PM&DC should not prepare the curriculum but give guidelines keeping in view the country needs-Prof. Majeed Chaudhry

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Panel Discussion on Medical Education during PSIM Mid-Summer meeting
PM&DC should not prepare the curriculum 
but give guidelines keeping in view the 
country needs-Prof. Majeed Chaudhry
RMU has started University Residency Training
Programme, we have organized 150 workshops
for faculty development-Prof. M. Umar
Simulators cannot replace patients and artificial
intelligence will never replace physicians but they
can add to competency-Prof.Khalid Masood Gondal

SWAT: Prof. Tariq Waseem moderated the panel discussion on Undergraduate Medical Education during the PSIM Mid-Summer meeting held here at Swat from August 29th to September 1st 2019. Members of the panel included Prof. Javed Akram VC UHS, Prof. Khalid Masood Gondal VC KEMU, Prof. Abdul Majeed Chaudhry Dean LMDC, Prof. Mohammad Umar VC RMU, Prof. Arshad Javed VC KMU, Prof. Irshad Hussain Dean Faculty of Medicine CPSP, Dr. Asif Abbas Naqvi, Prof. Sarosh Majid Solaria Principal AJK Medical College, while Miss. Fizza Ashfaq represented the students.


Miss. Fizza was the first speaker who stated that there are two systems being followed, the traditional and the integrated. The traditional system is lecture based and teacher centered. There is no discussion. There is no real activity and it is confusing to many students. Its drawback include that there is lot of irrelevant information, there is overload of curriculum, there is inadequate exposure to research. On the other hand in integrated system, it is easy to understand, it offers problem based learning, faculty works in collaboration, anatomy, physiology, medicine and surgery can be integrated. There is more group discussion, it ensures students participation. It makes the students self learners, critical thinkers. It is better to have more interaction. It is better to have discussion with the patient but there are time constraints. Her plea was that do not over burden the learners but the system must ensure critical thinking. She also suggested modification in traditional system and the curriculum should be scenario based.


Prof. Muhammad Umar Vice Chancellor Rawalpindi Medical University in his presentation stated that the first university was established in Italy in 1212. The job of the university is to produce scholars. It should bring a social change in the society. UK has twenty six universities and three Royal Colleges. There has been an evolution in medical education and universities are supposed to be research oriented. It should also have evidence based healthcare system. The three important components of the university are Truth, Wisdom and Science. We at the RMU and at its affiliated hospitals, he said, examine 3.1 million patients, 45,000 C. Sections are performed annually besides 3,300 CT Scans and five lac ultrasound examinations. We work as a team and have introduced twelve new subjects. We have the biggest department of infectious diseases, critical care, and medical emergency. We have 449 faculty members, 962 postgraduates. We have introduced University Residency Programme, have developed University Residency Programme curriculum. We have established ORIC, Quality Enhancement Cell. We follow integrated model of medical education. We do not call our training programme as MS, MD but University Residency Programme. We have research curriculum for undergraduates, postgraduates and faculty. He was of the view that the curriculum must be in line with the international system. Innovations must be a separate curriculum.


Prof. A. Majeed Chaudhry

Continuing Prof. Umar said that we have developed manuals for all programs. Standard Operating Procedures have been prepared for Disinfection Protocol, portfolio system and two hundred page Residency Training programme has been produced. We have Residency Training Programme, Programme for faculty while eighteen new programmes have been stated. We have changed up to 360 degree University Residents Evaluation Proforma which is based on competency Level one, Level two and level three. So far we have organized one hundred fifty workshops for faulty. We have invited international faculty. There is nine step model in place. We have student’s journal where the students publish their research work. We follow community research model which was started with a grant of five crore rupees. We have also established the Foundation Programme, he added.


