Advocacy in Medical Curriculum Toolkit How students become partners in their education
IFMSA Imprint Standing Committee Director Catarina Pais Rodrigues Contributors Isabelle Mckay Miguel Lince Duarte Nikolai J. Nunes Nouman Shuja Salma Soussi Stijntje Dijk Layout Firäs R. Yassine José Chen Content Editor Catarina Pais Rodrigues
Publisher International Federation of Medical Students’ Associations (IFMSA) International Secretariat: c/o IMCC, Nørre Allé 14, 2200 København N., Denmark Email: gs@ifmsa.org Homepage: www.ifmsa.org
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The International Federation of Medical Students’ Associations (IFMSA) is a non-profit, non- governmental organization representing associations of medical students worldwide. IFMSA was founded in 1951 and currently maintains 136 National Member Organizations from over 126 countries across six continents, representing a network of 1.3 million medical students. IFMSA envisions a world in which medical students unite for global health and are equipped with the knowledge, skills and values to take on health leadership roles locally and globally, so to shape a sustainable and healthy future. IFMSA is recognized as a nongovernmental organization within the United Nations’ system and the World Health Organization; and works in collaboration with the World Medical Association.
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Contents
Concept Note Introduction to Medical Curriculum A Student’s Curriculum Development Model A Student’s Guide to Advocacy in Medical Education Take Away Message Annex 1: Curriculum Assessment Tool Annex 2: Checklist on Student Engagement
www.ifmsa.org
Annex 3: Teaching and Assessment Methods Additional Resources
Concept Note
The IFMSA Standing Committee on Medical Education (SCOME) aims to involve medical students in the development of their education. This vision entails students with knowledge about educational strategies and curriculum development, skillful in advocacy and committed to establishing partnerships between students and faculty. To achieve this paradigm, students around the world have become scholars in medical education and have been avidly discussing and sharing best practices. The Advocacy in Medical Curriculum Toolkit intends to gather these experiences in student representation and provide a framework for medical students’ active participation and influence in their medical education. This document is a collection of ideas and references adapted to a student’s perspective, enabling possible action from within medical schools. The content is structured to fit anyone’s purpose; one can easily go through the sections and points they find most relevant or read the toolkit from top to bottom. Whatever the choice, the goal is the same: towards great student activists and a better medical education.
Introduction to Medical Curriculum Education is a process of which students are an integral part. As the receivers of a curriculum, students have an invaluable perspective to share and a responsibility to contribute to its improvement. Those interested in getting involved in curriculum development should aim to understand the theoretical principles and common trends in medical education, so the input is well reasoned, with quality and consistency. The following concepts aim to direct an initial analysis, providing a broad overview of the curriculum. It is important to note, they constitute a small sample of education theories and are not meant to dictate a uniforme curriculum. In fact, there is no such thing, as each school should be able to define its own vision and strategies to achieve it with the resources available. Upon reviewing the literature and the specific contexts, students should be able to identify learning gaps and points of improvement in their education.
Curriculum Definition
“Curriculum” refers to planned learning experiences. It includes the lessons and academic content related to an area of study, in a specific course or program or in the school. Despite inter-institutional variation, every curriculum consists of three base components: a declared curriculum, a taught curriculum and a learned curriculum.1 • A declared curriculum is what is assumed the students are learning; that is, what is set out to be communicated. • The taught curriculum is the specific content that is presented to the students by the teachers themselves. • The learned curriculum is the learning outcomes that the students take away after the curriculum completion. The successful intersection of these three components constitutes the most effective curriculum model, where faculty expectations are met by teacher delivery and student learning.1 A mismatch in these component will result in a ‘learning gap’, where the key messages intended by faculty or teaching staff are not taken away by the students.
declared curriculum
taught curriculum
learned curriculum
Educational Strategies Educational strategies are devised plans aimed towards the achievement of a certain learning goal. These strategies should be adopted considering the needs of health systems and the future health workforce, the spectrum of medical education and the needs of the learners.
Strategies
Goal
Transformative Learning “Each day students were subjected to interminable lectures and recitations. After a long morning of dissection or a series of quiz sections, they might sit wearily in the afternoon through three or four or even five lectures delivered in methodical fashion by part-time teachers. Evenings were given over to reading and preparation of recitations. If fortunate enough to gain entrance to a hospital, they observed more than participated” Flexner Report, 1910 Even though this quote may still be familiar for some students, there are many fundamental changes in medical education since this remark was made in 1910. At the time, education was purely informative with a sciencebased curriculum focused in acquiring knowledge and skills. The shift from producing experts to professionals occurred mid-century, introducing the concept of formative learning and the importance of socializing students around values. To the present time, where we aim for transformative learning to produce change agents with leadership attributes that can address the specific contexts, while drawing on global knowledge. Transformative learning is the process of effecting change in the way we understand our experiences and broaden them towards a more inclusive, discriminating, self-reflective and integrative perspective.
The adult learner: • Moves from dependency to increasing self-directedness as it matures and can direct its own learning; • Draws on its accumulated reservoir of life experiences to aid learning; • Is ready to learn when it assumes new social or life roles; • Is problem-centered and wants to apply new learning immediately; • Is motivated to learn by internal, rather than external, factors. Inherent in these assumptions are implications for practice as the need to develop learning objectives based on the learner’s needs, interests and skills levels, and learning activities designed to achieve certain objectives and applicable to real life context.
Pedagogy how children learn
Adult Learning Theory9 Medical students’ learning needs are different than those of children. Adult learning theories provide insight into how adults learn, enabling educators to develop practices more effective and more responsive to the needs of the learners they serve. Concretely, there is a distinction between pedagogy, “the art and science of helping children to learn” and andragogy, “the art and science of helping adults to learn”.
