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Presentation at the Quality Medical Education Conference held at the Faculty of Medicine King Fahd Medical City Riyadh on 30th March 2010 by Dr Mohammed O Al-Rukban Associate Professor of Family Medicine King Saud University
ABSTRACT
Quality is a value within the individual that manifests externally as exemplary performance. The best contribution that a member of the teaching faculty can make is to be a good role model of quality. More specifically the academic faculty's contribution to quality improvement is in 5 ways: (a) adopting the etiquette of the teacher, adab al mu'allim, (b) getting students to adopt the etiquette of the learner, adab al muta'allim, (c) continuous academic and professional self-development, (d) using state of the art curriculum development and delivery benchmarked against the best centers in the world, (e) student motivation, equitable assessment and feedback.
1.0 INTRODUCTION
1.1 Importance of quality in medical education
Medical education nowadays is becoming an art. It has its own regulation, polices and strategies. People moved from the stage of quantity to the stage of quality. The accreditation process, which became a mandatory requirement for all heath profession schools, supports this movement. Quality should not only be the concern of the academic leaders but also the concern of all stakeholders; the student, the faculty, the staff, the patient and the community.
1.2 Roles of faculty in quality medical education
The role of faculty on quality assurance in medical education is great. It starts by recruiting good faculty and passing through professional developmental programs and ending with program evaluation and promotion. This circle will not stop; planning, teaching, assessing, role modeling, mentoring and so on. We will try in this presentation to focus on the expected role of the faculty on quality assurance in medical schools.
2.0 QUALITY (IHSAN) IS THE CULTURE OF ISLAM
2.1 Ihsan (quality) is the one of the 3 fundamentals of the diin
Ihsan is excellence and is the highest level of din. Ihsan was defined in the sunnah as perfection of action[i]. It represents perfection in both Islam and Iman. It is excellence in worship, work, and in any social action. It is worship of Allah in the full knowledge that He is seeing you even if you cannot see Him. No activity goes by without being observed by Allah[ii]. The concept of excellence extends from prescribed acts of ibadat to all human endeavors and activities. Each human activity is an act of ‘ibadat and as such should be done with excellence. The quest for excellence is a motivation for a Muslim in whatever work he or she is engaged in. It is this quest for excellence and perfection that guarantees that believers are the only ones capable of establishing the best human civilization. The importance of ihsan is shown by its mention in many places in the Qur’an: as verb in the past tense[iii], as a verb in the present tense,[iv], in the imperative[v], as an adjective, and as a noun.
2.2 Quality Performance
Islam sets quality work and excellent performance in all spheres of life as its culture. Quality must permeate all activities. Allah accepts the best of work, taqabbalu ahsan al ‘amal[vi] and gives rewards for it, jazau ahsan al ‘amal[vii]; The prophet said that Allah loves ihsan in everything and advised Muslims to perfect every work that they undertake including the slaughter of animals[viii]. Humans in their earthly life are tested to see who performs the best, Ibtillai al naas ayyuhum ahsan ‘amalan[ix].
2.3 Enjoining quality in every thing
Islam enjoins excellence for parents, ihsan al walidayn[x], excellence in greetings, ihsaan al tahiyyat[xi], excellence in religion, ihsaan al ddiin[xii], excellence in arguments, ihsaan al mujadalat[xiii]; excellence in interpretation, ihsaan al taawiil[xiv]; excellence in speech, ihsan al qawl[xv]; excellence in reactionary response, al dafa’u bi al ahsan[xvi]; excellence in fulfillment of duties, ihsaan al adau[xvii]; excellence in divorce, tasriiuhu bi ihsaan[xviii]; excellence in following, ittiba’u bi ihsaan[xix].
3.0 THE ETIQUETTE OF THE TEACHER, adab al mu'allim
3.1 Characteristics of the teacher
Teachers should take their task very seriously. The education process, involving giving and receiving knowledge is noble[xx]. Teachers should have the humility to know that their knowledge is limited and that they can always learn more. Arrogance because of knowledge is condemned[xxi].
