MODERN TRENDS IN MEDICAL EDUCATION (Items Compilation of the Seminar held Jan. 30th –1st Feb. 2009) Edited by Hemang Dixit Sunil KumarJoshi Kathmandu 2009 Modern Trends in Medical Education 1 Published by: Kathmandu Medical College 184, Baburam Acharya Sadak Sinamangal, 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 2 Modern Trends in Medical Education PREFACE T 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 1 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 2 Modern Trends in Medical Education FOREWORD T 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 3 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 4 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 Nepal 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 5 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 6 Modern Trends in Medical Education Hemang Dixit Sunil Kumar Joshi CONTENTS INTRODUCTION 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 ENHANCING SELF-DIRECTED LEARNING 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 INTER-PROFESSIONAL LEARNING Interwoven themes and strands: Guiding student learning in a problem based learning curriculum ........................65 Wijma B USAGE OF IT FOR LEARNING Use of information technology in medical education ....81 Joshi SK Modern Trends in Medical Education 1 ASSESSMENT 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 CLINICAL EVALUATION Communication skills ................................................... 122 Sharma SK Ethics in medical education .......................................... 126 Adhikari RK Clinical evaluation exercise (mini-CEX) ....................... 132 Magar A POST GRADUATION MATTERS 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 Career in medical education ......................................... 163 Magar A Designing an innovative curriculum using PBL ........... 169 Staffan Pelling, Lars Uhlin 2 List of Participants ........................................................ 179 Modern Trends in Medical Education Development of medical education in Nepal 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. Abstract 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 M 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 1 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 2 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 country. 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: Mnemonic S student centred P problem based I integrated C community based E elective S systematic vs vs vs vs vs vs teacher centred information gathering discipline based hospital based uniformed/standard apprenticeship Modern Trends in Medical Education T I D H U A 3 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. 4 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 textbooks.” Stephen Peacock in ‘Oxford as I see it”. Harpers, 144: 738-45, May 1922. Modern Trends in Medical Education 5 References 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. 6 Modern Trends in Medical Education Contemporary challenges in medical education Marahatta SB WHO/TDR Research Fellow Abstract 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 effective ii. Evaluation modalities iii. Mature, professional attitudes to patients and collaborators iv. Improving research standards in medical education B 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 7 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 effective 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. I. Duration of course, knowledge acquisition and making skills training effective 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 8 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 setting. Modern Trends in Medical Education 9 How to synchronise the theoretical knowledge with hands-on skills? 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 10 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 11 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 professionalism. 12 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. Conclusion 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 13 References 1. Solyom AE. Contemporary challenges of medical education: morality and integrity of physicians. [cited 2009 Jan 6]. Available from: http:// www.ishm2006.hu/scientic/abstract.php?ID=290. 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; 319:1358-60. 14 Modern Trends in Medical Education A lesson plan template for tutor training and faculty development in PBL Baral N1, Tekian A2, Gelula MH2 1 B.P. Koirala Institute of Health Sciences, Dharan, Nepal, 2Department of Medical Education, University of Illinois at Chicago, USA Abstract 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. P 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 15 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. 16 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 learning8. 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 discussion. 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 17 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 commitment. 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. 18 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 Title Session Date(s) Audience: Audience Size: Goal(s): Goals: Objectives: Objectives relevant to the topic and activity (ies): Modern Trends in Medical Education 19 Topic Activity Resources Who Duration 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 group 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 pointed. 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 20 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 Conclusion 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. Acknowledgement 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. References 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: 550-8. 