The Medical Course at Buckingham

The Curriculum Philosophy - Guided Learning

The outcomes of the course are defined by the General Medical Council.  We will help you to reach those outcomes through an integrated set of learning experiences, some of which are structured by us to get you started, and, crucially, others which you must structure for yourself, so that you make your individual journey towards the outcomes. Our aim is to provide you with the raw material you need and the stimuli to build your understanding from that base. Mostly we will not expect you to discover facts for yourself - we can provide those efficiently for you. You have to discover understanding, as only you can do that. This involves working actively from the experiences we provide.

Constructing understanding

We will always aim to present factual material and concepts to you in an easily digestible way, but you must then build upon that by working with that material to develop the understanding that will allow you to apply it effectively to the practice of medicine. This means that you must continually explore and re-visit material as the course progresses, and apply it repeatedly in different circumstances so as to develop mental structures that will support your work as a doctor. We can stimulate you to do this, but only you can actually do so.

We cannot transplant understanding into your heads from ours. You have to construct that understanding for yourself through systematic exploration and application of ideas in many different contexts. That is what guided learning is about - stimulating you to do that so you may construct your own mental frameworks for effective medical practice. This requires active learning, which is the antithesis of the passive acquisition and regurgitation of material that you may have indulged in previously.

Learning in context

The key to constructing effective mental structures is to appreciate the ways in which that understanding will be used, or put another way the contexts in which it will need to be expressed. In medicine it is easy to see what the contexts will be - the problems that patients bring to doctors. Your task as a doctor will be to focus the breadth and depth of your understanding and knowledge onto the problems that individual patients bring to you. Guided learning is therefore all about stimulating you to focus your understanding on patient problems by continually revisiting material in the contexts of different patient problems. We help you to do this by providing a list of the common problems patients bring to doctors, and then using that list both to structure problem solving tasks to help you discover understanding, and assessment tasks that will test whether you have. As far as humanly possible we will structure your learning and assessment tasks around patient problems, ensuring that learning always takes place and is tested in context.

We do not however, like some courses, take the patient problems as the starting point for parts of the course. We believe that patient problems should be used to stimulate the construction of appropriately contextualised understanding of material that has already been presented to you. Material is therefore presented to you in a systematic way, but you then have to learn how to apply those ideas in lots of different contexts - crucially, contexts different to those in which you first learned it. This means that your mental representation of the material and concepts will become different to the way it was first presented to you.

This 'cognitive re-organisation' is the essence of learning to be a doctor. You must move away from learning material as it has been presented to you to understanding it in ways that you are going to use it. You need to be able to take a given concept and apply it in multiple different contexts, some of which you may have never met before. When you can do that you will be a good doctor, and we aim to help you reach that goal.

It is by this internal process that doctors all over the world are able to do essentially the same job, despite the huge variety of medical courses they have experienced. Whatever the course structure the final outcome is a set of mental structures related to the way in which you will have to work as a doctor in the real world.

Learning together

As a medical student you are privileged to have useful companions on your personal journey to the course outcomes - your fellow students. Like other journeys, a medical course can be easier and more fun in company and by working with other students you will both enhance your own learning, and acquire valuable skills of working with others that are vital for medical practice. Every student's journey through a medical course is different, as we all have different strengths and weaknesses, and by sharing learning everyone will benefit. You will therefore spend a lot of time working in groups, especially early in the course. Group work at Buckingham involves collaborative exploration of problems that we present to you. These problems relate to material that has been presented to you in lectures or by other means, and they involve exploration of that material in the context of the patient problems that we have defined. Group work is a way of developing shared understanding.

Group work at Buckingham is not however 'problem based learning' as used in some other medical schools. You will not have to hunt out material as a group. What you have to do is to help one another discover understanding by active discussion of ideas through joint problem solving.

