Renovating medical education in a changing vietnam

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MOVING THE MOUNTAIN: RENOVATING MEDICAL EDUCATION IN A CHANGING VIETNAM Luu Ngoc Hoat MOVING THE MOUNTAIN: RENOVATING MEDICAL EDUCATION IN A CHANGING VIETNAM Luu Ngoc Hoat ISBN: 978-604-66-0001-5 Front cover illustration: Photograph of the main building of Hanoi Medical University, the institution that led the process of change in medical education in Vietnam, with the support of the Ministry of Health, Ministry of Education and Training and the Netherlands-financed project. The building was completed in 2002 but in the style of the original university established 100 years earlier. VRIJE UNIVERSITEIT MOVING THE MOUNTAIN: RENOVATING MEDICAL EDUCATION IN A CHANGING VIETNAM ACADEMISCH PROEFSCHRIFT ter verkrijging van de graad Doctor aan de Vrije Universiteit Amsterdam, op gezag van de rector magnificus prof.dr. L.M. Bouter, in het openbaar te verdedigen ten overstaan van de promotiecommissie van de faculteit der Aard- en Levenswetenschappen op dinsdag 25 november 2008 om 10.45 uur in de aula van de universiteit, De Boelelaan 1105 door Luu Ngoc Hoat geboren te Nam Dinh, Vietnam promotoren: copromotoren: prof.dr. E.J. Ruitenberg prof.dr. G.J. van der Wilt dr. E.P. Wright dr. J.E.W. Broerse “Nếu kế hoạch một thì quyết tâm phải mười và biện pháp phải hai mươi.” “If the plan is one, the determination must be ten and the measure must be twenty.” Ho Chi Minh The first President of Vietnam Members of the Thesis Committee: • Prof.dr. J.C.C. Borleffs, University Medical Centre Groningen • Prof.dr. J.F.G. Bunders, VU University Amsterdam • Prof.dr. F. Scheele, VU University Amsterdam • Prof.dr. Truong Viet Dzung, Hanoi Medical University TABLE OF CONTENT Chapter 1: Introduction.................................................................................... 1 1.1. Aim and purpose of the thesis................................................................1 1.2. Theoretical Background .........................................................................2 1.2.1. Medical education development.................................................................... 3 1.2.2. Management of change ............................................................................... 5 1.3. Research design ................................................................................. 17 1.3.1. Main objectives and research questions .......................................................18 1.3.2. Brief case description..................................................................................19 1.3.3. Research methods ......................................................................................21 1.3.4. Research validity ........................................................................................25 1.3.5. Research team ...........................................................................................27 1.4. Outline of the book ............................................................................. 27 Chapter 2: The context for development of medical education in Vietnam .. 37 2.1. Health system in Vietnam .................................................................... 37 2.2. Human resources in the health system.................................................. 40 2.3. Health indicators and changing disease patterns.................................... 44 2.3.1. Health indicators ........................................................................................44 2.3.2. Changes in disease patterns........................................................................46 2.4. Development of medical education in Vietnam and need for intervention . 47 2.4.1. Colonial occupation by France (1886 – 1945) ...............................................48 2.4.2. Wars with France and America (1945 - 1975)...............................................49 2.4.3. After the wars but before innovation (“Doi moi”) (1975 – 1985) ....................50 2.4.4. After innovation but before the intervention of a Dutch project for medical education (1986 – 1994)..............................................................................50 Chapter 3: Medical education changes with support from an international project .......................................................................................... 55 3.1. Situation analysis at the beginning of the project ................................... 55 3.2. Main objectives, strategies and activities of the first phase of the project. 59 3.3. Main objectives, strategies and activities of the second phase in comparison with the first phase of the project........................................................ 67 3.4. Changes along the way: revision of plans on the basis of experience during implementation.................................................................................. 74 3.5. Limitations of the project in medical education development and efforts to overcome them.................................................................................. 76 Chapter 4: Constraints, challenges and lessons learned of the first phase of the project.................................................................................... 85 4.1. Obstacles to the introduction of change in the medical schools ............... 85 4.1.1.Isolation of Vietnam and its medical schools until recent years .......................85 4.1.2. Lack of standards for medical doctors as end-points for medical training........86 4.1.3.Low status of public health in medical schools ...............................................86 4.1.4.Time constraints..........................................................................................87 4.2.Constraints and obstacles in project implementation ............................... 88 4.2.1.The understanding between the four medical schools and KIT .......................88 4.2.2.Misunderstandings after Workshop 1 on curriculum .......................................90 4.2.3.Conceptual differences.................................................................................91 4.2.4.Identification of indicators for project monitoring...........................................91 4.2.5.Sustainability...............................................................................................93 4.3.Lessons learned ................................................................................... 