Guide To Effective Teaching And Learning In Africa

GUIDE TO EFFECTIVE TEACHING AND LEARNING IN AFRICA

MODULE 15

Teaching and Learning in Medical Sciences

Nimi D. Briggs

CONTENT

1. OBJECTIVES OF Module 15
2. General Remarks
3. Introduction

1. The Degree
2. The Trainee
3. The Trainer
4. The Environment – University, Laboratory, Hospital, Community
5. Curriculum and its Implementation
6. Teaching Medicine
7. Learning Medicine
8. Medical Technology
9. Examination of the Medical Student
10. Housemanship
11. Institutional Responsibilities
12. Role of Regulatory bodies
13. .Continuing Self Education
14. Professional Associations
15. North-South Collaboration
16. Conclusion

15.1OBJECTIVES OF MODULE 15

To give a guide on the degree required for the practice of medicine
To give guidance on effective teaching and learning in Medicine
To indicate the body of knowledge, skills and level of proficiency required of a doctor
To indicate how to inculcate professionalism in the doctor

15.2 GENERAL REMARKS

Several subjects are taught under the term “Medical Sciences”. They range from single honours non-professional subjects like Medical Biochemistry, Nutrition, Medical Physics and Human Physiology to several professional ones like Nursing, Physiotherapy, Dentistry and the Bachelor of Medicine, Bachelor of Surgery degree programmes. Guide to Teaching and Learning in the single honours non-professional subjects is similar to what obtains in most of the sciences and so does not need to be treated in this module – it will be better handled in Module 12 which deals with the Sciences. As for the professional subjects, their training and learning requirements, though reasonably similar to that of the Bachelor of Medicine and Bachelor of Surgery degree programme, are also sufficiently dissimilar, especially in the content of the professional aspects of their trainings, as not to be effectively handled through a single module. This is true even of Dentistry which shares so much in common with the Bachelor of Medicine and Bachelor of Surgery degree programme. Not surprising therefore, even for Pharmacy, which is currently taught under “Medical Sciences” in some Universities, there are agitations that this should no longer be so and that a different Faculty/College should house that programme. This Module, 15 in the series, will therefore serve as a Guide to Teaching and Learning in the Bachelor of Medicine, Bachelor of Surgery degree programme alone which leads to the qualification that is required for the practice of Medicine in most African Countries and one for which large number of students seek admission in many Universities in the continent.

As a guide, the point must be made even at this early stage of this Module that training a medical doctor or learning to become one, is a complex and time consuming venture, requiring hard work on the parts of the trainer and trainee and a heavy capital outlay, among others, on the part of the training institutions. Quite often, special arrangements have to be made for the trainee outside those of other students as the hours of work are unusually long and unconventional and the burden on the student of acquiring proficiency, knowledge and skills with which to save human lives, immense.

15.3INTRODUCTION

In order to guide effective teaching and learning in Medicine, the objectives of the teaching and learning process in the discipline (objectives of medical education) will be clearly articulated in this module. The body of knowledge and level of proficiency which the trainee is expected to have acquired at the conclusion of his training (curriculum) will be defined and so also, the modes of assessments at various stages, to confirm that the objectives of the training programme have been met (examinations).The mode of interaction and delivery of information expected of the teacher (trainer) to be able to impart knowledge will be stated and so also, the method of knowledge and skills acquisition that the learner (trainee) should use. Some description of the ideal environment which lends itself to the achievement of the stated objectives (University, laboratory, Hospital, Community) will be made. Reference will also be made to other matters that are contingent on the achievement of the stated objectives such as the one year compulsory housemanship programme and registration by an authorized body for medical practitioners.

Details of the objectives of medical education as run by individual universities are usually clearly stated in the curricula of such institutions. Although some variations which may be necessitated by local circumstances may occur, most contain the essential ingredients needed for the training of a doctor whose skills and proficiency will meet universally accepted standards. These requirements could be blended into just two for wider application, which, though generic, are sufficiently robust and elastic as to contain the fundamental elements of medical curricula. The objectives, as espoused in these curricula are:

To promote professionalism through the inculcation of attitudes of honesty and accountability with sincerity and precision in professional thoughts, words and actions and a willingness for continuing self education.
To train a graduate who is equipped with knowledge and skills to practise medicine and one who has acquired expertise and proficiency, having successfully passed through a prescribed and measurable educational process.

What follows subsequently in this Module 15, is a guide to the achievement of these broad objectives.

In doing so, the section on Teaching and Learning has been presented in two parts: Teaching Medicine and Learning Medicine. This is done in this manner to guide and give the teacher, for whom these modules are actually meant, the opportunity to understand what is expected of the student under his tutelage by the curriculum of his university and society at large and for the teacher to reassure himself that he has them. For he or she, the teacher, cannot give what he does not have.

15.4 THE DEGREE

Specific Objective:

To give guidance on the degree required for the practice of Medicine in Africa

At the end of the teaching and learning process in Medicine, a degree will be earned. This degree, which is usually the Bachelor of Medicine, Bachelor of Surgery degree (MB, BS or MB, Bch, or by whatever name called – depending on the language a university chooses with which to name the degree) to which reference was made in the section on General Remarks, is really two degrees in one. However, none is ever awarded alone and the two must be passed at one and the same examination sitting. The degree is awarded mostly following the British pattern of training as is the case in many parts of Africa. But some Universities award a Doctor of Medicine (MD) degree as the basic qualification for medical practice after the American pattern of medical education.. A private University of Medical Sciences which is to be established soon in Abuja, Nigeria, hopes to produce doctors using the four year MD programme, after an initial bachelor’s degree. It is possible therefore that the MD as the qualifying degree in medicine may soon become the vogue in Africa.

However, in most Universities in Africa, the MD degree is currently awarded as the highest academic postgraduate degree in Medicine (Universities of Port Harcourt, Ghana, Lagos), again following the British pattern of medical education. Furthermore, the degree is not usually classified (first, second – upper and lower, third class) as is typically the case with most university degrees that are awarded at the bachelors level. The expectation is that all who sit for and obtain the MB, BS qualification, must have minimum standards of professional skills and competence which render division of the degree into classes, unnecessary. But the degree could be obtained with honours (cum laude) and one could obtain distinctions in individual subjects in the programme.

15.5 THE TRAINEE

Specific Objectives:

To give guidance on the background of the candidate suitable to study medicine

To give guidance on the premedical training required

To give guidance on university requirements for admission of candidates

The candidate who wishes to study Medicine must be significantly motivated from within and should be young but mature – the programme is long and establishing oneself in the profession after graduation, time consuming. Furthermore, maturity to take on the arduous and rapid speed of work during training is also a necessity. So, students not younger than 18 and not older than 25 years are preferable. Gender is not a barrier.

The Premedical Training that is required is to enable the candidate to have a firm grasp of the fundamentals of the contributory sciences on which the medical training is based. The candidate should have an understanding of Biology, Chemistry, Physics and Mathematics up to the advanced level of the General Certificate of Examination (GCE A Level) The Pre Medical Programme could be included as a one year course of study before the commencement of the actual medical training in a university or carried out in other institutions, usually, a Higher School or College. But outside these foundation sciences, the prospective medical student should have a knowledge of human behavior and societal interactions Such a prospective student should therefore be an informed and educated man and it is this that serves as the basis for the requirement of a University/College Degree at the bachelors level in the Sciences or even the Liberal Arts, but with science at the O level, as a prerequisite, in the American system of medical education, which then ends up with a Doctor of Medicine (MD) Degree.

Admission qualification requirements therefore differ from university to university. They include five credits at the GCE Ordinary Level in the core subjects and English Language, or three advanced level papers in Biology, Chemistry and Physics. However, in some countries, a designated body is charged with the responsibility of conducting examinations for University matriculation at which candidates are expected to obtain a minimum score, described as a cut off mark. This is usually followed by some other selection process at the level of the university itself, often referred to as Aptitude Test, before matriculation.

