Rawal Medical Journal An official publication of Pakistan Medical Association Rawalpindi Islamabad branch Established 1975 Volume 36 Number 3 July-September 2011 Medical Education Evaluation of undergraduate anesthesia curriculum Muhammad Nasir Ayub Khan,* Amjad Ali,** Muhammad Zubair* Departments of Anesthesia, Shifa International hospital,* Islamabad and Bolan Medical College, Quetta,** Pakistan. ABSTRACT Objective To evaluate undergraduate anesthesia curriculum in Pakistan Methods A mail survey was performed and results are presented as descriptive statistics. Results Response rate was 87.5%. Only 54% medical colleges had organized anesthesia department. Curriculum content was mostly lectures. Acute pain, emergency medicine, resuscitation and critical care medicine were taught in 20, 46 and 61% of medical colleges. Methods of assessment were written in 11%, viva in 14%, multiple choice questions in 57% and Objective Structured Clinical Examination in 18% in different medical colleges.
Conclusions There is great need to further organize anesthesia department of medical colleges. Curriculum contents need to be revised and can be done by answering Hardens ten questions. Evaluation of teaching part should be done in more systemic way. (Rawal Med J 2011;36:229-231). Key words Undergraduate anesthesia teaching, curriculum, resuscitation. INTRODUCTION Curriculum evaluation is the process through which educators judge the quality of their curriculum. This means asking critical questions, collecting the right information, analyzing and interpreting the collected information, which is than used to improve teaching and learning. Evaluation is part of the curriculum development process. Important to this idea is that results from curriculum evaluation should make a difference; that is, they should, once made known through whatever model has been applied for whatever reason, feedback into curriculum. 1 The undergraduate anesthesia curriculum in Pakistan has not been comprehensively evaluated up till today. This study was designed to evaluate the under graduate anesthesia curriculum in Pakistan. SUBJECTS AND METHODS A postal survey and questionnaire targeting department heads of anesthesiology from different private and public medical colleges was used. One follow up postal reminder was sent to all non-respondents after two months. The questionnaire contained 30 items (Appendix). It included items related to the organization of anesthesia within the medical faculty, the medical college curriculum is general, which topics were covered by the anaesthesia department, the teaching of practical skills, resuscitation, critical care medicine and pain management, assessment of students performance and postgraduate
teaching. The majority of questions involved fixed response answers (yes/no), open-ended questions were also included for which written responses were required. RESULTS We received 87.5 % replies out of 32 medical colleges to which questionnaire was sent. Over 99% of these questionnaires were fully completed. Organization: In 54% of medical colleges the hospital and academic department of anesthesiology were organizationally separate unite, whereas in 46% of medical colleges had integrated department of anesthesiology. 57% of teaching hospitals had professor of anesthesiology as head of department. 68% department of anesthesiology was recognized by College of Physicians and Surgeons Pakistan for post graduate training. Residents were involved in the teaching of medical students in 64.28% of departments of anesthesiology. Curriculum content: 92.85% lectures, 7.14% tutorials and discussion done in operating room covers 85.7%pre-operative assessment, 97.85% pharmacology of anaesthesia drugs and care of unconscious patients for undergraduate teaching. Practical clinical skills were taught in operating rooms by almost all departments with airway management and intubations 97% and venous cannulation 92%. Practical skills were taught using patients 95% and mannequins 5%. Acute pain management: Acute pain management was taught in 20% of medical colleges. Acute pain was mostly taught in lectures 96.42%, wards rounds with the acute pain services 3.57% and supervised patient pain management in the recovery room by none. Emergency Medicine and Resuscitation: Resuscitation skills were taught by anesthesiologist in 46% of colleges. BLS and ACLS were taught in 50% of medical college in workshops. 79% departments of
anesthesiology were actively involved in BLS and ACLS workshops. ATLS was taught 36% medical colleges by surgeons by suing lecture as method of teaching. Critical care Medicine: Critical care medicine was taught in 61% medical colleges. Only in 5% medical college s critical care was taught by anesthesiologist. There was no consensus on CCM curriculum among anesthesiologist. Student Assessment: Passing anaesthesia module was not required by PMDC for final exam. Assessment is carried out by written essay type 11%, viva 14%, multiple choice questions 57% and objective structured clinical examination 18% in different medical colleges. DISCUSSION There are several advantages of using a questionnaire to evaluate a curriculum. The questionnaire is feasible and economical in terms of time and effort to collect a range of views from the population to be studied, rather than sampling some parts of the population. 1 Questionnaire data especially for closed rating scales question may be analyzed using statistical testing for significance and associations. 1 There are some disadvantages to the questionnaire method. There is a well-recognized problem with precoded responses, which may not be sufficiently comprehensive to accommodate all answers, forcing the candidate to choose a view that does not represent their views correctly. 1 The teaching of anesthesia became a part of the undergraduate curriculum in 1912. In 1947, General medical council (GMC) removed anesthesia from under graduate curriculum. However, in 1980 GMC reintroduced anesthesia as a part of under graduate curriculum because of new role of anesthesiologist. 2 Most of the previously published evaluations of undergraduate anesthesia curriculum looked at student knowledge of anesthesia, pre-operative investigations, training in resuscitations, training in trauma, the teaching of practical skills, pain management and teaching of critical care. Our survey looked at the
content. Like V. Cheung et al survey, our evaluation did not evaluate how extensively anesthesia was taught at undergraduate level. 2 Our response rate of 87.5% compared favorable with those quoted by previous authors. V. Chung et al reported an 89% across university departments of anesthesiology from the developed nations of various regions. 2 Lauder et al reported a 73% reply rate from anesthesia departments in the U.K and Gracia- Barbeo et al reported a 47% reply rate from critical care units across Europe. 3 Our relatively highly rate reflect that Pakistani anesthesiologists are very keen in undergraduate anesthesia teaching and respondents might have a hope that results of this evaluation could help to design competence based curriculum. Most of the departments of anesthesiology were recognized by College of Physicians and Surgeons Pakistan, but only half of them had professor as head of department. This shows that still there is a big room for young anesthesiologists. There was consensus among anesthesiologists that pharmacology of anesthesia drugs, pre-operative assessment, obstetric anesthesia and care of the unconscious patients should be included as part of undergraduate curriculum. There was also consensus that practical skills such as airway management, intubations and intravenous cannulation should be taught by anesthesiologists. 2 Only 20% of junior s doctors were able to prescribe satisfactory pain relief 2 so there is a reorganized need for effective teaching in acute pain. Acute pain management teaching was not taken seriously by anesthesiologists. The level of pain management skills among doctors in Pakistan need to be studied. The inadequacy of cardiopulmonary resuscitation skills among doctors and paramedics has been a subject of concern since the early 1980 s. This concern lead to the birth of American Heart Association in North America. BLS and ACLS were one of the first clinical practical skills to become universally established within the anesthesia undergraduate curriculum. 4 Surprisingly, we found that only 48% of
anesthesiology departments taught BLS and ACLS compared to 92% of anesthesia departments of developed world. Most of these skills were taught by workshops held by different non-government organization like Life Savers Pakistan. 2,4 There was very little concerns among anesthesiologists over what part of critical care medicine should be taught at undergraduate level. Infact, 5% of medical colleges in Pakistan and 74% of schools worldwide teach critical care at undergraduate level. Roger et al showed that to provide medical students with a more in-depth knowledge of the critical care management would require four weeks problem based attachment with a high level of supervision. 5 This requirement would not likely be possible in most undergraduate programs but would be very applicable to intern as suggested by Norman. 6 Harden s Ten questions need to be addressed to improve anesthesia curriculum. 7 CONCLUSION Based on the finding of our survey, we recommend use of Harden s Ten questions, a widely known method for looking at curriculum content in medical education. These questions can be used both in designing a curriculum, and to evaluate the course in systematic way. Correspondence: Dr M Nasir Ayub Khan Consultant Anesthesiologist, Shifa International hospital, Islamabad, Pakistan. E-mail: drmnasirayub@yahoo.com Received: September 29, 2010 Accepted: May 14, 2011 REFERENCES 1. Wall DS. Evaluation: improving practice, influencing policy. In: Understanding medical education. Edinburgh: ASME publications 2007;41:1-35. 2. Cheung V, Critcley LA, Hazlett C, Wong EL, Oh TE. A survey of undergraduate teaching in anaesthesia. Anesthesia 1999;54:4-12.
3. Garcia-Barbero M, Such JC. Teaching critical care in Europe: analysis of a survey. Crit Care Med 1996;24:696-704. 4. Casey WF. Cardiopulmonary resuscitation: a survey of standards among junior doctors. J Royal Soc Med 1984;77:921-4. 5. Rogers PL, Grenvik A, Willenkin RL. Teaching medical students complex cognitive skills in the intensive care unit. Crit Care Med 1995;23:575-81. 6. Norman J. Anesthesia pre-registration house officers. Anesthesia 1997;52:831-2. 7. Harden RM. Ten Questions to ask when planning a course of curriculum. Med Educ 1986; 20:356-65.
Appendix Outline of questionnaire. Organization of department Independent academic department Has a chair of anaesthesia Hospital department separate Resuscitation continued (trauma): Is primary survey taught Are ATLS principles taught How are these trauma skills taught Other emergency medicine topics taught Medical School Curriculum Duration of medical course Under or postgraduate course When in the course is anaesthesia taught Internship exposure to anaesthesia How is anaesthesia taught & contact hours Curriculum coverage- anaesthesia: Anaesthesia topics taught Practical clinical skills taught Critical care medicine: Is CCM taught What time is allocated to teaching CCM How is CCM taught What CCM topics are taught (free text) What CCM topics should be taught Acute pain management: Is acute pain management taught How is it taught How are these practical skills taught Resuscitation: Who teaches resuscitation Is basic life support taught Is advanced life support taught How are these resuscitation skills taught Student Assessment: Is passing a module mandatory How are students assessed Other comments Post graduate courses: