As part of the ALiEM Faculty Incubator program, teams of 2-4 incubator participants authored a primer on a key education theory, linking the abstract to practical scenarios. For the third year, these posts are being serialized on our blog, as a joint collaboration with ALiEM. You can view the first e-book here – the second is nearing completion and will soon be released.  You can view all the blog posts from series 1 and 2 here.

The ALiEM team loves hearing your feedback prior to publication. No comment is too big or too small and they will be used to refine each primer prior to the eBook publication.  (note: the blog posts themselves will remain unchanged)

This is the fifth post of Volume 3. You can find the previous posts here: Bolman and Deal’s Four-Frame Model; Validity; Mayer’s Cognitive Theory of Multimedia Learning and The Kirkpatrick Model: Four Levels of Learning Evaluation

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Thomas and Kern’s Curriculum Development

Authors: Chris Lloyd; Simiao Li-Sauerwine (@theSimiao); Shannon McNamara (@ShannonOMac)

Editor: Benjamin H. Schnapp (@schnappadap)

Main Authors or Originators: Thomas and Kern
Other important authors or works: Barsuk (citation at end)

Part 1: The Hook

Sally is a junior faculty member who has been tasked by her residency program director to develop an EKG curriculum for incoming Emergency Medicine (EM) interns. She has never had the opportunity to develop a course before. She thinks back to how she gained experience reading EKGs herself – on-shift experiential learning without a formal curriculum. How can she determine what content is appropriate? How can she include high-yield cases that are correctly tailored to her audience? What format should she use? How will she know if her curriculum was successful? Sally is not sure where to start in order to create the optimal curriculum.

Part 2: The Meat

Overview

Thomas and Kern’s Curriculum Development for Medical Educators is designed for use by medical educators as a framework for creation of educational experiences. Their model is organized into six steps:¹
1. Problem Identification/General Needs Assessment: What health care problem are you trying to solve? What gap requires attention? Once the need is identified, consider: What is the current approach? What is the ideal approach? Typically this will involves a review of the literature describing current strategies used to approach this problem.
2. Targeted Needs Assessment: What is needed here? This assessment analyzes the learners involved in the curriculum within their unique environment, as well as considering the local resources that may be required. What do the learners already know? Quantitative and/or qualitative data can be collected during this step.
3. Goals and Objectives: What are you going to accomplish? This step communicates what your curriculum is about to others. While goals can be more generalized, learner objectives must be specific and measurable: who will do how much of what by when?
4. Educational Strategies: What methods will you use? The type of methods employed depend on the objectives developed previously. Some objectives may be more amenable to simulation while others may be best achieved through small group discussion or asynchronous online resources. Including multiple strategies may help increase knowledge retention
5. Implementation: How do I put it all together? You must obtain local support for the curriculum, decide what resources are required, and determine barriers to overall success before starting. This phase often involves piloting your curriculum and a phase-in period before full administration, with adjustments based on what is learned.
6. Measuring Outcomes: What worked and what didn’t? The assessment phase will not only target the individuals participating in the curriculum but also the program itself. Evaluations can be formative (ongoing feedback for improvement) or summative (e.g. a “grade”). This step is also important for documentation of your achievements.

Background

Thomas and Kern’s six steps of Curriculum Development emphasize that there is much more to quality teaching than throwing together a slide set or simulation case. Designing a great curriculum is dependent on first having a clearly defined problem and then seeking out effective solutions. What are other institutions or organizations doing to solve the problem? What is the perspective of patients, learners, and educators? What is the ideal approach? This is an opportunity to gather evidence-based reviews, best practice guidelines, and original research that is applicable to your needs in order to find the best approach for your learners. For the intern EKG course from the introductory scenario, The Accreditation Council for Graduate Medical Education (ACGME) and the Residency Review Committee for Emergency Medicine (RRC-EM) both have core competencies that must be demonstrated in EKG interpretation. These competencies should be considered and included in the general needs assessment.

Once the problem is defined, one must determine what group is most affected by your learning gap – that is your targeted learner! This may be patients, providers, educators, or students. One may use surveys, informal discussion, formal interviews, tests or questionnaires to discover where specific gaps exist in your local population. In the EKG example above, faculty might utilize test scores, core competency committee reviews of resident performance, and informal discussion of knowledge gaps in EKG interpretation to create a targeted needs analysis.

