Improving Diversity in Learning Activities in a Teaching Curriculum in Higher Medical Education

Abstract

The growing demand for medical professionals in undergraduate and graduate/postgraduate medical education to attain comprehensive health training has not abated and necessitates the development of curricula encompassing relevant issues pertaining to clinical practice as well as the educational context. Therefore, diversity in learning activities should be embedded in a teaching curriculum to achieve the required competencies. This includes considering at least the following during the design and analysis of a teaching curriculum: Harden's ten questions to be posed when designing a curriculum; Canadian Medical Education Directives for Specialists (CanMEDS) competency framework which has been approved by the Royal College of Physicians and Surgeons of Canada; 21st-century skills; Diana Laurilliard's conversational framework; and general quality measures to improve diversity in a teaching curriculum.

Introduction

Becoming a healthcare practitioner demands the acquisition of sufficient skills and knowledge as achieving inadequate competencies could result in harm to patients and their families. Therefore, shaping the approaches for relevant and quality healthcare training should be directed by an acceptable framework/s demonstrated in a teaching curriculum. These frameworks serve as foundational educational components required for comprehensiveness, cohesion, and understanding of a curriculum. A teaching curriculum is a guidepost informing learning content and includes a schedule of learning activities which is a pivotal component that drives learning. ¹ Curriculum development is an iterative process that necessitates modification in response to the acquisition of new knowledge and experiences especially in domains such as patterns of disease profiles, migration, technology, socio-cultural values, fiscal issues, demography, and administrative policies. ¹ To cater for these ever-changing domains, diversity becomes an essential part of a teaching curriculum.^1,2 Despite the importance of ongoing curriculum analysis for the improvement of a programme, a step-by-step approach following a logical sequence that is based on accepted educational principles is under-described in the literature. ³ In this commentary, we explore various educational principles and frameworks, showcasing how their interplay may improve diversity in learning activities in curricula in higher medical education as summarized in Figure 1. The definition of diversity in this commentary encompasses the implementation of relevant educational principles required in a teaching curriculum to meet the demands in learning activities based on prevailing realities in the educational context including the individual learning needs of students, and is not limited to issues pertaining to racial, ethnic and cultural diversity. It includes among others giving due consideration to discipline-specific mandatory learnings, personality differences, communication skills, political preferences, and differences.

Figure 1.

Illustrating the interplay of educational principles and frameworks to enhance diversity in learning activities in higher medical education curricula. Explanation: All the educational principles depicted naturally incorporate diversity as each of them improves IFA-AIR-BEE. The learning outcomes determine the constituents of various components of the teaching curriculum. In a lesson, the learning objectives determine the learning activities and assessment, and the trio (objectives, activities, and assessment) should be constructively well-aligned and prespecified in a teaching curriculum. The implementation of a suitable curriculum will lead to the acquisition of intended skills and knowledge such as the 21st century skills which should be considered in the design of learning activities. The italicized items in the purple background may be used for evaluation of the entity they are linked to. Note that all the links and associations are not shown in the diagram to avoid the crisscrossing of lines and arrows. Abbreviations: CanMEDS, Canadian Medical Education Directions for Specialists; IFA-AIR-BEE, Integrity, Flexibility, Accessibility, Alignment, Inclusivity, Relevance, Balance, Engagement and Equity.

Designing a Curriculum With Diverse Learning Activities

Overall, the qualities of a good teaching curriculum that cultivates diversity inter alia are integrity (adhering to agreement and schedule), flexibility (using blended learning), accessibility (providing resources for learning), alignment (constructive alignment), inclusivity (including students’ viewpoints in the learning activities), relevance (providing useful content and familiar examples), balance (covering all aspects of the content), engagement (making students to develop interest and participate actively), and equity (ensuring that each student has the opportunity to achieve the expected standard) ¹ —mnemonic IFA-AIR-BEE. The elements in “IFA-AIR-BEE” are pertinent as they cover a wide range of principles/practices and are simple terminologies. For instance, active learning (ie, learning by doing something and thinking about it) may be regarded as part of engagement while student centeredness is the foremost essence of “IFA-AIR-BEE.” Furthermore, a teaching curriculum should be a thorough compilation, incorporating details such as module name and outline, learning outcomes, assessment strategies, the module's position within the degree/qualification program, prerequisite knowledge/psychomotor skills required by students, lesson names, learning objectives, learning activities, and the tools and resources required. ¹ These components are practical derivatives of Harden's ten questions (Table 1) that are used to bring order and coherence when designing a teaching curriculum. ⁴ While learning outcomes delineate what the student should achieve at the conclusion of the course, the learning objectives describe what the student should be able to perform after each learning activity. ⁵ The focus of the learning activities is to achieve/enhance the three domains (outcomes) of learning: cognitive domain (knowledge), psychomotor domain (skills), and affective domain (attitude). ¹ Furthermore, learning objectives should comprise relevant verbs based on the revised Bloom's taxonomy to describe the level of the cognitive domain (knowledge, application, comprehension, analysis, evaluation, and synthesis) as well as psychomotor and affective domains. ⁶ Moreover, Krathwohl's affective learning taxonomy is often a preferred taxonomy for assessing affective learning, and in ascending order it consists of receiving, responding, valuing, organization, and characterization. ⁷ Many other methods of assessing the psychomotor domain such as Simpson's taxonomy, Dave's taxonomy, and Harrow's taxonomy are available to evaluate the level of procedural and clinical skills of students in health sciences. ⁸

Table 1.

