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 Table of Contents  
MEDICINE AND SOCIETY
Year : 2021  |  Volume : 2  |  Issue : 1  |  Page : 43-47

Roadmap for reforms in physiology curriculum for medical undergraduates in India: A panel discussion report


Department of Physiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Submission15-Oct-2020
Date of Decision15-Dec-2020
Date of Acceptance23-Jan-2021
Date of Web Publication25-Apr-2021

Correspondence Address:
Dr. Poorvi Kulshreshtha
Department of Physiology, All India Institute of Medical Sciences, Rishikesh - 249 201, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JME.JME_104_20

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How to cite this article:
Kulshreshtha P, Goel A, Kathrotia R. Roadmap for reforms in physiology curriculum for medical undergraduates in India: A panel discussion report. J Med Evid 2021;2:43-7

How to cite this URL:
Kulshreshtha P, Goel A, Kathrotia R. Roadmap for reforms in physiology curriculum for medical undergraduates in India: A panel discussion report. J Med Evid [serial online] 2021 [cited 2022 Aug 12];2:43-7. Available from: http://www.journaljme.org/text.asp?2021/2/1/43/314611


  Introduction Top
Physiology is one of the essential subjects in the undergraduate medical curriculum. A genuine concern is raised time and again that physiology as a separate branch is at crossroads and suffering from an existential crisis. This could be due to the syllabus being too much theory-centered or less weightage given to this subject in post-graduate entrance examinations. Besides a big gap exists between what is being taught in undergraduate physiology classes and what is to be practiced in terms of clinical skills. Acquisition of clinical skills is often over-emphasised and underscored from a practical standpoint. Nevertheless, it is imperative that undergraduate medical students receive adequate training in the basics of human physiology before they venture into the clinical examination. Physiology is taught in the 1st year in medical schools, and hence, a physiologist becomes the first contact of a budding medico. Therefore, it is the duty of a physiology teacher to oversee that students develop values and attitudes that guide the transfer of scholastic skills to real-life challenges.
  Present Status Top
Present physiology curriculum in India is more or less similar which encompasses a series of didactic lectures and practical sessions. Medical students often complain of serious issues which include repetition of common topics, difficulty in the translation of basic life sciences to clinical sciences, the relevance of old techniques still being taught and a dearth of teacher–student interaction. A panel discussion was held at the department of physiology to address these issues. Senior physiologists, undergraduate and postgraduate students and clinicians were invited to deliberate on this topic. The panel discussion started with comments from the students who brought out some grass-root issues that they perceive as a big deterrent to effective learning. The panel first addressed these problems and went on to discussing reforms in teaching modalities and curriculum that could eventually address these issues. The members discussed how physiology can be reinvented as a subject and integrated with clinical sciences to serve the community better. The audience also contributed by giving valuable inputs and expressing their thoughts on the development of a new curriculum. Apart from academics, soft skill development, communication skills, ethics and learning by doing were discussed at length. This review is based on the various ideas garnered in a panel discussion and evidence present in literature that corroborates these convictions. The underlying principle of this review is that it promotes high standards of teaching learning in physiology and sets the basic requirements in all required domains to enable a physiology teacher to deliver effectively. We understand that the 20th century educational system which still persists is insufficient to meet the current demands. Students are currently better equipped and use technological tools, such as laptops and smartphones to access the latest information. With changing times, a physiologist in India should also be well informed in data science. Many members were of the opinion that physiology should be taught at all levels of medical school and not just 1st year. Physiology forms the core of medical practice so it should be continued to later years of the MBBS course wherein the students are more acquainted and can correlate basic concepts with the clinical context. Virtual laboratories could also be introduced for simulating traditional nerve-muscle physiology experiments. In fact, certain domains of applied physiology such as clinical electrophysiology can help diversify this subject as a major diagnostic branch. The panel discussion can be summarised in the following key points that emerged during the brainstorming discussion. Improving the curriculum
