Analysing Undergraduate Medical Curricula: Experience from a Saudi Medical College

Introduction

Curriculum is defined as “the statement of the intended aims and objectives, content, experiences, outcomes, and processes of an educational programme, including the following: a description of the training structure, a description of expected methods of learning, teaching, feedback, and supervision” [1]. Additionally,

a curriculum analysis refers to an effort to tease a curriculum separately into its parts. To analyse those parts and the way they fit together to make a whole, to recognize the beliefs and ideas to which the designers were dedicated and which either explicitly or implicitly shaped the curriculum, and to examine the implications of these commitments and beliefs for the quality of the educational experience. [2]

In other words, the process of analysis examines the curriculum from different approaches. Analysis is important, as areas of strength or weakness in the implemented curriculum are not always apparent to curriculum designers, faculty, or students [3].

Different tools are used in curriculum analysis [2]. Among these tools is Harden’s ten questions framework for curriculum analysis, which was developed and proposed by Harden at Dundee University in Scotland in 1986 [4]. This tool has been utilized in several universities worldwide due to its high validity and reliability [5], [6] .

Qassim University College of Medicine (QUCOM) is the first medical school in the Kingdom of Saudi Arabia (KSA) to adopt the problem-based learning (PBL) approach as its prime educational strategy [7]. The college started providing a hybrid PBL and community-oriented medical education in 2001, and the curriculum of the college mainly follows the student-centred, problem-solving, integrated, community-based, elective, and systematic (SPICES) approach to curriculum design [8]. QUCOM was recognized by the World Federation of Medical Education (WFME) in 2014 and by the National Centre of Academic Assessment and Accreditation (NCAAA) in 2016.

This study aimed to analyse the curriculum of QUCOM by exploring its strengths, weaknesses, and areas for improvement and to share an analysis of medical education in the Saudi context.

Methods

As part of a curriculum reform, QUCOM performed a curriculum analysis in April 2018. In this study, a qualitative descriptive study was used based on analysis of the college’s documents from 2001 to 2018. The QUCOM curriculum was analysed using Harden’s ten questions framework for curriculum development (Table 1). Thematic analysis was used to categorise the findings of the analysis resulting from Harden’s ten questions framework.

To ensure the validity of the obtained data, the main curriculum documents were analysed along with the student manual, programme and courses specifications, assessments regulations, previous self-study reports, reports of external evaluators and accreditors from WFME and NCAAA, and previous published studies from the college’s faculty and students.

Results

The results of the present study are presented following the order of Harden’s ten questions as listed in Table 1.

Question 1: What are the needs about the product of the training programme?

The curriculum was designed to meet the national requirements for qualified Saudi physicians, to reduce the country’s dependence on expatriate physicians [9], and to improve the physician-to-patient ratio, thus complying with the Strategic Plan for Higher Health Education of the KSA [10]. Curriculum designers adopted a multi-faceted approach to explore problem identification and needs assessment. The needs assessment was performed using the Wisemen approach and Delphi technique and considered community needs and expectations from medical graduates. The obtained data were reviewed in light of more than 25 undergraduate medical curricula at national, regional, and international levels. After this assessment and review, the curriculum was developed.

Question 2: What are the aims and objectives?

This curriculum aimed to graduate physicians capable of safely serving their community and continuing life-long learning and self-guided professional development. The curriculum objectives covered the knowledge, skills, and attitudes of the graduates; these objectives are shown in Table 2 [7], [11].

Question 3: What content should be included?

The current QUCOM curriculum was built on seven components, shown in Table 3: knowledge, patient interaction skills, clinical reasoning skills, life-long learning skills, research skills, communication and presentation skills, and teamwork skills.

Question 4: How should the content be organized?

The QUCOM curriculum was comprised of 35 medical courses in addition to six social and cultural courses. These courses were organised in three phases, as follows (Figure 1):

1. Phase 1 was comprised of a preparatory year programme, in which students were exposed to essential learning skills, communication skills, and medical ethics. In addition, the students’ English language skills were improved during this time.

