Vision for a More Effective Medical Curriculum in the Philippines

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

The 4th Dr. Rodolfo C. Dimayuga Memorial Lecture
Angeles University College of Medicine
February 22, 2001

 

Before I deliver my lecture, I like to thank the organizers and the family of the late Dr. Rodolfo C. Dimayuga for bestowing on me the honor and privilege to be the speaker of this 4th memorial lecture in honor of Dr. Dimayuga.

I don’t know Dr. Dimayuga very well. I met him only once, many many years back.

For this reason, I don’t think I am qualified to extol him in this memorial lecture. As the chosen speaker, however, I believe I can do him honor by linking my vision to his vision or his vision to my vision.

I like to believe that I was chosen because the organizers think that I have a vision on medical education that is congruent with, if not similar to, that of Dr. Dimayuga.

Everybody has a vision for something.

You too, I am sure, have a vision for something.

Dr. Rodolfo Dimayuga had a vision on medical education.

I too have a vision on medical education.

As I said earlier, I am confident that Dr. Dimayuga and I share a common vision on medical education, a vision for a more effective medical curriculum in the Philippines.

In my lecture, I will use the following outline:

1. What is a vision?

2. What is my vision on the medical curriculum in the Philippines?

3. What led to my vision on medical education?

4. What have I done to attain my vision on medical education?

5. What obstacles have I encountered in trying to attain my vision on medical education?

6. What remains to be done to attain my vision on medical education?

What is a vision?

Vision is a dream. We all know there are good and bad dreams. A vision is usually distilled from good dreams but it can originate from bad dreams, that is, converting bad dreams into good dreams. In the end, vision consists of a good dream, a dream for the betterment of something.

What is my vision on the medical curriculum in the Philippines?

For the moment, let me just say, I dream of a more effective medical curriculum in the Philippines.

The details will be crystallized as I answer the other questions listed in my lecture outline.

What led to my vision on medical education?

There are usually two triggers for a vision.

The first trigger is the experience itself, that is, being exposed to the situation.

The second trigger is desiring for something better, that is, after discovering some dissatisfaction with the situation.

The first trigger for my vision for a more effective medical curriculum in the Philippines consists of my being exposed to the medical curriculum in the country.

I have been exposed to the ins and outs of the medical curricula in the country for the past 30 years starting from the time that I studied medicine in 1970 and in my capacity as a trainor and faculty in various medical schools and teaching hospitals.

Thirty years is a period long enough to trigger me into formulating a vision for a more effective medical curriculum in the Philippines. Don’t you think so?

The second trigger for my vision for a more effective medical curriculum in the Philippines consists of desiring for something better after discovering some dissatisfaction with the medical curriculum in the country.

I vividly remember 3 situations that triggered me to take a close look at the medical curriculum, to target it as a root cause for all the problems we are having in the medical profession, and therefore, to aspire for change or improvement.

The first situation that triggered me to take a close look at the medical curriculum:

From 1982 to 1993, as a surgical educator of residents in the Philippine General Hospital, Ospital ng Maynila, Zamboanga City Medical Center, Tondo Medical Center, and other residents throughout the country, I discovered that there were a lot of “ill habits, attitude and practices” in medical reasoning, decision-making and continuing education (or study habits) whose root cause could be traced to the earlier part of residency training and even as far back as the medical school years. After more than 10 years of perseverently teaching surgical residents, I got burnt out and decided that I should target the root cause, which I considered to be the medical curriculum at the medical school level. Thus, in 1994, when I had the opportunity to design the curriculum for a new medical school, I did not hesitate to accept the challenge. I helped design the innovative medical curriculum of Zamboanga Medical School Foundation. This curriculum was later adopted by Southwestern University College of Medicine in 1995 and Bicol Christian College of Medicine, also in the same year.

The second situation that triggered me to take a close look at the medical curriculum:

From 1989 to present, a total of 11 years, as a hospital administrator of Manila Doctors Hospital in my capacity as an assistant medical director and chairperson of the quality assurance program, I discovered there were a lot of “ill-habits, attitude and practices”, not to say, incompetences, among consultants, not only in medical reasoning and decision-making in patient management but also in their way of managing a hospital unit or department assigned to them and their participation in hospital operation. Again, I attributed the root cause to be at the medical school level of training.

