malaysian journal of medical sciences, vol. 14, no. 2...

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HOW TO DEVELOP A CORE CURRICULUM IN CLINICAL SKILLSFOR UNDERGRADUATE MEDICAL TEACHING IN THE SCHOOL OF

MEDICAL SCIENCES AT UNIVERSITI SAINS MALAYSIA?

Shahid Hassan

Department of Otolaryngology & Medical EducationSchool of Medical Sciences, Universiti Sains Malaysia, Health Campus

16150 Kubang Kerian, Kelantan, Malaysia

Clinical skills program as a laboratory method is a valuable adjunct to other formsof undergraduate medical training. This article describes the process of developinga core curriculum in clinical skills based on the Dundee model for a clinical skillscentre. The School of Medical Sciences, in Universiti Sains Malaysia (USM) hasbeen provided with a well equipped skills centre. However, the PBL curriculum inthe undergraduate medical program in the school needs to be integrated with aclinical skills lab program. This is to counter the general feeling that the contributionof PBL is insignificant in terms of building clinical competency in an integratedsystem such as that used in USM compared to the traditional curriculi of othermedical teaching institutions in Malaysia. Integrating clinical skills laboratorytraining with the PBL curriculum will provide evidence of PBL as an effective andinnovative method for teaching and learning in Malaysia.

Key words : Clinical skills, skills lab, core curriculum, integrated clinical skills program

Introduction

Core curriculum and outcome objectives andthe use of problem-based learning with self directedexperiential approach is the adoption of adulteducational principle used by many medicalinstitutions. The outcome objectives of a curriculumprovides the blueprint against which the results ofthe training can be judged. Attaining a satisfactorystandard of clinical competency is the objective ofevery medical education curriculum atundergraduate as well as postgraduate levelsglobally. The external drive for clinical skills trainingcomes from recommendations by medicalprofessional bodies, an increase in student numbers,and the fact that patients’ nowadays are less tolerantof being examined by novices. The internal drivesare sociopolitical and cultural influences, problembased learning approaches and a move from hospitalto community and primary health centers inhealthcare practice (1).

Changes in the health care profession,community needs and innovative learning strategiesin medical education were the motivating factors25 years ago behind the creation of the School ofMedical Sciences (SMS) at Universiti SainsMalaysia. The ultimate objective of SMS was toproduce doctors that have a different approach andattitude from that being produced by the other twoinstitutions utilizing traditional curricula at that time(2). The curriculum adopted for SMS was based ona PBL method of learning and community-basedmedical education using the Community and FamilyCase Study (CFCS) program (Figure 1).

This new curriculum demanded students tomaster a range of prescribed clinical skills to be ableto utilize and feel self-sufficient while working incommunity away from the institution and facultysupervision. If the curriculum is the constitution ofan educational program then the outcome objectiveis the backbone of the curriculum. The outcomeobjectives of the SMS curriculum stated in

Submitted-6.11.2005, Accepted-15.12.2006

Malaysian Journal of Medical Sciences, Vol. 14, No. 2, July 2007 (4-10)

REVIEW ARTICLE

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Kurikulum Asas Semakan 1996 (Table 1) expectsthat upon graduation students will acquire asatisfactory standard of clinical competency.However, the method to be adopted for clinical skillslearning as elaborated in the “Guidance andObjectives of Phase II of Sidang Akademic 2005/2006” (Table 2) emphasizes that these clinical skillswill be acquired through a hospital teaching on realpatients.

SMS is the first medical school in Malaysiathat has adopted an innovative curriculum. It featuresintegration; a problem based learning approach andcommunity orientation. It is committed to producecommunity-inspired practitioners who are able tolook at problems holistically and apply solutions tothose problems at individual as well as at community(2) level.

The curriculum introduced many years agowas aimed at producing doctors who becomecompetent in clinical skills rather early in theirtraining to cope with community postings under theCFCS program where they are expected to workindependently without direct supervision.

Are we really producing such role-modelmedical graduates compared to those produced bymedical schools practising traditional curricula?

Incidentally the pattern of hospital-basedclinical skills training of our graduates and thosefollowing traditional curricula are similar except thatUSM graduates are exposed to clinical skills

methods as early as in year 2 (Phase II) at whichpoint problem-solving teaching have yet to bestarted. At this stage, the students’ learning curvehave just started and a full blown clinical exposureat this stage may have negative effects.

