When Things Go Wrong

Recently, I spoke with two programs trying to figure out and create a plan to address issues due to things not going how they intended, namely student outcomes and falling board scores.

In this newsletter, I decided to share my thoughts and experiences working with programs when things go wrong. Although many things affect the effectiveness of student outcomes, attainment of competencies, and successful board pass rates, including the admissions process, policies related to probation and dismissal, and faculty stability,  experience, and effectiveness, a major contributor is usually associated with the curriculum.

A common event that indicates things are going awry is dropping board passing rates. Unfortunately, by the time this becomes evident, it usually means there have been issues smoldering that have either not been addressed or inadequately addressed.

Multiple issues with a curriculum can lead to falling student success rates and board scores. I will cover some of the more common ones here, but they are not the only ones.

Outdated curriculum

A common contributor to things going wrong related to the curriculum is that it is not reviewed and updated regularly. All too often, I quickly discover a program hasn’t changed its curriculum in years, sometimes decades. Anyone who knows me knows my mantra:

Curriculum is dynamic, not static.

This is because things are always changing. Medicine changes, clinical practice changes, education changes, accreditation standards change, board exam blueprints change, and students change. If you have been in education for at least 10 years or more or went to PA school 15 or more years ago, you know that students have changed. In addition, what we know about how learning works from the research in neurobiology has resulted in significant changes to methods, tools, and approaches to teaching. A successful curriculum for students 20 or more years ago will likely not be successful with today’s students.

What commonly happens in programs where the curriculum is not reviewed regularly is that, eventually, things start to go awry. A few tweaks may have been made occasionally, but those quick fixes frequently don’t last. Since this is usually a gradual process, things go unnoticed until it is obvious there is a problem. Changes that signal potential curriculum issues include a drop in student performance on course exams, assignments, and assessments, significant student complaints about overload and overwhelm, increased remediation needs, course failures, probation and dismissals, ongoing complaints from preceptors that students aren't prepared, and falling board pass rates. Unfortunately, the last one usually gets the program's attention.

The one constant is change.

Therefore, curriculum must continually adapt and adjust

to stay relevant, current, and effective.

Another component of an outdated curriculum is that curriculum designs have changed. What we used 15 or more years ago, or the curriculum you had in PA school, may not be effective with today’s students. In my experience, students today require a curriculum with fewer courses per semester and more intentional bridging of concepts to help them integrate the material across courses and semesters. Curriculum models with upwards of 4 or more courses per semester, even if they are one credit, appear to create increased anxiety and overwhelm as students try to navigate each of these courses individually rather than recognizing the connection between them.

Sequencing and Scaffolding Issues

These issues relate to how the content is laid out over the length of the program. Making definitive choices about where and when students will learn certain material and skills is essential, as well as where (which courses) they will apply and practice that information during the semesters of the curriculum.

Scaffolding enters this process as we also look to challenge the students more each semester, taking things to a more complex and complicated level. First, they practice taking a medical history on a classmate, but eventually, later in the program, they will need to do it on a simulated patient in addition to a physical exam, differential diagnosis, and propose a treatment plan. If a curriculum does not intentionally and effectively sequence and scaffold the content across courses and semesters, it can also lead to student learning problems.

Another common issue I have seen is when the same content is taught at the same level, and sometimes the exact same lecture occurs multiple times in different courses in different semesters. Redundancy is essential as long as it is intentionally planned and not excessive. However, if a topic is to be revisited, it should move the student to a higher level of learning.

Essential education alignment and assessment

The mission statement and the program graduate outcomes or competencies drive a program’s curriculum. It is important to remember that each course’s learning outcomes are the stepping stones that guide the student through the curriculum to ensure they have met each of the program’s outcomes by graduation. Essential educational alignment refers to the assurance that the course learning outcomes are mapped to the program graduate outcomes within a course syllabus. They are used to define the course instructional objectives, which become the stepping stones within the course that help students attain and meet the course learning outcomes.

