A brief history of medical education

 
 

The Faculty of Medicine of Izmir University of Economics aims to contribute to medical education through a series of new and innovative concepts and practices that we define under the heading of "new generation medical education". This understanding of education which has emerged from the philosophy, its practices and experiences of contemporary medical education which has been successfully carried out in many medical faculties of our country; is a new phase in the training of "physician of the future" with its health perspective, medical education approach, curriculum-based themes and innovative practices.

 
 

How do we look at health?

 

The World Health Organization (WHO) defines health as not just a disease but a condition of good physical, mental and social well-being [1]. This definition has led to significant changes in the perception of health, the formation of health policies and health practices. Life span has been prolonged, child mortality has decreased, and poverty has been reduced despite the growing population. These achievements are a result of major advances in public health, health care, education, human rights, agriculture, infrastructure and technology. Our planet has supported this development with its ecological and biophysical systems; enabling people to access resources with vital resources such as clean air, food, potable water and energy. However, it is clear that these sources are not limitless. As a result of human activities, there is increasing evidence that environmental changes involving the entire planet have emerged, and that our planet has gradually lost its power to support human health.

 

Plantary Health

 

It is clear that natural systems cannot protect human health without ensuring sustainability. Human health is now linked to the successful coexistence of the natural world and social life. This new approach, called planetary health, points out not only the requirement of health care providers but also different sectors to take responsibility in the protection and development of health [2-4].

Planetary health is part of the “Human, Society & Planet” course in IUE-FoM training program. We believe that this program, which deals with the effects of environmental changes on human health, its results, solutions and obstacles, will contribute to the training of physicians who approach health in a holistic manner.

 
 

Health protection and improvement

 

Approaches that center the patient and prioritize patient safety in the provision of health care construct the basis of "good medical practice" [5]. For this reason, patient safety is an important component in the IUE-FoM training program and its applications. In this context, from the very beginning of the medical education, the trainings were designed to enable our students to perform risk management. For example, potential risks and safeguard measures are constantly addressed throughout laboratory practices. In the following years, the WHO-recommended patient safety curriculum has been integrated into the program [6]. This program contains accurate and timely reporting of laboratory results, infection control and antibiotic use programs, blood and blood product transfusion programs, prevention of catheter-related infections, surveillance, prevention of wrong side processes (removal of left kidney instead of right, etc.), preventive applications of patients to fall and related training as well as the other managerial processes.

 

Health protection and improvement

 

The effects of environmental factors on human health and the lifestyle preferences that are added to them lead to a number of health problems, including obesity, diabetes, and some neurological and mental problems. A significant portion of these problems, which create a serious economic burden on the health care system, can be avoided. For this reason, IUE-FoM prioritized educating physicians who are knowledgeable about healthy living preferences, able to reflect them on their own behaviours, and to be able to lead this issue. Topics such as healthy nutrition, exercise and stress management have been integrated into the medical education program. Our students are expected to pass on the information they have learned to families and to gain experience from the first hand in the fieldwork.

 
 

Personalized medicine

 

Personalized or, in other words, precision medicine represents a new insight into the genetic differences of individuals in the treatment of diseases. IUE-FoM treats the concept of personalized medicine as an approach not only for treatment choice but also for all areas affected by genetic differences such as nutrition, exercise, etc. This concept has been integrated into the IUE-FoM program to include genetic diversity and its effects.

 
 
 

Our Medical Education approach

 

IUEFoM (Izmir University of Economics Faculty of Medicine) aims to raise good physicians who can respond to the changing health problems and expectations of our country and the world. The 12 basic principles used for structuring the medical education in line with this objective and how they will be addressed in this context are defined below.

