M E D I C A L E D U C A T I O N
B E IN G IN THE T R A N S IT IO N PERIO D IN M ED IC AL EDUCATIO N:
TURKEY EXPERIENCE
Sibel K alaça, M .D ., MPH* / Çağrı K alaça, M .D .**
* D e p a r tm e n ts o f P u b lic H e a lth a n d 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 urkey.
* * D e p a r tm e n t o f F a m ily M e d ic in e , S c h o o l o f M e d ic in e , M a r m a ra U n iv e rs ity , Is ta n b u l, T u rk e y
INTRODUCTION
There are 47 medical schools in Turkey, 39 of which currently have undergraduate medical education. All th e se sch o o ls run their own program s independently. A ccording to the Undergraduate Medical Education Report of the Turkish Medical Association (1), 23 out of 39 scho ols nam ed their educational system as “integrated”, 9 a s “classical", 5 a s “integrated + active” and 2 schools a s “active”.
During the last 5 ye a rs in response to current challenges to reform medical education (2), a number of medical schools in Turkey initiated a changing p ro cess in their curricula as well as revising the educational methods (3,4). Although educational reform m ovem ents were initiated with different p e rsp e ctive s and exp erie n ce s, there have been important sim ilarities between the sc h o o ls in the fe a tu re s of the change p ro cess; such a s em p hasis on active learning instead of a p a ssive - lecture format, standardization in clinical skills by introducing the clinical skills lab, and early exposure to clinical m edicine. A ctu ally m any of the ch an g e s envisioned at different m edical schools had already been introduced elsew here (5,6).
A very few and “relatively young” medical schools in Turkey decided on “problem based learning" (P B L ) a s their innovative method and changed their entire curriculum to the new one (1,3), whilst many others preferred to take a “sa fe ” way by implementing P B L or other innovative methods within a number of courses (1,4). There are also some other “deep-seated" medical schools that are satisfied with monitoring this transition period and waiting for the first results. The need to change medical education is however greater in established medical scho ols, but innovations seem more difficult to achieve there (7).
Keeping in mind that transition period is not completed yet, four types of system/curriculum could be identified in medical education in Turkey at present: classical system (discipline based), integrated system (o rg an-system -b ased curriculum), problem based learning (it is called a s “active educatio n”), and a m ixture of integrated and innovative ones.
A s we have been passing through a transition period, this paper has aimed to focus on recently experienced and expected problem s of this special period; although there is no published research on this aspect. Investigation of the
M a r m a r a M e d ic a l J o u r n a l 2 0 0 2 : 1 5 ( 3 ) :2 0 1 - 2 0 5 Correspondence to: Sibel Kalaça, M. D, MPH, - Departments of Public Health and Medical Education,
School of Medicine, Marmara University, Haydarpaşa, 81326 Istanbul, Turkey, e.mail address: sibelkal@superonline.com
problems might provide an opportunity to achieve better response to them.
THE CHANGE PROCESS: PROBLEMS
AND EXPERIENCE OF OTHERS
There are important sim ilarities in both the problems and solutions involved in curricular change at any medical school (2, 4, 5). There are some problems and concerns which have been already experienced at the early stage of the process, such a s how to know if there is need for a change, how to convince som e of the teachers who believe that the old curriculum did not need any change, which model is better, what should be the objectives and structure of the new curriculum, what should be the depth and the speed of the curriculum change, how to overcome expressed (and unexpressed) faculty concerns about time commitment, resource allocation, and promotion, how to cope with concerns over loss of departmental control, how the proposed system can be named, and how to improve the active involvement of students In this change period. Som e of the problem a re a s are well known due to the others’ experience however they have not been studied as required. Therefore it se e m s that these problems will be experienced sim ilarly by the “observer” medical schools in Turkey in the near future such a s: how to identify and fix the m istakes in the m anagem ent of this change p ro ce ss, how to prom ote innovation and continued curricular evolution, how to evaluate the effect of the new curricula.
Som e of these problems have been d iscu ssed in the following sections relative to the situation in Turkey.
1.1. T h e fir s t f o c u s : L a c k of q u a lity in e d u ca tio n
For the last 20 years, the number of medical schools and students in Turkey has been rapidly increasing. There were 4 medical schools in 1964, 7 in 1970, 16 in 1975, and 24 in 1989; in 1998 the number becam e 47. The number of graduates w as 426, 778, 1149, 3264 and 4500 respectively (1).