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 21 Introducing PBL: A convert’s commentary Phillip Evans Senior University Teacher in Medical Education, Scottish Deans’ Medical Education Group Project Coordinator. Abstract 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. Article The debate about introducing problem-based learning (PBL) in Nepal, raises issues that have been debated in other medical schools. Conviction 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 22 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 PBL. 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 23 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. Resources 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, 24 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 content-coaching. 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. Assessment 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 25 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. References 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): 136-43. 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 26 Modern Trends in Medical Education 8. 9. 10. 11. 12. 13. 14. 15. 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. 1993;68:52-81. 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 27 Learning to teach learning Pandey AS Associate Professor of Biochemistry, Kathmandu Medical College, Duwakot, Nepal. Abstract 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. T 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 28 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 29 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 30 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 31 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. 32 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 http://hsl.mcmaster.ca/education/medicine/index.htm Modern Trends in Medical Education 33 Medical education, sites for students, learning resources http://www.rcsi.ie 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. 34 Modern Trends in Medical Education Conclusion 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. References 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:// www.thisismyindia.com/ancient_india/ancient-india-education. 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 35 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; 2:141-8. 17. Wilkerson L, Irby DM. Strategies for improving teaching practices: a comprehensive approach to faculty development. Acad Med. 1998; 73(4):387-96. 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; 77(5):361-7. 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. 36 Modern Trends in Medical Education Integrated basic medical science (IBMS) teaching learning activities in Nepal Thapa TP Academic Director, KIST Medical College. T 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 37 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. Traditional Teacher-centered Information gathering Discipline-based Hospital-based Uniform course Opportunistic SPICES Model: 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 TU, IOM Fig 1: Calendar of Operation at IOM 38 Modern Trends in Medical Education 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 S T A R T 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 Neurosensory Summer Vacation 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. Modern Trends in Medical Education 39 40 Modern Trends in Medical Education Anatomy TUE Physiology Biochemistry Anatomy Biochemistry Anatomy Pathology Physiology THU FRI Pathology Pharmacology Clinical Posting/ IBMS faculty meeting Pharmacology Microbiology MON WED Pathology Pharmacology 8.55 - 9.50 am 9.50-10.45 am SUN 8 -8.55 am Community Medicine Days B R E A K 11.55 am -12.50 pm Community Medicine Community Medicine Pharmacology Anatomy Pharmacology – C, D Histology – A, B Community Medicine 5 Physiology – D Pathology –A Microbiology –B Biochemistry – C Physiology – C Pathology –D Microbiology –A Biochemistry – B Pharmacology – A, B Histology – C, D L U N C H Physiology – B Pathology –C Microbiology –D Biochemistry – A DISSECTION 2 -4 pm Physiology Clinical Posting Microbiology Community Medicine Physiology – A Pathology –B Microbiology –C Biochemistry - D 11-11.55 am Fig 4: Total Class Hours at IOM KU, Dhulikhel 250 238 200 150 144 100 50 40 Theory Practical 96 42 39 31 133 136 144 112 91 50 41 48 40 8 To ta l 7 6 5 4 3 2 0 1 Lecture Hours Total Theory and Practical Classes Subjects 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 Subjects Unit II TH PR TH Anatomy 49 71 25 Biochemistry 63 25 Microbiology 32 20 Pathology 60 Pharmacology 51 Physiology Community Medicine Total Instructional Hours Unit IV Total TH PR TH PR 57 48 88 65 69 472 30 25 70 25 37 25 300 15 20 49 20 32 20 208 26 32 20 83 20 39 20 300 26 40 24 41 30 29 26 267 31 30 37 30 56 30 62 30 306 48 45 35 40 35 30* 24 30 287 20 Clinical Orientation Medical informatics Unit III PR 20 20 20 80 30 30 627 Self Study 446 326 653 524 2250 196 522 * Plus 1 Week for eld visits/practice. Note: Theory and practical hours given in the table are approximate hours of instruction. Modern Trends in Medical Education 41 Theory includes admixture of lectures, seminars, tutorials and problem-based learning. Practical include laboratory work, hands on skill development, etc. BPKIHS, Dharan Physiology Biochemistry Pathology Microbiology Pharmacology Community Medicine Forensic Medicine Psychiatry Other Disciplines SIS 58 63 53 61 47 70 21 7 5 4 LABEX 30 19 11 20 17 6 7 (FIP) - T-L Method PBL Anatomy Table 2: Academic Programme of the 1st MBBS Students at BPKIHS 3& Entire 16 (CLIP) CVS LABEX Pathology Microbiology Pharmacology Community Medicine Forensic Medicine Psychiatry Other Disciplines 84 94 36 59 34 58 18 4 7 - 47 15 9 17 7 7 7 (FIP) - 1 32 (CLIP) PBL Biochemistry SIS Physiology T-L Method Anatomy Table 3: Academic Programme of the 2nd MBBS Students at BPKIHS 4& entire visual System 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. 42 Modern Trends in Medical Education 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. Conclusion 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 Modern Trends in Medical Education 43 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. References 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. gmc-uk.org 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. 