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Presentation at the King Fahd Medical City Riyadh on 11th October 2008 by Professor Omar Hasan Kasule Sr. MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Professor of Epidemiology and Islamic Medicine, Institute of Medicine, University of Brunei & Visiting Professor of Epidemiology University of Malaya. WEB: http://omarkasule.tripod.com
OVERVIEW
This presentation will cover the speaker’s personal views and experiences with innovations in medical education over the past 13 years with special emphasis on an integrated curriculum and student-centered problem-based learning. Besides presenting a proposed medical curriculum, the presentation also addresses issues of student assessment. The contents of this presentation have been adapted from papers and presentations published by the author on his website.
1.0 OLD PERFUME IN NEW BOTTLES or NEW PERFUME IN OLD BOTTLES
1.1 Evolution vs. Revolution:
When we talk about modern trends in medical education we need to understand that we are not dealing with revolutionary phenomena but rather evolutionary ones. We are engaged in a process of changing, adjusting, and improving while responding to rapid changes in the medical education environment. In this process we may modify and update old approaches. We may also discard new approaches that are not working and go back to old ones. We may also innovate new approaches unknown before. These will also become modified with time as the educational and scientific environments changes.
1.2 Problem-Based Learning: A Historical Perspective:
The use of problem-based learning and student-directed learning are not new trends discovered this century. During the era of revelation, ‘ahad al risaalat, The Qur’anic method of instruction was essentially problem-based and prophetic teaching reflected most features recognized today as student-centeredness.
The Qur’an in the order we read it today existed in the lawh al mahfudh. Its chronological revelation did not follow that order. It was revealed gradually over a period of 23 years. A verse was revealed when a specific and relevant problem arose in the community. Scholars of the Qur’an such as Jalal al Ddin al Suyuuti (d. 911 H) wrote extensive books on the reasons for revelation, asbaab al nuzuul, which were the problems to be solved. This method of revelation ensured that the first generation of Muslims understood the Qur’an in a deep way because its verses were tied to actual practical problems that they had experienced.
1.3 Student-Centered Learning: A Historical Perspective:
Student directed learning was also prevalent during the era of revelation. Books of siirat record that the prophet used to speak little when sitting with his companions. He used to listen to them as they discussed in a sort of self directed learning. Many of the recorded hadith from the prophet were actually affirmations, iqraar, of the conclusions that the companions reached if they were valid. If they were not, he used to correct them. It is also recorded that the prophet used to teach his companions by asking them questions such that they were active and not passive learners.
1.4 Student-Centered Learning in Traditional Clinical Training:
During my medical training, the teaching of clinical medicine was problem-based and case-based. Students would be assigned cases at random for ‘clerking’. They were expected to take history, carry out a physical examination, and undertake simple investigations in the ward laboratory. They would then write up the whole case indicating the diagnosis, the differential diagnoses, and a plan of management. The professors would listen to the presentation of the case and make corrections or ask questions as needed.
1.5 Student-Centered Learning in the Traditional Anatomy Teaching:
When I was a medical student, the teaching of anatomy by cadaver dissection was very much student-centered. New medical students would be given a cadaver that they would dissect over a year learning its various structures in most cases in the absence of an instructor with them.
1.6 The Experiences of the Past 2 Decades:
Over the past 2 decades medical education has evolved into a specialty. Much research has been done on educational methods. Many new experiments have been carried out. The problem-based method became widely adopted with many modifications to suit local conditions such that there is no one monolithic approach.
Student centered learning was in a way a response to the change in most societies from authoritarian command systems to participation and sharing. Student-centered learning alongside problem-based learning empowers students and makes them active and not passive learners and most of them feel good about these approaches.
2.0 MODERN CHALLENGES TO MEDICAL EDUCATORS
2.1 Medical Information in the Public Domain:
The computer and information technology of the past quarter century has forced medical educators to make drastic changes in both the content of the medical curriculum and the method of delivery. Regarding content, much of what used to be taught as part of medical education is now known in the public domain by lay people who surf the internet or watch health-related television shows such as ER. Lay people as patients are more educated medically because they ask more questions of their doctors. This means that new medical students already have a lot of general knowledge about medicine and will require a deeper approach that could be vertical (providing more detailed new knowledge) or horizontal (integrating and explaining the various pieces of information acquired).
2.2 Information Technology and a Higher Learning Speed:
Computer-based teaching aids have helped increase both the speed and accuracy of learning visual information. Students who used to spend months slowly dissecting a cadaver to discover the secrets of anatomy or poring over histology slides on a microscope can now with a click of a mouse turn to any past of the body and study its 3-dimensional details in a matter of minutes. The fourth dimension has also been brought into play in studying progressive physiological processes. Students can watch on their screens in real but ‘speeded up’ time processes such as embryological and fetal development from fertilization to birth, mitosis, meiosis, and protein synthesis.