93 4.3.1.Language....................................................................................................94 4.3.2.Balance between motivation and sustainability ..............................................94 4.3.3.Time...........................................................................................................95 4.3.4.Strengths and weaknesses of the schools......................................................95 4.3.5.Future developments ...................................................................................96 Chapter 5: Participatory identification of learning objectives in eight medical schools in Vietnam ....................................................................... 99 5.1. Introduction ....................................................................................... 99 5.2. Project aim....................................................................................... 101 5.3. Methods to identify learning objectives (needed KAS) .......................... 101 5.4. Results of the steps in the process ..................................................... 102 5.4.1. Step 1: Inter-school workshop on KAS process...........................................102 5.4.2. Step 2: Policy documents ..........................................................................103 5.4.3. Step 3: Formulation and selection of KAS topics .........................................103 5.4.4. Step 4: Teaching staff contributions...........................................................105 5.4.5. Step 5: Achieving consensus .....................................................................106 5.4.6. Step 6: Skills levels ...................................................................................106 5.4.7. Step 7: KAS survey ...................................................................................107 5.4.8. Step 8: Final KAS book..............................................................................107 5.5. Difficulties with key concepts ............................................................. 107 5.5.1. Distinguishing among knowledge, attitudes and skills .................................107 5.5.2. Selecting the problems and issues for KAS lists ..........................................108 5.6. Coordination system.......................................................................... 108 5.7. Discussion ........................................................................................ 109 5.8. Conclusion........................................................................................ 111 Chapter 6: Practicing doctors’ perceptions on new learning objectives for Vietnamese medical schools...................................................... 115 6.1. Background ...................................................................................... 115 6.2. Methods........................................................................................... 117 6.2.1. Study design ............................................................................................117 6.2.2. Study participants.....................................................................................117 6.2.3. Data collection tools .................................................................................117 6.2.4. Qualitative data ........................................................................................119 6.2.5. Data analysis............................................................................................119 6.3. Results............................................................................................. 119 6.3.1. Key characteristics of the study population.................................................119 6.3.2. Relevance of skill levels set by teachers and perception of the practicing doctors .....................................................................................................120 6.3.3. Frequency of using selected skills according to discipline.............................122 6.3.4. Appropriateness of skill levels set by teachers compared to frequency of use by practicing doctors .................................................................................123 6.3.5. Priority of the selected skills as perceived by practicing doctors ...................125 6.3.6. Discrepancies between skill levels set by teachers and priority rating by practicing doctors ......................................................................................125 6.3.7. Focus group discussions............................................................................127 6.4. Discussion ........................................................................................ 129 6.5. Conclusions ...................................................................................... 131 Chapter 7: Perceptions of graduating students from eight medical schools in Vietnam on acquisition of key skills identified by teachers ...... 135 7.1. Background ...................................................................................... 136 7.2. Methods........................................................................................... 137 7.2.1. Study design ............................................................................................137 7.2.2. Study participants.....................................................................................138 7.2.3. Data collection tool ...................................................................................138 7.2.4. Data collection .........................................................................................139 7.2.5. Data analysis............................................................................................140 7.3. Results............................................................................................. 