Educational activities as a pathway to postgraduate standardization: a qualitative study

Abstract

Background

Educational activities (EAs) in health professional education play a crucial role in healthcare training curricula through a variety of methods, such as lectures, small-group discussions, simulation, case-based learning, and workplace-based experiences, that aim to develop knowledge, specific skills, and professional behaviours for clinical practice. In postgraduate education, EAs are frequently organised around learning competencies and Entrustable Professional Activities (EPAs)/national standards. However, there are few studies on how these activities systematically translate into structured postgraduate programs.

Methods

A qualitative research study using descriptive and comparative document analysis was conducted in consecutive stages to identify gaps in the curricula of the postgraduate training programs of the Saudi Commission for Health Specialities (SCFHS). At first, the data, including 124 randomly sampled curricula, were independently reviewed and coded by two reviewers, after which the results were categorised into themes and subthemes. Then, these themes were further developed into more comprehensive themes and subthemes as a proposed educational framework through a literature review and discussions with a team of experts.

Results

Initially, four key themes emerged regarding the structuring of EAs in the reviewed curricula. The four key themes were: Academic Instruction, Experiential Learning, Self learning and Evaluation, and EAs framework design recommendation. Additionally, these reviews noted significant variations and a lack of congruence in the educational activities implemented by training programs. To address this variability, expert discussions were undertaken to refine and standardise the thematic structure. This resulted in the development of a comprehensive framework comprising five major themes: Academic Activities, Practice-based Learning, Skills Training and Procedures, Scholarly Project, and Professional and Personal Development.

Conclusion

The integration of EAs into a cohesive structural framework better prepares trainees for clinical competency, professional behaviour, and practice readiness. The proposed framework provides a robust approach to implementing and evaluating competency-based postgraduate medical education programs.

Introduction

Health-related education involves various learning experiences delivered through several EAs to prepare students and trainees with the skills necessary for safe and effective clinical activity [1]. These EAs include but are not limited to didactic teaching, simulation, workshops, training sessions, self-learning, and workplace-based learning to enhance both technical skills and professional behaviours in undergraduate and postgraduate education across clinical and nonclinical settings [2, 3]. Such EAs are essential in health program training services as they are not only about providing knowledge and skills but also promoting healthy behaviour and well-being.

Curriculum design in education is intended to promote learning objectives and program outcomes by employing instructional strategies that facilitate learners’ use of knowledge, skills, and attitudes [4, 5]. A good program curriculum uses a variety of methods with clear objectives across all areas of learning, including work-based learning, which is fundamental to competency-based medical education (CBME) [6]. When incorporated into competence-based postgraduate training programs, such initiatives can be facilitated by a structured model that harmonises three key factors: modular curricula, coordinated assessment systems, and stakeholder participation across the training spectrum [7].

The literature base is heavily weighted towards specific teaching methodologies and their relationships rather than holistic approaches across the broader curriculum [8]. EAs are based on the medical literature; an internationally accepted classification of EAs is not available in practice [9]. The literature emphasises the need for improvements in clinical education. It provides a basis for enhancement recommendations, primarily offered in the context of undergraduate education, by first introducing efforts to develop an educational activity model [10].

Establishing a format for EAs may facilitate linking educational aims to teaching strategies, thereby reducing the lack of clarity and communication among interested parties [11]. This sharing will contribute to a vibrant learning community. The importance of integrating education with novel teaching approaches is essential for further advancement in the education and clinical environments [12]. As pointed out by Harden, “To avoid a growing gap developing between what is possible educationally and what is delivered, it is clear that we need a new paradigm for postgraduate medical education”, our research tried to structure that paradigm by emphasising standardisation of educational activities as a practical mechanism to close the delivery–possibility gap [13]. Therefore, developing a standardised framework for EAs can help align learning objectives with teaching methods, alleviating vagueness and confusion among stakeholders, and promote a rich learning environment [14].

