Curriculum How To

II. How to Use a Curriculum

Aside from being time-consuming to write, one of the most frequent complaints heard about curricula is that they are never used. That is why this section is presented before those that discuss writing the document. It must be clear from the outset that a curriculum should not be written to fulfill a program certification requirement but to serve as an educational tool. Because it is the plan for the educational program, the curriculum should not exist in isolation from the program. In other words, it should not be the last thing completed before the program application is submitted; nor should it sit on a shelf gathering dust until the next RRC site visit. For new programs, a well-structured curriculum should be developed before clinical or didactic experiences are scheduled. In fact, the educational goals and objectives described in the curriculum should be the focal point for discussions between the program director and those responsible for overseeing various resident rotations. For established programs, both residents and faculty should be aware of the curriculum's content and attempt to follow the educational plan it describes. Faculty and residents should regularly evaluate the appropriateness of the plan and the program's success in meeting its stated goals. Listed below are ways the various individuals involved in the residency program should use the curriculum.
The Program Director - While most commonly identified as the individual primarily responsible for writing the curriculum, the program director's real challenge is to see that the document is used. This begins, early in the writing phase, with a realistic assessment of the document's practicality and ability to convey information. A document that does not convey practical information will not be used. This concept will be covered in greater detail in Section V.

Once the curriculum is written it is the program director's responsibility to insure that relevant sections are shared with the personnel responsible for providing the residents' education and that these individuals actually accomplish what the document claims they do. Feedback is the essential component of this process. By requesting feedback that relates specifically to program goals and objectives, the program director invites active participation in the process and increases the likelihood that the program goals will actually be met. Feedback should be solicited on a regular basis and incorporated into revisions of the document.
The Emergency Medicine Faculty - It is probably a safe assumption that many emergency medicine faculty are unfamiliar with their program's curriculum. Nevertheless, these are the people responsible for providing or supervising at least 50% of the residents' educational experiences. At a minimum, the EM faculty should read the sections describing the Emergency Department rotations and the program didactics. They should participate in a regular evaluation of the program and its curriculum which involves assessing whether the curriculum accurately describes the residents' clinical and didactic experiences, whether resident evaluations accurately reflect their progress in meeting their educational goals, and perhaps most important of all, asking themselves if they function in a way that optimizes the program's ability to achieve its stated goals.
Off-Service Faculty - Expecting off-service faculty to have an interest in the emergency medicine curriculum is probably unrealistic, but the individuals responsible for coordinating off-service rotations and evaluating the residents should be aware of the educational expectations of those rotations. Before a program begins, rotation coordinators should indicate in writing that they are aware of the goals and objectives and will work with the program director to insure that these are met. For established programs, a periodic review of each rotation is essential to insure that high standards are maintained. This is also a good time sit down with each rotation coordinator, review the relevant educational objectives and discuss the feedback that has been exchanged relating to both resident and faculty performance.
The Residents - Ideally, residents' clinical experiences should be structured to insure that they begin with the most basic cases and proceed in an orderly fashion to cases of increasing complexity. Exposure should be provided to all rare disorders and redundant exposure to common disorders should be avoided. This ideal is often compromised in a medical education system that is based to a great extent upon clinical service needs. Although this system may be very effective, it is by design, inefficient. This inefficiency is potentially greater in emergency medicine because residents rely on other departments to provide more than half of their education. The curriculum is the tool the residents should use to insure that their time is well spent and that there are no gaps in their knowledge or experience base. Before each rotation residents should review the goals and objectives and the methods by which they will be expected to achieve them. A post-rotation evaluation should be submitted by all residents that focuses on the question, "Does the rotation meet its stated objectives?" Residents should also participate in a periodic evaluation of the program and the curriculum.

