Undergraduate

Aga Khan University 's Medical College (AKU-MC) has adopted a mode of undergraduate medical education curriculum delivery based on a problem-based learning (PBL) approach over five years. In this integrative, spiral curriculum, the input of basic medical sciences is stronger at first and then gradually decreases, but remains present until the end. The first two years focus on the combination of seven disciplines (anatomy, biochemistry, community health sciences, microbiology, pathology, pharmacology and physiology) together with a clinical component from the start. The Department of Biological and Biomedical Sciences (BBS) has the central responsibility of ensuring that the subjects of anatomy, biochemistry, pharmacology and physiology are entirely covered. The new curriculum was officially launched in October 2002 with the Class of 2007.

The integrative process of PBL encourages a strong incentive for self-learning and working as a team on the part of students. It is accomplished by small group learning that is medical case-based. Small group case-based learning is conducted in the form of two sessions per week with students divided into groups of eight. Each week, students are given short descriptions of medical cases with the diagnosis provided. Their task is to determine via group discussions what the learning objectives for the seven basic sciences should be for the case. Each group (eleven in all) is assisted by a trained facilitator whose responsibility is to encourage dialogue, individual participation and working together within the group to identify the learning objectives. The facilitator does not teach, give content information to the students nor tell them if they are correct or not in their group work. Cases are divided into modules, each of which has a different theme. There are five modules for the first year and six for the second. Each module runs from 4 to 9 weeks. The responsibilities of the BBS faculty include membership on module committees. It is in these committee meetings that cases are selected and refined to include appropriate "triggers" which will guide the students in identifying the learning objectives. Each of the four disciplines in the BBS department is represented by a BBS faculty member in each of the eleven modules; five in Year 1 and six in Year 2. BBS members of the module committees ensure that the material (the learning objectives that the department deems necessary for the students to master) is incorporated into the curriculum schedule. BBS members of the module committees also write the Facilitators Guide material for each case covering each BBS learning objective. These Facilitator's Guides aid the facilitators in their interaction with students.

The BBS faculty members and teaching assistants provide from five to seven facilitators for each module for both years. Thus a total of from 10 to 14 BBS personnel are facilitating at any one time during the academic year. At the end of each week, a wrap-up session is scheduled for both Year 1 and Year 2 in which the students are able to ask direct questions of the faculty for clarification and answers related to the learning objectives for that week. Each wrap-up session is chaired by a module coordinator, many of whom are BBS faculty members. At least four BBS faculty members (one per departmental discipline) attend every wrap-up session.

There are three other means of learning for the medical students in this curriculum. These are large class format sessions (LCF's), laboratory exercises and demonstrations and clinical skills training. The BBS faculty contributes significantly to the first two of these learning modes.

LCF's involve the entire medical class for each year. LCF's are not formal lectures but are interactive sessions between the presenter and the class and are usually one hour in length and held at various times during the week. The subjects under discussion in the LCF's are integrated with the cases that are presented during the week. Students are given the learning objectives and relevant references for the LCF's well ahead of the sessions so they are prepared to be interactive by bringing with them comments and questions. BBS faculty directs at least two of these LCF's every week in both Years 1 and 2.

BBS faculty is also responsible for planning and supervising student laboratories and demonstrations in all four disciplines. Some of these require the services of trained patients to provide blood and urine samples and hands-on experiences for the students. Other responsibilities require the planning and setting up of complex demonstrations for the students or actual activities that the students must carry out.

Assessment is a large part of the responsibilities of the BBS faculty members and the teaching assistants. Year 1 students write one formative and two summative examinations. Year 2 students write three summative examinations. The questions in these written examination are designed in an integrated form in which each question begins with a single clinical case followed by a list of about four to eight MCQ's, each of which covers basic science learning objectives that are embedded in the case. 60 MCQ's are tested in each of these examinations. MCQ's from each of the four BBS disciplines are collected from BBS faculty members for each summative examination. These are organized in an integrated fashion together with MCQ's from pathology, microbiology and community health sciences. A committee composed of BBS Teaching Assistants and representatives from each of other three basic sciences organizes these MCQ's in related groups and prepare an appropriate clinical scenario for each group of MCQ's. Short essay questions (SEQ's) are also written by BBS faculty in each discipline and are part of the summative examinations as well. The scenario-based questions are graded by computer but the SEQ's are graded by the faculty members who have written the questions.

At the end of each academic year the students take professional examinations consisting of two mornings of written examinations with sixty integrated MCQ's per examination and two and one-half days of Viva Voce examinations in which each student in each year is questioned by one internal and one external examiner. These oral examinations are designed to give the student a short case scenario in advance and to ask a series of "thinking" questions from each discipline. BBS faculty members are responsible for writing the actual Viva questions for the four BBS disciplines as well as the keys for each question. These represent the basic knowledge that students must demonstrate in order to pass. In addition, more complex questions can be asked to test whether the students can be given "honours" in the examination. BBS faculty provides four of the seven required viva examiners.

In addition to their responsibilities as facilitators and preparers of the scenario-based MCQ's for the summative and professional examination, the Teaching Assistants were assigned the responsibility of preparing self-testing multiple choice questions (STQ). These STQ's are an additional learning mode that is very much appreciated by the students. At the end of each week, these questions are posted on the Undergraduate Medical Curriculum website, AKUMed . The questions are answered by the students and graded automatically. The results are available only for the student who has completed the set of questions. These exercises are not for grading but are for learning. Each question is accompanied by feedback information explaining the correct answer. If the students select the incorrect answer, this feedback information is given to them.

The learning of basic sciences does not end with the completion of first two years of the undergraduate medical course. Although Year 3 and onwards mostly deal with medical and clinical disciplines, conscious efforts are being made to include contextual basic sciences learning objectives into real cases in order to introduce more complex basic concepts and to reinforce already visited concepts in first two years. Moreover, Pharmacology receives special emphasis throughout Year 3. Groups of four students do a presentation fortnightly, in which they critically evaluate the claims made by pharmaceutical companies in their drug promotions. Students are assigned drug advertisements pertinent to active cases and scrutinise the claims made on the basis of efficacy, safety and cost-effectiveness of that particular drug. Consistent with the essence of spiral curriculum and in order to encourage the simultaneous learning of contextual basic sciences along with clinical subjects, it has been decided in principle that a 15 per cent component of the Professional Examination at the end of Year 3 will be from basic sciences.

The requirements to design and maintain the undergraduate medical curriculum are very labor intensive and the BBS faculty and teaching assistants contribute a great deal to the effort.