In Saudi Arabia, the SCFHS oversees 180 postgraduate training programs across medicine, dentistry, nursing, pharmacy, and allied health, making standardisation particularly consequential for consistency, equity, and trainee mobility. Our analysis of 124 SCFHS curricula highlights significant discrepancies in educational terminology and methods across programs, a result similar to that of international training programs, supporting the widespread lack of curricula standardisation [15]. To mitigate such discrepancies, we tried to connect them through the proposed standardised training protocol for the SCFHS. This framework is designed to reduce confusion, encourage stakeholders’ uptake, and foster the competencies necessary for all trainees who attend to patient safety and the realities of doctor–patient interactions in postgraduate education [16]. To fill this gap, the current study explores how EAs are constructed, enacted, and experienced in postgraduate medical education [17, 18]. We sought, through a qualitative process, to identify the key themes used to develop a framework for incorporating EAs into competency-based postgraduate training programs.

The objective of our study was to propose a comprehensive, structured framework for postgraduate education programs to introduce new ways and methods to shape a curriculum that is relatively equal across teaching and learning approaches, ensuring homogeneous development and dynamics at the postgraduate level.

Methods

Design

Our purposes are to describe a qualitative content analysis summarising terms associated with EAs in curricula of the training programs and propose a conceptual framework for postgraduate health professional education at SCFHS. The research was conducted from February 2023 to September 2024 at SCFHS for the postgraduate training program level. The methodology investigated existing teaching strategies, methods, and techniques to foster practical solutions [19, 20]. A descriptive document analysis was used to categorise the EAs in an organised manner and to identify patterns and trends effectively [21]. This systematic approach helped us recognise differences in terminology, enabling us to address the lack of standardisation in postgraduate education and to propose a framework for activities within it.

Data collection tools

The SCFHS governs the training of 180 medicine, dentistry, nursing, and allied health programs and controls curriculum development and delivery. The study was conducted in three main phases: (1) analysis ofpostgraduate curricula from SCFHS, (2) literature review to identify the key health professional education research terms and classifications, and (3) expert consultation for finalisation of the recommended EAs framework. We conducted a targeted, predefined literature search across PubMed/Medline, CINAHL, and Google Scholar, focusing on postgraduate healthcare trainees (residents, fellows, or other postgraduate learners) rather than on undergraduate students or practising healthcare professionals undertaking continuing education. We used specific keywords including: “educational activity”, “teaching activity”, “educational method”, “teaching method or activity”, “teaching/Learning strategies”, “postgraduate”, and “Competency-based medical education”. We screened titles/abstracts to identify relevance to the definitions, categorisation, and implementation of EAs in the context of medical education.

Document collection and selection

Two reviewers randomly selected and reviewed 124 curricula from medical, surgical, nursing, pharmacy, dental and health-allied disciplines. The study population was derived from the SCFHS’s 180 postgraduate curricula editions between 2014 and 2022, which served as the sampling frame for this review. All curriculum materials were accessed through the official SCFHS website, where approved curricula are published.

An iterative review process was undertaken, and curricula selection was stopped at 124 upon reaching thematic saturation, defined as the point at which no meaningful new educational-activity themes emerged across successive batches of reviewed documents [22]. These documents serve as primary sources of data for our review of postgraduate health professional education programs at SCFHS. The reviewers abstracted detailed information about the individual EA and the curricula employed in each study into an Excel sheet. To ensure unbiased selection, the complete set of curricula was randomly assigned in equal numbers to two reviewers, with no overlap between them, using a random number table or online generator; curricula were reviewed in the order drawn.

Inclusion criteria for reviewed documents were: (1) the most recent SCFHS-approved curriculum, (2) availability of complete educational-activity and teaching-method sections, and (3) availability in the English language. Exclusion criteria consisted of incomplete or outdated curriculum documents.

Participants

For participants, the eligibility requirement was to be an accessible subject-matter expert possessing direct experience in curriculum development, medical education, or training within SCFHS programs. We used a pragmatic, purposive convenience approach involving a total of seven participants, two in the roles of medical education reviewer (n = 2), one for curriculum development officer (n = 1) and clinical pharmacy officer (n = 1), one physician(n = 1), and two training department officers(n = 2). The objectives of the study were explained to all included individuals, and consent was obtained. Reviewers accessed training curricula online. Participants were advised that the conversations would be recorded without imposition of emotional stress.

Expert consultation procedure: We convened a synchronous Zoom meeting (≈ 60 min) with seven subject-matter experts to review the preliminary EA framework derived from our thematic analysis. We presented the framework via PowerPoint (definitions, strategy families, and example mappings) and used a standardised verbal script to elicit ratings and suggestions for wording. Consensus was defined as explicit verbal agreement by all present (or ≥ 80% agreement), with proposed edits captured in meeting notes and the Zoom chat. One author moderated; a second author kept structured minutes and logged proposed wording. The verbatim question script and the instructions/terminology slide text shown to participants are reproduced in Appendix.