Community health needs are defined at local, national and international levels. For health problems at the local level, we contacted İzmir Health Directorate, İzmir Public Health Directorate, İzmir Metropolitan Municipality and İzmir Chamber of Medicine. The National Core Training Program (NCTP) has been considered for the national level. In addition, we communicated with the Ministry of Health and the Turkish Physicians Union. For the international level, information has been compiled from the World Health Organization (WHO), eCDC and CDC sources. IEUFM aims not only to manage diseases but also to raise effective and trained doctors in terms of protection and development of health. For this reason, the themes such as nutrition, exercise and stress management have been integrated into the curriculum.
The area of “Scientific Foundations of Medicine” consists of three separate "Foundations" blocks in semesters 1, 2 and 4. The first is the "Molecular, Cellular and Genetic basis of Medicine" block at the beginning of the first semester. This block constitutes the first phase, in which the normal structure and function of the organ systems will be discussed until the end of the first half of the second semester. This phase will end with a "life cycle" block. In addition to the biological and psychological stages in a life cycle from birth to death, we will discuss the measures to be taken to protect health.

​ The second foundations block is the "Mechanisms of defense and disease" block at the beginning of the second part of semester 2. During this block, the main pathology, medical microbiology, immunology, cancer and pharmacology topics will be discussed will be followed by the organ systems blocks which will discuss the abnormal structure and function that will last until the end of this block period 3. The last part of the third phase will be the "Life cycle" block, which is an integration block, in which the most common pathologies specific to age in a life cycle extending from birth to death will be discussed. The third foundations block is the 8-week "Introduction to Diagnostic & Therapeutic medicine" block. This block is at the beginning of the 4th semester, focuses on diagnostic medicine, medicolegal problems and therapy. Please click for the curriculum map.

​ Another sub-domain which will continue throughout the curriculum is "Research and Information Management" (RIM), which will enable students to learn critical thinking, research methods, biostatistics and evidence-based medicine concepts and series of activities to apply them to experimental / social research.

​ The "Introduction to diagnostic and therapeutic medicine" block at the beginning of semester 4 is an introduction to evidence-based medicine. Evidence-based medicine will be made a part of everyday clinical practice, such as using web-based resources (e.g. Medscape).

Bioethics education has been integrated as one of the main components of the curriculum throughout all periods. In semester 1, the students will discuss critical concepts of ethics (ethics, values, culture and norms), basic ethical values (truth and honesty, trustworthiness, respect, responsibility, justice, benevolence and care, citizenship). Phase I will focus on the discussion of real life practice examples of basic ethical values. Phase II is an introduction to bioethics, including medical ethics. In this context, the main issues of medical ethics such as First do No Harm, observing patient benefits at all times, autonomy, privacy will be discussed first. The same problems will be discussed later with in cases.

​ In the life cycle block at the end of Phase II, issues such as reproductive ethics (pregnancy rights, abortion, etc.), vaccination, children's rights, medical research, end-of-life problems will be addressed with cases. During the semester 4 and 5, monthly "reflection" meetings will be held with the students to discuss the medical problems and their ethical dimensions in the clinic. The goal of this phase is to improve the ability to interpret events in the framework of basic ethical principles.
The IUEFoM curriculum is based on five core competencies. These include: medical knowledge and lifelong learning, patient-focused medical care, communication skills and teamwork, professionalism and ethics, health systems and health advocacy. Period-specific milestones are defined for each of these areas. These qualifications are defined in the curriculum as "Scientific Foundations of Medicine", “Clinical Foundations of Medicine” and "Human, Society and Planet" areas (courses). Click for the curriculum map.

​ In discussing the basic values of ethics in the "The Human Body" block at the beginning of the semester 1, they will also get introduced to the core competencies for all students and staff of the IUEFoM. General competencies will play a leading role in terms of developing competencies for students' professionalism. This role will be reinforced by daily applications start of classes on time, zero tolerance to copy, mutual respect, etc.), and will be strengthened with reading and discussing the books on medicinal profession. Among the books to be read in this context are "Adventures in Human Being: A Grand Tour from the Cranium to the Calcaneum" and "Do No Harm. Stories of Life, Death and Brain Surgery ".

​ The training on professional and communication skills will be carried out in the "Clinical Foundations of Medicine" program during the first three semesters. This program will be carried out mostly in the "Clinical Skills & Simulation Center (CSSC)". In this center with advanced technology mannequins, models and simulators, our students will be able to apply all the skills and processes in the curriculum until developing a qualification, in a safe and supervised environment.

