PD Handbook

Fundamentals of an Academic Curriculum

Last updated: January 18, 2020

Authors

  1. Jason R. Bingham, MD, FACS; Assistant Professor of Surgery, Uniformed Services University, Director of Surgical Research; Madigan Army Medical Center, Tacoma, WA.
  2. Michael J. Malinowski, MD, FACS, RPVI; Associate Professor of Surgery, Associate Program Director, General Surgery; Medical College of Wisconsin, Milwaukee, WI.

Introduction

The Academic Curriculum serves multiple stakeholders within a General Surgery residency program including the institution, department, program director, patients and surgical resident learners. As adult learners, the three domains of learning must be encompassed in a comprehensive framework for the resident such that no educational or scholarship gaps remain. Although the cognitive content domain remains a robust area of academic curriculum due to the demands of board certification and entry into practice, psychomotor and affective domains can sometimes harbor the most challenging learner deficits to remediate and in their own right are just as important to success for both independent and group surgical practice.

CONTENT (Cognitive)

ACGME Citation

IV. B.1.c. Medical Knowledge: Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and social-behavioral sciences, as well the application of this knowledge to patient care.

Evidence/Data

Anecdotes

Establishing a solid competency-based curriculum is a joint endeavor that requires a dedicated core-faculty, motivated residents, and a tenacious support staff. Structuring a training program around Kern’s six-step approach to curriculum development is useful.

  1. Problem Identification and General Needs Assessment — The general needs/requirements for graduate medical education are outlined in the Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements.
  2. Targeted Needs Assessment — A diverse and structured curriculum designed to cover the breadth of surgical knowledge is essential. The American Board of Surgery (ABS) endorses the SCORE Curriculum. The curriculum outline can be found at http://www.absurgery.org/default.jsp?scre_booklet.
    1. The annual American Board of Surgery In-Training Examination (ABSITE) should be used to assess a resident’s strengths and address any deficiencies as they move toward the ABS qualifying and certifying examination.
    2. Mock oral examinations are useful both to access a resident’s depth of knowledge as well as prepare the resident for the ABS certifying examination. A formal mock oral exercise should be conducted at least annually if not biannually.
    3. Self awareness is crucial both from an adult learner perspective, but also from the residency program perspective to assess programmatic and curricular gaps.  This review can be just as vital to providing a comprehensive and impactful academic curriculum and requires the program director to review board pass rates, fellowship match results and ABSITE performance beyond individual learners to evaluate the larger cohort groupings.
  3. Goals and Objectives — Goals should be competency based and should align with the ACGME’s Core Competencies (https://www.ecfmg.org/echo/acgme-core-competencies.html). The surgical rotation schedule should be designed with these competencies in mind, and structured to give residents graduated responsibility and autonomy with supervision as they progress.
  4. Educational Strategies
    1. Protected and mandatory academic time set aside each week is a must. In the hectic day-to-day of a busy surgical practice, it is very easy to start encroaching on this protected time, however this tendency must be resisted. Vigorously protecting dedicated academic time sends a strong and clear message that the program’s educational mission is a priority. Typically, a half-day consisting of a mixture of didactics, resident led reviews, multidisciplinary conferences, and journal clubs is sufficient.
    2. Repetition is the key to adult learning, and as such, it requires dedicated and protected time to allow for repetition of learning across all domains within a mentored learning environment.
    3. Connectivism is the theory of how adult learners communicate across social groupings.  The theory reminds us that how residents learn is often more important than what they know at any particular point in training. Conflicts due to discordant learning styles of Millennials (i.e. Digital Natives) compared to the more traditional Socratic method practiced by older faculty must be resolved accordingly to establish an effective teaching method that matches learner needs. Resident learners require lifelong learning skills to continually expand their content knowledge in pace with the rapid expansion of surgical and medical knowledge in general. These concepts are explained nicely in George Siemens “A Learning Theory for the Digital Age,” and all faculty involved in resident education should be familiar with this theory.
  5. Implementation — Maintaining an academically rigorous program is a team effort. The Program Director is ultimately responsible for establishing and enforcing a culture of excellence, but teachers and learners at all levels should be actively engaged — faculty mentor residents, senior residents teach junior resident, all residents teach each other and medical students. Empowering learners to take part in their own education is critical in a field of lifetime learning.Peer review and periodic examination of curricular outcomes should be a fundamental part of the curriculum cycle, such that teaching methods, content, faculty development, assessment tools, etc. are all accountable to periodic evaluation and revision.  Implementation, evaluation and revision should be part of a shared process cycle to accommodate both learner and faculty needs.
  6. Evaluation and Feedback–  Perhaps one of the most challenging portions of curricular creation and revision is the incorporation of feedback and appraisal of evaluation methods.  Both formative and summative assessment methods are required to give learners clear feedback on performance standards required by the curriculum.  Evaluation methods of the program to ensure learning is effective and translational in a fiducial relationship with the learner is critical to ensure programmatic educational missions.