Data analysis

Data analysis of the curriculum was halted at saturation [22]. Cross-tabulation analysis was summarised in Microsoft Excel to facilitate comparison of learning activities between programs. The choice of Excel-based inductive content analysis to keep the workflow transparent and reproducible with tools universally available to curriculum committees [23].

Following the analysis, description, and comparison of the terminology used to characterise educational activity in the curricula, we entered the data into Excel for extraction. We analysed each document to determine the categories of educational activity addressed. Detailed information was extracted using a predefined Excel spreadsheet. Extracted variables included curriculum identifiers (name, discipline, edition year), types and description of academic activities and related teaching-learning methods, use of educational activities as formative assessment tools, associated assessment methods and forms and reviewers’ comments on clarity of academic activity descriptions, how they were used for assessment, and instances where formative and summative approaches were mixed.

This approach allowed us to open-code, reconcile disagreements, and synthesise themes using structured worksheets, providing a clear audit trail without relying on specialised software [24]. Themes and subthemes were identified using an inductive approach [25, 26].

Data extraction and coding: We extracted EA-related sections into a structured spreadsheet (program, discipline, level, EA label, description, frequency). Two coders performed open coding, and a total system was developed together. Disagreements between the two reviewers were first identified during independent review and documented. Reviewers then met online to discuss different items and attempt to resolve them by consensus. When consensus could not be reached, a third reviewer adjudicated unresolved issues through online discussions. Reviewers documented simple agreement during pilot coding on the shared Excel sheet. To build a defensible codebook and anchor labels to prior usage, we first reviewed terminology and EA classifications reported in standard curriculum-design texts, then reconciled them with SCFHS documents before coding [27, 28]. Five sessions, each lasting 1 h, were conducted by two evaluators who engaged in open coding and worked together to develop a comprehensive structure of 39 codes.

Labelling and category formation: Codes were grouped into methods and mapped to strategy families using decision rules: (1) dominant usage across ≥ 2 disciplines; (2) alignment with definitions in medical-education literature; (3) expert-panel adjudication for ambiguous cases. We then integrated codes into five strategy themes with subthemes reflecting authentic usage in curricula.

After additional coding, the themes were revised to align with the research aim. Feedback was evaluated and reviewed, a literature review was conducted, and an expert medical education panel endorsed an educational program outline for enhancement. During planned meetings with all authors, every document was critically reviewed throughout the development of this educational activity. Documents were then analysed by experts in medical education, who presented a framework for an academic activity to address curriculum deficiencies and used the results to define precise categorisations, which ultimately proved helpful in model generation.

Expert review

Following the document analysis, we conducted an expert review with a group of experts to develop the proposed EAs model. This process involved creating a structure for the appraisal, gathering feedback from professionals and the central training committee, and ongoing adaptation to ensure an end product deemed educationally sound and expert-based. This evidence-based, expert opinion, and stakeholder-driven methodology made the framework more practical for implementation in graduate medical education. The expert agreement was measured as verbal consensus during the meeting: for each item, the moderator restated the proposed wording and asked, “Do we agree on this final wording?” Agreement was recorded when all present indicated assent (or when ≥ 80% agreed by show of hands), and the decision, along with any edits, was logged in the minutes. Items without agreement were revised live and re-checked until consensus was reached.

Rigour and validity

Rigour and validity were addressed using the trustworthiness framework proposed by Guba and Lincoln. Credibility was enhanced through triangulation of multiple data sources, including postgraduate curricula documents, related literature, and expert input [29]. In addition, iterative reviewer discussions and consultations with subject-matter experts were used to clarify interpretations and refine extracted information until consensus was reached. Transferability was supported by providing a contextual description of the study setting, including the SCFHS context, program types, and representative examples of educational activities, allowing readers to assess applicability to similar settings [30]. Dependability was strengthened through coding by two reviewers using a predefined Excel-based extraction document, and through the resolution of disagreements via reviewer discussion and third-party adjudication when needed. Confirmability was addressed by maintaining an audit trail of the entire research process, including data collection and analysis, and by ensuring that the process was grounded in the source documents rather than reviewer assumptions [31].

