The problem with outcomes-based curricula in medical education: insights from educational theory Charlotte E Rees BACKGROUND Educators across the world are charged with the responsibility of producing core learning outcomes for medical curricula. However, much educational theory exists which deliberates the value of learning outcomes in education. AIMS This paper aims to discuss the problems sur- rounding outcomes-based curricula in medical edu- cation, using insights from educational theory. DISCUSSION The paper begins with a discussion of the traditions, values and ideologies of medical cur- ricula. It continues by analysing the issue of control within the curriculum and argues that curriculum designers and teachers control product-orientated curricula, leading to student disempowerment. The paper debates outcomes-based curricula from an ideological perspective and argues that learning outcomes cannot specify exactly what is to be achieved as a result of learning. CONCLUSIONS The paper argues that medical schools should adopt a model for co-operative con- trol of the curriculum, thus empowering learners. The paper also suggests that medical educators should determine the value of precise learning out- comes before blindly adopting an outcomes-based model. KEYWORDS education, medical undergraduate ��� *standards curriculum ��� *standards clinical compet- ence ��� *standards quality assurance, health care ��� *standards. Medical Education 2004 38: 593���598 doi:10.1046/j.1365-2923.2004.01793.x INTRODUCTION Although various national1,2 and international guide- lines3,4 exist outlining the required product of med- ical education, educators across the world are charged with the responsibility of producing core learning outcomes for their medical curricula. These learning outcomes are often defined as the knowledge, skills and attitudes required by medical students at gradu- ation (or at pre-registration house officer level in the UK). Although curriculum decisions are best made by a group of various stakeholders,5 such as discipline experts, clinicians, students and patients, in my experience decisions are all too often made by lone individuals. In addition, much educational theory exists which deliberates the value of learning out- comes in education.6 Indeed, educational theorists such as Grundy7 argue that outcomes-based curricula are antithetical to good educational practice. Grundy states that: �����it is not on the teacher��s shelf that one looks for the curriculum, but in the actions of the people engaged in education.���7(p 6) This paper begins with a discussion of the traditions, values and ideologies of medical curricula. It con- tinues by analysing the issue of control within the curriculum and debates outcomes-based curricula from an ideological education perspective. It ends with a discussion of the future directions that medical educators could take to minimise the problems outcomes-based teaching Institute of Clinical Education, Peninsula Medical School, Plymouth, UK Correspondence: Dr Charlotte E Rees BSc (Hons), PhD, MED, CPsychol, ILTM, Institute of Clinical Education, Peninsula Medical School, St Lukes Campus, Heritree Road, Exeter EX1 2LU 8BX, UK. Tel: 00 44 1392 262971 Fax: 00 44 1392 262926 E-mail: charlotte.rees@pms.ac.uk �� Blackwell Publishing Ltd MEDICAL EDUCATION 2004 38: 593���598 593

associated with outcomes-based curricula. This paper might appear to some readers to be controversial in the sense that it may seem antagonistic towards learning outcomes in education. This is not the author���s intent. The paper aims to stimulate thinking and discussion about the very real issues raised by the adoption of outcomes-based curricula in medical education. TRADITIONS, VALUES AND IDEOLOGIES OF MEDICAL CURRICULA According to Cookson,8 the National Health Service (NHS) has created a greater demand for account- ability and transparency in the delivery of undergra- duate medical education. As a result of this push for accountability, a new agenda for medical education now exists in the UK, with a readjustment from process to product.9 Harden9 argues that medical educators must make their learning outcomes expli- cit in order to deliver their learning programmes effectively and medical schools in the UK10 and the USA have engaged in this task.11 Both Harden9 and Bligh et al.12 argue that the public, the government and health care professionals are making justifiable requests for more explicit statements about the product of our medical schools in terms of the sort of doctors we are trying to train.9 Indeed, the aim of medical schools in the UK is to produce graduates who are able to fulfil their role as pre-registration house officers (PRHOs) in the NHS. This means that medical students must possess the knowledge, skills and attitudes deemed to be essential for PRHOs. To support his argument for more explicit learning outcomes, Harden9 cites the Quality Assurance Agency���s Handbook for Academic Practice,13 which states that institutions are expected to set out the intended learning outcomes of their programmes. MEDICAL CURRICULA AND THE PROBLEM OF CONTROL Given this climate of central accountability, it is not surprising that many medical schools in the UK are developing outcomes-based or product-orientated curricula.10,11 According to Grundy,7 the product- orientated curriculum is underpinned by a technical interest. This means that pre-specified learning out- comes fuel the design of students��� learning experi- ences and the effectiveness of educational experiences are determined by exploring the degree of match between the ��product�� of the learning experiences and the pre-determined outcomes.7 Grundy7 argues that a fundamental issue in the product-orientated curriculum is control. Although the curriculum designer and the teacher may be the same person, in many cases they are not. In such cases, the curriculum designer controls the activities of the teacher and the teacher controls the learning environment of the student.7 This implies a power differential between curriculum designers and teachers and between teachers and students, respectively. For example, while curriculum designers have a high degree of control over the curriculum, teachers may not and, as a result, may feel disem- powered. Indeed, a division of labour may exist between curriculum designers and teachers and Grundy7 suggests that this inequality can de-skill teachers to the level where they merely distribute pre- chosen materials. Moreover, students often have no control or autonomy over their learning experiences and may feel disempowered. Indeed, in the techni- cally informed curriculum, students have virtually no power to determine their own learning outcomes.7 However, product-orientated curricula seem at odds with the problem-based learning methods utilised at several medical schools in the UK. Problem-based learning (PBL) generally encourages student-centred learning by requiring that students examine problem outcomes-based teaching Key learning points Accountability to the NHS and patients has led to the development of outcomes-based (or product-orientated) medical curricula. Curriculum designers and teachers control product-orientated curricula, leading to stu- dent disempowerment. Learning outcomes cannot specify exactly what is to be achieved as a result of learning. Medical schools should adopt more whole- heartedly a model for co-operative control of curricula and should empower learners by giving them responsibility for contributing to curriculum content. Medical educators must establish the value of precise learning outcomes before blindly adopting an outcomes-based model. 594 �� Blackwell Publishing Ltd MEDICAL EDUCATION 2004 38: 593���598