1. Phase 2 was composed of three stages that students were sequentially exposed to:Introductory, contextual courses about the fundamentals of the human body and disease processes.

1. Trans-disciplinary body systems courses in which each body system was examined in both normal and disease circumstances. In parallel, students were exposed to longitudinal courses exploring health and disease in the community and providing clinical skills training in a controlled atmosphere.

1. A course targeting the integration and inter-relations of different body systems with a parallel skills course in which students met with patients under strict supervision.

1. Phase 3 was the clerkship phase in which bed-side teaching and patient interactions through different rotations comprised the core of the learning processes. During the fifth year, after studying Internal Medicine and/or General Surgery, students were exposed to the Family Medicine and Emergency Medicine rotations to emphasize common medical problems in the community and situations requiring early intervention.

After successfully passing all courses of the programme, the students began their internship year, which included three rotations each in Internal Medicine, General Surgery, Paediatrics, and Obstetrics and Gynaecology, in addition to optional specialities.

Question 5: What educational strategies should be adopted?

QUCOM adopted the SPICES educational strategies model [8] with minor modifications. The analysed curriculum contained no elective courses, and all courses were compulsory. Figure 2 shows the evaluation of QUCOM’s educational strategies in relation to the SPICES model according to external reviewers.

Question 6: What teaching methods should be used?

A broad range of learning opportunities and learning methods were described in this curriculum. The analysis showed that these methods were fostering a student-centred learning approach and life-long learning and that they included effective guidance from the faculty (Table 4).

Question 7: How should the assessment be carried out?

The assessment strategy in the college included formative (assessment for learning) and summative (assessment of learning) components. A wide range of methods were utilized in this curriculum, including continuous assessment by the supervisor, logbooks, multiple-choice questions, problem-solving questions, objective-structured practical examinations (OSPE), objective-structured clinical examinations (OSCE), student presentations, and research projects. Additionally, QUCOM is the leading college in Saudi Arabia in the multi-institutional progress test (PT). From May 2012 to March 2018, 10 rounds of the PT have been conducted, with the participation of more than 25,000 students in 27 colleges of medicine.

Question 8: How should details of the curriculum be communicated?

The QUCOM curriculum details were communicated through the student manual, which included the course objectives, contents, teaching and learning methods, and assessment methods. In addition, an session was held at the beginning of each course in which the students were introduced to the course by the particular course coordinator. Additionally, all course materials were uploaded to the learning management system, and students were introduced to the college’s curriculum and educational approach through their introductory medical education course.

Question 9: What educational environment or climate should be fostered?

The present analysis showed that QUCOM exerted great efforts to establish a motivating learning environment through strong academic guidance and support, clear communication channels with faculty, and comfortable learning resources. In 2012, Al-Mohaimeed evaluated the learning environment of QUCOM using the Dundee Ready Educational Environment Measurement (DREEM) [12]. In his study, student perceptions toward QUCOM’s educational environment were positive; they expressed that the college was well organized, that the teaching was stimulating, and that the atmosphere was relaxed.

Question 10: How should the process be managed?

The preparatory year programme was managed by specific deanship under university supervision. During phases 2 and 3, the medical programme was managed by the QUCOM administration, the Dean and Vice Dean of Educational Affairs. The entire process was overseen by the Curriculum Committee. Phase coordinators, course committees, and course organizers were responsible for programme provision at relevant levels (Figure 3). The course committees and course organizers were responsible for communicating the detailed timetable and the implementation of specified courses. Phase coordinators were responsible for monitoring the curriculum implementation in the trans-disciplinary body system courses and the clerkship phase, and they were supervised by the Vice Dean for Educational Affairs. Major curriculum modifications were proposed by the Curriculum Committee and were subject to the approval of the QUCOM Council and, eventually, the University Council.

