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12 Core Competencies, Milestones, and Entrustable Professional Activities
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A Practical Approach to Curriculum Development
BethanyD.Panchal andErickaBruce
13
Key Points
• Curriculum development is one of the most important
tasks of managing a family medicine residency
program.
• To ensure competently trained family physicians, residency educators must adapt to new methods of providing
education to “meet the resident where they are.”
• Understanding the audience of resident-learners and theory of teaching adults in the current environment is
important.
• A structured approach to developing an educational plan
will help the educator to stay organized and meet the end
goal.
• Curriculum developers must remain exible and be aware
of environmental elements and barriers that could change
during the planning and implementation of an educational
plan.
• Regular evaluation and feedback are crucial steps in curriculum development that will allow the residency program to provide the best education for their current
residents.
Introduction
ing that we as educators listen, understand, and provide
opportunities for learning that build on the resident’s past
experiences. “Meeting our learners where they are” is not
only an adage; it is the mantra that educators should strive to
achieve.
Curriculum development is a challenging task which
requires a fundamental understanding of the learners and
how they, as individuals, best gain and retain knowledge and
skills. The process of curriculum development needs to be
consistent and reproducible so that outcomes can be tracked
and the curriculum modied based on successes and failures.
Our diverse resident-physician population will receive and
process information in different ways. The delivery of the
curriculum could be through any number of modalities
including didactics, clinical experiences, small group discussions, simulation, or independent learning. Understanding
the importance of diverse teaching techniques and approaches
to education provides an opportunity to meet the residentphysician learner “where they are” in the process of their
personal and professional development. In this chapter, we
will outline various theories on adult learning and how they
relate to developing a curriculum that will produce competent family physicians who are able to function independently. We will explain a six-step approach to curriculum
development.
In our patient and societal interactions, we often refer to
empathetic care as “meeting our patients where they are.” [1]
The key components of this idea are that we account for the
patient’s need for medical care in the context of their environment, education level, family support, and other social
backdrops. This concept is similarly true as we educate family medicine residents to attain competence in practice.
Resident-learners come from diverse backgrounds, demand-
B. D. Panchal (*) · E. Bruce
Department of Family and Community Medicine, The Ohio State
University College of Medicine, Columbus, OH, USA
e-mail: Bethany.Panchal@osumc.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
R. Kellerman, G. Irwin (eds.), Graduate Medical Education in Family Medicine, Excellence in Medical Education 2,
https://doi.org/10.1007/978-3-031-70741-4_13
Adult Learning Concepts andApplication
The study of how adults learn has interested psychologists
and educators for centuries. With each new generation, the
way adults learn changes. To recognize the needs of the current adult resident-physician learner, it’s important to understand the changes in societal interactions which have
impacted their educational process.
Take for instances this medical student:
Taylor is a 26-year-old medical student about to start her family
medicine residency at a large academic hospital. She lives alone
121
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B. D. Panchal and E. Bruce
with her dog in a suburban apartment and when not in the hospital, enjoys riding her bike, attending live music events and trying
new restaurants in town. Taylor eases into each day checking
social media and reading about local and international news on
her smartphone. Throughout the day she toggles through various
electronic interactions; her smartphone for playing music, the
desktop computer for viewing a patient chart, a payment app to
re-imburse a friend for lunch, and listening to a podcast before
bed. Taylor is excited for the opportunities her future residency
program offers including various outpatient elective rotations,
the ability to volunteer at a local free clinic, and virtual and inperson educational conferences every week.
Taylor’s daily activities, specically her engagement with
multiple electronic communication modalities, are common
for her generation in the United States. Acknowledging the
breadth of activities and educational modalities available and
used by the current learner is important when considering
how curriculum should be delivered to them. The majority
(83%) of students who entered medical school in 2022 were
between the age of 20–25 years [2]. Generation Z or “Gen Z”
includes individuals born between the late 1990s and mid2010s [3, 4]. According to the Pew Research Center, members of Gen Z are more racially and ethnically diverse than
any previous generation, and they are on track to be the most
well-educated generation yet. They are also digital natives
who have little or no memory of the world as it existed before
smartphones [4].
Knowing this, how should undergraduate (UME) and
graduate medical education (GME) programs meet these
learners where they are? As the needs of our learners change,
so should our curriculum. To have a successful educational
plan, educators and the curriculum they develop must be
exible and allow for learner independence and personalization. Various learning theories and approaches to the education of adults have developed over time as generations of
learners and the technologies they use have evolved. The following section outlines some key learning theories and how
they can be implemented in graduate medical education. The
most common approaches to adult education incorporate the
cognitivist, behaviorist, humanistic, and social cognitive and
constructivist models of learning.