Concerning the undesirable attitudes, habits, and practices of consultants in hospital management aspect, I attributed the root cause to be due to the lack, if not absence of management course and training of physician to be co-players, managers and administrators of health institutions. There are only a few medical schools in the country that incorporate management course in their curricula. If only physician-managerial skills can be developed, hospitals will be easier to manage.

The third situation that triggered me to take a close look at the medical curriculum:

In my 20 years of practice, I have experienced a lot of irrational, ineffective, inefficient, and inhumane practices by my colleagues, which include not only co-physicians and co-specialists, but also co-teachers in medical education. I have witnessed a lot of flaws in the diagnostic and treatment processes which would end-up in unnecessary mortality and morbidity, unnecessary expenses in laboratory workups and treatment, unnecessary hospitalizations, unnecessary anxiety on the part of the patients and relatives, etc. Again, I attributed the root cause to be at the medical school level of training.

The 3 situations of dissatisfactions that I just presented triggered me to desire for something better in the medical curriculum in the Philippines.

I will now try to be more specific in my dissatisfaction with the medical curriculum in the country. I will just mention three major areas of dissatisfaction.

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. They should incorporate the health programs of DOH into their curricula.

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.

In the curriculum which I designed,

1. the DOH health programs are incorporated and implemented in the community immersion.

2. 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.

With the above 2 strategies, at the end of the day, the medical school can say that with its medical curriculum, it has contributed to the health development in the country.

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 which I designed, students are taught

1. common things found in the country

2. processes and procedures used in clinical practice

3. problem-based learning method

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 eeduce 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 which I designed, there is/are

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.

Thus far, here in my talk, I told you the two triggers that led me to my vision/aspirations for a more effective medical curriculum in the Philippines: the 30-years of exposure to the situation and the discovery of dissatisfaction with the present medical curricula.

I have also PARTLY described the details of my vision and what I have done to pursue it.

I will now try to answer the next question listed in my outline.

What have I done to attain my vision on medical education?

As I said earlier, I started formally and systematically pursuing my vision for a more effective medical curriculum in the Philippines in 1994 when I was given the opportunity.

That opportunity came to me by chance, by serenpidity. At that time, the Zamboanga Medical School Foundation was coming up. The designated dean happened to be a friend and who recognized my capability and willingness to assist him and his school. At that time, I also happened to be visiting Zamboanga on a monthly basis to assist the surgery training program of Zamboanga Regional Hospital.

The initial curriculum submitted by Zamboanga Medical School Foundation to the Commission on Higher Education for approval was a traditional curriculum. When I was asked to help, I suggested an innovative curriculum to which the designated dean readily agreed. The giving of trust and free-hand to me by Dean Fortunato Cristobal to design an innovative curriculum marked the start of my formal and systematic pursuit of my vision for a more effective medical curriculum in the Philippines. Lest I forget, I like to tell everybody that Dean Fortunato Cristobal was the catalyst in my pursuit of my vision on medical education. For this, I thank him.

Thus, the first thing that I did to attain my vision on medical education was to design what I think will be a more effective medical curriculum than the traditional one.

Then, I tried to develop it by formulating the frameworks and templates, writing some of the course packs, teaching the faculty, reaching out to the students, monitoring for flaws and improvement and lastly, revising it as necessary so that it will be what I envision it to be.

The last thing that I did was to help medical schools who want to use my medical curriculum model. Honestly, I dream of the day when all medical schools in the Philippines will adopt my medical curriculum model. If this is NOT possible, most likely it will NOT be, to be realistic about it, I will be contented with at least 5 medical schools in the country, distributed in Mindanao, the Visayas, and Luzon. So far, in Mindanao, Zamboanga Medical School Foundation is using my model; in the Visayas, Southwestern University College of Medicine in Cebu has used it; in Luzon, Bicol Christian College of Medicine in Legazpi City has adopted it. Come June, the Collegio de Santa Isabel College of Medicine in Naga City will adopt it. I just need one more medical school to adopt my curriculum model to be able to achieve my dream.

The RJOSON Medical Curriculum Model

I shall now describe to you in detail the curriculum that I designed and have developed so far.

