The system of medical education in Pakistan is undergoing a major crisis which needs urgent remedial measures. An in-depth analysis of the factors perpetuating this crisis is presented here. In this section, we will be discussing these factors such as outdated teaching methods, lack of research, ineffective assessment methods, poor curriculum design and substandard content delivery.
Outdated Teaching Methodology
In undergraduate and post graduate studies, the mainstay is standardized form of teaching. Delivering a lecture is considered as the optimum source of transferring education to the students with minimum interaction. It would not be exaggerated to say that the teacher comes and delivers a lecture, prepared straight out of the book and reads it to an uninterested audience day after day. Any interruption in the form of questions or comments is considered as highly disrespectful. Almost seventy five percent of the course content is taught through this mode. The first two years are spent in this form of routine whereas clinical rotations start from 3rd year. During clinical rounds, although there are patients, the preferred mode of teaching is still lecture. The highly busy educator will come, listen to two or three histories that the students have prepared, give a lecture on a relevant topic and leave. Even though concepts of situated learning can deeply engage and inspire a student, but the context is not utilized well by the educator due to his lack of knowledge of other teaching modalities. Sparapani & Perez (2015) argue that proponents of traditional teaching prefer the “order and stability” as opposed to “chaos and instability” in a classroom created by differential modes of instruction leading to complacence on the part of the educator and obstruction to learn on the part of the learner (p.83). It is unfortunate to see that “Education as transferring” and “Teaching as instructing” is still the major metaphor that would explain the teaching methodology with students being on the receiving end (Davis, Sumara, & Luce-Kapler, 2015).The attitude of educators is one that of ignorance, because having done a degree in the relevant subject, they consider that they are competent enough to teach a class. Most of the teachers have not gone through any formal teaching methodology course and this reflects in their status quo practices of didactic teaching. The senior the teacher is, the stronger is his attitude of ignorance of the current needs of the millennial learner. It can be well assumed that if an educator is unware of the theories of learning (Kaufmann & Mann, 2014; Hodges & Kuper, 2012), how will he ever shatter his bubble of ignorance and construct an environment to facilitate learning of his students? There is no definite process involved as far as teaching methodology is concerned and because the teaching is not linked to any theoretical framework, there is no thought process involved as to how to make it better or what objectives will be gained through a particular mode of teaching. Although all of these are serious deficiencies ready to ruin the learning potential of the student but what is alarming is that the educators have become so complacent that don’t feel the need to bring any change and there is no relevant authority in Pakistan that would evaluate the competencies of the teacher or hold them accountable. Once hired at a public medical college, the teachers have secured a lofty position till the age of retirement, whether they teach effectively, or they do not.
Even the students are conditioned to believe that only if they take the traditional lecture, they will be able to understand the topic. Although a popular dictum across all medical colleges is that “no one is going to teach here, you have to learn yourself”, but somebody needs to facilitate how that learning is to be done. Kaufmann and Mann, 2014, state self-directed learning as “evidence of higher levels of individual development” which also collaborates with Maslow’s hierarchy (p.17) but I would argue that this should come internally rather than coerced externally. The learner should be provided with basic knowledge and then should have the opportunity to develop his own deep understanding. Dewey (1938) in his ground-breaking book “Education and Experience” states that “any experience is mis-educative that has the effect of arresting or distorting the growth of further experience” (p.25). This holds true for the medical education as the students instead of becoming life-long learners or passionate about learning, eventually just end up in “economic utility mode” of learning; to pass exams and to earn well through the degrees attained (Sparapani & Perez, p.84, 2015). The result of this form of teaching is that the students are not being engaged and their learning is not being enhanced. The topic stays within the confines of the four walls of the classroom and has no relevance in their daily lives although these are matters of routine healthcare.
Substandard Content Delivery
Health Professions is one of the unique subjects where a lot of content is to be covered while keeping in mind the changing dynamics of healthcare professions. This requires the content to be delivered in effective ways for it to remain easy, relevant and understandable by the students. Technological advances such as online learning platforms, simulations, interactive learning applications, social media have taken the medical world by storm (Cheston, Flickinger & Chisolm,2013), but educators are still lagging behind to accept it in formal ways of teaching. They rely on Power point presentations for most of the content with pictures scanned from the textbook. Use of videos, animations or social media is almost nonexistent. They are stuck with the “presentational view” of content delivery which relies on the availability of selective images and text which although can generate interest of the student but does not provide opportunity to interact or create something new (Anderson, p.37). It is a pity to imagine that such an interesting field of medical education, where there is plethora of available resources to develop the concepts and inspire the learner, is only left to be studied through a textbook, view a presentation and the imagination of the learner. The content delivery is so boring that the only reason the students attend classes is to maintain attendance of that particular subject as it will be counted towards the final grade. The learner as well as the educators are aware of this fact and 10,000 hours of prescribed teaching along the 5-year teaching period are just wasted in this drudging manner.
