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070627P - TEACHING AND LEARNING METHODS IN AN INTEGRATED UNDERGRADUATE MEDICAL CURRICULUM

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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
Modern medical teaching and learning must be integrated, innovative, student-centered, and sensitive to local cultural and educational realities. This paper presents practical details on dividing the curriculum into themes and modules, writing course outlines, and writing learning objectives. It then discusses and critiques in detail two common methods of medical education: problem-based learning and lecturing. It ends by giving the author’s opinions about the roles of medical education units in a faculty of medicine.



1.0 GUIDING PHILOSOPHY
1.1 Integration
Modern teaching and learning in medicine has to be integrated. Various disciplines have to be coordinated in the process so that the student gets an overall view of a system of the body. Integration means that the anatomy of an organ is taught at the same time as its functions and disorders are taught. This method of teaching and learning is more effective that the traditional method when teaching was compartmentalized by discipline with little reference and coordination with other disciplines.

1.2 Innovation
Medicine and the methods it is taught are changing continuously because of the growth of knowledge. This requires an innovative approach in which changes are made continuously in response to changes. We cannot be fixated on a certain approach that proved successful in the past. It can quickly become irrelevant. What is needed is local innovation and not importing and implementing any new idea that we hear. That type of blind following, taqliid, is condemned by the Qur’an. Much of what is imported may be irrelevant in view of the local culture and local educational realities.

1.3 Student Centered and Student-Directed Learning (SDL)
Medical education like other disciplines has undergone a tremendous transformation from being teacher-driven to being student-driven and student-centered. The student is no longer a passive receiver of information but an active participant in the search for and internalization knowledge. This has forced a change in the role of the teacher to become a facilitator of the learning process. Practical experience with the new approach to medical education has shown its strengths and weaknesses. The conclusion from weighing the strengths and weaknesses is that the best approach is a judicious balance between teacher-directed and student-directed learning.

1.4 Sensitivity to Student Religious and Cultural Background
Medicine is not taught or learned in a cultural or ideological vacuum. The students are being educated to be future physicians who will work in a specific cultural milieu. They therefore must have cultural and religious values integrated in their education to equip them with the communication and other skills that will enable them to interact successfully with the patients.


2.0 THEMES AND MODULES
2.1 The Main Themes are: basic medical sciences, clinical disciplines, research skills, community health, psycho-social skills, and ethico-legal skills. These themes are covered all through the course with varying proportions. For example basic medical sciences are emphasized in the first 2 years while clinical disciplines are emphasized in the last 3 years.

2.2 Modules / Courses:
The themes are integrated into modules that are bound by semester or term.: The first modules cover basic life processes and the relation between function, and structure while later modules are based on organ systems.


3.0 WRITING A MODULE/COURSE OUTLINE/DESCRIPTION
All teaching activity should be organized as courses for proper definition of the material to be taught and the level of effort needed.
A course description should be written in such a way that a reader will be able to get a clear idea of what the course covers and how it is taught. A course description should preferably not exceed 1-2 pages. The main elements of a course description are the following:
  • Name of the Faculty: sometimes the courses may be joint involving 2 faculties
  • Name of Department: Some courses are specific for one department but the general tendency is towards interdisciplinary courses whose scope covers more than one academic discipline.
  • Program: This refers to the academic qualification to which the course contributes. I may be the medical degree for undergraduate medicine. It may also be for a post graduate program, a diploma, or any other program in the faculty
  • Course Title: This is a descriptive title for the course that should not exceed 50 words at the most. The best course titles are below 25 words. The course title should be written with care to include all the essential key words keeping in mind that many people will make various decisions regarding on the course based only on its title.
  • Course Code: For recording purposes each course should have a code that is used instead of writing out the full title. The code usually is a combination of letters and numbers. The letters represent the department while the numbers represent various facts about the course. The first digit could for example indicate the level of the course (e.g. 4=undergraduate, 5=diploma, or 6=postgraduate). The second digit may indicate the level of the course (1=introductory, 2=intermediate, 3= advanced). The third digit may indicate the serial number of the course if a certain subject matter is given in more than one course. The 4th digit may indicate the number of credit hours. In this way every letter and digit of the course code conveys information about the course.
  • Status: The course may be required or may be optional
  • Level: undergraduate or postgraduate
  • Credit hours: The amount of effort in a course is measured in credit hours. One credit hour is usually equivalent to 15 classroom contact hours. Each faculty should establish its own formula for equivalence between hours of classroom teaching and hours spent in other academic activities such as demonstrations or other forms of practical work.
  • Distribution of contact hours: The contact hours specified for the course should be broken down as lectures, assignments, practical work, demonstrations, etc
  • Pre-requisites: These are courses that should be taken before taking the present course. The pre-requisite course contains information that is necessary for understanding the present course.
  • Co-requisites: This is a course that helps understand the present course. Unlike the pre-requisite it can be taken contemporaneously with the present course.
  • Teaching methodology: This describes how the course will be taught. It could be lectures, assignments, presentations, problem-based, etc.
  • Methods of evaluation: This describes the various forms of course evaluation: class participation, continuous assessment, assignments, student seminar, and final examination.
  • Course coordinator: This is the name of the lecturer or lecturers responsible for the course.
  • Course objectives: This is a brief statement of the main objectives of the course.
  • Course synopsis: This is a summary of the scope and contents of the course.
  • Course outlines: This is a listing of all the topics of the lectures or sessions of the course
  • Required references (use most recent edition): This gives the main reference book for the course
  • Recommended references: Other references and supplementary material for the course.


