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Modern Trends in Medical Education

(Items Compilation of the Seminar held Jan. 30th –1st Feb. 2009)
Edited by
Hemang Dixit
Sunil KumarJoshi
Modern Trends in Medical Education
Published by:
Kathmandu Medical College
184, Baburam Acharya Sadak
PO Box 21266,
Kathmandu, Nepal
Computer Layout: Aman Shrestha
Price: Rs. 500/-
ISBN : 978-9937-2-1456-8
1st published May 2009
Printed at:
Hisi Oset Printers, Pvt. Ltd.
Jamal, Setodurbar, Kathmandu
Phone: 4226416
Modern Trends in Medical Education
he monograph deals with various aspects of medical educaon. One of
the authors describes the history of medical educaon in Nepal to the
present, others state the usefulness of integrated system for the benet
of learners as well as the need for the teachers to understand more about
modern concepts of medical educaon rather than scking to the old habit of
delivering didacc teaching. A detailed outline about postgraduate medical
educaon inside the country along with its development and training in
dierent universies is also dealt with. This in itself leads to thinking whether
uniformity in training in dierent instuons is necessary or it should be
le to each instuon to standardise its own programme, which could be a
reference to other instuons.
Besides teaching, it also points out for evaluaon of educaon in relaon to
achievement of its goals, for example, competencies of the trained product
aer compleon of a prescribed course. Some thoughts are expressed
regarding the duraon of the course, parcularly at undergraduate level (with
comparison to other professions) and a possible need for re-evaluaon of
the whole component including the me needed for sasfactory compleon
of such training.
Discussion on internship has also expressed the values of going beyond the
hospital sengs to make new graduates understand more about the needs
of the community as a whole, besides caring for the individual paent’s need.
This parcular issue was thought as early as 1934 in Britain and later applied
in US and Canada where plenty of posts for such training were available. This
is an important issue in Nepal, where each year increasingly large number
of foreign trained medical graduates, and those trained in the country, are
compeng for the limited number of available posions.
An important aspect on evaluaon of the trainees is also discussed with
emphasis on both formave and summave systems. In this regards,
universies have given very high weightage for the summave part when
actually the teachers involved with the training would be more important to
evaluate in the formave period.
Modern Trends in Medical Education
The value and importance of Problem Based Learning (PBL) system is
clearly explained, including analysis and feedback from the trainees and its
applicaon in other areas of health sciences besides the medial program.
It has also cauoned the teachers with old mind set to look forward for
meaningful delivery of educaon to the trainees.
The usefulness of modern technologies and skill laboratories form a part of
publicaon in this monograph. It is expected that teachers will be increasingly
using modern technology to supplement the delivery of learning resources. I
am sure its value will be analyzed and the so called “ADDIE” (analyse, design,
develop, implement and evaluate) framework will help organise such a
project for the benet of medical educaon.
Dr. N B Rana
Modern Trends in Medical Education
he knowledge of healing, inially passed on by learned men of the mes,
was taken up in the past by priest praconers too and was handed
down from generaon to generaon by a system based on a period of
apprenceship in the various sociees, guilds or groups exisng in those
days. The system of apprenceship in the Western society produced great
surgeons such as Hunter and Astley Cooper. Sociees like that of the
Apothecaries or Pharmacists licensed the praconers in the pracse and
art of the healing sciences.
We in Nepal have our own Jharphuks, Jhankris and Ayurvedic praconers.
Western medicine as we know it now was introduced into Nepal by Brish
physicians and surgeons posted in the Residency in Kathmandu. These
praconers were familiar with the diseases prevalent in India. In course
of me Medical Colleges were started in such cies as Calcua, Madras and
Bombay. Starng rst with Licenates, Nepalese went to study medicine
in India. Later students came back with medical degrees. Following the
ushering in of Democracy in India, a larger number of Nepalese went under
the Colombo plan to various other cies in India to study medicine. It was
these undergraduate doctors trained in India who went further a eld to UK
and USA for further training. Subsequent years saw Nepali students going to
other countries such as USSR, Pakistan, Sri Lanka, China and even Burma to
study medicine. More recently there have been marked increase in doctors
going to Bangladesh, China and Philippines to study medicine.
It is heartening for us in Nepal that we have to a certain extent been aware
of the educaon trends in medicine. IoM was the pioneer in this eld and it
is heartening for us that it has connued to play a major role in the eld of
medical educaon in Nepal. Inially the IoM trained manpower for the Basic
and Middle levels of health workers. As per the trend of the mes all focus
was on Health for All by 2000 (HFA 2000) and for providing health care as a
Health Team. Training of the higher levels of resources for health started in
1978 with undergraduate studies and later went on to PG studies in 1982.
IoM has thus been in the forefront of medical educaon in Nepal.
Modern Trends in Medical Education
We have travelled a long way since that me when a single instuon
was providing all aspects of medical educaon and producing the various
categories of human resources for health (HRH) in Nepal. The ninees
of the last century saw the development of a mul university concept in
Nepal. This has resulted in many instuons providing health educaon to
many avid learners. The enthusiasc learners, who have been sold many
opmisc dreams, have in certain cases been greatly disillusioned too. The
various professional councils such as Health Professional, Nursing, Medical
and Pharmacy have had to sort out many of the problems. Was it the
selecon process, the learning process or evaluaon / assessment processes
that need to be looked at? What is a certain fact is that there is a great
dearth of HRH required not only in Nepal but also in many of the countries
of the world. The products of our educang and training schools should be
of such a standard that they are accepted readily for their experse in the
countries where they are desirous to work.
There has been tremendous change in the number of medical instuons
in the country. From the two or three medical colleges that we had in the
late eighes, we have now reached a situaon when there are 13 medical
and 5 dental colleges already established and there are ve medical and one
dental in the pipeline.
The spurt in medical and dental educaon has brought about its own problems
viz. the shortage of facilies, facules and nances for the undertakings.
Somehow things are pulling along but for how long is anyone’s guess. This
is the situaon in Nepal but whilst some Indian students are coming here
to study medicine, a larger number are going out from Nepal to study the
healing arts in surrounding / neighbouring countries such as India, Pakistan,
Bangladesh, China and even Philippines. One therefore frequently hears that
as there is no shortage of students wanng to study medicine, one should
allow an unrestricted opening of medical or dental colleges.
One of the quesons, as far as medical educaon is concerned is regarding
the method of instrucon that is being followed. We in Nepal are familiar
with the tradional form that is followed on the Indian Subconnent which
in itself was inherited in its present format from developed countries such
as the UK and the USA. Whilst the inuence of UK has been passed on from
Colonial mes, the inuence of USA was in the immediate post independence
years by way of the Rockefeller Foundaon.
But the world has changed with new methods and technologies. There are
dierent methods of learning / teaching in dierent lands. We have been
acquainted with some of the newer methods of teaching / learning from the
Modern Trends in Medical Education
me that IoM was established. Some of these new thoughts and ideas have
been put into pracce but rather midly. This eort in which we have tried
to take a lead is because of genuine concern. Fortunately for us in Nepal,
we are trying out these new ideas but somehow the exisng instuons
pracsing these have kept aloof. It is with the hope that there will be more
exchange of thoughts and collaboraon between those of us working in this
eld that this seminar has been planned. Hopefully it will lead to a beer
understanding amongst all of us involved in health sciences educaon in
We can state quite condently that we in Nepal have had a fairly enlightened
educaonal programme for doctors. We have had access to dierent ideas
in medical educaon. With the development of the Informaon Technology
these ideas are literally coming to our ngerps. Aer the Jana Andolan
in 1989/90, health services educaon in Nepal developed almost by leaps
and bounds. First were BP Koirala Instute of Health Sciences (BPKIHS) as a
deemed university in 1993 and then KU subsequently in 1994. Later the PG
courses at Bir Hospital and the Valley Group of Hospitals were consolidated as
a separate enty called Naonal Academy of Medical Sciences (NAMS). The
three universies are all having PG programmes in their courses of studies. In
2009 another deemed university Patan Academy of Health Sciences (PAHS)
is expected to take students for MBBS. The Purbanchal University (PU) is
on the threshold of starng its own medical school at Itahari. Thus from
the single medical school in 1978 we have come to a situaon in which we
will soon be having by end of 2009 a total of 3 universies and 3 deemed
universies having a total of 13 Medical, 5 Dental and 3 PG conducng
instuons viz. TU, KU and NAMS. These colleges being components of a
Public and Private eorts, should with co-operaon, be of great benet to
the country.
Some 23 years ago, one of us had edited, together with Prof. Bishwa Keshar
Maskay the publicaon Medical Educaon in Nepal, which was brought out
by the Nepal Medical Council, and the Nepal Medical Associaon. It is our
privilege to edit a document that may be considered as a follow up on what
has been happening in the medical educaon eld in Nepal. Most of the
items that are included in this tome were the presentaons made at the
3-day seminar on “Modern Trends in Medical Educaon” held at Kathmandu
from 30th Jan. to 1st Feb. 2009. This Seminar organised by Kathmandu
University Medical Journal Commiee and the Kathmandu Medical College
was supported by the under-menoned ten other medical colleges:
Modern Trends in Medical Education
College of Medical Sciences, Bharatpur
Janaki Medical College, Janakpur
KIST Medical College, Imadol, Lalitpur
KU School of Medical Sciences, Dhulikhel
Manipal College of Medical Sciences, Pokhara
Naonal Medical College, Birgunj
Nepal Medical College, Aarkhel, Kathmandu
Nepalgunj Medical College, Nepalgunj
Nobel Medical College, Biratnagar
Universal College of Medical Sciences, Bhairahawa
Our hope is that this monograph will be a permanent record to aid in the
development of medical educaon in Nepal. It was the constant prodding
of Dr. Narendra B Rana, Dean of the School of Medical Sciences, KU and
Dr. MR Baral, Chairman of this Seminar that made us exert ourselves in
the eort to bring out this book. We would like to thank Mr. Subhash C.
Sharma, Mr. Kumar Raj Pant, Dr. Vivek Dhungana, Dr. Bonisha Sthapit,
Mr. Aman Shrestha, and all the volunteers involved for all their help, electronic
and otherwise in the preparaon of this manuscript. Our nal thanks are to
Mr. Pushpa Chitrakar of Hisi Oset Printers for his eorts in bringing out this
publicaon on schedule.
15th April 2009
Modern Trends in Medical Education
Hemang Dixit
Sunil Kumar Joshi
Development of medical education in Nepal ...................1
Dixit H
Contemporary challenges in medical education ..............7
Marahatta SB
A lesson plan template for tutor training and faculty
development in PBL .......................................................15
Baral N, Tekian A, Gelula MH
Introducing PBL: A convert’s commentary ....................22
Phillip Evans
Learning to teach learning ..............................................28
Pandey AS
Integrated basic medical science (IBMS) teaching learning
activities in Nepal ............................................................37
Thapa TP
Lesson planning...............................................................45
Pant CR
Microteaching-An integral component of teacher’s
training in Nepal .............................................................54
Magar A
Tutorship: Redefining the teacher role...........................59
Swahnberg K
Interwoven themes and strands: Guiding student learning
in a problem based learning curriculum ........................65
Wijma B
Use of information technology in medical education ....81
Joshi SK
Modern Trends in Medical Education
Students’ perception of Problem Based Learning in
Kathmandu University School of Medical Sciences .......88
Karmacharya BM, Risal P
Assessment of undergraduate medical students.............94
Rizyal SB
Rotating internship - Interns’ response ....................... 100
Shrestha D, Mishra B
PBL - Allied health sciences perspective ...................... 112
Risal P, Karmacharya BM
Communication skills ................................................... 122
Sharma SK
Ethics in medical education .......................................... 126
Adhikari RK
Clinical evaluation exercise (mini-CEX) ....................... 132
Magar A
Ten criteria for criterion-referenced assessment in
postgraduate MD/MS education .................................. 144
Bhattarai MD
Continuing medical education for the 21st Century: A
learning journey ........................................................... 159
Shrestha BM
Career in medical education ......................................... 163
Magar A
Designing an innovative curriculum using PBL ........... 169
Staffan Pelling, Lars Uhlin
List of Participants ........................................................ 179
Modern Trends in Medical Education
Development of medical education in
Dixit H
Professor, Department of Paediatrics, Kathmandu Medical College,
Sinamangal, Nepal
“There is nothing more difcult to carry out, nor more doubtful of success,
nor more dangerous to handle than to initiate a new order of things, for the
reformer has enemies in all who prot in the old order and only luke-warm
defenders in all those who would prot by the new order. The luke warmness
partly arises from fear of their adversaries, who have the law in their favour
and partly from the incredibility of mankind who do not believe in anything
new until they have actual experience of it.”
The Prince: Machiavelli – 1513 A.D.
The rst institution for training health workers started 75 years ago. Further
development of teaching / learning institutions, mainly governmental started
from the middle of the 20th century. It was however with the setting up of the
Institute of Medicine (IoM) under TU that training programmes for different
grades of health manpower were started. The last two decades has seen an
explosion of institutions involved in the training of health personnel. This is
possibly because of the huge demand of Human Resources of Health (HRH)
not only in Nepal, but worldwide. Various grades of HRH are going out of the
country and seeking their livelihood elsewhere.
Key words: IoM, BPKIHS, PAHS, HRH
edical education in Nepal started about 75 years ago when the Nepal
Rajakiya Ayurved Vidyalaya in 1933 was started at Kathmandu for
the training of Ayurvedic health workers1. The Civil Medical School at
Kathmandu, for compounders and dressers who were in fact the basic level
health workers for the provision of health care to the people was set up a year
later. The next stage was in 1972 when the IoM was started and began the
process for the training of different categories of basic, middle and higher
levels of Human Resources for Health (HRH). Though the idea for training
doctors was rst thought about in 1963, the programme for MBBS doctors
within the country started later. This course, started after a lot of thought
Modern Trends in Medical Education
and planning, was community oriented; system based and with integrated
teaching. What type of medical services the people desired, had been
determined by doing health surveys in four of the seventy-ve districts of
Nepal. These districts were representative of different parts of the country
were Tanau, Bara, Dhankuta and Surkhet. Though this course at IoM had the
McMaster concept of medical education, all the components thereof were not
fully implemented. The training of the MBBS doctors started in 1978 and
Post Graduate training of Masters in General Practice or MDGPs in 1982.
Initially only personnel who had been middle level health workers were
entitled to sit for a competitive examination to be selected for the MBBS
course. Middle level categories, such as health assistants, laboratory
technicians, nurses and ayurvedic workers were eligible to compete. As
these would be doctors were enrolled into the medical course, there was
great discussion as to whether they would be recognised elsewhere in the
world. Following visits by inspection teams, the MBBS course of IoM was
recognised by the Medical and Dental Councils of Bangladesh and Pakistan.
The Medical Council of India (MCI) however, only recognised it belatedly
after a long period. There has been talk too in the past 20 years about the
mutual recognition of degrees given by the Universities of the South East
Asia Region. In August 1996, a Regional WHO supported meeting was held
at IoM when Dr. Karmacharya was Dean, to try to solve the many problems.
The then President of the MCI, Dr. Ketan Desai attended and Dr. MA Hadi
represented the Medical and Dental Council of Bangladesh. This question of
the equivalence of qualications has still to be solved.
After the Jana Andolan in 1989/90, health services education in Nepal
developed almost by leaps and bounds. First were BP Koirala Institute
of Health Sciences (BPKIHS) as a deemed university in 1993 and then
Kathmandu University (KU) subsequently in 1994. Later the PG courses
at Bir Hospital and the Valley Group of Hospitals were consolidated as a
separate entity called National Academy of Medical Sciences (NAMS). The
three universities are all having PG programmes in their courses of studies. In
2009 another deemed university Patan Academy of Health Sciences (PAHS)
is expected to take students for MBBS. The Purbanchal University (PU)
is on the threshold of starting its own medical school at Itahari. Thus from
the single medical school in 1978 we have come to a situation in which we
will soon be having by end of 2009 a total of 3 universities and 3 deemed
universities having a total of 13 + (6)* Medical, 5+ (1)* Dental and 3 PG
conducting institutions viz. TU, KU and NAMS. The projected (*) six new
medical colleges are those of PAHS and PU and four others at Tansen,
Chitwan, Rajbiraj and Devadaha. The sole new dental college in the planning
stage is that of KIST medical college. These colleges being components of
Modern Trends in Medical Education
both Public and Private sectors should with co-operation be of great benet
to the country.
Other grades of HRH such as nurses, health assistants, community health
workers are being produced at about 200 schools scattered all over the country.
These are under the aegis of the Centre for Technical Education & Vocational
Training (CTEVT). What is noticeable with all these institutions all over the
country is the demand of teaching / learning facilities and materials. Though
of varying standards, what is welcome is production of these within the
Standards of education
Three different bodies are regularly checking the standards of education of
these medical and dental colleges:
1. Higher Technical Education Evaluation and Monitoring Committee.
2. The concerned University
3. Nepal Medical Council
After receiving permission to start the medical college the concerned
institution has to undergo yearly visits till it gets a permanent recognition.
This has helped to maintain standards.
Innovative teaching
What is remarkable is that when IoM started its MBBS course in 1978 it
departed from the traditional format and took ideas initially from McMaster
but later from Maastricht and others. The course was community based,
system wise and had integrated teaching. This continued on over the years
and when the MBBS course at BPKIHS was started the departure from the
traditional to problem-based learning increased. There were further inputs
of Maastricht as BPKIHS became a full member of the Network of the
Community Oriented Medical Schools.
With the coming of KU in 1990 and the starting of the rst course at Manipal
College of Medical Sciences the process of learning that had been laid down
continued on a bit further. The full stress in all the KU afliated medical
schools was on the SPICES model, which was basically:
student centred
problem based
community based
teacher centred
information gathering
discipline based
hospital based
Modern Trends in Medical Education
It was thus only in 1993 that Nepal Medical Council (NMC) brought out its
‘Recommendation of Undergraduate Medical Education’2. It also laid down
the minimum requirements for setting up medical schools within the country.
What may be appreciated is that NMC stipulated that a Medical Education
Unit / Dept were an essential component of a medical college3.
Later KU stared the innovative Problem Based Programme at its own School
of Medical Sciences at Chaukot / Dhulikhel in Kavre. With the inputs of
Harvard Medical School, KU went on to have two tracks of the medical
course - the traditional one and the Problem Based at KU School of Medical
Sciences (KUSMS).
The implementation of Problem Based Learning was tackled more earnestly
at (KUSMS) and the result now is that they are trying to encourage its
introduction at the medical colleges afliated to it. It is hoped that besides
Kathmandu Medical College, others under KU will also shift towards the
new innovative process.
The newly established Patan Academy of Health Sciences has had much
input from a number of worldwide institutions, which have been utilising the
PBL approach for a number of years and have adequate experience in this
eld. It is expected that there will be a bridging course prior to candidates
entering the planned ve years plus one year of internship course of MBBS.
Thus it is hoped that the implementation of the PBL approach will be much
more effective from now onwards.
Medical education departments
The idea of Regional Training Centres for Medical Education started in the
early seventies. By 1978 there were however only two such centres- one at
Perediniya in Sri Lanka and the other at Chulalongkorn in Thailand. WHO
SEARO made concentrated efforts to start medical education centres in all
countries of the SEAR. Students of individual countries, not getting a place
to study medicine in their own, continue to go to adjoining neighbouring
countries to study medicine. Doubts have been raised regarding the standard
of teaching at some of these institutions. Judging by the number of schools
being established, there seems to be a great demand but the question remains
as to for how long. Mutual recognition has been replaced by licensing
examinations. Our students wishing to go abroad sit for exams like USMLE,
PLAB and other tests. MCI has introduced licensing examinations for Indian
students who have studied outside the country. We in Nepal have made it
mandatory for fresh doctors to sit for a licensing examination irrespective
of whether they have qualied within or outside of the country. It seems that
mutual recognition of degrees will be a practise of the past.
Modern Trends in Medical Education
As far as Nepal was concerned, the Education Support unit was established at
IoM in January 1986. Just over a year later it was renamed Education Support
Centre with the objective to inculcate the new and old teachers of IoM into
the art of teaching. Further development went into the Medical Education
Department in 1990 with a further stress into being a teaching / learning
centre. A recommendation was made in 1994 for setting up a national centre
of Medical / Health Sciences education. This was further stressed upon and
recommended for implementation in 1997 but nothing has occurred in the
last 11 years. Nepal Medical Council, noting its importance decreed that each
medical college must have its own Medical Education Department.
Standards of Medical Education
Nepal Medical Council (NMC) has been giving guidelines on medical
education for over thirty years. Is it necessary, effective or even worthwhile?
Should we not have examinations even in the clinical sciences? What must be
remembered is that standards which have been laid down need to be revised
periodically to keep up with the times.
Many years ago, someone I met said that the concept of God is universal
and our desire is always to look up to him who is at the very top. He felt that
there are different ways to get to the top and what may be the best for one
individual may not be the best for others. This applies too to a certain extent
in the training of doctors in the healing arts. The various systems of healing
existing in the world vary in their methods of instruction. Even the modernised
form of medical treatment, which started from a form of apprentiship with
the ‘master’, went on to the different trades or guilds and ended up by being
the academic courses of the universities. The aim is to produce personnel
able to look after the health of one’s fellow beings. We in Nepal have a very
short history of Health Personnel education. We are fortunate that we in this
21st century have easy access to widespread information technology and to
the Internet or World Wide Web. Using it wisely will ensure rapid knowledge
transfer and dissemination from any corner of the earth. We should be able to
utilise this opportunity if we are to forge ahead.
“If I were founding a university I would found rst a room: then when I had
a little more money in hand I would found a dormitory; then after that, or
more probably with it, a decent reading room and library. After that, if I still
had more money that I couldn’t use, I would hire a professor and get some
Stephen Peacock in ‘Oxford as I see it”. Harpers, 144: 738-45, May 1922.
Modern Trends in Medical Education
1. Dixit H. Nepal’s Quest for Health. 3rd ed. Kathmandu: Educational
Publishing House; 2005.
2. Tuladhar TM. Milestones of Nepal Medical Council in Medical
Education in Nepal. Kathmandu: Nepal Medical Council / Nepal
Medical Association; 1995.
3. Nepal Medical Council. Requirements for starting Medical Colleges.
Kathmandu: Nepal Medical Council; 2003.
Modern Trends in Medical Education
Contemporary challenges in medical
Marahatta SB
WHO/TDR Research Fellow
Medical education is currently a major topic of discussion in health care and
related arenas. It has attracted people to be involved in designing educational
methods, assessment tools as well as researches. A revolution in health
care is occurring as a result of changes in the practice of medicine and in
society. These include changing demographics and the pattern of diseases,
new technologies, changes in health care delivery, increasing consumerism,
patient empowerment and autonomy, an emphasis on effectiveness and
deciency, and changing professional roles. These are the challenges which
will be faced by the medical professionals as we advance into the 21st
century and to which continuing medical education must respond. Most
importantly, the new millennium ushers in a new age of global relations,
science, technology, and medical practice which is not sufciently addressed
by the conventional medicine. New era needs new types of professionals. The
cultivation of competent professionals demands good medical education with
new approaches. The key issues to be addressed in contemporary medical
education arei. Duration of course, knowledge acquisition and making skills training
ii. Evaluation modalities
iii. Mature, professional attitudes to patients and collaborators
iv. Improving research standards in medical education
iomedical sciences and clinical medicine have achieved phenomenal
advances and successes during the past 50-60 years. The new and ever
improving diagnostic, pharmacological and instrumental armamentaria have
made physicians increasingly effective and powerful in combating diseases.
The detail to which the biological processes of the human body, including
the brain, have become knowable at the molecular and genetic levels have
made it seem that in the foreseeable future most everything medical will be
reducible to a molecular formula, and thus manipulabile and controllable. The
enormity of knowledge and the sophistication of technology have inevitably
led to increasing specialisation, i.e., to the parcelling up the human organism
into smaller manageable units. By the beginning of the 21st century, we have
Modern Trends in Medical Education
arrived at the threshold of being able to genetically design the characteristics
of babies we want, and, with the implantation of tiny technological devices, to
change or replace biological functions in the developed human organisms1.
Medical education faces a dilemma with the current information explosion
and knowledge volume challenges; should it increasingly specialise or will
it maintain a broad base? We are currently educating and training through
an increasingly steep pyramid, with specialisation and sub-specialisation
through the training grades, but is this meeting the needs of patients in the
optimum way2?
The tools for teaching and treatment approaches that served yesterday’s
doctors are inadequate for tomorrow’s doctors. Medical schools need to
respond to this ever-changing world with exciting curricular innovations
designed to prepare future physicians for practice in the 21st century. They
must respond to the rapid social, economic, and technological changes in the
healthcare profession. The cultivation of competent professionals demands
good medical education with new approaches3.
The key issues to be addressed in contemporary medical education are:
i.) Duration of course, knowledge acquisition and making skills training
ii.) Evaluation modalities
iii.) Mature, professional attitudes to patients and collaborators
iv.) Public health orientation
v.) Improving research standards in medical education
Medical education needs to adapt to society’s changing attitudes. Work based
training must be made more effective to counter reduced working hours. New
methods of assessment are needed to reect the focus on competencies. High
quality, relevant research requires more interdisciplinary collaboration. The
skills needed in a good doctor will still include listening, communicating,
thinking, doing, and caring4.
Duration of course, knowledge acquisition and making skills training
There is a widespread perception in the country that the MBBS curriculum is
too theoretical in its content. After four and half years of the main course and
one year of internship, the nished graduates are still not condent in ‘handson’ experience. Most graduates are not condent enough at that stage to even
provide primary healthcare services independently. The MBBS curriculum
is closely linked to a tertiary care hospital. And, therefore, the graduates
cannot function in a setting where there is no multi-disciplinary support, or
advanced diagnostic hardware. A large percentage of the graduates treat that
Modern Trends in Medical Education
stage as a launching pad for the post-graduate course. It is generally assumed
that the clinical experience to equip the doctor to deliver medical services is
only gained at the post-graduate stage. Whether this situation is inescapable,
has never been critically examined. The medical graduate course of ve and
half years is one of the longest professional courses. Lawyers undergo a 5
year course (after 12th standard), Masters of Business Administration a 2 year
course (after graduation), Engineers a 4 years course (after 12th standard),
etc. These other courses equip the individual to pursue their professions
independently, though, of course, the standard of performance improves with
time. Is the duration of ve and half years still inadequate?
Any professional course should equip the fresh graduate to practice his
profession at the level of the more common tasks and services. If the medical
graduate does not have the requisite skills and condence at the time of
graduation, the fault lies with the curriculum and the pedagogic methodology.
The fresh graduate must at least be able to deliver services contained in the
primary healthcare package. The suggestion that the duration of the course be
extended to give more intensive clinical exposure is not a practical proposition.
As it is, the graduate medical course is one of the longest professional courses,
the students and their guardians, are exposed to a prolonged nancial and
familial burden. With the extended time and substantial nancial resources
involved in a medical education, graduates are increasingly drawn towards
the more lucrative specialisations, their choice often being in direct conict
with broad community requirements. Increasing the duration of the graduate
course would only worsen those pressures.
The basic sciences and clinical subjects are taught in compartments, and the
pedagogic methodology does not connect the elements of these disciplines
with the diagnostic and therapeutic aspects of the clinical topics. In most
institutions, the teaching methodology is not problem-based and does not
integrate the various non-clinical and clinical subjects. The basic sciences
subjects, no doubt, form the bedrock of a scientically sound approach to
clinical diagnosis and therapy. However, in a practical sense, the total time
allotted to the clinical subjects (in all the modes of teaching–lectures, postings
and internship) would have to be balanced with the need for adequate clinical
exposure to equip a medical graduate to function as a competent working
professional. There is an overload in the syllabus on the information content
at the cost of clinical skills. As a result, the graduates are well equipped, with
a sound theoretical base, to go into post-graduate specialisation; however,
they are not adequately equipped to begin providing health services, at least
for the common and uncomplicated conditions in the primary healthcare
Modern Trends in Medical Education
How to synchronise the theoretical knowledge with hands-on
One of the most problematic aspects of the current system of medical education
is the gap between knowing and doing, between competence and performance,
between ticking a “done that” box and gaining insight, understanding, and
an ability to apply knowledge using appropriate skills, with a professional,
caring attitude. Portfolio or logbooks can be designed to support this aspect
of professional development, and some do, but practical developments are
needed in this area. Realists might argue that the performance competence
gap is a manifestation of pressure of work. Our doctor is certain to have
ordered time: time for individual education and development, time to explore
the important eld of informatics, time to review service delivery and develop
new multidisciplinary teams, time to give adequate, or even generous, support
to the doctors in training posts, and time to reect on what we have achieved
ourselves. A further prescription might be to ensure that we are able to act as
a positive role model to colleagues and training doctors; to enjoy our work
and to feel that we are making a contribution to our profession and the health
of the nation2.
The medical colleges have traditionally followed a curriculum stuffed with
information. With the explosion of medical knowledge in the last half century,
the students are faced with an ever-increasing burden of information. It is
necessary to nd a way to cope with this problem so that practical aspects
are clearly structured in the curriculum to impart the students with essential
clinical knowledge and hands-on experience.
Cognitive psychological research has shown that deliberate practice is a
far better method to acquire expertise than simple unstructured practice.
Deliberate practice in simple terms is the combination of acquiring expertise
with activities that help learners to become more conscious of their learning.
The key elements of deliberate practice are:
• Supervision and detailed feedback
• Well dened tasks to improve certain aspects of performance
• Ample opportunity to improve performance gradually by performing
tasks repeatedly.
Top athletes and musicians apply a similar approach. It is not just practice
that makes perfect; it is deliberate practice4.
In order to provide adequate skills to operate independently in the primary
healthcare domain, study time would enable the student to concentrate on
the ‘hands-on’ skills for providing service in the primary healthcare area.
More study time should be available to acquire the various essential skills for
Modern Trends in Medical Education
independent functioning - psychomotor and performance skills; attitudinal
and communication skills; judgment to take decisions on balance, without
access to accurate evidence.
II. Evaluation modalities
The assessment system in medical education largely determines the graduate
physicians it is producing. It is essential to move away from the knowledgedominated examinations to more skill-oriented examinations. It is well known
that the cases kept for examination are the so-called ‘interesting’ cases, which
are the uncommon ones. No attempt is made to test the knowledge of the
student in respect of the common conditions and the hands-on skills. In result,
the fresh graduate does not have the condence and skills for independently
handling the common conditions coming beneath the umbrella of Primary
Health Care. Looking to this undesirable trend, examination should be based
on common disease conditions and hands-on knowledge.
Medical competence has long been considered a combination of constructs—
psychological characteristics that, although cannot be observed directly, can
be measured. Constructs are assumed to be stable, generic, and independent—
someone’s intelligence, for example, does not uctuate from day to day
and is independent of extraversion. Typical constructs included in medical
competence are knowledge, skills, problem solving, and attitudes. Many
assessment instruments have been developed for each of these aspects, often
with the aim of being a single denitive test of a construct. A typical example is
the objective structured clinical examination, which was assumed to be the best
instrument to measure skills. Stable and generic constructs proved no longer
tenable, assessment has moved to competencies. Competencies are tasks that
a qualied medical professional should be able to handle successfully. New
instruments such as the mini-clinical evaluation exercise and 360° feedback
have become popular. In the mini-clinical evaluation exercise a consultation is
observed and scored on a generic rating scale including items such as problem
analysis, history taking, and organisation and efciency. In 360° feedback the
candidate asks colleagues and co-workers to complete a questionnaire on his
or her performance that rates technical skills, interpersonal skills, team skills,
education and research skills, etc. Evaluation should be directed to assess
observable behaviours. They help the supervisor or teacher to document and
monitor performance and provide feedback to the learner. As such, they also
imply that no single instrument can be used for each competency but that
the whole picture of someone’s medical competence requires use of various
instruments. Likewise, more marks should be allotted to internal assessments
and practical examinations4.
Modern Trends in Medical Education
Apart, the typical mind-set of the fresh graduate is to look towards an
opportunity for a post-graduate course. Many of those who do not get a postgraduate seat settle into general practice in a peri-urban or urban area with a
tie-up with some high-tech, diagnostic service providers. Through this cycle
of events, very few doctors are drawn into providing what is a conventional
primary healthcare service. The period of internship provides one whole year
when the attention of the to-be-doctor can be turned towards the hands-on
skills, which is meant to form the very foundation of his professional worth.
The common perception is that the students fritter away the period of
internship. This is a year when the theoretical training is over, and the student
is expected to only absorb hands-on knowledge during the attachments to
various departments. Various steps need to be considered to make internship a
more serious period of training. One of such consideration can be introduction
of the requirement to maintain a logbook during internship. All the handson work performed by the intern during internship should be entered in the
logbook. Already some Medical Colleges have introduced log books during
internship. The curriculum of internship should include the requirement to
write a dissertation on a topic encountered at the Primary Health Care/ Health
Post (PHC /HP) level. This will make the intern focus on some community
health issue, or on an issue relating to primary healthcare. An evaluation
of the ‘hands-on’ knowledge and skills should be made at the end of the
internship. This will put some pressure on the students to concentrate on
the events during the period of internship. Permanent registration with the
Medical Councils should be granted only after successful submission of the
dissertation and passing in the evaluation.
Medical profession is dynamic in nature but which needs frequent up-dating
to enrich knowledge and hands on skills. Continual medical education and
periodic licensing exam need to be conducted by Nepal Medical Council in
order to strengthen the quality of medical care and to uplift medical education
of the country.
III. Mature, professional attitudes to patients and collaborators
Modern medical education must foster professional attitudes, communication
skills and interpersonal skills relevant to our times. The public look to the
medical profession for help and guidance at many times in their lives. Often
this is when people are feeling apprehensive, in pain or in distress. They
expect to be cared for by a competent, ethical and wise doctor who they
can trust absolutely. For these students, their development into professional
practitioners involves many challenging and stressful encounters with doctors,
nurses, patients and carers, not to mention teachers and examiners. These
experiences form the learning resources through which they can develop their
Modern Trends in Medical Education
IV. Public health orientation
In order to equip a medical graduate with the skill mix essential for providing
broad-based community healthcare, the students should spend signicant
time in the hospital/eld along within the classroom. This objective would
not be achieved if there were only a casual relationship between the medical
college and the decentralised public health service centres. The participation
of the students in the activities of providing service would only be effective if
the service centres are under the management of the medical college.
V. Improving research standards in medical education
There is no doubt regarding the essence of improving standard of medical
education research. Rigorous and relevant research requires a combination of
well trained educationalists and researchers with good practical knowledge
of medicine and teaching. We also need to abandon dogmatic thinking. It is
not the method that determines whether a study is scientically rigorous; it is
the strength of the research question, the value of the operational denitions,
the extent to which the chosen method is the best for the specic research
question, and the care with which the study was done. Collaborations between
institutions both nationally and internationally are needed. The criticism that
medical education research is too locally oriented, is too rarely multicentred,
and yields few generalisable ndings is well deserved, and the “not invented
here syndrome” is over prevalent4.
Medical education needs to adapt to society’s changing attitudes. Work based
training must be made more effective to counter reduced working hours.
We have all been raised in a culture where assessment is synonymous with
punitive examinations whose sole purpose is to pass or fail candidates. It has
shaped our mind accordingly and made us fearful. Few people see assessment
as a way to improve professional activities in order to provide better patient
care and conduct better research. In medical schools students try to nd
out what the assessment is and prepare strategically instead of studying to
become better doctors. This is not a surprise, as in the past many approaches
to assessment have been extremely reductionist, aiming only to pass or fail
candidates. It is also unsurprising that many professionals choose continuing
medical education programmes in subjects that they are already good at,
as good formal postgraduate assessment programmes do not exist and self
assessment is apparently not adequate. New methods of assessment are
needed to reect the focus on competencies. Overcoming negative attitudes
to assessment will involve a cultural shift. There is no doubt regarding the
essence of improving standard of medical education research. High quality,
relevant research requires more interdisciplinary collaboration.
Modern Trends in Medical Education
1. Solyom AE. Contemporary challenges of medical education: morality
and integrity of physicians. [cited 2009 Jan 6]. Available from: http://
2. Martin S, Sue C. Challenges in the medical education-what the doctor
ordered. Postgrad Med J. 2000; 76:599-600.
3. Marahatta SB, Dixit H. Students’ perception regarding medical
education in Nepal. KUMJ. 2008; 6(2):273-83.
4. Lambert WT, CPM van der Vleuten. Challenges for educationalists
BMJ. 2006; 333:544-6.
5. Ebrahim S. Demographic shifts and medical training. BMJ. 1999;
Modern Trends in Medical Education
A lesson plan template for tutor
training and faculty development in
Baral N1, Tekian A2, Gelula MH2
B.P. Koirala Institute of Health Sciences, Dharan, Nepal, 2Department of
Medical Education, University of Illinois at Chicago, USA
B. P. Koirala Institute of Health Sciences (BPKIHS), Dharan, has adopted
an integrated curriculum incorporating the organ system and partial
Problem Based Learning (PBL) approach. This aims to include forward
looking instrumental innovation in medical education incorporating old
time honoured practices in traditional curricula through newer approaches.
