Surgeon educator perspectives of implementing a national undergraduate curriculum in otolaryngology

A Hall; H Jones; A Hannan

doi:10.1017/S0022215122000329

Surgeon educator perspectives of implementing a national undergraduate curriculum in otolaryngology

Published online by Cambridge University Press: 24 February 2022

A Hall

H Jones and

A Hannan

Show author details

A Hall*: Affiliation:
Noah's Ark Children's Hospital for Wales and University Hospital for Wales, Cardiff, Wales
H Jones: Affiliation:
Department of Otolaryngology, University Hospital Southampton, Southampton, UK
A Hannan: Affiliation:
Department of Otolaryngology, University College Hospital, London, UK
*: Author for correspondence: Mr A Hall, Noah's Ark Children's Hospital for Wales and University Hospital for Wales, Heath Park Way, Cardiff CF14 4XW, UK E-mail: andyhall07@googlemail.com

Article contents

Abstract
Objective
Method
Results
Conclusion
Introduction
Materials and methods
Results
Discussion
Conclusion
Competing interests
Footnotes
References

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Abstract

Objective

The General Medical Council will be implementing a national medical licensing assessment for all UK medical students by 2024–25. Surgeon educator perceptions on a national undergraduate curriculum in otolaryngology were reviewed accordingly.

Method

A mixed methods study was undertaken within a UK school of surgery assessing ENT surgeon educators. Perspectives on teaching content, quality and student experience were assessed with degree of agreement assessed (Likert scoring). Associated qualitative focus group sessions underwent detailed thematic analysis according to grounded theory.

Results

A response rate of 50 per cent was achieved involving 21 participants working across 14 hospitals. These showed strong agreement that implementation of a national curriculum would improve the standard of teaching delivered at a personal, institutional and national level. Further themes were identified relating to the personal, institutional and specialty related factors influencing practical delivery.

Conclusion

A series of practical recommendations are made to potentially assist the implementation of a national ENT curriculum.

Keywords

Curriculum Otolaryngology Education Medical Undergraduate

Information

Type: Main Article
Information: The Journal of Laryngology & Otology , Volume 137 , Issue 10 , October 2023 , pp. 1090 - 1096

DOI: https://doi.org/10.1017/S0022215122000329 [Opens in a new window]
Copyright: Copyright © The Author(s), 2022. Published by Cambridge University Press on behalf of J.L.O. (1984) LIMITED

Introduction

Historically, medical schools maintained a degree of individual autonomy in delivering a doctor following five years of intensive undergraduate study. The various medical schools, however, have held widely differing interpretations of the requisite underlying knowledge and skills that should be demonstrated and their financial distribution of resources.^{Reference McManus1,2} Traditional topics (e.g. anatomy, on which one medical school may spend a large amount of study time) within the curriculum could be covered much more briefly elsewhere.^{Reference Howe, Campion, Searle and Smith3} Sub-specialist areas of medicine, such as ophthalmology or otolaryngology, may be significantly under-represented within undergraduate teaching.^{Reference Fung4,Reference Farooq, Ghani and Hussain5} From 2024, the General Medical Council intends to implement a medical licensing assessment in the UK. In keeping with this change, an associated shift to a national curriculum has been considered broadly within the UK medical education literature and otolaryngology in order to unify undergraduate experience.^{Reference Lloyd, Tan, Taube and Doshi6,Reference Steven, Mires, Lloyd and McAleer7}

Our aim was to review the perceptions on future implementation of an undergraduate national curriculum in otolaryngology within a UK surgical training region. The focus of this initial study was on the specific perceptions of surgical educators as this process begins its ongoing development from theoretical concept to practical reality.

Surgeon educators represent an important group in the delivery of undergraduate teaching. They hold responsibilities for delivery of teaching to medical students on a weekly basis across a variety of hospital settings from lectures and tutorials to the bedside. They have a minimum experience in post-graduate teaching of medical students of five years. As such, they offer a unique and important insight into the challenges of undergraduate otolaryngology teaching ‘on the front line’ that can assist potential understanding as to how a national curriculum would best practically take shape. Additionally, perceived loss of autonomy through implementation of a national curriculum and associated resistance to change was felt to be most strongly represented within this cohort.

