Medical education in difficult circumstances: analysis of the experience of clinical medical students following the new innovative medical curriculum in Aksum, rural Ethiopia

Medical education in difficult circumstances: analysis of the experience of clinical medical... Background: In 2012, 12 medical schools were opened in Ethiopia to tackle the significant shortage of doctors. This included Aksum School of Medicine situated in Aksum, a rural town in Northern Ethiopia. The new Innovative Medical Curriculum (NIMC) is a four-year programme designed by the Ethiopian Federal Ministries of Health and Education. The curriculum is designed to train biomedical science graduates to become doctors in 4 years, with a focus on the healthcare needs of rural people living in poverty. Methods: This research was conducted at Aksum School of Medicine and included two hospitals (Aksum Referral Hospital and St Mary’s District Hospital). This study focused on medical students during their clinical years across multiple specialities (61 Clerkship 1 students and 13 Clerkship 2 students). We used primarily qualitative research methods supplemented with quantitative measures. There were 3 stages of data collection over a 1 month period, this included qualitative group interviews, direct observation of students in a clinical setting and direct observation of skills sessions followed by a questionnaire on the sessions. We analysed the data by reconstructing the student experience and comparing it with the NIMC. Results: The proposed typical week set out in the NIMC tended to differ from the real clinical experience of these students. Through qualitative group interview and direct observation of teaching, the main theme that was consistent throughout was the lack of doctors with specialist postgraduate training. Clinical need often took priority over education. However, students enjoyed taking early responsibility and gaining practical experience. Through direct observation of skills sessions and short questionnaires, these sessions were highly valuable to the students and they felt confident in carrying out the taught procedures in the future. Conclusions: The combination of poorly resourced hospitals and lack of specialist doctors provides a challenging environment for medical students to learn. However, it is a unique clinical experience that is rarely seen in developed countries and facilitates the acquirement of skills from an early stage. Supervision and specialist input is fundamental in enabling students to learn and this is a key area that was lacking in the students’ clinical experience. Keywords: Curriculum, Medical education, Clinical experience, Africa * Correspondence: c.a.morgan@smd13.qmul.ac.uk Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, EC1M 6BQ, London, UK Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Morgan et al. BMC Medical Education (2018) 18:119 Page 2 of 8 Background Research design Ethiopia is a country with a severe shortage of doctors We evaluated the experience of clinical students using especially in the rural areas [1]. According to the World qualitative methods supplemented with quantitative Health Organization (WHO), in 2010 the doctor to pa- measures. The research was conducted at Aksum School tient ratio in Ethiopia was 1:42,706, which is among the of Medicine and included two hospitals (Aksum Referral lowest in sub-Saharan Africa [1]. The WHO established Hospital and St Mary’s District Hospital). The research a critical threshold of 23 doctors, nurses and midwives included 61 C1 students and 13 C2 students. per 10,000 population as a minimum to enable the deliv- There were 3 stages of data collection, which we com- ery of essential maternal and child health services, yet pleted over a 1 month period: they found this figure to be 3 per 10,000 in Ethiopia [2]. Furthermore, it is estimated that 43% of doctors work in 1) Qualitative group interviews Addis Ababa (the capital of Ethiopia) despite only 5% of 2) Direct observation of students in a clinical setting the population living there [1]. The severe shortage of 3) Direct observation of skills sessions followed by a doctors in Ethiopia could be attributed to several rea- student questionnaire on the sessions sons including the emigration of qualified doctors, lim- ited number of medical schools, and difficulty in We completed Stages 1 and 2 over a 2-week period. accessing education [3]. Stage 1 consisted of eight structured group interviews, Aksum is a town in Tigray, Northern Ethiopia with an involving 2–4 participants per interview. We conducted estimated population of 66,800 people [4]. Aksum the interviews using a convenience sample of available University Faculty of Health Sciences was opened in students in the clinical area. We used this method as it 2012 along with 11 other medical schools to tackle the allowed the students to decide if they wished to partici- significant shortage of doctors in Ethiopia. The New In- pate, any students who wanted to participate were in- novative Medical Curriculum (NIMC) is a four-year cluded in the study. It was not possible to pre-arrange programme designed by the Ethiopian Federal Ministries interviews with the students due to network and power of Health and Education [5], which has been in place in outages which sometimes lasted multiple days making Aksum since 2012. There have been 4 years of clinical communication and organisation of meetings very students on the course, with the first cohort of students difficult. graduating in 2016. The curriculum is designed to train We used an interview guide that covered the students’ biomedical science graduates to become doctors in experience in Ophthalmology, Dermatology, Obstetrics 4 years, with a focus on the healthcare needs of rural and Gynaecology and Surgery. CM and MT developed people living in poverty. the guide after discussion with senior faculty members The four-year curriculum is split into two pre-clinical from Aksum University and review of the NIMC. We years and two clinical or clerkship years, known as asked the students to describe their current clinical ex- Clerkship 1 (C1) and Clerkship 2 (C2) (see Fig. 1). After perience, including details of their attachment and their these 4 years, the students will then undertake an intern- average day. We also asked what they felt worked well ship year. Upon completion of each academic year there on their attachment and areas that could be improved. are examinations and at the end of C2, the students sit The lead researcher (CM) attended both hospitals their final qualifying examination. (Aksum Referral Hospital and St Mary’s District Hos- There is known to be variation in clinical teaching ex- pital) alternating sites over a two-week period to carry perienced by medical students and that this often differs out the structured group interviews alongside a General from the curriculum intended to be delivered [6, 7]. Practitioner from Aksum (MT). CM and MT conducted However, evidence has shown the benefits of implement- these interviews together in the morning after locating ing a monitoring system that allows comparisons to be the medical students in the relevant departments within made across specialities and hospitals. This also allows the hospital. The morning was the time when the high- the identification of areas that are lacking in the stu- est number of students were present. The lead re- dent’s clinical experience [8–10]. To our knowledge this searcher (CM) collected the data through note taking. is the first paper examining the implementation of the The Aksum GP was known to the students which en- NIMC in Ethiopia. abled a strong rapport and trust to be built during the interview. Methods We obtained verbal consent prior to interviewing the The aim of this research is to identify and describe the students and all data was anonymised to maintain confi- real-world experience of the clinical students following dentiality. We retained a written register of the students the NIMC at Aksum and compare this to the proposed who verbally consented. We offered the students the curriculum experiences and outcomes. choice of participating and we explained that it would Morgan et al. BMC Medical Education (2018) 18:119 Page 3 of 8 Fig. 1 An overall summary of the curriculum taken and adapted from the New Innovative Curriculum [NIMC] document not affect their training in any way if they chose not to & KS) collected data by observational note keeping. A participate. We also obtained verbal consent from the debrief was undertaken after each session. The re- consultant in charge of each department prior to direct searchers (RB & KS) then compared the notes, collabo- observation and interviews. All interviews and teaching rated findings and any differences were discussed. Both sessions were conducted in English, which is the same medical students (RB & KS) were present at all skill ses- language the students are taught in. In Stage 2, CM