Many trainees find the medical programme rigorous and expensive. Some of the standard text books are costly and so also are the many gadgets which the student would have to acquire and be competent and proficient in their use. Dropout rate is therefore higher than is the case in most other disciplines., Consequently, irrespective of the way a trainee has his/her fees paid, sufficient funds should be available for his/her upkeep.

15.6 THE TRAINER

Specific Objectives:

To give information on the requirements of a teacher to teach medical students

To give guidance on the responsibilities of such a teacher.

Several trainers are involved in the training of the medical doctor. They range from the lecturers and Consultants to other persons who assist in one form or the other especially in the practical aspects of the training – Demonstrators, Physiotherapists, Midwives and Technicians. They all need to be dedicated to their work and commit themselves to the course of the training of the medical doctor.

It is preferable for every lecturer of medical students to have a basic qualification in medicine (MB, BS or the MD) in addition to the terminal qualification that enables him teach his branch of medicine (MDs, PhDs and Fellowships of various professional bodies). This should be so even for those who teach the non-clinical subjects like Anatomy, Human Physiology, Medical Biochemistry and Pharmacology as such teachers understand the relationship between the component parts of the programme better apart from the fact that there is a healthier cohesion and understanding between them and their clinical counterparts.

All medical trainers should understand and appreciate the place of research as integral to their responsibilities and even as clinicians, harbor a robust research portfolio that keeps them active in scientific publications. Furthermore, they must at all times realize that an important aspect of medical training is mentorship. Accordingly, they should practice their profession and conduct their private lives in such a manner that they will serve as role models to the medical students that they are training.

15.7 THE ENVIRONMENT

Specific Objective:

To give guidance on the environment needed for the training of the medical student, which should consist of the University, Laboratories, Hospital and a community for grass-root practice.
To give guidance on the functions and activities in each of these structures

Medicine cannot be thought anywhere. It requires an appropriate environment with defined structures, consisting of the following: University, Laboratory, Hospital and the Community

The University

In the distant past, medicine was taught solely by an apprenticeship arrangement without an authoritative organ to direct and certify its course of studies. Students of medicine in Africa, as elsewhere, should be trained under the aegis of a University which not only brings its intellectual sincerity to bear on their training, but also assures, through a number of ways, that the products of the programme acquire sufficient knowledge and expertise that would enable them meet universally accepted standards in the practice of their discipline.

The University should ensure that the medical programme is delivered to appropriately selected groups of students by well-qualified staff in its employment, as a properly-structured, time-based course of study with well-defined content and modes of instruction as well as modes of periodic assessment.

Admission of students to be trained in the medical programme should be done by the University directly or through its Faculty/College of Medicine using widely advertised criteria and transparent selection procedures; an oral interview could be included as part of the selection process. The University should provide accommodation for medical students even where this may not be the case for others on account of the peculiar nature of their studies. Furthermore, the University should ensure that a properly constituted Senate approves the award of the MB, BS degrees to successful candidates at the completion of the course.

The University should realize that medical education is a serious, complex and expensive venture. It should be alive to its many responsibilities to its Faculty/College of Medicine, including that of footing its bills. . Its overarching desire at all times should be to pitch instructions in its medical programme on a University plane.

The Laboratory

The entry of the laboratory into the structures required for the training of medical students derives from the knowledge that medicine is an essential part of modern science. The human being is a mammal whose body functions in a manner that is similar to those of others in the animal kingdom with which biologists are familiar. Many of its internal activities are processes which obey the laws of physics and chemistry which are also well known to scientists. The laboratory, which has become an integral part of medical education, therefore, should be used to enable to know how and why the human body functions the way it does in health and in disease. Using first principles, derived from work in the laboratory sciences, the student should work out the course of events when things go wrong in the human body and how to ameliorate them. Using the laboratory, the student should dissect the human body to see its component parts, organs and tissues; he should use the microscope to understand cellular operations in health and disease; carry out experiments to ascertain drug effects on tissues and much more

In an ideal setting, each trainee should have a locker in the laboratory of every department he passes through during the course of his study, including the clinical departments, for the storage of equipment, chemicals and reagents for his personal use to enable him carry out various tests, including those on body effluents, like sputum, urine and faeces.

The Hospital

A hospital, usually a tertiary one that is committed to teaching, research and patient care is required for the clinical aspects of the training of the medical doctor. Such a hospital should be affiliated to the University from which its medical students should originate. In such a hospital, medical students should have direct contact with patients, learn about their diseases and participate in their care, albeit, under the supervision of academic staff of the university who also serve as clinicians/consultants to the hospital. In return, the high class teaching and research carried out in the hospital by the academic staff of the University bring about higher quality of care of the patients of the hospital, than would have ordinarily been the case.

Teaching Hospitals are big health institutions which are also used for the training of other health professionals like nurses, midwives, physiotherapists and radiologists. Many of them have more than 500 beds for the admission of the sick and the responsibility on them to provide teaching facilities, amenities as well as recreational facilities for the trainees in their hospitals is enormous. Their management and routines is therefore complex.

The Community

Medical Practice and Education is about the Health and wellbeing of Communities of people. It should therefore be community-oriented in content and implementation, from the family and district levels, right up to the regional level. Opportunities should be created for grass-root community practice and learning experiences. Learners must appreciate the relationship between the socio-cultural and economic dynamics of communities and the state of their health – for instance, the relationship between poverty, ignorance and disease on the one hand, and health on the other. Importantly too, the host community of any Learning institution should be made to benefit from the teaching and learning activities going on in its domain.

The Community

These structures – the University and its Faculty/College of Medicine together with its various laboratories and a hospital designated for teaching, patient care and research as well as a Community where grass-root community practice and learning experience will be obtained are the fundamental structures needed for effective teaching and learning in medicine. They are so vital for the purpose that no contemplation for the training of a medical doctor should be entertained, unless adequate arrangements have been concluded for their establishment.

15.8 THE CURRICULUM

Specific Objectives:

To give guidance on the components, types and duration of medical curricula.

To indicate deficiencies in some curricula

To guide the implementation of a competency-based curriculum

To give guidance on quality assurance, uniformity in learning outcomes and valid measurements in clinical medicine.

. The curriculum is an important document as it determines not only the duration of study, but also, to a large extent, the quantum of knowledge which a trainee should have acquired at the end of his training. It should be prepared by the academic staff of the Faculty/College and approved by the Senate of the University. The Curriculum should avail the trainee with a defined core of scientific knowledge regarding the structure and function of the human body in health and disease and how these are affected by environmental, social and cultural factors. It should point the path to the problem-solving skills and competence required for an effective practice of the vocation of medicine and should seek to inculcate the essentials of a professional life that is based on honesty, discipline, responsibility and integrity.

TYPICAL MB, BS CURRICULUM [including pre-med]
YEAR	1	2	3	4	5	6
SECTIONS	PRE-MEDICAL	BASIC MEDICAL	BASIC MEDICAL	CLINICAL	CLINICAL	CLINICAL
SUBJECTS	BIOLOGY, PHYSICS, CHEMISTRY, MATHMATICS STATISTICS	ANATOMY, PHYSIOLOGY BIOCHEMISTRY	ANATOMY, PHYSIOLOGY BIOCHEMISTRY			SENIOR MEDICINE, SURGERY, PUBLIC HEALTH, OPTHAMOLOGY, ENT, ORTHOPAEDICS, FORENSIC MEDICINE, ETHICS
SUBJECTS	BIOLOGY, PHYSICS, CHEMISTRY, MATHMATICS STATISTICS		ANATOMICAL PATHOLOGY CHEMICAL PATHOLOGY HAEMATOLOGY IMMUNOLOGY PHARMACOLOGY	ANATOMICAL PATHOLOGY CHEMICAL PATHOLOGY HAEMATOLOGY IMMUNOLOGY PHARMACOLOGY JUNIOR MEDICINE, SURGERY, PUBLIC HEALTH,	PAEDIATRICS & OBS & GYNAE
EXAMINATIONS	FIRST [Premed]		SECOND [Part I MB;BS]	THIRD [Part II MB;BS]	FOURTH [Part III MB;BS]	FIFTH [Part IV MB;BS]

The typical curriculum which is based on the study of the component subjects of the curriculum should cover a six year course, after admission with credits in the relevant subjects at the O level. Broadly, in such an arrangement, year one should be used to teach Premedical Sciences; years two and three, Basic Medical Sciences; while years four, five and six are used to teach the clinical subjects, with some overlap between the basic and clinical sciences.