  1. The duration of didactic lectures in physiology is 160 h approximately. In settings with time constraints (just one year) of the first professional course, optimisation of teaching hours should be done without disturbing the curriculum. Some topics can be incorporated in the form of quizzes, seminars and interactive sessions. The topics taught in detail in premedical classes (e.g., cell cycle, mitosis, meiosis and genetics) can be pinned up as a quiz
  2. Most of the topics are redundant and repeated as stated by the students who participated in the discussion. Repetition and redundancy are not always unjustified, for they consolidate the memory. If the horizontal and vertical integration has to take place, then this issue should be addressed because it will save teaching hours which can be utilized to include other topics in teaching, for example, if there is the repetition of topics in biochemistry and physiology, then both departments should sit together and chalk out a common strategy. Diabetes mellitus and its pathophysiology are an important topic that has applied implications. Therefore, for such an important topic, careful sub-sessions can be planned well in advance where a biochemistry teacher can present pathways of cellular cascade machinery and investigations in a sequential manner. Similarly, physiology teachers can teach actions of insulin and applied aspect
  3. Conflicts between must know, nice to know and should know are subjective matters 'Nice to know' areas should be reconsidered. There is a gap between physiologists' understanding of important topics and what is actually required in clinical practice. This leads to extra weightage to some unnecessary questions in examinations. In fact, the scope and depth of material from which questions should be derived might benefit from extensive scrutiny by departmental faculty.[1] The main focus should be on 'must know' areas. This suffices for the time constraints. Nevertheless, brainstorming by faculty members is required to reach a departmental consensus to meet this requirement
  4. Although we believe that it is not reasonable to 'tag' that any topic in physiology as 'obsolete,' certain topics of lesser relevance can be deleted to pave space and time for current and latest topics. Time allotted to teaching the history of science can be lessened and similar-looking practical exercises can be clubbed together to make way for introducing the latest clinical investigations. It behooves us that in today's medical world, the subspecialties (cardiology, gastroenterology, nephrology and pulmonology), demand a thorough understanding of the human body for safe procedural practice. Therefore, nothing ideally should be left out in essence and vigour[2]
  5. Different pedagogical resources can be combined to complement one another, to ensure effective learning [Table 1] and [Table 2]. Implementing an integrated curriculum often goes hand in hand with issues of time constraints, increased workload, loss of original flavour and content, and the organisational, staff cohesion and sharing of teaching practices. Different backgrounds of the teachers and their goals have to be nimbly framed. Physiology in itself is a magpie of disciplines and some faculty members conspicuously oppose integration across disciplines. They fear that the purpose of providing in-depth knowledge would be lost and thus this requires further exploration and explanation. A study reports that integration is an abstract rather than enacted concept. Differences in how faculty members conceptualise the purpose and effects of integration affect the level and type of integration.[3] Therefore, planning of an integrated lecture requires tedious planning in advance.
Table 1: Module on reproductive physiology: Teaching methodologies

