Clinical Curriculum Revolution to Integrity and “Attunity”

Abstract

Reviewing the history of clinical educational curricula reveals enormous change and progress through successive antiquity up-to the current 21th century. Surely, there are stable fundamental criteria which are pillars in designing any curriculum; however there are torrential inevitable reforms which are important in filling the changeable gaps and fulfilling the ecological and temporal aspects. Over the last 20th century, numerous new paradigms for curricula reforms were constructed to adapt ebullient millennium needs, interactive pedagogical approaches and psychological/sociological learning theories. These reforms fostered clinical practice, integrating core competencies and reflection on designing, and achieving clinical curricula depending on outcome-based models such as clinical competences milestones. On the other hand, systematic approach of Kern’s framework adopts curriculum development through six consecutive interlinked and intersected steps which are refined to eight steps later. Moreover, taking contextual factors into account during curricula planning was evolved in other models such as PRISMS model. Despite all these pearly efforts, there are still caveats about inclusive gaps negligence between education process and overall health system. 3P-6Cs toolkit is deemed a recent novel paradigm that enrolls this role of health systems in clinical training during curricula design.

1. Introduction

1.1 Overview

Medical education process has faced many challenges which have to be considered and have not to be omitted in the current 21^th century by clinical educators and administrators. Pandemic covid-19 has invaded the earth and has made forcibly its own characteristic troublesome era [1]. Technology has disseminated and has profoundly integrated in the whole life; social, educational, political, societal, and professional/clinical life with its positive and negative impacts [2, 3]. Moreover, there are other deeply forked challenges into medical education practice, likewise the challenge of practicing clinical education being a secondary mission by many clinicians after their primary clinical profession, the challenge of commercialization of many health institutions, the challenge of narcissism overwhelming phenomenon in clinical skills education regardless ethics regard, the challenge of marketing which has been exploded and has devitalized emotional intelligence, ethical values and humane morals in medical field communication and the challenge of multitude of variable curricula types, thoughts, models, and aspects that have to be merged to achieve overarching holistic safe and successful medical practice [4, 5]. Continuous change of the medical education process, which has depended and has reflected mainly on curricula reforms, has become indispensable to meet stakeholders and societies’ needs.

Indeed, explicit (formal) aligned to implicit (informal) curricula are the flux and estuary of medical education and clinical training that link between educational and administrative aspects [6]. Explicit curriculum is considered the organized systematic plan model that most institutions follow in clinical training [6]. However, implicit curriculum is always extracted and is never separated from practicing the explicit one despite practicing it unconsciously and unsystematically in most times in real world. So, achieving an ideal curriculum is prospective complex aspiration within the upcoming medical education renaissance that has been evolved to encompass many aspects not only knowledge.

Curriculum design, being a sophisticated structure, should be planned considering multitude of factors, not related to content only but also to stakeholders (medical trainees, trainers, patients, administrators, and other healthcare workers) and institutional, environmental and local and global societies’ needs [7]. Hence, planning an ideal curriculum, which is suited all these factors, is somehow fallacious and antiquated and this requires pragmatic changes to execute individual, local and global benefits from it. This is closely related to the standpoint in the written articles about general learning issues by the writer, May Zyiada within the first half of 20^th century. She advocated, at that time, that “not all learning rules and projects that show success in west mean achieving the same success in east, however coping up what are updated is mandatory to apply what is suited with each community”. Accordingly, there is no ideal universal curriculum for every place or every time, because of many social, societal, cultural, political, economic, intellectual, emotional and psychological contexts that have to be considered [7, 8]. So, the impact of considering these detailed variables in tandem in each curriculum is reflected positively on medical education and health not only locally but also globally.

Despite the associated logic caveats on standardization a universal curriculum, outlining a contextual framework connecting the most fundamental elements can empower broad and profound success through constructing it in an organized coherent manner [9, 10]. Moreover, each curriculum should be supplied by metacognitive thinking about soft system approaches which interconnect all these elements and associated factors together in a coherent comprehensive emerging plan [11, 12]. These recent upcoming approaches are expected to tower curricula designs up to higher levels of thinking theoretically and achievement pragmatically through integrating health system care with clinical knowledge and skills.