Prof. Irshad Hussain said that he has been at the King Edward Medical College for the last thirty two years and we all have learnt through the traditional system of medical education. We had teaching in the OPD, it was practiced till the last seven eight years. Now KE has shifted to modular system and two batches have already passed. The traditional system, he opined, was not so bad. There has been a change in our attitudes which has resulted in the current state of medical education and training. We used to have students taking patient history late in the night and then present it in the morning at ward rounds but now the students are not interested. Old system, he further stated had many advantages in which we all had our training. In modular system it enables to pay attention to individual students. It is students oriented as compared to the old system which was teacher oriented. Integrated model is based on small group discussions but there are many problems with this system. Back ground knowledge is lacking in students as they do not know anatomy and physiology. We do need integration but the old system also needs some improvements. We have now 325 students in a class. With integrated system we need to make so many groups and we do not have the faculty for that. We must make small groups. There are system related problems as students do not come prepared for learning, he added.


Prof. Arshad Javed Vice Chancellor Khyber Medical University highlighted the problem in integrated system of medical education. It is good but it is not being implemented in its true spirit. Medical education, he opined, must encourage self-learning, ensure critical thinking and produce scholars. When we started with integrated model, initially it was opposed by the faculty members. Modular system is ideal and it has to be implemented in any way to have integrated teaching. We have the advantage that we have just one medical university in the province. It was a suggestion made by Prof. Manzoor to Prime Minister Benazir Bhutto when she visited Khyber Medical College. She was asked to upgrade the college as a medical university and this was in 1990. When a medical university was established in Khyber PK, Khyber Medical College was its constituent college. We received a grant of Rs. 165 million. Now we run many PhD programmes. There are certain areas which are beyond the scope of a medical college. We have established Institute of Health Professional Education and Research. We have two PhDs and they have been given the task of implementing this integrated system of medical education throughout the province. A cell has been created in Khyber Medical University. Now we are in a better position. We assess the faculty and the resources. We started with this integrated system in five medical colleges which included two in public and two in private sector apart from our constituent college. We run faculty development progamme throughout the year. All the five medical colleges selected for this have started implementing this programme. We will have integrated system from the next year and it will be implemented in all the medical colleges. We have trained the staff, we need to look at the scope of integration, and it should be vertical as well as horizontal integration. Identify the knowledge and skills, prepare a proper time table, have assessment model and it should be communicated to the staff and the students. But still many may be opposing the system, he remarked.


Participants of the panel discussion on Medical Education at PSIM Mid-Summer Conference
held at Swat on September 1st from (L to R) are Miss.Fizza who represented students, Prof. Irshad,
Prof. Arshad Javed,
Prof. Majeed Chaudhry, Prof. M. Umer and Prof.Tariq Waseem.

Prof. Abdul Majeed Chaudhry from Lahore Medical & Dental College was the next speaker. He pointed out that resistance to change has been there since long. We need to implement the integrated system of medical education. If we change our mind, things will improve but we must keep out our personal projection. We should be quiet workers, help other faculty members and you will remain ever young, he remarked.


He pointed out that it was in 1910 that Flexner report was published in United States and the problems he highlighted in medical schools in United States are all seen in medical colleges in Pakistan today. He believed that education should offer small classes, personal attention and hands on training. Graduates of his school (Flexner) were soon accepted at leading colleges and his teaching attracted considerable attention. Flexner examined the state of American Medial Education which led to far reaching reforms in doctors training. He exerted a decisive influence on the course of medical training and left an enduring mark on some of the Nation’s most renowned schools of medicine. The students no longer merely watches, listens, memorizes. His own activities are the main factor in his instruction and discipline. He believed that a student cannot effectively know, unless he knows how. From the student’s point of view, medical schools seeks to evoke the attitude and to carry him through the processes of the thinker and not of the parrot.