ob- sions. The survey consisted of the following 5 questions served a selection of students, based on convenience (based on a Likert-type scale): sampling, in the clinical environment. This involved both hospital wards and outpatient clinics. CM made Q1) How useful did you find the teaching? observational notes to compare with the described stu- Q2) Did you feel the teaching was right for your dent experience in the NIMC. We obtained ethical ap- level? proval from both Aksum University and Queen Mary Q3) How confident would you be in using the skills University of London. All researchers had received train- you learnt in the session? ing in collecting qualitative data. Q4) Was the session well organised? Two medical students (RB & KS) carried out Stage 3 Q5) What other aspects of this topic would you like of data collection. This involved direct observation of to see included? skills sessions using a structured observation teaching form, followed by an evaluation of the students’ experi- Data analysis ence using a cross-sectional survey. We anonymised the The lead researcher (CM) collated the observational survey to maintain the students’ confidentiality. We (RB notes from the three researchers who had taken notes Morgan et al. BMC Medical Education (2018) 18:119 Page 4 of 8 (CM, RB & KS) into a written document. This data in- Clerkship 1 cluded qualitative group interviews, direct observation Sixty-one medical students were studying Dermatology of teaching and direct observation of skills sessions. The (30) and Ophthalmology (31) at Aksum Referral lead researcher (CM) developed deductive codes which Hospital. The students were split into two groups and were derived from the interview guide, these included then into further subgroups of approximately 8, each ‘positive experience’, ‘areas for improvement’ and ‘struc- student spent 3 weeks on Ophthalmology and 3 weeks ture’. CM then developed inductive codes from further on Dermatology. Aksum Referral Hospital had just re- reading and analysis of the data. These included ‘super- cently opened and all clinical exposure was outpatient vision’, ‘teaching’, ‘level of responsibility’ and ‘workplace based. There was one specialist Ophthalmologist and dynamics’. Coding of the data allowed common themes one specialist Dermatologist. An average day would in- to be identified. The lead researcher (CM) then placed volve teaching by the specialist in the morning, via a the data into different categories, consisting of headings PowerPoint presentation that was then followed by a and subheadings which involved the year and speciality clinic. Groups had to have at least 1 day per week away of the medical students. CM then mapped the data to from the clinical environment due to there being only the NIMC. We categorised the data in this way as it one specialist in each department and 61 students. allowed conclusions to be drawn and recommendations to be made to the faculty leadership and individual de- Ophthalmology From direct observation, the ophthal- partments. Using the Likert-type scale, researchers RB mology clinic consisted of the ophthalmologist, specialist and KS collated the results from the cross-sectional sur- nurse and medical students. There was one ophthalmo- vey into a simple bar chart. An experienced qualitative scope in the department used by the specialist and a slit researcher (TCB) checked the data analysis and coding lamp; the students used a torch and goggles to examine framework. This helped to ensure reliability in the data the eyes. Jointly the students would take a very brief his- analysis and credibility of the coding. TCB identified any tory from the patient with the nurse. There appeared to discrepancies in the coding and revisions were made. be a good relationship between the specialist nurse and the students, allowing the students time to examine the Results patients. The students would then observe the ophthal- Stage 1 (qualitative group interviews) and stage 2 (direct mologist who at times gave teaching. The relationship observation of teaching) between the students and ophthalmologist appeared The main theme that was consistent throughout was the strained, primarily due to the clinical work load. From lack of doctors with specialist postgraduate training. Stu- observation, it was clear that the students were being ex- dents enjoyed being taught by specialists when available, posed to a wide variety of ocular pathology with ad- however, there were different levels of engagement vanced clinical signs. During the interviews the students across the different specialities. This was often due to spoke about the lack of hard copy Ophthalmology text- clinical need taking priority over education and special- books in the library and their reliance on a limited Inter- ists having to leave to attend emergencies, particularly in net connection for resources. They also spoke about the case of Surgery and Obstetrics. There was often poor their desire to learn how to use equipment such as an access to basic teaching materials such as ophthalmo- ophthalmoscope. scopes and specialist textbooks. However, students enjoyed taking early responsibility and gaining practical Dermatology The dermatology clinic comprised of the experience, for example delivering babies and perform- dermatologist and the medical students. From direct ob- ing minor surgical procedures. The proposed typical servation, approximately 8 students stood around the pa- week set out in the NIMC for C1 and C2 students (see tient and the students were asked to take a history from Table 1) tended to differ from the real clinical experience the patient, formulate differential diagnoses and consider of these students. appropriate investigations. Possible management plans Table 1 A proposed typical week in Clerkship 1 and 2 taken from the NIMC Time Monday Tuesday Wednesday Thursday Friday 8am – 10 am Lecture (C1) / Lecture (C1) / Social and Lecture (C1)/ Primary Health / Morning session (C2) Morning session (C2) Population Health Morning session (C2) Community attachment 10 am-12:30 pm Bedside teaching Inpatient/ outpatient care Inpatient/ outpatient care Bedside teaching 12:30 pm- 2 pm Lunch Lunch Lunch Lunch Lunch 2pm–4 pm Inpatient/ PCD Inpatient/ Inpatient/ Whole group session seminar/ outpatient care outpatient care outpatient care journal club/grand round 4 pm-5:30 pm Inpatient/ outpatient care Morgan et al. BMC Medical Education (2018) 18:119 Page 5 of 8 were then discussed with the students. From observation, and experience was important in preparing them for the dermatologist appeared highly motivated with a pas- their internship year. sion for teaching. The dermatologist ensured all students were involved in the teaching and reading materials were Obstetrics and Gynaecology The responsibility given given prior to the clinic. Much like Ophthalmology, when to these final year medical students was significant. interviewing the students, they spoke about limited access There was one specialist across the entire department. to textbooks and difficulty accessing online resources. The students were running their own clinics and admit- However, they enjoyed seeing a wide variety of dermato- ting, managing, prescribing medications and discharging logical conditions and were very positive in regards to the patients (see Table 2). They were also performing surgi- dermatologist. cal procedures such as manual vacuum aspiration with- out supervision. The students were using forceps and Clerkship 2 ventouse devices supervised by midwives as well as de- Thirteen students were on the Emergency Surgery and livering babies unsupervised. They were also managing Lifesaving skills module at St Mary’s District Hospital emergencies such as postpartum haemorrhage, which Aksum. This is a 12-week module made up of 6 weeks was observed during the data collection. There appeared of Surgery (6 students) and 6 weeks of Obstetrics and to be a good relationship between the students and the Gynaecology (7 students) and is the final module before specialist, with morning meetings approximately three they sit their final qualifying exam. The students were times a week to discuss current and difficult cases. The split into two groups and rotated after 6 weeks. students also appeared to be well supported by the mid- wives. During group interview the students commented Surgery There was one general surgeon covering the that often the specialist had to leave the hospital due to entire hospital and the different surgical subspecialties. obstetric emergencies in other rural health centres The students’ surgical rotation was split into 2 weeks of where the patients were unable to access transport to theatre and 4 weeks of ward work. Theatre involved the hospital. However, the time spent with the specialist, assisting in major surgery, involving all sub surgical sub- medical students found very valuable to their learning. specialities, which included