Letter from … Malawi: the first year of the College of Medicine of the University of Malawi

Prologue

The College of Medicine at the University of Malawi came into existence on 1 April 1991. Planning for this moment commenced some years ago. In 1986 a document ‘A Plan for Medical Education in Malawi’! was produced with the support of the Government of Malawi. Among other proposals, recommendations were made ‘that 25 eligible students be sent … to St Andrews’ University (15) and University College London (10) in order to gain their preclinical qualifications…’.

The students did not return in 1989 to commence Year 3 as planned, but, after doing 2 years of clinical work at London teaching hospitals - namely University College, St Bartholomew's, St Mary's and the Royal Free - returned in September 1991, to take their final undergraduate year in Malawi. By September 1991, teaching units had been built adjacent to the medical, surgical, paediatric and obstetric and gynaecological wards at the Queen Elizabeth Central Hospital in Blantyre.

Teaching and accommodation blocks were also completed at the town of Mangochi on Lake Malawi, in association with the Mangochi District Hospital, in order to facilitate the teaching of Community Health.

Academic staff (15 in all) had been appointed to the five clinical disciplines during the previous year and they arrived in May and June 1991, allowing time for the College of Medicine to plan and develop the curriculum, with emphasis on this inaugural year of final year teaching.

The curriculum conference

The conference was held at Nkopola Lodge on Lake Malawi from 7 to 13 July 1991. Fifty-one delegates were invited, representing all clinical disciplines of the College of Medicine, the Medical Council of Tropical Doctor, January 1993 Malawi, the Medical Profession in Malawi, the Ministry of Health and the four London teaching hospitals. Professor George Sweeney from the Department of Medicine at McMaster University was invited as Educational Consultant.

The aims of the conference were to determine: (i) objectives of the College of Medicine, (ii) its teaching philosophy, (iii) how the clinical disciplines will integrate with each other, (iv) how students will be assessed, and (v) the structure of the internship year.

In planning for the conference, academic staff paid close attention to the Alma-Ata declaration, to the ‘Six themes for the programme and strategy for world action in medical education’ as set out in the report on the World Conference on Medical Education held in Edinburgh in August 1988 and to the more locally orientated ‘Abuja Plan of Action? of July 1989. These documents with their trenchant recommendations for medical education helped to set the goals for the College to achieve. It was readily apparent that all staff were in favour of an integrated teaching programme with a community-orientated basis.

The objectives of the course were determined on the opening day. In essence they are: (1) for a broad community orientated teaching programme, with integration of teaching, (2) recognition of the role of the doctor in the community, and (3) inculcation of a spirit of self-learning.

The major task facing the delegates was to marry the teaching programmes from the four separate London teaching hospitals to the requirements of practice in Malawi. It was apparent that students had had no instruction in tropical medicine and that their community health, epidemiology and public health teaching was very much orientated to geriatrics and the problems of the western world.

The final year programme

After much discussion we made the following plans for the final year programme for the first cohort of students.

1. There would be 6-week attachments to each of the major hospital departments. Each attachment would include teaching on ‘emergency management’.

2. The first week of each attachment should be spent at the rural centre (Mangochi). Here the community dimensions of each hospital speciality would be explored, with teaching by staff of both the speciality and the Department of Community Health. Teaching would concentrate on the epidemiology of the relevant diseases and conditions as they occur in the community, including their origins, incidence, prevalence, costs, difficulties of prevention and management. Clinical teaching would centre around the Health Centre and include triage, clinical diagnosis, laboratory support and referrals. Adequate opportunity would be given for students to discuss with villagers and local health staff their own perceptions of health problems and to study the local environment.

3. A later period in the final year would be reserved for district experience; during this period, health care management, EPI and cold chain management, family spacing, quality assurance, and health economics would be covered.

4. There would be a 4-week block of teaching on community mental health, in which community psychiatric nurses would take part in the teaching.

5. A programme of integrated seminars would be held, covering all aspects of tropical medicine and infectious disease, perinatal morbidity, maternal and child health and other local problems not covered in the United Kingdom.

6. A record book (or log book) should be kept by each student throughout the year. The purpose of the record book was to ensure that in each attachment common diseases and problems pertinent to the situation in Malawi had been covered, and that practical procedures had been performed or observed.

7. Each department independently opted for small group teaching with self directed learning as far as our limited resources would allow.

8. Evaluation of students should include (a) continuous assessment (in this the record or log book was later to prove very useful), (b) a ‘long case’ at the end of each clinical attachment, (c) a final or end of year examination.

The form of this examination, the relative weighting of the exam and the continuous assessment during the year, and whether departmental autonomy should prevail or total integration occur, were the subjects of a spirited debate. ‘Let’s integrate’. ‘Yes but can you fail surgery and pass the integrated examination?’ ‘The continuous assessment will determine the right to sit the final examination’. ‘A student failing continuous assessment in final year is a failure of the teachers’. ‘Can you have integration with departmental autonomy?’ ‘ why not?’ In the end we decided that assessment 5 throughout the year would count for 60070 and the final examination for 40070 of the final year mark. Staff should meet with students weekly to discuss student performance, and interview every student at the end of each attachment to discuss their progress.

The intern year

The Medical Council of Malawi, the College of Medicine and the conference delegates agreed that 18 months was the appropriate duration for the internship, which would include 5 months each of surgery and obstetrics/gynaecology, 3 months each of medicine and paediatrics, and 2 months community health/district hospital work.

In the latter assignment, interns would spend one month learning hospital management procedures in association with the Malawi Institute of Management and one month studying epidemiological and demographic methods appropriate to district hospitals.

Both College of Medicine and Ministry of Health staff would supervise the interns during this 18 month training period - they would provide reports to the Medical Council of Malawi during this preregistration time on the performance of each intern in a manner similar to the final year ongoing assessment.

Continuing medical education

The College of Medicine was requested and willingly agreed to develop facilities and provide opportunities for all cadres of health workers to participate in continuing education. We agreed that further discussion should take place between the Medical Council, the Ministry of Health and the College towards the establishment of courses such as District Hospital Management and Masters in Public Health.

In his closing remarks at the end of the conference, Professor George Sweeney said:

‘The focus of this school is to be the community and their needs … The school can provide graduates sensitive to the community and educated in the principles of Community Health. It is up to the Ministry to create opportunities for such graduates so that their unique orientation does not die soon after graduation’

The first year in retrospect

How did these plans work out in practice?

We resolved that students should be represented both on faculty and on the curriculum committee. In this way important feedback concerning teaching, clinical practices and hospital and district opportunities was obtained.

The curriculum committee met following each attachment. The whole student body turned up to the first meeting! The curriculum committee met seven times during the year. Student feedback was an important factor in modifying some of the programmes that had been originally set out - eg the introductory programme is to be reduced to a week, some difficulties with Community Health modules and problems with the refugee segment of the Community Mental Health programme were accepted and acted upon (but objections to starting integrated seminars at 7.45 am were overruled!)

The success of the Primary Health Care week in association with each of the clinical attachments was a noteworthy part of the programme. The Department of Paediatrics opted for a second week at the end of their segment and conducted their final clinical examination in the district.

The ophthalmology/dermatology segment gave students a necessarily intensive (and proclaimed enjoyable) 2 weeks in Lilongwe.

The final examination

External examiners were appointed in each of the five major disciplines - four examiners were from the United Kingdom and one from Zambia. All held professorial appointments of long standing at various universities. In their reports examiners indicated that they would have preferred: (i) greater participation of the examiners in the direct clinical assessment of the students; (ii) less emphasis on the ongoing assessment and more on the final examinations; (iii) more clinical involvement for them in the Objective Structured Clinical Examination. They noted that pathology was somewhat neglected in the tuition in Malawi.

The examiners commented that the overall standard of our students was comparable to that of students at any western or United Kingdom Medical School.

All the comments made by the external examiners will be deliberated and acted upon.

Epilogue

Those of us who are involved in the College of Medicine are extremely fortunate, for it is rare to set up a new medical school these days.

We had people with a wealth and diversity of experience in community-orientated medical schools to guide us in establishing our teaching programme. It has been a most satisfying, strenuous, exciting and, at times, frustrating year. We are now setting up the second year of final year teaching - in 1992/93 we shall teach years four and five, and in 1993/94 commence teaching in the first year as well.

It remains now to thank the Government of Malawi for establishing the College of Medicine and the donors who have supported and, we hope, will keep supporting the College. I personally thank all the academic staff for their support, for their total commitment both to the College and to improving the health services in Malawi. To the administrative staff of the College my sincere thanks as well.