Dimensions of challenges in transformation from traditional to integrated modular curriculum - Experiences from Pakistan

Objective: The scarcity of successful implementation of integrated modular curriculum in Pakistan created a lack of evidence-based insight into the process of curriculum transformation. We explored the issue by exploring challenges faced by faculty in implementing integrated modular curriculum. Methods: An exploratory qualitative study was conducted in 2019-2020, data collected from November 2019 to August 2020, at undergraduate medical colleges in Lahore and Rawalpindi, with semi-structured online interviews of well experienced 11 faculty members. Two levels of faculty were sampled; one completed a successful implementation in two medical colleges, and another in transition process. Transcribed interviews were analyzed on Atlas.ti software. Results: Challenges were identified in five inter-connected dimensions: integrated modular curriculum (IMC) development, implementation, faculty transformation/change, institutional and regulatory body context. Conclusion: The curricular shift precipitates demoralizing challenges at multiple levels & directions. The identified themes and connections provide the framework for a well-informed curricular shift.


INTRODUCTION
In Pakistan, most medical institutions use a traditional subject-based curriculum, with a movement towards adopting integrated modular curricula.Overburdened with information, the students tend to forget the already learned material as they progress from the basic sciences to clinical application and integrative learning solely relies on individual student's abilities.This fragmented learning and ungauged integration can subsequently have implications on patient care. 1 Unfortunately, transformation towards integrated curriculum is full of off-putting challenges.3][4][5][6] Other constraints may include motivation and perseverance that are needed on part of stakeholders for success and sustenance. 7,8ence, an institution must have a clear vision to make a move towards integrated curriculum.The exponential increase of medical colleges in Pakistan and the dearth of experienced medical educationists can stall the process of change at crossroads. 9 The objective of this study was to identify the challenges experienced by faculty in transformation from subject based curricula into integrated modular curricula in Pakistani medical colleges.

METHODS
An exploratory qualitative study was conducted during 2019-2020, for detailed analysis of experiences and challenges faced by the faculty of two private undergraduate medical colleges that had transformed discipline-based curriculum into integrated modular curriculum (from Lahore and Rawalpindi) and one government college still in transition (from Peshawar).Duration of study was months from institutional review board approval (Ref: ERC/02/19/07) to manuscript writing.
The interview guide was developed after a systematic literature review of last ten years using PRISMA flow chart.The problems identified in the selected studies Ensuring confidentiality and informed consent, online interviews were recorded through "ZOOM" platform.After verbatim transcription of the interviews, the software Atlas.tiversion 7.5.7 was used for thematic analysis based objectively on participant's narratives only, which was read and re-read before coding.Respondent validation and data triangulation was carried out through involving respondents.Two private medical colleges in different cities that had, at different points of time, completed curriculum transformation, and an in-transition government medical college were sampled.Moreover, perspectives from different levels of change leaders & implementers among faculty were obtained i.e., heads of departments, medical educationists, module directors, clinical/basic faculty and junior/senior faculty.

RESULTS
The faculty characteristics are given in Table -

DISCUSSION
The question of challenges experienced by the faculty in traditional curriculum transformation to IMC is answered holistically.1][12][13] The local studies provided perceptions on the design and implementation difficulties but lacked in depth analysis.The international studies mentioned frameworks from the stand point of change management models, strategic planning, standards and inhibitors and implementation models, emphasizing preemptive awareness of challenges and an organized holistic approach but are difficult to comprehend by those without medical education background.
Our study explored challenges at macro and micro levels principally in five main dimensions i.e., integration, implementation, change, institution and regulatory body (PM&DC).It further added that these challenges are rather dynamically interconnected and changes in one dimension create challenges in other dimensions too.The challenges must be addressed in an all-inclusive manner (Fig. 1) for tackling uncertain complexities; hence both forward planning and backward planning is needed. 14To facilitate comprehension and alignment the results are interpreted under four well known core elements of the curriculum i.e., aims or objectives, content or subject matter, methods or procedures and evaluation or assessment.
In the development of IMC, the aim challenged nothing else but a focused rational discourse on traditional teaching inadequacy and informed decision on the development of integrative learning models.Primary challenges included discarding subject lines and shutting off avenues of rote learning.High quality integrated module and effective small group teaching became pivotal targets.After having IMC in hand, it is imperative to develop a clear road map for implementation.First milestone, the challenge of aligning the implementers to integration level that burdened faculty with extra workload, mainly due to double curriculum in transition, small groups, multitasking, work-fatigue, frequent assessments and early clinical engagements with hectic patient load.Second milestone, the challenge of adaptation to new curricular philosophy with change of traditional mindset and settlement for new roles; especially to represent subject in relation to overall module. 7hird milestone, challenge to institute faculty development program with clear outcomes of capacity building aligned to needs, capacity for collaborative teamwork, cohort of experts for sustainability, module development task, neophobia prevention, sensitization to recent trends and unlearning traditional teaching practices.The process was not without impediments like focus on practicable content only, participation hurdles, and perpetual need for training, time, effort, and money. 5,6,15The fourth milestone, challenge of deciding on financial non-feasibility, degree of fidelity of implementation and alignment to regulatory body criteria.Curricular change aim would have been a preplanned change model but the participants never experienced an informed change intervention.

Bottlenecks of IMC development
Need for alignment to integration outcomes "If assessment is not aligned to integration then the quality of teaching is also going to suffer... Unless we (assess) examine the module in relation to integration, the pure and true integration is not possible."excerpt P 1: 1:302 , (423:423)

Challenges of aligning implementers to integration level
Capacity building aligned to needs "…We have to know the specific methodology we are using in a particular method for example skill lab should be hands on, SGD should not be in the form of interactive lecture and so on…The teacher must adapt his style and approach according to the methodology or the specific method."excerpt P 1: 1:138 , (205:205)

Challenges of aligning structures to integrated design
Establish implementation feasibility "Yes, definitely, integrated curriculum needs different infrastructure, small group rooms, more faculty and more resources than traditional system."excerpt P 1: 1:304 , (425:425)

Challenges of establishing implementation receipt system
Capacity building for monitoring "The point is valid but there is no capacity building for this job (monitoring of implementation However, the challenges they faced can be organized as objectives of change i.e., sensitization, process initiation, consolidation and refinement, process conclusion, internalization and a perpetual cycle of change.The organizational setup was challenged to aim for conformity to the IMC design and PM&DC regulations, which in turn to facilitate it.IMC content development challenge was elimination of bottlenecks by defining criteria for content inclusion, exclusion, sequencing, validity, overload/renewal, learning objectives (LOs) overlapping, LOs restricted teaching and subject primacy issues.This summoned a need for expert validated content, integrated within and across different modules and phases.The implementation content encompassed physical/ organizational implementation structures needed for the roadmap like implementation hierarchy, faculty job description to avoid overlapping responsibilities, subject's faculty strength to module needs, trained faculty hiring, fully utilizing existing faculty, skill labs resources, flexible use of physical space and a systematic ward teaching including fixed students to ward ratio.The clinical subjects remained a challenge to plan implement structures for want of necessary departmentalized existence.Structures challenges also involved module authority, holistic accountability, module-based identity, structured linking of topics and task-specific training.The faculty resistance is the core content of transformational challenges that manifested as willful lacking implementation, hostile rigidity, and even resignations.The factors that lead to this resistance included non-inclusive decision making, rigid readymade curriculum, culture of silos, changing routine, avoidance of extra work, compensation, private practice, telescopic perspectives, age factor, by chance teachers, power shift, neophobia and insecurity, stuck to status quo and conflicts with teaching content.The content challenges of organizational and regulatory body included red-tapism, lacking legal cover, inadequate ancillary facilities and lacking DME capacity. 13,15he systematic method of IMC development involved three challenges.Firstly, bid for extra effort/resources, valid literature guidance, inclusive development, multi-dimensions effect.Secondly confront fault lines by establishing curricular alignments to faculty's implementation capacity, regulatory body obligations, a valid template like Harden's integration ladder, timetable for topic sequencing and instructional strategy for holistic learning. 16Thirdly establish interdepartmental collaborative-teamwork as a linchpin to ensure modular function by breaking silos and appreciating team effort. 7,17he lack of mindset, role understanding, uniform medical education background, co-ordination and leadership considered as main impediments. 5,6The method for a planned IMC implementation needed operation management approach with staged implementation strategy.The operationalization needed secured validated course modules, consultant oversight, DME to ensure fidelity, curriculum selfalignment structures, sanctioned human resources, infrastructure, internet/IT support and statutory budget allocation. 3,13he DME acting as a nerve center, confronted with the need for a full-time faculty and a clear mandate with challenges to provide leadership, curriculum development, faculty collaboration, effective communication, faculty training, operationalize curriculum and enable small group teaching. 8The structured method for the transformational change challenged multi-tiered leadership and establishment of support structures.The specific challenging leadership attributes at the highest level were clear concept of process, people and purpose, firm belief in change, confidence of stakeholders, involvement in process, open to diverse views and adaptive capacity.At faculty level academic credibility, coaching skills, good interpersonal skills, good managerial skills and being a dedicated self-directed learner are challenges of leadership.The challenges of establishing support to change process included open communication, autonomy, inclusiveness, collaborative teamwork, ownership, open faculty discussions, incentives, cultural embedment, top-down diffusion of change and carrot & stick approach.The red flags included discard of fair criticism, patchy support and fixation with faculty resistance. 10The challenges of a planned institutional and regulatory body method asked for financial autonomy, commitment, appraisals, freedom to plan & implement, shared value system and investment on faculty development.
The challenges of evaluation and assessment of IMC development necessitated for piloting and a prior framework for curriculum impact on students.The integrative assessment demonstrated a choking point partly due to the need for a functional assessment cell but mainly owing to the grinding challenges of lacking alignment to integration holistic outcomes and lacking in-depth subject-based evaluation.The perpetual appraisals and selective student's effort because of weighted based scoring remained unchanging challenges. 1,13he evaluation and assessment of implementation challenged for the implementation receipt system.The fundamental challenge was to acknowledge set-back of its absence.Evaluation needed the tasks of separate hierarchy, resource allocation, capacity building, valid & reliable feedback, recording recurring gaps and identifying quality constraints.The deferred verification included assessment results, evaluation outcomes and stakeholders' feedback. 1,18,19he need for real-time monitoring surfaced by the need for immediate rectifications but was hindered by lacking feasibility and acceptability.The challenges of evaluation and assessment of transformational change included hiring consultant oversight, assigning leadership, establishing feedback loops for timely conflict resolution.The regulatory body (PM&DC) needed to provide oversight and evaluation for the institution and for the process.This remained an insurmountable challenge due to political instability, fitful progress, restricted framework for integration, lack of holistic inspection and rudimentary DME. 4,19mitations of the study: Methodological triangulation was not feasible due to COVID-19 lock down and sensitive nature of information.Further research is needed to explore the medical college's strategic position in the existing overall healthcare system after this curriculum shift.

CONCLUSION
The challenges are multi-dimensional and have multiple facets.This needs involvement of all stake holders at each level to communicate and inclusively work for the curriculum transformation because it is not a one man show.The identified inter-connected themes can guide a framework to employ all aspects of the curriculum transformation in a stepwise, guided, and meaningful manner.

Table - I
: Participants Characteristics

Table -
III: Representative quotations It was a rotten system in which all the struggle was done by the students.You listen to a lecture or don't listen, with few exceptions, it was of no significance.Also the assessment system was by chance.