INTRODUCTION

Changes in the pattern of teaching have to be evolved in all disciplines of learning commensurate with the technical advancements world over. Medical education has also to be revamped incorporating newer advancements in the knowledge of medical science. With these ideas in mind, the Indian Medical Council has in 1997 come forward with regulations to change the curriculum of undergraduate medical education. The new curriculum has been devised for all the Medical Colleges in Kerala under the aegis of the Director of Medical Education after discussing all details in various workshops participated by all heads of Departments of the subjects covered in the undergraduate course. The regulations, syllabus and model question papers have been prepared based on the MCI norms of 1997. The basic concept of the new curriculum is to increase vertical integration of medical curriculum. The I MBBS course is reduced from 18 months to 12 months, increasing the training period of the II and III MBBS. The overall course duration is the same, but is reorganized into nine semesters of six months each. The reduction of six months of the I MBBS is meant to reduce the quantum of teaching of preclinical subjects to the medical students and give time during the later years for revising the preclinical subjects with relevance to the clinical teachings.

COURSE DURATION

The course is split into nine semesters. This introduces the semester system in Medical Education. Organisation of teaching is done with more emphasis on vertical integration. Vertical integration means the study of subjects in phase I along with the study of subjects is phase II and phase III of the course (e.g. session on thyroid or breast incorporating Anatomy, Pathology and Surgery or a session on hypertension incorporating Departments of Physiology, Pharmacology and Medicine). Horizontal integration means conducting combined sessions involving the subjects in the particular phase ( eg. session on jaundice incorporating Departments of Anatomy, Physiology and Biochemistry). Because of this change in curriculum, the student is exposed to the clinical subjects six months earlier than what used to be. The reduction of duration of I MBBS is meant to reduce the details of pre clinical subjects to the minimum so that more time will be available for clinical studies. The teaching of clinical subjects will be planned incorporating the teaching staff of preclinical and Para clinical subjects. Seminars are to arranged for the benefit of the students to simplify the process of learning. Seminars will be organised by departments incorporating vertical integration with the participation of preclinical, Para clinical and clinical teachers. Even though it is desirable to involve student participation in the seminars, it is inadvisable to put the whole stress on the students. Combined interdepartmental seminars and horizontal and vertical level will be arranged.

It is very important for the student that all the University examinations take place in time and the result of the Final MBBS examination is published before the end of the course that is four and a half years. This assumes great importance in the light of the fact that after the institution of the All India post graduate medical examinations, never has any batch of students from Kerala been able to write the examination scheduled for the particular year, due to delay in the completion of the course. It is hoped that the students will complete internship on time, so that they become eligible to write the All India Post Graduate Medical examinations held in January.

TEACHING METHODOLOGIES

Modern teaching schedules / methodologies are introduced. Basic knowledge of Anatomy, Physiology and Biochemistry of the human body will be transmitted to the students, giving a proper exposure to clinical studies to be undertaken later. Newer modalities of investigation like ultrasound, CT scan, contrast x-ray, NMR and DSA will be introduced to the students. Anatomy dissection will be reoriented to suit the objectives of the new regulation, rather than letting the students do their own dissection and consequently wasting precious time. The teachers should organise dissected specimen and teach the students more of clinical anatomy, stressing on surgical importance. The reduction in the course of I MBBS has reduced the burden of teaching of preclinical subjects (there being only one batch at a time). The time made available will be utilised for simplifying the learning process of the students. The new pattern of examination in anatomy does not envisage dissection. The clinical students will have clinical lectures from 8.00 to 9.00 a.m. from the third to the ninth semesters. With the advent of internet facilities and various web sites on medical learning, it is high time that teaching institutions start up online teaching facilities in the lecture halls and libraries. Audiovisual aids, micro teaching methodologies, projection slides, video projection facilities and LCD projection facilities should be incorporated in the lecture halls. A session on computer education will be an invaluable asset to the teachers of Medical Colleges. Facilities like Power point program and scanning hardware should be made available for organising the teaching of the students.

STUDENT POSTINGS

Pre clinical postings are given in the first two semesters. Clinical postings are given during the third to the ninth semesters organised for 142 weeks. The University examinations will be held at the end of semesters II (I MBBS), V (II MBBS), VII (Final MBBS Part I) and IX (Final MBBS Part II). Since the results of the examinations of I MBBS and Final MBBS part II have to be published before the end of the semester, the University examinations will have to start on the beginning of the 5^th month of the concerned semester. The final average examination which has to be conducted in the pattern of the University examination will take one month in a College having intake of 200 students. So the teaching has to be over by the end of the 3rd month of semesters II and IX. The posting will have to be over by the end of the fourth month of semesters V and VII. So semesters I, II, IV, VI and VIII can have full complement of six months of teaching, where as there will be four months of teaching in semesters V and VII and three months of teaching in semesters II and IX. Many clinical postings are currently lost for many students because of the examinations overlapping with clinical postings. This problem has been solved by avoiding clinical postings during the time of the examinations. Revision classes will continue during the period of the final internal assessment.