4.0 FORMULATING LEARNING OBJECTIVES
4.1 Description of Learning Objectives (LOBs)
The term LOB is used to refer to the educational outcomes from a teaching/learning session. LOBs have to be written for each topic in the course outline. There is no minimum or maximum number of LOBs per topic because topics differ in complexity and in the amount of time needed. The LOBs can be subdivided into logical subdivisions of the topic. They also can be subdivided according to the time period for example by day or by week. Teaching, student feedback, and assessment are based on LOBS. The teacher must make sure that all LOBs are covered adequately. Students have to give feedback on how well they were taught and how well they were satisfied with each LOB. The examination is also based on the LOBs. The examiner must have the LOBs in front of him while writing examination questions so that each examination question is related to a specific LOB.

4.2 Action Verbs Used in Formulating LOBs.
Learning objectives must be written in a direct, active, and action-oriented manner that is why verbs have to be used. The following list of verbs was developed by the School of Medicine at Flinders University. Verbs relating to knowledge are: define, repeat, record, list, recall, name, relate, and draw. Verbs related to application are: translate, interpret, apply, employ, use, demonstrate, dramatize, practice, illustrate, and sketch. Verbs related to comprehension are: restate, discuss, describe, explain, express, identify, locate, report, review, and tell. Verbs related to synthesis are compose, plan, propose, design, formulate, arrange, assemble, prepare, construct, create, set up, and organize. Verbs related to analysis are: distinguish, analyze, differentiate, appraise, calculate, experiment, test, compare, contrast, criticize, diagram, inspect, debate, question, relate, solve, and examine. Verbs related to evaluation are: estimate, measure, assess, compare, revise, and select.

4.3 Weekly Evaluation of Learning Objectives:
Students at the end of the week are given a questionnaire to evaluate their learning of LOBs. Alternatively they could be given a weekly MCQ quiz to test level of achievement. Results of the evaluation are used to remedy any deficiencies. The quantitative evaluation must state the minimum score, the mean score, the maximum score, the median score, and the standard deviation for each LOB.

4.4 Weekly Contact Hours
An estimate must be made of the contact hours needed to cover each LOB. At the end of the week or whatever other period of time is used, the estimated time is compared with the actual time and the variances are explained.


5.0 PROBLEM-BASED LEARNING
5.1 Description:
PBL is learning that starts with a problem. As the students search for the solution to the problem they get to learn. It is learning in the real world of actual problems. The best PBL is one built on an actual clinical problem with elimination of detailed information to avoid overloading the students. PBL is integrated learning spanning several disciplines at a time. It involves discovering and sharing knowledge. PBL involves the following key aspects: provision of data in a staged way, identification of the problem by the students, formulation of hypotheses to explain the problem, using the information given and further research to select the most likely hypothesis, and identifying gaps in knowledge that are the basis for making further research. At the end of the PBL students have to check to make sure that they have covered the learning objectives set for that PBL. The exact method of doing the PBL should respond to local culture and practice. Copying procedures from outside has caused disastrous results. Where the local culture encourages inquisitiveness and questioning PBL can perform very well. Where people are naturally quiet and want to think about what they want to say we need to make relevant modifications.

