How will you describe what must be learned? The 1956 publication of the first handbook of “Bloom’s Taxonomy” [1] is the tip of a vast iceberg of debate on the subject of how to define and classify educational objectives. Most curricula follow themes laid down in Bloom and colleagues’ texts and create a series of syllabi that look in some way at knowledge, skills and attitudes or values. Even the simplest of these needs careful thought. The most obvious way to define knowledge might seem to be to list a series of topics. Even with this simple approach care must be taken in describing the depth or breadth to which any topic must be explored at any particular level of progress through the programme. A first year medical student might be expected to know what an anterior cruciate ligament is. However, they might at that stage have a limited understanding of its function, and it will be much later in their training that they have an understanding of how a defective ACL can be diagnosed and even later still before they have acquired the skill to make an effective repair. In deciding how to construct a syllabus it is necessary to refer back to the purpose of the curriculum and its boundaries. What stages of training does this curriculum cover, what is expected of trainees entering this stage and what evidence will be acceptable as proof that they have met those expectations? Similar problems exist with a skills syllabus and even more difficulties arise in trying to define attitudes or values.

Many syllabi at present are “competence focused”. They seek to define the programme in terms of what the trainee must be able to do rather than just what they know. Other options exist, such as defining the syllabus in terms of the “Entrustable Professional Activities” concept developed by Ten Cate [10]. Training is necessarily a dynamic field, and by the time this chapter is published there will no doubt be others.

One of the most challenging aspects of any syllabus is the definition of attitudes and values. Such things are more often caught than taught and so can be difficult to define. They are also some of the most important items, having the most major impact on the future effectiveness of any clinician. The difficulty is sometimes overcome by the creation of a professional skills syllabus. The World Federation for Medical Education defines professionalism as follows:

“Professionalism describes the knowledge, skills, attitudes and behaviours expected by patients and society from individuals during the practice of their profession and includes concepts such as skills of lifelong learning and maintenance of competence, information literacy, ethical behaviour, integrity, honesty, altruism, service to others, adherence to professional codes, justice and respect for others” [11].

If this is your first attempt at curriculum writing begin by developing a knowledge syllabus and build up from there. The understanding you gain from this exercise will help you in tackling the rest.

There are two main types of assessments: summative (assessments of learning) and formative (assessments for learning), and a curriculum should contain both. Summative assessments are used for decisions on progress (e.g., a formal examination). Formative assessments are used to give feedback to the trainee on their performance and for trainers or tutors to understand how well the trainee is progressing in response to their efforts. Most people are familiar with formal examination type assessments but not the field of workplace assessment, where the trainee’s performance is reviewed, is a real-time clinical task. Designing or selecting workplace assessments may seem simple at first but not all assessment tools are suitable for all situations. If used incorrectly they not only provide misleading results but also add substantial costs to the training programme in terms of the time they take to complete. There does not appear to be a reliable, comprehensive guide to workplace assessment tools at present but a thorough description of the procedure-based assessment tool that is used throughout surgical training in the UK can be found in “Competence Evaluation in Orthopaedics – A ‘Bottom-up’ approach” [8].

No element of the curriculum is completely independent of any other. In terms of the assessment strategy it is vital that any assessments chosen can be mapped clearly to the syllabus. In other words, you cannot assess whether a trainee has learned something if you have not first said that it must be learned by including it in the syllabus.

Your curriculum must have a starting point. In order to enter your programme a trainee may need to have certain experience, qualifications or other attributes. These must be specified in the curriculum together with a description of any evidence that is acceptable as proof of experience or qualification. Such evidence might include qualification certificates, logbooks, references or even reflective records. Part of the success of your own education programme will depend on identifying the appropriate trainees to join it so it is important to identify these clearly. If you have thoroughly completed the specialty overview then you will be able to identify any agencies or institutions who might be providing candidates for your programme and consult them to establish that both your criteria for admission and evidence requirements are realistic and effective.

If your programme has several sections, then you will need to articulate what the evidence of successful completion of each part is and also the mechanism by which a trainee moves on to the next part of the programme.

The quality of training will stand or fall on the quality the trainers. In most of surgery and medicine training has been an intuitive activity with the trainer often emulating the behaviour of those who trained them until quite recently. The clinical specialties that have a long history of actually providing any sort of formalized training programme for their trainers have been in the minority. Nevertheless, it is essential in the curriculum to specify what skills the trainer should have and what evidence should be provided that they possess them. Many curricula in recent days have specified that a trainer must have, as a minimum, attended a training trainers course or programme. In the UK, the General Medical Council will in the immediate future be accrediting all clinical trainers against a set of standards that they have produced and specialties have been invited to adapt these standards for their own community. The surgical version of these standards, produced by the Royal College of Surgeons of Edinburgh, has received much acclaim for its clarity in this respect and can be found online at the website of the Edinburgh College [7] or the General Medical Council.

The curriculum development process can be a long one and it is worthwhile considering some multi-tasking in this respect. A project to develop training the trainers programme has an immediate relevance to improving the quality of the training programme. It can also provide a means of educating the specialty community and identifying a valuable community of potential pilot testers for the new curriculum.

Is the centre where the trainee is to be located fit for training? This is an important question. If the centre does not have appropriate training facilities or adequately skilled trainers then delivering the curriculum may be impossible. If the curriculum specifies certain levels or amounts of experience then the training centre (hospital, local clinical practice) must have this experience readily available. The curriculum must specify the standards and facilities of the local centre and specify what evidence is acceptable to prove that they have been reached.

Will it actually work in practice? Do you have enough suitably experienced trainers to deliver the programme? Is there too much/ too little material to be covered in the time available? Are the hospitals or medical schools that supply your trainees willing and able to provide the standard of individuals you need?