Discussion

Curriculum analysis in medical education is a vital process for identifying areas of strengths and weaknesses in the implemented curriculum that are not always apparent to curriculum designers, faculty, or students [2]. This study aimed to analyse the curriculum of QUCOM and explore its strengths, weaknesses, and areas for improvement. The tools used in this analysis have been used worldwide and have shown high validity and reliability (5, 6) .

Analysis of the QUCOM curriculum showed that the current curriculum was designed to meet the national needs of the Saudi community. The methodology used in the curriculum design was scientific and followed the international standards (1, 13, 14). However, recent trends in medical education are moving toward competency-based medical education (15, 16). The SaudiMED competency-based framework was published in 2011 [17] and was approved as the national framework for medical education in Saudi Arabia [18]. By adopting this approach, the medical curriculum would fully address the needs of the community.

This present analysis also found that the existing curriculum aimed to graduate physicians capable of safely serving their community and continuing life-long learning and self-directed professional development. While the current curriculum map (Figure 1) did not specify how infection control, patient safety, or professionalism were learnt, analysis of other curriculum documents showed that these tenants were incorporated as integral parts of different courses. A growing body of literature has suggested increasing the incorporation of these competencies into undergraduate medical curricula [19]–[22]. Therefore, these tenants should be more apparent and carry more weight in the QUCOM curriculum.

Training in research was also suboptimal in the current curriculum, as it was a part of health and illness courses. Undergraduate medical students should be trained in research in different ways, including research methodology courses, student research projects, and journal clubs [23], [24]. A standalone course for research methods should exist, followed by real practice, as an integral part of the curriculum. This was also recommended by QUCOM students in a previous study [25].

The SPICES model was well represented in the QUCOM curriculum, and the instructional methods used in the college were nearly all student-centred. However, a teacher-centred approach still existed in the curriculum. Great efforts were exerted by the college to improve the instructional methods through a faculty development programme, as well as through introducing new teaching methods, such as a flipped classroom. Flipped classrooms have been shown to be effective for undergraduate medical education [26], [27].

Furthermore, the current study revealed the systematic and horizontal and vertical integration of the curriculum. As mentioned, there were no elective courses. Studies have shown that elective courses in undergraduate medical education provide unique opportunities for students to design and organize individualized educational experiences [28], [29]. The introduction of elective and optional courses should be considered in the reform process.

The current analysis revealed that training in community settings represented almost 10% of the entire curriculum. This was markedly low compared to other colleges in the region adopting community-based medical education, such as Faculty of Medicine Gezira University in Sudan and Faculty of Medicine of Suez Canal University in Egypt (25% and 20%, respectively) [30], [31]. Increasing the weight of community-based training is a main component of the SaudiMED competency framework [17].

The current analysis of the QUCOM curriculum indicated that it was built on seven objectives, including knowledge, patient interaction skills, clinical reasoning skills, life-long learning skills, research skills, communication and presentation skills, and teamwork skills. These competencies were in agreement with international competency frameworks worldwide, as well as the SaudiMED framework [18], [32]–[34].

The current analysis also revealed that the curriculum used both formative and summative assessment with a variety of assessment methods targeting all intended programme learning outcomes. However, the study also found that there was no exit exam at the end of the curriculum. The use of an exit exam is considered a part of quality assurance and was recommended by accreditors from the WFME and NCAAA. Recent studies have shown the significance of incorporating an exit exam for undergraduate medical education [35], [36].

One strength of this curriculum was the presence of the PT. QUCOM is the leading college in the region in designing and implementing the multi-intuitional PT. More than 25,000 students from 27 colleges have sat for this test through its 10 rounds from 2012 to 2018.

The analysis also revealed positive learning environment. The learning environment of QUCOM, as shown by Al-Mohaimeed’s study in 2012, was positive compared to national and international colleges of medicine [12].