Cognitive Learning Theory
Cognitivist theory implies that knowledge is built and organized by learners based on their previous experience and
memory. Newly learned material is taken in by the learner
and organized in their memory based on prior knowledge
and experiences so that it can be successfully recalled [5].
Instructional strategies related to cognitive learning theory
may include classroom lecture, case study, discussion, and
reading [6]. One example found in residency education can
be in traditional, classroom-based learning called Grand
Rounds. These presentations focus on specic medically
related topics in a virtual or in-person format.
In grand rounds, the pedagogy is usually delivered by a physician from a podium to a receptive audience of physicians and
physicians-in-training, one of the latter of whom begins by presenting a patient case. Following the presentation, a physician
expert in that patient’s illness, discusses the case, bringing in
relevant peer-reviewed data and literature. There is then an open
forum of questions, answers and alternative opinions exchanged
between the physician expert and the physicians and physiciansin- training in the audience, providing another example of the
uidity of (medical rounds) pedagogy. [7]
This type of presentation helps physicians by prompting
them to draw upon the extensive body of medical knowledge
they already possess. Similar learning opportunities include
online modules, reading, lectures, problem-based learning,
watching videos, and listening to podcasts.
Behavioral Learning Theory
As the name implies, behavioral learning theory focuses on
an individual’s change in behavior in reaction to a stimulus.
Perhaps the most well-known behavioral learning theory is
classical conditioning as studied by Ivan Pavlov. Pavlov
looked for situations in which he could produce a natural
response (i.e., salivation) by using an unrelated stimulus
(i.e., bell) [5]. Educators who focus on this orientation
encourage effective behaviors by rewarding learners when
those behaviors are employed. A simplistic way to think
about this domain is that the external environment is leveraged to cause the learner to adjust their behavior. Within this
orientation to learning, the instructor is tasked with creating
an environment where desired behaviors are reinforced and
shaped. Therefore, behaviorists focus on building skills,
meeting performance objectives and (like cognitivists) displaying increasing levels of mastery [6].
Simulation is an example of applied behavioral learning
theory. Resident education today involves many different
types of simulation. Examples include cardio-pulmonary
resuscitation certication and learning how to perform joint
injections on a training manikin. Residency faculty are
charged with preparing realistic patient scenarios in simulated environments to aid in resident learning. Complex procedures that are rarely performed by residents in the clinical
setting are a good t for simulation. One published example
of this was found in the use of simulation for surgical residents learning airway management. In this study, residents
felt more comfortable in their airway management skills
after completing a multidisciplinary simulation scenario [8].
As clinical training time decreases (due to work hour restrictions), the use of simulation has become an increasingly
important avenue for residents to obtain familiarity with
infrequently performed technical skills.
13 A Practical Approach to Curriculum Development
123
Humanistic Learning Theory
The purpose of learning from a humanistic perspective is for
each individual to nd their purpose, grow, mature, and ultimately become self-actualized. Humanistic instructors support learners along a highly personalized and self-directed
path. Sources for learning and instructional strategies associated with a humanistic approach include personality assessments, 360-degree feedback, individual coaching, reection
exercises, personal development plans, and service-learning
experiences [6]. We nd this type of curriculum in medical
education through portfolio development, medical servicelearning projects, mentoring, and development of individualized learning plans. Allowing the resident learner to explore
their personal interests and take responsibility for their own
education is particularly important in this theory [9].
In humanistic theory, educators should help learners with
physical, psychological and emotional needs so they can better focus on their learning. A resident who is hungry, burnt
out or dealing with ongoing personal issues will have a hard
time concentrating and making the best out of their learning
opportunities. Pairing residents with mentors and coaches,
encouraging scheduled time off or employing interventions
that focus on the personal and humanistic aspects of medicine are important components to successful learning.
cess in which meaning is developed based on experience [5].
Learners can have both personal learning and still “share in
common knowledge” [5].
These two most recent learning theories, which are
favored by Millennial and Gen Z students, allow for a more
individualistic view on learning. This population of learners
“has grown accustomed to learning environments in which
multiple information sources are used and where opportunities exist to interact with others in the learning process. They
have also learned that multiple information sources are a
common part of learning and that one expert may not be the
only expert” [10]. These individuals are better networked
than any previous generation “through the use of text messaging, internet usage, after school initiatives, community
service efforts, team sports, cell phone use, instant messaging, and community-building media tools” [10]. Therefore,
they expect and want these resources to be present in their
learning environments.