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Table 2: Various teaching modalities

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Improving teaching and assessment (modules, assessment-driven learning, etc.,)
  1. Some faculty members suggested that teaching could be improved by incorporating a clinical vignette. It was inferred that the physiological principles must be taught as a concept. The students fail to learn if they are taught sporadically, where the lecture content nibbles out from various sources. This piecemeal manner of teaching becomes a sad predicament because they also tend to miss out on the true meaning of the underlying larger narrative and the original context of the physiological principles [Table 3]
  2. Eyes see what the mind knows. In this modern era where medical practice and diagnosis are investigation dependent, the importance of teaching traditional methods of bedside clinical examination skills and their physiological basis cannot be negated, for example, in a rural centre where an X-ray facility may not be available, simple clinical skills learned in clinical physiology laboratory and consolidated later in medicine classes such as inspection, palpation, percussion and auscultation can be utilized to reach a probable diagnosis in a suspected respiratory disorder. The students should be encouraged to participate in the discussions and no attempt should be made to lead them to a tunnel vision approach to learning
  3. Teaching practices are given attention maximally in pedagogic discussions. However, students read what is to be assessed so the curriculum should be aligned with mode and type of assessment, for example, electrocardiogram (ECG) can very well be taken up in theory as well as practical classes. The students should clearly know that this topic may be asked in examination in various forms such as OSPE questions, individual practical and multiple-choice questions and short answer type questions (SAQs). He may be asked to identify normal/abnormal rhythm or calculate the mean electrical axis in an ECG strip. He may be asked to record ECG in 12 leads and give a physiological basis of the formation of various waveforms
  4. Assessment forms a bridge between teaching and learning. Assessment-driven learning (ADL) should be the core of teaching. Content and context are very important. It has been seen that ADL effectively converts assessment into a learning strategy. It simulates a real-life environment and exposure from day 1 of the teaching program
  5. The specific learning objectives (SLOs) should be assessable and measurable. One is free to design and adopt new methodologies. Our viewpoint is that nothing favours an attempt to cover and conclude a whole chapter in just one session, with SLOs provided at the beginning of the chapter, a peg on which to hang our all laboriously acquired erudition. Students' role in such scenarios is entirely passive. Therefore, lectures which are the proper vehicles for a display of knowledge should be carefully planned and delivered
  6. Assessment method should be upgraded and it should be given more stress. There is no need to make fresh SLOs. Only certain corrections need to be made in the way we teach. Teaching should be need based
  7. AIIMS Rishikesh has set a new example by starting a whole multiple-choice examination format across all professional examinations. The question paper-making should not be the last moment ritual. It should be a time-taking process and should not be left to be done hurriedly. Each faculty member can be asked to prepare at least five questions based on the topic covered in a single lecture. Keeping the fact in mind that the purpose of the examination is to analyse the students' knowledge, here are some perspectives that every teacher should consider while setting a question paper
    1. Objective and scope of the examination
    2. Design of the paper and the relative weightage of the concepts
    3. Selection of questions
    4. Analysis of questions. The toughness level of questions should ensure that 50% of questions can be attempted by an average student, 20% by good students and the rest 30% by intelligent students.[4]
    5. A multiple choice question (MCQ) format as assessment tools of learning is ideal for several reasons, including feasibility, reproducibility and cost-effectiveness. We do feel that questions should be created to maximise the impact on the learner and to prioritise learning in a structured way rather than focus on facts. Ideally, an assessment should motivate students to change their preparation by promoting critical thinking, reduce the learner's ability to rely on recognition, improve later recall of content that has been assessed and allow for meaningful feedback to further the learning cycle. These skills such as critical thinking, problem-solving and communication skills are absolutely necessary for the medical students to convert into their role as a physician[5] Thus, if students are made to appear in an MCQ-based examination, then their capability to answer the SAQs may be compromised where a certain level of organising a thought process is required. It is imperative that small answer type questions may be asked in formative assessment on a monthly basis
    6. Modular teaching is not a novel concept and is rooted as an idea of an integrated approach to cover important topics in physiology at the undergraduate level. It envisages the concept of providing holistic knowledge with adequate stress on basic concepts through a wide variety of learning activities. Various teaching methodologies such as group discussions, photo demonstration, open discussion, quiz, video demonstration, panel discussion, panel forum and role play can be utilised in addition to didactic lectures. This practice at times becomes more effective as it breaks the boredom of a lecture.
Table 3: Clinical vignette for a physiology class