Andragogy how adults learn
SPICES Model The SPICES model8 is used widely to define which educational strategies should be considered while designing a medical curriculum. The acronym SPICES refers to six main concepts in medical education - student centered teaching, problem based learning, an integrated curriculum, community based teaching, electives with a core, and the use of systematic methods. These main concepts are presented in opposition to the traditional approach, as each medical school should be able to decide the emphasis it gives to each component. Traditional approach
SPICES
Teacher centered learning
Student centered teaching
Information gathering learning
Problem based learning
Discipline based teaching
Integrated teaching
Hospital based education
Community based education
Standard programme
Electives
The teacher and what is taught are the key The student is actively responsible for the figures, as if the learning process was unidi- learning, the emphasis is on what is learrectional. nt. The teacher encourages and guides the student through the process. Focuses on understanding the fundamentals Students acquire their knowledge and skills of each discipline and a logical progression through tackling problems, developing an of concepts integrated perspective of the knowledge Emphasizes the classical disciplines, in a building block perspective to get an overall picture of medicine. It allows teachers to convey specific messages and content that would possibly be overlooked or neglected.
It provides a more concentrated experience form of experience of a disease and allows for a wider range of learning experiences, closely monitored.
The subjects are interrelated or unified, either between parallel disciplines or disciplines traditionally taught in different phases of the curriculum. It improves the educational effectiveness of teaching and encourages a holistic approach Allows students to understand the health needs of the community and the social determinants of health. It introduces students to the health systems.
The focus is on the core or essential It increases students’ responsibility in components of medical curriculum. their learning and it meets their individual aspirations. It allows to cope with the expansion of medical knowledge and an overcrowded curriculum
Apprenticeship programme
or
opportunistic Systematic
The learning experiences should be planned Students are attached to a teacher or a and recorded to ensure all the necessary clinical unit for a period, learn or are taught content is covered. about the conditions as they present
Competency-based Education Aligned with the changes to the education paradigm, the term competency-based education was introduced, focusing on the outcome of the process and differing from what had been education practice before.2 From that perspective derived the taxonomy of educational objectives which consider three domains: cognitive (knowledge), psychomotor (skills) and affective (attitudes).3 This idea is very relevant while analysing a curriculum to understand if the educational objectives match the intended outcome of the curriculum, covering the different domains needed to achieve competency.
Knowledge - Skills - Attitudes
There are different examples of competency frameworks such as the Scottish Doctor5 or Tomorrow’s Doctors6 developed by professional organizations. Probably the most recognized competency framework is CanMeds 20157, , organizing the key competencies in 7 roles, presented in the diagram below.
Communicator Health Advocate
Collaborator
Medical expert Professional
Scholar
Leader
It is expected that throughout the medical education process, learners develop these competencies and that can entrusted to perform certain tasks adequately. The medical expert is the central role of the physician, integrating “all of the CanMEDS Roles, applying medical knowledge, clinical skills, and professional values in their provision of high-quality and safe patient-centered care.”7 On the context of medical education, there were three proposed criteria for curricula4 in order to achieve the intended outcome of Competency Based Medical Education, “a healthprofessional who can practice medicine at a defined level of proficiency, in accord with local conditions, to meet local needs”: • Organized around the necessary functions for the practice of medicine in a specific setting; • Based on the understanding that all students can master the basic performance objectives; • And on the justification that learning and learning processes can then be empirically tested.
A Student’s Curriculum Development Model After diving into medical education theory, we need to get practical. The opportunity to design a curriculum from scratch doesn’t come around that often, nor are we able to change a well-established structure through a single initiative in time. What we can do is to look into our context and understand what are the most necessary problems to be addressed and figure out the feasible solutions. In order to guide you through this process, we have looked into Kern’s six-step approach to curriculum development10, adapting it through a student advocate’s eyes. The reach of what you are working depends on your involvement with the medical school’s governance. Problems in medical curriculum are discussed and can have solutions in committees or dedicated bodies of the school to curriculum or education. If you are a student representative in those committees, you should have a broader vision that may include introducing changes in teaching and/or assessment methods or the addition of a new subject or topic to the curriculum. Yet, a change can be as impactful when students approach directly the teachers and heads of courses with solutions to problems they’ve been facing.
Identify the problem Evaluate and collect feedback
Conduct a needs assessment
Implement your plan
Structure the educational strategies Define proposed outcomes
Step 1: Identify the problem Students as receivers and products of education have a different insight of the learning process and often find issues that are missing or that could be better addressed in the curriculum. When debating over this matter, it’s important to identify the problem and its context in order to be able to understand the possible solutions. This is also the step where it is important to explore medical education literature, making sure you know the issue you will be advocating for, as well as you can.
Step 2: Conduct a needs assessment A needs assessment allows us to determine the gaps between the current and the desired conditions. When conducting a needs assessment, you should aim to understand the different aspects of the medical curriculum, the different perspectives of the students, faculty, (and community, if deemed necessary) regarding the current medical curriculum and what would be the ideal approach.
To understand how a specific topic is address in the curriculum, you can use the Curriculum Assessment Tool displayed in an annex of this document. This tool is structured in different parts to cover how the curriculum is, but also provide feedback on how the curriculum could be, considering the teaching and assessment methods, as well as the learning environment. Step 3: Define the proposed outcomes In the process of developing the curriculum you should set a goal and objectives considering the solution to the problem you have identified. On one hand you should set operational objectives that give you a concrete idea on the process to achieve the goal you have set, and learning objectives, clearly stating the outcome to be achieved by the end of the educational experience. Evaluating if the learning objectives are met along the way, will help us understand if our efforts are making an impact in their target. In order to set them, refer to the taxonomy of educational objectives3 mentioned in the introduction to medical curriculum and consider the three domains: knowledge, skills and attitudes. Problem
Students don’t have practice in suture skills
Learning Objetives
•
• •
Students are able to identify the tools and techniques for suturing Students demonstrate different suturing techniques Students confidently perform sutures on patientts
Operational • To hold a course with support of the Objetives
surgical department on suture skills with pre and post assessment of knowledge and skills perception
When defining operational objectives, keep in mind the SMART acronym11. Your objectives should be: • specific to your context and problem • measurable, indicating if there was any progress • assignable to have someone who will be responsible to work on them • realistic according to the available resources and support from the faculty • time-related to when they will be achieved. Step 4: Structure the educational strategies The first section of this toolkit introduces curriculum and educational strategies theory. Before advocating for changes, it is important to be familiar with these concepts and how the curriculum is organized, as well as have a clear idea on the issue you are tackling. Once that is covered, it is time to draft a proposal that contains: • Content - The content of the curriculum is found in the syllabus, in the handouts relating to the topics covered in lectures and in students’ study guides. When proposing changes to the content, it’s important to address the depth or extent of coverage: Does the content directly contribute to the course objectives? Does the content address the attainment of relevant knowledge, skills, and attitudes? Is the content already addressed or it needs to be addressed to equip students with knowledge or skills to tackle a later part of the course? Will the content allow students to develop intellectual abilities such as critical thinking? • Organization of the content - The organization may have to do with the already established curriculum organization.Nonetheless more than one perspective can be addressed in the medical curriculum. The approach chosen - traditional, integrated, problem-based, case-based or taskbased - should consider the most effective learning experience
• Teaching and Assessment methods - When approaching the teachers, one of the most common concerns is about the delivery of the content and the ability to evaluate the learning outcomes. Before being asked that question, you should try to understand what would be the most effective tools, given the objectives and school’s resources,
Output
Developed and conducted a survey to demonstrate that students don’t know how to suture and had a meeting with the dean to show it
Outtake
Suture skills course was initiated spontaneously by the head of the surgical department
Step 5: Implement your plan
Outcome
Suture skills course happened, indicators of success were achieved, as verified by the examination at the end of the course. However, this didn’t result from my efforts.
