Rehabilitation syllabus

I am currently involved in writing a syllabus for doctors training in Rehabilitation Medicine in the UK. This has involved considerable discussion within the group involved, which has meant considering, what is a syllabus? The Oxford English dictionary states it originated in the mid 17th century meaning ‘a concise table of headings of a discourse’, and gives its current general meaning as “the subjects in a course of study or teaching” I will explore this a little further, drawing on points of view expressed during our meetings.

Context

The desire for a syllabus arose because it was felt, quite understandably, that the training curriculum lacked any clear guidance on what needed to be learned. Anyone wishing to see the curriculum can find it and download it from here.

The purpose of the curriculum is quite clear: “to give the trainee doctor the specialist knowledge and skills needed to provide any rehabilitation service and team the doctor works with the medical expertise needed to provide a high quality, holistic and patient-centred service aimed at ameliorating the wider consequences of any illness.

It does this by setting out generic and specialist “high-level capabilities”. It then gives an outline of how these capabilities will be acquired, in terms of the range of experience, areas of practice, and so on that a trainee should be exposed to. It also sets out how knowledge and skills will be assessed, and covers other educational matters.

At no point does the curriculum give any specific guidance, such as that a trainee should “learn about this topic, and develop the skill to do this“. The design of the curriculum was developed through a considerable body of research, and is (I assume) based on sound educational grounds. Moreover the curriculum includes a requirement for trainees to fulfil the standards set out in a second document from the General Medical Council, the “Generic Professional Capabilities Framework”, available here. This covers the general requirements of any doctor, such as having skill at taking a history.

The lack of any guidance on what should be learned during higher specialist training in Rehabilitation Medicine led, understandably and correctly, to a request to develop a syllabus. Indeed, some curricula documents have a syllabus as a separate part of the curriculum document. So, what is a syllabus, and what is its purpose?

Syllabus – purpose and content

The debate about the syllabus has prompted me to ask (myself), what is the purpose of a syllabus? The meaning given, for example in the Oxford English Dictionary and given above, is to outline the subjects or topics to be covered. A syllabus gives, as in its original meaning in the 1650s, “a concise table of the heading of a discourse”; the ‘discourse’ in this case is the totality of the learning to be achieved.

This interpretation is consistent with the use of a syllabus in most educational settings. Examinations set out a syllabus to be covered, and courses give a syllabus of what they will teach. The syllabus does not specify the particular facts (or skills) that have to be learned or will be taught. The syllabus may give a selection of texts or other sources that are considered relevant to the syllabus.

This syllabus is for a training programme for doctors. These doctors will not only obtained a degree, but will have passed one further examination to qualify as a doctor and at least one more examination. Further, over the years preceding entry to the training programme, they will have been learning, much of that learning being self-directed. In addition, the trainees (in the UK) will have an Educational Supervisor whose role is to guide and monitor learning and progress.

Therefore the trainee doctors are, or should be and will to become, familiar with independent learning. There is a professional expectation that learning is fully integrated into their professional life. (See paragraphs 7 – 12 of the General Medical Council’s Good Medical Practice, available here.)

In medical training, as in most healthcare professional training, the doctor needs to acquire a broad range of knowledge ranging from basic science (biological and other), through sociology and human behavioural sciences, onto the relevant laws. The doctor will also need to learn many skills, some practical such as doing an invasive procedure, and most less obviously practical but more important, such as communication.

Given the great range of learning needed, and the variation between specialities in the areas of importance, some guidance is needed both for trainees, and for the trainers to judge whether the trainee is acquiring both the whole range of knowledge and the right amount of knowledge.

In this context, the purpose of a syllabus is to provide both the trainer and the trainee with a list of topics or areas that need to be learned by the trainee. It needs to be given in sufficient detail to ensure the range and depth of learning needed is clear. In other words, the syllabus gives guidance. It is not intended to give details.

The debate – detail v outline

There have been two areas of debate occupying our group: what are the ‘chapter headings’, the topics to be considered, and how much detail should there be? This section will consider the latter – how much detail?

One approach is to give just the chapter headings, anatomy, pharmacology, diagnosis and management of joint disorders, etc. This would obviously be unsatisfactory, because the headings are too imprecise and will be similar to those used in under-graduate and pre-clinical learning.

The other extreme is to set out in great detail every single piece of knowledge and skill needed. This is impractical. More importantly, some of the detail would be wrong before it was published, because advances in knowledge would make some items out-of-date, sometimes with risk of causing harm.

Various matters should be considered when resolving this dilemma.

Continuing professional development.
All professionals are expected to undertake continued learning throughout their career; doctors are no exception. Although mechanisms such as yearly appraisal have been developed to assist, in reality all development will depend upon the doctor recognising a need to learn something, and then organising to learn it.

Trainees entering ‘higher professional training’ will already have needed to do this for some years, and will certainly need to do so for many years in their future. Therefore, among other educational objectives, one objective should be ensuring that a trainee can successfully identify the need for and manage their own continuing professional development.