The goals of a curriculum will communicate the overall purpose to others. While a broad vision of developing a foundation for EKG interpretation in first year EM residents may be a worthy goal for a curriculum, the objectives must be specific and measurable. Bloom’s taxonomy can be helpful here to provide useful verbs. Objectives should be made with the individual learner as well as the overall program in mind. A cognitive learner-focused objective may involve a resident’s ability to describe the differential for ST-elevation. An aggregate program objective may aim for a specific percentage of residents in the program being able to do so. Aggregate objectives may also incorporate performance improvement on standardized assessments or simulation cases. Use of core competencies in the targeted needs assessment creates a smooth transition to these objectives. For example, a curriculum focused on EKG interpretation will encompass many of the competencies of patient care and system based practice.

The educational content of the curriculum in combination with the objectives will comprise the syllabus. This will include the educational resources required – articles, texts, simulation exercises, discussion sessions – and the planned assessment. Multiple methods should be employed to enhance knowledge retention. Be sure to match objectives with appropriate educational methods. Cognitive or knowledge-based objectives will be more congruent with lectures, online resources, and team-based learning. Psychomotor skills will be best approached with supervised clinical experiences and simulation.

Any curriculum requires resources for success, and implementation will require identification of what curricular time, faculty dedication, and monetary resources are needed. How often will interns need to meet for the ECG course? How many faculty are going to execute the curriculum? Minimal faculty development would be anticipated for a intern-level ECG course, but other curricular ideas may involve additional preparation. Orientation to the new curriculum should be employed regardless to ensure faculty are prepared. Keep in mind that the time required is not solely the face to face experience with the learners! Educators should budget time for pre-session preparation of materials, feedback for learners, and overall evaluation of the curriculum.

The evaluation of the curriculum and feedback provided to both learners and educators is the final step in the continuous loop of curriculum development. Were the goals and objectives of the curriculum met? For the EKG course example, one would likely target the learners and faculty in order to assess the performance of the curriculum. Formative feedback may be provided throughout the course followed by a summative ‘grade’ at the time of completion. Both evaluations should align with the core competencies/objectives decided on previously. Inherent in this step is deciding on appropriate evaluation questions and design. Once the assessment tool has been created and used, the data should be analyzed, and reported back to the key stakeholders in the curriculum.

Successful curricula will always be in a state of constant development and change. The steps outlined by Thomas and Kern are not meant to be used strictly in a static sequence. A targeted needs assessment and goal/objective creation can be done simultaneously. Realizing that resources, whether financial or otherwise, may be less than ideal may lead to alteration of the educational strategies employed. Additionally, the importance of continual program evaluation in order to provide objective feedback on how the curriculum is functioning cannot be overemphasized.

Modern takes or advances

1. Crowd-sourced curriculum development²
While many fields have expanded in recent years to large online learning centers, graduate medical education has not yet fully embraced this model. Creation of these centers is incredibly resource intensive and can initially appear to be an overwhelming endeavor. Shappell et. al. performed a comprehensive review of the online education content available for each step in Kern’s framework. They found that educational content and needs assessments are well represented. Development of goals/objectives and program evaluation/assessment tools are more sparse and is an area ripe for further innovation.

2. Competency-based medical education
Graduate medical education (GME) is shifting from a fixed training period to a competency-based model in which a resident must demonstrate specific knowledge and skills as well as demonstrating they can apply them independently.³ Acquisition of this expertise is independent of the duration of training. This evolution of the GME model fits in well with steps two and three of Kern’s model. The targeted needs assessment can be generated by reviewing what competencies are not yet being met. Specific curriculum objectives can then mirror the competencies being addressed. One example of such an approach examined the competency levels achieved by residents before entering into an EM residency program.⁴ Kern’s framework was used to develop an EM orientation program based on this needs assessment.

Other examples of where this theory might apply in both the classroom & clinical setting

Example 1:
While examples of curricular development in GME will tend to focus on students, we must also remember that as health care professionals we are also responsible for providing education to patients and families. A group of residents completing a global health elective utilized Thomas and Kern’s framework to create educational products for clinicians and patients that were implemented locally and abroad. Residents were introduced to Kern’s curriculum development structure, and they then identified a health care problem in the community such as pediatric dental hygiene. Subsequent steps led to creation of a one hour program on the relationship between hygiene and health that was delivered to local refugee groups and international clinics.⁵

Example 2:
Thomas and Kern’s model of curriculum development is also applicable in partnering with allied health professionals for professional training. For example, ultrasound-guided peripheral intravenous (IV) placement is a common procedure in the Emergency Department for patients with difficult IV access. Using the curriculum development process outlined here, courses have been developed to teach patient care technicians to be equally skilled at placing ultrasound-guided IVs as physicians.⁶

Annotated Bibliography of Key Papers

Thomas PA, Kern DE, Hughes MT, Chen BY. Curriculum Development for Medical Education: a Six-Step Approach. Baltimore: Johns Hopkins University Press; 2016.¹ 

This text is the complete guide to the Thomas and Kern model of curriculum development. It thoroughly discusses each of the six steps as they apply to patient and clinician education.

