Case study
Open Access

Student Selected Components - a modern curriculum to complement a systems-based medical degree.

Trevor Killeen[1], Jane Skinner[1], Yoon Loke[1], Barbara Jennings[1]

Institution: 1. UEA
Corresponding Author: Dr Barbara Jennings (b.jennings[email protected])
Categories: Assessment, Curriculum Planning, Educational Strategies
Published Date: 09/06/2016

Abstract

Abstract

The 2009 version of the GMC’s Tomorrows Doctors describes student selected components as “an integral part of the curriculum, enabling students to demonstrate mandatory competences while allowing choice in studying an area of particular interest to them”. The definition of SSCs and guidance for their delivery and assessment have been interpreted in a variety of ways by individual medical schools and by regional consortia of medical schools. 

To complement our systems-based MBBS modules we have developed a longitudinal Student Selected Studies (SSS) curriculum which has been reviewed and modified since 2011.

Throughout the SSS curriculum, students develop academic skills and competences such as literature review or developing a clinical or research question. In years 1 to 3 these competences are acquired whilst focusing on topics from a given theme of study, for example physiology, pharmacology or ethics. In year 4 the students apply the skills acquired in the earlier years to the evaluation of a case described in their own clinical-placement log-book.

In the first three years when students learn how to deliver formal presentations, using PowerPoint, conference-style posters, or anatomy demonstrations, they are given specialist tutor support, and feedback is given in formative assessments; allowing the students to make corrections and refine their skills before summative assessments take place.

Our curriculum development has been shaped by the use of a competency-based teaching and assessment strategy with a focus on the student’s longitudinal development through the use of a feedforward strategy (Hattie, 2007) during and after formative assessments.

Introduction

In 2002 Norwich Medical School (NMS) was launched at the University of East Anglia. The inaugural curriculum and the ethos behind its MBBS degree have been described previously (Cavenagh, 2011) but can be summarised as a 5 year systems-based programme that integrates theory and clinical practice from the first of 14 study modules. Teaching is delivered in a variety of ways; for example, through problem based learning; clinical placement; structured and simulated patient teaching and via formal lectures. Core themes such as physiology, pharmacology and ethics run longitudinally through the 5 year course and spiral delivery allows students to re-visit topics with increasing complexity and integration. At NMS we use student selected components (SSCs) organised by core theme teams or clinical specialties to complement our modular curriculum, we refer to these as Student Selected Studies (SSS).

As well as offering choice, SSCs were envisaged by the GMC to reduce the knowledge burden placed on medical students, and to offer the opportunity for students to study an area of interest in-depth.  However, by 2010 we noted that our module-linked-SSS-curriculum was creating a significant assessment burden, linked to the risk of attrition; and it was favouring some superficial strategies rather than deep-learning and engagement. We acknowledged an essential tension between the delivery of diverse, enjoyable SSS experiences and the delivery of a uniform and valid summative assessment.

Therefore, we undertook a review and modified our SSS curriculum significantly.  During this process we focused on GMC guidelines (GMC, 2009), student and staff evaluations at NMS, the practice of competency-based medical education (Frank et al., 2010) and the experiences from other medical schools (Murdoch-Eaton et al., 2004; Murphy, De, Remers, & Davis, 2009; Murphy, Seneviratne Rde, McAleer, Remers, & Davis, 2008; Riley et al., 2008; Stark et al., 2005), particularly those discussed at a review meeting co-hosted by the GMC and the Northern Medical Schools SSC consortium held in spring 2011. This report summarises the key principles of the SSS curriculum that has emerged at NMS.

Programme Development

To review the programme and complete the subsequent changes we developed an SSS steering group that included student representation and administrators in addition to academic leads. We recruited experienced and novice SSS tutors at an annual MBBS Away Day to scrutinise student (quantitative and qualitative) evaluations, and to draw up an outline curriculum with the following mission statement:

“Our aim is to have a curriculum that is enjoyable for students and staff and that matches guidelines for the best practice in delivering and assessing student selected components within a medical degree”

Subsequent curriculum development has been an iterative process but the significant features of the 2015 programme include the following:

  1. We have increased the menu of SSS themes offered to each student. Each option permits the in depth study of core disciplines (such as anatomy or genetics) or engagement in career planning activities (such as surgical attachments) or engagement in an active research project (in clinical and laboratory settings). Each student is supported by an expert academic tutor during an annual SSS attachment.  We have 20 themes of study available in total (see figure 1).
  2. The longitudinal SSS curriculum has defined objectives coupled to the assessment of mandatory competences; these are of increasing complexity with progression from years 1 to 4 (see Figure 1).  Whichever topics the students choose to engage in, each cohort is assessed against particular criteria. Individual assessments include the delivery of PowerPoint presentations, conference-style posters and evidence-based case presentations.
  3. Formative assessment is used to allow rehearsal before any summative assessment. Assessments have a rubric of skills linked to each competency, these skills are examined on a scale of 1 to 5 (with 3 marking the milestone of the proficient student who is ready for progression). This, coupled to qualitative feedback and ongoing tuition, allows students to clearly identify areas for improvement and to prepare for summative examination.
  4. There is a tension for SSC assessments between serving student choice (coupled with access to expert tutors) and robust assessment validity. In an effort to inform all SSS tutors about inter-examiner variability, data from summative assessments is subject to statistical analysis for outliers and this is disseminated to each SSS theme team. The number of summative fails is now too small for statistical analysis, but the proportion of distinctions per theme is analysed using a funnel plot and themes above or below a 95% confidence interval assuming a common binomial distribution are identified.  Standard setting is included in all staff training sessions and the use of electronic briefings has improved the access of staff to training opportunities.
  5.  A single SSS curriculum guide coupled to the assessment scheme is produced for staff and students for transparency. Curriculum documents and supporting electronic teaching material (including podcasts and screencasts) for each SSS theme are made available via the virtual learning environment, Blackboard.
  6. To promote equity of access to limited places available for some particularly popular themes, we have an electronic sign up system for all students that is available for a prescribed period each year. Students use this to rank 4 possible SSS choices. The themes available to them in year 3 are contingent on the selections made in years 1 and 2, with the students having to study at least one science subject and one social science subject in the first three years.  The program works by picking a student at random, giving them their first choice theme if this still has places and, if not, their second choice if this still has places, and so on.  Then another student is selected at random and the process repeated.  The program is run multiple times and the selection in which the greatest number of students get one of their preferences is used.  For example, for the first year in the academic year 2015/16, 83% of students were allocated to their first choice theme, 6.5% to their second choice, 6.5% to their third choice and 4% to their fourth choice.

     

    Figure 1.

    A Summary of the Longitudinal SSS Curriculum

    The menu of SSS themes that NMS students can select is shown for each year of study. The longitudinal development of mandatory competences with increasing complexity is illustrated by the assessment heading above each option list. Formative assessment is carried out in each year of study and summative assessments are held in years 1 to 3.

     

     

     

Outcomes (the good, the bad and the uncertain)

We are confident that we have kept a clear focus on the mission statement that we set for ourselves at the start of this curricular development, and the following observations make for encouraging reflection.

We have noted that SSS evaluations improved for those students who experienced both the expansion in the SSS theme menu, and the change of practice to always use a formative assessment step. The use of a longitudinal or feedforward strategy may have been beneficial given that feedback centred on corrective, rather than learner-focused aims, has been shown to be counter-productive in some contexts (Kluger & Van Dijk, 2010).  

We have noted a marked reduction in the number of summative assessment re-sits and an increase in the number of distinctions. Staff training and sharing performance data for the SSS curriculum may have modified examiner behaviour and assessment validity; we have seen fewer outliers over time, which is the experience described by Murphy et al. (Murphy et al., 2009). The mandatory competences for our SSS curriculum translate into core research and presentation skills, and increasing numbers of our students are now applying for support for conference presentations or intercalated research degrees.

One area for future attention is to better support and guide students as they make their SSS choices; some students are highly strategic, others can be disappointed if they miss out on career-planning opportunities because of a lack of clear communication on our part.

We acknowledge that this report is not describing a controlled scientific experiment and changes in the MBBS admission process; NMS infrastructure; external changes to the foundation programme application system; and faculty expansion could explain the observations that we tentatively record as much as, or more than, our planned curricular changes.

As we refine the SSS curriculum we will continue to audit student choice; student and staff experience; assessment validity; tutor development; and student progression rates. One of the authors has completed a systematic review of publications of SSC assessments in UK medical schools and did not identify any published primary studies that considered validity or reliability (Killeen, 2014). This finding highlights a need for research to address the use of high-stakes exams for this mandatory component of a UK medical degree.

Local research priorities, about this aspect of the undergraduate medical curriculum, include qualitative and quantitative studies; firstly, with cohorts of foundation-year, junior doctors to consider whether SSCs affect subsequent career planning, and secondly to monitor the uptake of intercalated research degrees and student conference expenditure at NMS, in response to local SSS curricular changes.