2.3 Rapid Change in Content of Medical Knowledge:
The rapid growth of scientific medical knowledge has challenged medical educators and I am yet to be convinced that they have answered the challenges adequately. Medicine practiced 2 centuries ago was essentially an art and not a science and could appropriately be described as ‘placebo’ medicine because it had few effective remedies based on our understanding today. Medicine today has tilted rather too much from being an ‘art’ to being a ‘science’ because of the scientific and technological revolution of the 20th century N. Since science and technology change and evolve at a breath-taking pace, the content of a medical curriculum has to catch up which in practice means changing the curricular content at annual or shorter intervals. If this were done, all stability and planning in medical education would become chaotic. The challenge to medical educators therefore is to concentrate on giving the students the methodological tools they need to look for and imbibe the changing knowledge base on their own so that they can be up to date. Stated in other words the curriculum needs to be less content-heavy and more methodology-based.
2.4 Assertive and Self-Reliant Students
Medical educators will also have to face the challenge of the changing student body. I have already mentioned above that students come to the medical school with a lot of sometimes detailed medical knowledge learned in the community, the mass media, and the internet. They therefore expect more depth from their medical curriculum. They may not be content with learning the facts of medicine; they would like to understand the interactions and relations amongst those facts. We are also facing the challenge of the student’s age. Countries with a 5 or 6 year medical course taking in students directly from high school ran the risk of producing doctors who appear too young to gain the respect of patients thus starting off their medical careers with low self-confidence. The practice in the US of graduate level entry seems to solve this problem and is spreading in the UK, Australia, and other countries.
2.5 A Common Foundation Curriculum for All Health Professionals
Medical educators are challenged to produce physicians who work comfortably in a multi-disciplinary health care team with other health professionals on the basis of mutual respect. The system of educating and training the various health care professionals does not prepare physicians for this role. The idea of a common foundation year in which all health professionals study together was advanced to address this specific problem. Starting with the 2008/2009 academic year we have started such a program at the Institute of Medicine at the University of Brunei. Students of medical professions (physicians, nurses, physiotherapists, nutritionists etc) are taught together during the first year with the hope and expectation that the camaraderie of that year will translate into mutually respectful cooperation as practitioners in future hospitals.
3.0 ISSUES IN MEDICAL EDUCATION: and the rationale for integration
3.1 Five Issues
The following paragraphs are adapted from a 1996 paper that I presented on conceptual issues in medical education at a conference held at the University of Science School of Medicine at Kota Bharu, Malaysia. I have re-presented the paper and taught its contents in several places over the past 12 years. It remains an essential milestone in guiding and motivating my thoughts and activities in developing medical curricula. The 5 conceptual issues are: purpose, integration, balance, service, and leadership.
3.2 Purpose
The purpose of medicine is to restore, maintain or improve the quality of remaining life. It cannot prevent or postpone death because the life span, ajal, is in the hands of Allah. Physicians’ primary aim is quality and not quantity of life. The aim of medical education is producing caregivers whose practice of medicine fulfils the primary purpose of quality and also fulfils the 5 purposes of the Law: preservation and promotion of diin, hifdh al ddiin; life and health, hifdh al nafs; progeny, hifdh al nasl; intellect, hifdh al ‘aql; and resources, hifdh al maal. Hospital medicine is most intimately related to the second, third, and fourth purposes.
3.3 Integration
Modern medical practice lacks optimal integration. It is fragmented by organ, disease process, and is not holistic. This disintegration is reflected in the medical curricula which if not remedied will produce more disintegrated physicians. An integrative paradigm is needed to replace the paradigm that is atomistic, analytic, and not synthetic. The problem-based inter-disciplinary approach to medical education is a worthy attempt to address the problem of lack of integration. Integration is not just putting two or more disciplines together. It is a fundamental philosophical attitude based on a vision and a guiding paradigm. Criticism of the fragmented medical curriculum is actually criticism of the underlying atomistic world-view which is good at analysis and not synthesis.
3.4 Balance and Equilibrium
In the absence of an integrating paradigm, modern medicine lacks balance and equilibrium in its therapeutic approaches. Very aggressive and extreme interventions turn out to be the cause of new diseases and problems. We will need to teach new paradigms of following the middle path, wasatiyyat; balance, mizaan; equilibrium, i’itidaal, and action-reaction, tadafu’u, in order to provide a conceptual framework for balanced medical practice.
3.5 Service
Medicine should be taught as a social service with the human dimension dominating the biomedical dimension. Medical education should prepare the future caregiver to provide service to the community. This will require skills of understanding and responding to community needs that can be acquired by spending part of the training period in a community setting away from the high technology hospital environment.