Though an early clinical exposure ofundergraduates is considered mandatory for PBL, itdefinitely demands a guided clinical environmentto avoid students from suffering reality shocks dueto insufficient preparation for adequate work-up ofreal life patients in clinics. This guided environmentis best provided by clinical skills lab methods in aclinical skills center (CSC). CSC provides a usefulclinical environment especially when clinicalteaching is introduced early in the curriculum as ithas both horizontal and longitudinal integration inan innovative curriculum (4).

How can this training requirement beachieved through an effective clinical skills centrein School of Medical Sciences is described in thisarticle.

Identifying the problem in PBL curriculum of SMSClinical skills program involves the second

and third phases of the SPIRAL curriculum of SMS.However, the teaching through Phase II ishorizontally integrated to the physiological systemand this in turn runs vertically through out the fiveyears of the curriculum. In the morning studentsattend system integrated lectures followed by PBL

HOW TO DEVELOP A CORE CURRICULUM IN CLINICAL SKILLS FOR UNDERGRADUATE MEDICAL EDUCATION IN SCHOOL OF MEDICAL SCIENCES AT UNIVERSITY SCIENCEMALAYSIA

Table 2 : Methods of teaching and learning clinical skills in curriculum

Table 1 : Outcome objectives of undergraduate curriculum

Upon graduation student should be able to:

I Understand the scientific basis of medicine and its application to patient care.II Acquire a satisfactory standard of clinical competency.III Understand and appreciate the socia-cultural background of patients and their families in formulating patient management plans.IV Undrestand the broader role and responsibly of medicine in society and play the role of leader in health care team and the community.V Acquire knowledge to pursue continuous medical education.

Clinical classes are done in the hospital. These classes will have emphasis on:

I A bedside clinical presentation which will be graded by a clinical tutor. The assessment marks must be entered into the clinical logbook and signed by the clinical tutor.II Preparation of a clinical case report of the patient clerked, which then be submitted to the clinical tutor for assessment and countersigning.III At the end of year 2 (after the second term examinations) student must submit their completed clinical logbooks to the academic office. Year 3 student must submit them a mothh before the Professional II examinations. A completed logbook is a prerequisite for sitting the professional II Examination.

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tutorials. Afternoons are devoted to wards andoutpatient teaching while reserving some time forself-directed learning.

Organizers at the skills centre, somehowmanages to squeeze little time out of the schedulein the afternoon to offer training in a few selectedclinical skills. The question is that do thisarrangement provides enough time for skills trainingin a lab setting? For instance in the respiratory block,do we teach students on those skills, with adequatesupervision, and then provide them with further timeto practice those skills as independent learning?

This is important for a skills lab method oflearning. We must aim to ensure that training in theclinical centre is timed well to introduce each skilleffectively as preparation for subsequent clinicalattachment. Once we achieve this objective, we willbe in a position to claim that an effective integrationof PBL with that of clinical skills methods has beenachived successfully.

Presently USM students in Phase II follow atraining program in the skills lab in which the CSCattempts to achieve the objectives of the organsystem block teaching. The obvious major problemis the lack of integration of our PBL curriculum with

Shahid Hassan

Figure 2 : Schema of the steps of principal curriculum development protocol (stages) as adaptedfrom Syme-Grant et al (2005)

Figure 1 : Diagramatic presentation of School of Medical ScienceUndergraduate Curriculum

PBL

Clinikal AttachmentsBasic

MedicalSciences

Community -Based Medicine

Year 1 Year 2 & year 3 Year 4 & year 5

Evaluate the programwith recommendations

for CS commitee

A brainstorm session involving

CS committee to listall relevant skills

Identify the essentialskills vs. nice to knowskills with agreement

Select the most relevantskills with counsensus

Integrate the agreed upon list of skills in the

curriculum

Periodic annualreview of topic list

Allocate slots in timetable forall clinical learning skills

Feedback: from students,tutors, exam result and

examiners

Accomplish delivery ofcurriculum with selected

skills activity

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such clinical skills training program although theskills centre are very well equipped. This lack ofintergration appear to make the efforts of the CSCas isolated from the flow of the curriculum. We mustbe reminded that a clinical skills lab is primarily alearning method. A well-designed programdeveloped for the clinical skills centre and integratedwith PBL will help to fill the gap between theoryand practice and contribute greatly to theeffectiveness of a medical curriculum.