Results

The materials were reviewed by seven expert reviewers in relevant disciplines. The initial review was led by two independent researchers; five others focused on data analysis and theme identification. One hundred twenty-four (69%) of 180 postgraduate training program curricula were included and assessed by random review. Curricula included residency (n = 46), fellowship (n = 57), and diploma programs (n = 21) in medical and health-related specialties.

EAs were directed in two ways: to their application to teaching and learning, and towards their use in formal assessment. Two or more phrases indicating educational activities were identified in the reviewed curricula (Table 1).

Table 1.

Terminology used to refer to educational activities

• Scientific activities

• Formal teaching

• Formal educational activities

• Academic training

• Academic activities

• Periodical education activities

• Academic curriculum

• Teaching and learning activities

• Teaching and learning opportunities

• Program-specific learning activities

• Teaching methods

• Structured activities

A qualitative content analysis was conducted to investigate the teaching and learning dimensions inherent in the curriculum, yielding 56 pedagogical approaches aligned with the definition of EAs. These EAs were subsequently stratified into three categories corresponding to the certification levels offered by each program (fellowship, residency, and diploma). EAs were widely shared between programs, although the extent of sharing varied. Additionally, the same EAs received different types of labels in the analysed curricula. More specifically, journal review, journal club, and systematic review were inconsistently named across distinct curricula, even though they shared the same intended outcome. The following statement was from one curriculum that describes the activity as a journal review:

Trainers and residents may present lectures, workshops, journal reviews, seminars, or case-based learning. All these activities can be conducted with different teaching styles (Saudi Board for Family Medicine Curriculum, 2022, p. 126).

On the other hand, other curricula wrote the activity as a journal club:

A monthly journal club activity should be planned with an assigned tutor…(Pain Medicine Fellowship curriculum, 2022, p. 50).

Expert discussions highlighted that this variability reflected underlying ambiguity in how educational activities were conceptualized across programs. For example, in reference to EAs, an expert stated:

The problem that we have is that we have three buckets, the three pillars, which are knowledge, skills, and attitude, and these buckets have no description, and you can’t blame anyone; people describe them as they understand them.

Some EAs, e.g., written tests, were found in relatively few curricula, while others, e.g., journal clubs, were more prevalent. These consisted of seminars, lectures, simulations, half-day workshops, and practical workshops (Figs. 1 and 2, and 3). As shown in the figures, EAs varied across program levels, but there is greater emphasis on scholarly engagement and reflective practice in followships than in the other levels. This may reflect some degree of heterogeneity in EAs’ use of the training program to instruct and learn year to year.

Fig. 1.

The most common educational activities in residency programs. UT = universal topic; JC = journal club; Lec = lectures; CP&MR = case presentation and morning report; CT = core topics; GR = grand rounds; HD = half day; Sim simulation

Fig. 2.

Most listed educational activities in diploma programs. UT = universal topic; JC = journal club; CP&MR = case presentation and morning report; Cor = courses; WQP = workshops, quality project procedures; SLIT = seminars/lectures/interactive talk/tutorial

Fig. 3.

Most identified educational activities in fellowship programs. UT = universal topic; HD = half day; JC = journal club; Lec = lectures; CP&MR = case presentation and morning report; Con = conference; GR = grand rounds; M&M = morbidity and mortality review

Data from the reviewed documents were coded and analysed, revealing four themes and 10 subthemes (Table 2). In addition, a review of available data and literature was used to generate recommendations to improve the organization by standardizing the delivery of EAs.

Table 2.

Educational activity themes and subthemes identified in the reviewed curriculum

1. Academic instruction

1.1. Didactic

1.2. Interactive

2. Experiential learning

2.1. Clinical

2.2. Authentic learning

2.3. Scholar

3. Self learning and evaluation

3.1. Extracurricular activities

3.2. Low-stake practice tests

3.3. Preassigned activities

4. EA framework design recommendation

4.1 Evaluate engaging EA information for use

4.2 Plan EA framework formulation

The first theme identified was academic instruction, and the research team’s examination of the documents identified two subthemes of EAs within this theme.

• A.Didactic: The analysed EAs often mirrored a didactic approach, imparting instruction and fostering learning among participants. These EAs usually occur in designated locations and involve passive learning. (Fig. 4)
• B.Interactivity: The element of active learning was a recurring approach across the examined curricula. One prominent example was an interaction case presentation, which featured in approximately 63% of the programs.