Assessment is an integral part of curriculum design, review, and revision. You cannot talk about curriculum without also talking about assessment. General decisions about ensuring alignment between what students are taught, the course learning outcomes, instructional objectives, assessment tools, and methods are essential to ensure you effectively assess your students.

 One of the quickest ways to evaluate this is to take a syllabus and highlight the verbs used in the learning outcomes and instructional objectives and then look at the assessment methods. Understanding Bloom’s Taxonomy of verbs and assessment is critical to performing this review.

For example, you have a mismatch if the verbs are describe and discuss, but the assessments used in the course are all multiple-choice exam questions. You are not assessing your students against how you asked them to know the material. You asked them to be able to describe or explain something, which cannot be done on a multiple-choice exam. Therefore, you are not assessing your students against your outcomes or objectives. Assessment methods and tools must be closely aligned with the measurable verbs used in the outcomes and objectives to provide evidence that the students accurately met the course outcomes. If there is a consistent mismatch across many courses, it can contribute to increasing failure rates during program assessments as well as on board exams.

Faculty

To maintain this alignment, all faculty must understand and work from a common working knowledge about the curriculum. Unfortunately, it is still fairly common that when faculty are hired, they are given a course assignment, a syllabus, and nothing else. They generally don't know that their course is part of the larger curriculum framework or that the curriculum defines the content each course must cover through the course learning outcomes. These should be established during curriculum design, review, or revision, not by individual faculty.

Faculty members can be autonomous in their courses but not independent. Course learning outcomes should be determined and set as part of the curriculum design and not changed unless those overseeing the curriculum support the change. Faculty members have the freedom to lay out and design their courses according to format, assignments, activities, and assessments. However, since most faculty come into PA education without formal training or knowledge about education, teaching, or curriculum, I strongly recommend that all syllabi be reviewed by someone or a committee knowledgeable in curriculum design, learning outcomes, instructional objectives, and assessment to ensure each course syllabus is doing its part in the bigger picture of the curriculum. This includes ensuring the assessment methods and tools align with the measurable verbs. It also provides an opportunity to work with faculty and help them understand their role and that of their course in the curriculum. When faculty believe they are the sole decision-makers regarding all aspects of their courses, this commonly can lead to a disconnection between their course and the rest of the curriculum. If one or several faculty work from this premise, the curriculum will cease to function as it needs to, and problems will arise. Providing faculty with an understanding of the program's curriculum and how it works and relates to their courses can help to mitigate some of these issues.

Components of a curriculum review

Depending on the nature of the issues the program is having determines the level of review needed. However, if a full review is done at least every 2-3 years, most of the issues discussed above will be mitigated.

Review of the mission statement

Is it still relevant? Does it need to be revised? Does it accurately reflect the mission of your program? Sometimes, the program curriculum changes direction, but the mission statement isn’t altered to ensure alignment.

Review of the program or graduate outcomes or competencies

Are they still accurate for PA practice today and for your program? Do they reflect what you are teaching?

Review and mapping of every course learning outcome to your program graduate outcomes. 

Remember, the course learning outcomes should not be changed unless that is a curriculum-level decision. Faculty should inherit syllabi where these are already defined.

Review and mapping your curriculum content to the NCCPA content blueprint. This helps to notice areas of excessive redundancy or omissions and ensure the required content is covered.

Review and map your curriculum to the accreditation B standards. Everyone should be planning this, with the 6^th edition releasing soon.

Review each syllabus before it goes to the students to check for essential education alignment. Ensuring that the instructional objectives accurately reflect the content defined in the course learning outcomes and that the assessments the faculty has selected align with the methods and tools selected based on Bloom’s taxonomy verbs.

Many things can go wrong with a curriculum. I recommend full curriculum reviews every 2-3 years. Doing routine reviews helps to illuminate problem areas early before they become larger issues, helps to keep the curriculum updated, can illuminate potential problem areas early, assists in having all faculty have a greater understanding of the importance of curriculum, and illuminates massive changes before a site visit.