Residency spiral concussion curriculum design

Resident‐focused concussion curricula that measure learner behaviours are currently unavailable. We sought to fill this gap by developing and iteratively implementing a Spiral Integrated Concussion Curriculum (SICC).

Evaluation: A mixed-method evaluation with a pre-/post-test design and interviews was utilised.Surveys and knowledge tests were used to measure knowledge and confidence pre-AHD and 6 months post-AHD.Interviews at 6 months explored programme perception and behaviour change.Of the 141 programme attendees, 114 (80%) participated in the pre-intervention knowledge test and 33 completed the pre-and post-AHD test.Immediate pre-/post-testing demonstrated statistically significant improvement in knowledge (p = 0.042).At 6 months post-AHD, residents in Cycle 1 (n = 5) had a knowledge decrease of 3.33% (p > 0.05).Residents in Cycle 2 (n = 7) had a knowledge increase of 11.6% (p > 0.05).Both cycles of residents had an increase in confidence (Cycle 1: 65.0% [p = 0.025]; Cycle 2: 62.8% [p = 0.0014]).
Residents (5 out of 6) reported positive behavioural changes at 6 months.Valued programme elements included concussion diagnosis and management, the self-study guide resource and the organised structure.
Implications: The SICC enriched these residents' learning and fostered sustained knowledge improvement and behavioural change at 6 months post-intervention.This approach may provide a workable design for future competency-based curriculum development.
Medicine (DFCM), University of Toronto (UofT) and Education Development Fund, North York General Hospital The SICC enriched these residents' learning and fostered sustained knowledge improvement and behavioural change at 6 months post-intervention.

| BACKGROUND
Concussions are complex to diagnose and treat; patients' awareness of concussions and demands for concussion care are rising. 1Family physicians are key to better health outcomes following concussion injury.However, in 2017, family medicine (FM) residents at the University of Toronto showed knowledge gaps in concussion care and diagnosis; 32% believed that seeing a physician was not essential for concussion care, and 12% reported having no training in concussion management. 2 Insufficiency in concussion care can lead to devastating long-term sequelae for patients, including substantial disabilities and death.Gaps in knowledge about concussion diagnosis and management may result in inadequate patient counselling.As such, a need exists for improved concussion education and research into how to train through effective curriculum design. 3,4 response to this need, using the utilisation-focused evaluation framework (described below) as the construct, 5 we developed an innovative concussion curriculum for first-and second-year FM residents (PGY1&2s).Given FM residents' limited time during training, this curriculum was designed to maximise education within a short timeframe by combining horizontal teaching techniques (single session teaching) with vertical longitudinal learning opportunities (spirally deepening learning over time). 6is utilisation-focused evaluation framework is an iterative evaluation process with a specific evaluative purpose at each cycle to match the maturity of the developmental stage of the curriculum and the specific research inquiries. 5This approach allows iterative evaluation cycles to maximise the utility of our evaluation efforts.To illustrate this concept, we utilised the following research questions iteratively to create our SICC: 1. What is the effect of the spiral integrated curriculum on concussion knowledge acquisition and knowledge retention among FM residents?(Effectiveness) 2. How do residents perceive the programme elements of the concussion curriculum?(Acceptability) 3. What practice changes do residents identify due to their participation in this programme?(Effectiveness) After creating our SICC, we sought to evaluate its effectiveness and learner acceptability.

| Spiral integrated concussion curriculum development: Theories, design and objectives
With the transition to competency-based education (CBE) in Canada, an opportunity existed to utilise a developmental evaluation framework 5 to co-create an evidence-informed spiral curriculum design with residents for resident competency acquisition.Our curriculum was based on the principles of social cognitive learning theories. 6We proposed a spiral integrated curriculum approach to improve concussion learning efficiency for FM residents. 4,7spiral approach involves longitudinal learning opportunities with iterative exposures to relevant content domains, leading to deeper learning at each subsequent encounter. 8This spiral concept also exploits evidence that integrating different teaching techniques fosters more active learning compared to using only one teaching technique. 9 develop this curriculum, we followed Kern's Curriculum Development for Medical Education, 10 using a constructivist, utilisationfocused framework 5 for continuous curricular improvement.Our competency-based spiral integrated concussion curriculum (SICC) features include (see also Tables 1 and 2) the following:

Educational principles
Why is this a good approach?
Adult Learning Theory with learner goal-oriented approach 11 Meaningful learning stimulates intrinsic motivation to learn. 14