Many PBL themes each of one-week duration having basic science subjects
interfaced with clinical disciplines have been made for Phase I Curriculum.
Introduction of PBL through the faculty members trained in lecture based
experience necessitates instrumental faculty development programs through
tutor training. After making database of academic staffs, a regular workshop
is held to train prospective potential tutors in PBL process. A lesson plan
template is prepared for workshops to emphasize all aspects of tutor skills
like curriculum planning, case writing, facilitating tutorial process and
comprehensive training program in group dynamics. Therefore Medical
Education Department of BPKIHS has formulated faculty development
program for future tutor training activities for pedagogic improvement.
Key words: Tutor training, Faculty development, BPKIHS.
BL is the method of learning in which the learning results from the
process of working towards understanding or resolving a problem1. PBL
in medical education was ofcially introduced rst at McMaster University
in Canada in 19692. At present, there are many medical institutions which
have introduced PBL as a new approach to medical education, but there is
no uniformity of implementation of PBL in different schools and there are
apprehensions about changing from traditional system to PBL curricula3.
Some institutions are reluctant to adopt a PBL system because of lack of
sufcient numbers of trained and motivated tutors, in spite of willingness to
adopt PBL as strategy of learning.
Modern Trends in Medical Education
In this regard, BPKIHS has adopted an integrated curriculum incorporating
the organ system and “partial PBL” approach which aims to include forward
looking instructional innovation in medical education incorporating old time
honoured practices in traditional curricula with newer approaches. There have
been several deliberations to implement a greater integration of basic sciences
and to motivate the students to learn and apply these sciences in their clinical
practice. Encouraged by the reports received from innovative schools and
a few exposures of teaching faculty to problem-based learning approaches
through various workshops and lectures, ultimately it was decided by the
members of the curriculum committee to introduce “partial problem-based”
courses in the rst phase of MBBS and BDS courses. Overall response from
the students towards PBL has been favorable4. PBL was found to be a useful
and enjoyable method of learning for the majority (96 %). PBL facilitated
integration (100 %) and helped in the development of self-directed learning (88
%) and problem-solving skills (81 %). It appears that the introduction of PBL
as part of the curriculum is appropriate for medical schools with established
departmental structure and limited resources. Unlike earlier studies where
students perceived PBL as a stressful method of learning medicine, a fair
number of students at BPKIHS enjoyed PBL blocks as an effective way of
learning and participated with interest and enthusiasm4.
More than 12 PBL themes each one about one-week duration are organized
during phase I (rst 2 years), which have basic science subjects integrated
around organ systems and are interfaced with clinical disciplines. About 2025% of the MBBS curriculum was covered through partial PBL for the last
12 years and the institute is considering adoption of “total PBL” for the entire
curriculum. Cardiovascular systems have already been converted into total
PBL curricula.
Rationale of faculty development in PBL
Tutorials are the heart of the learning process in PBL. The pivotal role of tutors
in effective small group discussion is facilitating students’ learning process or
tutorial skills for active learning in PBL need not to be overemphasized. Tutor
functioning has a direct causal inuence on the functioning of small group
tutorials, which in turn inuences students’ interest in the subject matter.
These results reect the importance of tutors’ abilities to guide a tutorial
group in an adequate way5.
Faculty does not readily accept adopting new roles in which the student
is given considerable control over various aspects of his or her learning.
Students exposed to PBL devote more time in medical discussions, in the
number of computer searches and independent study. Therefore, students have
considerable control over various aspects of their learning. Hence, becoming
a tutor requires a major change in orientation for most faculty members6.
Modern Trends in Medical Education
Since most faculty members at BPKIHS have primarily lecture-based
experience, they have hardly any role models for tutoring. They have
expertise in the discipline in which they have been trained and have limited
training for tutoring but they are asked to tutor a group addressing a topic/
problem. With this background it is understandable they feel uncomfortable
with the new role in PBL serving as tutor and conducting the group process,
writing cases, etc. Thus, faculty development is considered a necessity at
present circumstances and is instrumental in its implementation. Not only
those involved in the renewal of instruction have to acquire new teaching
skills but also have to discard a number of beliefs pertaining to learning and
instruction that are shared widely among teachers. Faculty development offers
opportunities for the acquisition of new skills. Faculty are asked to construct
problems to direct small group tutorial sessions for analyzing problems,
to provide learning resources to the needs of students, and act as resource
persons without interfering students’ self directed learning. Moreover, in the
case of switching to the total PBL curriculum, a sufcient number of tutors
need to be trained in PBL skills to initiate and assume new roles. Tutors
with content expertise may endanger the most important goal of PBL: the
development of students’ skills in active self-directed learning. Thus, there is
need for tutors with content expertise to undergo faculty development to alert
them to the pitfalls and dangers of their knowledge and authority.
Pedagogic shift from traditional teaching to a student-centered approach
where learners are placed in control of their learning requires a change in
the role of the educator7. The benets of a student-centered approach include
enhanced learning opportunities to elaborate one’s knowledge through active
involvement and verbalization, enhanced motivation through an increase
in relevance and personal control and practice of skills needed in life long
Faculty development is central to comprehensive curricular conversion
from traditional to a PBL. The conversion requires fast and effective faculty
development and training for more than 150 medical teachers at BPKIHS.
Objectives of faculty development include the following:
1. Understanding concepts of adult learning
2. Training faculty to be tutors; acquiring general tutoring skills in PBL
3. Understanding the dynamics of a small group and learning through group
Framework of tutor training
Developing and implementing PBL means anticipating and preparing
teachers for new educational roles as curriculum planners, tutors, case writers,
resource experts and evaluators. The role of a tutor in a PBL curriculum
Modern Trends in Medical Education
mainly consists of facilitating the tutorial process. The tasks of the tutor are to
facilitate students through the learning process, to encourage students to attain
a deeper level of understanding, to ensure that all students are involved in the
group process, to monitor the progress of individual students, to motivate
students and to help the student group to deal with their own problems of
interpersonal dynamics1. Faculty development programs intended to address
the development of specic tutoring skills and to practice them for feedback.
Faculty development programs need to include opportunities for individual
tutors to be observed in simulated and actual tutorial interactions for purposes
of coaching and feedback. Student and faculty evaluation of essential skills
for PBL tutor can serve as basis for the planning of tutor training activities.
Such type of training objectives should be as follows:
1. To make new faculty members familiar with educational concepts relevant
to PBL.
2. To provide insight into the various teaching roles they have to full
e.g., that of a tutor, a member of a planning group, developer of teacher
independent learning resources, and assessor.
3. To discuss problems the faculty encounters in implementing the
educational philosophy and to invite them to participate in attempts to
improve the approach.
Methods of tutor training
A database of all academic staff is prepared who are potential tutors to
contribute to the teaching program, some are afliated to clinical departments
and some are from basic science departments. A regular workshop should be
held which train prospective tutors in the PBL process. All tutors irrespective
of their background or seniority have to undergo formal training prior
to tutoring. These workshops will be conducted over 2 days. Before each
academic year, a form is distributed to all academic staffs inviting them to
tutor during the rst and second year of MBBS. Potential tutors are asked
to indicate preferences for the unit in which they would like to tutor. An
option of team tutoring may be introduced in which two tutors could share
tutoring. Team tutoring provides more exibility for teachers with heavy
Workshop No. 1 “Introduction to PBL” is offered regularly around the year.
It lasts 2- half days and is obligatory for every faculty member who wishes to
play a role in the PBL curriculum. During such workshops, participants are
introduced to the principles, rationale, denition and characteristic of PBL.
The workshop is set up according to ideas that are characteristics of PBL:
learning in small groups, active participation by group member and high
degree of self-directness.
Modern Trends in Medical Education
Workshop No. 2 “Tutor training workshop” is conducted with brief
discussion, information packets and practice sessions. This training is a 2-half
days experience in tutoring and is offered four times a year approximately
3 weeks after each introductory workshop. There should be small group of
8-10 with a total of 25 participants working with a semi-structured program
in workshop. The goal of this program is to emphasize all the aspects of the
tutor skills: posing stimulating questions and tutor intervention, evaluating a
group session, giving feedback to individual students. Thus this training is a
comprehensive program in-group dynamics.
Participants receiving a tutor’s manual and directions on how to prepare
for the workshop proceeds for two days with a lesson plan template (Figure
1). Tutor training process and Case-oriented Problem Stimulated Learning
Process (COPS) approach to learning as suggested by DB Holmes and DM
Kaufman9 in which a seven step clinical or scientic reasoning process will
be used to help students identify steps in clinical reasoning. A group of eight
participants will simulate a tutorial with participants playing the role of
students in small groups being led by one of the tutor trainers acting as a
model tutor. Other less powerful methods or activities for teaching faculty
about the tutorial process include videotaped demonstrations, small group
discussions, and short lectures about tutorials.
During the second day of tutor training workshop, the participants practice
being tutors with small groups of student volunteers. These students (MBBS,
BDS) are recruited from across the institute. Teachers receive feedback from
their peers, tutors trainers and the students.
Evaluation of this “hands on practice tutorial” workshop by 25 participants is
done through a questionnaire, and will be collected and analysed.
Fig 1: Lesson Plan Template for Workshop
Session Date(s)
Audience Size:
Objectives relevant to the topic and activity (ies):
Modern Trends in Medical Education
Elapsed Time
Skills of the tutor
A skilled tutor should be a role model for students in such areas as quantity
and quality of work, critical thinking, tutorial democracy and enthusiasm
and growth. Rules for tutorial behaviour are difcult to codify. There must
be exibility without jeopardising the efcient functioning of the group
or compromising learning needs of the group. A good facilitator should
be non-directive. Directive participation is discouraged in order to permit
“Discovery Learning” on the part of students who would thus gain ownership
over acquired knowledge, study skills and information seeking abilities.
Tutors should learn to ask probing questions that open up rather than close
down discussion. With these values in place, a tutor needs to develop specic
tutoring skills.
In the present tutor training workshop for faculty members of BPKIHS are
guided for seven specic tutor skills drawn from the descriptive problembased literature1 in relation to overall ratings of tutor performance.
1. Encouraging critical appraisal of information
2. Questioning and probing reasoning process
3. Helping student to balance basic science and clinical application in
problem discussion
4. Facilitating and supporting good interpersonal relationship in the
5. Promoting synthesis of multi- disciplinary perspectives
6. Encouraging student direction of tutorials
7. Providing frequent feedback
Planning tutor evaluation
For evaluation of tutor skills, the monitoring of staff conducting this role
is required. It is desirable to have instrument available in order to collect
information about the performance of the tutor. Such an instrument would
enable the medical school to provide tutors with feedback. Training and
remedial teaching could be provided to tutors based upon the shortcomings
Questionnaire can provide teachers with feedback. Items should reect key
features of the tutor role. It should be based on the task set for the tutor at
the medical school in which instrument will be used. Two aspects of tutor’s
Modern Trends in Medical Education
performance is essential; content knowledge input, commitment to the
group’s learning. Based on this consideration a tutor evaluation questionnaire
is made reecting three aspects of tutor’s performance5:
1. Guiding students through learning process
2. Content Knowledge input
3. Commitment to group’s learning
Faculty development in PBL has great potential to help individual teachers
signicantly change the role to small group facilitator (tutor), a pivotal position
in a PBL system. Teachers’ training workshop will provide an opportunity
for faculty member to explore a new approach to their role as facilitators.
Therefore, lesson plan template will help future planning for tutor training
which is instrumental in implementation of PBL as an educational approach.
Authors acknowledge with thanks to FAIMER, USA for nancial support
and Department of Medical Education, University of Illinois at Chicago, IL,
USA for invaluable support.
1. Barrows HS, Tamblyn RM. Problem Based Learning: An approach to
medical education. New York: Springer; 1980.
2. Cambell EJM. The Mc Master Medical School at Hamilton, Ontario.
Lancet. 1970; 2: 763-7.
3. Bhattacharya N. Student’s perceptions of problem based learning at
B. P. Koirala Institute of Health Sciences, Nepal. Medical Education.
1998; 32: 407-10.
4. Chapagai, Bhattacharya N, Jain BK, Kaini KR, Koirala S ,
Jayawickramarajah PT. Introducing problem based learning into an
organ system programme. Medical Teacher. 1998; 20 (6): 587-9.
5. Dolmans DHJM, Wolfhagen IHAP, Schmidt HG, CPM Van der
Vleuten. A rating scale for tutor evaluation in problem based
curriculum: Validity and reliability. Medical Education.1994; 28:
6. Nayer M. Faculty Development for Problem Based learning Programs.
Teaching and learning Medicine. 1995; 7 (3): 138-48.
7. Maudsley G. Roles and responsibilities of the problem based learning
tutor in the undergraduate medical curriculum.BMJ. 1999; 318:65761.
8. Schmidt HG. Problem Based learning: rational and description. Med
Educ. 1983; 17:11-6.
9. Holmes DB, Kaufman DM. Tutoring in problem based learning: a
teacher development process. Medical Education.1994; 28: 275-83.
Modern Trends in Medical Education
Introducing PBL: A convert’s
Phillip Evans
Senior University Teacher in Medical Education,
Scottish Deans’ Medical Education Group Project Coordinator.
Problem based learning is as important in Nepal as it is elsewhere. Its
introduction may be justied out of conviction, supported by best-evidence
in medical education, that students become competent and caring clinicians,
equipped for a life-time of learning. Though curriculum reform may present a
challenge to the institution, in adopting PBL, medical schools should consider
the resource implications, and the benets of adopting innovative curriculum
structures. They should recognise the inuence that appropriate assessment
strategies have on student attitudes and development.
The debate about introducing problem-based learning (PBL) in Nepal, raises
issues that have been debated in other medical schools.
The successful introduction of a PBL-based curriculum is dependent upon
the senior management team having conviction in the evidence about, and the
philosophy and principles of PBL, that is sufcient to overcome the weight
of opinion of those who may oppose it. What is at the core of the conviction?
1n 1993, The General Medical Council1 set out a series of recommendations,
which included “learning through curiosity, the exploration of knowledge,
and the critical evaluation of evidence, should be promoted and should ensure
a capacity for self-education; the undergraduate course should be seen as the
rst stage in the continuum of medical education that extends throughout the
professional life” Principal Recommendations, 2, page 23.
If a medical programme is to develop attitudes about and skills in lifelong learning, then the medical school must adopt appropriate educational
approaches at the heart of the undergraduate medical programme. Such
mechanisms when adopted do make a difference2. Curriculum managers who
introduce problem-based learning are opting for a system that is humanistic,
constructivist, evidence-based, and students-centred. They are aiming to
prepare students who are able to judge what they need to know, can search
Modern Trends in Medical Education
out their own information, and express what they have learned, and are
competent and reective practitioners3. Such individuals rely on their own
powers of analysis and synthesis. To succeed, the students have to be selfmotivated and diligent.
Curriculum matters
Major curriculum reform is always challenging to any institution. The nature
of the curriculum is an important component of the image of the institution
as the labels used in the programme provide ‘visibility’ to the academic
department. In a conventional curriculum there are often disputes about the
boundaries of academic territory, and for example, the number of hours given
to teaching anatomy, physiology, biochemistry, or the necessity of having
surgery in the nal year. There is normally a great deal of horse-trading about
the amount of time given to the various departments and specialties. The
balance between pre-clinical science and clinical teaching, the identity of the
various ‘ologies’ and the balance between community-based and hospitalbased teaching, and the endless discussions about the number of hours given
to topics delivered by lectures will all be familiar to those with experience in
curriculum reform.
Generally, conventional programmes are lecture-based, teacher-centred,
and content driven, with formal ‘obstacular’ assessments of memory. This
classical model is attractive because large number of students can be taught
and assessed relatively efciently, assuming that there is a lecture theatre
large enough, that the library has enough books, and there is a hall large
enough to accommodate the examination. Generations of students have
passed through this system, and some have returned as lecturers to perpetuate
the culture. Reforms that embrace PBL at their core are challenging because
they raise issues, not only about content, but, more fundamentally, about the
characteristics of the medical graduate.
David Boud4 reports examples of successful and unsuccessful reforms, and
the experience at Otaga, New Zealand has been carefully documented5. In
1996, three UK medical schools, Liverpool, Manchester and Glasgow made
the successful transition from their conventional curriculum to one that was
problem-based. All three schools were judged to be ‘excellent’ in the National
quality assurance reviews that followed. Since 1996, other UK schools have
adopted PBL as part of an increasing trend of recognition of the merits of
Framework for learning
A PBL curriculum replaces conventional lecture-based courses, with a
framework for learning that is based on a series of cases or problems. The
Modern Trends in Medical Education
criteria for identifying the cases is sometimes determined by a consensus of
what is common and what is rare but important because it illustrates some
important underlying principle. The University of Glasgow, for example,
recognised a series of presenting symptoms and common conditions (such
as pain, or headache) and has developed a series of cases that accommodates
these. The University of Liverpool adopted the life-cycle as a framework for
their cases, with the early cycle emphasising relatively normal situations, such
as family planning and conception, and more abnormal conditions, such as
infertility and difculty with conception, in the second cycle. In this respect,
cases can be developed that have a regional signicance. For example, the
University of Gifu have an on-line curriculum for South-East Asia, “Rakuichi”,
which includes the case of oral cancer caused by chewing bettel nut in a
patient in rural Vietnam. Cultural variance is not only important in problembased learning, but in all aspect of medical education. The author recently
visited a medical school in the Middle-East where the students reported that
the communication skills training was very good. However, the difculties of
applying theory to practice was made difcult because they rehearsed their
skills in English, but their patients spoke Arabic, and the English phrases
did not translate so easily. This emphasises the point that many text-books
and web-based materials are written in English and primarily address the
needs of a 1st world medical community. Problem-based learning presents an
opportunity for the students to adjust and apply the international principles to
their local situation.
Limitations of resources that might arise in terms of books and access to the
web will not be resolved because of problem-based learning. However, PBL
sessions can include discussions as to how resources can be found and used
effectively. Such discussions may also promote the principle of best-evidence
based medicine, and the best evidence may not necessarily be in a text-book,
or found on the web.
Staff provision is often a difculty in a problem-based learning programme.
The calculation depends upon the number of students in the programme. A
cohort of 80 students having 30 hours of lectures per week requires roughly
the same number of staff to deliver PBL to 10 groups, assuming there are two
one-and-half hour PBL sessions per week. However, if the numbers rise above
80 students, then more staff will be required. However, the advantage lies in
the qualities of the staff that are available. In a conventional programme,
lectures are normally only given by experts in the eld, which normally
means that topics are limited to the availability of experts. This restriction
need not apply in problem-based learning as the cases can include any topic
that the Faculty desires, and the PBL facilitators become expert in the case,
Modern Trends in Medical Education
and so are not restricted by content. In point of fact, the cases can be arranged
to include a wide range of issues, and might include issues, such as Ethics,
with more exposure than could be delivered in lectures.
Therefore, although the calculation in terms of FTE’s might be unfavourable,
there is ‘added-value’ in terms of the quality of student experience and the
potential diversity of curriculum content.
Conventional curricula and problem-based learning have problems that are
related to quality assurance and control, David Taylor6 discusses these in
terms of staff development and student support.
Staff preparation and ongoing development has to be a priority in a problem
based course7. There is also a variance in the style of the PBL facilitators.
Whilst most aim to facilitate to the best of their ability, there is a range of styles
that lies between the ‘tellers’ and those who stay silent. Consequently, there
is a need to have regular meetings that aim to establish a similar approach,
and to overcome the tendency for the process of facilitation to be replaced by
Students frequently report difculties in judging the depth and breath of the
content required to cover a topic. Groups also suffer from dysfunction due to
personality-immaturity, or difculties in time-tabling rooms, or groups being
required to meet in the last half of the last day of the week (which is Friday
in the UK). The psychological aspects of PBL on the students should not be
overlooked, particularly for exceptionally gifted students8, or the potential for
developing Emotional Intelligence9.
Although evidence in the literature indicates PBL promotes student satisfaction
and motivation10, it is also the case that assessment drives student learning.
Therefore there is an opportunity to develop formative and summative
assessment mechanisms that t into a PBL curriculum11, 12. Such mechanisms
can assess the students’ facility of the process of PBL as well as the cognitive
and affective domains. Imperial College, London, provides an example of how
the process of PBL may be assessed. The students are given a scenario and a
two weeks time window in which they can investigate the problem. They then
sit a conventional examination paper that has short answer questions related to
the scenario. The examiners take care to prepare a paper that may be answered
by students who follow the normal learning activities associated with PBL in
the College. The cognitive aspects of PBL (i.e. the academic content) may
be assessed using conventional summative assessments in the form of exam
papers that have objective questions (multiple-choice or extended matching
Modern Trends in Medical Education
items) or free-response short answer questions. The affective domain may
also be assessed using in-course techniques. This might include experiencebased written items, to include in the student portfolio that develops reective
thinking, student peer-appraisal13, or an appraisal of behaviour. Appraisal of
behaviour may be completed using a simple peer-review mechanism where
students are asked to write a short analysis about their peers in their PBL
group, using a ‘two stars and a wish’ structure in their comment. This is a very
powerful tool for developing aspects of the personal-professional curriculum.
Peer-appraisal in PBL has been used in the University of Edinburgh for a
number of years and has been well received by students and staff.
Adopting a PBL curriculum affords advantages for students, not only in Nepal,
but, in any country or culture. A great deal of evidence has been amassed in the
research literature, about the benets (or not) of adopting a PBL programme,
though eliciting the universal truths from the evidence is not easy. Norman14
emphasises the importance of rigorous investigations, and outlines some of
the challenges that investigators face. However, Koh et al15 having completed
a review of the evidence concludes, ‘problem based learning during medical
school has positive effects on physician competencies, especially in the social
and cognitive dimensions’. (Page 40). There is a very strong case that PBL
does prepare students who are competent and caring practitioners who are
equipped for a life-time of learning.
1. General Medical Council [homepage in the internet]. Tomorrows
Doctors; 1993. Available from: http://www.gmc-uk.org
2. Reid WA, Duvall E, Evans P. Relationship between assessment
results and approaches to learning and studying in Year Two medical
students. Med Edu. 2007; 41: 815-21.
3. Simpson JG, Furnace J, Crosby J, Cumming AD, Evans PA, FriedmanBen DM, R.M. Harden RM, et al. The Scottish doctor - learning
outcomes for the medical undergraduate in Scotland: a foundation for
competent and reective practitioners. Medical Teacher. 2002; 24(2):
4. Boud D, Feletti G. The Challenge of Problem-based Learning. 2nd
edition. UK: Routledge Publisher. 1997.
5. Schwartz PL, Heath CJ, Egan AG. The art of the possible: ideas from
a traditional medical school engaged in curricular revision. Dunedin:
University of Otago Press. 1994.
6. Taylor DCM. Reections from the salt mine - 8 years’ experience of
problem-based learning. The Clinical Teacher. 2004; 1 (2): 59-61.
7. Evans P, Taylor D. Staff development of tutor skills in problem-based
Modern Trends in Medical Education
learning. Med Edu. 1996; 30(5): 365-6.
Hmelo-Silver CE. Problem-Based Learning: What and How Do
Students Learn? Educational Psychology Review. 2004; 16(3): 23566.
Austin E, Evans P, Magnus B, O’Hanlon K. A preliminary study of
Empathy, emotional intelligence and exam performance in MBChB
students. Med Edu. 2007; 41(7): 684–9.
Albanese MA, Mitchell S. Problem-based learning; a review of the
literature on its outcomes and implementation issues. Acad Med.
Willis SC, Jones A, Bundy C, Burdett K, Whitehouse CR, O’Neill PA.
Small-group work and assessment in a PBL curriculum: a qualitative
and quantitative evaluation of student perceptions of the process of
working in small groups and its assessment. Medical Teacher. 2002;
24(5): 495-501.
Tousignant M, DesMarchais JE. Accuracy of Student Self-Assessment
Ability Compared to Their Own Performance in a Problem-Based
Learning Medical Program: A Correlation Study. Advances in Health
Sciences Education. 2002; 7(1): 1573-1677.
Sluijsmansa DMA, Moerkerkea G, van Merriënboera JJG, Dochyb
FJR. Peer assessment in problem based learning. Studies In
Educational Evaluation. 2001; 27(2):153-73.
Norman G. The end of educational science. Editorial. Adv in Health
Sci Educ. 2008; 13:385-9.
Choon-Huat Koh G, Hoon Eng Khoo, Mee Lian Wong, Koh D. The
effects of problem based learning during medical school on physician
competency: a systematic review. CMAJ. 2008; 178(1): 34 – 41.
Modern Trends in Medical Education
Learning to teach learning
Pandey AS
Associate Professor of Biochemistry, Kathmandu Medical College, Duwakot,
Modern medical teaching advocates a focus on the student where the student
is guided towards self learning by the teacher. This concept is largely
implemented in the form of Problem Based Learning (PBL), which has been
started in medical institutions like Institute of Medicine, Kathmandu University
School of Medical Sciences, BP Koirala Institute of Health Sciences and more
recently in Kathmandu Medical College. A major challenge that has emerged
in the implementation of PBL is scepticism regarding its appropriateness in a
developing world setting where the traditional methods of teaching introduced
by the British system of education prevail. Teachers who are alive to the
requirements of students in class have always felt the need to adopt some
modications in the current system of education. Modern medical education
as being followed in medical schools around the world is built on this very
notion of getting to know what the students need, which in turn requires the
teachers to become mentors who can provide an environment in the classroom
that becomes conducive to questioning, discussion, student-teacher as well as
student-student interaction and two way learning. An acknowledgement of
inadequacies in the current system of teaching, a realisation that “modern
teaching” is not synonymous to “use of modern technology” and an openmindedness towards the idea of faculty development is the need of the hour.
A consensus on following a method of assessment that tests a wider range of
student skill needs to be attained. The result may not be very different from
an education system that existed in India and Nepal thousands of years ago.
he psychology of learning identies ve fundamental laws of learning:
interest, attention, association, repetition and success1. The process of
learning is often regarded as an object of study itself, and has not found active
recognition amongst educators as a part of teaching until recently. Many
teachers all over the world have time and again expressed their views on the
methods of teaching they have been following. The insights of these men and
women have evolved into newer methods which for the most part focus on
the student as a learner, rather than a recipient of knowledge. This concept
has found the widest application amongst Medical Schools in the form of
“Problem Based Learning”, and is being successfully implemented at various
Modern Trends in Medical Education
institutions around the world. (University of Maastricht, the Netherlands,
McMaster University, Canada, John Hopkins School of Medicine, Baltimore,
USA). This concept has also been introduced and implemented in various
medical institutions in Nepal like the Institute of Medicine (IOM), Kathmandu
University (KU), BP Koirala Institute of Health Sciences (BPKIHS), but
has not been successful enough to nd wider acceptance and enthusiastic
enforcement. A major stumbling block remains the lack of appropriate
number of faculty willing to incorporate an idea that has so far worked in
developed countries only, into their own teaching methods. Guiding a student
towards learning, which is the crux of PBL, might involve some self learning
strategies on the part of the teachers. A few points of relevance to self learning
by teachers are discussed.
Ancient ways of teaching in Nepal and India- Coming full circle
The rst institutional education system in India and Nepal was the GuruShishya system. The aim of the education was to bring out the pupils innate
capacities2. The thinking principle, “Manana Shakti” was considered higher
than thinking itself. The pupil had to educate himself and attain mental growth
through his own efforts. He was required by the principle of Manana to form
his own opinion about what he had heard from his Guru.
Ayurveda, is the ancient science of herbal medicine believed to be more than
5000 years old3 The knowledge of Ayurveda was transferred from Guru to
Shishya orally and the Shishya was instructed to commit it to memory. This
growing mass of knowledge was nally written down in the rst century AD
by Ayurveda’s legendary physician, Charaka. According to Charaka’s treatise,
although most ayurvedic medicines are from plant sources, the remainder
comes from minerals and animal products often used in combination with
plants, so the student was required to possess a wide knowledge of Chemistry,
Botany and Zoology. A student who desired to learn Ayurveda chose his own
teacher and branch of Ayurvedic science, and once accepted, stayed at his
teacher’s home as a family member. The instruction was given free of charge,
and students followed a rigid schedule till the teacher considered the students
education complete. The current system of medical education being followed
in India and Nepal was introduced by the British, but the traditional reverence
for the Guru has lingered.
Most changes in medical education by way of modernizing it have been in the
curriculum. Teaching faculty at medical schools have now become familiar
with “collaborative learning”, “cooperative learning”, “active learning” etc.
When the Institute of Medicine in Kathmandu, Nepal, started its MBBS course
in 1978, it departed from the traditional format and took ideas initially from
McMaster but later from Maastricht and others4. The course was community
Modern Trends in Medical Education
based, system wise and had integrated teaching. With the establishment of
the BP Koirala Institute of Health Sciences, Kathmandu University School
of Medical Sciences and various Medical colleges afliated to Kathmandu
University (KU), innovative teaching methods like PBL have found wider
acceptance and implementation. A major concept of these modern methods
of teaching is to invoke curiosity amongst the students so that they become
self motivated learners. They are encouraged to question and seek instead of
being inactive recipients of information. This is reminiscent of the ancient
concept of the Guru-Shishya system, and it is in this light that we, the teachers
of Nepal, long having followed the lecture based ow of knowledge, need to
look at the principles of modern medical education.
Teacher’s response to PBL
The Medical Institutions in Nepal are served by teachers from Nepal
and India. To a majority of these teachers, the concept of Problem Based
Learning is new. Its implementation has not found popularity amongst the
faculty, as it has amongst the students. The reservation of senior Professors
in accommodating PBL as a regular method of teaching originates from
an incomplete introduction of the concept of PBL. The latter is perceived
to be an idea of the “West” with its much higher standards of living and
education, as well as a vastly different standard of the medical students.
Modern Medical Education is not a dictum; it is an evolving science that
changes with geographical location and societal needs. The Problem Based
learning methods were introduced in Canada, The Netherlands and the US
in the 1970s and 1980s and have been largely acclaimed as successful. The
medical institutions in Nepal have kept up with the trends and have met with
various degrees of success, as well as scepticism. A major impediment for the
implementation of these newer methods has been a lack of steady faculty that
would be involved passionately with a student oriented method of teaching.
Considerable doubt has been expressed by the senior members of the faculty
about the success of any other method of teaching except the existing ones.
For example, implementation of PBL by KU was perceived more as a
“corrective” by some professors, who were also a little piqued at the audacity
of it. The success of implementation of modern medical education has to
full the requirement of full hearted participation of our Professors, along
with training of available faculty members who believe that this is a system
that works.
Student requirement
India and Nepal have followed the same system of student assessment for
about 80 years. What a student is capable of achieving is based upon his/
her percentage score from a yearly examination. A lack of success in the
student is perceived as being due to laziness or lack of interest on his/her
Modern Trends in Medical Education
part. The selection of students for the MBBS course is based upon a written
entrance test conducted by the University, and most students appearing on the
test manage to get into the colleges of their interest. This system of student
selection is not consistent; selection criteria differ over colleges and keep
changing according to the needs of the colleges. Not withstanding the criteria
of entry, the quality of students on average, seems to be consistently below that
expected of a medical student. This apparent inadequacy may not be a result
of a below average intelligence; there are a plethora of other factors involved
which include a lack of motivation, discouragement due to bad scores,
bad reading habits, difculty with the English language, allegedly unfair
assessment methods, lack of applicability of curriculum etc. Students prefer
not to speak in class, lest they be seen as “troublemakers” and invite more
difcult questions during verbal exam. A student’s frustration with learning
sometimes manifests in the form of bad behaviour in or a complete absence
from the class. Many of these factors are not insurmountable problems and
addressing these is a component of modern medical education methods. For
example; all students nd motivation in applicability, all students want to be
active participants in learning. Student centered learning has its foundation
in social constructivist theories5. This perspective contends that learning
occurs as knowledge is negotiated among learners, often facilitated by a more
knowledgeable group member and that students need to be active, intentional
learners6, 7. It is easy to see the role that teachers will have to play in the
realisation of these solutions.
Rising to the occasion
Irrespective of the methods of teaching, there are always the good teachers
and the bad teachers. How one teaches and the strategies that are applied are
intimately related to teachers’ beliefs about the nature of the teaching-learning
process8, The factors that prevent a person from being counted amongst the
good students might also be what causes a teacher to be seen as a “bad teacher”.
Students in general hold their teachers in great respect and scarcely go into a
class with a prejudiced mind. Teachers who are friendly, accessible, regular,
prepared and interactive are seen as good. Teachers who are knowledgeable
but not able to see the student’s perspective are mostly feared. Our students
in Nepal, similar to other parts of the world, can also be referred to as the
“net generation”. The Net Generation are the present student generation that
have grown up in a world in which technology has become an integral part of
their lives9, 10. It has been suggested that there are fundamental differences in
the way that Net Generation students learn. They are more comfortable with
technological environments that are rich in multimedia, especially visual and
audio. They prefer to be actively engaged in tasks rather than writing about
them, and are motivated to learn from being actively involved in projects.
They also prefer to work in groups in which they can talk about what they are
Modern Trends in Medical Education
doing and help fellow group members. These students provide a challenge to
traditional approaches to undergraduate medical education11.
Many teachers have realized the changing needs of the students over the period
of their teaching careers. The changing needs of the student have necessitated
a radical change in the method of teaching, which is highly feasible today
because of the support of the administration. This change requires the training
of teachers in various methods of teaching, organization, administration and
learning, which is the idea behind “faculty development”.
Faculty development
At one time anyone who graduated from Medical School was considered
capable of teaching. It became apparent, however, that teaching was not
an innate gift12. Besides content, teaching also required “process”, and to
develop the art of teaching, academics required support13. So began some of
the rst faculty development, also referred to in the literature as “professional
development” or “staff development”14, 15. The concept of faculty development
is dened by Sheets and Schwenk16 as
“Any planned activity to improve an individual’s knowledge and skills in areas
considered essential to the performance of a faculty member in a department
or a residency programme”
The theories underpinning student learning have played a major role in the
evolution of staff development12. For example, in line with the behaviourist
theory in vogue in the 1970s, faculty development aimed to develop the
attributes and competencies of the “good” teacher: someone who could
use various teaching aids, reinforce important concepts and communicate
effectively17. In the 80s and 90s, reform to more student-centered and selfdirected learning required a metamorphosis of the teacher, from a didactic
conveyer of knowledge to a facilitator of student learning18, 19. To make this
transition, teachers needed new skills, which required training, The new
millennium brought ‘outcomes-based education’, with competencies being
identied for graduating medical students20, 21. The teachers in Medical
Institutions in Nepal are at various chronological stages of this kind of
evolution, the common thread being the didactic way of teaching, with some
use of audio visual aids. Most of these changes have occurred by choice of
the individual through experience rather than as a requirement at institutional
level, till recently. The development of faculty for taking on the responsibility
of student centered or outcome based learning has not had a smooth running
in the short period of time it was carried out.
Modern Trends in Medical Education
Many factors impede faculty development, ranging from unsupportive
leadership, resistance to change, lack of faculty motivation and an unwillingness
of faculty members to acknowledge deciencies in their teaching ability,
knowledge or skills15, 22. Teacher’s attitudes and misconceptions about their
teaching reduce the likelihood of participation in faculty development15. To
this end they may underestimate their teaching ability, may not perceive the
benets of training or may fail to recognize any link between teaching and
clinical skills or between teacher training and teaching excellence.
Current “modern” methods of teaching
For a majority of teachers, junior or senior, use of a PowerPoint is the modern
way of teaching. The faculty members using the board as a teaching tool have
become conscious of this difference between the new and the old. The use of
visual aids is the method of choice of teaching amongst the younger faculty.
More often than not, a transparency sheet projected on the overhead or a
PowerPoint presentation serves more as storage of information for the day’s
lecture, with the teacher seemingly reading out the points. This involves zero
participation from the students, who cannot keep pace with the lecture and
lose interest. The students learning method of choice stays the chalkboard,
which is also in widespread use, especially by the senior faculty. The teaching
occurs at a decent pace and the students are actively engaged. However, few
presenters by their oratory alone have the skills necessary to command the
attention of an audience over a period23. There are also severe limits to the
amount of information and messages that can be conveyed effectively to the
audience using only the oral channel of communication in comparison to
what can be achieved with a carefully integrated oral and visual presentation.
A study24 conducted on three different groups to whom a Physiology lecture
was delivered on chalkboard, PowerPoint and both respectively found the
students who attended the lecture using both to have higher scores than either
of the other two groups. In the medical institutions in Nepal, the choice of not
using PowerPoint for teaching purposes is more often due to unfamiliarity
with the use of the same. The judicious use of PowerPoint and overhead
slides by the faculty will perhaps require some training and support23.
Teacher, the student
The student centered learning revolves around the curiosity of the student
who then gets motivated to investigate and explore. Students have access to
abundant information on the World Wide Web that they can use as alternative
sources of information. For example
Guides to internet resources for medical students
Modern Trends in Medical Education
Medical education, sites for students, learning resources
The modern day medical teacher has to be aware of this fact at all times.
