News #5 | April, 2009
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The Evolution of the Curricular Reform of the Faculty of Medicine of the University of Lisbon
The Evolution of the Curricular Reform of the Faculty of Medicine of the University of Lisbon
Fernando H. Lopes da Silva 
Emeritus Professor of the University of Amsterdam, 
Professor at the Higher Technical Institute
Guest Professor at the Lisbon Faculty of Medicine

30th of March 2009

Institutions are living organisations and are thus in constant evolution. This is the case of universities, and naturally of medicine faculties. In general, the evolution of this type of institutions does not develop in a uniform manner, but through phases in which it is often the institution itself that starts to question its own method of working and then starts a process of reform through which it may achieve a new stage of improving its performance. This is what happened with the Faculty of Medicine of the University of Lisbon (FMUL) in 2005 

Acknowledging that institutions’ capacity for self-reform is very limited, the FMUL asked three specialists from outside the organisation to make a diagnosis of the medical curriculum in force at the time and to recommend adequate measures for improving the teaching at the Faculty. So an Ad-hoc Committee was formed by three specialists and to which I was invited, along with Professors Alistair Warren of the “Department of Biomedical Science” and director of “Undergraduate Studies and the Learning and Teaching Development” of the University of Sheffield Faculty of Medicine (UK) and Joseph Gonnella, Director of the “Center for Research in Medical Education and Health Care” and “Dean Emeritus, Jefferson Medical College of Thomas Jefferson University”, Philadelphia (USA). The three members of the committee have international experience in relation to the organizing of curricula in medicine, including in Portugal, as they belong to the Monitoring Committee that has accompanied the new medical curriculum of the University of Braga for the last eight years. The Dean of the FMUL asked this committee to make an analysis of the curriculum and on that basis to propose recommendations about reforming the FMUL medical curriculum.  

Briefly, the diagnosis made by this committee in February 2006 was simple: the FMUL was not accompanying the evolution in medical teaching that had been taking place in many other faculties abroad over the last thirty years. More specifically, the FMUL had not introduced the method of integrated teaching instead of the classical method of teaching of subject isolated from each other, nor practical teaching centred on clinical problems from the early years of the course, nor a system of continuous assessment of the students, nor even a system of adequate monitoring of the teachers. In general terms, the committee identified six crucial points to which it called the Faculty’s attention:

1) Lack of a framework for the Medical Curriculum in general;
2) Insufficient system of communication between Faculty;
3) Too heavy load for staff (and students) with secondary issues;
4) Lack of a comprehensive assessment strategy (staff and students);
5) Necessity to establish an Executive Curriculum Committee;
6) Necessity to modernize the methods of selection and recruitment of new Faculty

This situation led this Ad-hoc Committee to make a number of practical recommendations in order for the FMUL to gradually overcome the limitations identified and create a new curriculum compatible with the evolution of ideas about medical teaching at the beginning of the XXI century. Obviously, it was up to the FMUL to define the aims of this curricular evolution and to organise the process in order to introduce new forms and methodologies of teaching. The Direction of the FMUL was swift and firm in its decision to promote the setting up of the new principles of organisation of the curriculum immediately in the 2006/07 academic year.  
I had the privilege of being invited to preside over the Monitoring Committee for the curricular reform over the first three years. Despite natural hesitations and doubts by some members of the Faculty in relation to whether the path drawn out for the curricular reform would bring real benefits, I must state that the Monitoring Committee and its associates faced this complex challenge with determination and good collegiate spirit.  

Three years after the beginning of this reform process, the direction of the FMUL once again requested the collaboration of the Ad-hoc Committee in order to make an critical analysis of how this process has evolved and how the reform of teaching in the first three years should be articulated with the final phase of the curriculum. So the Ad-hoc Committee visited the FMUL once again, this time without Professor Joseph Gonnella due to logistical impossibility.  

The committee was pleased to note that the FMUL had made considerable efforts to introduce significant reforms in the organisation of the teaching of the first three years, which is without any doubt deserving of praise. In contrast to the reform of the organisation, characterised by the introduction of the semester regime and the integrated modules, the committee noted weak points as to the manner that these reforms had been implemented. Namely, the committee noted an essential deficiency as to the degree of integration of several modules, which became evident through the simple analysis of some module exams, which are a sum of partial exams, and show that the process of integration of the several disciplines within these modules had not yet been brought about in practice. The lack of this integration results in an effect contrary to that desired. It is in addition to the workload for students, who end up having exams in four subjects simultaneously instead of a unified exam in which they can demonstrate how they themselves are able to use knowledge of different kinds in order to solve a concrete problem. It appears that evaluation of student performance continues to be based on examination of factual or even encyclopaedic knowledge instead of tests aimed at determining the students’ capacities to solve problems.  

Besides this essential limitation, the committee found that the six points considered crucial in 2006 remain in 2009, which is obviously a reason for concern, although it is understandable that three years is a short time to carry out profound reforms, even though some have been successfully carried out. The committee is well aware of the degree of difficulty that the Faculty has faced in carrying out the changes that in the meantime have been planned, which require a modification of the traditional patterns of teaching methods that belong to old habits. 
The incorporating of Training Periods in Health Centres, which began in the last academic year and will be repeated over the coming years, is a very meritorious step, and will contribute towards widening the bases of Medical Teaching beyond a traditional teaching based on the university hospital or the like. 

