In medical education, Kern’s Six-Step Approach to Curriculum Development is a widely recognized framework that guides the systematic design and improvement of educational programs. It includes the following steps:
(1) problem identification and general needs assessment, (2) targeted needs assessment,
(3) setting goals and objectives, (4) selecting educational strategies, (5) implementation, and (6) evaluation and feedback. This model ensures that curricula are built on clearly defined problems and are aligned with learner needs.
One significant challenge I have observed within my medical faculty’s curriculum is the insufficient preparation in clinical reasoning during the pre-clinical years. Many students report feeling underprepared when transitioning into clinical rotations, particularly in applying foundational knowledge to real patient scenarios. This gap suggests a disconnect between theoretical learning and its practical application—an essential competency in medical education.
Step 1: Problem Identification (General Needs Assessment)
To address this issue, I would begin by conducting a general needs assessment to define the problem broadly and understand its scope. This process would include:
• Reviewing national and institutional standards (e.g., AAMC Core Entrustable Professional Activities, CanMEDS competencies)
• Gathering feedback from residency program directors regarding the preparedness of new graduates
• Analyzing academic trends and clinical skills examination results (e.g., OSCE scores)
This would help establish that the issue is not just anecdotal but represents a broader educational gap between what students are expected to know and their actual clinical performance.
Methods:
• Literature review to identify common curricular deficiencies in early clinical reasoning
• Benchmarking against peer institutions’ curricula
• Consultations with faculty members and clinical preceptors to gather insights on recurring student challenges
Step 2: Targeted Needs Assessment
After defining the general problem, I would conduct a targeted needs assessment to delve deeper into specific gaps and learner needs contributing to the issue.
Methods:
1. Surveys and Focus Groups:
• Engage both pre-clinical and clinical students to assess their perceptions of preparedness and confidence
• Involve clinical preceptors to pinpoint common weaknesses in students’ reasoning and decision-making skills
2. Curriculum Mapping:
• Identify where, how, and to what extent clinical reasoning is currently taught in the curriculum
• Detect content gaps, redundancies, or delays in teaching key concepts
3. Performance Data Analysis:
• Examine student performance in early clinical assessments, simulation labs, and PBL (problem-based learning) sessions
• Identify common patterns of misunderstanding or underperformance
4. Stakeholder Interviews:
• Gather insights from course directors, curriculum committee members, and assessment teams regarding current instructional strategies and barriers to implementation
Conclusion
By systematically applying Kern’s two-step needs assessment model—starting with broad problem identification and narrowing down to specific learner needs—we can design curriculum interventions that are both relevant and impactful. A solid needs assessment not only highlights where change is necessary but also increases the likelihood of creating meaningful, sustainable improvements in medical education.
Dr Dania thank you for such a detailed application of Kern's framework for curriculum development, specifically focusing on the initial needs assessment phases. It effectively illustrates how to identify a broad problem and then narrow the focus for a targeted assessment. The example of dental students struggling to integrate foundational biomedical knowledge into clinical decision-making is particularly insightful, highlighting a common challenge in many professional education programs where theoretical knowledge and practical application diverge. The proposed methods for deeper exploration, such as think-aloud protocols and clinical vignette assessments, are excellent practical approaches to pinpoint specific gaps in learning and application.
Considering this comprehensive approach to identifying educational gaps, my question is: How might the insights gained from such a rigorous needs assessment, particularly the 'disconnect between biomedical science instruction and clinical training,' be proactively integrated into curriculum design from the outset to prevent similar issues in future iterations of the program, rather than solely addressing them reactively?
One significant challenge I have observed in my medical faculty’s curriculum is the insufficient development of clinical reasoning skills during the pre-clinical years. This often results in students feeling unprepared and lacking confidence when they begin their clinical rotations.
Problem Identification and General Needs Assessment
According to Kern’s Six-Step Approach to curriculum development, the first step is identifying the healthcare or educational problem (Thomas et al., 2016). In this case, the broad issue is the gap between students’ theoretical knowledge and their ability to apply it in clinical settings. To conduct a general needs assessment, I would:
Review current curriculum documents to determine the extent to which clinical reasoning is explicitly taught.
Compare the curriculum with national and international standards that emphasize early integration of clinical reasoning.
Consult with faculty to gain insight into current teaching practices and perceived deficiencies.
Analyze student feedback and performance during early clinical years to highlight consistent concerns or areas of struggle.
This comparison between the current and ideal approaches provides the basis for the general needs assessment, helping to clarify the scope of the problem.
Targeted Needs Assessment
After identifying the general gap, the next step is to conduct a targeted needs assessment to understand the specific needs of learners. I would employ the following methods:
Surveys and focus groups involving students and recent graduates to gather perceptions about their preparedness for clinical reasoning tasks.
Interviews with faculty to identify perceived barriers in teaching these skills and gather suggestions for improvement.
Curriculum mapping to determine where clinical reasoning is currently introduced and identify any inconsistencies or omissions.
Assessment analysis to evaluate how students perform on tasks requiring clinical reasoning and decision-making.
