Emerging Trends in the Training of Filipino Physicians

Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg, MHA

Postgraduate Course and 1st Alumni Homecoming
Carlos Dominguez Conference Hall
Zamboanga City
April 26, 2002

Programme

Emerging Trends in the Concepts of Health			Dr. Fortunato Cristobal
Emerging Threats to the Filipino Health			Dr. Jimmy Tan
(A Socio-economic, political analysis)
Emerging New Roles of Filipino Physicians			Dr. Jimmy Tan
(Bio-Social Perspective)
Emerging Trends in the Training of Filipino Physicians 	Dr. Reynaldo O. Joson

Greetings!

Thank you for the invitation to be one of the speakers in this Postgraduate Course and 1st Alumni Homecoming of the Zamboanga Medical School Foundation.  Thank you also for the invitation to revisit the school that I helped established in 1994 and to interact with the graduates.

I consider the invitation an honor and privilege, an opportunity for a de javu of my more than 7 years of challenging and exciting moments in Zamboanga City, as well as a driving force for me to think of and to learn something from the topic assigned to me. 

In preparing for my talk today, a month ago, I asked the organizers the program of the postgraduate course.  I usually do that because I want to adjust my talk according to the theme of the course and also so that I know where to focus my talk on considering the time allotment and considering there are other speakers who may touch on some aspects of my topic.

Thus, the program as given to me last month showed the following titles for presentation and discussion:

Emerging Trends in the Concepts of Health
Emerging Threats to the Filipino Health
Emerging Trends in the Training of Filipino Physicians
Emerging New Roles of Filipino Physicians

When I saw the titles for presentation and discussion, my initial reaction was on the order of presentation.  I felt that Emerging Trends in the Training of Filipino Physicians should be placed on the last slot rather on the third slot.  This being a postgraduate course sponsored by a medical school, isn’t it more logical after presenting the emerging trends in the concepts of health, threats to Filipino health and new roles of Filipino physicians to follow them with how Filipino physicians should be trained in consideration of the above?  

I brought this to the attention of the organizers and they have decided to make the necessary changes.

Be that as it may, I have decided that the central message for my talk should be the emerging trends in the training of Filipino physicians in Philippine medical schools in consideration at the very least of the emerging trends in the concepts of health, emerging threats to Filipino health, and emerging new roles of Filipino physicians.  

I did NOT communicate with the other speakers when I prepared my talk.  I don’t know what they will say on the emerging trends in the concepts of health, emerging threats to Filipino health, and emerging roles of Filipino physicians.  Strictly speaking, whatever be the content in the three other titles in today’s postgraduate course or whatever the speakers will say on the three topics, should have an influence on the training of Filipino physicians.  The only question left to answer is, is there an emerging trend in the training of Filipino physicians or in the medical curriculum in the Philippines that considers the emerging trends in the concepts of health, emerging threats to Filipino health, and emerging new roles of Filipino physicians?  I will try to answer this question later.

For the moment, I would like to dissect the topic assigned to me, with your permission, unmindful of what the other speakers will say or have said on their topics.

Emerging Trends in the Training of the Filipino Physicians.  This is the topic given me to develop and discuss with you.

Emerging Trends as I perceived it means something starting to be practiced in a certain community, whether global or local.  

Emerging Trends in the Training of the Filipino Physicians as I perceived it means what is that something starting to be practiced in the training of Filipino Physicians.  Training of Filipino Physicians can either be training in medical schools or postgraduate training after medical schools, such as residency or fellowship training programs.  However, for purposes of today’s postgraduate course, which is sponsored by a medical school, I will focus on training in medical schools.

Thus, the content of my talk today will essentially consist of emerging trends in medical education in the Philippines.

The phrase “emerging trend” implies there is a previous state or condition and there is a change which leads to a new state or condition.  Thus, when I talk of emerging trend in medical education in the Philippines, I cannot help looking first at the previous state or the original or traditional medical education system before or when I talk of changes occurring.  Furthermore, when I talk of the changes I cannot omit explaining what are the reasons for the changes and how the changes going on at present.

Thus, be prepared to hear and see the following in the talk:

A picture of the traditional medical education or curriculum system

A picture of the emerging medical education or curriculum system and the factors leading to the change

A picture of how the changes are being implemented and the status of the changes, including the associated problems.

Before I give you a picture of the traditional and emerging trends in medical education or curriculum system in the Philippines, let me state categorically that the medical education or curriculum system in the country or in any country for that matter is governed by two factors:

1.	The weighted objectives of the school administration in establishing and maintaining a medical school 
	Business objective
		Community health development objective 
		Other objectives like excellence and social responsibility 
	
2.	The trend in the medical education, both global and national

The type of curriculum adopted by a school administration will be greatly influenced by how it perceives the trend in medical education and the importance it gives to it in consideration of its weighted objectives.  Weighted objectives means how much weight it puts on business objective compared to its other objectives.