140 7.3.1. Students’ perception on whether they reached the level of skill listed in the KAS book. .................................................................................................140 7.3.2. Students’ perception of skill achievement ...................................................141 7.3.3. Study sites for learning skills .....................................................................146 7.4. Discussion ........................................................................................ 148 7.5. Conclusion........................................................................................ 151 Chapter 8: Community - University Partnership: Key elements for improving field teaching in medical schools in Vietnam ............................ 155 8.1. Introduction ..................................................................................... 155 8.2. Methods........................................................................................... 157 8.3. Results............................................................................................. 158 8.3.1. Challenges for FT before intervention ........................................................158 8.3.2. Building a community-university partnership model ....................................161 8.3.3. Main strategies and activities to improve FT in the eight schools. ................163 8.3.4. Intervention activities for field teaching .....................................................165 8.3.5. Results after interventions.........................................................................165 8.3.6. Evaluation of intervention by different stakeholders ....................................168 8.4. Discussion ........................................................................................ 169 8.5. Conclusion........................................................................................ 172 Chapter 9: Motivation of university and non-university stakeholders to change medical education in Vietnam....................................... 179 9.1. Introduction ..................................................................................... 179 9.2. Methods........................................................................................... 181 9.3. Results............................................................................................. 182 9.3.1. Ministry representatives ............................................................................184 9.3.2. Health service providers............................................................................185 9.3.3. Part-time teachers from hospitals and other institutions ..............................185 9.3.4. Local FT preceptors ..................................................................................186 9.3.5. Community leaders and members..............................................................187 9.3.6. University stakeholders .............................................................................188 9.4. Discussion ........................................................................................ 192 9.5. Conclusion........................................................................................ 194 Chapter 10: Discussion and conclusions ...................................................... 197 10.1 Discussion ....................................................................................... 197 10.1.1. Medical education – why change it? .........................................................197 10.1.2. Medical education – change in which direction? ........................................199 10.1.3. Research in medical education.................................................................206 10.2. Conclusions .................................................................................... 208 Abbreviations................................................................................................ 219 Summary ................................................................................................... 221 Samenvatting ............................................................................................... 225 Tóm tắt ................................................................................................... 229 Acknowledgements ...................................................................................... 234 List of Publications Chapter 4: Hoat L N and Wright E P (2001). Constraints, challenges and lessons learned (In TT. Bach and D. Burck (eds), Implementing community-oriented teaching in medical education - A case from Vietnam (pp 77-88) KIT Health, Bulletin 348, Amsterdam, ISBN: 90-6832-837-9.) (Reproduced with the permission of the publisher.) Chapter 5: Hoat L N, Yen N B, and Wright E P (2007). Participatory identification of learning objectives in eight medical schools in Vietnam; Medical Teacher. 29 683-690. Chapter 6: Hoat L N, Dung D, V, and Wright E P (2007). Practicing doctors' perceptions on new learning objectives for Vietnamese medical schools; BMC. Medical Education. 7 19. Chapter 7: Hoat L N, Son N M, and Wright E P (2008). Perceptions of graduating students from eight medical schools in Vietnam on acquisition of key skills identified by teachers; BMC. Medical Education. 8 5. Chapter 8: Hoat LN, Wright EP: Community - University Partnership: Key elements for improving field teaching in medical schools in Vietnam, accepted for publication in Rural and Remote Health, September, 2008. Chapter 9: Hoat, LN, Viet, NL, van der Wilt, J.E.W, Broerse, J., Ruitenberg, E.J. and Wright, E.P. Motivation of university and non-university stakeholders to change medical education in Vietnam, submitted for publication, October, 2008. CHAPTER 1 INTRODUCTION 1.1. Aim and purpose of the thesis Medical education systems must be able to train doctors with qualities that satisfy the needs of society for medical care (Dowton & Brown, 2004; Lewkonia, 2001; Peabody, 1999, Woollard, 2006). In consequence, when society changes, medical education has to change as well (Boelen, 1999; Gibbons, 2006). To change medical education in relation to societal needs is not a straightforward process. It demands commitment from the education and health policy makers as well as from the medical universities themselves. To ensure that the process responds to the needs of the society, involvement of stakeholders outside the university is important, but often less convenient to organize and achieve. In this thesis, the