44 Modern Trends in Medical Education Lesson planning Pant CR Department of Ophthalmology, Kathmandu University, School of Medical Sciences, Dhulikhel, Nepal. L 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 be • 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. Modern Trends in Medical Education 45 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 application. 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 better. 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. 46 Modern Trends in Medical Education The following is an example of lesson planning. Objectives ¾ ¾ ¾ ¾ ¾ 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 guidelines. Modern Trends in Medical Education 47 Pretest Pretesting? DEEP THINKING ¾ Vitamin A deficiency is one of the most important causes of childhood blindness. ¾ Today there are nearly 250 million children are sub clinical vitamin A deficient 48 Modern Trends in Medical Education ¾ 3 millions suffer from xerophthalmia ¾ 0.3 millions are Blind with keratomalacia ¾ It constitutes 10% of all blind children in the world. ¾ ¾ Since the publication of Indonesian study in 1986 its has been found that vitamin A is closely related with mortality and morbidity of children Several studies has shown varying percentage of child mortality in vitamin A deficient communities. Modern Trends in Medical Education 49 ¾ • WHO recommended • • 50 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 supplementation Measles related mortality of children could be reduced by 66% with vitamin A supplementation Modern Trends in Medical Education 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 ¾ Animal sources ¾ Vegetable sources ¾ Artificial sources Modern Trends in Medical Education 51 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 52 Modern Trends in Medical Education Evaluation ¾ ¾ ¾ ¾ ¾ ¾ ¾ Question/ answers Clarification Discussion Post-test Feedback Assignment inspiring Cheer up Modern Trends in Medical Education 53 Microteaching-An integral component of teacher’s training in Nepal Magar A CMCL-FAIMER Fellow 2009, Christian Medical College Ludhiana, Punjab, India Introduction 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 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. Purpose 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 54 Modern Trends in Medical Education 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 1. 2. 3. 4. 5. 6. 7. 8. 9. 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. Modern Trends in Medical Education 55 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. Plan State the Objective and Teach Observer’s Opinion Observers’ Criticism Re-teach Re-plan Fig 1: The Cycle of Microteaching4 Advantages 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 56 Modern Trends in Medical Education 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) Yes No Cannot say Not applicable 1. The speaker stated the objectives F F F F 2. The speaker presented the matter in organised sequential manner F F F F 3. The speaker used jokes or humor to lighten the mood F F F F 4. The speed of presentation varied with emphasis F F F F 5. Example/illustrations were used to emphasize the component F F F F 6. The speaker summarized the topic at the end F F F F 7. The speaker suggested additional sources of reading F F F F 8. The speaker used audiovisual aids (slides, charts, chalk-board, overhead projector, model) F F F F If he did use the aids, they were clear, explanatory, well prepared F F F F 10. The speaker allowed students to participate actively by: F F F F F F F F F F F F F F F F F F F F 9. a) Allowing questions b) Inviting questions c) Suggesting questions d) Suggesting questions and answering the questions 11. Any suggestions for the speakers to improve the teaching/learning exercise Modern Trends in Medical Education 57 Criticism 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 skills1. References 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. jpgmonline.com/text.asp?1993/39/3/142/613 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/ wiki/Microteaching 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. 58 Modern Trends in Medical Education Tutorship: Redefining the teacher role Swahnberg K Associate Professor in Gender & Medicine, Linköping University, Sweden. T 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 ward”. 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 Modern Trends in Medical Education 59 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 content-expertise. 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 difcult. 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 60 Modern Trends in Medical Education 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 group. 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. Modern Trends in Medical Education 61 Tip 4 “Do not dominate group discussion but rather facilitate the process” 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 contribute 62 Modern Trends in Medical Education • • • • 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. Evaluation Now talking about examination in PBL, we use the following for examination: • Self-assessment • Peer-assessment • Tutor assessment • Examination Modern Trends in Medical Education 63 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. References 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. 64 Modern Trends in Medical Education 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. A 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. Modern Trends in Medical Education 65 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 66 Modern Trends in Medical Education 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 skill 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 below). 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. Modern Trends in Medical Education 67 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 functions Students play an active role in all parts of curriculum creation and evaluation 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. 