plastics, vascular, orthopae- dics and paediatric surgery. They also undertook minor Stage 3: Direct observation of skills sessions followed by procedures unsupervised, such as draining abscesses. a short questionnaire From direct observation on the wards the students The skills sessions consisted of 60-min-long tutorials, would clerk patients, prescribe medications, consent pa- delivered by two senior clinicians from the obstetrics de- tients for surgery and manage uncomplicated patients. partment, to groups of 15 students. The sessions were From group interview the students sometimes felt over- conducted in a well-equipped skills lab. The content of whelmed by the responsibility given to them and the the session would be oriented to lecture based teaching number of unwell patients. They also found the working that had been delivered by residents in the same week. conditions hard, these included no running water in the For example, on a week discussing termination of preg- hospital and lack of basic medical supplies. However, as nancy, the skills session was to familiarise students with they were in their final year, they felt this responsibility manual vacuum aspiration. These topics would also be Table 2 Typical day for a final year medical student on Obstetrics and Gynaecology reconstructed from direct observation and student interview Time Typical day for a final year medical student on Obstetrics and Gynaecology Rotation 7:30 am Arrive at St Mary’s Hospital via mini-bus. 8am – 9 am Morning meeting led by the specialist [twice a week] to discuss complicated patients and deliveries. 10 am–11 am Ward round – led by specialist [twice a week], other times carried out by masters students or the medical students without supervision. 11 am – 12 pm The 6 students would split off – 2 would run the outpatient clinic, 2 would be on the general ward, 2 would be on labour ward with little or no supervision 12 pm–1 pm Mini-bus would take the students back to their accommodation for lunch. 1pm–5 pm The students would continue in their designated areas. The students on labour ward were also able to go to theatre. Twice a week the students would have a tutorial where they would take turns at presenting a topic to the other students and specialist. 5pm–6 pm The mini-bus would take the students back to their accommodation. 6 pm-8 am Each student would work one night and one Saturday or Sunday per week – known as ‘duty’. They would then stay at the hospital the following day after a night duty. Morgan et al. BMC Medical Education (2018) 18:119 Page 6 of 8 selected based on feedback from previous students who had struggled with this area in their assessments. The initial skills session would act more as an interactive tu- torial, establishing the students’ prior knowledge and introducing them to the equipment generally, before be- ing followed by a supervised practice session. These skills sessions were well received by the stu- dents who mostly had little or no prior experience of the procedure being taught (Fig. 2). The interactive nature of each session, in addition to students receiving feed- back and being supervised while practicing resulted in 91% of students reporting feeling either confident or Fig. 3 A bar chart showing the confidence of students using the very confident to carry out the procedure in the future skills learnt in the session (n = 11) (Fig. 3). Four students did not respond to the questionnaire. Medical student comments were also broadly positive students are clinically competent in certain procedures about the session stating that it was “necessary” and when graduating medical school, which is something should be “continued” while also seeking further oppor- that could be implemented into the NIMC. tunity to practice, either in the skills lab or on patients. Furthermore, Fig. 1 clearly demonstrates the summary of the NIMC for each year. However, what should be Discussion noted is that Dermatology and Ophthalmology are spe- The combination of poorly resourced hospitals and lack cialties that are timetabled for C2 students. However, of specialist doctors provides a difficult environment for during the data collection period, the C1 students were medical students to learn. A shortage of specialist doc- on Dermatology and Ophthalmology attachments. The tors is a huge problem across Ethiopia, especially in rural faculty of medicine in Aksum explained this change was areas such as Aksum. Supervision is fundamental in en- due to the difficulty in recruiting specialist doctors to abling students to learn and progress into safe clinicians deliver parts of the curriculum, for example in Radiology [11] and this is a key area that was lacking in the stu- or ENT. Therefore, they had to reach a compromise and dents’ clinical experience. This highlights the urgent since there was a specialist Dermatologist and Ophthal- need for more specialist doctors or trainee specialists in mologist available, they decided to deliver these areas areas such as Aksum, alongside stronger guidance on during C1 instead of C2. This highlights the difficulty in medical students’ duties and responsibilities. Neverthe- delivering a curriculum in a developing country and the less, it should be remembered that the NIMC was put in challenges that need to be overcome. However, it also place to address this shortage of doctors, therefore there demonstrates the forward thinking of the Aksum leaders is not a quick fix to this problem but a longer-term in their ability to quickly adapt to the circumstances and strategy in place. A recent study at a medical school in to deliver successful modules in Dermatology and Tanzania has identified the need for the curriculum to Ophthalmology. A study carried out in Kenya evaluating clearly specify the level of competence required for per- the quality and relevance of curriculum development in forming certain procedures [12]. This ensures the health training, found that there are major gaps in the quality and adequacy of the training [13]. The study also highlighted the need for a national standard framework to guide curriculum review. A common theme that should be discussed is the dif- ferent levels of engagement from the specialist doctors. Each department had only one specialist which placed enormous strain on these doctors. St Mary’s, a 150 bed district general hospital in Aksum is estimated to serve 1.5 million people. The burden of disease in Ethiopia measured in terms of premature death is estimated at 350 disability adjusted life years lost per 1000 popula- tion, which is the highest in Sub-Saharan Africa [14]. The combination of the disease burden and one special- Fig. 2 A bar chart showing the students previous experience of the ist per department often leads to specialists being called skills being taught (n = 11) away to emergencies. This can lead to students being left Morgan et al. BMC Medical Education (2018) 18:119 Page 7 of 8 on the wards unsupervised potentially placing them- Access to basic teaching materials for specialities such selves in difficult situations. However, overall the stu- as Ophthalmology and Dermatology are very important dents seemed to have a very positive approach to these in the students’ learning and their absence was a com- circumstances and were happy to take on the added re- mon theme highlighted by the students. This was the sponsibility and adapt to meet the patient demand. first time that Aksum Referral Hospital had Dermatology Other healthcare professionals such as specialist nurses and Ophthalmology teaching clinics for the students as and midwifes were also very supportive of the students, the hospital had recently opened and these departments demonstrating a team approach in providing the best pa- were the first to become operational. The medical school tient care possible with the limited resources available. recruited the patients for the clinic by organising a cam- High levels of responsibility and a huge disease burden paign in the week prior to the clinic. This involved an can be advantageous to a medical student’s education. individual with a ‘megaphone’ driving up and down the Exposure to tropical diseases such as Leishmaniasis and main road in Aksum inviting anyone who had any eye patients consistently presenting at extremely advanced or skin problems to come to the hospital. This again stages of disease is a unique experience that is rarely demonstrates the creativity of the medical school in seen in developed countries. This allows Aksum medical organising and delivering the curriculum. As more students to continue to develop their history and exam- departments open this will provide invaluable learning ination skills and formulate diagnoses without becoming opportunities across different specialities for the medical dependent on investigations. The Aksum students students. It is important that Ophthalmology and enjoyed gaining practical experience which involved Dermatology resources including