3.6 Leadership
The medical curriculum and experience should be a lesson in social responsibility and leadership. The best caregiver should be a social activist who goes into society and gives leadership in solving underlying social causes of ill-health. The caregiver as a respected opinion leader in close contact with patients must be a model for others in moral values, attitudes, and thoughts. She must give leadership in preventing or solving ethical issues arising out of modern biotechnology. She must understand the medical, legal, and ethical issues involved and explain them to the patients and their families so that they can form informed decisions. She should also provide leadership in advocating for the less privileged and provide leadership in advocacy for human needs.
4.0 AN INTEGRATED CURRICULUM
4.1 Overview
Over the past decade several colleagues and I have been engaged in producing integrated undergraduate curricula in Malaysia, Brunei, and other countries in the region. I have been guided by the 5 issues above in all these endeavors. I am working on a prototype integrated curriculum which is not yet completed. When completed I will be presenting it to the curriculum review committee of our university where it will be discussed with other similar proposals in order to make changes to our current curriculum. I take opportunity of my current visit to the King Fahd Medical City to present the basic elements of this on-going with high hopes of receiving feedback that will enable me make needed improvements.
4.2 Phase 1: Curriculum Map Leading to the Bachelor of Health Science
The term pre-clinical, used to refer to phase 1 of our curriculum, is a misnomer because our students are exposed to patients from the beginning. Phase 1 lasts 3 academic years after which the student is awarded a Bachelor of Health Science degree. The curriculum is basically health science-driven with correlations being made to 3 other themes: patient care (clinical), community health, personal and professional development that includes research skills. After phase 1, students proceed to phase 2 which is predominantly clinical teaching and at the end of 3 years they are awarded a medical degree.
Table #1 shows the skeleton of the proposed curriculum and its 5 major themes. It is to be delivered mainly by the problem-based method. There are however conceptual issues dealing with the structuring and classifying information that can only be delivered by traditional lectures.
Horizontal integration is the distinguishing characteristic of the proposed curriculum. Each quarter covers 2-3 organ systems. Then, the PBL cases tries to trigger all aspects dealing with health sciences, patient care, community health, personal and professional as well as research skills relating to that organ system.
One of the motivations for proposing this curriculum outline was personal dissatisfaction with the cases that we used. We acquired these cases from an overseas institution and made some modifications to suit our circumstances. The cases tended to be more inclined to clinical aspects and I felt that they could not trigger all the specific pieces of health science that the student needed to know. The underlying problem being that the case writers did not have in front of them a detailed curriculum map with specific and detailed learning items. The PBL process therefore could end with some gaps in the students’ knowledge that we increasingly tried to fill by giving them traditional lectures. Since I was not satisfied with this reactive approach I decided to propose a detailed curriculum map so that in the future we will write our own cases making sure that a case triggered all what we anted to cover and that lectures were assigned in advances to cover aspects not triggered by the cases.
4.3 Phase 2: Curriculum Leading to the Medical Degree
I have not yet worked out all the details of this phase. The preliminary ideas I have is that the student will rotate through clinical postings in the major 4 disciplines (internal medicine, surgery, pediatrics, and obstetrics gynecology) in the first 4 quarters of clinical training. Then she will rotate through medical and surgical sub-specialties in 2 quarters before returning to rotate through the 4 major postings in the final 4 quarters.
The routine of the work on wards and at outpatient clinics provides a lot of free time for the student to engage in other activities that continue the correlation with the 4 or 5 themes that were started in phase 1. An extra theme of community or family medicine could be added at this stage. In this we can maintain the paradigm of an integrated curriculum all through the stages of the medical program.
5.0 PROBLEM BASED LEARNING (PBL)
5.1 Overview
I shall in the following paragraphs present my experience with PBL in the past decade. I embraced PBL because I was intellectually prepared for it as explained at the beginning of the paper. It also proved to be a teaching method that could deliver integration and was student centered. My enthusiasm for PBL was tempered by a realistic understanding that PBL was not new but was an evolving practice. This frame of mind left me free to observe, critique, and try to suggest improvements where needed.
5.2 The Objective of PBL: Content vs. Method
In the summer of 2007 I spent 8 days at the Faculty of Medicine, University of Science and Technology in Sana’a conducting workshops on medical education. I had lively discussions with the academic administrators and the PBL tutors about the PBL method. A recurring theme in those discussions was whether PBL should deliver knowledge content or should be used to train students in systematic thinking and systematic search for knowledge. Holders of the first view would minimize the role of traditional lectures. Holders of the second view would deliver all content by traditional lectures and look at PBL as methodology training. In reality both views are extreme and the truth perhaps lies somewhere in between.
