Barakzai Q / Acta Pharmacol Sin 2004 Sep; 25 (9): 1220-1232

Transition from traditional to innovative teaching in and beyond pharmacology at Ziauddin Medical University

Qamaruddin BARAKZAI

Department of Pharmacology, Ziauddin Medical University, Clifton, Karachi, Pakistan

¹ Correspondence to Prof Qamaruddin BARAKZAI.

Received 2004-03-02 Accepted 2004-06-01

KEY WORDS integrated curriculum; problem based learning; community-based; medical education

ABSTRACT

Innovative teaching methodologies in different parts of the world are being practiced since last 3 decades. The aim of this review is to report the transition from traditional to innovative self learning process in Ziauddin Medical University, a new medical institute of Pakistan. Various problems encountered have been duly looked after by inducting faculty training programs and regular review sessions in which monitoring of the transition process was duly observed as well as further advancements were also planned. The University being a pioneer has attracted other institutions which have also planned to induct PBL in their curriculum.

Vertical and horizontal integration has also inducted better understanding of subjects and fruitful advantages had been accomplished in subjects as pharmacology and pathology. In conclusion, the initial decision of the university to adapt innovative teaching methodologies along with following an integrated curriculum based on PBL and Community Oriented Medical Education system has now made ZMU a Novel institute amongst other medical institutes in the country.

INTRODUCTION

Ziauddin Medical University (ZMU) is a new institution which emerged in 1996 admitting 50 students as its first batch. Since then every year similar number entered and the first batch graduated in 2001. The batches are identified as batch numbers (Batch I,II,III) or by year of graduation (batch of 2001, 2002, 2003). By now 3 batches have graduated.

In its total life span of 55 years, Pakistan has been fortunate to have about 48 Medical Institutions which are represented chronologically in Tab1: This is the first institute amongst the existing 24 Public sector and 24 private medical institution to introduce a curriculum structured around the tripod of COME (Community Oriented Medical Education), INTEGRATED and PROBLEM BASED education system^[1].

Tab 1. Medical Institutions in Pakistan.

Year	Number of medical/dental institutions
	Public	Private
1947	2	Nil
Excluding	those in	intact east wing
1971	5	Nil
1973	11	Nil
1983	11	1
1988	11	2
1992	11	3
2003	24	24
2003Unrecognized*	6	6

* Pakistan Medical and Dental Council (PMDC) is a regulatory body which authorizes medical institutions to function after due inspection. Rules and regulations regarding establishment of a medical/dental college are strictly observed. Details available at PMDC website www.pmdc.org.pk

From the table it can be easily assessed that initially Pakistan had only Government run Medical colleges till 1983 when a first Private Medical University of the country emerged followed by two others till 1992 and then a number of Private Medical and Dental colleges surfaced and in 2003 we have 48 medical institutions including 5 dental colleges.

The Government run medical colleges were/are affiliated with the corresponding university present in the city or province. These colleges had a curriculum provided by the university prepared by the faculty of the medical colleges. The syllabus was purely subject oriented and just listed the topics of the concerned subjects. The method of teaching in basic sciences included didactic lectures, Small group Tutorials that could be called mini-lectures and according to the subjects were designated as demonstrations. Practical classes in the basic subjects were/are also teacher oriented but students did perform dissection in anatomy and some skilled procedures in physiology, bio-chemistry, pathology and pharmacology.

Presently, same methodology is prevailing in nearly all institutions except in some, where endeavor to adapt innovative teaching techniques is being tried. This bold step taken has proved to be a laborious phenomenon due to lack of training facilities and unavailability of trained people around.

ZMU as mentioned above took the very start from an entirely changed system. Prof Naeem A Jaferey, the first Vice Chancellor very wisely has steered the system to a point safe enough to provide a beacon to other interested institutes. To start with, ZMU had a solid plan to adapt PBL as mainstay of the academic system. ZMU was lucky enough to have two more education experts with a trained McMaster background, though new but confident to start the process independently.

The Basic Philosophy of ZMU in Medical Education Involved following major objectives:

1. Curriculum development.

2. Faculty development.

3. Implementation of the system from the first batch.

4. Designing tools of evaluation.

5. Monitoring the process to keep a check and balance in the system.

CURRICULUM DEVELOPMENT

The phenomena of globalization has made the world too small, the ever changing input arising from minute to minute information readily available has widened the boundaries of specialties to such an extent that a single subject has been sub-grouped into many (Surgery: Cardiac surgery, Neuro-surgery, Plastic surgery etc, medicine: Internal medicine, Pediatrics, neuro-medicine, dermatology). Older Concept are being discarded to be replaced by new ones and facts are piling up^[2].

