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Curriculum Goals and Learning Outcomes of Medical Ethics and Professionalism Courses in Undergraduate Medical Curriculum of Pakistan

Arslaan Javaeed[1]

Institution: 1. University of Ottawa
Corresponding Author: Dr Arslaan Javaeed ([email protected])
Categories: Curriculum Planning, Educational Strategies, Professionalism/Ethics, Learning Outcomes/Competency, Undergraduate/Graduate
Published Date: 06/06/2019

Abstract

The objective of this paper is to develop curriculum goals and learning outcomes of medical ethics and professionalism courses in undergraduate medical curriculum of Pakistan which is the next step after general needs assessment and targeted needs assessment. The Medical Ethics and Professionalism curriculum has been designed to be implemented at undergraduate level of medical education. The logic model presented in the paper may act as a blueprint for educators developing a Medical Ethics and Professionalism course for teaching guiding principles of practice of medicine to prospective doctors. The logic model highlights the elements e.g. human, financial resources and PMDC’s support, impact of short terms and long-term outcomes for learners, educators and patients that should be taken into account at every step of implementation.

Keywords: Curriculum planning; medical ethics; professionalism; goals; learning outcomes

Introduction

In Pakistan, once medical students complete their MBBS they start a one-year clinical internship also known as a house-job, which is required to get a license to practice. The duration of MBBS is five years while house-job is for one year. During the first two years of medical school, they are taught Anatomy, Physiology, and Biochemistry. In the third year, they study Pharmacology, Forensic medicine, and General Pathology and Microbiology. Special Pathology (Organ System Pathology), Community Medicine, Otolaryngology, and Ophthalmology are taught in 4thyear whereas in the final year of medical school they learn about Medicine, Surgery, Obstetrics/Gynecology, and Pediatrics. The medical students in Pakistan start their clinical rotations from 3rdyear. They are posted to different clinical disciplines (e.g. Gynecology, Surgery, Medicine, Ophthalmology, etc.). After graduation, they start their house-job in which they have consecutive on-call duties and maximum interactions with the patients and their families. It is in 3rdyear where interaction with the patients and their families start and I would say it is that time from where they might show unethical and unprofessional behavior owing to no concept of medical ethics and professionalism. Medical ethics and professionalism are left onto the personal opinions and views of the faculty of that department, as there is no concept of learning medical ethics and professionalism.  The MBBS Curriculum developed jointly by Pakistan Medical and Dental Council (PMDC) and Higher Education Commission (HEC) of Pakistan (PMDC, 2018)does not address the needs of medical ethics and professionalism unlike other developed countries such as Canada, USA, and UK where this course is an integral part of the undergraduate curriculum (Johnston and Mok, 2015a). Therefore, throughout the journey of becoming a practicing physician or even a consultant, this critical aspect remains deficient, which becomes the root cause of many avoidable ethical issues. 

During the last decade, social media has taken our world by storm and medical students and physicians face ethical challenges concerning professionalism and doctor-patient relationship more than ever (Asghari, Samadi and Rashidian, 2013). The aim of incorporating medical ethics and professionalism course in MBBS curriculum is to fill this gap by increasing the ability of prospective doctors to recognize, analyze, and respond to issues in medical ethics and professionalism.  This course will enable future doctors to behave according to the ethical principles by providing an overview of the major ethical issues that arise in the practice of medicine, medical education, and research. Moreover, research shows that medical students found the learning experience of medical ethics very useful and positive (Johnston and Mok, 2015b). This paper proposes curriculum goals and learning outcomes of medical ethics and professionalism courses in the Undergraduate Medical Curriculum of Pakistan. Ethical approval was not required for this research.

Assumptions

  1. The general needs assessment has been conducted, which emphasized the significance of incorporating medical ethics and professionalism in the undergraduate curriculum.  
     
  2. Following the six-step approach of the curriculum (Thomas et al., 2015), the next step after a general needs assessment was the targeted needs assessment. The targeted needs assessment was performed by obtaining systematic data collection through focus groups, interviews, and surveys of all the stakeholders.  
     
