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Table of Contents
Year : 2021  |  Volume : 4  |  Issue : 3  |  Page : 91-95

Using outcomes-based curricular planning to improve clinical education: Examples from a veterinary neurology clerkship

1 Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, 501 D.W. Brooks Drive, Athens, GA 30602, USA
2 Department of Academic Affairs, College of Veterinary Medicine, University of Georgia, 501 D.W. Brooks Drive, Athens, GA 30602, USA

Date of Submission08-Sep-2021
Date of Acceptance20-Oct-2021
Date of Web Publication01-Feb-2022

Correspondence Address:
Dr. Renee Barber
Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, 501 D.W. Brooks Drive, Athens, GA 30602.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/EHP.EHP_28_21

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Clerkships are an important part of veterinary education, but the many inherent challenges to teaching in a service-oriented setting result in widely variable, sometimes insufficient learning opportunities for students. There is a large body of literature devoted to improvement of clinical education, but there has been little focus on curricular planning as a means to improve clerkships. Here, we advocate for outcomes-based curricular planning of individual veterinary clerkships to maximize learning opportunities and overcome problems often reported with clinical education, such as a lack of clear learning objectives and inadequate assessments and feedback. We provide examples of the straightforward process and benefits gained when we utilized backward design and competency-based veterinary education frameworks to revise the neurology clerkship at our institution.

Keywords: Backward design, clerkship, curriculum

How to cite this article:
Barber R, Clouser S. Using outcomes-based curricular planning to improve clinical education: Examples from a veterinary neurology clerkship. Educ Health Prof 2021;4:91-5

How to cite this URL:
Barber R, Clouser S. Using outcomes-based curricular planning to improve clinical education: Examples from a veterinary neurology clerkship. Educ Health Prof [serial online] 2021 [cited 2022 May 23];4:91-5. Available from: https://www.ehpjournal.com/text.asp?2021/4/3/91/336972

  Introduction Top

The experiential learning that occurs during clerkships is a critical component of health professions education, allowing for gain of necessary clinical competence and professional skills.[1],[2],[3],[4],[5] This is especially important in veterinary medicine where the majority of graduates enter the workforce without additional training. But, clerkship education has numerous inherent challenges and can be insufficient,[1],[6] with many veterinarians reporting inability to independently perform essential tasks for up to a year after graduation.[7]

There has been a focus on betterment of clinical education in the health professions with development of educational strategies to advance learning and assessment[8],[9],[10],[11],[12],[13],[14] and implementation of training programs aimed at enhancement of instructor skills.[1],[15] However, intentional curriculum design as a means to improve clinical education is infrequently discussed in the literature. As such, established guidelines for clerkship curriculum development are lacking. But in medical education, learning objective-driven guidelines provided by national specialty organizations[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26] are widely used and reported to be beneficial.[17],[19]

Curricular planning of clerkships can occur at many levels. Programmatic planning can be instituted to ensure that clerkships are an integrated, holistic component of the overall curriculum. Clerkship coordinators often establish learning objectives and a syllabus outlining expectations for the clerkship. Administration may set guidelines for reporting student evaluation and feedback. But, importantly, much of the planning for day-to-day teaching and assessment is done by the individual clinical instructor. Despite this, the majority of academic clinicians lack formal instruction in education and often teach how they were taught. Additionally, when starting a new faculty position, many clinical instructors adopt an already established clerkship curriculum without stopping to assess if the learning goals, assessments, or teaching methods are appropriate.

With the help of an education specialist (SC), a single clinical instructor (RB) utilized the outcomes-based curricular planning framework backward design to revise the neurology clerkship at our institution. The competency-based entrustable professional activities were also incorporated to supplement backward design.[27] Examples are provided to highlight the process and numerous benefits gained. In addition to maximizing learning opportunities, it allowed us to overcome several problems often reported with clerkship education, such as lack of clear, well-communicated learning objectives[6],[28] and inadequate assessments and feedback.[6],[29]

  Outcomes-based Curricular Planning Top

The backward design planning framework[30] has been successfully used in virtually all areas and levels of education,[31],[32],[33],[34],[35],[36],[37],[38],[39] including development of clinical training programs.[40],[41] Learning goals are identified first; then, assessments are created to provide evidence of achievement of those goals; and, finally, instruction is planned to support that achievement. This outcomes-based approach helps teachers to plan more suitable, coherent instruction and to better assess student learning.[31] It also has been associated with students adopting deep learning approaches and having overall improved performance.[38],[39]

Additionally, to ensure students’ proficiency at graduation, there has been a shift in the health professions to competency-based education, and the American Association of Veterinary Medical Colleges (AAVMC) has published nine domains of competency. Of particular interest to planning clerkship curricula, consensus-derived entrustable professional activities (EPAs) have been published for veterinary educators, translating the competencies into professional workplace activities that can be used by instructors to make entrustment-based assessment decisions.[27] EPAs have been successfully utilized in medical education to encourage assessment of often overlooked behaviors (e.g., discernment and self-confidence)[42],[43] and promote more reliable judgments by clinicians,[44] and a guideline for using EPAs for curriculum development has been published.[45]

  Examples From a Veterinary Neurology Clerkship Top

For the first step of backward design (i.e., establish the learning objectives), this question was considered: “What must veterinarians know and be able to do to successfully evaluate and manage small animal neurological patients?”

An initial list of learning objectives was generated by answering this question based on the author’s (RB) experience as both a general and specialty neurology practitioner. Following a literature review, including review of the published EPAs,[16],[46-51] and consultation with other neurology faculty and general practitioners, no significant changes were made to the initial list. Most of the learning objectives closely mirrored those of the clerkship as previously taught, as well as the workplace activities outlined in EPAs one through three[27] (e.g., acquire a history, perform the neurological exam, generate a neuroanatomic lesion localization and differential diagnosis list, develop a diagnostic and treatment plan).