Over the next section - “A Student’s Guide to Advocacy in Medical Education”, there are many examples on how you can build on your position in your school, getting your plan out and actually implement some, if not all of it. Step 6: Evaluate and collect feedback Even if the written proposal seemed to be flawless and the project appears to be implemented as planned, it is important to evaluate and collect feedback on the actions undertaken and their results. It is important to evaluate in order to measure if the set objectives have been achieved and the impact of your efforts. • Indicators and Means of Verification Once you set your objectives, you should also set your indicators of success and decide on how you are going to make sure they were achieved or not by defining means of verification • Output, Outtake and Outcome Output, what have you invested in this initiative. Outtake, what resulted from your investment in this initiative. Outcome, the result of the initiative Objective
100% of students are able to suture by the end of the course
Indicator
100% demonstrate successfully 3 different suture techniques
Conduct an examination Means of verification at the end of the course where students demonstrate 3 different suture techniques
Beyond your specific efforts, students have an important role in the continuous monitoring and quality assurance mechanisms within faculties. It is not just about meeting a target of students that have achieved a certain learning objective, but also monitoring the percentage of students that succeed, if there’s a difference between different classes or different years. In order to get a better perspective of the learning environment, you can implement: • Feedback questionnaires; • Conduct focus groups or interviews; • Review student assessment results and reports; • Report on your observation
A Student’s Guide to Advocacy in Medical Education A plan is worth as much as you are able to make of it and turn it into reality. Students become advocates when they choose to act on their concerns, develop ideas to improve the curriculum and make them happen. This section presents some concepts, commonly thrown around when talking about advocacy, interpreted in the context of medical schools, and a structure to plan initiatives from choosing the issue to setting the goal, the actions and timeline. It also includes different scenarios to address the relationship between students and faculty and provide ideas on how to “tip the scale” in favour of students’ interests.
Advocacy Principles ADVOCACY
Public support for or recommendation of a particular cause or policy. It comprises a set of organized activities designed to achieve the necessary change.
DIPLOMACY
Art and practice of creating relationships, sharing values and negotiating to achieve each party’s objectives through mutual agreement.
GOVERNANCE
The way organizations are managed, conducting the policy and affairs with an established authority. It should be accountable, transparent and enable participation.
Principles or plans to guide decisions, actions and outcomes. It can take the form of written documents or unwritten practices.
POLICY
To take action to effect change that can occur in a myriad of ways and in a variety of forms
ACTIVISM
To attempt to influence and persuade one to support or oppose a particular issue
LOBBYING
A series of organized activities with a particular purpose
CAMPAIGN
Student activism has proven to achieve important changes in the medical school. The students’ organization has a strong policy of being involved and contributing actively to the governance of the medical school. Last year, the students’ advocacy for changing the exam date was successful. The student representative started by lobbying with the staff to have their support while conducting a campaign where all students were called on to sign a petition and to reach out to their teachers on this topic. By the end, the representative and the head of the course reach an agreement, and the latter praised the hard-work and skillful diplomacy of the students.
Become an advocate What do we want? Many issues can be identified while analyzing a curriculum. Focus on those you are passionate about and where you see an opportunity for change. Once you decide, research thoroughly about it, so you can set a SMART goal!
Issue
Who do we to talk to? There are a lot of people and entities involved in managing and developing the curriculum. Those are our stakeholders and for the interest of medical education, they should also be our partners with whom we foster a relationship with. For each issue we are advocating for, the interests and powers may change.
Stakeholders
What do we do? To achieve the desired meaningful change, a structured campaign must take place, this includes setting a clear message and actions to get the message across. The message should reach the target group and appeal to them, answering the question “Why should I care?”
Message
consequences
causes
Goal
Dean, Administrative Staff, Individual Teachers, Heads of Courses, Students, University’s Rector, Governance bodies and committees of the medical school, student organization, accreditation agency,…
High Level of Interest
Low Level of Interest
High Level of Power
Key-Players
Meet their needs
Low Level of Power
Show consideration
Minimal contact
Consider the group you are conveying the message to and the approach needed - full length document, quick-fire message or different messages for specific target groups. Any message should be simple, reasonable and evidence based, solution focused and appropriate for the audience in language and content
Actions and Timeline
Examples of actions: lobbying decision-makers, public awareness campaigns, online or media presence, mobilizing others to take action with protests or petitions, build partnerships and alliances, meetings, activities such as conferences and roundtables
Tipping the scale In order to apply the advocacy principles, you need to understand the context. Each circumstance is different, considering your stakeholder and the topic you are addressing. When working with the medical school sometimes students are heard and work with teachers, whereas other times it’s harder to get in touch with the governance bodies. Let’s think of it like “weights on a scale”, on one side you have the students and the other you have the teachers. The weights are always shifting considering the power, the influence and the interest the two parties might have and the challenge is to know how to tip the scale to promote the change you’d like to see. The scenarios presented aim to help you create partnerships between students and teachers, a synergy towards a better Medical Education. When placing yourself in the scenarios, please acknowledge they are dependent on the particular circumstances, the stakeholders and the topic you are discussing together. Thus, for different situations you can use different scenarios. If you don’t know where to start, it may help to use our “Student Engagement checklist” in annex 2.
