N E W CURRICULUM DESIGN AT M A R M A R A U N IVER SITY
SCHOOL OF M EDICINE
Ö zlem Sarıkçıya, M .D .* / B errak
Ç .Y e ğ e n , M .D .**
Şule O k ta y , M .D ., P h .D .***
* D e p a r tm e n t o f M e d ic a l E d u c a tio n , S c h o o l o f M e d ic in e , M a r m a r a U n iv e rs ity , Is ta n b u l, T u rk e y . * * D e p a r t m e n t o f P h y s io lo g y , S c h o o l o f M e d ic in e , M a r m a r a U n iv e rs ity , Is t a n b u l, T u rk e y . ' * * D e p a r t m e n t o f P h a r m a c o lo g y a n d C lin ic a l P h a r m a c o lo g y , S c h o o l o f M e d ic in e , M a r m a r a U n iv e rs ity , Is ta n b u l, T u rk e y .G oal of education
World Health A ssem bly, the principal governing body of the World Health O rganization, encourages all countries to undertake activities to reform m edical education and to organize appropriate programs of basic and continuing education (1) in order to attain the goal known as ‘health for all’. The aim of medical education is em phasized as “to educate and to train skilled and com petent m edical d octo rs”. Optimal educational approaches should be used to train the future graduates a s “care provider, decision maker, communicator, community leader and m anager” physicians. B ased mainly on a report prepared by the Tu rkish M edical D o cto rs’ Association (2), the aim of undergraduate medical education at M arm ara U n iversity School of Medicine w as defined a s “to educate qualified medical doctors equipped with the knowledge, skills and attitudes to provide a qualified health care for the individual and the community, in order to attain the goal of “health for all" in March 1999.
Current status d e v e lo p ed according to
the needs fo r change
Marmara University School of Medicine w as founded in 1983, based on a standard integrated
curriculum adopted originally from C a s e W estern R e se rve University, Ohio. In accord an ce with the in cre a sin g interest in reform ing m edical education worldwide, the first national Medical Education Sym posium , which directed attention to the new concepts in m edical teaching in Tu rkey, w a s organized by M arm ara University School of M edicine in 1993 in Istanbul (3). In Feb ru ary 1995, two faculty m em bers visited Liverpool University School of M edicine to gather information about their new curriculum based on problem-based learning and how they managed this rad ical ch a n g e in their und erg rad uate m edical cu rricu lu m . T h e first step w a s implemented at our Institution in the academ ic year of 1998-1999, when three new bodies were formed for the developm ent of new strategies and methods to create a model for a change and its m anag em en t: 1) T h e Institutional Undergraduate M edical Education R e se a rc h , Planning and Coordination Com m ittee (R P C C ) w a s established in D ecem ber 1998 (Tab le I). 2) A committee w as selected in Feb ruary 1999 to plan and o rg an ize p ostg rad uate training a ctiv itie s. 3) T h e D epartm ent of M edical Education w a s established in N ovem ber 1999, in an attempt to guide the educational reforms and to a s s e s s the impact of curricular ch an g e s.
M a r m a r a M e d i c a l J o u r n a l 2 0 0 2 ; 1 5 ( 1 ) : 5 6 - 6 2 Correspondance to: Özlem Sar ikaya, M. D, - Department o f M edical Education, School o f Medicine,
Marmara University, 81326 Haydarpaşa, Istanbul, Turkey, e.mail address: ozlemsarika@ ixir.com
Medical Education at Marmara
Therefore, due to the current algorithm of the m anagem ent of education in Marmara University School of Medicine (Fig 1), the main functions carried out by the R P C C will be thereafter taken over by this departm ent, under the consultancy of the R P C C .
B ased on a survey on the ongoing educational system among the graduates of the year 2000,
the needs for change were determined by the R P C C , and the following innovations were designed and implemented (4-7).
Footprints in change m anagem ent
Historically, c la s s e s in m edicine have been taught via lectures and visual aids. In recent
T a b l e I: C o m m itte e s for th e d e s ig n a n d im p le m e n ta tio n of th e in n o v a tio n s in th e e d u c a tio n a t M a rm a ra U niversity S c h o o l of M e d icin e.