The key steps of guided learning

Guided learning is most prominent in the first part of the course - Phase 1, which takes up the first two years. In this part of the course you are putting together the underpinning cognitive structures that will enable you to work as a doctor. You will be working largely in the classroom or simulated clinical environments, so will be applying material to 'virtual' patients. You will also, of course, meet real patients in the 'Clinical Skills Foundation Course' and the 'Narrative Medicine' course, and you should always take any opportunity you can to apply your learning to those real patients as well as virtual ones. Later in the course - Phase 2, you will be working almost entirely in the clinical environment, so here your learning involves focusing your developing understanding onto the problems presented by real patients.

In phase 1:

• We will present ideas and material to you mostly through lectures, supplemented by guided reading of material in textbooks and other resources.
• You will then move rapidly into group work, where you will address, as a group, structured problems relating to the material that has just been presented, its relationships to other material and the application of those concepts to common patient problems. It is at this stage that you will identify what you do not understand, and develop your understanding through discussion with your colleagues. Your work in groups will be supported by tutors, who are mostly junior doctors able to intervene and support the group work.
• The group work is followed up by self directed study, where you will work on the ideas further using a variety of resources, some suggested by us, others identified by yourselves, in order to finalise your understanding, link it to other material across the course and be able to apply it to a wide range of patient problems.

The idea is that you are guided through repeated reflective cycles of learning. First ideas are presented, then you are stimulated to think about those ideas, and identify what you do not yet understand by testing your developing understanding through problem solving. You will then refine your understanding by discussion and self directed study and test it again repeatedly until you have developed the effective cognitive structures that will enable you to use that material in a wide range of contexts as a practising doctor (and of course pass the assessments that we set for you!).

As the course progresses you will go round this reflective learning loop time and time again, each time developing your understanding a little more and linking ideas together so that you may use them in lots of different contexts.

The curriculum structure

The curriculum is designed as a whole, but inevitably for logistic reasons it must be organised in parts. The component parts of the course are however just that. They are not separate entities to be considered and learned separately, just a convenient way of ensuring that topics are treated systematically. Your task is to look beyond the course structure and build your own understanding of all of the material by re-organising it in your brains to the form in which you are eventually going to use it. The course is not 'modular', and crucially the assessments do not test the component parts separately, as they are all synoptic and fully integrated.

Overall the course is divided into two phases. Phase one, which lasts two years is mostly based in the University, though you will spend up to one day a week in the clinical environment. Phase two lasts two and a half years and is based almost entirely in the clinical environment, in hospitals and the community. This guide refers mainly to Phase one, as you will receive a second detailed guide to Phase two just before it begins.

Phase 1 is divided into 'units' spread over six terms. Each term has twelve teaching weeks, and there are three in each year of Phase 1. Terms are separated by periods of assessment and holiday. In each term the units run concurrently, and each unit is allocated one session per week. A session is half a day, typically three to four hours of contact time. A given unit always runs in the same half day each week, so is made up of twelve long teaching sessions. In each term there are four University-based units, plus one or two sessions for the 'Clinical Skills Foundation Course' and the 'Narrative Medicine' course which spread over all six terms. The overall structure is depicted in the Clickable Course diagram from which you can access unit information and materials.

Each component of the course has a comprehensive 'workbook' which includes a definition of the outcomes to be achieved from that part of the course, and their relationship to the overall outcomes defined by the GMC, the structure of the course, and all the materials that are necessary for you to undertake the unit. These materials are presented to you through the Medical School moodle site, and you will have an iPad provided so that you may access the materials as you need them.

The moodle site will enable you to access, for each unit:

• The broad aims of that unit as they relate to the course as a whole
• The specific outcomes from the GMC list above which are addressed by that unit
• Additional more detailed outcomes to guide further your learning in the unit
• Contact details for the unit leader and other staff teaching on the unit
• An overview of the structure of the unit, including the topics to be dealt with in each session
• Structured handouts for each lecture in the unit
• Guided reading tasks
• Tasks for each group work session and templates to record the outcomes of the tasks
• Guidance for self directed learning
• Links to resources for learning during the unit including a reading list
• Links to self-tests and other formative assessment material to help you monitor your learning during the unit

The structure of the clinical skills foundation course and narrative medicine reflect their unique structures, and are presented in their own workbooks. The other units, apart from student selected components (see below) all have the same basic structure reflecting the 'guided learning' philosophy described above. Each session has the same broad structure. Most start with a lecture to introduce material, followed by a period of group work where the concepts introduced in the lecture are explored and linked to other materials and patient problems through consideration of structured problems presented in the workbook. There is then generally a plenary review session to review ideas and move them on, and a definition of tasks for self directed study to take place between that session and the next.

