Outcome-based education is a performance-based approach to creating, implementing
and evaluating physician assistant (PA) curricula. The emphasis of instructional
design is on the product—the type of physician assistant graduate that the program
wishes to graduate. In outcome-based education, the outcomes dictate curriculum
content, teaching methods, assessment strategies and curriculum organization
and structure. Performance outcomes also provide a framework for curriculum
Curriculum design did not always include an emphasis on outcomes. Harden1 described
the historical progression of the concept of curriculum as follows: Initially
a curriculum consisted of two components. The first was the subject matter that
the students studied. The second was the tests that were designed to assess
student mastery of the content. The concept of curriculum has evolved to include
the methods and educational strategies used to teach the content that coincides
with the objectives of the program. Learning outcomes now play a critical role
in curriculum planning and design.
Opponents of outcome-based education mistakenly assume that teaching will be
inappropriately limited by this model. They fear that a lack of freedom in teaching
methods will interfere with the uniqueness of their academic program. This is
a misunderstanding of the basic role of the outcome in curriculum design. For
example, consider a cross-country road trip that ultimately leads to New York
City. While all roads lead to New York City and the ultimate destination is
clear, the actual route taken, time allotted, and number of stops, etc., will
vary greatly from one trip to the next. The process of getting to the endpoint
is a dynamic and iterative one, individualized to meet the needs of each person.
The ultimate goal, however, keeps the journey in focus and moving in the right
direction. A statement of the patient care-oriented qualities and skills required
by a physician assistant graduate will help us oversee the process of education.
At the same time, programs can readily achieve great diversity in scope and
design. Outcome-based education provides programs with an approach to curriculum
decision-making based on the patient care competencies students should demonstrate
at the end of their educational program.
Several advantages have been identified in adopting an outcome-based model
for medical education2:
- Relevance: Outcome-based education focuses curriculum planning on
the practice of medicine. While many technical skills have long been
a part of medical training, expertise in such areas as communication
skills, informatics and multicultural awareness have often been neglected
or overlooked. A focus on practice also requires that the level of student
mastery extend beyond the simple recall of facts to more complex levels
of learning including higher level clinical problem-solving skills.
- Controversy: Examining the outcomes we strive for in medical education
forces a discussion about what we are doing and why. Too often, established
programs have become habituated to an existing teaching model. Focusing
on outcomes assesses why a particular strategy is used and to what end.
- Clarity: Designing curricula with a focus on outcomes should be simple
and straightforward. aFramework for decision-making: Outcomes provide
a strong roadmap for the curriculum by identifying the ultimate goals
to be accomplished. This framework connects each element of the curriculum
to another. Individual course objectives are tied to curriculum goals
and the program mission. Instructional objectives and assessment strategies
integrate the individual classroom experience into the larger learning
- Accountability: Outcomes provide a standard by which to judge whether
or not the goals have been met.
- Self-directed learning: By articulating a clear roadmap of the educational
process, outcomes allow students to have a metacognitive understanding
of the educational program and their role in that process. It also encourages
active discussion of those goals and the values they embrace.
- Flexibility: Outcome-based education allows each program to dictate
its own course of completion. The context of learning can all change
based on the needs of the program driven by student mastery and achievement.
The result is a fluid and dynamic educational model that is also responsive
to societal changes in the context of health care.
- Assessment guidelines: Outcomes tell us a great deal about how and
what we need to assess in our students. Historically, students were
often deemed competent if they completed a specified period of time
in training or a preconceived number of residencies and could pass a
test of measuring their “knowledge” of the topic. Outcome-based education
places a priority on performance-based assessment that measures student
mastery of higher level knowledge, skills and attitudes of practice,
leading to clinical competency.
- Collaboration in planning: Specified outcomes encourage participation
from multiple disciplines and interest groups. Outcomes provide a common
goal that often requires the input of various medical disciplines. Interdisciplinary
curriculum planning and education, fostering collaborative learning
across various professions and areas of medical practice, is perceived
as a valuable addition to the educational process. Input from constituencies
like the community, patients, graduates, etc., is raised to a new level
of importance in defining outcome mastery.