Institutional Undergraduate Medical Education Research, Planning and Coordination Committee (RPCC)
Subcommittees / study groups Output of the activities
Baseline evaluation of the old educational system
• A survey on the graduates’ opinion about needs for change in the educational system
• A report about the students' grades and overall success rates In all classes, the performance of our graduates in the postgraduate placement exams and the relationship among these parameters
Core curriculum coordination • A search for different core curricula from other countries
• A survey on the “knowledge, skill and attitude objectives" from the point of view of faculty members • Core disease/condition/symptom, core skills and core behavior/attitudes lists for institutional core curriculum
based on the above mentioned survey and the report prepared by the Department of Public Health, which summarizes the priority health problems in Turkey
• Staff meetings to discuss core lists
Phase 1 organization • A guide-book on how to facilitate interactive study modules • Planning and application of interactive study modules
• Implementation of “Introduction to Clinical Practice” course including communication skills and first aid • Implementation of vertical integration
Phase 2 organization • Reorganization of the clerkship programs based on the core topics and skills survey • Clerkship guides including aims and objectives of the program
• Implementation of the elective clerkship and clinical development module
Assessment and evaluation • A software program for the item analysis of multiple choice questions (MCQ) • Regular MCQ analysis and feedback to the related departments
• “Teacher training" courses on student assessment and evaluation techniques
Teacher training • “Teacher training" courses on new learning and teaching methods
Phase 3 organization • A survey to understand Interns' problems and comments on their education • A survey for the skills objectives of internship programs
Development of clinical skills laboratory
• A clinical skills laboratory with manikins, models and other teaching materials essential for the Introduction to Clinical Practice course.
• This working group forwarded its responsibility to the Head of the Clinical Skills Lab reporting to the Coordinator-in-chief.
Library • Subscription to new journals
• New books and internet access to biomedical sources
• Guidance to students and academic staff for the interactive study modules
Teaching quality assessment and medical education unit
• Establishment of the Medical Education Department to undertake several functions of the subcommittees / working groups such as organization of “teacher training" courses, item analysis of MCQs, etc.
Project preparation • A project supported by the Turkish Government Planning Commission Postgraduate Medical Education Council
• Evaluation of the current status of postgraduate education via meetings, questionnaires • Log-books for research assistants
• Training of research assistants ori basic principles and planning scientific research projects, presentation of data and essential ethical aspects of research and medical practice (178 research assistants attended these courses.)
• Advanced courses for research assistants on use of experimental animals in research (handling, anesthesia, drug administration etc.) (75 research assistants attended these courses.)
• Handbooks for the above courses • Guidelines on how to write a thesis
years, medical educators have been challenged to develop new , inno vative and cre ative educational m aterials that en h an ce problem solving skills, encourage group d iscu ssio n s, and engage students in interactive learning (8). R ecently, there h as been a trend at m any institutions to reduce the number of lecture hours and provide more instruction through small-group problem-based learning se ssio n s.
At M armara University School of Medicine, in order to motivate the faculty to apply student- centered interactive teaching techniques and to encourage the use of sm all-group teaching m ethods, a “te a ch e r training ” program w a s developed in Septem ber 1999. S in ce then, a total of 133 faculty m em bers (62 % of the academ ic staff) have attended a 5-day course to acquire mostly interactive educational skills organized by trained faculty m em bers. S in ce changing the curriculum without modifying the examination system is not advocated (9 ), w e aim ed to improve our present exam ination system , while planning and applying more relevant methods of student a s s e s s m e n t. T h e above-m entioned faculty m em bers (62 % of the academ ic staff) were also trained on student a sse ssm e n t and evaluation techniques through a short course between 2000-2002 (10). S in ce there w a s no formal education to learn how to teach u n d erg rad uates, the E x e c u tiv e Com m ittee decided to make these co u rse s a prerequisite for assistant professorship candidates.
Knowing that consulting and publicizing the changes are essential steps in the m anagem ent
of curricular ch an g e s, in Septem ber 2001, two “Teaching Quality and Curricular R econstruction” meetings w ere organized by the D ean ’s Office with attendance of 66 % of the faculty m em bers. Sm all group d iscu ssio n s and plenary se ssio n s w ere held during these two-day w orkshops, particularly on new trends in medical education, how to catch up with the world in this respect, and, on the implemented curriculum ch ang es. Encouraging faculty m em bers to propose their ideas and openness to com m unication helped to reduce resistan ce against ch ang e s and positively influenced efforts in this area.
