Specifying learning outcomes and competences

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7 Specifying learning outcomes and competences

A range of approaches can be used to identify and define the expected learning outcomes.

Specification of learning outcomes

The previous chapter highlighted the benefits to be gained from the adoption in education of an outcome-based approach. The first step in implementing OBE is to define the learning outcomes required by the end of the training programme. This process is often initiated at a national level. In the UK the General Medical Council has set out in Tomorrow’s Doctors their expectations for the learning outcomes of a graduate in a UK medical school. There are similar initiatives by the regulatory or accrediting bodies in the USA, Canada, Australia, the Netherlands, Saudi Arabia and many other countries. National examinations where they exist may also be viewed indirectly as statements of the expected learning outcomes.

While the learning outcomes will be to some extent specific to the context of a country, there are learning outcomes relating to what constitutes a good doctor that can be shared across geographical borders. In Europe, through a consultation process, generic and subject-specific competences expected of students at set points in the education programme are being identified. The International Institute for Medical Education in New York defined in terms of learning outcomes what they considered to be the ‘global minimum essential requirements’ for a doctor, whether in China or the USA.

The specification of learning outcomes is both a top-down and a bottom-up activity. A medical school can build on a national statement of learning outcomes with an expanded version reflecting the particular mission of the school. A community-oriented medical school or a school with the aim of qualifying the future researchers or leaders in medicine will reflect these orientations in its statement of learning outcomes. The Scottish medical schools, in ‘The Scottish Doctor’ report, specified the learning outcome domains subscribed to by all five Scottish schools. While the domains were agreed by all schools, more detailed learning outcome statements varied from school to school, mirroring the differences in the curriculum of the five schools.

Within each institution, detailed learning outcomes will be specified for each course and for each lecture or clinical training session within a course. These identify how each specific learning experience contributes to the exit learning outcomes for the school’s education programme.

Just as with basic medical education programmes, OBE and the specification of learning outcomes are now features of training programmes for many specialties in medicine with the learning outcomes or competences agreed by the postgraduate training body or authority. In the USA the Accrediting Committee for Graduate Medical Education and, in Canada, the Royal College of Physicians and Surgeons have led the field.

Learning outcomes and the continuum of education

For the most part, undergraduate, postgraduate and the continuing phases of education have been organised in separate silos each specifying independently their learning outcomes and the design of their learning programme. For almost 100 years there has been strong criticism of this separation or segregation. In 1932, the Final Report of the Commission of Medical Education in New York stated ‘Artificial segregation of the basic medical course, the internship, the training of the specialist, or the continuation education of the general practitioner is very likely to create serious gaps in the education of physicians which should be avoided’. More recently, Cook, Irby and O’Brien, in Educating Physicians, a Carnegie follow-up to the 1910 Flexner Report in the USA, expressed concern that ‘there is no single agency responsible for regulating and financing medical education; multiple agencies participate in this process and often hold conflicting expectations of programs and learners’. They highlighted the need for learning outcomes to bridge the continuum.

The development of an outcome-based approach offers a vocabulary that can facilitate discussion across the phases of education and hopefully this will serve as a catalyst for a more seamless continuum of medical education.

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Fig 7.1 The learning outcomes and the different phases of education.

Involvement of stakeholders

The specification of learning outcomes is a key step in the education process and the range of stakeholders should be involved. This may include:

• university staff

• hospital practitioners

• general practitioners

• recent graduates

• students

• other professions, e.g. nurses

• representatives of employers

• patients and representatives of patient groups

• the public.

The need for a wider consultation process is now accepted and is in keeping with a more patient-centred approach to care and a more general move to customer involvement in product development. Many of these stakeholders are now actively involved in curriculum committees. Such collaboration may help to align undergraduate, postgraduate and continuing education.

Approaches to identifying learning outcomes

The expected learning outcomes must match future expectations for the health care we want to see provided. Approaches that can be used to specify the expected learning outcomes include:

• the Delphi technique

• a critical incident survey

• studies of errors in practice

• task analysis

• a study of existing curricula and publications

• interviews with recent graduates.