This should not be a cause of dismay for the modern educator as long as s/he
is willing to acknowledge not knowing everything. The teachers have long
harboured the view that the students respect them because of what they know.
This does hold some truth, as teachers need to be conversant with what they
need to teach, and a lack of preparation on the part of the teacher does not go
very well with the students. Occasionally, however, the student might be the
bearer of relevant information not known to the teacher. This is offensive to
most of our teachers, and a cause for embarrassment. In a classroom, learning
is a two way process, as at times the role of the teacher and learner might
be reversed. A willingness on the part of the teacher to learn more leads to
more open mindedness towards information from the students, as well as to
better preparation for the classes. The teachers should not stop being students
themselves, while assuming the duties of the educator. This will also make
the students less reluctant to speak in class in addition to encouraging them to
look up information and sharing it in the classroom.
Assessment drives learning
Exams are the motivation for studying for most of our medical students.
Students learn about 6-8 systems in a year and are tested on these at the end of
the academic year. Most students feel this is not a fair system of assessment.
If teaching was transferring heaps of information from the teachers to the
student, and the test was how much of it was retained by the latter, this would
be an acceptable way of assessment. At the end of the year, the student writes
in detail, pages upon pages on a particular topic while a major part of the
curriculum gets left out. The students are tested on each system throughout the
year, but the tests do not gure in the nal scores of the students. As a result,
they absent themselves with impunity or take the tests without preparation.
In trying to introduce methods of teaching where the student does a good part
of learning himself/herself, the motivation to be an active part of this kind
of learning method will probably be absent. Without a student assessment
in alignment with say, PBL, the whole learning strategy will be futile25. The
problems studied and their related objectives should constitute the basis of
the examination blue print26. MCQ questions should be rich in context. Other
types of written tests which probe into the students’ reasoning, application
and interpretation of knowledge, would support PBL strategy such as key
features, short answers and modied essay questions26. Though it is not in the
hands of the faculty to devise nal assessment method, the onus of making
the concerned branch know about this requirement does lie with the faculty.
Modern Trends in Medical Education
Following a call by the Kathmandu University to the various medical colleges
afliated to it, to implement student centered teaching in the form of Problem
Based Learning, which advocates guiding the students towards learning, and
introspection on the part of teachers is required. An appreciation of the need
to change the methods of teaching to match the needs of a new generation and
society might convince the sceptics amongst us to be more accommodating
to the concept of Problem Based Learning. For a start, there is a need to
make the student teacher relationship more amenable, which can be boosted
by maintaining interaction with the students in the classroom and providing
them with fairer means of being assessed.
1. Lettenberger J. Teaching Methods in Medicine or how effective is our
teaching. Chest. 1938; 4:22-8.
2. This is my India [homepage on the Internet]. Available from: http://
3. Patnaik N. The Garden of Life. England: Aquarian Press; 1994.
4. Dixit H. Development of Medical Education in Nepal. KUMJ. 2008.
5. Hmelo-Silver CE, Barrows HS. Goals and strategies of a Problem
Based learning facilitator. The Interdisciplinary Journal of Problem
Based Learning. 2006; 1(1): Article 4.
6. Bereiter C, Scardamalia M, editor. Intentional learning as a goal of
instruction. 1989.
7. Palincsar AS. Social constructivist perspectives on teaching and
learning. Ann Rev Psych.1998; 45:345-75.
8. Schoenfeld AH. Toward a theory of teaching-in-context. 1998.
9. Oblinger DG, Oblinger JL. editor. Educating the Net Generation.
Washington DC: EDUCAUSE. 2005.
10. Sanders J, Homer M. Reective learning and the net generation. Med
Teach. 2008; 30(9):877-9.
11. Sanders J, Morrison C. What is the net generation? The challenge for
future medical education. Med Teach. 2007; 29:85-8.
12. McLean M, Colliers F, Jacqueline M, Wy V. Faculty development:
Yesterday, today and tomorrow. Med Teach. 2008; 30:555-84.
13. Benor DE. Faculty development, teacher training and teacher
accreditation in medical education: Twenty years from now. Med
Teach. 2000; 22(5):503-12.
14. Guskey TR. What makes Professional development effective? Phi
Delta Kappan. 2003; 84(10):748-50.
Modern Trends in Medical Education
15. Steinert Y. Staff development. Harden JDR, editor. London: Elsevier,
Churchill Livingston. 2005.
16. Sheets KJ, Schwenk, TL. Faculty development for family medicine
educators: an agenda for future activities. Teach Learn Med. 1990;
17. Wilkerson L, Irby DM. Strategies for improving teaching practices:
a comprehensive approach to faculty development. Acad Med. 1998;
18. Knowles MS. The Modern Practice of Adult Education: From
Pedagogy to Andragogy Englewood Cliffs, NJ: Prentice Hall
Reagents; 1980.
19. Entwistle NJ, Ramsden R, Ramsden P. Understanding Student
Learning. New York: Nichols Publishing Company; 1983.
20. Carraccio C, Wolfsthal SD, Englander R, Ferentz K, Martin C.
Shifting paradigms: From Flexner to competencies. Acad Med. 2002;
21. Simpson JG, Furnace J, Crosby J, Cumming AD, Evans PA, David
M, et. al. . The Scottish doctor - learning outcomes for the medical
undergraduate in Scotland: a foundation for competent and reective
practitioners. Med Teach. 2002; 24(2):136-43.
22. Hitchcock MA, Mylona ZE. Teaching faculty to conduct problembased learning. Teach Learn Med. 2000; 12(1):52-7.
23. Harden RM. Death by PowerPoint the need for a dget index. Med
Teach. 2008; 30(9):833-5.
24. Meo S. Power of PowerPoint and the role of the chalk board. Med
Teach. 2008; 30(6):240-1.
25. Hamdy H. The Fuzzy world of problem based learning Med Teach.
2008; 30(8):739-41.
26. Hamdy H. Blueprinting for the assessment of health care professionals.
Clin Teach. 2006; 3:175-9.
Modern Trends in Medical Education
Integrated basic medical science
(IBMS) teaching learning activities in
Thapa TP
Academic Director, KIST Medical College.
he history of undergraduate medical education is quite old but in Nepali
context, the undergraduate programme began only in 1978 at Institute of
Medicine, Maharajgunj. After the restoration of democracy in1990, the multi
university policy of the government led to the establishment of BPKIHS and
Kathmandu University (KU). This spurred on the establishment of many
private medical colleges within the country.
The total duration of the MBBS course globally ranges from four to six years.
In Nepal all the medical colleges have a four and half years of total course
duration of which two years are taken up with the integrated basic medical
science subjects. The traditional methods of teaching of subjects like anatomy,
physiology and biochemistry as preclinical and pharmacology, pathology
and microbiology as para clinical subjects are still practiced in countries like
India, Bangladesh and Pakistan. However, in Nepal all the above six subjects
are taught in the rst two years as IBMS integrated basic medical science
(IBMS) subjects.
Experts in medical education from different countries were involved in
developing the MBBS curriculum in Nepal. The curriculum gives emphasis
in integrated spiral approach of learning of different basic medical science
subjects, early clinical contact, problem oriented educational process and
community based learning approach. The curriculum provided the student
with holistic medical education marked by academic excellence.
The traditional method of basic medical science teaching
The traditional way of discipline-based teaching of basic medical science
subjects promotes the authority of disciplines to impart their knowledge in a
content delineated fashion. The factual details are so heavily loaded that they
neglect the goals of the curricula. The learning objectives get lost in the vast
factual detail of the subjects. Therefore, course contents and evaluation are cut
off from other departments and learning becomes isolated. The encapsulated
factual overload detaches the student from the real world of problem solving,
and learning becomes passive. This kind of education mainly focuses on
Modern Trends in Medical Education
obtaining knowledge Result: most of the medical student complains that
basic medical science subjects are dry and boring.
Educational strategies
To prevent passive and isolated learning process of basic medical sciences
subjects, medical educationists have developed different educational
strategies. Some of the pertinent points are:
i. Prevention of factual detail in a delineated fashion.
ii. Promotion of meaningful learning by focusing on common clinical
problems so that students can acquire skills.
iii. Implementation of competency-based approach by introducing modern
methods of education like PBL and correlation seminar.
iv. Promotion of active and self-directed learning.
v. Applying valid and reliable evaluation tools.
One of the popular models that is followed is SPICES Model.
Information gathering
Uniform course
S tudent-centered
P roblem-based
I ntegrated
C ommunity-based
E lective+core
S ystematic
Present scenario of teaching learning activities of IBMS at different
universities of Nepal:
I. Tribhuvan University (TU), Institute of Medicine (IOM)
II. Kathmandu University, Nepal
III. BP Koirala Institute of Health Science, Dharan
Fig 1: Calendar of Operation at IOM
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Fig 2: Marks distribution with total number of hours at IOM
Calendar of Operation:
KIST Medical college 1st year MBBS Calendar
1st Mangsir
30th Asoj
1st Asoj
Int. assessment
Final e xamination
Dashain Vacation
General concepts 1
14th Poush
15th Poush
Winter vacation
15th Magh
24th Bhadra
16th Magh
Community Diagnosis
Ge neral conce pts (contd.)
25th Shraw an
14th Chaitra
24th Shraw an
15th Chaitra
M usculoske le tal
2nd Ashad
1st Ashad
15th Jestha
14th Jestha
Fig 3: Class routine at IOM
Integrated Basic Medical Science (Current)
Total Marks = 1100 marks
(Institute nal + Internal assessment)
(Paper II - Neuro/Musculo) = 160+40*
(Paper I - Respi/Cardio/GI) = 160+40*
Paper III - Repro/Endo/Renal/Electrolyte = 160+40*
Practicals (Final):
1. Anatomy 2. Physiology 3. Pathology 4. Pharmacology 5. Microbiology 6. Biochemistry Total:
*Internal Assessment
= 200 marks
= 200 marks
= 200 marks
100 marks
100 marks
100 marks
100 marks
50 marks
50 marks
1100 marks
Lecture Hours:
Theory = 1094 hrs.
Practical = 927 hrs.
Total Lecture Hours Including Practical:
= Theory + Practical
= (1094+ 927) hrs
= 2021 hrs.
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Clinical Posting/ IBMS faculty meeting
8.55 - 9.50 am 9.50-10.45 am
8 -8.55 am
11.55 am -12.50 pm
Pharmacology – C, D
Histology – A, B
Medicine 5
Physiology – D
Pathology –A
Microbiology –B
Biochemistry – C
Physiology – C
Pathology –D
Microbiology –A
Biochemistry – B
Pharmacology – A, B
Histology – C, D
Physiology – B
Pathology –C
Microbiology –D
Biochemistry – A
2 -4 pm
Clinical Posting
Physiology – A
Pathology –B
Microbiology –C
Biochemistry - D
11-11.55 am
Fig 4: Total Class Hours at IOM
KU, Dhulikhel
133 136 144
Lecture Hours
Total Theory and Practical Classes
Where Subjects,
1 means General Topics
2 means Musculoskeletal System
3 means Neurosensory System
4 means Respiratory System
5 means Cardiovascular System
6 means GI System
7 means Reproductive/Endocrine System
8 means Renal/Electrolyte System
Table 1: IBMS Teaching Hours Allotment at KU
Unit I
Unit II
Total Instructional
Unit IV
Clinical Orientation
Medical informatics
Unit III
Self Study
* Plus 1 Week for eld visits/practice.
Note: Theory and practical hours given in the table are approximate hours of instruction.
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Theory includes admixture of lectures, seminars, tutorials and problem-based learning.
Practical include laboratory work, hands on skill development, etc.
BPKIHS, Dharan
Community Medicine
Forensic Medicine
Other Disciplines
7 (FIP)
Table 2: Academic Programme of the 1st MBBS Students at BPKIHS
Community Medicine
Forensic Medicine
Other Disciplines
Table 3: Academic Programme of the 2nd MBBS Students at BPKIHS
SIS stands for structured interaction session.
LABEX stands for laboratory exercise.
Evaluation (assessment methods):
Formative evaluations are conducted during the teaching learning activities
of the system or at the end of the system. Similarly, summative evaluations
are conducted at the end of rst year and second year. Students cannot attend
third year classes till s/he passes all the basic medical science subjects.
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Correlation seminar, OSPE, orals and written examinations are conducted to
evaluate the student’s performance. Maharajgunj Campus, TU, IOM conducts
correlation seminar at the end of each system whereas BPKIHS conducts
similar type of evaluation called multisystem seminar as a separate unit.
In correlation seminar, a disease or problem is selected as the main “topic”
related to the system. Each department prepares objectives in relation to the
topic. Each and every student is given one or two objectives as assignment.
The maximum allotted time of presentation varies from ve to ten minutes.
Students are allowed to present their assignment in front of the faculties
present from all departments. The advantage of correlation seminar is that it
helps to develop presentation skill and self-directed learning.
The nal University examination comprises of theory and practical like in
traditional universities. Though there are papers, which include different body
system but the answer sheet, are separate for different disciplines. Similarly
the practical examinations are conducted in the respective departments with
concerned faculties.
Integrated method of learning of different basic medical science subjects are
denitely benecial to student as well as to the faculties. This kind of activities
provides opportunity to faculties for inter and intradepartmental interaction
and helps to prevent unnecessary teaching of factual detail to the students. As
problems, rather than topics are discussed among different departments there
is promotion for meaningful learning. As for the students, learning different
basic medical science subjects on a system basis, at a given time, in different
departments, promotes coordination and cooperation of real learning process
of a clinical problem. Because of introduction of PBL in packages as learning
method, active and self-directed learning is also facilitated.
As different learning tasks are given to the students, under disease problem
there is Implementation of competency-based approach. The students
develop self-directed learning skill and presentation skill. They become more
condent and independent.
However there is still some lacunae in the total integration. This has been
felt particularly in the nal evaluation process. As most of the basic medical
science faculties are not trained in innovative education system and have a
background of traditional system, the approach and implementation of total
spiral integrated evaluation system has not been possible. Ideally it would
have been excellent to set a theory question including all different basic
medical sciences subjects in one paper but it seems it is inconvenience to
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evaluate the answer sheet. Similarly by gathering all different faculties in one
common place to conduct the practical examination, seems very difcult to
college management and examination section. Also the present trend of more
than 100 intakes of medical students in medical colleges will make this kind
of process more difcult and complex.
1. World Federation for medical education. Proceedings of the
World Summit on Medical Education.HJ Walton, Ed, Medical
Education1993; 28.
2. General Medical Council [homepage in the internet].Tomorrow’s
Doctors: Recommendations on Undergraduate Medical Education.
General Medical Council, UK, 1993. Available from: http://www.
3. Shumak. Canada: Medical Curriculum Changes in Ontario. Lancet.
1992; 340:1152.
4. Medical Council of India. Recommendations on Undergraduate
Medical Education, 1981.
5. MBBS Programme: Asian Institute of Medicine, Science and
Technology, Kedah, Malaysia.
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Lesson planning
Pant CR
Department of Ophthalmology, Kathmandu University, School of Medical
Sciences, Dhulikhel, Nepal.
esson planning is a science as well as an art. It is a process through which
teachers lead the students
• to learn the subject matter in question in a systematic way and to the
desired level of understanding
• to be able to implement that learnt
• to be able to recall that learnt in the future
The common practice in lesson planning is to subdivide the assigned topic into
several components such
• the title of the topic
introductory remarks
• objective
• learning materials
• main subject matter
• teaching methodology
• evaluation the contents taught (and nally)
• feedback from the learners and encouragement to the learners.
The prerequisites for planning an educational session are that there should
• adequate teachers’ training
• prior knowledge about the audience
• adequate time and place
Among all these components adequate teachers’ training is of rst and
foremost importance. A trained teacher, well-versed in his/her job and
following established teaching methodologies, can better ensure sustained
learning and deeper understanding of the subject matter by the students.
The other components such as the prior knowledge of the size of the
audience, with their educational background and their future responsibilities,
also assist the teacher in planning the content in terms of level and amount to
be delivered to the audience in order that, once delivered, it can achieve the
desired result.
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Last but not the least considering the setting for the session, whether it is in
class room or community eld, is equally important as it inuences how the
teacher may meet the specic objectives.
Although there is no gold standard formula for teaching and learning
methodologies, experience has shown that the following components have
stood to the test of time.
1. State the objective of the teaching /learning session. It deals with what
students need to learn or what the students will be able to do at the end of
the session.
2. Be clear about the content, what is the main subject matter to be learnt.
How much do the students need to learn? Make clear and be specic
about the “must-know” areas within the subject matter .
3. Plan the Pre-test assessment which provides the teacher with the
knowledge about how much students already know about the subject
matter and what specically they ought to know but they don’t know..
This is usually tested in the form of written questions / answers format.
4. Select the methods of learning that will best help the students learn. There
are numerous methods and prior selection of one which involves the
students in active learning is most likely to be helpful. In this regard a
Chinese proverb reminds us .
If I hear, I forget it
If I see, I remember it
If I do, I know it .
Learning is an active process and both teacher and students should actively
participate in this process for better learning, longer retention and future
It is like a teacher teaching students to swimming. If the teacher and his
students don’t repeatedly practice swimming in the pool they will never
learn to swim. Additionally the use of a variety of methods of learning in
the session will help students with different learning preferences to learn
5. Select the material for learning. The aim is to capture the attention of
the students and to arouse their curiosity so they learn the subject matter
better. Although numerous materials for learning have been developed
and could be developed for the session the most suitable materials involve
real objects, real specimens, real patients and real scenarios.
Finally, but most importantly, comes the planning for evaluation of the
session. This will reveal what students have learned .This could be done
by giving the students oral or written questions, home assignments and/or
conducting a Post-test assessment of their knowledge and skills.
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The following is an example of lesson planning.
At the end of the session
students Will be
Able to state the percentage of
child survival in various vitamin
A studies and their interpretation
To compare the results of
various measles related
mortality reduction with vitamin
A supplementation
To know various sources of
vitamin A in diet
Able to state the principle and
practice of National vitamin A
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¾ Vitamin
A deficiency is
one of the most
important causes of
childhood blindness.
¾ Today there are
250 million children are
sub clinical vitamin A
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¾ 3 millions suffer from
¾ 0.3 millions are Blind with
¾ It constitutes 10% of all blind
children in the world.
Since the publication of
Indonesian study in
1986 its has been found
that vitamin A is closely
related with mortality
and morbidity of
Several studies has
shown varying
percentage of child
mortality in vitamin A
deficient communities.
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WHO recommended
These studies also
have shown impact
of vitamin A in
measles related
child mortality.
Nearly 26% of child
mortality could be reduced
with adequate vitamin A
Measles related mortality
of children could be
reduced by 66% with
vitamin A supplementation
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¾ An
operational study was done In order to
find out magnitude of vitamin A deficiency as
well as cost effective strategy for vitamin A
delivery in Nepal.
Sources of Vitamin A
Animal sources
Vegetable sources
Artificial sources
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National Vit A Guidelines
¾ At the end of the study a significant
reduction of vitamin A deficiency was
observed in all the study districts
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Cheer up
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Microteaching-An integral
component of teacher’s training in
Magar A
CMCL-FAIMER Fellow 2009, Christian Medical College Ludhiana, Punjab,
Medical teachers unlike most other teaching professionals are unique in that
no special prior or in-service training on pedagogic techniques is considered
necessary for their recruitment as teachers, or for their continued efcient
performance in that capacity. Under these circumstances their ability to teach
is largely dependent on one of two modalities of self training: a) observation
of other teachers or b) process of trial and error while actually teaching in a
classroom situation1.
Due to lack of proper training most of the teacher learn the art of teaching
by hit and trail in most part of the world including Nepal. If microteaching is
introduced in our country it would help to sharpen the teaching skill of any
teacher and would help students to learn effectively.
Microteaching is an innovative technique of teacher training with an
opportunity to improve their teaching skills2. It is analogous as to put
the teacher under a microscope while s/he is teaching so that all faults in
teaching methodology are brought into perspective for the observers to
give a constructive feedback1. It is a method whereby the teacher reviews a
videotape of the lesson after each session in order to conduct the same lecture
in the class room. Teachers nd out what has worked, which aspects have
fallen short, and what needs to be done to enhance their teaching technique.
It was introduced in the mid 60’s at Stanford University by Dr. Dwight Allen.
Micro-teaching has been used with success for several decades now as a way
to help teachers acquire and hone new skills3.
The aim of microteaching is to enhance teaching skills of a teacher by
analysing, practising and evaluating their own way of teaching style. It
provides teachers the opportunity for the safe practice of an enlarged cluster
of teaching skills while learning how to develop simple, single-concept
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lessons in any teaching subject. It also helps to develop specic teaching
skills such as questioning, the use of examples and simple artefacts to make
lessons more interesting, interactive, effective reinforcement techniques and
closing lessons more effectively.
Inherent in the process of microteaching is the “component skills approach”,
i.e. the activity of teaching as a whole is broken down for learning purposes
to its individual component skills. Microteaching has individual component
teaching skills (Table 1)1.
Table 1: Components of Microteaching
Lesson planning: having clear cut objectives, and an appropriate
planned sequence.
Set induction: the process of gaining student’s attention at the
beginning of the class.
Presentation: explaining, narrating, giving appropriate
illustrations and examples, planned repetition where necessary.
Stimulus variation: avoidance of boredom amongst students
by gestures, movements, focusing, silence, changing sensory
channels etc.
Proper use of Multimedia: audio visual aids.
Reinforcement: Recognising pupil difculties, listening,
encouraging student participation and response.
Questioning: uency in asking questions, passing questions and
adapting questions.
Body Language: Silence and nonverbal cues
Closure: method of concluding a teaching session so as to bring
out the relevance of what has been learnt, its connection with past
learning and its application to future learning.
A short lesson is taught by the presenter to a group of four to six peers or
pupils for a period of 5-10 minutes. The emphasis is on how to teach rather
than what to teach. The sessions can be organised for the proper use of any
visual aid such as chalk-board, specimens, models, projection instruments
such as projector, overhead projector (OHP), slide projector, audio or
audiovisual aids4.
Microteaching cycle
The Microteaching cycle starts with planning. In order to reduce the
complexities involved in teaching, the teacher is asked to plan a “micro
lesson” i.e. a short lesson for 5-10 minutes which he will teach in front of
a “micro class” i.e. a group consisting 3-4 peer groups with a supervisor.
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The teacher is asked to teach concentrating one or few of the teaching skills
enumerated earlier. His teaching is evaluated by the peers and the supervisor
using checklists to help him. Video recording is done. At the end of the 5
or 10 minutes session as planned, the teacher is given a feedback on the
deciencies noticed in his teaching methodology (Table 2). Feedback can
be aided by playing back the video recording. Using the feedback to help
himself, the teacher is asked to re-plan his lesson keeping the comments
in view and re-teach immediately the same lesson to another group. Such
repeated cycles of teaching, feedback and re-teaching help the teacher to
improve his teaching skills one at a time. Several such sequences can be
planned at the departmental level. Colleagues and postgraduate students can
act as peer evaluators for this purpose. It is important, however, that the cycle
is used purely for helping the teacher and not as a tool for making a value
judgment of his teaching capacity by his superiors.
State the
Objective and
Fig 1: The Cycle of Microteaching4
Microteaching has several advantages. It focuses on sharpening and developing
specic teaching skills and eliminating errors. It enables understanding of
behaviours important in classroom teaching. It increases the condence of the
learner teacher. It is a vehicle of continuous training applicable at all stages
not only to teachers at the beginning of their career but also for more senior
teachers. It enables projection of model instructional skills. It provides expert
supervision and a constructive feedback and above all it provides for repeated
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practice without adverse consequences to the teacher or his students1.
Table 2: Observer Chart2
Observation Chart for peers/pupils
(Please indicate the observations in the right hand column)
The speaker stated the objectives
The speaker presented the matter
in organised sequential manner
The speaker used jokes or humor
to lighten the mood
The speed of presentation varied
with emphasis
Example/illustrations were used to
emphasize the component
The speaker summarized the topic
at the end
The speaker suggested additional
sources of reading
The speaker used audiovisual aids
(slides, charts, chalk-board, overhead projector, model)
If he did use the aids, they were
clear, explanatory, well prepared
10. The speaker allowed students to
participate actively by:
Allowing questions
Inviting questions
Suggesting questions
Suggesting questions and answering the questions
11. Any suggestions for the speakers to improve the teaching/learning exercise
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Lack of adequate and in depth awareness of the purpose of microteaching has
led to criticisms that microteaching produces homogenised standard robots
with set smiles and procedures. It is said to be (wrongly) a form of play acting
in unnatural surroundings and it is feared that the acquired skills may not be
internalised. However, these criticisms lack substance. A lot depends on the
motivation of the teacher to improve himself and the ability of the observer to
give a good feedback. Repeated experiments abroad have shown that over a
period of time microteaching produces remarkable improvement in teaching
1. Ananthakrishnan N. Microteaching as a vehicle of teacher training--its
advantages and disadvantages. J Postgrad Med [serial on the internet].
1993; [cited 2008 Dec 26] ;39:142. Available from: URL: http://www.
2. Singh T, Natu MV, Singh D, Paul VK. Better Pediatric Education.
New Delhi: IAP Education Center; 1997.
3. Wikipedia [homepage on the internet]. Microteaching [online]. 2008
[cited 2008 Dec 26]; Available from: URL:http://en.wikipedia.org/
4. Singh T, Singh D, Paul VK. Principles of Medical Education
(Microteaching & Taking a Lecture). Tanta Medical Sciences Journal.
2007 Apr;2(2):1-4.
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Tutorship: Redefining the teacher
Swahnberg K
Associate Professor in Gender & Medicine, Linköping University, Sweden.
his paper is written to inspire old and new tutors using problem based
learning (PBL). It is based on the works of Samy A. Azer at the University
of Melbourne and Diana H.J.M Dolmans et al at Maastricht University1,2.
Before going into the tutors’ role, it is necessary to dwell a little on the
educational objectives in and the philosophy of PBL.
PBL – Educational objectives
The pedagogy of PBL is student centred. It takes a great interest in how
the student links and integrates knowledge as well as the development of a
humanistic attitude in the students. Azerat has summarised the educational
objectives with PBL as follows3.
• “Enhance students’ skills to acquire principles and key concepts
that should be better retained by the learners and allow them to use
information learnt in other similar situations
• Develop students’ clinical reasoning skills, critical thinking and
decision-making strategies
• Develop students’ skills in integrating knowledge across disciplines
and better understanding of the role of a humanistic attitude towards
professional performance
• Prepare students to pursue lifelong learning
• Promote small-group learning, the need for effective teamwork and
collaborative learning – equal to everyday practice at any clinical
To develop a humanistic attitude and promote personal growth is an important
preparation for meting future patients in an optimal way. For this purpose
we have a Humanist strand in our medical curriculum. There are obligatory
courses in literature, ethics, and communication skills training.
The philosophy of PBL
The PBL view of knowledge is based on Constructivism which means
that there is no absolute knowledge independent of context. Knowledge is
constructed by the learner based on previous knowledge and overall views
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of the world. Because it is a construction, knowledge cannot be discovered
or “found”. It is the learner who constructs new knowledge and who is at the
centre of the educational process “doing knowledge”.
In practice this means that the PBL tutors are teaching students to learn and
thereby prepare them for a fast-changing world in which they must constantly
acquire new skills and knowledge. To achieve this goal we have to redening
the teacher role from lecturing content-expert to facilitator - with or without
Studies on process variables, have showed that content-expert tutors use
their subject matter expertise more to direct the discussion, whereas noncontent-expert tutors use their process facilitation expertise more to direct the
discussion; food for thoughts but I will not go into this discussion here2.
The role of PBL tutor
As a tutor I like to see myself as a facilitator and not focus on the detailed
content. The aim of facilitation is to make the process easier and more
convenient rather than answer questions or provide a lecture for the students.
There are many pitfalls such as the students’ expectations, and your own
expectations on yourself as an expert. The facilitator keeps the group focused
and guides them to achieve their goals. Naturally there is less attention on the
facilitator than the “brilliant lecturer” and all the glory falls on the students –
that is a personal challenge!
To foster self-directed learning the students need to learn to identify their
learning needs i.e. to learn how to formulate learning goals for each scenario
in accordance with the study plan. Many students (and tutors) nd this
Now to some other challenges for the facilitator/tutor:
• What do I have to think of when I start a new group?
• How can I ensure that the group is moving forward?
• How can I facilitate understanding, discussions and problem solving
without dominating the group?
To deal with these challenges Azerat has formulated 12 tips for successful
group facilitation1. I will present some of these tips with comments from my
own experiences as a tutor in inter-professional tutorial groups. Later Azerat
also formulated 12 tips for students but I will not go into those here3.
Tip 1 “Ask your group to identify their ground rules in the rst tutorial”
When I start a new group I encourage my students to make a contract that
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states what is and what is not accepted in their group. At our faculty we have
a ready-made contract that the students can add to or use partly. The contract
is made up by a number of statements about practical things (be on time,
switch of the mobile, be prepared etc), expectations (on each other and the
tutor), and how to work together.
First the students takes their own stand to the statements (do not agree - agree
strongly), and then they have to come to an agreement in the group.
Tip 2 “Discuss with your group the different roles they may play”
In most groups, some participants takes on formal roles e.g. chairman,
secretary, clock master or informal roles such as the activator, the comedian,
the leader etc. To maintain the group dynamics and to facilitate personal
development it is crucial to make the students aware of their roles and the
importance of rotating roles. I tell them that every time you start in a new
group, it is a unique possibility to try a new role and maybe change something
that you are not satised with in your way of being with others.
In the rst course “Health, ethics and learning” (HEL I), a course that all
students starting at our faculty have to take, we use a videotaped communication
exercise to visualise different roles in the group. The group is videotaped
while solving a task. Afterwards when watching the video comments like “I
was talking all the time!” and “I did not know that Sandra worked so hard to
get the group going in the right direction” are common. This exercise is an
eye opener and the reections above are useful to optimise the work in the
Tip 3 “Build trust and encourage bonding of group members”
It is very important to spend time on the bonding process especially during
the rst two weeks in a new group. Every group has its honeymoon but it will
not last for ever. To prioritise bonding in the beginning strengthens the group
and gives them better odds to manage later hardship - that will come.
As a tutor I have a big impact and I can use it to facilitate the group process. If
I am careful to include all students, see all students, make them feel that they
are seen in the group, they will behave in the same way toward each other and
later, I like to believe, toward their patients.
As a tutor I must show a good attitude and be inclusive, caring and positive
and show the students respect.
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Tip 4 “Do not dominate group discussion but rather facilitate the
Think empower, not control! Do not rush to ask questions or provide
information – one of the students will soon say what you want to say… I was
astonished when I rst noticed this as a fact and I expressed my astonishment
long before I read about it.
Tip 5 “Be a role model for your group and monitor your teaching skills”
To be a role model includes many things, from practical ones (be on time,
prepared etc) and attitudes (e.g. to promote positive attitudes in the group) to
promote human values (democratic, non racist, freedom of speech etc).
Monitor the timing and the type of your interactions to improve yourself.
To continue to develop as a tutor you need feedback on your teaching style
from students and colleagues. A “reection book” or a diary can also be
helpful for self assessment.
When you ask your students to give you feedback make sure they feel safe to
say what is on their minds and acknowledge your mistakes.
Tip 6 “Encourage understanding”
Understanding is the process of integrate knowledge and making links.
What is the reasoning behind opinions? How does this t with your prior
understanding and experiences? Usually I ask these questions in the
beginning, but once the students get the hang of it they will ask and question
each other.
Tip 7 “Foster critical thinking and enhance the group’s ability”
A tutor should try to foster critical thinking in the group and enhance the
following abilities in them.
• Debate issues rather than argue
• Weigh evidence as they rank/rene their hypotheses
• Analyse data and information provided
• Synthesize information into informed conclusions
• Emphasise understanding over memorisation
Tip 8 “Ask open –ended questions”
A tutor must always promote open ended question. Asking the student “what
else?” is equal to telling them to READ MY MIND. Open ended questions
help in the following ways.
• Expand discussion and allow more members in the group to
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Keep the group focussed on issues discussed
Foster self-directed learning
Help understanding difcult/complex concepts
Allow students to see the big picture as well as some ne details
Tip 9 “Promote group dynamics”
This is done in many ways. For instance, as a tutor I shall help the group to
focus on gains, not losses. When students realise that they handled a scenario
too widely, so they could not answer their questions properly, I can help them
see this as an experience rather than a failure.
Tip 10 “Solve problems in the group with a win-win approach”
It is important to trust the group’s ability when the hardship comes. Do not
overdo it; sometimes it is enough that students know that you are aware
and at other times you have to intervene but you should always document
problematic situations that arise in the group.
Actions should be taken by the tutor if it becomes detrimental to students’
learning. Then it might be wise to consult with a colleague or the course
management about possible solutions.
Tip 11 “Provide feedback that builds the group up”
“And follow up identied problems”
Tip 12 “Tell the students about your role”
I think it is very important that the students express their expectations on
PBL, working in a group and on me as their tutor. Realistic expectations are
a necessary presumption for success. In these discussions I can also explain
how and why my role as a tutor is different from traditional teaching, and
maybe/probably different from what they are used to.
I can also prepare the group for how my role alters during the course; naturally I
am more active and visible in the beginning of a course and their expectations
also alter during the course as they become more and more independent.
Now talking about examination in PBL, we use the following for
• Self-assessment
• Peer-assessment
• Tutor assessment
• Examination
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But are these accurate measures?
These measures alone are not accurate. Self-assessment tends to be
underestimated and peer-assessment tends to be overestimated.
In combinations these measures maybe accurate. All these forms of evaluation
are equally important but they need to be combined and learnt and trained.
They are important tool for the learning process, for reection and selfawareness; the fundament for lifelong learning.
1. Azer SA. Challenges facing PBL tutors: 12 tips for successful group
facilitation. Med Teach. 2005; 27(8):676-81.
2. Dolmans DHJM, Gijselaers WH, Moust JHC, de Grave WS,
Wolfhagen IHAP, van der Vleuten CPM. Trends in research on the
tutor in problem-based learning: conclusions and implications for
educational practice and research. Medical Teacher. 2002; 24(2):17380.
3. Azer SA. Becoming a student in a PBL course: twelve tips for
successful group discussion. Medical Teacher. 2004; 26(1):12-5.
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Interwoven themes and strands:
Guiding student learning in a
problem based learning curriculum
Wijma B
Professor of Gender and Medicine, Senior consultant Obstetrics and
Gynecology, licensed psychotherapist; Institute of Clinical and Experimental
Medicine, Faculty of Health Sciences, Linköping University; and Department
of Obstetrics and Gynaecology, University Hospital; Linköping, Sweden.
t the medical faculty of Linköping University (LiU), a Problem Based
Learning (PBL) curriculum was introduced in 1986. It was met with
enthusiasm, skepticism and resistance by different faculty members. Revising
it is a continuous ongoing process, although a formally revised curriculum
was implemented in 2004 to correct some of the beginner’s mistakes and
stimulate teachers to try new approaches – once more.
My personal experience of the introduction in 1986 was that it was
revolutionary. Like so many revolutions, it might work and it might not.
Wait-and-see felt like an appropriate stance for me. But one thing was clear
to me from the very beginning: PBL organised knowledge for the students so
that they could later directly use it. For me that had not been the case.
Organizing knowledge
When I studied medicine we learnt for a whole year about all diseases, their
pathogenesis, symptoms, biochemical/physiological/pathological anatomical
manifestations, course, treatment options, prognosis and differential
diagnostic problems. Every disease was studied separately which meant that
all knowledge concerning that disease was put into one and the same box; with
few connections to other diseases with similar clinical presentations. When I
met my rst patients in reality, after many years of studying according to these
principles, I was shocked. The way I had studied was totally inappropriate for
the needs of the patients coming with symptoms, not diseases, and I had to
gure out, all on my own, how to bridge that gap.
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Fig 1: My knowledge was not organised to t the reality I met when I started
practicing medicine
With the PBL approach of learning and organising new knowledge, the
students do not waste all that much time to take an extra loop by rst having
to totally reorganise what they have learnt. It is already stored in the way in
which they will use it.
Fig 2: Knowledge organisation in traditional teaching and in PBL
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But what is knowledge?
Epistemology has worked on that question for centuries and most teachers
regard the question as practically irrelevant. But in fact it is not. There
are decisive steps to be taken from nding facts and information about a
phenomenon, elaborating and integrating them into what was already known;
i.e. learning, and lastly, storing that knowledge so that it remains available
and retrievable in a sufcient amount – in that specic situation where it is
needed. Usually teachers are less interested in the process, students have to
move along this path, and to nd out what factors stimulate and facilitate
the different steps. For medical students it is however not even sufcient to
have enough understandable knowledge available: a concordant activity is
also needed. This latter step is even less explored within medical education.
Figure 3 illustrates the discordance between teaching facts and having learnt
a behaviour.
Fi 3: The concepts of teaching and learning – and performing the concordant
Overviews or details?