III. Essentials of a Written Curriculum

This section describes the essential components of a curriculum from a functional point of view, i.e., What does each accomplish? In its most basic form, the curriculum should answer the following questions:

  1. What is the overall intent of the educational program and its component parts? In other words, what are the goals? These may be broad, pertaining to the program as a whole, or more specific, pertaining to a single rotation or even a single lecture. However, they are generally conceptual in nature, describing the desired end-point.
  2. What specific skills or changes in behavior should the participants be able to demonstrate upon completion of the program? Unlike goals, the program objectives must be distinct, observable or measurable skills or behaviors. Attainment of the program objectives is evidence that the goals have been achieved.
  3. How will the skills or changes in behavior be taught? A number of methods are used either singly or in combination to take participants from the starting point to attainment of the program objectives. Typically these include clinical experiences, lectures, reading assignments and other special educational activities such as tutorials, skills workshops and computer simulations.
  4. How will program success be measured? In other words, what system of evaluation exists to demonstrate that participants meet the educational objectives?
  5. How will information about the program's strengths and weaknesses be collected and used to improve the program? In other words, how is feedback solicited and used?
  6. What is the subject matter upon which the program is based? In other words, what is the program content?

IV. Getting Started

For most program directors, creating a curriculum is an unpleasant task and certainly one they hesitate to begin. It is a huge amount of work and it often must be done at just the wrong time. New program directors are busy setting up clinical rotations and resolving the political problems associated with a developing program. Experienced program directors often revise their curricula while preparing for an upcoming RRC site survey and are preoccupied with correcting potential program deficiencies. Although it is understandable that attention frequently is directed elsewhere, a key to successful curriculum development is integration of the process with these seemingly more important activities. In other words, planning or modifying a program and writing or amending a curriculum should not be viewed as distinct activities, but as part of the same process.

The principle that program planning and curriculum development are concurrent, integrated activities is particularly relevant when deciding who should write the curriculum document. Given the size and complexity of the task, many programs elect to have a team of emergency medicine faculty involved. This is an effective approach as long as team members asked to write sections of the curriculum are simultaneously working on program planning. It is difficult to accurately describe a program without firsthand knowledge and involvement. In addition to sharing the workload, there are other significant advantages to a team approach: 1) there will be a greater exchange of ideas that may strengthen the program, and 2) integrally involved faculty will develop a greater commitment to successful curricular implementation.

Given the time limitations and size of the task, a common starting point when writing a curriculum is to borrow documents from several program directors to serve as models. New directors correctly assume that there are many common elements of residency programs and that it is unnecessary to reinvent the wheel. It is helpful to look at several completed curricula while the document (and the program) are still in the planning phase. This review will provide a realistic assessment of the resources and planning necessary for a successful program. Reading several documents gives exposure to a variety of styles and ideas and helps develop a better sense of what works. This review also gives a clearer idea of what the finished product should look like. One danger in reading other curricula in preparation for writing one is that others' mistakes may be repeated. ACGME accreditation is not a guarantee of a high quality curriculum. A greater danger in modeling a program's curriculum after others' is that the final product will inadequately describe those features that make that program unique. When reviewing other programs' documents it is important to remember that the curriculum is the plan for a distinct program, intended for use by that program. Therefore, the finished product must clearly describe that program.

As noted previously, reviewing other programs' curricula provides a better idea of the resources needed to build a program. It can thus be a useful exercise to help reassess the quantity and quality of the available resources. It is amazing how often the absence of essential resources does not become clear until after the document is written and the RRC has paid a visit. It is also appropriate to ask hard questions relating to the adequacy of the educational experiences being planned. Is the ED patient population comprehensive or is some pathology lacking? What off-service rotations will be needed to round out the residents' education? Can these rotations realistically accomplish their desired goals and objectives? Who will provide the didactic portion of the program? How will training in specific areas such as EMS and research be provided? These are just a few of the many questions that must be asked while writing the curriculum.

Perhaps the most immediate resource-related concern is finding the time and manpower needed to complete the document. If this is a new document, it is reasonable to expect the program director to receive protected time averaging 12-16 hours per week over a six month period devoted solely to program planning and curriculum development. Other members of the program planning/curriculum development committee will also require protected time proportional to the extent of their involvement. The program director should have a full-time secretary with access to word processing.

It is essential that a timetable for completion of the document be developed and that the timetable is followed. It is realistic to expect that each step will require 50% more time than initially expected. It is a good idea to add sufficient time to have an unbiased reviewer critique the document prior to RRC submission. Paid consultants are available to assist in this task.