Knowledge of the different educational theories presented
here will allow medical educators to design a curriculum that
ts the needs of the family medicine resident and ensure they
are competently trained to become independent physicians.
Next, we will discuss a six-step process to develop curriculum specically targeted for family medicine residency
programs.
Social Cognitive andIndividual
Constructivist Theories
The purpose of learning in social cognitivism is to master
new roles and behaviors. This is often facilitated, whether
formally or informally, by individuals who are more experienced. In a collegiate context, these role models may be
upperclassmen, the captains of an athletic team, an inuential member of a peer group or a person with a formal title in
a student organization [6]. In residency program education,
this is frequently demonstrated by escalating levels of
responsibility and authority based on postgraduate year.
According to this theory, learning comes by seeing behavior
modeled by others. The part of the work where people can
observe others is the source of their education. There is often
little to no formal programming—the individual learns by
observing the norms and ways of being exemplied by valued group members [6].
Two of the most common forms of constructivism are
individual (also known as cognitive constructivism) and
social. Individual constructivism emphasizes individual
meaning-making, whereas social constructivism highlights
the role of social interaction in knowledge development. Key
assumptions of these models include: 1. knowledge is constructed from experience, 2. learning results from personal
interpretation of knowledge, and 3. learning is an active pro-
Curriculum Development andDesign
The word curriculum carries with it any number of denitions, depending on the situation. In the broadest sense, a
curriculum is a “planned educational experience” [11]. In the
world of medical education, an area of specialization (i.e.,
cardiology, behavioral health, practice management, etc.)
becomes a curriculum when we want to assure an organized
approach to teaching and learning [11]. We will spend the
rest of this chapter offering high yield information for family
medicine faculty members tasked with developing, restructuring, and/or improving a residency program curriculum.
In order to keep focused on the end goal of educating residents to competency, it is important to have an organized
approach to the development of a curriculum. Though there
are many approaches that have been suggested for development of a curriculum that can be used in medical education,
adopting a step-wise approach is recommended. We will reference the widely cited six-step approach by Patricia Thomas
MD etal. with examples from family medicine specic curriculum. The six steps are: 1. Problem Identication, 2.
Needs Assessment, 3. Goals and Objectives, 4. Educational
Strategies, 5. Implementation, and 6. Evaluation and
Feedback [11]. A structured approach to the development of
a curriculum is key to successful implementation and continual process improvement. The steps of curriculum devel-
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opment are not meant to be performed linearly. Rather,
curriculum development is a cyclical process; each step
overlapping or occurring simultaneously with the others as a
“dynamic, interactive process” [11].
Identify theProblem
The rst step in the process of curriculum development is
multifactorial. Several questions need to be answered when
identifying the problem that the curriculum is to address.
These questions will need to be answered: 1. What is the
specic problem? If this is a new curriculum, why does it
need to be developed? If this is a curriculum revision, why
does it need to be revised? 2. Who does the problem affect
and how? 3. What is the status quo? and 4. What should ideally be happening?
Changes in or need for a new curriculum may be affected
by several factors such as availability of resources, changes
in expertise or number of teaching faculty, interests of the
learners, or dissatisfaction with the status quo [12].
Institutional changes within which the program works may
prompt the need for curricular revision (i.e., the medical center institutes a quality improvement (QI) project focused on
team rounding and patient satisfaction). Or perhaps there are
new ACGME requirements that need to be met (i.e., presence of a point-of-care ultrasound experience or a minimum
number of vaginal deliveries in which a resident must be
involved) [13].
Once the problem is identied, the curriculum developer
must dene who the problem affects and how. A curriculum
may affect a single class of family medicine residents or the
entire residency program. Curricular changes that benet a
large number of individuals (i.e., learners, faculty, staff, and
patients) may be given more attention and have an increased
likelihood of stronger support [11].
To clearly understand the problem and how it needs to be
addressed, the status quo must be identied. What is currently being done by medical educators, institutions, and
society about the problem now? Especially knowing what
providers are doing now is important since they are our targeted group for curricular changes.
The next thing you might ask is “what are others in family
medicine doing?” Looking to other family medicine residency programs both locally and nationally can help you
gather more information about the problem and how it might
be addressed. Performing a literature search or querying the
Association of Family Medicine Residency Directors listserv offers a good starting point. You may nd that the curriculum you are looking to develop already exists in another
program. You can study another program’s curriculum and
learn how it might be molded into one that can be applied to
your specic needs. Perhaps there are several different
options available to address the problem, in which case, they
may need to be evaluated and compared to ensure the most
applicable approach is being considered for your program
[11].