recent and successful process of change in medical education in Vietnam is dissected and analyzed to provide evidence about how to develop a community-oriented medical curriculum in eight medical schools in only a few years. Vietnam has changed rapidly over the past two decades; economic development and an open door policy have stimulated both economic growth and social change, and have brought Vietnam into a different phase of epidemiological transition. The main diseases for large segments of the population are no longer the diseases of poverty, but increasingly diseases that are seen in wealthier societies (Ministry of Health, 2007). However, development is unequally distributed around the country, and the gap between rich and poor is increasing. While health problems related to a more prosperous lifestyle, such as cardiovascular disease, diabetes and obesity, have started to appear more often among the wealthier and usually urban segment of the population, those in both urban and rural poor communities still commonly suffer from infectious diseases and malnutrition (World Bank et al, 2001). As social and policy changes brought about alterations in disease patterns and other health issues, medical education in the medical schools of Vietnam also needed to change. Because making the needed changes was beyond the financial and technical capacity of the Vietnamese medical schools and ministries at that time, assistance was sought from external sources and found from the Netherlands’ Government. The Dutch-supported project started its first phase late in 1993, and continued with a second phase for a total of 12 years, involving the eight main medical schools in Vietnam. The first phase included a situation and organization analysis, resulting in the aim to integrate the topics of Primary Health Care and Epidemiology in the curriculum of four medical schools. The second phase focused on strengthening the community orientation of the curriculum and the quality of teaching in all eight medical schools. In the second phase, the systematic process of change started with better-defined learning objectives, leading to a revised curriculum, appropriate teaching and learning materials and methods, and student assessment tools. It was a long process that involved the 1 CHAPTER 1 participation of many institutions and contributors from within and outside the medical schools. Stakeholder involvement during the process was very important for the success and sustainability of the innovations supported by project interventions. Even with external support, the project was a long and complex process that required moving and motivating thousands of teaching staff in eight schools around the country, bridging not only geographical distances, but also differences in ideas, experience and expectations. Because of this complexity, a number of strategies and approaches were applied at different times, in different situations, at different steps of the process. “Trying to change the teaching in medical schools is harder than trying to move a mountain!” Remark made by a teacher in one medical school during an evaluation survey. In this thesis, the complex and complicated process of change in the eight medical schools is described and dissected. The aim is to identify and to analyze the factors, actors and conditions that influenced the achievements and failures of this project in its efforts to change medical education in eight medical schools. The results and lessons learned from the study provide evidence to support the Ministry of Health, the Ministry of Education and Training and the medical schools in Vietnam to continue with the successes and to overcome difficulties to continue the cycle of renovation in medical education. The results are also made available for medical educationalists and scientists in other countries through published books and articles as well as this thesis. This chapter is the introduction to the thesis research. It includes a brief description of the aims and purpose of the thesis, followed by the theoretical framework, presenting the theories, models and approaches that were used to facilitate the changes in medical education and to analyze the process of change, in the context of the project. Next it describes the research design, mapping how the theories, models and approaches were applied in the two phases of the project, chapter by chapter, and the publications related to each set of results. The chapter finishes with an outline of this book. 1.2. Theoretical Background The work described in this thesis grew from the context of medical education in Vietnam but was strongly influenced by changes taking place in medical education around the world. As described in the first section below, the past decades have seen a great deal of innovation and experimentation in medical education, some of which was in response to social changes in many countries. The analysis of the process of change in this thesis made use of a number of models that were developed for management in the commercial sector but have been fruitfully applied to education as well. The choices of models applied to help understand the process of change in the Vietnamese medical schools are explained in the second part of this section. 2 INTRODUCTION 1.2.1. Medical education development Education in general, from primary through secondary to university education, has been undergoing a change in approaches to learning during the past few decades (Bush and West-Burnham, 1994; McNeil et al 2006, Guilbert, 2004). In Western countries this was partly in response to other social changes taking place at the same time (Prideaux 2007). Although those changes have not all necessarily been paralleled in Asia, many universities in Asia have taken up the lessons learned from the experience in other countries and have started to adapt their training programs as well (Amin et al, 2005; Cheng, 1991). The focus on the learning by the student instead of the teaching by the teacher has also profited from the developments in technology and the increasing availability of information (Peer & Martin, 2005; Prideaux 2007). If the graduates of medical schools are to meet the needs of the health system even as those needs change with the evolving economic and social situation, then