At present, there are about 30 medical schools in the country.  Again, I like to categorically state that there are as many types of medical curriculum as there are medical schools in the country.  In other words, no two medical curricula are the same and will be the same unless there is a common owner for several medical schools and unless a medical school is willing to adopt the medical curriculum of another medical school.

The medical curriculum in the Philippines has evolved and still evolving. 

Earlier, I said, I will first give you a picture of the traditional medical education or curriculum system in the Philippines before I give you the emerging trend.  Since the medical curriculum has evolved and still evolving and since I said that NO two medical curricula are the same, I am now in a quandary on how to identify the so-called traditional medical education or curriculum and the so-called emerging trends.

With your permission, in identifying the traditional medical curriculum, I will simply look at the predominant types of medical curriculum adopted and being adopted by most medical schools in the country in the past and even up to the present times.  When I say types of medical curriculum, I may include the philosophy-orientation-objectives, content, teaching-learning methods, assessment methods and other elements of a curriculum.  In identifying the emerging trends, I will simply look at what is/are different from the traditional curriculum that is/are starting to be practiced by at least two medical schools in the country and that is/are perceived to be an improvement or something better than the traditional ones.  Furthermore, I will put a time element as another criterion to consider something as the emerging trend – something different and better that is starting to be practiced during the past 10 years.  Again, that something different and better may be in the philosophy-orientation-objectives, content, teaching-learning methods, assessment methods, and other elements of a curriculum.

You may be wondering why I use the number of at least two medical schools in the country as a criterion for emerging trend.  I am sure you will NOT agree if I use one as the criterion.  If only one medical school in the Philippines is making an innovation of the traditional curriculum, I don’t think we can consider that innovation as the emerging trend.  If ten schools or more out of the 30 medical schools in the Philippines are practicing the same innovation of the traditional curriculum, I am sure you will agree with me that innovation is an emerging trend.  Right?  The reason why I place two rather than 10 or 15 or other number bigger than 2 is that instituting change in medical schools in the country is extremely difficult even if it is known and established that there is already something better that should be adopted. If two schools are practicing the same innovation of the traditional medical curriculum, personally, I feel that innovation can already been considered as an emerging trend.  

Again, you may be wondering why I use 10 years as the criterion for emerging trend.  The reason is the same as the one I used for choosing 2 medical schools, that is, instituting change is difficult and it takes quite a while to be perceived as a trend.

At this point, I am ready to show you a table that will give you a picture of the traditional curriculum as well as the emerging trends.

 
	Predominant Traditional Practice	Emerging Trends
	
Philosophy-orientation
	Competency-based curriculum with lip service to community-orientation and holistic concept of health	Competency-based curriculum with more community-orientation; application of holistic concept of health with attention on psychosocial concerns	
			
Objectives	Competency-based curriculum with lip service to attitude and skills	Competency-based curriculum with more attention towards attitude and skills	
			
Content	Everything that are published including nice to know and all biases of faculty	Must know
Concept teaching	
	Discipline or subject based	Organ-system integration	
			
Teaching-learning methods	Lecture-based learning	Problem-based learning	
	Classroom teaching	Clinical teaching	
	Lip service to self-indirected learning	More of self-directed learning methods	
	Print learning materials	Electronic learning materials	
			
Assessment methods	Less of practical exam	More of practical exam	

At this point, I have a feeling that you will be asking me which schools or how many schools in the country are adopting the emerging trends in medical education in the Philippines?

My estimate is that there are about 10 schools or even more out of the 30 schools in the country which are adopting some if NOT all of the emerging trends in medical school.  I will NOT mention which schools anymore because it is difficult to identify categorically and with absolute certainty.  First, the emerging trends are NOT adopted in toto, but piecemeal or in parts, and if they are being adopted,  there are in the varying stages of change.  Second, if I mention a school which is NOT adopting the emerging trend, chances are I will receive a denial and will be charged with presenting inaccurate data. No school will accept that it is NOT keeping with the change of times and the emerging trends in medical education.

After giving you an estimate of the number of schools in the Philippines adopting the emerging trends in medical education, the next question is that I will try to answer is:

What are the driving forces for the changes or the emerging trends, aside from survival reason and keeping up with the trends?

As I see it, there are two big forces.  One, is the continuous drive to be more effective and efficient.  This drive is applicable to the changes and trends seen in the content, teaching-learning methods, and assessment methods of the curriculum such as must-know and concept teaching; problem-based learning methods, and electronic learning materials.

