Presentation for lecturers by Dr Omar Hasan Kasule MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Professor of Epidemiology and Islamic Medicine Institute of Medicine, Universiti Brunei Darussalam. On 18th July 2009
ABSTRACT / SUMMARY
The PPSD curriculum equips students with ethico-legal, research and personal skills necessary for successful medical practice. It is an integral part of the problem-based teaching methodology used by the institute of medicine. Its teaching methodology is student-centered and student-driven. The learning and assessment strategies emphasize skills rather than accumulation of facts.
1.0 VISION OF PPSD
1.1 PPSD and the total curriculum
PPSD is an integral and essential part of medical education and training. It complements knowledge and skills of biomedical technology with skills that the medical student needs to be an effective well-rounded physician able to function efficiently inside and outside the hospital.
1.2 Components of PPSD
PPSD skills can be classified as ethico-legal, research, and personal skills. The vision of PPSD is a physician who is ethical in his professional and personal activities, who has the skills of life-long learning through research on the frontiers of knowledge, and who has leadership and management skills that he needs as a leader of a healthcare team.
1.3 PPSD as skills
The PPSD curriculum is not about student acquisition of a large corpus of information either passively or actively. It aims at equipping them with specific ethico-legal, research, and personal skills that can be employed in various situations.
1.2 SCOPE OF PPSD
2.1 Integration of PPSD throughout the 3-year program
The table below shows the PPSD curriculum map for the 3 years of the pre-clinical medical program. The curriculum covers the three components of the PPSD vision mentioned above. These components are covered all through the program being fully integrated vertically and horizontally with the three other themes of the program namely health sciences, patient care, and our community.
2.2 PPSD curriculum map
CURRICULUM OUTLINE ON PROFESSIONAL and PERSONAL SKILL DEVELOPMENT (PPSD)
ETHICAl, LEGAL, & FIQH ANALYTIC SKILLS [ET] | RESEARCH SKILLS [RS] | PERSONAL DEVELOPMENT SKILLS [PS] | |
Yr1 Sem 1 | Basics/fundamentals: (Ethics: theory and principles) | Mathematical foundations: (Probability) | Formation of the physician: (Team-work) |
Yr1 Sem 2 | Ethico-legal issues (Informed consent) | Descriptive statistics: (means and proportions) | Trans-cultural skills: (Culture, lifestyle, and civilization) |
Yr2 Sem 1 | Ethico-legal issues: (Balance of injury & benefit) | Disease measures: (Incidence and prevalence) | Communication & negotiation skills: (Public speaking, win-win negotiation) |
Yr2 Sem 2 | Ethico-legal issues: (Privacy & confidentiality) | Analytic statistics: (Hypotheses testing) | Personal skills: (Psychosocial development) |
Yr3 Sem 1 | Ethico-legal issues: (Disclosure and truthfulness) | Study design and analysis: (Clinical drug trials) | Leadership Skills: (Characteristics of effective leadership) |
Yr3 Sem 2 | Ethico-legal issues: (Fidelity & loyalty conflicts) | Study interpretation: (Bias) | Management skills: (Strategic planning & management) |
3.0 METHODOLOGY OF PPSD
3.1 PPSD is student-centered
In conformity with the general methodology of IM, teaching of PPSD will be largely student-centered learning (SCL) and student directed learning (SDL). Ethical, legal, and fiqhi issues will be taught using case scenarios with students being required to identify and solve ethical and legal problems that arise in the case. Research skills will be taught as very brief presentation with students learning by working on actual data sets or review of journal articles. Personal skills will be taught by discussion of case scenarios.
3.2 Time scheduling for PPSD
Two hours every week will be devoted to PPSD. The first hour will be used for personal skills or research skills with the 2 alternating on a weekly basis. The second hour of every week will be used for discussion of ethico-legal issues as well as solving ethico-legal problems. Thus in a semester of 14 weeks, 7 hours will be devoted to personal skills, 7 hours to research skills, and 14 hours to ethico-legal skills.
3.3 PPSD is sensitive to time constraints
The PPSD curriculum is sensitive to the time constraints under which students work because they have to look up a lot of information for the weekly CBL/PBL case. Therefore all SCL and SDL activities will be completed during the time assigned to PPD and this may necessitate providing students with a 1-page background information on the issues to be discussed. The background provides principles and the task before the students is to apply those principles to the solution of a problem.
3.4 Added-value training in speaking and self-confidence
An added value to the PPSD methodology will be training in communication and confidence building. Students (2-4) will be pre-selected every week to summarize the background information before other students before the discussions begin. This will give continuous practice in oral presentation for each student at least once in 1-2 weeks and the benefit will be cumulative over the 3-year program. The standard of excellence aimed at is that on graduation any student will have the confidence to stand up and deliver a convincing and interesting impromptu presentation on a general medical topic.
3.5 PPSD Case scenarios / problems
The case scenarios and problems that will be discussed will be an extension of the week’s CBL/PBL case and can be considered as an extra or extension sheet with just extra information directly relevant to PPSD.
3.6 PPSD tutors
In order to integrate PPSD fully into the IM curriculum as many as academic staff as will have the time will be mobilized and trained to be PPSD tutors or PPSD discussion leaders. However it will still be possible for one instructor to handle the class if necessary. In such a case the whole class by having the 2-3 discussion groups sitting around separate tables in the classroom for discussion and then presenting their findings for plenary discussion.
3.7 Assessment of PPSD
3.7.1 Problem-based questions (PBQ)
PPSD will be assessed as problem-based questions (PBQ) in the examinations. Success in the examination will be based more on having the necessary skills than on recollection of many facts. Students will be given a scenario with issues that may be ethical, legal, quantitative, or personal. They will be required to describe the problem (identification, definition, and ranking) and to suggest a solution.