The future of medical education has long been taken outside the realm of a classroom where online teaching courses, online simulation skill labs, mobile applications, gaming and interactive teaching interfaces are being introduced to create a powerful learning experience (Mehta, Hull, Young & Stoller, 2013; Gentry, Car, Car & Zary, 2016). The millennial using all these technologies in other aspects of life in the outside world and then coming to attend a power-point presentation in a classroom will not only feel disinterested but also disconnected. Keren-Kolb, 2013, argues that for a technology to be skillfully used for effective learning, it has to engage the learner by motivation and switching his role from a passive learner to an active one, enhance his learning by demonstrating it through unique means using the technology and extend his use of technology in his everyday life making him a lifelong learner i.e. “ the triple E framework” that the educators must keep in mind while planning activities. As the students are constantly using their cell phones, the educators can manipulate the potential through the principles of triple-E and provide educational content through these means. Social media is increasingly being recognized as a great tool for medical education as content from all over the world can be viewed through Twitter, Facebook, Educational blogs etc. Although e-learning and use of social media is backed by learning theories (Flynn, Jalali & Moreau, 2015) but these sources of knowledge are still considered as disruptive and shunned by the medical educators in Pakistan. During the entire 5-year period, the only time the student actually engages with the content is when the exams are due which is a gross failure on the part of the educator. Anderson argues that the modern education has to “support a journey towards capacity rather than competence” (p.42) so that the learners can deal with the challenges of the future. This current mode of medical education is nowhere near achieving this capacity in its students.
Poor Curriculum Design
The MBBS curriculum, jointly prepared by the Pakistan Medical and Dental Council (PMDC) and Higher Education Commission, is a 120-page document, to be followed by all the medical colleges in the country. It is considered to be the guiding principle on which the curriculum of each medical college is to be based. As very few medical colleges have a department of medical education so the curriculum is implemented as it is with no changes. Going through the principles of curriculum development (Thomas & Kern, 2015) and then revisiting the PMDC curriculum, I found it to be rudimentary at best. The curriculum is deemed to be all the chapters of a text book in a sequential order. There is no working on why a specific topic should be included or excluded. Although medical education is one of the most complex programs, it is still presented in a narrative form with only emphasis on the learning objectives. How these learning objectives were derived or how are they to be achieved is not specified in the curriculum. Majority of the educators are unaware of critical concepts of Bloom’s taxonomy or Maslow’s hierarchy of needs so although the blanket term of “knowing the content” is used throughout the curriculum, it is not defined at what level. A general heading of teaching strategies is mentioned but does not specify when to be applied. The deplorable state is that its implementation and evaluation is not monitored so it is on the discretion of the educator to leave a particular topic or stress excessively. There is no accountability of completing the whole curriculum and much is left to the student to study himself. The topics deemed important from examination point of view are covered in detail whereas others, which might be more important in local or public health context, are left by the educators. Such discrepancies in developing and following the curriculum are in stark comparison to the process of curriculum design and development in the developed world of medical education (Thomas & Kern, 2015; Prideaux, 2003).
Lack of Research
There is hardly any research that is taking place in the medical colleges although one expects it to be the hub of new ideas. This is partly due to the “follower mindset” of the educators rather than the “innovator”. One would argue that a country producing 9000 doctors annually should be at the forefront of research regarding educating health professionals but sadly that is not the case. The educators themselves are naïve of the research culture and cannot supervise or support the students in the process. There is no mandatory requirement to submit a research paper as part of the undergraduate curriculum so the students although interested, get demotivated by the lack of support they receive in this regard. As the educators are not identifying needs of the students, developing curriculum, improving teaching methodology or working on new methods of assessments, it is also not deemed as a significant exercise to spend time in research.
Ineffective Assessment Methods
One of the key issues plaguing the undergraduate medical education is the ineffective methods of assessments. The programs are based on summative assessment at the end of the year which will render the student successful or otherwise. As the formative assessment throughout the year does not carry much weightage, students tend to work harder towards the end of the year rather than whole year round. The educators are often unaware of what to assess as their assessments are not based on any theoretical framework such as Bloom’s taxonomy or Miller’s hierarchy (Downing & Yudkowsky, p.4).The second issue is that they don’t know how to assess the content effectively as the strengths and weaknesses of each type of assessment such as multiple choice questions, short assay question, modified essay question, true/false, simulation etc. are not known in detail to them (Epstein, 2007; Al-Wardy, 2010) Rote learning is still widely appreciated over understanding the content and is considered as hallmark of intelligence and hard work. Epstein, 2007, suggests that multiple methods of assessments can overcome the weaknesses of individual assessment and provide richer data to analyze a student’s progress (p.388). The majority of colleges follow multiple choice questions and short essay questions as their preferred mode of assessment for theory whereas objective structured practical examination (OSPE) and an oral exam is conducted for practical procedures. The construction of these assessment modes is not understood by most of the educators resulting in ineffective assessment methods. According to Van der Vleuten’s five criteria of utility of a particular assessment method (cited by Epstein, 2007, p.388), the assessments conducted in Pakistani medical colleges are not reliable, lack validity and do not have a significant impact on future learning.