MEDEV

School of Medical Sciences Education Development

The core curriculum with options or special study modules

An extended summary of AMEE Medical Education Guide No 5 by R M Harden and M H Davis

Published in Medical Teacher (1995) 17, 2 pp 125-148

Guide overview:

A powerful strategy in medical education is the combination of a core curriculum with options or special study modules (SSMs) or Student Selected Components (SSCs). This helps to solve the problem of curriculum overload, to ensure that students acquire the knowledge, skills and attitudes required for the maintenance of standards and allows students to take more responsibility for their own learning by choosing subjects they wish to study in greater depth. It also provides a curriculum framework within which students can proceed at a pace which suits their individual development. The guide examines:

• reasons underlying the trend towards core curricula with options or special study modules
• the philosophy underpinning the concept of a core curriculum and the nature of options or special study modules
• the different ways in which the core and special study modules can be delivered in the curriculum
• approaches to identifying the core practical issues in implementing the approach

Background

The concept of a core curriculum with options or SSMs is arguably the most exciting and significant development in medical education thinking in recent years. It features prominently in the recommendations by the General Medical Council (1993, 2002) to UK medical schools and has been widely covered in the medical education literature.

Many medical schools, specialist bodies and organisations are actively pursuing the specification of core curricula in their fields. Advances in medicine and the so called ‘information explosion’ have led to an increasing and potentially intolerable burden for the student. Curriculum developers need to make provision for the inclusion of new topics such as palliative care, drug abuse and health promotion without neglecting traditional course content such as anatomy, physiology or surgery, at a time when the duration of the medical course in many countries is being reduced. There is also an increasing recognition that while students may not be able to study all areas in depth, there is a need to provide an opportunity for them to have time scheduled to study some subjects in more depth.

What is the core curriculum?

There are different perceptions of what constitutes ‘core’, For example:

• Core as essential aspects of all subjects or disciplines: the key aspects of the subjects studied in the curriculum, eg medicine, surgery, ophthalmology etc;
• Core as essential competences for practice: eg cardiopulmonary resuscitation, the management of a patient with abdominal pain, etc;
• Core as a study of what are perceived as the key disciplines: eg, medicine and surgery are included, but minor specialties such as otolaryngology and anaesthetics are not;
• Core as transferable areas of study relevant to many disciplines: generic competences such as communication skills, problem solving etc.

The concept of the core curriculum and options or SSMs – the seven Cs

The philosophies underpinning the development of the core curriculum with options or SSMs can be described as the seven Cs:

• Certification: As greater accountability is demanded, by institutions, government and the public, it is important to ensure that doctors, on qualification, have the knowledge, skills and attitudes expected of them. The core curriculum is a public statement from institutions that details the essential competences their graduates must achieve.
• Capability: The need to include in the core curriculum key generic competences such as communication skills, interpersonal skills, problem-solving ability and decision-making ability.
• Comprehensiveness: The notion that all essential aspects of the subject or topic will have been covered and mastered.
• Consistency: The need for consistency and agreement in the content of the basic medical curriculum – important at a time of increasing globalisation - whilst maintaining each school’s autonomy in bringing to the curriculum any special aims, objectives and ethos with which that school wishes to be identified.
• Constructivism: The constructivist psychology of learning dictates that new knowledge builds on a sound foundation of core knowledge acquired previously. This is exemplified in a spiral curriculum. Students may build their understanding of abnormal structure and abnormal function as they relate to each body system on their core understanding of normal structure and function gained in the earlier years of the curriculum.
• Choice: The core is supplemented by options or special study modules, giving the student freedom to choose what he or she wishes to study. In the UK, the General Medical Council (1993) recommended that the core should not take up more than two-thirds of the time available. In the optional elements of the course, students choose the subject to be studied. During the study of the selected areas, students may be expected to master core learning outcomes such as skills in self-learning.
• Compacted curriculum: Core and options provides flexibility for the below-average student who takes longer to master the core. Similarly, it caters for the above-average student by offering the possibility of a compacted or accelerated curriculum. Alternatively students who master the core in the minimum time allocated can proceed to more ambitious SSMs.

Determination of core

A range of stakeholders can contribute to what should be included in a core curriculum. These may include the government, the public, the professions, students and teachers within an institution. The framework for the learning outcomes for the medical school curriculum may be determined by centrally accountable bodies with the provision for some diversity to reflect local requirements and teachers’ responsibility for curriculum development locally. Within the medical school, the determination of the core should be a team effort, involving all concerned with the education of medical students, with the ultimate decision resting with a curriculum committee with good representation.

A range of methods is available for the determination of the content of an educational programme. These include the ‘wisemen’ approach, Delphi techniques, critical incident studies, and analysis of current practice and job analyses of health care professionals.

• The importance of the topic in key decisions to be taken by a doctor
• The commonness or rarity of the problem
• The extent to which one can generalise from the subject to other topics in medicine.

The core curriculum will change with time and should reflect medical trends and changes in emphasis.

Options, special study modules or student selected components

‘Options’, Special Study Modules or Students Selected Components are intended to offer opportunities for choice of topics that excite the interest and imagination of the student and that lead to exploration of the sources of knowledge relating to such topics and evaluation of the evidence on which such knowledge is based. They should not be thought of as offering the student the opportunity to decide the elements he/she would like to leave out of the course, but rather as what to add in to augment the core.

Special study modules offer a number of advantages when linked to a core curriculum.