  3. PMDC and HEC have agreed to incorporate this course in the undergraduate medical curriculum.

Curriculum Goals

The third step in curriculum development is describing goals or objectives which is defined as an end towards which an effort is directed (Thomas et al., 2015). The intention of the “Medical Ethics & Professionalism” course  is to educate prospective doctors to choose the right course of action among available choices by recognizing ethical issues that may arise during the  patient care delivery (e.g. decision making, clinical judgement, patient’s privacy, confidentiality, breaking bad news, informed consent, use of social media, religion, culture, spirituality, gift acceptance, management of challenging patients and their family members, resources allocation, research with human subjects and conflict of interest) (Carrese et al., 2015). The specific goals of this curriculum are listed in Table 1.


Table 1: Medical Ethics & Professionalism Curriculum Goals

This curriculum aims…

1

To recognize common ethical issues likely to arise in medicine

2

To know ethical norms in medicine

3

To apply their knowledge and skills to anticipate ethical problems 

4

To handle ethical problems effectively

5

To understand and articulate the complexity of end-of-life issues

6

To understand the scope of medical students and physicians’ professional responsibilities

7

To adhere to professional ethics with consequential improvements in a doctor-patient relationship which can improve clinical outcomes

Learning Outcomes

The main goal of medical education is to train physicians who are capable of delivering quality health care leading to improved patient outcomes (Moreau and Eady, 2015). The significance of exploring subject matter to be learned in terms of intended learning outcomes is established. Learning outcomes can be defined as broad statements of what is achieved and assessed at the end of the course of study (Harden, 2002). The learning outcomes of the Medical Ethics and Professionalism curriculum are presented in Table 2.

Table 2: Medical Ethics & Professionalism Curriculum Learning Outcomes

By the end of this course, students will be able to

1

Comprehend the basis of responsibilities especially relevant ethical principles that will enable you to make the right decisions.

2

Recognize the skills needed to act professionally after making the right choices.

3

Applying the knowledge and skills appropriately in a given situation.

Educational Strategies

After defining the curriculum goals and determining the learning outcomes of Medical Ethics and Professionalism curriculum, the 4thstep of curriculum development i.e. Educational Strategies will be discussed which ensures the achievements of curricular objectives. The specific material to be included in the curriculum called as content and the way by which that material is presented or delivered is known as a method, are components of educational strategies.  Educational strategies are the heart of the curriculum and they provide the means by which curriculum objectives are achieved (Thomas et al., 2015).

To deliver this content, various educational strategies will be employed such as a combination of lectures, readings, small group discussions, large group discussions, submission of papers, problem-based learning, presentations, and audio-visual reviews aligned with the goals of the curriculum. This course will be delivered over five years. In the first two years of medical school, lectures will be delivered by the subject specialist and most general topics in Medical Ethics and Professionalism such as principles of ethics, informed consent, confidentiality, and research ethics will be presented in lectures. Students will be required to read selected readings from the selected journals and participate in discussions through Problem-based learning. In 3rdand 4thyears, facilitation of openness, role-models, and reflective writing strategies will be used to equip the students with knowledge and skills required to anticipate an ethical dilemma, analyze, and present a solution to the problematic situation involving ethics or professionalism. In the fifth year, ethical questions raised by the cases will be addressed using demonstration by the experts and role-play strategy for instance a student (acting as a physician) will demonstrate the skills of breaking the bad news to the fellow student (acting as the patient or the family of the patient) in the presence of a facilitator or a subject specialist and the performance will be recorded with the audio-visual equipment. The facilitator will then provide feedback to the student. Research papers and elective opportunities will be optional and available to those students who aspire to excel further in this field. The educational strategies aligned with the goals and learning outcomes are listed in Table 3.

Table 3: Medical Ethics & Professionalism Curriculum Content

1

Books

  1. Ethics and Professionalism: A Guide for the Physician Assistant 1st Edition by Barry Cassidy Ph.D. PA-C (Author), J. Dennis Blessing Ph.D. PA-C (Author)
  2. Case Files Medical Ethics and Professionalism by Eugene C. Toy (Author), Susan P. Raine (Author), Thomas I. Cochrane (Author)
  3. Professionalism and Ethics in Medicine A Study Guide for Physicians and Physicians-in-Training

2

Journals

  1. Canadian Journal of Bioethics
  2. American Journal of Bioethics
  3. Journal of Medical Ethics
  4. Journal of Clinical Research & Bioethics