The Premedical Sciences subjects that the curriculum should address are Biology, especially Zoology, Chemistry, Physics as well as Mathematics with Statistics. The idea is to bring up the student’s knowledge in these foundation subjects to the A levels to enable him understand, follow and participate in the next and subsequent phases of his studies. Strong emphasis should be laid on laboratory work to be accomplished by the student himself to enable him acquire scientific techniques. He should be tested at the end of the one year course and should pass to be able to proceed. No carry over should be permitted.

The Basic Medical Sciences subjects should be Human Anatomy, Human Physiology and Medical Biochemistry as well as Anatomical Pathology (Morbid Anatomy), Immunology, Medical Microbiology and Parasitology, Chemical Pathology, Haematology and Blood Transfusion, and Pharmacology. Whereas the first three of these subjects should all be taught and tested for within the two years of the basic medical sciences’ course, teaching in the others should commence in the second year and extend to the first year of the clinical programme at which time they too should be tested for. Candidate should not be permitted to proceed to the clinical programme unless he has passed the examinations in Anatomy, Physiology and Biochemistry. Similarly, candidate should not continue with the clinical programme unless he has passed the examinations in the rest of the basic medical sciences course for which he should be tested at the end of the first year in the clinical programme. Strong emphasis should be placed here again on hands-on experience as the candidate should be expected to dissect the complete human body, carry out experiments on the anaesthetized dog to understand physiological processes, study cellular activities and functions under the microscope and many others. The first part of the basic sciences curriculum should be designed to teach structure and function of the normal body while the second part, the derivatives of Pathology (anatomical pathology, microbiology and parasitology, chemical pathology and immunology) and the drug science of Pharmacology should commence the introduction of the student to body structure and functions under pathological/abnormal states.

The clinical section of the curriculum should deal essentially with ill health and diseases in man and the community: their nature, identification, prevention, treatment, cure, rehabilitation and the follow up of patients afflicted by disease. This principle should then be applied to various human situations, for example, to children as in Paediatrics and Child Health; Women, within and outside pregnancy as in Obstetrics and Gynaecology, the Eye as in Ophthalmology; and so on. Medicine, Surgery, Paediatrics, Obstetrics and Gynaecology and Public Heath should be taught as standard subjects in every medical curriculum but the extent to which these are divided into subsets like Therapeutics, Orthopedics, Anesthesia, Ear Nose and Throat, and many more, which have become individual subjects in their own right, may differ. The clinical sciences should be designed to teach the student the science and art of taking care of patients and preventing ill health. He should do this not as a standby observer, but as a hands-on learner through clinical clerkship of History Taking, Physical Examination, Making a Provisional Diagnosis and mapping out a course of management of the patient’s condition. The modern day training of medical student in the clinical sciences should be designed therefore, not to supplant but to supplement apprenticeship which was the sole mode of training of the early years of the discipline.

The clinical sciences should be examined in two parts – first for Obstetrics and Gynaecology as well as Paediatrics at the end of the second clinical year and the rest of the subjects at the last clinical year.

Other types of curriculum which could be used to train medical students are the Organ-based Curriculum as introduced by Western Reserve in the 1950s, Problem-Based Learning by McMaster in the 1970s, Primary Care Curriculum by New Mexico in the 1980s and New Pathway by Harvard Medical School in the 1980s.

Summary of deficiencies in most of the current curricula in use

1. Lack of early clinical orientation of students.

2. Disjointed methods of practice, teaching and assessment, due to absence of any regional ‘road map’.

3. Lack of community orientation and poor understanding of regional health needs, resulting in limited preparation of students for practice in the real world.

4. Discordance in the prioritization of the missions of the Teaching Hospitals and the Medical School.

5. Undermining of standards by admission of weak students through re-sit examinations, without exposure to repeat learning experiences for remediation and non enforcement of exit regulations.

6. Poor understanding by teachers, of the processes of Testing, Examination, Assessment and Evaluation.

7. Non-provision of statutory Academic staff Development in Educational pedagogy.

Guides to the Content and Implementation of a Competency-based Curriculum

1. The content of a competency-based curriculum should necessarily be summarized in a Table of Specifications, which shows all the subject headings, their percentage proportion of the subject, how they are to be delivered for learning purposes, how their learning will be verified and examined for as well as the cognition level at which they will be tested. A sample Table of Specification is shown below for one course in Paediatrics.

Table of Specification for Delivery and Assessment for Preventive Paediatrics and the School Health Programme

COURSES	CREDIT UNITS [%age]	Specific Topics / Skills	% age of Course Coverage	DURA TION	MODE OF DELIVERY					LEVEL OF COGNITION
COURSES	CREDIT UNITS [%age]	Specific Topics / Skills	% age of Course Coverage	DURA TION	Self Instruction	Tuto rial	Semi Nars	Clinicals	Work Shops	LVL-I	LVL-II	LVL-III
Levels of Prevention	5 [35]	Definitions	10		5	0	5	0	0	2	3	5
		Principles	20		10	0	10		0	4	6	10
		Applications of Level One	10		5	0	0	5	0	2	3	5
		Applications of Level Two	20		10	0	0	10	0	4	6	10
		Applications of Level Three	20		10	0	0	10	0	4	6	10
		Applications of Level Four	10		5	0	0	5	0	2	3	5
		Applications of Level Five	10		5	0	0	5	0	2	3	5
Health Supervision	2 [15]	Core Concepts and General Principles	25		5	5	5	5*	5	5	5	15
		Supervision by Age-groups-	25		5	5	5	5*	5	5	5	15
		Early &Middle Childhood	25		5	5	5	5*	5	5	5	15
		Adolescence	25		5	5	5	5*	5	5	5	15
The School Health Programme	7 [50]	Value and Scope	25		5	5	5	5*	5	5	5	15
		Components	25		5	5	5	5*	5	5	5	15
		Administration	25		5	5	5	5*	5	5	5	15
		Evaluation	25		5	5	5	5*	5	5	5	15

*Under Health Supervision and the School Health Programme, The term ‘Clinicals’ is equivalent to Practical Activities during Home or School visits

Cognitive Level of Questions: Level -I = Recall (facts) [20%]

Level -II = Comprehension and Application, [30%]

Level -III = Analysis, Synthesis, Evaluation and Creation [50

2. Learning Experiences should be Competency-based and directed to specific Learning Objectives.

3. Wherever possible, an integrated system-based approach should be adopted.

4. Emphasis must be placed on Community Orientation in Practice, Learning and Assessments.

5. Formative Feedback processes should be routinely practiced and reinforced.

6. Learners should be encouraged to acquire a Self-directed Learning, Research and Audit orientation.

7. Learning itself should be competency-driven.

8. Priority should be given to Achieving the triad of Quality Assurance in Practice; Consistency and Uniformity in learning outcomes; Fair, Reliable and Valid Measurements in Clinical Medicine. This is a major challenge in Medical Education which can be addressed by the:

a. use of Check-offs / Check-lists, to make the measurement process defensible, valid and reliable. A sample checklist / check-off for assessment of the general Inspection component of Genitourinary System examination is shown below. Development of these checklists is a major challenge for all engaged in medical education in the twenty first century developing world.