5.3 Different Forms of PBL
In my experience in our institution and from visits to many other institutions there is no one form of PBL. No institution is like another one because each one tries to made adjustments and modifications to the basic PBL structure to fit local conditions. The need for modifications may be student or tutor-driven.
At the International University in Malaysia we used a slow-release PBL format that was held in 2 sessions. In the first session students were challenged to develop hypotheses about the underlying diagnosis and then use the clinical and investigation data released to them progressively and in stages to test the hypotheses until they narrow down the diagnosis. With the tutor playing a passive role, the students were first given a clinical scenario with some clinical data from history or examination. The next release depending on the case would be either more clinical information or would move on to provide routine laboratory investigatory profiles that would be done for any condition: full blood count, and electrolytes. Then they would be given more specific laboratory and radiological data that can help narrow down the diagnostic possibilities; where relevant, more specific investigation or testing information such as ECG would be given. All the information mentioned above was released in a progressive fashion the students being asked to discuss the possible diagnosis at each stage. With information release they could refine their hypotheses until they reached the final diagnosis. In the course of considering the information while looking for the diagnosis the students would come across many issues that they did not know or did not understand. They wrote them down as learning objectives. The tutor helped them organize these objectives into a meaningful list that they would take away and during their self-directed student learning they would look up information and come and present their findings at the next and final PBL session for that case.
At the Institute of Medicine of the University of Brunei we experimented with 2 forms of PBL. The first one started in the first year challenged the students with a clinical background written as 1-3 paragraphs. The key words would them act as a trigger for a free to all exploration by the students. With the tutor playing a very passive role they were left free to imagine, explore, and interpret. In the course of this they would compile a list of student learning objectives which was in reality a list of the students’ ignorance. They would then during their SDL look up more information and discuss at the next 2 PBLs. The last PBL was basically for conclusion and tidying up.
From the experience of the first 2 batches of students we decided to replace the open-ended PBL format in the first year with the slow release format that was applied to all the years. The cases were local adaptations of cases from an overseas institution. Students met in 3 tutorials to finish a case. New information was released at each tutorial. The information was a mixture of clinical and investigation data. Students were challenged to develop and eliminate hypotheses along the way. The final tutorial was for rounding up. Students had plenty of time on the weekly schedule for student-directed learning. Towards the end of the week they had an experts’ session at which clinical and non-clinical experts would be invited to respond to students’ questions on the case. They also had large session at which all the PBL groups would meet for a specific learning objectives.
5.4 Example of Weekly Integrated Learning Objectives
Overview: The ideal of full integration of all the curricular themes in one PBL case could not be achieved for various reasons. The first reason is that the case would be extremely long and unwieldy and being written by people from many disciplines could fulfill the prophecy of too many cooks destroying the broth. The second reason is that some aspects of the themes like statistics were skills to be taught and learned and could not be acquired by exploration since they were outside the realm of common sense or general knowledge. In practice the weekly PBL case came to be recognized as basically a health science one. The coordinators of the other themes rearranged their curriculum delivery such that they would cover material relevant to or related with the health science issue(s) of the week. They would all however submit their learning objectives so that a weekly set of learning objectives would be compiled as shown in the example below.
Example #1: Weekly learning objectives - Year 3
Health Science Leaning Objectives
1. Explain the physiology of menstruation from menarche to menopause
2. Explain the physiology of peri-menopausal menstrual function using your knowledge of menstruation and ovulation
3. Explain the patho-physiology of dysfunctional uterine bleeding (DUB) and its treatment
4. Describe some common physiological causes of abnormal uterine bleeding e.g., an ovulation leading to endometrial hyperplasia: adenomyosis, endometrial Ca, fibroids
5. Describe the anatomical, pharmacological and physiological basis of treatment options for dysfunctional uterine bleeding including expectant management and medical / surgical treatment
6. Describe the physiology of the menopause and its consequences
7. Outline treatment options for menopausal symptoms including lifestyle, medical and alternative
8. Explain the differential pharmacology of medical treatments for dysfunctional uterine bleeding and menopausal symptoms
9. Briefly outline the symptoms of premenstrual syndrome and its diagnosis
10. Outline the procedure of hysterectomy and relate this to the anatomy of the pelvis
Patient Care Learning Objectives
1. List important components of a patient presentations
2. Practice presenting patient histories
Our Community Learning Objective
1. Discuss the presentation and management of menstrual disorders in the primary care setting, including the psychosocial aspect.
Personal and Professional Development Learning Objectives: ethico-legal-fiqh principles
1. Discuss the presentation and management of menstrual disorders in the primary care setting, including the psychosocial aspect.