VACATION

There will be two spans of vacation during the course; one at the end of semester II and the other at the end of semester IX after the University examinations. Over and above, there will be a week’s holiday each for Onam and Christmas every year. There will be no regular vacation in May. This is to organise time for study leave.

udent is exposed to the clinical subjects six months earlier than what used to be. The reduction of duration of I MBBS is meant to reduce the details of pre clinical subjects to the minimum so that more time will be available for clinical studies. The teaching of clinical subjects will be planned incorporating the teaching staff of preclinical and paraclinical subjects. Seminars are to arranged for the benefit of the students to simplify the process of learning. Seminars will be organised by departments incorporating vertical integration with the participation of preclinical, paraclinical and clinical teachers. Even though it is desirable to involve student participation in the seminars, it is inadvisable to put the whole stress on the students. Combined interdepartmental seminars and horizontal and vertical level will be arranged.

It is very important for the student that all the University examinations take place in time and the result of the Final MBBS examination is published before the end of the course that is four and a half years. This assumes great importance in the light of the fact that after the institution of the All India post graduate medical examinations, never has any batch of students from Kerala been able to write the examination scheduled for the particular year, due to delay in the completion of the course. It is hoped that the students will complete internship on time, so that they become eligible to write the All India Post Graduate Medical examinations held in January.

VERTICAL AND HORIZONTAL INTERGRATION IN MBBS CURRICULUM

The Medical Council of India regulation on graduate medical education 1997 has stipulated organisation of Vertical Integration training programmes for the students undergoing MBBS degree course. This means that from the very first year of MBBS 1st semester onwards, the MBBS students shall be exposed to the teacher of the clinical and paraclinical subjects. Vertical integration means a preclinical student gets trained in para clinical subjects (those subjects in semesters III, IV and V) and the clinical subjects to be covered in semesters III, IV, V, VI, VII, VIII and IX. The students should be having classes, discussions and seminars incorporating topics and teachers belonging to paraclinical and clinical subjects. Similarly the clinical semester students should be having classes, discussions and seminars incorporating topics and teachers belonging to preclinical and paraclincial subjects. Horizontal Integration indicates similar sessions incorporating subjects of the same semester; eg. Anatomy, Physiology and Biochemistry in the first semester.

Based on the basic principles of vertical integration, a schedule of seminars is presented. During the 1st semester there shall be at least two seminars incorporating the paraclinical and clinical subjects. In the 2nd semester there shall be atleast three seminars incorporating the paraclinical and clinical subjects as detailed below. During the three semesters for the paraclinical subjects (III, IV and V), there shall be two seminars each during each semester incorporating the preclinical and clinical teachers. During the clinical semesters VI, VII, VIII and IX, there shall be two seminars during each semester incorporating teachers of preclinical and paraclinical subjects. Some areas where teaching programmes can be conducted semester wise are listed below.

Semester I - Upper limb pathology and lower limb pathology incorporating teachers from Orthopaedics and Surgery

Semester II - Symposium on endocrine glands incorporating teachers from Pathology, Medicine and Surgery. Symposium on digestive system incorporating teachers from Pathology, Medicine and Surgery.

Semester III - Symposium incorporating Pathology and Medicine on thyroid, endocrine glands

Semester IV - Symposium on Anaesthesia incorporating teachers from Anaesthesia and Surgery.

Antidiabetic drugs incorporating teacher from Pathology and Medicine

Semester V - Symposium on infection incorporating teachers from Medicine, Surgery and Gynaecology. Symposium on autopsies incorporating teachers from Pathology, Medicine and Surgery.

Semesters VI, VII - Symposium on communicable diseases incorporating Anatomy, Pharmacology and Pathology.

Semesters VIII, IX - Symposium on gastro intestinal malignancy incorporating Anatomy, Physiology and Pathology, Infection incorporating Microbiology and Pathology.

STRESS OF BEING A MEDICAL STUDENT

Some of the stress factors faced by medical students are common to many people; these include financial worries, strained relationships and social pressures. In addition, medical students and residents are challenged by a number of unique demands, including long and intensive study and training that leave limited time for rest and personal activities. Students have also reported stress arising from competition with peers, intimidation, abuse and harassment.

The academic burden of modern medical education can be awesome. After passing out plus two or pre degree at the relatively young age of about 18 years, they are suddenly exposed to an entire new academic setting.

Most of the current medical students come from highly protected home and school environments. Most learning is of a passive acquisitive nature. Suddenly they are asked to ingest vast amounts of information and to acquire a wide range of practical and correlative skills. Nothing in their previous learning experience has prepared them to deal effectively with the new types of demands.