Developing a core curriculum in clinical skills inSMS

To develop the core curriculum in skills labtraining we recommend the Dundee clinical skillscentre model (5). As the first step in this model, weneed to create a clinical skill curriculum

development group. This group, which shouldinclude the skills lab co-coordinator, Phase II andIII coordinators, block coordinators, someenthusiastic senior lecturers and clinicians, will beengaged in clinical skills model development. It ismandatory that all participating clinicians should beinterested in undergraduate teaching and PBL as aneducation method. The group should work in asystematic manner in stages (Figure: 2) as under.

Step 1 (a and b): Brainstorming and Identifyingskills.

Each system in block teaching shouldperiodically identify clinical skills related to itsteaching. This stage must be imaginative andinclusive. Subsequently the group will set thepriority of clinical skills in terms of “need to know”

Table 3 (a) & (b) : A proposed respiratory block timetable with 2 clinical skills, intubation (3a)and tracheostomy (3b) to which other 2 clinical skills on imaging and breathsounds may be included during the first two weeks of PBL block learning (4)

Week 3 Exercise Details of outcome Patient/Simulation

Week 4 Exercise Details of outcome Patient/Simulation

2.00 to3.00 pm

Historytaking

Introduction to patient contered practice withairway problemComponents of standard historyOpen and closed questioning ensuringcompletenessSummarizing information.

Simulated patient (SP)

2.00 to2.30 pm

Historytaking

Practice of skills learnt during week 1Patient centered historySummarizing information

Practicing with each other

2.30 to3.30 pm

Examination Practice of general examination on a patientwith airway problem

Role - play

3.30 to4.45 pm

Tracheostomy Learning the steps of tracheostomy and safeinsertion of the tracheostomy tube

Video demonstration and practice on mannequin

3.00 to4.00 pm

Examination ConsentIntroduction to general examination withairway problemIntroduction to respiratory system.Assesment of emergency in acute airwayproblem

Simulated patient (SP)and also observing few realpatients during A and Eposting

4.00 to4.45 pm

Table: 3b

Table: 3a

Intubation Demonstration/ Individual practice Intubation tubes andmannequin

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vs. “nice to know”. History taking and examinationshould rank higher in the list of competencycomponents. The horizontal and vertical integrationof clinical skills should always be kept in mindtogether with USM’s SPIRAL concept of thecurriculum e.g. advance procedural skills such asterminal illness can be taught in subsequent yearsrather than in the beginning of Phase II teaching.There has to be a consensus in defining essentialclinical skills for each block teaching.

Step 2: Best updated clinical skillsA senior practicing clinician in that particular

discipline should be invited to comment on theprioritized list, keeping updated clinical skills inview. He may also help to identify an appropriateperson to develop the protocol together with ademonstration model. Guidance from the outcomeobjective of USM curriculum should be used to alignclinical skills with undergraduate teaching.

Step 3: Curriculum IntegrationThis is one of the most important steps in

which the curriculum development group willcarefully integrate the PBL teaching in each blockwith clinical skills whilst keeping an eye on theoverall teaching of years 2 and 3. Areas ofduplication must be avoided whilst maintaining thehorizontal integration within blocks. Verticalintegration at various phase levels should be decidedat brainstorming sessions of the curriculumdevelopment group where everybody must bepresent.

Step 4 (a and b): Timetabling and Teachingmethodology

This is the most important stage of curriculumdevelopment and needs good coordination betweenthe skills lab, Phase and block coordinators tooptimize teaching of clinical skills in conjunctionwith block teaching. This will ensure appropriatesequencing and time allocation for each skill. Theskills lab training must be guided by the detaileddescription of outcome of each skill to be trained.The mode to accomplish delivery of the curriculumwith selected CS activity is also decided and agreedupon by all coordinators.

Step 5 (a and b); Feedback and EvaluationThe coordinator clinical skills committee will

collect feedback from all stakeholders such asstudents, tutors, and examiners to evaluate theclinical skills training program. Recommendations

can later be prepared based on the feedback forfurther consideration of committee members duringthe annual review meeting.

Step 6: Periodic annual reviewAnnual review of clinical skills program

should be done by the curriculum developmentgroup based on the evidences drawn from thestudent’s feedback, examination results and visitingexternal examiners critique of the clinical teaching.All stages should be revised in an annual reviewmeeting as a routine practice.