Teacher perceptions of the implementation process of this new strategy have not previously been examined, and areas of attention were the potential impact on underlying teaching content, teaching quality and the student experience. Teaching content was defined as what knowledge or skills should be transmitted from teacher to student fundamentally (i.e. ‘what they should know’). Teaching quality was defined as the successful transmission of intended knowledge or skills from teacher to student.

Materials and methods

The target sample selected for review were 42 surgeon educators, delivering regular undergraduate teaching within the North Thames (London) surgical training region. A purposive sampling approach was taken to obtain the viewpoints, experiences and perceptions of these teachers using both quantitative and qualitative methods. Requisite ethical approval was obtained from the University of Leicester and local approval from the lead clinician overseeing undergraduate medical school teaching in otolaryngology. Informed consent was sought for participants with anonymity safeguarded.

A quantitative survey format was selected to obtain numerical data from a representative cohort as to their perception of applying a UK national curriculum in otolaryngology with ‘real-time’ secure and anonymised data collection.^{Reference Gill, Leslie, Grech and Latour8}

The questionnaire contained three sections. The first section included relevant demographic information with gender, level of training and undergraduate medical school recorded. The second section comprised closed question survey instruments to collect data on five-point Likert scale questions for measuring teachers' perspectives. The third section comprised open-ended questions for teachers to express their concerns and opinions about implementation of a national curriculum. A small pilot study was conducted before the actual data collection to ascertain overall clarity of the research instrument, although no concerns arose.

The questionnaire (Table 1) consisted of seven items of which five used a five-point Likert scale to rank the responses. The scale ranged from 1 (strongly agree) to 5 (strongly disagree) and was used to categorise the response of each surgeon educator to the questions. Successfully implementing a structural upheaval will require significant engagement with those delivering the curriculum to students. As such, uncertainty (a score of 3) is an equally important result as agreement or dissent.^{Reference Chyung, Roberts, Swanson and Hankinson9} Two questions were free-text areas allowing more detailed thoughts to be provided.

Table 1.

Percentage of respondents agreeing with statements describing potential teaching content in a national undergraduate otolaryngology curriculum

Subsequently, three separate focus group sessions of three to four individuals were adopted for qualitative evaluation.^{Reference Gill, Stewart, Treasure and Chadwick10} Historically, small focus groups have been shown to have greater potential than larger focus groups.^{Reference Krueger and Casey11} These were recorded, anonymised and immediately transcribed in full. The interviewees’ opinions on a national curriculum and undergraduate otolaryngology teaching were explored through a thematic coding approach undertaken by the lead researcher, underpinned by grounded theory.^{Reference Glaser and Strauss12} Anonymised transcription of the audio recording was typed and printed. Comments were manually separated, compared, grouped and categorised accordingly. Each separate focus group transcript was assessed in isolation, seeking to first identify codes that may lead to the creation of core categories. This process was then repeated for each of the three focus groups. Following assessment of the similarities and differences of the three focus groups, analogous codes and categories could be distilled further into discrete themes.^{Reference Braun and Clarke13} These then led to the eventual development of thematic networks for the overall subject matter and to interpret recommendations. Individuals were anonymised and referred to as T1–10 within the subsequent analysis.

Data analysis was performed using both Microsoft Excel® and Sofa Statistics™ packages. Parametric analysis was performed for the Likert scores as per the recent work of Norman,^{Reference Norman14} which clarified the benefits of this over and above non-parametric tests. Median scores were used accordingly owing to the non-linear format of the five-point Likert score.^{Reference Sullivan and Artino15}

Results

Participant characteristics

An overall response rate of 50 per cent (21 individuals) was achieved, which compares favourably with similar otolaryngology curriculum surveys.^{Reference Constable, Moghul, Leighton, Schofield and Daniel16} This improves the overall generalisability of the survey, while the response rate may in itself hold additional value because engagement was on the basis of interest and perceived ‘personal need’.