Fig. 4.

Selected EAs mentioned in all discipline training programs. UT = universal topic; JC = journal club; Lec = lectures; CP&MR = case presentation and morning report; GR = grand rounds; HD = half day; Sim = simulation; M&M = morbidity and mortality review

The second theme identified in the analysis of the teaching and learning components of the curricula and associated EAs was experiential learning. Considerable diversity was apparent in the instructional approaches associated with the experiential learning theme, and three subthemes were identified.

• A.Clinical: In competency-based medical education programs (CBMEs), 25% of the reviewed curricula included practical training. In 12% of the simulations, more than 7% addressed clinical skills and procedures. A few programs (mainly in dental programs) offered specialized activities, such as anatomy labs, flap dissection, small animal labs, and communication consultations; however, these EAs were infrequent.
• B.Authentic learning: Only 14% of the programs used nontraditional methods based on real, authentic clinical learning, such as practice-based, work-based, team-based, problem-based, and self-directed learning. These were most common in fellowships, less common in diplomas, and least common in residencies.
• C.Scholar: Scholarly activities included research, mentoring, method refinement, and community work. These EAs were emphasized in fellowships and largely absent in diplomas.

The third theme identified was self-learning and evaluation, comprising three subthemes.

• A.Extracurricular activities: Many curricula highlight participation in conferences, meetings, and preparatory seminars as keys to professional development. Fewer programs included accreditation involvements, mandatory volunteering, community service, or safety and quality certifications.
• B.Low-stakes practice tests: Among the evaluated curricula, a limited 10% incorporated detailed written assessments, such as multiple-choice questions (MCQ) exams or quizzes, within their educational approach. The performance outcomes from these evaluations then serve as a basis for formative purposes.
• C.Preassigned activities: Regulatory requirements have resulted in the widespread incorporation of specific educational elements within most programs. A significant example of this was the inclusion of activities such as a universal topic review- a program designed to help healthcare professionals build strong, practical knowledge in key medical areas through updated, evidence-based content- which was employed by 69% of all programs, and core specialty topic reviews, which were utilized in 52% of the programs across diverse disciplines. In addition to those core activities, another range of educational methods was observed: online/self-study modules were used in 27% of the programs, whereas scheduled courses or symposia were used in 15%.

The last theme, EA framework design recommendations, is based on stakeholder input and EA data analysis, and a consensus emerged on the need to update training curricula. Experts proposed a strategic roadmap to improve the EA structure, divided into two sub-themes.

• A.Evaluating engaging EA information for use: The participants recommended clarifying and integrating engaging EAs into CBMEs, defining their purpose and use. One participant suggested building on existing strengths to align with regulations and ensure stakeholder acceptance. As one of the experts recommended:

If we standardize these wordings, it would be better and easier for everyone to understand, especially the Academic Activities. Sometimes an academic half-day means literally half a day, and sometimes it means all educational activities.

• B.Plan EA framework formulation: The participants agreed on the need to revise the existing EA to align with competency-based curricula. They noted gaps in teaching and learning strategies and recommended developing a new framework to address evolving needs. Suggestions included reviewing postgraduate health professional education literature—particularly on CBMEs—and consulting key stakeholders, including trainees, for feedback during the framework review process.

Consequently, the EA framework was developed through a literature review and input from subject experts, who identified five main themes in educational activity strategies (Fig. 5). Subthemes, instructional methods, and techniques were also identified within these categories. E-learning through internet technology has revolutionized medical education by offering flexible, interactive resources that can be used either in person or online, with subthemes that can be tailored to individual needs. The components of the EA framework are interconnected across all stages, as shown in Fig. 6.

Fig. 5.

Main strategic themes in educational activities

Fig. 6.

Diagram of the proposed framework of postgraduate educational activities

Theme one

Academic activities focused primarily on intellectual development, scholarly pursuits, and knowledge acquisition through three main subthemes of educational methods.