textbooks are available delivering babies and performing minor surgical opera- for the students to help consolidate their learning. tions. A study carried out in Tanzania found that Investing in equipment such as ophthalmoscopes and clinicians felt clerkship students should be performing teaching the students how to use them will provide them procedures such as a lumbar puncture under minimal with important skills that they can apply in hospitals supervision [12]. Allowing the medical students to throughout Ethiopia [16]. develop these practical skills and gain ‘hands-on’ experi- A recent study looking at how medical students con- ence is important for when they take on further respon- tribute to healthcare in Sub-Saharan Africa showed stu- sibilities as qualified doctors. dents are valuable resources in the health facilities [17]. It does appear that the curriculum undergoes some de- They had a positive effect on workload, quality of care gree of tailoring to knowledge gaps identified in assess- and working environment. This also appeared evident ment, as evidenced by the skills sessions. The fact that from observation of the students in Aksum, highlighting these sessions were engaging, interactive and resulted in the positive impact that students can have in rural hos- the students having a high level of confidence in their abil- pitals. It is however important to have the resources to ity to perform the taught practical skills, are all examples support these students to ensure they further their of good educational practice. The development of confi- knowledge and develop into competent doctors. dence in practical procedures is hugely important for when these skills are transferred into a clinical setting, Conclusion especially if the students are performing skills with limited Clinical medical students at Aksum University have high supervision. Students’ positive comments in feedback levels of experience, expertise and responsibility. How- further illustrates the value of this practice. Further collec- ever, there is a need for more senior supervision across tion of feedback and tailoring of the curriculum to the the field to maximise the students’ clinical experience students’ needs should be encouraged [15]. and to optimise patient care. The implementation of the A limitation of this study is the fact that convenience NIMC is an important area that should continue to be sampling was used, which may not be representative of reviewed regularly, not only in Aksum but across all thewhole cohort of students.Only13C2students were medical schools throughout Ethiopia. involved in this study due to the remaining C2 students being placed at hospitals outside of Aksum; these hos- Abbreviations pitals were not accessible by public transport. To en- C1: Clerkship 1; C2: Clerkship 2; NIMC: New Innovative Medical Curriculum; sure the data is fully representative further research PCD: Professional competency development; SPH: Social and population health; WHO: World Health Organization could be conducted in these hospitals. Further research could also explore different specialties that were not covered in this study. Another limitation to the data Acknowledgements We would like to acknowledge the Tropical Health and Education Trust collection is that the interviews were not directly (THET) and UK Department for International Development (DfID) for recorded and transcribed due to the lack of available providing essential funding for the Ethiopian Medical Education Partnership equipment in Ethiopia. Project via the Health Partnerships Scheme. Morgan et al. BMC Medical Education (2018) 18:119 Page 8 of 8 Availability of data and materials 9. Howley LD, Wilson WG. Direct observation of students during clerkship The datasets used and/or analysed during the current study are available rotations: a multiyear descriptive study. Acad Med. 2004;79(3):276–80. from the corresponding author on reasonable request. 10. Seabrook MA, Woodfield SJ, Papagrigoriadis S, Rennie JA, Atherton A, Lawson M. Consistency of teaching in parallel surgical firms: an audit of Authors’ contributions student experience at one medical school. Med Educ. 2000;34(4):292–8. CM and TCB initiated the idea for the research. CM, MT, RB, and KS collected 11. Kilminster SM, Jolly BC. Effective supervision in clinical practice settings: a the data. CM and MT analysed the data. All authors contributed to the writing literature review. Med Educ. 2000;34(10):827–40. of the manuscript. All authors read and approved the final manuscript. 12. Konje ET, Kabangila R, Manyama M, van Wyk JM. What basic clinical procedures should be mastered by junior clerkship students? Experience at Authors’ information a single medical school in Tanzania. Adv Med Educ Pract. 2016;6(7):173–9. CM graduated from the University of St Andrews with a BSc [1st class] in 13. Mumbo HM, Kinaro JW. Assessment of quality and relevance of curricula Medicine, and completed her MBBS degree at Barts and the London School development in health training institutions: a case study of Kenya. Hum of Medicine. She is currently a Foundation Doctor at Imperial College Trust. Resour Health. 2015;13:67. MT is a General Practitioner at Aksum University. She completed her medical 14. African Health Observatory and World Health Organisation. Ethiopia: degree in Addis Ababa, Ethiopia and also has a Masters in Public Health. TCB Analytical Summary. Retrieved 25 Nov. 2016 http://www.aho.afro.who.int/ is a public health registrar currently undertaking a PhD at the London School profiles_information/index.php/Ethiopia:Analytical_summary_-_Health_ of Hygiene and Tropical Medicine. He is an honorary clinical lecture at Barts Status_and_Trends and the London School of Medicine and project lead for the Aksum 15. Ende J. Feedback in clinical medical education. JAMA. 1983;250(6):777–81. University partnership. He graduated from the University of Nottingham with 16. Cordeiro MF, Jolly BC, Dacre JE. The effect of formal instruction in a MBBS and Masters in Medical Education. He has also completed a Masters ophthalmoscopy on medical student performance. Med Teach. 1993;15(4):321–5. in Public Health and is a member of the GMC Education Associate and 17. Talib Z, van Schalkwyk S, Couper I, Pattanaik S, Turay K, Sagay AS, Baingana Curriculum Advisory Group. RB is a fourth-year medical student at Barts and R, Baird S, Gaede B, Iputo J, Kibore M, Manongi R, Matsika A, Mogodi M, the London School of Medicine, with an MRes in Neuroscience from Ramucesse J, Ross H, Simuyeba M, Haile-Mariam D. Medical education in Newcastle University. KS completed his MBBS at Barts and the London decentralized settings: how medical students contribute to health care in School of Medicine alongside completing a BSc (Hons) in Medical Education. 10 sub-Saharan African countries. Acad Med. 2017;92:1723–32. He is currently an academic Foundation Doctor in Dundee. Ethics approval and consent to participate The research was approved by Queen Mary University of London and the Ethics Committee at Aksum University. We obtained verbal consent prior to interviewing the students and all data was anonymised to maintain confidentiality. We retained a written register of the students who verbally consented. Competing interests The authors declare that they have no competing interests. Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Author details Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, EC1M 6BQ, London, UK. Faculty of Health Sciences, Aksum University, Aksum, Ethiopia. Received: 21 August 2017 Accepted: 20 April 2018 References 1. African Health Observatory and World Health Organisation. Ethiopia: Health Workforce. Retrieved 25 Nov 2016. http://www.aho.afro.who.int/profiles_ information/index.php/Ethiopia:Health_workforce_-_The_Health_System 2. Global Health Workforce Statistics database, World Health Organization, Geneva. Retrieved 25 Nov 2016. http://www.who.int/hrh/statistics/hwfstats/ 3. Abraham Y, Azaje A. The new innovative medical education system in Ethiopia: background and development. Ethiop J Health Dev. 2013; 27(Special Issue 1):36–40. 4. Population Of Aksum. Retrieved 25 Nov 2016. http://www.citypopulation. de/Ethiopia.html 5. Federal Ministory of Health and Federal Ministory of Education. The new innovative medical curriculum for Ethiopia. Addis Ababa: Ethiopian Government; 2010. 6. Cottrell D, Kilminster S, Jolly B, Grant J. What is effective supervision and how does it happen? A critical incident study. Med Educ. 2002;36(11):1042–9. 7. Jolly BC, Macdonald MM. Education for practice: the role of practical experience in undergraduate and general clinical training. Med Educ. 1989; 23(2):189–95. 8. Kowlowitz V, Slatt LM, Kollisch DO, Strayhorn G. Monitoring students’ clinical experiences during a third-year family medicine clerkship. Acad Med. 1996; 71(4):387–9. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Medical Education Springer Journals