68 Modern Trends in Medical Education Fig 4: Curriculum overview Modern Trends in Medical Education 69 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 function. 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 70 Modern Trends in Medical Education 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 Notes: 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. Modern Trends in Medical Education 71 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 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 72 Modern Trends in Medical Education 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. Box III Content formulation for lectures in a pbl curriculum 1. 2. 3. 4. 5. 6. 7. Dene central and often used expressions and concepts Focus on core items Combine overview of mechanisms with explanations of difcult passages 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 Modern Trends in Medical Education 73 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 70% retention Fig 8: With a holistic perspective of knowledge the retained knowledge still “makes sense” 74 Modern Trends in Medical Education 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. Examinations 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 correspondence. 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. Strands 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 Modern Trends in Medical Education 75 2. 3. 4. 5. 6. 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 chair. 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. Consensus 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. 76 Modern Trends in Medical Education Evaluations 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 tests. 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) Conclusion 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 77 Theme groups Pros: 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. Cons: Naturally there will be ghts and conicts when very individualistic persons are forced to adjust to one another. 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 energy. Strands Pros: 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. Cons: 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 contempt. The importance of caring for one’s own moral resources to manage ethical dilemmas becomes evident. 78 It seems to be a slow process to convince all faculty members about the importance of caring for future physician’s development as human beings. Modern Trends in Medical Education My personal experiences Pros: 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. Cons: 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, 2000. 5. Home page of the FHS: http://www.hu.liu.se/ 6. Home page of the medical program: http://www.hu.liu.se/lakarprogr/ om_lakarprogrammet 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_ handl Modern Trends in Medical Education 79 10. Results from evaluations by alumni 2000-2004 and 2006 organized by the Swedish Medical Association: http://www.hu.liu.se/lakarprogr/ alumni 11. List of publications in pedagogy from FHS: http://www.hu.liu. se/content/1/c6/03/66/69/Publikationslista%20pedagogik%20 HU20060906.pdf 12. List of publications on line: http://www.hu.liu.se/pedagogisktcentrum/ pub_online 80 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, Nepal. T 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 Modern Trends in Medical Education 81 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. 82 Modern Trends in Medical Education 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 Modern Trends in Medical Education 83 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 possible. 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 itself. 84 Modern Trends in Medical Education 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 use10: 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. Modern Trends in Medical Education 85 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 conditions. 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? Conclusion 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. 86 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. Acknowledgement I would like to thank Dr. Suvash Shrestha, an Intern from Kathmandu Medical College for his generous feedback on the article. References 1. Information Technology Association of America. Denitions of Information technology. ITAA: US. Available from: http://www.itaa. org/es/docs/Information%20Technology%20Denitions.pdf 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 87 Students’ perception of Problem Based Learning in Kathmandu University School of Medical Sciences Karmacharya BM1, Risal P2 1 Problem Based Learning Coordinator, 2Lecturer, Department of Biochemistry, Kathmandu University School of Medical Sciences, Dhulikhel, Nepal. Abstract 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 University P 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 88 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 issues1,2. 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 89 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. Results 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 (n=34) Third year MBBS students (n=44) Total (n=78) 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 information. 8 (1.5) 7(2.3) 7 (2.1) Statements 90 Modern Trends in Medical Education 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 91 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 learners10. 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 92 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 learning. References 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; 34:721-8. 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; 32(4):407-10. Modern Trends in Medical Education 93 Assessment of undergraduate medical students Rizyal SB Founder Principal, Nepal Medical College, Jorpati, Nepal. Keywords: Assessment; learning, learner; facilitator; undergraduate medical students. L 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) 94 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. Pre-test 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 95 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? 