3

Websites

  1. Society, the individual, and Medicine, https://www.med.uottawa.ca/sim/Data/Serv_Ethics_e.htm
  2. University of Toronto Joint Centre for Bioethics (JCB), http://jcb.utoronto.ca
  3. Bioethics.net, Where the World Finds Bioethics, http://www.bioethics.net
  4. National Institute of Health, Department of Bioethics, https://www.bioethics.nih.gov/home/index.shtml

Assessment Strategies

Standards for Educational and Psychological Testing defines assessment as any systematic method of securing information from tests and other sources, used to draw inferences about characteristics of people, objects, or program(American Educational Research Association, American Psychological Association and National Council on Measurement in Education, 2014). Miller’s pyramid is considered as a useful model of knowledge regarding health professions education assessments. There are four levels of Miller’s pyramid i.e. Knows (Knowledge), Knows How (Competence), Shows How (Performance), and Does (Action). The first two levels are concerned with knowledge and it will be tested through multiple choice questions, short answer questions, modified essay questions, script concordance test, matching items, and true & false items. For third and fourth level performance, assessment methods such as Objective Structured Practical Examination (OSPE), direct observation and video reviews will be used (Downing and Yudkowsky, 2009). The assessment strategies appropriate for the learning experiences are listed in Table 4.

Table 4: Medical Ethics & Professionalism Learning Outcomes, Educational Strategies & Assessment Strategies

Learning Outcome

Classification

Assessment Strategies

 

Educational Strategies

Upon completion of this curriculum, medical students will be able to

Cognitive

Affective

Psychomotor

Comprehend the basis of responsibilities especially, relevant ethical principles e.g.autonomy, nonmaleficence, beneficence, justice, etc., that will enable them to make the right choices 

 

 


       X


X

 

Multiple Choice Questions 

Short Answer Questions 

Modified Essay Questions 

Script Concordance Test 

Matching Items

True & False

 

Readings

Lectures

Discussions

Problem-based learning

Online learning resources 

Recognize the skills needed to act ethically after taking the right decisions.

 

 


      X


X

 

Multiple Choice Questions 

Short Answer Questions 

Modified Essay Questions 

Script Concordance Test 

Objective Structured Practical Examination 

Short Cases 

Long Cases

 

Readings

Lectures

Discussion

Problem-based learning

Online learning resources

Facilitation of openness

Role-models

Reflective writing

 

Applying the knowledge and skills appropriately in a given situation.

 


X

 

X

 

X

Objective Structured Clinical Examination

Direct Observation

Video Review

Standardized Oral Exam

Standardized Patient Exam 

 

Demonstration

Role-plays

Standardized Patients

Audio or visual review of skills


Programmatic assessment will be applied. There will be nine assessments over the course of five years. One assessment will be conducted at the end of the first year, and two assessments every six months onwards. As all assessment methods have limitations and not a single method can assess a student’s ability, therefore, each assessment moment will be considered as a single data point and at the end of five years, students will be declared pass or fail or awarded distinction based on their performances on all assessments. Feedback will be given at the end of each assessment to facilitate students in improving their knowledge and skills. The distinction, pass and fail criteria are listed in Table 5.

Table 5: Criteria for Distinction, Pass and Fail

Percentage (%)

Remarks

85 or above

Distinction

50 or above

Pass

Below 50

Fail

Conclusion

The Medical Ethics and Professionalism curriculum has been designed to be implemented at the undergraduate level of medical education. The logic model presented in Table 6 may act as a blueprint for educators developing a Medical Ethics and Professionalism course for teaching guiding principles of practice of medicine to prospective doctors. The logic model highlights the elements e.g. human, financial resources and PMDC’s support, the impact of short terms and long-term outcomes for learners, educators, and patients that should be taken into account at every step of implementation.

The curriculum focuses to educate prospective doctors to understand why a physician should act in one way rather than another. It involves reasoning behind believing why one course of action is better than another. Physicians are expected to counsel, explain and give reasons for the choices they make as doctors to their patients, patients’ families and to their colleagues. This curriculum empowers physicians to understand and respond to relevant medical issues.

