UNIVERSITY OF PERPETUAL HELP SYSTEM DALTA
THE CURRICULUM PRIOR TO CHANGE
The Traditional Flexner Model (1996-2000)
The curriculum was originally organized according to the Flexner Model: two years of Clinical Sciences. At the heart of this model is the assertion that science should be the basis of medical practice; that training a student to be a good scientist will produce a good physician. Students are required to do a research project, present it orally and write a scientific paper in Microbiology and Parasitology, Pharmacology and Preventive Medicine and Community Health. It remains critical that students understand the science basic to medical practice. Also, the four-year medical course progresses from the study of the normal to the abnormal or diseased human being. The basis of such is to establish what characteristically represents a normal human being. Any deviation to its representation would be considered abnormal or pathological. However, changes in the external environment required rethinking the Flexner model.
The Synchronized Model (2000 -2010)
Under the leadership of the Academy Chair, synchronization of course by system was encouraged such that when the Respiratory System is being discussed in Anatomy, it should also be the system being presented all the other subjects like Histology, Physiology, Internal Medicine, Pediatrics, surgery, etc. Also, small group discussions were being started with vignettes and case-based discussions including early exposure to patients in certain subjects. This was based on the idea that learning the basic sciences should be correlated with clinical medicine. Experiencing the clinical setting early and discussing subject matter in smaller groups enabled the students to freely express themselves without fear of being embarrassed in a large group, and to apply the basic science concepts in a real patient.
Competence Based Curriculum (2010-2015)
Aside from synchronizing the presentation of courses where it was applicable, modifications were also being implemented as a result of yearly feedbacks. Competencies expected from the student after completing the course were now being spelled out in terms of knowledge, skills and attitude. The strategies include: 1) inclusion of case-based problem-solving in small groups; 2) journal reporting in relation to the subject matter being discussed; 3) more video clips were being incorporated in lectures to emphasize clinical correlation; 4) visits to cancer facilities and geriatric homes were included for a holistic approach in managing the patient; 5) evaluations were now a combination of the objective MCQ and the objective Structured Clinical Examination (OSCE) for the Clinical Sciences; 6) the research ethic was strengthened through annual competitions and funding.
In short, the modified curriculum yielded a novel form with several innovations with the following key elements: 1) a reduction in the didactic hours, now devoted mainly to basic sciences; 2) introduction of problem-based cases and learning experiences in SGD’s; 3) exposure to clinical experiences early in the curriculum; 4) improved integration of basic and clinical sciences around biological principles and body systems; 5) interdepartmental curriculum organization and synchronization; 6) a set of competencies were defined and must be demonstrated by the student, by performance evaluation; and 7) re-orientation of the clinical experiences to better reflect the health care delivery system.
THE CURRICULUM PRIOR TO CHANGE
A. External Factors
Medical education, perhaps more than at any other time, faces pressures for change in response to the rapid development in medical and health care delivery, advances in information technology, globalization influencing medicine and education, changing political and public expectations, demands from within the profession and developments on how we look at teaching and learning. The vision of a transformative education is: All health professional is all countries should be education to mobilize knowledge and to engage in critical reasoning and ethical conduct so that they are competent to participate in patient and population – centered health systems as members of locally and globally connected teams (Lancet, 2010).
National Movement for Reform in Medical Education
Implementation of Outcomes-Based Education (OBE) is now the main thrust of the Philippine Higher Education Institution’s (HEI’s) to compete with the regional and global academic field, on the premise that they are able to offer quality degree programs that meet world-class standards and produce graduates with life-long learning competencies. In addition, the Commission on Higher Education (CHED) supported the development of HEI’s into mature institutions by engaging them in the process of promoting a culture of quality. This was based on a shared understanding of quality and that CHED encouraged institutional flexibility of HEI’s in translating policies into programs and systems that lead to quality outcomes, assessed and enhanced within their respective internal quality assurance (QA) system. The starting point of QA is the articulation of the desired quality outcomes, set within the context of the HEI’s Vision, Mission and Goals (VMG).