Another aspect of organising knowledge is that it is easier to rst learn a
subject broadly and then later, when there are boxes of knowledge into
which new facts can be sorted, add more detailed information. This principle
is demonstrated in the Phase approach of the PBL curriculum of LiU (see
Why learning in groups?
According to Freire, building knowledge is something which cannot be given
from above, but grows from bottom up in groups where members share their
experiences. This is a good description of the process taking place in the basegroups of the PBL curriculum. Moreover, students have a lot of fun while
studying in groups; which they invariably document in their evaluations and
which probably adds to the quality of their learning. Mostly they also nd
out together the answers to all difcult questions and things they did not
understand, while studying individually to the base-group session.
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Example of A PBL Based Curriculum from LiU
In Box I the key-words for a PBL curriculum are given.
Box I: Key-words for a PBL curriculum
Key-words for a PBL curriculum
A view on knowledge that is up-to-date and concordant with the
PBL philosophy
Subjects are integrated into organ systems according to their
Students play an active role in all parts of curriculum creation and
Learning is self-directed, and students take on responsibility for
their learning according to the goals given
Base-group studying plays a major part
Early contact with professional practice
Communication skills are trained from early on
Students train to nd, choose and evaluate information to be
prepared for a life-long revision of knowledge
A “holistic” attitude throughout the curriculum, making symptoms
consciously “complex”, i.e. based in a reality context
Reduced number of lectures
Learning skills are consciously trained: to nd, choose and
evaluate information sources
Figure 4 gives an overview over the present curriculum at the Faculty of
Health Science for medical students at LiU.
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Fig 4: Curriculum overview
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Subject integration and early patient contact
The curriculum has three phases:
I. Health and biological function (term 1-2). This phase contains basic
science concepts and gives an overview over the organ systems and
their normal functioning.
II. Health and disease (term 3-5). Here pathological functioning on a
basic science level is integrated with details of normal structure and
III. Patient and prevention (term 6-11). These emphasise on clinical
practice and applied theory.
Vertical integration
From the rst till the last term basic science and clinical practice are integrated.
During the rst year the main focus is on basic science, which, however, from
the rst day is built on scenarios. Already during the rst term the students
start training patient communication in primary care settings (see below).
During the third phase the emphasis is instead on clinical practice but the
students have to anchor there clinical decisions in basic science knowledge.
Figure 5 illustrates how the focus shifts over the years, between basic science
and clinical practice but how the vertical integration is maintained throughout
the syllabus.
Fig 5: Vertical integration
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Horizontal integration
As the overview of the curriculum in Figure 4 illustrates, there do not exist
any subjects but only themes. Per term two or three themes are represented,
and all themes return during each of the three phases. The themes are
organized by theme groups, constituting of 8-10 experts in the different elds
that are involved in the theme. These groups are given the responsibility
and all the resources necessary to organize the theme activities throughout
the curriculum. This includes the objectives of the theme weeks, the total
program for these weeks, scenarios for the base-groups during the theme
weeks, and examinations for the relevant terms together with the other theme
groups represented at the term. A maximum of 15 scheduled hours/week
during theoretical studies and of 30 scheduled hours/week during clinical
clerkships is allowed; the remaining time is devoted to self-directed learning
activities. The themes are presented in Box II.
Box II: Theme groups in the Linköping PBL curriculum
Theme groups in the Linköping PBL curriculum
1. Life cycle – Endocrine – Reproduction – Neoplasi:
16 weeks
2. Gastroenterology – Nutrition – Metabolism:
11 weeks
3. Circulation – Respiration – Kidney – Erythrocyte:
20 weeks
4. Immune system – Dermatology – Infectious diseases: 13 weeks
5. Neurology – Sense organs – Psychiatry – Locomotion: 21 weeks
6. Disease mechanisms – Diagnostics – Treatment:
10 weeks
7. Professional attitudes – Public health
18 weeks
2 – 3 themes/ term.
Theme groups get resources and responsibility to organize all teaching
activities, including examinations.
Maximum 15 hours/week are scheduled during theoretical studies and
30 hours/week during clinical clerkships.
This curriculum design required a great work to become established, as
subject boundaries were transgressed and professors/teachers from different
disciplines were made to solve a big amount of practical problems together;
while seeing how the time left over in the curriculum for “their subject” had
shrunk (Figure 6). After some hard years, faculty members seem to have
adapted to the new trends and are able to even recognize the advantages.
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Fig 6: “No lectures – no obligate textbook – no exams in my subject…. Bare
foot doctors…”
Objectives aid the students’ learning process. They are formulated according
to the Bologna principle, i.e. they state what the student should be able to
master after having studied a specic theme during a term, a term, or a phase.
There are objectives for each of the phases, for each of the terms and for each
theme during every term. Term objectives are separated into those regarding
theoretical knowledge and those concerning hands-on skills. For each of them
there are three levels, which are specied in Table I. All the objectives stated
for a specic term are specied according to this system. Objectives stated in
the syllabus may be examined at any time during the education
Table 1: Term objectives
Level I
Level II
Level III
Theoretical knowledge
Know about
Can handle with supervision
Can handle independently
Hands-on skills
Have seen/experienced
Can perform with supervision
Can perform on his/her own
Lectures/Scenarios for Base-Groups
In the present curriculum for medical students at LiU, lectures have a
much less prominent role than earlier. Some important aims for lectures
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are formulated in Box III. Holding back a never ending urge to increase the
number of lectures is an important task for the theme groups.
Content formulation for lectures in a pbl curriculum
Dene central and often used expressions and concepts
Focus on core items
Combine overview of mechanisms with explanations of difcult
Make internal and external coherence evident
Bring up topics which are not to be found in text-books; e.g.
relevant practical knowledge
Stimulate students to study scientic papers, i.e. knowledge not
yet available in textbooks
Prepare students for the life-long need to revise their knowledge
Topics that cannot be dealt with by lecturing may be given emphasis in various
other ways: An objective for the theme/term/phase formulates what should be
achieved. Examination questions focus on the topic. A seminar is built where
the topic is included. A scenario for a base-group meeting is constructed.
The relevance of studying from a scenario has many aspects. Finding and
discussing new knowledge becomes a group exercise, and the knowledge is
directly connected to clinical practice, i.e. the context where it nally will be
used. The scenarios are interactive and web-based (“EDIT” scenarios).
The work of a base-group round a scenario follows the “ovale” and is
summarized in Figure 7.
Fig 7: The base-group step-wise work-up
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As the work in the base-group builds on existing knowledge, i.e. existing
structures in memory all through the curriculum, and is related to a meaningful
context, the retention of knowledge in the long run may be expected to be
better than in a curriculum where students study to be able to remember facts
to an exam. Time-saving is another aspect of the students’ process of rst
identifying prior knowledge, then acquiring new knowledge and tuning that
in on what was known already: i.e. students identify what they need to know,
subtract what they already know, and are left with what they need to learn.
A complexity is naturally built into the scenario, as it deals with an individual
living in a vaguely dened context. Often the students will project somewhat
different associations to the questions chosen by the group as focus of
studying, and they will return to the next session with somewhat different
sources of knowledge - which enables a fruitful discussion. Often the
students will for a long time remember the cases illustrated in the scenarios
and will refer to them as models, on which facts can be hooked on even in
their future studying. When both external and internal coherence is built into
the knowledge gained, the proportion retained over time will be organized in
a meaningful way, even if reduced (Figure 8).
The development of a fragmented and a holistic
perspective of knowledge over time
Fig 8: With a holistic perspective of knowledge the retained knowledge
still “makes sense”
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Learning How to Learn
In a PBL based curriculum students are continuously trained in how to
nd and evaluate new knowledge and how to organise new knowledge in a
way which makes it useful for those future situations when context specic
knowledge will be asked for. As knowledge today is perishable, this is a most
useful approach. Students are also concretely encouraged to reect over their
own learning and possibilities to improve it, by writing down reections on
how they learnt and what the outcome was, and by making their individual
future learning plans. In the base-group setting they also discuss study
techniques and learn to take on the full responsibility for their own learning.
This responsibility transfer to the students is one of the corn stones in PBL.
To construct examination tasks is a major one for the teachers of a PBL
curriculum. In our version, teachers from different clinical subjects and basic
science areas have to cooperate to build a MEQ scenario together, which
takes into account all these different aspects. That means often hard work,
where also teachers learn from each other’s elds, and train cooperation.
Exams are adapted to the way in which students learn, i.e. they are built on
scenarios in which students step-wise get more information about a case and
before new information is provided have to make decisions and motivate in
essay form why and by what mechanisms certain phenomena are expected
to occur. The emphasis in the exam is on global understanding of coherence
and mechanisms; not on facts on a detailed level. Earlier exams are available
on the web, why the content and forms of the exams exert a great inuence
on what and how students study. In this form of curriculum, objectives and
exams are the major tools to direct students’ learning. When oral exams are
held parallel to written exams as described above, the results of individual
students from the different examination forms almost invariably show great
Clinical training
During each of the last 5 terms there are usually 4 weeks of clinical training.
The students get their individual clinical supervisor for that period, with whom
they plan the activities they need to learn to master in order to reach the goals
they have set for themselves. Each clinical period is mutually evaluated.
There are several strands running vertically through the curriculum and some
of them will be presented below.
1. Interpersonal skill training takes place term 1-4, during half a
day every second week. The same group trains consultation skills
with patients coming to a primary care physician. Each student’s
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consultation is videotaped and afterwards watched and discussed in
the group together with the primary care physician and a psychologist.
During term 9 the students attend a one week boarding course and
rene the training with role plays and video feed-back.
Humanistic strands have two different approaches. During term 1-2
a base-group meets 8 times and reads and discuss literature related to
moral issues. During term 3-4 the theme is ethical dilemmas and the
role of the physician, and is also running for 8 sessions.
Leadership and professional roles are the headings for a one week
boarding course during term 9 and for a mentor programme for
female medical students during term 10-11.
Interprofessional learning is practiced during the course Health –
Ethics – Learning running for 7 weeks as the start of all professional
programs at the Faculty of Health Sciences; i.e. future physicians,
nurses, physiotherapists, occupational therapists, speech and language
therapists and bioanalyticals. Two years later all students have a two
week course in Sexology, again applying interprofessional learning
in base-groups with members from all the programs. In the end of
the programs, students from the different programs run together
under supervision a “student ward” for two weeks, where they very
concretely learn to cooperate around patients and respect each other’s
professional competence.
Professional patients are co-instructors when students learn how to
perform the pelvic examination during term 4 and 11. These women
are healthy women who have got special education and who act as
the students’ teachers from the patient’s position in the examination
Violence is a theme in three different sessions during term 1, 5 and 11.
Students are confronted with the existence of violence as one cause
of ill-health, learn about intervention strategies, meet with earlier
victims and recognize their professional responsibility to handle their
future powerful position in the health care with respect for victims’
situation and needs.
All the students at the Faculty of Health Sciences are organised in the same
student organisation, Consensus, which exerts a great inuence on the
educational system. Students are represented in all groups and boards at the
Faculty and play an important role. Their voices are listened to with respect.
By means of very frequent evaluations of the program activities, the students
have possibilities to improve their education, should the curriculum not be
able to full its intentions.
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The medical students are very much content with their education (Figure 9)
and do at least as well as students from other faculties in the nal national
Fig 9: Summary of results from sex national enquiries regarding junior
physicians’ view of their undergraduate education after the internship;
performed by the Swedish Medical Association yearly 2000-2004 and
2006 (FHS=Faculty of Health Sciences, Linköping University)
Below advantages/disadvantages connected to the themes and strands are
summarised, as well as my personal experiences of having been in a PBL
curriculum for 22 years.
Modern Trends in Medical Education
Theme groups
The vertical and horizontal
integration creates a widened scope
for the teacher.
The resources given to the theme
group feeds responsibility.
In the group the members have
much concrete work to do together,
which means that teachers learn
to cooperate and improve their
interpersonal relations.
The faculty becomes more of one
coherent group.
Naturally there will be ghts and
conicts when very individualistic
persons are forced to adjust to one
The work in the group is time
consuming; especially the
construction and correction of the
exams for each term and phase.
It is difcult for one theme groups
to get an overview of what the
others plan, why overlapping and
missed areas may be problems.
Some of the group members may
feel forced to participate and
insidiously refuse investing enough
These parts of the curriculum create
close personal relations between
students and teachers, as they
meet as human beings discussing
a common issue more than as
students and experts. For both parts
a widened scope often follows.
Also this activity is time consuming
for the teachers.
The value of human rights is
emphasized in a natural way.
This part of the curriculum is by
some faculty members met with
The importance of caring for one’s
own moral resources to manage
ethical dilemmas becomes evident.
It seems to be a slow process to
convince all faculty members about
the importance of caring for future
physician’s development as human
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My personal experiences
As a teacher I myself have learnt
what studying according to PBL
means, which has been fascinating. I
learnt inter alia to trust the students’
ability to take responsibility for their
studies and to feel a great deal of
respect for them.
As not all faculty members are
enthusiastic, there are weak parts
in the system, and “a chain is never
stronger than its weakest part”.
Moreover, bad modelling becomes
very confronting for the PBL
trained student, who has learnt to
The PBL system challenges the show respect and appreciate high
traditional hierarchal system of morals.
health care, as teachers and students Some of the students therefore
work together on more equal terms. experience transition difculties,
When I as teacher treat my students when they realize that reality does
with respect, I assume that they will not always correspond to the moral
treat their future patients similarly values they have learnt.
(parallel processes).
Finally, a well functioning PBL
fosters democracy, with its emphasis
on respect for the individual and his/
her human rights.
Some Literature on PBL in General and on PBL at the Faculty of
Health Sciences, Linköping University
1. Barrows HS, Tamblyn RM. Problem-based learning. An approach to
medical education. New York: Springer Publishing Company, 1980.
2. Norman GR, Schmidt HG. The psychological basis of problem-based
learning: A review of the evidence. Acad Med 1992; 67: 557-65.
3. Schmidt HG. Foundations of problem-based learning: some
explanatory notes. Med Educ 1003; 27: 422-32.
4. Freire P. Pedagogy of the oppressed. New York: Continuum, 1994,
5. Home page of the FHS: http://www.hu.liu.se/
6. Home page of the medical program: http://www.hu.liu.se/lakarprogr/
7. Planning documents: http://www.hu.liu.se/lakarprogr/planeringsdok
8. EDIT web scenarios (web based scenarios for the base-group
activities): http://www.hu.liu.se/edit
9. Rules for clinical clerkships: http://www.hu.liu.se/lakarprogr/kllin_
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10. Results from evaluations by alumni 2000-2004 and 2006 organized
by the Swedish Medical Association: http://www.hu.liu.se/lakarprogr/
11. List of publications in pedagogy from FHS: http://www.hu.liu.
12. List of publications on line: http://www.hu.liu.se/pedagogisktcentrum/
Modern Trends in Medical Education
Use of information technology in
medical education
”Introduce PDAs but let them not replace our stethoscopes”
Joshi SK
Medical Education Department, Kathmandu Medical College, Sinamangal,
he Information Technology Association of America (ITAA) denes
Information Technology (IT) as “the study, design, development,
implementation, support or management of computer-based information
systems, particularly software applications and computer hardware”1. Today,
these two terms – Computers and IT - are almost synonymous and together
they have webbed the whole globe in a way that there is not a part in the
world or an incident that we can not know of and the amazing part is that we
do not even need to leave our room for all these. In a way, IT has brought the
world to our ngertips. I am sure it would not be an exaggeration to say so.
When I collected two sacks full of medical text books from the library of
a state owned Soviet medical university two decades back, I never thought
that a day would come soon when no medical student would be doing such
an exercise. It was a cumbersome job to stand in the queue for almost few
hours, get the books on your back to your hostel. The same process has to be
repeated at end of the year to submit these back. Nowadays I hardly believe
that a medical student in any part of the world has to do that.
With the development in Information Technology, there has been a signicant
change in the medical education all over the world. The changes is that
majority of the medical students are computer literate these days. Instead
of heavy books, the students rather carry CD-ROMs, or small drives in their
pockets and these can be used anywhere and anytime. New information
on medical topics is more readily accessible via the Internet and handheld
computers such as palmtops, PDA.
Use of IT in Medical Education
Information Technology can assist medical education in various ways such as
in college networks and internet. Computer-assisted learning, Virtual reality,
Human patient simulators are some options. With the help of college networks
and internet, the medical students as well as the teachers may stay in contact
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even when they are off college. Rapid communication can be established
with the help of e-mails and course details, handouts, and feedbacks can be
circulated easily. Many medical schools these days use online programmes
such as “Blackboard” or “student central” to underline and coordinate their
courses. Such programmes allow speedy access to information and quick
turnaround of evaluation and messaging, and allow all tutors, assessors, and
students at any site to look at the curricular context of their own particular
contribution. Similarly, the Internet provides opportunities to gain up-todate information on different aspects of health and disease and to discuss
with colleagues in different continents via net conferencing. Free access to
Medline, various medical journals, online textbooks and the latest information
on new development in medicine also encourages learning and research.
As computer assisted learning (CAL) is gaining more popularity, these days
many medical schools encourage the students to purchase computers, and
others are making strategies for integrating medical informatics into the
curriculum2, 3. CAL is considered as an enjoyable medium of learning and
very suitable for conceptually difcult topics. Interactive digital materials for
study of histopathology, anatomy, heart sounds are used widely. Development
of anatomical three dimensional atlases of various internal organs using
computed tomography and magnetic resonance imaging are very illustrative
and help the students to understand the subject matter clearly.
There are realtime visualisation of surface based anatomy on any personal
computer featured with advanced ”speed up” techniques. The data are visible
human body and students can build and deconstruct a 3-D model of brain and
head etc. Similarly, Advanced Life Support (ALS) simulators and Haptics
”the science of touch” simulators are used in medical education to develop
various clinical skills such as electrocardiograph interpretation, appropriate
intervention such as ABC, drugs, injections, debrillation without working
on a real patient. These days, highly sophisticated simulators “virtual reality”
with highly advanced medical simulation technologies and medical databases
are available in the advanced medical schools that expose the medical students
to the vast range of complex medical situations. It can emulate various clinical
procedures such as catheterisation, laparoscopy, bronchoscope etc. With new
technology, the students can virtually go inside each and every organ and see
how they actually look like from outside as well as from inside. We now have
proofs that we can have virtual trainings that improve the surgical skills of
young surgeons4, 5. Is that not a wonderful gift of IT? Yes, there is no doubt
in that.
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Fig 1: A laparoscopic impulse device coupled
with a virtual surgery simulator6
Not only that, these days, we can also have web based learning7. The learning
materials are uploaded in the internet, so that anyone in any corner of the
world can read them. I appreciate this system very much not only because
we can learn more things but also because it sends a message across the
world that education and knowledge are basic human rights and we should
rise above the national and political barriers and share knowledge with all.
In more organised forms, we can even have formal online medical courses
and trainings which are checked and certied by particular medical councils.
The courses are designed by medical experts, then peer reviewed and edited
by doctors. Students or doctors can attend those courses like any course in a
medical college. At the end of the course, one can also get an evaluation and
grades or credits accordingly8. This system is a perfect one because one does
not have to move from one place to the other to join the courses, in which
case he would have had to take a break from his present job and also spend
a lot of money on travel and accommodation besides the regular fees for the
course. And when one has to manage so many things before he could join a
course, he would probably think not to join it at all. So, there are few doctors
who train and attend the course, which is detrimental to the medical education
system. But with online courses, none of such problems seem to arise. In
addition, I am sure a lot more doctors would take the course which will raise
the standards of health care delivery system. The same applies to medical
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seminars and conferences. Many doctors cannot attend them just because
he can not afford the high expenses. This is especially true for the doctors in
developing countries. But with video conferencing and live lectures, IT has
provided a perfect solution.
Information technology and medicine
Like any other eld, medical system has also updated itself with information
technology. IT is widely used in all medical and surgical disciplines. Let me
pick an example to see how IT could improve the patient care in a hospital.
In Sweden, every person has his personal identity number9 and his every
personal details including his health records are digitalised and uploaded
in a network system. So, as soon as he enters any health centre, with his
identication number, the doctor can get detail information on his medical
history including the past surgeries, major events and any on going treatment
details. Not only this, doctors from different specialities can review the patient
at the same time though they are working in different corners of the hospital.
This means that a patient with abdominal pain would not have to go from his
general practitioner (GP) to the radiologist, then to the pathologist, then to a
surgeon and back to his GP after a long day of painful trip inside the hospital
to nally get his prescription for the simple pain. Is it not a better service to
the patient that he does not have to take such pain anymore? The bottom line
is we need inter speciality cooperation which we call an integrated approach
to a patient. And this is very important because only with such co operation
can we deliver quality health service. And thanks to IT, which has made it
Information technology for the developing countries
We all agree that there is a huge difference between the education system and
quality of the education between the developing countries and the developed
ones. With limited resources, the developing countries can not afford big
researches, big conferences and scientic gatherings. As I mentioned above,
even mere participation in such events becomes difcult. The colleges have
poor infrastructures; they don’t have enough trained faculties. Sometimes,
due to small number of faculty members and learning resources, colleges
have to cut down on the number of students they enrol in a year. In such
cases, as far as I can see, only IT can provide a rescue. We can design the
courses that every student can take at home; we can have discussion forums
where the teachers and students can have interactive sessions. It does not
sound ethical to allow many students in the operation theatre considering the
increased risk of contamination and unnecessary crowd. But we can record
all the surgical procedures and let the students watch and learn which I guess
would be equally informative and effective as going to the operation theatre
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The other problem medical education system faces in developing countries is
the access to journals. Due to limited resources, they can not subscribe all the
renowned international journals, which make a very essential part of medical
education. In fact, reading journals keeps the doctors and students updated
with every new therapies and concepts and it’s what makes the doctors smart.
So, what do we do now? Yes, we can denitely turn to IT for help. Its the IT
that has made it possible to have online databases like HINARI, PUBMED,
Cochrane etc. and online journals like BMJ, Nature, Annals, and a lot others.
Is that not a privilege we get through IT?
IT has also helped a lot to promote research activities in developing countries.
First, it gives access to many previous research articles on the topic, so that
people could learn about the methodology previously designed. Next, they
could design their own methodology so that the results could be comparable
with the previous ones because non comparable ndings are not much worth.
Besides, unless and until, the ndings of a research are published and reach out
to numerous people, it does not carry any signicance. And, only with IT we
can have huge number of readers because very few countries and associations
subscribe journals where most of our research articles are published. So, IT
has helped to put our national journals in an international arena. Had they not
have an online version, no body would have heard of them.
Problem based learning and evidence based medicine are supposed to be the
pillars of modern medicine and education system. The essence of these systems
lie in the study of researches, literatures and experiments and it requires
access to vast amount of information which only internet can provide. So, IT
has become indispensible in the present day medical education system.
Besides these, there are many benets of e-learning, which encourages their
1. Self paced courses
2. Available anytime, anywhere
3. Guaranteed consistency
4. Personalised and relevant
5. Easily updated
6. Easy tracking and reporting
7. Reduces logistical costs (travel, space, materials)
Difculties ahead
IT seems to have a solution to everything but then, have we been able to
implement all our ideas about IT in medical education? Perhaps NOT! There
are many hurdles in front of us and the path is not easy.
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The rst major problem is the technology. Computers and internet services
are still a luxury in many places of our country. Even in cities, the services are
not satisfactory. Slow internet connections and non-reliable ISPs are simply
enough to discourage the use of IT in education. On the top of these, the daily
power cut is a heavy blow. Usually, Personal Digital Assistants (PDA) are
supposed to be very useful and handy to use indoors. But, their high prices
simply make them inaccessible.
The free access to information should be taken with caution because at
times it proves to be an exaggerated statement. Many big medical researches
are conducted and many new things discovered. A lot of new theories are
proposed and they are published as well. It would have been very nice
to know all of those and implement them in health care system. But, we,
specially the developing nations get hiccups on the very rst step – we don’t
get access to that information at all. We are forced to subscribe to those online
versions as well which we can not afford. So, IT doesn’t seem to help in such
Another hurdle in proper use of IT in medical system is that not everyone
know how to use computers and IT. Specially, most people of the older
generation don’t have much idea of it. So, in such condition, how can we
expect to computerise our education system. It does not seem easy.
The other problem could be quality control. If we see the online study
materials, there are millions of websites and materials. So, how do we rate
them, how do we lter them? It’s a big challenge in itself. If the students
get the wrong information instead of the right ones, it would be the biggest
backre we can ever expect.
One more difculty in integrating IT and medicine could be the fact that
students have to learn both of the specialities. Often, there are reports and
discussions that medical students have too much to study and they are
unnecessarily burdened with loads of studies. On the top of that if they have
to learn computers and also many other application programs in order to be
able to use IT efciently, would not that be an extra burden to the students?
Would not it affect their studies?
There is no argument over the inuence of IT in medicine and education. But
in context of the developing countries, there are still many areas which need
to be improved before we could utilise IT to its full extent. In the meantime,
it would be best for the developing countries to make a balance between the
traditional education system and the new IT based education system.
Modern Trends in Medical Education
Last but not the least however advanced the technology gets; it can never
replace the interaction of the doctors and students with the patient and the
clinical judgements which make great doctors. So, in the pursuit of modern
technologies, we should be careful that the doctor patient relationship does
not get overlooked in our medical education system.
I would like to thank Dr. Suvash Shrestha, an Intern from Kathmandu Medical
College for his generous feedback on the article.
1. Information Technology Association of America. Denitions of
Information technology. ITAA: US. Available from: http://www.itaa.
2. Elam CL, Rubeck RF, Blue AV, Bonaminio G, Nora LM. Computer
requirements for medical school students—implications for
admissions. J Ky Med Assoc. 1997; 95 (10):429–31.
3. Kaufman DM. Integrating informatics into an undergraduate medical
curriculum. Medinfo. 1995; 8(2):1139–43.
4. Seymour NE, Gallagher AG, Roman SA, O’Brien MK, Bansal VK,
Andersen DK, et al. Virtual reality training improves operating room
performance: results of a randomized, double-blinded study. Ann
Surg. 2002; 236(4):458-63.
5. Seymour NE. VR to OR: a review of the evidence that virtual reality
simulation improves operating room performance. World J Surg.
2008; 32(2):182-8.
6. Panesar S, Shah A, Mckay-Davies I. Future Imperfect. Student BMJ.
2005; 13 :116-7.
7. McKimm J, Jollie C, Cantillon P. ABC of Learning and teaching:
Web based learning. BMJ. 2003; 326: 870-3.
8. BMJ learning. BMJ Publishing group. BMJ learning. [accessed on
17th Feb 2009]. Available from: www.learning.bmj.com.
9. Swedish tax agency. Population Registration in Sweden. 3rd ed.
Sweden: Swedish tax agency. 2004.
10. Roach JO. E-learning: is it the end of medical schools? SBMJ. 2001;
9: 174-5.
Modern Trends in Medical Education
Students’ perception of Problem Based
Learning in Kathmandu University
School of Medical Sciences
Karmacharya BM1, Risal P2
Problem Based Learning Coordinator, 2Lecturer, Department of Biochemistry,
Kathmandu University School of Medical Sciences, Dhulikhel, Nepal.
Introduction and Background: Problem based learning (PBL) is an
innovation in medical education, in which students rst encounter a problem,
followed by a student-centred inquiry process. Some of the medical colleges
in Nepal have applied PBL in hybrid manner, where conventional teaching
methods are also used. Since the inception seven years back, the pre-clinical
years in Kathmandu University School of Medical Sciences (KUSMS) has
been having PBL with hybrid curriculum with about one third of all academic
time based on PBL.
Objectives: This study which is a part of a broader series tried to nd out the
students’ perception of problem based learning in KUSMS.
Materials and methods: A form with ve statements was given to 34 second
year and 44 third year students of MBBS to give their rating to each of the
statements related to their experience and attitude to PBL. The data was
collected maintaining the anonymity of the participants.
Results: The overall experience and attitude towards PBL was found to be
very positive and the students were also willing to have PBL in the clinical
years. They also thought that they were condent of facing self-directed
learning in future as well.
Conclusion: Broader studies are required to get stronger conclusions in this
matter. This study however gives a glimpse of students’ positive experience
and attitude towards PBL in the Nepalese context.
Key words: Students, Problem Based Learning, Nepal, Kathmandu
roblem-Based Learning (PBL) is a method of learning in which students
rst encounter a problem, followed by a student-centered inquiry process.
Both content and the process of learning are emphasised in PBL. Although
many variants of PBL have been developed over the past decades, its essential
elements have remained relatively constant. Typically, ve to eight students
work collaboratively in a group (tutorial), together with one or more faculty
Modern Trends in Medical Education
facilitators (tutors), to identify and dene problems, develop hypotheses to
explain the problem(s), and explore pre-existing knowledge relevant to the
Generally, a problem is a description of a set of phenomena or events that
can be perceived in reality. The phenomena that are described have to be
analysed in terms of underlying principles, mechanisms or processes. This is
accomplished in the tutorial group by discussion of the problem, activation of
prior knowledge and formulation of learning objectives. The group process is
followed by individual study of the relevant information resources. Finally,
the results of the self-directed learning are reported in the tutorial group,
the knowledge is integrated, is then checked to ensure the objectives of the
problems have been met3.
Background of problem based learning in Kathmandu University
School of Medical Sciences
Since the inception of the medical program, KUSMS has been having problem
based learning academic program in the pre-clinical sciences (i.e., the rst
two years) of MBBS course. In the basic sciences, approximately one third
of the total academic hours are covered by Problem Based Learning. Each
group comprises of 7 to 10 students and there are six groups. Each PBL case
is covered in total three alternate day sessions in a week. After each session
of two hours, another two hour PBL preparation time is allotted. The students
are supposed to use this time and also other time for the preparation related
to PBL. Each group comprises of at least one tutor, who is generally a MBBS
doctor. Besides that, other faculties from the basic sciences as well as clinical
sciences also participate in the PBL sessions. The PBL coordinator is the
overall in-charge of the whole PBL system. The coordinator, in coordination
with the tutors and other faculty is responsible for case designing, faculty
training, students’ training, and developing problem based questions.
Support from the students and the commitment from the faculties is the
greatest strength of the program. Rapid turnover of the tutors, evaluation
system not very compatible with the PBL program are some of the major
challenges faced currently. The willingness of the students and the faculties
made us consider the approaches to initiate problem based learning in the
clinical years as well. In view of that it was realised that a general idea from
the students regarding their experience and attitude towards PBL would be
very relevant and appropriate.
Materials and methods
In July 2008, the KUSMS students of second year and third year MBBS were
given a form with ve statements (Table 1). Each statement was supposed to
Modern Trends in Medical Education
be scored in a scale of 1 to 10 reecting the intensity of the agreement to the
statement where 1 was ‘strongly disagreeing’ and 10 was ‘strongly agreed’.
The students who were willing to participate in the survey were only included
and they did not need to mention their identity in the survey form so as to
make the response entirely anonymous.
Out of the 45 students in each of the two years, only 34 from second year and
44 from third year were present. All these students who were requested to
participate in the survey agreed to participate. The mean value of the scores
(with standard deviation) of each statement was taken. The results revealed
that the students had quite positive experience and attitude towards problem
based learning (Table 1). There were relatively similar scores in the both
batches regarding their attitude towards the usefulness of PBL in the clinical
years as well.
Table 1: In a scale of 1 to 10, what would you score for each point if 1 is
strongly disagree and 10 is strongly agree
Mean Scores (±S.D)
Second year
MBBS students
Third year MBBS
1. The PBL sessions
have proved to
be useful for my
learning process.
8 (2.1)
7.5 (2.4)
8 (2.3)
2. I think that I have
understood the
concepts and the
process of PBL
8 (1.5)
7 (2.6)
7 (2.2)
3. The cases that
are given in the
sessions are very
interesting and are
sources for further
exploration of
8 (1.5)
7 (2.1)
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4. I think that
continuing PBL in
the clinical years
will be benecial.
9 (2.2)
8 (2.2)
8 (2.2)
5. I am condent that
I shall be able to
face conditions
of self-directed
learning in future
as well.
8 (1.9)
8.5 (1.6)
8 (1.7)
Discussion and conclusion
Several medical colleges have PBL sessions in the teaching program.
However, KUSMS has a fully integrated PBL curriculum in basic sciences,
with highest percentage of time allotted for problem based learning program
as compared to other colleges. It has been seven years now since the problem
based learning program started. During these years, there have been numerous
changes in the whole method of PBL in this institution as well. However the
essence of problem based learning has remained same throughout.
The experience of PBL in KUSMS can be of great use for other medical
institutions willing to try such program in their colleges. There have been
endless debates all around the world regarding its real benets and scientic
basis4,5. However, it is now beyond doubt that PBL has been a rapidly
expanding development in the eld of medical education all around the
world3. There had been concerns whether PBL would be as appropriate in
Asian setting as it had proved to be in the Western setting because of the
huge change in culture and also values in relation to the relationship between
the teachers and the students. Studies had shown that despite many sceptic
attitudes towards this sort of system, it has however been quite successful and
popular in the institutions where it has been tried6.
There are several Asian medical schools that have started to use PBL in hybrid
curricula, where PBL tutorials are run together with other modes of learning
such as lectures, small-group tutorials, special study modules and research
attachments. The preliminary data from the University of Hong Kong are
encouraging. Nandi et al. reported that, since the implementation of PBL is
September 1997, surveys of both teachers and students have indicated that
teacher-student relationships are far more interactive than they used to be in
the old curriculum. Their students became more communicative, showed more
initiative and were more positive about preclinical training. They adjusted
more readily to clinical clerkships, were more likely to ask questions and
seemed to have superior independent learning and problem-solving skills7.
Modern Trends in Medical Education
At the National University of Singapore, a report8 indicated that their students
also enjoyed Problem Based Learning. After one semester, 138 students out
of a total of 200 completed an anonymous questionnaire comparing their
experience with PBL and with traditional lectures. In general, the students
felt that PBL had increased their own interest and enthusiasm for the topics
studied. The ndings in our study are also similar to that. The students in
that study also reported that the PBL sessions had improved their reasoning
ability, communication skills and ability to work in small groups.
Gwee and Tan described their experience with implementation of a hybrid
curriculum, with 20% of curriculum time devoted to PBL at the National
University of Singapore Medical School. They concluded that ‘appropriate
training and changing the mindset of staff and students, strong leadership
from the dean and a deep commitment by all concerned are essential to ensure
the successful implementation of PBL within a traditional school9. Their
colleagues have reported on the importance of training tutors and medical
students, respectively, before the implementation of PBL so as to allay the
anxieties raised by a new method of teaching/learning. As a result, their
students and staff reported enjoying PBL and becoming more independent
The Manipal College of Medical Sciences in Nepal reported that their
students found PBL sessions to be benecial in a combination of didactic
lectures with problem-based learning sessions. Here, an overview lecture in
physiology was given to the entire class of 100 students before PBL tutorials
were conducted. These students’ nal examination results were found to be
better than those of earlier batches of students who had not been exposed to
PBL tutorials11. The BP Koirala Institute of Health Sciences in Nepal also
reported positive perceptions of PBL in their students12.
It has to be realised that the current study only shows one aspect (i.e., the
students’ perspective) of the whole issues of problem based learning in
KUSMS. Hence, the results need to be interpreted with caution. Perspectives
from the point of view of the faculty, co-workers and also the patients need
to be analysed and more scientically designed long-term prospective studies
need to be done further to get a broader perspective on the matter. The authors
are already conducting broader studies related to PBL in KUSMS. Let this
report be considered as a preliminary report of the series. However, the current
study at least gives a glimpse on the matter and shows that the prospect of
problem based learning in our setting is very bright and encouraging. It has
to be remembered that the students participating in this research do have the
problems related to the poor evaluation system (which does not account their
performance in the problem based learning sessions). The noteworthy point
Modern Trends in Medical Education
is that despite such limitation, the experience and attitude towards PBL is
quite good. This should be considered not just as a result to be cherished but
probably also as a sort of green signal to proceed further with problem based
1. Neufeld VR, Barrows HS. The McMaster philosophy: An approach
to medical education. J Med Educ. 1974; 49(11):1040-50.
2. Schmidt HG. Foundations of problem-based learning: some
explanatory notes. Med Educ. 1993; 27: 422-32.
3. de Goeij AFPM. Problem-based learning: What is it? What is it not?
What about the basic sciences?. Biochemical Society Transaction.
1997; 25:288-93.
4. Colliver J. Effectiveness of problem based learning curricula. Acad
Med. 2000; 75:259-66.
5. Norman GR, Schmidt HG. Effectiveness of problem-based learning
curricula: theory, practice and paper darts. Medical Educ. 2000;
6. Khoo HE. Implementation of problem-based learning in Asian
medical schools and students’ perceptions of their experience. Med
Educ. 2003; 37:401-9.
7. Nandi PL, Chan JN, Chan CP, Chan P, Chan LP. Undergraduate
medical education: comparison of problem-based learning and
conventional teaching. Hong Kong Med J. 2000; 6(3):301-6.
