Thank you Honor and Privilege Speaker Everybody has a vision for something. You have a vision for something.

Thank you

Honor and Privilege

Speaker

Everybody has a vision for something.

You have a vision for something.

I also have a vision on medical education.

Dr. Rodolfo Dimayuga has a vision on medical education.

Vision

for a

More Effective Medical Curriculum

in the Philippines

Rodolfo C. Dimayuga, MD

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

Lecture Outline

• What is a vision?• What is my vision on the medical

curriculum in the Philippines?• What led to my vision?• What have I done to attain my vision?• What obstacles have I encountered in

trying to attain my vision?• What remains to be done to attain my

vision on medical education?

What is a vision?

DREAM

= GOOD DREAM

= A DREAM FOR THE BETTERMENT OF SOMETHING

What is my vision on the medical curriculum

in the Philippines?

Vision

for a

More Effective Medical Curriculum

in the Philippines

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

What led to my vision on

medical education?

VISION

Two triggers:

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

2. Desiring for something better, that is, after discovering some dissatisfaction with the situation

What brought about my Personal Vision/Aspirations for a More Effective Medical Curriculum in the Philippines?

1st trigger for a vision - the experience itself, that is, being exposed to the situation

medical curriculum in the Philippines


1st trigger - experience and exposure to the medical curriculum in the Philippine

Length of Exposure -

30 YEARS (1970-2000)Trainor/FacultyMedical Schools and Teaching Hospitals

INS AND OUTS / IMPACT OF CURRICULUM IN THE PHILIPPINES


2nd trigger for a vision - desiring for something better after discovering some dissatisfaction with the

situation

3 situations - to take a close look at medical curriculumto target it as a root cause for all the problems we

are having in the medical professiontherefore, to aspire for its change or improvement


2nd trigger for a vision - desiring for something better after discovering some dissatisfaction with the situation

1st situation:

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,



1982 to 1993, as an educator of surgical residents

I discovered a lot of “ill-habits, attitude and practices” in medical reasoning, decision-making and continuing education whose root 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 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.



2nd situation:

From 1989 to present, as a hospital administrator of Manila Doctors Hospital in my capacity as an assistant medical director and chairperson of quality assurance program,



I discovered a lot of “ill-habits, attitude and practices”, not to say, incompetences, not only in medical reasoning and decision-making among consultant staff but also in their way of managing a hospital unit or department assigned to them and in their participation in hospital operation.



Again, I attributed the root cause to be at the medical school years level.



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 in medical schools, hospitals will be easier to manage.



3rd situation:

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 the medical academe.



3rd situation:

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.



3rd situation:

Again, I attributed the root cause to be at the medical school level of training.


2nd trigger for a vision - desiring for something better after discovering some dissatisfaction with the

situation

3 situations - to take a close look at medical curriculumto target it as a root cause for all the problems we

are having in the medical professiontherefore, to aspire for its change or improvement



Areas of Dissatisfaction

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



Areas of Dissatisfaction

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

3. Present medical curricula are NOT student-friendly.


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 the main 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.

My vision and aspiration:

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. DOH health programs are incorporated and implemented in the community

immersion.

2. as part of requirements for graduation, students with the help of faculty

should solve (at least attempt) one health problem in their assigned community formally documented through an action research.

With the above 2 strategies, at the end of the day, medical school can say that with its

medical curricula, it has contributed to the health development in the country.


2a. Students are taught things that are uncommon and rare in the

country with the same emphasis as common medical conditions.

Example: Crohns’s disease, ulcerative colitis, rare hereditary and newborn diseases, etc.


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.


2b. Students are taught things which are NOT used in clinical practice.

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 aspirations:

Medical curricula should be relevant.

In the curriculum I designed, students are taught

1. common things found in the country2. 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”.

3b. There is NO coordination among various disciplines.

3a. There is NO standardization of “processes.”

There are as many philosophies of medical management as there are medical

teachers.

As many approaches in medical management as there are medical

teachers.

As many diagnostic approaches as there are medical teachers.

As many treatment approaches as there are medical teachers.


There are as many prescribed study methods for students as there are medical teachers.

There are 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 andto 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 thestudents 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 among various disciplines or specialties.

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.

3b. There is NO coordination among various disciplines or specialties.

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 aspirations:

Medical curricula should be student-friendly to be more effective, efficient, and humane.