2. Describe ethico-legal guidelines on handling research animals.
3. Discuss the purposes and relevance of animal research to human disease.
4. Discuss ethico-legal guidelines for choosing animals for research.
Personal and Professional Development Learning Objectives: Ethico-Legal-Fiqh Issues In Clinical Practice
1. Discuss ethico-legal issues in use of HRT to treat menopausal disorders.
2. Discuss ethico-legal and fiqh issues in dysfunctional uterine bleeding.
Personal and Professional Development Learning Objectives: Case Analysis
1. Discuss ethico-legal issues in this case.
Personal and Professional Development Learning Objectives: Personal Development and Professionalism
1. Discuss the concepts and theories of communication.
2. Explain practical guidelines for successful small group communication.
Example #2: Weekly Learning Objectives – Year 3
Health Science Learning Objectives
1. Define pelvic inflammatory disease and outline the common causes.
2. Define STIs, and list common examples.
3. Describe the principles of management, mode of action, contraindications, risks and benefits of the different methods of contraception.
4. List the relative effectiveness of methods of contraception.
5. Explain the mechanism of action of emergency contraception and list its risks and its efficacy.
6. Describe the main chemical features of estrogen and progesterone and their synthetic analogues and explain how they exert their contraceptive effect.
7. Describe how hormonal contraceptive preparations interact with other medicine given concurrently.
8. Outline briefly the effects of androgens and anabolic steroid administration, including the misuse of these compounds.
9. Identify the structures of the female perineum and give their clinical relevance.
10. Describe the anatomy of the female pelvic cavity, including peritoneal reflections, blood supply and lymphatic drainage.
11. Revise the pelvic viscera, including peritoneal reflections.
Patient Care Learning Objectives
1. Demonstrate understanding of the Handbook on Clinical Skills and the Reflective PPD Portfolio and the Patient Care theme plan for Year 3, including the various means of assessment planned.
2. List the parts and the format of a medical history and examination important for a Patient Clerking. This is part of documentation of written information on patients (only if applicable).
3. Identify factors in patients’ notes which commonly cause misunderstanding and might compromise patient care (only if applicable).
Our Community Learning Objectives
1. Outline the issues related to the prevention and control of diseases of public health interest.
Personal and Professional Development: Research Skills - Sample Selection and Data Collection:
1. Explain the role of sample size Determination.
2. List and describe advantages and disadvantages of various sources of secondary data.
3. List and describe four methods of questionnaire administration with the advantages and disadvantages of each.
4. Summarize the principles of data management and data analysis.
Personal and Professional Development: Ethico-Legal Skills – Contraception
1. Explain the difference in legal consideration between contraception as a choice of a couple and contraception as public policy.
2. Explain circumstances in which female contraception is allowed even if the husband refuses.
3. Explain guidelines on choice of contraceptive methods.
4. Describe allowed male contraceptive methods.
5. Describe allowed female contraceptive methods.
6. Explain the legal position about contraception out of marriage.
7. Explain the legal position regarding sterilization.
8. Explain how easy availability of contraception causes sexual promiscuity.
9. Explain demographic effects of wide-spread contraceptive use.
Personal and Professional Development: Problem Solving Skills – Contraception & Sterilization Based On a Case Scenario
1. Discuss ethic-legal issues relating to abortion without parental consent.
2. Discuss ethic-legal issues relating to sterilization for the mentally retarded.
5.5 Weekly integration of subject matter
Table Showing the weekly schedule (actual durations not shown for simplicity)
AM | PM | ||||
Monday | SSM 1 | SDL | Comm Skills | SDL | |
Tuesday | Lecture 1 | Lecture 2 | MIB | Clinical & Communication skills | |
Wednesday | MIB | PPD | ECA | ||
Thursday | PBL 2 | Our Community | Lecture 3 | Lecture 4 | |
Saturday | Expert Forum | PBL 1 | LGS | Lecture 5 | |
The example of a weekly schedule above shows the horizontal integration across the themes of the curriculum. The aim is to have the week as an integral learning unit centering on an issue. Problems arise when more than one week is needed to cover that unit and it proves difficult to sub-divide it in any meaningful way. Our experience has so far been doing one case a week with each case requiring three tutorials on 3 days with SDL in-between. I however could envisage a situation in which 2 shorter cases could be covered in a week especially to cover health science objectives.
5.6 Weekly Feedback by Students
At the end of the week students make an evaluation of each learning objective on a 1-5 scale. PBL tutors and theme coordinators receive and discuss these evaluations. The evaluation scale is as follows: 1= very dissatisfied, 2= moderately dissatisfied, 3= neural, 4= satisfied, 5= highly satisfied.