3.2 The learning process
Teachers must make the learning process interesting and avoid boredom[xxii]. They should make the atmosphere and circumstances of learning easy for the students[xxiii]. Teachers must be careful in their actions, attitudes, and words at all times because being models and leaders they are seen and are emulated. They must be aware that sometimes they can teach using body language without saying anything[xxiv]; they have to be careful about their public dispositions They should be ready to carry out their function at all times and at any opportunity[xxv].
3.3 Communication with the students
They should have an appropriate emotional expression. They can raise the voice to emphasize an important point[xxvi]. They can show anger or displeasure when a mistake is committed[xxvii]. Asking students questions to ascertain their level of knowledge is part of the teaching process and is not in any way a humiliation for them[xxviii]. Teachers should make sure that the students understand by constant repetition[xxix]. Teachers should strive to pass on to the students as much knowledge as they can. Hiding knowledge is a cause of punishment, uqubat man katama ‘ilma[xxx].
4.0 THE ETIQUETTE OF THE STUDENT, adab al muata'allim
4.1 Respect for the teacher
The Islamic etiquette of the relation between the student and the teacher should be followed. In general the student should respect the teacher. This is respect to knowledge and not the individual. The prophet taught admiration and emulation of the knowledgeable[xxxi].
4.2 The learning process
Students should be quiet and respectfully listen to the teacher all the time[xxxii]. Students should cooperage such that one who attends a teaching session will inform the others of what was learned[xxxiii]. Students can learn a lot from one another. The student who hears a fact from a colleague who attended the lecture may even understand and benefit more[xxxiv]. Students should ask questions to clarify points that they did not understand or which seem to contradict previous knowledge and experience[xxxv]. Taking notes helps understanding and retention of facts[xxxvi]. Study of medicine is a full-time occupation; students should endeavour to stay around the hospital and their teachers all the time so that they may learn more and all the time. They should avoid being involved in many other activities outside their studies[xxxvii].
5.0 CONTINUOUS FACULTY ACADEMIC AND PROFESSIONAL SELF-DEVELOPMENT
5.1 Basic qualifications
Academic staff must be qualified. Appointment and promotion of academic staff should depend only on academic merit and character. Good staff means high quality. The minimum qualification for basic medical science lecturers is a doctoral degree. Clinical teachers must have the professional specialist qualification for that discipline.
5.2 Skill training
All academic staff must undergo training in teaching methodology including writing course descriptions, writing learning objectives, lesson planning, effective use of audio-visual aids, and assessment systems. All lecturers must upgrade their knowledge and skills by attending conferences or special training courses.
5.3 Research and publication
Academic staff must engage in research to be at the frontiers of knowledge in their chosen discipline. Academic staff must be given incentives for good research. They must be given time for research. This requires careful balancing of teaching and research which may be difficult when there is a shortage of teaching staff. Research distinguishes a university from a secondary school. It also enhances the academic standards by making the medical teachers producers of knowledge instead of being only consumers of knowledge who just pass it on to the students. Teachers who engage in research have up to date knowledge. Even if the research undertaken is simple, it can yield useful results if it is focused. Another academic product that must be encouraged is producing teaching materials. Lecturers should be encouraged to write up each lecture given. These can be accumulated over the years and can be published as a book.
5.4 Academic conferences
Conference attendance is useful for purposes of presenting research results and getting feedback from other researchers. Just attending a conference without any paper presentation is not very useful.
6.0 CURRICULUM DEVELOPMENT and DELIVERY
6.1 Curriculum documentation
Curricula must be fully documented. They should reflect a stated underlying vision and mission of the faculty. They should cover knowledge, skills, and attitudes. They should have horizontal and vertical integration. They should be benchmarked against the best faculties of medicine in the region and internationally. They should also be accredited by the national medical licensing authority to make sure that graduates will be registrable and employable in the local hospitals. Recognition of the final qualification by other universities especially overseas is a good indicator of quality. Denial of recognition does not necessarily indicate poor quality because political factors are often invoked. The curricula should be reviewed every 3 years in view of the rapid growth of knowledge and methods of teaching and learning. These reviews should result in refining, redirecting, and restructuring the curriculum. The process of curriculum review should be evolutionary and not revolutionary. Revolutionary changes cause a lot if dislocation and confusion and in the process do not last long.