Although no learning objectives from the original course were removed, several new learning objectives were added (e.g., determine when to refer a patient to a specialist, recognize when rabies is an important differential diagnosis that should alter case management). Historically, these were not stated learning objectives so related instruction occurred sporadically. As discussed in step 3, adding them as defined learning objectives prompted us to alter teaching to ensure that all students receive this instruction.

For the second step of backward design (i.e., create assessments to verify achievement), we asked ourselves, “How can we assess whether our students are accomplishing the stated learning objectives?”

At our institution, there are required, specialty-specific interim- and end-block evaluations that must be used by all clinical instructors for the 3-week clerkship. Although these cover the nine AAVMC competencies, like all mid- and end-block evaluations, they often rely on global impressions gathered after a period of time working together and do not facilitate in the moment feedback. To address this issue, two additional assessments were added to determine student achievement of the desired outcomes.

First, the ability to perform a neurological exam is central to the clerkship and necessary for all downstream learning objectives. To demonstrate the value of this learning objective to students and to ensure direct observation and timely feedback, assessment using a dedicated rubric is now scheduled for students at least once a week during the clerkship.

We also utilized the EPAs to create a formative, direct-observation assessment for student evaluation of a new referral patient. The first three published EPAs[27] were modified to encompass the initial patient evaluation (gather a history; perform physical and neurological exams; generate a neuroanatomic localization and prioritized differential diagnosis list; develop a diagnostic and/or treatment plan; communicate findings and plan with the client). Entrustability is determined on a 5-point scale ranging from student can observe the activity to student can supervise others performing the activity. This assessment is completed once per clerkship independently by both student and instructor, who then meet to compare and discuss results. In addition to improving timely feedback, this has helped prompt assessment of previously under-assessed learning objectives (e.g., history acquisition and client communication).

For the final step of backward design (i.e., plan instruction and learning activities), we asked, “How can we teach to support attainment of the stated learning objectives?”

Although many of the existing teaching methods supported attainment of the learning objectives, taking the time to ask ourselves this question allowed us to discover numerous ways to modify and improve our teaching.

First, we added instruction for the new learning objectives. For example, to ensure a student can recognize when rabies is an important differential diagnosis, for every neurological patient evaluated, students are directed to determine, “Could this patient have rabies?” and “Based on known risk factors, do I need to alter case management or communication to protect others?”

Additionally, as all skills included in the learning objectives are intended to be used in a first opinion practice setting despite training occurring within a tertiary referral hospital, diagnostic tests and treatments available in first opinion practice are now a focus of teaching. For each case, students are asked, “What would you do in first opinion practice if referral were not an option?” Students also now select a small number of cases to practice writing generalist-style medical records with immediate feedback given.

Supplemental topic rounds were also adjusted to better facilitate achievement of desired outcomes. Historically, topic rounds were content-driven and utilized primarily to reinforce knowledge. For example, seizure rounds were a review of clinical presentation, etiologies, and treatments. Now, students are directed to independently review relevant content during inevitable downtime,[1] opening up topic rounds time for the instructor to support students as they work through a series of case-based problems to hone their clinical skills.

Finally, review of the published EPAs and associated elements encouraged us to expand our teaching to be more holistic. For example, the first element of EPA 3 reminds instructors that clinical decision-making must also incorporate medical, ethical, legal, economic factors, and client desires. It is easy to routinely discuss economic factors and client desires with each new referral or emergency case evaluated.

  Conclusion Top

Overall, the process of backward design was straightforward and, in combination with the use of EPAs, facilitated more intentional assessment of each learning objective. Importantly, the focus on desired end-goals translated to better instructor preparation and subsequent ability to capitalize on available teaching moments. For example, heightened awareness of client communication as an important learning objective reminds us to include it in daily teaching. During rounds or case discussions, we ask students, “How would you present this information to the client?” We have also pre-planned our specialty. Multiple times during the rotation, a student will generate a differential diagnosis list for a middle-aged dachshund with a T3-L3 myelopathy. We are now prepared to take advantage of these moments and prompt students to do the same for a young or old large-breed dog with differences in downstream diagnosis and management highlighted.

Additionally, there was a shift in student feedback after the changes were implemented. Although overall evaluation scores remained in the above expectations to exceptional range, the comments reflect the changes made. There are now a substantial number of comments regarding the fact that all teaching is geared toward helping students become a day-one practitioner.

At our institution, one challenge in planning the curriculum was the lack of student preparation secondary to time limitations in the pre-clerkship curriculum. Unfortunately, this often redirects clinical teaching to review of foundational content. As has been done successfully for medical school clerkships,[26],[52-55] this instructional challenge was best combatted by developing a supplemental curriculum for students to work through during downtime. Ideally, as our institution undergoes curricular revision, clerkships will become an integrated part of the planning process, which will facilitate changes to the pre-clerkship curriculum that support adequate student preparation.

Numerous other limiting factors beyond caseload and time constraints were identified. For example, the strong reliance on house officers to aid in teaching and assessment of students makes it requisite that they should be included in the planning process. Additionally, not all faculties that teach a certain specialty will want to participate in the process or change their methods of teaching or assessment.

Ultimately, backward design cannot fix time and caseload or lack of student preparation. But it can aid clerkship coordinators and clinical instructors in setting clear, achievable learning objectives; it can support the design of assessments to ensure student proficiency; and it can encourage teaching that supports day-one competency. And it can, in the process, improve transparency, promote communication with students, and enhance student achievement of learning objectives, with downstream effects of improving student motivation and teacher enthusiasm.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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