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Paper presented at a Medical Education Workshop held at the Faculty of Medicine University of Science and Technology Sana’a, Yemen 14-27 June 2007 by Professor Omar Hasan Kasule Sr. MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Professor of Epidemiology and Islamic Medicine at the Institute of Medicine Universiti Brunei Darussalam. WEB: http://omarkasule.tripod.com
ABSTRACT
The paper presents and discusses modern approaches to medical education emphasizing an integrated curriculum that is student-centered and student-driven. It provides an outline of the contents of a curriculum that in the opinion of the author will produce a physician with the appropriate knowledge, skills, and attitudes to practice in a modern medical setting. The following themes are proposed for the curriculum: basic medical sciences, clinical disciplines, research skills, psycho-social skills, and ethico-legal skills. They are taught in an integrated way that is based on a medical problem as a trigger and the aspects of the various themes relevant to that problem are then taught at the same time.
1.0 INTEGRATION
1.1 Vertical & Horizontal Integration:
The curriculum is not isolated pieces of information that the student has to put together in his mind. The teachers must design the curriculum in such a way that there are logical connections within one theme and between themes. This ensures that the student gets ‘integrated’ understanding of the body and medical treatment. This also conforms to what happens in the real world. A student confronted by a patient will have to use knowledge and skills learned in different disciplines to manage the illness.
1.2 Integration of Themes and Modules:
The major themes of the curriculum should be integrated throughout the length of the medical program as well as in each module. The modern approach to medical education is to teach all themes from the start however the proportion of time allocated to each theme varies according to the stage of education. In the first year basic medical sciences predominate whereas in the third year clinical disciplines predominate. Within each block of study the student should be able to integrate the various themes. For example if a block of time is devoted to the study of the respiratory system, various themes will be taught in that same week: the anatomy of the respiratory system, the histology of the bronchial tree and the alveoli, the mechanics of breathing, the physiology of gaseous exchange, respiratory disorders, physiological measurements and experiments about respiration and gaseous exchange, psychological and social impact of respiratory disorders, Islamic teachings relating to the respiratory process and respiratory disorders, ethico-legal issues relating to respiratory disorders, the epidemiology of respiratory disorders, clinical skills (in the clinical skills laboratory) related to respiratory disorders, visit to a hospital ward or health clinic to see the management of patients with respiratory disorders.
1.3 Integration of Islamic Values:
Medicine cannot be practiced in a social and cultural vacuum. Successful communication and interaction between a physician and the patient requires that the physician understands and appreciates the patient’s socio-cultural background. The Islamic input in the medical curriculum can either be on basic conceptual issues such as the role of pre-determination, qadr, in the causation and cure of disease or it can be on ethico-legal issues in medicine, fiqh tibbi, such as for example how does a sick patient pray or what is the Islamic ruling on non-therapeutic abortion.
1.4 Integration of Knowledge, Skills, Attitudes, and Behavior:
Medical education should be holistic in approach. The skills and knowledge that are taught must be reflected in the attitudes and behavior of the physician.
2.0 BASIC MEDICAL SCIENCE THEME
2.1 Scope
An integrated study of structure (macroscopic anatomy, microscopic anatomy, and biochemistry); function (biochemistry, physiology, and pharmacology), disease (pathology, microbiology, and parasitology), and clinical correlations
2.2 Study of Structure
2.2.1 Microscopic anatomy/histology: structure of different types of cells and tissues: cardiovascular system (arteries, veins, blood capillaries), respiratory system, excretory system, reproductive system, endocrine system, alimentary system, hematological system, immune system, musculoskeletal system (cartilage, bone, joints, skeletal muscle, cardiac muscle, smooth muscle), nervous system (neurone, central nervous system, peripheral nervous system, somatic nervous system, and autonomic nervous system)
2.2.2 Developmental anatomy: developmental periods, gametogenesis, fertilization, implantation, formation of germ layers and early differentiation, organogenetic period: 4-8 weeks, and fetal period (9 weeks to birth), post natal development (briefly).
2.2.3 Macroscopic anatomy by body region (regional anatomy): upper limb, thorax, abdomen and pelvis, lower limb, head, neck, and spinal cord. Macroscopic anatomy can be learned using cadaver dissection, computer models, or plastic models in the anatomy resource room.
2.2.4 Functional/clinical anatomy relating structure to function by organ system: cardiovascular, respiratory, excretory, reproductive, endocrine, alimentary, hematological, immune, musculoskeletal, and nervous systems, sensory system (optic, auditory, tactile, temperature, etc).