3.7.2 Assessment of the logical process and not necessarily the final answer
Apart from some statistical and epidemiological aspects, there will generally be no one correct answer. Several answers will be acceptable as long as the student can demonstrate the logic used to reach the answer.
4.0 ETHICAL THEORIES AND PRINCIPLES
4.1 Basis for ethical analysis
In our analysis of ethical issues we shall draw upon both European and Islamic sources in addition to other traditions relevant in Brunei such as Budhism, Hinduism, Confucianism, and Taoism. In the course of the analysis we will use the concepts and tools of various traditions without the need to consistently label all of them because our aim is the skill of logical ethical analysis. The term European is used here not in the geographical sense but in a cultural sense to refer to the Greco-roman heritage of people of European origin regardless of where they have settled: Europe, America, Africa, and Australasia.
4.2 European ethical theories
The six major European ethical theories are the utilitarian consequence-based theory, the Kantian obligation-based theory, the rights-based theory based on respect for human rights, the community-based theory, the relation-based theory, and the case-based theory.
According to the utilitarian consequence-based theory, an act is judged as good or bad according to the balance of its good and bad consequences. Utilitarianism means attaining the greatest positive with the least negative. This theory has a problem in that it can permit acts that are clearly immoral on the basis of utility.
The obligation-based theory is based on Kantian philosophy. Immanuel Kant (1724-1804) argued that morality was based on pure reasoning. He rejected tradition, intuition, conscience, or emotions as sources of moral judgment. A morally valid reason justifies action. Acts are based on moral obligations. The problem with the Kantian theory is that it has no solution for conflicting obligations because it considers moral rules as absolute.
The rights-based theory is based on respect for human rights of property, life, liberty, and expression. The individual is considered to have a private area in which he is master of his own destiny. Rights may be absolute or relative. A positive right is one that has to be provided to the individual. A negative right is one that assures prevention of or protection from harm. There is a complex inter-relation between rights and obligations. Individual rights may conflict with communal rights. The problem of the rights-based theory is that emphasis on individual rights creates an adversarial atmosphere.
According to the community-based theory, ethical judgments are controlled by community values that include considerations of the common good, social goals, and tradition. This theory repudiates the rights-based theory that is based on individualism. The problem with this theory is that it is difficult to reach a consensus on what constitutes a community value in today’s complex and diverse society.
The relation-based theory gives emphasis to family relations and the special physician-patient relation. For example a moral judgment may be based on the consideration that nothing should be done to disrupt the normal functioning of the family unit. The problem of this theory is that it is difficult to deal with and analyze emotional and psychological factors that are involved in relationships.
The case-based theory is practical decision-making on each case as it arises. It does have fixed philosophical prior assumptions.
4.3 European ethical principles
The 4 basic European ethical principles autonomy, beneficence, non malefacence, and justice. The Principle of Autonomy is the power of the patient to decide on medical procedures. The Principle of Non-maleficence is avoiding causation of harm. The Principle of Beneficence is the providing benefits and balancing them against risks and costs. The principle of justice is distribution of benefits, costs, and risks fairly.
4.4 Islamic ethical theory
Islam has one theory of ethics expressed as the purposes of medicine which are preservation, protection, and promotion of: morality (hifdh al diin), life and health (hifdh al nafs), progeny (hifdh al nasl), intellect (hifdh al ‘aql), and resources (hifdh al maal). Any medical intervention must fulfil or not violate these purposes to be considered ethical.
4.5 Islamic Ethical principles
Five principles of the Law are considered ethical principles: intention (qasd), certainty (yaqeen), injury (dharar), difficulty (mashaqa), and precedent (urf).
The Principle of intention has three implications: each action is judged by the intention behind it; what matters is the intention and not the letter of the law; means are judged with the same criteria as the intentions.
The principle of certainty has 2 implications: established medical procedures and protocols are treated as customs or precedents; and all medical procedures are considered permissible unless there is evidence to prove their prohibition.
According to the principle of injury, medical intervention is justified on the basic principle is that injury, if it occurs, should be relieved. An injury should not be relieved by a medical procedure that leads to an injury of the same magnitude as a side effect. In a situation in which the proposed medical intervention has side effects, we follow the principle that prevention of a harm has priority over pursuit of a benefit of equal worth. If the benefit has far more importance and worth than the harm, then the pursuit of the benefit has priority. Physicians sometimes are confronted with medical interventions that are double edged; they have both prohibited and permitted effects. The guidance of the Law is that the prohibited has priority of recognition over the permitted if the two occur together and a choice has to be made. If confronted with 2 medical situations both of which are harmful and there is no way but to choose one of them, the lesser harm is committed. A lesser harm is committed in order to prevent a bigger harm. In the same way medical interventions that in the public interest have priority over consideration of the individual interest. The individual may have to sustain a harm in order to protect public interest. In the course of combating communicable diseases, the state cannot infringe the rights of the public unless there is a public benefit to be achieved. In many situations, the line between benefit and injury is so fine that a prayer of consultation, salat al istikharat, is needed to reach a solution since no empirical methods can be used.
According to the principle of hardship, medical interventions that would otherwise be prohibited actions are permitted under the principle of hardship if there is a necessity.
According to the principle of custom or precedent, the standard of medical care is defined by custom. The basic principle is that custom or precedent has legal force. What is considered customary is what is uniform, widespread, and predominant and not rare. The customary must also be old and not a recent phenomenon to give chance for a medical consensus to be formed.