- Program evaluation: Outcomes provide a way to evaluate whether PA
educational programs and curriculums have been successful in delivering
the requisite knowledge, skills and attitudes for practice. While all
evaluations are designed to answer different questions and serve different
needs they all provide critical data that informs decision-making through
all steps of academic program development and implementation.
Expressing the Outcomes
In the 1990s the Pew Health Professions Commission3 released results of
several studies that indicated that competency assessment of health care
professionals was nonexistent. In part in response to this announcement,
many medical associations have been working toward articulating discipline-specific
learning outcomes for medical education. In 1996, the American Academy
of Physician Assistants (AAPA) developed a policy statement and paper
on professional competence that is currently undergoing revision. A recent
collaborative effort between AAPA, the Association of PA Programs (APAP),
the Accreditation Review Commission on Education for the Physician Assistant,
Inc. (ARC-PA) and the National Commission for the Certification of PAs
Inc. (NCCPA) is now attempting to establish joint competencies for PA
Physician assistant clinical competencies are made up of a combination
of knowledge, skills and professional attitudes, some of which are unique
to the profession and others that overlap with related disciplines. Competencies
can be expressed in many ways. For example, The Accreditation Council
for Graduate Medical Education (ACGME) has proposed six general competencies
in the areas of patient care, medical knowledge, practice-based learning
and improvement, interpersonal and communication tools, professionalism
and systems-based practice. The
ACGME competencies are readily adaptable to physician assistant graduates.
Similarly, the increasingly complex role PAs play in the ever-changing
health care environment are similar to those suggested by Harden
et al4 who proposed twelve professional outcomes in three
general areas including those related to: the performance of tasks expected
of a doctor, the approach adopted by the doctor to the performance of
tasks; and professionalism.
Determining the characteristics of the competent PA is often a moving
target, subject to shifts in emphasis in response to a dynamic health
care system. A focus on outcome-based education and clinical competencies,
however, offers many advantages in helping PA educators frame appropriate
curricula. Learning outcomes expressed as clinical competencies emphasize
the complex interaction and integration of these knowledge, skills and
attitudes in medical practice. Albeit necessary, learning objectives often
fragment and artificially separate these domains. Learning outcomes represent
the authentic integration of all three in practice. General student outcomes
provide guidelines for shared responsibility between students and faculty
for teaching and learning. The building blocks of this curriculum are
the outcome-based objectives that create a roadmap for student assessment
and course evaluation.
1Harden, R.M. (1986) Ten questions to ask when planning a
course or curriculum. ASME Medical Education booklet no 20, Medical
Education, 20, pp. 356-365.
2Harden, R.M. (1991) AMEE Guide No. 14: Outcome-based education:
Part 1—An introduction to outcome-based education. Medical teacher,
Vol 21, No. 1, 1999.
3Critical Challenges: Revitalizing the Health Professions
for the Twenty-First Century, Third Report of the PEW Health Professions
Commission. December 1995.
4Harden, R.M. (1986) Ten questions to ask when planning a
course or curriculum. ASME Medical Education booklet no 20, Medical
Education, 20, pp. 356-365.
The best teaching environment is often one-one-one. Improve
teaching by incorporating one-on-one teaching strategies in group
or lecture sessions.
LeMoyne College PA Program
A 45-60 minute lecture is the limit before a time of relief
is necessary. Breaks are offered with general comments. The students’
attention upon return is generally improved.
St. Vincent Catholic Medical Centers of New York PA
Provide students with an advance planner/roadmap at the
start of each lecture to facilitate understanding of the goals of
Drexel University PA Program
Appeal to three types of learners – sequential,
intuitive, and practical learning styles. Sequential learners learn
best when information is presented in an orderly outline, intuitive
learners like to figure things out for themselves, and practical
learners need to know the purpose or application of the subject.
Most students of medicine are intuitive learners.
Utah PA Program