Curriculum Review for Transformative Learning Prof Lilian Dudley Health Systems Strengthening Focus This research has been supported by the President’s Emergency Plan for AIDS relief (PEPFAR) through HRSA under the terms of T84HA21652 SURMEPI Stellenbosch University Rural Medical Education Partnership Initiative

Social Accountability Medical schools ‘‘to direct their education, research and service activities towards addressing the priority health concerns of the community, region and the nation that they have a mandate to serve’’ Boelen 1995

Lancet report on training health professionals for the 21 st century – shift from the ‘science based’ to a ‘competency based’ curriculum – promote greater integration of education with health systems – graduates to contribute as change agents within health systems Frenk et al, 2010

Health needs Health system Competencies Outcomes Curriculum Assessment Competency-based education model

Graduate Attributes

SURMEPI focus on health systems strengthening Public Health Health Systems and Services Research Evidence Based Health Care Infection Prevention and Control

Curriculum development: Kern’s six steps 1. Problem identification and general needs assessment 2. Needs assessment of targeted learners 3. Goals and specific measurable objectives 4. Educational strategies 6. Evaluation and feedback 5. Implementation Health care problem Current approach Ideal approach General needs assessment

Curriculum Review Objectives To identify the key PH, HSSR, EBHC and IPC competencies required for MB,ChB graduates to function in and contribute to the SA healthcare system To describe the extent to which the current MB,ChB curriculum supports the acquisition of these competencies

Definition A competency is an observable behavior that combines knowledge, skills, values, and attitudes related to a specific activity

Ideal: Which Competencies do graduates require? Literature review of competencies for EBHC, PH, HSSR, IPC National workshops on PH & HS competencies Key informant interviews Refinement of competencies through dissemination of documents for comment

General needs assessment: Current approach: MB,ChB curriculum Document review Survey of recent graduates Interviews with lecturers

Methods – Document review 64 module study guides (2011) Standardised data extraction forms Four teams: EBHC, PH, HSSR, IPC Extracted relevant learning outcomes – Knowledge – Skill – Attitude Knowledge outcomes: Bloom’s taxonomy – Matched verbs in the learning outcome to verbs in corresponding level of Bloom’s taxonomy

Methods– Survey 980 MB,ChB graduates Electronic questionnaire reached 788 – Likert scale questions – Open-ended questions 378 (35%) responded Mostly medical officers (28.5%), registrars (24.3 %), interns (14.2%), community service doctors (13.5), and general practitioners (13.2%).

Methods – Faculty Interviews Purposive sampling of lecturers/module convenors Focus group and individual interviews Informed consent Record and transcribe interviews Analysis according to emerging themes

Document Review Results EBHC, IPC, PH and HSSR covered to varying degrees In isolated pockets, mainly Community Health and Family Medicine modules, and not integrated into clinical rotations No progression of learning from lower to higher level of cognitive functioning Key competencies not covered (health systems, human rights, health promotion) Key graduate attributes poorly represented e.g. communicator, collaborator, health advocate

Graduate Survey Results PH, HSSR, EBHC and IPC seen as important Teaching perceived as adequate to prepare them for practice, except for Health systems Newly qualified doctors lacked adequate skills to practice PH, EBHC, IPC and HSSR in the health system Many PH, health systems and health management problems for which they did not feel adequately prepared.

Graduate Survey “Do as I say, not as I do” Teaching should be integrated into clinical rotations more practical and problem based training in the ‘practise’ environment More interactive teaching methods, as well as online learning platforms and social media Topics have to be seen as an important and essential part of the curriculum

Survey results: Selected quotes “To integrate EBHC into clinical practice. Students must be encourage to use EBHC during their clinical blocks for effective management of patients.” “Let the students find more examples of EBHC around them, which are practical.” “We need demographic specific analysis and interpretation skills” “More practical. At the time we did it, it felt a bit out of place. Now with more experience behind me I realize the value but it need to be done in a certain context.” “We need to know better how to collaborate with the community on health issues.” “ Our academic teachers need experience in the new health system to effectively teach students what a systematic approach to holistic care means”

Faculty Perspective 5 focus groups (21 participants) 10 individual interviews Included all disciplines Emerging themes – mixed understanding of the terms – Pressure on academics to teach, do research and do clinical work – The lack of resources and support provided by the university and the health faculty – conflict between teaching the specifics of each department with the general areas – Difficult to assess, so may be ignored by students as not often examined – Support ‘ golden threads’ but not clear who will teach?

Key Lessons ‘Change agent’ competencies not adequately integrated into curriculum Poor continuity and progression of learning More practical and experiential learning in ‘working’ context needed Role models across disciplines needed Greater inter-disciplinary collaboration required Faculty lack clear understanding of ‘health systems’ competencies Capacity and willingness of faculty an issue

Process of curriculum development Curriculum in context of general needs Overall goals of the curriculum Specific Goals and Measurable Outcomes Educational Strategies and Content Learning experiences (incl. assessment) in order to reach outcomes Learning experiences (incl. assessment) in order to reach outcomes Evaluation and feedback      

Learning Outcomes 1. Determinants of health – To manage patients holistically within their context (individual to population perspective) – To advocate for health improvements 2. Health Systems Organisation, management and financing – To identify, analyse and solve health system problems – To manage health resources efficiently 3. Evidence and information – To use evidence to inform practise – To identify or create, appraise, and utilise data to improve health and health care

“The hardest conviction to get into the mind of a beginner is that the education upon which he is engaged is not … a medical course, but a life course, for which the work of a few years under teachers is but a preparation.” Sir William Osler, The Student of Medicine

Acknowledgments Faculty and students of the FMHS, SU SURMEPI HSS team Ms Anke Rohwer, Dr Taryn Young, Prof Lilian Dudley, Dr Bart Willems, Dr Fidele Mukinda, Dr Neil Cameron, Prof Shaheen Mehtar, Dr Frederick Marais, Dr Angela Dramowski SURMEPI PI’s, Prof’s Jean Nachega and Marietjie De Villiers, and Management This research has been supported by the President’s Emergency Plan for AIDS relief (PEPFAR) through HRSA under the terms of T84HA21652