R ec e n tly
Im p le m e n te d
C u rric u la r
Changes
in
M a r m a r a
U n iv e rs ity
School of M ed icin e
A) Horizontal and Vertical Integration of Basic
and Clinical Sciences:
In the teaching system of M arm ara University School of M edicine, preclinical y e a rs (P h a se 1; ye a rs 1, 2 and 3) w ere organized a s subject co m m ittees su ch a s resp irato ry sy ste m , card iovascular system , hematopoietic system , etc. during which the related topics w ere taught in an integrated m ann er. H o w e ve r, the integration w a s betw een b a sic m edical disciplines in y e a rs 1 and 2, and between clinical sc ie n ce s, pathology and pharm acology in year 3. The new organization of the subject com m ittees involves a vertical integration of the b asic and clin ical s c ie n c e s in addition to the above- mentioned horizontal integration (Tab le II and Fig. 2). During P h a se I, “an interactive study m odule” is im plem ented in e ach su b ject
Medical Education at Marmara
T a b l e II: Subject Committees and Interactive Study Modules in Phase 1.
Subject Committees Interactive Modules
Year 1:
• Introduction to Cell and Cellular Replication • Down Syndrome
• Cellular Metabolism and Transport • Cystic Fibrosis
• Tissue and Immune Response • In Vitro Fertilization
• Basics of Nervous and Endocrine Systems • Pain
Year 2:
• Cellular and Tissue Injury • Neoplasia brdrs
• Musculoskeletal and Integumentary Systems • Sports in Medicine
• Hematopoietic System • Hematology Cases
• Respiratory System * Cigarette smoking
Year 3:
• Cardiovascular System • Hypertension
• Gastrointestinal System and Metabolism • Arteriosclerosis
• Endocrine Diseases and Neuropsychiatrie Disorders • Obesity
• Urinary and Reproductive Systems • AIDS
I iK n m p l k ( f r i c n t u t i o n P H A S E 1 Year I Year 2 Year 3
i
PHASE 2 Y ear 4 B a s i c S c ie n c e s : B io c h e m i> ir \ . M e d ic a l B io lo g y . M i c r o b io lo g y . H is to lo g y and h m b r io lu g y . P h y s io lo g y . B io p h y s ic s . A n a to m y I n t r o d u c t i o n t o C l i n i c a l P r a c t i c e : F a m ily M e d ic in e . M e d ic a l F .lh ic s a n il D e o n to lo g y . M e d ic a l E d u c a tio n . P u b lic H e a lth . B ii* s ta lis tic s a nd o th e r re la te d d e p a rtm e n ts Interactive StudyA
Modules C l i n i c a l S c ie n c e s : C a r d io lo g y . C a rd io v a s c u la r and T h o r a c ic S u rg e ry . C h e st M e d ic in e . P h a rm a c o lo g y . F a n n ie M e d ic in e . G y n e c o lo g y a n d O b s te tric s . In fe c tio u s D iseases. In te rn a l M e d ic in e . O rth o p e d ie s . P a th o lo g y . P e d ia tric s . P h y s ic a l Therapy a nd R e h a b ilita tio n . P s y c h ia try . P u b lic H e a lth . R a d io lo g y . N e u r o lo g y . N e u ro s u rg e ry . N u e le a i M e d ic in e , a nd o th e rs.Clinical Clerkships: In te rn a l M e d ic in e , P e d ia tric s , G e n e ra l S u rg e ry . O b s te tric s a n d G y n e c o lo g y , a n d C li n ic a l P h a rm a c o lo g y K n o w l e d g e I .e e lu re s C ase d is c u s s io n s In te ra c tiv e s tu d y m o d u le s S k i l l s B e d s id e v is its a n d ease d is c u s s io n s C lin ic a l s k ills tra in in g
P a tie n t f o llo w u p u n d e r g u id a n c e
y _
C li n ic a l E th ic s Year 5 T PH ASE 3 Year 6 ( ' ( i m p l e x p a r t i c i p a t i o nClinical Clerkships: A n e s th e s io lo g y a nd R e a n im a tio n . D e r m a to lo g y . F o re n s ic M e d ic in e . O p h th a lm o lo g y , O r t h o p c d ic s .O to r h in o la r y n g o lo g y P e d ia tr ic S u rg e ry , P h y s ic a l T h e r a p y and R e h a b ilita tio n , P la s tic a n d R e c o n s tric tiv e S u r g e ry . P s y c h ia try , R a d io lo g y , N e u r o lo g y , N e u ro s u rg e ry . T h o r a c ic S u r g e ry . U r o lo g y
K n o w le d g e L e c tu re s , case d is c u s s io n s , in t e r a c t ! 'c stud y m o d u le s S k ills B e d s id e v is its a nd case d is c u s s io n s , c lin ic a l s k ills tr a in in g , p a tie n t f o llo w u p u n d e r g u id a n c e
C l i n i c a l D e v e l o p m e n t M o d u l e
Internships:
E m e rg e n c y M e d ic in e , G y n e c o lo g y a n d O b s te tric s , In te rn a l M e d ic in e , P e d ia tric s , P s y c h ia try . Public-H e a lth . a n d E le c tiv e s
A d v a n c e d M e d ic a l T r a i n i n g : H is to ry ta k in g , d ia g n o s is , tre a tm e n t p la n s , p a tie n t m o n ito r in g a nd r e p o rtin g u n d e r g u id a n c e
C o m m u n it y - b a s e d M e d ic in e : P rim a ry ca re u n it v is its H o m e v is its
R e sea rch p la n n in g , a n a ly z in g a nd re p o rtin g
committee on a topic closely related to the main theme of the program.
B) Introduction to Clinical Practice (ICP)
In the old curriculum , students w ere first being introduced to patients in their 4th year and they w ere required to acq u ire clin ical sk ills by practicing on real patients without any previous training. Th e modern trends in medical education are to gain clinical skills a s early a s possible and to practice on m anikins and volunteers before approaching real patients. Therefore, a tnree- year, longitudinal and interdisciplinary course (IC P ) with a primary em p hasis on preparing students to care for patients and fam ilies in a humanistic, competent and professional m anner designed by the Departm ent of Fam ily Medicine and implemented in the academ ic year 1999- 2001 in cooperation with the Departm ents of Medical Education, Public Health, Psychiatry, Internal Medicine, G e ne ral Surgery, Pediatric Su rg e ry, P h arm acolog y, M edical E th ics and
Deontology, m ainly. Th e co urse goals are to provide a clinical context to the b asic scien ce curriculum , to acquire and dem onstrate attitudes n e ce ssa ry for the achievem ent of high standards of medical practice in the se rvice of individuals and the community, to acquire the skills of independent, self-directed learning and life learning and to acquire b asic procedural skills with hum anistic p rin cip les. G e n e ra l learning topics of the program include, proficiency in medical decision making and in obtaining data, most common signs and sym ptom s in general m edical p ractice , e vid e n ce -b a se d m edical practice, health m aintenance protocols, health promotion and d ise a se prevention, ethical and legal issu e s in general m edical practice (Table III). Short lectures on the core content, case- based se ssio n s, panel se ssio n s, sm all group d isc u ss io n s with fa cilitato rs, role play, sim ulated/standardized patient e x e rc is e s, video taping, practicing on m anikins and m odels are being used a s learning tools w hen appropriate.
Table III: Curriculum Content of Introduction to Clinical Practice Course
Topics Content
Communication skills Communication in medical education-medical settings, basic interpersonal communication skills, public speaking skills, intercultural communication, introduction to the medical interview, physician-patient relationship, patient education
First aid Survey of the accident area and the victim, transportation of the victim, resuscitation, soft tissue injuries, seizures, poisonings, shock, frostbite, bleeding, burns
History taking and physical examination Medical interview, history taking, general and focused physical examination, difficult topics/sensitive issues, difficult patients
Outpatient clinics experience Second and third year students visit determined outpatient clinics of Marmara University Hospital throughout the year to observe physician-patient relationships, history taking and/or physical examination using checklist and/or algorithms.
