Middle East Journal of Family Medicine

Dr. Thamer Kadum Yousif Al Hilfy
MBChB/DCM/FICMS/JMHPE/MsC/Member/medical education
Director Health For All Center (NGO) / Iraq-Baghdad
Assistant Professor / Alkindy College of Medicine/Baghdad

Tel. +96417721963, +9647703459903
Mobile. +9647901734108
E-mail: thamer_sindibaad@yahoo.com, thamer_center2005@yahoo.com
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ABSTRACT

The health professions in Iraq in general include physicians, dentists, pharmacists, nurses and lab technicians.

The documents prevail that the already existing health system is based on curative side and shifted toward hospital orientation.

The total number of health centers in Iraq according to the latest reports prevail the presence of 1285 health centers among which only 50% have a health professional.

There are 20 colleges of medicine in Iraq, seven colleges of nursing, 10 colleges of dentistry and 8 colleges of pharmacy in addition to 6 technical colleges and 20 colleges of sciences which take the responsibility for supporting health care services and delivery.

We are in great need to reform our health professional education through following the global standards toward unity of agreed standards.

Tikrit college of medicine has followed since 1987, competency based education programs/problem based learning. This paper provides a comparison to evaluate Iraq's experience against global standards.

The WFME recommends the following set of global standards in basic medical education. The standards are structured according to 9 areas with a total of 36 sub-areas. The TUCOM (Tikrit University College of Medicine) was established many years before the production of the WFME standards (1988). Nevertheless, it is a valuable exercise to compare and evaluate the college's performance against these global benchmarks.

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MISSION & OBJECTIVES

In the self-study of TUCOM the statement of mission was not adequately addressed. Looking into the main curriculum document, it appears that a statement of mission does exist however; however the self-study has ignored it. As for the institutional objectives TUCOM has 5 clearly stated objectives, addressing 5 main issues. These are:

The self-study concentrated only on the educational objectives and ignored other institutional objectives like role in research, providing services, social accountability and contributing to professional development. Aldabbagh (2003)

The self-study mentioned the participation of a few stakeholders who participated in the formulation of mission and objectives. These included university authorities, international organizations and staff from the Ministry of Health. However, the study ignored the contribution of important stakeholders like: community leaders, students and professional organizations.

Suggestion: As part of a routine periodic revision all stakeholders are to be approached and actively involved

Medical education in Iraq is totally run under the patronage of the ministry of higher education and scientific research. The medical school is almost totally funded by two types of governmental budgets; a yearly regular budget and a project-based developmental budget. Both budgets are granted according to a request from the college based on real needs and future projection. All academic departments and centers participate in such an exercise based on the requirement of implementing the curriculum. Once the budget is granted the college authority is autonomous in distributing and spending the allocations according to priorities. However such an arrangement depends on the financial status of the government revenues and budgets could vary accordingly. In recent years, TUCOM as well as all other medical schools in Iraq started to compete in attracting foreign students to be enrolled against paying tuition fees in hard currencies. The greater part of such income is used by the college for developmental purposes. (TUCOM curriculum document)

Suggestion: Accordingly TUCOM should make the best of its innovative educational program to attract more funds.

The competencies at graduation are clearly defined in the TUCOM curriculum document. The level of performance of these competencies at graduation are closely related to the job description for the two years foundation residency program that each graduate should pass before being allowed to start any kind of practice and postgraduate training. It is also unique to note that the competencies include all those required by a general practitioner with emphases on primary health care and family medicine in addition to all other clinical disciplines.

Suggestion: In future revisions of educational program, the graduates' competencies should be revisited to align with the new development in professional practice and health system development including postgraduate training schemes.

TUCOM is the first medical school in Iraq to introduce problem-based learning curriculum and still the only one among the 19 operating medical schools at the present time. The curriculum document clearly defines and describes the learning strategies based on the following characteristics (TUCOM document)

Suggestion: In future revisions the problem-based learning methodologies should be modernized to match the new developments in learning strategies including the case presentation curriculum (CPC) with the use of clinical flow charts and scripts. Meanwhile, new advances in e-learning should also be considered

The program adopted by TUCOM is based on analysis of common problems. Also the six years program contains a curricular research project assignment in 4 years (years 2-5) where groups of student learn by doing scientific thinking and research methodology that usually has each project ending in producing a scientific, publishable article.

Suggestion: An in-depth evaluation of the program is needed to identify strengths and weaknesses.

The first 3 years of the program are devoted to address basic medical sciences in integrated modules, based on health problems.