The VMG can be stated in operational terms as the HEI’s institutional outcomes (i.e. attributes of ideal graduates and desired impact on society) that would serve as the foundation for the development of a proper learning environment (i.e. teaching-learning and support systems). It is important to note that the learning environment needs to be focused on developing the attributes of the HEI’s ideal graduates.
CHED’s definition of OBE is: an approach that focuses and organizes the educational system around what is essential for all learners to know, value, and be able to do, in order to achieve the desired level of competence. Thus, this kind of teaching-learning system will have its appropriate assessment of student performance.
CHED is also adopting an outcomes-based approach to assessment (monitoring and evaluation) because of its potential to greatly increase both the efficiency and effectiveness of higher education. This is to demonstrate that our achievement of outcomes matches international norms.
The Philippine Qualification Framework (PQF) was designed to make our system more aligned with these norms, including the Association of Southeast Asian Nations (ASEAN) Qualification Reference Framework.
B. Internal Forces
JFSM’s curriculum was reviewed internally four separate times during the decade prior to the initiation of the OBE curriculum. First, after four years of the Flexner Model, The Academy spearheaded the initiation of the Synchronized model in 2000 with the modifications in strategies based on yearly feedbacks and evaluations from students and faculty. This was also the time when Problem-Based Learning (PBL) strategies were on the rise; however, JFSM could only utilize hybrid representations of PBL. The second time was when JFSM had to spell out the competencies expected of its graduates in terms of knowledge, skills and attitude in 2010. During this time, results of yearly feedbacks focusing on greater clinical correlations and more objective evaluations in both the basic and clinical (OSCE) science were also being implemented. In 2013, using the self-study instrument of the Association of Philippine Medical School, the status of JFSM and the competency –based curriculum it was implementing, was presented by the newly appointed Dean. The presentation was successfully delivered based on the objective assessment of the following 8 key areas: Curriculum and Instruction, Faculty, Students, Physical Plant, Library, Research, Administration and Clinical Training /Service Facilities. This was the third time that the curriculum was reviewed internally. Later in 2014 up to 2015, most medical schools were gearing up to transforming their curriculum to Outcomes-Based Education (OBE) as a result of the main thrust o Philippine Higher Education Institution, CHED and APMC. Seminar-workshops on OBE were being conducted nationwide orienting and guiding medical school representatives in planning and designing their respective OBE curriculum with emphasis on what kind of graduate they wanted to produce. This was the fourth time in its two decades of existence that the curriculum of JFSM was revisited, reviewed and redesigned.
All in all, these curriculum reviews made a number of recurring recommendations for change:
1. To promote students’ independent learning and analytical skills;
2. To develop and enhance faculty teaching skill;
3. To improve methods of student evaluation and course evaluation;
4. To include topics relevant to medical practice such as: professionalism, ethics, disaster-preparedness, geriatrics, nutrition, empathy and care for the cancer patient, public health, patient safety, etc;
5. To allow greater participation of faculty and students in curriculum design and implementation.
FOUNDATIONS FOR CHANGE Changes are always occurring, and the question is: whether to ignore changes while hoping for the best; observe changes and respond to them; or anticipate changes and plan prospectively for them. It’s like being startled by an animal. Whether one goes back, stands still or goes forward-depending on how fearsome or big the animal is. In medical education, many external forces are big and most internal force is relatively harmless although annoying. But we find ourselves in a challenging era. Faculty face a dilemma: the easiest course of action is to let others make changes in response to new forces and then try and pick the best of their changes. It is much more challenging to be a leader for change. Planning for and implementing change provide an opportunity to be flexible, to adapt to ever-changing external forces, and to remain relevant.
Some of the major issues prompting us to move forward were these:
1. Rapid advances in biomedical science;
2. Rapid changes in health care delivery system, with shifting priorities and relocation of services from in-patient facilities;
3. Changes in health care financing that influence the environment in which the physician-patient encounter takes place, including caring for increasing numbers of uninsured patients; and
4. Information technology that is redefining everything we used to do from cataloguing, managing and retrieving data and information.
