Intended for healthcare professionals


Spicing up medical education

BMJ 2009; 339 doi: (Published 22 July 2009) Cite this as: BMJ 2009;339:b2779
  1. Henry P O’Connell, consultant psychiatrist, psychiatry of later life1, clinical skills/problem based learning tutor2
  1. 1An Triu Aois Day Hospital, Portlaoise, County Laois, Ireland
  2. 2Graduate Entry Medical School, University of Limerick, Ireland
  1. hpoconnell{at}


Six cornerstones in teaching medical students today

The acronym SPICES refers to six main concepts in medical education—student centred teaching, problem based learning, an integrated curriculum, community based teaching, electives with a core, and the use of systematic methods (fig). An awareness of these principles means that medical students can take a more active role in their learning. Students who are well informed about medical education principles, such as the SPICES criteria, are more likely to be able to provide constructive feedback about their own medical education experience, contributing in the long term to course improvements.

Different aspects of the SPICES model are adopted to a greater or lesser degree by medical schools. It has been suggested that each medical school should be scored according to how much of the SPICES model they use in their curriculum.1 There is, however, a dearth of evidence on how different medical schools perform with regard to the SPICES criteria and how they compare with each other. The level of adoption by a medical school of the SPICES criteria can be measured objectively in terms of the scheduled number of hours allocated for each educational strategy. What are the six concepts in the SPICES model, and what are the advantages and disadvantages of each?

Student centred teaching

This concept moves the emphasis of the medical curriculum away from being teacher centred and towards being more student centred.2 Two approaches that can help this change are the creation and use of study guides and an adaptive curriculum.34 Study guides show students what to learn, identify educational resources available to help, and give activities to help students understand and remember the material. An adaptive curriculum involves working collaboratively with everyone involved (students, dean of faculty, and all other staff) to create a flexible and relevant curriculum.

Advantages—The emphasis is on what the student learns and not what the teacher teaches, and students are more motivated. Students are also better prepared for continuing education after graduation because they are allowed to be more actively involved in their own learning and so take more responsibility for it.

Disadvantages—Teachers who have experienced a predominantly teacher centred approach may find it difficult to teach in a more student centred approach. Likewise, students may find a student centred approach more threatening and demanding initially, especially if their previous experience was in the teacher centred model. More demands are also placed on teachers in the preparation of a wide range of learning experiences and resources, as opposed to the relatively easily prepared and perennially repeatable lecture series.

Problem based learning

First introduced in McMaster University in Canada in the 1970s by Howard Barrows, problem based learning is a student centred approach to learning that aims to help students develop critical thinking and clinical judgment and to provide a clinically relevant focus for their learning.5 This process is usually facilitated by a tutor (box 1).

Box 1: Problem based learning

  • (1) Students are presented with a clinical scenario or problem

  • (2) Students determine learning outcomes and objectives

  • (3) Students decide knowledge needed to solve problem

  • (4) Students attempt to achieve self determined learning outcomes (individually or in small groups)

  • (5) Tasks are allocated among group members

  • (6) Students present their work or contribution to group

  • (7) Further learning points might be generated

  • (8) Information and competencies are synthesised

Advantages—Real world clinical scenarios are used, preparing students for clinical practice. This form of learning encourages early development of decision making skills, a holistic approach to clinical problems, and the development of team working skills.

A study that compared costs in terms of faculty time of problem based learning and conventional pathology programmes indicated that problem based learning is feasible for schools with class sizes of less than 60-100 students.6 The main costs relate to hours of time for teachers and facilitators to run problem based learning sessions. The main effectiveness relates to the positive nature of the student experience, something that is more difficult to quantify. The ideal total class size is 60-100 students, with problem based learning groups within the class generally consisting of about eight students.

Task based learning may be used if problem based learning is difficult in a clinical setting.7 Task based learning is an educational strategy that integrates theory with practice. Student learning centres around real cases encountered in the wards, outpatient departments, ambulatory care clinics, or general practice surgeries. The students make use of study guides for each of the clinical cases to help them to learn about the condition for themselves. Students can individually customise their learning and can learn when they need to. One recent study showed that students involved in a task based, community oriented teaching model of family medicine outperformed a control group in terms of acquisition of knowledge and skills, and reported high degrees of relevance and student satisfaction.8

Disadvantages—Some students may feel insecure, especially if used to an information gathering approach. Problem based learning, with requirements for print based scenarios and small group work, may be difficult to introduce in clinical situations. Task based learning was developed to tackle this shortfall.

Integrated curricula

Integration of the curriculum promotes a holistic and cross discipline approach to patients and their problems. It can also help promote learning in context. Discipline based learning focuses on clinical problems that are largely confined to individual medical specialties; for example, cardiology or psychiatry cases. Box 2 lists some of the teaching methods that promote an integrated curriculum.

