Student evaluation of medical school curriculum transformation in Iraq

Abstract

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Introduction: Decades of political and social unrest negatively impacted medical education in Iraq. Recently, new opportunities arose for medical schools to engage international education organizations and the World Health Organization to implement medical school curriculum changes, replacing older discipline-based, teacher-focused systems with a systems-based, student-focused reformed curriculum.

Methods: A descriptive, cross sectional quantitative study was designed to survey medical students near the beginning (years 2-3) and at near the end (years 5-6) of their six-year program at the Al Kindy College of Medicine, University of Baghdad, Iraq.

Results: A validated questionnaire collected data on thirty-two issues, including student perception of learning, student perception of teachers, academic self-perception and student self-perception. Seven of the thirty-two questions included in this survey resulted in significantly different responses from group 1 (second and third year) vs group 2 (fifth and sixth year) students.

Conclusions: This study concluded that the two student groups were significantly different in their awareness of the need for curriculum change, but that student self-perception in both groups was less than ideal at present. In the future, studies are planned to assess student confidence in their professional development, as teaching institutions advance toward broader accreditation and thus opportunities for their students.

Introduction

Decades of social unrest, magnified by the impact of large internally displaced populations within and surrounding Iraq, the unintended consequences of international sanctions and fluctuating oil prices, has severely and negatively impacted medical education in Iraq ( Simpson, 2017; Kron et al., 2019). After the fall of the previous regime in 2003, there were tremendous disruptions to Iraqi society, including the destruction of over 20% of the nation’s hospitals and widespread kidnapping or death of more than 2,000 physicians and medical students (Al-Kalisi, 2010; Al-Kalisi, 2013; Amin and Khoshnaw, 2003; Barnett-Vanas et al., 2016; Burnham, Lafta and Doocy, 2009; Jalili, 2007; Tarzi, 2015; Webster, 2009). Unofficial statistics from the Al Kindy College of Medicine (AKCOM), University of Baghdad, indicate that only a small minority of medical graduates have the opportunity to take USMLE step exams because they are not offered in-country and the costs of traveling outside of Iraq for exams is prohibitive. Not surprisingly, the prevalence of post-traumatic stress amongst Iraqi citizens in 2015 was calculated at 11%, particularly affecting women of all ages ( Bradley, 2016; Steel, 2009; WHO, 2019).

The first Iraqi medical school was established in 1927 based on a British model, however by 1988 the entire medical education structure had been disrupted by the Iraq-Iran war. Inrecent years, with leadership from the World Health Organization, the World Federation of Medial Education, and the National Council for Accreditation of Medial Colleges in Iraq, major initiatives have been undertaken to transform the core structure of medical education in all thirty Iraqi medical schools by modifying curriculum content and teaching styles in order to provide students with appropriate learning environments, knowledge and skill sets that will in turn restore excellence and self-confidence as they progress to more independent patient care (WHO, 2016; Yousif, 2007; Hani and Gouda, 2014; Al-Shamsi, 2017).

In 2016, the Iraqi Ministries of Health and Education and AKCOM engaged its administration and curriculum committee to critically review its entire medical school curriculum, and with input from a variety of international accreditation agencies, work to transform a traditional discipline based curriculum and teacher-centric mindset, into a more modern integrated and student centered teaching atmosphere ( Quintero et al., 2016; Enns et al., 2016; Costly, 2015; Norman and Schmidt, 1992). As in most countries, major transformations in curricula have the potential to at least temporarily, increase anxiety or confusion in the students and faculty, since there is often no other structure with which to gauge the success of new quality improvement measures.

Therefore, to gain information about student perceptions about curriculum change, as well as their general perception of learning, teachers, academic self-perception and social self-perception, a formal survey of these elements was designed, implemented and completed ( Richards, 2000; Stromso, 2004). In the future, this data will be critically important to measure and guide the continued transformation of medical education in Iraq. Understanding student perceptions and responses to new academic pressures in a country experiencing special social-cultural challenges including the displacement of millions of culturally distinct populations, is considered key to appropriate redesign and modification of new integrated curricula that will in turn lead to broader accreditation opportunities for institutions and students ( Al-Hemiary et al., 2017; Al-Hilfy, 2015; Lafta et al., 2018).