In this chapter we will retrieve curriculum etymology origin and its historical story. We will touch on crucial curriculum criteria regardless the place of its execution. We will elucidate the importance of curricula designs in educational process. We will demonstrate diverse curricula types and frameworks, particularly Kern’s foundational six steps framework and PRISMS strategy. Emerging metacognition within the already used curricula designs is the recent trajectory in clinical education to interconnect all elements of curricula and surrounding factorial circumstances to be attuned, so we will read this out under the term 3P-6Cs toolkit. Hoping this chapter will be a catalyst to invest ecology in constructing more effective and efficient curricula ideas in this widely opened era that only accepts everlasting adventurous progress. Finally, you will face some footnotes through reading this chapter which are little bit away from medical writing rules. However these are not so far from the aim of this chapter which is to interlink medical to societal, psychological, administrative or even literary aspects. These footnotes help to approximate the meaning of integrating ecological life into medical practice.

1.2 Etymology and history

1.2.1 Etymology

“Curriculum” with its Latin root means race. It is derived from “currere” word which means to run or to proceed or “curricle” which means chariot. “Curriculum vitae” is also a mutual term which shares the same meaning of progressive continuity, hence; this meaning reflects that it is a continuous evolving not-stationary not stagnant process, so it needs endless assessment and improvement to maintain and metastasize its virtues and to overcome its shortcomings [13].

Footnote:Do not be stagnant in this turbulent race, think about curriculum reform.

1.2.2 History

Earliest ancient centuries, Before Common Era (BCE), testified the outset of medicine by Egyptian and Babylonian priests in ancient Egypt and Iraq. Evolving of medical knowledge and development of medical education started and transferred by Hippocrates during Greece culture then by Galen which was eminent during Roman Empire [14, 15]. Islamic civilization had a potent influence on medical education especially after its invasion to Europe. Revolution was transmitted from Arabian to European areas between the ninth to fourteenth centuries. Razi and Ibn Sina, excelled at this time, in diagnosis, management and in medical education [14, 16, 17]. Then, in Europe, 19th century came to prove, classify, develop and apply the educational theories in a frame of systematized educational practice [14, 15]. With the beginning of 20^th century, Flexner exploded his report for medical education reform to be applied in all US areas and all medical institutions without distinction or segregation [18]. In 1949, Tyler started structuring curriculum in a four-staged organized framework. Then Harden 10 question adjusted in depth and breadth more details about content of each of Tyler’s 4 stages considering the relation between curriculum elements and stakeholders, institution support and community conditions to be more reflective on practice [8, 19]. Later, Kern developed the six steps framework which has been become the popular systematized framework in medical education till our current days [8, 20].

The current open 21^th century mandates continuous life-long learning in medical education. This requires contemplation of history’ events to confront the present facilities and challenges and to adapt the everlasting changing future without missing the fundamental rules, without omission of basic knowledge and theories monograph and without neglecting the variables of stakeholders needs.

Footnote:Be firm in roots (by applying what is sturdy from curriculum history), flexible in twigs (by continuous required reforms).

1.3 Importance

The educational process is complex and is loaded by many elements which need to be determined, organized and linked together. These elements include defining goals and objectives, content intelligibility, targeting general and learners’ needs, detection of educational strategies, implementation and assessing of the whole educational process [9]. Inter-link between all these elements in a clear organized plan is what ended by a curriculum design [8]. Repercussions are obviously attained in educational process if there is no clear specific organized plan. The role of curriculum plan is to organize what to be learned (content of program, learners will do), who will receive this (learners, stakeholders), how to learn this (strategies, methods, and implementation), why this important to be learned (goals, objectives and assessment), when (timetable, environment and resources) and where the learning process (environment, resources) are carried out in a conceptual framework. Moreover there are many factors and forces that should be considered during achieving this sophisticated process [21]. These factors entail social, societal, political, commercial (which is obvious in private institutions), academic and health service aspects [8]. Consideration of all these factors, during curriculum mapping, is important to reveal curriculum translation into practice and to reflect the practice impact on curriculum development as well [8, 21, 22]. Recently in addition to these factors consideration in curricula planning, system based thinking and regulation are overarched to fill gaps in health care system [23].

