Rupa Singh Piyush Gupta Kuldeep Singh Shekhar Koirala

From the Department of Pediatrics, B.P. Koirala Institute of Health Sciences, Dharan, Nepal.
Reprint requests: Dr. Rupa Singh, Department of Pediatrics, B.P. Koirala Institute of Health Sciences, Chapa Camp, Dharan, Nepal.
 

B.P. Koirala Institute of Health Sciences (BPKIHS), an autonomous Institute established through an act of Nepalese Parliament in 1993 is a major step towards making Nepal self-reliant in the field of health care. The largest Nepal-India cooperation health project in Nepal so far, BPKIHS is envisaged as a nucleus of excellence in all aspects of health care deli very system at all levels and educating socially accountable physicians, nurses and allied health man- power. It will also cater to post graduate medical education and research so as to pro- vide specialists arid medical teachers to the country. Products of BPKIHS are expected to be a blend of academic excellence and conscientious commitment to the cause of positive health(1).

BPKIHS is a residential university situated over a sprawling 699 acre campus with lush green vegetation at the foothill town of Dharan in Eastern Nepal. It has a functional 210 bedded hospital, which will be eventually upgraded to a 500 bed facility. Forty students are now being enrolled every' year to the MBBS programme after a rigorous selection. The faculty comprises of eminent medical specialists both from Nepal and India.

Development of a Need Based Curriculum

Need based education in Nepal stems from the fact that this country is' one of the least developed and its health problems are commensurate with that of low level of social development and poor economy(2). The founders of this Institute went through an evaluation of the existing medical systems, perceptions of the professionals and common people before deciding on the philosophy of the Institute. The broad objectives laid down for the institute were translated into action plan at an International Conference on Medical Education held in December 1993 at Dharan, participated in by eminent medical educationalists and, health services leaders from Nepal, India and WHO consultants. The MBBS curriculum of BPKIHS is ultimate outcome of this workshop and builds on the strength of old by adding forceful and validated new thoughts(3).

The principal objective of medical education is to produce doctors who possess clinical competence of a high order, have a sound community orientation, are proficient in communication skills and demonstrate attitudes befitting a health, professional. There are more than 1350 medical schools in the world ( over 135 in India). Except for a few of them, the rest follow subject based, teacher centered, theory laden, examination driven and specialization, oriented programs going on for decades without a review(4).

BPKIHS curriculum is designed to be need based, student centered, community oriented, throughly integrated, partially problem based and incorporates the organ system approach; a blend of idealism and realism in line with innovative medical education programs epitomized in the Edinburgh declaration of 1988(5,6). The curriculum encompasses all the six parameters outlined in the SPICES model and therefore differs markedly from the conventional model. Table I depicts the contrasting approach between these two curriculum strategies(7). While devising this curriculum, inspiration was also drawn from the curriculum and programs of Care Western Reserve University, Cleveland, USA, School of Medicine, McMaster University, Hamilton, Canada (pioneer in use of interdisciplinary problem based self directed learning), New Castle Medical School in Australia and Center of Medical Education, Dundee, Scotland.

The MBBS curriculum of BPKIHS is committed to produce an undifferentiated generalist doctor capable of providing health services on his own to a large extent. During the Phase I of two years, the emphasis is on applied basic sciences along with community medicine and professional skills, while in Phase II spanning over next two and half years the stress is on clinical sciences with a high degree of integration between clinical and community medicine and applied basic sciences. The curriculum incorporates early patient contact and emphasize on importance of study of community medicine and behavioral sciences from the very beginning. The focus remains on thorough integration aimed to be achieved at both horizontal and vertical levels throughout the entire course. Problem based Learning (PBL) exercises are organized at the beginning or end of an organ system to reinforce and recapitulate the basic concepts. The conceptual framework of the MBBS program isdiagramatically depicted in Fig. 1(5).

Pediatrics: A Separate Subject

Children under 14 years account for 42.4% of the total population of Nepal. In addition, Nepal has one of the poorest child health indicators with a Infant Mortality Rate of 79 per 1000 live births and under 5 mortality of 118 per thousand. Childhood malnutrition is rampant; underweight and stunting being prevalent in 49% and 64% children respectively. An estimated 90,000 under 5 deaths occur in Nepal every year predominantly of causes that are either preventable, easily treatable or manageable as a result of inadequate child health care system, inadequate child care practices and child mal- nutrition(8-10). To improve the existing preventive and promotive health care system for children, it is thus imperative that the community physician has a proper training in common childhood ailments.

BPKIHS in its innovative MBBS curriculum has laid special emphasis on pediatric teaching by keeping it as a separate subject and more importantly giving equal weightage to bring Pediatrics at par with other major subjects including Medicine, Surgery, Obstetrics and Gynecology in terms of both time allotted for clinical posting as well as' marks allotted for final evaluation(5).