8. Khoo HE, Chhem RK, Gwee MC, Balasubramaniam P. Introduction
of problem-based learning in a traditional medical curriculum
in Singapore-students’ and tutors’ perspectives. Ann Acad Med
Singapore. 2001; 30(4):371-4.
9. Gwee MC, Tan CH. Problem-based learning in medical education:
the Singapore hybrid. Ann Acad Med Singapore. 2001; 30(4):35662.
10. Singh K, Chhem RK, Gwee MCE, Khoo HE, Balasubramaniam P,
Tan CC. Preparing tutors for problem-based learning-the Singapore
experience. 1st Asia Pacic Conference on Problem-Based Learning;
December 1999; Hong Kong: Blackwell Publishing; 1999.
11. Ghosh S, Dawka V. Combination of didactic lecture with problembased learning sessions in physiology teaching in a developing
medical college in Nepal. Adv Physiol Educ. 2000; 24(1):8-12.
12. Bhattacharya N. Students’ perceptions of problem-based learning at
the BP Koirala Institute of Health Sciences, Nepal. Med Educ. 1998;
Modern Trends in Medical Education
Assessment of undergraduate medical
Rizyal SB
Founder Principal, Nepal Medical College, Jorpati, Nepal.
Keywords: Assessment; learning, learner; facilitator; undergraduate medical
earning and assessment always go together with all forms of academic
programs. The calendar of operation of an academic program is not
complete without the mention of examinations. Learning without assessment
fails to get formal status in academics because such learning cannot be
considered to have attained mastery. Assessment / examination / evaluation,
whatever name one gives, forms the modus operandi for nding out the
outcome, quality, competency of learning experiences. Hence, as in the case
of the students of other disciplines, assessment forms an integral part of
learning for the undergraduate medical students also.
Facts on assessment
George Miller (1973) stated, “Scientic studies prove that it is the assessment
rather than educational objectives or curricular or instructional methods that
has the most profound impact on what the students ultimately learns”. This
holds truth for undergraduate medical students too.
Assessment is related to stimulation of sympathetic system leading to
increased adrenaline secretion among majority of examinees resulting
sometimes into examination phobia / examination fever. The assessors in
some cases consider it as extra work.
Learning just before the assessment is a pandemic phenomenon among
students. Assessment does help to nd out how much learning has taken place
and where does a learner stand on the “learning – scale”.
Nature of assessments
Medical education, starting from undergraduate education is a professional
education and it bears signicant importance for providing health care.
Starting from the entry level to acquiring terminal level competencies,
learning experiences build up in an undergraduate medical student (learner)
Modern Trends in Medical Education
by understanding from simple to complex; from making observation to
becoming able to drawing inferences; by practicing psychomotor skills and
developing hands on skill; by listening more to patients and giving attention
to each and every aspect thereby respecting human values, are to be tested by
appropriate tools of assessment.
The pre-test (asking random questions to students before teaching a topic to
nd out the level of understanding of the class in general) is done by some
teachers to perform the level of teaching required for the session by assessing
the level of understanding of the whole class.
The pre-test (at times done by paper / pen also) gives feed back to the teacher
on the general understanding of the topic and helps to deliver the instruction
which becomes easily understandable and comprehensible to the learners.
Formative tests
Formative tests are meant for taking place in-between instructions and the
sole purpose is to nd out how much learning has occurred in a learner who
has the right to get the feed back on his / her learning from his / her facilitator.
The learner also reserves his / her right to go through the answer scripts and
nd out the mistakes committed and learn from the mistakes. The formative
tests are spread through out the MBBS program and provide in depth level
of skill, knowledge, attitude (SKA) of students to teachers as well as to the
individual learners.
Summative test
These are for nding out the terminal level competencies mostly done by
norm – referenced assessment (valued on the basis of comparison done of
an individual answer paper based on the answers given by the whole class)
and least practiced by criterion referenced assessment where pre-determined
answers are listed and individual learner is judged on the basis of how many
pre-determined answers one gets right, are used. This form of assessment is
used for certication of the learner, at the termination of the course of study.
Weightage given to formative and summative tests
The undergraduate medical education program has higher number of formative
tests than the summative ones, in any subject included the MBBS program.
However, the formative examination either gets no or very little weightage of
marks (under some university) from the total allocated to a subject included
in the undergraduate medical education program. The summative assessment
gets the maximum weightage in most cases and takes place once at the end of
the course of instruction.
Modern Trends in Medical Education
Categories of authorities related to assessment
Three categories of authorities related to assessment of undergraduate medical
education programs are in practice (1) departmental / faculty level for
continuous assessment; (2) institutional / college / campus level – formative
assessment and (3) university level – summative assessment.
Assessment in professional perspectives
Professions, e.g., medical, dental, other health professional, demanding
continuous update with the latest trends in order to be capable of providing
up to date care to the patients, calls for self-appraisal and self-assessment on
the skill, knowledge and attitude required for discharging the responsibilities
of the profession.
The purpose of learning for passing the examination must give way to the
purpose of caring for the patients; the practice of rote learning before the
examinations must give its way to the practice of every day learning for
gaining experience required for providing care to patients and the role of
the examiner (teacher) to nd out how much the examinee (student) has
learnt must give its way to how much have I (teacher) been able to bring
in the change in learning of student by my instructions. If the facilitators
would be able to inculcate this in them, the fear attached to students related
to assessment / examination would be replaced by experiential learning,
enjoyable by all learners and assessments would be considered as a tool for
nding out how much learning has taken place in learners rather than how
much the student does not know, and would be acceptable by the learners as
a part of learning.
The paradigm shift related to assessment of undergraduate
medical education program
Very important questions related to the assessment of undergraduate medical
students start hovering over the mind. Eminent scholar and educationist
R. Thorndick’s saying “if the students have not learnt, the teacher has not
taught” echoes clear and loud even today.
It is the teacher, not the academic institution / college or the university who is
primarily responsible for the learning that occurs in the students.
It is indeed very true, who else would know about the learning style, speed and
depth of a student’s learning more than the teacher who remains maximum
in contact with the student. This is a general remark and holds truth even in
undergraduate medical education program. Haven’t we heard the external
examiners asking the internal examiners on how a student had been in the
class, in situation when the external examiner nds difculty in making own
judgment on a student’s performance in the university examination?
Modern Trends in Medical Education
It would not be inappropriate if one recalls from the Hindu philosophy
“Guru Brahma, Guru Bishnu, Guru Devo Maheshwora, Guru Shakchayat
Parabrahma, Tasmai Sri Gurubryo Nama” which narrates the characteristics
of a Guru or teacher, one who dispels the cloud of ignorance from the mind
of a student and illuminates him / her with knowledge and wisdom. Guru, the
teacher or the facilitator or the mentor knows the characteristics of his / her
“sishya” or the student / learner and creates the learning ground for learning
in the form of “Brahma”, the creator; the Guru in the form of “Bishnu” the
purveyor who supplies the information of knowledge and wisdom to his / her
student by knowing the individual characteristics of the learner and nurtures
and facilitates the learning and nally the Guru in the form of “Maheshwora”
the assessor nds out how much learning has taken place at the end of the
study in his / her sishya / student and assesses the learning of the individual
as “Maheshwora” does to individuals at the end of the journey of life. One
needs to respect the value of the Guru / teacher in the light of above stated
narration which holds truth even today.
If one believes that the learner is inuenced by the facilitator and that the
characters which are imbibed in the learner is the result of interactions with
the learning environment but much more inuenced by the facilitator, then
the abilities to nd out about his / her learning lies much more with his / her
facilitator / teacher. If one agrees to this thinking then the new approach to
assessment of the undergraduate medical student needs to be looked at from
professional perspective as regards to allocation of weightage of marks to
formative and summative assessments, and must be changed vice versa.
Suspicion and threat
Innovations made in medical education have always been looked with
suspicion and threat and have always been challenged both by the medical
fraternity as well as authorities who have major control on the undergraduate
medical education program.
Giving away power one possesses is always looked with threat and this
holds truth in assessment of student also. Allocation of maximum marks
to the departmental / teacher level poses doubts of dishonesty in the minds
of academic hierarchy, even though it is and believed that hundred percent
teaching is done by the teacher / department, in which no one has even fraction
of doubt on the dishonesty of a teacher / departmental.
Capacity – building with self condence of teachers:
Teachers form the pillars of the institutions / colleges which are classied
as good or bad by the consumers. Students always run after good colleges /
institutions which are good because of good academics. To create a cadre of
Modern Trends in Medical Education
such good faculty, on needs to trust whole heartedly and cast no doubts on
matters related to teaching and assessment, to own faculty members.
Trends in medical education
With the emerging innovations in medical education one must try to adopt
the contemporary trends, as medical education is a global phenomenon. The
parts of the human body remain the same throughout the world so do also the
If one believes that small group learning facilitated by a preceptor / mentor
is becoming popular and helping the learners learn better than the didactic
method, then, the preceptor / the mentor, the facilitator and the department
which is constituted by faculty members must get maximum importance for
undertaking the assessment of undergraduate medical students.
The new approach to assessment of undergraduate medical
It is proposed on the above pretext that all the examinations except the nal
MBBS examination be held by the individual campus / colleges / institutions
giving maximum weightage to the formative assessment. As the university is
the sole authority which grants the MBBS degree, for granting certication,
the nal MBBS examination becomes the right of the university for certifying
the candidates whether they meet the university requirements meeting the
standard of the candidates of other universities or not. External examiners
from other universities must be invited to check whether the candidates
have achieved the terminal level competencies as demanded by the MBBS
The time is ripe to changing the traditional system of assessment of
undergraduate medical students and adopting new policy to self determination
of own products by the individual faculty and colleges and building self
condence in quality assurance of medical graduates in Nepal. Judging
the quality of the end products does not lie in the hands of the teaching /
certifying bodies but lies with individual patient and the society at large:
Towards making all round development take place in a learner and becoming
accepted as a good medical doctor, the teacher / mentor / facilitator must
always become a role model to the learner.
Modern Trends in Medical Education
1. Health Learning Materials Centre: Institute of Medicine. Essentials
of medical education. Kathmandu: HLMC, IoM; 1996.
2. K.L. Wig Centre for Medical Education and Technology. Assessment
in medical education trends and tools. All India Institute of Medical
Sciences (AIIMS), New Delhi.
Modern Trends in Medical Education
Rotating internship - Interns’
Shrestha D1, Mishra B2
Lecturer, Department of Orthopaedics, Kathmandu University Medical School,
Dhulikhel, Nepal; 2Relevant Institute for Supplementary Medical Education,
Kathmandu, Nepal.
Background: Internship is an integral part of MBBS training programme
and is mandatory to all students. Kathmandu University School of Medical
Sciences (KUSMS) has adopted a programme of compulsory one year
rotating internship including 6 weeks community exposure in out reach
clinics of students. The purpose of this study of the rst batch is to evaluate
interns’ feedback concerning learning, education and satisfaction.
Materials and methods: A questionnaire with 47 questions was administered
to 30 interns who had nished one year rotating internship in KUSMS. A
total of 42 responses were graded according in Likert scale and 5 open-ended
questions were analysed for common themes.
Result: The mean age of the interns was 24.77±0.67 years with a female
to male ratio of 1.5:1. Condence level of communication of interns with
faculties was less than that with junior doctors and patients. Junior doctors and
colleagues contributed more in interns’ learning than faculties. Community
exposure for 6 weeks was considered lengthy and lacking of clear objectives.
However, 53.3% interns agreed that achievement of objectives of community
posting was high or very high. Fifty percent interns perceived certain degree
of physical, mental, or sexual harassments during internship. Interns raised
the issue of not involving them as a part of team during clinical posting.
Clinical competencies for most of the skills were high or very high.
Conclusion: Interns have learned clinical skills and patient care in one
year internship programme with contribution from junior doctors and
colleague more than teachers. Clear objectives are needed before clinical and
community postings. Process of providing regular feedback from interns and
vice versa should be implemented to improve interns’ learning, education and
Key words: Clinical skills, Communication, Community postings, Education,
Internship, Harassments.
100 Modern Trends in Medical Education
nternship is as an integral part of MBBS programme. Before registration in
Nepal Medical Council (NMC), it is mandatory for all students to complete
one-year internship programme adopted by respective colleges or universities
or as recommended by NMC. After four and half years of extensive learning
with lectures, tutorials, focused group discussion, seminars in the class room
and number of bedside case presentations plus frequent visits to community,
internship is a period of learning the art and method of applying theoretical
knowledge acquired during his/her training. After completing one year of
internship, interns are expected to be competent not only in clinical skills
and procedures but also expected to learn to play a role of caretaker, decision
maker, communicator, community leader and manager, the ve expertise
of the doctor identied by Charler Boelen1. When internship starts, acute
transition occurs in role of student as a learner to as a doctor who has to work
as a team in the hospital with senior colleagues. So, there are possibilities
of confusion and conicts in perception of internship as a working versus
learning, the attitude of the supervisor as a evaluator versus coach, the culture
of the training setting as a work-orientated versus training-orientated, the
intern’s learning attitude as a passive versus proactive and the nature of the
learning process as informal versus formal2.
Constant and constructive feedbacks from interns to supervisor and from
supervisor to interns are needed to improve the internship programme because
improvement in internship programme is a dynamic process which needs to
be updated according to need of the country and institutional philosophy. We
present a qualitative study, which critically analyse the feedback provided by
the interns regarding learning, education and satisfaction after completion of
compulsory rotating one-year internship in KUSMS and review the literature
regarding effectiveness of internship programme in learning process of the
Materials and methods
Study design
A qualitative cross sectional study.
Participants and background
Thirty interns who had completed one year rotating internship programme
in KUSMS were enrolled in the study. Condentiality of participants was
maintained by using no personal identier except gender, age and schooling
background. Kathmandu University School of Medical Sciences which runs
MBBS programme in three different hospitals namely Dhulikhel Hospital in
Dhulikhel, B and B Hospital in Kathmandu and Scheer Memorial Hospital
in Banepa, has adopted student centered, problem based, integrated and
Modern Trends in Medical Education 101
community based learning method3. For the rst batch of students (20012006), one year rotating internship programme was designed in above
mentioned three hospitals for different clinical specialties and out reach
centres with different level of facilities for community exposure. Out reach
centres were under direct supervision of Dhulikhel Hospital and each intern
was posted for 6 weeks in such centre.
Assessment tool
The assessment tool was a questionnaire containing 47 questions under 16
headings. Participants had to respond in 42 questions in ve point Likert
scale and remaining 5 were open ended questions. The questionnaires
were designed to evaluate participant’s level of communication skills,
condence of handling illness and competence of clinical procedures. The
clinical procedures were selected from the logbook of KUSMS internship
programme and decided after discussing among authors. Similarly interaction
with colleagues, contribution of different learning materials and awareness
of universal precaution, educational material and monitory support, logistic
facilities, maintenance of patient’s condentiality and interest developed
towards research were also graded. Participants were asked to respond
regarding achievement of objectives and effectiveness of community exposure
in learning process. Participants had to respond regarding any physical or
sexual or mental harassment if experienced. Finally they were asked to
answer about role of problem based learning in their learning, overall rating
of internship strategies and fullment of their expectation after completion
of internship. In open ended questions, participants were free to comment
upon improvement of community exposure, logistic facilities and internship
programme as a whole. Two questions were about their interest of specialty
in future and possible place of working.
Data collection
Fourteen participants returned lled up questionnaire personally and 16
participants answered by e-mail which took 4 to 22 days for responding.
Statistical analysis
Responses were collated into a single ‘‘master document’’ for analysis and
interpretation. Interns’ responses were organised into sections corresponding
to the questions. Response to open ended questions were collected according
to ‘‘editing analysis style’’ to identify meaningful segments of the text
and grouped into common theme. We selected representative quotations
to illustrate the various themes and edited them for grammar, spelling and
readability without any substantive changes to the texts. SPSS version 11.5
software was used to calculate mean or median whichever is appropriate and
Man-Whitney test was used to calculate level of signicance.
102 Modern Trends in Medical Education
All 30 interns lled up the questionnaire. Fig.1 shows sex and age distribution
of the interns. The mean age of the interns was 24.77±0.67 years with a female
to male ratio of 1.5:1. Twenty nine interns had school education in private
school and only one had in public school. Similarly 28 (93.3%) interns had
school education in urban area and 2 had in rural area. Twenty (66.67%)
interns preferred to work within country, 4 (13.2%) preferred USA and
remaining 6 (19.8%) were uncertain. No statistically signicant co-relation
found between their future choice of working within country or abroad and
schooling background (p=0.46) and gender (p=0.91). Nine interns wanted
internal medicine or its sub-specialty as a possible future carrier. Similarly,
9 interns wanted to have surgical carrier; 3 interns wanted gynaecology and
obstetrics; 3 interns wanted paediatric; 1 intern wanted anaesthesia and 5
were undecided. Their future interest of specialization was inuenced by
interest in subject (7 interns), better impression during posting (4 interns)
and unavailability of such specialist in the country or hospital (2 interns) and
remaining did not specify reason.
The ndings of questionnaire with 42 items under 11 headings are summarised
in Table1. Majority of interns had acquired high degree of communication
skills with patient and colleagues but communication skill with faculty was
either moderate or very low in 36.7% and 93.3% responded good or very good
interaction level with medical ofcers or junior doctors as compare to 63.3%
with faculties, 56.6% with nurses and 50% other paramedical staffs. Medical
ofcers and junior residents, colleagues and patients were major source
of learning during internship. 73.4% agreed that medical ofcers, junior
residents and colleagues contributed high or very high in learning process as
compared to 50% contribution by faculties and 43.4% by books. 56.7 % had
high degree of condence of handling the cases independently but only 60%
had moderate, low or very low condence talking, breaking bad news with
like death or diagnosis of tumour. 89.7% interns graded universal precaution
awareness high or very high. 56.7% interns agreed that the contribution of
problem based learning process during his/her MBBS training was high or
very high. Certain level of harassment was perceived by interns. Two interns
mentioned about sexual harassment; ve interns had physical harassment and
eight had mental harassment. 53.4% responded that their expectation after
internship was fullled moderately or less and 51.6% rated overall internship
programme as moderate, poor or very poor.
Achievement of objectives of community posting was graded high or very high
by 53.3% interns but only 32% considered it highly or very highly effective.
14(46.2%) interns considered community posting was long and should be
shortened and time saved could be utilized for other clinical posting. Eight
Modern Trends in Medical Education 103
interns favoured community posting to be started after completion of clinical
posting. They suggested fewer but dened objectives, clear instructions and
guidelines before going to community and posting along with instructors or
seniors were other themes concerning community postings. Interns pointed
out need of better transportation, communication and referral system and
were concerned about lack of basic medications and uncooperative behaviour
of health personals. Few interns were not able to differentiate the learning
objectives of during community posting teaching as a student during his/ her
MBBS training period and during internship as a care provider. Followings
are some examples of interns comment:
“…. should be started after interns have nished major postings and
know how to perform minor procedures before going to community,
….posting time can be reduced to make it available for other posting
like laboratory, radiology, dental….”
“….more effective objectives should be clearly laid out at the outset
of the posting….”
“….should be a part of health projects which will be followed by
subsequent interns till completion rather than just going for talk
programme….needs referral facilities to the hospital …. no change in
the objectives from community posting as students having impressions
that villages being used for study but not for community benets….”
“….would have been better if interns are with seniors ….”
Community postings was perceived as an unique experience of rural setting
of health care but there were interns who considered the posting was a just
break from busy schedule in hospital.
“….internship in both urban and rural hospitals gave me wide
exposure and helped in learning process….”
“I don’t think the community posting is good for anything except a
break from busy schedule from hospital.”
More than 50% interns graded facilities of accommodation, transportation;
learning material and stipend were moderate, poor or very poor. 53.4%
considered accommodation provided is poor or very poor. Accommodation
for interns especially for night duties was major concern for them. Similarly
lack of learning materials like easily accessible internet and books in library
and inadequate managerial and administrative guidance were pointed out.
“…. proper lodging facilities should be provided especially for night
104 Modern Trends in Medical Education
“….stipends would have been enough if paid on time …….learning
materials weren’t enough as we didn’t have good access to library
and internet …”
“…. no managerial or administrative guidance were available…”
Lack of interns’ involvement as a team member by seniors in patient’s care
was the major point raised by the interns. They were either not informed
when they were on duty or were involved in clerical work only. They were
not clear about learning objectives before starting the posting. Inadequate
academic activities, lack of supervision and internship coordinator were
other issues of concern. Many interns thought that no necessary change were
made in co-ordination, management and other logistic facilities in spite of
pointing out those problems repeatedly. Frequent change in posting schedule
had created confusion during internship. Some representative comments on
overall improvement for internship programme are listed below.
“…..teachers should teach about approach to the patient rather than
just observing in wards or OPDs……..procedures should be done under
supervision so that correct methods and dealing with complications if
occur can be learned….”
“….medical ofcers should also share some work so that interns have
more time for learning procedures….”
“…. objectives should be clearly elucidated to the interns before each
“….would have been more effective if it had more academic
“….ward rounds should be made more productive to all the interns
with more discussions….”
Modern Trends in Medical Education 105
Table 1: Response to various items by interns (% of total response in
Very good
Very low
Very high
Interest towards medical
research (N=28)
Awareness of universal
precautions (N=29)
Communication skill with
Condence of
handling medico-legal cases
talking death or breaking bad
handling cases independently
Interaction with
consultant/ faculty/teacher
junior doctors
allied health personals
Contribution in your learning
Did u maintain patient
Community postings
Did you achieve objectives?
How effective?
Facilities during internship of
Pocket expenses
Learning materials
Very low
Very less
Very High
Very good
106 Modern Trends in Medical Education
Skills developed in
ECG interpretation
NG insertion
Pleural tapping
Foley’s catheterization
Vein cut down
Conducting normal deliveries
Suturing episiotomy
Insertion/Removal of Norplant
I.V. access in paediatric patients
Emergency resuscitation
Nasal packing
Tooth extraction
Syringing for Nasolacrimal duct
Cast (PoP) application
Not at
Sexual (N=29)
Mental (N=29)
Physical (N=27)
Very low
Very high
Fig 1: Age and sex distribution of 30 participants
Modern Trends in Medical Education 107
Internship is the crucial event in whole medical training programme for both
the students and the institution and can be considered as a foundation of future
medical carrier for students. The impression made by the students during
internship remains for long time and inuences his/her role in the society
because it is a period of intense physical and emotional stresses with lots of
information and learning of variable degree of importance4. For institution, it
is the opportunity to teach not only the clinical skills but also to train students
to achieve the vision, mission and goal followed by the institution.
Active involvement of interns enhances the formation of powerful
conceptual structures and constructive feedbacks from clinical staff in a
positive atmosphere enhance learning5. This needs good communication and
interaction among interns, teachers, junior staffs, nurses and paramedical
staffs. The present study revealed good communication and interaction of
interns with patients, colleagues and junior staffs as compared to faculties
which may be the concerning point for the teachers. 93.3% nterns had good
or very good interaction level with junior doctors where as only 63.6%
interns found interaction with teachers good or very good. This indicates
unseen barriers between teachers and the interns. One of the reasons may be
the hierarchy of communication that can occur if there are too many people
in the team may exclude learners6.
The learning resources for interns are variable and depending upon the nature
of learner as a passive or active, he/she might use various resources. Senior
faculties are usually not involved in teaching clinical skills but students would
like more contact with them because they feel they could learn a lot and
correct method from them7. Though the role of junior doctors for teaching
skills have been questioned by various authors because of level of expertise,
competency in their own skills and making frequent mistakes themselves,
junior doctor as the main teacher in the clinical setting has been established
by many studies8,9,10. The similar ndings was revealed in the present study
which showed that only 50% interns considered teachers as a contributor in
their learning where as their own colleagues and junior doctors contributed
in 73.4% interns. The various reasons are postulated for this observation. A
good doctor does not always automatically mean a good teacher or provider
of feedback. In busy hospital schedule, teachers nd limited time to teach
interns in OPDs ward rounds and operation theatre and think that his junior
doctor or residents will teach necessary clinical skills to interns. Some of
teachers may feel practical difculties to involve intern with their private
patients. On the other hand, interns may nd learning with junior doctors
easy because they do not feel hesitation to ask questions or discuss the
problems or don’t feel humiliation even when they make stupid mistakes and
108 Modern Trends in Medical Education
they consider junior doctor as a peer as there is not much age difference7. The
role of the books as a learning material during internship period was found
very low. These were rated as moderate, low, or very low by 56.7% interns.
The reason behind this nding may be interns do not get enough time to study
the books or they do not think books can help in learning clinical skills but
sound theoretical background knowledge is needed consolidate clinical skill
and this point should be emphasised to interns.
It has been observed in various studies that traditional setting of teaching
interns in the hospital has many disadvantages because they are most often
considered as a passive member in the team creating a confusion in the role
they have to full and in bigger hospital, they have to compete with residents
in trainings and paramedical students for learning clinical skills7,11. Clinical
teaching in community hospitals and properly structured residential posting
in such hospital as a part of internship programme can be the solution of the
problem and hence the policy has been adopted in KUMS. The managerial
and leadership skills can be taught in the community more effectively than in
hospital set up in cities and also enhance intern’s condence to handle patients
independently12. But intern’s feedback regarding community posting after
completion of internship in KUMS was not encouraging. The community
posting was rated as moderate, less, or very less effective by 68% interns. They
could not appreciate difference between preventive medicine subject teaching
in the out reach health centre and residential posting during internship. They
were not clear about the objective they have to accomplish in the community
in the given time period and hence many considered community posting as
lengthy and not effective. There was confusion whether they have to act as a
learner as designated by the institute or health care provider as expected by the
community members. Interns who had not been adequately exposed to clinical
departments in hospital before going to community, considered community
posting as waste of time. Lack of supervisor and resources constraints made
dealing with patient more difcult for interns. This nding clearly indicates
the gap between intended objectives of the programme and outcome. The
solution for this problem may be a session for the interns to explain the
objectives and interns’ role as a learner as a part of health care providing
team, as a manager to listen carefully about health related problem and as a
planner to formulate appropriate solution. These objectives can be achieved if
they are made responsible for a part of project for specied duration for each
group of interns posted in community and subsequent group can continue or
start another programme. At the same time members in the community and
the clinical staffs should also be explained about the objectives of posting
interns in their health centre. This will help to reduce the possible conict
between interns and community members. So, clear objectives with well
planned management are necessary for exposure to interns in the community
for expected results.
Modern Trends in Medical Education 109
Most of the intern’s responded skill developed for life saving measures were
good or very good except for venous cut down which was good or very
good in only 20% interns. Similarly skill of extraction of tooth which can be
considered as an essential skill to learn for interns posted at out reach health
centre also was not satisfactory.
The reasons behind lower rating of internship strategies in the present study
may be multiple, ranging from inadequate logistic supports, inadequate
supervision and learning materials, lower level of interaction with teachers,
unclear objectives of community postings and insufcient coordination from
management side
Some kind of physical or mental harassments to new comers in medical
education system is unfortunately common in Indian subcontinent but there
are few studies reporting harassments perceived during internship also13. The
present study revealed 8 (26.6%) interns had perceived mental harassments
and 2 interns had experienced sexual harassments but we had not asked to
specify the type of mistreatment or the source of the harassment. Though
perceived mistreatments may be just a misunderstanding or wrong perception,
the reporting should be considered very seriously to avoid unexpected
consequences in future.
In conclusion, professional competencies learned by interns during one year
compulsory rotatory internship programme in KUMS are satisfactory but
there are substantial space to improve in learning and teaching environment
and the method. Setting the objectives for both clinical and community posting
should be taken with priority and should be clearly explained to the students,
teachers and the community in a session before posting starts. Logistic
and managerial support plays vital role in intern’s performance and hence
an internship coordinator should be designated. Teachers having different
background of medical education system need training and workshops to
understand changing system of medical education. Recognitions of interns
as a responsible team member will not only enhance the learning but also
strengthen interaction level with teachers. Interns should also realise that
there are plenty of learning opportunities in all formal or informal activities.
It may be just critical observation of doctor patient relationship to active
participation in surgical procedures. Regular feedback from students to
teachers and vice versa with intention to improve helps in improving each
other performance both as a learner and a teacher.
1. Boelen C. Medical education reforms: The need for global action.
Acad Med. 1992; 67(11):745–9.
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Deketelaere A, Kelchtermans G, Struyf E, Leyn PD. Disentangling
clinical learning experiences: an exploratory study on the dynamic
tensions in internship. Med Educ. 2006;40 (9):908–15.
MBBS Curriculum, Clinical Sciences, Kathmandu University, School
of Medical Sciences. 2006;1.
Levine RB, Haidet P, Kern DE, Beasley BW et al. Personal Growth
During Internship: A Qualitative Analysis of Interns’ Responses to
Key Questions. J Gen Intern Med. 2006;21:564–9.
Irby D.M. Three exemplary models of case based teaching. Acad
Med. 1994; 69:947–53.
Sheehan D, Wilkinson TJ, Billett S. Interns’ Participation and
Learning in Clinical Environments in a New Zealand Hospital. Acad
Med. 2005; 80:302–8.
Remmen R, Denekens J, Scherpbier AJJA, CPM van der Vleuten,
Hermann I, van Puymbroeck H, et al. Evaluation of skills training
during clerkships using student focus groups. Med Teacher. 1998;
Jolly BC, Macdonald MM. Education for practice: the role of practical
experience in undergraduate and general clinical training. Med Educ.
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ST Clair EW. Assessing house staff diagnostic skills using a cardiology
patient simulator. Annals of Int Med. 1992; 117:751- 6.
Remmen R, Denekens J, Scherpbier AJJA, Hermann I, van der
Vleuten C, van Royen P, et al. An evaluation study of the didactic
quality of clerkships. Med Educ. 2000; 34:460–4.
O’Sullivan M, Martin J, Murray E. Students’ perceptions of the relative
advantages and disadvantages of community-based and hospitalbased teaching: a qualitative study. Med Educ. 2000; 34:648-55.
Sen Gupta TK, Murray RB, McDonell A, Murphy B, Underhill AD.
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Daugherty SR, Baldwin DC, Rowely BD. Learning, Satisfaction
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Modern Trends in Medical Education 111
PBL - Allied health sciences
Risal P1, Karmacharya BM2
Lecturer, Department of Biochemistry, 2Problem Based Learning Coordinator/
Lecturer, Department of Medicine, Kathmandu University School of Medical
Sciences, Dhulikhel, Nepal.
Background: Problem Based Learning (PBL) has long history in the
medical education and now being spread all over the world and is a familiar
component of many medical programmes in Nepal. PBL is an educational
method of learning in which cases similar to the real scenario is administered
to small group of students to stimulate their self learning on the base of their
prior knowledge and the process of learning continues with integration and
application of knowledge to solve the problem under the supervision of a tutor.
It has been suggested that PBL may solve some of the persistent problems of
medical education, such as the irrelevance of some of the knowledge which
students have to acquire in traditional curriculum, lack of integration of
subjects and need of continuous education after graduation.
Objective: The objective of the present study is to explore perception of
Allied Health Science (AHS) students towards PBL.
Materials and methods: Qualitative cross sectional study design was done
with fourteen close-ended and three open ended structured questionnaires to
assess the students’ perception related to different aspects of PBL. All total
students (84) of certicate in Health Science General Medicine, Physiotherapy
and Laboratory Technology of Kathmandu University, who are having
experience of PBL as a component of their teaching learning methodology
were included in the study
Results: Out of 84 total students 77 were able to ll the questionnaire. The
learning experience was felt valuable by 76 (98.5%) of them. Similarly 56
(72.3%) students strongly agreed that PBL helped them to think critically. All
of them felt searching for answers to the learning issues exciting, 72 (93.9%)
students felt that PBL was a worthwhile method of learning, and all students
found reading about the learning issues stimulating. Seventy (98.5 %) students
felt that the PBL stimulated their thinking process. Likely 76 (98.5%) felt that
the group interaction was the most valuable part of learning, and 76 (98.5%)
respondent felt that group interaction enhanced there learning but 6 (7.6%)
respondent felt difcult in sharing their ideas and thoughts in the group and
65 (84.7%) respondent felt that student in their groups was supportive. Three
percent felt that the tutor was not facilitating the group interactions. Every
112 Modern Trends in Medical Education
respondent liked to have more opportunities for PBL. Similarly, 70 (90.8%)
of the students preferred the PBL method to the traditional-lecture method.
About open ended question that were focused on likes and dislikes of PBL
and their personal opinion about how PBL could enhance their learning,
students felt that PBL would increase the sprit of teamwork and increase
communication skills. Students also indicated that group discussion is the best
part of PBL and likely stimulation for self-study, which will be benecial for
their further study as well as to keep them updated during their professional
Conclusion: The students have perceived PBL highly positive. Students’
belief that PBL will help them think critically and will help them acquire self
learning skill is very important indicator of a self realisation that there is a
difference between teaching and learning. This will further motivate them for
self-study. PBL could be one of the alternate teaching learning methods in
allied health science. There should be further research regarding the outcomes
of students’ progress to apply PBL in full strength.
Key words: PBL, Allied Health Science, Nepal
roblem Based Learning has long been implemented in medical education
since 1950s and has exciting results. There are many studies supporting
the role of PBL in students learning skills and higher problem solving abilities
in comparison with those with conventional lecture method1, 2. Meta-analysis
of all the studies conducted during the period of 1970-1992 comparing PBL
with the conventional approach in medical education, found that PBL was
better than conventional approach with respect to the students’ attitudes and
opinions 3. The ndings also showed that PBL students not only gave more
emphasis on understanding the underlying scientic knowledge compared to
students from traditional programmers, but also showed a greater independence
in their learning method than did in the conventional lecture type students 3.
Popularity and wide implementation of PBL in medical school of Europe,
America, Australia, and even in Asia is the evidence of its success. Moreover
the implementation of PBL in other discipline like arts, commerce, business,
and law has highlighted the scope of PBL in any discipline. In this regards
Maastricht University, Netherlands has been implementing PBL in their other
discipline since its inception4.
History of PBL in Allied Health Science is almost similar as in medical
education and the outcome that has been reported in many studies supports
its glory.
To my knowledge, in Nepal, PBL is limited to medical education only and
is also not with a long history. Kathmandu University School of Medical
Modern Trends in Medical Education 113
Sciences has been implementing PBL in its basic medical sciences from
its very beginning and is exploring its horizon in clinical sciences as well
as other Allied Health Science programmes. There are many hopes and
encouraging facts to support implementation of PBL in allied health science
Students of Allied Health Science get lesser time to study all the basic science
and clinical sciences subjects as compare to medical students. In existing
curriculum of AHS in Council for technical education and vocational training
(CTEVT) and KU, students have to study Physics, Chemistry, Biology,
Mathematics, Anatomy and Physiology during rst year. During second year
they study all the major specic subjects with little exposure to the clinical
settings. During third year they are posted to various clinical departments
as in internship or clerkship. Therefore students are overburden with lots of
information within short period of time, which is very difcult to cope with.
There is lack of integration because in conventional method each subject
expert delivery the knowledge in their own way and there always remains
gap in making connection and integration of different discipline with clinical
problems where the theoretical knowledge has to be applied. There is no
clear-cut boundary or limitation of the extent of learning as the topics and
subjects are almost same as in medicine. The duration of study is less and the
area of study is vague therefore most of the time students lack to concentrate
in the basic skill and knowledge or major competencies. The report of Nick
Simons Institute (NSI), Nepal also supports the same 5. In PBL method, cases
could be constructed around the competencies required for allied health
science students and learning objective could be made so that discussion
goes more on differential diagnosis and management without going depth in
pathophysiology. With the report of NSI majority of health care in rural areas
of Nepal has been provided by the mid level health manpower where medical
graduates are not available 5. In this regards effective training to the mid level
health manpower is justiable for development of overall health care services
of the country.
Students of Allied Health Sciences are more likely to be heterogeneous
and most of the time they are having short-term training in their respective
discipline like Community Medicine Auxiliary, Laboratory Assistant
etc. So their knowledge backgrounds are quite different. Therefore they
perceive knowledge differently. In the lecture-based method, teacher cannot
individualise teaching but in PBL small group share their knowledge and
each student starts learning from their own level and construct accordingly.
The reason is based on view of constructivism, which says that ‘knowledge’ is
not absolute, but is constructed by the learner based on previous knowledge.
It is the learner who constructs new knowledge and who is at the centre
114 Modern Trends in Medical Education
of the educational process6. With all these positive indications we came to
decision to use PBL as one of the complementary teaching method in our
programme. Success or failure of any programme can only be decided by
critical analysis and research. We are still in the process and the session is
not yet completed. We cannot evaluate the knowledge of students’ at present
rather can only try to evaluate attitude and perceptions of the PBL. This study
also investigates whether PBL is a more preferable method to the traditional
method of instruction or vice-versa.
For this we focused on the following research objectives
1. To explore the students’ thinking about PBL in comparison to the
conventional lecture type model. What students’ like/dislike about
PBL experience?
2. To nd out from students, up to what level PBL promote student’s
learning in terms of cognitive development, group learning, and
communication skills?
3. To nd out up to what level do students favor the PBL method to the
conventional teaching method?