5.2 Historical Basis:
Medical education in the clinical disciplines has traditionally been problem-based. Students were given a patient to take history, examine, make a diagnosis, and suggest management. They would then go and read up more about the case and make a presentation to the instructor. It is therefore not correct to say that PBL is a recent tool in medical education. It has just been extended to the basic sciences area but the essence remains the same.

5.3 Qur’anic Basis / ta asiil islami:
In our approach to PBL we have to base on our intellectual heritage if we are to succeed. We cannot just copy ideas of others who have a different culture, a different world view, and different experiences. PBL is Qur’anic and was used to teach the message to the sahaba. It was so effective that the sahaba were the best generation of Muslims because they understood the Qur’an in a very profound way. Verses of the Qur’an were revealed when there was a specific problem to be resolved. Thus the learning was tied to a real problem enabling deep understanding and retention of the message. PBL involves encouraging students to look for facts and evidence in solving specific problems. This is in the Qur’anic tradition of relying on evidence as authority, hujjiyat al burhan

5.4 Advantages and Disadvantages
Advantages: student-centered learning and student-driven learning, teach how to fish instead of providing the fish, develop long-term search for knowledge, develop an inquisitive research-oriented mind, integration across disciplines, it is like the clinical process when the physician tries to reach a diagnosis.
Disadvantages: cultural incompatibility, gaps in knowledge, lack of focus and integration, missing linkages

5.5 Case Writing:
Based on a clinical problem not necessarily taught before, slow release of information, students formulate and test hypotheses, students fill in gaps of their knowledge, case information emphasizes laboratory or radiological data relating to basic medical sciences and not clinical skills / knowledge. Sitting down to craft a case from the start is difficult and the product may not be ‘real’.

The best approach is to have LOBs listed and then look for an actual clinical case that has clinical and most important laboratory data relating to the LOBs. The clinical case may not cover all the LOBs and it may be necessary to combine data from more than one case and this is easily done by having a patient with two or three diagnoses or 2-3 complications of an original diagnosis.  We should avoid providing more data in the case beyond the LOBs. The method of case writing suggested above assumes that PBL will be supplemented by lectures and that it will not be the only means of learning. It is better for a case to be discussed by a group of people knowledgeable in that area but the writing should be carried out by one person to ensure consistency and logical flow. After the case is written it should be reviewed in depth by several peers either sitting together or working separately. However it will be the responsibility of the case writer to incorporate their suggestions and criticisms to produce the final product. Although the starting point of all PBL cases is a clinical problem, the data provided should reflect the LOBs. If teaching basic medical sciences the data should be laboratory and radiological investigations. If teaching clinical sciences, the data should be predominantly are symptoms and signs supplemented by relevant investigations. If LOBS are on ethico-legal aspects the data should be relevant and so on.

5.7 Tutor selection and training:
Tutors should preferably be medical graduates or those scientists with a broad grasp of medical sciences including clinical correlations. There is an opinion that the tutor should be a non-specialist to avoid interfering with the student knowledge discovery process by giving them clues and shortcuts. To start with the tutor should avoid this during the PBL process but when the students have completed and presented their work, the tutor should go over the information pointing out where they made mistakes or where they did not dig deep enough. Presence of a tutor who knows the subject is also important for assessment because he will set the questions with full knowledge of what actually took place and how much the students gained. The tutor also will be able to know what has to be covered in the lectures if the LOBs were not satisfied in the PBL. Workshops are needed to train tutors.

5.8 Classroom management
Principles of Group Formation and Group Work: A group is several interdependent and interacting persons. Work is enjoined in groups that are united, cooperative, open and trusting. Group members must be similar, empathetic, supportive, and sharing. Separation from group is condemned. Group norms must be respected. Breaking norms, secretive behavior, concealment of information, and secret talks destroy groups. Group membership has benefits of integration, stimulation, motivation, innovation, emotional support, and endurance. Group performance is superior to individual performance. Group membership has the disadvantages of arrogance, suppression of individual initiative, member mismatch, and intra-group conflict. Group formation has 4 stages: forming (acquaintance and learning to accept one another), storming (emotions and tensions), initial integration (start of normal functioning), total integration (full functioning), and dissolution. Mature groups have group identity, optimized feedback, decision-making procedures, cohesion, flexibility of organization, resource utilization, communication, clear accepted goals, interdependence, participation, and acceptance of minority views. Groups fail when constituted on the wrong basis, when members cannot communicate, when there is no commonality (interests, attitudes, and goals), and when they have diseases of hasad, nifaq, namiimah, gaybah, kadhb, riyah, kibriyah, hubb al riyasa, tajassus, and dhun al soo. An effective group follows the Qur'an and sunnah, members feel secure and not suppressed, members understand and practice sincere group dynamics, members are competent and are committed to the group and the leadership.