It is usually claimed by opponents of the PBL program that graduates of such program are somehow deficient in basic knowledge. However several research studies showed that PBL graduates are better in applying knowledge in their professional practice.

The curriculum document does not show clearly separate modules on behavioral sciences. It is apparent that such elements are deeply embedded within the whole curriculum. For example the weekly student self-evaluation and group peer evaluation are based on behavioral performance of students. Such exercise provides students with actual practicing of behavioral and ethical issues.

Suggestion: A comprehensive analysis of the curriculum is needed to identify the behavioural and ethical practices experienced by the students during their 6 years of the study and to add what would be seen as missing elements.

The students are given the opportunity to get in contact with the community including patients as early as the first week of the program. In addition all training in hospitals, primary health care centers and community setting is done from a systematic and pre determined list with clear students' objectives and tasks. However, many of the clinical teachers go beyond the schedule training to concentrate on their personal interests.

Suggestion: Strict supervision and monitoring of students training outside teaching facilities under the control of the college is needed to ensure systematic training with full use of standard operation procedures (SOPs) and checklists.

The six year curriculum follows the natural history of health and disease. It starts with promotive and protective health and passes through the stage of early detection of disease and the history of pathogenesis to prepare the student for the interventional stage of diagnosing, managing and rehabilitating individuals, families and communities. During all these stages special emphasis is made on community priority health problems and targeting the state of population wellbeing.

Suggestion: As population health is dynamic by its nature, new challenges are to be periodically followed up and to be incorporated into the curriculum on regular bases.

In TUCOM the curriculum committee and its structural curriculum unit is headed by the dean. In addition to secretary and administrative staff, the committee is composed of members representing different academic departments and the coordinators of each year. The committee is responsible for managing all the learning and student assessment activities. Departments are only responsible for teaching and training of students according to the schedules and time-tables organized and supervised by the curriculum committee.

Suggestion: Continuous evaluation of the work of the committee is needed to ensure efficiency and effectiveness.

Students' learning outcome is to be measured using two strategies. Formative assessment is used for feedback and continuous development. Students are verbally fed-back at the end of every week during the face-to-face peer and tutor evaluation at the end of each problem. At the same interval, each student reports on the week's learning achievement. The report is reviewed by tutor and written feedback is provided and discussed if necessary. The second strategy is the summative method for scoring, passing and ranking.

First, Continuous assessment (10%): This assessment takes place during almost all learning activities in the form of quizzes, peer evaluation (negative marking only), reporting, attitude, tasks during field, practical and clinical sessions.

Secondly, End-of-Block Assessment: At the end of each block, there is one integrated MCQ paper (10%) and a 10-15 stationed OSCE (10%).

Final Assessment at the end of the year, a grand block/subject is assessed through assessing two blocks together using an integrated single paper of MCQ (20%) and an integrated OSCE (20%). So, final marks for each subject are calculated as Continuous Assessment in 2 blocks (10%x2) + End -of-Block Assessment (20%x2) + Final Assessment (40%) = 100%.The criteria for passing any part of the assessment is to score at least 50%. All assessments are organized and conducted by the curriculum committee and in collaboration with the concerned department. Accordingly the test questions are evaluated before and after the test and students are given a feedback.(TUCOM curriculum document)

Suggestion: New technologies should be looked for to enhance and ensure validity, reliability and objectivity of the test.

The aim of assessment is to be always based on the educational objectives. Teachers and trainers are asked to submit several questions and training tests based on the specific objectives they followed during teaching and training. The curriculum committee will evaluate the material submitted and choose the final sets to be administered for the students' assessments. All tests, theoretical and practical, are based on sets of integrated subjects. However, during the last few years several teachers in different departments started to administer subject based guises and mini-tests.

Suggestion: Strengthening of the integrated assessment is of a high priority to maintain and ensure a close relationship between assessment and learning objectives.

The policy for admission to higher education institutes is uniform for all institutes in Iraq. This policy is based on competitive application for enrollment in different colleges based on demand and number of seats. The major criteria are the academic scoring in the secondary school final examination after 12 years schooling. However, enrollment in medical schools in particular is conditioned on passing a special interview selection by a special committee headed by the dean to ensure characteristics other than the academic record. The role of this exercise is unfortunately a limited one.

Suggestion: New and decisive role should be given to the interview plus introduction of new psychological and social tests.

Students' intake is decided annually by the ministry of higher education and scientific research and is tied to the national need, as submitted by the ministry of health. In general terms, not all capacities at the college are seriously considered. The college is usually consulted on the already decided number of the student intake and an approximate number is compromised between the different colleges so that the total national number of intake is made.