SKILL: GENERAL INSPECTION: IN GENITO-URINARY SYSTEM EXAMINATION		PERFORMANCE CHECK-OFF
Examination No					Date
	PERFORMANCE / DO STEPS	NOT	Badly	Fairly	Well	ITEM
		Done(0)	Done(1)	Done(3)	Done(5)	Score
1	General : Inspection
A	Pallor
B	Oedema
C	abdominal size
D	Hair changes
E	Skin changes
		Zero(0)	Bad(2)	Fair (6)	Good(10)
	Overall attention to sequence
		Zero(0)	Bad(1)	Fair(3)	Good(5)
	Speed of performance
	Composure
	Courtesy
	Affect
	COLLATED SCORES
	SPECIFIC FEED-BACK COMMENTS

b. use of Subject-specific, generically derived uniform Practice, Learning and Assessment Protocols [Clinical Summary and Reasoning Format] which conform to the realistic, measurable and challenging objectives. A sample Clinical Summary and Clinical Reasoning Protocol for practice, learning and assessment of the clinical clerking is shown in the page below. Development of Practice, Learning and Assessment Protocols is another major challenge for all engaged in medical education in Africa.. These are essential tools that require institutional, national and regional consensus to develop.

STRUCTURED CLINICAL SUMMARY AND REASONING FORMAT

PATIENT’S NAME:			Age:	Date of Birth		Gender	Date
ADDRESS
S/No	Symptoms Obtained (from PC & ROS )	Other Aspects of History (From HPC, RxHx.,,PMH to F&SH)			Signs Elicited (Positives1^st) (From Physical Examination)
1
2
3
4
5
6
7
8
9
10
11
12

ANY BEDSIDE INVESTIGATION OR SIDELAB RESULTS OBTAINED

Test-1:	Result-1:
2	2
3	3

System/s most likely involved in disease, in order of Evidence-Based Priority

Review the two most likely Systems in the numbered spaces below for each named System

A			B
I	Ii	Iii	I	Ii	Iii
Iv	V	Vi	Iv	V	Vi
Vii	Viii	Ix	Vii	Viii	Ix
X	Xi	Xii	X	Xi	Xii
Xiii	Xiv	Xv	Xiii	Xiv	Xv
Xvi	Xvii	Xviii	Xvi	Xvii	Xviii

Pathological Process/es likely occurring in the system/s

A		B		C
Functional abnormalities, in System/s or organs, elicited from History and or Physical Examination			Structural abnormalities, in System/s or organs, elicited from History and or Physical Examination
1	2		1		2
3	4		3		4
5	6		5		6
7	8		7		8

FUNCTIONAL DIAGNOSIS /ES

ANATOMIC DIAGNOSIS /ES

IMPORTANT / DIAGNOSTIC INVESTIGATIONS INDICATED

PATHOLOGIC DIAGNOSIS / ES

AETIOLOGIC DIAGNOSIS /ES


Student’s Name	Signature	Date

15.9 TEACHING MEDICINE

Specific Objectives:

To give guidance on the various ways of teaching medicine

To enhance quality delivery of information
To guide supervisory activities and the teaching of clinical skills

To indicate programme time lines for courses

To indicate duration of teaching in the medical programme

. The teaching of Medicine should be largely through getting the student to listen, observe, experience and do. It should no longer be enough to teach the student to listen, observe and memorize only; he should now also be taught to do and carry out several activities through a participatory teaching process.

There are several ways in which this should be brought about which I will attempt to classify into:

- Formal lectures
- Supervisory actions
- Ward rounds/bedside teaching
- Reviews/Seminars/Journal clubs/Workshops/Conferences
- Hands-on teaching
- Distance teaching
- Mentoring

Formal Lectures

This is the formal presentation of information before an audience, usually orally, in order to teach or disseminate facts about a particular subject. It is the commonest mode of teaching of all subjects in the University, including Medicine, where lectures are delivered on various topics, in all the departments of the College/Faculty, as the prescribed basis for formal instruction. A few hints are hereby given as guide to enhance the effectiveness of a lecture.

The lecturer should:

Ensure proper preparation of the lecture.
During the lecture, position himself in such a manner that most members of the class he is teaching are able to see him and he too, able to see them.

Not let his presentation to extend beyond one hour, at the most.
Observe the countenance of his students to see if they are understanding the message of the lecture
Take pains to explain difficult issues to enhance students’ understanding.
Make the lecture interactive – invite questions and comments.
If available, utilize multimedia facilities like the power point and other measures that will enhance and sustain students’ interest in and understanding of the lecture.
Sufficiently motive the students during the lecture as to be innovative and seek further knowledge on their own.

Supervisory Actions

Several activities which the student is expected to carry out require the supervision of his teacher, the essence of which is for the student to perform the particular act but at the same time to guide and direct him to prevent him from going markedly astray. The need for such supervision frequently arises during the training of the doctor especially while training in the laboratory sciences. They include:

Dissections in the Anatomy laboratory.
Microscopy work in Histology and Histopathology
Animal experiments in Physiology
Bench work in microbiology

Students at an anatomy dissection

Ward Rounds/Bedside Teaching

Teaching during ward rounds by the bedside of ill patients is a very important method of instruction during the clinical aspect of medical education. The teacher, who is usually an academic staff of the university with clinical responsibilities in the teaching hospital, should point out signs of ill health that are manifest in the patient. He should then correlate these signs with the patient’s complaints and explains how a diagnosis is arrived at. The teacher should frequently invite the student to give an account of his own clinical clerkship and to examine the patient in the presence of everyone. On such occasions, the teacher should carefully watch the student on his approach and his ability to elicit the correct signs of ill health – called physical signs. A teaching ward round in a ward of 30 beds with patients would normally last about 3 to 4 hours and could cover discussions on a wide range of subjects in clinical medicine

Students should attend ward rounds with small pocket note books into which they should make recordings of important information as the rounds proceed and traditionally, staff and students should attend ward rounds, dressed in clean white coats. Teaching at ward rounds is a significant way of delivering clinical instructions and should be very visible in the teaching of:

Internal Medicine
Surgery
Obstetrics and Gynaecology
Paediatrics, among many others.

Bedside clinical teaching

Reviews/Seminars/Journal Clubs/Workshops/Conferences.

Other than the formal manner of delivering instructions through lectures, teaching at ward rounds and supervising laboratory work, there are a number of informal ways by which Medicine could be taught. They include Review of Journal Articles, holding of Seminars on selected topics, discussions at Journal Clubs and attendance at Workshops and Conferences. It is the responsibility of the trainer to draw the attention of the trainees to these informal avenues and to encourage the trainees to utilize them. On their part, students also like these avenues of informal training as they are mostly carried out in more relaxing environment and the mode of delivery more inviting.

From the commencement of their training, students should be encouraged to read medical journals and other materials outside their recommended standard text books and their teacher’s lecture notes/handouts. They should be persuaded to form clubs in which they could review and critic Journal articles. Thereby, apart from acquiring knowledge, the students should be made to gradually become familiar with the art of medical writing which is an important part of their education.

Seminars and Tutorials should be regarded as extension of lectures. They should be organized by departments or individual lecturers on a group of subjects (say, hypertension, descending aorta, lung function tests, menorrahgia, road traffic accidents,diaorrhoea) on which formal lectures would normally have been delivered. At the seminars, which rightly should be dominated by students, but under the general supervision of academic staff, the topics should be discussed extensively, beyond the one hour presentation they had received at the formal lecture. Correlation between various lecture subjects should be identified (like correlation between hypertension, diabetes mellitus and arthrosclerosis) and the way and manner issues under discussion could be applied to others, expatiated upon. The idea is that the exercise should lead to a better understanding of the subject(s) under discussion.

Conferences should be made popular with staff and students and they should constitute an important source of education for both. Furthermore, not only should they serve as avenues through which to offer and receive information from a wide spectrum of persons, they should also afford the opportunity to make new academic and professional acquaintances. It is not surprising therefore that universities use attendance at conferences, especially in the instances in which the academic staff made presentation, as one of the measures of the staff’s academic capability for the purpose of promotion to higher academic positions.

