Special Pathology in the course content of Third Year MBBS: Views of students and teachers

Objective: The students and teachers are major stakeholders whenever there is a change in the curriculum. Objective of the study was to assess the views of Third Year MBBS students and college teachers involved in teaching Third Year MBBS class regarding the inclusion of special pathology to the already cumbersome course content. Methods: It was a cross-sectional descriptive study carried out over a period of eight months from April, 2019 to December, 2019. An online questionnaire was used to collect the data from 110 third year MBBS students and 35 medical college teachers involved in teaching the third year MBBS class at HBS Medical & Dental College, Islamabad, Pakistan. The questionnaire contained open ended questions along with a short questionnaire based on 3-point Likert scale for a semi-quantitative analysis. The open ended responses in the interviews were assessed using Mayring’s qualitative context analysis. The similar comments were bundled up as the comments were sequentially processed and the replicates were grouped. The responses were then ranked by the number of times they were selected using Microsoft Excel 2013 and SPSS 21. Results: A total of 105 medical students and 32 medical teachers participated in the study. n=94 (89.5%) of the students agreed that the content taught was incoherent and n= 92 (88%)agreed that the time allocation for the various modules was inappropriate. The important reservation of the students was that the assessment strategies of the past continued to prevail and they were not aligned with the change in the curriculum. They suggested to spread Pathology over four years of MBBS so that true integration can be done. The top ranked reason amongst the students who were in favor of this system was that they could easily leave microbiology on choice and study selectively to pass the exam as the extensive course inhibited the examiners to assess every aspect of Pathology comprehensively especially Microbiology and general Pathology being compromised upon. As far as the teachers are concerned n=28 (88%) agreed that the course content is inappropriate and the students are being bombarded with selective knowledge in a shorter period of time. Important reservation of the faculty members was that they were not trained to deliver the content according to this sudden change which has seriously affected the student’s results. Conclusions: Although curriculum change is a dynamic process and leads to refinement of the existing content but it should be implemented after proper planning, training and validation so that the students and the teachers can cope with and derive maximum benefit.


INTRODUCTION
Curriculum revision is encouraged and is frequently practiced in the medical colleges of Pakistan. 1 Over the past few years with the introduction of the integrated modular curriculum; the medical institutions in Pakistan are rigorously trying to modify the existing Correspondence: Dr. Wafa Omer E-mail: wafamuniransari@yahoo.com curriculum. However, the criteria and the duration after which these revisions should be made is still unclear. 2 The students and teachers are major primary stakeholders whenever there is a change in the curriculum 3 Their views and concerns are a significant variable in order to implement any change and a failure to do so deskills both students and teachers leading to failure in achieving the desired learning objectives. Curriculum revision and evaluation is a dynamic process but it needs to be implemented according to the rules of curricular organization and validation. 4 Integrated modular curriculum was introduced in our setup with the intention of reducing the repetition of knowledge and for exposing the students to the academic load in a way that it is palatable and is free of unnecessary content.
The idea behind an integrated curriculum was to make the learning experience of the students more meaningful rather than bombarding them with excessive content and camouflaging our teacher centered beliefs of content delivery behind a veil of student centered activities. College observed a drastic drop in the academic performance of the students during their internal block exams along with harsh feedback from the students and the senior faculty members.
The students and faculty members of Islamabad Medical and Dental College however seemed to be satisfied with the change though they did not share the details of their program and modified table of specifications with the rest of the stakeholders for critical appraisal (IMDC/2020/11 minutes of meeting, Dated 20-11-2020). Hence, objective of the study was to assess the views of students of 3 rd Year MBBS and the faculty of Pathology, Forensic Medicine and Pharmacology involved in teaching this class at HBS Medical and Dental College to understand the problems faced by these primary stakeholders so that we can come to a favorable solution for the problems encountered.

