Boston University Global Health Collaborative Primary Care System Strengthening Through Post-graduate Curriculum Development in Cambodia Laura Goldman MD Jeff Markuns MD Boston University Global Health Collaborative

Activity Disclaimer ACTIVITY DISCLAIMER It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. Laura Goldman and Jeff Markuns have indicated they have no relevant financial relationships to disclose.

Learning Objectives Describe the challenges to development of a competency-based curriculum Explain an approach to developing competencies appropriate to local context Describe a method used in Cambodia to engage local educators in writing curriculum and updating teaching and evaluation skills

The Kingdom of Cambodia Constitutional monarchy 15 Million people 95% Buddhist Increased GDP 6% year past decade ASEAN 2015 agreement to allow free flow of health care workers across nations 15 million people 95% Buddhist Khmer empire ruled the region for 600 yrs, fell in 15th century, built Angor Wat, which is huge complex of temples which led the spread of Buddhism and Hinduism and is a world heritage site. Protectorate of France until 1953 Khmer Rouge took power in a coup in 1970 and modeled state on Mao’s cultural revolution, committed genocide from 1975-1979, when 2 million, or 25% of population was murdered. Defeated by the Vietnamese in 1979. A coup in 1997 put power into the Cambodian People’s Party with Prime minister Hun Sen; who is still in power today. One of the fasting growing economies in the region, average 6% annual growth in the last decade.

Khmer Empire 9th-15th century French protectorate 1863-1953 Vietnam War 1969-1973 Khmer Rouge 1970-79 Genocide 1975-79 Cambodian-Vietnamese War 1979-1991 UN protectorate 1992-93 1997 Coup, Prime Minister Hun Sen and Cambodian People’s Party

Primary Care in Cambodia No primary care specialty in Cambodia No licensing requirement for health care providers Untrained providers account for 20% of all outpatient visits Public sector: 960 health centers and 80 referral hospitals Private sector: 2 of 3 outpatient visits

University of Health Sciences of Cambodia: Our Strategic Partnership Only public medical school New leadership and desire to become leaders in academia, training and research 6 years pre-service; then specialty training or 2 years general medicine training Introduction of exit examination as a requirement for graduation in 2014

UHS Strategic Plan Develop competency-based curriculum What does that mean? Outcomes based on observed trainee behavior Based on the role of the generalist doctor Last curriculum 2007 consisted of a series of lectures

Needs Assessment: Learning Environment Medical school Outdated library, few computers, no internet Few faculty, no skills lab Hospital Poor communication with UHS Morning rounds: 20 learners/20 patients/1 teacher General medicine trainees observers Afternoons free

Needs Assessment Review of local regulations and MOH policies for health care delivery Discussions with stakeholders Discussions with faculty What are the jobs for the general medicine doctor?

General Medicine Curriculum Revision MOH documents Comparison tool Faculty workshops MPA Guidelines CPA Guidelines Core Competency for the new GP Mapping of Competencies Competencies from “Core Competency for the new GP “ listed in left column Compared with diseases MPA and CPA guidelines Separate pages for internal medicine, pediatrics, obstetrics/gynecology, surgery Faculty selected competencies from tool that are in the present general medicine curriculum Wrote learning objectives Chose teaching and evaluation methods Identified Gaps MPA, CPA list services and diseases treated Core lists diseases and skills, behaviors

Internal Medicine Curriculum

Curriculum Analysis Report Strengths Written by Cambodian faculty Outcome-based and competency-based New curriculum in many critical skills Being used to improve training experience Limitations Very few generalists on faculty GAPS

Gaps in Curriculum With MOH documents With family medicine Outdated and incomplete Do not map to each other With family medicine First contact care Whole patient approach Outpatient or chronic disease management Prevention or risk assessment Family or community focus Mental health, care of the elderly, palliative care

Recommendations for Implementation of Curriculum Faculty development workshops Learner-centered teaching New evaluation tools Varied teaching methods such as skills lab, simulation, small group learning Additional clinical sites and better oversight Focus on evidence-based teaching Investment in library resources

Systemic Barriers Hierarchical system of lecturers Examination at year 6 in which the top 50% scorers enter into specialty training and the bottom 50% into general medicine Lack of experience with, and no vision of, high quality primary care or family med

Recommendations for Development of Family Medicine Adaptation of curriculum Faculty champion and future leaders Development of academy, jobs and regulations Establish department of FM at UHS Develop research in FM Advocate with MOH to create jobs Standardize curriculum and certification

Conclusions Cambodian faculty were able to produce a competency-based curriculum Identification of significant gaps led to specific recommendations Huge challenges to implementation Discussions on development of family medicine with key stakeholders