Once you have claried what is currently being done, you
will next decide what should ideally be happening.
Discovering best practices that involve other specialties or
health professionals may help dene the ideal. Referencing
new recommendations or requirements of professional societies (including those of other specialty societies) can be
helpful in ensuring the curriculum is evidenced based and
current with the medical world as a whole. Family medicine
residency programs must balance any ACGME requirements
and, the expectations of the American Board of Family
Medicine (ABFM) for board eligibility with new medical
recommendations from the United States Preventive Services
Taskforce (USPSTF), American Academy of Family
Physicians (AAFP), American Academy of Pediatrics
(AAP), American Congress of Obstetricians and
Gynecologists (ACOG), American Heart Association (AHA),
and any other important professional societies that create
clinical practice guidelines. The AAFP and the Society for
Teachers of Family Medicine (STFM) are excellent resources
that keep their members updated on latest
recommendations.
Overall, it is important to remember that the ultimate purpose of family medicine residency education is to improve
the health of patients, families, and communities [13].
Identifying the health problem that needs to be addressed
and dening the desired outcomes will help in the subsequent steps of curriculum development and continual
improvement.
Assess theNeeds
A needs assessment is a systematic process to determine and
address the gaps between where you want to be and the status quo [11]. A needs assessment should be performed during the initial development of a curricula as well as during
the process of continual improvement. A diabetes lecture that
has not been updated in the last 5years will be sorely out of
date because of new medications on the market. A rotation
that requires a resident to work with a super-specialized physician (i.e., lung transplant) may not be meeting the needs of
the resident to experience a broad range of pulmonary conditions. An effective needs assessment can expose the gap of
“what is” and “what should be” and sets the stage for change.
There are four fundamental types of educational needs
and clarifying the type of need will help guide curriculum
development. A normative need is one in which an individual or group needs to reach an established standard (i.e.,
passing the ABFM board exam at the end of residency).
13 A Practical Approach to Curriculum Development
125
Anticipated needs are related to projected demands (i.e., the
new ACGME requirement of 20 vaginal deliveries in a program with limited labor and delivery exposure) [13]. A per-
ceived need for change is driven by a particular incident or
observation. For example, multiple highly televised racially
motivated incidents may be the impetus for a program to reevaluate and update their health equity curriculum. Finally,
comparative needs occur when one program has something
another does not but wants or needs to include [11]. For
example, other programs may have a highly developed pointof-care ultrasound curriculum that another program does not
have but would like to create.
Part of the needs assessment involves identifying the target audience. Since we are discussing graduate medical education in family medicine, we can assume the curriculum
being developed will focus on the education of family medicine residents.
There are several methods to gather the information
required to assess the needs of the target audience. Each
method has its own advantages and disadvantages. Since the
target audience is resident-learners, the constraints of time
and energy for information gathering must be considered.
One method of information gathering is individually
focused interviews. These can be structured or unstructured,
or a combination of both. Unstructured interviews may occur
while working together in clinic or while waiting for a patient
to deliver on labor and delivery. The advantages of this
method are in its spontaneity and in-the-moment follow-up
of interesting responses. Unstructured interviews may contain much detail and qualitative information. The disadvantages of this method are that it is not systematically conducted
and may include interview bias depending on the relationship between the interviewer and interviewee. In addition, it
may only occur with a small number of individuals and is
entirely situational [11].
Structured interviews use consistent questions. Responses
can be collated, analyzed, and compared. With both structured and unstructured interviews, it is important for the
questioners to maintain a neutral attitude and a structured
format may make this easier to attain.
Questionnaires or surveys are another method used to
obtain information from the target audience. This method of
data collection has many advantages. Information from multiple individuals can be gathered using a structured format
without the variance of different individuals performing
interviews. Results can be tabulated, analyzed and directly
compared with other data. The questionnaires or surveys can
be completed anonymously, creating a safer atmosphere in
which the individual can feel free to be honest and they can
be completed at the individual’s convenience. On the other
hand, survey fatigue (the phenomenon an individual feels
due to being asked to complete too many surveys, thus being
less likely to respond) and time constraints of individuals
may lead to low response rates and partial completion [11].
For surveys targeting health professionals, a response rate of
60% or better should be the goal [14]. Educators can possibly avoid the disadvantages, at least partially, in a few ways.