To use this model we propose a clinical skillslab program in the respiratory block, which startsearly in year 2 of Phase II teaching. Intubation andtracheostomy are identified as clinical skills to betaught in a comprehensive timetable (see Table 3).This block comprises of 4 weeks and follows theGeneral block and the CFCS program. The first twoweeks can be allocated to study breath sounds,imaging in respiratory diseases and some core skills(if desired) pertaining to investigations like arterialblood gases and pulse dosimeter. These core skillsand tracheostomy can alternatively be taught laterin the curriculum as advanced skills in Phase III ifnot accommodated during these 4 weeks. Week 3and 4 will discuss the patient with airway problemand its management (Figure 3a and 3b)

A finalized list of competences considered asessential for this block is listed as follows : historytaking, general examination (hand, face, tongue etc),examination of the chest and respiratory system,imaging, assessment of airway emergency,completing laboratory request forms and intubationand tracheostomy.

Realizing the importance of early exposureto clinical methods in year 2, the teaching will bedesigned to concentrate in fundamental aspects ofthe core curriculum (see Table 3). Thus the timeallocated for history and examination therefore willbe greater compared to completing laboratory formsand understanding investigation procedures. Laterin the program more core skills may be included forexample, to discuss investigations like arterial bloodgases, pulse oximetery and others. Once theobjective of mastering basic skills in the respiratoryblock is achieved it can be applied to a wide rangeof situations with real patients during subsequentclinical postings.

Discussion

It has been observed that the best outcomes

Shahid Hassan

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are achieved when PBL is integrated with a clinicalskills lab program in the timetable since manystudents find learning procedures on real patientsvery stressful (6). Therefore the lack of a well-designed skills lab program for training in soft skillssuch as history taking and application of examinationmethods will inhibit them from performing the taskwell. This will in turn result in poor understandingof the educational value of any innovative program.This is specially likely to happen when students intheir early clinical teaching is exposed to clinicalpractice with real patients in wards or outpatientclinics. The PBL curriculum, if modified asproposed, will be unrecognizable in the traditionalsense as the results of the teaching will than be seenas attainment of measurable outcomes rather thanthe mere going through of an organ system ordiscipline-based blocks.

Performance of good clinical skills are notlimited to medical students, they are also expectedof residents of internal medicines (7). The increaseduse of simulation technology to supplement skillstraining with repetitious, standardized training wouldappear to be a logical solution to the problem.Several key organization have recognized the roleof simulation technology in medical education andhave recently implemented guidelines or programsto foster its development (8). Despite the availabilityof devices with advanced simulation technologymany medical schools fail to employ such devicesto teach and evaluate learners’ skills (9).

The mere presence of these tools is notenough. Evidence based outcome must guidemedical educators who are willing to bring effectivechange. Outcome objectives of problem basedlearning perhaps may also be best achieved byintegrating PBL with clinical skills lab training asexperienced by the University of Maastricht medicaleducation program for undergraduate students (10).Outcome-based medical education in itself is aninnovative model, which provides a powerfulperformance-based approach at the cutting edge ofcurriculum development (11).

In PBL we have adopted an organ systemapproach which uses clinical scenarios as triggers.In each PBL block students undergo collaborativelearning which promotes discussion, self directedlearning and acquisition of knowledge without thepresence of real patients during each small groupsessions. There is a gap in the acquisition ofknowledge and its application (practice on patient)unless an exposure to relevant patient is achievedeither through an immediate encounter of real

patients in the clinic or ward (which is difficult toarrange most of the time) or simulated patient/mannequin in a CSL setting (which is alwaysavailable). Furthermore, the probability of gettingthe type of patients relevant to the discussion pointsin the PBL trigger for specific clinical skillsdemonstration and practice may not be possible dueto the unusual practice of haphazard andopportunistic clinical teaching.

Learning through problem-based clinicalscenarios in the early part of medical education (year2) compared to clinical teaching in traditionalmedical education (year 3 and year 4) require at leasta demonstration of clinical skills related to theproblems discussed in the triggers. This can beachieved by clinical skills training coordinated withPBl in the timetable. This particularly will helpclinical training of those students who have not yetundergone clinical exposure and prevent realityshock due to lack of experience.

Learning the skills through CSC allowsstudents to practice the clinical procedures as soonas they learn about it theoretically. Training with SPor mannequin allows mistakes and repetition ofskills. This helps in building their confidence forsubsequent handling of real patients. Additionallythe collaborative and peer learning environmentprovide them with an instant feedback especially inthe absence of supervision which is not veryuncommon in our clinical setting. Increasingawareness of patient consumerism and decreasingnumber of patients in clinics are the other problemslinked to a traditional clinical learning.

