**3. Modern curriculum frameworks**

Flexner started and reported in the last century that clinical education has to be reformed to transmit practice into curricula and the reverse. He stated that it is important to standardize any reform on all health care service and medical educational institutions regardless the socioeconomic status [18]. Evolving leap has been occurred in medical educational curricula designing to cope patient care, clinician competency and local/global health service [28]. However, in each design there is still a gap which can be filled and remediated by coherence and interrelation between other elements included in the design [4]. Indeed, keening in the details of only one or two aspects prohibits clear viewing the whole process. It is the conception, regarding clinical curricula reforms, that is appeared in the current 21th century to construct overarching curricula [4]. This reminds me by Indian quote "Sometimes you just need to distance yourself to see things more clearly".

Diverse curricula frameworks have been arisen in modern era of medical education [29]. These curricula have endeavored to flourish professional practice which is composed of knowledge, skills and attitude based on adult learning theories and active teaching methods and are oriented by ecological and communities' circumstances [30, 31]. We will elucidate in the first subsection 3.1, Kern's six steps and outline PRISMS models being a recent and advanced framework in clinical education. Then, in the following subsection 3.2, we will invite you to create your conceptive curriculum thoughts in a way that integrates health systems within clinical training. This invitation will be through the catalyst which will be demonstrable in the novel creative 3P-6C toolkit [11].

#### **3.1 Modern frameworks examples**

#### *3.1.1 Kern's six steps framework*

Kern declared that, systematic approach helps profoundly in reaching the objectives. This systematic approach of curriculum design and development is formed of six

#### *Clinical Curriculum Revolution to Integrity and "Attunity" DOI: http://dx.doi.org/10.5772/intechopen.99460*

steps in a sequence manner. However working on one step and looking at other step/s at the same time can promote the whole process by intersection between the targeted all steps [20, 29]. Six steps are usually started by **problem identification and general need assessment** [20] step while you are sitting back and contemplating on the whole situation. This helps in picking up *the start of the knot* (problem) based on health care problem, quality of clinical training, clinical outcome, and incongruent clinical practice with health care system and your community' needs. In this first step, it is important to identify who are affected by this problem (patients, learner, trainers, and administrators) and to reveal the current and the ideal approach to treat this problem [20, 32].

From the first step, identifying **target need assessment** being the second step is the cue and clue to construct goals and objectives in the third step. This step aims at assessing needs of two bases of education process; learners/stakeholders and learning environment. Learners' needs are detected by discovering their experiences, expectation, actual competencies and their learning style. Regarding learning environment, identifying availability of the required resources is inevitable to proceed in curriculum process, in addition to manifest barriers and enablers. Various methods for assessing needs can be achieved, for instance, by formal interviews, observation, informal discussion, audits and/ or questionnaires [20, 32, 33]. Without **goals and objectives**, content are not clearly structured, training methods and strategies cannot be chosen properly and assessment is got unfair. Goals aim at putting broad non measurable lofty vision of curriculum [20, 33]. Objectives target outcomes and have to be specific, measurable, attainable, realistic and timetable regarding cognitive, psychomotor and/or affective domains [34]. Levels of objective selection according to Bloom taxonomy are determined by the desired outcomes and needs assessment [35].

The fourth step; **educational strategies** pertain content with its resources and events, and plan to use multiple interactive teaching methods which are suitable to connect objectives with outcome depending on brain storming and metacognition [20, 29]. Going from the designed plan to achieving it is what is occurred in the fifth step; **implementation** wherein it checks resources for obtaining financial, administrative, material and political support in addition to addressing barriers to solve them. Piloting curriculum before executing it with friendly audience can be helpful to predict its success and to provide a chance for improvement and remediation [20, 32]. Last but not least, assessment is the sixth step where the curriculum is ended and is started by for development. **Assessment** is performed to assess learners and program using different summative and formative methods through the whole program. Learners' assessment depends on correlation between objectives and what they actually perform. On the other hand, program is assessed regarding the quantity and quality of every achieved step. All assessed data have to be collected and analyzed to be used for further **maintenance** (the seventh step) and **dissemination** (the eighth step) in other institutions locally and globally, in the case that this curriculum proves its success [20, 32].