CONTEXT
Scenario 1: Scale only represents teachers There are situations where student’s voices aren’t taken into consideration, whether because the teachers don’t recognize their relevance or students don’t take the initiative to be involved. In such cases, it’s important to raise student awareness over the issues and their credibility as part of the discussion
Structure student representation by electing representatives, establishing organizations, holding decision making forums, starting petitions. Build on your position by researching, conducting surveys, seeking external support and mobilizing fellow students. Understand the governance mechanisms and opportunities for students to be involved by looking into the hierarchy of decision making processes, school’s committees or councils and establishing a relationship with the administration.
Success Story – Portugal In 2008, the Portuguese Ministry of Health affirmed the need to change the national exam to access residency, considering it of poor quality and insufficient for its purpose. ANEM, the official representative of medical students, adopted a policy document on the students’ stance on the structure and content of the new exam. Despite the publication of a government report presenting evidence on the declining state of the medical education system, progress on the improvement of the residency exam continued to stall. In response, ANEM mobilized more than 1000 students in action for the future of the medical education and proceeded with a series of position papers and meetings with government officials, political parties and medical associations. Over time, the student organization went from a bystander reacting to a governmental decision to being included in government working groups - first as observer and then with voting rights. Eleven years after that first governmental decision, a new national exam to access residency will take place and most of the changes are in accordance to the students’ views. This story that change may take time, but it will come about and students can present their stances and grow their influence overtime.
Scenario 2: Scale only represents students In some cases, the movement towards addressing curriculum gaps is driven entirely by students. The lack of teacher/administrator involvement can often mean that these student efforts go unrecognised, despite the potential value they bring to the cohort. However, these student-led initiatives can be extremely relevant to medical education, in part because they are designed by users of the curriculum. This brings a unique perspective to the curriculum, demonstrating student-perceived learning gaps and needs. Develop activities that address curriculum gaps such as clinical skills workshops, problem based scenarios, etc and collect data on their impact. Get the medical school’s recognition for activities that bring value to the curriculum by issuing certificates, adding them to the diploma or as extra credit. Propose activities to be added to the curriculum, a class in the semester or an elective course.
Success Story – Australia Global health teaching and advocacy was identified as a learning gap at the University of New South Wales in Sydney, Australia. In response to this curriculum deficit, a student group decided to design and run their own ‘short course’ across four weeks of the year. This group, the Medical Students’ Aid Project (MSAP), approached global health experts around the state and invited them to be guest speakers on a variety of topics, ranging from refugee welfare advocacy right through to career pathways with Médecins Sans Frontières. The course was so successful that it was run again the following year, and again the next. Very quickly, it became the largest medical event on campus, attracting over three hundred attendees each week. In order to demonstrate the value of global health teaching to faculty, MSAP approached the Dean of Medicine and asked them to provide signed certificates to each attendee. This created course recognition from the faculty, and also allowed students to acknowledge course completion in their portfolios and résumés. This is an excellent example of student-led education being used to leverage faculty recognition and change.
Scenario 3: Scale is shifted to the students’ side Both the teaching and student cohorts have a role to play in curriculum development, but when action is being driven largely by students, this imbalance can result in feelings of burnout and can impact the efficiency of the change process. However, having some degree of faculty involvement, even just a little, opens the door to collaboration. It becomes a matter of seizing opportunities to encourage greater engagement from teachers, such as external attention on the medical schools, restructuring and renewing of the hierarchies or the process of curricular reforms. Prepare thoroughly the issues that are being discussed, not only in terms of knowledge about the content, but also the stakeholders’ views on them to understand the dynamics of negotiation and decision making. Foster relationships with all involved parties, including those that may be considered opponents. There’s always the possibility to find a middle ground, when there’s respect and recognition of value between everyone involved. Intervene by giving input, voicing your opinion or putting proposals forward. Contrary to popular belief, students aren’t told to shut up that often and they may even be carefully heard when their stances are constructive and supported by evidence.
Success Story – Jamaica At the University of the West Indies, Mona Campus in Jamaica, the new Dean empowered student leaders to lead engagement in curriculum review and development, social accountability, and interprofessionalism resulting in the first Faculty-student collaboration in course design, student input into designing socially accountable admissions policy, and interprofessional health professions students volunteer-driven service and outreach to rural and underserved communities respectively. Faculty response has not only been positive but encouraging with the staffstudent relationship improved. When the scale is shifted to the students’ side it simply reinforces that the students must take the initiative as change agents.
Scenario 4: Scale is shifted to the teachers’ side Most schools acknowledge the importance of students’ feedback to a certain extent, conducting end of semester surveys, having students sit in some committees or sporadic meeting between representatives and the administration. However, having “a seat at the table” does not suffice, as it is a matter of what we do and how we are able to influence the decision making. Strengthen student involvement by engaging fellow students in your efforts and setting a common vision between all student representatives, allowing for a cohesive action at different levels of governance. Seek support from external parties, these can be within the institution, for example the governance bodies when the issue is at a course level; or when the issue is at an institution level, by involving the university’s governance, external agencies, etc. Speak truth to power. Fostering relationships with the faculty is very important. Students should follow diplomatic steps and involve the relevant parties to overcome the issues, however we shall not be intimidated to speak up, disagree respectfully and take stronger actions in necessary cases.
Success Story – Pakistan Delay in the adoption of the Integrated Medical Education System in Medical Schools of Pakistan is an example of teacher-centered education being emphasised at the expense of student-centered education. Student opinion is widely in favour of this system in medical school, but final authority is with teachers. In order to spread awareness and familiarize students and teachers with this system, members of IFMSA-Pakistan initiated a 3-day project modelling the Integrated Medical Education System, in which students were tackling emergencies and solving scenarios and at the same time learning from it. To encourage support from a stafflevel, teachers were requested for judging and a set scoring proforma was designed with the help of medical educationists of the country were given to them. After seeing the impact of the activity and garnering support from Pakistan Medical and Dental Council, medical teaching staff developed an interest in the new system and now many of the medical schools are in the implementation phase of this system.