• A.Scheduled teaching activities guide trainers and trainees through face-to-face, hybrid, or online interactive educational techniques, such as lectures, seminars, tutorials, grand rounds, data interpretation, book reviews, flipped classrooms, critical appraisals of literature, journal clubs, morning reports, online learning, case presentations, and morbidity and mortality reviews.
• B.Half-day education, which is protected time for structured teaching of basic and clinical sciences. There are unlimited educational methods, practical techniques, and/or knowledge that can be delivered through this EA directly or via e-learning hubs: scheduled teaching activities, simulations, case-based learning, problem-based learning, and procedures and skills.
• C.Tests enhanced learning, including exercises performed to enrich learning (NEJM Knowledge+, toolbox, ROSCH, PRITE, and MOCK), can help assess knowledge, strengths, and weaknesses and implement improvements in clinical practice with focused assistance.

Theme two

Practice-based learning is a continuous process occurring through hands-on experience in a real-world setting, emphasizing practical skills and performance evaluations to enhance trainees’ engagement in relevant activities. The theme includes two subthemes, each with its own set of techniques.

• A.The collaborative approach involves trainees and instructors working together in groups to improve understanding and problem-solving, using techniques such as team-based and problem-based learning.
• B.Critical Thinking and Problem Solving: This subtheme supports learners by using techniques such as case-based learning, daily real or virtual rounds, on-call responsibilities, clinic-centered learning, supervision, and interactive case discussions, including multidisciplinary case discussions and joint specialty meetings, to enhance critical thinking and problem-solving skills.

Theme three

Skill training and procedures involving interactive communication between the educator and trainee in patient-related tasks in clinical (e.g., inpatient/outpatient) or nonclinical (e.g., simulation laboratory) settings. Various teaching strategies address challenges in providing safe patient care and promoting learning. This theme involves multiple methods, including role-playing, feedback, creating a secure environment, self-reflection, and patient involvement. This approach yielded two subthemes with associated techniques.

• A.Nonclinical setting educational methods in physical or virtual environments, such as simulations, OSCE labs, and anatomy labs, that do not involve direct patient contact. These EAs can follow the cognitive apprenticeship model, including modelling, coaching, articulation, and exploration.
• B.In the clinical setting, educational methods use authentic situations or digital technology, such as clinical (practical) teaching and training-activated demonstrations, telemedicine, SNAPPS, procedures, and one-minute preceptors.

Theme four

Scholarly projects engage trainees in various programs that involve research, quality improvement, or scholarly activities incorporating study design, data collection, analysis, and findings presentation. Projects such as Patient Safety & Quality Assurance and Civic Engagement require systematic inquiry, critical analysis, and evidence-based practices to enhance patient care and healthcare delivery. There are many subthemes within this theme:

• A.Community engagement includes research, data analysis, academic contributions, and the development of evidence-based educational materials, such as techniques for community activities and volunteering hours.
• B.Research projects support training programs using various teaching methods, covering different aspects of the research process through techniques such as research conduct, biostatistics, and research methodology.
• C.Trainees as Teachers and patient safety and quality assurance projects include safety and quality management manuals, workshops, quality projects, and accreditation inspection techniques. One expert, in reference to the scholarly activity, said:

We are used to thinking only of research when we hear the word scholar, but a scholar is not only about research; it also includes teaching and having our trainees serve as educators.

Theme five

Professional and personal development EAs enable trainees to engage in structured educational programs for professional and personal growth, covering various topics such as healthcare knowledge and practice. These activities include lectures, workshops, and practical sessions offered through diverse learning formats.

This strategy encompasses three subthemes and techniques for use.

• A.Formal teaching activity methods can be used by many teams, such as core education programs and modules, teaching file reviews, and online and mobile self-study modules.
• B.Self-directed learning is an educational method that should furnish trainees with the ability to master any domain of learning independently. Some of the techniques incorporated include reviewing self-assessment portfolios, practices focused on reflection, and mentorship guidance.
• C.General learning opportunities in clinical and academic settings aim to enhance expertise and professionalism through various methods, such as conferences, symposia, workshops, committee involvement, and non-academic volunteer activities, such as administrative tasks, patient care, and community service. Examples of this type of work include public education efforts in public spaces or participation in activities related to Hajj, a mass annual religious pilgrimage.

Discussion

This study was conducted to analyse EAs in postgraduate health training curricula at the SCFHS and establish a structured framework for use. Variations in the terms used for EAs across specialties revealed inconsistencies in methods, objectives, and nomenclature. Confusion arose from mixing up activities with instructional strategies or assessment tools. Specific specialized teams may have overlooked pertinent information regarding EAs, potentially due to differences in interpreting or applying curriculum development protocols [27].