Medical education in difficult circumstances: analysis of the experience of clinical medical students following the new innovative medical curriculum in Aksum, rural Ethiopia

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Abstract

Background: In 2012, 12 medical schools were opened in Ethiopia to tackle the significant shortage of doctors. This included Aksum School of Medicine situated in Aksum, a rural town in Northern Ethiopia. The new Innovative Medical Curriculum (NIMC) is a four-year programme designed by the Ethiopian Federal Ministries of Health and Education. The curriculum is designed to train biomedical science graduates to become doctors in 4 years, with a focus on the healthcare needs of rural people living in poverty. Methods: This research was conducted at Aksum School of Medicine and included two hospitals (Aksum Referral Hospital and St Mary’s District Hospital). This study focused on medical students during their clinical years across multiple specialities (61 Clerkship 1 students and 13 Clerkship 2 students). We used primarily qualitative research methods supplemented with quantitative measures. There were 3 stages of data collection over a 1 month period, this included qualitative group interviews, direct observation of students in a clinical setting and direct observation of skills sessions followed by a questionnaire on the sessions. We analysed the data by reconstructing the student experience and comparing it with the NIMC. Results: The proposed typical week set out in the NIMC tended to differ from the real clinical experience of these students. Through qualitative group interview and direct observation of teaching, the main theme that was consistent throughout was the lack of doctors with specialist postgraduate training. Clinical need often took priority over education. However, students enjoyed taking early responsibility and gaining practical experience. Through direct observation of skills sessions and short questionnaires, these sessions were highly valuable to the students and they felt confident in carrying out the taught procedures in the future. Conclusions: The combination of poorly resourced hospitals and lack of specialist doctors provides a challenging environment for medical students to learn. However, it is a unique clinical experience that is rarely seen in developed countries and facilitates the acquirement of skills from an early stage. Supervision and specialist input is fundamental in enabling students to learn and this is a key area that was lacking in the students’ clinical experience. Keywords: Curriculum, Medical education, Clinical experience, Africa * Correspondence: c.a.morgan@smd13.qmul.ac.uk Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, EC1M 6BQ, London, UK Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Morgan et al. BMC Medical Education (2018) 18:119 Page 2 of 8 Background Research design Ethiopia is a country with a severe shortage of doctors We evaluated the experience of clinical students using especially in the rural areas [1]. According to the World qualitative methods supplemented with quantitative Health Organization (WHO), in 2010 the doctor to pa- measures. The research was conducted at Aksum School tient ratio in Ethiopia was 1:42,706, which is among the of Medicine and included two hospitals (Aksum Referral lowest in sub-Saharan Africa [1]. The WHO established Hospital and St Mary’s District Hospital). The research a critical threshold of 23 doctors, nurses and midwives included 61 C1 students and 13 C2 students. per 10,000 population as a minimum to enable the deliv- There were 3 stages of data collection, which we com- ery of essential maternal and child health services, yet pleted over a 1 month period: they found this figure to be 3 per 10,000 in Ethiopia [2]. Furthermore, it is estimated that 43% of doctors work in 1) Qualitative group interviews Addis Ababa (the capital of Ethiopia) despite only 5% of 2) Direct observation of students in a clinical setting the population living there [1]. The severe shortage of 3) Direct observation of skills sessions followed by a doctors in Ethiopia could be attributed to several rea- student questionnaire on the sessions sons including the emigration of qualified doctors, lim- ited number of medical schools, and difficulty in We completed Stages 1 and 2 over a 2-week period. accessing education [3]. Stage 1 consisted of eight structured group interviews, Aksum is a town in Tigray, Northern Ethiopia with an involving 2–4 participants per interview. We conducted estimated population of 66,800 people [4]. Aksum the interviews using a convenience sample of available University Faculty of Health Sciences was opened in students in the clinical area. We used this method as it 2012 along with 11 other medical schools to tackle the allowed the students to decide if they wished to partici- significant shortage of doctors in Ethiopia. The New In- pate, any students who wanted to participate were in- novative Medical Curriculum (NIMC) is a four-year cluded in the study. It was not possible to pre-arrange programme designed by the Ethiopian Federal Ministries interviews with the students due to network and power of Health and Education [5], which has been in place in outages which sometimes lasted multiple days making Aksum since 2012. There have been 4 years of clinical communication and organisation of meetings very students on the course, with the first cohort of students difficult. graduating in 2016. The curriculum is designed to train We used an interview guide that covered the students’ biomedical science graduates to become doctors in experience in Ophthalmology, Dermatology, Obstetrics 4 years, with a focus on the healthcare needs of rural and Gynaecology and Surgery. CM and MT developed people living in poverty. the guide after discussion with senior faculty members The four-year curriculum is split into two pre-clinical from Aksum University and review of the NIMC. We years and two clinical or clerkship years, known as asked the students to describe their current clinical ex- Clerkship 1 (C1) and Clerkship 2 (C2) (see Fig. 1). After perience, including details of their attachment and their these 4 years, the students will then undertake an intern- average day. We also asked what they felt worked well ship year. Upon completion of each academic year there on their attachment and areas that could be improved. are examinations and at the end of C2, the students sit The lead researcher (CM) attended both hospitals their final qualifying examination. (Aksum Referral Hospital and St Mary’s District Hos- There is known to be variation in clinical teaching ex- pital) alternating sites over a two-week period to carry perienced by medical students and that this often differs out the structured group interviews alongside a General from the curriculum intended to be delivered [6, 7]. Practitioner from Aksum (MT). CM and MT conducted However, evidence has shown the benefits of implement- these interviews together in the morning after locating ing a monitoring system that allows comparisons to be the medical students in the relevant departments within made across specialities and hospitals. This also allows the hospital. The morning was the time when the high- the identification of areas that are lacking in the stu- est number of students were present. The lead re- dent’s clinical experience [8–10]. To our knowledge this searcher (CM) collected the data through note taking. is the first paper examining the implementation of the The Aksum GP was known to the students which en- NIMC in Ethiopia. abled a strong rapport and trust to be built during the interview. Methods We obtained verbal consent prior to interviewing the The aim of this research is to identify and describe the students and all data was anonymised to maintain confi- real-world experience of the clinical students following dentiality. We retained a written register of the students the NIMC at Aksum and compare this to the proposed who verbally consented. We offered the students the curriculum experiences and outcomes. choice of participating and we explained that it would Morgan et al. BMC Medical Education (2018) 18:119 Page 3 of 8 Fig. 1 An overall summary of the curriculum taken and adapted from the New Innovative Curriculum [NIMC] document not affect their training in any way if they chose not to & KS) collected data by observational note keeping. A participate. We also obtained verbal consent from the debrief was undertaken after each session. The re- consultant in charge of each department prior to direct searchers (RB & KS) then compared the notes, collabo- observation and interviews. All interviews and teaching rated findings and any differences were discussed. Both sessions were conducted in English, which is the same medical students (RB & KS) were present at all skill ses- language the students are taught in. In Stage 2, CM ob- sions. The survey consisted of the following 5 questions