In 1995, the Association of Directors of Medical Student Education in Psychiatry (ADMSEP) underwent a process of producing and endorsing a set of learning objectives for a junior psychiatry clerkship (1). Preliminary results of a recent ADMSEP membership survey suggest the learning objectives promulgated in 1995 have been widely used in undergraduate psychiatry education in a variety of ways (2).
In 2003, an ADMSEP Task force was convened and charged with reviewing and revising the learning objectives for the junior psychiatry clerkship. To be better informed for this activity, the first action of the Task force was to review the state of clerkship learning objectives for the core clinical specialties that have been developed and endorsed by national specialty organizations. This article will present the results of a comparative analysis of nationally endorsed learning objectives for seven core clinical specialties (Table 1). As background, terminology will be defined and a conceptual model for where learning objectives “fit” in undergraduate medical education will be presented along with a brief historical overview of learning objectives in clinical clerkships. Directions and challenges for revising psychiatry learning objectives will be discussed.
The model for clinical education espoused by Sir William Osler at the beginning of the 20th century became widely adopted by U.S. medical schools and evolved into the third-year clerkships we know today. Despite acceptance of the clerkship model for clinical education, there were few specific guidelines for standardization of teaching and learning in these apprentice experiences, and with isolated exceptions, explicitly stated learning goals for the clerkships were lacking and the learning experiences varied considerably. Hence, by the 1930s the Association of American Medical Colleges (AAMC) began calling for “learning objectives” to direct and standardize clinical education (3). Ongoing efforts primarily through the AAMC panels and task forces have continued to identify “learning objectives” in some form as a concern (4–7). The range of concerns raised in these reports includes: 1) a need for institutional objectives; 2) a need for clinical clerkship objectives; 3) a need for learning objectives to go beyond knowledge acquisition and include “behavioral” elements; 4) a need for learning objectives to emphasize fundamental clinical skills; and 5) a need to relate student performance assessment to the stated learning objectives. Reflecting this pattern of concern, the Liaison Committee on Medical Education (LCME) added the need for “objectives” to the requirements for program accreditation in 1985 (8).
By the 1980s, the Association of Professors of Gynecology and Obstetrics (APGO) and the Association of Surgical Educators (ASE) had articulated learning objectives for their junior clerkships and obtained organizational endorsement (9, 10). This activity set a precedent for national specialty organizations to develop and endorse clerkship learning objectives as a resource to assist clerkship directors and teaching faculty. In the 1990s, the Council on Medical Student Education in Pediatrics (COMSEP), the Association of Directors of Medical Student Education in Psychiatry (ADMSEP), the Clerkship Directors in Internal Medicine (CDIM), and the Society of Teachers of Family Medicine (STFM) developed and endorsed learning objectives for junior clerkships in pediatrics, psychiatry, internal medicine, and family medicine, respectively (1, 11–13). In 2000, curriculum guidelines for neurology instruction were developed and endorsed by the American Academy of Neurology (AAN), the Association of University Professors of Neurology (AUPN) and the American Neurological Association (ANA) (14).
Since 2000, national specialty organizations representing virtually all the core clinical specialties either have completed a revision of their clerkship learning objectives or are in the revision process. The separate but related events of reinstituting the clinical skills examination (CSE) component of the U.S. Medical Licensing Exam (USMLE) and the launch by the Accreditation Council on Graduate Medical Education (ACGME) of the Outcomes Project with six core competency domains have influenced the direction of these revision efforts to emphasize skills and attitude learning objectives and to link stated learning objectives to performance assessment (15).
Learning objectives are fundamental to education at any level and simply define what is to be learned. In medical education this terminology has been used in a variety of contexts meaning different things to different people. The recent addition by the ACGME of “competencies” to the medical education jargon has further increased the potential for confusion in discussions of learning objectives and curriculum (15). Hence, for the sake of clarity it is reasonable to define terminology and conceptualize the interaction of various curriculum elements in an educational program.
At the institution or school level, the desired learning outcomes can be best described as “educational goals.” These goals are typically broad and programmatic, and refer to the final outcome (i.e., upon graduation from medical school). At times when outside agencies have called for medical schools to develop needed “learning objectives,” this has led to a flurry of activity at the course or clerkship level, when the request was actually for schools to develop educational goals for their undergraduate program (6, 7).