Conferences may be held locally or outside the base of the institution; participants may be from one’s university or outside it; and may even come from other countries – local and international conferences. The trainer must encourage students to attend conferences as among others, they afford him the opportunity to receive instructions from a variety of sources under a single roof.

Hands-on teaching

The Chinese adage of “tell me – I forget; show me – I remember; Let me do and I know” is well-known to many and nowhere is the lesson of this adage more applicable than it is in the need to ensure that the trainee medical students acquire hands-on education on the clinical methods and use of tools that they will require for the practice of their profession after graduation. The teaching of these clinical methods and use of tools should commence during the introductory classes to clinical medicine and should continue throughout the postings in the clinical departments. Thus, the would-be doctors should be trained to be competent in physical examination of patients as part of clinical clerkship. Specifically, they should be taught how to examine various parts of the body – the abdomen, chest, limbs and so on. The list of examination procedures is long and cannot be included in a document such as this. .

Furthermore, the would-be doctors should be taught to be proficient in the use of the many instruments and gadgets as used in clinical practice. The list of such instruments and gadgets is again long and differs from department to department. So, mention will be made of only a few in this module. They include being taught how to:

Use a clinical thermometer, clinical watch, and sphygmomanometer to check and record the vital signs of patients- temperature, pulse, respiratory rate, blood pressure
Use a stethoscope to listen to heart beats, breath sounds and bowel movements
Use Syringes and needles to carry out venepunture to obtain blood for various purposes.
Use a spatula to depress the tongue so as to be able to examine the tonsils.
Set up an intravenous fluid line
Pass a vaginal speculum to visualize a woman’s cervix
Use an ophthalmoscope to examine the eye
Use the surgical knife to lance an abscess
Use the needle holder, needle and suture material to suture the edges of a clean wound.
Use a pin to test for sensation in the limbs.

Field Trips/Community-Based Learning and Experience (COBES)

Students should visit Public Health Facilities like abattoirs, incinerators, sewage disposal systems and water treatment plants. Such visits should afford students the opportunity of understanding the public health measures that are involved in safe guarding a clean environment and the health of members of the community as well as the significant role that such measures play in securing individual happiness and health of people in the community. The student should be made to appreciate the preventive approach to health that Community and Public Health Medicine offer as opposed to the treatment of individual ill patients in various hospitals.

In the same vein, the posting in rural medicine, whereby the students are made to go to a rural environment to take care of the priority health and social needs of underserved communities should be taken seriously as there are many undeveloped rural areas in Africa, where it might be the lot of the doctor to practise. Such an environment should be one that lacks the comfort and amenities of a teaching hospital and one that would therefore get the student to learn to attend to the needs of patients without the usual paraphernalia of a teaching hospital. The major tool that a student should rely on in such an environment should be his clinical skills. Apart from the learning experience that a student should gain during his rural postings, members of the rural community also benefit immensely, as by this arrangement, they have an improved access to health care. . Such outposts in rural settings where students gain wide-spread clinical experience have grown to become major research centers where important research activities with global impact have taken place. The Centre for Community-based Learning and Experience of the University of Ilorin (World Health Organization Collaborative Centre), the University of Ibadan Igbo-Ora model and the Rural Health Centre established by the University of Port Harcourt in collaboration with the Liverpool School of Tropical Medicine and Hygiene are notable examples.

Students at a rural posting

Distance Learning

Technological advances have made distance learning whereby students can be taught by teachers at far away locations, possible. Video conferencing for lectures, operating sessions, are applications of this advance in technology. However, this method of teaching is not yet available in many African countries on account of cost and problems associated with constant electricity supply with steady and correct voltage which is needed for their operations.

Mentoring

Training by personal example is common in the professions especially medicine. It does not involve the delivery of lectures or supervision of bench work. Rather it is the education that a teacher imparts by the way he conducts his personal life. It is an important aspect of every trainer’s responsibility to serve as a role model to his students. The trainer should be aware that students note his

level of commitment to his work
depth of knowledge of the subject he teaches
level of personal hygiene
mode of dressing
manner of personal comportment
punctuality to lectures and other events

and they form an opinion regarding accepting him as their mentor or role model from which they do not depart subsequently. Having studied medicine in the mid 1960s, I still remember the impression various teachers made on me till this day – more than 40 years ago!.

It is difficult to give an exhaustive account of the ways a trainer can contribute to the training of a student in the realization of the student meeting the stated objectives of his training course in medicine but a fair attempt has been made in this Module. The trainer should at all times put the interest of the trainee above every other consideration and so assist him in every legitimate way to meet his aspiration of becoming a doctor. One important way by which this can be done, is to motivate the student by challenging him and by getting him involved in all that the trainer does in his professional and academic life. In the final analysis, there is hardly a better way to train a doctor.

The Tables after the next paragraph, which were adapted from a recently reviewed Curriculum of the University of Ibadan, Nigeria, with a MacArthur Foundation Grant, give information on the allotment of time to the teaching of various subjects. The programme covers a period of six years similar to the one on which Module 15 is predicated. But the programme was made to be sufficiently elastic as to be able to dovetail with the four year MD degree programme if and when this comes on board.

At the Makerere University in Uganda, a Bachelor of Medicine and Bachelor of Surgery (MBChB) programme which consist of two (2) years of pre-clinical instruction and examination by Makerere University School of Biomedical Sciences (Anatomy, Physiology, Biochemistry), and Makerere University School of Health Sciences (Pharmacology), followed by three (3) years of clinical instruction and examination by Makerere University School of Public Health and Makerere University School of Medicin

NEW MB;BS. PROGRAMMES TIME [MONTHS & WEEKS] OUTLINE {Adapted from University of Ibadan. 2010 Curriculum}
PART I [18 MONTHS / 72 weeks]	MONTHS	WEEKS
General Introductory Orientation	0.5	2
Applied Medical Sciences	0.5	2
Medicine as a Profession- History, Ethics, Communication and Learning Skills	1.5	6
Multidisciplinary Health Care Delivery	1.0	4
Human Nutrition	0.5	2
Environment and Health [PSM ]*	1.0	4
Clinical Application of Basic Medical Sciences	1.5	6
Complementary and Alternative Medicine	0.5	2
Anatomy [with Embryology and Genetics]	3.0	12
Human Physiology	3.0	12
Medical Biochemistry*	3.0	12
Revision	0.5	2
Examination	0.5	2
Holiday –Mid and End Programme	1.0	4
Programme Total	18.0	72

THE PART II MB;BS. PROGRAMME LEARNING TIME [ IN WEEKS] OUTLAY
PART IIA [6 MONTHS / 23 weeks]	WEEKS		PART IIB [6 MONTHS / 25 weeks]		WEEKS
Introduction to Clinical Medicine	6		Pathology – Systems		12
School Health Programme [PSM]	2		Pharmacology –Systems		6
Pathophysiology and Introductory Pathology	4		Therapeutics – Systems		2
Introductory General Pharmacology	6		Revision		2
Revision	2		Examination		2
Examination	2		Holiday		1
Holiday	1
Programme Sub-Total	23		Programme Sub-Total		25
Part A – Theory Part B – Practical/Clinical Exposure
THE PART III MB;BS. PROGRAMME LEARNING TIME [ IN WEEKS] OUTLAY
PART IIIA [6 MONTHS / 24 weeks]		WEEKS		PART IIIB [6 MONTHS / 24 weeks]		WEEKS
Paediatrics and Child Health -Theory & Practice		6		Paediatrics and Child Health -Practice		10
Obstetrics and Gynaecology – Theory & Practice		6		Obstetrics and Gynaecology -Practice		10
Preventive Paediatrics		2		Revision		2
Preventive Obstetrics & Gynaecology		2		Examination		1
Revision		4		Holiday		1
Examination		2
Holiday		2
Programme Sub-Total		24		Programme Sub-Total		24

THE PART IV MB;BS. PROGRAMME LEARNING TIME [ IN WEEKS] OUTLAY
PART IVA [6 MONTHS / 24 weeks]	WEEKS		PART IVB [6 MONTHS / 24 weeks]		WEEKS
Internal Medicine – Theory and Practice	6		Internal Medicine – Practice		8
Surgery – Theory and Practice	6		Surgery – Practice		8
Preventive and Social Medicine	6		Preventive and Social Medicine		4
Revision	2		Revision		2
Examination	2		Examination		2
Holiday	2
Programme Sub-Total	24		Programme Sub-Total		24

1. LEARNING MEDICINE

Specific Objectives:

To give an account of the cognitive framework in which medicine is learnt

To give guidance on the various ways medicine can be learnt.

