Sequencing the content and the spiral curriculum

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12 Sequencing the content and the spiral curriculum

Sequencing the content can prove complex. Some approaches may be more effective than others in helping the learner to achieve the expected learning outcomes.

The importance of sequencing

Much attention has been paid to the different elements that comprise the medical curriculum – the learning outcomes, the content of the curriculum, teaching and learning methods, educational strategies and assessment. Less attention has been paid to the overall organisation and sequence of learning within the curriculum. It is important to consider the big picture of the curriculum and how courses are sequenced as well as which courses are included. Sequencing of courses in the curriculum involves:

• The arrangement of courses in a specific order. Prerequisites for one course may include the learning outcomes achieved in an earlier course. The order of courses can help students to organise meaningful patterns in the vast amount of content knowledge so that they are less likely to forget what they have learned and are able to apply knowledge to new problems or unfamiliar contexts. The earlier introduction in the curriculum of clinical experiences provides students with a context for their learning.

• Establishing the connectivity and interdependence of courses. Students should be assisted in identifying connections between what they are currently learning, what they have previously learned, and what they have still to learn.

Guidelines for sequencing

Of prime consideration in the sequencing of courses are:

• The prerequisites. The knowledge or skills that the students need before entering the course.

• The course content. What the students are required to study to master the expected learning outcomes.

• Application of the competencies gained. Students’ continued learning following the course.

Curriculum sequencing involves managing the students’ learning route in a way that makes it easier for them to achieve the learning outcomes. This may involve moving from:

• the simple to the complex

• general information or principles to a more detailed consideration

• basic principles to applications in practice.

This does not necessarily represent the optimum learning sequence. If students fail to see the relevance of courses to their ultimate goals they may lack motivation and learning may be ineffective. This is one reason for the move to introduce clinical courses and experiences earlier in the curriculum.

In some situations the sequencing of courses may be influenced by logistics. In clinical rotations, for instance, students may undertake clinical specialty attachments in different sequences, not all being optimal.

There is no doubt that issues relating to sequencing are complex, but here are two thoughts that merit consideration when the sequence of subjects in a curriculum is being determined:

1. The logical ordering of content that is already obvious to a subject specialist is not necessarily the most appropriate way for a student to learn the subject.

2. The prime aim in ordering the content of a course is to help students to learn most effectively. The introduction of students to patients in the early years of the course leads to better learning of the basic medical sciences.

Early clinical experience

An important issue in sequencing relates to the relationship between the basic sciences and the clinical subjects. In the traditional undergraduate curriculum it was assumed that students should first acquire an understanding of the structure and function of the body before they considered pathology and clinical medicine. Students commenced their medical studies with courses relating to the basic medical sciences and, having completed these, they progressed to clinically-based courses. In recent years, this sequence of courses in the curriculum has been questioned. Early clinical experience has been shown to have major advantages. By demonstrating relevance it motivates students and leads to more effective learning of the basic sciences. It orientates the medical curriculum towards the social context of medicine and eases students’ transition to the clinical environment. It also influences students’ career choice.

There is a strong argument for continuing the study of the basic medical sciences into the later years of the course. Peter Garland, former professor of biochemistry at the University of Dundee, proposed that the biochemistry course be scheduled in the later years of the curriculum rather than in the early years. He was of the view that students would as a result be better equipped to appreciate the importance of the biochemistry they were studying.

Progression

The sequence of courses in the curriculum should enable students to progress continuously towards the exit learning outcomes, with the learning outcomes at each stage being challenging and achievable.

Four dimensions can be considered in relation to students’ progression through the curriculum (Harden 2007):

1. Increased breadth. As they progress through the programme, the learners can extend their area of competence to new topics and to different practice contexts. In clinical medicine, for example, they can learn about heart murmurs not previously considered and learn about this aspect of medicine as applied to children as distinct from adults.

2. Increased difficulty. Students can progress by gaining a greater understanding through addressing a learning outcome in more depth. They may learn more about the pathogenesis of a disease or be able to interpret an atypical example of a cardiac murmur already studied.

3. Increased utility and application to practice. Students can progress from a more theoretical understanding of a subject to its application in medical practice. In the early years students may practise communication skills with their colleagues or with simulated patients. In the later years they move on to communicate with patients in a range of clinical settings, at first supervised and later unsupervised.

4. Increased proficiency. Students may demonstrate increased proficiency in an area associated with more efficient and effective performance. This may be exemplified by less time required for a clinical task or the achievement of higher standards with fewer errors.

The four dimensions are described in Appendix 9.

A spiral curriculum

Relevant to the concept of sequencing is the idea of a spiral curriculum where there is an iterative revisiting of topics, subjects or themes. A spiral curriculum is not simply the repetition of the topic taught. It requires the deepening of understanding with each successive encounter building on the previous one. The following are the features of a spiral curriculum:

• Topics are revisited. Students revisit topics, themes or subjects on a number of occasions during a course. A body system such as the cardiovascular system may be studied in the early years and again at a later stage in the curriculum.

• There are increasing levels of difficulty. The topics visited are addressed in successive levels of difficulty. Each return visit has added learning outcomes and presents fresh learning opportunities to help the student work towards the final learning outcomes.

• New learning is related to previous learning. New information or skills introduced are related back and linked directly to learning in previous phases of the spiral. For example a cardiovascular system course in year 3 of a curriculum will build on the understanding of normal structure and function achieved in the cardiovascular course in year 1. In a third loop in the

Fig 12.1 An example of a spiral curriculum.

(Modified from Harden and Stamper, 1999.)

spiral in the final year, students have the opportunity to study cardiovascular problems in the context of patients they see in their clinical attachments.

• Competence of students increases. The learner’s competence increases with each visit until the final learning outcomes are achieved.

Transition between courses

As students progress through the curriculum it is important that the transition between the different phases or courses is as seamless as possible. To facilitate this, a bridging programme may be necessary. Transition courses may take into account students’ individual achievements and competencies and ensure that they have the prerequisites necessary for the next step in their training programme. Should deficiencies be identified, learning opportunities can be provided to fill the gaps. Transition programmes are particularly important at the interface between undergraduate and postgraduate programmes before students take up their first medical appointment as trainee doctors. Such a programme may include a period of shadowing a senior doctor in post or a review of the practical skills expected of a junior doctor with remediation where necessary. Induction programmes can introduce the new doctor to administrative and procedural arrangements and to other members of the team.

Reflect and react

1. Think of your own course in the context of a spiral curriculum. Does it help students to build on what they already know? What will your course add?

2. If students fail to master the learning outcomes for your course, is there a remediation plan in place to help them before they move on to the next phase of their training?

3. Is there a need for an orientation or transitional course between your own course and what precedes or follows it?

Exploring further

If you have a few hours

Dornan T., Littlewood S., Margolis S.A., et al. How can experience in clinical and community settings contribute to early medical education? A BEME systematic review. BEME Guide No. 6. Med. Teach.. 2006;28:13-18.

The rationale for the early introduction of clinical experience in the medical curriculum.

Harden R.M. Learning outcomes as a tool to assess progression. Med. Teach.. 2007;29:678-682.

Harden R.M., Stamper N. What is a spiral curriculum? Med. Teach.. 1999;21:141-143.

A description of the concept of a spiral curriculum.

Harden R.M., Davis M.H., Crosby J.R. The new Dundee medical curriculum: a whole that is greater than the sum of the parts. Med. Educ.. 1997;31:264-271.

A case study of a spiral curriculum in action.

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