Methods

A cross sectional descriptive quantitative study was carried out among students in the 2 ^nd through 6 ^th year of the six-year curriculum of the Al Kindy College of Medicine. Data was collected between December 10, 2016 and May 18, 2017. Responses were collected from 294 students, 159 in group 1 (second and third year students) and 135 in group 2 (fifth and sixth year students). The 32-question survey was self-administered and included two questions about student awareness of the type of curriculum being taught and an additional thirty questions about student perceptions of learning, perceptions of teachers, academic self-perception, perception of atmosphere and social self-perception ( Seneviratne, 2001). This survey was approved by the research ethics committee of the AKCOM.

Collected data were organized, tabulated and analyzed using Statistical Package for Social Sciences (SPSS) for windows, version 17.0, IBM, USA. Descriptive statistics of variable were presented as frequencies and percentages for categorical variables. Comparisons between student groups 1 and 2 were tested by student’s test (Chi Square) for all continuous variables according to categorical variables (stage). P values were calculated as levels of significance and values <0.05 were considered significant.

Results/Analysis

Seven of the thirty-two questions included in this survey resulted in significantly different responses from group 1 (second and third year) vs group 2 (fifth and sixth year) students [ Table 1]. Fifth- and sixth-year students (group 2) were more aware in general of the types of curriculum in medical school (traditional vs integrated) than second and third year students (group 1). However, the groups were equally aware or unaware of the type of curriculum they were then experiencing. On the topic of student perception of learning, 48.4 % of group 1 agreed that teaching is student-centered compared to only 34.8% of group 2. 68% of all students agreed or somewhat agreed that teaching was too teacher-centered. 92.4% of group 1 students seemed agreeable that teachers were knowledgeable about their assigned subjects compared to 92.9% of group 2, and a minority in each group had the opinion that teachers were not knowledgeable. Group 1 and group 2 students differed on whether their problem-solving skills were being well-developed but group 1 more than group 2 believed that the new curriculum was enhancing their communication and research skills. Group 2 students were more bothered from classroom crowdedness but also were more positive than group 1 in terms of academic self-perception. The overall picture of social-self -perception was less than ideal, with 53.4% of all students (group 1 plus group 2) having an unfavorable view of existing support systems, specifically those for students feeling stressed by any combination of academic or external pressures.

Table 1. Survey administered to 294 students at the Al Kindy College of Medicine, University of Baghdad, Iraq.

Questions	Responses				P value
1. How many types of curriculum are in our college?	Don’t know	One	Two	Three
	25.8%	5.0%	64.3%	4.8%	0.03*
2. What type of curriculum are you engaged with?	Traditional	Integrated	Neither	Both
	44.1%	46.3%	4.8%	4.8%	0.00