U nfortunately extrem e d isp arities em erged among m edical sc h o o ls a s a predictable
outcome of this rapid in c re a se in num bers; particularly with re sp e ct to ed ucatio nal reso urces. For instance the number of reference books in medical libraries per student is 13 in Ankara, 14 in Çukurova, 53 in Dokuz Eylül, 1 In Atatürk, 2 in Dicle, 1 in T ra k y a and 0 In Süleym an Dem irel M edical S c h o o ls (1 ). T h e s e fa cts provoked a “quality in m edical e d u ca tio n ” discussion. The Turkish Parliam ent founded a co m m ission for the p roblem s of m edical education in 1990 (8). It has been dem onstrated that most of the young graduates do not feel confident (and w orse, are not competent) in many of the common health problems of the community and required procedural skills. Y e s, the basic dilem m a in medical education w as lack of quality in education (1, 3). Th is w a s the initiation point for the reform m ovem ents in medical education.
1 .2. A n u n e x p e c te d o u tc o m e of a re p ro d u c tive h ealth s e r v ic e s p ro je c t: A n a tio n a l m o v e m e n t fo r " tra in in g the tr a in e rs ”
In 1992 an International project w a s launched aiming to introduce a com petency-based course for family planning methods in undergraduate education by Ministry of Health, In cooperation with Jo h n s Hopkins and Hacettepe U niversities. W ithin this project a “train -the -train ers” programme called “improving training skills of trainers ” w as put into practice. Th is programme introduced the co m p e ten cy-b ased education m ethod, a s a part of interactive learning methods. Th e participants w ere not only learning the content, but also actively Implementing many Innovative educational methods within the course programme. A m aster trainer group w as formed at national level supported by ad vance levels of educational co urse s. O ver 150 professors and lecturers w ere educated within a few years. Th is period played an important role for all parties in understanding the problems of current medical education system , especially problems in teaching methods. It w a s noticed by som e of the schools that the enthusiasm and energy that characterized the early ye a rs of foundation were waning. However, a modest co urse providing the faculty with a methodological and structured e xp e rie n ce for a strong er interaction with students, turned out to be a kind of “magic touch”.
Transition period in Medical Education
1.3. T h e fir s t big s te p : D o ku z E y lü l M edical S c h o o l
M eanwhile, another important event happened and one of the medical schools (Dokuz Eylül University Medical School) decided to change the system of education to an active one with problem-based learning. The main philosophy of the new curriculum w a s defined to deal with “biological”, "behavioral" and “social" aspects of the whole “life cy c le ” and complete Integration of different disciplines (3).
The decision of Dokuz Eylül Medical School w as considered a s a reform in medical education and monitored by about 10 medical schools with an interest in adopting sim ilar program m es In the future. H o w ever, only one m edical school, P a m u k k a le , am ong the follow ers aim ed to implement P B L with a curriculum-wide approach. In fact, we do not know what argum ents were used in different schools to prove the need for a change. Dokuz Eylül University, for instance, used g en eral inform ation on the quality of medical education in Tu rkey and took a decision to establish a curriculum which covered the common health problems and basic needs of people as stated in the Edinburgh Declaration and the T u rkish M edical A sso ciatio n (3). M arm ara University Medical School has also referred to those two and relied on students’ opinions about the status of medical education (4). However, this w as not enough to convince who those believed that the old curriculum needed no change.
1.4. T h e n e w d is c u s s io n : T h e m ethod of c h a n g e p ro c e s s
Actually, once the decision w a s made on the direction of reform the second step has been alw ays the sam e for any medical school: to set up a new curriculum committee. Construction of the new committee has had a central role during the p ro cess a s much a s Its products. First of all, the new curriculum committee needed to be more rep resentative than the previous one. H o w ever, w hen w e looked at e xam p le s in Turkey, it w as seen that both old and new committee m em bers were assigned by the dean. Th is approach cau sed another discussion on the “method of the change p ro ce ss” in addition to u n satisfacto ry arg u m en ts for the need for curriculum reform and unfortunately resulted in a
som ewhat harmful effect on som e of the medical schools.
Another problem with the new curriculum committee w as that except for a few exam ples, this assigned group consisted only of faculty members and students were not given a place. However, student feedback w as one of the important factors in defining the efficacy of new curricula (9).
It has been usual practice for student opinion to be sought on pre-existing curricula, usually by issuing them with q u estio n n aires. L ik e w ise , several studies have been conducted a s an Important instrument for students' Involvement In the reform efforts in Turkey (4, 10, 11). While this type of feedback plays an important role in curriculum updates and revisions, students are also capable of providing valuable information for medical educators designing new curricula (9). It must be admitted that som e procedural m istakes have occurred during the transition period in Turkey and the widespread inclusion of faculty and students in the process of change
have not been achieved.