5.7 Personal and Professional Skill Development (PPSD)
I can talk with more authority on PPSD because I was the coordinator at the International University in Malaysia for the 10 years I was there and also at the University of Brunei for the past 3 years. The aim of the PPSD theme is to equip the medical students with skills that will ensure life-long professional success. Table #2 shows the PPSD curriculum map used in this academic year. PPSD is integrated in the PBL system. It is case-based but is taught at a separate time slot from the rest of the PBL system because it requires the tutor to be a specialist. This is because it involves quantitative skills (statistics and epidemiology) as well as medical jurisprudence, fiqh tibbi, which cannot be handled by a non-specialist tutor. These two areas require a lot of explanation for the students and unlike health sciences do not end with mere acquisition of facts. The case used for the PPSD session is an extension of the case of the week but is written to trigger specific issues in the PPSD curriculum map of that week.
Over the past three years I have been experimenting with the delivery of the PPSD theme attempting to make it as student-driven as possible. I either provide background material on ethical legal issues or professionalism in advance or ask the students to search for it. In class the students take turns presenting that information and we discuss it together as a class. Then we study and discuss the case of the week which is an extension of the main PBL case written to trigger PPSD learning objectives of the week. Sometimes the PPSD sub-case is written up as a problem requiring statistical analysis to find a solution. We use this as a vehicle for teaching statistical techniques.
5.8 Balance Between Lecture and PBL
At the international university in Malaysia PBL was an additional method of education with main reliance being on traditional lectures. We started the program at the Institute of Medicine in Brunei with the ideal aspiration to have our program 100% PBL but the reality dictated otherwise. We realized that three curricular themes (Our community, Patient care, and Personal and professional development, as well as epidemiology / statistics could not be delivered fully in the PBL based on cases whose primary emphasis was health sciences with clinical correlations. Attempts to deliver these themes via PBL cases would have required writing more extensive cases with so many issues and triggers that the students would have been confused. Lectures were therefore set for these themes. Practice also showed that the PBL process did not deliver all the health science learning objectives to the depth required so we started having supplementary lectures. With time the number of such lectures has increased as a compromise between the orthodox who wanted only PBL and the heretics who wanted a mixture between PBL and lectures.
My personal view is that health science content as facts can be delivered by the PBL process. However there are aspects that will require lectures by experts. These lectures should center on conceptual issues of classifying and organizing various pieces of knowledge and understanding the relations among them. The lectures therefore deal with the concept of structuring knowledge which is a very important component of the intellectual function. Extending Piaget’s theory of structures of childhood intellectual development, we can surmise that as medical students get more information and delve into the details of the human organism, they organize that information in structures. As more information is accumulated those structures have perforce to change. This change needs to be guided by a lecturer to avoid serious confusion.
5.9 Balance between Health Sciences vs. Clinical Experience
Phase 1 of the curriculum is mainly health sciences with clinical correlations. We have been debating the right mixture of science and clinical experience. There is no point giving too much space to clinical experience when students will have 3 years of clinical training after the Bachelor of health science degree. My approach to the problem in the proposed curriculum outline is to limit clinical experience to history taking on major disease symptoms, physical examination for signs of disease of the organ systems, and investigations (laboratory and radiological).
5.10 Ideas on Writing Cases
Over the past 13 years I have seen how difficult it was to write good cases. At the International University in Malaysia, lecturers were motivated to write cases. However it was difficult to get enough cases quickly enough especially since there was a policy that a case once used would not be recycled until 4 years later. Case writers with time adopted a simple but effective way of writing a health sciences case. They used a short clinical introduction and the information in the subsequent slow release sheets was mostly investigations that gradually led to the diagnosis. Tutors’ notes were in some cases photostat copies of relevant pages from a text book. At some stage I became frustrated with the writing process and had suggested using clinical case notes from the hospital which would be reformatted and anonymized. I dropped the idea because it could not get support from all the lecturers. There were also concerns about the confidentiality of medical records and whether the hospital would be cooperative.
At the Institute of Medicine, University of Brunei, we started off by adapting cases acquired from overseas. The adaptations were mostly changing the cultural setting including names to be suitable to the local situation. Cases were distributed among lecturers to make such adaptations. A few cases were also written de novo attempting to follow the style of the overseas consultant. The process however continues to be challenging.
Any case written reflects the academic background of the writer(s) which may be biased to some disciplines and not others. The way to resolve this problem would be involving all disciplines in case writing which may produce the proverbial ‘too many cooks spoil the broth’. The broth could be improved if each subsequent sheet in the slow release PBL case is assigned to a certain discipline but this may break up the case into several cases that may not have a smooth logical flow and integration that we would expect.
One of the problems facing a case writer is to determine what triggers for various learning objectives to include without duplication among cases and without leaving gaps in the student’s learning map. This prompted me to prepare the curriculum map presented before. It can provide a basis for systematic coverage of the learning objectives.