Information about the detailed logistics, such as room allocations and timings will be presented to you through moodle. You must check this information frequently in case of any changes.

Each unit has as much time allocated for self directed study as there is contact time. This self directed work is very important, and is the key stage to ensure the cognitive re-organisation that constructs effective understanding generalisable to a wide range of patient problems. Each unit suggests starting material for self directed learning, but as its name suggests, you also have to play a major part in structuring the work. We have designed the course so that the self-directed learning you undertake routinely as the units progress will be an excellent preparation both for practice as a doctor and, very significant from your point of view, success at the assessments that you will have to pass in order to progress on the course. If you work steadily week by week you can avoid the need to 'cram' for examinations by organising your mental structures to be able easily to answer the questions that are set. The key to this is to realise that all written assessment questions are structured around the list of common clinical presentations you will be given at the beginning of the course. You will be tested on your ability to apply material from the course to those problems, and by far the best way to do that is to re-organise material as you learn it so that you may easily relate it to the contexts in which it will be tested. You will be shown strategies for doing this in a unit early in Phase one - the 'Clinical problem Solving' unit, which concentrates on enabling you to re-organise and relate material to clinical scenarios. We cannot stress too much that the key to success on the course is this self-directed learning task, and you should allocate significant study time to it.

In Phase one you should expect to work a consistent 40 hour week in term time. Fifteen to twenty hours of that time will be scheduled for you as indicated above. The remainder of the time should be spent in self directed learning as described above. If you work consistently in this way then you will be very prepared for examinations when they occur, and you will not need to undertake excessive hours of 'revision'. You may timetable your self-directed learning as you wish, so you can expect to have plenty of time for an appropriate balance of work and recreation so long as you are organised.

Learning in the clinical environment

Learning in clinical environments is a vital part of the medical course, taking a significant proportion of your time in Phase one, and nearly all of your time in Phase two. Working with practising doctors and real patients is very motivating and stimulating, and you must always aim to maximise your exposure to clinical work. All the evidence shows that those who are most successful on a medical course are those who spend most time in clinical work. You can never have too much clinical exposure, and you should seek it out at every opportunity. Early in the course we will work hard to structure your clinical learning, so you may learn how best to profit from clinical exposure. The reality is, however, that clinical environments have very different priorities to educational environments. In the University the experience is built around you and your needs. In clinical environments the needs of patients are always paramount, and learning must fit around that. As the course develops into phase two you must develop strategies that allow you to fit your learning around the experiences available to you, so you may always maximise your learning whatever is going on in an environment where the care of patients is always top priority.

In the clinical environment the safety and dignity of patients is also critical, and you must therefore be sure always to behave appropriately. You will be given extensive guidance on how to dress, and how to conduct yourself so that you do not put patients at risk, or offer them offence.

Following your interests - Student Selected Components

During both Phase 1 and Phase 2 there are periods of time allocated for 'Student Selected Components' (SSC). Unlike the rest of the course (the 'Core Course'), student selected components offer you a chance to choose what you study so you may broaden your perspective. Some of the outcomes in 'Tomorrow's doctors' are generic enough that they may be reached by studying many different topics, and it is these outcomes that are addressed through SSCs.

In Phase 1 there are two SSC slots, and in each you will be offered a choice of different courses, some extending material in the 'core' course (the other units where you all study the same material), others allowing wider study to broaden your overall perspective as a doctor. In Phase two the SSCs allow you to extend your clinical experience in areas of your choice, and especially to explore possible career options within medicine.

Each SSC is assessed separately, and you must pass each SSC in order to progress.

Moodle will contain full details of each of the SSCs on offer at each stage of the course.