Basic clinical skills Practice to acquire basic clinical skills such as injections, suturing, nasogastric tube insertion, etc. Human in medicine Courses/workshops/studies in medical humanities subjects. Ethics, social concepts in health, arts and
humanities are some of the major course titles.
Evidence-based medicine An evidence-based learning program is given by Departments of Public Health and Biostatistics for subjects as basic medical statistics, introduction to epidemiology, literature reading, etc.
Community continuity experience This program may provide the students with an opportunity to observe patient care setting outside the hospital and to obtain experience in physician-patient relationships by following up on an assigned patient and/or family.
Student projects and
Marmara Student Congress (MaSCo)
Within the program, students are required to plan and perform research projects (mainly epidemiological studies) and encouraged to present their results at MaSCo.
Medical Education at Marmara
C) Clinical Training Period (Clerkships)
Th e clinical y e a rs of undergraduate medical education (P h a se 2; y e a rs 4 and 5) are designed a s cle rk sh ip s in clin ical d iscip lin e s. Y e a r 4 clerkship s are in Pediatrics, Internal Medicine, C lin ica l P h arm ac o lo g y, G yn e co lo g y and O bstetrics, and G eneral Surgery, w hereas at the end of year 5, the students are expected to s u c c e s s fu lly com plete cle rk sh ip s in A n e sth e sio lo g y and R e an im atio n , F o re n sic M edicine, P e d iatric S u rg e ry , Derm atology, P h ysical Th erap y and Rehabilitation, Thoracic S urg ery, Ophthalm ology, Otorhinolaryngology, Neurology, N eurosurgery, Orthopedics, Plastic and R e co n stru ctive S u rg e ry , P sy ch ia try , Rad iolog y and U rology. A 3 w eek-elective clerkship period is also implemented in the program.
Th e goals of P h a se 2 are to acquire medical history taking, inspection and exam ination skills, to com prehend the principles of basic therapy and rehabilitation, to understand the social and environm ental com ponents of different d ise a se s and to consider the balance between individual and com m unity health ca re , preventive and therapeutic ca re ; to learn to promote healthy lifestyles with ethical and social responsibility, and to handle the team work with individuals and organizations. Th erefo re , the clinical training period is considered a s an integrated educational period during w hich stud ents acq uire b asic knowledge a id skills in order to be able to give hum anistic a id effective health care. The goals of the teacl ers are to facilitate learning, to en co urag e nd ependent id e a s, to improve positive attitu ie to the patients, and to teach the habit of lifetin e learning. There is a tendency to in c re a se e le ctive program elem en ts when Institutional O r e Curriculum studies com e to an end in order, t > allocate time for the students’ in depth learning n a re a s of interest.
The last year is the internship (P h a se 3; year 6) at the Departm ents of Public Health, Internal Medicine, Pediatrics, G ynecology and Obstetrics, Psychiatry and Em ergency Medicine (Fig. 2). The students are expected to act like physicians under the guidance of their professors.
D) Clinical Development Module:
In the a c a d e m ic y e a r 1999-2000 the subcom m ittee of the R P C C on P h a s e 2
programs raised attention to the necessity to create time for elective clerkships in accordance with the new trends. Additionally, as a first step of “institutional core curriculum + electives” study, it w as agreed by the Departments of Nuclear Medicine and Radiation Oncology that the core content of the two disciplines might be better included by a multidisciplinary interactive study module instead of a two-week clerkship, in year 5. Th e module w a s nam ed a s “C linical Developm ent Module" and the goals and o b jectives w ere se t a s to develop clinical reasoning in order to im prove clinical com prehension, which is essential in medical practice on the selected topic of “ca n ce r”. The Clinical Development Module is organized and implemented by the Departments of Nuclear Medicine and Radiation Oncology in cooperation with several faculty m em bers from Physiology, General Surgery, Pediatric Surgery, Pathology, Derm atology, M edical O ncology, M edical Education, Orthopedics, Medical Biology, etc. In the year 5, students attend short lectures on the core content, case-b ased se ssio n s, a panel discussion and small group d iscussio ns (role playing and sim ulated/standardized patient e xercises) once a w eek for one sem ester (twelve w eeks).