Footnote:Practicing education, using elements without knitting each of them in comprehensive organized steps, resembles breaking up of one bead from a continuous necklace beads. Other elements (or beads) will be easily lost.

So, connect all elements (beads) to construct useful curriculum (necklace).

2. Curriculum classification

2.1 Criteria

There are many curricula classification and types, each determines the way of preparation and delivery of the education process. Each curriculum -to be effective- requires fulfilling specific criteria of different aspects [24]. Although there is an evolving renaissance in medical education and curricula designing, there is still no evidence that the new curricula are more effective than the iterative old ones [25]. On the other hand, following fundamental criteria (in Figure 1) for curriculum planning and achievement guarantees -to greater extent- a realistic, not only a theoretic, curriculum which is attuned with contexts. These criteria include the relevance of curriculum to health service and learners’ needs, filling gaps to reach outcomes, flexibility with surrounding changes, relatedness to practice, organized timetabled plans and continuous assessment and remediation at each curriculum stage in addition to final assessment as well [24].

Figure 1.

Fundamental criteria.

Footnote:Each body –to be healthy- requires basic balanced mixtures of different sorts of diet, each soul –to be sober- requires acquiring perceptions from different cultures. Likewise, each curriculum -to be effective- requires matching specific criteria of different aspects.

So, make your curriculum effective by considering its fundamental criteria.

2.2 Curriculum models

There is continuous mounting in classification of various curriculum types and in development of different frameworks. The most of these curricula variants are derived from the following two models; prescriptive and descriptive [26].

2.2.1 Prescriptive model

It is the origin of outcome based curricula which is commonly used in the present medical education. It depends on objectives and goals (intent) rather than other affecting factors on the process (context). Objectives are determined using behavioral verbs. Tyler four staged curriculum, in 1949, is the initial example of this objective model which fosters the intended clinical competencies, knowledge, skills and/or attitude outcome [7, 26, 27].

2.2.2 Descriptive model

It depends robustly on internal and external contextual factors analysis of curriculum situation in addition to the intent which is the target of the prescriptive model. This model describes and analyses the context of different inter-linked elements (including intent, content, teaching strategies and assessment) of curriculum design regardless the definite ordered manner of these elements [7, 26, 27].

Table 1 outlines the differences between perspective and descriptive models.

Prescriptive	Descriptive
Rely on intent (outcome)	Rely on context (means)
Concerned with objectives and outcome rather than content and process	Concerned with internal and external factors affecting content and process
Translate curriculum to practice (obligatory)	Reflect practice into curriculum (reflective)
What will be done	How this will be done
Core Competencies	PRISMS models

Table 1.

Perspective and descriptive curricula models differences.

2.3 Curriculum types

Under and post-graduate medical education can be delivered depending on different curricula types or categories. Each curriculum type has its pros and cons; there is no ideal or perfect curriculum one hundred percent. Some medical schools or institutes use single standalone curriculum, whereas integrating two or more of these types are more consistent with contemporary milieu and expanding medical health system and education needs [4, 10, 26].

Common curricula types are listed and described briefly in Figure 2.

Figure 2.

Curriculum types.

3. Modern curriculum frameworks

Flexner started and reported in the last century that clinical education has to be reformed to transmit practice into curricula and the reverse. He stated that it is important to standardize any reform on all health care service and medical educational institutions regardless the socioeconomic status [18]. Evolving leap has been occurred in medical educational curricula designing to cope patient care, clinician competency and local/global health service [28]. However, in each design there is still a gap which can be filled and remediated by coherence and interrelation between other elements included in the design [4]. Indeed, keening in the details of only one or two aspects prohibits clear viewing the whole process. It is the conception, regarding clinical curricula reforms, that is appeared in the current 21^th century to construct overarching curricula [4]. This reminds me by Indian quote “Sometimes you just need to distance yourself to see things more clearly”.

