Dr Sun Yat Sen, – outcome based education, and outcome based medical training

Tai-fai Fok 霍泰輝

HK Pract 2011;33:121-125

First. I would like to express my gratitude to Dr Ruby Lee, President, and the council of the HK College of Family Physicians for bestowing on me the honour and privilege of serving as this year's Sun Yat Sen Orator. Dr Sun as we all know is the founding father of Republican China, and the first Provisional President when the Republic of China was founded in 1912. He was a great statesman and political leader. His legacy left to China or even the whole world, including his political philosophy, the Three Principles of the People: namely Nationalism 民族, Democracy 民權, and People's Livelihood 民生, is enormous and far reaching. No wonder he is one of the most celebrated figures across the Taiwan strait in both Mainland and Taiwan, and even in the UK. He was a visionary, a strategist, a patriot, and of course for some time, a medical practitioner. What is less known is that he was also an advocate and a practitioner of the outcome-based approach in his teaching throughout his revolutionary career. In his will addressed to his people in China, he was very emphatic on the fact that the cause of the revolution had only one end or outcome in view: the elevation of China to a position of freedom and equality among the nations. In his another will which this time was addressed to the leader of the Soviet Unions, he stated that the expected outcome of the revolution was to free China from the control of foreign imperialism and colonialism. In his speech to the students of the University of Hong Kong in February 1923, he gave a very vivid illustration of how one should aim and achieve his or her outcome with patience and perseverance, and taking alternative route if necessary. He used the example of a piece of rock rolling down from the Victoria Peak: if it were to achieve the outcome of reaching the level ground, it would not stop just because its path was temporarily blocked by a tree. Rhetorics of similar spirit were found in his other famous quotes.

In November this year, we will be celebrating the 145th birthday of Dr Sun Yat-sen. In the past oneand-half centuries since this great man was born and studied medicine, the whole world has gone through enormous changes in many respects. Following the industrial revolution which started in Europe in the 18th century, technological advancements had changed the face of medical practice and medical teaching. Medical education has also gone through several phases of evolution. In the Middle Age, physicians were trained in monastery infirmaries until the establishment of universities in Western Europe when medical training gradually shifted to medical schools. Whether in the monastery infirmaries or universities, the training was basically apprenticeship. In the 17th and 18th century, medical education began to assume the modern characters with introduction of basic science teaching and application of scientific principles to patient management. However, clinical teaching remained poorly organized and unstructured. In most part of the 20th century, the Flexnerian curriculum had dominated medical education in the western world. A graduate of Johns Hopkins University in Education, Abraham Flexner was commissioned by the Carnegie Foundation to make recommendations on the way forward for medical education in the US. His famous report severely criticized the low standards of American medical schools, and suggested the abolition of apprenticeship, and replacing it with robust basic science training in the laboratories, to be followed by clinical teaching in teaching hospitals. He believed that the two sets of training should be very distinct with no overlapping in between. One of the problems of the Flexnerian curriculum was compartmentalization of basic science and clinical teaching. As a result, there was little coordination between the two and one end did not know what the other end was doing. The undesirable consequence was, amongst others, excessive and unnecessary teaching in basic science that was of no relevance to clinical practice.

In 1993, the General Medical Council published the famous book "Tomorrow's Doctor" which criticized the then existing curriculum as burdening the students with excessive factual information and unnecessary memorization, and lacking training in the skills that physicians needed to acquire before they could provide holistic and compassionate care to their patients. Hence both medical schools in Hong Kong followed the world trend and reformed their medical curriculum.

The new format of medical education, whether we call it integrated curriculum, problem based learning, or others, places emphasis on the importance of selfdirected learning. This concept derives from the repudiation of the traditional belief that teaching is equivalent to learning. If the assumption that what the teacher teaches is what the students will learn is true, then effective information transfer can be achieved by lecturing, or by teachers assigning readings. However, as a number of studies have shown, the retention of information through these means is very limited, and declines with time especially in the first year. There is also evidence showing that the retention rate is the poorest with lectures and becomes much better if the learner can participate actively in the learning process such as taking part in discussion groups, or better still through practice by doing, and by teaching others. These findings confirm the importance of active, selfdirected learning, rather than passive learning. Thus the trend in higher education, including medical education, is undergoing a paradigm shift, moving from being teacher-centred towards student-centred, and placing emphasis on the outcome of the graduates.