Alignment of Knowledge Organization with Learning Practices 12
Explicit connections among concepts through integrated presentations.This integrated learning will support the ease of using learned information. 15cial Cultural Learning Theory 6 Situated learning through peers, coaches, and mentors can ease learning, as the processes of learning become experiences. 6gnitive Psychology Learning Theory 6 Learning can be enriched by comparing clinical examples to identify deep features of basic concepts. 12This deeper understanding of a concept synthesises new learning. 6ggested placement: place in "Approach" section after Table 1.
• Asynchronous learning followed by synchronous learning and knowledge applications through case-based interactive workshops.
(A 'flipped classroom' delivery of a self-study guide and a 2-h AHD.) • Integration of scaffolding strategies and teaching techniques to facilitate self-reflective learning supported by external feedback.
• Deliberate practice for mastery learning at dedicated subject specialty clinics.
• Facilitation of tailored learning experiences (e.g., participants generate their learning objectives before clinical rotations, and their learning objectives will be focused on during rotations).
• Promotion of independence with authenticity. 6| EVALUATION

| Developmental Evaluation
We utilised a rigorous developmental evaluation framework that depicts a participatory, collaborative and utilisation-focused approach to develop a credible and accurate SICC with end-user feedback. 5Our curriculum evaluation aimed to enhance the SICC and inform ongoing decision making to better meet resident and patient needs.An explanatory, sequential mixed-methods design was used to evaluate our curriculum's preliminary effectiveness and acceptability.
For programme evaluation, we used the Kirkpatrick Four-Level Training Evaluation to measure the effectiveness of our curriculum.3. Descriptive analysis was conducted using IBM SPSS.
4. Group proportions were compared using chi-squared tests.

| Qualitative data collected and measures
Six months post-AHD, residents participated in 30-min-structured interviews to assess their behavioural changes (Kirkpatrick's Level 3) and curriculum perceptions (Kirkpatrick's Level 1: acceptability).Two investigators (first iteration: Brain Sum and AK; second iteration: AK and AH; third iteration: AK and GZ) used generic descriptive thematic analysis.

| Short-term impact results
Step 1. From June 2021 to June 2022, we assessed knowledge gaps of 114 out of 141 participants (80% response rate) that completed the pre-intervention survey.We identified similar knowledge gaps as Mann's 2017 study (Illustration S2). 2 Of nine concussion knowledge questions included in both studies, the mean baseline score in our cohort of residents was 4.5 out of 9 (SD 1.2; 95% CI 4.3 to 4.7) in comparison to Mann's mean of 5.2 out of 9 (SD 1.4; 95% CI 4.9 to 5.6). 2 Our residents demonstrated deficits in concussion diagnosis and management: • Concussion management: 32% (n = 36/114) answered correctly.
Step 2. Based on the knowledge gap analysis, we created our curricu- Self-reflective learning: Self-reflective learning opportunities through.a. pre-and post-AHD reflection survey b. end-of-rotation reflection survey, and c. 3-min-case log reflective practice monthly for 6 months

SICC Educational Objectives
After completing the SICC, residents will be able to: 1. Diagnose concussion with specific diagnostic criteria, ruling out other comorbidities.

Manage concussion symptoms and
support return to activities for patients with non-complex concussions.3. Utilise resources and initiate referrals early for complex concussions.3).There was no significant difference in resident demographics between Cycles 1 and 2 (Table 4).

| Acceptability
Residents valued this SICC's structured approach, appreciated that the curriculum improved their concussion diagnosis and management and perceived the study guide as a resource (Table 5).
Residents valued this SICC's structured approach, appreciated that the curriculum improved their concussion diagnosis and management and perceived the study guide as a resource.

| Change in practice
Five out of six residents reported that the curriculum changed their practice.At the 6-month follow-up, residents to use the study guide.

| Ethics statement
Ethical approval for the research was granted by the University of Toronto Research Ethics Board (REB# 40656).