​ Medical students need to be equipped with medical law, health related basic legal regulations, as well as administrative tools to obtain qualification in the field of management. These include process and risk management and conflict management. We envisaged that, process and risk management training will deepen students' understanding of medical risk assessment and prevention measures.
One of the most important paradigm shifts in education is that, educator-centered education left the centre stage to an education model with students at its centre. Student-centered education (SCE) can be defined from different perspectives. For example, learning experiences that support different learning needs of students can be achieved with an approach including educational strategies and academic support strategies. Izmir University of Economics offers personalized learning opportunities to its students through its Blackboard Learning Management System with integrated Panopto infrastructure. In addition, the assessment-evaluation system, which will be implemented in IUEFoM, is structured so that students will recognize the improvements they need to make to achieve the learning objectives during the process. This organization is aimed to increase the efficiency of the learning process by integrating it with an effective consulting system.

​ One of the two most important components of “qualification-based education” is that it is based on outputs and the other is being student-cantered. The second feature of this education approach is that it accepts the different temporal needs of individuals in terms of adequate learning. A part of the “Clinical Foundations of Medicine” program in IUEFoM is based on competencies in longitudinal medical experiences and offers the students the opportunity to be competent at their own pace for each skill. This program is not graded; the assessment is based on a satisfactory-unsatisfactory criterion. Students continue their training and evaluations until they demonstrate competency within a defined period of time, deemed satisfactory.

​ On the other hand, it defines a model in which the students of the SCE learn their own learning responsibilities and play an active role in the realization of the learning activities. Problem based learning (PBL), team-based learning (TeBL), task-based learning (TaBL), and research projects are in the centre of student-centered learning. The IUEFoM adopts a hybrid education model. This model offers rich learning opportunities, including presentations as well as educational activities as listed above. The presentations at IUEFoM are organized in interactive, real-life-related examples and are designed in such a way that students can participate effectively in the learning process. The clear and defined learning objectives of each educational activity, the provision of ample reading resources on topics and plenty laboratory practices will ensure that the learning process is more efficient.

​ Effective learning processes are also indispensable for our students to improve their competencies in terms of being lifelong learners and self-improving physicians.

​ The IUEFoM aims that students should closely monitor their problems, solve them as soon as possible, establish an open and mutually respectful relationship among the trainers, and that all these are sustainable as part of student-centered education.
IUEFoM accepts the definition of Health as the World Health Organization definition, it is not only a lack of disease, but as a state of full well-being, including physical, mental and social aspects. In this context, biological, economic, social, environmental and political determinants of health are considered. In Medical Education, the effects of these determinants on Health should be considered as a whole. Health determinants in the IUEFoM curriculum will be discussed in detail in the PBL sessions and Life cycle block, as well as in the "Human, Society & Planet" course.

​ In life cycle block at the end of Phase I and II, how health determinants affect all stages of life from birth to death will be integrated through model illnesses and health problems.
IUEFoM considers that medical education completed only at tertiary level hospitals offer limited experience for preparing medical students to work in different environments when they graduate. IUEFoM, in this context plans to use primary and secondary level health institutions, municipal sanitation, drinking water sanitation services, garbage collection and disposal areas, private doctor's offices, pharmacies, elderly care centers, nurseries, detention centers in the training for different learning experiences.

​ The longitudinal medical experiences program in the curriculum is intended to bring such experiences in a structured way. Within the scope of this program, students will be given families to follow for six years starting from their first semester. The team, consisting of two medical faculty students and a nursing student, will monitor 2 to 4 families within their responsibilities for 5 years. In this practice named “Family Health Program”, the students in the first 3 years of their medical education will observe the families for lifestyle choices such as shelter, nutrition, exercise and addictions in the environment they live, and are expected to give training and advice about their health preservation and development. This program will be integrated with Family Physicians, aims to provide first-hand experience to medical and nursing students in community health issues, acquire knowledge of health preservation and development and gain knowledge and experience in health education training and experience the teamwork in the early stages of education.
E-learning has started to be widely used in medical education in recent years. IUEFoM will effectively use e-learning opportunities in education. For this purpose, we have created the "e-Medicine" platform, which will use Blackboard Learning Management System ™ (BLMS), and provides students with presentation materials, reading materials, educational materials such as videos in digital media form. This platform will allow students to access educational materials on BLMS as well as web-based educational materials that have been verified and approved by educators.