Six steps kern's framework with the main elements of each step are outlined in **Figure 3**.

#### *3.1.2 PRISMS model*

By the start of 21th century, **PRISMS** model asserted on the importance of clinical practice reflection on clinical training program, integrating modern active teaching methods and modern technology in an evidence-based symbiotic learning, considering needs of learners, patients and health services. **PRISMS** acronym refers to the six elements of this model; wherein **P** refers to Product-based which means that learning focus on clinical practice rather isolated knowledge only and that assessment focus on doing rather knowing. **R** refers that learning has to be Relevant to learners,

#### **Figure 3.**

*Kern's six steps framework.*

communities and updating evidence based knowledge, skills and behavior. **I** refers to inter-professional collaboration in learning process and teamwork role between clinical, academic research and administrative members. **S** refers to **S**horter courses duration of learning combined with **S**maller groups of learners to ensure interactive teaching and conform the millennium needs. **M** refers to **M**ultisite learning to expand learning from larger academic hospitals to involve rural areas and smaller hospitals and units using information technology. Lastly, **S** refers to **S**ymbiotic actions of the above five items to be incorporated with each other. Prideaux resembled PRISMS model by prism which encloses and radiates the light elements! [29, 36].

#### **3.2 Upcoming system thinking curricula (3P-6Cs)**

Awakening of consciousness and metacognition help in continuous probing and picking up gaps in previous plans to go through higher stages and to profound details to fill these gaps efficiently and effectively. This inducts what is continuously desired in medical curricula reforms in 21th century of coping with patients and learners needs, to overcome learning environment challenges and recently to integrate health system into clinical education process [37]. Curricula which are called system thinking curricula aim at filling gaps of health system to be attuned within clinical curricula. Thus, curricular designers, trainers and learners (clinician) are able to broaden their conception to regard health system needs parallel to the desired progressive life-long knowledge, skills and attitude outcomes [38], so the upcoming learning process tends to bind *ecology* with *clinic-ology*.

3P-6Cs Systems Thinking Toolkit is deemed a paradigm of soft thinking reforms that connects the all fragmented elements together in a comprehensive curriculum that is used in clinical training and practice to express how these elements work together [39]. 3P-6Cs systems thinking toolkit is assumed to be able to resist any affection by unpredicted environmental change. The acronym 3P refers to cohere between the main three aspect; **Personal** (learner or clinician learning), **Program** (curriculum outcome and assessment) and **Practice** (system and teamwork) [11].

So learners' **Personal** aspect reflects what they know, how they learn and assure their learning by assessment (**3C**: **C**ontent, **C**ognition and **C**onfirmation). **Program** aspect targets **6Cs** as the study reported; the first **3Cs** targets training outcomes, relation to contextual environment and what are the teaching methods *Clinical Curriculum Revolution to Integrity and "Attunity" DOI: http://dx.doi.org/10.5772/intechopen.99460*

and strategies (**3C**: **C**ommand, **C**ontextualization and **C**oordination) and the other **3Cs** targets the summative/formative assessment of each learner, connects different competencies and activities and relates all these to program evaluation (**3C**: **C**ollection, **C**ollation and **C**onnection). Finally, to close this connected circuit, **Practice** aspect calibrates learners outcome in relation to circumstances and program goals/objectives, assesses the role of teamwork/communication and confirms the existence of long-life learning through (**3C**: **C**alibration, **C**ollaboration and **C**ontinuous development) [11]. Although there is no enough evidence in real world that 3P-6C toolkit is more practical, but it is a great chance to assess this new perception in practice and to create new ones.

**Footnote:** *Designed clinical curricula are truncate without coherence of clinical knowledge with ecological, ethical, emotional, intellectual, social, societal contexts. Unleash your thoughts and apply new overarching reforms to foster attuned health system in clinical curricula.*