Diverse curricula frameworks have been arisen in modern era of medical education [29]. These curricula have endeavored to flourish professional practice which is composed of knowledge, skills and attitude based on adult learning theories and active teaching methods and are oriented by ecological and communities’ circumstances [30, 31]. We will elucidate in the first subsection 3.1, Kern’s six steps and outline PRISMS models being a recent and advanced framework in clinical education. Then, in the following subsection 3.2, we will invite you to create your conceptive curriculum thoughts in a way that integrates health systems within clinical training. This invitation will be through the catalyst which will be demonstrable in the novel creative 3P-6C toolkit [11].

3.1 Modern frameworks examples

3.1.1 Kern’s six steps framework

Kern declared that, systematic approach helps profoundly in reaching the objectives. This systematic approach of curriculum design and development is formed of six steps in a sequence manner. However working on one step and looking at other step/s at the same time can promote the whole process by intersection between the targeted all steps [20, 29]. Six steps are usually started by problem identification and general need assessment [20] step while you are sitting back and contemplating on the whole situation. This helps in picking up the start of the knot (problem) based on health care problem, quality of clinical training, clinical outcome, and incongruent clinical practice with health care system and your community’ needs. In this first step, it is important to identify who are affected by this problem (patients, learner, trainers, and administrators) and to reveal the current and the ideal approach to treat this problem [20, 32].

From the first step, identifying target need assessment being the second step is the cue and clue to construct goals and objectives in the third step. This step aims at assessing needs of two bases of education process; learners/stakeholders and learning environment. Learners’ needs are detected by discovering their experiences, expectation, actual competencies and their learning style. Regarding learning environment, identifying availability of the required resources is inevitable to proceed in curriculum process, in addition to manifest barriers and enablers. Various methods for assessing needs can be achieved, for instance, by formal interviews, observation, informal discussion, audits and/ or questionnaires [20, 32, 33]. Without goals and objectives, content are not clearly structured, training methods and strategies cannot be chosen properly and assessment is got unfair. Goals aim at putting broad non measurable lofty vision of curriculum [20, 33]. Objectives target outcomes and have to be specific, measurable, attainable, realistic and timetable regarding cognitive, psychomotor and/or affective domains [34]. Levels of objective selection according to Bloom taxonomy are determined by the desired outcomes and needs assessment [35].

The fourth step; educational strategies pertain content with its resources and events, and plan to use multiple interactive teaching methods which are suitable to connect objectives with outcome depending on brain storming and metacognition [20, 29]. Going from the designed plan to achieving it is what is occurred in the fifth step; implementation wherein it checks resources for obtaining financial, administrative, material and political support in addition to addressing barriers to solve them. Piloting curriculum before executing it with friendly audience can be helpful to predict its success and to provide a chance for improvement and remediation [20, 32]. Last but not least, assessment is the sixth step where the curriculum is ended and is started by for development. Assessment is performed to assess learners and program using different summative and formative methods through the whole program. Learners’ assessment depends on correlation between objectives and what they actually perform. On the other hand, program is assessed regarding the quantity and quality of every achieved step. All assessed data have to be collected and analyzed to be used for further maintenance (the seventh step) and dissemination (the eighth step) in other institutions locally and globally, in the case that this curriculum proves its success [20, 32].

Six steps kern’s framework with the main elements of each step are outlined in Figure 3.

Figure 3.

Kern’s six steps framework.

3.1.2 PRISMS model

By the start of 21^th century, PRISMS model asserted on the importance of clinical practice reflection on clinical training program, integrating modern active teaching methods and modern technology in an evidence-based symbiotic learning, considering needs of learners, patients and health services. PRISMS acronym refers to the six elements of this model; wherein P refers to Product-based which means that learning focus on clinical practice rather isolated knowledge only and that assessment focus on doing rather knowing. R refers that learning has to be Relevant to learners, communities and updating evidence based knowledge, skills and behavior. I refers to inter-professional collaboration in learning process and teamwork role between clinical, academic research and administrative members. S refers to Shorter courses duration of learning combined with Smaller groups of learners to ensure interactive teaching and conform the millennium needs. M refers to Multisite learning to expand learning from larger academic hospitals to involve rural areas and smaller hospitals and units using information technology. Lastly, S refers to Symbiotic actions of the above five items to be incorporated with each other. Prideaux resembled PRISMS model by prism which encloses and radiates the light elements! [29, 36].

3.2 Upcoming system thinking curricula (3P-6Cs)

Awakening of consciousness and metacognition help in continuous probing and picking up gaps in previous plans to go through higher stages and to profound details to fill these gaps efficiently and effectively. This inducts what is continuously desired in medical curricula reforms in 21^th century of coping with patients and learners needs, to overcome learning environment challenges and recently to integrate health system into clinical education process [37]. Curricula which are called system thinking curricula aim at filling gaps of health system to be attuned within clinical curricula. Thus, curricular designers, trainers and learners (clinician) are able to broaden their conception to regard health system needs parallel to the desired progressive life-long knowledge, skills and attitude outcomes [38], so the upcoming learning process tends to bind ecology with clinic-ology.

3P-6Cs Systems Thinking Toolkit is deemed a paradigm of soft thinking reforms that connects the all fragmented elements together in a comprehensive curriculum that is used in clinical training and practice to express how these elements work together [39]. 3P-6Cs systems thinking toolkit is assumed to be able to resist any affection by unpredicted environmental change. The acronym 3P refers to cohere between the main three aspect; Personal (learner or clinician learning), Program (curriculum outcome and assessment) and Practice (system and teamwork) [11].

So learners’ Personal aspect reflects what they know, how they learn and assure their learning by assessment (3C: Content, Cognition and Confirmation). Program aspect targets 6Cs as the study reported; the first 3Cs targets training outcomes, relation to contextual environment and what are the teaching methods and strategies (3C: Command, Contextualization and Coordination) and the other 3Cs targets the summative/formative assessment of each learner, connects different competencies and activities and relates all these to program evaluation (3C: Collection, Collation and Connection). Finally, to close this connected circuit, Practice aspect calibrates learners outcome in relation to circumstances and program goals/objectives, assesses the role of teamwork/communication and confirms the existence of long-life learning through (3C: Calibration, Collaboration and Continuous development) [11]. Although there is no enough evidence in real world that 3P-6C toolkit is more practical, but it is a great chance to assess this new perception in practice and to create new ones.

Footnote:Designed clinical curricula are truncate without coherence of clinical knowledge with ecological, ethical, emotional, intellectual, social, societal contexts. Unleash your thoughts and apply new overarching reforms to foster attuned health system in clinical curricula.

4. Conclusion

Clinical education no longer persuades by copying and imitation, hence creative overarching smart thoughts have been the ways for comprehensive improvement. Expressing and applying these thoughts in planned designs and realistic manner is an art which requires overview and in depth look in past, present and future clinical curricula. So, you, being curriculum designer or clinical educator, start now and unleash your thoughtful imagination and cultivate new thorough curricular design which emerges health system in clinical training curricula based on your practical experience and evidence based medical education research.

Conflict of interest

There is no conflict of interest.

Notes/thanks/other declarations

I would like to note that Table 1, Figures 1–3 and footnotes are my work, and are not quoted or paraphrased from other references. The purpose of these footnotes is to get you overwhelmed that clinical education is not separated from daily life and other fields. They act like metaphors to make the meanings more obvious by interlinking medical to societal, psychological, administrative and even literary aspects which are not separated from daily practice.

I dedicate this work to my father’s soul, my mother, my inspiring brother and my darling family.

Special thanks to the sincere multi-talented members of the team; (Training Of Teachers for medical education) at Princess Fatimah Academy at Egypt.

Appendices and nomenclature

PRISMS

Product based, Relevance to learners, Inter-professional collaboration, Shorter courses Smaller Groups, Multisite, Symbiosis.

3P-6Cs

(Personal, Program, Practice, Command, Contextualization and Coordination, Collection, Collation and Connection).