Scenario 5: Scale is balanced The ideal approach in curriculum development would be the harmonization of both students and faculty’s vision towards improvement. The decision-making should be structured in a way that promotes rational, equal and balanced collaboration between faculty and students in designing or bringing change in areas of the curriculum. Establish a common vision and goals not only for the medical school’s curriculum, but also for the collaboration between students and faculty, assuring its sustainability and continuity over time. This can take the form of a signed protocol, designated positions in the committees for students or adding quotas of representation to the school’s regulations. Negotiate based on principles rather than positions to avoid strain relationships and allow a good, lasting partnership where everyone’s interests are taken into consideration when creating solutions. Share responsibilities in terms of drafting documents and developing proposals, committing to the decisions reached and communicating them to fellow students.
Success Story – Morocco Few years after creation of the simulation center in the faculty of medicine of Marrakech, Morocco, the programme evaluation committee published results showing that the facilities of the center were under-used based on the local students’ surveys. Student representatives and simulation center staff held meetings to structure a new programme to optimize the use of the various simulators, high-fidelity mannequins, and other educational facilities. Currently, the programme offers a variety of courses with online registration to students in both undergraduate and postgraduate education and free access during 5 days of the week. Two types of courses are organized: prescheduled courses led by a faculty member, courses led by students themselves for peer-teaching and peer-assessment. The programme evaluation shows very positive results and many medical schools in Morocco are now adopting the structure of the programme.
Take Away Message If there was a single message to take away from this toolkit, it would be to actively pursue a better medical education, to act upon the issues you encounter. Research and learn more about the topic you are concerned about, about its context in your medical curriculum and in medical education. Propose solutions that build on the strenghts of your medical school and turn its faults into opportunities.
Discuss and collaborate, allowing ideas to be questioned and further developed with fellow students, teachers, administrative staff and members of the community. It is in our hands to lead the change with our wide-eyed innocence and irreverence to think differently. Do not let the status quo discourage you to challenge what is established. Reach your hand out and become a partner in your education!
At any point in your endeavours, remember there’s a community of unsettled advocates for Medical Education willing to help! Make a post on IFMSA - Standing Committe on Medical Education facebook group or send an email to scomed@ ifmsa.org
Annex 1: Curriculum Assessment Tool Conducting a curriculum assessment is a demanding task required when we want to understand the scope of the issue we want to advocate for, as well as find possible solutions. This questionnaire was developed to assess the undergraduate medical curriculum, at a medical school level. It aims to provide a comprehensive overview of the curricular structure regarding a chosen topic, as well as to understand the students’ perception and learning environment. •
General Instructions
• The assessment is organized in two parts. The curricular structure part is to be filled out after an in-depth analysis of the curriculum, it can be done individually or by a group of interested students. Regarding the students’ perception, this part was designed for wide input collection, sharing a survey amongst students to understand the satisfaction with the curriculum, analyse possible gaps between the planned and learned curriculum and gather suggestions. In case the goal is to compare the curricula of different medical schools, filling out this questionnaire per medical school will enable the users to structure the comparison between curricula.
• Throughout the questionnaire there is the distinction between topic and areas - “topic” refers to the main thematic the questionnaire is covering and “areas” refer to concrete concepts that should be explored. Areas of the same topic can be approached differently in the curriculum. Examples of areas (topics): surgical specialitiies (vascular, thoracic, plastic); addressing discrimination of vulnerable groups (women, minorities, LGBTQI+)
• An introduction section should always be added displaying the overall aim of the questionnaire and include a brief explanation of the topic and why it’s relevant should be included. It should be clearly stated in the introduction that this questionnaire aims to assess undergraduate medical curriculum in medical schools and that this is the scope when referring to “medical curriculum”. • Above all, this is a proposal on how to assess the curriculum, it’s up to each one’s discretion to use the tool as it is or making the necessary adjustments to fit their purpose. Keep in mind: • Overall, the questionnaire needs to be detailed enough to gain quality feedback, but can’t be too lengthy or students will be deterred from participating. • Closed questions should be preferred to ensure reproducibility and reliability of the results - i.e. mostly MCQ or Y/N • An option for short answer responses at the end of each section may be added, when deemed necessary
Part I - Curricular Structure When addressing [insert topic], which areas are included in your school’s medical curriculum? At what stage of your studies are the following addressed? Area X •
Pre-clinical or basic sciences studies
•
Clinical or practical studies
•
Spread throughout the entire curriculum
•
Elective (optional part of the curriculum)
•
The topic is not addressed in the curriculum
Area Y
Area Z
Considering the general approach to [insert topic], how would you rate the focus of the following educational strategies used in your school’s medical curriculum? Rating applies to a proportion of educational strategies being used. For example, if most of the classes are information and knowledge based, but there are a couple of moments presenting cases and problems, the rating would be 2 in the first line. N/A in case it is not approached 1 •
(1) Information and knowledge gathering - (5) Problem based learning
•
(1) Specific course in the curriculum - (5) Integrated in different disciplines and stages
•
(1) Learning based in the hospital environment - (5) Learning based in the community environment
•
(1) Undefined, based on the opportunity to approach the topic - (5) Planned and systematic approach
2
3
4
5
N/A
Considering the general approach to [insert topic], what kind of teaching methods are used to address it in your school’s medical curriculum? 0-25% •
Lectures
•
Case based learning (small groups)
•
Problem based learning (small groups)
•
Simulaton
•
Clinical tutorial (large groups)
•
Clinical orientation (small groups)
•
Individual study hours
•
Other
25-50%
50-75%
75-100% N/A
Please elaborate
Considering the approach to [insert topic], how is it assessed in your school’s medical curriculum? Area X •
Continuous (in-course assessment)
•
End of course (final assessment)
•
Both
•
The topic is not assessedd in the curriculum
Area Y
Area Z
Considering the general approach to [insert topic], what kind of assessment methods are used to address it in your school’s medical curriculum? 0-25% •
Written assessment (multiple choice or short answer questions)
•
Written assessment (long essays)
•
Oral examinations
•
Clinical examinations
•
Evaluation reports by tutors or supervisors
•
Portfolio assembled by the students
•
Other
25-50%
50-75%
75-100% N/A
Please elaborate
Does your medical school curriculum include other relevant content not listed above? If so, please add a short description of the content.