Box 2: Teaching methods that promote an integrated curriculum

  • Problem based learning

  • Task based learning

  • “Hot case” learning—Learning around recently encountered real world clinical scenarios

  • A spiral curriculum—Revisiting topics and increasing levels of difficulty

  • Multiprofessional learning—Students of different healthcare professions learning together

Advantages—Integrated curriculums promote learning in context. Higher learning objectives, such as application of knowledge and problem solving skills, are more easily met and irrelevant information is less likely to be included in the curriculum.

Medical courses are less fragmented in an integrated curriculum. This encourages a more holistic view of a patient’s problems; increased motivation levels among students; better educational effectiveness of teaching because learnt material is applied; more emphasis on higher learning objectives, such as application of knowledge and problem solving skills; and promotion of staff communication and collaboration, with a more efficient use of teaching resources.

Disadvantages—The fundamentals of a discipline might be neglected; some topics may be omitted; teachers might be less enthusiastic and less comfortable when not teaching in their own discipline; discipline based teaching may be cheaper; and students might develop a clearer picture of a discipline as a career in the discipline based method.

Community based learning

Medical students’ education is geared towards providing specialised experience in a hospital. Recently, medical education has shifted from addressing the hospital inpatient to healthcare delivery in community settings. Two terms are used in this area: community based education and community oriented education. In community based education, students are taught in community facilities, such as day hospitals and general practices. Community oriented education emphasises the planning and delivery of diagnosis and medical treatment outside of the acute hospital setting.

Advantages—Community based learning is often cheaper than teaching in a hospital, and most people with medical disorders are treated in the community. In the community, students are less likely to meet patients who have already been interviewed and examined by medical students in the past. Patients who have had less contact with students in the past present more authentic clinical problems in that they are less likely to direct the student to what they may perceive as the correct parts of the history or examination. Students get a broader and more realistic introduction to all aspects of a healthcare system, such as screening programmes and continuity of care.

Disadvantages—Recruiting and funding primary care doctors who are prepared to teach can be difficult. Such doctors must be able to change their practice to balance clinical time with teaching. Some learning experiences, such as surgery, cannot be gained if the student learns only in the community setting, and some students may wish to spend more time exploring specialist areas as opposed to primary care as a career choice.

Electives with a core

The main content of an elective with a core is determined by the outcomes the students must achieve by the end of the course. In this system, some of the material conventionally taught in the undergraduate years or in basic training is moved to the postgraduate phase of training. The more traditional approach is of each student completing a uniform or identical course. This concept was developed in response to an overloaded curriculum.

Advantages—Time can be freed for students to study extra topics or subjects of their own choosing. Furthermore, some topics traditionally taught in undergraduate years may be moved to postgraduate years. This system gives students more responsibility for their own learning and facilitates career choice. Electives may also help students meet their individual aspirations and help bring about changes in attitude because of exposure to real world clinical problems and the often challenging social and cultural problems that may contribute to such problems.

Disadvantages—Teachers who facilitate the extra parts of the curriculum can become overloaded with work or unable to support the student adequately. Electives may impinge on other coursework. These components may be difficult to assess fairly and uniformly.

Systematic methods

Two approaches to making the curriculum more systematic are outcome based education and curriculum mapping. In outcome based education, student learning is focused on predefined learning objectives. Curriculum mapping is a comprehensive approach to designing and delivering medical curriculums by defining what is taught, how it is taught, when it is taught, and when it is assessed or examined. The curriculum map makes the curriculum transparent to all students, teachers, and the public. Areas in a curriculum map include the expected learning outcomes, the curriculum content or required areas of expertise, assessment procedures, learning opportunities, learning resources, a timetable, the staff involved, and measures for future curriculum development.

Advantages—Exposure to a wider variety of health problems should lead to more awareness and the understanding of the most important competencies. Systematic approaches are much less likely to miss required areas of knowledge and competencies than the traditional apprenticeship model of medical education.

Disadvantages—Teaching by systematic methods is less easy to arrange than the traditional apprenticeship model of education and might interfere with continuity of teaching.


Many of the ideas in the SPICES model of medical education are already in place to some extent in medical schools around the world. An evidence base for effectiveness of the newer approaches is only emerging and will take several years to accumulate.

The newer approaches, however, seem to have some validity compared with the often ineffective and anachronistic models of learning and curriculum development employed in more traditional settings. Rigorous and regular application of concepts within the SPICES model is therefore recommended in the development of current and future medical curriculums. Medical students should be actively involved in the process of advocating for and introducing the innovative principles involved in the SPICES model of curriculum development.


View Abstract