the medical curriculum should focus on the desired outcome (Dowton, 2005; Harden 2002; Harden et al., 1999; McNeil et al, 2006; Wellbery, 2006). Outcome-based education is focused on the capacity of the graduates, the products of the training process, more than on the training process itself. This focus has been at the basis of many of the developments in medical education during recent years (Harden et al, 1999a and 1999b). Focusing on the expected capacity also demands reviewing and revising the process, including the curriculum contents and the materials and methods used in the teaching. In several European countries, a set of learning objectives based on expected outcomes was developed by groups of experts, to guide the development of the curriculum and teaching in all medical schools in that country (Metz et al, 1991, 2001; Rubin & Franco-Schwarz, 2002; Simpson et al, 2002). As Hays (2007) described, graduates of different medical schools in different countries or even regions within one country may be expected to have different capacities, related to the demands of the local situation. There have also been attempts to develop a basic standard curriculum that could be applied for medical education around the world (Core Committee, 2002; Schwartz & Wojtczak, 2002), with the idea that any doctor practicing anywhere would need at least a basic set of competencies that could be defined by international agreement. These attempts, however, have not yet resulted in a consensus about the minimum requirements for medical education. Innovation in medical schools has often been proposed to take advantage of an opportunity such as establishment of a new medical school in a new region. For example, in Malaysian medical schools, new approaches were seen in new medical schools, while existing schools were slow to take up the innovations (Azila et al, 2006). The innovative curricula were first developed according to professional expectations, while the movement towards communityorientation and student-centered learning gradually made them more responsive to internal and external factors that affected outcomes (Azila et al, 2006). In this process, dissemination of information and involvement of teachers in decision-making were keys to ensuring that they implemented the renovated teaching as planned (Azila, 2002). Reform of medical education, like other change processes, is closely related to the existing organizations and the power structures in each country and context. For example, Jippes and Majoor (2008) recently compared the power structures in different countries and the 3 CHAPTER 1 success of introduction of problem-based learning among more than 100 medical schools in Europe. It was clear that PBL was more successful where there was more openness to innovation. In Vietnam, the process of change proceeded slowly and over several years, using lessons learned from the experience of other countries as described in reports and publications, as well as visits from experts and study visits. But the process and the changes were adapted to fit the Vietnamese cultural context, in which the authority of the leaders is still highly regarded, at least in the traditional organizations such as state enterprises and universities (Nga, 2005; Quang & Vuong, 2002). Changes in a university’s curriculum can be introduced either from the top – using the authority of the leaders to require participation by the staff – or through involvement of staff at all levels and other stakeholders – a more bottom-up approach (Prideaux, 2001; Stratton et al, 2007). The top-down approach was more common in earlier decades, and the bottom-up approach was introduced in the 80s. Currently a mixture of the two is considered necessary, depending on the local situation and culture (Macdonald, 2003). The conflicting demands between the need to steer curriculum development and the advantages of a participatory approach require exploration of different strategies to find the balance that can work in each situation. Stratton et al (2007) compared the management and monitoring of the educational process to the production of a complex product, because the education of a medical doctor also requires a series of processes that have to be structured, sequential and measurable. One feature of the complex process is the involvement of a wide range of stakeholders in the process both of medical education and of medical education reform. To be successful, the process should involve the different stakeholders within the school, including not only the managers and decision-makers, but also teachers and students (Genn, 2001; McLean, 2003). Wahlkvist et al. (2006) were able to assess the effects of input from student feedback and found that descriptive, open-ended feedback both initiated and validated longterm development of the training. The curriculum reform can take any of several directions, and hybrid or mixed approaches are common. One feature that is increasingly common is increased orientation to the needs of the community, which often involves a period of time for the students to work in the community, in one of a variety of approaches. An early example of the community-oriented approach was at the Christian Medical College in Vellore, India, where many inexpensive strategies were developed to provide community experience for the students (Abraham & Abraham, 1993). Many other schools followed with increasing community orientation, especially – but not only – in developing countries (Mash and De Villiers, 1999; Mennin et al, 1996; Okasha, 1995; Sharma et al, 2007; Tamblyn et al, 2005). Wellbery (2006) reported that although a medical curriculum should be patient-centered as well as student-centered, in fact in many cases what was taught in the schools was not quite relevant enough for what the students encountered during placements in real working situations. Another feature of the reform can focus on the methods and related materials used in the teaching. The range includes the classical lecture approach as well as a variety of more active and interactive approaches, including problem- or scenario-based learning (Schmidt, 1993). Problem-based learning (PBL) was pioneered and is still used at McMaster University 4
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