Medical education in Bangladesh needs overhauling
Saturday, 26 December 2009
Dr. Md. Anwarul Azim Majumder
"Knowing is not enough; we must apply." -- Goethe
A doctor needs to continuously update his medial knowledge from the every first day of his or her professional life and it continues until retirement from clinical practice. The quality of medical education, performance of medical students and graduates, and the provision of health care are interrelated. In Bangladesh, patients are always concerned about the physicians' performance and the treatment they render to them. But nobody ever speaks about the quality of medical education in the country. And an occasional discussion does not touch the real issues. One of the main reasons for it is that, medical education always gets a low priority in the political as well as professional agenda.
Medical education in Bangladesh began with the establishment of the Dhaka Medical School (now Sir Salimullah Medical College) in 1875. The medical education system inherited the typical features of colonial education of the traditional lecture-based, teacher-centred, discipline-based, examination-driven and hospital-oriented pattern. The movement for a reorientation on need-based and community-oriented medical education started early in the 1980s. To promote this concept, the Centre for Medical Education (CME) was established Dhaka in 1983 under a UNDP-funded project. A national community-oriented and competency-based curriculum, developed for the undergraduates in 1988, was later introduced in all the medical colleges of the country. Under the project, the centre for Medical Education gave reorientation training to about 600 medical teachers on the science of medical education and teaching methodology. Medical education units (MEU), established in eight medical colleges, were equipped with books, journals and audio-visual equipment. A number of teachers were sent to overseas institutes to be acquainted with need-based and community-oriented medical teaching. A new career structure for junior teachers at medical colleges was also drawn up.
In 1992, the Further Improvement of Medical Colleges Project was established under the Fourth Health and Population Project, supported by the World Bank with Overseas Development Administration and International Development Association components to re-orient and strengthen medical education in Bangladesh. The objective was to strengthen undergraduate teaching with stress on community-orientation in medical education, integrated MCH/FP training, upgrading physical facilities for better academic environment, logistic support for students and teachers and resource development in medical education. Under the project for further improvement of medical colleges, programme was taken for the re-orientation of the curriculum to increase the extent of community-oriented teaching in three priority disciplines of paediatrics, obstetrics and gynaecology and community medicine besides in other areas. Under it, a need-based internship training programme was developed, mother and child health and family planning training programmes were promoted through model clinics, residential field-site training programmes were developed for rural areas. For urban demonstration areas, primary health care teaching programme was developed in the medical college hospitals. Innovative teaching methods followed by newly established medical skills centres encouraged community-orientation and skills development. A teaching module was developed on communication skills and lesson plans for psychomotor skills. Study guides were prepared and published on obstetrics and gynaecology, paediatrics, and community medicine. Community-based teaching sites were established for residential field site training in rural and urban demonstration areas. To improve the quality of medical education, a National Quality Assurance Body (QAB), a Project Implementation Committee, course committees, MEU Faculty, FST Implementation Committees and curriculum development committees were established. Performance-based assessment methods were introduced to assess the students' competence in relation to community health needs.
A faculty development programme was also created, under the project for further improvement of medical colleges, to provide opportunities for developing skills in community-oriented teaching by extra-regional long-term training on medical education, regional fellowship on community-oriented teaching, in-country short-courses on educational science, instructional media development, quality assurance in medical education, medical ethics and educational research methodology. About 100 medical teachers received diploma, masters or PhD degrees on medical education from overseas institutions.
For undertaking a number of reforms, in collaboration with international agencies, the 1980s and 1990s can be considered as the "golden age" of medical education in Bangladesh. No other country in south or South-East Asia could do this at that time. The programmes and reforms, based on the centres for medical education, were very successful. But it is unfortunate that Bangladesh could not consolidate or sustain the achievements. No big reforms were taken afterwards for further improvement of medical colleges. Only routine activities were carried out on "ad-hoc" basis sponsored by other agencies and the centres for medical education ceased to be key players.
The Health and Population Sector Programme (HPSP) for human resource development through pre-service education and in-service training was designed to foil the declared objective of bringing changes in the medical education in Bangladesh. Why else the project for further improvement of medical colleges was abandoned at the peak of its success.
The centres of medical education should be adequately funded with a leading role to re-orient medical education in Bangladesh. The teachers trained in the new concept of medical education should be posted in the right places so that their expertise could be utilised. The director of a centre for medical education should be a committed and trained medical educationist with visionary leadership. He or she should not come from administration. Or someone, who wants to pass the last days before his or her retirement in the capital city, should not be made a CME director. Now the CME, running an MSc course on medical education receives students from other south Asian countries. Degrees or diplomas on medical education should be an "essential criterion" for promotion.
