Backward Design Moves to the Front of the Class in Surgical Education

Surgical educators have long been handed the responsibility of shaping the next generation of operating surgeons, yet most program directors and education leaders arrive at the task without formal training in curriculum theory. A new open-access paper in Global Surgical Education, the journal of the Association for Surgical Education, argues that a planning framework borrowed from general education, known as backward design, offers surgical departments a simple and adaptable way to build everything from year-long simulation bootcamps to a single hour of faculty development. The authors, Emma G. Burke of the Michael E. DeBakey Department of Surgery and Peter Boedeker of the Huffington Department of Education, Innovation and Technology at Baylor College of Medicine, walk readers through the method step by step and then demonstrate it with two real programs from their own department, providing one of the first detailed operational guides for the framework within surgical training.

Backward design was first described by Grant Wiggins and Jay McTighe in their influential book Understanding by Design, and it inverts the sequence that most instructors instinctively follow. Traditional curriculum planning typically begins with a topic, moves on to lectures and lesson content, and only afterward defines exams and projects, with learning objectives retrofitted to whatever activities were already built, if they are articulated at all. Backward design forces the planner to start with the end in mind. The first phase asks educators to identify the broad understandings they want learners to retain, described by Wiggins and McTighe as the big ideas that students should carry with them long after the details have faded, and then to translate those understandings into specific, observable, learner-centered objectives. Only after those outcomes are fixed does the planner move to the second phase, determining what evidence would count as proof that the objectives have been achieved, and finally to the third phase, designing the learning activities themselves.

The technical machinery of the first phase leans heavily on Bloom’s taxonomy, the classic hierarchy of cognitive and psychomotor performance that scaffolds verbs from simple recall to creative synthesis. A learner at the lowest level might be asked to list the steps of a predefined process, while a learner at the apex of the taxonomy might be asked to create a novel process to solve a problem. By choosing the verb deliberately, the curriculum designer fixes the level of performance expected and, crucially, sets up the second phase, because the verb chosen for the objective dictates the appropriate form of assessment. If the objective says list, then an acceptable demonstration is an independent listing of the steps; if the objective says create, then learners must be handed a problem and asked to generate a solution. This tight coupling between objective and evidence is what gives backward design its reputation for alignment, ensuring that what is taught, what is tested, and what is intended all point in the same direction.

The assessment phase distinguishes between summative and formative evaluation, two categories with distinct purposes in the learning cycle. Summative assessment places a deadline on learning and lets the learner exhibit the degree to which the larger understandings have been achieved, while formative assessment occurs during learning itself and opens channels for feedback from instructors and peers that can improve later performance. The authors note that formative assessment is already a familiar rhythm in clinical medical education, and that the backward design framework naturally creates feedback moments, particularly when sessions are built to be active. Multiple-choice examinations tend to test recall or recognition, whereas performance tasks are better suited to probing the deeper understandings that the framework prizes, a distinction that matters enormously in a field where the ultimate test is a patient on the table.

The third phase brings active learning to the foreground. Because the objectives were written to demand application rather than memorization, passive lecturing rarely fits, and the framework pushes designers toward methods such as think-pair-share, minute papers, concept mapping, and case-based learning. Active learning, rooted in constructivist theory, requires learners to engage directly in acquiring knowledge and skills and to reflect on the process, and it has been shown to outperform passive lectures across fields including medicine. The authors emphasize that backward design is not a rigid linear checklist but an iterative loop: resource limitations may force a reassessment of which performance tasks are feasible, prompting revisions to objectives and even to the original understandings, and activities may need adjustment once the summative assessment is finalized. Revisiting earlier phases is what keeps outcomes, assessments, and activities tightly aligned.