Part II - Students’ Perception Learning Experience Considering the approach towards addressing [insert topic], how would you rate it in terms of inclusiveness and emphasis on its importance? Rate from 1 to 5, from dismissive to inclusive. N/A in case it is not approached 1 •
Area X
•
Area Y
•
Area Z
2
3
4
5
N/A
Considering the approach towards addressing [insert topic], how would you rate it in terms of openness and availability to further discuss and elaborate further on the topic? Rate from 1 to 5, from disengaged to cooperative. N/A in case it is not approached 1 •
Area X
•
Area Y
•
Area Z
2
3
4
5
N/A
Considering the approach towards addressing [insert topic], how would you rate the concepts and terminology in terms of accuracy?
Rate from 1 to 5, from exclusively personal and subjective to accurate and approapriate, based on recent scientific data with the societal consideration. N/A in case it is not approached 1 •
Area X
•
Area Y
•
Area Z
2
3
4
5
N/A
Considering the approach towards addressing [insert topic], how accepting is the faculty to receiving and applying feedback from the students?
Rate from 1 to 5, from condescending and disregarding to accepting and willing to implement the feedback. N/A in case it is not approached. 1 •
Area X
•
Area Y
•
Area Z
2
3
4
5
N/A
Besides medical school’s curriculum, do you have extracurricular opportunities to address [insert topic]? Promoted by the Promoted by medical school the student organizations •
Area X
•
Area Y
•
Area Z
Promoted by other organizations
No
Satisfaction and Suggestions Are you satisfied with your medical school’s approach to [insert topic]?
Options yes/no/not sure can be added instead of the rating. N/A in case it is not approached. 1 •
Area X
•
Area Y
•
Area Z
•
Overall approach to the topic
2
3
4
5
N/A
Considering the general approach to [insert topic], how would you rate the following curriculum aspects used in your school’s medical curriculum? N/A in case it is not approached
1 •
Content, in terms of depth and extent of coverage
•
Teaching Methods
•
Assessment methods
•
Overall curriculum
2
3
4
5
N/A
Are you satisfied with the learning acquired through your medical curriculum regarding [insert topic]? N/A in case it is not approached 1 •
Area X
•
Area Y
•
Area Z
•
Overall approach to the topic
2
3
4
5
N/A
When addressing [insert topic], at what stage of your school’s medical curriculum would be most relevant to addressed? Area X •
Pre-clinical or basic sciences studies
•
Clinical or practical studies
•
Spread throughout the entire curriculum
•
Elective (optional part of the curriculum)
•
The topic should not be addressed in the curriculum
Area Y
Area Z
Considering the general approach to [insert topic], how would you rate the following educational strategies for a better learning experience?
Rating applies to a proportion of educational strategies being used. For example, if you consider that most classes should be information and knowledge presentation with a couple of moments presenting cases and problems, the rating would be 2 in the first line. N/A in case it should not be approached. 1 •
(1) Information and knowledge gathering - (5) Problem based learning
•
(1) Specific course in the curriculum - (5) Integrated in different disciplines and stages
•
(1) Learning based in the hospital environment - (5) Learning based in the community environment
•
(1) Undefined, based on the opportunity to approach the topic - (5) Planned and systematic approach
2
3
4
5
N/A
In case you’ve selected “the topic should not be addressed in the curriculum” and N/A, please elaborate on why you don’t find these areas relevant to include in medical curriculum.
Would you like to add something in regard to addressing [insert topic] in the medical curriculum?
Annex 2: Student Engagement Checklist Student involvement can take different forms – students being informed, consulted or sharing decisions - and in different aspects of governance – management, administration, curriculum. The following statements refer to the student body as a whole and its representation, rather than individual perspectives. The purpose being that students evaluate their involvement in the medical school and understand the missing steps to have an optimal engagement, one where students and faculty have a shared responsibility to shape the educational experience provided by the school.
Student involvement in.... • Governance bodies of the medical school • Implementing the school’s mission and strategy • Curriculum development • Facullty development and progression • Quality assurance processes, as students’ surveys • Assessment needs
of
training
• Selection of the course content and its organization • Development and selection of learning resources • Selection of teaching methods • Selection of assessment methods • Formal and/or informal peer teaching activities • Scheduling of courses and exams
Students are not involved
Students Students are are informed consulted
Shared decision making
Annex 3: Teaching and Assessment Methods After identifying learning gaps in your medical school curriculum, you may be asked to suggest an alternative that can better meet student needs. This requires an appraisal of different teaching and assessment methods, to ascertain the most effective strategy to deliver a new curriculum. This section will provide a brief outline of some different methods you may wish to consider and understand when discussing curriculum alternatives with your peers, teachers and administrators.
Teaching Methods Put simply, a teaching method is any technique intended to deliver information to students in a meaningful way, in order to facilitate learning13. This can take a variety of forms, from classroom-based discussion through to simulations and immersive excursions. Different teaching methods may be used to target different domains of learning, be it cognitive development, affective development or psychomotor development3,14. The intricacies of each will not be discussed here, but a brief overview of a few key techniques will be outlined.
Cognitive development • • • •
Discussion Questioning Team teaching Recitation
Affective development • • • •
Modeling Simulation Games Role-playing
Psychomotor development • • • •
Inquiry Demonstration Experimentation Projects
Teaching should not center solely on one individual delivery method. Integration of several different strategies across the course of the curriculum will appeal to a variety of student learning styles and promote learning in a variety of contexts. This analysis must be undertaken on an individual basis, as no two learning environments are the same, and each environment has the capacity to evolve over time. To select the appropriate teaching methods, some constraints should be taken into consideration.15 • Subject matter which influences the efficacy of the teaching strategy, as different areas require different didactic settings and student interaction. • Instructional objectives that must be decided by the teacher before planning a lesson and guide the course of the curriculum. • Learner, considering the cohort’s age, level in training and acquired ability, as well as the number of students. • Teacher, its familiarity with the chosen method and the appropriate preparation. • Time, selecting and adjusting the teaching methods to the time allocated to the subject in the curriculum. • Classroom environment from the infrastructure to the logistics. provided.