1.5. S t u d e n t s ’ m o tiv a tio n , le a rn in g , evalu atio n
One of the important facts is a change in the system of education requires a ch ang e in students’ learning and studying style. This is actually desirable. It is believed that new system offers many advantages to the students and thus students do much better. However, it should not be forgotten that it is not ea sy for a student to make a change in learning style, since it w as formed early on.
The educational system in Turkey, from primary school, is like the traditional curriculum, lecture- based and competitively graded. There has alw ays been a strong external control, which takes over or substitutes learning and thinking activities from students (12). Th is created an important difficulty for students when they were exposed to a new system based on self-learning activities.
Th is might have been experienced even more complicated among the medical students where P B L or any innovative method implemented in
less-broad spectrum approaches. It has been stated that the most critical elem ent that m akes sing le-course im plem entations of P B L problematic is competition for student attention from courses operated in traditional curricula. Faced with an imminent test or assignm ent deadline in cla ssic system , students will often forgo activities in a P B L course (13). Actually this situation is the sam e in Turkey since most of the medical schools have adopted a mixture of the new and old educational system . Furtherm ore, characteristics of the c la s sic system have been more obvious for the students since these two syste m s have been run in a very different educational atm osphere.
Marmara University Medical School introduced a number of interactive studying modules within its major organ system based-integrated curriculum in addition to other curriculum changes and has been experiencing som e problems related to these changes. One of the problems at the school has been about a sse ssm e n t. Students are being exposed two different system s at the sam e time. It could be considered an advantage on the one hand since each student might serve as his/her own “identical” control. On the other hand, it would be very difficult to m easure the effect of a specific method, since they are not exposed to all asp ects of the new system but only some and also each student is influenced by the two methods.
It is well documented that evaluation methods have a large “steering" effect on student learning (14). Without making any chang es either in the curricula or in the a sse ssm e n t system , educators may counsel students to avoid studying for the test, saying that the important thing is “really learning” instead of just “passing e x a m s”. But it is unlikely that this steering effect will go aw ay. A far more adaptive strategy is to use knowledge of the steering effect to explicitly direct student learning in desirable situation (14).
Different system s have required different types of asse ssm e n t approach and techniques; however it has been more difficult to achieve this within a mixed educational system . Interactive studying modules at Marmara Medical School have been based on P B L and took a relatively sm all part in the curriculum . T h u s, they cannot defensibly serve as the b asis for a pass/fail decision. Yet, it
is known that if they are not used for decision, the steering effect will be lost. W hat we do is, we evaluate students’ effort during the sm all group work in order to keep steering effect for newly introduced co urse s (14).
CONCLUSION
Som e of the problems of the transition period in m edical education in T u rk e y h ave been sum m arized in this paper. It is said that, in medical education “how it is taught” has the sam e importance with “what is taught". Our experience in Turkey has shown that the sam e approach could be applied to the p ro cess of changing; “how” is a s important a s “w hat”. Although there are m any more problem s than presented here, we think they all need the sam e approach, which is to achieve ch ang e s in the “culture" of the school. Th e culture should be changed in the direction of greater collegial relationship among students, faculty, and the administration rather than the former sim ple te a ch e r-le a rn e r m entality. An innovative curriculum , which aim s to promote life-long, self- directed learning, could be better applied where students are considered as adults and where students are more mature.
It is now vital to contact and cooperate with other medical schools and educational bodies to share exp eriences in order to cope with the problems of the new period and also to improve the active medical education system .
S u m m a r y p o i n t s : / M a i n r e a s o n f o r c h a n g e : T h e g a p b e tw e e n c o m m u n ity h e a lth n e e d s a n d th e m e d ic a l c u rric u la / M a in p r o b l e m s o f t h e c h a n g e p r o c e s s : • R e s is ta n c e o f te a c h e rs a n d s tu d e n ts : s o m e te a c h e rs d o n o t b e lie v e in n e e d fo r re fo rm ; w h ils t s tu d e n ts h a ve d iffic u ltie s in a d a p tin g th e ir le a rn in g s ty le s
• P ro b le m s in c o n s tru c tio n o f th e n e w c irru c u lu m c o m m itte e • L a c k o f s tu d e n ts ’ p a rtic ip a tio n in th e p ro c e s s / P r o b l e m s of t h e “ m i x e d s y s t e m s ” : • s tu d e n ts d o n o t g iv e e q u a l im p o rta n c e to th e c o u rs e s o p e ra te d in n e w c u rric u la / C h a l l a n g e : • to a c h ie v e c h a n g e s in th e “c u ltu re ” o f th e s c h o o l.
Transition period in Medical Education
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