5.11 The PBL Tutor
The PBL process cannot succeed unless the PBL tutors are competent but then this begs several new questions: why should the tutor be competent if he is so passive in the whole process? Why should we even think of the tutor’s education background if all he has to do is be a monitor? Why should we have a tutor at all if we can trust the students to manage the discussions on their own?. The answers to these questions are not easy and straightforward. The issue of the tutor’s academic qualification can be understood when we realize that the PBL process is integrating many disciplines so it is impossible to find one person who can be a ‘specialist’ in each of the many disciplines that are covered. We could also think of a pre-PBL workshop for tutors to be equipped with the necessary briefing about the case by a group of discipline specialists. The tutor will need this knowledge in the rare instances when he has to intervene to bring wandering students from deviating from the set learning objectives.
There is a role for a PBL tutor as an examiner that I have not seen being emphasized. The tutor observes the students’ learning process. He sees areas of strength and weakness. He also is aware of which issues they understood well and which ones they did not understand. Being a participant in an integrated learning situation the tutor is well placed to write examination questions or to review them after they have been written. The writing of examination questions should not be left to discipline specialists who did not participate in the PBL process.
5.12 Customizing to the Culture
PBL cannot be viewed in isolation from other contemporary intellectual changes in the world. Over the past 40 years all countries in both industrialized and non-industrialized worlds have been changing from being authoritarian to being more participatory. This change has manifested as more transparency and participation in the political arena, open markets in the economic arena, and individual human rights in the social arena. PBL thus acknowledges that the student has to participate actively in the process of searching for knowledge and cannot be a passive learner receiving knowledge from an authoritarian instructor. Viewed in this way the PBL process is very progressive. It however has to face the challenge of medical students whose previous education was teacher driven and authoritarian.
In my experience our students were brought up to accept assertions and not to question. Their previous primary and secondary education emphasized memorizing facts and reproducing them in the examination. They never had opportunities for analysis, comparison, and synthesis of new ideas. They were therefore overwhelmed when thrust in the PBL process on entry into university and found themselves challenged by a new educational experience. Some were able to make the transition and felt very satisfied with the empowerment from the PBL process while others felt lost.
I think that the PBL process is essentially good and should not be changed to fit the culture of the students. We however must consider the cultural incongruity between the students’ background and the PBL process in designing our teaching not to rely only on PBL to deliver the curriculum. This brings back to conclusions reached earlier that a few traditional-format lectures still have a role.
6.0 ASSESSMENT OF STUDENTS
6.1 Overview
I have always held the view that examinations create unnecessary tensions in the education process but we cannot do away with them. The tension they create acts as a sort of motivation for students to attend class and to do the necessary work. The alternative to examinations was used in traditional educational systems in which a student would stay with the teacher for a number of years and when the teacher was satisfied with progress he would award a certificate, called ijazah, which in effect means permission to teach others. Since such an informal system is not possible in our systematic education system we will have to continue with examinations because we cannot do without them. We however need to think very creatively about innovative ways of assessing student progress without the tensions and other disadvantages associated with traditional examinations.
6.2 Modern vs. Traditional Examinations
The examination system must mirror the teaching methodology. The examination must therefore feature: being based on a practical problem, integration of various disciplines, critical thinking and exploration as well as problem solving. The challenge of transition from the traditional examination format emphasizing memorization and reproduction of specific facts to a system based on testing ability to integrate knowledge and using to solve specific problems has not been easy but we have been able to make remarkable progress and there is lot more to learn.
Preparing examinations under the PBL system is a more elaborate task than in the traditional system. In the traditional system each lecturer was asked to submit questions about the lectures given and the effort was individualized. In the PBL system several disciplines have to work together to produce an integrated examination. This requires very systematic and consistent work. When questions are written several long meetings have to be held to vet them. Model answers have to be written so that the wording, the style, and the marking of the questions can be assessed in view of the expected answers.
6.3 The Short Answer Question (SAQ)
I have sort of specialized in short answer questions. We always provide a clinical scenario as the stem. It served to focus the mind of the candidate on a specific area of the curriculum. We try to include in the stem triggers for all the 5 questions that we ask but this is not always observed sometimes one of the question, though related to the stem, may not have a specific trigger. Over the past 2 years I have developed the practice of submitting questions showing the learning objective from which it is derived or to which it is related. In the following example the learning objectives and model answers have not been shown for reasons of space.
Example of a Short Answer Question
The director of medical centers carried out an epidemiological study confined to patients in the TB clinic and found a relationship between self reported obesity and self reported heavy smoking. The senior epidemiologist in the Ministry of Health rejected the report and called it biased.
