prideaux 2000). More importantly, students’ need to know that their style of learning will be respected and that they will be supported academically and emotionally as they strive towards the advertised outcomes. In essence, curriculum process and outcomes are often neglected in a busy academic environment, but are probably more important than curriculum content. Content, process and outcomes are dynamic, relying upon student evaluation for affirmation or revision and on the changing conditions in health care delivery (World Federation for Medical Education 2003). As learners experience the curriculum, their feedback on all aspects of the course and their experiences improves the programme for the next cohort. Student evaluation is therefore an important vehicle for ensuring that successive cohorts of students develop skills, knowledge and attitudes to meet the changing health care needs of the communities they serve.
Tip 8: A flexible curriculum Allow time for independent learning and pursing areas of interest Having accepted that each student is an individual, with personal goals and aspirations, and acknowledging a biomedical information explosion, we owe it to learners to provide flexibility in terms of time for independent self-study and 228
opportunities to pursue the areas of interest that cannot be covered in the core curriculum. The UK model of a core curriculum with student-selected components (SSCs) meets this need (Harden & Davis 1995; Yates et al. 2002; Riley 2009). Electives or selectives offered by many medical schools, either locally or abroad, have a similar outcome of offering students a chance to experience a branch of medicine, science or perhaps the humanities that may be of interest to them. As with the rest of the core curriculum, clear aims and objectives are required for these courses to ensure that they benefit from what may be a very different experience for each student. Not only is a clear structure for the SSCs needed (Riley et al. 2008), but involving students in the process and providing them with a clear understanding of why they are important for their development is equally important (Riley 2009)
Tip 9. Curriculum content Regularly review the core curriculum content (not forgetting local needs) As the biomedical and clinical knowledge grows exponentially, the core curriculum needs constant revision. Many innovative curricula are now guilty of the same criticism of the traditional programme – factual overload. If new content is added (e.g. bioinformatics), there needs to be a concomitant removal of more outdated information which may no longer be regarded as ‘core’. Senior students would have considerable insight, for example, into what biomedical information may no longer be ‘core’ curriculum. As stated previously, medical education has been internationalised, with most medical schools now admitting a significant proportion of foreign students. Taking cognisance of the need for an international component (e.g. global health) in the curriculum, each institution should, however, remain true to its mission. The core business of any state-funded schools should be to train doctors who are ‘fit for purpose’, i.e. graduates who should be able to function within the local context. Each institution therefore needs to define its core curriculum in relation to the requirements of the community it serves.
Tip 10. The medical education continuum Recognise that medical education continues beyond graduation Medical education does not end when students graduate. It continues into the workplace. Just as we needed to support students as they made the adjustment from school or their undergraduate studies to medicine, so too we must ensure that they are prepared for the chasm that has traditionally demarcated medical school from professional practice. We have a moral and ethical responsibility to ensure that this is a smooth transition for which they are prepared rather than a quantum leap. Much of what has been discussed thus far applies to this transition: developing problem-solving and analytical skills, using evidence to inform clinical decisions,
Twelve tips: Learner-centred education
Tip 11. Professional development
patient approach in health care, so should medical education practice view each learner holistically. Our activities should be focused on all aspects of student well-being (Maslow 1954), not just the cognitive domain, which has historically been the case. In partnership with our learners, we have a social and moral responsibility to pay attention to all aspects of their lives while within our care. After all, their parents have entrusted us with their welfare. A conducive learning environment, free of ridicule and abuse, in which students are sufficiently at ease to ask questions and voice opinions and concerns should be the minimum standard. If the clinical culture does not integrate and manifest the values that are encouraged in students, it will undermine their professional development and will reduce the impact of the curriculum (Howe 2002).
Provide ample opportunity for student professional development
Conclusions
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developing skills that would allow them to deal with real-life ethical and moral issues, exposing them to excellent clinical role models and inculcating in them the need for selfevaluation, reflection and life-long learning as a social responsibility. We should not only facilitate students’ learning, but also develop their status as an independent learners in a real world. This would involve frequent exposure to real-life learning, in real-life situations, with effective support and feedback. As a minimum, hospital orientation and communication and clinical skills training with simulated and real patients should be included in the curriculum.
Opportunities should be available to allow students to develop along the professional pathways that their ability and their personalities support. Some will be tomorrow’s leaders or researchers. Others will be our future teachers or health care managers. Allow students to actualise their potential. This can be achieved by engaging students directly in experiences that mirror their future roles, by creating opportunities that allow them to practice skills involved in managing such situations and by allowing them to reflect on and take responsibility for the outcomes of their experiences and consequences of their actions or behaviours (Howe 2002). The final year apprenticeship model seen in more innovative curricula is a good example (Liverpool 2009). Our expectations of medical students are undeniably high. We expect them to develop into competent, caring, reflective, problem solvers who are capable of regulating their own personal and professional lives. This may culminate in more stress than satisfaction for many students. Since competence and reflection come with practice and with careful supervision, and empathy needs to be modelled (Hojat et al. 2002; Larson & Yao 2005), excellent clinical supervisors whose behaviour students wish to emulate are critical for developing our overarching aspirations for our graduates. Clinicians who demonstrate the skills and attitudes that we wish our students to develop are a rare commodity. These ‘champions’ need to be identified and rewarded so that learners are exposed to them more often than is currently the case. Equally important, but highly neglected, is consideration for the students we have admitted but who may not reach their full potential or perhaps those who, on reflection, have decided that medicine may no longer be their ambition. In a truly learner-centred curriculum, there should be career exit points and guidance offered in terms of how newly acquired knowledge and skills may be used vocationally.
Tip 12. Practice what we preach Adopt a ‘whole’ student approach Finally, and most importantly, as medical educators, we must not pay lip service to learner-centredness. If we truly subscribe to learner-centred education, just as we advocate the whole
Creating a learner-centred curriculum has advantages for both faculty and students. Implementing it is, however, not an easy task. Understanding the concept and applying it requires diligence, thought and effective management. If implemented and practiced correctly, it should ensure that the professionals we wish to develop are ‘fit for purpose’, providing quality health care in the twenty-first century. We believe that if learner-centredness is not truly embraced, it will culminate in stress for both faculty and students. We advocate that prevention is better than cure. If we take care of our learners from the time they enter the medical school, and if we nurture and support them through their studies and develop the appropriate relationships with them, we believe we will improve the quality of our graduates. Today’s medical students are not only tomorrow’s doctors; they are also tomorrow’s teachers. We would want them to look upon their learners through the same caring lens through which we viewed them. This article has attempted to draw together aspects which we believe enhance the understanding of a learner-centred philosophy. No doubt, each reader will be able to propose other suggestions about what might contribute to an improved conceptualisation of learner-centredness. If this is indeed the case, then we have achieved an important objective: stimulating readers to think about what learner-centred embodies.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.
Notes on contributors MICHELLE MCLEAN is in Medical Education at the Faculty of Medicine and Health Sciences, United Arab Emirates University. She is interested in student learning and faculty development. TREVOR GIBBS is a WHO consultant in Medical Education and Primary Care. He is presently the Chair of Family Medicine and Medical Education at the Ukraine National Medical Academy of Postgraduate Education, Kiev. As a general practitioner and medical educationalist, his interests lie in international curriculum transformation, community-based education and the development of Family Medicine.
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