V. Designing the Curriculum

Few topics spark a livelier debate among program directors than curriculum design. There are a numerous approaches, each with its share of advocates and detractors. Many program directors choose a particular curriculum design based upon their perceptions of what the RRC expects the document to look like. This is a mistake that often leads to production of a non-functional curriculum. There is no need to become involved in a complicated and cumbersome process in the mistaken belief that this is what the RRC expects. Therefore, the curricular model used is much less important than the effectiveness with which it is used. A curriculum should be designed to accurately and efficiently describe an educational program. It's that simple.

Irrespective of the approach taken, the curriculum must describe educational goals and objectives, the methods by which the objectives are achieved, and evaluation and feedback methods. Standard methods for achieving the educational goals include clinical experiences, lectures, reading and special skills labs or workshops.

Section VI provides a basic outline of an Emergency Medicine curriculum. It is organized according to the major disciplines or topics that make up the specialty. This model was chosen because EM is to a certain extent a composite of the acute care aspects of these disciplines and because this is the best fit with the approach used in most residencies, i.e., a series of clinical rotations based on those disciplines. Also included are broad topics particularly pertinent to EM such as ED Administration, EMS, Environmental Illnesses, and Resuscitation. This approach avoids much of the redundancy associated with other models and allows coordinated presentation of clinical experiences (both in and out of the ED), didactics and required reading for each discipline.

An alternate approach is to individually present experiential, didactic and literature-based curricula. The strength of this model is its organization, but it requires presentation of most subjects in at least three separate sections, increasing the potential for fragmentation and redundancy. This is likely to make the document less usable (particularly for a resident) than if all information relevant to a particular discipline were presented in a coordinated fashion.

A third approach that can work well is to organize the document according to the major organ systems. This is apt to produce a detailed and thorough document, but its weakness is that most programs are not structured in this way. For example, there are generally no clinical experiences in Abdominal Disorders or Head and Neck Disorders, but, instead, in Medicine, Surgery, Ophthalmology, and ENT. A separate description of these experiences still needs to be included when this approach is used.

While only one organizational approach is outlined, the program director is urged to consider several options and decide which works best in his own setting. Other approaches are certainly acceptable provided that they contain the necessary elements and facilitate use by faculty and residents. With this proviso in mind, it is appropriate to comment on an approach that has become popular recently, modeling the curriculum after the Core Content.

It is our good fortune to practice and teach a broad discipline. Unfortunately this breadth creates problems when program directors are required to describe what they are trying to teach. The problem has been further complicated by the mistaken belief that a curriculum is not complete unless it specifically addresses all 1000+ items listed in the Core Content. It is important to maintain the perspective that the Core Content was not developed to serve as a list of educational objectives. To suggest that residents will be knowledgeable in every item and that programs will be able to document their residents' proficiency in every item is pure fantasy. It is not necessarily even a desirable state of affairs. Modeling a curriculum after the Core Content presents major design problems. Such a document is abundantly and redundantly detailed. While the leaves may be in sharp focus, the forest is a blur. In addition, the long lists of Core Content items often make these documents unreadable. A document that is difficult to read will not be used. Finally, Core Content-based curricula frequently do not mirror the residents= educational experiences. Most residency programs are not structured as a list of 1000+ items to be learned. Rather, a typical residency consists of a collection of clinical experiences, a series of lectures or workshops, and a fair amount of reading. These are the items upon which the curriculum should be focused.

Is there a place then for the Core Content in the development of curricula? Absolutely! As the only comprehensive list of topics relevant to the discipline it serves as a useful tool to insure that there are not gaps in the residents' education. There are several ways in which this tool can be used. For example, an index of Core Content headings may be appended to the curriculum indicating the location of relevant material within the document. Alternatively, when describing program objectives throughout the curriculum, the relevant Core Content areas may be referenced. Both of these approaches maintain the descriptive character of the curriculum, while simultaneously ensuring that program content is not compromised.