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Improving the laboratory equipment and experimental objectives
  1. High-fidelity patient simulators provide contextualisation of fundamentals of physiology. In fact, simulators can act as a springboard for integrated teaching where anatomical surface marking landmarks can be amalgamated with physiological principles.[6] High-fidelity simulations are considered as an established excellent method for improving clinical skills and a viable approach to bridge the gap between basic and clinical sciences. Simulation integration in the physiology curriculum can render an empirical approach to achieve desirable medical learning outcomes and experiences[7]
  2. Practical laboratories in physiology need up-gradation to match the latest standards. Relevance of continuing hematology laboratory within realms of undergraduate physiology teaching was discussed at length. A study carried out in Karnataka medical students infers that doing hematology practical work is necessary because it improves their knowledge, skills and attitude, making them more empathetic and confident doctors.[8]
Improving the clinical significance and applicability
  1. The curricular plan should be clinically oriented right from the beginning as our purpose is to make them good clinicians, for example, they should know how to check the pulse if a patient presents with damaged (both) upper limbs. He should be clear that in such a scenario, the pulse can be checked from the lower limbs However, it is imperative to accept that the principles of physiology may not have a direct and immediate clinical bearing, for example, knowledge of membrane potentials and methods of their recording is important. The attached clinical significance and application can be understood in the following example. Calcium acts as a membrane stabiliser and hypocalcaemia can give rise to nerve excitability. Similarly, cellular transport mechanisms (Na-glucose symport mechanism) form the basis of the formulation of oral rehydration solution.
  2. Understanding of the subject can be greatly improved if they are asked to contribute in small groups and make simple working models, for example, spirometry, sliding filament mechanism, dialysis, etc., can be shown by models. In our institute, the annual physiology working-model exhibition is a regular event where students participate in creativity and their learning is improved. It will take away the monotony of students and should be included from the very beginning
  3. Exposing medical students to patient care or community medicine postings at the beginning (right from the first year) is the need of the hour. Students should be exposed to relevant patients mainly from the systems being covered in physiology classes. It is crucial to discuss important symptoms and elicit the related clinical examination/findings on patients. This practice shall fortify the principles of Physiology taught in their regular classes.[9] AIIMS Rishikesh has set up an example of posting students to trauma and emergency care also. This practice is time tested in the west and can be replicated elsewhere in India also
  4. Apart from teaching communication skills to students, it is essential that students learn basic skills that can be life-saving. Implementation of clinical skills workshops should be well-timed, for example, a basic cardiopulmonary skills workshop can be organised after cardiovascular and respiratory physiology has been taught to students.[10] Clinical skill workshops can be organised now and then where each student can learn clinical skills such as injections and blood pressure recording.

  Conclusion Top
Physiology provides a foundation upon which medical students can scaffold the understanding of the whole human body dynamics and kinetics. The ideas shared in this review article hold relevance for other disciplines as well. They can be used to reform our current medical education system into something more functional, relevant and holistic. The curricular reform in physiology as suggested in the panel discussion should be in sync with the current educational innovation and paradigm, follow a clear vision and pay attention to the real needs of the stakeholders (students). Similarly, the implementation of the suggested reforms should be gradual, stepwise and requires careful planning and monitoring. The curriculum reforms also require constant review and multifaceted re-evaluation keeping with the constant changes in the medical education. Acknowledgment We are grateful to UCOST, Dehradun for financial assistance for holding the workshop on '28 July, 2018 titled 'Reforming Physiology Curriculum: A case study for other medical disciplines' where this panel discussion was held, which forms the basis of this review article. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

 
  References Top

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Memon I. Cadaver dissection is obsolete in medical training! A misinterpreted notion. Med Princ Pract 2018;27:201-10.  Back to cited text no. 2
    
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Mawdsley A, Willis S. Exploring an integrated curriculum in pharmacy:Educators' perspectives. Curr Pharm Teach Learn 2018;10:373-381.  Back to cited text no. 3
    
4.
Verma SS. Setting and Evaluation of a Question Paper. Available from: https://www.dailyexcelsior.com/setting-and-evaluation-of-a-question-paper/. [Last accessed on 2020 Oct 10].  Back to cited text no. 4
    
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Bird JB, Olvet DM, Willey JM, Brenner J. Patients don't come with multiple choice options: Essay-based assessment in UME. Med Educ Online 2019;24:1649959.  Back to cited text no. 5
    
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Hillyer JM, Gordon KA. Connecting anatomy and physiology concepts in an interdisciplinary high-fidelity patient simulation with undergraduate nursing and allied health students. Adv Physiol Educ 2020;44:113-8.  Back to cited text no. 6
    
7.
Zheng J, Lapu R, Khalid H. Integrating High-Fidelity Simulation into a Medical Cardiovascular Physiology Curriculum. Adv Med Educ Pract 2020;11:41-50.  Back to cited text no. 7
    
8.
D S, A T. Student perceptions of “doing” hematology physiology practicals. Adv Physiol Educ 2020;44:65-71.  Back to cited text no. 8
    
9.
Rawekar A, Jagzape A, Srivastava T, Gotarkar S. Skill learning through early clinical exposure: An experience of Indian medical school. J Clin Diagn Res 2016;10:JC01-4.  Back to cited text no. 9
    
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Saiyad SM, Saiyad M, Pandya CJ. Implementation of cardiopulmonary resuscitation workshop in first MBBS. Int J Appl Basic Med Res 2015;5:S11-3.  Back to cited text no. 10
    



 
 
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