Assessing your learning

The General Medical Council requires us to be certain that each of you has met all of the outcomes defined above by the end of the course. We cannot award you a medical degree unless you do. We must therefore assess you rigorously during the course to make sure that you are making appropriate progress towards the outcomes, and at the end of the course to ensure that you have achieved them. It is equally important that you know that you have reached the outcomes, so you may feel confident in your practice as a new doctor, and be sure of what you can (and more significantly what you cannot yet) do. Most important of all, however, is that your patients must be confident that you know what you are doing, and you will not put them at risk so long as you are appropriately supervised.

We therefore make no apologies for assessing you rigorously, but we are also very concerned that our assessments should be valid - they test what they are supposed to test, and reliable - that is they should distinguish fairly between students who are performing well and those who are performing badly.

Full information about assessments is to be found in two documents the 'General regulations for the MB ChB', which defines the rules under which assessments operate, and the 'Code of Practice for Assessment' which describes in detail how the assessments are actually conducted. You should study these two documents and any additional guidance we provide. The following section is a brief overview, and where there is doubt about interpretation it is always the regulations and code that will be the definitive rule.

The Code of Practice has been constructed for the whole of your course, right until year five. You must note however, that the assessment scheme is always developing, and is also under the detailed scrutiny of the GMC, who may require changes as the course progresses. The Medical School therefore reserves the right to change the assessment procedures as your course proceeds. We will always however give you at least a year's notice of changes, and publish a revised Code of Practice for Assessment each year to explain those changes to you.

The assessment Philosophy

The Code of Practice defines the assessment philosophy in detail. It has a number of key features. 

• The first key feature is that each of the outcomes defined by the GMC is tested repeatedly as the course progresses in different contexts, according to a 'whole course blueprint'. This defines for each assessment in the course which GMC outcomes are to be tested in that assessment, and in what contexts. 'Context' means which of the clinical presentations in the list we provide you with will be used as the vehicle for structuring the written question or assessment task. All assessments are therefore built around the list of common clinical problems that you been given and the outcomes you have also been given making the overall process transparent to you, though not of course the precise content of each assessment item. You should however realise that if you structure your learning for assessments around the outcomes and the common clinical problems you will have a high chance of success.
• The second key feature is that all assessments are synoptic - that is to say that they test all your learning to date in the course. Assessment is very definitely not 'modular'. You cannot succeed on this course by using a 'learn, test, forget' strategy. Any material can, in principle, come up in any assessment.
• The third key feature is that progression rules (what you have to achieve to progress from one part of the course to the next or to graduation) are conjunctive. This means that you must pass each part of the assessments separately, and there is no compensation between assessment elements.
• The fourth key feature is that the types and formats of assessment used are consistent across the course; so that we may test outcomes systematically with consistent assessment instruments, but so that you will always know what is coming for any particular type of assessment.
• The fifth key feature is that assessment instruments (ie the type of examination or task used) are chosen to be the best possible test of groups of outcomes, both in terms of validity - testing what they should, and reliability - doing so fairly. In general:
  • Outcomes under the heading 'Doctor as a Scholar and Scientist' are tested mainly, but not exclusively using unseen written assessments.
  • Outcomes under the Heading 'Doctor as a practitioner' are tested mainly, but not exclusively using structured clinical examinations where you will have to demonstrate competence at appropriate tasks.
  • Outcomes under the Heading 'Doctor as a Professional' are tested in part in written and clinical examinations, but mainly through the assessment of a portfolio of evidence collected by you the student demonstrating that you have identified appropriate learning experiences throughout the course, and reflected upon them so as to demonstrate achievement of the outcomes concerned. You will be using an electronic portfolio format that is in use across a number of UK schools, and which is closely matched to the portfolio format that you will have to use as a practising doctor should you practise in the UK.
  • You must realise that working as a doctor involves drawing together outcomes from all three groups, so some assessment tasks will span the broad categories of outcomes and the separation will not be complete
• In each case, the assessment tasks will be structured and quality controlled so as to achieve a high degree of reliability as assessed for formal psychometric means.
• In each case appropriate standard setting processes will be used to define robustly the performance that must be achieved to pass that assessment. There will be no arbitrarily fixed 'pass marks'. The outcome of assessments will be reported as a grade - one of
  • Unsatisfactory
  • Borderline
  • Satisfactory
  • Excellent
• The sixth key feature is that all assessments will be designed to provide feedback to you after the assessment so you may identify your strengths and weaknesses and seek to improve for the next assessments