6.2 Benchmarking
The curricula in the faculty should be compared with curricula in other faculties. This process has now become easier because many universities put their curricula on their websites. The purpose of benchmarking is not to copy or be like everybody. It serves the purpose of indicating whether in general we are ‘moving with the crowd’. If a curriculum differs in major ways from comparable institutions a rational explanation must be found otherwise there is some problem.
Another approach to benchmarking is registering students to take international medical examinations. The Americans have the MCAT and USMLE examinations. The MCAT examination is taken by pre-medical students. The USMLE I examination is taken by students who have completed the medical sciences curriculum. The USMLE II is taken at the end of clinical training. There are equivalent UK
7.0 STUDENT MOTIVATION, ASSESSMENT AND FEEDBACK.
7.1 Good students
Admitting good students means high quality. Only the best should be admitted. Besides the academic grades, consideration should be given to character and motivation to study medicine. Experience has shown that diversity improves quality. The proportion of internationals should be at least 10% for good quality. Student counseling services should be provided for all students. There must exist mechanisms for identifying and counseling failing students as early as possible.
7.1 Motivation: an Islamic perspective
Faculty must encourage students to exert themselves to excel Motivation can be intrinsic (self motivation), extrinsic (motivation by external rewards), or reactionary (temporary response to events). Jannat is a positive motivator. Jahannam is a negative motivator. Motivation starts with commitment to an intention Ikhlaas al niyyat. The reward for work is commensurate with the niyyat. Any work without niyyat is not recognized. The best of work is consistent and continuous. Performace may fall short of the niyyat. Work can be good work, ‘amal hasan or bad work, ‘amal sayyi. High job satisfaction is directly related to high motivation. Motivated workers know that work is ibadat and that Allah observes all they do so they strive for excellence, ihsaan. The salary meets the needs of the worker and family so that he can devote time and energy to the work and is not a just return for the work. Work is ‘ibadat and only Allah can recompense for it. Other sources of motivation are honor, sharaf, generosity, karam, and fulfillment, wafaa
7.2 Methods and techniques of motivation
The academic staff can be motivating leaders in the medical educational process. Motivated and motivated leaders clarify goals, set objectives, consult and respect followers, deal with followers kindly, humanely, and with fairness, have good 2-way communication, and make followers feel secure. Positive reinforcement (appreciation, reward and praise) is a motivator. Negative motivation is due to worries, lack of self-confidence, low self-esteem, low self-worth, negative opinions in the work place, poor working conditions, poor leadership, inequity, and injustice. Negative reinforcement such as reprimand demotivates.
7.5 Early Muslim physicians as a motivator
Ancient Muslim physicians were encyclopedic in knowledge, all-rounded, motivated, hardworking, and productive. They excelled in medicine as committed Muslims because Islam is not incompatible with science. Their achievements are a motivator for today’s medical students and physicians. Abubakr Al Razi (251-313H), wrote more than 100 books (the most famous being al Hawi al Kabir), investigated diseases (gynecologal, obstetrical, hereditary, eye, small pox, and measles), discovered surgical sutures, used anesthetics, used ammonia to control diarrhea, considered psychological factors in disease treatment, and was director of hospitals in Baghdad and Rayy. Ibn Sina (370-428H) wrote many books (the most famous being al Qanuun fi al Tibb), recognized that TB was contagious, accurately described the symptoms of diabetes mellitus, discovered ancylostomiasis, and contributed to science, mathematics, chemistry, and philosophy. Al Zahrawi (d. 404H) had interest in surgery, pharmacology, and anatomy. He designed over 200 surgical instruments. His book Kitaab al tasriif, became a standard textbook of surgery. He was an expert in cancer surgery and tooth extraction. Ibn Zuhr (d. 487H), lived in Andalusia and Morocco and authored the book al Taysir translated into Latin and used in Europe . Ibn Rushd (d. 595H) was a philosopher and a medical practitioner. His book al Kulliyat translated in Europe . He made the observation that smallpox infected only once. Ibn Al Nafees (d. 686H) described blood circulation before William Harvey and authored Sharh tashriih al qanuun in which he explained pulmonary circulation.