 

Fig. 1. Conceptual framework of the MBBS program at BPKIHS Clinical Sciences (Figures in parenthesis indicate total duration of clinical posting in weeks) MCP : Major Clinical Po stings [Medicine (12), Pediatrics (12), Surgery (12), O&G (12)] CM : Community Medicine(6) ACP : Allied Clinical Po stings: [Orthopedics (4), Emergency Medicine (8), Ophthalmology Otolaryngology and Head and Neck Surgery (4), Anesthesiology (2), Psychiatry (2), Laboratory Medicine (2), Oral health (2), Dermatology (2), General Practice (4) and Radiodiagnosis (2)], Elective: (10) Basic Medical Sciences (BMS): Anatomy, Physiology, Biochemistry, Pathology, Pharmacology, Microbiology.

Pediatric MBBS curriculum at BPKIHS is need based with due consideration for common local childhood problems, National Health Policy and programs. It has emphasized on 'must know' areas by drawing up a core curriculum and deleted the redundant to prevent factual overloading of students. Common childhood problems like those concerned with growth and development, infectious diseases and neonatal care have been given due importance to meet the real community needs. Developmept of essential communication skills are also stressed besides possessing a sound knowledge professional skills and medical ethics.


Learning Tools

The various instruments of learning in- cluded in the Pediatric curriculum have been given titles that have originated in BPKIHS (11).

SIS (Structured Interactive Sessions): The one hour theory sessions, named so be- cause they are not intended to be a one way communication and more over sounds user friendly. In contrast to didactic teaching, the facilitator outlines the objectives, scope and content of the lecture. The stress is laid on the 'must know" areas which are already specified in the curriculum.

UNCLE (Unconventional Learning Exercise): Reinforcement of concepts is achieved through student seminars, quiz sessions, question hours, small group discussions and PBL sessions. Such exercises are collectively labeled as. UNCLE. Learning through discussions with the colleagues helps in acquiring facts through experiential learning rather than through rote memory.
 

Fig. 2. Teaching hours allotted in Pediatrics for different teaming tools during MBBS (SIS: structured interactive session, UNCLE: unconventional learning exercise. CLIP: clinical posting).

This approach also helps the students to attain presentation skills.

CLIP/CBL (Clinical Posting/Case Based Learning): This includes three hour practical sessions in the ward, emergency, out patient department as well as in the community (learning in field). Of the total clinical posting in Pediatrics, one .sixth of time is devoted to learning in field, i.e., in a rural setting or a district hospital.

Figure 2 depicts the number of teaching hours allotted in Pediatrics for different learning tools during the' entire MBBS program.

Learning Experiences

Pediatrics occupies about 6% of the total time of the MBBS curriculum and about) 2% of the total time allotted for clinical postings. The teaching in Pediatrics starts right from the beginning of Phase I of MBBS program and continues till the end of Phase II. Teaching through lectures is restricted to a bare minimum while PBL and other unconventional learning experiences are encouraged.

Phase I (I-IV semester): Basics of normal growth and development and methods of their assessment are taught in 4 theory sessions of one hour each. Besides this, Pediatrics is involved in (i) Multisystem integrated student seminars that include topics on acute diarrheal, diseases, respiratory infections, rheumatic heart disease and common infections such as malaria and Kala-azar; and (ii) Problem based multidisciplinary learning exercises at the end of each organ system (each one bf these exercise lasts for a week).

During Phase I clinical posting in Pediatrics, the basic art of history taking and physical examination of different systems is learnt supervised by a tutor. The students are encouraged to l1ake presentations and learn through discussions.

Phase II (V-IX semester): Theoretical concepts are learnt through SIS arranged in the organ system fashion. The theory topics specific for Pediatrics start from V semester and are continued in the VIII and IX semesters. Unconventional learning is carried out through small group discussions and problem based sessions assisted by a tutor. Students are exposed to their first block posting in Pediatrics in the V semester. During this five week posting, five sessions are allotted to learning in field in a rural setting or district hospital.

During VI and VII semesters, students are primarily posted in allied clinical subjects (Fig. 1). However, they do keep intact their touch with pediatric patients by attending at least once a week clinical postings in the subject, named as Sharpen Your Clinical Skills (SYCS) sessions. Students are also introduced to two entirely new subjects, i.e., General Practice and Emergency Medicine with clinical postings of 4 and 8 weeks, respectively. Pediatrics is a major component of these two innovative subjects which are taught in an integrated fashion and includes the general practice and emergency problems of major as well as allied clinical subjects. SIS are held for pediatric problems commonly encountered in general practice (acute respiratory infections, diarrheal diseases, immunization, fever, behavioral and growth problems) and emergency (shock, poisoning, respiratory distress, congestive failure, anemia, convulsions, etc.). UNCLE continues through small group discussions, student seminars and problem solving sessions.

During the VIII semester, students again have a chance of coming back to Pediatrics during anyone of their five blocks of elective postings of two weeks each.' Final Clinical posting in Pediatrics in VIII and IX semester is scheduled for a period of total seven weeks. A typical weekly schedule for students during VIII and IX semester during Phase II is shown in Fig. 3. A large part .of the student's time is spent in independent study pursuing topics and learning issues either derived from tutorial sessions or self generated. Some time is also spent interacting with faculty members who act as important resources for learning.
 

Fig 3. Sample schedule of student week during Phase II, Semester VIII and IX of the BPKIHS curriclum.