Conclusion and fu tu re plans
Efforts to reform the curriculum and increase teaching quality at Marmara University School of Medicine highly motivated a large group of the academ ic staff. Most of the academ ic staff is now struggling eagerly to change into a “facilitator” rather being a “teacher” in the students’ learning process. T e a ch e r training co urses for faculty members are being organized several times a year. Increasing the number of people involved in the m anagem ent of ch ang e in education provides more creative ideas and encourages the teachers to think about new proposals to enhance the quality of teaching. Moreover, as more people are involved in the “backstage” of the modifications, there will be le ss friction or resistance to the implementation of proposed changes.
In addition to managing the problems we will face in the application of the above-m entioned
curricular ch ang es, future plans are to finalize the “institutional core curriculum and e le c tiv e s ” study, to start developing a multiple choice question bank to enhance the quality of such exam s and to m easure the impact of curricular changes on the quality of teaching and the satisfaction of the students.
Acknowledgm ent. Th e authors would like to exp ress their gratitude to all the faculty m em bers who have contributed to these activities.
REFERENCES
1. Doctors fo r H ealth (A WHO g lo b al strategy fo r changing m e d ic a l e d u c a tio n a n d m e d ic a l p ractice fo r health fo r all), World H ealth
Organization, 1 9 9 6 .
2. Türk T abipleri Birliği M ezuniyet Ö ncesi Tıp Eğitimi Raporu, Dr. İs k e n d e r Sayek ve Dr. Bülent l\ılıç (Editörler), Ankara, 1997.
3. H aklar O, Oktay Ş, E m erk R. Ö ğrenci Gözüyle M arm ara Ü niversitesi Tıp Eakültesinde Eğitim, 2 1 . Yüzyılda Tıp E ğ itim i S e m p o z y u m u , İstanbul, 3 0 Eylül-1 Ekim 19 9 3 .
4. Bilsel S, A rbak S, O nat F, O ktay Ş, Akdaş A. M a rm a ra Ü n iv e rs ite s i Tıp E a k ü lte s i'n d e m ezu n iyet ö ncesi te m e l tıp eğitim inin öğrenci
g ö z ü y le d e ğ e rle n d irilm e s i, Türk T a b ip le ri Birliği, T ü rk iy e 'd e Tıpta T e m e l B ilim le rd e Eğitim S em p ozyu m u , Ankara, 1 5-17 Hisarı 1 9 9 4 , (Toplum ve H ekim , 1 9 9 4 ; 5 9 ; ö ze l ek; 15).
5. Ralaça S, Ran B, G üney İ, Ç akın A, Tözün H. S tu d e n ts ' p e rc e p tio n a b o u t m e d ic a l education at M arm ara University S chool o f Medicine. M arm ara Med. 2 0 0 0 ;1 3 :1 3 1 -1 3 6 . 6. O ktay Ş, Ralaça S, Rotiloğlu E. Tıp Eğitim inde
Değişim : M arm ara Ü niversitesi Tıp Fakültesi Örneği, II. Ulusal Tıp E ğitim i kongresi, İzm ir, 2 4 -2 8 Hisan 2 0 0 1 .
7. Raravuş M, Ralaça S, Sarıkaya Ö zm en Ö, O k ta y Ş. Tıp F a k ü lte s i D ö n e m IV öğrencilerinin a ld ıkları ve a lm a k ta o ldukları tıp e ğ itim in e b a k ış a ç ıla rın ın d e ğ e rle n d irilm e s i. II. U lu sal Tıp E ğ itim i kongresi, İzm ir, 2 4 -2 8 Hisan 2 0 0 1 .
8. Marston RQ, Jones RM. M ed ical Education in tra n s itio n . P rin ceto n , HJ: RW J o h n s o n Foundation, 1 9 92.
9. G u ilb ert JJ. E du catio nal H an d b o o k fo r H ealth Personnel. WHO Offset Publication Ho. 3 5 , G eneve, 1 9 92.
10. Alican İ, A rzık A, Çalı Ş. M arm ara Üniversitesi Tıp E akültesinde Eğiticilerin Eğitim i Programı, II Ulusal Tıp E ğitim i kongresi, İzm ir, 2 4 -2 8 Hisan 2 0 0 1 .
