A decade of reform in medical education: Experiences and challenges at Tehran University of Medical Sciences

Abstract

Purpose: In this paper, we present the major curricular reform in MD program of Tehran University of Medical Sciences, the oldest and the largest medical university in Iran, initiated about a decade ago.

Materials and methods: Following a comprehensive program evaluation, many of the basic challenges of the traditional curriculum were revealed, namely, lack of pre-defined competencies for graduates, over-reliance on teacher-centered teaching methods, over-emphasis on knowledge base in student assessments, and focusing solely on biomedical aspects of patient care. In 2010, a vision statement for reform was created and approved by the University Council. The new curriculum was launched in 2011.

Results: The changes included: revising the content of the courses, assimilating horizontal and vertical integration, emphasizing clinical skills, encouraging active involvement in patient management, providing more opportunity for supervised practice, integrating behavioral and psychosocial topics into the curriculum, incorporating interactive teaching methods, assessing students’ higher levels of cognition, and strengthening workplace assessments. To evaluate the changes, data were continuously collected and analyzed from the beginning.

Conclusions: Changing the curriculum of an MD program is a laborious task which should be planned and undertaken carefully and cautiously. It is an endless, yet invaluable and satisfying endeavor toward better future.     

Small group activities within academic communities improve the connectedness of students and faculty

Background: The University of California, San Diego, School of Medicine implemented a curriculum change that included reduction of lectures, incorporation of problem-based learning and other small group activities. Six academic communities were introduced for teaching longitudinal curricular content and organizing extracurricular activities.

Methods: Surveys were collected from 904 first- and second-year medical students over 6 years. Student satisfaction data with their sense of connectedness and community support were collected before and after the implementation of the new curriculum. In a follow-up survey, medical students rated factors that contributed to their sense of connectedness with faculty and students (n?=?134).

Results: Students’ perception of connectedness to faculty significantly increased following implementation of a curriculum change that included academic communities. Students ranked small group clinical skills activities within academic communities significantly higher than other activities concerning their sense of connectedness with faculty. Students’ perception of connectedness among each other was high at baseline and did not significantly change. Small group activities scored higher than extracurricular activities regarding students’ connectedness among themselves.

Conclusions: The implementation of a new curriculum with more small group educational activities including academic communities enhanced connectedness between students and faculty and resulted in an increased sense of community.     

Training junior faculty to become clinical teachers: The value of personalized coaching

Abstract

Background: Junior clinical faculty require institutional support in the acquisition of feedback and clinical supervision skills of trainees. We tested the effectiveness of a personalized coaching versus guided self-reflection format of a faculty development program at improving faculty skills and self-efficacy.

Methods: Participants were evaluated both before and after the program using a four-station Objective Structured Teaching Exercise (OSTE). A gain-score analysis, one-way ANOVA, and paired t-tests were used to evaluate both groups. The impact on the learning environment was measured by resident ratings of the Maastricht Clinical Teaching Questionnaire.

Results: One hundred and twenty-seven participants completed the study over a three-year period. Both groups had significant improvements in self-efficacy. Participants in the coaching group demonstrated superior performance in encouraging learner self-reflection, teaching effectiveness, verifying learner understanding, exploring feelings/needs, and defining learning objectives. Over a 5-year period, the overall institutional learning climate significantly improved concerning faculty role-modeling, coaching, articulation, and explorations skills.

Conclusion: Offering a contextualized faculty-development program using OSTEs that provides multiple opportunities for feedback and is focused on creating a community of practice is an effective method to facilitate the transfer of skills to the clinical environment, supports teacher identity development, and favorably impacts the learning climate.     

A systematic review of faculty development initiatives designed to enhance teaching effectiveness: A 10-year update: BEME Guide No. 40

Background: This review, which focused on faculty development initiatives designed to improve teaching effectiveness, synthesized findings related to intervention types, study characteristics, individual and organizational outcomes, key features, and community building.

Methods: This review included 111 studies (between 2002 and 2012) that met the review criteria.