Conclusion

Our SSS curriculum allows students to select diverse topics of study and educational experiences but the learning objectives and assessment criteria are uniform. Whatever vehicle-of-study is chosen by each student they have a curriculum that results in the longitudinal development of competences, of increasing complexity as they progress from year to year.

Our curriculum development has been shaped by the use of a competency-based teaching and assessment strategy and the practice of using feedforward, formative assessments.

Take Home Messages

  • Student selected components (SSCs) are integral to undergraduate medical curricula and are examined summatively. There is a tension between the provision of student choice, in both topic and educational experience, with the delivery of high stakes assessments that have robust validity and reliability for the whole cohort.
  • The assessment validity and the enjoyment of SSCs at Norwich Medical School have been enhanced by the use of a longitudinal competency-based teaching and assessment strategy including the practice of using feedforward strategy in formative assessments.

Notes On Contributors

Barbara A Jennings, PhD. Senior Lecturer and Academic Lead for Student Selected Studies at Norwich Medical School from 2011 to 2016. [email protected]. Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK.

Trevor Killeen, MBBS, MClinEd. Student Representative for Student Selected Studies and Graduate of Norwich Medical School.

Jane Skinner, PhD.  Lecturer and Deputy Academic Lead for Student Selected Studies at Norwich Medical School.

Yoon K Loke, MD. Professor of Medicine and Pharmacology, member of Academic Team for Student Selected Studies at Norwich Medical School.

Acknowledgements

The authors are grateful to Deborah Murdoch-Eaton and Brian Stewart for useful discussions about student selected components within undergraduate programmes.  The authors are also grateful to their colleagues and students at Norwich Medical School who have contributed to the design and delivery of our SSS curriculum.

Bibliography/References

Cavenagh, P., Leinster, S.J., Miles, S. (2011). The Changing Face of Medical Education. Oxford: Radcliffe.

Frank, J. R., Snell, L. S., Cate, O. T., Holmboe, E. S., Carraccio, C., Swing, S. R., Harris, K. A. (2010). Competency-based medical education: theory to practice. Med Teach, 32(8), 638-645.

http://dx.doi.org/10.3109/0142159X.2010.501190  

GMC. (2009). Tomorrow's Doctors. London: General Medical Council.  

Hattie, J., Timperley, H. (2007). The Power of Feedback. Review of Educational Research, 77(1), 81-112.

http://dx.doi.org/10.3102/003465430298487  

Killeen, T. (2014). Validity and Reliability in the Assessment of Student Selected Components of the Undergraduate Medical Curriculum in the UK: A Systematic Review. (MClinEd), UEA.  

Kluger, A. N., & Van Dijk, D. (2010). Feedback, the various tasks of the doctor, and the feedforward alternative. Med Educ, 44(12), 1166-1174.

http://dx.doi.org/10.1111/j.1365-2923.2010.03849.x   

Murdoch-Eaton, D., Ellershaw, J., Garden, A., Newble, D., Perry, M., Robinson, L., Whittle, S. (2004). Student-selected components in the undergraduate medical curriculum: a multi-institutional consensus on purpose. Med Teach, 26(1), 33-38.

http://dx.doi.org/10.1080/0142159032000150494

Murphy, M. J., De, A. S. R., Remers, O. J., & Davis, M. H. (2009). 'Hawks' and 'doves': effect of feedback on grades awarded by supervisors of student selected components. Med Teach, 31(10), e484-488.

http://dx.doi.org/10.3109/01421590903258670   

Murphy, M. J., Seneviratne Rde, A., McAleer, S. P., Remers, O. J., & Davis, M. H. (2008). Student selected components: do students learn what teachers think they teach? Med Teach, 30(9-10), e175-179.

http://dx.doi.org/10.1080/01421590802337138  

Riley, S. C., Ferrell, W. R., Gibbs, T. J., Murphy, M. J., Cairns, W., & Smith, S. (2008). Twelve tips for developing and sustaining a programme of student selected components. Med Teach, 30(4), 370-376.

http://dx.doi.org/10.1080/01421590801965145  

Stark, P., Ellershaw, J., Newble, D., Perry, M., Robinson, L., Smith, J., Murdoch-Eaton, D. (2005). Student-selected components in the undergraduate medical curriculum: a multi-institutional consensus on assessable key tasks. Med Teach, 27(8), 720-725.