Suggestion: Exact number of intake in the college is to be determined and maintained, according to the real capacity and size of teaching and training opportunities available.

Limited support and counseling is available as part of a national policy. Some support is provided in respect of housing, transport and cafeteria services. Social and psychological counseling is unavailable.
Suggestion: This important aspect of support to the students should be seriously considered. Also, financial support and grants should be extended to cover students with distinction as was done prior to 2003.

In TUCOM the student union is active in several ways. Each year the central committee is formed of two representatives from each year, freely elected by all students. One representative of students is present as a member in the college council and one in each department council. In addition the student union establishes each year several committees in different activities in arts, athletics, poetry, literature and other non-curricular activities.

Suggestion: Such activities need to be supported financially, logistically, and morally.

A central policy exists at the national level. However, eligible staff can choose to submit their application to each medical college and will be considered according to their qualification and experience. Each application will be considered by the college according to the vacancies available and approval of university and ministry of higher education authority.

Suggestion: Provided that scientific criteria is met, the college should have a policy to be given the right and authority, to recruit the needed staff and decide the appropriate salary and motivation without submitting the application for approval by the university and the ministry.

As part of career development, each member of staff should pass a course in principles of medical education during the first two years of service. In order to be promoted to the title of professorship, staff members should pass through three stages of promotion with certain criteria to be met, including teaching, research and service, with annual appraisal.

Suggestion: Because of the shortage of qualified candidates willing to work in the medical college, the ratio of teachers to students varies from one department to another. Salary scale and motivations should be reconsidered to encourage qualified people to work in different departments of the college. Also incentives should be given to encourage attracting qualified staff from the ministry of health to train medical students.

2. Outside college campus and includes: Tikrit teaching hospital, primary health care centers and other community settings
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Suggestion: The learning environment for the students should be improved by regular updating and extension of the facilities to match developments in educational practices.

Basic standard:
The medical school must ensure adequate clinical experience and the necessary resources, including sufficient patients and clinical training facilities.

Suggestion: Students should be provided with support to get training outside Tikrit, for example in Baghdad specialized hospitals.

The computer interactive lab provides excellent opportunities for students and staff to use simulated training programs and internet connection.

Suggestion: To update and to increase the number and improve the quality of the information technology facilities at regular periodic bases.

TUCOM is the only medical school in Iraq that adopts a curricular research program extending over four years (years 2,3,4,5). Groups of students plan, choose topics, implement, data collect and analyze, discuss and write a publishable field interventional research. Each year this curricular research is presented by the students in front of an examining committee with a continuous appraisal and scoring by a faculty staff supervisor. The resulting overall score system has a pass or fail mark for each student.

Suggestion: Continuous monitoring and evaluation of all projects by the supervising committee is needed.

The college employs an educationalist who acts as a member and adviser to the medical education unit in the college. The unit plans, implements and evaluates the medical education activities. These activities include a weekly journal club on medical education, staff development workshops (at least one a year) and publication of research on medical education.

Suggestion: Activities and publications related to medical education need to be more encouraged and motivated. Research in medical education should be treated in a similar way to scientific and clinical research in the process of promotion.

The curriculum includes a strategy to evaluate the programme through the following activities (internal and external):

Suggestion: Program evaluation should always and periodically, be revisited and generated to ensure new blood in the life of the college

Teacher annual appraisal is done in two ways; firstly through the supervisor and secondly through students. Feedback from both is given to the teacher on the one hand and to the medical education unit and college council on the other hand.

Suggestion: This is a very important subject that needs attention as it leads to significant results

This is poorly dealt with as program evaluation is only sent to the university and the ministry of higher education.

The dean leads the college activities and chairs the medical education committee and unit and college council with clear authority, delegation and job description of heads of departments and members of committees.

The total budget of the college is allocated according to uniform chapters including clear parts devoted for education.

The college is regarded by law as an independent administrative entity headed by the dean and other senior managers. The educational process is at the top of the college priorities.

Suggestion: The administrative staff should be motivated and link to educational achievements.

This is a very important aspect. TUCOM is very closely related to ministry of health for example:

The college performs a comprehensive program evaluation every five years. Both external and internal experts participate in this exercise. A special document is produced on such occasion. In addition, the ministry of higher education conducts an annual performance evaluation for the college covering inputs, process, and outputs. According to the result of this annual appraisal all colleges of higher education are ranked according to specialty and the first three colleges in each profession is declared and awarded a certificate of excellence.