Table 6: Medical Ethics and Professionalism Logic Model

Table 6: Medical Ethics and Professionalism Logic Model

Inputs

Activities

Outputs

Short-Term Outcomes

Long- Term Outcomes

Students

 

Educators

 

Lecture Hall

 

Discussion Rooms

 

Multimedia

 

Technical Support

 

Financial Resources

 

PMDC Support

Educators

Deliver lectures
 

Select readings from the journals
 

Develop learning activities
 

Facilitate problem-based learning
 

Conduct assessments

Educators

List of topics
 

Number of facilitators and educators
 

Numbers of hours for educational strategies
 

Number and types of assessments
 

Number of research papers

Educators

Improved teaching and research skills
 

Better understanding of effective pedagogies
 

Increased understanding of effective assessments strategies for the content

Educators

Improved career satisfaction
 

Successful implementation and establishment of Medical Ethics & Professionalism course in undergraduate medical curricula

Students

Participate in discussions

 

Attend lectures

 

Participate in Problem-based learning
 

Participate in assessments

Students

Course attendance

 

Communication with the facilitators and educators

 

Performance on assessments

Students/Doctors

Understanding of ethical norms in medicine
 

Ability to resolve an ethical issue
 

Demonstration of professional and ethical behavior

Students/Doctors

Increased job satisfaction
 

Improved mindfulness regarding ethical issues
 

Improved ability to resolve or prevent an ethical issue
 

Burn-out prevention due to stress level related to ethical issues
 

Minimizing litigation

Patients

Patient confidentiality
 

Improved ability to make right choices related to a specific treatment influenced by the patient-physician interaction

Patients

Improved patient safety and confidentiality

Improved patient outcomes

Increased patient satisfaction level


The curriculum focuses to educate prospective doctors to understand why a physician should act in one way rather than another. It involves reasoning behind believing why one course of action is better than another. Physicians are expected to counsel, explain and give reasons for the choices they make as doctors to their patients, patients’ families and to their colleagues. This curriculum empowers physicians to understand and respond to relevant medical issues.

Take Home Messages

Physicians are expected to counsel, explain and give reasons for the choices they make as doctors to their patients, patients’ families and to their colleagues. 

Notes On Contributors

Dr. Arslaan Javaeed wrote this paper as one of the assignments of the course "Curriculum Design for Health Professions Education", taken to fulfil the requirements of Masters in Health Profession Education (MHPE) from Faculty of Education, University of Ottawa, Canada.

(ORCID: https://orcid.org/0000-0002-8089-4221)

Acknowledgements

Thanks are due to Dr. Katherine Moreau for her guidance at every step of this paper.

Bibliography/References

American Educational Research Association, American Psychological Association and National Council on Measurement in Education (2014) Standards for educational and psychological testing. AERA.

Asghari, F., Samadi, A. and Rashidian, A. (2013) ‘Medical ethics course for undergraduate medical students: A needs assessment study’, Journal of Medical Ethics and History of Medicine. 2013; 6: 7.

Carrese, J. A., Malek, J., Watson, K., Lehmann, L. S., et al. (2015) ‘The Essential Role of Medical Ethics Education in Achieving Professionalism’, Academic Medicine, 90(6), pp. 744–752. https://doi.org/10.1097/ACM.0000000000000715

Downing, S. M. and Yudkowsky, R. (2009) Assessment in health professions education. Routledge.

Harden, R. M. (2002) ‘Learning outcomes and instructional objectives: is there a difference?’, Medical Teacher, 24(2), pp. 151–155. https://doi.org/10.1080/0142159022020687

Johnston, C. and Mok, J. (2015a) ‘How medical students learn ethics: an online log of their learning experiences’, Journal of Medical Ethics, 41(10), pp. 854–858. https://doi.org/10.1136/medethics-2015-102716

Johnston, C. and Mok, J. (2015b) ‘How medical students learn ethics: an online log of their learning experiences’, Journal of Medical Ethics, 41(10), pp. 854–858. https://doi.org/10.1136/medethics-2015-102716

Moreau, K. A. and Eady, K. (2015) ‘Connecting medical education to patient outcomes: The promise of contribution analysis’, Medical Teacher, 37(11), pp. 1060–1062. https://doi.org/10.3109/0142159X.2015.1060307

PMDC (2018) Curriculum of MBBS. Available at: http://www.pmdc.org.pk/LinkClick.aspx?fileticket=EKfBIOSDTkE%3D (Accessed: February 2018).

Thomas, P. A., Kern, D. E., Hughes, M. T. and Chen, B. Y. (2015) Curriculum development for medical education: A six-step approach. Johns Hopkins University Press.

Appendices

None.