2.3 Study of Normal Life Processes
2.3.1 Basic Life Processes at the cellular level: anatomy of the cell, organelles structure and functions, cell growth, cell differentiation, cell multiplication, cell genetics (including structure, function, metabolism, and replication of nucleic acids: DNA & RNA), definition and functioning of genes, abnormalities of cell division and replication, genetic control of protein synthesis, the cell membrane (structure and functions), transport mechanisms within and between cell, abnormal cell growth (mutation & neoplasia, hyperplasia, and hypertrophy, and dysplasia).
2.3.2 Basic Life processes at the molecular level: structure, function, and metabolism of enzymes & co-enzymes; structure, functions, and metabolism of dietary macromolecules (carbohydrates, lipids, proteins); structure, function, and metabolism of dietary micromolecules (vitamins, minerals, trace elements); respiration (aerobic and anerobic, gaseous exchanges); classification, action, and metabolism of therapeutic agents; metabolism of nucleic acids, metabolism of hemoglobin, immune mechanisms, inflammatory mechanisms, metabolic diseases,
2.3.3 Basic life processes at the tissue or organ level: digestion and absorption, respiration, liver metabolism, renal excretion, hormonal control and regulation, water balance, electrolyte balance, acid-base balance, heat balance, energy balance, inflammatory responses and sequelae, membrane and action potentials in neurons, the neuro-muscular junction, contraction of muscles, and the heart as a pump, blood circulation, and temperature regulation
2.3.4 Physiological functions including homeostasis, control, and equilibrium for organ systems: cardiovascular, respiratory, excretory, reproductive, endocrine, alimentary, hematological, immune, musculoskeletal, and nervous systems, sensory system (optic, auditory, tactile, temperature, etc). The study will involve understanding quantitative physiological measurements and laboratory physiology experiments
2.4 Study of Abnormal Life Processes (Structural and Functional)
2.4.1 Causes of cell/tissue injury: trauma, toxins, infection, immune reaction, chemical agents, physical agents like radiation, nutritional deficiencies
2.4.2 Reaction of cells and tissues to injury (pathology); genetic basis of disease, pathological processes at cellular levels (necrosis, apoptosis), pathological processes at tissue level (inflammation, genetic disorders, infection, immunity, and neoplasia), pathological manifestations at tissue or organ levels (wound healing, thrombosis, embolism, edema), pathological manifestations by organ system: cardiovascular, respiratory, excretory, reproductive, endocrine, alimentary, hematological, immune, musculoskeletal, and nervous systems, skin, eyes, ears; pathological manifestations of multi-system disease (SLE, RA, Sarcoidosis, diabetes mellitus, amyloidosis, etc)
2.4.3 Interaction with the microbiological environment (infection and immunity): classification, structure, epidemiology, and infections of common bacteria, viruses, fungi, protozoa, and helminthes.
2.4.4 Interaction with artificial molecules (pharmacology, drug therapy, poisons and toxins): pharmacokinetics and pharmacodynamics, classes, properties, and therapeutic uses of pharmacological agents, drug interactions, adverse drug reactions, writing and reading drug prescriptions, types of poisons (chemicals, pesticides, drugs of abuse)
2.4.5 Determinants of human disease: Biological determinants (age, gender, genetic), behavioral determinants (lifestyle, malnutrition), environmental determinants(infections and physical agents such as heat, cold, and radiation, air pollution, water pollution, soil pollution, ecopoisons, pesticides). Social determinants (the socio-economic status, occupation, race, ethnicity, and medical care).
2.4.6 Common disorders: Etiology, symptoms, signs, psychological response, patho-physiological manifestations, investigation, and management of disorders of organ systems: cardiovascular, respiratory, excretory, reproductive, endocrine, alimentary, hematological, musculoskeletal, nervous systems
2.5 Clinical Correlations
2.5.1 Background: Aspects of basic medical sciences taught in a week or any other selected block of time should be correlated with clinical experience by having students discuss actual relevant clinical cases. If for example the anatomy of the upper limb is taught, students can be given cases of fractures of the humerus, the ulna and the radius for analysis. They will be able to study the effects of the fracture on the nerves and blood vessels of the upper limb. The case could be extended to study the effects of an infected compound fracture and other aspects. The underlying philosophy is to let them realize that the knowledge they get has actual real life applications.
2.5.2 Problem-based study of clinical correlations in basic sciences by organ systems: cardiovascular system (coronary artery disease, congestive heart failure, venous thrombosis), respiratory system (pulmonary tuberculosis, lung cancer, chronic obstructive pulmonary disease, cyanosis), excretory system (urinary tract infection, renal failure, benign prostatic hyperplasia), reproductive system (menstrual disorders, infertility, cervical cancer, disorders of sexual function, genital tract infection), endocrine system (diabetes mellitus, disorders of the thalamus, pituitary disorders, hypo/hyper thyroidism, hypo/hyper parathyroidism, adrenal disorders, pancreatic disorders), alimentary system (gastro-intestinal bleeding, diarrhea and vomiting, malabsorption, inflammatory bowel disease, colon cancer, liver failure, gall bladder stone, hepatitis, liver cirrhosis, ascites, splenomegaly), hematological system (anemia, leukemia, clotting disorders, thrombosis), musculoskeletal system (fractures & dislocations, arthritis, muscle diseases, disorders of the neuro-muscular junction, back pain, spinal fracture, spinal degeneration), nervous system (degenerative dementias, meningeal infections, cerebrovascular disease, median /radial nerve injury, cranial nerve injuries, head injury), skin (eczema, psoriasis, infections, incisions, burns), eye (refractory errors, papilledema, glaucoma, paralysis of extra orbital muscles), ear (otitis media, hearing disorders), nose (sinusitis, rhinitis, epistaxis), teeth (dental caries, gingivitis).
2.6 Signs of the Creator
2.6.1 Reading 2 books: There are 2 books for humans: the Qur’an which is the books of revelation, kitaab al wahy, and the environment, kitaab al kawn. Both books contain the signs of Allah, ayaat al llaah. Each of the books leads to belief, iman, but for deeper iman the 2 books should be read together. Studying medical sciences is reading the kitaab al kawn.
2.6.2 Signs of the Creator in the human organism, ayaat al allah fi al anfus: Study of medical sciences with deliberation reveals the following signs of Allah in His creation: perfection, kamal al khalq; optimality of creation, beauty of creation, jamal al khalq; incomparability of Allah’s creation, ‘ajz al shurakaa.
3.0 CLINICAL DISCIPLINES THEME
3.1 Scope
Clinical training consists of history taking (general and by organ system), physical examination (general and by organ system), and basic clinical skills
3.2 Sites
Clinical training takes place in the hospital, health clinics, special institutions, and the clinical skills laboratory
3.3 Basic Clinical Skills Learned in the Clinical Skills Laboratory
The following are examples of clinical skills that can be taught in the clinical skills laboratory. The list is not exhaustive.
· abdominal centesis,
· anthropometric measurements,
· audiometric measurements
· catheterization of the urethra,
· collection of sterile urine,
· ECG recording using 12 leads,
· examination (per rectal & per vaginal),
· figure prick and simple tests,
· injection (im, iv, sc, id), close wound using steri strips,
· life support(basic),
· lumbar puncture,
· naso-gastric tube insertion,
· operating theater protocol (scrubbing & gowning),
· refraction measurements,
· respiratory measurements (peak flow),
· taking a swab for microbiological examination,
· temperature measurement,
· venepuncture,
· wounds (cleaning, dressing, and simple suturing),
· writing and reading a drug prescription,
3.4 Basic Laboratory Skills
There are many laboratory skills that a medical students needs to learn performing. This has two purposes. In practice it may be quicker for the physician to carry out a simple test in of 2-3 minutes his office instead of collecting and sending a specimen to the laboratory. Carrying out such tests makes the physician appreciate the results and their level of accuracy and reliability because he has gone through the process instead of relying on a printed laboratory report. Examples of such simple tests are: urinalysis (microscopy, distix, culture urine on agar plate), dextrostix examination, H&E staining,
3.5 Major Clinical Postings (8-12 Weeks Each):
· internal medicine
· general surgery,
· pediatrics,
· obstetrics and gynecology,
· psychiatry
3.6 Sub-Specialty Medical Clinical Postings (0.5-2 Weeks Each)
· intensive care unit,
· endocrinology,
· gastro-enterology,
· neurology,
· onco-hematology,
· renal,
· cardiology,
· oncology,
· geriatrics)
3.7 Sub-Specialty Surgical Postings (0.5-2 Weeks Each)
· A&E/triage,
· anesthesia,
· cardio-thoracic surgery,
· neuro-surgery,
· ophthalmology,
· orthopedics
3.8 Para-Medical Postings (0.5-2 Weeks Each)
· radiology,
· chemistry laboratory,
· microbiology laboratory,
· pathology/forensic laboratory,
· nutrition and dietetics
4.0 RESEARCH SKILLS THEME:
4.1 Scope
Quantitative and methodological skills (epidemiology & biostatistics
4.2 Mathematical Foundations
Introduction to quantitative methods; Probability; Variables; Hypotheses I: use of the null and alternative hypotheses in the scientific method; Hypotheses II: hypothesis testing and interpretation of tests of results; Sampling; Introduction to computing.