served a selection of students, based on convenience (based on a Likert-type scale): sampling, in the clinical environment. This involved both hospital wards and outpatient clinics. CM made Q1) How useful did you find the teaching? observational notes to compare with the described stu- Q2) Did you feel the teaching was right for your dent experience in the NIMC. We obtained ethical ap- level? proval from both Aksum University and Queen Mary Q3) How confident would you be in using the skills University of London. All researchers had received train- you learnt in the session? ing in collecting qualitative data. Q4) Was the session well organised? Two medical students (RB & KS) carried out Stage 3 Q5) What other aspects of this topic would you like of data collection. This involved direct observation of to see included? skills sessions using a structured observation teaching form, followed by an evaluation of the students’ experi- Data analysis ence using a cross-sectional survey. We anonymised the The lead researcher (CM) collated the observational survey to maintain the students’ confidentiality. We (RB notes from the three researchers who had taken notes Morgan et al. BMC Medical Education (2018) 18:119 Page 4 of 8 (CM, RB & KS) into a written document. This data in- Clerkship 1 cluded qualitative group interviews, direct observation Sixty-one medical students were studying Dermatology of teaching and direct observation of skills sessions. The (30) and Ophthalmology (31) at Aksum Referral lead researcher (CM) developed deductive codes which Hospital. The students were split into two groups and were derived from the interview guide, these included then into further subgroups of approximately 8, each ‘positive experience’, ‘areas for improvement’ and ‘struc- student spent 3 weeks on Ophthalmology and 3 weeks ture’. CM then developed inductive codes from further on Dermatology. Aksum Referral Hospital had just re- reading and analysis of the data. These included ‘super- cently opened and all clinical exposure was outpatient vision’, ‘teaching’, ‘level of responsibility’ and ‘workplace based. There was one specialist Ophthalmologist and dynamics’. Coding of the data allowed common themes one specialist Dermatologist. An average day would in- to be identified. The lead researcher (CM) then placed volve teaching by the specialist in the morning, via a the data into different categories, consisting of headings PowerPoint presentation that was then followed by a and subheadings which involved the year and speciality clinic. Groups had to have at least 1 day per week away of the medical students. CM then mapped the data to from the clinical environment due to there being only the NIMC. We categorised the data in this way as it one specialist in each department and 61 students. allowed conclusions to be drawn and recommendations to be made to the faculty leadership and individual de- Ophthalmology From direct observation, the ophthal- partments. Using the Likert-type scale, researchers RB mology clinic consisted of the ophthalmologist, specialist and KS collated the results from the cross-sectional sur- nurse and medical students. There was one ophthalmo- vey into a simple bar chart. An experienced qualitative scope in the department used by the specialist and a slit researcher (TCB) checked the data analysis and coding lamp; the students used a torch and goggles to examine framework. This helped to ensure reliability in the data the eyes. Jointly the students would take a very brief his- analysis and credibility of the coding. TCB identified any tory from the patient with the nurse. There appeared to discrepancies in the coding and revisions were made. be a good relationship between the specialist nurse and the students, allowing the students time to examine the Results patients. The students would then observe the ophthal- Stage 1 (qualitative group interviews) and stage 2 (direct mologist who at times gave teaching. The relationship observation of teaching) between the students and ophthalmologist appeared The main theme that was consistent throughout was the strained, primarily due to the clinical work load. From lack of doctors with specialist postgraduate training. Stu- observation, it was clear that the students were being ex- dents enjoyed being taught by specialists when available, posed to a wide variety of ocular pathology with ad- however, there were different levels of engagement vanced clinical signs. During the interviews the students across the different specialities. This was often due to spoke about the lack of hard copy Ophthalmology text- clinical need taking priority over education and special- books in the library and their reliance on a limited Inter- ists having to leave to attend emergencies, particularly in net connection for resources. They also spoke about the case of Surgery and Obstetrics. There was often poor their desire to learn how to use equipment such as an access to basic teaching materials such as ophthalmo- ophthalmoscope. scopes and specialist textbooks. However, students enjoyed taking early responsibility and gaining practical Dermatology The dermatology clinic comprised of the experience, for example delivering babies and perform- dermatologist and the medical students. From direct ob- ing minor surgical procedures. The proposed typical servation, approximately 8 students stood around the pa- week set out in the NIMC for C1 and C2 students (see tient and the students were asked to take a history from Table 1) tended to differ from the real clinical experience the patient, formulate differential diagnoses and consider of these students. appropriate investigations. Possible management plans Table 1 A proposed typical week in Clerkship 1 and 2 taken from the NIMC Time Monday Tuesday Wednesday Thursday Friday 8am – 10 am Lecture (C1) / Lecture (C1) / Social and Lecture (C1)/ Primary Health / Morning session (C2) Morning session (C2) Population Health Morning session (C2) Community attachment 10 am-12:30 pm Bedside teaching Inpatient/ outpatient care Inpatient/ outpatient care Bedside teaching 12:30 pm- 2 pm Lunch Lunch Lunch Lunch Lunch 2pm–4 pm Inpatient/ PCD Inpatient/ Inpatient/ Whole group session seminar/ outpatient care outpatient care outpatient care journal club/grand round 4 pm-5:30 pm Inpatient/ outpatient care Morgan et al. BMC Medical Education (2018) 18:119 Page 5 of 8 were then discussed with the students. From observation, and experience was important in preparing them for the dermatologist appeared highly motivated with a pas- their internship year. sion for teaching. The dermatologist ensured all students were involved in the teaching and reading materials were Obstetrics and Gynaecology The responsibility given given prior to the clinic. Much like Ophthalmology, when to these final year medical students was significant. interviewing the students, they spoke about limited access There was one specialist across the entire department. to textbooks and difficulty accessing online resources. The students were running their own clinics and admit- However, they enjoyed seeing a wide variety of dermato- ting, managing, prescribing medications and discharging logical conditions and were very positive in regards to the patients (see Table 2). They were also performing surgi- dermatologist. cal procedures such as manual vacuum aspiration with- out supervision. The students were using forceps and Clerkship 2 ventouse devices supervised by midwives as well as de- Thirteen students were on the Emergency Surgery and livering babies unsupervised. They were also managing Lifesaving skills module at St Mary’s District Hospital emergencies such as postpartum haemorrhage, which Aksum. This is a 12-week module made up of 6 weeks was observed during the data collection. There appeared of Surgery (6 students) and 6 weeks of Obstetrics and to be a good relationship between the students and the Gynaecology (7 students) and is the final module before specialist, with morning meetings approximately three they sit their final qualifying exam. The students were times a week to discuss current and difficult cases. The split into two groups and rotated after 6 weeks. students also appeared to be well supported by the mid- wives. During group interview the students commented Surgery There was one general surgeon covering the that often the specialist had to leave the hospital due to entire hospital and the different surgical subspecialties. obstetric emergencies in other rural health centres The students’ surgical rotation was split into 2 weeks of where the patients were unable to access transport to theatre and 4 weeks of ward work. Theatre involved the hospital. However, the time spent with the specialist, assisting in major surgery, involving all sub surgical sub- medical students found very valuable to their learning. specialities, which included plastics, vascular, orthopae- dics and paediatric surgery. They also