The learning associated with each area of knowledge should be achieved by the trainee, guided by a trainer. At the point of entry into the training programme, a doctor should already be able to identify, with guidance, what learning is needed. They should also be able to learn it using any one of many methods: self-directed research and reading; textbooks; review articles; published guidelines; attending taught courses or workshops or seminars; learning with peers; and learning from other doctors during their work.

Length and usability.
A syllabus is there to guide the trainee and the trainer. Both will be busy, and have many demands on their time. The syllabus must be something that can be used with least effort. Obviously layout of the document can help. Nevertheless there are likely to be 35-40 topics. A shorter general guide is more likely to be used. In addition consistency across all topics in the format of the guidance and in the level of detail is needed.

Risks.
There are risks associated with too much detail.

If an explicit detail is given, such as learning a specific screening test for cognition, then it is possible that the trainee will feel that knowing all the detail given is sufficient, and all that is needed. Unless the syllabus is of text-book length, some trainees may not learn sufficient, feeling that the detail in the syllabus is all that is needed. Moreover, a trainee may not recognise that other screening tests (for example) exist and have some strengths.

A second risk is that a syllabus that is too prescriptive will reduce the need for a trainee to learn how to determine their own need for further learning, and reduce their learning about how to learn. In other words, the trainee may become dependent on the syllabus and the trainer. Such a trainee will find life as a consultant difficult.

On the other hand, there are also risks associated with too little detail.

The major risk is a failure to appreciate the range and extent of the learning needed. The trainee may also misunderstand what the topic is, and learn material not needed but fail to learn material that is relevant.

In addition, some trainees may not accept advice from the trainer, simply stating that they are competent. In that case, the trainer is likely to face difficulties in persuading a trainee that further learning is needed. The existence of some guidance setting out some expectations over and above the competency is a powerful tool.

The resolution of this dilemma is to have a syllabus with indicative details, showing examples of general matters that need to be learned, and at what standard. They are used to guide learning, they are not a comprehensive description of everything.

Assessing learning.
The training programme needs to include a mechanism for the trainer and trainee to gauge how well learning is progressing, and whether the extent of knowledge is adequate. A detailed syllabus might appear to be better, as it will define particular pieces of learning that can be tested.

However, clinical practice is unpredictable and varies greatly, and it would be difficult to list all the individual bits of learning needed to manage every conceivable future situation. The trainee needs to learn much more broadly, with an appreciation of how to use the knowledge and skills they have. Too much emphasis on details risks “not seeing the wood for the trees“; the trainee risks being able to identify, categorise and count trees, without noticing that there is a forest.

In other words, assessment needs to based not only on specified knowledge and skills, but on the trainee’s ability to use the knowledge and skill safely and effectively in their work.

The conclusion to be drawn from these considerations is that it is important to provide sufficient but not too much detail within a syllabus. Of course there is no evidence on what constitutes sufficient or on what constitutes too much. In the absence of evidence, it will be a matter of judgment.

The rehabilitation syllabus

The medical rehabilitation syllabus has yet to be written in detail, and even the chapter headings are not fully worked out. However the general format is clear, and it is shown in this drawing here. This illustrates the spectrum from learning individual pieces of knowledge and individual skills through to being a consultant

The details of the syllabus will be given in a blog, when they have been decided upon. Some general matters will be discussed here.

The so-called chapter headings (list of subjects) will be based around competencies. A competency is a more specific level of detail than a capability. The curriculum has 14 capabilities, and will probably have 39 competencies. Competencies relate more to direct clinical matters relating to a patient. Capabilities relate more to service functions across all patients, and extending to matters not directly relating to individual patients. (See here for a bit more detail.) Competencies are more granular and specific.

Photo by Nick Kwan on Pexels.com

I will illustrate this with two likely competencies. One concerns management of bowel and bladder problems: “Able to analyse the factors causing or maintaining impaired control over excretion, identifying treatable factors and planning a management strategy.” The other concerns patients with an amputation: “Able to assess and manage any patient of any age who has a loss of any part of one or more limbs, from the hip or the shoulder.” [The wording may change, but the topics are likely to remain.]

The competencies cover particular conditions, or common problems seen in many conditions, or treatments used in many conditions, or processes involved in rehabilitation in all situations.

The development of the Rehabilitation Medicine syllabus for doctors training in rehabilitation is work in progress. This blog sets out some of the issues we have considered in the group, and are still trying to resolve. As usual, there is no straightforward answer. There is also no evidence known to me. If any reader has evidence or has views, I would like to know the evidence of the views. Reply below.

Acknowledgements
I acknowledge the input of all members of the Training Advisory Group who have posed challenging (and pertinent) questions that have certainly helped me develop my ideas and thoughts. More importantly I think the discussions are leading to a high quality syllabus. We will not know for about three years how good it is, but I am hopeful. Members of the group will have to live with the outcome as the trainees move on to be colleagues.

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