The delphi technique

The Delphi technique is a commonly used and successful way of identifying the expected learning outcomes. It relies on the judgement of an expert panel of ‘wise men’. The ‘experts’, usually about 20 although it may be more, are required to define the learning outcomes that they consider necessary for medical practice. The circulated responses are then analysed, amended and added to or deleted where necessary by the participants, and the process is repeated until a consensus about a final list of learning outcomes is reached. The Delphi approach has been used to identify learning outcomes for basic medical education and for the training programmes in a range of medical specialties.

A critical incident survey

Qualified individuals (not necessarily doctors) are asked to describe medical incidents that happened to them or that they observed which reflected good or bad medical practice. As the number of individually described incidents increases, the incidents tend to fall into natural clusters and the areas of essential competence in medicine begin to emerge. Blum and Fitzpatrick (1965) described a classic example of the use of this approach by the American Board of Orthopaedic Surgery. A variation of the critical incident survey is where those studied are regarded as ‘star performers’ and the features of a ‘star performer’ are identified.

Studies of errors in practice

Errors occurring in medical practice may be an indicator of problems with the existing curriculum, and identification of these can contribute to the development of learning outcomes. This may be carried out in collaboration with medical defence or medical insurance bodies. The identification of a common pattern of errors in medical practice attributed to poor communication skills provided evidence that skills in communication should have a greater emphasis in the specification of learning outcomes and in the curriculum.

Task analysis

Task analysis requires a researcher to follow a doctor on the job for a week or so and carefully list the tasks that the doctor carries out. The list provides a description of the activities that constitute the practice of medicine and can be the basis for the specification of the required learning outcomes. This approach is based on current practice and tells us what is done by a doctor today rather than what may be expected in the future. Nor does it give an indication necessarily of the competences or abilities required to undertake the tasks recorded.

Study of existing curricula and publications

A useful starting off point for the determination of learning outcomes is a study of what is currently taught in a range of medical schools or postgraduate programmes, and the related outcomes. Analysis of the content of current textbooks and other publications may also be helpful.

Interviews with recent graduates

Surveys of recent graduates can identify the strengths and weaknesses of the existing education programme and the stated learning outcomes. This can be done through interviews, focus groups or a questionnaire survey.

None of the techniques described is a panacea for specifying learning outcomes. It is likely that the development of an appropriate set of learning outcomes will require the use of a combination of different methods.

Reflect and react

1. If learning outcomes for your course have been produced, how were they derived and who was responsible?

2. If learning outcomes are not available, how would you set about producing them?

Exploring further

If you have a few hours

Blum J.M., Fitzpatrick R. Critical performance requirements for orthopaedic surgery: I. Method: II. Categories of performance (AIR-56-2/65-TR). Pittsburgh, PA: American Institutes for Research; 1965.

An early description in orthopaedics of the application of the critical incident approach.

Broomfield D., Humphris G.M. Using the Delphi technique to identify the cancer education requirements of general practitioners. Med. Educ.. 2001;35:928-937.

An example of the use of the Delphi technique in continuing medical education.

Dunn W.R., Hamilton D.D. The critical incident technique – a brief guide. Med. Teach.. 1986;8:207-215.

A useful review of Flanagan’s critical incident technique.

Dunn W.R., Hamilton D.D., Harden R.M. Techniques of identifying competencies needed of doctors. Med. Teach.. 1985;7:15-25.

A description of the range of approaches that can be adopted in the specification of learning outcomes.

General Medical Council. Tomorrow’s Doctors. London: General Medical Council; 2009.

Outcomes for undergraduate medical education.

Laidlaw J.M., Harden R.M., Morris A.M. Needs assessment and the development of an educational programme on malignant melanoma for general practitioners. Med. Teach.. 1995;17:79-87.

A description of how the learning needs were addressed for a continuing education programme for general practitioners.

Paterson A., Hesketh E.A., Macpherson S.G., Harden R.M. Exit learning outcomes for the PRHO year: an evidence base for informed decisions. Med. Educ.. 2004;38:67-80.

An example of the use of the Delphi process in the establishment of learning outcomes.

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