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Tuesday, September 2, 2014

Medical Education – Then and Now

The following article was sent to me by Sanath on my request. Feedback in the form of "Comments" by viewers (both members of the batch and others who might read it, including those based outside Sri Lanka) would be much appreciated. Those viewers who may not be familiar with the commenting process are kindly requested to follow the instructions provided in a previous post titled "How to post a comment". You may even send in comments to my personal e-mail address: adnl1102@gmail.com. I will post them on your behalf.


Medical Education – Then and Now 
Sanath P. Lamabadusuriya MBE  

THEN

When we entered the Colombo Medical Faculty in 1962, we followed a traditional curriculum lasting about 5 years. Since the British started the medical school in 1870, the curriculum has remained more or less the same. The structure of this traditional curriculum was inherited from the British during the colonial era. 


The teaching consisted mainly of didactic lectures, practicals and anatomy dissections during the first two years; clinicals commenced in the third year and the didactic lectures and practicals continued. There were three end of course evaluations, namely the 2ndMBBS, 3rd MBBS and Final MBBS examinations. There was hardly any continuous assessment apart from the ‘Anatomy Spots’.  

There was only minimal contact with the community except for a short family visit during the professorial paediatric appointment. Exposure to psychiatry or psychological medicine was minimal and it was not evaluated. Evaluation in paediatrics consisted of two questions in one of the two written papers in medicine and a short clinical examination.  We, the students were of the view that what was not evaluated need not be studied to pass the examinations. Therefore our knowledge of paediatrics and psychological medicine was rather rudimentary. Most questions of written papers were “essay type” and there were no MCQ papers. (Majority of us answered a MCQ paper for the first time, when we sat for the ECFMG examination after graduation) 

Interim Period

Paediatrics was the first discipline to introduce a MCQ paper, at the end of the professorial appointment. Other disciplines gradually introduced MCQ papers. Paediatrics became a separate subject at the Final MBBS examination in the 1980’s. Together with the Department of Community Medicine (called Public Health during our time) the Department of Paediatrics started a family attachment so as to expand exposure to the community. However, the traditional curriculum prevailed up to the 1990’s and students were taught many conditions that were never or hardly ever seen - for eg. Chaga’s Disease, Sleeping Sickness etc. 

NOW 

The build-up 

During the 1980s the WHO recommended reforms in undergraduate medical education. Reorient Medical Education (ROME) was the theme. In the early 1990’s the Colombo Medical Faculty, which was one of four medical faculties at that time, decided to change the medical curriculum in keeping with the country’s needs. Several workshops were held with representatives of  other medical faculties, Ministry of Health consultants and administrators , general practitioners, representatives from Professional Colleges, The Sri Lanka Medical Council, GMOA, senior administrators such as the Vice Chancellor of  the University of Colombo,  members of the UGC etc., 

Several members of the academic staff were provided with opportunities of visiting medical education units overseas by the WHO awarding short term fellowships.  These were to University of New South Wales, Sydney, Australia, University of Science in KotaBharu, Malaysia, University of Singapore, University of Dundee, in Scotland and University of Maastricht in the Netherlands.

 After much deliberation a “new curriculum” was introduced with the A/L 1993/1994 intake of students who eventually graduated in 2000. This was a major change and very staff intensive with both (old and new) curriculae running within the faculty during the period of transition. In later years medical faculties in Peradeniya, Kelaniya, Galle and Sri Jayawardenapura followed suit and initiated changes in their teaching programmes. 

Structure of New Curriculum

Several new and some even unique “streams’ “modules” etcwere introduced. Examples were  the Introductory Basic Sciences Stream (IBS), students  being introduced to clinicals during the first 2 years itself, Applied Sciences Stream (with a modular structure in the  3rd, 4th and 5th years) Clinical Stream, Community Stream and Behavioural Sciences Stream; the last three streams ran through the entire course. Clinical teaching that was introduced during the first year rapidly expanded during the next five years. First Contact Care was also another new aspect- and students were posted to peripheral hospitals and were attached to a General Practitioner, and a Municipality clinic.  (I functioned as the founder chairman of the Clinical Stream) 

Basic and Applied Sciences Stream

The Applied Sciences Stream initially consisted of 18 modules, dealing with different systems eg. CVS, GIT, CNS etc. Later, by joining certain modules it was reduced to about 15. Wherever possible clinical appointments were made to coincide with the relevant modules. 

Community Stream

In the Community Stream, a family attachment was made mandatory; two students had to look after a family for several months and deal with their health and social problems. A research project was also made mandatory so as to introduce students to basic aspects of research, as this was considered to be very important for their future career in any chosen field.  

Behavioural Science Stream
 

During this stream effective communication skills, self-development, time management, team work and medical ethics were emphasized. “breaking bad news”, “caring for a dying patient” and “reducing conflicts in health care teams” were some of the other important components.  

The final year professorial appointments were for 2 months each and psychological medicine was also introduced in to the final year. 