Case-based Learning (CBL) It provides an opportunity for students to apply theoretical knowledge to clinical practice and real-life situations. The teacher uses inquiry-based methods, which may be structured with explicit mandate and instructions or an open approach, where students are presented with an initial stimulus and are encouraged to freely explore as they see relevant. This method offers relevance for the adult learner and allows teachers to direct learning towards critical thinking, changes in behaviour or generalizability to new cases. It differs from PBL as the focus is on the content, not as much on the process of problem solving. 15-17 Problem-based Learning (PBL) It promotes cognitive learning, assisting students in the compilation of knowledge and appropriate synthesis of this knowledge. The teacher guides a discussion, posing open-ended questions to facilitate the expression of views and ideas. Students are divided into small groups and encouraged to engage with the topic from various angles and exercise their own cognitive strategies to digest the content. Afterwards, all groups are brought back to the full class for further discussion as a whole. 15-17 Clinical Orientation It allows students to immerse themselves in a realistic environment and demonstrate procedures, decision-making and critical thinking. This experiential learning can include role-play, interactive videos, simulation mannequins and bedside experiences. It is designed to prepare students for a future reality through the gentle breakdown of unfamiliarity in a safe, controlled environment. A crucial feature of this style of learning is a debriefing that allows the teacher to comment on the student’s cognitive process as well as their technical ability to apply a learned skill. Additionally, a good debrief also allows the student to provide feedback on the teaching itself and the perceived value to student education.17
Assessment Methods Assessment is a critical part in the process of medical education, as the saying goes it “drives learning”.18,19 Instead of detailing different assessment methods, this section’s aim is to have the reader reflect over the different levels of cognition and behaviour18 involved in each method, as well as the questions to consider when it comes to assessment.
Does
Performance integrated into practice (direct observation, work place assessement)
Shows How
Demonstration of learning (simulation, OSCEs)
Knows How Knows
Interpretation/Application (extended matching, essays, case presentation) Fact gathering (true or false, multiple choice questions)
Assessment is a critical part in the process of medical education. There are six important questions to consider when it comes to assessment. Why assess the student? A major distinction of assessment has been whether the assessment is formative where feedback is the main goal, or summative, where it is determined if the learning objectives have been achieved. To understand which type and method is more suitable, the purpose of the assessment should be considered: as the tool to grade or rank students; to decide whether the learner has achieved the minimum standard of mastery; to enhance student’s learning and motivation as a form of accountability; and to provide feedback for the teacher on the learning gaps How should the student be assessed? The selected method should be valid and reliable20, meaning it should assess the competencies to be tested and have shown reproducible and consistent results. It should also be considered the method’s feasibility and how it can positively impact the What should be assessed? Assessment should be matched with the specified learning outcomes. Thus, mapping of assessment to the learning outcomes should occur. What is assessed, in tandem with the learning objectives, forms the product of medical education. Importantly, attitudes and behaviors are just as crucial as clinical knowledge and skills in the making of a ‘good’ doctor, though the former are easier to assess than the latter. Competency-based assessment along with Entrustable Professional Activities (EPAs) are some of the most modern techniques and tools of assessment that serve to assess comprehensive competences that go beyond assessing only clinical knowledge and skills to include attitudes and behaviors such as ethics and teamwork.
Who assesses the student? There are multiple stakeholders in medical education because public health encompasses global, regional, and local systems. And assessment shouldn’t be only the responsibility of the teacher, as the student should also be called for its own assessment, as well as its peers, and the patients should also be encouraged to participate. Furthermore the importance of departments and the schools in monitoring assessment must not be neglected. When should the student be assessed? With competency-based education, the focus is on acquiring a specific level of mastery versus what is accomplished within a particular time frame. Therefore, competencybased education and assessment will challenge traditional time-based assessment. Curriculum developers need to identify the adequate sequence of assessment. Again, the choice will depend on the aims of the assessment as to be at the beginning of the course, continuous (in-course assessment), end of course and mixed. Where should the student be assessed? In the classroom, in the clinical setting, both, beyond.
Additional Resources There is more to medical education than just “doing what feels right” or “having teaching experience”. There are a vast amount of resources and research available in the field of medical education. AMEE, an international association for medical education, refers to this concept as Best Evidence Medical Education rather than Evidence-based medical education. Here you can find some -non exhaustivesuggested further reading materials for concepts of quality medical education that we could not address in depth in our toolkit, as well the references used along the document. Books • Essential Skills for a Medical Teacher. An introduction to teaching and learning in medicine. Ronald Harden, Jennifer Laidlaw. • Oxford Textbook of Medical Education. Kieran Walsh. • Understanding Medical Education: Evidence, Theory and Practice. Tim Swanwick. Journals • Medical Teacher – http://www.medicalteacher.org/ • Academic Medicine – https://journals.lww.com/academicmedicine/pages/ default.aspx • Medical Education / The Clinical Teacher - https://www.asme.org.uk/publicationsresources/our-journals.html • BMC Medical Education - https://bmcmededuc.biomedcentral.com/ • MedEdPublish (Open Access) - https://www.mededpublish.org/home Organizations A few organizations worth checking their resources, platforms, recommended readings, publications and documents, or joining their networks • World Federation for Medical Education - https://wfme.org/ • AMEE - An international Association