Newly recruited medical and other health professional teachers, including in a medical university, should be required to have degree or diploma on medical education during their probation period. The CME should provide online degrees and diplomas, not just for medical education, but also to others in the healthcare and public health services. The online module on 'swine-flu' for all health professionals would enable the present government fulfill its commitment of - "Digital Bangladesh" at least partially. CME should use e-learning, video conferencing and distance learning for continuing professional development (CPD) programmes on medical education, clinical sciences, and health promotion.
The enormous challenge ahead for improving the standard of medical education in Bangladesh needs political commitment and leadership in the arena of medical education together with allocation of enough funds and resources. Many countries around the world opted for the reorientation of medical education.
For example, "The Edinburgh Declaration" of the World Federation for Medical Education (WFME) and "Tomorrow's Doctors" of the General Medical Council (GMC) of the UK outlined a number of specific strategies to guide reforms and bring need-based changes in medical education. In September 2009, GMC published the revised version of "Tomorrow's Doctors," first published in 1993, to make medical education fit-for-purpose and time to improve the health and care of patients.
The GMC has also published Good Medical Practice and other guidance which sets out the positive standards expected of good doctors in the new world of partnership with patients and colleagues. Organizations, such as the Association for the Study of Medical Education (ASME), British Medical Association Medical Students Committee, Medical Schools Council, Postgraduate Medical Education and Training Board, British Medical Association's Board of Medical Education, Royal College of Physicians, Association of American Medical Schools, American Medical Association, also published a series of reports or guidelines on medical education to improve the quality of medical education.
In Bangladesh, no single organisation has the specific mandate to oversee medical education as a whole. And no one is ready to take full responsibility to improve the medical education in the country. There should be a separate and independent medical education directorate responsible for training and development of human resources in medical, dental, pharmacy, nursing, paramedical and other health disciplines.
The roles and responsibilities of various authorities need to be defined in relation to medical education. It should be clear that all the organisations have different but complementary roles in medical education.
(The writer is a medical educationist and lecturer, Clinical Sciences Department, School of Life Sciences, University of Bradford, UK. The writer can be reached at e-mail: a.a.majumder@bradford.ac.uk)
"Knowing is not enough; we must apply." -- Goethe
A doctor needs to continuously update his medial knowledge from the every first day of his or her professional life and it continues until retirement from clinical practice. The quality of medical education, performance of medical students and graduates, and the provision of health care are interrelated. In Bangladesh, patients are always concerned about the physicians' performance and the treatment they render to them. But nobody ever speaks about the quality of medical education in the country. And an occasional discussion does not touch the real issues. One of the main reasons for it is that, medical education always gets a low priority in the political as well as professional agenda.
Medical education in Bangladesh began with the establishment of the Dhaka Medical School (now Sir Salimullah Medical College) in 1875. The medical education system inherited the typical features of colonial education of the traditional lecture-based, teacher-centred, discipline-based, examination-driven and hospital-oriented pattern. The movement for a reorientation on need-based and community-oriented medical education started early in the 1980s. To promote this concept, the Centre for Medical Education (CME) was established Dhaka in 1983 under a UNDP-funded project. A national community-oriented and competency-based curriculum, developed for the undergraduates in 1988, was later introduced in all the medical colleges of the country. Under the project, the centre for Medical Education gave reorientation training to about 600 medical teachers on the science of medical education and teaching methodology. Medical education units (MEU), established in eight medical colleges, were equipped with books, journals and audio-visual equipment. A number of teachers were sent to overseas institutes to be acquainted with need-based and community-oriented medical teaching. A new career structure for junior teachers at medical colleges was also drawn up.
In 1992, the Further Improvement of Medical Colleges Project was established under the Fourth Health and Population Project, supported by the World Bank with Overseas Development Administration and International Development Association components to re-orient and strengthen medical education in Bangladesh. The objective was to strengthen undergraduate teaching with stress on community-orientation in medical education, integrated MCH/FP training, upgrading physical facilities for better academic environment, logistic support for students and teachers and resource development in medical education. Under the project for further improvement of medical colleges, programme was taken for the re-orientation of the curriculum to increase the extent of community-oriented teaching in three priority disciplines of paediatrics, obstetrics and gynaecology and community medicine besides in other areas. Under it, a need-based internship training programme was developed, mother and child health and family planning training programmes were promoted through model clinics, residential field-site training programmes were developed for rural areas. For urban demonstration areas, primary health care teaching programme was developed in the medical college hospitals. Innovative teaching methods followed by newly established medical skills centres encouraged community-orientation and skills development. A teaching module was developed on communication skills and lesson plans for psychomotor skills. Study guides were prepared and published on obstetrics and gynaecology, paediatrics, and community medicine. Community-based teaching sites were established for residential field site training in rural and urban demonstration areas. To improve the quality of medical education, a National Quality Assurance Body (QAB), a Project Implementation Committee, course committees, MEU Faculty, FST Implementation Committees and curriculum development committees were established. Performance-based assessment methods were introduced to assess the students' competence in relation to community health needs.