To achieve the educational goals for a program of learning, “learning objectives” are needed. In this context learning objectives are the detailed, specific working elements that explicitly describe the learning experience. As the incremental steps over the course of study, mastery of the individual learning objectives is essentially equivalent to attainment of the program’s desired goals. Auscultating the chest and assessment of cognitive functioning are examples of possible learning objectives topics that drive curriculum design and support the broader educational goals of the institution (e.g., ability to perform a comprehensive patient evaluation).
As illustrated in Figure 1, learning objectives not only reflect the educational goals of the institution by directing curriculum content but further support these goals by providing the basis for assessment. Assessment of learning should reflect the stated learning objectives and use “competency” to describe that level of performance or achievement that is acceptable as consistent with programmatic goals. Each institution defines for itself the acceptable level of achievement or threshold for performance by the learner that is considered competent. In this paradigm, concerns arise when one or more of the three curricular elements (i.e., educational goals, learning objectives, asssessment) is not adequately crafted or operationalized to support the other elements. If educational goals are not adequately defined to direct selection of learning objectives, if learning objectives do not reflect the institution's goals, or if learning objectives are not articulated as measurable outcomes linked to an assessment process with performance expectations, the final outcome of the educational program may be difficult to determine and deviate from what is desired.
Seven clinical specialties were identified, which provide the so-called core clerkship experiences at the majority of medical schools, obstetrics and gynecology (OB/GYN), surgery, internal medicine, pediatrics, psychiatry, family medicine, and neurology (16). The principal national organizations for each of these specialties that has developed and endorsed learning objectives for clinical clerkships were identified (Table 1). Learning objectives documents and support materials representing each specialty were obtained from the published literature and organizational websites. Clerkship learning objectives for each clinical specialty were compared with regard to: dates developed and revised; the organizational format and curriculum focus; special features including supporting educational resources; compatibility with ACGME competency domains; and funding sources for learning objectives development and revision. Personal inquiries directed to the National Specialty Organizations were made via websites or by phone as needed for clarification.
The findings of the investigation are summarized in Table 2. The procedural specialties, surgery and OB/GYN have had nationally endorsed clerkship learning objectives for decades and have undergone multiple revisions. The remaining five specialties launched nationally endorsed learning objectives for the first time in the 1990s. Since 2000, pediatrics, internal medicine, family medicine, OB/GYN and psychiatry either have recently completed revisions or are in the process of revising their learning objectives documents. Recent learning objectives revision initiatives have been sponsored by outside funding sources. Health Resources and Services Administration (HRSA) grants provided funds for pediatrics, internal medicine, and family medicine learning objectives revisions. The OB/GYN learning objectives revision initiative received pharmaceutical industry support.
In the recent revisions for pediatrics, OB/GYN, and internal medicine, a trend has been to expand the focus beyond the traditional junior clerkship to include recommendations for specialty education throughout the 4-year undergraduate curriculum. The family medicine revision process, referred to as the curriculum resource project, has developed three separate learning objectives/curriculum resource guides for preclerkship, clerkship, and postclerkship education with the latter emphasizing preparation for graduate medical school.
The breadth and format of the learning objectives documents are quite variable among specialties, ranging from an outline of major topics of interest to relatively exhaustive curriculum resource guides. Learning objectives documents are all divided into sections, but the organization varies considerably by specialty. Depending on the specialty, learning objectives sections may be defined by presenting problems (e.g., abdominal pain in surgery), diagnoses (e.g., anemia in internal medicine), general topics (e.g., growth in pediatrics), or treatments (e.g., psychopharmacology in psychiatry). In its last revision internal medicine organized learning objectives into two principal sections. The first section defines learning objectives for broad topic areas (e.g., prevention, geriatric care) and the second section defines learning objectives for signs, symptoms, lab abnormalities, and specific disease conditions. Within a topic area, internal medicine has categorized specific learning objectives into the domains of knowledge, skills, or attitudes. For surgery each topic area includes general objectives and separate specific skills objectives.