To guide the learning of Clinical Clerkship

To encourage Clinical Reasoning

The cognitive framework, within which learning, including that in medicine is achieved, requires that the student acquires discrete facts and information which he should comprehend, understand and appreciate. He should then apply what he has understood and also explore the interrelationship between different bodies of thought and information. Additionally, he should think creatively and generate new value from existing information. Based on this framework, there are several ways by Medicine should be learnt. Again, I will give guidance on the following recommendations:

- Attendance at lectures
- Reading recommended text books and having access to other medical materials.
- Clerking of patients
- Group discussions
- Using the Library
- Seeing medical procedures performed
- Doing medical procedures by yourself
- Analyzing what you have learnt

Attendance at Lectures

This is a principal way by which medicine is learnt as not only is prime information given at lectures, issues that are difficult to understand, in the particular subject on which the lecture is based, are usually explained. The learner should do the following at lectures:

If possible, attend all lectures and on time too.
Dress decently, not provocatively.
Do not distract the attention of others, including that of the teacher.
Show respect to the lecturer.
Do not take calls from your cell phones or send/receive text messages.
Keep awake and be attentive. Do not read magazines and books during lectures.
Strive to understand what is being taught.
Do not copy what is being said verbatim but make notes as you understand the lecture.
Be interactive; ask sensible questions.

After the lecture, find time to look at the notes you took and reflect on the subject of the lecture. If possible, read it up in a standard text book. Keep the notes you made handy; you will need them later for revision. Attendance at lectures is so important, that some universities/departments demand a minimum attendance of 75% of the lectures, in order for a student to qualify to sit an examination in that course.

Reading Recommended Text Books and access to other medical materials

Every department through which the student rotates during his training in Medicine should hand over a list of recommended text books to the student which he should purchase and own personally as part of the process of building up his own personal library. The student must find time to read these books and assimilate their content as they compliment what is received during lectures. A student could mark or highlight information in a book in colour to which he would want his attention drawn during revision, provided the book is his. Colouring or marking pages of a book should certainly not be done to any book from any of the libraries of the University which is loaned out to a student.

Other than standard textbooks, there are lots of other documents which contain information that a medical student or even a practicing physician should know – journals, magazines, periodicals and some others. The learner should be an avid reader. In addition, various electronic media – radio, television and others also carry educational information, including those in medicine which should be of interest to the student. .

Clerking Patients

Clinical Clerking is vital for learning clinical medicine. It is the gathering and utilisation of information on a patient regarding his possible illness. The components should include

history taking,
physical examination,
bedside investigations,
clinical diagnosis,
identification of problems needing intervention,
differential diagnosis
investigations
Plan for immediate management and long term follow up.

Patients should be distributed to medical students on their first arrival in clinical departments and also as new patients get admitted into the wards. Students should clerk and participate in the management of all such patients that have been allotted to them – their various tests (investigations), treatment (injections, tablets, IV fluids, others including surgery) and also, follow them up – for example, going to homes of patients who had been treated for tuberculosis to do contact tracing or helping to explain how to care for a patient with colostomy to the spouse of a patient with one. From clerking patients, students should learn to:

sequentially obtain complete history, including information outside the patient’s complains
perform orderly physical examination,
perform relevant bed side investigation,
articulate a clinical summary,
use the information obtained to engage in clinical reasoning,
carry out cost-effective investigations,
document the findings sequentially,
plan and implement appropriate treatment,
project on the course of illness,
prognosticate and
Institute any required preventive measures.

In the course of clinical clerking and clinical reasoning, the possible progressive sequential conclusions a student should reach, based strictly on the patient-derived information should include;

Number of symptoms obtained,
Number of other aspects of History that are important,
Number of signs obtained,
System/s most likely involved in the disease,
the pathological process/es most likely causing the disease,
any functional abnormalities present,
any structural abnormalities present,
any defendable functional diagnosis/es,
any defendable anatomical diagnosis/es,
any defendable pathological diagnosis/es,
what investigations would be needed to confirm the pathological diagnosis or determine the aetiology under consideration,
the most probable Aetiological diagnosis,
the most appropriate treatment required,
the differential diagnosis

With this sequential thinking, the mandatory questions which a student should ask after clerking a patient should include those indicated below:

MANDATORY QUESTIONS

What system/s could be involved?
What pathological process is occurring?
What system/s must I review thoroughly?
What functional abnormalities are identified?
What anatomical abnormalities are identified?
What is the patho-physiology involved?
What diagnosis do I have information to make?
Do I need any bedside investigations?
What is it that needs to be done for the patient?
How best do I proceed cost-effectively?
What is the possible course and outcome of the disease?

Clinical Clerkship is probably the most important tool that a would-be doctor should take away from the Medical College to his subsequent practice as a doctor. It is a tool he will use for Clinical Reasoning in every single patient that comes to him as a doctor as well determining their course of treatment.

Clinical Reasoning and the Clinical Reasoning Pyramid

Defined concisely, Clinical Reasoning is Logical thinking, with sequential defendable conclusions, using patient derived information. Thus, the answers to the mandatory questions should facilitate clinical reasoning in such a way that the process will be similar to the building of a stable pyramid. The base of the pyramid will constitute the Symptoms, Other Aspects of History, Signs elicited and Bedside investigations, while the Apex of the pyramid should be the Differential Diagnosis. The Clinical Reasoning Pyramid is illustrated below.

Group Discussions

Learning medicine is enhanced by group discussions. In the basic medical sciences, it is advisable to form such groups around those who dissect together on the same cadaver or share the same desk at Physiology or Pathology laboratories while in the Clinical Sciences, this should be formed with other students who are in same clinical firm and study under the same consultant. Discussions should be held in the evenings, usually for about an hour to give time for all to attend to other matters. Topics should derive from those in practical sessions or lectures or clinical cases and should be led by a student who should have prepared to lead the discussion. To be effective and to avoid being unwieldy, such membership of a group should not exceed five persons.

Using the Library

A medical student should have access to several libraries which he should use effectively. These should include, the University Library, College/Faculty Library and Departmental Libraries. Some universities also have library facilities in the Clinical Students Hostels. The stock of books and Journals differ with increasing specialization in the direction of the departmental libraries. The Library should be used by the student as a place where he could assess books and journals, including their electronic versions, which he does not have and also as a quite environment where he can study. Only individual modes of study are allowed in a library; group discussions, lectures and others should be prohibited. The student should ensure that books borrowed from the library are returned on or before the due dates so as to allow others the opportunity to borrow the same book, should they so wish.

Seeing Medical Procedures Performed.

The student must seek to see as many medical procedures as possible performed during the course of his training in the College/Faculty even when he is not able to participate in them. During his training in the basic medical sciences, the student should watch anatomical dissections and laboratory bench work in physiology, biochemistry and pharmacology. In particular, he should attend autopsy sessions where clinico-pathological sessions are held and symptoms and physical signs correlated with organ pathology and general ill health. Seeing medical procedures performed is even more important during the student’s course of study in the clinical subjects. Of particular reference here is that of surgical operations which the student must make every effort to see, even if he would have to go to departments in which he was not having his clinical posting as of the time. Watching procedures enhance assimilation while reading up the same subject material. Furthermore, seeing is a prelude to doing, which is the ultimate bench mark of the clinical training process.

