MED-NET Conferences 1998, Lille & 1999, Maastricht
Anthology of presentations 3.1.

New profile of the medical school

Kati Hakkarainen (Tampere, Finland)

Introduction

When the medical faculty of Tampere University began the innovation of the medical undergraduate curriculum in 1994, it first appointed a curriculum committee to plan and implement the change. This committee defined the qualifications of a good physician :

• human approach
• ability to analyse and solve problems
• ability to gather information independently
• ability to assess information critically
• ability to absorb new knowledge
• good clinical skills
• teamwork skills

The committee then selected the key elements in the learning and teaching methods which would enable our students to reach these goals.
Those key elements were:

• integration
• problem-based learning method
• early patient contacts
• clinical skills
• communication skills

Integration

The curriculum of Tampere Medical School is fully integrated (Fig. 1.) During the first two years the organs and functions of human body are studied in integrated 3-8 week blocks. Then the same entities are dealt with again in a setting where different clinical symptoms emerge. Social and behavioural sciences are also integrated in appropriate blocks. In the last two clinical years the integration is reversed: clinical subject matter is studied integrated with basic sciences (anatomy, biochemistry etc.) and also with clinical-theoretical sciences (pathology, clinical chemistry and microbiology etc). For instance organ specific pathology is studied totally in the last two clinical years.

The curriculum is designed so that the opportunity to gain knowledge is offered at a time, when the students are most likely motivated to receive it and put it into practice. As an example; the theoretical background on antimicrobial drugs, antimicrobial resistance mechanisms, hospital infections etc. is studied in the block called infection in the fall term of the third year, but throughout the clinical years reasonable and effective care and diagnostics of infections is stressed.

Working dialogue between faculty members is a prerequisite of successful integration. Each block is planned by a group consisting of faculty members from different areas of medicine, clinicians from the university central hospital and students. It is obvious that the actual integration leads to best innovative results in groups where the members have imagination and creative thinking to spare for teaching purposes.

Problem Based Learning

The Tampere medical faculty started implementing the PBL method by first educating its teaching staff to act as tutors and planners. For this purpose several education events were organised, where experts from MacMaster University, Maastricht University and Tampere University Faculty of Educational Sciences instructed us in different aspects of PBL.

The faculty has since those early days established its own continuing education programme for the teaching staff. Three faculty members, who themselves are actively tutoring, educate others in 1-2 day courses.

Students are coached in PBL method during a three week long introduction block, where they study PBL from different sources and also rehearse PBL in tutorials. Our experiences have been the same as reported (1), that introduction of students and teachers into PBL method is essential for its success in later studies. Tutoring is a demanding task for medical teaching staff, whose qualifications are earned elsewhere, mainly in scientific work (2).

The actual PBL is based on continuous group work, where 8-10 students meet twice a week with a tutor. They study the subject matter through problems, which are designed so the students are challenged to reflect their present knowledge and define their learning goals. The students gain their knowledge using all the resources the academic surrounding has to offer: library, computers, lectures, laboratory practice, etc.

Early patient contacts

Early patient contacts are promoted starting from the first days of studies. The students have their first patient contacts in the introduction block. Different aspects of history taking, clinical examination and patient/doctor relationship are dealt together with subject matter included in the block.

The students experience early patient contacts as a strong motivating factor. In Finland the legislation and attitudes of patients and staff members in hospitals and other health care institutions are generally positive towards medical students participation in patient care.

Clinical skills

Even though we in Finland have an easier access to patients during the early phases of medical studies than in many other countries, it has been held especially important that clinical skills can also be rehearsed in a laboratory setting using phantoms, computer programs and other simulated situations. The faculty has a Clinical Skills Laboratory, where students study in each block according to a separate clinical skills plan.

Communication skills

A special task force is dedicated to promoting students communication skills. The curriculum includes teaching events dealing with these issues, like lectures, video-taped rehearsals and group discussions. Moreover, every faculty member should in all teaching events promote aspects that lead to good patient doctor relationship. To enhance faculty members capabilities to meet this challenge a special training program has been initiated.

Evaluation and Assessment

It is evident that a thorough curriculum reform needs an effective evaluation system to monitor the opinions of students and teaching staff throughout the process. Students give feed-back to teaching staff in a closing discussion organised at the end of each block. They also give written evaluation in a structured form. This evaluation is collected during block examination. Student evaluations are recorded and sent to the planning group of the block and also to the curriculum planning committee as well as all the teachers involved in the block. When the block is again planned the next year, the work starts from the careful analysis of last year’s evaluation.

It is also evident, that in a radical change from a traditional way of teaching medicine to a student centred learning environment, strategies of assessment must also progress. In Tampere faculty factual medical knowledge is assessed in a written test after each block and three times annually in a Progress test.

Since PBL should promote students abilities to master complex entities and relationships between different entities, assessment methods should also reward those, who gain these kind of capabilities. In our block test instructions we instruct the teachers to ask open-ended, preferably integrated questions, which would rather demand applying newly gained knowledge in a different settings than just check if details have been learned by heart. Multiple choice and right/wrong questions can also be used, but they cannot be a dominant part in the test.

In Progress testing we apply the same format as in Maastricht (3), but with our own questions.

Clinical skills are assessed in an OSCE-type test (4). So far our resources enable the testing of third and fourth year students. Communication skills are evaluated in video-taped sessions using simulated patients. These evaluations are part of the teaching event, where a student can discuss his/her progress with the evaluators.

Discussion

The Tampere medical faculty has implemented a thorough change in undergraduate medical education. Its roots are in the history of the faculty. When the faculty was founded in 1971, many of the new faculty members were informed of newest trends in medical education and tried to implement them in the curriculum as integration and student centred attitudes in teaching. Most of the innovations faded away rapidly, when enthusiasm vanished under inside and outside pressures. Interest in medical education and its innovations remained alive in some members of the teaching staff. Thus, the changes now implemented have been built on an own tradition.

Once a complete change in medical education is initiated, it starts to feed itself. The existence of an effective evaluation system means that when you start implementing a change in the curriculum, the process can never stop. To implement change is one challenge, to keep it alive is another, a bigger one. In Tampere faculty we are just ending the first stage; the students, who started with the PBL method are now in the fifth year of their studies. It remains to be seen, how we meet the second challenge, the continuous development of the curriculum.

References

1. Evans P.A. and Taylor D.C.M.Staff development of tutor skills for problem-based learning. Medical education 1996,10, 165-166.
2. Dolmans D.H.J.M., Wolfhagen I.H.A.P., Van der Vleuten C.P.M. Long-term stability of tutor performance, Academic Medicine 1996: 71:1344-47.
3. Albano M.G., Cavallo F., Hoogenboom R., Magbi F., Majoor G., Manenti F., Schuwirth L., Stiegler I., Van der Vleuten C. An international comparison of knowledge levels of medical students: the Maastricht Progress test. Medical Education 1996, 30, 239-43.
4. Reznick R. An objective structured clinical examination for the licentiate: report of the pilot project of the Medical Council of Canada. Academic Medicine 1992: 67.487-94.

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