Are curricula in medical ethics and law effective in producing ethical doctors? Assessment is central to this question, both in setting the standards that students are expected to meet and in establishing the extent to which learning correlates with these. Medical ethics and law: a practical guide to the assessment of the core content of learning from the Education Steering Group of the Institute of Medical Ethics is an excellent guide for educators in approaching this curriculum task. If the teaching moment is temporally antecedent to assessment, it is not logically prior to assessment decisions as if these were simply retrospective, and we cannot speak meaningfully of assessment without also speaking of intended learning. The IME assessment guide places emphasis on the alignment of learning, teaching and assessment in curriculum design; on specifying in advance the learning opportunities available to students; on delivering these via appropriate forms of learning; and on matching suitable methods for testing this learning in both summative and formative modes. Variety in assessment is essential across the cognitive, the affective and the psychomotor domains of learning, and the IME assessment guide provides illustrative examples of, and templates for, types of assessment that are relevant to these. The practical advice offered is as applicable in schools of nursing and in dental schools as it is in medical education.
- Education for Health Care Professionals
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Of College labours, of the Lecturer's room All studded round, as thick as chairs could stand, With loyal students faithful to their books, Half-and-half idlers, hardy recusants, And honest dunces—of important days,
Examinations, when the man was weighed
As in a balance! of excessive hopes,
Tremblings withal and commendable fears…
—William Wordsworth, The Prelude, Book III.1
Assessment can indeed engender trembling in the heart, not only of the loyal student, but also that of the course director. For clinical and other tutors whose professional background is primarily in another specialty, Medical ethics and law: a practical guide to the assessment of the core content of learning from the Education Steering Group of the Institute of Medical Ethics is an excellent remedy for such commendable fears.
If the teaching moment is temporally antecedent to assessment, it is not logically prior to our assessment decisions as if these were simply retrospective. We cannot speak meaningfully of assessment without also speaking of intended learning outcomes, and from the beginning the IME assessment guide places emphasis on (a) alignment of learning, teaching and assessment in curriculum design; (b) specifying in advance the learning opportunities provided to our students; (c) delivering these via appropriate modes of learning; and (d) matching suitable methods for assessment of this learning. The practical advice offered by Angela Fenwick and coauthors—theoretically robust without making research literature the focus—is as applicable in schools of nursing and in dental schools as it is in medical education.
Such professions with a competence-based approach to their curricula place particular importance upon what learners actually do in clinical contexts. At a time when there is much public discussion on the importance of patient safety culture in healthcare settings, it is often implied (on the basis of management models from organisation theory) that workplace culture is somehow distinct from the practices of insiders as if it were a superorganic determinant of the adequacy whereby health professionals attend to their duties of patient care. But this is to reify the construct: culture is an account of practices in a given context and so cannot be a means of accounting for them since organisational culture has no essence independently of what people do.2 While there can be systems factors constraining the practitioner that have the potential to compromise patient welfare, the individual's duty to maintain standards of practice is a matter of ethics.
So are our curricula in medical ethics and law effective in producing ethical doctors? Assessment is central to this question. The IME guide is careful to differentiate between, and emphasise the need for variety in assessment across, the distinct modes of understanding that correspond to Bloom's taxonomy of learning in the cognitive, the affective and the psychomotor domains. In education for healthcare professions, meeting performance standards in clinical skills is just as decisive for students’ progression as is the essential ‘book knowledge’ required for clinical practice. Should this also therefore apply to clinical ethics? This leads to the question of what assessment is for in order to be fit for educational purpose. Is the purpose of assessment then to weigh the person, as in a balance, or to measure performance of practical tasks, or to test propositional knowledge?
There are problems with each of these if taken on their own. Assessing in order to apply a label to the learner—idler, hardy recusant, honest dunce (to echo Wordsworth's categorisation of his student colleagues)—is reductively countervailing to the progressive endeavour of education. Equally, critics of competence-based education rightly draw attention to the limits of focusing narrowly on the observable and operational in a crudely behaviourist vein. At the same time, in ethics learning especially, there are circumstances where intellectual grasp alone is not quite enough, as is the case in education for clinical practice.
The IME guide identifies key functions of assessment that include motivating learning, providing students with feedback on their progress, and fulfilling institutional requirements. There is a truism that assessment drives learning, which relates partly to the empirical fact that students will tend to prioritise their coursework towards what is covered in the approaching examinations (thus ‘motivating’ their learning). In line with this, the authors stress that omitting to test learning summatively gives a negative signal, and by contrast they indicate the desirability of setting a pass grade for ethics and law as a prerequisite for progression within the course, or even for qualifying at the end.
But there is another, more profound sense in which assessment drives learning; that is, the deeper purpose that all assessment is for learning. The authors recognise that most assessment combines formative and summative functions, but almost seem to suggest that when conducted expressly to nurture learning it is oriented more towards the formative than the summative end of the continuum. The provision of feedback is certainly formative, but summative assessment can engage students formatively in a more thoroughgoing way. Good summative assessment will be scheduled within the calendar to support rather than interrupt learning; will examine course content with the principal goal of reinforcing learning rather than with a view to institutional obligations; will use formats that match the mode of learning rather than taking an indiscriminate approach; and after the event will order the nature, structure and timing of the information reported to students on how they fared so as to foster subsequent learning most effectively, rather than stifle it. Moreover, teachable moments that arise post hoc from the test can further promote learning through assessment.
Finally, the IME assessment guide is commendable in providing illustrative examples of (and templates for) different types of assessment, although it important to be aware that those relating to age of legal capacity and to adults with incapacity only apply mutatis mutandis across jurisdictions, even within the UK. The text is highly readable for those who are not specialists in assessment, and all who consult it will benefit from the insight and experience that the authors are so generous to share.
Competing interests AD is a member of the Education Steering Group of the Institute of Medical Ethics and was a referee for the IME assessment guide.
Provenance and peer review Commissioned; internally peer reviewed.