To facilitate my description of this curriculum, allow me to use the label – RJoson Medical Curriculum Model or simply, my curriculum model when I refer to it.

Because of time constraints, I will just describe some outstanding features of my curriculum model.

The RJoson Medical Curriculum Model is a comprehensive vertically integrated curriculum. (see diagram)

It vertically 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.

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 in my curriculum model 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. In my curriculum model, I go beyond that. I 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 Blueprint of the RJOSON Medical Curriculum Model

I will now show you the blueprint of my curriculum model in terms of places of learning and course-content by year, teaching-learning strategies, and evaluation methods.

Blueprint of places of learning (see table)

I like to point out the following features:

1. Community-based learning design of the curriculum.

2. Step-ladder design being advocated by DOH

3. Incorporation of distance education or learning in the community.

Practically 50% of the time in the entire medical course, the students are immersed in the community learning medicine. Thus, the community-based learning design.

The step ladder design is seen in the school-community to-and-fro pattern with students progressively applying what they learn from the school in the community.

Distance learning is done when the students are in the community.

Blueprint of course-content by year (see table)

I like to point out the following:

1. The modular design – MD-competency-based and problem-based

2. The use of DOH-priority health problems early on in the curriculum, in the 2nd semester of Year Level I – Trauma, Infection-Infestation, and Maternal and Child-Health Problems (this goes for relevance and indigeniously Filipino model)

3. The use of an initial overview, followed by frameworks and concepts, progressing to foundation, development, and ending in mastery.

3.1 The design of Orientation and Introduction

3.2 The overall overview-framework-foundation-development-mastery design

Blueprint of the Teaching-Learning Methods (see table)

I like to point out that the teaching-learning methods consist primarily and essentially of the problem-based learning educational method.

Blueprint of Evaluation (see table)

I like to point out the following specific requirements for graduation:

 

 

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 used:

1. Management Process – Situational analysis, problem-identification, planning, implementation, evaluation, and improvement

2. Management of a Patient Process (see figure)

3. Problem-based Learning Format (see figure)

4. Templates for discussion of biological foundation and basis on clinical management

5. Templates for Course Pack Writing and Development (see figure)

6. Action-research format for the community health problem solving project

7. Templates for end-of-course symposia

At this point of my talk, after presenting so many ideas, concepts, and projects, I can feel that you want to ask me this question already: What is the result or outcome of all these things that I presented to you?

Right off, I can honestly say I am satisfied with the outcome so far. Remember, this curriculum model is just on its 7th year with only 1 to 2 batches of graduates from the 3 medical schools that have utilized it. I will also tell you honestly and openly that there is still a lot of things remain to be done, to improve and to develop as I shall explain to you in the last two questions in my lecture outline.

I like to tell you now why I said I am satisfied.

1. Through the community health management courses, specifically, through the action-research projects, actual and comprehensive contribution to health development in various barangays in various parts of the country [specifically, in Region V (for BCCM in Legazpi); Region VI (for SWUCM in Cebu); and Region IX (for ZMSF in Zamboanga] has been made by the respective medical schools, faculty, and students which have adopted my curriculum model. Because of the adoption of my curriculum model, I can say that somehow I also contributed to the health development in these various regions in the country.

Here are some examples of titles of action-research projects that were done by BCCM faculty and students. (see table) These action-research projects constitute concrete evidences of the contribution of BCCM on health development in Region V.

2. As to board-passing and passers, off-hand, I don’t have exact statistics. What I can only tell you is that graduates of my curriculum model have passed the Philippine Board of Medicine exam and the board passing rate of the Zamboanga graduates is around 90%. This now dispels the doubt that graduates of a PBL medical curriculum will NOT be able to pass the Philippine Board of Medicine exam.

3. From my interactions with various medical students from different medical schools with different medical curricula, I can sense the differences which constitute the impact of my curriculum model. I can feel the advantages of the problem-based learning format in small group in terms of better retention of learning, easy recall, and development of skills such as problem-solving, critical thinking, communication, interpersonal, cooperative learning, and self-directed learning.

Let me repeat: the task is NOT yet completely done. There are still a lot to accomplish which I shall expound in a little while.

What obstacles have I encountered in trying to attain my vision on medical education?