In Pakistan, the medical course is overburdened and too fully occupied to permit a healthy assimilation of much which the students is taught. We place too heavy burden on the medical students and it needs to do something not to break his intellectual back remarked the General Medical Council of UK in 1957. The system which was being followed is calculated to obstruct the acquisition of sound knowledge as it heavily favours crammer and the grinder is a disgrace the GMC further added. Historically integration focused on the study of bodily systems rather than separate pre-clinical disciplines. The term curriculum, Prof. Majeed Chaudhry said refers to all the activities, experiences and learning opportunities for which an institution or teacher or learner takes the responsibility. It includes formal as well informal, the recognized and overlooked, the intentional and unintentional. It is assumed that integrated learning will result in a more relevant, meaningful and student centered curriculum but this assumption often remains untested. It is easier to retrieve and use information when it is combined in a meaningful schemes.


Prof. Javed Akram VC UHS, Prof. Khalid Masood Gondal VC KEMU, Prof. Arshad Javed
VC KMU, Prof. Bikaram VC LUMHS, Prof. Irshad, Prof. Majeed Chaudhry, Prof.Asif Abbas
Naqvi, Prof.Tariq Waseem, Prof. Sajid Abaidullah, Dr. Somia Iqtidar, Prof.Intekhab Alam,
Dr. Zaman, Dr. Shehla Akram and others photographed after the session on Medical
Education at PSIM Mid-Summer meeting held at Swat last month.

Continuing Prof. Majeed Chaudhry said that Sir William Osler had stated that “It is more important to know what patient has a disease that what disease the patient has”. Integration was promoted in teaching and learning approaches rather than assuming the students would somehow integrate their disciplinary knowledge on their own. Integration was once regarded as a mark of innovation in medical education but now it is more widely accepted as a feature of all programmes. He was of the view that PM&DC should not prepare the curriculum but it should give guidelines keeping in view the needs of the country. Prof. Umar at RMU has done a wonderful job. Prof. Gondal has done a good job at KEMU. However, almost 80% heads of the medical institutions, he alleged, do not know what is meant by curriculum. We teach our students in isolation. It does not go into their long term memory hence it cannot be retrieved when it is required. Integration is a feature of all programmes. Medical institutions all over the world are going for modular system. It is no more an innovation. We need to transfer knowledge and its practical application. Do not go for separate building blocks. Basic science teachers are opposed to it. We need to break barriers in learning various subjects. There is no dearth of resources, it was just an excuse not to change. There is lot of space and small groups can be made, he remarked.


Speaking about the principles of curriculum integration Prof.Majeed Chaudhry said that it involves making connections and seeing real purpose for their learning. It is based on topics of substance and significance. It is actively involved in negotiating the contents and direction of their learning. In this Knowledge, Skills, Values and attitudes are all integrated. Learning builds, extends and expands a student’s personal knowledge and experience and it also provides a range of learning styles. Its characteristics include student directed, real world application, research based, multiple resources, and embedded knowledge. Characteristics of applied skills include generalization, social skills and empowerment. It must include relationship among concepts, thematic units, flexible schedules, flexible groupings, combined subjects, lay emphasis on projects and goes beyond textbooks. The disadvantages of integration, he said, are that sometimes it becomes too lengthy and less relevant. This results in compromise in depth of topic, interest and enthusiasm of students. The lecturers need to be trained to take the role of facilitator. All topics may not fit easily into the planned integrated curriculum. We had planned an integrated curriculum model at a meeting held at University of Health Sciences. What is needed is to get it implemented in those institutions who can implement it. We cannot live in social isolation. All will have to change whether they like or not. We need a change and Change is a Must, he remarked.

Prof. Javed Akram VC UHS said that they have to cater to seventy three medical and dental colleges in the province and look after twenty thousand students. It is risky to opt for any new system with so many numbers to tackle. Both system i.e. traditional and integrated modular system have some advantages and disadvantages. Colleges have different faculty and infrastructure and this is a major move for integration of teaching. We are doing an experiment with Central Park Medical College pursuing one system and the University of Lahore pursing another system and at the end of the programme we will see which system produces better doctors who are patient oriented. Communication skills are very important. Students are not coming because of poor quality of lectures. We must look at the ground realities and we have to look at blended learning.