In the curriculum I designed, there is/are

1. Standardization of management of a patient process

2. Standardization of managerial process 3. Frameworks (being used all

throughout)4. Standardization of learning method –

PBL5. Integration/coordination among

various disciplines

Thus far here in my talk,

I have told you the two triggers that led me to a vision/aspirations for a more effective medical curriculum in the Philippines:

•30-years of exposure to the situation •discovery of dissatisfaction with the present

medical curricula.

I have also partly described to you my vision and what I have done to pursue it.

What have I done to attain my vision

on medical education?

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.

Thank you

Dr. Fortunato (Khryss) Cristobal

Dean

Zamboanga Medical School Foundation, Inc.

To attain my vision on medical education -

1. I designed what I think will be a more effective medical curriculum than the traditional one.

2. 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.

3. Helped medical schools who want to use my medical curriculum model.

RJoson’s

Medical Curriculum Model

RJoson’sMedical Curriculum Model

A comprehensivevertically integrated curriculum

community-oriented-based learningcompetency-based learningproblem-based learningdistance learning

vertically individual health management learning

community health management learningintegrated

biophysical issues learningcurriculum psychosocial issues learning

bioethical issues learningmedicolegal issues learningresearch issues learning

basic medical sciencesclinical medical sciences


The Blueprint

Places of learning Course content

Teaching-learning strategiesEvaluation methods

RJoson’s Medical Curriculum ModelThe Blueprint

Places of learning

Features:• Community-based learning design of the

curriculum• Step-ladder design being advocated by DOH• Incorporation of distance education or

learning in the community

RJoson’s Medical Curriculum Model

Places of learning

YrSem

I1st

I2nd

II1st

II2nd

III1st

III2nd

IV1st

IV2nd

Mo.

1 CM CM CM CM CM H H AC2 CM CM CM CM CM H EL AC3 CM CM CM CM CM H EL AC4 AC AC AC AC AC AC AC AC5 AC AC6 AC AC


Course Content

Features:

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

2. The use of DOH-priority health problems early on 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)


Course Content

Features:

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 Introduction3.2 The overall overview-framework-foundation-

development-mastery design


Yr Sem Phase Courses CommunityImmersion

I 1st Orientation /Introduction

Orientation to Schooland Community;Physician-to-bePlanning;Management inMedicine; How toStudy (PBL)

Orientation and IntroductionGeneral Objectives

• Orient

• Motivate

• Give an overview

• Build a framework

• Lay down foundation to facilitate learning to become a physician

Orientation and IntroductionConcept Map

Orientation Training

SchoolFramework Foundation

How to Study

CompetenciesExpected

Development*

Mastery*



I 1st Competenciesof an MD

Health Management Ind’l Health Mgt Family Health Mgt Com’ty Health MgtMgt of a Patient Screening for health problem Solution of a health problemMD-Teacher-learnerMD-ResearcherMD-AdministratorEmergency Medicine



I 1st CommunityHealthManagementI

CommunityDiagnosis4-yearComprensiveCommunityHealth Plan



I 2nd DOH PriorityHealthProblems

TraumaMaternal and Child HealthCancer


Yr Sem Phase Courses Community Immersion

I 2nd CommunityHealthManagementII

Action Research Proposalfor an Identified HealthProblem in the Communityusing Primary Health CareApproach



II 1st –2nd

Organ/SystemProblems

Cardiovascular;Pulmonary;Abdominal; Nervous;Mind; EENT



II 1st –2nd

CommunityHealthManagementIII and IV

Implementationof ActionResearchProposalAnd CommunityHealth Plan



III 1st Organ/SystemProblems

Renal; Skin and SoftTissues; Bone andJoint; Hematologic /Immunologic;Sexuality



III 1st CommunityHealthManagementV




III 2nd HospitalImmersion

Pediatrics; InternalMedicine; Surgery;Obstetrics-Gynecology



III 2nd CommunityHealthManagementVI




IV 1st –2nd

Elective Hospital rotation;specialty rotation;others



IV 1st -2nd

CommunityHealthManagementVII



Course Content

Features:

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

2. The use of DOH-priority health problems early on 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)


Course Content

Features:

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 Introduction3.2 The overall overview-framework-foundation-

development-mastery design

A COMPETENT PHYSICIAN IN THE COMMUNITYEffective, Efficient, Humane

Orientation and Introduction

Management

How to Study

Health Management

Concept of Health and Disease

Community Health Mgt

Individual Health Mgt

Family Health Mgt

Other MD CompetenciesMD-Researcher

MD-Teacher-LearnerMD-Manager

OthersManagementof a Patient

Emergency Medicine


Learning Strategies/Approaches/Activities/Resources

ACTIVE LEARNING ACTIVITIES

SELF-DIRECTED LEARNING ACTIVITIES

PROBLEM-BASED LEARNING METHOD



•Community-based learning

•Competency-based learning

•Problem-based learning



•Group discussions

•Lecturettes

•Independent studies



•Demonstration and return demonstration

•Simulated learning

•Actual/direct patient contact/learning

•Actual/direct community contact/learning



•Tasks/projects

•Hand-outs

•Self-instructional programs



ACTIVE LEARNING ACTIVITIES

SELF-DIRECTED LEARNING ACTIVITIES

PROBLEM-BASED LEARNING METHOD


Assessment Methods

•Practical examinations

•Oral Examinations

•Written Examinations

•Outcome of tasks/projects


Evaluation Tools - Expected Terminal Competencies

Specific Requirements for Graduation

•Completion of and satisfactory verbal and written presentation of an action-research project on a selected community health problem

(Evaluation tool for the community health problem solver competency that is expected of the graduates)


Evaluation Parameters - Expected Terminal Competencies


•Completion of and satisfactory verbal and written Case Presentation and Management of at least 27 different clinical cases corresponding to the problem-courses

(Evaluation tool for the physician-clinician competency that is expected of the graduates)


Evaluation Tools - Expected Terminal Competencies


•Passing of all the problem-courses

•Passing of a year-end comprehensive examination

(Evaluation tools for the physician-clinician and potential Philippine Medical Board Examination passer competences expected of the graduates)


Use of Frameworks and Templates


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


Samples of Frameworks and Templates

• Management Process • Management of a Patient Process • Problem-based Learning Format • Templates for discussion of biological foundation

and basis on clinical management• Templates for Course Pack Writing and

Development • Action-research format for the community health

problem solving project• Templates for end-of-course symposia

Management Process

• Situational analysis - problem-identification

• Planning

• Implementation

• Evaluation

• Improvement

Management of a Patient Process

Patient

Interview (Symptoms)

MD

GOALHealth Problem Resolution

Physical Exam (Signs)

Clinical Diagnostic Process

Pattern Recognition

Prevalence

Clinical Diagnosis Advice


Patient

MD


Paraclinical Diagnostic Process

Indication (Certainty Deg/Mgt Plan)

Selection (Benefit/Risk/Cost/Avail)


Interpretation (Clinical Correlation)

Pretreatment DiagnosisAdvice



Patient

MD


Paraclinical Diagnostic Process

Specific Objective of Treatment

Selection (Benefit/Risk/Cost/Avail)


Mgt Outcome Evaluation

Pretreatment Diagnosis Advice

Treatment

Health Maintenance Advice


Problem-based Learning in Medicine

Learningthe science and art

of medicine in the

functional or clinical context

PBL in Medicine in Small GroupFormat

Session I (2 hours)

1. Facilitator presents a problem (simulated or actual).

2. Students attempt to understand and solve the problem throughbrainstorming, discussion, and consensus.

They learn from each other as well as discover learning issues(later converted to students' learning objectives).


Session I (2 hours)

3.Students decide on a learning plan with or without the help of the facilitator.

The learning plan contain the following:Learning objectives

How to attain the learning objectivesMethods

Reading - what and which books, journalsAsking - who, where, whenDoing - what, where, when

Individual work or division of laborHow to assess attainment of learning objectivesTimetable


Session I (2 hours)

Independent Study (based on timetable in the learning plan)Students implement learning plan.

Session II (2 hours)


Session II (2 hours)

1.Students report and discuss the learning gained during the independent study in trying to understand and solve the initial problem.

2.Student may be given another problem to apply what they have just learned for reinforcement purposes.

