Educational Strategies Outcome-Based Education

The move to outcome-based education has been one of the most important trends in health-profession education in recent years. This paper defines outcomes and outcome-based education, describes the development of outcome-based education, identifies several different ways that outcomes have been presented, and discusses the advantages and disadvantages of the outcome-based educational approach. The implementation of outcome-based education at the University of Dundee medical school, Scotland, UK is described as a case study for curriculum planners in veterinary medical education. The lessons learned in Dundee from six years’ experience with outcome-based education are identified to aid veterinary medical educators wishing to implement the approach. DEFINITION OF OUTCOMES AND OUTCOME-BASED EDUCATION An outcome is a culminating demonstration of learning;1 it is what the student should be able to do at the end of a course. Outcome-based education is an approach to education in which decisions about the curriculum are driven by the exit learning outcomes that the students should display at the end of the course. “In outcome-based education,” suggest Harden and colleagues, “product defines process. Outcome-based education can be summed up as results-oriented thinking and is the opposite of input-based education where the emphasis is on the educational process and where we are happy to accept whatever is the result” (emphasis original). 2 There is a significant difference between outcome-based education and simply producing outcomes for an existing curriculum. “Outcome-based,” insists Spady, “does not mean curriculum based with outcomes sprinkled on top. It is a transformational way of doing business in education. ”1 THE DEVELOPMENT OF OUTCOME-BASED EDUCATION Much of the work on the development of outcome-based education was carried out in pre-university education in the US by Spady.3 The Coleman report, published in 1966, demonstrated problems in the pre-university educational system, with results attributed almost entirely to the socioeconomic and ethnic background of the students who attended the school. A need for reform of the American educational system was identified. Clarity of focus, expanded opportunity, and high expectations were the corner stones of reform. Educators turned to the work of Carroll4 and Bloom5 to achieve the desired reform. Carroll had argued that it was inappropriate to fix the time for study and expect variable learning results from students. What was needed was a uniform minimum standard that all students would be expected to achieve and that all would be given the time needed to achieve. Bloom developed Carroll’s thinking into the notion of mastery learning, in which a fixed level of performance was to be achieved by students by changing the relationship between time and learning. The learning became fixed and the time to achieve the learning became the variable. These ideas became the underlying educational principles of outcome-based education. The State Board of Education, Pennsylvania, decided in 1992 to replace rigid adherence to the traditional school calendar with a set of performance capabilities that students had to achieve. One school in Glendale Arizona took the decision, on its own, to extend the school day to better deploy its resources for the benefit of student learning. Aurora public schools in Colorado identified five, role-based, exit outcomes in 1990: self-directed learners, collaborative workers, complex thinkers, community contributors, and quality producers. The promise of far-reaching reform through increased accountability and more school autonomy and flexibility was seductive. These reforms in pre-university education impacted on health-profession education at a time of dissatisfaction with medical education. In the US the General Professional Education of the Physician (GPEP) Report, published by the Association of American Medical Colleges (AAMC) in 1985, called on medical schools to give each student the knowledge, skills, values, and attitudes that all physicians should have. In the UK in 1993 the General Medical Council (GMC) published its recommendations for undergraduate medical education in Tomorrow’s Doctors, a document that signaled farreaching reform of the undergraduate medical curriculum. As part of that report, the education committee of the GMC identified the attributes of the independent practitioner. The search for the outcomes of medical education had begun. PRESENTATION OF THE OUTCOMES Exit learning outcomes for the health care professions can be presented in a number of ways. Smith and Dollase6 identified nine abilities expected of graduates of their MD2000 medical program at Brown University in Rhode Island (Table 1). JVME 30(3) © 2003 AAVMC 227 Table 1: Nine abilities expected of graduates of the Brown University medical program The English National Board of Nursing, Midwifery and Health Visiting identified ten key characteristics as the basis for the learning outcomes required for the higher award.7 These are 1. ability to exercise professional accountability and responsibility, reflected in the degree to which the practitioner uses professional skills, knowledge and expertise in changing environments, across professional boundaries and in unfamiliar situations 2. specialist skills, knowledge and expertise in the practice area where working, including a deeper and broader understanding of client/patient health needs, within the context of changing health care provision 3. ability to use research to plan, implement and evaluate concepts and strategies leading to improvements in care 4. team working, including multiprofessional team working in which the leadership role changes in response to changing client needs, team leadership and team building skills to organise the delivery of care 5. ability to develop and use flexible and innovative approaches to practice appropriate to the needs of the client/patient group in line with the goals of the health service and the employing authority 6. understanding and use of health promotion and preventative policies and strategies 7. ability to facilitate and assess the professional and other development of all for whom responsible, including where appropriate learners, and to act as a role model of professional practice 8. ability to take informed decisions about the allocation of resources for the benefit of individual clients and the client group with whom working 9. ability to evaluate quality of care delivered as an ongoing and cumulative process 10. ability to facilitate, initiate, manage and evaluate change in practice to improve quality of care Long lists of outcomes are, however, somewhat difficult to remember and manage. McNeir8 suggested, in relation to identification of outcomes, that “the key for most schools seems to be developing outcomes that are broad in their vision but specific enough to be taught and measured effectively. ” In 1998 the AAMC developed a set of goals for medical education and identified the attributes that physicians need to meet society’s expectations of them.9 These attributes were memorably stated in four groups: the physician must be altruistic, knowledgeable, skillful, and dutiful. Charles Boelen of the World Health Organisation (WHO) advanced the idea of the five-star doctor for the twenty-first century.10 S/he would be a care provider, decision maker, communicator, and manager and be community-minded. In Canada, the CanMEDS project11 presented its understanding of the essential roles and key competencies of specialist physicians: medical expert, communicator, collaborator, manager, health advocate, scholar, and professional. What all of these groups were saying, in essence, was represented by Harden and colleagues2 in a three-circle outcome model, shown in Figure 1. Figure 1: The three-circle outcome model 1 Effective communication 2 Basic clinical sciences 3 Using basic sciences in the practice of medicine 4 Diagnosis, management, and prevention