Materials and methods
Subjects and background
The subjects for the study were all students (84) of certicate in Allied
Health Sciences program of school of medical sciences, KU. The students
of Laboratory Technology, Physiotherapy and General Medicine second year
and third year were involved in the study. All of them were having experience
of PBL as one of the teaching method. As the course is still in progress, only
the PBL evaluation of the rst few months of their study will be reported in
this paper.
Appropriate tutorial size was made. Each tutorial group was assigned with
qualied tutor who was responsible for marking their assignments, conducting
regular tutorials and day schools as well as answering queries.
Study setting
Before starting the PBL system, tutors were trained in ways to develop
tutoring. Tutors were expected to conduct student-centered rather than
teacher-centered tutorials unlike in the conventional method of education.
Their roles were well dened- not to lecture in the tutorials but to facilitate
students learning activities. PBL cases and their objectives were designed
with the consultation of the expert and tutorial guide was also provided to
each tutors. The problems were built around objectives derived from a number
of index clinical situation, which form the core knowledge and skill of our
Modern Trends in Medical Education 115
curriculum and also identied as core competencies NSI, Nepal 5. Prior to the
commencement of the academic year both students and tutors involved in this
study were well informed about the PBL system of education. Students were
described with PBL process, role of each group leader, scriber and group
members. Students were also involved in the mock PBL session by giving
very basic problem scenario based on their prior knowledge before starting
PBL as one of the teaching model in their academic activities.
Groups of eight to nine students and tutor meet twice in seven days; initially
for two hours to discuss the problem and then again for two hours to discuss
what they have found out. There is three days gap in between to do selfstudy. Problems were administered when basic knowledge was delivered
by interactive lecture method. Rapport session or resource session was
also conducted with the help of subject expert to answer more quires and
enthusiasm about the topic. Their other regular classes, practical and posting
were not hampered except two hours time was allocated in their regular class
schedule for self study at the PBL day.
Seventeen items questionnaire were administered to measure the perceptions
and attitudes of the students toward the PBL method of instruction out of
which fourteen questions were close-ended type. Respondent had to respond
in four point likert scale (1 = strongly disagree and 4 = strongly agree). The
validity and reliability of the questions have been justied in the work done by
Khoiny7. Rest three was open-ended questions. Three open- ended questions
asked for student’s opinions and like/ dislike of PBL. The questions were
only restricted to the students’ PBL experience in general, and the general
preference of PBL to traditional lectures or vice versa.
Statistical analysis
Responses were organised into sections corresponding to the questions for
quantitative analysis. For the open-ended questions responses were grouped
into common themes to identify meaningful segments of the text and “editing
analysis style” was used. Relevant representative quotation will be presented
in this study
Among 84 students 77 students were able to complete the questionnaire due
to various reasons. Among the total students 46% were female and 54% were
male and their mean age ranged from 19.27±1.30 years.
The PBL quantitative results can basically be summarised into three aspects:
cognitive development, group learning and expectation.
116 Modern Trends in Medical Education
With respect to cognitive development shown in Table 1, 76 (98.5%) felt that
PBL was a valuable learning experience among which 45 (58.5%) agreed
strongly. About the inuence of PBL in critical thinking all students felt that
PBL helps them to think critically. This was strongly agreed by 56 (72.3%)
students. Searching for answers to the learning issues was found exciting
by 77(100%) students, 72 (93.9%) students felt that PBL was a worthwhile
method of learning, and all students found reading about the learning issues
stimulating. Seventy six (98.5%) students felt that the PBL stimulated their
thinking process.
With respect to group learning as represented by the items shown in Table
2, over 76 (98.5%) felt that the group interaction was the most valuable
part of learning, this was strongly supported by 57 (73.9%) students, and
all respondent felt that group interaction enhanced their learning. Six (8%)
respondent felt difcult in sharing their ideas and thoughts in the group and
12 (15.3%) respondent felt that student in their groups was not supportive.
Two (3%) felt that the tutor was not facilitating the group interactions.
As far as student expectation about PBL is concerned as shown in Table 3,
every respondent liked to have more opportunities for PBL. Similarly, 70
(90.8%) of the students preferred the PBL method to the traditional-lecture
About open ended question that were focused on likes and dislikes of PBL
and their personal opinion about how PBL could enhance their learning,
students felt that PBL would increase the sprit of teamwork and increase
communication skills. Students also indicated that group discussion is the best
part of PBL and likely stimulation for self-study, which will be benecial for
their further study as well as to keep them updated during their professional
career. Following are some of the common themes as for example from the
“Yes. In fact I could understand that I have to work in team in the hospital
with my colleagues and seniors and also with nurses, laboratory personnel,
physiotherapist, radiologist and many others, communicating and sharing
ideas and knowledge will help me to do my job efciently. If we nally have
to do it in the future… why don’t we try to get used to this now?
” I feel embrace sometime when my friends try to ignore my idea by this way
I feel it is very important to listen carefully to others and give constructive
feedback rather than negative criticism or ignorance.”
Modern Trends in Medical Education 117
“I think PBL is the best method of learning because health care profession
is every changing profession and we cannot limit on what we have learnt in
during your college time so any new discovery or development during our
practise should be updated by our own”.
“PBL encourage me to speak out whatever is my knowledge or information
about the subject mater. Usually I makes mistake and as most of the people
do, I also learn by making mistake and which gives makes greater impact in
my memory”
“Most of the time I used to think that I know many things but when I have
to explain some thing to my group I feel difcult and I realize that I have to
work more”.
“I like the conventional method because I feel lazy in searching material on
my own. I also think that teacher could give us more reliable and optimum
information that could be helpful for exam preparation and this is the way
how we are been passing exams.”
Table 1: Cognitive Development (% of total response)
PBL is a valuable
45 (58.5%) 31(40%)
PBL helps me to think
56(72.3%) 21(27.2%)
Search for answers to
the learning issues is
PBL is a worthwhile
method of learning.
38(49.3%) 34(44.6%)
PBL stimulates my
thinking process.
Reading about the
learning issues is
35(46.1%) 42(53.9%)
118 Modern Trends in Medical Education
Table 2: Group learning (% of total response)
Group interaction in the
PBL was the most valuable part of learning.
57(73.9%) 19(24.6%)
An active participant in
the PBL experience.
26(33.6%) 45(58.5%)
Tutor facilitated the
group interactions.
36(46.2%) 41(53.8%)
Group interactions
enhanced my learning.
44(56.9%) 33(43.1%)
Felt at ease sharing ideas/
28(36.9%) 43(55.5%)
thoughts in the group.
Students in my group
were supportive of each
20(26.2%) 45(58.5%) 11(13.8%)
Table 3: Student’s Expectation (% of total response)
Would like to have more
opportunities for PBL.
43(55.4%) 34(44.6%)
Prefer PBL method rather
than traditional-lecture
36(46.2%) 34(44.6%)
Every educational programme should be student-centred rather than teachercentred. With the objectives of building ability of the students to apply
knowledge in practice, students have to develop learning activities and skills.
PBL could be one of the best methods that enhance the learning activities of
the students which have also been agreed in this study where 100% students
felt searching answer to learning issues is exciting and 100% students felt
reading about the learning issue is stimulating. Learning habits makes them
life long learner, which is also very important in their future career. The
students in this study also realise this. PBL has been perceived positively by
the students which is proved by the facts that 98.5% students has felt PBL as
valuable learning experience and 90.8% students preferred PBL rather than
Modern Trends in Medical Education 119
traditional lecture method but all students felt the need of more opportunity
of PBL in their curriculum. Students in this study has agreed many good
aspects of PBL among which more than 98.5% students has realised that
group discussion was the valuable part and almost all students felt that group
discussion has increase their learning. Some of the students (7.7 %) felt that
they were not taking active participation in the PBL discussion, which may
be due to the fact that 7.6% students did not felt easy for sharing their ideas
and knowledge during group discussion. With all these positive reections
from the students we are encouraged to further strengthen PBL and move
accordingly but there are also many more constrains and limitations which
we cannot overlook. First of all students are too young for searching learning
materials in their own, secondly and most important is they are trained in
traditional way of education since their schooling, where teachers deliver
scientic facts and principles during their lectures and most of the time
provide notes that are helpful to revise during their study time. These notes
are also useful for their exam preparation. Third and also equally important is
resource constrain, textbook especially designed for the AHS students are not
readily available in the market and the books written by the Nepali authors
to address the community health problems prevailing Nepal is quite limited.
Fourth is our tutors are trained in their traditional way and the relation of
teacher and students in our culture is not supportive to the PBL format. There
is quite a difference between being tutor and teacher. Therefore teacher
dissatisfaction and opposition is quite obvious during initial period. Hope is
always there to change the attitude of teacher and the way we can do that is
by providing good tutor’s training and also educational researches to evaluate
students’ progress and perception towards PBL.
In conclusion, the students of allied health sciences have perceived PBL as
a highly positive method of learning. The group learning activity, which is
valued by students, is believed to be a stepping-stone for students who are
particularly inferior. Students’ belief that PBL will help them think critically
and the PBL will help them to acquire self learning skill is very important
indicator of self realization that there is a difference between teaching and
learning. This will further motivate them for self-study. PBL could be one of
the substitute or alternate teaching learning method in allied health science
as many of our students prefer and like to have more opportunity for PBL but
there should be further research regarding the outcomes of students’ progress
to apply PBL in full strength. Students who prefer a traditional lecture method
of instruction can be provided with a high degree of structure and direction by
the tutor to help them identify what precisely they want to learn about, why
it is important, where they can best nd the relevant materials and how these
materials are relevant to solve the problem-based activities.
120 Modern Trends in Medical Education
1. Albanese MA, Mitchell S. Problem-based learning: A review of
literature on the outcomes and implementation issues. Academic
Medicine.1993; 68 (1): 52-81.
2. Bridges EM, Hallinger P. Problem-based learning for administrators.
Eric Clearinghouse on Educational Management, University of
Oregon. Oregon; 1992.
3. Vernon DTA, Brake RL. Does problem-based learning work? A meta
analysis of evaluative research. Acad Med. 1993; 68: 550-63.
4. De Goeij AFPM. Problem-based Learning: What is it? What is
it now? What about the basic sciences? Biochemical Society
Transactions.1997; 25: 288-93.
Nick Simons Institute. Measuring the quality of Rural Based
Government mid-level Health Care Workers, A clinical Skills
Assessment. Nick Simons Institute. August 2007.
6. Savery JR, Duffy TM. Problem-based learning: an instructional
model and its constructivist framework. Educational Technology.
1992; 35: 31-7.
7. Khoiny FE. The effectiveness of problem-based learning in nurse
practitioner education. Doctoral dissertation, University of Southern
California. UMI Number: 9614036; 1995.
Modern Trends in Medical Education 121
Communication skills
Sharma SK,
Head of Department, Department of Surgery, Kathmandu Medical College,
Sinamangal, Nepal.
ommunication is a two way process which is about conveying ones
message to others clearly and unambiguously. This is a double lane
where it is also about receiving information that others are sending with
obviously little distortion as possible.
There is involvement of both the sender and the receiver. Jack Gibb identies
a certain amount of noise that is extra information under the conscious control
of either the sender or the receiver. This extra information alters the message.
Improving communication skills develops ones ability to understand the variety
of the “noise” or reduce and control it. Jack Gibbs sees communication as a
“people process” rather than a “language process”. Accordingly to increase
the effectiveness in the communication one can change the interpersonal
relationship so that the receiver doesn’t feel threatened. Threat apparently
closes the window of perception and thus turns the eye inwards unto the self,
far away from the message or the sender.
This can be illustrated in an example where the teacher asks, “Where have
you been?” If there is no threat perceivable in the question to the student
he will answer it in a simple manner believing it is a genuine request for
further information. However it is more likely that the student will feel it is a
condemnation of his act. If he feels threatened then his response will evoke
a defensive route. This will furthermore heighten the defensiveness in the
teacher leading to a continuous spiral. Here the whole communication is lost
and a protective cast is thrown.
Gibbs however feels this is communication continuums.
Gibbs has identied six categories of behaviour which tends to raise
defensiveness during communication and has identied other six which tend
to be open and supportive. These have been slightly modied to be rated
from defensive to highly open. These are classied as defence producing or
122 Modern Trends in Medical Education
Evaluative- Descriptive
Both verbal and non verbal message which evaluate the listener is defensive.
“Don’t you understand?” is an example. Instead “Tell us what you understand.”
makes the same questionnaire more descriptive and supportive. Sometimes
this process is more subtle. Here the communication is descriptive thus the
receiver does not necessarily have to agree or disagree with the message.
Controlling- Cooperative
Messages perceived as an attempt to inuence the receiver’s attitude or
change his or her behaviour is seen as defence producing. An example being
“Did we not agree on conducting research for your promotion?”
However when there is a desire from the sender to participate the same
message creates the spirit of cooperation. This implies a willingness on the
part of the sender to allow the receiver to set his or her goals and take ones
own decision.
Hidden –Open
It is quite obvious that a hidden message or one that has to be read between
the lines sparks suspicion and puts again the defensive mode.
An open transparent message is clear.
Neutral –Empathetic
A neutral message gives the feeling of commonness where the receiver feels
uncared or valued for.
An empathetic message however gives the feeling of being supported
Superior –Equal
When the sender communicates from the position of authority the receiver
is bound to be defensive with feeling of insecurity. This is very much true
in our medical teaching where the hierarchy of medicine maintains a strong
Modern Trends in Medical Education 123
However this can be changed with the authority showing willingness to
cooperate and listen. The sender must engage in a dual process of problem
solving. Here he or she must also participate with the receiver as an equal.
Certain –Provisional
When the sender is absolutely certain and corrects the message sent will
create a defensive mode. This doesn’t allow any space for discussion.
However a provisional communication allows space for further research and
problem solving.
When considered together the six categories on the right side reect a pleasant
attractive personality whereas the left denotes the other spectrum. Clearly
it is not possible to have all the six desirable attributes but a slow steady
change towards the right leads to a better communicator. Thus realising
these and making small amendments denitely leads to improvement in
The question whether the true guru exists is one that all of us in the teaching
fraternity question. Yet we all fail to realise that all of us have the capability
of being the true guru. Our communication and teaching capabilities advance
and improve only when dealt with army precision of repetition that leads to
perfection. Practice makes perfect has only to be stressed with repetition.
However a dual learning and receiving during this is a must in the process.
There again certain pointers help in improving our communications. Firstly
being more aware of what our concerns really are enables us to get the
message across clearly.
Secondly identication of questions or statements that alter or force value
position into another person helps in recreating the situation to one that is less
defensive for the receiver.
The third is to be aware of the put down statements and to avoid it.
Problems of communication can occur at any stage of the communication
process. This consists of the sender, encoding the channel, decoding,
the receiver, feedback and the context. At each stage there is potential of
misunderstanding and confusion. To be an effective communicator ones goal
has to be to lessen the frequency of problems at each stage. We will follow
the various stages as we proceedd.
124 Modern Trends in Medical Education
As the source of the message you need to be clear about why you are
communicating and what you want to communicate. You also need to be
condent that what you are communicating is useful and accurate.
This is the information you want to communicate. In our teaching methodology
one can quote this to lesson plan.
This is the process of transferring the message. This could be a lecture or
a group discussion or a simulation etc. However ones success in encoding
depends on his/her clarity and simplicity. It is here that that confusion
regarding cultural issues, mistaken assumptions and group diversity can alter
the message totally.
Use of lectures, computer aids, projections, ip charts, telephones or text
messages are examples of the channel. Ones maturity to see the strengths
and weakness of each of this system in different surroundings is essential.
A computer power point presentation with very little visual aids is a disaster
to a non technical group. However to a motivated group this will be very
The receiver must be able to decode your message. If he or she is unable
to comprehend due to lack of knowledge or lack of other sources; then the
communication is useless and a failure.
When communicating to a large group such as in our teaching practice, it
is necessary to understand that though it is a large group this group is made
of individuals with various backgrounds and preconception and knowledge
levels. Thus though the same message is being encoded and channelled and
delivered the decoding at the receiver end is very different. Understanding
this variation aids the communicator to be more successful.
This both verbal as well as non verbal feedback is the only litmus test to tell
you whether you are being understood or not. This will help you to make
further changes thus enabling one to be a better communicator.
Thus to be effective communicator one has to realize these barriers and
remove these barriers at each stage. To summarise, this is a two way trafc
with learning and giving throughout the communication continuum.
Modern Trends in Medical Education 125
Ethics in medical education
Adhikari RK
Professor, Child Health, Institute of Medicine, Kathmandu, Nepal.
n terms of medical profession, ethics means the rules or standards of
conduct governing the members of medical profession. The national code
of ethics promulgated by Nepal Medical Council, World Medical Association
and International Code of Ethics all are expected to guide the medical
professionals in their practice. The activities which help to bring a change
in the behaviour of a person that enables that person to carry out certain
tasks which she or he was not able to perform earlier are generally known as
“education”. Does the current medical education incorporate those activities
which prepare the medical professionals to conduct themselves according
to the code of conduct laid down by the national and international bodies?
How are the members of medical profession prepared to conduct themselves
ethically? Is it adequate or some additional efforts are needed to improve the
teaching of ethics in medical education? What efforts are underway in this
regard and what preparation educational institutions will have to undertake in
this regard? These are some of the issues discussed in this article.
Ethics and medical practice
The code of ethics or conduct promulgated by most medical councils or
professional bodies is aimed at protecting the interests of the profession by
promoting the interests of the patients or people it serves. The oldest code
often quoted in modern, western medical discipline is supposed to be more
than 2000 years old and is generally known as Hippocratic Oath. Code
of Hammurabi and Charak Samhita are other ancient texts which contain
guidelines for medical practice. The basic tenet of all these texts has been to
exhort doctors or medical professionals to carry out activities which “benet”
or at least “do no harm” to the patients. In addition, these deal with relationship
among the professionals and the rules of setting up practice etc.
Practice of medical profession is getting more complex in recent times,
Advances in technology and development of newer therapeutic approaches
have made it possible to cure certain incurable diseases, prolong life of people
who can no more sustain living. Yet, it has created a great potential for harm
in case of failure of technology. Extensive surgery has helped save lives as
well as cause signicant “medical harm” in terms of death and disability.
126 Modern Trends in Medical Education
Similarly, increasing awareness among population groups has created strident
demands for equitable distribution of health services; however, it is almost
impossible to provide health care services of uniform standard across the
world or different parts of a country in face of uneven level of socioeconomic
development. Lack of fairness and equity in the access and availability of
health services; presumed or true negligence of the health professionals and
a sense of injury among the marginalised people are resulting in conicts
which threaten the health care system and the health professionals.
Advances in technology cost expenses. Some of these advances are almost
perceived as miracles heightening the people’s expectations from health
technology. Unfortunately, in many instances, such expectations are
unfounded. Someone who pays for expensive services and is left with a
negative result is bound to be angry leading to litigations, violence and other
negative behaviour. In many of such instances, lack of proper communication
between the health professionals and their patient was blamed for the
unfortunate conict ensued violence.
Till recently, provision of health care services was seen as the responsibility
of the government and health services were relatively less expensive. With
the participation of private entrepreneurs in providing health services, the
costs have escalated. It has improved the quality of services for those who can
afford to pay but it has created a situation in which government’s commitment
to provide health services is getting more diluted. However, those who can
pay are more demanding and intolerant of the faults of medical profession
and health care system; again, another recipe for conict.
Relevance of ethics in medical education
A review of the expectations that people have from physicians show that care,
compassion and availability come at the top of the list. However, it is being
increasingly commented that the type of education we provide in medical
schools is not adequate to produce such a doctor1,2.
Newer requirements of a “global physician” that can “think globally and act
locally” have identied certain competences in a physician: professionalism,
commitment to ethical values, critical reasoning and communication skills
in addition to a sound foundation in science, population health and clinical
skills. Again the current curriculum and the teaching learning experiences
offered to medical students are found lacking to achieve the goal of producing
a compassionate, caring, ethical doctor who can reect on what s/he reads or
Modern Trends in Medical Education 127
Initiatives at the regional level
In response to this realisation, World Health Organization (WHO) had taken
steps to promote teaching of ethics in health care practice and research at
both the global and regional levels. One of the activities carried out by WHO
South East Asia Regional Ofce (SEARO) had been to review situation with
regards to teaching of ethics in six countries of the region (Bangladesh, India,
Indonesia, Myanmar, Nepal and Sri Lanka). The study concluded that the
teaching of ethics in these countries was in a state of infancy, mostly based
in the department of forensic medicine which mainly emphasized negligence
and malpractice2. In response, WHO SEARO has developed a curriculum3 on
medical ethics for undergraduates for South East Asian Medical Schools. The
curriculum was presented and nalised in the expert group meeting held in
WHO SEARO on 25 and 26 September 2008. The proposed curriculum was
subsequently endorsed by the medical councils of the region in the second
meeting of the Network of Medical Councils of SEARO held in Chiang Mai,
Thailand from November 10-12 2008.
Curriculum on medical ethics
The objectives of the module on medical ethics are to enable the students to
a. Critically analyse ethical issues commonly encountered in medical
practice and formulate a framework within which such issues could
be resolved
b. Demonstrate the ability to resolve ethical issues faced during common
clinical scenarios
c. Demonstrate awareness of the main professional obligations of
d. Practice according to statutory requirements and codes of conduct for
medical practice
e. Identify the ethical aspects involved in conducting research and apply
ethical principles in conducting research
f. Demonstrate sensitivity to ethical issues and ethical behaviour within
and outside professional practice
Content areas
The content recommended in the module include core topics and other
topics. Under the core topics, principles of medical ethics, clinical ethics
and professional ethics are to be discussed. Similarly, under other topics,
special issues in clinical ethics and research ethics are to be discussed. When
one is dealing with clinical ethics under the core topic, different aspects
of doctor patient relationship, patient autonomy, condentiality, informed
consent, veracity, truthfulness, helping with end of life decisions, patients’
rights and social justice are to be discussed. While helping students to
128 Modern Trends in Medical Education
acquire competences related to professional ethics, teachers need to help
the students to become familiar with various codes of conduct, concept of
professionalism, what constitutes medial negligence and how to avoid them,
what is professional misconduct, what ethical dilemmas face medical students,
what should be the doctors’ relationship with pharmaceutical industry and
issues related to privatisation of health care.
“Other topics” are content areas which are of relevance to different clinical
disciplines for examples under clinical ethics, the module recommends to
provide students with knowledge related to ethical concerns in reproductive
health, ethical aspects of genetics, organ donation and transplantation,
treatment of mentally ill and children, treatment of patients with HIV/AIDS,
resource allocation in health care system, ethics of public health and health
promotion, dealing with other systems of medicine etc. Under “research
ethics” the module recommends to provide adequate opportunities for
learning about principles of research and publication ethics.
Organisation of learning experiences
It has been proposed that the principal or dean of the medical school is made
responsible for identifying the faculty members and resources for teaching
of medical ethics. Institutions having a functioning department of medical
education should entrust the task of coordinating the teaching of medical
ethics to this department. A core faculty is to be identied to teach the core
topics and the discipline related topics are to be discussed in the related
departments. Case studies, as developed by the SEAHEN study, could be
used as the problems around which ethical issues could be discussed till such
times that local case illustrations are available.
The duration of the total module is proposed to be 20 hours for the core topics.
As it is expected that the module should run from the rst year to the end of
internship, core topics are discussed in the rst two years and clinical and
community medicine related topics are dealt with during the whole course.
It has been proposed that the module is integrated with the MBBS curriculum
through the following means:
Teaching learning methods
In order to help the students to achieve the objectives outlined above a number
of teaching learning methods have been identied. These include a range of
teaching/learning activities including lectures, small group discussions, role
play, ward based assignments and student seminars. It is recommended that a
modular approach which utilizes all the methods mentioned above is used to
achieve the learning outcomes.
Modern Trends in Medical Education 129
Learning resources
The expert group has recommended that WHO SEARO should facilitate in
the development of learning guides for the students as well as the facilitators.
The materials developed by South East Asian Health Ethics Network of
WHO4 and by Faculty of Medicine of Colombo University were suggested as
some of the case scenarios that could be used for the teaching of ethics. It has
been recommended that attempts should be made to develop country specic
case studies in each country by the teachers involved in this task.
Assessment methods
An array of assessment methods need to be used and these should be based
on authentic and contextual case scenarios. Assessment should ideally be
continuous and incorporated with the formative and summative assessment in
different disciplines. It has been recommended that the timing of assessment
should be prior to granting permission to practice (licensing examination)
The assessment tools should include case based multiple choice questions
(MCQs), short essay questions (SEQs), practically assessed clinical
examination skills (PACES) and objective structured clinical examination
(OSCE) and reective logs and assignments. Resources permitting, use of
audiovisual materials and peer observation can be used for assessment.
Implementation status
The curriculum on medical ethics was presented at the second meeting of the
regional network of medical councils of South East Asia Region in Chiang
Mai in November 2008. It is expected that the respective medical councils in
each country of the region will direct the medial universities in their country
to implement this curriculum with certain variation in their implementation
Nepal Medical Council has already included medical ethics in the core
curriculum which it had developed and endorsed in June 2008.
Universities and health science institutions in Nepal will have to get together
and develop a plan for implementing a strategy for teaching of ethics in the
1. Agrawal CS. Curricular determinants: Public expectations. J.Inst.
Med.1994; 16,19-22.
2. Adhikari RK, Comment A, Concept W, Magar A, H. Physician and
principle centred delivery of health services. JNMA. 2004; 42 (145).
130 Modern Trends in Medical Education
Kasturiaratchi N, Lie R, Seaberg J. Health ethics in South Asia. vol 1.
New Delhi: WHO SEARO. 1999
Fernando D. Module on Teaching of Ethics in the Undergraduate
Curriculum. Meeting of Regional Medical Councils at Chiang Mai;
November 2008; Thailand.
Seaberg J (ed). Teaching health ethics [CD-ROM]. New Delhi,
Modern Trends in Medical Education 131
Clinical evaluation exercise (mini-CEX)
Magar A
CMCL-FAIMER Fellow 2009, Christian Medical College Ludhiana, Punjab,
n one way or another, most practicing physicians are involved in
assessing the competence of trainees, peers, and other health professionals
throughout their career as a medical teacher in different institutes. They have
to evaluate the examinees’ knowledge, attitude, practice, procedural skills,
professionalism, interest in learning and system based practice1.
After the introduction of privatisation in the medical education in early 90s
with increasing numbers of medical graduates in Nepal with increasing
number of doctor production from different institutes, the question of quality
control is inevitable. The forerunners in the eld of medical education are
pushing their limit to acquire the understanding of how best they can deliver
their experience and knowledge in a best possible way. Along with the use
of various methods of teaching, an important part of their teaching learning
includes to have a sound system of assessment during their training.
Assessment is the process of documenting the knowledge, skills, attitudes
and beliefs, usually in measurable terms. Assessments can be done by
many different ways. The most important distinctive are: (1) formative and
summative; (2) objective and subjective; (3) referencing (criterion-referenced,
norm-referenced, and ipsative); and (4) informal and formal2. These different
methods have got their own strengths and intrinsic aws (Table 1).
132 Modern Trends in Medical Education
Table 1: Commonly Used Methods of Assessment1
Type of use
within courses
or clerkships;
licensing, and
Difcult to
write, especially
in certain
content areas;
can result in
cueing; can
seem articial
and removed
from real
Can assess
many content
areas in relatively little
Not yet proven
to transfer
to real-life
situations that
require clinical
Assess clinical
problemsolving ability,
avoid cueing,
can be graded
by computer
and formative
in courses and
dependent on
training of
Avoid cueing,
and problemsolving ability
limited use in
to grade,
must work
to establish
long testing
time required
to encompass
a variety of
Avoid cueing,
use higherorder cognitive processes
and sometimes
in clinical
Often based on
reports and case
rather than on
direct observation, subjective
Use of
raters can
variability due
to subjectivity
Written exercises
questions in
either singlebest-answer
or extended
Key-feature and
licensing and
script-concorClinical reasoning
dance questions
Ability to
diagnostic tests
Synthesis of
Assessments by supervising
Global ratings
with comments
at end of
Clinical skills,
work habits
Modern Trends in Medical Education 133
with checklists Communication
for ratings (e.g., skills, clinical
exercise or
video review)
Limited use in
clerkships and
a few boardcertication
Selective rather
than habitual
relatively timeconsuming
sex and race
Limited use in
bias has been
clerkships and
reported, timecomprehensive
medical school
require training
clinical reasoning assessments,
of examiners,
some boardsummative
need two or
more examiners
Clinical simulations
patients and
Formative and
assessments in
Some clinical
courses, clerkskills, interships, medical
personal behavior, schools, nacommunication
tional licensure
certication in
Primarily used
in research;
some courses,
clerkships, and
residencies use
for formative
Actual practice
134 Modern Trends in Medical Education
by credible
by credible
Timing and
setting may
seem articial, require
of disbelief,
may penalize
examinees who
use shortcuts,
Tailored to
goals; reliable,
consistent case
and ratings;
can be
observed by
faculty or
prior consent,
Very realistic,
most accurate
way of
skills, teamwork,
simulated clinical
and some
Timing and
setting may
seem articial, require
of disbelief,
may penalize
examinees who
use shortcuts,
Tailored to
goals, can be
observed by
faculty, often
realistic and
anonymity, and
trainee buy-in
with future
and clinical
Multisource (“360-degree”) assessments
feedback in
courses and
medical school
for board
work habits,
Formative and
Ability to
gain patients’
trust; patient
satisfaction, com- use by insurers
munication skills to determine
Provide global
rather than
of specic
source of
ratings generally
high with little
skills, attitudes,
Do not
describe actual
unless training
and feedback
reection and
of learning
Modern Trends in Medical Education 135
Formative and
All aspects of
uses across
and within
appropriate for
and residency
learning and
improvement and used by some
U.K. medical
schools and
Learner selects
best case
material, timeconsuming to
prepare and
projects for
review, foster
reection and
of learning
Mini clinical evaluation exercise
The mini-Clinical Evaluation Exercise (mini-CEX) is primarily a formative
assessment intended to give feedback to the trainee on their performance. The
mini-CEX is a reliable tool for performance assessment and is acceptable to
and well received by both learners and supervisors3.
Mini-CEX was originally developed in the USA to assess medical residents
in real life settings4. It is a 15-20 minutes snapshot of a single doctor/patient
interaction. It is designed to assess the clinical skills, attitudes and behaviours
essential to providing high quality care. The mini-CEX tool can be used to
assess a range of core competencies that a trainee uses during day to day
encounters with patients. Through being observed undertaking a number
of cases, over a period of time, with a number of different assessors, these
individual brief encounters add up to provide a reliable measure of a trainee’s
performance. The literature indicates that at least four encounters per training
year are needed in order for the mini-CEX to be a reliable measure of a trainee’s
ability (when used as a summative evaluation) 5. Skills such as history taking,
communication skills, physical examination and the management of patients
and their problems can be difcult to assess reliably within the workplace and
in the past such assessment has therefore been suboptimal.
The mini-CEX assessment involves observing the trainee interact with a
patient in a clinical encounter. The areas of competence covered include:
history taking, physical examination, professionalism, clinical judgement,
communication skills, organisation/efciency and overall clinical care.
Assessors do not need to have prior knowledge of the trainee. The assessor’s
evaluation is recorded on a structured checklist that enables the assessor
to provide developmental verbal feedback to the trainee immediately after
the encounter (Table 2). Feedback would normally take about ve minutes
(Table 3).
136 Modern Trends in Medical Education
Table 2: Mini-CEX Evaluation Form4
Mini-Clinical Evaluation Exercise (mini-CEX)
Student Name:
Setting: F Ambulatory Clinic
F Inpatient Unit
R1 FR2 FR3
Patient ID:
Male F Female
Patient Problem/Diagnosis:
Complexity of Encounter:
FLow F
Moderate F High
Focus of Evaluator Observation: FData Gathering
1. Medical Interviewing Skills
(not observed)
Marginal Satisfactory Superior
2. Physical Examination Skills
(not observed)
3. Counselling Skills
(not observed)
4. Clinical Judgement
(not observed)
5. Professionalism/Humanism
(not observed)
6. Overall Clinical Competence
(not observed)
Providing Feedback: _______Mins
Mini-CEX Time: Observing_______Mins
Evaluator Satisfaction with Mini-CEX
Resident Satisfaction with Mini-CEX
Evaluator’s Signature
Student’s Signature
Modern Trends in Medical Education 137
Table 3: Descriptors of competencies demonstrated during the mini-cex
Facilitates patient’s telling
of story; effectively uses
questions/directions to obtain
accurate, adequate information
needed; responds appropriately
to affect, non-verbal cues.
Physical Examination Skills:
Follows efcient, logical
sequence; balances screening/
diagnostic steps for problem;
informs patient; sensitive to
patient’s comfort, modesty.
Humanistic Qualities/Professionalism: Shows respect, compassion,
empathy, establishes trust;
attends to patient’s needs
condentiality, information.
Clinical Judgment:
Selectively orders/performs
appropriate diagnostic studies,
considers risks, benets.
Counseling Skills:
Explains rationale for test/
treatment, obtains patient’s
regarding management.
Prioritizes; is timely; succinct.
Overall Clinical Competence:
synthesis, caring, effectiveness,
Medical Interviewing Skills:
Assessors can work out further and elaborate the main six categories according
to the following sample and can have a uniform marking by different assessors
and for variety of cases too.
138 Modern Trends in Medical Education
1. History Taking
Insufcient history to make an acceptably safe diagnosis.
Unstructured. No exploration.
Basic history obtained but questions unstructured with some
important areas left unexplored.
Reasonable structured history obtained but few probing questions
asked, and some relevant questions unasked. On own agenda “going down list of questions”. Little response to patient’s cues /
Comprehensive history obtained with adequate probing and
exploration of key areas relevant to management plan. Facilitates
patient’s telling of story. Reasonable use of time.
Comprehensive, accurate history taken. Additional information
relevant to management plan elicited. Consultation ows naturally,
trainee shows some intuition, patient generally leads areas for
discussion. Time is used efciently.
A standard more usually expected of a more experienced doctor.
Novel, interesting, and owing questions. Key areas quickly
identied and thoroughly explored. Excellent, efcient time
2. Physical Examination
Incomplete examination, some illogical order, poor or missing
explanation to patient. Little attention paid to infection control.
Unstructured or occasionally inappropriate technique. Inadequate
explanation to patient. Little respect for patient or patient carelessly
Appropriate clinical examination. Respect for patient but inadequate
explanation. Consent may not be gained for every stage of
procedure, or the patient may be occasionally carelessly handled.
Structured examination which ows smoothly. Good positioning.
Clear explanation to patient with informed consent. Equipment
handled appropriately. Sensitive to patient’s comfort & modesty.
Full structured examination. Condent, experienced approach
to examination - appropriate, efcient, logical and uent. Clear
explanation. Good use of equipment and assistance. Gentle,
sensitive to patient’s comfort & modesty. More complex points will
be investigated, as well as some less obvious areas.
Modern Trends in Medical Education 139
Performance more usual in a more experienced doctor. Thoroughly
condent, experienced approach to examination – appropriate,
efcient, logical and uent, Clear explanation. Good use of
equipment and assistance. Some demonstration of expertise in the
relevant specialty.
3. Communication Skills
Any rudeness, no greeting or introduction. Insensitive behaviour
with no consideration for patient’s feelings. No attempt to listen to
The trainee may appear nervous, arrogant, show little empathy, or
use medical terms. Limited moderation of language/words used
according to patient’s age/culture or use of language. Inadequate
information given to patient, or information deliberately or
inappropriately withheld.
Adequate introduction and basic explanation to patient, with little
use of medical jargon. Some attempt at listening and exploring
patient’s concerns. Some attempts at moderating language. Empathy
displayed occasionally. Information given with minimal attempt at
checking back.
Appropriate friendly & professional introduction and greeting.
Listens attentively to patient and explores concerns appropriately.
Modies language appropriately. Open & empathic, gives clear
information without jargon and checks understanding.
Demonstrates condence and expertise with the patient showing
awareness of patient’s concerns. Listens attentively, develops
rapport and language may be appropriately adapted. Gives clear
appropriate explanation and reassurance. Information will be
checked back fully with the patient, and alternative sources offered.
The standard expected of a more experienced doctor. Condent,
empathic, listens. Excellent choice of words and phrases to enable
patient to understand and feel valued. Gives clear explanations
using appropriate visual aids / analogies which creates an equal
professional relationship. Checks understanding and agree
management plan
140 Modern Trends in Medical Education
4. Clinical Judgement
Poor recognition of key problem areas. May not seek help when
appropriate and may be incapable of decision making. May be
unable to recognise a sick patient
Appears overcondent and rarely seeks help or appears uncondent,
always seeks help, and struggles to make decisions. Trainee may
make inappropriate independent decisions, be unable to initiate
simple treatment without reassurance, or may suggest inappropriate
Trainee recognises some key problems but struggles to prioritise or
triage. Generally able to make decisions but lacks condence, or is
reluctant or incapable of working independently under pressure.