Pediatrics, internal medicine, and OB/GYN provide a “rationale” justifying the significance of each learning objectives section. Pediatrics, internal medicine, and surgery have included “prerequisites” for each learning objectives section. Pediatrics describes “competencies” for each learning objective section, which outlines measurable performance outcomes and assessment strategies. Similarly, in the recently completed OB/GYN revision, learning objectives are accompanied by recommendations for evaluation methods and performance expectations. It is anticipated that upon completion of the current revision of internal medicine learning objectives that assessment strategies and performance expectations will be included. In the recently revised OB/GYN curriculum resource guide all learning objectives are referenced to ACGME competency domains. Likewise the internal medicine revision is expected to reference learning objectives to the six ACGME competency domains. In contrast to referencing the ACGME competency domains, the newly completed family medicine curriculum resource guide uses the six ACGME competency domains as a principal organizational strategy for learning objectives and curriculum.
Pediatrics, OB/GYN, surgery, and internal medicine all provide clinical case problems that support specific topic areas and/or learning objectives. The case problems can be used as instructional tools and for assessment. Pediatrics provides tables of differential diagnoses for signs, symptoms and test results, and a resource manual on teaching and learning in pediatrics. The psychiatry learning objectives document includes diagnostic screening instruments for problems such as substance abuse and domestic violence. Internal medicine refers to its revised learning objectives document as a “resource package” and provides materials on course administration and educational methodologies, and at the end of the current revision process will offer assessment strategies. Over the years surgery has generated extensive resource support in the form of “teaching hints” for each learning objective and numerous publications available through ASE on teaching and learning methodologies, course administration and evaluation, and academic career counseling. These resources are particularly well written and relevant to nonsurgical medical education.
The new family medicine curriculum resource guide describes itself as “a living web-based entity” and references each curriculum topic to a web-based “evolving set of resources” that includes published materials, clinical cases, standardized patient cases, and other support materials. The reader is referred to the Family Medicine Curriculum Resource Project website www.stfm.org/curricular/index where progress updates and draft materials are regularly posted.
The curriculum resource for OB/GYN has an associated glossary of relevant terms, lecture outlines, and “teaching tips” that are available to members of APGO. In 2005 APGO completed a second curriculum resource, the Women’s Health Care Competencies for Medical Students (WHCCMS) (17). WHCCMS is the product of a multispecialty effort led by APGO to “optimize women’s health care by teaching medical students.” A unique feature of this curriculum, which overlaps considerably with the OB/GYN clerkship curriculum guide completed in 2004, is a reference section that provides literature support for each specified learning objective. In addition to supporting the OB/GYN clerkship, the WHCCMS curriculum is anticipated to be a resource for other specialties that address women’s health care issues and facilitate interdisciplinary educational efforts.
Although clinical clerkships have evolved since their inception 100 years ago, they remain the frequent target of criticism, as “unstructured apprenticeships” (6, 7). Changing medical practice patterns and demands on clinical faculty that dilute teaching time compounds the traditional problems of clerkships. A consequence is that clerkship educational experiences can vary considerably, even within the same small clerkship group. Although not a replacement for declining availability of faculty teaching time, well constructed learning objectives and support materials are an important resource for medical educators and their institutions. Rather than being prescriptive, the learning objectives guides endorsed by national specialty organizations have been provided as a resource, which can be adopted, modified or modeled based on the unique creativity, strengths and resources of individual programs (1).
Since 2000, national specialty organizations have been involved in almost continuous revision of clerkship learning objectives, which are evolving into increasingly sophisticated sets of curriculum guidelines and support materials. In their most recent iterations, these curriculum guidelines generally articulate the learning objectives as measurable outcomes in the areas of knowledge, skills and attitudes, provide strategies for instruction and assessment, and make recommendations for performance standards to define competence. Additional revision trends include the emphasis of clinical context by providing case-based problems to support learning objectives, referencing learning objectives to the six ACGME competency domains, and expanding the timeframe for achieving specialty learning objectives from the third-year clerkship to the entire 4-year undergraduate curriculum. Although at times learning objectives have been criticized as something that is periodically reviewed and archived, data suggest that the learning objectives and curriculum support materials developed by national specialty organizations are considered useful by medical educators and are being implemented in U.S. medical schools (2, 18, 19).
Updating Psychiatry Learning Objectives
ADMSEP developed and endorsed a first iteration of psychiatry clerkship learning objectives in the 1990s and, like most specialty organizations, has recently initiated a learning objectives revision process. In contemplating directions for this revision process, it is apparent that scientific advances in the field of psychiatry, changing societal demands on practitioners, and the evolution of medical education over the last decade necessitate change in the format and content of the current learning objectives. Table 3 lists possible directions for the psychiatry learning objectives revision process. Of course the revision effort will update learning objectives content to reflect scientific advances and newly developed treatments, and coordinate with the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM). More provocative to consider are changes to the organizational format of the learning objectives document and development and organization of resource materials to support the learning objectives.