As our results demonstrated, across SCFHS programs, journal club was the most frequently mentioned, consistent with PGME literature showing that journal clubs remain near-universal and are routinely required in many training programs [32]. In contrast, simulation is often underused due to limited resources and factors related to program structure, despite substantial educational value [33], which explains our result of the least utilization of simulation.

The initial theme, academic instruction, revealed confusion between instructional methods and strategies, affecting the alignment of EAs with rotational goals. The medical education literature often categorizes EAs as methods or techniques, such as “half-day sessions,” even though they are instructional strategies [34]. This lack of organization contradicts optimal practices for trainee performance [35].

The second theme, experiential learning in health professional education, matched current teaching methods [36]. Most instructional tools used with CBMEs work well; however, confusion exists between specific methods and broader strategies [37]. For example, some programs presented work-based learning as a methodological tool, whereas the associated descriptions were better suited to a strategic classification, thereby generating ambiguity [38]. The ‘scholar’ subtheme lacked organization, making it difficult to determine whether scholarly activities were part of training or merely mandatory [39]. The 14% uptake of authentic, clinically anchored methods mirrors reports that postgraduate programs still lean toward didactics despite CBME’s emphasis on learning in and from work. Evidence shows that workplace/experiential learning, along with aligned tasks (e.g., EPAs), strengthens transfer and readiness for practice [40].

The third theme focused on self-directed learning and performance reviews, highlighting a lack of clear goals in educational initiatives. Various instructional methods, including extracurricular activities, have been used to enhance trainees’ progress; however, research on postgraduate training is limited. Identifying activities is crucial for improving quality and impact on education [41]. These activities should align with program competencies and use a task-based learning (TBL) approach for professional development [42]. The goal is to refine competencies and prepare trainees for real-world applications in clinical and academic settings [43]. Modified TBL approaches can effectively support postgraduate education goals [44].

The final theme, EA framework design recommendations, provided practical suggestions for designing an EA framework to address existing shortcomings. This theme focused on structuring instructional processes and ensuring effective learning outcomes. The recommended EA framework aims to streamline planning processes, support curriculum development, and employ backward design methodology in assessment procedures [28]. The purpose of this framework was to encompass all learning areas, from clinical practice to academic study, across all training initiatives [45]. The framework’s development involved common stages incorporating established instructional strategies [46, 47].

Lastly, the experts’ input on reviewing the literature guided us in proposing our findings for the framework. It shows that postgraduate training involves far more than lectures and ward rounds. It spans academic activities, practice-based learning, skill training, scholarly projects, and professional development. There was a call for a more defined framework of instructional activities in undergraduate education [10]. We found that organizing postgraduate medical education practices into categories helps reduce overlap and inconsistency. By doing this, programs can ensure learners have a balanced mix of didactic, experiential, and reflective learning opportunities, rather than relying on tradition or convenience.

Furthermore, our framework themes highlight the importance of aligning teaching methods with competency-based outcomes [48]. This is achieved by integrating simulation, e-learning, and problem-based approaches, which are effective teaching methods in postgraduate medical education [5]. At the same time, including scholarly projects and leadership development aligns with calls for graduate medical education to place greater emphasis on research, quality improvement, and patient safety [40]. In this sense, our results support the view that postgraduate education is evolving toward a more holistic, learner-centered model. Moreover, we see value in how this framework can humanize training experiences. Rather than treating EAs as isolated requirements, the five themes illustrate how intellectual growth, practical skill, and professional identity development are interconnected. This resonates with calls for reflective practice and self-directed learning as essential elements of medical professionalism [49].

Targeted application of the framework’s themes can tighten the link between activities and competency outcomes. For instance, within Theme One (Academic activities), programs should explicitly map scheduled teaching (e.g., seminars, journal clubs, flipped classrooms) and half-day education to milestone-level knowledge goals [50], then close the loop with practice (retrieval) tests to diagnose gaps and trigger individualized remediation [34, 51]. In Theme Two (Practice-based learning), the collaborative approach (team-based/problem-based learning) and the “critical thinking and problem solving” subtheme (case discussions, on-call, daily rounds) can be sequenced so that trainees first co-construct mental models in teams and then stress-test those models during real or simulated clinical decision-making [37, 52]. Similarly, Theme Three (Skill training and procedures) benefits from a deliberate progression: begin in nonclinical settings using a cognitive apprenticeship arc [53], then transition to clinical micro skills, e.g., SNAPPS [54], one-minute preceptor [55] with structured feedback and reflection to consolidate performance under supervision [56].