Makes appropriate diagnosis and formulates a suitable management
plan. Orders appropriate investigations. Is aware of limitations of
knowledge and judgement, but is prepared to work independently
and take responsibility within knowledge limitations. Can always
recognise a sick patient, identify key problem areas, and prioritise
and initiate safe simple treatments e.g. antibiotics and seek prompt
Recognises and quickly prioritises a range of problems, is able to
accept responsibility and seeks help appropriately. Trainee is able to
perform as an independent thinker ordering investigations according
to problem areas rather than by protocol using their specialty
knowledge appropriately. Considers risks / benets of investigations
& therapy. Shows competent, thoughtful management planning and
decision making
Condent and competent at recognising all key problem areas
and able to prioritise them, and initiates safe complex treatments
condently and independently. Is always aware of own limitations
and seeks help appropriately. Is able to independently make
complex decisions and explain them to patients and others as well as
researching any deciencies in clinical knowledge
5. Professionalism
It is difcult to dene , nevertheless, negative traits are easily recognisable.
Some of them are like below.
Disrespectful/Dishonest: Inappropriate dressing, dirty nails/bad breath, rude,
ippant, arrogant, patronising, inappropriate humour, ignorant of cultural/
religious diversity, lying
Modern Trends in Medical Education 141
Lacking Condentiality: Discussing patients by name in open areas,
identiable paperwork in portfolio/house etc, lack of privacy etc
Lacking compassion: Ignoring patient’s concerns, lack of empathy / caring
Poor team working: inconsiderate of colleagues, “dumping” duties, openly
criticising profession / nurses / managers / organisation
Little or no attention to patient’s needs of comfort, respect or
condentiality. No awareness of own limitations. Demonstrates
aspects from 3 or 4 of the above categories.
Weak in 2 areas of the 4 above
Weak in 1 area of the 4 above.
Behaves fundamentally professionally but may appear easily
distracted or inconsistent. Does not always inspire condence in
patients or colleagues.
Shows respect, compassion, empathy and establishes trust.
Behaves in an ethical manner and is aware of limitations. Respects
Trainee will be smartly and appropriately presented, may appear
condent, knowledgeable and caring, easily gaining the patient’s
trust and condence. They may allow space for patient to express
themselves, and be receptive to concerns, responding appropriately
and sensitively.
Basic understanding of ethical and legal frameworks.
Respects and is considerate to team members.
Trainee may show exceptional sensitivity to patients and are
attentive and empathic, putting the patient at the consultation’s
core and empowering the patient to express questions and actions.
Approach each doctor-patient relationship in professional manner.
Can control emotions and rapidly switch tasks. Non-judgemental.
6. Organization/Efciency
Very slow, unstructured
Slow, unable to prioritise tasks
No use of other team members
Slow, long summary
Unable to clearly prioritise tasks
Confuses patients with own confusion
142 Modern Trends in Medical Education
Timely in dealing with situation
Appropriate degree of urgency
Appropriate use of resources (team, own time)
Can appear rushed at times
Condent, good use of time, succinct, summarises and prioritises
appropriately. Gives patient appropriate time
Fluent, efcient and effective in all aspects. Good time management
Overall clinical care
Final category = global rating
It can demonstrate satisfactory information synthesis, management planning,
clinical decision making and judgement, caring, effectiveness, efciency
and appropriate use of resources. It can also balance risks and benets of
investigations and therapies etc.
1. Epstein RM. Assessment in medical education. N Engl J Med.
2. Wikipedia [homepage on internet]. Microteaching [online]. 2008
[cited 2008 Dec 26]; Available from: URL:http://en.wikipedia.org/
3. Nair BR, Alexander HG, McGrath BP, Parvathy MS, Kilsby EC,
Wenzel J, Frank IB, et al. The mini clinical evaluation exercise (miniCEX) for assessing clinical performance of international medical
graduates. MJA. 2008; 189 (3): 159-61.
4. Norcini JJ, Blank LL, Arnold GK, Kimball HR. The mini-CEX
(clinical evaluation exercise): a preliminary investigation. Ann Intern
Med. 1995 Nov 15;123(10):795-9.
5. Norcini JJ, Blank LL, Duffy FD, Fortna GS. The mini-CEX: a method
for assessing clinical skills. Ann Intern Med. 2003;138(6):476-81.
Modern Trends in Medical Education 143
Ten criteria for criterion-referenced
assessment in postgraduate MD/MS
Bhattarai MD
Medical Education Unit, National Academy of Medical Sciences,
The principle objective of postgraduate MD/MS education is to produce a
competent basic specialist. Thus the aim and approach for the evaluation
process is to assess the standard of competency by criterion-referenced
assessment. The standard to be met by the postgraduate specialist implies
that the person is capable of doing what s/he is expected to do later. In the
context of the criterion-referenced assessment for MD/MS training, a mixture
of ten criteria of the achievement of the competency is relevant to guide the
students, faculty members and the institution; these ten criteria are used
explicitly or implicitly under two broad categories. They are (A) Eligibility
for nal exit examination: (1) Attendance of working as full time residents,
with regular and 24-hour duties, not less than 90% of the training during
each academic year; (2) Completion of horizontal and vertical, i.e. spiral
upward, rotation training posting; (3) Completion of minimum numbers
of most important procedures / experiences; (4) Completion of minimum
numbers of presentations; (5) Completion of mandatory basic courses; (6)
Certication of thesis as satisfactory; (7) Achievement of the minimum
pass percentage in the Applied Basic Science examination held earlier; (B)
Exit examination with its different components and pass percentage: (8).
Fulllment of theory paper requirement; (9) Fulllment of clinical practical
requirement; and (10) Achievement of the minimum pass percentage in the
nal exit examination, considering its components and internal assessment
marks. All the stakeholders in the health care eld such as health policy
makers, health providers in the community, and the faculty in the profession
should ensure a criterion-referenced assessment system in the postgraduate
medical education for the need and safety of the community.
Key words: Criterion-referenced assessment, MD/MS programme, normreferenced assessment, postgraduate medical education
144 Modern Trends in Medical Education
ssessment is measure of student learning. Evaluation is a wider concept
than assessment, although the data resulting from assessment can often
be used in evaluation. Evaluation is the appraising of teaching. All assessment
implies evaluation because to decide what type of assessment is required, or
even if it is required at all, is an evaluation1. Assessment procedures can serve
a number of purposes, like to grade or rank the student; to select candidate
for a course; to see whether a candidate is competent or not; to evaluate the
teaching event or training programme; to provide feedback to the student;
to provide feedback to the teachers; to motivate the student for training;
to set standards for a professional body; to actually certify a standard of
performance, e.g. the award of degree, with external validation; to measure
the effectiveness of educational institutions and departments; to control the
number entering a profession etc1-3. One concept that is helpful in thinking
about such purposes is that of criterion-referenced and norm-referenced
Normative or norm-referenced assessment
Norm-referenced assessment is a common method of referencing. It ranks
students and students can be compared with each other. Norm referencing
simply describes an individual’s performance in terms of their position in the
group1. Thus the principles of norm-referenced assessment are often utilized
in entrance examination selecting the candidates. However, there are many
limitations of the norm-referenced assessment, for example it fails to provide
a clear picture of what the student can or cannot do, it does not provide useful
feedback i.e. pinpoint strengths and weakness, and it cannot discern to what
degree an educational programme has met these standards1, 5. As there is often
a mismatch between what is taught and what is examined in norm-referenced
assessment, there is lack of content validity5.
Criterion-referenced assessment
Recognising the norm-referenced assessment’s limitations, Glasser in 1963
formalised the concept of criterion-referenced assessment6. Standards of
performance are set using minimal levels of competence before the test is
applied. The assessor sets the level of performance which is required. It may
be the total mastery of a task or it may be the minimal acceptable level.
Thus, criteria-referenced assessment allows to pinpoint students’ capabilities
i.e. what they can or cannot do. In this way, by dening clear objectives the
learning process is enhanced and the criterion referenced assessment helps in
the training of the students1.
Entrance versus exit examination of postgraduate MD/MS
For practical purpose, norm-referenced assessment is equivalent to ranking
and criterion-referenced assessment to competence. These two methods
Modern Trends in Medical Education 145
of assessment are not inherently right or wrong. They are, however, often
unknowingly applied in inappropriate circumstances and interpreted
incorrectly. As the principal objective of medical education is to produce a
competent physician, then, unquestionably, the basic aim and approach for the
evaluation process is to assess the standard of competency and not the rank
order of students5. To this end, criterion-referenced testing is necessary and
must become the principal method of evaluation within medical education.
Norm-referenced testing on the other hand is severely limited when used for
purposes other than the ranking of students for selection. Important differences
between the entrance, a prototype of norm-referenced, and exit, a prototype
of criterion-referenced, examinations of postgraduate Doctor of Medicine
(MD) / Master of Surgery (MS) programme are outlined in the Table 1.
Table 1: The differences between the entrance and exit examinations of
postgraduate MD/MS programme
MD/MS Entrance Examination
1. To select by ranking, norm-based
2. Aim is to select the limited
number, i.e. majority fails to get the
3. Competitive examination
4. Examination, mostly theory only, is
the mode of assessment
MD/MS Exit Examination
1. To see competent or not by dened
standards applied during the training
period, criterion based
2. Aim is to pass and certify all, at least
ultimately, by arranging appropriate
training to help achieve the dened
3. Cooperative learning
4. Examination, theory and clinical
practical, are just a part of the total
5. MCQs with assessment of factual
knowledge and rare, ambiguous
conditions may be applied
5. MCQs with assessment of factual
knowledge and rare, ambiguous
conditions are not ideal
6. Reliability and condentiality much
6. Validity including by external review
system required
7. Major responsibility of holding it
lies with all the Ofcials, as per the
principles laid down by the Academic
Section may or may not be involved
considering condentiality issue and
policy of the institute.
7. Major responsibility of achieving
it lies with the Subject Committee
and Examination Section, as per
the principles laid down by the
Academic Council.
Note: The licensing exam of Nepal Medical Council is like exit, criterion-referenced exam of
MBBS level.
146 Modern Trends in Medical Education
The entrance examination for the admission of the postgraduate Basic
Specialist Training of MD/MS is usually held in common with all the
candidates going through the same questions covering the course of MBBS.
The merits of this system are that learning of the whole MBBS is assessed,
which is required in all the elds of MD/MS, and candidates can choose as
per the overall merit list on rst come rst serve basis. For the further Higher
Specialist Training like DM, MCh, and Fellowship, the entrance examination
is frequently held covering the content of the super-specialty for which the
candidates apply.
Pass percentage and prize or honour grade in criterion-referenced
Criterion-referenced testing compares student performance to a preset
criterion and not to the class average. Consequently, it challenges the existing
practice of adjusting marks to guarantee a xed percentage of students who
will fail or achieve honours. Medical graduates have already been rank
ordered and selected. It is the task of the faculty and institutions to motivate
students to a high level of uniform competence and, as such, the percentage
failures should depend upon the achievement of mandatory criteria and not
the relative class standing5. Thus, as per the satisfaction of achievement of the
criteria and performance in the examination, all candidates may pass or fail.
Examinations are difcult to design, so anything which makes the task more
difcult (such as ranking candidates) will further reduce the reliability of
the exam, and should be avoided3. Any temptation to convert a competencebased examination into an examination which is norm-based (e.g. by putting
in a prize or an honours grade) immediately means that the examination has
to be much more carefully carried out, and will lose some its discriminatory
value in testing competence. The temptation to tack a prize or an honour
grade on to a competence-based examination should be resisted3.
Quality assurance in Medical Education
“Meeting the required standards” and “Fitness for purpose” are two notions
that highlight quality assurance7. Both are related ideas in that we need to
consider the criteria against which the achievement of standards is going to
be measured, and a major criterion must surely be the tness for purpose7. A
product of good standard should t for the purpose for which it was produced.
The standard to be met by the postgraduate MD/MS doctor implies that the
person is capable of doing what s/he is expected to do. The rst question in
the Harden’s ten questions to ask when planning a course or curriculum is
“What are the needs in relation to the product of the training programme?8” In
commercial world, the market helps determine the product. Doctors also need
to be trained in a way appropriate to meeting the community needs. The interrelated ideas of standards and tness for purpose were implicit in the World
Modern Trends in Medical Education 147
Health Organisation’s emphasis in the 1970s on Competency-based Medical
Education and Health for All by 2000 through Primary Health Care7. It was
emphasized that the doctor had to have competence in dealing with the health
care needs of the society s/he would be serving. Similar ideas are promoted
through the concept of the Five Star Doctor and focus on Outcomes-based
Medical Education7, 9.
Criterion-referenced assessment in postgraduate medical
At the end of the training programme, it is necessary to certify the candidate’s
level of knowledge, skill and competence. For example to certify in MS
(General Surgery), it has to be assured that the candidate has the necessary
experience of working in General Surgery and s/he has achieved the necessary
competency level to operate the required surgeries like appendicectomy or
cholecystectomy independently etc. This certication cannot be achieved
just by the theory or clinical practical examination in the exit examination.
A mixture of assessment criteria and methods has to be documented. The
experience of postgraduate medical training like MD/MS in Nepal is almost
two decades now, particularly with the establishment of Postgraduate Medical
Education Coordination Committee (PGMECC) in 1994 involving Institute
of Medicine (IoM) and Bir Hospital and Maternity Hospital and other valley
group of hospitals. Later MD/MS has been started in B P Koirala Institute
of Health Sciences (BPKIHS) and Kathmandu University (KU) as well.
Following the PGMECC, National Academy of Medical Sciences (NAMS)
has been established involving Bir Hospital and other different hospitals in
the country. The criteria of competency are being evolved quite well over the
years in Nepal. In the context of the criterion-referenced assessment for MD/
MS training, a mixture of ten criteria of the achievement of the competency
is relevant to guide the students, faculty members and the institution. They
are also used or recommended in one or the other forms in varying degrees by
different institutions in Nepal. These ten criteria for the criterion-referenced
assessment in MD/MS programme are used explicitly or implicitly under two
broad categories:
A. Eligibility for nal exit examination
1. Attendance of working as full time residents, with regular and 24hour duties, not less than 90% of the training during each academic
2. Completion of horizontal and vertical, i.e. spiral upward, rotation
training posting
3. Completion of minimum numbers of most important procedures /
148 Modern Trends in Medical Education
Completion of minimum numbers of presentations
Completion of mandatory basic courses
Certication of thesis as satisfactory
Achievement of the minimum pass percentage in the Applied Basic
Science examination held earlier
B. Exit examination with its different components and pass
8. Fulllment of theory paper requirement
9. Fulllment of clinical practical requirement and
10. Achievement of the minimum pass percentage in the nal exit
examination, considering its components and internal assessment
A. Eligibility for nal exit examination
“Whatever you want your students to do, include it as a part of the assessment,
they will do!”
Once eligibility is expressed clearly, then it is obvious that all candidates
have to achieve it before they can appear in exit examination and subject
committees and examination section have to ensure they are achieved. Passing
the examination is the major focus of students. Indeed, regulations, like the
eligibility for nal exit examination, and examination are the only languages
students try to understand fully and take seriously.
1. Attendance of working as full time residents, with regular and
24-hour duties, not less than 90% of the training during each
academic year
In the regulations for MD/MS education, the Nepal Medical Council (NMC)
has categorically emphasised that all postgraduate students should work as
full time residents during the period of programme attending not less than
90% of the training during each academic year and should be given full
time responsibility having regular duties and 24 hours duties e.g. twice a
week10. Any postgraduate training without working as residents and without
regular and emergency duties may not be recognised by the NMC. Training
and learning would not occur properly if there is no such working. Teaching
and learning basically occur while managing cases in the units. The focus
is on developing skills of reexivity, not just remembering. The residents
have to manage patients and face different situations, so the materials to
be learned are personally relevant and responsibilities to learn fall on the
learners themselves as well. This is an example of task-based learning (TBL),
the strategy that focuses student learning around real cases that the students
Modern Trends in Medical Education 149
meet in the wards, out-patient departments etc11. The meaningfully learned
knowledge is retrievable, durable and generalisable12. The students acquire
basic science knowledge and clinical reasoning skills in the context of actual
patient cases13. Other various formal sessions and teaching approaches will
add to learning effectively only if active ward/unit team working is present.
As it is an important criterion of the training, the outline of regular and
emergency duty schedule outline in the three years of the training should be
documented in the logbook, so that it can be continuously reviewed by the
faculty and the external reviewer and improved.
2. Completion of horizontal and vertical, i.e. spiral upward,
rotation training posting
In postgraduate residential training, the students are rotated in different units
related to their subject of post-graduation. During such rotations, the exposure
in different sub-specialties required and skill, other learning opportunities and
sufcient work load available should be considered to decide regarding the
postings and their durations. But the concept of making the training during
the rotation postings is not just horizontal; it is also vertical and progressive,
i.e. spiral upward. In the beginning of the training, the students are posted as
junior residents in their subject of post-graduation for about some months
to a year to get the basic knowledge and skills. Next they will be rotated
in different subspecialties or related units as rotating residents. Finally they
need to be rotated back as senior residents to their subject of post-graduation
for about a year. During this nal posting as senior residents, they work
with increased experience and responsibility of managing the unit with
wider perspective and decision making responsibility, including supervision
of junior residents, thus, to have the overview of the subject. The concept
of problem based learning (PBL), i.e. a learning strategy characterised by
self-directed active learning starting with problems or inquiries that learners
themselves identify14 is thus inherently incorporated in the third year posting.
As it is an important criterion of the training, the rotation schedule in the
three years of the training should be documented in the logbook, so that it
can be continuously reviewed by the faculty and the external reviewer and
3. Completion of minimum numbers of most important
procedures / experiences
Postgraduate residents are required to maintain a record (log) book of the work
carried out by them10. The pocket size of the logbook to t in the apron pocket
makes it easier to carry around easily for recording and supervision on the
spot. But without the specications of the minimum numbers of experiences
required checking the logbook remains a vague idea and will just make it
a formality for the residents to get it signed, even at the last hour before
150 Modern Trends in Medical Education
examination. The clear specication of operative skills is particularly vital in
surgical specialties. NAMS has recently strengthened the criterion-referenced
assessment of all MD/MS programme by spelling out in the curriculum and
logbook the minimal number of most important procedures / experience which
will automatically ensure many other necessary background experience as
well15. The examples of Anesthesia and Obstetrics and Gynecology are given
in Table 2 and Table 3 respectively.
Table 2: Minimal number of most important procedures / experience
required to be eligible for Final Examination in MD (Anesthesia)
S. No.
Procedures / Experience
General anesthesia
Risk factors ASA >3
Spinal anesthesia
Epidural anesthesia
Neuro-anesthesia (head injury)
Neonatal anesthesia
Geriatric anesthesia (>70 yrs)
CVP line
Arterial line
Peripheral blocks: BPB, Inguinal and 3 in 1 blocks
Min No.
Table 3: Minimal number of most important procedures / experience
required to be eligible for Final Examination in MD (Anesthesia)
Procedures / Experience
Instrumental Delivery
Caesarean Section
Min No.
MRP/cervical tear repair/Haematoma Drainage/3rd
degree perineal tear
D&C, MVA, including PAC and CAC
Minilap / laparoscopic tubal ligation
Laparotomy for ectopic pregnancy
Abdominal Hysterectomy, Oophorectomy,
Vaginal Hysterectomy/Fothergill’s operation
Modern Trends in Medical Education 151
Cu T/ Norplant
Cervical cancer screening and treatment of cervical
Investigation/ treatment for subfertility: HSG, PCT,
Sonoslapingograpgy, Follicular monitoring, Sperm
preparation, IUI
With the documentation of such criteria of important procedures, then external
examiners can give necessary feedback. The experts in the eld can discuss
the related vital issues, for example “What is the domain of General Surgery
now in the changing medical and demographic scenario like increasing old
age and problem of benign prostatic hypertrophy, development of laprascopic
surgery, the scarcity of urology operation theatre (OT) and redundancy of
general surgical service with mostly asymptomatic gall stones available to ll
the OT list?”; or “Should the consultants and Higher Specialist Training like
MCh (General Surgery) cover laprascopic surgery or transurethral resection
of prostate with Urologists dealing the area beyond the prostate?” etc16.
4. Completion of minimum numbers of presentations
Formal presentation is an important part of training in postgraduate medical
training, e.g. case presentation, topic presentation, seminar, teaching to
juniors by the candidates etc. In the curriculum and logbook of all MD/MS
programmes in the NAMS, the minimum numbers of such presentations
to be achieved by the candidates have been documented which have to
completed and entered in the logbook to be eligible to appear in the nal
exit examinations. The average numbers of the common activities of all
the MD/MS programmes in the NAMS are shown in the Table 415. In some
specialties the numbers are more and in others less and many have other types
of presentations specic to their specialty.
Table 4: Average minimum number of different presentations required to be
eligible for Final Examination in MD/MS in the NAMS
S. No.
Journal club
Topic or seminar
Case presentation
PG to Jr PG or subordinate teaching
CRC / CPC meeting
Mortality/ Morbidity meeting
152 Modern Trends in Medical Education
Average Number
5. Completion of mandatory basic courses
Certain basic courses are essential in MD/MS training. In the curriculum
and log book of all MD/MS programmes in the NAMS, such mandatory
basic courses have been documented which have to completed and entered
in the log book to be eligible to appear in the nal exist examinations. For
MD/MS programmes of all the subjects, the three mandatory basic courses
are Research Methodology, Medical Education and Advance Cardiac Life
Support. In General Surgery, Orthopedics, Obstetrics and Gynecology, and
General Practice, the two more mandatory basic courses are Basic Surgical
Skills and Trauma Life Support. Trauma Life Support is there also in MD
(Anesthesiology) and in MD (GP) there is Palliative Care15.
6. Certication of thesis as satisfactory
Submission and approval of thesis work a well known pre-requisite to become
eligible to appear in the nal exit examination in MD/MS programme. NMC
has laid down essential guidelines in this regard.10 The value of inclusion
of thesis work in postgraduate medical education has indeed increased now
considering the wonderful development of the concept of the evidence-based
medical (EBM) practice. But while planning the training it is also equally
important to remember that thesis work is just only one criterion out of the ten
criteria in postgraduate medical education. It should be conducted honoring
the principles of the basic medical ethics and should not hamper the training
of the candidate to achieve the other nine criteria.
7. Achievement of the minimum pass percentage in the Applied
Basic Science examination held earlier
One of the characteristics of the adult learners is that they base their learning
upon the experiences they have17. The skills required for patient care depend
upon learning in both the basic science and clinical areas18. A lack of solid base
of applied basic science foundation during the clinical training programme
will be a serious handicap for learning the concepts of the subject. If the
students can correlate and apply their knowledge of applied basic science
related to the subject of postgraduation during the context of their training,
then they are likely to have the full understanding of the concepts and
principles of the specialty. For this, the students have to acquire the required
base of knowledge on time during the initial phase of training itself. The
internal annual assessments are not taken seriously, because students do
not have to repeat the examination even if they fail and the proportion of
markings to be added in the nal exit exam is not much. If the applied basic
science examination is held at the end of the nal year, the students will
naturally prepare for it at that time only. But the aim is not just to assess
applied basic science knowledge of the students at the end, but to train them
in their actual eld specialisation integrating all the required knowledge. As
Modern Trends in Medical Education 153
such the relevant applied basic science aspect will of course again be covered
in the nal exit examination. When even the small children in school are not
allowed to continue the next year’s education without being prepared and
examined, MD/MS is a highly professional training concerned with the need
and safety of the community. Instead of having all the papers at the end of
the third year, the paper of Applied Basic Science is to be held in the rst
year. With only the difference of the examinees it will be same workload
for the faculty and the examination section. In IoM applied basic science
examination is held at the end of the rst year in many subjects of MD/MS. If
any candidate fails in the applied basic science examination, s/he will have to
take the examination again. But the clinical training programme is continued
as scheduled. Without rst clearing the applied basic science examination, the
candidate cannot appear in the nal examination. The programme would, thus,
help to achieve the aim of formative assessment, which is the identication of
deciency during the training period in order to correct them1. As the focus
of areas of varied subjects of MD/MS like anaesthesia, medicine, surgery,
gynaecology, eye, radiology etc are obviously different, the question paper for
Applied Basic Science Examination for each of such specialty will have to be
separate. It cannot be a combined single paper. For each subject, the content
coverage, i.e. the division of proportions of the questions of the Applied Basic
Science related to the specialty, including the basic clinical approach and
interpretation, should be decided, and the questions prepared accordingly, by
the concerned subject committee member and experts of the specialty, not by
the basic science teachers. The pattern of the questions and minimum pass
percentage would be as per the practice in the nal examination.
B. Final exit examination with its different components and pass
After the candidate fulll the criteria of the eligibility of the nal exit
examination, s/he is allowed by the subject committee and the examination
section to appear in the nal exit examination, the quality and the standards
of which is safeguarded through the external examiner system. The external
examiners could also verify the achievement of the criteria of the eligibility
by checking the details clearly spelled out in the logbook, as well as give
necessary feedback, and will conduct the nal exit examination along with
the internal examiners to evaluate and certify the candidate. The details of
requirements for external examiners are given in the NMC regulations10.
8. Fulllment of theory paper requirement
NMC postgraduate regulations states that there shall be three/four papers10.
In BPKIHS and in different institutes like All India Institute of Medical
Sciences (AIIMS), Post-Graduate Institute (PGI) Chandigarh in India, there
are total four papers, e.g. on applied basic science, principles, practice and
154 Modern Trends in Medical Education
recent advances. With one paper of applied basic science at the end of the
rst year of training, the three other papers at the nal exit examinations
will perhaps be ideal to cover the content adequately. Once the contents in
the subject are divided in the four papers, the most appropriate format of
the questions to ask appears to be structured short answer question (SSAQ).
The content coverage and reliability are the two major benets of MCQs;
they are also suited best to the examinations, like entrance, with many
candidates when the markings need to be done quickly, reliably and with
clear rankings19. MCQs with assessment of recall factual knowledge and
rare, ambiguous conditions are not ideal in criterion-referenced assessment.
When we read the merits and uses of MCQs or MEQs in Western literature,
we should consider the systematic way of their production including the
quality and content coverage. Without the assurance of the quality and the
content coverage of the MCQs, it may be better to avoid them in the MD/
MS nal examination when the contents of the subject are easily covered
by the SSAQs in four papers. As the number of the candidates in the exit
postgraduate examinations is a few only, the examiners can reliably assess
the answers if the format of questions is structured. Further MCQs do not
assess the spontaneous generation of answer and organization of thoughts19.
In different institutes, like AIIMS, PGI etc, of India also, MCQs are not asked
in the nal exit examinations of MD/MS. In each of all the papers, about
twenty SSAQs can be asked covering different important short contents with
a few clear spelled out structured areas, e.g. aetiology, pathophysiology,
signs, ow-charts, diagrams etc. Unlike SSAQs, it is difcult to answer and
assess unstructured short answer questions (unstructured SAQs), like shortnotes, reliably. Similarly, structured long answer questions (SLAQ) limit the
content coverage, so they are inappropriate. Appropriate reliable modied
essay question (MEQ) is also difcult to prepare, as it needs pre-test and
agreement among the experts rst. As such too much marking given to one
MEQ, even if appropriately and reliably prepared, prevents adequate content
9. Fulllment of clinical practical requirement
In clinical practical, 15 to 30% of the marks are from internal assessment,
14 to 25% from viva, 15% from OSCE and rest 43% to 50% from clinical
cases in different institutes in Nepal. Clinical cases are important in MD/MS
examinations and it should be allocated higher proportions of markings. So it
seems better to reduce the proportions of the marks given to viva and internal
assessment in the institutes where they are allocated higher percentage. Once
more markings are given to the clinical case examination it can perhaps avoid
the extra requirement to pass this section separately even within the clinical
practical heading, as is practiced in the NAMS.
Modern Trends in Medical Education 155
10. Achievement of the minimum pass percentage in the nal
exit examination, considering its components and internal
assessment marks
The nal theory and clinical practical component each has 15% to 30% of
total marks from such internal assessments in different institutes in Nepal.
Adding too much mark percentage of earlier examinations may be injustice
to the candidate if the knowledge, skill or attitude decient earlier has been
acquired now when s/he is appearing in the nal examination. Thus the
percentage of markings from internal assessments to be added in the nal
exam has to be balanced. The other relevant issue in internal assessment is
balancing both annual and end of the posting assessment. In the NAMS the
marks from both end of the posting assessments and annual assessments are
added in the nal examination; in other institutes only annual assessments are
added. The posting assessment empowers and involves the unit consultants in
the training and supervision of postgraduate residents, who work under them.
The posting assessment is also useful to assess and to stimulate the learning
of attitude, patient care, sincerity and reliability. The residents will also be
aware that the unit consultant, wherever they work, has some say in their
assessment and they are likely to be motivated to achieve the requirements
mentioned in the card. The third issue regarding adding of internal assessment
marks to the nal examination is related to the re-examination candidates. For
re-examination candidates in BPKIHS, no marks from internal assessment
are added in theory and clinical. This practice seems justied from the point
of the view that the internal assessment marks have already been considered
in earlier nal examination.
To pass the nal exit examination a minimum of 50% marks in theory as
well as practical separately are considered mandatory by the regulations for
postgraduate MD/MS education10. It is obvious that the marks are given only
for the theory and clinical practical components, not for the other equally,
or perhaps more important, seven criteria of competency as included in
the eligibility criteria for the nal exit examination. So the marks achieved
in theory and clinical practical exit examination alone cannot reect the
competency of the candidate and the marks cannot be given in the nal
certicate of postgraduate examination. The MD/MS certicate in different
institutes like AIIMS, PGI etc in India, also just indicates pass or fail, i.e.
competency achieved or not. To give marks in the nal certicate, markings
will have to be done for all the criteria of competence spelled out, which
is obviously not easy. As the markings are not given for all the criteria,
the markings cannot be given in the nal certicate and honour grade or
medal cannot be given based on the marks of the nal theory and clinical
156 Modern Trends in Medical Education
The above discussed are the ten criteria of the criterion-referenced assessment
of the postgraduate MD/MS education. Once clearly spelled out like this,
the students will focus accordingly. The educational impact of the criterionreferenced assessment is obvious. All the stakeholders in the health care eld
such as health policy makers, health providers in the community, and the
faculty members in the institute or country or the region or even globally,
should ensure a criterion-referenced assessment system in the postgraduate
medical education for the need and safety of the community. The education
faculty has to keep going and fulll their responsibility, even though, unlike
the service and research work, the education role of the faculty is as such not
given priority, glamorized or paid similarly by the institutes, community, or
even the international medical fraternity. The teaching faculty designations
like Professor itself appears to be linked more with the ideas of any research
and paper publication, rather than with educational activities or with the
practice and research of evidence-based medical education20. It is perhaps
high time now to dene the domain and develop the criteria of the education
faculty, including for the revalidation of Professors.
1. Centre for Medical Education. Principles of Assessment. Dundee:
Centre for Medical Education; 2005.
2. Harden RM. Assess students: An overview. Medical Teacher. 1979;
1 (2): 65-70.
3. Bulstrode C, Hunt V. Examining Consultants. Med Edu. 1997; 32
(3): 239-43
4. Harden RM. Self Assessment. Medical Teacher. 1979;1: 49-50.
5. Turnbull JM. What is … normative versus criterion-referenced
assessment? Medical Teacher 1989; 11(2): 145-50.
6. Glasser R. Instructional technology and the measurement of learning
outcomes. Am Psychologists. 1963; 18: 519-21.
7. Steward A. Quality Assurance in Medical Education. Dundee: Centre
for Medical Education; 2005.
8. Harden RM. Ten questions to ask when planning a course or
curriculum. Medical Education. 1986; 20 (4): 356-65.
9. Boelen C. The Five Star Doctor. WHO. Changing Medical Education
and Medical Practice. 1993: 3.
10. Nepal Medical Council. Regulations for Postgraduate Medical
Education (MD/MS Programs). Kathmandu: Nepal Medical Council;
Modern Trends in Medical Education 157
11. Harden RM, Crosby JR, Davis MH, Howie PW, Struthers AD. Taskedbased learning: the answer to integration and problem-based learning
in the clinical years. Medical Education. 2000; 34: 391-7.
12. Stewart A. Trends in Teaching and Learning. Dundee: Centre of
Medical Education; 2005.
13. Kaufman DM, Mann KV, Jennet PA. Teaching and Learning in
Medical Education: How Theory can Inform Practice. Edinburgh:
Association for the Study of Medical Education (ASME); 2000.
14. Ananthanarayanan PH. Problem based learning. In: Ananthanarayanan
N, Sethuraman KR, Kumar S, eds. Pondicherry: Alumni Association
of National Teacher Training Centre, JIPMER; 2000. 89-98.
15. National Academy of Medical Sciences. Curriculum For MD/MS
(as per the specialty). Kathmandu: National Academy of Medical
Sciences; 2008.
16. Bhattarai MD. General surgery units, asymptomatic gallstones and
benign prostatic hypertrophy. The Surgeon – Journal of the Royal
College of Surgeons and Edinburgh and Ireland. 2003; 1: 361.
17. Knowles MS. The Modern Practice of Adult Education: From
Pedagogy to Andragogy. New York: Cambridge Books; 1980.
18. McLeod PJ, Harden RM. Clinical Teaching Strategies for Physicians.
Medical Teacher. 1985; 7: 173-89.
19. Bhattarai MD. Multiple Choice Questions and Open Ended Questions
for Written Assessment. Kathmandu: 2005.
20. Harden RM, Grant J, Buckley G, Hart IR. Best Evidence Medical
Education. Dundee: Association for Medical Education in Europe;
158 Modern Trends in Medical Education
Continuing medical education for the
21st Century: A learning journey
Shrestha BM
Basics Science Coordinator, Kathmandu Medical College, Duwakot, Nepal.
“Gone are the days when newly graduated doctors were armed with most of
the information they would need for a lifetime of practice.1”
The doctors today denitely cannot boast of what they have learnt in the past
as being still good enough. With new developments in science and technology,
and more demanding patients for quality care and outcome, physicians have
to update themselves continuously by educating themselves. This is a life
long process.
Davis DA dened Continuing Medical Education (CME) as - “any and all the
ways by which doctors learn after formal completion of their training” 2.
The primary purpose of continuing medical education is to maintain and
improve ones clinical performance and be accountable to public by ones
competency, effectiveness and safety of patient care.
There are many challenges in 21st Century which could only be met with the
CME which are well crafted, targeted, innovative, internationally accepted
and relevant to patient care. The challenges are as follows3.
Changing demographics and pattern of diseases
New technologies
Changes in the health care delivery
Increasing consumerism
Patient empowerment and autonomy
Emphasis on effectiveness and efciency
Changing professional role
Traditional CME programme, as we have now, is delivered by lecture series
which has lot of valuable information but unt to acquire the skill that the
new trends in health care demand for. Continuing Medical Education is
largely designed to plug supposed gaps in knowledge.
So CME in the 21st Century should address the following4 and be:1. Educationally effective in relation to health outcomes
Modern Trends in Medical Education 159
Planned systematically on the basis of needs assessment and
Responsive to rapid changes in the world
Inclusive of service providers and users
Addressed to promote self directed learning and problem solving
Based on proved effective educational process
Informed by the experience of others
In 2003, two signicant reports conrmed large gaps in the quality of American
health care. McGlynn5 found that Americans receive recommended services
only 54.9% of the time, and the rst National Healthcare Quality Report6
demonstrated a similar “chasm” between evidence-based and actual care.
The gap between what should be done and what is actually practiced appears
to be widening. CME providers should come together to more adequately
determine the learning needs of physicians, develop effective learning
venues, design methods for periodically assessing knowledge and skills, and
implement stronger oversight mechanisms to close this gap7.
Dr. Jordan Cohen, President of the Association of American Medical Colleges
in his address, A New Vision for Continuing Medical Education on March
2006, said •
CME’s ineffectiveness is a major obstacle to closing the nation’s gaping
quality chasm.
Reforming the nation’s entrenched CME system will be a tremendous
Traditional lecture format only for basic science
CME should employ self-directed, interactive, and relevant learning
This is a true fact and essential too. It should not be taken as a programme for
recertication and renewal of medical practice licensure as needed in many
parts of world.
In 2007 US based Josiah Macy Foundation sponsored a conference on the
state of Continuing Medical Education and suggested that1. The quality of patient care is profoundly affected by the performance of
individual health professionals
2. Traditional lecture based continuing education is largely ineffective
in changing the performance of health professionals and in improving
patient care
160 Modern Trends in Medical Education
Continuing education should be less reliant on presentations and lectures
and more focused on practice based learning
Similarly Robert F Woollard8 writes that the current unsystematic and casual
approach to much of continuing education fails to meet the standards of rigour
that society expects of professionals. CME can produce measurable outcomes
by continuing professional development and improvement for doctors to
enhance quality of care, support professional activities, assess professional
educational needs, elicit professionalism, motivate learners.
So it is not an easy task for CME providers.
Alfredo Pisacane suggests the following points to be necessary for CME to
be effective9.