Second, is the realization, even if late, of the true values that must be honestly brought out by the school and inculcated into the graduates.  This drive is applicable to the changes and trends seen in the philosophy-orientation-objectives. That is, the curriculum must be truly community-oriented and truly contributing towards health development of a target community. The curriculum must put the holistic concept of health into practice and put equal if NOT more emphasis on the development of attitude and skills of the physicians-to-be.

After giving you the driving forces for the emerging trends, the next question that I will try to answer is:

How are the changes being implemented or what is the status of the trend in the Philippines and their associated problems, if any? 

How are the changes being implemented?  The answer right away is WITH DIFFICULTY but the changes definitely will occur in due time.

As I said, about 10 of the 30 medical schools in the country are now adopting the emerging trends in medical education.  More schools will be forthcoming in adopting the trends.  The buzzword today when it comes to emerging trend in medical education is problem-based learning.  More and more schools are wanting to go into problem-based learning method.  All new schools coming up this year include an advertisement that they are using problem-based learning method.

I don’t think I have to expound on what problem-based learning is all about considering that you are all graduates of a problem-based learning curriculum of Zamboanga Medical School Foundation.  
 
What are the problems in adopting the emerging trends in medical education in the Philippines?

I can readily identify two sources or two problem areas.  One is the school administration that put more weight on the business objectives (viability of the school) over emerging trends.

Second is the faculty, most of whom, do NOT have the competency to teach and do NOT understand the philosophy and principles of andragogy or teaching-learning and on top of this, most of whom put more weight on  income generation (personal viability) over commitment and love of teaching.  

The end-point of these two problem areas is resistance to change.

At this point, I like to make a recap of what I said or did so far before I proceed further.

I have shown to you the traditional medical education or curriculum system, emerging trends, factors leading to change, how the changes are being implemented, the status of the changes and their associated problems. This was how I developed the topic assigned to me: Emerging Trends in the Training of Filipino Physicians.

 I can end my talk here if you wish.  However, if you will permit me, I would like to share with you some of my thoughts, vision, and aspiration for an effective medical education in the Philippines which somehow will expound and reinforce what I said earlier.

Dissatisfaction 1:

1.	Present medical schools and their curricula have NO documented direct and significant impact on the health development in the country.

1a. Present medical schools are contented merely with graduates passing
the board.
1b. Present medical schools consider that with production of board-
certified physicians and with the latter practicing in the country,  they have already contributed to the health development in the country.
1c. Present medical schools consider incorporating a community
immersion subject a way of contributing to the health development in the country.
1d. Present medical schools do not work closely with the Department of
Health which is supposed to be the main and lead agency in charge of health development in the country.   

	My vision and aspiration:

Medical schools and their curricula should have documented direct and significant impact on the health development in the country.
	
They should go beyond producing board passers, community immersion, and should work closely with DOH by incorporating the latter programs in their curricula.
As part of the requirement for graduation, the students with the help of 
the faculty should solve (or at least attempt to solve) one health problem in their assigned community formally documented through an action research.

Please allow me to show some examples of titles of action-research projects that were done by BCCM faculty and students. These action-research projects constitute concrete evidences of the contribution of BCCM on health development in Region V.

Community Health Management – Action Research Outputs

Reducing the Incidence of Diarrheal Diseases in Barangay Bantonan, Camalig, Albay, Through a 4-year Community Participated Intervention Program Using a Primary Health Care Approach 

Reducing the Incidence Rate of Intestinal Parasitism Among Children 1 to 14 Years Old From 90% To 50 % by the year 2000 in Barangay Taladong, Camalig, Albay Using a Primary Health Care Approach

Reducing the Prevalence Rate of Underweight (2nd and 3rd Degree) Children (0 -5 Years Old) in Barangay Bariw, Camalig, Albay Using a Primary Health Care Strategy.

I am sure Zamboanga Medical School Foundation have produced similar outputs on community health management.

With such a strategy in the community health management courses, with the action researches, at the end of the day, the medical school can truly say that with its medical curriculum, it has contributed to the health development in the country.

Dissatisfaction 2:

2.	A lot of things in the present medical curricula are NOT relevant.

2a. Students are taught things that are uncommon and rare in the country
with the same emphasis as the common medical conditions.
	
Example: Students are taught Crohns’s disease, ulcerative
colitis, rare hereditary and newborn diseases and other rare conditions with equal emphasis as the common medical conditions.
2b. Students are taught things which are NOT used in clinical practice.
Example: Students are taught traditional medical recording which
is NOT done by certified physicians.
Another example: We often heard medical teachers saying “you
have to do this while you are still students.  Once you are a consultant or an expert like me, you don’t have to do it anymore.”
2c. Students are NOT taught effective “study methods” of certified
physicians, which is in the form of problem-based learning. Practically, all certified physicians after graduating from medical schools learn medicine using the problem-based learning method.  Yet, this is not being taught to the medical students until recently when slowly a number of schools have adopted PBL as a learning method.