Before starting a survey, the individual being asked to complete it should be informed of the goal, possibly increasing
the likelihood of completion. The curriculum developer
should ensure questions are clear and easily answered. Openended questions (i.e., free text) may be less likely to be
answered completely or robustly. They are more difcult to
analyze and, therefore, should be used sparingly. The survey
questions need to focus on the curricular objective. Asking
the most important questions early in the survey will increase
the odds of them being answered. The use of a variety of
return options (i.e., email, easy to navigate hyperlinks or traditional mail with stamped self-addressed return envelopes)
can increase the likelihood of response [11].
Focus groups are another useful method for establishing
the needs for curriculum development. A skilled facilitator
can lead a group of people with a common experience to
share their collective thoughts.
Example
To assess the needs to revise rotation schedules, individuals from different residency classes along with faculty and program administrators were brought together to
share their experiences with the current rotation schedules
and suggest ways they could be improved. The group was
led by a faculty member specializing in behavioral health
who had group facilitation experience. Within a few
hours, the group was able to identify rotations that could
benet from change or could be discontinued altogether,
thereby creating space for new opportunities and to meet
updated accreditation requirements for the following academic year. ◄
To be effective, a focus group should be representative of
the various stakeholders but not be large. Five to nine individuals in a focus group are ideal. The facilitator should
encourage participation by all, ask open-ended questions and
foster brainstorming in a nonjudgmental manner [11].
The steps of curriculum development are cyclical and
uid. Before beginning the targeted needs assessment, the
educator should have a general idea of the goals and objectives for change. The data collected during the needs assessment will affect the subsequent steps of creating specic
goals and objectives, developing educational strategies,
implementing the curriculum and evaluating outcomes. The
needs assessment process can serve as an advertisement for
curricular change and engage stakeholders (the residents,
faculty and staff). The data collected during the needs assessment will not only be helpful in guiding the upcoming process of developing and implementing the curriculum; it is
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also important for dissemination of the learnings (such as
presentations at national conferences) to other educators
with similar needs and learners. Performing a thorough general and targeted needs assessment can result in the educator
becoming a content expert and provide a solid foundation for
the next step, developing goals and objectives.
Goals andObjectives
The ACGME states that every residency program must
develop “competency-based goals and objectives for each
educational experience designed to promote progress on a
trajectory to autonomous practice” [13]. Keeping this in
mind will help in the development of each goal and objective
for any curricular element within the residency program.
Once the needs are identied, well-written goals and objectives will help determine the curricular content. Educational
strategies and teaching methods can be developed to meet
the needs of the resident-physicians based upon them.
Goals dene the end to which a curriculum is directed and
are important because they communicate the overall aim or
purpose of the curriculum. In family medicine education,
autonomous practice upon completion of residency is a goal.
For example, by the end of residency, we aim for our residents to be able to care for the acute and chronic medical
problems of adults and children, deliver a baby, repair a laceration, and explain preventive health recommendations
autonomously without supervision. Objectives offer specic
guidance in the development of effective educational methods to reach these goals and set the stage for evaluation of the
educational experience [11].
There can be confusion when identifying the difference
between a goal and an objective. For the purposes of residency education, a goal indicates a broad curricular aim
whereas an objective is a specic and measurable curricular
component. Goals are usually established based on a longer
time frame than objectives. In family medicine education,
3 years is a frequently used time frame to set a goal.
Objectives are based on shorter time frames, such as the end
of a rotation or the end of a postgraduate year. Though both
goals and objectives dene outcomes, goals do not dene the
specic methods used to get to the outcome. Objectives
describe specic measurable actions to be taken or tasks to
be completed to reach the goal. Goals dene the destination;
objectives explain the roadmap.
Goals
Goal oriented statements should be made in terms of overall
learner outcomes and be realistically attainable by the com-
pletion of the residency program. The goals should align
with the program’s overall mission and aims. They should be
stated in terms of learner knowledge, behavior and attitudes
and describe real world behaviors to be used by the learner.
For example, the stated goals of a longitudinal maternity care
curriculum could include the following:
Upon completion of residency, the family medicine graduate
will independently:
• Perform a thorough medical and psychosocial obstetrical history.
• Provide comprehensive preconception counseling and
care to patients who desire to become pregnant.
• Manage the uncomplicated pregnant patient through
outpatient prenatal care.
• Competently manage a normal, uncomplicated labor
and perform a vaginal delivery.
• Provide comprehensive postpartum care for the
uncomplicated patient.
The goals of the curriculum are broad and specify what
the program wishes for the resident to “know,” or perform
independently by the time they graduate from the program.
The objectives will help guide the specic curriculum components to reach these goals.