4.3 Descriptive Statistics
Data storage and retrieval; Data presentation as diagrams; Discrete data summary; Continuous data summary I: averages; Continuous data summary II: measures of variability based on the mean; Continuous data summary III: other measures of variability: quantiles, the range, and the percentile rank; Continuous data summary IV: other measures of variability / dispersion):
4.4 Quantitative Disease Measures
Incidence I: incidence number and incidence rate (IR); Prevalence (P): point and period prevalence; Cumulative incidence (CI) and the relation IR and P; Measures of excess disease occurrence I: OR and RR; Measures of excess disease occurrence II: RD and AR; Statistical parameters of diagnostic tests I: sensitivity, specificity, and PV; Statistical parameters of screening tests II: FP, FN, lead time and length bias
4.5 Analytic Statistics
Discrete data analysis; Continuous data analysis; Correlation analysis; Regression analysis I; Regression analysis II; Time series analysis; Basics of survival analysis;
4.6 Study Design and Analysis
Sample selection and data collection; Cross-sectional study; Case control study; Follow-up / cohort study; Randomized study: community; Randomized study: clinical; Health surveys;
4.7 Study Interpretation
Measures of association: t test; Measures of association: F test; Measures of association: chi square; Measures of effect: risk ratio and odds ratio; Sources of bias & treatment of bias I: selection bias; Sources and treatment of bias II: misclassification bias; Sources and treatment of bias III: confounding bias.
5.0 COMMUNITY HEALTH SKILLS THEME
5.1 Scope
Descriptive epidemiology of disease, disease prevention and health promotion
5.2 Public Health
Health promotion & disease prevention; Health and environmental protection; Scope and functions of public health; Methods and strategies of public health; Health policy, planning, and financing; Contemporary challenges of public health
5.3 Exposure Epidemiology
Environmental exposures; Occupational exposures; Nutritional exposures; Radiation exposures; Genetic exposures; Other exposures:
5.4 Disease Epidemiology
Disease: description and classification; Disease: determinants and risk factors; Disease: control and prevention; Disease: surveillance; Disease: screening for early detection;
5.5 Communicable Diseases Epidemiology
Epidemiology of viral diseases; Epidemiology of bacterial diseases; Epidemiology of protozoal diseases; Emerging and re-emerging infections; Management of disease epidemics;
5.6 Non-Communicable Disease Epidemiology
Epidemiology of cancer; Epidemiology of cardiovascular diseases; Epidemiology of chronic respiratory disease; Epidemiology of diabetes mellitus);
5.7 Social Epidemiology
Lifestyle and addiction problems; Violence; and Poverty
6.0 PSYCHO-SOCIALSKILLS
6.1 Scope
Psychology and sociology
6.2 Psycho-Social Changes in the Life Cycle
Infancy, early childhood, late childhood, adolescence, young adulthood, middle age, old age
6.3 The Family Institution, Al Bayt:
Gender, family as a natural social unit, marriage, parents and relatives, children
6.4 Community Institutions, Muassasaat Al Jama’at:
Masjid, ukhuwwat, takaful, shuura, maal
6.5 Community Problems, Mashaakil Al Jama’at:
Life-style, sexual perversions, addiction, poverty, violence
6.6 Community Action, Al ‘Amal Al Ijtima’e:
Dawa, enjoining the good and forbidding the bad, amr & nahy, social change, taghyiir ijtima’e, professional and occupational organizations, social welfare and disaster relief organizations.