A breakdown by medical school attended and teaching style of individual surgeon educators was reviewed. Our cohort showed a considerable variation in background with the 21 individuals attending 12 of the 33 recognised UK-based medical schools. The three main medical school teaching styles were represented, with 14 per cent undertaking a problem-based approach as an undergraduate, whereas traditional and integrated approaches made up 43 per cent each. The mean undergraduate teaching experience of this cohort was eight years, highlighting a high level of experience.

Teaching content

A summary of the data (Table 1) suggests participants were very supportive of broad goals of standardising teaching content from topics, resources, practical experience and overall length of time for the programme. Surgeon educators appear overall to wish to preserve a degree of institutional and educator autonomy within the overall structure of the national curriculum. They were less supportive of more proscriptive initiatives in teaching provision, particularly those stating who (consultant-led) would teach and how (setting or teaching method) teaching would occur. Clarity and consistency in the overall vision is crucial to the success of large-scale institutional change in education, and therefore the involvement of teaching stipulations other than specified content would need to be carefully considered.^{Reference Ansell17}

Table 2 highlights support for a broad range of distinct goals for a national curriculum in undergraduate otolaryngology. An essential principle of understanding a curriculum is assessment of its underlying aims in ensuring that the included content befits the intended purpose. Significant variation between the perceived aims of a curriculum as viewed by participants and the actual purposes of those implementing would likely manifest in poor overall delivery. A successful curriculum is one that when completed satisfies the original intentions behind its construction, essentially achieving its statement of intent.^{Reference Prideaux18}

Table 2.

Percentage of respondents agreeing or strongly agreeing with statements describing the intended aims of implementing a national undergraduate otolaryngology curriculum

Teaching quality

The level of support by participants for a national curriculum in potentially improving not only their teaching but teaching within medical schools nationwide was strong (Table 3). The interpretation of ‘risk’ from undertaking this process was also negligible, with only one individual feeling that it could adversely affect teaching innovation and no one feeling it would negatively impact on teaching within their institution. These results appear to suggest there is confidence in this mechanism within our school of surgery as a potential conduit to institutional improvement.

Table 3.

Percentage of respondents agreeing with statements describing the likely outcomes of implementing a national undergraduate otolaryngology curriculum on teaching quality and student experience

Student experience

Additionally, 19 surgeon educators felt that the students themselves would benefit from the implementation of a national curriculum, with 16 feeling it could improve overall access to educational resources. Interestingly, within higher education, much criticism has been made of the restrictive nature of national curricula,^{Reference Curtner-Smith19} but here there appears a degree of positivity and idealism as a method to advance teaching.

Classically, we acknowledge that more experienced staff are more resistant to changes in established practices.^{Reference Ungar and Magen20} Given the level of experience of the participants, it is interesting to see that only a third (33 per cent) feel that a barrier to implementation would be at the level of the teaching staff themselves (Table 4). Instead, what is demonstrated is that barriers are more likely to exist at the medical school level, with the lack of perceived need and incentive to motivate change in practice. All but two participants felt an absence of an over-arching authority to oversee the process, and perhaps given the literature demonstrating external involvement, this would benefit from further promotion.²¹ These findings, although small in scale, provide us with knowledge on where the perceived challenges to this potential change exist and therefore illustrate the areas in need of attention to overcome them.

Table 4.

Percentage of respondents agreeing or strongly agreeing with statements describing the possible barriers to implementing a national undergraduate otolaryngology curriculum

Participants’ responses to the question on whether they would support the implementation of a national undergraduate curriculum in otolaryngology was overwhelmingly supportive, with 95 per cent feeling they strongly agreed or agreed with the statement. Five per cent were unsure, with no disagreement as to the principle. This is an important aspect, given the level of influence the surgeon educators hold in the undergraduate teaching process.

Qualitative data analysis

The participating individuals represented a mixture of sexes that is representative of modern otolaryngology training (40 per cent female)^{Reference McNally22} and an overall experienced cohort in undergraduate education, with median time participating in regular undergraduate teaching of eight years. A summary of the thematic analysis process is shown below (Table 5).

Table 5.

Thematic network displaying the personal, institutional and external factors related to use of a national curriculum in undergraduate otolaryngology

Individuals were anonymised and referred to as T1–10 within the analysis. GP = general practitioner; F1 = Foundation Year 1 Doctor; SPA = Supporting Professional Activities