1. Concentration on small groups
2. Agreed objectives for educational activities
3. Evaluated providers
4. Commited resources by Health institutions
5. Masked use of new technology
6. Creation of a central fund
7. For doctors to pay and avoid Drug Company funding for continuing
medical education as this may affect doctors’ independence.
It might be a good idea to have an institute for CME as well. This is also
suggested by Paul C. Hébert10 who suggests to:
• propose a mandate of Institute of Continuing Health education, which
will • Set guidelines and standards for efcacious, unbiased continuing
• Develop, support and promote inter professional educational
• Monitor sources of all funds and set accreditation standards for
continuing education providers
• Provide continuing education grants to accredited institutions
• Identify education and treatment gaps
• Develop more effective ways to educate health professionals
• Find new ways to integrate education into clinical practice
• Help health care professionals overcome barriers to lifelong
• Act as a central clearing house for continuing education for all
health professionals
Modern Trends in Medical Education 161
To survive in this 21st Century our education system should be changed. We
all have to face the challenges and educate ourselves to move with the time.
“Not every thing that is faced can be changed. But nothing can be changed
until it is faced” – James Arthur Baldwin.
1. Shaughnessy AF, Slawson DC. Changing the doctor-patient
relationship - Are we providing doctors with the training and tools for
lifelong learning?. BMJ. 1999; 319 (7220): 1280.
2. Davis DA. Global health, global learning. BMJ. 1998;
3. Towle A. Education and debate continuing medical education:
Changes in health care and continuing medical education for the 21st
Century. BMJ. 1998; 316(7127):301-4.
4. Richards T. Continuing medical education. BMJ 1998; 316:301-4.
5. McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro
A, et al. The quality of health care delivered to adults in the United
States. N Engl J Med. 2003;348: 2635-45.
6. Agency for Healthcare Research and Quality. National healthcare
quality report: 2003. Rockville, MD: Department of Health and
Human Services. 2003.
7. Barnes B. Minding the gap: can continuing medical education bridge
the quality chasm? J. Am. Coll. Cardiol. 2004 ;44(1):199-200.
8. Woollard RF. continuing medical education in the 21st Century Needs to recapture professionalism in lifelong learning. BMJ. 2008;
316(7128): 337:a119.
9. Pisacane A. Rethinking Continuing Medical Education. BMJ. 2008;
316(7128): 337:a937.
10. Hébert PC. The need for an Institute of Continuing Health Education
[editorial]. CMAJ 2008.
162 Modern Trends in Medical Education
Career in medical education
Magar A
CMCL-FAIMER Fellow 2009, Christian Medical College Ludhiana, Punjab,
pecialists in the theory and methods of education are known as
educationists. In general terms the individuals are termed as teacher. They
facilitate student learning, often in a school or academy or perhaps in another
environment such as outdoors. Different ways to teach are often referred to
as pedagogy. When deciding what teaching method to use, teachers consider
students’ background knowledge, environment, and their learning goals as
well as standardised curricula as determined by the relevant authority. Many
times, teachers assist in learning outside of the classroom by accompanying
students on eld trips. The increasing use of technology, specically the rise
of the Internet over the past decade has begun to shape the way teachers
approach their role in the classroom1.
There are a variety of bodies designed to instil, preserve and update the
knowledge and professional standing of teachers. Many governments around
the world operate teacher’s colleges, which are generally established to serve
and protect the public interest through certifying, governing and enforcing
the standards of practice for the teaching profession.
Medical teachers unlike most other teaching professionals are unique in that
no special prior or in service training in pedagogic techniques is considered
necessary for their recruitment as teachers or for their continued efcient
performance in that capacity2. However there are different institutes who
have come forward to ll this gap such as Foundation for Advancement of
International Medical Education and Research (FAIMER) which is providing
an opportunity to pursue Career in Medical Education.
The FAIMER is a non-prot foundation committed to improving world
health through education. It was established in 2000 by the Educational
Commission for Foreign Medical Graduates (ECFMG®). In partnership with
ECFMG, FAIMER promotes excellence in international health professions
education through programmatic and research activities.
FAIMER is an organisation whose mission is “to support the Educational
Commission for Foreign Medical Graduates (ECFMG)” as it promotes
international medical education through programmatic and research activities.
Modern Trends in Medical Education 163
Its activities include:
• Creating Educational Opportunities for Medical Educators that
support the exchange of educational expertise, acquisition of new
methodologies in teaching and assessment, and pursuit of advanced
degrees in medical education.
• Discovering Patterns and Disseminating Knowledge about the
relationship between medical education and health care, and the
impact of physician workforce and migration issues on the functioning
of health care systems.
• Developing Data Resources to develop and maintain accurate,
publicly-available data resources that promote understanding of the
medical education systems in the world today, and how they should
look tomorrow.
• The International Medical Education Directory, a listing of all
medical schools that are recognised by the government agencies in
the countries where they are located.
• To create and enhance educational resources for those who teach
physicians committed to improving and maintaining the health of the
communities they serve.
• To investigate and understand the educational experiences and
migration patterns of international medical graduates and to determine
their impact on population health.
• To be the best source of information on international medical
The idea was to establish a separate foundation from ECFMG’s longstanding commitment to promoting excellence in international medical
education. This commitment began with ECFMG’s rst faculty exchange
program in 1983. In the years that followed, ECFMG increased resources
for exchange programs, introduced consultation services, and considered a
number of research initiatives related to international medical schools and
their graduates. However, ECFMG’s Board of Trustees believed that more
could be accomplished by a separate organization with dedicated resources
focused on the international health professions community. Discussions
began in early 2000, and, in July of that year, the ECFMG Board of Trustees
approved a resolution to establish an ECFMG foundation.
The Foundation for Advancement of International Medical Education
and Research (FAIMER) was incorporated as a non-prot foundation of
164 Modern Trends in Medical Education
ECFMG in September 2000, and FAIMER’s Board of Directors held its rst
organisational meeting in December 2000. An executive search initiated at
the end of 2001 resulted in recruitment of the Foundation’s rst President and
Chief Executive Ofcer, John J. Norcini, Ph.D., who joined FAIMER in May
2002. Throughout the period from 2001 through 2003, the membership of the
Foundation’s Board expanded with the election of Directors-at-Large. By the
end of 2003, all positions had been lled, and, in April 2004, the Board held
its rst meeting with full membership.
Beginning in 2001, FAIMER’s Directors initiated strategic planning to dene
the Foundation’s focus and priorities. These planning sessions culminated,
in 2004, in the adoption of a formal strategic plan that identies the
Foundation’s areas of thematic and geographic focus, as well as short- and
long-term goals for each area of activity. A number of key staff appointments
and reorganisation of FAIMER’s Board, both accomplished in 2004, ensure
the expertise and oversight required to support the activities outlined in the
According to FAIMER’s strategic plan, the Foundation would concentrate its
efforts in three thematic areas: creating educational opportunities for health
professions educators, discovering patterns and disseminating knowledge,
and developing data resources. In approaching these activities, the Foundation
would maximize its impact by concentrating its efforts and resources in
specic, geographical areas: developing regions in South Asia, Africa, and
Latin America. The strategic plan also calls for FAIMER to identify and
collaborate with appropriate partners to leverage resources and maximize
Results have been achieved in each of FAIMER’s three areas of activity.
In keeping with its goal of developing resources on medical education
worldwide, FAIMER introduced the International Medical Education
Directory (IMED) in 2002 and enhanced access to IMED in 2003 with the
introduction of the IMED Subscription Service. In 2004, development of two
new directories was approved: the Directory of Organizations that Recognize/
Accredit Medical Schools and the Postgraduate Medical Education (PME)
Project. With respect to its commitment to create resources for health
professions educators, the transition of ECFMG’s educational programs for
the international health professions community, which began in 2001, has
been completed, and the Foundation established a new fellowship program,
the FAIMER Institute, in 2001. FAIMER has aligned these programs to create
a pathway for educational leadership for international health professions
educators. In the realm of research, FAIMER staff has identied important
questions regarding international medical graduates and medical education
and have engaged with the data resources and organisational partners that
will enable meaningful research on these issues.
Modern Trends in Medical Education 165
FAIMER’s fellowship
These programs are targeted to international health professions education
faculty who have the potential to play key roles in improving education in
their schools. These programs develop skills that allow participants to serve
as resources for their colleagues, institutions, local communities, and global
regions. The programs emphasise education methods, education leadership
and management, and development of a community of educators. Participants
focus on education innovation projects of their choosing that are supported by
their home institutions. Preference is given to projects where these is a clear
link to improving community or population health. Implemented projects
serve as relevant, local working models for ongoing enhancements in health
professions education.
FAIMER institute
FAIMER’s educational programs currently focus on serving health professions
educators and institutions in South Asia, Africa and Latin America.
Applications from other regions will be given lower priority. Applicants must
full an eligibility criteria as per shown in Table 1.
Table 1: FAIMER Eligibility Criteria
Reside and work in their home countries at the time of application
and at the time of acceptance of the fellowship award;
Have a graduate or professional degree;
Hold an academic appointment as a faculty member in a health
profession school or a postgraduate health profession education
Be in a position of leadership with respect to curriculum and
educational policies and procedures. Preference is given to midcareer applicants;
Be willing to travel to the United States;
Have at least three years work experience as a faculty member in
the home country following completion of their formal academic
and clinical training;
Demonstrate competence in written and spoken English;
Have the endorsement of a home country medical school or
postgraduate health professions education institute for the
proposed educational project; and
Have a position in the home country health professions school,
or institution to which they will return upon completion of the
166 Modern Trends in Medical Education
The FAIMER regional institutes
They are based in South Asia, Africa and Latin America and follow the same
two-year format and have the same components as the FAIMER Institute
but the two residential sessions are shorter in length. The Regional Institutes
provide similar opportunities to health professions educators who may have
more restricted time or mobility or who prefer the regional context.
FAIMER Regional Institutes are modelled on the FAIMER Institute
curriculum. They include residential sessions, as well as distance learning
sessions. Each participant is also required to propose and implement an
education innovation project that is supported by the home institution. The
length and number of the residential sessions as well as the number of Fellows
accepted each year varies among the Regional Institutes.
Table 2: FAIMER Regional Institutes
GSMC-FAIMER Regional Institute: Mumbai, India
CMCL-FAIMER Regional Institute: Ludhiana, India
Brazil-FAIMER Regional Institute: Tabuba, Brazil
PSG-FAIMER Regional Institute: Coimbatore, India
Southern Africa-FAIMER Regional Institute
East Africa-FAIMER Regional Institute (in development)
West Africa-FAIMER Regional Institute (in development)
1. GSMC-FAIMER regional institute, Mumbai, India
The GSMC-FAIMER Regional Institute, the rst Regional Institute to
be developed, started in June 2005 and is based at the Seth G.S. Medical
College in Mumbai, India. The College’s Medical Education and Technology
Unit mount the program each year. The program is open to interested health
professions educators from South Asia. Sixteen Fellows are accepted each
2. CMCL-FAIMER regional institute, Ludhiana, Punjab, India
The CMCL-FAIMER Regional Institute, under the direction of Tejinder
Singh, welcomed its rst group of Fellows in January 2006. It is based at the
Christian Medical College at Ludhiana in Punjab. The program is open to
interested health professions educators from South Asia. Sixteen Fellows are
accepted each year.
3. Brazil-FAIMER regional institute: Tabuba, Brazil
The rst residential session of the Brazil-FAIMER Regional Institute, under
the direction of Henry Campos and Eliana Amaral, took place in February
Modern Trends in Medical Education 167
2007 in Tabuba, Brazil. The program, conducted in Portuguese, is open to
interested health professions educators from Latin America. Twenty-ve
Fellows are accepted each year.
4. PSG-FAIMER regional institute: Coimbatore, India
The PSG-FAIMER Regional Institute, under the direction of Thomas Chacko,
welcomed its rst class of Fellows in April 2007. It is based at PSG Institute
of Medical Sciences and Research in Coimbatore in southern India. The
program is open to interested health professions educators from South Asia.
Sixteen Fellows are accepted each year.
5. Southern Africa
The rst session of the Southern Africa-FAIMER Regional Institute (SAFRI)
took place in February 2008 in Cape Town, South Africa, marking the
launch of FAIMER’s rst regional initiative on the continent of Africa.
SAFRI is being shepherded by a new “voluntary association” made up of a
collaboration of FAIMER Institute Fellows working at a number of different
health professions education institutions in the region. They have devised
an innovative program model that includes three residential sessions during
the two-year program. Fellows participate in two residential sessions,
approximately four months apart, during the rst year of the program. Their
third residential session takes place the following year, and overlaps with
the rst residential session of the incoming class of Fellows. The program is
open to interested health professions educators from Africa. Sixteen Fellows
are accepted each year.
1. Wikipedia [homepage on the internet]. Teacher [Online]. [Cited 2009
Jan 20]. Available from: URL: http://en.wikipedia.org/wiki/Teacher
2. Ananthakrishnan N. Microteaching as a vehicle of teacher training--its
advantages and disadvantages. J Postgrad Med [serial on the internet].
1993; [cited 2008 Dec 26] ;39:142. Available from: URL: http://www.
3. The Foundation for Advancement of International Medical Education
and Research (FAIMER). FAIMER [Online]. 2001 [cited 2009 Jan
22]. Available from: URL:http://www.faimer.org
168 Modern Trends in Medical Education
Designing an innovative curriculum
using PBL
Staffan Pelling1, Lars Uhlin1
Faculty of Health Science, Linköping University, Sweden
he aim of this article is to give a short and condensed introduction to
some theories and experiences that might be valuable when engaging in a
process of change and scrutiny of educational practice and organisation. The
article is divided into the following three themes.
What kind of doctor do we want?
This involves the actual target, the aim of our efforts as educators. If we have
the answer to that question then we can pose the next.
How to organise education to reach the goal?
The means and tools to help us look on the organisation of a medical
curriculum from the perspective of the whole learning process, the students
experience. We will also address the question.
Will the student learn?
This looks at how the students learn and how we maintain our knowledge.
The article is basically a compilation of thoughts and theories that we have
found useful.
What kind of doctor do we want?
When investigating this question it is essential not to be blindfolded by old or
new misconceptions, habits or prejudices and to seek our answers with the help
of proper tools. So we will turn to Dr Charles Boelen1 . In the early nineties
in response to the call for “Health for all by the year 2000”, he formulated
some essential functions that the doctor of the future needs to full. There
was a need for a new type of doctor and Boelen calls this ideal doctor The
Five Star Doctor1. The World Health Organisation (WHO) then took the
initiative of changing medical education and agenda for action in line with
his ideas. This initiative stressed the importance of a new medical curriculum
focusing on problem-based learning, the needs of the local population and
the creation of community-campus partnerships between the university and
the local community, integrating innovations in medical curriculum and in
service delivery.
Modern Trends in Medical Education 169
The rst star of the Five Star Doctor is the care provider, who considers
the patient holistically as an individual and as an integral part of a family
and the community, and provides high quality, comprehensive, continuous
and personalised care within a long term relationship based on trust. Along
with this goes individual treatment pending to total needs of the patient and
full range of treatments- preventive, curative and rehabilitative. It has to be
dispensed in ways that are complemetary, integrated and continuous and the
treatment has to be of the highest quality.
The second star, the decision maker who chooses the technologies to apply
ethically and cost-effecively, while enchancing the care he or she provides.
This also means that you have to work in a climate of transparency, take
decisions that can be justied in terms of ethics and cost and that are most
appropriate in a given situation. On the community level it often means
dealing with limited resources available for health care that must be shared
out fairly to the benet to every individual of the community.
The third star is the communicator who is able to promote healthy lifestyle by
effective explanation and advocacy and thereby empowering individuals and
groups to enhance and protect their health. Life style aspects such as balanced
diet, safety measures at work, types for leisure pursuits and respect for the
environment. In order to involve the individual in protecting and restoring
his or her own health, you need an exellent communicator to pursuade
individuals, families and communities in their charge to adopt healthy life
styles. Communication in this sense is pedagogy.
A community leader, the fourth star, who having won the trust of the people
among s/he works can reconcile individual and community health requirements
and initiate action on behalf of the community. Is this a community leader in
the sense of a politician or an expert? Maybe it’s a true balance act between
the two. For the leader, the skills of being a good communicator are of course
The last star is the manager who can work harmoniously with individuals
and organisations inside and outside the health system to meet the needs
of patients and communities making appropriate use of avaliable health
data. This star deals with the doctor as both team player and to a certain
extent an agent in society and community development. Many are engaged
in that kind of activities. A doctor in a team often means involvment in
interprofessional work. As in any other trade it is hard to make a difference in
solitude or isolation, teams and cooperation accomplish more. This asks for
communication skills of other kinds than when meeting one patient, family
or acting in society.
170 Modern Trends in Medical Education
All the competencies that a doctor needs are e quite openly framed and
formulated quite widely, but expectations are very high. How one can
consider this, is if one condent that this picture of the ve star doctor is ones
own. I don´t know if the ve star doctor is a label one like to use to put on the
“product” that you produce at ones institution. Another question is whether
your own criteria are formulated in the same way as by your colleague sitting
together at this very moment. What about your neighbour at home or the
patient that you will meet next week? The answers to all these questions call
for dialogue and negotiation.
Simple, complicated and complex problems
And then there is the problem. What kind of problem do medical staffs deal
with. Let us see if this metaphor can help us – ‘I don´t know what kind of
images you can see before you in the medical eld when baking a cake,
sending a rocket to the moon and raising a child is considered’2. Baking
a cake might be similar to writing a prescription of anitbiotics for a well
known infection or making some minor surgical procedure. Whereas sending
a rocket to the moon is already addressing healthcare as a system, producing
good results while taking in a multitude of aspects, facts, agents and systems.
And raising a child is of course the meeting with the human being; the patient,
your neighbour or your child.
Baking a cake is relatively easy, it still has not one solution but the complexity
of every situation makes the cake baking solution rather limited. We stay
before the challenge to educate students who will be able to handle everything
between a minor incision and an everyday prescription, to address epidemics
in a geographical area or tragic life events in a person’s life. In the midst of
this also trying to organise the health care system on different levels. But
solving simple problems with sound methods and practice is maybe what
doctors do day out and day in, a way which in itself to solve parts of the
complex problems.
We do not send rockets to the moon though, but we elaborate sophisticated
health care systems, organize care processes, take medical records and the
patient and the society wants us to reach the moon every time. Doctors are not
alone in this, expertise from several areas including logistics, administration,
cleaning, other medical- or health professions are with the doctors in this. If
you look on your every day professional life you’ll nd yourselves as part of
a complicated or sophisticated system, but does this system do the job every
time? This is what our customers, our patients want.
The real complexity starts when you are involved with people, children,
patients, human beings. The guarantees for solving a problem remain uncertain
Modern Trends in Medical Education 171
in these cases. Doctors know that, have to live with it and develop skills and
methods, attitudes, ethical reasoning and acting to handle and diminish the
How to organise education to reach the goal?
So how should we organise production of ve star doctors, if that is what we
want? How should we organise medical education to satisfy our expectations
of a knowledgeable, nice, condent, skilled doctor with high morale and
working capacity? This is where curriculum design comes in and we will
now briey present a few theoretical models that might be helpful in this
complex task.
The SPICES-model
Ronald Harden with colleagues in Scotland proposed six themes to consider
when planning or developing a curriculum, the SPICES model3. They thought
each of these themes as a continuum with more recent development located
to the left and more traditional strategies to the right. They suggest that by
considering where a curriculum is be placed on each of these continua, a
curriculum can be reviewed or planned from scratch more effectively.
The model was originally developed to apply to an undergraduate medical
education, but has been adapted to a variety of settings. Organising a
curriculum of this kind would be a challenge because we wish the student to
develop a variety of skills, attitudes and knowledge.
Standard Programme
Fig 1: The SPICES-model3
172 Modern Trends in Medical Education
The rst might be to become a lifelong learner, nding sources of information,
to develop curiosity and intrinsic motivation, value authorities for what they
are worth etc. This might follow a more student-centred approach. To learn
how to work with real life problems already from day one, what would
the argument against such an approach be? Problem-based learning vs.
information gathering that also leads to certain types of examination where
you give back the information to your teacher again. Integration of subjects
and disciplines is something that all professionals do intuitively in everyday
work along with integration and teamwork with other professions. Writing
a prescription does not only involve pharmacology. And community-based,
to work in the community or in the hospital, one does not nd you have
to choose, both arenas for struggling against disease are places where the
medical profession has a role. But Harden challenged old rooted conceptions
of what medicine was all about. The same goes for arguing for electives and
challenge the old apprenticeship based education. Instead you can organize
a curriculum systematically considering differences and variations between
subjects, skills, levels of advancement during the educational programme etc.
A variety of learning and teaching methods, a conscious approach to how a
curriculum is communicated both to students and faculty is important. These
are parts that are needed in a systematic approach. We want this rocket to
reach the moon every time in our effort to produce professionals.
Spiral curriculum
If we aim for a doctor or any other professional to become increasingly mature
and knowledgeable, to become a professional who is able to make judgements,
plan actions and justify decisions over the course of their studies, we might
nd a curriculum in a spiral form helpful. Bruner formulated already in the
60´s the idea of the spiral curriculum – “A curriculum as it develops should
revisit the basic ideas repeatedly, building upon them until the student has
grasped the full formal apparatus that goes with them”4. This has later been
adapted in medical education5. The development of learning and problem
solving, communication and other generic skills has many possibilities
to develop if opportunities to practice come back on different levels of
the programme. You learn, you re-learn and you test in new increasingly
complex situations. As an example communication with patients might be
practiced very early in the curriculum even if the conversation might not
address complex medical decisions. The curriculum design is then a question
of decision of which building blocks or core components or subjects should
be used to make it possible for students to address increasingly complex
problems and patients. Horizontal integration between disciplines as well as
vertical with the application of different kinds of knowledge in a clinical
context is built into this model. Awareness of the context by students, faculty
and clinicians is central; we don’t have a hidden curriculum. Both students
Modern Trends in Medical Education 173
and faculty are able to argue as for the reasons for their learning and studying
a certain aspect or part. The discussion or even the dispute in how to develop
a curriculum is in itself a possibility for the faculty to scrutinise assumptions
and expectations. Thorough agreement on the aims for the faculty is central
to go forward.
Curriculum cycle
Bernard Bernstein has constructed a model illustrating the struggle between
the parts and the whole which he calls it the Curriculum cycle6. In the
integrated curriculum, the emphasis is not on the autonomy and separation
of subjects, but on the connection between them. The purity rule is rejected,
and the governing principle here is ’things shall be put together’ – in the
interest of ’relevance’ and the capacity of a programme to justify itself to
others. Knowledge is organised in themes and the timetable is structured to
support the exploration of such themes. The boundaries between areas of
study are seen as entirely provisional and can be suppressed or dismantled;
and new exible combinations can be devised. Bernstein suggests further that
the two types of curriculum bear a cyclical relationship to each other, such
that when an integrated curriculum is in place, there may be a progressive
redenition of boundaries, to reconstitute a collection curriculum6. In turn,
when a collection curriculum is in its ascendancy, a progressive collapse of
boundaries may again produce an integrated curriculum and so on. Although
it should be emphasised that this is recursive ’spiral’, not a closed loop: when
boundaries are re-established, they are in a different place. I think even if I
would advocate an integrated curriculum you have to answer the question;
integration of what? One will have to dene what the parts are, so the
Curriculum cycle may thus form a spiral of its own, a battle ground between
academics and clinicians, scientists and all sorts of interests. And that might
be an illustration of development.
”things must be kept apart”
Collection curriculum
Integrated curriculum
”things may be put together”
Fig 2: The Curriculum cycle6
174 Modern Trends in Medical Education
A Swedish study on retention of knowledge after the study of physiology
shows that students showing deep understanding are using learning modes
where detail and whole is in interaction. This is not seen in the opposites or
merely in linear connection. Both detail and whole fertilise reasoning and
understanding and those students easily climb between different levels and
kinds of knowledge7.
Will the students learn?
One can give two indications of an answer to this question. Constructing
knowledge with the use of differences and the retention of learning, what still
is there after we have forgotten everything.
First, one must remember the Kolb’s learning cycle. Kolb claims that the
learning process starts from concrete experience8. The concrete experience
makes one observe and reect and one forms an abstract concept and makes a
generalisation. One can test these implications of concepts in new situations.
Testing Implications
of Concepts in New
Observation and
Formation of Abstract
Concept and
Fig 3: Kolb’s Learning Cycle.8
Modern Trends in Medical Education 175
Actually David Kolb elaborated this into a learning style grid where he tested
people on their learning prole. In the grid we differ on two axes - between
abstract and concrete thinking and between activity and reection. He made
tests to see where different professions statistically are located. But learning
styles develop especially during organised study. We can make use of these
individual differences; Kolb’s material is of course a statistical of many
individuals. But in a base-group in a PBL concept we can make the same
test and see that the learning styles differ a lot. This makes it possible also to
complete the problem solving process in a much better way than otherwise.
The least productive group is actually the one with too many students that
have learning styles that are alike. So this is an urge to use the group.
If we are lucky we will remember 70% of what we learned. A traditional
curriculum built from the bottom and up, knowledge is often pre-packed by
the education and presented as building blocks for the students to learn by
adding one block to another during the education. But in a spiral curriculum
with the intention to interconnect parts of the programme the loss will look
differently. Losses do not seem as detrimental; knowledge on different levels,
facts and gures, skills, experiences, theoretical assumptions and models are
intertwined just as when you learn them. And they form a web of understanding
of phenomena and mechanisms and how to use them. Would you pass the
examination from the rst semester in your undergraduate studies? One is
not sure, partly because the needs one has of facts and skills nowadays differ
a lot from at the time, when I was mostly interested in passing the exams.
So the applicability of the knowledge has changed as well as its adequacy
in the situations where it could be exposed or used. Judgement of what is
sufcient knowledge has also changed, I have added a lot but also have
let a lot go. To remember it and use the knowledge it has to be achievable,
understandable and retrievable in the situation when it is needed. Knowledge
is not something that one just stores in ones head but it is something that one
has to demonstrate in interaction with the complex world.
Constructive alignment
To nish the short journey through theories, models and experiences of the
complexities of education, one must address John Biggs’ ideas of constructive
alignment which has become an inuential idea and an important tool for
curriculum design in higher education worldwide9. The two basic ideas are
that students construct their own meaning from what they learn and the
education is designed and planned to align learning activities and assessment
with the learning outcomes.
176 Modern Trends in Medical Education
Learning and
teaching activities
Designed to meet
Learning Outcomes
Designed to assess
Learning Outcomes
Fig 4: Constructive alignment9
Design always begins with formulation of the intended learning outcome,
just as the ideas about the ve star doctors we referred to earlier in our article
with. Then, to be able to know if the outcome is reached, learning has to
be assessed according to certain criteria used in the assessment activities
which are aligned with the outcomes. Appropriate learning activities are also
designed to produce intended outcomes. An aligned curriculum is transparent
for both students and faculty and will guide students in constructing their own
learning and knowledge. The student must be an active agent in this, be aware
of the expectations, the possibilities and the challenges. Being a complex
activity formed by human beings one can not foresee some learning that
will come out as an extra asset, which might call for revision of the learning
outcomes. Houghton has made a concept map illustrating the main parts of
constructive alignment and the relation between them in the Curriculum
Design Process, which might be interesting to have further look at10.
In conclusion a curriculum is a product needing a high degree of consideration,
patience, negotiation, imagination and even courage to be changed.
Designing a new curriculum or revising an old one involves many challenges
and difculties, but also a lot of learning opportunities and new discoveries
of possibilities. Some theoretical models, thoughts and experiences found
useful in thinking about and designing innovative medical education have
been shared here. These may be interesting, useful and applicable in Nepal.
The assumptions of the nature of learning and the design for learning are the
same and form the basis for PBL. And the acknowledgement of the need for
thorough investigation of what constitutes good learning in a certain context
Modern Trends in Medical Education 177
is the same as for PBL. The start in the endpoint, what kind of professional do
we really want and the use of everyday problems are the same.
1. Boelen C. Challenges and opportunities for partnership in health
development. Geneva: WHO. 2000.
2. Glouberman S, Zimmerman B. Complicated and Complex Systems:
What Would Successful Reform of Medicine Look Like? In: Forest
PG, McIntosh T, Marchilden G (eds). Health Care Services and the
Process of Change. Toronto: University of Toronto Press. 2004.
3. Harden RM, Sowden S, Dunn WR. Some educational strategies
in curriculum development: the SPICES model. Med Educ.
4. Bruner J. The Process of Education. Cambridge, Mass.: Harvard
University Press. 1960.
5. Harden RM, Stamper N. What is a spiral curriculum? Medical
Teacher. 1999; 21(2): 141-3.
6. Bernstein B. Class, codes and control (vol 1). London: Routledge.
7. Fyrenius A, Wirell S, Silén C. Student approaches to achieving
understanding approaches to learning revisited. Studies in Higher
education. 2008; 32( 2): 149-65.
8. Kolb D. Experiential Learning: Experience as the Source of Learning
and Development. Englewood Cliffs, NJ.: Prentice Hall. 1984.
9. Biggs J. Teaching and for Quality Learning at University. Buckingham:
Open University Press. 1999.
10. Houghton W. Engineering Subject Centre Guide: Learning and
Teaching Theory for Engineering Academics. Loughborough: HEA
Engineering Subject Centre. 2004.
178 Modern Trends in Medical Education
List of Participants
Asian College for Advanced Studies
1. Mr. Shrestha Suresh, Kathmandu
2. Mrs. Rajbhandari Nirmala, Kathmandu
3. Ms. Suwal Punya Shori, Kathmandu
BP Koirala Institute of Health Sciences
1. Dr. Baral Nirmal, Dharan
College of Medical Sciences
1. Mr. Shaik Munvar Miya, Bharatpur
2. Dr. Singh Arjun, Bharatpur
3. Dr. Kumar Jeetendra, Bharatpur
Faculty of Health Sciences, LiU, Sweden
1. Dr. Pelling Steffan Linköping, Sweden
2. Dr. Swahnberg Katarina Linköping, Sweden
3. Dr. Uhlin Lars Linköping, Sweden
4. Dr. Wijma Barbro Linköping, Sweden
Institute of Medicine
1. Dr. Adhikari Ramesh Kant, Kathmandu
2. Dr. Aacharya Ramesh, Kathmandu
3. Dr. Agarwal Jagdish P, Kathmandu
Kathmandu Medical College
1. Dr. Adhikari Sailendra Raj, Kathmandu
2. Mr. Aryal Umesh Raj, Kathmandu
3. Dr. Baral Manindra Ranjan, Kathmandu
4. Dr. Bajracharya Binod, Kathmandu
5. Dr. Bhatta Chandra Prakash, Kathmandu
6. Dr. Chandyo Ram Krishna, Kathmandu
7. Dr. Dixit Hemang, Kathmandu
8. Dr. Dixit Siddharth, Kathmandu
9. Dr. Dixit Punam, Kathmandu
10. Dr. Hada Sylvia, Kathmandu
11. Dr. Joshi Binita, Kathmandu
12. Dr. Joshi Sunil Kumar, Kathmandu
13. Dr. Joshi Keshav Das, Kathmandu
14. Dr. Joshi Mukund Raj, Kathmandu
15. Dr. Joshi Robin, Kathmandu
16. Dr. Karki Chanda, Kathmandu
17. Dr. Magar Angel, Kathmandu
18. Dr. Maharjan Dhiresh, Kathmandu
19. Dr. Malla Banshi Krishna, Kathmandu
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
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[email protected]
[email protected]
[email protected]
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Modern Trends in Medical Education 179
Dr. Malla Om Krishna, Kathmandu
Dr. Manandhar Dharma S, Kathmandu
Dr. Nath Shambhu, Kathmandu
Dr. Padhye Saraswati, Kathmandu
Dr. Pandey Arti Sharma, Kathmandu
Dr. Pandey Santwana, Kathmandu
Dr. Paudel Keshab Raj, Kathmandu
Dr. Pradhan Sailesh, Kathmandu
Mr. Poudel Ajay, Kathmandu
Dr. Pradhan Binita, Kathmandu
Dr. Pradhan Sudarshan N, Kathmandu
Mr. Raza Mohammad Shahid, Kathmandu
Dr. Razik Abdul, Kathmandu
Dr. Shakya Kashyap Narsingh, Kathmandu
Dr. Sharma Govinda Prasad, Kathmandu
Mr. Sharma Subhash Chandra, Kathmandu
Dr. Sharma Sunil Kumar, Kathmandu
Dr. Shrestha Bisharad Man, Kathmandu
Dr. Vaidya Abhinav, Kathmandu
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
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[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
Kathmandu University School of Medical Sciences
1. Dr. Karmacharya Biraj, Kavre
2. Dr. Marahatta Sujan, Kavre
3. Dr. Rana N B, Kavre
4. Dr. Pant Chet Raj, Kavre
5. Mr. Risal Prabodh, Kavre
6. Dr. Shrestha Deepak, Kavre
KIST Medical College
1. Mr. Acharya Gopal Prasad, Lalitpur
2. Dr. Acharya Sudeep, Lalitpur
3. Dr. Adhikari Krishna P, Lalitpur
4. Dr. Baral Reetu Sharma, Lalitpur
5. Dr. Kashyap Akhilesh Kumar, Lalitpur
6. Dr. Thapa Trilok Pati, Lalitpur
Manipal College of Medical Sciences
1. Ms. Bhutia Rinchen Doma, Pokhara
2. Mr. Bhat Nishanth B, Pokhara
3. Dr. Jauhari Akhilesh C, Pokhara
4. Mrs. Nagamma T, Pokhara
5. Dr. Upadhyay Dinesh, Pokhara
National Academy of Medical Sciences
1. Dr. Basnet Shiva Bahadur, Kathmandu
2. Dr. Basnet Ranga Bahadur, Kathmandu
3. Dr. Bhattarai Madur Dev, Kathmandu
4. Dr. Gurung Ganesh Bahadur, Kathmandu
180 Modern Trends in Medical Education
[email protected]
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[email protected]
Dr. Jha Brahma Dev, Kathmandu
Dr. K.C K N, Kathmandu
Dr. Kayastha Bhaskar Mohan, Kathmandu
Dr. Manandhar Tara, Kathmandu
Dr. Pahari Shambhu Kumar, Kathmandu
Dr. Panthee Mukund Raj, Kathmandu
Dr. Rana Resham Bahadur Kathmandu
Dr. Rayamajhi Ajit, Kathmandu
Mrs. Tembe Pramila Dewan, Kathmandu
Dr. Vaidya Achala, Kathmandu
National Medical College
1. Dr. Hissaria Shambhu Nath, Birgunj
2. Dr. Sharma Loknath, Birgunj
Nepal Institute of Health Sciences
1. Ms. Pradhan Rina
2. Dr. Pradhananga Yogendra Prasad
3. Ms. Thapa Nilu
4. Mrs. Thapa Rupa Pandey
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
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[email protected]
[email protected]
Nepal Medical College
1. Ms. Bista Durga, Kathmandu
2. Mr. Chaudhary Ganpat, Kathmandu
3. Mr. Dulal Hari Prasad, Kathmandu
4. Mr. Prajapati Rajesh, Kathmandu
5. Dr. Rizyal Shekhar Babu, Kathmandu
6. Dr. Sharma Anjani Kumar, Kathmandu
7. Mr. Shrestha Om, Kathmandu
8. Dr. Tapas Pramanik, Kathmandu
9. Dr. Shrestha Sangita, Kathmandu
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
Nobel College
1. Mr. Upadhyaya Surath, Kathmandu
Nobel Medical College
1. Mr. Niroula Dilli Ram, Morang
2. Dr. Pokhrel Babu Ram, Morang
3. Mr. Singh Ganesh Kumar, Morang
MB Kedia Dental College
1. Dr. Shrestha Suprabhat, Birgunj
2. Dr. Thapa Deepak, Birgunj
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
1. Dr. Shah Moin, Kathmandu
Modern Trends in Medical Education 181
Janaki Medical College
1. Ms. Gupta Anju, Janakpur
2. Dr. Gupta Deepak, Janakpur
3. Dr. Jha Raj Kumar, Janakpur
4. Dr. Kumar Arun, Janakpur
5. Mr. Pandey O P, Janakpur
6. Dr. Shah Hukum Dev, Janakpur
7. Dr. Singh Abinash, Janakpur
Seminar Secretariat
Organising Secretary: Dr. Sunil Kumar Joshi
Joint Organising Secretary: Mr. Subhash Chandra Sharma
Assistant Organising Secretary: Mr. Kumar Raj Pant
Volunteers: Dr. Vivek Dhungana
Dr. Bonisha Sthapit
Dr. Neha Agarwal
Dr. Mukti Ghimire
Dr. Dilasha Bam
Dr. Anuj Kayastha
Dr. Surendra Kunwar
Mr. Mahesh Ghimire
Ms Tulika Dubey
Mr. Abirodh Ranabhat
Ms. Anjali Poudel
Ms. Shrinjaya Basnet
Mr. Nishant Rauniyar
182 Modern Trends in Medical Education