QSN 1: Define and illustrate selection bias (2 marks)
QSN 2: Define and illustrate misclassification bias (2 marks)
QSN 3: Define and illustrate confounding bias (2 marks)
QSN 4: Explain the prevention of confounding bias during study design (2 marks)
QSN 5: Explain the handling of confounding bias after conclusion of the study (2 marks)
6.4 The problem-based question (PBQ)
PBQ is perhaps the best examination format because it perfectly mirrors the PBL process. It is an assessment format that is difficult for both the assessor and the student. Basically the question starts with a clinical scenario. The student is given some data that is to be used to generate hypotheses about the diagnosis or problem being studied. The examination and answer scripts are them taken away and the student is given additional information that can be used to generate more refined hypotheses. The process is continued 3-4 times. In addition to solving the problem the student may be asked content questions related to the case. It will be too long to give an example of a PBQ in this presentation but I am reproducing below a content question I recently wrote for an assessment. Model answers have not been shown for space reasons.
Example of a content question in a PBQ/mini-case
Mr. Plumley is diagnosed as having had a pulmonary embolism which was large enough to cause homodynamic impairment. He experiences cardiac arrest at 9.00 pm. There was no advance directive from Mr. Plumley regarding resuscitation. The physicians decided to carry out CPR in the absence of informed consent. On recovery and against the wishes of his family, Mr. Plumley said in the presence of witnesses that he would not approve of any future CPR procedures.
QSN 1: What is your view about CPR for cardiac arrest with no prior consent? Give reasons to support your point of view (3 marks)
QSN 2: Outline the procedure for a DNR (do not resuscitate) order (3 marks)
QSN 3: Explain a disadvantage of an advance directive regarding CPR (3 marks)
QSN 4: Explain the doctrine of clinical futility as the basis for a DNR order by a physician for an incompetent patient (2 marks)
QSN 5: Explain ethico-legal considerations in cases of a DNR order for an infant born with a congenital abnormality not compatible with life to adulthood (2 marks)
6.5 The Multiple Choice Questions (MCQ)
The performance of the students on MCQ is affected by background culture. Our students do not perform well as compared with my experience teaching North American students. In examination post mortems students tell me that they have a problem choosing the right answer because they are not 100% sure although they may be 95% but they lack the courage (or the guts) to guess with the result that many questions are left unanswered. MCQ is therefore not a test of knowledge but also is a test of other skills the most important is ability to make a decision based on partial knowledge or incomplete evidence.
At the International University in Malaysia we tried to accommodate the cultural bias mentioned above by using a form of assessment that some purists would dismiss as not belonging to the MCQ family. We wrote a stem that had triggers for 5 statements and the student was expected to indicate TRUE or FALSE for each statement. We had a system of negative marking to discourage guessing. We found that this approach was culturally more in tune with our students than the system requiring choosing one correct answer out of 4-5 alternatives.
The following are examples of questions that I used before
(a) Visiting a person with a contagious disease is prohibited
(b) Isolation of persons with contagious disease is discriminatory and is prohibited
(c) Discovery of a contagious disease in a spouse after marriage is a valid reason for nullification of marriage
(d) Discrimination of people with contagious diseases like HIV is allowed because they are to blame for their disease
(e) Excluding persons with contagious disease from congregational salat is recommended
(a) Excluding people with contagious disease from hajj is not valid
(b) There is no shariah basis for imposing a quarantine in times of an epidemic
(c) Involuntary mass immunization to contain an epidemic violates the shariah
(d) Involuntary treatment or prophylaxis in an epidemic is allowed by the shariah.
(e) Destruction of property to contain an epidemic is allowed provided compensation is paid
(a) Forced relocation of the people in a medical emergency is not allowed by the shariah
(b) Pre-marital screening for infectious disease is obligatory for all couples
(c) A spouse cannot refuse conjugal rights for fear of sexually transmitted disease
(d) Diagnosis of sexually transmitted disease is a valid basis of conviction and punishment for zina
(e) Diagnosis of sexually transmitted disease in a spouse is a valid basis for divorce or khul'u
(f) A spouse is legally liable for medical complications of sexually transmitted disease
(a) Wudhu and ghusl can be valid by wiping over bandaged wounds
(b) A physically disabled person should pray as much as she can and cannot abandon salat
(c) Impotence due to paraplegia can be a valid basis for nullification of marriage
(d) Employment of the physically handicapped should consider their condition and not compel them to do work beyond ability
(e) Some physical handicaps like blindness and deafness disqualify a person from being a judge
(a) A brain-dead person has no dhimmat (legal personality)
(b) A brain-dead person is considered legally dead
(c) A brain-dead person cannot have legal liabilities or obligations
(d) Forgetfulness or absent-mindedness invalidates salat completely
(e) It is better to delay salat and not offer it when in a state of semi-consciousness