Assessments in Phase one

In Phase one there are two progression points:

• Progressing from year one to year two
• Progressing from year two to Phase two

In each case you must pass all the assessments in the year preceding the progression point in order to progress. If you do not, then your course will be recommended for termination. The pattern of assessment for the 'core course' (see above) is the same in each year. There is one written assessment after each term, and one structured clinical examination at the end of the year. The results of the written assessments after terms one and two in each year are combined to a single grade, so you must achieve at least a satisfactory grade in each of:

• The combined written assessments after the first and second terms
• The written assessment after the third term
• The structured clinical examination after the third term.

If you do not meet all three criteria then you will have to take and pass a 'qualifying examination' made up of a written examination and a structured clinical examination held just before the next year begins. If you do not pass the qualifying examination then your course will be recommended for termination.

In the second year you must also take and pass assessments in each of the student selected components. These are assessed separately to the core course, and if you are unsatisfactory at first attempt then you will have one resit opportunity for each SSC, and you must pass both either first time or at resit otherwise your course will be recommended for termination.

Your portfolio will be considered during Phase one and assessed formatively. Poor performance in the portfolio alone will not prevent progression, but will be noted, and you will enter a 'concerns process' which will monitor your progress closely to make sure that you get back on track.

The written assessments for the core course are in the same format at all stages of the course. They consist of a number of question sets, each following a case vignette describing one of the common clinical problems drawn from the list used for blueprinting, which has been provided to you. All the questions in the question set relate to that clinical problem, but they may be drawn from any part of the course up to that point. In Phase 1 most of the questions are constructed response - that is to say you have to write a short answer which should be as concise and accurate as possible. The answers will be marked by a robust process and the standard setting group will decide how many marks must be obtained to 'pass' that question set. In Phase 2 an increasing proportion of the questions will be 'selected response' meaning that you will have to choose the single best answer from a list. Whether or not you pass the written assessment overall will be determined by how many question sets you 'pass'. This way of setting how examinations are passed is designed strongly to discourage you from selective learning. You will be at high risk of failure if you avoid learning about parts of the course in the hope that you will 'get by' in the assessment without them. You will not.

Structured clinical assessments are in the same format over the whole course and operate in the OSCE (Objective Structured Clinical Examination) format, where you will undertake a series of practical tasks in sequence. These will vary from OSCE to OSCE, and will become more complex and integrative as the course progresses, but each will always relate to one of the common clinical problems described above. A standard setting technique is used to define the minimum performance necessary to pass each task, and the outcome of the OSCE overall determined by the number of tasks 'passed'.

The e-portfolio

You are required to maintain a portfolio of evidence as the course progresses in order to show that you are progressing towards the outcomes defined under 'The Doctor as a Professional'. These include monitoring your own learning and progress, reflections upon your strengths and weaknesses and the impact on you of the wide range of experiences you will have both during the course and your broader life. The use of a portfolio is the main way in which you will be assessed as a practising doctor in the future, and it is essential that you develop the skills of assembling a meaningful portfolio from a very early stage. Moodle contains guidance as to the types of evidence that need to be included in your portfolio and how you may record your reflections upon that evidence.

In Phase 1 the portfolio is assessed formatively. You must discuss it with your tutor and show that you are making good progress. Problems with the portfolio cannot stop your progression in Phase 1, but if you are in difficulties this will be reported to the 'concerns group', which will intervene to get you back on track, to reduce the risk that you will be caught out when the portfolio is summatively assessed in Phase 2.