96 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 97 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 diseases. 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 student 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 curriculum. Conclusion 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. 98 Modern Trends in Medical Education References 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 99 Rotating internship - Interns’ response Shrestha D1, Mishra B2 Lecturer, Department of Orthopaedics, Kathmandu University Medical School, Dhulikhel, Nepal; 2Relevant Institute for Supplementary Medical Education, Kathmandu, Nepal. 1 Abstract 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 satisfaction Key words: Clinical skills, Communication, Community postings, Education, Internship, Harassments. 100 Modern Trends in Medical Education I 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 interns. 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 Result 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 duties….” 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 posting….” “….would have been more effective if it had more academic exercises….” “….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 parentheses) Item Low Moderate 2(6.7) 3(10) 10(33.3) Good 22(73.3) 16(53.3) 15(50) Very good 6(20) 11(36.7) 4(13.3) 3(10) 3(10) 12(40) 14(46.7) 10(33.3) 13(43.3) 9(30) 17(56.7) 2(6.7) 3(10) 3(10) 2(6.7) 1(3.3) 3(10) 1(3.3) 9(30) 1(3.3) 8(26.7) 14(46.7) 1(3.3) 10(33.3) 6(20) 10(33.3) 12(40) 19(63.3) 9(30.3) 22(73.3) 7(23.3) 3(10) 10(33.3) Very low Low Moderate 2(6.7) 3(10) 1(3.3) 5(16.7) 10(33.3) 7(23.3) 11(36.7) High 15(50) 13(43.3) 20(66.7) 8(26.7) Very high 15(50) 2(6.7) 2(6.7) 5(16.7) Interest towards medical research (N=28) 2(7.4) 9(32.1) 13(47.4) 4(14.28) Awareness of universal precautions (N=29) 1(3.4) 2(6.8) 14(47.6) 12(40.8) 1(3.3) 16(53.3) 12(40) Communication skill with patients colleagues teachers Condence of handling medico-legal cases talking death or breaking bad news handling cases independently Interaction with consultant/ faculty/teacher junior doctors nurses allied health personals patients Contribution in your learning Patients Teachers Colleagues Books Did u maintain patient condentiality? Community postings Did you achieve objectives? How effective? Facilities during internship of Accommodation Pocket expenses Transportation Learning materials Very low 1(3.3) 1(3.3) 2(6.7) 1(3.3) 1(3.3) Very less 3(10) 3(10) Less 2(6.7) 4(13.3) Moderate 9(30) 14(46.7) High 13(43.3) 7(23.3) Very High 3(10) 2(6.7) Very poor 8(26.7) 4(13.3) 5(16.7) 5(16.7) Poor 8(26.7) 3(10) 5(16.7) 5(16.7) Moderate 7(23.3) 13(43.3) 13(43.3) 11(36.7) Good 5(16.7) 9(30) 7(23.3) 5(16.7) Very good 2(6.7) 1(3.3) 106 Modern Trends in Medical Education 4(13.3) 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 (ABCDE) Intubation Nasal packing Tooth extraction Syringing for Nasolacrimal duct Cast (PoP) application 2(6.7) 9(30) 1(3.3) 1(3.3) 14(46.7) 6(20) 1(3.3) 1(3.3) 15(50) 7(23.3) Not at all 27(93.2) 21(71.4) 22(81.5) Harassments Sexual (N=29) Mental (N=29) Physical (N=27) 1(3.3) 6(20) 2(6.7) 1(3.3) 3(10) 7(23.3) 6(20) 9(30) Low 2(6.8) 3(10.2) 1(3.7) 4(13.3) 1(3.3) 4(13.3) 5(16.7) 3(10) 10(33.3) 6(20) 12(40) 14(46.7) 12(40) 6(20) 5(16.7) 4(13.3) 16(53.3) 13(43.3) 15(50) 4(13.3) 2(6.7) 14(46.7) 14(46.7) 7(23.3) 18(60) 15(50) 14(46.7) 9(30.0) 3(10) 7(23.3) 24(80) 3(10) 17(56.7) 9(30) 25(83.3) 4(13.3) 11(36.7) 12(40) 4(13.3) 4(13.3) 2(6.7) 1(3.3) 1(3.3) Very low Moderate Very high 2(6.7) 2(6.7) 1(3.4) 4(13.6) 4(14.8) 10 9 Count 8 8 6 6 4 3 3 Gender 2 Female 1 0 24 25 Male 26 Age Fig 1: Age and sex distribution of 30 participants Modern Trends in Medical Education 107 Discussion 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. References 1. Boelen C. Medical education reforms: The need for global action. Acad Med. 1992; 67(11):745–9. 110 Modern Trends in Medical Education 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 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; 20:428–32. Jolly BC, Macdonald MM. Education for practice: the role of practical experience in undergraduate and general clinical training. Med Educ. 1989; 23:189-95. 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. Rural internships for nal year students: clinical experience, education and workforce. Rural and Remote Health Journal [serial on internet]. 2008; 827. Available from: http://www.rrh.org.au/ Daugherty SR, Baldwin DC, Rowely BD. Learning, Satisfaction and mistreatment during medical internship: A national survey on working conditions. JAMA. 1196;279:1194-9. Modern Trends in Medical Education 111 PBL - Allied health sciences perspective Risal P1, Karmacharya BM2 1 Lecturer, Department of Biochemistry, 2Problem Based Learning Coordinator/ Lecturer, Department of Medicine, Kathmandu University School of Medical Sciences, Dhulikhel, Nepal. Abstract 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 career. 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 P 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 programmes. 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. Instruments 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 Results 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 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 career. Following are some of the common themes as for example from the respondents: “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) Strongly agree Agree PBL is a valuable experience. 45 (58.5%) 31(40%) PBL helps me to think critically. 56(72.3%) 21(27.2%) Search for answers to the learning issues is exciting. 49(63%) Disagree 1(1.5%) 28(37%) PBL is a worthwhile method of learning. 38(49.3%) 34(44.6%) 5(6.1%) PBL stimulates my thinking process. 47(61.5%) 1(1.5%) Reading about the learning issues is stimulating. 