This second point here highlights yet another global movement in education reform, the implementation of outcome-based education, or OBE. As a matter of fact, OBE has been introduced in many parts of the western world for quite a long time. The outcomebased approach could be traced back to the 1960s and 1970s in the United States of America. Formal introduction of OBE into high schools in USA started as early as the beginning of the 1990s. In Europe, representatives of the Ministry of Education of 29 European countries met in Bologna, Italy in June 1999. The objective of the meeting was to establish a common European Higher Education Area with an overall aim to improve the efficiency and effectiveness of higher education in Europe. The Bologna Declaration spelt out the importance of "learning outcomes" and that all programmes in third level institutions throughout the European Higher Education Area should be redesigned to adopt an outcome-based approach in teaching and learning. In Hong Kong, some years ago, the University Grants Committee (UGC) has requested all the subvented higher education institutes to adopt an outcome-based approach in all their undergraduate programmes, and the year 2012 will be the year for implementation.

So what is outcome-based teaching and learning or outcome-based education or OBE?

In a report on OBE released by the US Department of Education in 1994, James Kearny stated that the OBE model began by asking what student outcomes were desirable, and then working backward to determine curriculum, materials, activities and teaching methods to achieve those outcomes.

Outcome-based education is a student-centered learning model that focuses on measuring student performance or outcomes at the completion of the learning activity, and contrasts with traditional education which primarily focuses on the resources that are available to the student (e.g. number of hours of teaching) and the contents of teaching (the syllabus). Using the analogy of taking a bus journey, in OBE, one should determine the destination first (outcome), and then decide on how to get there (curriculum). If we do not decide on the destination or outcome from the beginning of the trip, and just jump on any bus and let the driver (who in the case of education, is the teacher) steer its course according to his own agenda, then we may end up going anywhere which is not necessarily where we want to be.

This outcome-based approach sounds very logical and should be a matter of course, and many of you might think that we have been doing this in all our high school, undergraduate and postgraduate education. However, when we examine our traditional curriculum carefully, we have to admit that the traditional way of designing educational programmes is not at all outcome based. It usually starts from the content of the course. Teachers decide on the content they intend to teach, and then plan how to teach this content. This teacher-autonomy is even more obvious in clinical teaching. Using the pretext that there is no limit in the scope of clinical situations, the breath and depth of a clinical teacher 's teaching depend very much on the teacher's hunch, his expertise, and how much he knows rather than how much the student should know. As an example, when I was a student, we had to learn and memorise the procedural details of many complicated surgical operations such as the Lewis Turner oesophagectomy which was commonly asked in the final year examination, when most of us would never have a chance to have any association with these procedures in our entire medical career.

Outcome-based learning does not specify or require any particular style of teaching or learning, which could be lectures, tutorials, problem-based learning, or didactic teachings, and for that matter, large class or small group teaching. The keys to the successful implementation of outcome-based education are (1) identification of the appropriate outcomes, which in medical education, could be a range of skills, knowledge, or attributes; and (2) when writing learning outcomes, it is important to write them in such a way that they are capable of being assessed. The objective of the assessment is to test whether or not the learning outcomes have been achieved. Therefore it should be the kind of assessment that is standard-based or criteria-referenced, i.e. students are measured against a set of absolute objectives, the outcomes, rather than relative achievements or the so-called norm-referenced assessment, with which students are given grades and rankings compared to each other. In fact, under the traditional model, student performance is expected to vary according to the statistical rule of normal distribution, and the failure of some students is accepted as part of the norm and unavoidable.

In OBE, this will no longer be the case. Any student who has been able to achieve the preset outcomes required of him will pass. In fact, according to the early proponents of outcome-based education, OBE represents a rejection of the traditional bellcurve view of student performance. Such systems are based on the notion that all students, not just the brightest, can reach high levels of achievement.

One of the onerous tasks in introducing outcome-based education is the writing of the outcome statements. I am not going into the details but it will suffice to say that the outcome statement can be very general, but if they are too general, they probably will not be of help to teachers in designing the curriculum. The statements can contain a little more details like this one which outlines the expected outcome of the entire medical curriculum. It is again still quite general and at best serves as a framework for curriculum design. Outcome statements on the other hand can be very detailed and specific, delineating the objective and the achievable goal of the whole programme, each year's or each semester's studies, or even down to individual learning activities such as each lecture or tutorial. An example of this is the system introduced in this document "The Scottish Doctors", which was prepared by a collaborative effort of all the five Medical Schools in Scotland. This is also the system to which we in our Faculty are making reference in the preparation of our own outcome statements.