This targeted needs assessment would provide a deeper, more precise understanding of learner gaps, enabling the design of a curriculum that addresses actual, evidence-based needs.
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Reference
Thomas, P. A., Kern, D. E., Hughes, M. T., & Chen, B. Y. (2016). Curriculum development for medical education: A six-step approach (3rd ed.). Johns Hopkins University Press.
### Context: The Curriculum Challenge
A significant challenge observed in many medical faculties is the inadequate development of clinical reasoning skills during the preclinical years. Students often excel in factual knowledge but struggle to apply it to clinical scenarios when transitioning to clinical rotations. This gap can lead to difficulties in diagnostic accuracy, patient management, and professional confidence. Using Kern’s model, I will outline how to identify this problem and assess the needs to address it effectively.
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### Step 1: Problem Identification and General Needs Assessment
**Problem Identification**
The first step in Kern’s model is to identify the broad problem affecting the curriculum. This involves gathering data from multiple sources to confirm the existence and scope of the challenge. For the issue of insufficient clinical reasoning skills, the problem might be identified through:
- **Stakeholder Feedback**: Faculty members report that students entering clerkships lack the ability to synthesize clinical information effectively. Clerkship supervisors note frequent errors in differential diagnosis or clinical decision-making.
- **Student Performance Data**: Analysis of student assessments (e.g., Objective Structured Clinical Examinations [OSCEs] or case-based exams) reveals lower scores in clinical reasoning compared to factual recall.
- **Graduate Feedback**: Recent graduates indicate they felt unprepared for clinical decision-making during their early residency years.
- **Literature Review**: Studies in medical education highlight that early exposure to clinical reasoning improves diagnostic accuracy and reduces cognitive errors (e.g., Schmidt et al., 2016).
By triangulating these sources, the broad problem is defined as: **The preclinical curriculum does not adequately prepare students to develop clinical reasoning skills, impacting their performance in clinical settings.**
**General Needs Assessment**
The general needs assessment aims to understand the scope of the problem by comparing the current state of the curriculum (what *is* happening) with the ideal state (what *should* be happening). This involves:
- **Current State Analysis**:
- **Curriculum Review**: Examine the preclinical curriculum to identify content related to clinical reasoning. For example, is clinical reasoning taught explicitly, or is it assumed to develop implicitly through basic science courses?
- **Teaching Methods**: Assess whether current methods (e.g., lectures, problem-based learning [PBL]) foster clinical reasoning. Lectures may prioritize memorization, while PBL may vary in effectiveness depending on facilitation.
- **Assessment Practices**: Review whether assessments evaluate clinical reasoning (e.g., through case-based questions) or focus solely on recall.
- **Faculty Perspectives**: Conduct informal interviews or surveys with preclinical faculty to understand their perceptions of clinical reasoning integration.
- **Student Perspectives**: Gather student feedback through focus groups to explore their confidence in applying knowledge to clinical scenarios.
- **Ideal State Definition**:
- **Competency Frameworks**: Refer to standards like the Association of American Medical Colleges (AAMC) Core Entrustable Professional Activities (EPAs) or CanMEDS framework, which emphasize clinical reasoning as a core competency.
- **Literature Benchmarks**: Evidence suggests that early, structured exposure to clinical reasoning (e.g., through case-based learning or simulation) enhances diagnostic skills (e.g., Bowen, 2006).
- **Stakeholder Expectations**: Clinical faculty and residency program directors expect incoming students to demonstrate basic clinical reasoning skills, such as formulating differential diagnoses.
- **Gap Analysis**: The general needs assessment reveals gaps, such as:
- Limited explicit teaching of clinical reasoning in preclinical years.
- Overreliance on lecture-based instruction, which may not foster higher-order thinking.
- Assessments that prioritize factual recall over application.
- Faculty variability in teaching clinical reasoning due to lack of training.
The general needs assessment confirms that the curriculum lacks structured opportunities for students to develop clinical reasoning skills, creating a need for targeted interventions.
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### Step 2: Targeted Needs Assessment
The targeted needs assessment narrows the focus to specific learner needs, identifying precise learning gaps and areas for improvement. For the challenge of insufficient clinical reasoning skills, the following methods would be employed to delve deeper:
1. **Focus Groups with Learners**
- **Purpose**: To explore students’ perceptions of their clinical reasoning abilities and identify barriers to learning.
- **Method**: Conduct semi-structured focus groups with preclinical students (e.g., second-year medical students). Use open-ended questions like:
- How confident do you feel in applying basic science knowledge to clinical scenarios?
- What opportunities do you have to practice clinical reasoning in the curriculum?
- What challenges do you face in developing these skills?
- **Analysis**: Use thematic analysis to identify recurring themes, such as lack of case-based practice or unclear expectations.
- **Rationale**: Focus groups provide rich qualitative data and allow students to share experiences in a supportive setting (Kern et al., 2016).
2. **Surveys of Faculty and Students**
- **Purpose**: To quantify the extent of the gap in clinical reasoning instruction and assess stakeholder priorities.