This current study had several strengths, including the method with which the study examined the curriculum and other related documents beginning with the establishment of QUCOM. Moreover, it included previous self-study reports and feedback from external evaluators and accreditors, providing a sort of triangulation of the obtained data. However, some limitations also existed, as the current study depended mainly on existing documents. Therefore, further qualitative and quantitative studies are needed.

Acknowledgements

This work would not have been possible without the support of the Medical Education Department and the steering committee of the curriculum review.

References:

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Table 1: Ten questions to be asked when planning a course or a curriculum [4]

What are the needs about the product of the training programme

What are the aims and objectives?

What content should be included?

How should the content be organized?

What educational strategies should be adopted?

What teaching methods should be used?

How should assessment be carried out?

How should details of the curriculum be communicated?

What educational environment or climate should be fostered?

How should the process be managed?

Table (2) learning Objectives of QUCOM

Utilize his skills in information management effectively to retrieve relevant information, analyze it critically, and apply it to the solution of clinical/health problems in a scientific reasoning manner

Use an evidence-based approach to apply the most effective and up-to-date knowledge, skills, values, and attitudes in his medical practice and in his pursuit of postgraduate studies and life-long learning

Identify, diagnose, evaluate and manage common or serious health problems competently in individual patients, families, and the community, with special reference to Saudi Arabia, including provision of care for high-risk groups and follow-up measures

Educate and counsel patients and others (especially in the promotion of health and healthy life style, prevention of disease and securing consent) using effective communication skills

Observe medical ethics strictly in his practice, in the efficient and optimum use of available resources and their equitable allocation especially for minority, disadvantaged and high-risk groups

Help patients adjust to their condition when managing clinical problems with due consideration to the family and social environment, and the personal needs, limitations, and abilities of each patient;

Refer cases beyond his capacity whenever required and extend support, empathy, respect, and friendliness to the patient, family members and relatives without traversing the bounds of professionalism and medical ethics

Diagnose and manage common emergencies and deal with unfamiliar situations

Work effectively and harmoniously within a health team that includes physicians, other health and health-related personnel, and community members or agencies

Participate in peer review activities and respond positively to constructive criticism

Act as a change agent and contribute to community development with special reference to the development and success of health care programs and health institutions

Conduct relevant health research to contribute to the solution of health problems and the evolution of medicine

Table (3) contents of QUCOM curriculum

Knowledge:

A comprehensive understanding of coherent manner normal structure and function of human body during the different stages of lifeAwareness of the various types of human diseases with their pathogenesis and clinical manifestations, and their impact on patient and communityPrinciples of management of the various human diseases

Patient encounter Skills

Appropriate professional communication with patients, and performance of physical examination and basic medical diagnostic and interventional procedures with consideration of patient safety as the core of the health care process

Clinical Reasoning Skills,

Interpretation of data obtained through patient encounter, its integration with medical knowledge from relevant sources and critically-evaluating it for evidence-based decision making regarding health of individuals and community.Development of management plans for health problems of the individuals and community.

Life-long learning skills

Empowering the potential for advancing personal learning and professional development through self-directed continuous medical education

Research Skills

Understanding the basic principles and steps of medical research, and apply relevant bio-statistical techniques in evidence based medical practice and research.

Communication and Presentation skills

Written and oral communication skills with colleagues, patients and other stakeholders of health care settings

Teamwork skills

Ethical and professional behavior in personal and professional relationships, effective participation in health care team, and exercise leadership when appropriate

Table (4) Instructional methods used in QUCOM Curriculum

Problem-based learning

Bed-side teaching

Self-directed learning

Case-discussion sessions

Interactive lecture

Simulation-based education

laboratory sessions

Students-led Seminar

Community based learning activities

Online discussion forums

Students assignments

Students research

Team-based learning

Evidence-Based Learning Sessions

Medical audit

Figure (1) Organisation of QUCOM curriculum (Curriculum Map)

Figure (2) Evaluation of QUCOM at SPICES continuum by external reviewers

Figure (3) QUCOM Organisational Curriculum Management