Monitoring your progress

In addition to the summative assessments described above there will also be frequent formative assessments, often presented electronically through Moodle. The results of these assessments will not determine progression, but if you do not engage with them it will be noted, and may become a cause for concern.

After each summative assessment you will also get feedback about your performance in each question set or OSCE station and have the opportunity to discuss that with a member of staff.

You should use your e-portfolio to record your formative assessment results and your summative assessment feedback together with your reflections on what you feel you need to do to improve and what support you will seek to do so.

The Medical School will also monitor your progress in summative assessments, and if it is giving cause for concern (ie unsatisfactory or borderline grades) then you will be referred to a 'concerns process' which will analyse your situation and refer you to a range of different support service to help you address any issues that may be impacting on your study and maximise the chances that you will succeed.

It is vital to understand that the medical school has a strong wish that you should succeed on the course, and will put in place all support in its reasonable power to help you do so. We can, however never relax the standards that you must achieve, whatever your situation, as we have an over-riding duty of care to patients to ensure that you meet the course outcomes. It remains your responsibility to work hard and succeed on the course whatever your situation.

Reasonable adjustments

Students with disabilities must declare these before the course begins. Appropriate assessments will be made by an appropriate service (see sections on 'Looking after you'), that will define 'reasonable adjustments' to be put into place for assessments. The Medical School will comply with these adjustments. Once adjustments are made however, a disability may not be offered as mitigation for performance in assessments. In the case of a disability being diagnosed during the course adjustments will be put in place as quickly as possible.

Mitigating circumstances

The Medical School recognises that on occasion personal circumstances interfere with study and assessments. It is crucial that you report such circumstances as early as possible, so that support may be put in place for you, and your circumstances may be taken into account in progression decisions. There is a form on Moodle which you must complete if you believe that your preparation for, or performance in assessments has been affected by circumstances beyond your control. You must submit this before any results are published, and normally before an assessment is taken, unless events are very sudden at the time of the assessment. Any claim of mitigating circumstances must be supported by evidence, and there is guidance provided on Moodle as to what that evidence should be. All claims of mitigation are considered by a Mitigating Circumstances Group whose members are not at that stage aware of the results of the assessment. The group will decide whether to accept the mitigation. If mitigation is accepted that may affect a subsequent progression decision. You must understand that mitigation can never change the grade you are awarded for an assessment, only the consequences of that grade for your progression. If you present yourself for assessment then you are declaring yourself 'fit to sit' that assessment, and whatever grade you obtain will always stand. If you do not sit an assessment and your mitigation is not accepted then you will be graded as unsatisfactory in that assessment. If you do not sit an assessment and your mitigation is accepted then you may take a qualifying examination (or resit in the case of SSCs) as a 'first sit', meaning that you will automatically be offered a repeat period of study should you not succeed.

Progression

At each progress point your performance will be considered by the Board of Examiners. If you have met the progression criteria for that point by achieving a satisfactory grade in all required assessments, then you will progress automatically to the next stage of the course, or at the end to graduation. If you fail to meet any of the criteria for progression then the Board of Examiners will normally recommend to the University Senate that your course be terminated.

If you have offered mitigation before the Mitigating Circumstances group and that mitigation has been accepted by the group, then the Board of Examiners may offer you an opportunity to re-take the year, or in the case of Phase two the preceding period of study (see the 'General regulations'). Normally you will only be allowed to repeat a period of study on one occasion during your course. The Board of Examiners is never able to permit a student to proceed on the course if they have not met the progression criteria whatever the mitigation or other circumstances. A repeat period of study is the most positive outcome possible. Normal course fees will apply to any repeat period of study.

Appeal

Any student has the right to appeal a decision by the Board of Examiners to recommend the termination of their course. Appeals may only be made on the grounds of:

• Procedural irregularity in assessment processes
• New mitigation that could not reasonably have been known at the time of the assessment

Guidance on the appeals process is provided on Moodle. Appeals are considered by a panel made up of persons outside of the Medical School, and the decision of the panel is binding and final. The most favourable decision that the panel may make is exceptionally to allow a further repeat period of study.