METHODS
It was a cross-sectional descriptive study carried out over a period of eight months from April, 2019 to December, 2020. An online self-completion questionnaire was used to collect the data from 110 Third Year MBBS students and 35 medical college teachers involved in teaching the Third Year MBBS class at HBS Medical & Dental College, Islamabad, Pakistan. The study was approved by the Institutional Ethical Review Board (Ref. HBSMDC/2020/01, Dated: 29-01-2020) and informed consent of the study participants. Those who failed to give consent were excluded from the study. The questionnaire contained open ended questions along with a short questionnaire based on 3-point Likert scale (agree, neutral, disagree) assessing the views of students and teachers. 5 The first segment of the questionnaire consisted of nine statements under the following major categories; time management and the appropriateness of content. The students and the faculty had to respond according to . The similar comments were combined as the comments were sequentially processed and the replicates were grouped. The responses were then ranked by the number of times they were selected using Microsoft Excel 2013 and SPSS 21. The evaluators ranked the responses and discussed categorization. The interviews questionnaires were reviewed multiple times by the evaluators to reach a consensus.

RESULTS
One hundred and five medical students of 3 rd year MBBS and 32 medical teachers of HBS Medical and Dental College who were actively involved in teaching the 3 rd year MBBS class participated in the study. Ninety two (88%) of the students and 23 (72%) of the teachers agreed that the time allocation for the various modules was inappropriate (Table-I).
Detailed views of teachers regarding time management after this change in the curriculum content are shown in Table-II. One of the major concerns was that only 25% of the students and 13% teachers thought that the current change in curriculum of Pathology would benefit them during their clerkship years ahead. As far as the teachers are concerned 80% agreed that the course content is inappropriate and the students are being bombarded with selective knowledge in a shorter period of time. The students were unable to apply the underlying principles of general pathology to special pathology as they were unable to understand the content of general pathology owing to the extensive course and shortage of time. The main problem that the students highlighted was that the learning objectives were vague and teachers and the course content was compromised as compared to the content delivered to the senior batch. ( Tables-III & IV).
The foremost reservations of the students were that the assessment strategies of the past continued to prevail and they were not aligned with the change in the curriculum while that of the teachers was that they were not trained to deliver the content Distribution of Special Pathology Course content    according to this sudden change and the results of the students had suffered considerably due to this change (Table-V).
The foremost suggestion of the students and faculty was to spread Pathology over four years of MBBS so that true integration can be done (Table-VI).

DISCUSSION
Curriculum change is a gradual process and its implementation requires extensive measures. 4 This study shows that the sudden shift of Special Pathology to 3 rd Year MBBS along with General Pathology, Forensic Medicine and Pharmacology led to a number of problems highlighted by the faculty members and the students. Time management remains an essential component of successful delivery and understanding of the course content. According to the views analyzed the course content was not congruent with the time allotted due to which teachers had to stick to the 'must know' content which led to knowledge of the students being compromised. 6 The students were bombarded with content by Forensic Medicine, Pharmacology and Pathology as the faculty had not been given a chance to prepare for this curriculum change neither were the students well prepared to modify their learning strategies to cope up with this abrupt change. 7 One of the reasons for the students and the faculty to be unable to manage time effectively could be that they were not trained or equipped with the proper teaching and learning strategies before the change was implemented. 8 The major reservation of the students and the teachers was that the assessment strategies were not congruent with the change in the curriculum 9 and while the learning objectives across the different colleges were different the exam paper remained the same for all the affiliated colleges of SZABMU leading to deteriorating results shown by the students in the Block Exams. A possible reason for this might be the lack of coordination between the affiliated colleges and a communication gap between the students and faculty members of the affiliated colleges. 10 Another observation was that one of the affiliated colleges was not sending the 3 rd Year class for clinical rotation unlike the remaining three colleges where 3 rd Year MBBS class was being sent for clinical rotation once a week. This might have been another contributing factor to the difference in the response Riaz Shahbaz Janjua et al.  of students to the change in curriculum. Clinical exposure since the very beginning of medical school has been encouraged and its importance has been highlighted in multiple studies 11 therefore all the colleges should have been taken into confidence and this discrepancy should have been pointed out for better alignment of learning objectives. An important recommendation which came forward was that Pathology should be spread over four years of medical school and should not be capped in third year alone. A possible reason for this could be that the topics in General Pathology can be integrated very well with Anatomy, Physiology and Biochemistry. 12 An example of this integration