Trend in health professions education

1. Trend in Health
Professions Education
Hirotaka Onishi, MD, MHPE, PhD
Dept. of International Cooperation for Medical Education,
International Research Center for Medical Education,
Graduate School of Medicine, The University of Tokyo

2. Age of Mobility
 Both health patients and
professionals easily
move from one country
to another.
 Some countries develop
health professionals but
many of them leave
their countries for better
job.
 Some patients seek
better care across the
border.

3. Overview
1. Outcome-based education
2. Professionalism
3. Learning by simulation
4. Interprofessional education/work
5. Community-based medical education

4. 1.Outcome-based education

5. Goals of Medical Education
 Begin with patient/society needs
 Balance between basic sciences, clinical
studies, and clinical practice
 Balance of knowledge, attitude, and skills.
 Not only recalling information but also using
it to solve problems (deep knowledge)

6. Outline of Outcome-based
Education (OBE) System
Educational environment
Support
Assessment
How to learn
(Methods)
What to learn
(Contents)
Trainee
Outcome
Progress

7. Examples of OBE (1)
 6 outcomes of Postgraduate training:
ACGME (Accreditation Council for
Graduate Medical Education)
ACGME Outcome Project: http://www.acgme.org/Outcome/
 Patient Care
 Medical Knowledge
 Practice-Based Learning and Improvement
 Interpersonal and Communication Skills
 Professionalism
 Systems-Based Practice

8. Examples of OBE (3)
The Scottish Deans’ Medical Curriculum Group’s
Three circle model (Simpson et al. Med Teach 2002, 24, 136-143)
Medical informatics
Patient management
Patient investigation
Clinical skills
Communication
Practical procedures
Health promotion and
disease prevention
Personal
development
Role of the doctor within
the health service
Attitudes, ethical
understanding and
legal responsibilities
Decision-making skills
and clinical reasoning
and judgement
Basic, social and clinical
sciences and underlying
principles

9. Points of OBE
 Integrated competencies (e.g.
critical thinking and professionalism)
are more clearly targeted.
 Assessment for comprehensive
performance is more emphasized
 Nowadays “competency” is often used instead of
“outcome” if mentioned for curriculum
(e.g. competency-based curriculum)

10. Why Outcome-based
Education?
 info explosion
 Changing public expectation
 Accountability
 Informing curriculum decisions
 Integrating teaching and assessment
 Planning the continuum of education

11. Distinctions between Instructional
Objectives and Learning Outcomes
(Harden. Med Teach 24: 151–155, 2002)
Area of difference Instructional objectives Learning outcomes
The detail of the
specification
Extensive and
detailed
Learning outcomes can be
described under a small number of
headings
Specification Level
of the emphasis
Instructional intent at a
lower and more detailed
level
A broad overview with a design-
down approach to a more detailed
specification
The classification
adopted and
interrelationships
Classified into discrete
areas: knowledge, skills and
attitudes
Interrelationship of learning
outcomes with nesting of outcomes,
knowledge embedded and
metacompetences recognized
Intent or
observable result
Statement of aims and
instructional objectives are
perceived as intentions
Learning outcomes are guaranteed
achievements
Ownership By the curriculum developer
and reflect a more teacher-
centred approach to the
curriculum
The development and use of
learning outcomes can engage
teaching staff and reflect a more
student-centred approach

12. Overview
1. Professionalism
2. Learning by simulation
3. Interprofessional education/work
4. Community-based medical education

13. 2. Professionalism

14. Transition of How to Deal
with Ethical Issues
Bioethics (1970s-80s)
Clinical Ethics (1990s)
Professionalism (2000~)
Specific Cases
General Cases
Societal Issues

15. Bioethics (1970-80s)
 Civil-rights movement in 1960s
 Emerging issues related with medical
technology innovation
 Organ transplantation, Respirator, ICU,
Gene analysis…
 Ethical principles became clearer but it
was difficult to develop code of conduct.

16. Clinical Ethics (1990s)
 Clinicians began to try direct
discussions on dilemma in the real
clinical settings
 Terminology and tools to describe
issues became available.

17. Why Does Professionalism
Become Important?
 The US: Image of medical practice
came down in 1980s (rich physicians,
many accidents, cost consciousness)
 Japan: Protest to physicians by mass
media after series of medical accident
cases broadcasted

19. Professionalism
A Physician’s Charter
 In 2002, both American College of
Physicians and European Federation of
Internal Medicine proposed this at the
same time.
 Professionalism has become an
emerging area for medical education
since then.

20. Fundamental Principles
 Primacy of patient welfare
 Physicians should prioritize patient’s preference.
 Patient autonomy
 Physicians must be honest with their patients and
empower them to make informed decisions.
 Social justice
 Physicians should work actively to eliminate
discrimination in health care, whether based on
race, gender, socioeconomic status, ethnicity,
religion, or any other social category.