THE TRAUMA

HEALTH PROBLEM

AN INSTRUCTIONAL PROGRAM FOR PRIMARY HEALTH CARE PHYSICIANS

DESIGNED FOR:

PROBLEM-BASED LEARNINGCOMPETENCY-BASED LEARNING

IN- AND OFF- CAMPUS LEARNING

Author:Reynaldo O. Joson, MD, MHPEd, MS Surg

1999

THE TRAUMA

HEALTH PROBLEM

Content

Title Goals and Strategies

Content .................................................................................A

About the Author ............................................................... B

Preface.................................................................................. C

The Course Pack - Content and How to Use ................... D

THE TRAUMA

HEALTH PROBLEM

Content ...Folder 1: Instructional Design............................................ I

Folder 2: Hypothetical and Actual Patient Management. II

Folder 3: Problem-based Learning Issues - Form ....….. III

Folder 4: Learning Objectives ...........................…..……. IV

General Learning Objectives ...................… IVAClinical Competencies ..............................… IVBBiological Foundation and Basis of Clinical

Management ……............................ IVC

THE TRAUMA

HEALTH PROBLEM

Content ...

Folder 5: Learning Resource Materials and References .V

List of Recommended References ............VA

Learning Resource Materials

Folder 6: Evaluation ....................................................… VI

THE TRAUMA

HEALTH PROBLEM

Content …Folder 7: Details and Format .......................….........… VII

Guidelines and FormatOverview and Personal Perspective .… VIICPublic Health Education ..........……… VIIDCommunity Health Management .....… VIIECase Presentation and Discussion ....…VIIFHypothetical Patient Management .......VIIG

THE TRAUMA

HEALTH PROBLEM

Content …Folder 7: Details and Format .....................…….........… VII

Guidelines and Format Psychosocial Issues ..............................VIIH

Bioethical Issues ..................................VII-IMedicolegal Issues ...............................VIIJResearch Issues ..............................…..VIIKGlossary ...............................................VIILSelf-Evaluation ....................................VIIMPresentation in a Symposium ............ VIIN

Module Making in

Medicine

Dear Module Maker or Student:

Thank you for your interest in making MODULES IN MEDICINE.

A TEMPLATE or SAMPLE is provided to make your task easy.

Module Making in

Medicine

1. Just change the name of the HEALTH PROBLEM.

Examples of health problems: HEADACHE, BURNS, DYSPNEA, PALLOR, DYSURIA, etc.

Module Making in

Medicine

2. Practically, what you are going to SUPPLY for the completion of a MODULE are just the following:

1. Patient simulations or hypothetical patients 2. Clinical abstracts 3. Specific clinical competencies 4. Biological foundation of clinical management 5. Evaluation

Module Making in

Medicine

I shall guide and help you as you go along.

When you make the MODULES IN MEDICINE, have in mind the contribution you will be giving to the development of effective, efficient, and humane physicians and in turn, to the health development of the country.

Thank you for joining hands with me in such an endeavor.

Reynaldo O. Joson, MD, MHA, MHPEd

What is the result or outcome

of all these things that I presented to you


of all these things

that I presented to you

SATISFIED SO FAR!

BUT STILL A LOT TO DO !


of all these things


SATISFIED …...

CONTRIBUTION TO

HEALTH DEVELOPMENT

Community Health ManagementAction 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 (With Pictorial)


• 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


of all these things


SATISFIED …...

BOARD PASSING


of all these things


SATISFIED …...

BETTER LEARNING


of all these things


SATISFIED …...

BETTER retention of learning

easy recall

development of skills

problem-solving, critical thinking, communication, interpersonal, cooperative learning, and self-directed learning


of all these things


SATISFIED SO FAR!

Repeat: Task is NOT yet completely done.There are STILL A LOT to accomplish.

What obstacles have I encountered

in trying to attain my vision on

medical education?

Obstacles Expected

•SCHOOL ADMINISTRATION

•FACULTY

Obstacles Expected

•SCHOOL ADMINISTRATION

NOT AN OBSTACLE AFTERALL!

Obstacles Expected

•FACULTY

BIGGEST AND HARDEST OBSTACLE!

Obstacles Expected

FACULTY

BIGGEST AND HARDEST OBSTACLE!

•CULTURE of traditional medical curriculum + BIASES + HABITS

•LACK OF TRAINING IN ANDRAGOGY

•LACK OF GENUINE DEDICATION TO TEACHING

What remains to be done to attain my vision

on medical education?

What remains to be done?

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

I will continue toStrengthen 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 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.


End-point -

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 Almighty God,

I am confident that I will be able to attain my dream.

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

Thank you Honor and Privilege Speaker Everybody has a vision for something. You have a vision for something.

Documents

philippines slide

effective medical curriculum

situation medical curriculum

situation slide

medical education

vision desiring

medical schools

medical reasoning