- **Method**: Develop a Likert-scale survey for preclinical faculty and students, including items like:
- “The curriculum provides sufficient opportunities to practice clinical reasoning” (1 = Strongly Disagree, 5 = Strongly Agree).
- “I am confident in my ability to teach/assess clinical reasoning” (faculty).
- “I feel prepared to formulate a differential diagnosis” (students).
- **Analysis**: Use descriptive statistics to identify areas of consensus or discrepancy. For example, if faculty rate their teaching confidence highly but students report low preparation, this suggests a misalignment.
- **Rationale**: Surveys provide scalable data to complement qualitative findings (Thomas et al., 2016).
3. **Performance-Based Assessments**
- **Purpose**: To objectively measure students’ clinical reasoning skills and identify specific deficiencies.
- **Method**: Administer a diagnostic reasoning assessment, such as a script concordance test (SCT) or key-feature problem, to preclinical students. These tools evaluate students’ ability to interpret clinical data and make decisions under uncertainty.
- **Analysis**: Score responses to identify patterns (e.g., difficulty prioritizing relevant data or generating hypotheses). Compare results to expected benchmarks for preclinical learners.
- **Rationale**: Performance-based assessments provide direct evidence of learner competencies and gaps (Norman et al., 2007).
4. **Curriculum Mapping**
- **Purpose**: To identify where and how clinical reasoning is addressed in the curriculum.
- **Method**: Create a curriculum map that tracks clinical reasoning-related learning objectives, teaching methods, and assessments across preclinical courses. For example, note whether courses include case discussions, simulations, or explicit instruction on diagnostic reasoning.
- **Analysis**: Identify gaps (e.g., courses lacking clinical reasoning content) or redundancies. Assess alignment between objectives, teaching, and assessment.
- **Rationale**: Curriculum mapping ensures a systematic evaluation of content integration (Harden, 2001).
5. **Observation of Teaching Sessions**
- **Purpose**: To evaluate how clinical reasoning is taught in practice.
- **Method**: Observe preclinical teaching sessions (e.g., PBL sessions or lectures) using a structured observation tool. Assess whether facilitators model clinical reasoning, encourage hypothesis generation, or provide feedback on students’ reasoning processes.
- **Analysis**: Summarize findings to identify effective practices and areas for improvement, such as inconsistent facilitation in PBL.
- **Rationale**: Direct observation provides insights into teaching quality and fidelity to intended outcomes (Kern et al., 2016).
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### Synthesis and Implications
The targeted needs assessment would likely reveal specific gaps, such as:
- Limited case-based learning opportunities in preclinical courses.
- Faculty needing professional development to teach and assess clinical reasoning.
- Assessments not adequately evaluating higher-order thinking.
- Students lacking structured guidance on hypothesis-driven reasoning.
These findings inform the next steps in Kern’s model (e.g., defining goals and objectives, selecting educational strategies). For example, the curriculum could incorporate early clinical exposure through virtual patients, train faculty in facilitating PBL, and redesign assessments to include case-based questions.
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### Conclusion
Using Kern’s model, the initial problem identification and general needs assessment) establishes the broad challenge of insufficient clinical reasoning skills in the preclinical curriculum, driven by gaps in content, teaching methods, and assessment. The targeted needs assessment, employing focus groups, surveys, performance-based assessments, curriculum mapping, and teaching observations, provides granular insights into learner needs and curriculum deficiencies. This rigorous, multi-method approach ensures that subsequent curriculum revisions are evidence-based, addressing specific gaps while aligning with stakeholder expectations and educational standards. For a master’s student in health professions education, this process underscores the importance of systematic needs assessment in driving meaningful curriculum reform.
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### References
1. Bowen, J. L. (2006). Educational strategies to promote clinical diagnostic reasoning. *New England Journal of Medicine*, 355(21), 2217–2225. https://doi.org/10.1056/NEJMra054782
2. Harden, R. M. (2001). AMEE Guide No. 21: Curriculum mapping: A tool for transparent curriculum development. *Medical Teacher*, 23(2), 123–137. https://doi.org/10.1080/01421590120036547
3. Kern, D. E., Thomas, P. A., & Hughes, M. T. (2016). *Curriculum Development for Medical Education: A Six-Step Approach* (3rd ed.). Johns Hopkins University Press.
4. Norman, G., Bordage, G., & Schmidt, H. G. (2007). Script concordance testing: A tool to assess clinical reasoning. *Medical Education*, 41(6), 556–561. https://doi.org/10.1111/j.1365-2929.2007.02766.x
5. Schmidt, H. G., et al. (2016). The role of deliberate practice in the acquisition of clinical reasoning. *Academic Medicine*, 91(12), 1680–1686. https://doi.org/10.1097/ACM.0000000000001392
6. Thomas, P. A., Kern, D. E., et al. (2016). Needs assessment in curriculum development. In *Curriculum Development for Medical Education* (3rd ed.). Johns Hopkins University Press.