21. Case Report
Case Report
2005 Ministry of Health, Labour and Welfare (MHLW) has formed a
research group to seek causal relationship between Tamiflu
and abnormal behaviour.
2006
Aug
This research group received MHLW research grant but its
amount was only 4 mil yen in 2006. Several researchers
discussed how to manage the research with a MHLW officer
and the pharmaceutical company producing Tamiflu. The
company offered 6.27 mil yen to the chief researcher of this
group. The MHLW officer knew such flow of money.
2006
Fall
This group issued a report that no causal relationship
between Tamiflu and abnormal behaviour was found.
2007
Mar
Two teenager influenza patients who took Tamiflu behaved
abnormally and died.
2007
Apr-
May
Newspapers wrote articles that the company offered 6.27 mil
yen to the researcher. MHLW announced that the researcher
would be replaced.

22. 3. Learning by simulation

23. Simulation Teaching
 In 2000s, it became difficult to involve
patients in the practical training in Japan
 Rapid dissemination of simulation
teaching using
 Simulated/standardized patients
 Simulators/mannequins
 Team simulation program

24. Simulation vs Reality
 Learning from real experiences is always
important for physicians/students
 Some novices (students/interns) might
be hurt by real experiences

25. Relationship between Fidelity,
Learning Volume and Expertise
Low Fidelity (realism) High
Most cost-effective
Best learning
Expert
Experienced
Novice
（Alessi, 1988）

26. Is Simulation Enjoyable?
 If the program is well establish, yes!
 Some people really like TV games
 Facilitation and feedback is important

27. 4. Interprofessional
Education/Work, IPE/IPW

28. Patient centered medicine
Patient
Medical
doctor
Dentist
Pharma-
cist
Nurse
Rehab．
Techni-
cians
Nursing
care staff

30. Interprofessional Education
(IPE)
 Two or more health professionals cooperate
and learn to improve the quality of practice
 Reasons
 Complicated care, elevated expectation,
diversification of health professionals, community
based care, tem work, conflict between different
providers, new model practice, redefinition of
health professionals, effect of well prepared IPW

31. Different
Terminology
Care planCare desicionIndividual relaship
Parallel
Practice
Multidisciplinary
Practice
Interprofessional
Practice
pt
pt
pt
Minimal communication
More communication among health professionals
Trustful relationship among health professionals
Journal of Physical Therapy
Education 15 (2), 2001

32. Stages for Collaborative
Practice
 Communication: temporary or planned information
exchange
 Consultation: one way communication to obtain
advices and orders
 Cooperation: short term unofficial relationship
 Coordination: official relationship to have shared
objectives, structure and plans
 Collaboration: authorized persons cooperate to
seek shared solution
 Collaborative practice: interprofessional team with
expertise and synergy effect construct good
relationship to improve clinical outcomes

33. WHO 2010
Improved
Health
outcome
Local Health
Needs
Collaborative
Practice study
Health
workforce
Health and Education System
Local context
Present and
Future Health
workforce
Optimal
health
service
Source: WHO, 2010. Framework for Action on IPE and CP
Fragmented
health system
Interprofessional
Education
Collaborative
Practice
Strengthened
health system

34. How To Develop IPE
Collaborative
Professionals
Present and
Future
Professionals
Interprofessional
Education
Staff
training
Institutional
support
Management
commitment
Learning
outcomes
Champions
Logistics &
scheduling
Program content
Compulsory
attendance
Shared
objectives
Adult learning
principles
Learning
methods
Contextual learning
Assessment
Educators
Mechanism
Curriculum
Mechanism

35. How To Organize IPW
Optimal
health
services
Collaborative
practice-ready
workforce
Collaborative Practice
Governance
models
Shared operating
resources
Personnel
policies Supportive
management
practices
Structured
protocols
Communication
strategies
Conflict resolution
policies Shared
decision
making
procedures
Built
environment
Space design
Institutional
Support
Mechanisms
Environmental
Mechanisms
Facilities
Working Culture
Mechanisms

36. Comptencies Focused in IPE
1. Teamwork
2. Roles and responsibilities
3. Communication
4. Learning and reflection
5. Patient-health professional relationship,
understanding of patients’ needs
6. Ethical practice (WHO 2010)

38. 5. Community-based
Medical Education

39. Community Needs
 Most countries have concerns about
disproportion of physicians to cities.
 To increase the number of physicians
working in the community, medical
education should be conducted in the
community as early as possible.

40. Percentages of General Practitioners
Specialists
Others

41. Morey and Lovel: My Name is Today.1986
WHERE DO WE TEACH OUR DOCTORS OF THE FUTURE?
Students follow the example and lifestyle of teachers.
“I wonder which I will
get when I specialise”
The hidden curriculum
“I wonder how we
can serve our
People better”
Teaching in “disease palaces” Teaching in the community

42. 3 Week Community-based
Practice Training

43. Points
 CBME should be initiated by community
needs.
 Students should feel the need from
community people.