7.6 Assessment of students
Student assessment with appropriate feedback should be systematic and continuous. Assessment of students takes place before admission, during the course, and at the end of the course. It must be systematic and the faculty must have written policies and guidelines for examinations. These should include what to do when students fail or when students cheat in the examinations.
7.7 Student feedback
Students are the most important customers in the educational process. Therefore their satisfaction is very important. We have to listen to them and address their concerns. We can get student feedback from the examinations. It is however also necessary to get their feed-back by use of questionnaires. These questionnaires are more effective if administered regularly usually at the end of each unit or module. Students should be asked to indicate their degree of satisfaction with each individual learning objective. If there are too many objectives we may group them into natural categories and choosing 1-2 objectives from each category for inclusion in the questionnaire. These formal means of getting student feedback are not a substitute for informal means of getting student views on the curriculum. The students may be more honest and forthcoming in informal settings.
7.8 Student tracer studies
An identifiable product of an educational system are the students. After graduation they take the knowledge and skills learned to the outside world. Their job performance and character reflect to a certain extent the quality of the education that they received. Thus a faculty of medicine should follow up and trace its graduates to find out how they are performing. The tracing can be by using questionnaires or telephone interviews.
Notes
[i] (KS66: Bukhari K2 B37; Muslim K1 H1, 5, 7; Tirmidhi K38 B4; Nisai K46 B5, Nisai K46 B6; Ibn Majah intr B9; Ahmad 1:27, Ahmad 1:51, Ahmad 1:52, Ahmad 1:318; Ahmad 2:107, 426; Ahmad 4:129, Ahmad 4:164; Tayalisi 21)
[ii] yunus:6
[iii] (, 17:7, 3:172, 5:93, , , 39:10, 53:31)
[iv] (18:104)
[v] (28:77, 2:195, 2:83)
[vi] (46:16)’
[vii] (29:7, 39:35)
[viii] inna al llaaha yuhibbu al ihsaan fi kulli shay…idha dhabahtum fa ahsinu al dhabhat..
[ix] (11:7)
[x] (29:8, 6:151, , 46:15)
[xi] (4:86)
[xii] (4:125)
[xiii] (16:125, 29:46)
[xiv] ()
[xv] (41:33, )
[xvi] (41:34)
[xvii] (2:178)
[xviii] (2:229)
[xix] (9:100)
[xx] (MB70 Bukhari 1:79)
[xxi] (MB102 Bukhari 1:124)
[xxii] (MB62 Bukhatri 1:68)
[xxiii] (MB63 Bukhari 1:69)
[xxiv] (MB75 Bukhari 1:85 and MB76 Bukhari 1:86)
[xxv] (MB74 Bukhari 1:83)
[xxvi] (MB55 Bukhari 1:57)
[xxvii] (MB79 Bukhari Bukhari 1:90, MB80 Bukhari 1:91, and MB81 Bukhari 1:92)
[xxviii] (MB56 Bukhari 1:59)
[xxix] (MB82 Bukhari 1:95)
[xxx] (KS390 Abudaud K24 B9, Tirmidhi K39 B3, Ibn Majah Intr B24, Ibn Sa’ad J4 Q2 p56, Ahmad 2:263, Ahmad 2:296, Ahmad 2:305, Ahmad 2:344, Ahmad 2:352, Ahmad 2:495, Ahmad 2:499, Ahmad 2:508, Tayalisi H2534)
[xxxi] (MB66 Bukhari 1:73)
[xxxii] (MB101 Bukhari 1:122)
[xxxiii] (MB78 Bukhari 1:89)
[xxxiv] (MB61 Bukhari 1:67)
[xxxv] (MB88 Bukhari 1:103)
[xxxvi] (MB93 Bukhari 1:112)
[xxxvii] (MB98 Bukhari 1:118)