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David gordon

Keynote speech เรื่อง Creative Accreditation for Better Quality Education บรรยายโดย Professor David Gordon, President, World Federation for Medical Education (WFME) ในการประชุม การพัฒนาคุณภาพการศึกษาสำหรับบุคลากรสุขภาพ ครั้งที่ ๖ “ประกันคุณภาพเชิงสร้างสรรค์ สู่คุณภาพการศึกษา”

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David gordon

  1. 1. Creative accreditation for better quality education Sixth Annual National Health Professional Education Reform Forum Bangkok 25 November 2019 David Gordon President, WFME
  2. 2. • Positive ˗ I really believe that accreditation can be creative and can lead to better quality education • Provisos ˗ Much of what I say may seem negative, but: 1. It is not intended to be, but is aimed to promote a positive way forward 2. Culturally determined – both in content and (indeed) in humour One positive, and two provisos
  3. 3. Outline of the presentation • Some personal background • About WFME • Three milestones in the development of medical education ˗ Flexner ˗ The Lancet Commission (“Frenk and Chen”) ˗ Accreditation • The nature of evidence in the future of medical education • The personal background - Faculty of MDNP in Manchester – medicine, dentistry, nursing and pharmacy, later also psychology
  4. 4. The World Federation for Medical Education aims to enhance the quality of medical education and to promote the highest standards. It is a partnership organisation of the world’s six regional associations for medical education, also working with its two founding members WHO and WMA, and three executive members, JDN, IFMSA and ECFMG. It was founded in 1972 by WMA and WHO. Three main priorities among many others: • promotion of accreditation through the WFME Recognition Programme • raising the standards for BME, PGME and CPD • maintaining the World Directory of Medical Schools Introduction
  5. 5. WFME Executive Council
  6. 6. Regional members of WFME
  7. 7. Enhancing the quality of medical education 3 projects – separate but connected
  8. 8. • 1837 – the “most lawless” • 1910 – the Flexner report Why “1837 to 1910” in the process of improvement of medical education?
  9. 9. • Insistence on suitable and high standards for medical education ˗ Academic content of the course: quality of staff: duration of the course: facilities: etc. ˗ Importation of the best practice from elsewhere (particularly German universities) • Closure of half of all the medical schools in the USA Positive outcomes of Flexner
  10. 10. • “Education must be scientific” – but what is science? ˗ (The example of JHU) • Little possibility of integrated curricula • Education outside the hospital, for example in primary care, less likely • Anatomy, physiology, biochemistry, pharmacology and so on, but little opportunity for anthropology, sociology, economics, medical law and so on… • “… in this dissertation, ethnographic, historical and epidemiologic data are brought to bear on the subject of the Acquired Immune Deficiency Syndrome (AIDS) in Haiti” But – less positive outcomes of Flexner (1)
  11. 11. • The loss of 5/7 “historic black medical schools” • “The negro needs good schools rather many schools ...” • Only Howard (Washington) and Meharry (Nashville) survived, and still survive • Before then … ˗ “…some free Negro students either traveled to Europe or trained at a small cadre of eastern or midwestern universities. Notable among these were the University of Pennsylvania … Harvard ... Yale …” ˗ “The first black physician to earn a formal medical degree was James McCune Smith, who studied … at the University of Glasgow” Less positive outcomes of Flexner (2)
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  13. 13. Leonard Medical School, Raleigh NC, 1882 - 1918
  14. 14. • In conclusion, Flexner was overwhelmingly positive for the future of medical education: but not entirely positive • Next example: the Lancet Commission
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  17. 17. • Confidence in the financial data is not helped by the statement in the web appendix that “we arrived at rough estimates of $xxxxx and $yyyyy [sic] for annual expenditures in medical and nursing education, respectively.” Those are indeed “rough estimates”. Without substituting real figures for $xxxxx and $yyyyy we can draw no conclusions about the costs of medical and nursing education.
  18. 18. • The IIME was an offshoot of the China Medical Board of the Rockefeller Foundation • The China Medical Board website is now silent on the IIME, but … • “we arrived at rough estimates of $xxxxx and $yyyyy [sic] for annual expenditures in medical and nursing education, respectively.” One dishonest idea about development of medical education
  19. 19. • Gordon, David and Karle, Hans (2012) "The State of Medical and Health Care Education: A Review and Commentary on the Lancet Commission Report, "World Medical & Health Policy: Vol. 4: Iss. 1, Article 9. • Of 10 “instructional reform elements” included in Frenk and Chen, we concluded: ˗ “No” to 4 ˗ “Yes, but already done” to 3 ˗ “Yes” to 3 • For example, the most important of our “no” was on competence-based curricula, where Frenk and Chen ignored all the expert literature on this subject
  20. 20. • Also – and crucially – we argued that the conclusion of Frenk and Chen, that failures in education were the cause of failures in health care was wrong: rather, education tends to lead, and not to hinder or harm health care
  21. 21. • A marketplace in Egypt in Roman times • A new doctor wishes to use space in the market to open his medical practice • Examined by the manager of the market. Where was he educated? Who were his teachers? What evidence has he got of his competence? • (He was writing to his mother) • Professor Vivian Nutton For how long have we known “what is a doctor” – or, for how long as education been accredited?
