Editorials
PRISMS: new educational strategies for medical education
What will the medical curriculum look
like in the future? We have seen enor-
mous changes over recent years in the
ways we teach and learn, especially with
the increased use of small group and
problem-based learning methods, more
teaching in the community and shorter,
more structured postgraduate training
programmes. Many of these changes
draw heavily on the SPICES model of
curriculum planning in which student-
centred approaches, problem-based
learning, integrated teaching, commu-
nity-orientation, elective study periods
and systematic approaches to curricu-
lum planning have been the building
blocks of modern curricula across the
world.1
Circumstances have altered sub-
stantially since the initial publication of
the SPICES model. Medical teachers,
managers and clinicians are facing dif-
ferent organisational and educational
challenges in the continuous drive to
achieve an effective balance between
teaching, research and clinical work.
For example, student numbers are
increasing and there is a greater
awareness that teaching and learning
should be evidence-based and re¯ect
changes occurring in clinical practice,
health service management and clinical
governance. In addition, the public
expect to be served by an accountable
medical profession in a cost-effective
health service. Teaching hospitals
remain the cornerstone of clinical
teaching in the later twentieth century,
but increasingly treat patients experi-
encing short-term and acute care epi-
sodes. Most other medical conditions
are managed elsewhere in the commu-
nity. These factors require the devel-
opment of a revised set of principles to
guide medical education in the new
millennium.
Correspondence: Professor J Bligh, Peninsula
Medical School, ITTC, Tamar Science
Park, Davy Road, Plymouth PL6 8BX, UK
520
In recent years we have reviewed and
learned from a large number of differ-
ing approaches to medical teaching in
different parts of the world and would
like to propose new strategies for future
curriculum development. We have
taken into account the growing impact
of information technology, the emer-
gence of problem-based learning as a
teaching method of choice by many
medical schools, the need for greater
clinical experience amongst medical
students and for more protected learn-
ing time during postgraduate training.
The proposals are built on educational
principles that are familiar to us all:
respect for the autonomy of the indi-
vidual while also recognising the power
of group learning, the importance of
critical re¯ection on practice, the direct
relationship between assessment and
learning methods, and the fundamental
need to ensure that learning is context-
based, relevant and meaningful in the
eyes of the learner.
First, medical programmes will be
product-focused. By this we mean
that curricula will increasingly empha-
sise clinical practice and be practice-
based wherever possible. This does not
mean a return to a wholly apprentice-
ship-based system. Rather, the princi-
pal focus will be on clinical work and
the acquisition of professional behav-
iours. Students will learn about basic
science by applying it in the context of
real clinical problems. They will learn
by doing, seeing and discussing mainly
in structured, organised environments
that are supported by modern technol-
ogy and by feedback from patients.
Programme planning will emphasise
learning outcomes congruent with
clinical practice rather than the use of
educational processes or learning
objectives.
Second, learning will become more
relevant both to communities and to
students. Learning programmes that
are planned around outcomes can link
clinical knowledge, skills and behav-
Ó Blackwell Science Ltd ME D I C A L ED U C A T I ON 2001;35:520±521
iours to the needs of local health servi-
ces and populations. The syllabus will
be more frequently reviewed to ensure
it is contemporary, and learning activ-
ities will be directly related to mean-
ingful clinical tasks and to career
development. Up-to-date teaching and
learning resources will be selected on
the basis of evidence-based decisions.
Third, the medical curriculum of the
future will be interprofessional in
character. Programmes will espouse,
encourage, and re¯ect a culture of
effective, multiprofessional learning and
value interdisciplinary learning experi-
ences, with an expectation that team-
work and collaboration in educational,
research and clinical contexts is based
on mutual respect and understanding.
Fourth, medical courses will be
shorter and the numbers involved will
be much smaller. This does not mean
that the total number of students or
participants will decrease but that
learning activities will take place in
smaller units, locally, wherever poss-
ible, and will combine modern tech-
nology with independent and open
learning techniques. Outside North
America, undergraduate medical cour-
ses will increasingly be reduced from six
to four years by encouraging graduates
and mature entrants to study medicine.
Closer collaboration between teachers
in medical schools and in hospital
training will make the `continuous'
curriculum more attainable by easing,
and ®nally dropping, some of the arti-
®cial barriers presented by transitions
between the ®nal school year and uni-
versity, the preclinical and clinical years
of initial medical education, and from
undergraduate to postgraduate train-
ing.
Fifth, modern medical education will
be based in multisite locations. The
narrow patient mix of teaching hospi-
tals has resulted in students being
increasingly educated in primary care
settings, and smaller hospitals and
units. The smaller units are unable to
Editorial · J Bligh
Clinical
education
Figure 1 The symbiotic curriculum.
accommodate a large number of stu-
dents at one time ± hence the need for a
greater number of sites. In the rural
areas of some countries for example,
where the medical workforce must be
concentrated to meet population needs,
multisite education will give students
valuable experience, and equip them
with the knowledge, skills and attitudes
they will need to practise in such
settings after graduation. Multisite
education supported by information
technology and open learning approa-
ches, is more likely to provide a
product-focused, relevant and inter-
professional context for learning.
Furthermore, extended experience in
smaller sites will enable students to
establish the closer relationships
between patients and health colleagues
that are essential for contemporary
medical practice.
Ó Blackwell Science Ltd ME D I C AL ED U C AT I ON 2001;35:520±521
Product Related
Relevant
Interprofessional
Shorter, smaller
Multi sites
Symbiotic
Sixth, medical education will be
symbiotic. We have compared the
symbiotic curriculum with a prism (see
Figure 1) to illustrate that the curricu-
lum of the future will be seen as an
organic whole with several constituent
elements.
In the PRISMS model, clinical edu-
cation is the driving force. The symbi-
otic curriculum must separate, and at
the same time bring together in part-
nership, all six elements. Why are
partnerships between learners, teach-
ers, organisations, and the communities
they serve, so important? They are
essential as the health care agenda
becomes more diffused, open-ended
and contested.2 Doctors contribute
only one voice to a health care system
whose values, needs and demands are
continually changing. Other voices in
health care education, including those
responsible for organizing and man-
521
aging health care organizations, must
achieve the same equality of importance
if congruency and accountability are to
be achieved. Symbiotic educational
partnerships within a dynamic health
care system must be diverse and ¯ex-
ible, recognise the existence of different
learning styles, modalities and choices
that seek to balance student-centred
and teacher-centred learning approa-
ches. Assessment will emphasise
`doing' rather than `knowing', and
continuous methods of formative
assessment, such as portfolios, will
predominate. Learning will take place
within the health care system and the
system itself will start to develop its own
learning capacity.3 We hope that
PRISMS will be a platform for future
debate and a catalyst for new ideas,
thoughts and discussions.
John Bligh
Plymouth, UK
David Prideaux
Adelaide, Australia
Glennys Parsell
Liverpool, UK
References
1 Harden RM, Sowden S, Dunn WR.
Educational strategies in curriculum
development: the SPICES model. Med
Educ 1984;18:284±97.
2 Cribb A. The diffusion of the health
agenda and the fundamental need for
partnership in medical education. Med
Educ 2000;34:916±20.
3 Nutley SM, Davies HTO. Developing
organizational learning in the NHS.
Med Educ 2001;35:27±34.