Objectives
Writing curricular objectives is a skill that is important for
family medicine educators to develop but is often overlooked. Badly written objectives can cause a curriculum to
be poorly implemented, unfocused and open to various interpretations. It is crucial that the educator take time to thoughtfully and meticulously write objectives that relate to the
goals of the curriculum. When writing objectives, the family
physician educator should answer the question, “What will
the learners be able to do by the end of this particular curricular experience?”
Objective statements should be specic and measurable
and answer ve basic elements: 1. Who? 2. Will do? 3. How
much? 4. Of what? 5. By when? [11]. Use of the SMART
(Specic, Measurable, Achievable, Relevant, Timebound)
acronym is very useful here [15]. The objectives should identify exactly what is expected to be achieved and who will
achieve it. The objectives should express the expected change
and how it will be measured (i.e., rotation evaluations, intraining service examination scores, etc.). It is important for
the objective to be achievable and attainable by the end of the
stated time frame. For example, it may be unreasonable to
expect a PGY1 resident to independently perform a specialized procedure without the support of a senior resident or
attending physician by the end of their rst year of residency,
13 A Practical Approach to Curriculum Development
127
but it may be a reasonable goal upon completion of residency.
Finally, the objectives should be timebound and specify when
they should be achieved (i.e., upon completion of a workshop,
at the end of the rotation, by the end of PGY1, etc.) [11].
The use of focused action verbs helps to minimize misinterpretation of the objective. Bloom’s taxonomy (Table13.1)
consists of six levels of progressively more complicated cognitive abilities. Educators have been relying on this taxonomy
since Benjamin Bloom PhD and his associates identied the
levels and specic associated action verbs in 1956 [16]. Bloom
identied and classied increasingly complex cognitive processing skills at each level. Knowledge is the most basic cognitive level and refers to gathering and obtaining discrete
pieces of information. Higher levels of cognitive processing
include comprehension, application, analysis, synthesis, and
evaluation. As a family medicine resident progresses from an
undifferentiated medical student into a competently trained
independently practicing graduate, they will develop an
increasing ability to apply higher level cognitive processing
skills. The curriculum objectives should reect this expected
progression. Table13.1 provides a visual aid and examples of
appropriate action verbs to use in writing useful objectives.
The following are examples of written objectives:
By the end of the rst year of inpatient rotations, the PGY1
resident will be able to:
• Explain the management of common inpatient conditions including CHF, sepsis, COPD, DKA, and
osteomyelitis.
• Complete a patient admission in less than 2.5 hours
that includes collecting a thorough history, performing
a physical examination, and conducting a medication
reconciliation.
• Coordinate the care and management of a family medicine inpatient census of 10–12 patients.
At the end of the colposcopy workshop, residents will be
able to:
• Identify reasons a patient may require a colposcopy.
• Recognize the parts of a colposcope and how to manip-
ulate the equipment.
• Demonstrate the steps required for a satisfactory col-
poscopy examination.
The goals and objectives for a family medicine residency
curriculum should be written with the six ACGME competencies and the individual specialty’s milestones in mind.
Specically linking the goals and objectives with one or more
of the six competencies (Patient Care, Medical Knowledge,
Professionalism, Interpersonal and Communication Skills,
Practice-based Learning and Improvement, and Systemsbased Practice) is helpful [17]. Additionally, the milestones
were developed to provide educators and learners markers in
performance and a road to mastery for the resident. Each level
marks the journey of the resident-physician from novice to
advanced beginner to competency to prociency and eventually to mastery. The resident learner should move from novice
(beginning of residency) to competence and prociency by
the time they graduate. Mastery is a reach goal that may not
be obtained for several years out of residency training. Each
objective should fall under one or more of the six competencies and link to a milestone. For example, the PGY1 inpatient
medicine objective cited above links to the Patient Care and
Medical Knowledge competencies. More specically, the
objective links to the FM Milestones PC-1 (Care of the
Acutely Ill Patient) and MK-1 (Demonstrates Medical
Table 13.1 Bloom’s taxonomy: examples of action verbs grouped by cognitive processing level
Complexity level Cognitive level Illustrative verbs
Low Knowledge
Comprehension Classify, convert, defend, discuss, distinguish, estimate, explain, express, extend, generalize, give
Application Apply, change, choose, compute, demonstrate, discover, dramatize, employ, illustrate, interpret,
Analysis Analyze, appraise, breakdown, calculate, categorize, classify, compare, contrast, criticize, derive,
High Synthesis Arrange, assemble, categorize, collect, combine, comply, compose, construct, create, design, develop,
Evaluation Appraise, argue, assess, attach, choose, compare, conclude, contrast, defend, describe, discriminate,
Arrange, dene, describe, duplicate, identify, label, list, match, memorize, name, order, outline,
recognize, relate, recall, repeat, reproduce, select, state
example(s), identify, indicate, infer, locate, paraphrase, predict, recognize, rewrite, report, restate,
review, select, summarize, translate
manipulate, modify, operate, practice, predict, prepare, produce, relate, schedule, show, sketch, solve,
use, write
diagram, differentiate, discriminate, distinguish, examine, experiment, identify, illustrate, infer,
interpret, model, outline, point out, question, relate, select, separate, subdivide, test
devise, explain, formulate, generate, plan, prepare, propose, rearrange, reconstruct, relate, reorganize,
revise, rewrite, set up, summarize, synthesize, tell, write
estimate, evaluate, explain, judge, justify, interpret, relate, predict, rate, select, summarize, support,
value
128
B. D. Panchal and E. Bruce
Knowledge of Sufcient Breadth and Depth to Practice
Family Medicine) [17].