Selection and Size of the PBL Group
For efficiency a PBL group should have 4-8 students. More than 10 is too much and may not be conducive to participation by all students which is a cardinal requirement in the PBL process. Selection of the students must be done carefully to make sure that the group will operate smoothly. No hard and fast guidelines can be given for this selection because many factors including local culture may have to be considered. In some situations it may be better to separate males and females. In some other situations it may be better to separate the quiet from the loud-speaking domineering students. In yet other circumstances the weaker students may be separated from the stronger ones. On the other hand it may be judged more appropriate to mix the various categories of students to create equilibrium.

Responsibilities of the PBL Tutor
The PBL tutor plays a very passive role and can interfere only if students are deviating from the topic or there is a break down of order. The PBL tutor has to resist the tendency to interfere in the learning process because it has to be student-centered and student-driven. I do not agree with the practice of some faculties to choose a PBL tutor who is a non-specialist in the subject matter to ensure that he will not interfere with the PBL process. This is a form of solving a potential problem by creating another problem. The PBL tutor must be a specialist who will watch the learning process, detect mistakes and misunderstandings, and decide how to cover the deficiencies in lectures that I must believe must complement the PBL process for complete grasp of the subject matter. Having a specialist tutor also helps in setting the examination questions because the writer of the question has an intimate knowledge of what knowledge the students discovered on their own and how deep that knowledge was. A writer of question items who did not attend the PBL process will write questions that are irrelevant or that are either too easy or too difficult.

Student Leadership of the PBL
The students have to select a chairman for each PBL session.  The leadership should rotate so that each member of the PBL group has a chance to be a chairperson. The chairman controls the discussions and makes sure that the work is accomplished within the allocated time. The students also select an official scribe who writes down on the board the ideas that are generated so that they can be seen by all as the discussion progresses.

The PBL Process: Steps of a PBL session: (1) clarification of new terms (2) Problem identification and description (3) Understanding the problem (4) Solving the problem (5) identify gaps in knowledge requiring further study and research. The PBL is best held in 2 sessions. The first session deals with problem definition and description. While the second session deals with discussion of results of student research on items that were identified in the first session as information gaps. In some schools students in the first PBL session are not allowed to bring in reference material like books. They are supposed to discuss the problem at hand using only the information released to them. I have had good experience with PBL sessions in which students are free to used reference material freely. This could even be extended to allowing them use of the internet. The problem that arises from this approach is that time management becomes more difficult and the possibility of deviation from the topic becomes more likely.

Staged Information Release: The PBL material is released in stages to parallel the actual life situation when a patient presents with a complaint. More information is then obtained by taking history and examining the patient. More information is obtained by progressively more complex investigations.

Problems in PBL
·  Inpatient tutors interfering unnecessarily in the learning process or turning PBL into a mini-lecture if students are quiet or deviating.
·  Cleverer students getting bored with the slow pace of learning
·  Quiet students who just want to listen and learn but do not want to contribute to the learning process
·  Difficult students: jokers, comedians, know-all, domineering, sensitive


5.0 LECTURES
5.1 Description
Lectures have been the traditional method of education. The teacher speaks while the students listen. The students may ask questions during or after the lecture. Over time lecturing has acquired a negative reputation as being spoon-feeding passively-learning students and being authoritarian. These criticisms are valid but they do not invalidate lecturing. All what is needed is to change the lecturing process to make it more interesting and to involve the students actively in the learning process. 

5.2 Advantages
Lecturing has the advantage of a well planned learning process. A lot of ground can be covered in a short period of time. Lecturing can be used to present concepts and information effectively and efficiently. The best lectures are given by teachers who have mastery of the subject such that they can present complicated concepts in a concise, simple, and interesting way. They can show how concepts relate to one another. They are also able to link what is taught today with what was taught before to create a ‘mind map’ for the students that makes understand and internalize the subject matter.