VI. A Curriculum Online

A. INTRODUCTION - This section provides a brief overview of the program, its resources and its educational philosophy.
B. SUBJECTS OR DISCIPLINES TO BE TAUGHT - In this section a list is provided of the subjects that will be taught during the residency. This is the framework around which the program is constructed. It is essentially a means of breaking down the broad topic, Emergency Medicine, into a series of discrete and manageable subjects. In this document the curriculum is organized according to broad medical disciplines but other approaches can be used such as organ systems or Core Content headings.
C. INDIVIDUAL SUBJECT CURRICULA - In this section, a curriculum is provided for each of the subjects. This includes goals, objectives, implementation methods, evaluation techniques, and feedback. It is important to describe how objectives and implementation methods vary depending upon the clinical setting and the year of training. For example, Anesthesia (Appendix A) is described not only as a clinical rotation, but also as a subject taught in the ED. There are distinct objectives in Anesthesia for each year of the program, and distinct activities designed to accomplish these objectives. Because this is the way the subject is often taught, this description is likely to be more accurate than the typical isolated description of an Anesthesia rotation. Descriptions such as this also provide solid evidence that graduated responsibility exists in a program.

Appendices A and C provide examples of a basic framework or list of subjects into which Emergency Medicine can be subdivided, as well as a description of a curriculum for Anesthesia. The latter is provided as an example of the essential elements that should be included in a curriculum, not as a model of how a particular program should be structured. Appendix D lists goals and objectives for each of the 24 subjects listed in Appendix C. These could easily be modified to describe the unique characteristics of a particular program.
E. EVALUATION - A carefully planned system of evaluation is the tool programs use to determine whether or not the educational objectives have been met. Both subjective and objective methods can be successfully incorporated into a residency program. The evaluation methods selected should be matched to the particular performance or behavior one wishes to measure. Objective techniques are best suited to quantitatively measurable performances (e.g., number of patients seen, number of procedures successfully performed, quiz scores, attendance at lectures). Subjective techniques are frequently used for complicated behaviors or qualitative assessments (e.g., judgement in patient management, interpersonal skills). Evaluations may be designed to test a minimal performance standard (e.g., ability to intubate), or they may be relative comparisons to peer performance (e.g., percentile score on ABEM inservice exam). Both approaches have strengths and weaknesses, so most programs use a combination of performance parameters matching the appropriate method to the particular objective.

The evaluation tools should match up with program objectives. Too many evaluations focus heavily on a variety of subjective resident characteristics but never determine if residents achieve the program objectives. All written evaluations should specifically refer to the relevant educational objectives (see Appendix A).

In addition to specific rotational or course evaluations, it is necessary to describe the overall system of evaluation that exists in the educational program. Appendix B describes a number of evaluation methods that may be used.
F. FEEDBACK - Feedback is the mechanism by which residents and faculty learn whether they are meeting the program objectives. This section of the curriculum should describe the overall system by which information obtained from the evaluation process is shared with residents and faculty. It should be clear that feedback is provided in a regular and systematic fashion. The precise responsibilities of various faculty members in the feedback process should be detailed and a schedule for those activities should be provided.

Both formal and informal methods should be described. For example, formal mechanisms may include written evaluations and semi-annual reviews; informal mechanisms may include direct verbal or written communications relating to a specific occurrence.
G. PROGRAM CONTENT - Every curriculum should list the subject matter that the program intends to teach, i.e., the program content. This task has been simplified in Emergency Medicine by the availability of the Core Content. However, simply reprinting the Core Content and appending it to the curriculum is not informative. Instead, the curriculum should include a system that ties Core Content items to specific program educational objectives. This will document that the program is designed to teach all important content items. In Appendix E the Core Content has been cross-referenced to the list of goals and objectives provided in Appendix D. In addition, the list of goals and objectives has been cross-referenced to indicate the related Core Content items.

VII. Suggested Reading

  1. Tyler R. The Curriculum - Then and Now, in Proceedings of the 1956 Invitational Conference on Testing Problems. 1957. Princeton N. J. Educational Testing Service.
  2. English F. Fundamental Curriculum Decisions. 1983, Alexandria: Association for Supervision and Curriculum Development.
  3. Tabba H. Curriculum Development: Theory and Practice. 1962, New York: Harcourt, Grace, Jovanovich, Inc.
  4. Tyler R. Curriculum Theory in Milwaukee, in Curriculum Theory Conference. 1976. University of Wisconsin Milwaukee: Association for Supervision and Curriculum Dev., 1701 K Street, N.W., Suite 1100, Washington, D.C. 2006.