Elective Appointment

An elective appointment was introduced, which could be spent locally or overseas. One or two students together could do an elective appointment which may include a research project. A sub-committee of the Clinical Stream supervised the elective appointment. 

Skills Laboratory

It is a laboratory setting to allow learners to acquire skills which are embarrassing (eg. vaginal or rectal examination), painful (eg. catheterization), difficult (eg. suturing of an episiotomy) IV cannulation, funduscopy, otoscopy etc. These procedures are practised on models under supervision. Several modules and the Introductory Clinical Sciences Stream use it for teaching skills.   

Methods of Teaching

Didactic lectures and anatomy dissection hours were drastically reduced. (Prosected specimens largely replaced dissections)New methods such as Problem Based Learning (PBL) Integrated Teaching, Seminars, Small Group Discussions (SGDs), Computer Assisted Learning. Fixed Learning Modules (FiLMS) are used extensively. There are many student led assignments. The students are encouraged to do “self-study,” prepare reports and present these to their colleagues at formal teaching sessions. These methods, made the students to lose “stage fright” and develop public speaking skills and become good communicators, early in their career. 

The clinical appointments in the new curriculum were similar to what we went through except for the addition of some new sub-specialities and aligning them with the module based teaching of the 3rd and 4th years. The final year professorial appointments were for two months each and psychological medicine was also included. 

Methods of Evaluation

The basic principle was that whatever that was taught or a sample of it should be evaluated and given a mark. Continuous assessment was given a prominent place in contrast to “end of course” evaluation in the old curriculum. MCQs and structured essays are the hallmarks of written examinations. OSPE (Objectively Structured Practical Examination) OSCE (Objectively Structured Clinical Examination) are also used as tools of evaluation. 

Psychological Medicine was made a separate subject for the Final MBBS examination from 1998 onwards. All this meant a huge exam overload as well as report writing, research projects, etc. At present .there are over 30 different evaluations adding to student stress. The Community and Behavioural Sciences Streams also have their final evaluations at the end of the course, adding to be students work load.  

Evaluation in Paediatrics

During the 2 months appointment in the final year, a continuous assessment mark of 40% was given in the new curriculum. Continuous assessment  was made as objective as possible based on their attendance, clinical presentations, written discussions, work place based interviews and OSCE’s; we even attempted to assess attitudes through an exhaustive mechanism. The final paediatric clinical examination was conducted at the end of the appointment with one long case and two or more short cases (30% of the final mark is given for it). At the end of the course at the Final MBBS examination two written papers are held (structured essay and MCQs) and 15% is given for each paper. In the near future it has been decided to postpone the paediatric clinical examination and for it to be part of the Final MBBS examination at the end of the course. This is mainly because a common order of merit has to be made for all the medical graduates from the different medical faculties for purposes of employment in the Ministry of Health. Therefore methods of evaluation have to be somewhat similar in all medical faculties.  

As you can see dear colleagues, over the years, the medical curriculum has been turned “upside down and inside out”! As I was fully involved in this very tedious process, I am convinced that it is for the better!

 
 


 

 

 

2 comments:

  1. Thanks so much Lama for that most interesting and educative post. I thought we were fortunate to be trained the way we were, and indeed there were many positives such as good teachers, exposure to a truly amazing clinical range ("good pathology" as we used to call them!) under the guidance of excellent and gifted clinicians, comprehensive theoretical curriculum etc In one day we could palate 4 spleens, listen to the whole range of cardiac murmurs, listen to all the abnormal breath sounds, examine a paraplegic, a couple of brain tumours, may be the odd Guillain-Barre etc. However, I realised more and more as I matured that there were glaring short comings too, many of them outlined by you in your post. Having contact with the system in the UK (which too has evolved as you might expect), I am glad that things taken for granted here such as continuous and summative assessment, relevance to practice, more sensitive tests such as MCQs compared to the old essay methods, communication skills etc etc have all been introduced in Sri Lanka. I am totally impressed and of course I see some results of these changes when these young doctors come over here for further experience/education. The name of the game is not to stand still but to continuously assess , evaluate and introduce changes not for the sake of change but in order to produce better and more able doctors who will have the correct mindset to keep this process going for as we say, learning in Medicine is a Life-Long process. Very well done and your own very significant contribution is appreciated by all of us.

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  2. The transformation in Medical Education which you have been a large part of is truly admirable. Students from 1994 have been extremely fortunate to benefit from it. Three things particularly appeal to me:More stress on psychological medicine,continuous assessment rather than end of year,and getting students to present reports to one another. Improvement in communication skills you have introduced is a significant advancement too. To me, one of the short comings of the older system was the lack of encouragement in further reading and training in the writing of scientific papers.Your reorganised curriculum has adequately covered this as given in your article under 'Behavioural science stream' and 'Elective appointment' . Finally, may I say, our batch should be truly proud of you!
    Zita

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