A medical student assisting in a surgical operation

Doing Medical Procedures by yourself

The student should be able to carry out some medical procedures by himself, again under supervision, initially. This should be so because carrying out a procedure is the surest way of ensuring that one can execute that action if and when it may be demanded of him. In this respect, a student should, for example, be able to check and record the blood pressure of a patient, set up an intravenous line, as well as assist the surgeon, in many common surgical operations, such as repair of hernia, appendicectomy, caesarean section, and many others. So important is this method of learning that departments should demand a documentation of all the procedures a student had carried out, witnessed and assisted with, while in the department.

It is by these diverse and often complex methods of studies that the student of medicine should acquire the knowledge and expertise that are expected of him and as defined in the objectives of the curriculum of his university. The onus should not only be on the student but also on the trainee who should ensure that the student is sufficiently guided and motivated to study in the appropriate ways that would yield the anticipated results upon graduation.

1. MEDICAL TECHNOLOGY

Specific Objectives:

Indicate the role of medical technology in medicine

Indicate how medical technology is used to aid effective teaching and learning in medicine.

To make a case for the possession of the laptop and constant access to the internet by every medical student

Technology, the practical application of knowledge, using tools, machines and other devices, to a particular human endeavor, is today, at the very core of all aspects of medicine – teaching, learning, prevention, diagnoses, cure of diseases, patient care, rehabilitation and much more. So strong is this presence of technology that a whole new field of study, known as Medical Technology now exists. While the immense benefits of technology in medicine and the quantum leap it has enabled medicine to achieve in the area of research and patient management are not in doubt, some concerns remain about its negative effect on patient’s privacy and erosion of the doctor-patient relationship.

In the same vein, technology’s contributions, especially Information Technology (IT) to teaching, learning and research – the enhancement of the process of enquiry; assemblage, packaging, delivery as well as retrieval of information; acquisition of knowledge; performance of skills as well as assessment and evaluation, have been overwhelming. But once again the ability of technology to corrode the teacher-student relationship, whereby the teacher motivates the student to work hard, challenges him to be innovative and mentors him to professionalism, may be at risk.

Discussion on the entire field of Medical Technology which will include issues like Nuclear Medicine for the treatment of malignant disease should be seen as being beyond the scope of this Module which is principally concerned with teaching and learning. So the balance of the discussion here will be on the way technology assists the teaching and learning process in Medicine.

Reference has already been made to a list of technological equipment, mastery of which the student has to acquire in the course of his clinical studies. They are many and differ from department to department. They should include the stethoscope, sphygmomanometer, thermometer, ophthalmoscope, auroscope, proctoscope and speculum.. Audio-visual aids like microphones and loud speakers as well as power points should be used as aids for the presentation of lectures Various Manikins and Simulators should also be commonly used in training of medical students such as manikin of the complete human body with transparencies for teaching and learning Human Anatomy, Pelvic manikins for studies in Gynaecology, Airway and Ambu Manikins for training in Anaesthesia, Blood Pressure Arms Simulators and many more. The use of these manikins for hands-on experience should enable the student to acquire some level of competence and familiarity with relevant structures before he actually carries out the medical procedure on live patients.

Stethoscope Manikin

In addition, there are some equipment which are very expensive and so it is not required of students to own them. Some are imaging machines that are used in the Radiology and Radiotherapy while others are in the various laboratories of Pathology Department. While the student is neither expected to own them nor have a mastery of their use, he is expected to know what they are used for and to have seen them in use before he graduates as a doctor. Such equipment include Blood Analyzer, Computerized Axial Tomography (CAT), the Mammogram Machine, linear Accelerator (Linac), Fluoroscope,

CAT Scan Machine

Audio-visual recording and play back of skills performance has been in use in medical schools abroad for a long time. However, their wide spread use in Africa has been limited by personnel and equipment requirements. Recently, the University of Port Harcourt Medical School, with part funding from the MacArthur Foundation of Chicago, has adapted advanced digital technology for use in a Clinical Clerking Skills laboratory. This is a Digital Video Image Capture Facility for Learning and Assessment of all psychomotor skills in medicine and other performance-skill-intensive professions. A learner uses a video model of any chosen skill [where available] to study the performance of the skill until sufficiently proficient and mentally ready to attempt its practice on live patients.

But there is probably no other place in which technology has made it greatest contribution to teaching and learning than in the area of Internet Access with its instant global reach to information on virtually all topics and issues in medicine. In addition, all reputable Journals and other means of disseminating information in medicine are available on line and should be accessed via the internet – some require subscription for access. Every medical student should therefore be encouraged to own a laptop or other similar device like the iPad for information storage and retrieval, including photographs, during lectures, group discussions, seminars, and conferences. In addition the institution should make it possible for the student to have unhindered access to the internet to enable him read up any issue whatsoever in medicine.

1. EXAMINATION OF THE MEDICAL STUDENT

Specific Objectives:

To ascertain that regular periodic examinations are means of confirming that objectives of teaching and learning process are being met

To offer Modular Professional Examination as means of examination of medical students

To lay down Exit Conditions
To indicate time lines for examinations in medicine

An important way of ensuring that the objectives of the teaching and learning process are being attained by the student is to examine him periodically. In Medicine, this should be done through

Modular Professional Examinations of the Parts I,II,III & IV Programmes
Laying down Exit Conditions

Modular Professional Examinations of the Parts I, II, III & IV Programmes [ No re-sit exams covered ].

1. The Training and Examinations should remain in the modular form of Parts I, II, III & IV Programmes format, each programme retaining its Content but with realistic Context Placing of specific learning Areas. The details of each Part should be specified in Curriculum content.

2. Part I should remain as a single training and examination module while each of Parts II, III & IV should be split into A & B [ theoretical and practical/clinical exposure, respectively] components, pass in A being required to progress to B postings. Without passing all the components of Part IIA at one sitting, trainees cannot progress to Part IIB postings. Same applies to Part III & Part IV.

3. No module should suffer training exposure neglect because of re-sit examinations while all Orphan courses should be assessed as parts of a barrier examination.

4. Those who fail any Part should repeat the entire posting and represent themselves for the next examination, progressing at their pace without causing system drag. This is similar to the situation in other University degree programmes where a failed course is carried over [repeated] and graduation period extended.

Exit Conditions

Screening at Part I should be stringent. Failure of 3 subjects at first attempt should attract withdrawal from Medical School. Failure of two out of the three subjects should attract repeat of the entire training and examination. Failure of only one of three subjects should attract repeating training in that subject and presenting in the next Part I examination [6 monthly]. Three attempts at the training and examination of each Part should be the maximum allowed.

	OVERALL PROGRAMME TIME LINE AND SUBJECTS/AREAS TO BE EXAMINED
PROGRAMME		MONTHS	WEEKS	SUBJECTS TO BE EXAMINED	No.
PART I		18	72	Orphaned Subjects, Anatomy, Biochemistry and Physiology	4
PART IIA		6	23		1
PART IIB		6	25		2
PART IIIA		6	24		2
PART IIIB		6	24		2
PART IVA		6	24		3
ELECTIVE PERIOD		2	8		0
PART IVB		6	24		3
OVERALL DURATION

Orphaned subjects like Ethics, Pass in these not required for continuation

1. HOUSEMANSHIP

Specific Objective:

To confirm the one year Housemanship as part of the teaching and learning process in medicine.

At the successful completion of his studies in medicine, the newly qualified doctor is expected to undergo a one year period of greater supervision in clinical practice before being fully registered as a Medical Practitioner. This aspect of his studies is not under the auspices of the university as it is completely hospital- based. The Housemanship year is compulsory. The doctor should normally undertake a three monthly rotation in the Departments of Internal Medicine, Surgery, Obstetrics and Gynaecology and Paediatrics and Child Health. To be able to do this, he needs a Temporary Registration from the Medical Council in the country. The Housemanship training is carried out under the supervision of Consultants working in hospitals that are approved by Council to undertake such assignments. These consultants should sign off the candidate and censor him if his performance was unsatisfactory. On completion, the candidate should present himself to the Medical Council for Full Registration as a medical practitioner.