In most of the discussions, the following arguments for curricular change began to be defined:
1. The continued growth of medical knowledge is becoming a progressive impediment to student learning, in part because factual material is presented in piecemeal fashion without sufficient opportunity for integration.
2. The expectations of society for the medical profession are not well addressed. This is particularly relevant to communication, skills, ethics and cultural diversity, and to health promotion and disease prevention.
3. Similarly, public health policy, and the organization and economics of medicine have not been adequately addressed.
4. Modern medicine’s dependence on technology has diluted the pedagogical emphasis on fundamental clinical skills.
5. The ways in which physician’s use information to make clinical decisions should be explicitly taught in medical school such as the science of information management itself.
6. Medical students need to be imbued with a firm commitment to independent lifelong learning.
Following these efforts was a statement of JFSM’s guiding mantra essential for the OBE curriculum, which was used as a focal point of reference for the elements to be incorporated in the substance of the curriculum. JFSM’s guiding mantra involved: Self, Society and being answerable to a Supreme Being specifically emphasized its mission statement as the 3s: JFSM is dedicated to developing a professionally competent and holistic healer (SELF), socially responsive to the needs of humanity (SOCIETY) and imbued with moral, ethical and spiritual values (answerable to a SUPREME BEING).
In consonance with the goal of medical education which is to prepare broadly educated, responsible physicians capable for pursuing postgraduate medical education in any clinical discipline and/or pursuing a career in medically related research, it is essential that every JFSM student should be proficient in:
1) Knowledge of the scientific basis and language of Medicine;
2) Information management;
4) clinical data gathering;
5) clinical decision making;
7) commitment to health promotion and disease prevention; and
8) commitment to lifelong learning.
PROCESS OF CHANGE By early 2014, the Curriculum arm of the Academy started a series of seminar-workshops on OBE involving the Basic Sciences departments initially, then the Clinical Science departments. Dissemination of information had been gradual and repetitive for faculty and student representatives to imbibe the significance and need to institute modifications or changes in the existing curriculum. Resistance may have been present in the beginning but patience and perseverance in presenting the need for JFSM to address both external and internal forces surrounding the OBE curriculum, faculty and students gradually embraced the necessity. Various strategies were included in the instructional design and evaluations focused on the objectives stated. Also, disaster-preparedness was emphasized in applicable areas since this was the essence of a JFSM graduate.
DESIGNING THE OBE CURRICULUM
1. A first important change was the initiation of the effort to move from the traditional curriculum, although synchronized and competency-based, with its sharp demarcation between the basic and clinical science to a graduated, OBE curriculum in which basic and clinical science are represented throughout the four years with emphasis on the JFSM disaster-preparedness graduate. This process involved instituting disaster-preparedness sessions in different courses namely; Preventive Medicine and Community Health, Medicine, Pediatrics, Surgery, etc. It also involved strategies which would carry Basic and Clinical Science education all throughout the four years;
2. The second step was to increase students’ exposure to communities, facilities for geriatrics and cancer patients as well as providing additional out-patient experiences in clinical core course;
3. A third step was to institute an orientation or immersion process for the student to be acquainted with the different areas in the hospital (ICU, ER, wards, specialty clinics, OPS, triage, etc.) as early as the second year.
4. Fourth was to institute modular formats where applicable and utilize self-instructional materials/modules;
5. Fifth, evaluation of faculty and courses were standardized in order to identify issues in a manner to which The Academy could respond. Faculty development thus, is essential and the OBE program of the Academy was made the cornerstone of faculty training and education program;
6. Sixth, topics relevant to medical practice but were not found in the previous curriculum were to be incorporated into the four-year program such as: Professionalism and Ethics; Patient Safety and Disaster-Preparedness; Service and Empathy, Geriatrics and Nutrition.
The Dean’s office relevant to medical practice but were not found in the previous curriculum change. It includes support staff and faculty to help create and present the new OBE curriculum, assess it, and support interdisciplinary courses and central services. There is a budget for these functions. Prior to this, little attention was given to identifying the budget for education. The process of curriculum reform is not an easy task. Meetings and forums seem, at times, interminable. They occur among students, faculty, administration, coordinators, The Academy and chairs.