Barsuk JH, Cohen ER, Wayne DB, Siddall VJ, McGaghie WC. Developing a Simulation-Based Mastery Learning Curriculum. Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare. 2016;11(1):52-59.⁷

The Barsuk paper uses both the six-step model for curriculum development and mastery learning techniques to create a robust simulation-based ACLS curriculum. This model is a helpful framework to consider when building similar curricula.

Lucas R, Choudhri T, Roche C, Ranniger C, Greenberg L. Developing a Curriculum for Emergency Medicine Residency Orientation Programs. Journal of Emergency Medicine. 2014;46(5):701-705. doi:10.1016/j.jemermed.2013.08.132.⁴

The Lucas group uses the six-step model to do a complete curriculum development process for Emergency Medicine Intern Orientation. This is a particularly accessible and realistic application of this curricular design model on a common educational situation.

Limitations

The most glaring limitation of this theory is the time intensive approach it requires. The overall effectiveness of Kern’s framework is highly dependent on the educator demonstrating a thorough commitment to each step.

The six steps are not linear, but rather, occur in a dynamic way as the curriculum evolves. Though robust needs assessment and post-implementation data may not always be available, it is still important to include these elements in some way to augment the effectiveness of the curriculum implemented.

Part 3: The Denouement

Sally was introduced to Kern’s model for curriculum development and applied it to her EKG course for new interns. She identified the problem by conducting an informal survey of faculty and residents on the current approach to EKG teaching. Sally discovered that the interns had disparate backgrounds with respect to prior EKG knowledge. Some interns had solely cardiology lectures from the first two years of medical school, while others had delved into EKG reading with advanced courses and rotations in their clinical years. The inconsistencies in background were furthered by the variation in exposure to interesting cardiology cases while working clinically. She then developed a general needs assessment by identifying the gap between the ideal and current approach, and felt that dedicated coursework during intern year was required. She tailored this to create a targeted needs assessment by taking into account the needs of stakeholders (interns, faculty, residency program, school of medicine) and was able to determine that while residents generally performed well in the cardiology portion of the in-service exam, there were gaps in the knowledge of individual interns when applied to specific clinical cases. Sally then composed goals and objectives. She determined that her goals were for interns to recognize the most common abnormal EKGs encountered by emergency medicine physicians; specific measurable objectives included increased accuracy in reading a selection of essential abnormal EKGs. After some research, Sally decided that the best educational strategy was a longitudinal case-based curriculum that would be implemented during intern morning report on conference days. She was able to implement the course successfully by obtaining support of the program director and education faculty, introducing the curriculum after piloting, and refining over the course of the academic year. Finally, she obtained evaluation and feedback by creating formative and summative individual assessments for individuals and a program evaluation of the course. After all her hard work, all stakeholders agreed that her course was a smashing success!

Don’t miss the 6th post in the series, coming out Tuesday, May 28, 2019!

PLEASE ADD YOUR PEER REVIEW IN THE COMMENTS SECTION BELOW

Reference List

1. Thomas PA, Kern DE, Hughes MT, Chen BY. Curriculum Development for Medical Education: a Six-Step Approach. Baltimore: Johns Hopkins University Press; 2016.

2. Shappell E, Chan T M, Thoma B, et al. Crowdsourced Curriculum Development for Online Medical Education. Cureus 9(12): e1925.

3. Long DM. Competency based residency training: the next advance in graduate medical education. Academic Medicine. 2000;75:1178-1183.

4. Lucas R, Choudhri T, Roche C, Ranniger C, Greenberg L. Developing a Curriculum for Emergency Medicine Residency Orientation Programs. Journal of Emergency Medicine. 2014;46(5):701-705.

5. Sweet, LR, Palazzi, DL. Application of Kern’s Six-step approach to curriculum development by global health residents. Educ Health 2015;28:138-41.

6. Duran-Gehring P, Bryant L, Reynolds JA, Aldridge P, Kalynych CJ, Guirgis FW. Ultrasound-Guided Peripheral Intravenous Catheter Training Results in Physician-Level Success for Emergency Department Technicians. J Ultrasound Med. 2016; 35(11):2343-2352.

7. Barsuk JH, Cohen ER, Wayne DB, Siddall VJ, McGaghie WC. Developing a Simulation-Based Mastery Learning Curriculum. Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare. 2016;11(1):52-59.