Appreciable changes in the philosophy, curriculum, and assessment methods in medical education, such as a move towards student centred approaches, project work, and wider use of educational technology, may change the learners expectations^[3]. It is also of great change in any significant way since independence, which concerns that the present MBBS curriculum was not based what the British used at the time of world war II^[4]. Hence it was realized that in order to meet the changing scenario in medical education worldwide the curriculum needed review and redesigning in order to meet the changing socio-economic conditions. This curriculum should provide students ample opportunity to learn methods than mere memorization. It should motivate self learning and develop critical thinking^[6].

The University is maintaining a monitoring system by assembling all faculty members thrice a week in which presentations are made for review, comments, modifications of education material which includes PBL's, MCQ's, Schemes and Planners, for the running courses. Reports are the major presentations which give feedback for making any positive improvement in the teaching process. These meetings are chaired by the University President (VC) and attended by senior and junior faculty members including people from medical education and examination departments. Problems are scrutinized and approved for the PBL's for all academic years. The MBBS course duration is 5 years in Pakistan and the subjects taught in sequence as shown in Tab 2.

Tab 2. Existing details of subjects in 5 year curriculum in medical colleges of Pakistan. Family Medicine and Community Medicine only run in some private medical colleges parallel throughout 5-year course.

Year	Designation	Subjects	Comments
1	1st Professional part I	Anatomy	Exam conducted in systems covered
		Physiology
		Biochemistry
2	1st Professional part II	Anatomy	Exam conducted in systems covered
		Physiology
		Biochemistry
3	2nd Professional	Pharmacology	Exam conducted in all three subjects
		Forensic Medicine
		General Pathology
4	3rd Professional	Special Pathology	Exam conducted in Special Pathology
		Community Medicine	Community Medicine
		Otolaryngology
		Pediatrics, Medicine
		Surgery, Oby/Gynae
5	Final Professional	Medicine	Exams conducted in Otolaryngology
		Surgery	Pediatrics, Opthalmology
		Opthalmology	Medicine, Surgery

At ZMU all 3 subjects of 1st year are integrated and a system based curriculum was designed and course objectives framed. The System could be understood from Tab 3 (a) & (b) which shows Planner for 1st and 2nd year course.

Tab 3. (a) Proposed planner for 1st Year MBBS.

Tab 3. (b) Proposed planner for 2nd Year MBBS.

While framing the objectives, the main concern was what to include and what not to include. The concern of the subject specialist was that each and every detail is included in the course objectives and at the end of the course the student should be able to know every minor details. For example, in Anatomy it was expected that after a module dealing with head and neck, students should be able to describe all the foramina in the skull and after completing the anatomy of the locomotion system the students should know the details of all the surfaces, sulci, grooves, origin/insertion of muscles/ligaments on long bones. One could assume that these minor details are unnecessary for a medical graduate to remember; instead the course should contain relevant material which is essential to be known by a young doctor going to a primary care health Unit. In the making of the objectives a panel of basic science faculty and clinicians from all specialties worked together to formulate teaching material relevant to the requirement of a graduate clinician. The team had a very strong agenda of implementing a modified medical curriculum through teaching strategies never practiced in Pakistan.

Now at age of seven years, ZMU has not only implemented innovated strategies but also had strictly maintained the education system based on PBL-, integration- and COME-based curriculum. Important elements in the curriculum are vertical integration, i.e. integration between the clinical and basic science parts of the curriculum and horizontal integration between different subject areas. Vertical integration between basic sciences and clinical medicine in a PBL setting has been found to stimulate profound rather than superficial learning, and thereby stimulates better understanding of important biomedical principles. Integration probably leads to better retention of knowledge and the ability to apply basic science principles in the appropriate clinical context^[7].

One of the major hurdles in introducing integration is that it requires transfer of control over curriculum from the departments to curriculum committee. This is a change that is not acceptable to many department heads, thus integration is not just a curricular change, it is a change in social structure of the medical college as well. In traditional system departments organize and follow their own curriculum, while in the integrated system different departments formulate and follow common course objectives

In 1990 onwards importance of community oriented medical education (COME) took a pace in the developing countries and keen interest developed in its adaptation specially in the third world countries. Tireless efforts were made to introduce this important component as a major part of medical education^[9].