| IMPLICATIONS
We designed and implemented our SICC using a utilisation-focused evaluation approach.Our findings suggested the potential of this spiral integrated design to deliver complex concussion education topics and maximise learning within a short timeframe (e.g., a 2-h AHD instead of a 6-h workshop).Given our positive findings, a spiral integrated curriculum design allowed us to provide a well-received, impactful adaptive curriculum that improved resident-end-users' learning and work efficiency.Our curriculum can potentially shape the future of CBE in Ontario, Canada, as the University of Toronto's FM residency catchment area reaches out to rural and remote communities.
Our findings suggested the potential of this spiral integrated design to deliver complex concussion education topics and maximise learning within a short timeframe ….A spiral integrated curriculum design allowed us to provide a wellreceived, impactful adaptive curriculum that improved resident-end-users' learning and work efficiency.
The utilisation-focused evaluation framework allows multi-level evaluation.Our findings align with previous studies that used mixed teaching techniques for concussion knowledge tests and did not find significant differences in mean knowledge scores. 2,11However, using a cohort observational study of small sample size (Illustration S1: Pre-AHD score (Mean± SD) Some limitations should be noted.This study was conducted at a single university for in-depth exploration of SICC through qualitative interviews; however, quantitatively, more studies across sites and disciplines would be useful to achieve greater generalisation of data.It is difficult to know if these results could be generalised to other sites because this cohort study was conducted in academic settings with residents eager to take on leadership.Although residents were not randomised in this quantitative evaluation, the effect was minimised by using an iterative usability approach to establish the short-term impacts of AHDs at a broader audience (i.e., AHDs were delivered to 7 out of a total of 14 residency sites).
Randomisation in medical education is difficult to achieve, given that it involves the coordination of AHD schedules with clinical rotations.A non-randomised format ensures greater feasibility and maintains an ethical approach to providing equal learning opportunities.
A strength of our curriculum design is our developmental-focused approach. 5To our knowledge, our study is the first to demonstrate the concept of learning efficiency with peer teaching in a spiralintegrated curriculum at the postgraduate medical education (PGME) level.Instead of isolated learning activities and a didactic teachingonly approach, an integrated educational delivery allows for a transition from fragmented to synthesised education delivery. 6An integrated education approach, utilising learner-tailored curricula, teaching methods and resources, has been proposed to improve residents' learning efficiency. 6Curriculum learning efficiency is essential for residents, as clinical content overload in the data-driven medicine community negatively impacts learning effectiveness and increases the risk of burnout. 13Our results indicate that a spiral curriculum improves residents' learning efficiency.This end-user benefit also aligns with one of the 'Quadruple Aims'-an internationallyrecognised framework for the design of effective healthcare systems-that of improving provider work-life experience.
An integrated educational delivery allows for a transition from fragmented to synthesised education delivery.
In conclusion, our curriculum demonstrates the importance of using the utilisation-focused evaluation approach in the early stages of curriculum development to elevate the quality of programme evaluation.Implementing a spiral-integrated curriculum design within the PGME competency-based medical education framework may contribute to the enhancement of competency-based curriculum development in other health professions.
In future studies, we aim to evaluate curriculum outcomes among peer teachers who have dual roles as learners and teachers, to optimise teaching and learning efficiency and resource use in the future healthcare system.

AUTHOR CONTRIBUTIONS
Our evaluation assessed whether the curriculum objectively measures effectiveness (i.e., knowledge and confidence [Kirkpatrick'sLevel 2]   and behavioural change [Kirkpatrick's Level 3]), as well as whether it appropriately addresses the clinical concussion education challenges (Kirkpatrick's Level 1 acceptability; Illustration S1).3.1.1| Quantitative data collected and measures 1. Demographics (sex, age and concussion education experience) were collected.2. Knowledge (Kirkpatrick's Level 2) and confidence (Kirkpatrick's Level 2) were measured at pre-AHD and 6 months post-AHD using surveys consisting of 18 multiple-choice questions adapted from previous concussion knowledge tests 2 and a 5-point Likert scale.Knowledge changes within participants were measured using paired t tests and McNemar's test.
lum to address the gaps.The post-AHD knowledge assessment showed significant positive change (n = 33 out of 114 completed both pre-/immediate post-test), with a preintervention mean of 10.5 ± 1.6 and a post-intervention mean of 11.1 ± 1.7 (p = 0.042).T A B L E 2 Spiral Integrated Concussion Curriculum (SICC) teaching techniques and objectives.Learning objectives (#) matching with evidence-based teaching techniques: 1, 2, 3. Flipped classroom learningA self-study guide and a 2-h interactive case-based virtual academic half day (AHD) on concussion were implemented.

3. 3 |
Long-term impact results 3.3.1 | Effectiveness: Knowledge and confidence No significant knowledge change existed between Cycles 1 and 2 (p values insignificant), but a significant change occurred in confidence at both Cycle 1 ( p = 0.011) and Cycle 2 ( p = 0.0014).There was a sustained knowledge increase of 11.6% in Cycle 2 with an additional peer teaching technique (Table

Cycle 1 :
n = 5, and Cycle 2: n = 7), we can overcome the various learning cultures within each cycle and monitor long-term curricular T A B L E 3 Comparison of pre-and post-intervention mean knowledge test scores for two study cycles.
Comparison of variables between Cycle 1 versus Cycle 2 groups.