5.3 Disadvantages
A disadvantage of the lecturing method that has been mentioned before is that students learn passively which as agreed by most educators is less effective than active learning. The criticism of passive learning is however not related to the lecturing method. It is more related to the changing cultural and profile of the students. In the modern fast-paced world with short attention spans, traditional lecturing is boring. In an earlier age when attention spans were longer, the students listened attentively to the words of the teacher, learned them, and then started actively turning them around in their mind, relating them to what they already knew, and critiquing them. In the process they could come up with new ideas of their own or could understand the words of the lecturer at a deeper level. This type of student can be said to have been active learners using the lecturing method. It is unfortunate that they are now a rare species in the generation raised on watching television with small attention spans. We can conclude from the above that what has changed is the nature of the student putting traditional lecturing methods at a disadvantage in the educational process.

5.4 Innovative Ways to Improve Lectures
  • Use lectures to define terminology and present concepts instead of presenting dry facts that the students can obtain on their own
  • Make lectures interactive by allowing students to contribute ideas and to criticize what the lecturer is presenting
  • Revert to what the term lecture originally meant which is reading by the lecturer and the student. Thus students could also be asked to prepare some parts of the lecture and make presentations to the class while the lecturer listens and critiques
  • Use audio-visuals as an aid to learning and not as an end in themselves. The educational purpose is lost if the AV aids become a form of entertainment and the intellectual focus on concepts is lost.

5.5 Etiquette of Teaching and Learning
Etiquettes of Searching for Knowledge, adab talab al ‘ilm
Intention: the student must have as intention learning so that he may serve. If the intention is glory or personal gain, there is no blessing in the learning. The story of Musa and Khidhr is very educative about the adab talab al ilm. The student must try to seek to understand first. Unnecessary and sterile argument, jadal, is not part of the Islamic tradition.

Etiquettes of Teaching, adab al mu’allim
The teacher must transmit both knowledge and character. In the earlier history of the ummat, teachers were models of character. With the secularization of education, morals became separated from knowledge and teaching. It should be the aim of the new education strategy to close this gap.

Freedom
Knowledge can not grow and develop in an atmosphere that lacks freedom of expression. Assuring freedom of expression for everybody implies among other things that even the ignorant who can mislead others must have their freedom. This risk is worth taking because there is no humanly possible method of knowing in advance what someone will say. If they say something wrong it can be countered with argument and evidence. On balance when both truth and falsehood are given equal chances for expression, the truth in the final analysis predominates. The Qur’anic educational method, tarbiyat qur’aniyyat, is guidance in this matter. The Qur’an has preserved for eternity the words and opinions of the worst people in human history like Pharaoh, Nimrod, and the polytheists. Their opinions are reported honestly as they were said sometimes in direct speech using their actual words. These bad people had freedom of expression even in the Qur’an. They were countered by Qur'anic arguments and evidence to the ultimate benefit of knowledge growth.


6.0 MEDICAL EDUCATION UNIT
6.1 Prescribed Function
Establishment of medical education units or departments is a recent phenomenon in faculties of medicine. The reason behind them is very understandable: to train medical specialists as teachers. In the past any medical specialist without any preparation or training found himself a teacher in front of medical students. He knew nothing about the philosophy of education or its methods. At the end of the semester he found himself writing examination questions and marking examination scripts without any previous training. The results were very frustrating for the teacher, the students, and the faculty administrators. Exceptional medical specialists managed to be excellent teachers either by natural inclinations or by ‘learning on the job’. However the majority needed additional support leading to establishment of medical education departments. The original purpose of these departments was teacher training. However with time they outgrew this function and explained below entered other areas of endeavor which has led to major changes in medical faculties.

6.2 Extended Functions and Problems
The establishment of medical education departments coincided with major changes in medical curricula including integration of various disciplines and problem-based learning (PBL). These educational innovations had to be taught to medical lecturers. Medical educational departments were the natural choice for this task. The new innovations also required changes in the curricula and medical education departments led the way. In the process these departments took control of the whole education process. With time they took control of assessment and examinations. The center of gravity moved from the specialist physician in an academic department of the faculty of medicine to the head of the department of education. The problem was that the head of the department of education was not a specialist in say biochemistry or pediatrics. By being in charge of the curriculum as well as the examinations, he usurped the role of the specialist. This usurpation laid the ground to mistakes being made especially in examinations because the control was no longer in the hands of the person most knowledgeable in a discipline. The solution to this problem is for medical education departments to resume their supportive role in medical education by providing training and information and desisting from taking charge of the curriculum and the examinations. Respect for specialist knowledge should never be eroded.