​ Students will also be encouraged to access online open access courses such as Coursera ™ and FdX ™. Among the courses to be determined by the educators, the students could choose what they want as elective courses.

The characteristics of educational environments and culture (climate) significantly affect the quality of education. The institutional climate, also called the secret curriculum, is particularly influential in the development of professional identities of students and in their preferences for occupational practice. Thus, general core competencies have been defined for all students and staff of the IUEFoM. A managerial structure will be established to encourage all employees to adopt these behaviours.

In the "clinical integration & reflection" program (CIR), which is progressing parallel to the clinical internships in the semesters IV and V, students will get through a period which they will be able to question and share their clinical experiences along with problem based (PBL) or the case-based learning (CBL) and medical decision-making applications.
Medicine requires interdisciplinary and interdisciplinary cooperation. In this context, medical students must conceptualize the importance of teamwork and develop an understanding of the role of team members. As an institutional philosophy, IUEFoM sees all the health-related faculties and schools within the IUE as its own partners and regards them as part of the same ecosystem. Shared applications for medical, nursing and SMYO students are planned as a reflection of this philosophy. “Student Clinic” practice is an example for this. This practice aims to enable team members to perform their duties effectively through some medical situation scenarios.

​ "Peer-to-peer" applications will be implemented to enable students to experience the importance of collaboration with non-medical fields, to improve their problem-solving and entrepreneurial skills. This practice aims to accommodate medical students to collaborate with other students in the IEU for the solution of determined problems.
Assessment and evaluation deeply affects learning. Evaluation is systematic data collection to assess the success of a program or course in terms of achieving the learning objectives foreseen for the students. Formative evaluation indicates that collected data will be used for the purpose of creating or revising an educational initiative. It is also used to monitor students' learning and create an opportunity for self-improvement. Summative evaluation is used to assess outcome achievement or to decide. By means of students, it means the determination of learning levels (according to a standard) within an educational activity. A standardized, reliable method which is appropriate for the level of learning outcome and measured competency, should be employed for the collection of data (measurement) which will be used for evaluation. Using different methods increases reliability.

​ Grades from multiple choice, true false, gap filling, match making, short case examinations as well as quizzes, assignments, Objective Structured Practical Examinations (OSPE) prepared according to learning levels are taken for consideration in the scientific basis of the medicine program.

​ Tıbbın bilimsel temelleri programında öğrenme düzeyine göre çoktan seçmeli, doğru-yanlış, boşluk doldurma, eşleştirmeli, kısa olgu tarzı sınavlar yanı sıra, kısa sınavlar (quiz), ödevler, eğitsel etkinliklere katılım, nesnel yapılandırılmış uygulama sınavları (NYUS) (Objective Structured Practical Examination, OSPE), vb ögelerden alınan puanlar değerlendirmeye katılır. Tıbbın klinik temelleri programı yeterliliklere dayalıdır. Dönem 3’de simüle hastalar aracılığıyla biçimlendirici değerlendirmeler ve Nesnel Yapılandırılmış Klinik Sınavlar (NYKS) (Objective Structured Clinical Examination, OSCE) ile değerlendirilecektir.

​ Longitudinal Medical Experience (LOME) will be assessed with monthly progress reports, feedbacks from families and partners, project reports, medicine logs etc.

​ IUEFoM prefers to evaluate with a portfolio rather than the traditional approach in which decisions are made with a single exam. We see the portfolio as a collection of evidence chosen by the student to demonstrate his own efforts, development and achievements. There are two types of portfolio in the IUEFoM training program. First is the “course portfolio” which covers a course’s whole assessment and evaluation process except form examination and second is the “graduation portfolio” which consists of the evidence of best clinical practices that are collected throughout six years of education.