http://dx.doi.org/10.1080/01421590500271530

Appendices

Declarations

There are no conflicts of interest.
This has been published under Creative Commons "CC BY-SA 4.0" (https://creativecommons.org/licenses/by-sa/4.0/)

Reviews

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Deborah Murdoch Eaton - (02/08/2017) Panel Member Icon
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This paper demonstrates the importance of monitoring curricular components for their impact upon learning – all learners are intuitively looking to jump through the assessment hoops in the most efficient ways (and especially when time pressured) thus the best laid plans may (over time) in reality result in a change in intended educational outcomes.
Student Selected components have a key underpinning intention of individualised and purposeful skill and knowledge development – to particularly complement , and some might say compensate! – for a heavily competency driven core curriculum. UEA demonstrated a careful review considered the purpose of this curricular theme, and look for ways to ensure the individual components can be summatively and individually coherent in this aim.
Dujeepa D. Samarasekera - (28/07/2017) Panel Member Icon
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Enjoyed reading this paper! This is quite useful to many medical educators who are involved in curriculum development, course management and educational leadership. The paper discusses how best to employ Student Selected Components in a curriculum to achieve the desired outcomes. This paper will add value and insights to many educators who are unfortunately pressed to cut down learning/training duration and to reduce the curricula time in the name of improving efficiency.
However I would have liked to see more details of the curriculum, how the SSC's are scheduled and more details about the outcomes achieved.
Emma Jones - (28/06/2016) Panel Member Icon
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This paper discusses the development of the Student Selected Studies component of a 6 year medical degree and will be of interest to medical educators. The program develops students’ ability to engage with research and present their ideas and findings. Allowing students to pursue areas of their choice may improve their engagement in the program and aid them with future career choices.

The authors found that over time there were a fewer number of re-sits, a greater number of students achieving distinctions and more student interest in presenting research; a beneficial outcome for both the students and the reputation of the medical school. The potential disadvantages of elective programs include variation in student educational experiences and increased cost or difficulty in finding suitable mentors, as electives generally require a greater mentor-to-student ratio.

I believe that student presentations of their placements to the other students is both interesting and educational. This model can inform the students who missed out on a placement they desired which may help them decide if they are still interested in that topic as a potential career pathway.

Important details of the program that were not included in this paper include the number of weeks per year that were allocated to Student Selected Studies. With many medical schools shifting to a more flexible approach to the curriculum it is interesting to assess the impact of elective programs versus a standard program on the experiences and performance of the students.
Leila Niemi-Murola - (13/06/2016) Panel Member Icon
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This is a very interesting description of an ongoing SSC program and it is certainly of a great value for undergraduate educators planning a Curriculum renovation. SSS is a basic component of our curriculum, but a formal assessment is very seldom included. After the renovation of our curriculum, the demand for SSCs has increased rapidly. Therefore, it was very interesting to read about these experiences. Support and guidance is certainly needed by the first year students, who are not so familiar with the system and unsure about their future. It will be interesting to know the long term effects of the SSS curriculum on the career choices of the students.
Richard Hays - (10/06/2016) Panel Member Icon
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While SSCs are not new – indeed they are widely used, particularly in UK medical schools – they are usually specific activities within a prescribed period of time, usually around 2-3 months, generally in the second half of medical programs. The model proposed here is interesting because it allows for a much more immersive research experience that follows a more structured research training process. This approach is similar to that being adopted in several Australian medical schools, where a move to Masters degree level graduate outcomes requires a more uniform and ‘guaranteed’ level of research experience. Research skills are developed over the whole program (4-5 years), involving initial formal training, then some form of longitudinal or capstone project, and, finally, reporting and presenting in the final year. It would be interesting to see some comparative data on any differences in outcomes from the longitudinal model with respect to work readiness and career progress.
Style: Well written and easy to read
Target audience: undergraduate medical educators
Trevor Gibbs - (09/06/2016) Panel Member Icon
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It was inevitable that the concept of SSMs, as initially described in the earlier literature, would transcribe into SSCs and that the outcomes derived from the SSCs would eventually overlap with some of the core outcomes within the main curriculum. This very well written and easily read paper described very clearly that metamorphosis of the next generation of SSCs- or as the authors wish to call them- SSSs ! The description of their curriculum activity is based on need and structured to an appropriate longitudinal learning activity which I feel sure will evolve into a very valued learning / assessment activity. Although it is still early in its development and has no evaluation data as yet, it is a very good ideas paper that all involved in this element of a curriculum should read