Findings: Overall satisfaction with faculty development programs was high. Participants reported increased confidence, enthusiasm, and awareness of effective educational practices. Gains in knowledge and skills, and self-reported changes in teaching behaviors, were frequently noted. Observed behavior changes included enhanced teaching practices, new educational initiatives, new leadership positions, and increased academic output. Organizational changes were infrequently explored. Key features included evidence-informed educational design, relevant content, experiential learning, feedback and reflection, educational projects, intentional community building, longitudinal program design, and institutional support.

Conclusion: This review holds implications for practice and research. Moving forward, we should build on current success, broaden the focus beyond individual teaching effectiveness, develop programs that extend over time, promote workplace learning, foster community development, and secure institutional support. We should also embed studies in a theoretical framework, conduct more qualitative and mixed methods studies, assess behavioral and organizational change, evaluate transfer to practice, analyse key features, and explore the role of faculty development within the larger organizational context.     

The alignment imperative in curriculum renewal

Abstract

Rationale: There are perennial calls for MD curricula to reform in order to meet the changing needs of students, patients, and society. And yet, efforts at renewal have also been suggested to have minimal impact on the pedagogy and outcomes of medical education. One reason may be misalignment between the components of the curriculum during design and implementation. The University of Toronto MD program recently renewed its undergraduate preclinical Foundations curriculum. Mindful of the pitfalls of misalignment, the renewal process focused deliberately on alignment between the various components of the curriculum: instructional methods, student assessment, faculty development, and the larger purpose of serving students and society.

Innovation: Educational evidence was used to drive the alignment process which resulted in three major changes. First, we created a spiral curriculum centered on 72 virtual patient cases designed to integrate content and prepare students for clinical learning. Second, we introduced a novel medical psychiatry component to address a core societal need in mental health. This exposed students early to experiences of complexity, ambiguity, and integrated patient care. Lastly, a shift to assessment for learning and programmatic assessment was designed and implemented concurrently to reinforce the pedagogy of the curriculum. Synchronous faculty development was developed for the new roles required of faculty.

Conclusions: Early program evaluation shows alignment of these curricular components requires ongoing attention and resources in order to be successful. The potential benefits of this alignment are well prepared students who can meet the needs of their patients and society in an increasingly complex health system.     

How does peer teaching compare to faculty teaching? A systematic review and meta-analysis*

Purpose: In undergraduate medical education, peer-teaching has become an established and common method to enhance student learning. Evidence suggests that peer-teaching provides learning benefits for both learners and tutors. We aimed to describe the outcomes for medical students taught by peers through systematic review and meta-analysis of existing literature.

Methods: Seven databases were searched through 21 terms and their Boolean combinations. Studies reporting knowledge or skills outcomes of students taught by peers compared to those taught by faculty or qualified clinicians were included. Extracted data on students’ knowledge and skills outcomes were synthesised through a random effects model meta-analysis.

Results: The search yielded 2292 studies. Five hundred and fifty-three duplicates and 1611 irrelevant articles were removed during title-screening. The abstracts of 128 papers were screened against the inclusion and exclusion criteria. Ten studies have been included in the review. Meta-analyses showed no significant difference in peer-teaching compared to faculty teaching for knowledge or skills outcomes, standardised mean differences were 0.07 (95% CI: ?0.07, 0.21) and 0.11 (95% CI: ?0.07, 1.29), respectively.

Conclusion: Students taught by peers do not have significantly different outcomes to those taught by faculty. As the process of teaching helps to develop both tutor knowledge and teaching skills, peer-teaching should be supported.     

Taking stock of what is known about faculty development in competency-based medical education: A scoping review paper

Abstract

Purpose: The primary objective was to inventory what is currently known about faculty development (FD) for competency-based medical educations (CBME) and identify gaps in the literature.

Methods: A scoping review methodology was employed. Inclusion criteria for article selection were established with two reviewers completing a full-text analysis. Quality checks were included, along with iterative consultation on data collection and consensus decision making via a grounded theory approach.

Results: The review identified 19 articles published between 2009 and 2018. Most articles (N?=?15) offered suggestions as to what should happen with FD in CBME, but few (N?=?4) adopted an experimental design. Six main themes were identified with three main features of FD noted across themes: (1) The importance of direct and timely feedback to faculty members on their teaching and assessment skills. (2) The role of establishing shared mental models for CBME curricula. (3) That FD is thought of longitudinally, not as a one-time bolus.

Conclusion: This work illustrates that there is limited, high quality research in FD for CBME. Future FD activities should consider employing a longitudinal and multi-modal program format that includes feedback for the faculty participants on their teaching and assessments skills, including the development of faculty coaching skills.     

Students perceive skills learned in pre-clerkship PBL valuable in core clinical rotations

Abstract

Purpose: Problem-based learning (PBL) is an instructional method widely used by medical educators that promotes an environment in which students effectively learn the foundational knowledge and skills that are prerequisites for graduation. This study evaluated medical students’ perceptions of the helpfulness of skills acquired in PBL to core clerkship rotations.

Methods: A 25-item survey was designed to assess students’ perceptions of skills learned in PBL that were helpful on core clerkships and transferable to the clinical setting. A random sample of students with at least 8?months of clerkship experience were invited to complete the survey.

Results: Of 68 students, 35 (52%) returned questionnaires. Results suggest a clustering of themes based on their perceived value. Skills learned in PBL that students rated most highly as helpful or very helpful during core clinical rotations include: comfort discussing concepts, identifying key information, presentation skills, interpersonal skills, diagnostic thinking, finding information, self-awareness, and organizing information. Other items rated highly included: forming questions, time management, primary literature (engaging with published original research articles), and leadership. The skills acquired in PBL were associated with multiple competency domains.

Conclusions: Although conditions of the pre-clerkship curriculum are substantially different from the learning environment of clerkship rotations, skills learned in PBL are perceived as applicable to authentic clinical training.     

School of Medicine of Federal University of Rio Grande Do Norte: A traditional curriculum with innovative trends in medical education

Abstract

Introduction: The Medical School of the Federal University of Rio Grande do Norte (UFRN) is one of the biggest public medical schools in Northeast Brazil. In the last decade, significant investment in faculty development, innovative learning methodologies and student engagement has been key milestones in educational improvement at this medical school, harnessed to recent political changes that strengthened community-based and emergency education. This study describes how curriculum changes in UFRN Medical School have been responsible for major improvements in medical education locally and which impacts such transformations may have on the educational community.

Methods: A group of students and teachers revised the new curriculum and established the key changes over the past years that have been responsible for the local enhancement of medical education. This information was compared and contrasted to further educational evidences in order to define patterns that can be reproduced in other institutions.

Results: Improvements in faculty development have been fairly observed in the institution, exemplified by the participation of a growing number of faculty members in programs for professional development and also by the creation of a local masters degree in health education. Alongside, strong student engagement in curriculum matters enhanced the teaching-learning process.

Conclusions: Due to a deeper involvement of students and teachers in medical education, it has been possible to implement innovative teaching-learning and assessment strategies over the last ten years and place UFRN Medical School at a privileged position in relation to undergraduate training, educational research and professional development of faculty staff.     

Development,implementation, and evaluation of an integrated multidisciplinary Objective Structured Clinical Examination (OSCE) in primary health care settings within limited resources

Background: In ordinary circumstances, objective structured clinical examination (OSCE) is a resource-intensive assessment method. In case of developing and implementing multidisciplinary OSCE, there is no doubt that the cost will be greater.

Aim: Through this study a research project was conducted to develop, implement and evaluate a multidisciplinary OSCE model within limited resources.

Methods: This research project went through the steps of blueprinting, station writing, resources reallocation, implementation and finally evaluation.

Results: The developed model was implemented in the Primary Health Care (PHC) program which is one of the pillars of the Community-Based undergraduate curriculum of the Faculty of Medicine, Suez Canal University (FOM-SCU). Data for evaluation of the implemented OSCE model were derived from two resources. First, feedback of the students and assessors through self-administered questionnaires was obtained. Second, evaluation of the OSCE psychometrics was done. The deliverables of this research project included a set of validated integrated multi-disciplinary and low cost OSCE stations with an estimated reliability index of 0.6.

Conclusion: After having this experience, we have a critical mass of faculty members trained on blueprinting and station writing and a group of trained assessors, facilitators and role players. Also there is a state of awareness among students on how to proceed in this type of OSCE which renders future implementation more feasible.     

Cutoff score evaluation of undergraduate dental curriculum

Abstract

Background and objectives: Exams at the Faculty of Dentistry (KAUFD) are usually constructed to match King Abdulaziz University (KAU) policy of a fixed 60% cutoff score, though they have never been tested or evaluated. The purpose of this study was to validate the cutoff scores of three final fifth-year written exams of the undergraduate Endodontic course to assess whether they were similar to KAU regulation using the Angoff rating method.

Design and settings: This study was conducted between May 2014 and February 2015 at the Faculty of Dentistry, King Abdulaziz University.

Methods: Using the Angoff rating method, three final fifth-year undergraduate Endodontic written exams were evaluated by four senior faculty members.

Results: The cutoff scores for exams 1, 2 and 3 were 57.4%, 62.9% and 63.1%, respectively. Adjusting the exams’ cut off scores would cause changes in some students’ results.

Conclusions: Although the cutoff scores for all exams were close to 60%, slight deviation from the accepted cutoff score could definitely affect the students’ results. Therefore, all exams should be validated before being given to students to certify that the cutoff score is credible and defensible.     

Educating universal professionals or global physicians? A multi-centre study of international medical programmes design

Abstract

Introduction: Medical schools increasingly offer curricula that specifically aim to prepare students for an international medical career. This is challenging as well as controversial: curriculum designers must balance specific local healthcare requirements with global health competencies doctors need in our globalised world. By investigating how international medical programme designers experience this balancing act, this study aims to contribute insights to the debate on local versus global medical education.

Methods: We conducted a multi-centre instrumental case study across three universities with international medical programmes in three countries. The study involved 26 semi-structured interviews with key curriculum designers recruited through purposive sampling. Additionally, we performed a curriculum document analysis. Data were thematically analysed within a multidisciplinary team.

Results: Participants described two profiles of international medical programme graduates: ‘a global physician’, equipped with specific competencies for international practice, and ‘a universal professional’, an overall high-level graduate fit for future practice anywhere. These perspectives presented different curriculum design challenges.

Conclusions: International medical programmes teach us how we can rethink graduate profiles in a globalising world. Yet, educational standardisation poses risks and securing equity in global health education is challenging, as is preparing students to be adaptable to the requirements of a rapidly changing future local healthcare context.     

Can communication skills training improve empathy? A six-year longitudinal study of medical students in Japan

Background: Empathy is an important component of overall clinical competence; thus, enhancing empathy in medical education is essential for quality patient care.

Aim: This longitudinal study was designed to address the following questions: 1. Can a targeted educational program in communication skills training enhance empathy in medical students? and 2. Can such a program have a sustained effect?

Methods: Study participants included 116 students who entered Okayama University Medical School in 2011. Students participated in a communication skills training program aimed to enhance their empathy, and completed the Jefferson Scale of Empathy (JSE) five times: at the beginning of medical school, prior to participation in the program, immediately after the program, and in last years of medical school. A total of 69 students, representing 59% of the cohort, completed the JSE in all five test administrations.

Results: Students’ total scores on the JSE and its two factors (Perspective Taking and Compassionate Care) increased significantly (p?Conclusions: Targeted educational programs to enhance empathy in medical students can have a significant effect; however, additional reinforcements may be needed for a sustained effect.     

Student participation in the development of interprofessional education courses: Perceptions and experiences of faculty members and the students

Abstract

Introduction: Student participation has shown positive effects on the curriculum development process for a single health profession. This qualitative study explores faculty members’ and students’ perceptions and experiences regarding student participation in interprofessional course development.

Methods: Interprofessional courses were developed and implemented by interprofessional teams of faculty members and students. Two focus group discussions were carried out: one with faculty members and one with students.

Results: Students contributed to both the process and the results of interprofessional course development in a complementary manner. Student participation was facilitated via motivation for and through work on interprofessional education, a balance between clarity on tasks and students’ autonomy, and a low-hierarchy team atmosphere. Students developed professionally, and faculty members saw them as future ambassadors for interprofessional collaboration.

Conclusions: This study provides multiple qualitative evidence for a positive, complementary role of student participation in interprofessional course development. A number of factors were identified that should be nurtured to facilitate this effect. Our findings may stimulate and guide other schools to actively involve students in the development of interprofessional education.     

Evaluating an interprofessional education curriculum: A theory-informed approach

Background: This paper retrospectively reports on an evaluation framework applied to a local interprofessional education (IPE) curriculum design. The theoretically informed IPE curriculum spans the undergraduate health and social care programmes of over 10 professions as a curriculum theme. The teaching design and its impact were informed by psycho-social and learning theories.

Aims: This meta-analysis is presented to share the importance of longitudinal IPE, whole curriculum evaluation for comparisons and to advance our understandings of what works and why.

Method: The meta-analysis used the Presage, Process and Product conceptual framework outlined by Biggs in 1993, and the Kirkpatrick in 1996, evaluation outcome model. Data are shared on the final overall learning from evaluating the teaching and the outcomes from students, teachers, practitioners, patients and carers.

Results: The evaluation highlighted cyclical issues relating to students experiences, facilitators abilities and highlights the challenges of learning in practice which was highly praised by students. The problems and challenges were solved through the application of theory to illuminate our understandings.

Conclusion: We lament at missed opportunities for the application of theoretically informed research questions that still require to be addressed. However, we share this framework as having offered a complete and comprehensive evaluation process.     

Effectiveness of a rural longitudinal integrated clerkship in preparing medical students for internship

Background: We interviewed graduates from the first two cohorts of a postgraduate medical program that had a senior year longitudinal integrated clerkship (LIC) in a practice setting in rural New South Wales, Australia to determine how well their training prepared them to be junior doctors (3–4 years after graduation), and what aspects of that training they thought were particularly useful.

Methods: In-depth interviews.

Results: Fourteen junior doctors were interviewed. Participants reported feeling well prepared in ability to develop close relationships with clinical supervisors, good clinical and procedural skills, ability to work autonomously and work in teams, knowledge of health systems, ability to ensure self-care, and professionalism. Consensus view was that a rural placement was an excellent way to learn medicine for a variety of reasons including relationships with clinicians, less competition for access to patients, and opportunities to extend their clinical skills and act up to intern level.

Conclusion: The advantages we found in the training these junior doctors received which prepared them well for internship were integral both to the longitudinal, unstructured placement, and to the fact that it was carried out in a rural area. The two aspects of these placements appear to act synergistically, reinforcing the learning experience.     

Warwick Medical School: A four dimensional curriculum

Abstract

Medical curricula vary hugely across the world. Notions of horizontal and vertical integration and spiral curricula are present in many modern curricula although true integration happens to a varying degree. By seeing the development of a curriculum as fundamentally about integration, rather than as a process of seeking to integrate separate elements, we have developed a program that prepares students well for the complexities and rate of change of practice. The risks inherent in bringing forward the point at which learners need to deal with such substantive and fundamental complexity produces challenges. Such challenges are ones that our students have shown they can not only deal with, they are often better equipped than faculty to provide solutions for themselves, their peers and those who follow them. We present the three dimensions of integration in the Warwick Medical School curriculum and note the fourth dimension provided by our students, being student led teaching and support far beyond what is normally found in medical courses.