35(46.1%) 42(53.9%) 29(37%) 118 Modern Trends in Medical Education Strongly Disagree Table 2: Group learning (% of total response) Strongly agree Agree Disagree Group interaction in the PBL was the most valuable part of learning. 57(73.9%) 19(24.6%) 1(1.5%) An active participant in the PBL experience. 26(33.6%) 45(58.5%) 5(6.2%) Tutor facilitated the group interactions. 36(46.2%) 41(53.8%) 2(3%) 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 other. 5(6.1%) 20(26.2%) 45(58.5%) 11(13.8%) Strongly Disagree 1(1.5%) 1(1.5%) 1(1.5%) Table 3: Student’s Expectation (% of total response) Strongly agree Would like to have more opportunities for PBL. Agree Disagree Strongly Disagree 6(7.7%) 1(1.5%) 43(55.4%) 34(44.6%) Prefer PBL method rather than traditional-lecture 36(46.2%) 34(44.6%) method. Discussion 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 References 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. 5. 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. C 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 supportive. 122 Modern Trends in Medical Education Defense Evaluative Controlling Hidden Neutral Superior Certain Supportive Descriptive Cooperative Open Empathetic Equal Provisional. 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 discipline. 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 communication. 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 Source 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. Message This is the information you want to communicate. In our teaching methodology one can quote this to lesson plan. Encoding 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. Channel 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 effective. Decoding 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. Receiver 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. Feedback 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. I 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 sees. 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 doctors 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 strategy. 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 country. References 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 3. 4. 5. 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, WHO. Modern Trends in Medical Education 131 Clinical evaluation exercise (mini-CEX) Magar A CMCL-FAIMER Fellow 2009, Christian Medical College Ludhiana, Punjab, India I 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 Methods Domain Type of use Limitation Strength Summative assessments within courses or clerkships; national in-service, licensing, and certication examinations Difcult to write, especially in certain content areas; can result in cueing; can seem articial and removed from real situations Can assess many content areas in relatively little time Not yet proven to transfer to real-life situations that require clinical reasoning Assess clinical problemsolving ability, avoid cueing, can be graded by computer Summative and formative assessments in courses and clerkships Reliability dependent on training of graders Avoid cueing, assess interpretation and problemsolving ability Preclinical courses, limited use in clerkships Timeconsuming to grade, must work to establish interrater reliability, long testing time required to encompass a variety of domains Avoid cueing, use higherorder cognitive processes Global summative and sometimes formative assessments in clinical rotations Often based on second-hand reports and case presentations rather than on direct observation, subjective Use of multiple independent raters can overcome some variability due to subjectivity Written exercises Multiple-choice questions in either singlebest-answer Knowledge or extended matching format National Key-feature and licensing and script-concorClinical reasoning certication dance questions examinations Short-answer questions Structured essays Ability to interpret diagnostic tests Synthesis of information Assessments by supervising clinicians Global ratings with comments at end of rotation Clinical skills, communication, teamwork, presentation skills, organization, work habits Modern Trends in Medical Education 133 Structured direct observation with checklists Communication for ratings (e.g., skills, clinical mini-clinicalskills evaluation exercise or video review) Limited use in clerkships and residencies, a few boardcertication examinations Selective rather than habitual behaviours observed, relatively timeconsuming Subjective, sex and race Limited use in bias has been clerkships and reported, timecomprehensive consuming, Oral Knowledge, medical school require training examinations clinical reasoning assessments, of examiners, some boardsummative certication assessments examinations need two or more examiners Clinical simulations Standardized patients and objective structured clinical examinations Formative and summative assessments in Some clinical courses, clerkskills, interships, medical personal behavior, schools, nacommunication tional licensure skills examinations, board certication in Canada Incognito standardized patients Primarily used in research; some courses, clerkships, and residencies use for formative feedback Actual practice habits 134 Modern Trends in Medical Education Feedback provided by credible experts Feedback provided by credible experts Timing and setting may seem articial, require suspension of disbelief, checklists may penalize examinees who use shortcuts, expensive Tailored to educational goals; reliable, consistent case presentation and ratings; can be observed by faculty or standardized patients; realistic Requires prior consent, logistically challenging, expensive Very realistic, most accurate way of assessing clinician’s behaviour Hightechnology simulations Procedural skills, teamwork, simulated clinical dilemmas Formative and some summative assessment Timing and setting may seem articial, require suspension of disbelief, checklists may penalize examinees who use shortcuts, expensive Tailored to educational goals, can be observed by faculty, often realistic and credible Condentiality, anonymity, and trainee buy-in