Outcome-Based Education
by Anita Duhl Glicken, MSW

Outcome-Based Education
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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 evaluation.

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 experience.

• 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 practice.

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.

Outcome-Based Education
	Instructional Objectives and Teaching
Outcome-Based Education Instructional Objectives and Teaching Approaches to Writting Outcome-Based Learning Objectives Writting Instructional Goals Writting Instructional Objectives Creating a Set of Learning Objectives Using Objectives for Classroom Instruction Teaching and Testing at various Levels Using Objectives in Assesing Student Performance