• They provide the opportunity for students to study in greater depth an area of their choosing, facilitating the achievement of higher-level objectives, such as critical thinking and reasoning.
• They facilitate the development of integrated themes, giving a multidisciplinary and multiprofessional direction to the curriculum.
• SSMs recognise the importance of generic competences or transferable skills eg, communication skills or time management, and the student is encouraged to take more responsibility for learning.
• SSMs allow significant extension of the range of subjects or topics covered in the curriculum, catering for different interests and career aspirations.
• As schools move towards a common core, the range of SSMs offered in any one medical school may reflect that school’s direction or emphasis. A menu of interesting SSMs may attract potential students and influence their choice of medical school.
• SSMs can utilise a range of teaching resources and encourage the involvement of staff who may not otherwise have a role in the curriculum.
• SSMs can be attractive, both to staff and students.

Special study modules and electives

During the past two decades, elective studies have played an increasingly important part in medical curricula. Conventionally, ‘electives’ are periods of eight weeks or more where students individually choose a subject for study or an attachment often outside their own institution. Electives can be viewed as a special type of SSM. Whilst they may share the same objectives, there are a number of differences between an elective and a standard SSM. SSMs are often seen as a more formal part of the curriculum with a more limited choice of subjects and a greater structure imposed.

Topics covered in SSMs

The type of subject studied for options or special study modules may lie in three categories:

1. An extension of the core: eg, following a study of the locomotor system as part of the core course, the student may choose to study one particular joint in more depth or to do an SSM in sports medicine. Alternatively the student could undertake remedial or revision work relating to the core.
2. A topic related to medicine but not included in detail in the core: eg, computing, information technology, history of medicine.
3. A topic not related directly to medicine: eg a foreign language, business studies.

Important criteria for the selection of SSMs are the contribution they can make to overall course learning outcomes and the availability of suitable resources in the medical school.

Is the subject consistent with the school’s learning outcomes and will the student become more able to practise as a doctor? Does the SSM lead to mastery of learning skills, critical thinking and information retrieval relevant to the practice of medicine? Might the SSM help the students in their choice of a future career?

SSMs should not be used to reintroduce redundant detail left out from the core or be restricted to superficial cramming of a new topic.

Management of SSMs

To ensure success SSMs must be seen as an opportunity for creativity and not as a step towards chaos.

• At least one senior member of staff must have their organisation and coordination as a major personal responsibility. This person must have the authority of the appropriate committees within the university.
• Adequate resources must be made available, eg finance, library facilities etc.
• There should be some flexibility in the duration of SSMs, eg, one, two or four weeks or longer.
• The number of SSM slots offered should be greater than the number of places required by students.
• Guidelines and advice should be offered to students concerning their choice of SSMs and what is expected of them.
• SSMs should be assessed as stringently as the core, preferably with an external examiner.

Relationship between core and SSMs

Four approaches can be identified to implement a curriculum with core and SSM components. Each has its advantages and disadvantages.

• Integrated Approach: The SSM is related to a subject and is integrated with the core teaching of the subject. It may be difficult, however, to protect the time allocated for the SSM and the core may expand to fill the time allocated for the SSM.
• Concurrent Approach: The SSM runs in parallel with the core but is not necessarily related to the core. An advantage is that the student has, at any one time, a varied diet of core and option. A disadvantage is that each may compete for the student’s time.
• Intermittent Approach: Blocks of time (e.g.10 weeks) are allocated for SSMs intermittently at different stages in the curriculum. This ensures protected time for the option or SSM.
• Sequential Approach: Each block of core in the curriculum e.g 16 weeks is followed by an SSM e.g 8 weeks. This model allows a fundamental curriculum rethink and an assessment-to-a-standard approach. Students proceed to SSMs only when they have demonstrated mastery of the core. The model allows the best use to be made of teaching staff, those with the necessary training being assigned to remedial students and others with more specialised interests providing teaching on SSMs.

Time allocation for core and for SSMs

In the UK, SSMs take up between 20-40% of the curriculum. The balance between core and SSMs will be influenced by, among other things, the amount of core to be covered and the resources available to provide a wide range of learning opportunities. Perhaps most important will be the institution’s view of the education process and entrenched views about traditional approaches to teaching and learning.

Student assessment

The introduction of a core curriculum with SSMs has major implications for assessment of students. Assessment should reflect expected learning outcomes and it follows that it is likely that the assessment procedures for core and SSM parts of a course will differ.

What matters in the core component of the course is the standard students reach, not the time they take to do so. Students should be expected to demonstrate a high level of mastery of the core of a course on completion of the curriculum, as well as at the end of each phase.

In the assessment of SSMs, decisions must be taken as to whether to adopt a pass/fail system or a grading system and how that influences the overall assessment of students. The assessment may be a written test, essay, dissertation, oral or practical exam. External examiners are important in helping to maintain standards comparable between different SSMs.

Postgraduate studies

The concept of core and SSMs is relevant also to postgraduate education. The constructivist approach should continue through the continuum of education, with postgraduate training building on a sound core of competences and a strong framework developed during the undergraduate phase. Increasing demands on postgraduate training, with greater specialisation, rapid expansion, new developments in medicine and time constraints, are arguments for the introduction of a core training programme with SSMs. SSMs would let trainees work in some area in a greater depth and for those with academic ambitions, the optional part of the training might have a greater emphasis on teaching and on research.

Conclusion

The need to liberate the medical curriculum from its present factual overload is well recognised, as is the need to provide both breadth and depth of study. Freedom of choice while maintaining standards and mastery of the essential competences required for medical practice are a real step forward in thinking about medical education.

From a traditional perspective, core and options challenges the fundamental belief that all students should have a uniform curriculum throughout their training, completed more or less in the same set time. The arguments and pressures for a move to a curriculum with special study modules are overwhelming – not only in undergraduate but also in postgraduate education. However, it does require a new approach to curriculum planning.

The introduction of core and special study modules allows great efficiency in the use of time and facilitates achievement of significant and highly desirable curriculum objectives.

© 2002 AMEE

The full text of this guide comprises 19 pages and 43 references and is available from:

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