Student perception of learning	Agree	Somewhat agree	Disagree
3. The teaching is student-centered	42.2%	39.8%	18%	0.011*
4. The teaching is well focused	17.7%	57.8%	24.5%	0.131
5. The teaching helps to develop my self-confidence	27.9%	41.1%	31%	0.036*
6. I am clear about the learning objectives of modules and lectures	25.9%	53.0%	21.1%	0.089
7. The teaching is too teacher-centered	22.4%	42.5%	35.1%	0.047*
8. Technology is used to deliver information in the classroom	38.1%	42.5%	19.4%	0.130
9. Crowded classrooms hamper the use of teaching methods	48.0%	27.9%	24.1%	0.095
10. Students are actively involved in planning learning and choices	23.1%	40.8%	36.1%	0.811
Student perceptions of teachers
11. Teachers are knowledgeable	46.3%	46.6%	7.1%	0.044*
12. Teachers have good communication skills	18.4%	58.5%	23.1%	0.132
13. Teachers give clear examples	28.6%	53.7%	17.7%	0.081
14. Teachers are well prepared for class	26.8%	54.8%	18.4%	0.242
Student academic self-perception
15. I am confident that I will pass this year	53.7%	38.1%	8.2%%	0.403
16. I feel I am being well prepared for my profession	26.2%	48.6%	25.2%	0.088
17. I can memorize all that I need to	11.2%	51.0%	37.8%	0.631
18. My problem-solving skills are being well developed	18.7%	53.4%	27.9%	0.046*
Student perception of atmosphere
19. Atmosphere is relaxed during labs	28.9%	42.9%	28.2%	0.426
20. Atmosphere is relaxed during lectures	26.2%	49.3%	24.4%	0.270
21. Atmosphere is relaxed during seminars/tutorials	31%	40.1%	28.9%	0.356
22. Cheating is a problem in this school	33.0%	29.6%	37.4%	0.964
23. I can ask questions when I need to	31.6%	41.2%	27.2%	0.250
Student social self-perception
24.There is a good support system for students who get stressed	17.3%	29.3%	53.4%	0.820
25. I am too tired to enjoy lectures	50.3%	36.1%	13.6%	0.431
26. My curriculum enhances patient management skills	69.7%		30.3%	0.135
27. My curriculum enhances communication skills	75.5%		24.5%	0.031*
28. My curriculum enhances research skills	74.5%		25.5%	0.042*
29. My curriculum enhances ability to work in health teams	67.0%		33.0%	0.267
30. My curriculum enhances independent learning skills	68.0%		32.0%	0.000
31. The curriculum is more time consuming	62.0%		38.0%	0.617
32. The curriculum is more stressful	71.1%		28.9%	0.994

P values refer to differences between the two student groups surveyed. Group 1: 159 2nd and 3rd year students. Group 2: 135 5th and 6th year students. Asterisks (*) indicate statistically significant differences between the two groups. Percentages indicate the total responses of group 1 plus group 2.

Discussion

This survey represents findings from the first medical student evaluation of a major curriculum change in more than a decade at the Al Kindy College of Medicine. As part of new student orientation, discussions and documents regarding curriculum structure is presented. However, when new curriculum was being implemented, there was concern that students in their 5 ^th and sixth years of medical school might be confused or upset by the major changes. Ideally, measures of the success of the new curriculum would involve comparison of variations in knowledge between Iraqi schools that have or have not implemented new teaching methods. At present, there is no internal country wide examination that is administered to students at all 30 Iraqi medical schools.

Correlation between perception of the learning environment and performance (academic success) needs to be studied. In the spirit of new teaching methodology, continuous formative evaluation of the curriculum is required through teacher and student feedback to identify and solve problems to foster a more inclusive and cooperative learning environment. During the transition from discipline based- to integrated curriculum, there still may be too much of a dependence on formal lectures that do not fully shift the balance toward student-driven learning (more beneficial in the long term.) From the faculty perspective, such a major transition to integrated or problem based learning will still require ongoing encouragement and non-threatening positive feedback that is aimed at further improving the student-teacher relationship.

Integration of curriculum with early clinical exposures is intended to reduce the number of information “silos” and should help to avoid redundancy that leads to information overload. From the student perspective, the broadly beneficial effects of integrated learning should be all the following: improved motivation and satisfaction, professional socialization, enhanced self-reflection and self-appraisal, reinforced learning, better preparation for life-long learning, heightened relevance of new materials, facilitated curriculum updates and review and better clinical reflections on basic science principles. Changes in Iraqi curricula are intended to highlight and reinforce the American Association of Medical Colleges goals for medical education, as well as the World Health Organizations concept of the “five-star doctor for the twenty-first century: a physician should be a care provider, decision maker, communicator, manager and leader, community minded and cognizant of relevant up-to-date research ( Boelen, 1994; Cooke, 2006).

Given the history of societal upheaval in Iraq, “academic self-concept” and social-self-concept are sometimes difficult to separate, yet they lie at the heart of long term efforts to maintain self confidence in a medical education system that no longer will allow itself to fall behind the times. Academic self-concept is the perception that a student has about his/her own academic abilities, and is one of the most important variables in the academic world, because of its influence on learning. Social self-perception is defined as the individual’s belief about himself or herself, including the person’s attributes. Encouraging movement toward these goals is exemplified by forward thinking and optimistic AKCOM student’s enthusiastic endorsement of the Universal Declaration of Human Rights ( SCORP, 2016).

Conclusion

This study concluded that the two student groups were significantly different in their responses to seven of the thirty-two survey questions. They differed in their awareness of the need for curriculum change, and student self-perception in both groups was less than ideal at present. Group one and group two students were significantly different in their understanding of curriculum design, learning self-perceptions, teaching structure and knowledge in teacher effectiveness. In the future, studies are planned to assess student confidence in their professional development, as teaching institutions advance toward broader accreditation and thus opportunities for their students.

Take Home Messages

• •Medical students in Iraq face complex academic and socio-cultural challenges, some of which are the result of immense societal upheaval over the past several decades.
• •Recent transformative changes in medical school curriculum and teaching styles pose a new challenge to students contemplating medical school as well as for those already studying within the established six-year medical structure.
• •The reasons for sweeping curriculum changes being implemented by Iraqi schools are not uniformly understood by current students.
• •There is cautious optimism that new approaches will lead to improved student and teacher performance, and greater opportunities for school accreditation.

Notes On Contributors

Huda Noori Jawad is a medical student in good standing presently enrolled at the Al Kindy College of Medicine, University of Baghdad who participated in this survery as part of a student led project. All students equally participated in the design, collection and interpretation of data.

Zainab Amir Abd-alnabi is a medical student in good standing presently enrolled at the Al Kindy College of Medicine, University of Baghdad who participated in this survery as part of a student led project. All students equally participated in the design, collection and interpretation of data.

Layla Mohammed Abd-alKadir is a medical student in good standing presently enrolled at the Al Kindy College of Medicine, University of Baghdad who participated in this survery as part of a student led project. All students equally participated in the design, collection and interpretation of data.

Noor Falah Hassan is a medical student in good standing presently enrolled at the Al Kindy College of Medicine, University of Baghdad who participated in this survery as part of a student led project. All students equally participated in the design, collection and interpretation of data.

Zahraa Abbas Mutlaq is a medical student in good standing presently enrolled at the Al Kindy College of Medicine, University of Baghdad who who participated in this survery as part of a student led project. All students equally participated in the design, collection and interpretation of data.

Krishna Doshi is a third year medical student at the Medical College of Wisconsin who focused on medical education in Iraq for her Global Health Pathway concentration area. Her contributions included data organization and manuscript formatting issues.

Taghreed Alhaidari is professor of Obstetrics and Gynecology at the Al Kindy College of Medicine, University of Baghdad. She is the faculty supervisor of all students for this project. In addition, she contributed in terms of study design, statistical analysis and data interpretation. ORCID iD: https://orcid.org/0000-0001-8494-8760

Michael A. Kron is a professor of Medicine, Medical College of Wisconsin, Milwawukee, Wisconsin USA. He is a medical education collaborator who played a key role in assisting Al Kindy College of Medicine leadership in its curriculum reform process. In addition, he assisted with formatting, data analysis and writing of this manuscript. ORCID iD: https://orcid.org/0000-0002-8240-5209

Declarations

The author has declared that there are no conflicts of interest.

Ethics Statement

The institutional research committee of the Al Kindy College of Medicine, University of Baghdad reviewed and approved this curriculum evaluation study on 11 August 2016, document reference number 142.

External Funding

This article has not had any External Funding