The framework also clarifies where scholarly and professional growth intersect with patient care. In Theme Four (Scholarly projects), curricula can braid research methods/biostatistics with safety and quality projects so trainees learn study design while advancing tangible QI outcomes [57] and “Trainees as Teachers” can formalize peer-teaching via workshops and PAL to spread expertise across cohorts [58]. Theme Five (Professional and personal development) then sustains longitudinal growth through self-directed learning (mentored portfolios, reflective practice) and general learning opportunities (conferences, committee work, civic engagement, e.g., Hajj-related public-health activities), ensuring identity formation and systems awareness evolve alongside clinical skill [59]. Together, these subthemes operationalize a coherent sequence—from knowledge acquisition to applied performance, scholarship, and professionalism—reducing variability across programs while preserving flexible delivery (face-to-face, hybrid, or e-learning) aligned with competency-based aims.

Limitations of the study

The study has two main limitations: the lack of established enterprise architecture EA frameworks for guidance and the lack of representation of key stakeholders, such as trainees and representatives from nursing and health-aligned programs. Involving these groups in future development and seeking feedback could enhance the framework.

Recommendations for future research

Future research should incorporate the proposed EA framework into postgraduate training programs, allowing flexibility to account for resources available to trainees and trainers.

Conclusion

Creating an evidence-based framework for postgraduate education fosters ideal learning conditions and aligns with training goals. The framework includes adaptable strategies, diverse methods, and focused techniques, guiding instructional choices and emphasizing the crucial role of assessment in supporting learning. Designed as a universal model, the EA framework is suitable for a wide range of programs and training environments.

Abbreviations

SCFHS

Saudi Commission for Health Specialties

EAs

Educational activities

CBME

Competency-Based Medical Education

OSCE

Objective Structured Clinical Examinations

MCQ

Multiple-choice questions

TBL

Task-based learning

SNAPPS

Summarize, Narrow, Analyze, Probe, Plan, Select

PAL

Peer-assisted learning

Appendix

Full question(s) asked aloud (verbatim script)

Opening prompt.

“We will show each part of the framework (strategy → method → technique).

For each item, please tell us if the definition is clear, if the set feels complete for postgraduate training, and suggest exact wording changes if needed.”

(Clarity).

Q1 Is the definition of Strategy: Scheduled/Synchronous Teaching clear as written? If not, what exact wording would you use?

Q2 Is the label and definition of Method: Journal Club clear? If not, propose precise edits?

Q3 Is the label and definition of Technique: Structured Appraisal Checklist clear? Suggested wording?

(Completeness).

Q4 Looking across the lists, are we missing any strategies, methods, or techniques that are common in postgraduate training?

(Applicability).

Q5 As written, is this framework applicable to CBME in postgraduate programs?

(Feasibility).

Q6 Is it feasible to use these labels/definitions in program documents?

(Global edit).

Q7 Please propose exact text to improve any definition or label you rated as unclear.

Authors’ contributions

AR contributed to data collection, analysis, and the development of the process and methodology. He was also involved in writing and refining the manuscript and coordinating the panel meeting.AO focused on analyzing and contributing to the methodology, interpreting the reviewed documents, and compiling data related to the definition of educational tools and theme design. TK was instrumental in formulating the themes and facilitating stakeholder perspectives. She also helped organize the manuscript. NR emphasized data discovery and conducted literature reviews, data interpretation, and thematic preparation. FC was important in conceptualization, reviewing, and rewriting the development of the process and methodology, as well as addressing the journal reviewers’ comments. All authors supervised, reviewed, and approved the final manuscript.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability

The data used in this study are available from the corresponding author upon request.

Declarations

Consent for publication

Not applicable.

Ethics approval and consent to participate

Ethics approval and informed consent was obtained in accordance with the guidelines for non-clinical research. Verbal informed consent was obtained from all the participants, including for the publication of their anonymized responses. This study was approved by the Institutional Review Board of the Ethical Committee at the postgraduate academic Center, Security Forces Hospital, Riyadh, Saudi Arabia (H-01-R-069). The data were stored securely. Confidentiality was upheld. This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki.

Competing interests

The authors declare no competing interests.