The resources below may be useful in building a structured educational strategy that provides oral, visual, and interactive based on the principles of adult learning.

Resources

PROFESSIONALISM AND SCHOLARSHIP (Affective)

ACGME Citation

IV. A. 5-6. Advancement of residents’ knowledge of ethical principles foundational to medical professionalism; and advancement in residents’ knowledge of basic principles of scientific inquiry, including how research is designed, conducted, evaluated, explained to the patients and applied to care.

IV. B.1.a. Residents must demonstrate a commitment to professionalism and an adherence to ethical principles.

Evidence/Data

  • Boyer EL. Scholarship Reconsidered: Priorities for the Professoriate, The Carnegie Foundation of Advancement of Teaching, New York: John Wiley and Sons, 1990.  Highlights four domains of academic scholarship: Discovery, Integration, Application and Teaching.
  • Glassick CE, Huber MR, Maeroff GI.  Scholarship Assessed: Evaluation of the Professoriate, San Francisco: Jossey-Bass, 1997.  Reviews six characteristics that define academic scholarship:  Clear goals, Adequate preparation, Appropriate methods, Significant results, Effective Presentation and Reflective critique.
  • Harken AH, et al.  Professionalism in Surgery, from the American College of Surgeons Task Force on Professionalism, 2003.
  • American Medical Association. Declaration of professional responsibility, Chicago: American Medical Association, 2003.

Anecdotes

  • Creating a sense of ownership in the era of work hour restrictions, while maintaining the traditional professional standards of the practice of surgery remains a primary challenge of professional development.
  • Ethical challenges arise from changing relationships between surgeons and industry as well as increasing transactional relationships between physicians with all aspects of hospital based patient care.   All these changing environments and stresses on the adult learner demand that curriculum provides a moral keel to assist them in navigating the affective components of modern practice as both leaders and educators.
  • Participation in quality improvement projects equips future leaders of high reliability organizations. Having a structured quality improvement curriculum with resident led initiatives is strongly encouraged.
  • Adult learners require appropriate mentorship and facilitation to be fully engaged in academic scholarship and therefore transform their professional career into a vehicle of dissemination to future learners and stakeholders.

Resources

PSYCHOMOTOR SKILLS (Psychomotor)

ACGME Citation

IV. B. 1b).2. Residents must be able to perform all medical, diagnostic, and surgical procedures considered essential for the area of practice.

Evidence/Data

  • Sadideen H, Alvand A, Saadeddin M, Kneebone R.  Surgical Experts: Born or Made?  International Journal of Surgery, 2013: 11 (9), 773-778.

Anecdotes

  • Simulation should be a foundational component of psychomotor teaching and assessment to ensure technical proficiency is commensurate with resident level.  Simulation does not necessarily require large institutional funding since simple task trainers alone can have substantial impact on basic surgical skills training for a resident learner.
  • Rigorous faculty development is necessary to identify surgeon educators that are passionate about education and knowledgeable about simulator use in the evolution of advanced surgical techniques.
  • Resident’s are busy, and time in the simulator center is generally not a priority unless held accountable.  Residents should demonstrate a standard level of competency in simulated procedures prior to actual case participation.
  • Resource management within this area requires ongoing review and reappropriation based on departmental and programmatic evaluation.

Resources

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