Competency based education is not unique to medical education and was rst used in the 1960s [18]. Competency based
education is learner focused and aims to ensure the resident
reaches the written objectives. A resident may need to spend
additional time on a rotation or receive focused instruction in
a specic topic area in order to meet a specic objective before
being allowed to progress in the program [19].
Developing clear well-written learner-based objectives is
important and effects the overall process of curriculum
development. Spending adequate time in writing them is crucial. However, they are still just one step in the process. Next,
we will discuss different educational strategies that can be
used for delivering the curriculum.
Educational Strategies
Once the goals and objectives are written, the educational
strategies for the curriculum must be determined. Strategies
refer to both educational content and method of delivery of
that content. The ACGME Review Committee (RC) requires
that the “curriculum must be structured to optimize resident
educational experiences, the length of the experiences, and
the supervisory continuity. These educational experiences
include an appropriate blend of supervised patient care
responsibilities, clinical teaching, and didactic educational
events” [13]. When considering the method by which a curriculum will be taught, there are three basic categories within
family medicine residency education to consider: block rotation, longitudinal and didactic. Some aspects of the curriculum may be best taught and learned through one of these
categories (i.e., didactic teaching for dental health; longitudinal teaching in the outpatient residency ofce practice for
continuity of care experiences) and some can be learned
using all three categories (i.e., care of children, health
equity). Though the main goal of a resident is to learn, they
are also responsible for many aspects of patient care in the
hospital and in the outpatient setting. Educators must
acknowledge this and incorporate the patient care responsibilities into the learning objectives.
Block rotation curriculum objectives outline what a resident should learn during an experience within a limited time
frame. For example, many residency programs use block
rotations that are each 4-week long with 13 blocks per academic year, each of which can be a unique experience. A
resident will work on many different rotations during their
residency training. They will work in various areas of the
hospital and in outpatient settings and within different specialties. Logistically, the educator who is planning a block
rotation curriculum will need to consider not just the subject
area to be taught, but also who will be teaching it, how it will
be taught and where it will occur.
If a resident is going to perform a rotational experience
outside the home institution, it is important to consider that a
Program Learning Agreement (PLA) is necessary. This is a
legal agreement between the sponsoring institution and the
institution at which the resident will be working. Specically,
the PLA identies the individuals responsible for education,
supervision and evaluation of the resident, the content and
duration of the educational experience and the policies and
procedures that govern the educational experience. The PLA
ensures the sponsoring institution that the resident is receiving the education expected, is being supported appropriately
and helps to cover the resident if any medicolegal concerns
should arise.
The ACGME lays out specic requirements that a family
medicine resident must meet to graduate.
Example
The most recent requirements (2023), state that the “resident
must have 200hours (or 2months) of experience dedi-
cated to the care of children in the ambulatory setting, to
include well, acute, and chronic care for infants, pre-
school aged children, school-aged children and adoles-
cents” [13]. To satisfy this, a family medicine program in
a large metropolitan city partnered with the local chil-
dren’s hospital and their large outpatient care network to
allow PGY2 and PGY3 family medicine residents to
rotate in their ambulatory clinics, thus receiving dedicated
education about the care of children from pediatric spe-
cialists. ◄
This is one of many examples of required experiences that
are probably best satised by developing a block rotation
curriculum in a specic area of medicine.
Longitudinal curriculum encompasses requirements for
knowledge that cannot or should not be done within a set
time period. For example, the teaching of practice management might be best accomplished over the entire length of
the residency experience, so the individual can build upon
their knowledge and continuously implement it in multiple
venues such as the hospital, skilled nursing facility and
outpatient continuity practice. The longitudinal education
that occurs in the family medicine residency center is
another example and should have its own set of goals of
objectives. The Family Medicine Review Committee
acknowledges that longitudinal education is crucial to the
education of a resident to ensure they are progressively
able to competently perform with progressively less
supervision.