undertook minor Stage 3: Direct observation of skills sessions followed by procedures unsupervised, such as draining abscesses. a short questionnaire From direct observation on the wards the students The skills sessions consisted of 60-min-long tutorials, would clerk patients, prescribe medications, consent pa- delivered by two senior clinicians from the obstetrics de- tients for surgery and manage uncomplicated patients. partment, to groups of 15 students. The sessions were From group interview the students sometimes felt over- conducted in a well-equipped skills lab. The content of whelmed by the responsibility given to them and the the session would be oriented to lecture based teaching number of unwell patients. They also found the working that had been delivered by residents in the same week. conditions hard, these included no running water in the For example, on a week discussing termination of preg- hospital and lack of basic medical supplies. However, as nancy, the skills session was to familiarise students with they were in their final year, they felt this responsibility manual vacuum aspiration. These topics would also be Table 2 Typical day for a final year medical student on Obstetrics and Gynaecology reconstructed from direct observation and student interview Time Typical day for a final year medical student on Obstetrics and Gynaecology Rotation 7:30 am Arrive at St Mary’s Hospital via mini-bus. 8am – 9 am Morning meeting led by the specialist [twice a week] to discuss complicated patients and deliveries. 10 am–11 am Ward round – led by specialist [twice a week], other times carried out by masters students or the medical students without supervision. 11 am – 12 pm The 6 students would split off – 2 would run the outpatient clinic, 2 would be on the general ward, 2 would be on labour ward with little or no supervision 12 pm–1 pm Mini-bus would take the students back to their accommodation for lunch. 1pm–5 pm The students would continue in their designated areas. The students on labour ward were also able to go to theatre. Twice a week the students would have a tutorial where they would take turns at presenting a topic to the other students and specialist. 5pm–6 pm The mini-bus would take the students back to their accommodation. 6 pm-8 am Each student would work one night and one Saturday or Sunday per week – known as ‘duty’. They would then stay at the hospital the following day after a night duty. Morgan et al. BMC Medical Education (2018) 18:119 Page 6 of 8 selected based on feedback from previous students who had struggled with this area in their assessments. The initial skills session would act more as an interactive tu- torial, establishing the students’ prior knowledge and introducing them to the equipment generally, before be- ing followed by a supervised practice session. These skills sessions were well received by the stu- dents who mostly had little or no prior experience of the procedure being taught (Fig. 2). The interactive nature of each session, in addition to students receiving feed- back and being supervised while practicing resulted in 91% of students reporting feeling either confident or Fig. 3 A bar chart showing the confidence of students using the very confident to carry out the procedure in the future skills learnt in the session (n = 11) (Fig. 3). Four students did not respond to the questionnaire. Medical student comments were also broadly positive students are clinically competent in certain procedures about the session stating that it was “necessary” and when graduating medical school, which is something should be “continued” while also seeking further oppor- that could be implemented into the NIMC. tunity to practice, either in the skills lab or on patients. Furthermore, Fig. 1 clearly demonstrates the summary of the NIMC for each year. However, what should be Discussion noted is that Dermatology and Ophthalmology are spe- The combination of poorly resourced hospitals and lack cialties that are timetabled for C2 students. However, of specialist doctors provides a difficult environment for during the data collection period, the C1 students were medical students to learn. A shortage of specialist doc- on Dermatology and Ophthalmology attachments. The tors is a huge problem across Ethiopia, especially in rural faculty of medicine in Aksum explained this change was areas such as Aksum. Supervision is fundamental in en- due to the difficulty in recruiting specialist doctors to abling students to learn and progress into safe clinicians deliver parts of the curriculum, for example in Radiology [11] and this is a key area that was lacking in the stu- or ENT. Therefore, they had to reach a compromise and dents’ clinical experience. This highlights the urgent since there was a specialist Dermatologist and Ophthal- need for more specialist doctors or trainee specialists in mologist available, they decided to deliver these areas areas such as Aksum, alongside stronger guidance on during C1 instead of C2. This highlights the difficulty in medical students’ duties and responsibilities. Neverthe- delivering a curriculum in a developing country and the less, it should be remembered that the NIMC was put in challenges that need to be overcome. However, it also place to address this shortage of doctors, therefore there demonstrates the forward thinking of the Aksum leaders is not a quick fix to this problem but a longer-term in their ability to quickly adapt to the circumstances and strategy in place. A recent study at a medical school in to deliver successful modules in Dermatology and Tanzania has identified the need for the curriculum to Ophthalmology. A study carried out in Kenya evaluating clearly specify the level of competence required for per- the quality and relevance of curriculum development in forming certain procedures [12]. This ensures the health training, found that there are major gaps in the quality and adequacy of the training [13]. The study also highlighted the need for a national standard framework to guide curriculum review. A common theme that should be discussed is the dif- ferent levels of engagement from the specialist doctors. Each department had only one specialist which placed enormous strain on these doctors. St Mary’s, a 150 bed district general hospital in Aksum is estimated to serve 1.5 million people. The burden of disease in Ethiopia measured in terms of premature death is estimated at 350 disability adjusted life years lost per 1000 popula- tion, which is the highest in Sub-Saharan Africa [14]. The combination of the disease burden and one special- Fig. 2 A bar chart showing the students previous experience of the ist per department often leads to specialists being called skills being taught (n = 11) away to emergencies. This can lead to students being left Morgan et al. BMC Medical Education (2018) 18:119 Page 7 of 8 on the wards unsupervised potentially placing them- Access to basic teaching materials for specialities such selves in difficult situations. However, overall the stu- as Ophthalmology and Dermatology are very important dents seemed to have a very positive approach to these in the students’ learning and their absence was a com- circumstances and were happy to take on the added re- mon theme highlighted by the students. This was the sponsibility and adapt to meet the patient demand. first time that Aksum Referral Hospital had Dermatology Other healthcare professionals such as specialist nurses and Ophthalmology teaching clinics for the students as and midwifes were also very supportive of the students, the hospital had recently opened and these departments demonstrating a team approach in providing the best pa- were the first to become operational. The medical school tient care possible with the limited resources available. recruited the patients for the clinic by organising a cam- High levels of responsibility and a huge disease burden paign in the week prior to the clinic. This involved an can be advantageous to a medical student’s education. individual with a ‘megaphone’ driving up and down the Exposure to tropical diseases such as Leishmaniasis and main road in Aksum inviting anyone who had any eye patients consistently presenting at extremely advanced or skin problems to come to the hospital. This again stages of disease is a unique experience that is rarely demonstrates the creativity of the medical school in seen in developed countries. This allows Aksum medical organising and delivering the curriculum. As more students to continue to develop their history and exam- departments open this will provide invaluable learning ination skills and formulate diagnoses without becoming opportunities across different specialities for the medical dependent on investigations. The Aksum students students. It is important that Ophthalmology and enjoyed gaining practical experience which involved Dermatology resources including textbooks are available delivering babies and performing