Declarations

There are no conflicts of interest.
This has been published under Creative Commons "CC BY-SA 4.0" (https://creativecommons.org/licenses/by-sa/4.0/)

Ethics Statement

This was a review article and did not involve any human, human tissue or animal or animal tissue. Therefore, it did not require any ethical approval.

External Funding

This article has not had any External Funding

Reviews

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Ken Masters - (25/09/2019) Panel Member Icon
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The paper deals with an explanation of the process of developing curriculum goals and learning outcomes of medical ethics and professionalism courses in an undergraduate medical curriculum of Pakistan. The background information regarding the students’ experience is well explained, as is the process of developing the curriculum.

There are some things that I would like to see addressed:
• It would be useful if Thomas et al’s six steps could be summarised in the Introduction.
• I’m a little unclear as to where the activity in this paper fits into the process. I think, from what I can see, that it comes after the three identified areas in the “Assumptions”. If that is so, then it might be better to rename the “Assumptions” to indicate this (e.g. something like “Previous Work” or “Work Previously Performed”). That way, readers would not expect more detail about how the needs assessment was conducted, the focus groups, etc. Also, if any of that previous work has been written up and is publicly available, either as reports or papers, then references would be useful. If these are not available, then it would be useful to expand a little more on some of the details, just so the reader has assurance that the groundwork has been performed to a suitable standard.
• Table 6, and the description of it (in the first paragraph of the Conclusion) should be moved to the area before the Conclusion, as it introduces new information.
• The Conclusion is too brief, and needs some more information (The last paragraph of the Conclusion appears to have been duplicated.)
• The Take-Home Message is really far too brief, and needs some more information.

Minor
• There several language, punctuation and similar errors, and it would be a good idea for the paper to be carefully proof-read and corrected.
• Some inconsistencies in the writing, e.g. “In 3rd and 4th years” and then “In the fifth year”

Overall, a nice and succinct paper, needing some attention to detail.
Possible Conflict of Interest:

For transparency, I am an Associate Editor of MedEdPublish. However I have posted this review as a member of the review panel with relevant expertise and so this review represents a personal, not institutional, opinion.

Gary D. Rogers - (19/06/2019) Panel Member Icon
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Thank you for this interesting paper, which is an important starting point in the development of an ethics and professionalism curriculum for Pakistan. It is indeed concerning to learn that ethics, professionalism and interpersonal skills are not well developed in the current national MBBS curriculum for the country (though on following the link to the document, I do note that there are some very rudimentary ethical learning outcomes under the heading ‘Law in relation to medical men’ [presumably, they don’t apply to medical women!] in the general section on ‘Forensic Medicine and Toxicology’, under the heading ‘Medical ethics’ in the ‘Community Medicine’ section and as broad statements like ‘[d]emonstrate polite and gentle patient handling’ and ‘[u]phold medical ethics’ in the outcomes for particular clinical areas).

The author is to be applauded to beginning the process of developing a comprehensive approach to the development of both defined human capabilities and detailed ethical understandings for the national curriculum. There is still a great deal of work to be done though, and what is presented here needs a lot more development before it will be ready for implementation. The author says that ‘targeted needs assessment was performed by obtaining systematic data collection through focus groups, interviews, and surveys of all the stakeholders’ but hasn’t provided us with any detail of how these processes were undertaken. This makes it very difficult for the reader to make an assessment about the appropriateness of the methods.

The learning outcomes are also in need of further development as they don’t really cover what the author has recognised is needed and would be currently very difficult to design specific assessment for. It is very good to see that table 5 recognises the vital importance of all three Bloom domains in this area, but the mapping between learning outcomes and assessment methodologies, across the three domains, also still needs a lot of work to be implementable. Finally, it is very difficult to know what the numerical values provided in table 6 actually mean in terms of achievement of particular capabilities.

In summary, this paper represents important work towards a critically important aim, but it is only the first step in designing a valid practical and implementable curriculum. I would strongly encourage the author to partner with an experienced curriculum designer in this area to further develop this work into a comprehensive, culturally appropriate ethics and human capabilities curriculum, which, as he points out, is vitally important to the wellbeing of patients in Pakistan.
Rohini Ganjoo - (13/06/2019)
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No doubt this is an important topic and necessary in today's world. The logic model makes sense as all the stakeholders need to be involved as we push for a empathetic healthcare society. For the learning objectives I would add cultural sensitivity.