Didactic curriculum is structured learning that is typically offered in small doses such as 30-minute presentations
(i.e., at noon conferences or morning report) or with online
modules. Didactic teaching can be used for teaching about
subjects that the resident may be exposed to infrequently
13 A Practical Approach to Curriculum Development
129
(i.e., care for on-eld sports emergencies or disaster preparedness), for workshops during which a resident can practice procedural skills in a controlled simulated environment,
for an introduction to new therapies (e.g., monoclonal antibodies) or for an overview of treatment options (e.g., diabetes medications). Adult learners learn best when exposed to a
subject using multiple teaching modalities [8].
As discussed previously, the needs of adult learners have
changed over the years. The lecture format still has relevance but might be used in smaller doses and with less frequency than 20 years ago. The modalities for didactic
education are expanding and limited only by the imagination of the educator. More recently, online modules and
gaming have expanded the toolkit of educational experiences beyond what anyone could have imagined 100years
ago. Articial intelligence may offer many additional opportunities. Referring back to the curricular objectives will help
in deciding which educational teaching methods will be
best. Higher order cognitive objectives may be best
addressed by one teaching method compared to lower order
cognitive objectives which may lend themselves to another
teaching modality. For example, new content can be presented using lower cognitive level teaching methods such as
textbooks, lectures or audio/video resources. Higher order
cognitive objectives might better lend themselves to group
discussions, problem-based learning, or supervised clinical
experiences.
Interestingly, an overreliance on goal-directed learning
may be counter-productive. Goal-directed learning is intentional and, oftentimes, directed toward acquiring dened
cognitive knowledge. But goal-directed learning may imbue
constraints on thought processes such as problem-solving,
brainstorming, and thinking intensely about a specic and
limited task or problem at hand. Though goal-directed learning is important to ensure the curricular goals and objectives
are being met, learners also require time to allow their minds
to wander and rest. During these restful and wandering times,
research has shown that learning continues and allows innovative and creative thoughts to develop [20].
Occasionally, a learner may require additional time to
achieve the objectives of the curriculum. As goals and
objectives are created, the educator must consider neurodivergent resident-learners who do not reach the set goals and
objectives in the time allotted. On the other hand, if a signicant portion of the learners are not meeting the set
objectives, the educator should ask if the curriculum is part
of the problem and whether the objectives or teaching
modalities should be re-evaluated. It is important to remember that in residency education, it is imperative that objectives are met as patient care can be greatly affected. Often,
there are complex reasons that a learner may not be meeting objectives and it is the duty of the program faculty to
uncover the barriers and ensure the residents have support
in managing them in order to effectively meet the curriculum objectives [11]. There is growing evidence that knowing why a learner is not meeting objectives can help in
guiding remediation strategies [21]. However, some competencies are more difcult to remediate than others. For
example, remediating a problem with a resident’s professionalism is a much different process than remediating a
medical knowledge decit. Ultimately, some residents may
not be able to meet the established objectives and each program must decide the signicance of the patient care and
public safety consequences in these cases.
Implementation
The nal step in the development of a curriculum is implementation. This may take place at the same time as the needs
assessment if there is a problem that needs to be addressed
immediately. Or implementation may be projected to start in
the future after completion of the rst four curriculum development steps, depending on the cycle of the curriculum or
timing of the academic year for the residency program.
Example
A dermatology rotation is losing one of its main faculty members with whom residents work regularly. You’ve
been given 3months’ notice to implement a change in the
block rotation experience. At the same time, you’ve noted
that the rotation goals and objectives have not been
updated for 5years. During this time of curriculum revision, you will need to go through all the steps for curriculum development simultaneously so as not to interrupt the
residents’ scheduled educational experience. ◄
Example
A residency program is developing a new Point-ofCare Ultrasound curriculum which will include workshops and bedside experiences. Since this is not currently
part of the active curriculum, the program may wait until
the beginning of the next academic year to implement the
curriculum into the new rotation schedule to avoid interruption of the current schedules. ◄
Before making the curriculum a reality, the educator
must ensure resources are available and stakeholders are
in agreement and ready to initiate the experiences associated with the proposed curriculum [11]. As the educator
follows the steps of curriculum development, they must
keep in mind the goal of implementation. For implementation to occur, several items must be identied and solidied including: identifying and securing resources,
obtaining stakeholder support, ensuring administrative