The one-year housemanship can be carried out in a hospital other than the one in which the candidate had his clinical training as a student, within or outside the country where he studied. Such a hospital does not have to be a “Teaching Hospital” except that it has to have been approved for the training of pre registration House Officers by the Medical Council. During the final aspects of the training of the doctor, he should be made to be aware of these statutory provisions as it is his responsibility to seek for placement in a hospital of his choice for the housemanship.

1. ADDITIONAL INSTITUTIONAL RESPONSIBILITIES

Specific Objective:

To confirm the place of staff development as an important tool for enhancing effective teaching and learning in medicine.

In addition to the responsibility of providing Facilities and Staffing, the University and its medical school has the responsibility of Educational Development of its Academic Staff as well as regular Monitoring and Evaluation of Trainees and Trainers’ Progress. The maintenance of the accreditation status of the institution, in line with extant demands of training and minimum standards should always be top priority in the institutional goals.

Academic staff themselves should take some responsibility for their own self development by carrying out relevant and meaningful research and publishing them in respected Journals, locally and internationally. In the absence of an active staff development policy, academics run out of ideas on what to teach and so they recycle old and outdated information to the detriment of their students.

1. ROLE OF REGULATORY BODIES

Specific Objectives:

Indicate the role of regulatory bodies on the teaching and learning process in medicine

Guide the student on his relationship with these regulatory bodies

Indicate steps for registration as a medical practitioner

Medical education has the privilege of having two regulatory bodies that are statutorily established in most African countries; i.e. the universities regulatory body [National Universities Commission in Nigeria (NUC), Higher Education Council in Ghana, and Commission on Higher Education in South Africa] and the professional medical regulatory body [Medical and Dental Council of Nigeria (MDCN), Ghana Medical and Dental Council, and Health Professions Council of South Africa]. Whereas the University Commissions regulate the academic content of medical education by setting Minimum Academic Standards and ipso facto, the award of degrees by university senates, the professional medical councils are concerned with the professional aspect of the training of doctors. They license, register and regulate the professional activities of all qualified doctors who seek to practise in the country and censor such doctors when they engage in malpractices. However, the line of demarcation in the functions of the two organs may be blurred as is shown by a recent controversy in Nigeria between the MDCN and the NUC regarding an order given by the former to some medical schools in the country to stop all further admission of students until certain conditions are met, without clearance from the latter..These organs of government should ensure Quality Assurance in the academic content of curriculum, Quality Assurance in professional competence of practitioners and maintenance of minimum standards and benchmarks through periodic Accreditation, Monitoring, Evaluation and Visitation of Universities, the Faculty/Colleges and Teaching Hospitals in which the students train..

A trainee medical student should be made to be aware of his responsibilities to the medical regulatory body in his country. He should know that he would use the degree certificate awarded to him by the university at the successful completion of his studies to register with the medical registration body of that country to obtain a license which would authorize him to practice, first as a pre registration House Officer, and then, later, as a fully registered medical doctor.. He should know that whereas he needs the former certificate to obtain the latter one, he cannot practise medicine with the former one alone.

1. CONTINUING SELF EDUCATION

Specific Objectives:

To situate continuing self education as a key component in medical education

To give guidance on how to achieve continuing self education

An important objective of medical education is that it should produce a graduate who takes responsibility for his own continuing self education. The doctor should do this to enable him keep abreast with new knowledge in his discipline, changing patterns of disease, their extant management as well as advances in medical technology. It is the responsibility of his trainers to inculcate this idea of continuing self education into his mind during the course of his training. Several avenues are open to the doctor to achieve this. They include

Reading new books and medical journals in the profession. The doctor should establish avenues whereby he is informed of new books which have been published in his area of interest since he passed out of Medical College. Furthermore, he should subscribe to some journals and other forms of medical literature so as to be constantly abreast with reports and research findings in his field.
Attending conferences. For every doctor, there should be several conferences held within and outside his country of practice which should have enough scientific and professional content as to be of educational value to him. The doctor should identify a few of these and attend them regularly. Furthermore, he should make sensible and useful contributions at these conferences by commenting on presentations and making presentations himself. This way, not only does the doctor learn but he is known by his peers and respected as one who contributes to the body of knowledge of the profession.
Doing research and publishing one’s research findings. All doctors should have a mind of scientific enquiry which should enable them to keep accurate records of their professional activities – the patients that they see, their diagnoses, treatment and outcome. With modern technology such as the laptop, such recording keeping should be easy. Review and publication of such data over a ten or twenty year period should contain interesting information which others would want to have. Research as such, does not need to be highfaluting and does not necessarily have to be based in a university.

1. Professional Association

Specific Objectives:

To draw attention to the need for doctors to belong to professional association

Indicate the benefits of belonging to Professional Associations

The medical profession in Africa has several professional associations at different levels – continental, country, sections of country and city. These associations are either generic (for all doctors, like the Zimbabwean Medical Association) or subject specific (for doctors who had trained in a particular field like the Society of Obstetricians and Gynaecololgists of Libya). Some exist even at the Medical Students level and as a medical student, I recall that a classmate of mine was the Vice President of the African Medical Student Association at that time.

Doctors should join professional associations and relate to one another professionally as is indicated in the “Hippocratic Oath” which states, inter alia, that “My colleagues shall be my brothers”. In addition, members of such professional associations sometimes receive rebates for purchase of airline tickets, paying for hotel rooms as well as other perquisites. Such professional fora also serve as platforms for “trade union activities” for bargaining for better conditions of service with employers. The Annual Conferences which many Professional Medical Associations hold are important source of continuing medical education.

Again it is the responsibility of his trainers to draw the attention of the would-be medical graduate to the need to join some Professional Associations upon graduation.

15.18 North-South Collaboration

Specific Objectives:

To give guidance on how to bring about collaboration between the various countries in Africa to collaborate on the training of the doctor.
To indicate advantages of such a collaboration.

An important way of encouraging collaboration between universities in various African countries is to standardize matriculation requirement, duration of courses and curricula contents as is being done through these Guide to Teaching and Learning Modules. Once these are done and accepted widely, it should be possible and easy for a student to move from one university to another of his choice, at well defined periods in his learning. These periods are:

After the premedical training programme
After the basic medical science programme
At the end of his formal training to do his Housemanship in an affiliate hospital of another university.

In the same vein, teachers can establish collaborative research projects amongst themselves on issues that would attract funding to their various universities. Donor Agencies, many of which are currently operating in Africa, will no doubt be willing to support such ventures that increase the mobility of staff and students.

Apart from encouraging social cohesion and understanding, such trans-border education will more readily address issues that are of common concern to Africans. Universities would also be in a position to share their scarce resources in the training of medical student, especially in the area of the use of technology in teaching and learning.

15.`19Conclusion

Module 15 has dealt exclusively with teaching and learning within the programme that trains a medical doctor since it is the one that is most sought after by students who apply to a College or Faculty of Medical Sciences in a University in Africa. The course of study is complex and arduous, to learn and to teach and demands commitment and hard work, including the application of modern technology, from both teachers and learners. The curriculum that should be designed to achieve the objective of training the doctor should be challenging and one that is well-articulated and structured with realistic time lines for the completion of various aspects of the programme and for assessment of the trainees. When correctly applied and executed, training with such a curriculum should produce a well-rounded and proficient physician, steep in professionalism and equipped with the knowledge and skills required to prevent ill health and bring succor to the sick.

Teaching such a graduate should be seen as a privilege and honour. Taken seriously and properly done, teaching medical students is one of the most exciting, gratifying and rewarding career one can ever embark upon especially as the teacher watches his students become responsible physicians and academics who are of tremendous service to the community. I have found it so. I hope my colleagues all over Africa do too.

June, 2011

Emeritus Professor

Guide To Effective Teaching And Learning In Africa

No. 1 Arochukwu Street

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