Harden's 10 questions are to be posed when designing a curriculum. ⁴

1.	What are the requirements in relation to the outcome of a curriculum?
2.	What are the specific aims and objectives?
3.	What content should be incorporated?
4.	How should the content be structured?
5.	What are the educational strategies that should be implemented?
6.	What teaching methods should be applied?
7.	How should assessment be performed?
8.	How should particulars of the curriculum be transmitted?
9.	What type of educational environment or climate should be promoted?
10.	How should the process be presided over?

In response to the need for an approach to assess and teach/deliver quality postgraduate medical education, the Royal College Physicians and Surgeons of Canada approved a competency framework known as CanMEDS which guides the essential competencies that physicians should acquire for optimal patient care. ⁹ These abilities are grouped under seven roles: professional, leader, advocate, communicator, medical expert, collaborator, and scholar ⁹ —mnemonic PLACE-CS. To assess these competencies, an authentic/outcome-based assessment with appropriate Entrustable Professional Activities (EPAs) is recommended. ¹ The EPAs are measurable and observable units of minimum competency that a trainee in a particular level of training in a medical discipline should achieve without supervision. ⁹ Finally, a teaching curriculum should nurture the acquisition of the envisioned learning such as 21st-century skills and knowledge. ¹⁰ Popular among the 21st-century skills are skilled communication; collaboration; real-world problem solving and innovation; digital/information and communication technology (ICT) for learning; self-regulation in learning; and knowledge construction. ¹ The 21st-century skills are endorsed by many investigators and institutions; and help with knowing which knowledge is of most worth. ¹¹ Furthermore, there is evidence to support the fact that 21st-century skills enhance foundational, human, and metaknowledge and equip learners with the skills needed to keep pace with technological advancement. ¹ To achieve this, it is pertinent to reiterate that the learning activities in a curriculum should encompass and provide for the aforementioned three domains of learning. ¹ Although it is important to equip students with the learning needed to deal with and make use of technical advances, many of the skills have been important and in existence for decades. However, the 21st-Century Learning Design (21CLD) learning activity rubric provides additional insight into the level of a learner's participation/engagement in each 21st-century skill learning activity and may guide the design of a teaching curriculum to ensure that the required level of skill is embedded in the curriculum.^1,12 To ensure that all types of learners succeed, various learning activities may be adapted by applying Diana Laurillard's six learning/engagement types namely: collaboration, acquisition, practice, production, investigation, and discussion ¹³ —aide-mémoire CAP-PID. As an example, the learning activities under “discussion” may include seminars, discussion groups/forums, web conferencing, and chat tools, applying concepts to experiences/examples, and sharing experiences. Following implementation, these learning activities under “discussion” will achieve learning on how to argue, comment, critique, compare, contribute, debate, defend, define, describe, rationalize, and reflect. ¹³

Relevant Quality Assurance Tools

To successfully achieve the objectives of a curriculum, there is a need to critique the curriculum using evaluation tools during its development. For this quality assurance, the hierarchy of the learning outcomes in a teaching curriculum may be assessed using the Structure of Observed Learning Outcomes (SOLO) taxonomy. ¹⁴ SOLO can be utilized to define the intended learning outcomes, and by extrapolation determine the forms of teaching/learning activities that support the outcomes as well as the forms of assessment used to evaluate to what extent the outcomes were achieved. ¹⁴ To evaluate the effectiveness of a teaching curriculum, the four-level evaluation model by Kirkpatrick may be used as an appraisal tool.^1,15,16 In order of increasing hierarchy, Kirkpatrick's framework evaluates the learner's reaction (or level of satisfaction) to the program, what was learned from attending the program (skills gained, attitudes changed, and knowledge improved), behavior change, and application of new knowledge in real life, and assessing tangible results (societal/patients’ impact).^15,16

Possible Barriers to Implementing Diversity in Learning Activities

The development and transformation of medical and scientific knowledge are rapid, while educational processes including curriculum development are slow. Hence the a need for continuous dialogue and reflection about the aims, content, and organization of a curriculum among stakeholders. Determining the readiness of higher education institutions to accept and implement change is complex and is influenced by many factors including social needs, technology, university-industry alliances, education ministries, university administrators, local governments, the demand–supply gap of producing new graduates, and current trends in learning globally. ¹⁷

Furthermore, to lead a change such as diversity in teaching curricula in higher education institutions, it is crucial to create a sense of urgency, forge a coalition, articulate a strategic vision, communicate the vision to ensure buy-in by many people, eliminate barriers, produce short-term triumphs to convince skeptics, sustain the drive towards the new developments, and institutionalize the change into the culture of the institution. ¹⁸ Scaling up and scaling out the change to ensure widespread adoption requires the creation of an enabling environment and learning what works. ¹⁹ Invariably, these processes will need the support of the leadership of the institution to avoid accusations of threatening the institutional hierarchies or values. Ultimately, there should be an alignment of clinical and educational goals and values to ensure that the proposed changes will help students in their clinical practice. ²⁰

Certainly, scholars may have different preferences in terms of which educational principles and frameworks best improve diversity in learning activities. In the context of our definition of diversity, the principles cited are certainly relevant although what is best may be arguable.

Conclusion

The ever-changing healthcare needs of society dictate that teaching curricula in medical institutions embrace diversity in learning activities to ensure that students have ample opportunities to acquire the essential knowledge and skills to achieve learning outcomes, so they are equipped to provide the best quality of care. In this commentary, relevant concepts have been expounded on to assist medical educators with the design of teaching curricula that incorporate diversity in learning activities.