essential Ratings encompass habitual behaviours, credible source, correlates with future academic and clinical performance Multisource (“360-degree”) assessments Formative feedback in courses and comprehensive medical school assessments, formative assessment for board recertication Peer assessments Professional demeanour, work habits, interpersonal behaviour, teamwork Patient assessments Formative and Ability to summative, board gain patients’ trust; patient recertication, satisfaction, com- use by insurers munication skills to determine bonuses Provide global impressions rather than analysis Credible of specic source of behaviours, assessment ratings generally high with little variability Knowledge, skills, attitudes, beliefs, behaviours Do not accurately describe actual behaviour unless training and feedback provided Selfassessments Formative Foster reection and development of learning plans Modern Trends in Medical Education 135 Portfolios Formative and summative All aspects of uses across competence, curriculum especially and within appropriate for clerkships practice-based and residency learning and programs, improvement and used by some systems-based U.K. medical practice schools and specialty boards Learner selects best case material, timeconsuming to prepare and review Display projects for review, foster reection and development of learning plans 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) Evaluator: Date: F Student Name: Setting: F Ambulatory Clinic F Inpatient Unit R1 FR2 FR3 FER FOther: F DOB: Patient ID: Male F Female Patient Problem/Diagnosis: Complexity of Encounter: FLow F Moderate F High Focus of Evaluator Observation: FData Gathering FDiagnosis FTherapy FCounselling EVALUATION: Unsatisfactory 123 1. Medical Interviewing Skills (not observed) Marginal Satisfactory Superior 4 56 789 2. Physical Examination Skills (not observed) 123 4 56 789 3. Counselling Skills (not observed) 123 4 56 789 4. Clinical Judgement (not observed) 123 4 56 789 5. Professionalism/Humanism (not observed) 123 4 56 789 6. Overall Clinical Competence (not observed) 123 4 56 789 Providing Feedback: _______Mins Mini-CEX Time: Observing_______Mins Evaluator Satisfaction with Mini-CEX LOW 1 2 3 4 5 6 7 8 9 HIGH 5 6 7 8 9 HIGH Resident Satisfaction with Mini-CEX LOW 1 2 3 4 Comments: 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 of comfort, modesty, condentiality, information. Clinical Judgment: Selectively orders/performs appropriate diagnostic studies, considers risks, benets. Counseling Skills: Explains rationale for test/ treatment, obtains patient’s consent, educates/counsels regarding management. Organization/Efciency: Prioritizes; is timely; succinct. Overall Clinical Competence: Demonstrates judgment, synthesis, caring, effectiveness, efciency. 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 1 Insufcient history to make an acceptably safe diagnosis. Unstructured. No exploration. 2 Basic history obtained but questions unstructured with some important areas left unexplored. 3 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 / agenda 4 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. 5 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. 6 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 management. 2. Physical Examination 1 Incomplete examination, some illogical order, poor or missing explanation to patient. Little attention paid to infection control. 2 Unstructured or occasionally inappropriate technique. Inadequate explanation to patient. Little respect for patient or patient carelessly handled. 3 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. 4 Structured examination which ows smoothly. Good positioning. Clear explanation to patient with informed consent. Equipment handled appropriately. Sensitive to patient’s comfort & modesty. 5 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 6 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 1 Any rudeness, no greeting or introduction. Insensitive behaviour with no consideration for patient’s feelings. No attempt to listen to patient. 2 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. 3 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. 4 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. 5 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. 6 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 1 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 2 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 management 3 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. 4 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 help 5 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 6 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 1 2 3 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. 4 Shows respect, compassion, empathy and establishes trust. Behaves in an ethical manner and is aware of limitations. Respects colleagues. 5 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. 6 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 1 Very slow, unstructured 2 Slow, unable to prioritise tasks No use of other team members 3 Slow, long summary Unable to clearly prioritise tasks Confuses patients with own confusion 142 Modern Trends in Medical Education 4 Timely in dealing with situation Appropriate degree of urgency Appropriate use of resources (team, own time) Can appear rushed at times 5 Condent, good use of time, succinct, summarises and prioritises appropriately. Gives patient appropriate time 6 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. References 1. Epstein RM. Assessment in medical education. N Engl J Med. 2007;356:387-96. 2. Wikipedia [homepage on internet]. Microteaching [online]. 2008 [cited 2008 Dec 26]; Available from: URL:http://en.wikipedia.org/ wiki/Assessment 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 education Bhattarai MD Medical Education Unit, National Academy of Medical Sciences, Kathmandu Abstract 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 A 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 assessments4. 