This process of change would certainly be made easier if the Faculty could acquire new teachers trained in the contemporary forms of teaching methodologies. In this sense it is important for members of the Faculty to be exposed to these forms of teaching through training periods or visits to faculties where these methodologies were introduced years ago. It would also be very useful to create a Unit of Medical Teaching, with the aim of not only monitoring student assessment and teacher performance, but also to function as a guide for the development of new methodologies of teaching and learning dedicated to the Faculty and to teacher and tutor training. This could be carried out if this unit had a high professional level and adequate authority 

Besides the more technical aspects of how to improve the integration of the modules and of the respective tests and how to monitor student performance in a continuous manner, as well as that of teachers, one problem that became evident when the Ad-hoc Committee heard the presentations referring to the curricula of the last years is that the Faculty in the wider sense, as the set of all the professors, has not clearly formulated its most essential mission; that is, what type of doctor the Faculty wishes to educate and introduce to society in the coming years. It is important to realise that these doctors will be active during the first half of the XXI century, and will thus face major scientific, technological and social changes, some of which are under way at a rapid rate.  

It should be stressed that the Direction of the Faculty presented an overall view in which medical education is wisely seen as a continued medical education from under- to post-graduation in order to prepare young doctors for a future of “life long learning” and to promote their integration into multidisciplinary teams. In the current phase it is important for the Faculty, understood as the set of professors with curricular responsibilities, to draw up this vision, taking from it the necessary practical consequences. 

The evolution of health services in the most developed countries points towards the fact that new doctors increasingly have to be trained as elements of multidisciplinary teams rather than as individualist professionals, and have to have a great capacity to bring together new knowledge and advanced techniques that are in constant flow. The most important thing is to educate the student of medicine in his capacity to solve problems instead of memorising facts, and to try to find, evaluate and integrate information rather than to be an archive of encyclopaedic knowledge. The essential thing is that the recently-graduated doctor gets from the Faculty the “fundamental skills” needed to later on be able to develop in the several different possible directions within the vast field of Medicine, ranging from specialisation in Family Medicine or in the more technological specialties, and to choose his field of professional activity, which may range from Epidemiology to laboratory medicine or to work in the tropics. It is this product of the medical curriculum that we should call “basic medicine”.

The essential thing for the Faculty is to define what those “fundamental skills” are that the “basic doctor” should have acquired at the end of the curricular years. In this sense an example that I know most closely is the effort carried out since 2001 by the eight Dutch Medical Faculties working together in order to formulate those “fundamental skills” in order to make the several different curricula comparable not only in terms of curriculum content in detail, but in relation to the final aim, the training of the “basic doctor”. These measures are a part of a process that has been carried out in several countries in Europe and North America. The most accessible reference in this context must be the document “Tomorrow’s Doctors”, which was published in the UK under the guidance of the General Medical Council in 2003( in which the “standards for knowledge, skills, attitudes and behaviours that medical students should learn at UK medical schools” are specified along with the arguments that led to establishing these general principles.  

Dialogue with the FMUL professors responsible for the final curricular years revealed their concerns in relation to the Faculty’s capacity to deal with the increased number of students, which seems to be touching on the limits that the faculty can handle. This fact on its own implies the introduction of adequate teaching methods through the recruiting of a network of teachers/tutors who are duly trained and capable of supervising small groups of students in their contacts with clinical practices, both on the hospital and extra-hospital level (“to learn working under supervision”). These groups should receive specific tasks that the students can carry out in an autonomous manner and the results of which will be tested, weekly for example, by the teacher/tutor or another supervisor. The final years of the curriculum should be organized according to increasing levels of complexity, always bearing in mind the range of capacities that each “basic doctor” should have acquired, without intending to train specialists during the six years of the Faculty course.  

Alongside the general training of the “basic doctor”, the Faculty may consider the organization of a Masters programme dedicated to the training of researchers with different orientations. In a timely manner, the possibility of students carrying out training periods dedicated to duly-supervised scientific research has already been included in the new curriculum. These possibilities should be stimulated and should become the base for the scientific Masters and PhD programmes to be developed. 

An example of this type of programme is the case of Faculty of Medicine of the Erasmus University of Rotterdam, which provides a small number of students chosen due to their motivation and capacities shown throughout the course with the following “Research Masters” (“Masters of Science”): in “Clinical Epidemiology and Clinical Research”, in “Molecular Medicine”, in “Neuroscience” and in “Infection and Immunity”; this last Masters will only start in August 2009. in general terms, the programme for these Masters takes two and a half years, according to the case, but is carried out alongside the basic medical curriculum, which only very motivated and gifted students are capable of carrying out.

Allow me to leave a personal recommendation here. In this period in which the curricular reform is starting to take root, the Faculty should nominate a small “Executive Curriculum Committee” in accordance with recommendation # 5 of the 2006 report (preferably with three people, but no more than five) with two main aims: to propose (1) a definition of the Mission of the FMUL Medical Course, and (2) a model for the articulation between the several different forms of teaching and the methodologies of assessment and monitoring of the curriculum reform.

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Prof. Doutor J. Fernandes e Fernandes
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