  22. 22. • September 2010, Philadelphia, Pennsylvania, 8th International Conference on Medical Regulation • First announcement of the 2023 plans of ECFMG ˗ “… school must be accredited through a formal process … or that uses other globally accepted criteria, such as those put forth by the World Federation for Medical Education (WFME)” • We had the criteria (WHO-WFME) but how to create a process to evaluate accrediting agencies? How did the recognition programme happen?
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  24. 24. • A process like the accreditation of a medical school – self evaluation, documents, site visit … • Plus examination of the final decision-making process of the accrediting agency • ... And a final decision-making process on whether the accrediting agency should be ... Accredited? Accepted?? Recognised???
  25. 25. Choosing the right word • Accrediting the accreditors/accrediting medical schools?? • Standards for medical education/standards for accreditation?? • Medical schools are accredited measured against standards for medical education • Accrediting agencies are recognised using criteria for recognition
  26. 26. Choosing the right word (2) • Accrediting the accreditors/accrediting medical schools?? • Standards for medical education/standards for accreditation?? • Medical schools are accredited measured against standards for medical education • Accrediting agencies are recognised using criteria for recognition
  27. 27. • Because much of the advice was from the USA, the processes felt like those of LCME – we have worked to make them feel more “global” • Timescale of the recognition process – originally the final decision-making meeting was planned to happen just once each year • The papers were too long! – two particular reasons ... • Many details to be worked out ... ˗ Recruitment of assessors ˗ Training of assessors ˗ Evaluation of assessors ˗ Travel and SV policies, etc. etc.... • A very overworked organisation We have been feeling our way
  28. 28. • $60,000 plus expenses: systematically worked out in ~2014 • Principles: ˗ must as far as possible cover true full cost ˗ process to help countries and accrediting agencies with little money ˗ payment before final assessment • Does it meet those principles? – barely: yes, support for less developed countries is in place: not always • Strategies to meet the shortfall The cost
  29. 29. • Process using the model of accreditation ˗ Medicine-specific ˗ Self-evaluation ˗ Site visit observation ˗ Recognition Committee • Pre-defined criteria ˗ 2005 WHO/WFME policy on accreditation ˗ Criteria based on an expert consensus of good practice ˗ Updated 2018, updated again 2019 • WFME as a “partner in development” “improvement as well as compliance” Recognition Programme recently
  30. 30. • Twenty agencies recognised • (Thailand was number 12) • Three with the site visit completed • Many more in 2020 • ten close to site visit: eleven at an earlier stage Progress 0 2 4 6 8 10 12 2012 2013 2014 2015 2016 2017 2018 2019
  31. 31. • Have you turned anyone down? • Surely you know that medical education in XXXXXXX is the best in the world and therefore does not need external assessment? • Does the accrediting authority in my country have to come in for Recognition? • When will ECFMG clarify its 2023 policy? Questions we are asked
  32. 32. • Who gives WFME the authority to do this? ˗ “Earned” not “positional” authority; developing trust in what we do • Is it right for WFME to have a monopoly? • What are your problems, or what are you worried about? Questions we ask ourselves • How to keep accreditation and recognition processes fair but not inappropriately rigid or even mindless (“put that tape measure away”) • Cost-effectiveness Questions we should be asked
  33. 33. • There is some evidence ˗ van Zanten and Boulet (2013, Quality in Higher Education, 19:3, 283- 299) ˗ Alrebish et al. (2017, Medical Teacher, DOI:10.1080/0142159X.2016.1254746) • Note: accreditation not as “passing the examination” but as a long- term quality improvement process. • History cannot be ignored • We should not berate ourselves for lack of evidence of the benefits of accreditation ˗ There is a lack of evidence for most activities in medical education Is accreditation effective?
  34. 34. • Education is not a “hard” science”, it is developed and adapted by society • Therefore we should not expect the evidence for anything in education to be as definite as evidence in (for example) physiology or molecular biology • Therefore, any statement of ideas on instructional skills, learning theory, learning objectives, integrated learning, curriculum design, and so on and so on, should be examined thoroughly and with caution • Anyone selling a new idea in education should be looked at with the same care as anyone selling a new drug Education
  35. 35. • “The most important task of the new Director-General of WHO is to create a common curriculum to be used in every medical school in the world so that all graduates can go and work in the USA without taking another examination [i.e. the United States Medical Licensing Examination ® ]” • A very senior administrator in a Ministry of Health ~10,000 km from here • WRONG in at least three ways ˗ The DG of WHO has more important things to do ˗ There is no way in which every medical school in the world could or should be the same ˗ Would the USA or any other country accept this??? Crazy ideas in education…
  36. 36. Clinical medicine can be equally prone to bad ideas about evidence
  37. 37. • “It is not true that people stop pursuing dreams because they grow old, they grow old because they stop pursuing dreams.” Gabriel García Márquez
  38. 38. Filipe Pinto Soares, Lisbon, Portugal