The unique problems faced by medical students (BMA 1992) are

l        Constant face to face evaluation of their skills by both staff and patients

l        Dealing with death, diseases, suffering and ethical issues

l        Performing intimate physical examinations when the student is at an age when sexual knowledge experience is still relatively immature

l        Long hours of work, a large number of examinations, fewer holidays and consequently less time for social interactions with friends and relatives.

l        Consequently less time for social interactions with friends and relatives

Simultaneously they are subjected to frequent evaluations. Failure and low performance are common. These students, most of whom had hither to been at the very top in their respective institutions find this hard to accept. Anxiety, depression and low self esteem are the frequent results.

The new medical curriculum (1977) has increased the stress in the first year of the course as the basic science training has been compressed to one year instead of the previous 18 months. This has been done without proportionate reduction in the volume of course content.

Compounding these stress factors is an uncertain training environment. Today’s medical students often feel pressured to make early decisions about their career path, before they have had adequate opportunity to experience a wide range of options. Many are burdened by the concern that they will be locked into a career choice with restricted opportunity. In addition, students face the relatively recent prospect of limited practice opportunities or unemployment upon completion of their training.

SCOPE – A NEW INITIATIVE

Scope is a new initiative designed to deal with the different kinds of stress faced by medical students and thereby improve the academic environment.

OBJECTIVES OF THE PROGRAMME

1.        Promote a culture within the institution, which emphasizes the importance of personal mental health and wellbeing during medical college years and throughout the whole of one’s professional life

2.        Encourage a culture of caring for students early’ with the intention of preventing problems reaching a crisis

3.        Develop and maintain procedures that assist and encourage medical students with mental health or stress related problems to seek appropriate and confidential help.

STRATEGIES OF IMPLEMENTATION

a.                    Ensure a faculty structure is created that is responsible for the design and maintenance of an education programme that promotes the mental health of students.

b.                   Communication and listening skills required for working with patients and their families, colleagues, administrators and journalists.

c.                    Preparation for a number of roles, including clinician, consultant, advocate, educator, supervisor and patient.

d.                   Identification of the social and psychological factors that can lead to stress related problems, recognition of early intervention. For example, problems such as fatigue, overwork, irritability and anger can all translate into stress related problems.

e.                    Recognition of healthy lifestyle practices (related to nutrition and exercise and the use of alcohol, nicotine and other drugs) and the importance of developing and maintaining interests outside of medicine.

f.                     Training in the development of strategies to manage change and stressful events.

g.                   Identification of specific mental health problems (for example, anxiety, depression and substance abuse) common among medical students.

h.                   Recognition of mental health and stress related problems in fellow medical students and the importance of supporting and assisting fellow students.

i.                     Promote good study habits, exam techniques and other coping skills such as stress management.

j.                     Develop a mentor support programme for students ensuring requisite confidently.

METHODS

Faculty Counselors:

The counselors will be selected from among the faculty with requisite experience. Each counselor will be assigned five students. The counselors will act as mentors and guides for these students for the entire period of their course. It is expected that these counselors will establish the necessary rapport with their wards so that the students will have no hesitation in approaching them for advice and help. The faculty counselors will be given special training in students psychology as well as counseling principles and methodologies. A second level counseling team will also be constituted. This team will help students who are referred to them by the faculty counselors.

Course book

To make the programme structured, each student will be issued a course book at the beginning of the course. Entries of all the sessional marks, details of clinical postings and extracurricular activities will be made in the course book by the respective departments/units. The counselor will examine the course book at each contact with the ward.

Objectives

1.                    To assist ward to improve academic progress.

2.                    To assist ward to cope with any stress situations including evaluation

3.                    To help them maintain physical & mental well being.

4.                    To intervene whenever required.

5.                    To encourage the ward to approach the counselor whenever need arises.

6.                    To resolve problems at the counselor level.

7.                    To refer the ward to a second forum if required.

Guidelines

1.                    Interact with the ward at least once a month.

2.                    Record the meetings in the concerned course book

3.                    Monitor the progress by examining the marks, attendance in different departments including clinical postings and remarks of HOD/unit chief.

4.                    Record accurately about the extracurricular achievements in the course book.

5.                    Identify the physical and / or psychological problems, if any, unbiased.

6.                    Intervene, if indicated.

(i) Indications for intervention

1.             Attendance less than 50%

2.             Marks less than 35%

3.             Absence from examinations.

4.             Any other situation, the counselor thinks appropriate.

(ii) Mode of interaction

1.             Identify the reason for lack of attendance, shortage of marks or absence from examinations.

2.             Counsel according to the reason found out if any

3.             Report the situations which cannot be dealt with by the counselor to the expert counseling committee.

4.             Keep all details of interactions absolutely confidential.