No particular method has yet to be identified as a superior organizational format for learning objectives. The concept of delineating individual learning objectives as principally related to knowledge, skills, or attitudes (KSAs) emphasizes the breadth of achievements desired for a medical school graduate and is consistent with the renewed interest in better defining the fundamental clinical skills for medical school graduates. Use of the six ACGME competency domains presents another possible method of organizing psychiatry learning objectives (15). However, with the exception of family medicine, rather than adopting the six ACGME domains as the principal organizational structure, most specialty learning objectives revisions have chosen to develop their own organizational structure and reference each learning objective to one or more of the competency domains.
Less well established but worth consideration in a revision process is the rank order of learning objectives: 1) as to their priority for inclusion in the clerkship (e.g., core, highly desirable, enrichment, etc.) or elsewhere in a general curriculum (e.g., preclerkship, multispecialty clerkship, etc.); and 2) with regard to the level of mastery that should be achieved (e.g., knows, knows how, etc.)(20). As schools are challenged to prove they teach what they say they teach and with consideration of time and resource limitations, there is recognition that only so many learning objectives can be meaningfully accomplished during a given period of time. Hence, although priority and level of achievement are not stand-alone organizational systems, their inclusion in a learning objectives resource is likely to be useful for clerkship directors and curriculum committees.
In addition to careful selection of an organizational format for the psychiatry learning objectives revision, there is a need to link learning objectives to clinical case problems, recommendations for instructional methods, assessment strategies and performance expectations. These inclusions will provide utility for users of a psychiatry curriculum guide and are consistent with the now established trend for curriculum revisions by other specialties. The ACGME Outcome Project Toolbox and Miller’s levels of competence have been used as a resource by several specialties for recommending appropriate assessment methodology and student performance expectations for learning objectives (15, 20).
Although numerous resources can be developed to support learning objectives (e.g., literature references, lesson plans, teaching manuals, faculty development programs), the most basic and consistent resource across specialties is clinical case problems. Clinical case problems linked to individual learning objectives, whether elaborately designed or simple in their construction, have application for instruction and for formative and summative assessment. They shift the learning focus from knowledge acquisition to knowledge application, which is consistent with the traditional case method in medical education and models the critical reasoning required of physicians. Although not a substitute for actual student-patient encounters, linking clinical case problems to learning objectives can help ensure some level of standardized experience for all students regardless of the difficult to control fluctuations in the variety and types of student-patient encounters. At a time when the LCME is requiring quantification of “real or simulated” patient encounters in clinical education, a clinical case component for the psychiatry learning objectives would be a valuable resource for psychiatry educators (8).
A principal challenge for the psychiatry learning objectives revision process is financial support. Most specialty organizations have relied on the voluntary contributions by their membership to develop and review earlier iterations of clerkship learning objectives. However, as the scope of the work has expanded from relatively simple lists of learning objectives to elaborate curriculum resource guides, specialty organizations have relied on outside funding. Government and philanthropic granting organizations need to be explored for funding of the psychiatry learning objectives revision initiative. Although there are examples of industry sponsored curriculum revisions, industry funding raises a potential conflict of interest (21).
As many schools reduce the length of their psychiatry clerkship, a further challenge for the learning objectives revision process and psychiatry education in general is how to accomplish core learning objectives with reduced curriculum time (22). One goal is that out of the learning objectives revision process will come creative ideas for addressing this concern, either justifying return of curriculum time for the psychiatry clerkship or identifying opportunities for achieving psychiatry learning objectives outside of the third-year clerkship. On the horizon is the possibility of innovative collaborations in clinical education with multi-specialty faculty working together to achieve shared learning objectives (23). Ultimately the goal of the psychiatry learning objectives revision process is to provide a meaningful resource that has value for psychiatry educators and student learners alike. The direction appears clear: organize and prioritize learning objectives; link learning objectives to clinical context, instructional methods and assessment strategies; and, focus beyond the clerkship to the entire undergraduate curriculum. There is much to do.