My vision and aspiration:

Medical curricula should be relevant.
	
	In the curriculum, students should be taught

		1. common things found in the country
2. processes and procedures used in clinical practice
 		3. problem-based learning method

Dissatisfaction 3:

3.	Present medical curricula are NOT student-friendly.

3a. There is NO standardization of “processes.” 
	There are as many philosophies of medical management as there
are medical teachers.
	There are as many approaches in medical management as there are
medical teachers.
There are as many diagnostic approaches 
		as many treatment approaches 
		as many prescribed study methods for students AND
as many biases that the students will have to contend
with as there are medical teachers.
	The end result of this lack of standardization is that the students are
confused and to survive, they just try to please their master-medical teachers from whom they will get their passing grades.

	Another end result of this lack of standardization is that the
students expend too much energy and become exhausted 
which is UNNECESSARY because there is A way to	 reduce and prevent it.  In other words, the present medical curricula in the country are NOT student-friendly.

		3b. There is NO coordination of and among various disciplines.
			Each specialist faculty wants the students to learn his/her
discipline.
			There are overlaps among disciplines.
			Furthermore, there are conflicts among disciplines, the conflicts
consisting of different philosophy and approaches.  As I said earlier, there are as many philosophy and approaches as there are medical teachers.
			The end result of this lack of coordination and integration among					various disciplines is again, confusion and exhaustion on 
the part of the students.  In other words, NOT student-friendly.
 	
My vision and aspiration:

Medical curricula should be student-friendly to be more effective, efficient, and humane.
	
	In the curriculum, there should be

1.	Standardization of management of a patient process
2.	Standardization of managerial process  
3.	Frameworks that is/are being used all throughout the course.
4.	Standardization of learning method – problem-based learning.
5.	Integration and coordination among various disciplines.

Permit me to expound on frameworks and integration.

Integration:

I go for a model of a curriculum that is both comprehensive and vertical that  integrates community-oriented-based learning, competency-based learning, problem-based learning, and distance learning; individual and community health management learning; biophysical, psychosocial, bioethical, medicolegal, and research issues learning; and it vertically integrates basic and clinical medical sciences. See diagram.

A vertically integrated curriculum

				community-oriented-based learning
				competency-based learning
				problem-based learning
				distance learning
 
				individual health management learning
				community health management learning

				biophysical issues learning
				psychosocial issues learning
				ethical issues learning
				medicolegal issues learning
				research issues learning

				basic medical sciences
				clinical medical sciences

The integration is vertical in the sense that all the above types of learning are incorporated in one sitting when trying to solve an individual or community health problem.  Also, the integration is vertical in the sense that all the above types of learning are done using an integrated template starting as early as the first year continuing up to the last year.  This vertical integrated model is a marked deviation from the usual design of the traditional medical curriculum, which is mainly unintegrated or at most horizontally integrated.  For those curricula with horizontal integration, the integration is usually “patchy”, meaning either confined to some groups of related disciplines like neuroscience or in some year levels of training, say on the first and fourth year levels only.

The vertical integration that I am aspiring for is comprehensive in the sense that it integrates all that should be integrated for a wholistic management of a patient or a community.  Again, this comprehensiveness is a marked deviation from the usual integrative procedures that are being done by other medical schools both locally and internationally.  The usual procedure is just to integrate the basic and clinical medical sciences.  I like to go beyond that.  I like to integrate the various social sciences issues as well.  I integrate individual and community health management. That’s my basis for saying the integration is comprehensive and wholistic.

The Use of Frameworks and Templates

To make the curriculum not only faculty- and student-friendly but also to promote efficiency and mastery of the processes used in the practice and teaching of medicine, frameworks and templates are used.

The following are some of the frameworks and templates that can be used and are being used in the curriculum of the BCCM:

1.	Management Process – Situational analysis, problem-identification, planning, implementation, evaluation, and improvement
2.	Management of a Patient Process 
3.	Problem-based Learning Format 
4.	Templates for discussion of biological foundation and basis on clinical management
5.	Templates for Course Pack Writing and Development
6.	Action-research format for the community health problem solving project
7.	Templates for end-of-course symposia

I will end my talk here.

Let me repeat for the last time that whatever prescriptions given by Dr. Fortunato Cristobal on the changing concept of health and Dr. Jimmy Tan on the emerging roles of the physicians in the Philippines should be incorporated into the emerging training of physicians in the Philippines.

Thank you for your kind attention.