The full details of involvement COME in the teaching system of ZMU will not be elaborated here due to space limitation, but as evident in the planners in Tab 3 certain courses are run throughout the five year span by Department of Community Health Sciences (CHS). These courses include active practice of epidemiology and biostatistics involving clinical data practically in a community setting.

FACULTY DEVELOPMENT

In Pakistan it is one of the most difficult tasks to get trained faculty. It is not obscure that this third world country lacks facilities in research and training at public and most of the private institutional levels but since last 2 decades some progress is visible in this field. There is only a very small number of PhD's available in basic medical sciences. ZMU started enrolling junior faculty members as postgraduate candidates and their dual role as instructors as well as researchers was a successful experiment as education and research was being achieved side by side. Presently about 30 instructors are involved in this; a couple of them are about to complete their research to be awarded M.Phil degrees. About 6 have already qualified and one senior faculty member has achieved a PhD degree getting trained at ZMU. This policy of ZMU has resulted in a position to be self sufficient regarding faculty development.

IMPLEMENTATION OF INNOVATIVE TEACHING METHODLOGIES

This aspect of ZMU endeavor will be reviewed in context with the Teaching of pharmacology by PBL which integrates basic pharmacology with clinical subjects. Students encounter Pharmacology when they enter Third Year. By now they are well versed with the process of PBL which they have being doing in their first and second year. Though the problems which they were doing were also clinical oriented by which they were probing their basic subjects of Anatomy, Physiology and Biochemistry. Also they are now used to the phenomena of self learning, they have developed their skills to look for the information not only books but also elsewhere utilizing computer based information sources as they have a free access to internet at ZMU and at home. They are lucky that unlike their counterparts in other medical colleges, they have learnt skills of basic clinical examination during their first two years which include examination of all systems (Cardiovascular, Respiratory, Nervous, Abdominal), additionally they are versed with how to take and interpret ECG, and identify information revealed by X-rays, CAT scan and MRI. This year they find it more interesting as now it is the treatment side which is being introduced and also their posting with the clinical and family medicine department further encourages their learning.

There is a usual affair that student entering every year is provided with a "Guide book". It contains information such as the year planner, objectives of all subjects, learning resource information, list of books, details about teaching strategies which will be adapted.

The course of third year MBBS spans a time period of about 48 weeks (See planner Tab 4). The schedule is divided into 2 semester. The semesters are designated as Semester V (22 weeks) and Semester VI (26 weeks). Semesters I to IV have been completed in first and Second year MBBS.

Tab 4. Proposed planner for 3rd year MBBS.

PLANNING OF STRATEGIES

The following is the plan regarding running of a module. The objectives are listed with the teaching strategies to be adapted during the module. For comparison the objectives and strategies adapted this year and those planned for the coming batch are given. It is evident that visible changes have been made in the objectives as well as the strategies are more inclined towards PBL and case-based sessions. "Case histories" are being planned to be included in the guidebook for in respective modules so that students coming for the case based sessions are versed with the patient problems which will be discussed by them. These case-based sessions imply vertical integration of pharmacology with all the clinical subjects.

The above table shows a clear transition of the teaching from a teacher-centered conventional traditional system to a modern student-centered approach. Experience in the last few years has taught the faculty that how a self-learning behavior can be induced in the students who prefer teacher-centered system as they have to work comparatively less but they become totally dependent on the spoon-feeding from their teachers. The introduction of the PBL's has reversed the system towards development of self learning attitudes in the students. The clinical problems create probing behavior in them and when they are able to interpret and achieve their task, they feel more self confident.

The situation in Pakistan is not different from that in Hong Kong as reported by Nandni et al^[10] in the following observation: Students of the problem-based learning curriculum found learning to be "more stimulating and more humane" and "engaging, difficult, and useful", whereas students of the conventional curriculum found learning to be "non-relevant, passive, and boring". Students who used the problem-based learning method showed better interpersonal skills and psychosocial knowledge, as well as a better attitude towards patients. Students using the conventional model, however, performed better in basic science examinations. Teachers tend to enjoy teaching the newer curriculum. All the following benefits of small group methods in medical teaching^[11] have been achieved:

1. Understanding the subject.

2. Skills in assemble and present information.

3. Critical Thinking.

4. Asking questions.

5. Interpersonal relationship

6. Improved articulation.

7. Stimulation of reading skills

8. Problem solving attitudes.

Tab 5 shows the number of the PBL's in batch VI.

Tab 5. Chronological review of teaching strategies (pharmacology).