A successful implementation of clinical skillsprogram in Phase II will give us sufficient andadequate experience to expand our clinical skillsprogram to Phase III and maybe even in Phase I aswell. Though clinical teaching in Malaysia, likemany other developing countries, uses hospital-based clinical teaching with real life patients forundergraduate medical education, the everincreasing number of students in medical collegesresults in failure to maintain a balance between theavailable resources (real patients) and the learners(medical graduates). This fact has been experiencedin Europe and rest of the developed countries. Thepre-clinical lab-based skills training willcomplement the ward and ambulatory clinicalteaching to attain better motivation and pleasure oflearning.

The ideal PBL environment should have alearning task cycle comprising of PBL, skills laband self-directed learning. The School of Medical


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Sciences, USM has been blessed with a well-equipped clinical skills centre where skills trainingprogram is being run on the basis of see-one do-one. Though a skills lab is an expensive facility anda dream for many medical institution it has beenestablished in School of Medical Sciences, USMwith updated facilities. An adequate utilization ofthe clinical skills centre using a well-definedcurriculum integrated with PBL is essential formaximum efficiency of our curriculum.

Adopting clinical skills training integratedwith PBL in Phase II (year 2 and year 3) as suggestedabove will not only define our core curriculum forclinical skills program but will also help to achievethe outcome objectives of the curriculum of theSchool of Medical Sciences and allow our studentsto acquire satisfactory standards of clinicalcompetency.

Conclusion

The outcome objectives of the PBLcurriculum can be achieved more efficiently if it isintegrated with the clinical skills lab program andintroduced in the preclinical years of medicaleducation in Phase II at the School of MedicalSciences. This will facilitate a sound and safe clinicalskills training of medical students prior to theirexposure to real life patients in subsequent clinicalyears of Phase III and also during their internshiptraining after the graduation.

Corresponding Author :

Assoc. Prof. Dr. Shahid Hassan MBBS, D.L.O.,MCPS, MHPE (Maastrich University).Department of OtolaryngologySchool of Medical Sciences,Universiti Sains Malaysia, Health Campus,16150 Kubang Kerian, Kelantan, MalaysiaTel: + 609-766 4101/4095Fax: +609-765 3370Email: [email protected]

References

1. Strak, P. and Fortune, F. (2003) Teaching clinical skillsin developing countries: Are Clinical skills centre theanswer? Education for Health, 16(3), pp 298-306.

2. Roslani, A. M. M. (1981) The School of MedicalSciences Malaysia at Universiti Science Malaysia.Proceedings of the International Workshop on MedicalEducation, School of Medical Sciences, 16-21,February 1981.

3. Rogayah Jaafer and Zulkifli Ahmad; Careerpreferences of medical students in a communityoriented medical school, Annals of community orientededucation, 1993 vol. 6, pg. 301-310

4. Syme-Grant, J., Stewart, C. and Ker J. (2005) Howwe develop a core curriculum in clinical skills, MedicalTeacher 27(2), pp 103-106.

5. Du Boulay C, Medway C. The clinical skills resource:a review of current practice.Medical Education 1999;33: 185-91.

6. Gaskin, P.R., Owens, S.E., Talner, n. s., Sanders, S. P.and Li, J.S. (2000) Clinical auscultation skills inpediatric residents, Pedriatrics, 105(6), pp. 1184-1187.

7. Medical School Objectives Writing Group (1998)Medical school objective project: Medical informaticsobjective.http://www.aamc.org.htm accessed 10January 1999. Association of American MedicalColleges.

8. Kassebaum, D.G. & Eaglen, R.H. (1999).Shortcomings in the evaluation of student’s clinicalskills & behaviors in medical school, AcademicMedicine, 74, pp. 842-849.

9. Issenberg, S.B., Gordon, M.S., Ordon, D.L., Safford,R. E. and Hart, I. R. (2001) Simulation and newlearning technologies, Medical Teacher, 23(1), pp. 16-23.

10. Harden, R. M., Crosby, J. R., Davis, M. H. (1999)AMEE Guide No. 14: Outcome-based education: Part1- an introduction to outcome-based education.Medical Teacher, vol. 21, No. 1, pp.7-14.

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