Pakistan Society of Internal Medicine organized a panel discussion on Medical Education
during its Mid-Summer conference at Swat recently. Picture shows Prof. Javed Akram Vice
Chancellor University of Health Sciences and President PSIM presenting Mementoes to
Prof. Khalid Masood Gondal VC KEMU, Prof. Bikaram VC LUMHS, Prof. Intikhab Alam,
Prof. Asif Abbas Naqvi and Dr. Saima Chaudhry.

Prof. Hamid Saeed from AKU said that they have produced top class doctors by following the integrated system of medical education. We have looked at the level of integration, it has to be implemented gradually, it has to be progressive and start with integration of some skills. Prof. Aziz opined that we need to identify the problems and then try to find an indigenous solution. Jinnah Sindh Medical University and DUHS have stated that they are going back to the traditional system. Prof. Asif Abbas Naqvi stated that it is not easy to go for integration but it will be advisable to follow a mid-level. It should be a process of evolution, progressive problem based learning for other areas. Since it is an evolutionary process, there will be issues with faculty, resources and without taking care of all these things, any new system may not work. Dr. Iftikhar from LMDC said that they are doing lot of integration at LMDC and we expose the students to clinical scenario from the first year.

Prof. Bikaram VC Liaquat University of Medical & Health Sciences said that we must remember and find out what we expect from an MBBS doctor. They are supposed to identify and manage the common medical problems. Our students are good in theory but poor in practicals, since they are away from the patients. At present teachers are also not so good. Our teachers used to be very good, hence we may divide teaching into pre-clinical and clinical. Prof. Intikhab Alam from Lady Reading Hospital Peshawar said that we must accept division between preclinical and clinical. Students should have knowledge before they enter the clinical side. We can go for horizontal integration in basic sciences and vertical integration in clinical sciences. We should not discard the traditional system but discuss at which level and how much integration is useful.

Postgraduate
Medical Education

This session was moderated by Dr. Saima Chaudhry from University of Health Sciences Lahore. The speakers included Prof. Javed Akram, Prof. Khalid Masood Gondal, Prof. Bikaram, Dr. Asif Abbas Naqvi, and Dr. Intikhab Alam while Dr. Abdul represented the Residents. It was pointed out that one has to take care of Knowledge, Skills and Attitudes which are the impotent pillars. Definition of learning, interpretation, facts gathering and professional authenticity were all discussed in detail. The teacher who shows how to do it is considered best. Students should have internal assessment, they should have adequate knowledge. Presentation skills, it was sated, are more important as compared to competency. Leadership qualities, administrative management and the attitudes towards the patients are better assessed in the test. Duty hours are long and there is no structured training programme which makes the matters worse. One has to see what these doctors are doing at their place of work.

Prof. Khalid Masood Gondal remarked that there have been lot of innovation in medical education. In the past we used to have apprenticeship model which was more commonly known as Piree Mureedee. Now we have seen the competency based model in competency based medical education. At times it is simulation based and we have best simulators. However, one cannot replace patients with simulators. They can add but will never replace the patients. Similarly artificial intelligence is being used through robots. They too cannot replace the physicians though they can add to the competency. We in Pakistan has no dearth of clinical material. At postgraduate level, we may have shortage of patients where one can use simulators. At the KEMU we are working side by side on academics, research and innovations. We have started PhD in basic sciences for which we are accredited. We have lot of postgraduate programmes. We have liaison with twenty leading universities overseas. We have quality assurance programme. Now we have acquired 238 acres of land in the Knowledge City in Lahore where we will have a hundred bed Kind Edward Medical University International Hospital which will generate funds for the university. We are going to have an advanced skills lab and Robotic Center and KEM Alumni is going to help us in this regard, he remarked.