Implementing Lifestyle Medicine in Undergraduate Medical Education at Riphah International University, Pakistan

Abstract

The Need of the LM content in Medical undergraduate curriculum was imperative based on the mortality and morbidity statistics in Pakistan along with lack of LM training and unhealthy lifestyle of physicians themselves. Aims and Objectives for integrating LM content were designed including cognitive, affective and psychomotor domains of learning. while embedding LM content in an integrated modular system, every step was technically monitored and matched with the academic year, teaching methodology and importance of the topic. LM content was integrated in every educational activity from first to final year by adding or modifying LM learning objectives. The alignment of learning domains was in accordance with the teaching and assessment strategies. Teaching methods chosen were according to the designed learning objectives and phase of curriculum. LM content was assessed in formative and summative assessment through, single best and case cluster MCQs, reflections, OSPE. LM curriculum was communicated to teaching faculty and medical students through academic calendar, module guides and timetables. It was shared on Moodle and Teams. Educational environment incorporated both physical and virtual learning and has been supportive of lifestyle practices among medical students. The entire process of embedding LM content in medical education has been multifaceted. Different committees were formed including Steering, Core, implementation, and Evaluation Committees. Students were part of each committee. This write-up describes the evidence-based approach used to embed LM content in Undergraduate Medical Education and offers guidance to other undergraduate medical colleges that may wish to implement lifestyle medicine content.

“The Need of the LM curriculum was imperative based on the mortality and morbidity data of lifestyle related diseases in Pakistan along with lack of LM training and unhealthy lifestyle of physicians themselves.”

Worldwide scientific evidence associates unhealthy lifestyle practices with morbidity and mortality related to non-communicable chronic diseases. Globally, there is insufficient lifestyle medicine training of physicians at undergraduate and postgraduate level. Chancellor Riphah International University Mr Hassan Muhammad Khan took the lead in Pakistan by establishing Riphah Institute of Lifestyle Medicine (RILM) in 2019 under the directorship of Dr Shagufta Feroz. Along with the other goals, integration of lifestyle medicine content in undergraduate medical curriculum was one of the prime objectives of RILM. The first step was to train the medical teaching faculty by offering them a 6 month certificate course named “lifestyle medicine postgraduate course.” This motivated them to appear for the International Board of Lifestyle Medicine (IBLM) and obtain certification.

A team of medical doctors who were certified in IBLM and holding master’s Degree in medical education designed, developed, and implemented lifestyle medicine curriculum in undergraduate teachings. At the medical college, based on World Federation of medical education standards, an internationally accredited system based spiral integrated modular curriculum has been utilized. Harden’s 10 rules of curriculum design were used as a theoretical framework for integrating LM content in undergraduate medical education in the following manner.

• 1. What are the needs in relation to the product of the training program?

• 2. What are the aims and objectives?

• 3. What content should be included?

• 4. How should the content be organized?

• 5. What educational strategies should be adopted?

• 6. What teaching methods should be used?

• 7. How should assessment be carried out?

• 8. How should details of the curriculum be communicated?

• 9. What educational environment or climate should be fostered?

• 10. How should the process be managed?

The Need of the LM curriculum was imperative based on the mortality and morbidity data of lifestyle related diseases in Pakistan along with lack of LM training and unhealthy lifestyle of physicians themselves. Medical curriculum has limited nutrition education in preventive health and other pillars were lacking as well. Addressing the needs, following are the 5-year curriculum Aims and Objectives for integrating LM content are:

• 1. LM content covering knowledge part of curriculum was addressed by emphasizing the primary role of lifestyle medicine in chronic disease.

• 2. LM content covering change in attitude part of curriculum was addressed by applying the principle of LM in the management of chronic disease.

• 3. LM content covering practical part of curriculum was addressed by implementing lifestyle medicine practices for self-care.

Curriculum Objectives were further translated into modular objectives and followed by learning objectives at the mode of lesson plan.