​ The "Course Portfolio" consists of collection of personal achievements and homework that are structured by lecturers. The personal achievement collection is a portfolio component that helps the student support achieving course outcomes with his / her selected activities outside the educational program. Students will participate in the activities which they find useful for achieving learning outcomes (such as reading books, reviews and articles, attending courses, webinars, seminars, conferences, symposiums, concerts, theatres, research and social responsibility projects and voluntary internships) and will contribute to their own assessment and evaluation by uploading reports that explain the activities’ contribution on education. We think that personal performance collection is important in terms of learning-centred learning.

​ “Graduation Portfolio” is a document which consists of the best evidence that is formed and selected by the student proving he or she is a good physician and/or a researcher. Students can build their graduation portfolios on e-MED and they can move these portfolios to different digital platforms.

Preparation for international exams IUEFoM is the first Turkish university to become a member of “UCAN’s Medical Faculty Network”(https://www.ucan-assess.org/cms/networks/medical-faculties/ )which was initiated by Heidelberg University Faculty of Medicine and gradually spreading throughout European Union. Through this network, our students will have access to the content of examinations held at medical faculties in EU countries.

We are also in contact with National Board of Medical Examiners for preparation for USMLE which is required for practicing medicine in northern American countries (USA and Canada). Clinical Practices which forms the 3rd phase of education will be evaluated with short case (vignette) type questions, OSPEs and other question formats (see above). In addition, attendance to CIR session will also be taken into account.
Increasing knowledge and experience in areas of interest to medical students is important for future career choices. For this purpose, the IUEFoM provides tracks for willing students to choose from the beginning of term II. “Research” track is for students willing to do biomedical research and “social” track is the option for the students interested in social aspect of health.

The research track track is for students who want to be "physicians-scientists" in the direction of biomedical sciences and translational medicine themes. Participation of our students in national and international projects will be encouraged and supported in order to contribute to development of their knowledge and skills. Our students will be members of a research group led by faculty members from within or outside the institution and will be co-authors of scientific studies in proportion to their contributions at the end of the process. Moreover, research activities will be indicated in the overall success evaluation and in transcripts.

Social track is for our students who are interested in the field of human – society – planet and first step health services. Students who choose this pathway will be involved in activities under the supervision of the instructors in the field, either through research or projects. They will be able to find opportunities to observe issues related to community health with domestic and international tours. In addition, during the first three years, our students will be able to take different elective courses offered at the university. In clinical years, we offer elective internships to be held either in our own hospital or in other health institutions.
For lifelong learning, students should learn how to learn, identify areas of interest and curiosity, learn to love, conceptualize work basics, read aloud, deal with topics outside of their field, create observations, ask questions, think about what they learn, practice what they learn. Even though there is a lifelong personal motivation, it is possible to develop this mentality by creating appropriate training strategies, assessment and evaluation approaches, supportive and enjoyable learning environment, plenty of reading opportunities, practice and teaching opportunities. IUEFoM believes that it will make a significant contribution to the acquisition of lifelong learning competence with the applications for the previous principles.
 
Resources
  1. WHO. Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June 1946, and entered into force on 7 April 1948.
  2. Lang T, Rayner G. Ecological public health: the 21st century’s big idea? An essay by Tim Lang and Geof Rayner. BMJ 2012;345: e5466.
  3. Horton R, Beaglehole R, Bonita R, Raeburn J, McKee M, Wall S. From Public to Planetary Health: A Manifesto. Lancet 2014; 383; 847.
  4. Whitmee S, Haines A, Beyrer C, et al. Safeguarding Human Health in the Anthropocene epoch: report of The Rockefeller Foundation- Lancet Commission on planetary health. Lancet 2015; 386: 1973-2028.
  5. Promoting excellence: standards for medical education and practice. General Medical Council. 2015.
  6. http://www.who.int/patientsafety/education/curriculum/en/ (7 Mayıs 2017 tarihinde erişildi)