1. 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

2. 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.

3. 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

4. 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 , 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.

5. Khmer Empire 9th-15th century
French protectorate
Vietnam War
Khmer Rouge
Genocide
Cambodian-Vietnamese War
UN protectorate
1997 Coup, Prime Minister Hun Sen and Cambodian People’s Party

6. 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

7. 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

8. 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

9. 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

10. 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?

11. 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

13. Internal Medicine Curriculum

14. 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

15. 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

16. 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

17. 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

18. 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

20. 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