There are two obstacles that I expect to encounter when I try to promote my medical curriculum model in the country, one from the administration of the school and the other one from the faculty.

However, the obstacle from administration of the school turned out NOT to be a problem afterall, primarily because I decided it should not posed as a problem to me. I knew it would be hard to convince established medical schools to change their curricula. I decided NOT to convince them but let them be convinced with what I am doing and with my curriculum model.

As I narrated earlier, I started with Zamboanga Medical School Foundation, Inc. It being a new school and with Dean Fortunato Cristobal and the Board of Trustees being very supportive, I did NOT encounter any problem in introducing my medical curriculum model.

After piloting it in Zamboanga Medical School Foundation, I did not have any problem with other schools adopting my model simply because I did not go out of my way to tell them that they should change their curricula. I did not go out of my way to promote my model. I banked on my reputation and the reputation of my curriculum model. I just waited for request of other school administrations for demonstration and assistance. In 1995, requests came from the administration of the Bicol Christian College of Medicine and Southwestern University College of Medicine. Last January, 2001, another request came, this time from Collegio de Santa Isabel of Naga City, which plans to open a medical school.

The biggest obstacle I tell you comes from the medical teachers.

Practically all medical teachers presently teaching in medical schools are graduates from a traditional medical curriculum. They have imbibed the culture of a traditional medical curriculum in terms of what should be taught to medical students and what teaching-learning methods should be utilized. They cling firmly to the saying, “if it ain’t broke, why change.” They believe that how they were taught before should be how they should teach. For this reason, it is extremely difficult to institute change in these medical teachers because of their biases and habits.

Confounding the resistance for change among the medical teachers are the following:

1. The lack of formal training in pedagogy, andragogy, or on how to teach by practically all of the medical teachers in medical schools. There are only a few medical teachers who have masters in health sciences or health profession education. A change in medical curriculum or education would be a lot easier if all the medical teachers have training on how to teach.

2. The lack of genuine dedication to teaching among medical teachers. Teaching is NOT easy. Moreover, the financial renumeration is low. Teaching takes a lot of sacrifices, not only of time but also of opportunity cost. Most medical teachers realize these sacrifices they have to make when they apply for a teaching job in medical schools. Yet, after being accepted as faculty in medical schools, if there are conflicts of schedule between teaching duties and private medical practice, most would readily sacrifice teaching over their medical practice, which gives higher renumeration. This should NOT happen if there is a genuine dedication to teaching. Most medical teachers lack this genuine dedication. Most of them got into medical schools as faculty just to get the prestige, to be known as a professor of this and that medical school. When it comes to doing their share of responsibility (that is, improving their teaching competency) and giving their share of sacrifice (that is, dedication), most of them would either run away or would grudgingly oblige.

How I wish there will be more medical teachers with competency in teaching and genuine dedication to teaching.

The last question in my outline is:

What remains to be done to attain my vision on medical education?

I will continue to develop the medical curriculum which I designed.

I will continue to

Strengthen the frameworks and templates;

Write course packs;

Teach faculty – to produce more masters in medical education with genuine dedication in teaching;

Reach out to students to make the curriculum student-friendly

I will document the impact of my medical curriculum model – whether it is really more effective than the traditional ones and other innovative curricula; whether it has better impact on the health development in the country; whether it has more relevance to the health problems in the country; and lastly, whether it is more student-friendly.

Of course, the end-point of what I will continue to do will be when I attain my vision, which is, at least five medical schools in the country, spread out in Luzon, the Visayas, and Mindanao, institutionalizing my medical curriculum model.

With your help, with the help of Dr. Rodolfo Dimayuga who I am sure is listening to me and is pleased to hear our shared vision, and with the help of the Almighty God, I am confident that I will be able to attain my dream.

On this note, I like to say thank you once again for the honor and privilege to be your speaker this afternoon. I hope you enjoyed my talk. I hope also that somehow I have inspired all of you to join Dr. Dimayuga and myself in contributing to a more effective medical curriculum in the Philippines.

Thank you and good day.

Vision for a More Effective Medical Curriculum in the Philippines [ Powerpoint || RTF ]

Vision for a More Effective Medical Curriculum in the Philippines