"The Scottish Doctors" is a very complicated system, identifying learning outcomes according to 3 essential elements or pillars: firstly, what the doctor is able to do which refers to the technical competencies expected of the doctor (which ensures that the doctor is doing the right thing), secondly, how the doctor approaches his or her practice, is it with knowledge and understanding and appropriate attitude and decisionmaking strategies (or doing the thing right), and thirdly, the doctor as a professional (or to ensure that the right person with the right ethics, right attitude, and right professionalism, is doing it). The three pillars at this level one category are subdivided into 13 domains giving more specific details about the expected outcomes.

No matter how we write the outcome statements, the statements should satisfy certain criteria in order to fulfill its intended purpose: these are that: the outcomes must be achievable, measurable, and must be clearly spelt out. In a recent consultation paper issued by the Government on the proposed curriculum of the moral and civic education to be introduced into the primary and secondary school curriculum here in Hong Kong, the consultation paper had reportedly quoted an example of how to evaluate the patriotic feeling of the students by assessing their degree of jubilation and joy when hearing the achievements of the nation. Jubilation and joy are certainly not easily measurable outcomes and this represents a very bad example of writing outcome statement.

There are many advantages of outcome based education. For the students and teachers, OBE enables the students and teachers to have better understanding of the relevance of what they are learning and teaching, to be able to focus on activities which help achieve outcomes, and to realize their own responsibility in achieving outcomes.

For the institutions, OBE enables them to improve the quality of teaching and learning, to enable curriculum design that allows institutional role differentiation, and to ensure international competitiveness.

So much for OBE in undergraduate education, what about postgraduate medical training which is the responsibility of the Hong Kong Academy of Medicine and its Colleges?

According to education experts, outcome-based learning and teaching are particularly suitable for vocational training such as that in medicine. When writing about embracing learning outcomes in medical education, Harden commented that "where it has been implemented, outcome based education has had a significant and beneficial impact. Clarification of the learning outcomes in medical education helps teachers, wherever they are, to decide what they should teach and assess, and students what they are expected to learn".

So, is our residency training supervised by the Hong Kong Academy of Medicine and its Colleges adopting an outcome based approach?

I am afraid it might not necessarily be the case. Just taking one look at the training duration of our trainees will give the evidence of what I said. The training duration is uniformly 6 years across all the specialty colleges. But if we look at the expected or desirable outcomes of the trainees, does it really take the same training time to train a paediatrician as a surgeon, a family doctor, a pathologist, a radiologist, and an anaesthesiologist, just to name some examples?

If we look at the North American system, there is obvious difference in the training duration of the medical and surgical specialties. Even within the same specialty, should we not take a closer examination of the optimal training period and training curriculum of trainees who are planning to do different things upon completion of their training?

It will be inappropriate for me to comment on the training curriculum of other Colleges as I do not know enough details. As an example I would like to use the Paediatric training programme with which I am quite familiar, and more importantly I have obtained the permission from Professor PC Ng, President of the Hong Kong College of Paediatricians to make reference to his College's training programme in my presentation. The views expressed of course are all mine and do not represent the position of the President or the College.

From past statistics, while some paediatric trainees will stay working in the hospital, many will leave for their own private practice and will be engaged mostly in primary care, maybe with a little secondary care. However, their training as a trainee is mostly hospitalbased, with little attention paid to the need for primary care paediatricians.

For example , exposure to child psychiatry, psychology, infant feeding and infant nutrition in the primary care setting, common childhood ENT or skin conditions, which are important for primary care paediatricians, is lacking or very minimal. In their 6-years training, many spend up to 2 years or sometimes even longer in the paediatric and neonatal intensive care units when as a matter of fact, most of them will not and should not be handling critically ill children or newborns in their future career as primary care paediatricians. Their training also very often rotates them through highly specialized areas such as oncology, interventional cardiology, rare metabolic diseases etc which again are irrelevant to their future practice.

The undifferentiated training programme, besides being an unnecessary burden to many of our trainees, actually has significant implication on our manpower planning and investment on human resources. If we separate residency training which provides general training from fellowship training which provides subspecialty training, (as in many overseas countries), then trainees who are planning to be primary care paediatricians should be ready to join the primary care workforce in only 3 years, after leaving the University instead of the present 7 years. By so doing, we can economize on the training time, and produce the much needed primary care paediatricians in a more efficient way, perhaps also train up many more competent subspecialists as well.

So ladies and gentlemen, outcome-based learning and teaching is the global trend in education and curriculum design. It is now the mainstream approach in our school and university education system. Maybe an outcome-based approach is also desirable in our postgraduate medical training. It is certainly worth considering by our Colleges and the Academy. On this note, I would like to end my presentation. I would once again like to thank Dr Ruby Lee and the Hong Kong College of Family Physicians for this opportunity, and thank you all for your patience and attention.