The Content to be included was based on the principals of ACLM and teachings in “The Lifestyle Medicine Hand-book” co-authored by Drs Beth Frates, Jonathan Bonnet, Richard Joseph, and James Peterson. It included 6 pillars of lifestyle medicine:

• 1. Improving health through exercise

• 2. The nutrition health connection

• 3. Sleep matters

• 4. Stress and resilience

• 5. Substance abuse

• 6. The power of connection

Along with this content, Behavior change, Positive Psychology, and Empowering self and others, was added in behavioral science module which is vertically integrated from first to third year.

For Content Organization, there were 2 suggestions by the experts to organize LM content in medical education. First was to keep it a stand-alone module of one month duration in fourth year and second was to integrate learning objectives in already taught but relevant teaching sessions. After brainstorming sessions, the latter was accepted because of its minimal cognitive load on students and alignment of medical education principles to integrate spirally in all years. Despite the complexity of Integration of LM content in an integrated modular system, quality was ensured, every step was technically monitored and matched with the academic year, teaching methodology and importance of the topic. LM content was integrated in every educational activity from first to final year by adding or modifying LM learning objectives. The alignment of learning domains was in accordance with the teaching and assessment strategies. For example, learning objective covering “role of lifestyle modification in preventing stroke” was added in CVS (Cardiovascular system) module in second year of medical studies. Teaching methodology was PBL (Problem-Based Learning) session in the form of case scenario and was assessment tool used was case cluster MCQ.

One of the most important steps was to align the content with educational strategies. Riphah has already adopted the SPICES (Student-centered, Problem-solving, Integrated, Community-based and Systematic educational strategies) model of education in medical education. Same was adopted for LM content; however, provision of Lifestyle Medicine Electives is still under process. Teaching methods chosen were according to the designed learning objectives. Learning objectives of cognitive domains were mostly taught in the first phase of curriculum in interactive lectures and problem-based learning sessions. Learning objectives of affective domain were taught mostly in preclinical subjects through history taking, communication skills, and Case-based Learning sessions. Psychomotor learning objectives were mostly taught in clinical years during clerkship modules, field visits, and ward rotations. Assessment of lifestyle Medicine content was based on a table of specification; what and how it was taught. Lifestyle medicine content was included as part of formative and summative assessment. All 3 learning domains of LM were assessed based on Miller’s pyramid. Content taught in lectures and small groups were assessed by single best, single correct and case cluster MCQs, affective domain by self-assessment in the form of reflections, checklists, and psychomotor by OSPE/OSCE and bedside VIVA.

Holistic model of LM integration along with the teaching and assessment strategies is shown in Diagram 1.

Diagram 1.

LM Integration model along with teaching and assessment strategies.

LM curriculum was communicated to teaching faculty and medical students through academic calendar, module guides and timetables. It was shared on Moodle and Teams. Educational environment incorporated both physical and virtual learning and has been supportive of lifestyle practices among medical students. Frequent healthy food festivals, poster and debate competitions and folk shows have been arranged. Students are encouraged to participate in international lifestyle medicine conferences. The student Task force for the health club has also been developed inclusive of students from all years. The entire process of embedding LM content in medical education has been multifaceted. Different committees were formed including Steering, Core, implementation, and Evaluation Committees. Students were part of each committee. Every step was rigorously monitored and improved after feedback.

Operational layout of the complete process is shown in Diagram 2.

Diagram 2.

Operational layout of embedding LM content in Medical Education.

At this moment, we are in the phase of assessing the LM content at end of year exams. We are planning to hold a 360-degree evaluation involving internal and external evaluators to refine the process and improve the outcome. This write-up describes the evidence-based approach used to embed LM content in Undergraduate Medical Education and offers guidance to other undergraduate medical colleges that may wish to implement lifestyle medicine content to improve LM knowledge and practices of future doctors to not only reduce disease burden but also optimize health.