minor surgical opera- for the students to help consolidate their learning. tions. A study carried out in Tanzania found that Investing in equipment such as ophthalmoscopes and clinicians felt clerkship students should be performing teaching the students how to use them will provide them procedures such as a lumbar puncture under minimal with important skills that they can apply in hospitals supervision [12]. Allowing the medical students to throughout Ethiopia [16]. develop these practical skills and gain ‘hands-on’ experi- A recent study looking at how medical students con- ence is important for when they take on further respon- tribute to healthcare in Sub-Saharan Africa showed stu- sibilities as qualified doctors. dents are valuable resources in the health facilities [17]. It does appear that the curriculum undergoes some de- They had a positive effect on workload, quality of care gree of tailoring to knowledge gaps identified in assess- and working environment. This also appeared evident ment, as evidenced by the skills sessions. The fact that from observation of the students in Aksum, highlighting these sessions were engaging, interactive and resulted in the positive impact that students can have in rural hos- the students having a high level of confidence in their abil- pitals. It is however important to have the resources to ity to perform the taught practical skills, are all examples support these students to ensure they further their of good educational practice. The development of confi- knowledge and develop into competent doctors. dence in practical procedures is hugely important for when these skills are transferred into a clinical setting, Conclusion especially if the students are performing skills with limited Clinical medical students at Aksum University have high supervision. Students’ positive comments in feedback levels of experience, expertise and responsibility. How- further illustrates the value of this practice. Further collec- ever, there is a need for more senior supervision across tion of feedback and tailoring of the curriculum to the the field to maximise the students’ clinical experience students’ needs should be encouraged [15]. and to optimise patient care. The implementation of the A limitation of this study is the fact that convenience NIMC is an important area that should continue to be sampling was used, which may not be representative of reviewed regularly, not only in Aksum but across all thewhole cohort of students.Only13C2students were medical schools throughout Ethiopia. involved in this study due to the remaining C2 students being placed at hospitals outside of Aksum; these hos- Abbreviations pitals were not accessible by public transport. To en- C1: Clerkship 1; C2: Clerkship 2; NIMC: New Innovative Medical Curriculum; sure the data is fully representative further research PCD: Professional competency development; SPH: Social and population health; WHO: World Health Organization could be conducted in these hospitals. Further research could also explore different specialties that were not covered in this study. Another limitation to the data Acknowledgements We would like to acknowledge the Tropical Health and Education Trust collection is that the interviews were not directly (THET) and UK Department for International Development (DfID) for recorded and transcribed due to the lack of available providing essential funding for the Ethiopian Medical Education Partnership equipment in Ethiopia. Project via the Health Partnerships Scheme. Morgan et al. BMC Medical Education (2018) 18:119 Page 8 of 8 Availability of data and materials 9. Howley LD, Wilson WG. Direct observation of students during clerkship The datasets used and/or analysed during the current study are available rotations: a multiyear descriptive study. Acad Med. 2004;79(3):276–80. from the corresponding author on reasonable request. 10. Seabrook MA, Woodfield SJ, Papagrigoriadis S, Rennie JA, Atherton A, Lawson M. Consistency of teaching in parallel surgical firms: an audit of Authors’ contributions student experience at one medical school. Med Educ. 2000;34(4):292–8. CM and TCB initiated the idea for the research. CM, MT, RB, and KS collected 11. Kilminster SM, Jolly BC. Effective supervision in clinical practice settings: a the data. CM and MT analysed the data. All authors contributed to the writing literature review. Med Educ. 2000;34(10):827–40. of the manuscript. All authors read and approved the final manuscript. 12. Konje ET, Kabangila R, Manyama M, van Wyk JM. What basic clinical procedures should be mastered by junior clerkship students? Experience at Authors’ information a single medical school in Tanzania. Adv Med Educ Pract. 2016;6(7):173–9. CM graduated from the University of St Andrews with a BSc [1st class] in 13. Mumbo HM, Kinaro JW. Assessment of quality and relevance of curricula Medicine, and completed her MBBS degree at Barts and the London School development in health training institutions: a case study of Kenya. Hum of Medicine. She is currently a Foundation Doctor at Imperial College Trust. Resour Health. 2015;13:67. MT is a General Practitioner at Aksum University. She completed her medical 14. African Health Observatory and World Health Organisation. Ethiopia: degree in Addis Ababa, Ethiopia and also has a Masters in Public Health. TCB Analytical Summary. Retrieved 25 Nov. 2016 http://www.aho.afro.who.int/ is a public health registrar currently undertaking a PhD at the London School profiles_information/index.php/Ethiopia:Analytical_summary_-_Health_ of Hygiene and Tropical Medicine. He is an honorary clinical lecture at Barts Status_and_Trends and the London School of Medicine and project lead for the Aksum 15. Ende J. Feedback in clinical medical education. JAMA. 1983;250(6):777–81. University partnership. He graduated from the University of Nottingham with 16. Cordeiro MF, Jolly BC, Dacre JE. The effect of formal instruction in a MBBS and Masters in Medical Education. He has also completed a Masters ophthalmoscopy on medical student performance. Med Teach. 1993;15(4):321–5. in Public Health and is a member of the GMC Education Associate and 17. Talib Z, van Schalkwyk S, Couper I, Pattanaik S, Turay K, Sagay AS, Baingana Curriculum Advisory Group. RB is a fourth-year medical student at Barts and R, Baird S, Gaede B, Iputo J, Kibore M, Manongi R, Matsika A, Mogodi M, the London School of Medicine, with an MRes in Neuroscience from Ramucesse J, Ross H, Simuyeba M, Haile-Mariam D. Medical education in Newcastle University. KS completed his MBBS at Barts and the London decentralized settings: how medical students contribute to health care in School of Medicine alongside completing a BSc (Hons) in Medical Education. 10 sub-Saharan African countries. Acad Med. 2017;92:1723–32. He is currently an academic Foundation Doctor in Dundee. Ethics approval and consent to participate The research was approved by Queen Mary University of London and the Ethics Committee at Aksum University. We obtained verbal consent prior to interviewing the students and all data was anonymised to maintain confidentiality. We retained a written register of the students who verbally consented. Competing interests The authors declare that they have no competing interests. Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Author details Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, EC1M 6BQ, London, UK. Faculty of Health Sciences, Aksum University, Aksum, Ethiopia. Received: 21 August 2017 Accepted: 20 April 2018 References 1. African Health Observatory and World Health Organisation. Ethiopia: Health Workforce. Retrieved 25 Nov 2016. http://www.aho.afro.who.int/profiles_ information/index.php/Ethiopia:Health_workforce_-_The_Health_System 2. Global Health Workforce Statistics database, World Health Organization, Geneva. Retrieved 25 Nov 2016. http://www.who.int/hrh/statistics/hwfstats/ 3. Abraham Y, Azaje A. The new innovative medical education system in Ethiopia: background and development. Ethiop J Health Dev. 2013; 27(Special Issue 1):36–40. 4. Population Of Aksum. Retrieved 25 Nov 2016. http://www.citypopulation. de/Ethiopia.html 5. Federal Ministory of Health and Federal Ministory of Education. The new innovative medical curriculum for Ethiopia. Addis Ababa: Ethiopian Government; 2010. 6. Cottrell D, Kilminster S, Jolly B, Grant J. What is effective supervision and how does it happen? A critical incident study. Med Educ. 2002;36(11):1042–9. 7. Jolly BC, Macdonald MM. Education for practice: the role of practical experience in undergraduate and general clinical training. Med Educ. 1989; 23(2):189–95. 8. Kowlowitz V, Slatt LM, Kollisch DO, Strayhorn G. Monitoring students’ clinical experiences during a third-year family medicine clerkship. Acad Med. 1996; 71(4):387–9.

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BMC Medical EducationSpringer Journals

Published: May 31, 2018

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