A faculty development programme was also created, under the project for further improvement of medical colleges, to provide opportunities for developing skills in community-oriented teaching by extra-regional long-term training on medical education, regional fellowship on community-oriented teaching, in-country short-courses on educational science, instructional media development, quality assurance in medical education, medical ethics and educational research methodology. About 100 medical teachers received diploma, masters or PhD degrees on medical education from overseas institutions.
For undertaking a number of reforms, in collaboration with international agencies, the 1980s and 1990s can be considered as the "golden age" of medical education in Bangladesh. No other country in south or South-East Asia could do this at that time. The programmes and reforms, based on the centres for medical education, were very successful. But it is unfortunate that Bangladesh could not consolidate or sustain the achievements. No big reforms were taken afterwards for further improvement of medical colleges. Only routine activities were carried out on "ad-hoc" basis sponsored by other agencies and the centres for medical education ceased to be key players.
The Health and Population Sector Programme (HPSP) for human resource development through pre-service education and in-service training was designed to foil the declared objective of bringing changes in the medical education in Bangladesh. Why else the project for further improvement of medical colleges was abandoned at the peak of its success.
The centres of medical education should be adequately funded with a leading role to re-orient medical education in Bangladesh. The teachers trained in the new concept of medical education should be posted in the right places so that their expertise could be utilised. The director of a centre for medical education should be a committed and trained medical educationist with visionary leadership. He or she should not come from administration. Or someone, who wants to pass the last days before his or her retirement in the capital city, should not be made a CME director. Now the CME, running an MSc course on medical education receives students from other south Asian countries. Degrees or diplomas on medical education should be an "essential criterion" for promotion.
Newly recruited medical and other health professional teachers, including in a medical university, should be required to have degree or diploma on medical education during their probation period. The CME should provide online degrees and diplomas, not just for medical education, but also to others in the healthcare and public health services. The online module on 'swine-flu' for all health professionals would enable the present government fulfill its commitment of - "Digital Bangladesh" at least partially. CME should use e-learning, video conferencing and distance learning for continuing professional development (CPD) programmes on medical education, clinical sciences, and health promotion.
The enormous challenge ahead for improving the standard of medical education in Bangladesh needs political commitment and leadership in the arena of medical education together with allocation of enough funds and resources. Many countries around the world opted for the reorientation of medical education.
For example, "The Edinburgh Declaration" of the World Federation for Medical Education (WFME) and "Tomorrow's Doctors" of the General Medical Council (GMC) of the UK outlined a number of specific strategies to guide reforms and bring need-based changes in medical education. In September 2009, GMC published the revised version of "Tomorrow's Doctors," first published in 1993, to make medical education fit-for-purpose and time to improve the health and care of patients.
The GMC has also published Good Medical Practice and other guidance which sets out the positive standards expected of good doctors in the new world of partnership with patients and colleagues. Organizations, such as the Association for the Study of Medical Education (ASME), British Medical Association Medical Students Committee, Medical Schools Council, Postgraduate Medical Education and Training Board, British Medical Association's Board of Medical Education, Royal College of Physicians, Association of American Medical Schools, American Medical Association, also published a series of reports or guidelines on medical education to improve the quality of medical education.
In Bangladesh, no single organisation has the specific mandate to oversee medical education as a whole. And no one is ready to take full responsibility to improve the medical education in the country. There should be a separate and independent medical education directorate responsible for training and development of human resources in medical, dental, pharmacy, nursing, paramedical and other health disciplines.
The roles and responsibilities of various authorities need to be defined in relation to medical education. It should be clear that all the organisations have different but complementary roles in medical education.
(The writer is a medical educationist and lecturer, Clinical Sciences Department, School of Life Sciences, University of Bradford, UK. The writer can be reached at e-mail: a.a.majumder@bradford.ac.uk)