for Medical Education – https://amee.org/ • International Federation of Medical Students’ Associations - https://ifmsa.org/ • Foundation for the Advancement of International Medical Education and Research - https://www.faimer.org/ Standards These standards can give insight into some of the expectations that global organizations or expert groups have into what makes basic quality or excellence in several fields of medical education. • WFME standards on Basic Medical Education, Postgraduate medical education, Continuing professional development - https://wfme.org/standards/ • ASPIRE criteria for Recognizing Excellence in Education - https://www.aspire-toexcellence.org/Areas+of+Excellence/ • Student toolkit on Social Accountability in Medical Schools, including university assessment form - http://ifmsa.org/social-accountability/ • Global Consensus on Social Accountability of Medical schools - http:// healthsocialaccountability.org/ • Ottowa Consensus framework for good assessment - https://amee.org/ getattachment/home/Draft-2018-Consensus-Framework-for-Good-Assessment. pdf
Medical Education Papers This list is far from exhaustive, however these resources include some systematic and non-systematic reviews of evidence in their respective topics and may offer a good introduction to some of their related areas. Best evidence medical education • Haig, A, Marshall D. “BEME Guide no 3: systematic searching for evidence in medical education--Part 1: Sources of information.” Medical teacher 25.4 (2003): 352-363. Outcome based education • Harden, RM. “AMEE Guide No. 14: Outcome-based education: Part 1-An introduction to outcome-based education.” Medical teacher 21.1 (1999): 7-14. • Frank, JR., et al. “Competency-based medical education: theory to practice.” Medical teacher 32.8 (2010): 638-645. Curriculum mapping and development • Harden, RM., Susette S, William RD. “Educational strategies in curriculum development: the SPICES model.” Medical education 18.4 (1984): 284-297. • Harden, RM. “AMEE Guide No. 21: Curriculum mapping: a tool for transparent and authentic teaching and learning.” Medical teacher 23.2 (2001): 123-137. Integrated curriculum in medical education • Brauer, DG., Kristi JF. “The integrated curriculum in medical education: AMEE Guide No. 96.” Medical teacher 37.4 (2015): 312-322. • Malik, AS, Rukhsana HM. “Twelve tips for developing an integrated curriculum.” Medical teacher 33.2 (2011): 99-104. Faculty development • Steinert, Y, et al. “A systematic review of faculty development initiatives designed to improve teaching effectiveness in medical education: BEME Guide No. 8.” Medical teacher 28.6 (2006): 497-526. Roles of a teacher • Harden, RM, and J. O. Y. Crosby. “AMEE Guide No 20: The good teacher is more than a lecturerÐthe twelve roles of the teacher.” Medical teacher 22.4 (2000): 334347. Student engagement in medical education • Peters, H, et al. “Twelve tips for enhancing student engagement.” Medical teacher 41.6 (2019): 632-637. • Fletcher, A. “Meaningful student involvement: Guide to students as partners in school change.” Olympia, WA: SoundOut Books (2005). Patient involvement in medical education • Towle, A et al. “Active patient involvement in the education of health professionals.” Medical education 44.1 (2010): 64-74. Continuing medical education and continuing professional development • Peck, C, et al. “Continuing medical education and continuing professional development: international comparisons.” Bmj 320.7232 (2000): 432-435. Transformational medical education • Frenk, J, et al. “Health professionals for a new century: transforming education to strengthen health systems in an interdependent world.” The lancet 376.9756 (2010): 1923-1958. Clinical and community settings • Dornan, T, et al. “How can experience in clinical and community settings contribute to early medical education? A BEME systematic review.” Medical teacher 28.1 (2006): 3-18. • Howe, A. “Twelve tips for community-based medical education.” Medical teacher 24.1 (2002): 9-12.
Toolkit References 1. Harden, RM. “AMEE Guide No. 21: Curriculum mapping: a tool for transparent and authentic teaching and learning” Med Teach. 2001 Mar;23(2):123-137. 2. Tyler, RW. “Basic Principles of Curriculum and Instruction” Chicago: University of Chicago Press, 1949. 3. Bloom, B.S. “Taxonomy of educational objectives: The classification of educational goals“ New York, NY: Longmans, Green, 1956. 4. McGaghie, WC, Sajid, AW, Miller, GE, Telder, TV, Lipson, L. et al. “Competencybased curriculum development on medical education: an introduction.“ Public Health Pap. 1978;(68):11-91. 5. Scottish Deans Medical Curriculum Group (2001). “The Scottish Doctor Undergraduate learning outcomes and their assessment: A foundation for competent and reflective practitioners”. 6. General Medical Council (2003). “Tomorrow’s Doctors”. 7. Royal College of Physicians and Surgeons of Canada (2015) “Can Meds 2015 Physician Competency Framework”. 8. Harden, RM., Sowden, S., & Dunn, W. R. “Educational strategies in curriculum development The SPICES model. Medical Education”, 1984, 18, 284-297. 9. Knowles, M. “Andragogy in Action: Applying Modern Principles of Adult Learning” 1984.. San Francisco, CA: Jossey-Bass. 10. Kern DE, Thomas PA, Hughes MT, eds. “Curriculum Development for Medical Education: A Six-Step Approach” Baltimore (MD): Johns Hopkins University Press; 2009. 11. Doran, G. T. . There’s a S.M.A.R.T. Way to Write Management’s Goals and Objectives, Management Review, 1981 Vol. 70, Issue 11, pp. 35-36. 12. Fletcher, A. Meaningful Student Involvement Guide to Students as Partners in School Change. 2005 13. Ebiere Dorgu, T. Different Teaching Methods: A Panacea for Effective Curriculum Implementation in the Classroom. International Journal Of Secondary Education, 2015, 3(6), 77 14. Anderson, L.W. & Krathwohl, D.R. A taxonomy for teaching, learning, and assessing: A revision of Bloom’s taxonomy of educational objectives. New York, NY: Longman, 2001 15. Thistlewaite JE, Davies D, Ekeocha S, et al. The effectiveness of case based learning in health professional education. A BEME systematic review. BEME guide number 23. Med Teach. 2012;34:E421–E444 16. McLean SF. Case-Based Learning and its Application in Medical and HealthCare Fields: A Review of Worldwide Literature. J Med Educ Curric Dev. 2016 Apr 27;3 17. Jeffries PR. A framework for designing, implementing, and evaluating simulations used as teaching strategies in nursing. Nurs Educ Perspect. 2005 Mar-Apr;26(2):96-103 18. Miller GE. “The assessment of clinical skills/competence/performance” Acad Med. 1990 Sep;65(9 Suppl):S63-7. 19. Norcini, J, et al. “2018 Consensus framework for good assessment.” Medical teacher 40.11 (2018): 1102-1109. 20. Wass V(1), Van der Vleuten C, Shatzer J, Jones R. Assessment of clinical competence. Lancet. 2001 Mar 24;357(9260):945-9
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