6.7 Community Transactions:
Civil transactions, mu’amalat madaniyyat; financial transactions, mu’amalat maliyyat; and judicial transactions, mu’amalat qadha’iyyat
7.0 ETHICO-LEGAL SKILLS
7.1 Sources, Purposes, Principles of the Law:
Sources of the law, masadir al shari’at, purposes of the law, maqasid al shari’at, principles of the law, qawa’id al shari’at, & regulations of the law, dhawaabit al shari’at
7.2 Ethico-Legal Basis of Medicine:
Purposes and principles of medicine; regulations of medical procedures, dhawaabit al tatbiib; regulations of research procedures, dhawaabit al bahath; regulations of physician conduct, dhawaabit al tabiib; regulations about professional misconduct, dhawaabit al inhiraaf al mihani
7.3 Etiquette of the Physician, Adab Al Tabiib
Etiquette with patients and families, etiquette with the dying, etiquette with the health care team, etiquette of research on animals, etiquette of research on humans
7.4 Fiqh ‘Ibaadaat Al Mariidh(Physical Acts of Worship for the Sick):
Taharat, salat, saum, zakat, and hajj
7.5 Fiqh al ‘aadaat (Physiological Conditions): menstruation, al haidh; human sexuality, shahwat al jins ; pregnancy, al haml; delivery, wadhau al haml; breast-feeding, ridha’a
7.5 Activities of Normal Living, ‘Aadaat Al Ma’ishat: hygiene, al nadhaafat; 24.2 foods, at 'imat; drinks, ashribat; activity, nashaat; sleep and rest, nawm & raahat
7.6 Fiqh al amraadh (Pathological Conditions): conditions of organ systems; psychiatric conditions, amraadh nafsiyyat; neurological conditions, amraadh al a’asaab; age-related conditions, amraadh al ‘umr
7.7 Fiqh mustajiddaat al tibb (Modern Medicine): assisted reproduction, taqniyat al injaab; contraception, mani’u al haml; reproductive cloning, al istinsaakh; abortion, isqaat al haml; artificial life support, ajhizat al in’aash; euthanasia, qatl al rahmat; solid organ transplantation, naql al a’adha; stem cell transplantation, naql al khalaayat; change of fitra, taghyiir al fitrat
8.0 PERSONAL DEVELOPMENT SKILLS
8.1 Character Development
Character, determined by personality, is internal. Its outward manifestation is behavior, good or bad. Consistent observation of behavior over a long time reveals true character. The following are some of the components of a positive character: Piety, generosity, charity, chastity, trust, humility, balance, moderation, patience, endurance, cooperation, forgiving, ignoring stupid company, reconciliation, honor and dignity, shyness, modesty, integrity, courage, and wisdom. These traits are best manifested in an atmosphere of positive attitudes, optimism, and behavior. Positive behavior includes: controlling appetites (eating little, fasting, sexual self-control), fulfilling needs of others, mercy, good words and acts; and good deeds which wipe out bad ones.
8.2 Self-Improvement
Self-improvement requires commitment, effort and action to achieve goals, taking responsibility, learning from previous experiences (positive and negative), interdependence, pursing real needs and not mere wants, a positive attitude, a futuristic outlook, assertiveness, self-confidence, and self reliance, and contentment.
8.3 Taking Charge
Being assertive is learning to take control. A person who has self-control can stand up to the temptations of shaitan. The following are ingredients of self control: self-confidence, self-esteem, self-reliance, self-discipline, and self-development. Self-confidence is to know yourself, your strengths and weaknesses, to be comfortable with what you are, and to be psychologically secure. Psychological security raises self-esteem. Self-help and self-improvement are in essence taking charge of your life, relying on yourself in solving problems, and taking the initiative to improve. Self discipline is needed for success and consists of control of whims and emotions, sticking to goals, acting according to long-term and not short-term interests, avoiding impulsive acts, following the head and not the emotions, and trusting your instincts. An entrepreneurial attitude requires initiative, optimism, self-confidence, creativity, taking calculated risks, looking for and exploiting opportunities, perseverance and determination.
8.4 Social Development
Social development starts with selection of a spouse and starting a family. It involves learning to develop social networks and taking social responsibilities in the community.
8.5 Professional Development
The factors behind professional success are a good basic education, postgraduate training, apprenticeship to a good mentor, setting goals and a time frame to achieve them, adopting a growth strategy, delivering quality results in the work and not seeking cheap publicity. Professional networking involves identification of strategic partners for mutual benefit and not manipulating or exploitation. The networking starts within Muslim circles and extends to the wider professional and social circles. Nurturing contacts is very important otherwise they get lost. Economic empowerment should have the objective of eventual self-employment. A long-term development plan must be made. Putting side some of the monthly earnings for asset accumulation and investment ensures financial stability and expansion of the Muslim economic base.