To show the framework in action, the Baylor team first applied it to a complete redesign of the simulation bootcamp for postgraduate year one residents in the 2025 to 2026 academic year. The existing curriculum had been organized around activities, such as arterial line placement, without clear benchmarks for evaluation. Educational leadership gathered input through anonymous surveys and two focus groups weighted equally from current interns and senior residents, who identified level-appropriate tasks including arterial line placement, central venous catheter insertion, laparoscopic camera driving, and the tasks of the Fundamentals of Laparoscopic Surgery examination. Learners also flagged a key flaw in the old format: prior labs centered on performing an entire procedure rather than mastering discrete component skills. From this input the team defined broad understandings and then task-specific learning objectives that doubled as lab-level expectations, all vetted by simulation leadership before any assessment was considered.

With objectives fixed, assessment design followed logically. Direct observation by instructors during each skills session served as formative assessment, with facilitators given the session objectives to keep feedback consistent, and learners able to use the same objectives for self-assessment during independent practice. The summative capstone took the form of an Olympics-style competition at the final session of the year. Five stations mimicked the five Fundamentals of Laparoscopic Surgery examination tasks using the official scoresheet, while central venous catheter and arterial line stations evaluated each procedure in three segmented phases: ultrasound evaluation, preparation, and vascular access, with points awarded for each correctly completed phase and scored on accuracy and time by senior residents or faculty. Only after this assessment architecture was in place did the team plan the lessons: weekly two-hour skills labs over six weeks, in which facilitators demonstrated each skill by breaking it into parts, reviewing each component, and then showing the whole, before learners performed the skill under direct supervision in a pattern echoing the first two elements of the traditional see one, do one, teach one mantra.

The second example compressed the framework into a single hour, demonstrating its flexibility for short-cycle planning. Departmental leadership had decided to convert general surgery resident didactics from two-hour faculty lectures into large-group case discussions mixing residents of all postgraduate levels in groups of five or six, a shift grounded in literature showing the benefits of active learning for clinical judgment and reasoning. Burke and Boedeker were asked to prepare faculty for the change, and they began not with slides but with desired outcomes: participants should understand why active learning outperforms passive formats, feel supported in the transition, and be able to identify institutional resources, evaluate an active learning session, and describe how a didactic session should be delivered. With roughly ten minutes allocated to a summative large-group discussion and an optional post-workshop survey for self-reflection, the bulk of the hour was devoted to a mock case discussion on pediatric abdominal pain, in which faculty members role-played residents at different postgraduate levels, receiving patient information and debating workup, imaging, operative planning, and complication management. The immersive design flowed directly from the objective that attendees should be able to evaluate an active learning session, illustrating how the framework disciplines even the smallest allocation of scarce time.

The authors are candid about limitations. Backward design demands faculty development before it can be applied faithfully, and its first phase can be more time-intensive than anticipated, although that effort is largely front-loaded and later iterations rarely require a full reapplication of the framework. More fundamentally, the efficacy of backward design in undergraduate and graduate medical education has not yet been formally evaluated, and both curricula described here received positive participant feedback without any evidence that they outperform programs built with other frameworks. The authors also contrast their approach with Kern’s widely used six-step model, noting that Kern begins with formal needs assessments that may be infeasible under time or resource constraints, and places evaluation last, whereas backward design requires no needs assessment and positions assessment design immediately after objective selection. Neither framework guarantees a good curriculum; both merely maximize the chance of one by enforcing alignment. What emerges from the Baylor experience is a pragmatic message for a specialty under pressure from competency-based milestones and entrustable professional activities: by starting with what learners must ultimately be able to do, surgical educators can build shared mental models, consistent feedback, and efficient programs without new resources, simply by planning in reverse.

Subject of Research: Application of backward design curriculum planning to surgical education

Article Title: Design with intention: operationalizing backward design in surgical education

Article References: Burke, E. G., & Boedeker, P. (2026). Design with intention: operationalizing backward design in surgical education. Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 131. https://doi.org/10.1007/s44186-026-00534-2

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00534-2

Keywords: backward design, surgical education, curriculum design, Bloom's taxonomy, active learning, simulation training, faculty development, resident didactics, learner-centered outcomes, formative assessment, summative assessment, competency-based medical education