The objectives of medical education: reflections in the accreditation looking glass.

The authors explored the extent to which medical schools have established institutional and departmentalized educational objectives, by examining the accreditation databases, institutional self-studies, and site visit reports of 59 schools surveyed by the Liaison Committee on medical Education (LCME) in 1994-1996. In this study, the individual school was the unit of analysis, and the dependent variables were statements--in outcomes' terms--of institutional and departmental learning objectives. Objectives were classified as "robust" when they were expressed as measurable learning outcomes in the domains of knowledge and skills and behaviors. Departmental objectives were assessed separately for core basic science courses and clinical clerkships. A number of independent variables were studied for their association with the elaboration of outcomes-based educational objectives: centralized management of the curriculum, curricular reform, an office of education, an institutionalized faculty development program, problem-based learning, interdisciplinary teaching, systematized assessment of educational outcomes, and structured clinical skills assessment. Of the 59 schools, 15 (25%) had robust institutional objectives that identified items of measurable knowledge, skills, and behavior, while 44 (75%) had modest objectives, usually descriptions of the purpose of the curriculum, global statements about the knowledge and behavior qualities that students should acquire, and the subjects that instructors intended to tech. Schools with well-articulated learning outcomes were more likely to have centralized management of the curriculum, a record of curricular reform, a program of problem-based learning, rich basic science course and clerkship objectives, and structured assessment of students' clinical skills. Well-stated and diverse educational objectives were found for basic science courses in only 13 of the 59 schools (22%). Thirty of the schools (51%) had clerkships with robust learning objectives, more commonly in the generalist specialties of pediatrics, family medicine, and internal medicine. Clerkships with stout objectives more often employed structured assessments of students' clinical skills. Schools that paid attention to the explication of learning objectives were more likely to link specific institutional and departmentalized outcomes with methods of evaluating students, in turn guiding the content and methods of instruction. Schools with vapid objectives attracted 40% more accreditation citations for shortcomings in curricular management, course and clerkship quality, and the evaluation of student achievement, especially in the clinical skills domain. In the future, accreditors should focus more closely on this association.