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 programme 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 admission 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 criteria 3. Cooperative learning 4. Examination, theory and clinical practical, are just a part of the total criteria 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 required 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 Council; regular Examination 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 system 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 programme 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 year 2. Completion of horizontal and vertical, i.e. spiral upward, rotation training posting 3. Completion of minimum numbers of most important procedures / experiences 148 Modern Trends in Medical Education 4. 5. 6. 7. 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 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. 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 improved. 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) in NAMS S. No. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 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 Total Min No. 300 25 50 25 30 10 10 20 10 10 490 Table 3: Minimal number of most important procedures / experience required to be eligible for Final Examination in MD (Anesthesia) in NAMS S.No. 1. 2. Procedures / Experience Instrumental Delivery Caesarean Section Min No. 30 30 3. MRP/cervical tear repair/Haematoma Drainage/3rd degree perineal tear 15 4. 5. 6. D&C, MVA, including PAC and CAC Minilap / laparoscopic tubal ligation Laparotomy for ectopic pregnancy 30 5 5 7. Abdominal Hysterectomy, Oophorectomy, Myomectomy 15 8. Vaginal Hysterectomy/Fothergill’s operation 10 Modern Trends in Medical Education 151 9. Cu T/ Norplant 10 10. Cervical cancer screening and treatment of cervical dysplasia 10 11. Investigation/ treatment for subfertility: HSG, PCT, Sonoslapingograpgy, Follicular monitoring, Sperm preparation, IUI 5 Total 165 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. 1 2 3 4 5 6 Presentation 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 7 8 18 14 7 5 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 percentage 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 coverage. 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 examination3. 156 Modern Trends in Medical Education Conclusion 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. References 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; 2006. 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; 1999. 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. 1. 2. 3. 4. 5. 6. 7. 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 2. 3. 4. 5. 6. 7. Planned systematically on the basis of needs assessment and prioritization 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 challenge Traditional lecture format only for basic science CME should employ self-directed, interactive, and relevant learning experiences 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 3. 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 education • Develop, support and promote inter professional educational opportunities • 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 learning • 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. References 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; 316(7128):385-9. 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, India S 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. FAIMER3 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. FAIMER Vision • 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 education History 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 plan. 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 impact. 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 program; 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 fellowship. 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 1. 2. 3. 4. 5. 6. 7. 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 year. 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. References 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. jpgmonline.com/text.asp?1993/39/3/142/613 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 1 Faculty of Health Science, Linköping University, Sweden T 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 essential. 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 uncertainty. 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. S Student-centred Teacher-centred P Problem-based Information-gathering I Integrated Discipline-based C Community-based Hospital-based E Electives Standard Programme S Systematic Apprenticeship-based 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. RULE OF PURITY ”things must be kept apart” Collection curriculum Boundaries redefined Boundaries collapsing Integrated curriculum RULE OF RELEVANCE ”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. Concrete Experience Testing Implications of Concepts in New Situations Observation and Reections Formation of Abstract Concept and Generalization 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 Intended Learning Outcomes Aligned Aligned Learning and teaching activities Designed to meet Learning Outcomes Assessment methods Aligned 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. References 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. 1984;18(4):284-97. 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. 1971. 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] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] Modern Trends in Medical Education 179 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 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] [email protected] [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] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 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] [email protected] [email protected] [email protected] [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] Individuals 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