Batch	Year	Traditional	Innovative
		Didactic lectures, Tutorials,	PBL's, case-based sessions
		Demonstrations,	Computer-simulated Experiments on
		Animal experiments	Pharmacokinetics and Pharmacodynamics
1	1998	75 %	25 %
2	1999	70 %	30 %
3	2000	65 %	35 %
4	2001	65 %	35 %
5	2002	60 %	40 %
6	2003	45 %	55 %
7 (projected)	2004	40 %	60 %

PBL PROCESS

At ZMU, the process of PBL is supposedly not different from what it is practiced elsewhere. There are about 9 hours are accorded to one PBL which includes 3 sessions of 3 hour each. Routinely a PBL finishes in a week but sometimes due to tight schedule any of the session may be shifted to another week. The first session is the introductory session when the group reads the problem and formulates the learning goals after discussing the problem according to prior knowledge which helps them to demarcate a strategy to go through various resources. The second session is an unmonitored slot of 3 h declared on the following day whence the group is probing available sources of information as in the coming third session they have to complete task given in the problem. The tutor is facilitating the process, keeping students on the track of discussion sometimes initiating questions which are expectedly answered in relation to the problem to reach the goal. The whole process is being evaluated by the tutor and the scoring is to be submitted to be added to the cumulating marks of the continuous assessment being recorded in the account of each student. The tutor also prepares a report about the overall performance of the group to be included in the final report which is compiled by the PBL coordinator and which is to be presented in the next faculty meeting. In this meeting, the feedback of the PBL is duly discussed and the corresponding tutor duly replies any queries raised by the participants. Any new learning goals are recorded with appreciation to be included next time when the same PBL is run in the next batch.

A SAMPLE PBL TRIGGER PROBLEM

The following example is taken from a trigger problem in the Module of Anti-inflammatory Drugs for Batch IV during Semester V:

Painful ankle A 50 year old man with past medical history of mild Hypertension for 2 years diet controlled Diabetes Mellitus for one year, presented to his doctor with one day history of severe pain in his right ankle. He woke up from sleep due to severe pain around 4:00 am. He was unable to move his ankle. Pain was so severe that even the pressure of blanket over right ankle was unbearable. Pain was burning and throbbing in nature and constant. The ankle was swollen, red and felt hot. He was not able to bear any weight on his right boot. He also felt feverish, but did not check his temperature. He recalled having similar episode of severe pain in left big toe about two years age that revolved in two days after taking some pain medicines.

3rd Year MBBS (Batch - VI) 2002-2003. Semester V, Module-2 - inflammation, mediators of inflammation and antiinflamatory drugs. Anti-inflammatory drugs

S#	Objective	Strategy
		Lectures	Tutorials	PBLs	Practicals	Others
1.	Describe the role of inflammation in the defense	1
	mechanisms of the body.
2.	Describe mechanism of vascular changes of acute	1
	inflammation.
3.	Describe the mechanism of chemotaxis, opsonization,	1
	phagocytosis and Lysosomal injury.
4.	Differentiate between exudate and transudate.	1
5.	List the important chemical mediators of inflammation.	1
6.	Describe the pathway of Arachidonic Acid metabolism.			1
7.	Discuss the role of products of Arachidonic Acid			1
	metabolism in inflammation.
8.	Describe the mechanism for development of fever,					Case based lecture
	with reference to exogenous and endogenous pyrogens.
9.	Describe chronic inflammation and its pathogenesis.					Case based lecture
10.	Describe granulomatous inflammation, types and causes.					Case based lecture
11.	Describe the significance of Acute Phase protein.	1
12.	Describe the mechanism and management of					Case based lecture
	malignant hyperthermia and heat stroke.
13.	Describe the pathogenesis, clinical features and			1
	management of gout and rheumatoid arthritis.

Anti-inflammatory drugs

S#	Objective	Strategy
		Lectures	Tutorials	PBLs	Practicals	Others
1.	Discuss the therapeutic uses of products of Arachidonic Acid metabolites	1
2.	Classify anti-inflammatory drugs on the basis of mechanism of action	1
3.	Describe the clinical uses and adverse effects of NSAIDs			1
4.	Describe the management of Acute and Chronic Gout
5.	Describe the acute Toxicity of prototype NSAIDs (ASA, Acetaminophen)	1

Planning of the same module for Batch 7 2003-2004

S#	Objective	Strategy
		Lectures	Tutorials	PBLs	Practicals	Others
1.	Describe the role of inflammation in the defense mechanisms of the body.	1
2.	Describe mechanism of vascular changes of acute inflammation.					CBS I
						(4 hrs)
3.	Describe the following cellular events in acute inflammation: