Curriculum Goals and Learning Outcomes of Medical Ethics and Professionalism Courses in Undergraduate Medical Curriculum of Pakistan

The objective of this paper is to develop curriculum goals and learning outcomes of medical ethics and professionalism courses in undergraduate medical curriculum of Pakistan which is the next step after general needs assessment and targeted needs assessment. The Medical Ethics and Professionalism curriculum has been designed to be implemented at undergraduate level of medical education. The logic model presented in the paper may act as a blueprint for educators developing a Medical Ethics and Professionalism course for teaching guiding principles of practice of medicine to prospective doctors. The logic model highlights the elements e.g. human, financial resources and PMDC’s support, impact of short terms and long-term outcomes for learners, educators and patients that should be taken into account at every step of implementation.


Introduction
In Pakistan, once medical students complete their MBBS they start a one-year clinical internship also known as a house-job, which is required to get a license to practice. The duration of MBBS is five years while house-job is for one year. During the first two years of medical school, they are taught Anatomy, Physiology, and Biochemistry. In the third year, they study Pharmacology, Forensic medicine, and General Pathology and Microbiology. Special Pathology (Organ System Pathology), Community Medicine, Otolaryngology, and Ophthalmology are taught in 4 th year whereas in the final year of medical school they learn about Medicine, Surgery, Obstetrics/Gynecology, and Pediatrics. The medical students in Pakistan start their clinical rotations from 3 rd year. They are posted to different clinical disciplines (e.g. Gynecology, Surgery, Medicine, Ophthalmology, etc.). After graduation, they start their house-job in which they have consecutive on-call duties and maximum interactions with the patients and their year where interaction with the patients and their families start and I would say it is that time from where they might show unethical and unprofessional behavior owing to no concept of medical ethics and professionalism. Medical ethics and professionalism are left onto the personal opinions and views of the faculty of that department, as there is no concept of learning medical ethics and professionalism. The MBBS Curriculum developed jointly by Pakistan Medical and Dental Council (PMDC) and Higher Education Commission (HEC) of Pakistan (PMDC, 2018)does not address the needs of medical ethics and professionalism unlike other developed countries such as Canada, USA, and UK where this course is an integral part of the undergraduate curriculum (Johnston and Mok, 2015a). Therefore, throughout the journey of becoming a practicing physician or even a consultant, this critical aspect remains deficient, which becomes the root cause of many avoidable ethical issues.
During the last decade, social media has taken our world by storm and medical students and physicians face ethical challenges concerning professionalism and doctor-patient relationship more than ever (Asghari, Samadi and Rashidian, 2013). The aim of incorporating medical ethics and professionalism course in MBBS curriculum is to fill this gap by increasing the ability of prospective doctors to recognize, analyze, and respond to issues in medical ethics and professionalism. This course will enable future doctors to behave according to the ethical principles by providing an overview of the major ethical issues that arise in the practice of medicine, medical education, and research. Moreover, research shows that medical students found the learning experience of medical ethics very useful and positive (Johnston and Mok, 2015b). This paper proposes curriculum goals and learning outcomes of medical ethics and professionalism courses in the Undergraduate Medical Curriculum of Pakistan. Ethical approval was not required for this research.

Assumptions
The general needs assessment has been conducted, which emphasized the significance of incorporating 1.
medical ethics and professionalism in the undergraduate curriculum.
Following the six-step approach of the curriculum (Thomas et al., 2015), the next step after a general needs 2. assessment was the targeted needs assessment. The targeted needs assessment was performed by obtaining systematic data collection through focus groups, interviews, and surveys of all the stakeholders.
PMDC and HEC have agreed to incorporate this course in the undergraduate medical curriculum. 3.

Curriculum Goals
The third step in curriculum development is describing goals or objectives which is defined as an end towards which an effort is directed (Thomas et al., 2015). The intention of the "Medical Ethics & Professionalism" course is to educate prospective doctors to choose the right course of action among available choices by recognizing ethical issues that may arise during the patient care delivery (e.g. decision making, clinical judgement, patient's privacy, confidentiality, breaking bad news, informed consent, use of social media, religion, culture, spirituality, gift acceptance, management of challenging patients and their family members, resources allocation, research with human subjects and conflict of interest) (Carrese et al., 2015). The specific goals of this curriculum are listed in Table 1.

1: Medical Ethics & Professionalism Curriculum Goals
This curriculum aims… 1 To recognize common ethical issues likely to arise in medicine 2 To know ethical norms in medicine 3 To apply their knowledge and skills to anticipate ethical problems 4 To handle ethical problems effectively 5 To understand and articulate the complexity of end-of-life issues 6 To understand the scope of medical students and physicians' professional responsibilities 7 To adhere to professional ethics with consequential improvements in a doctor-patient relationship which can improve clinical outcomes

Learning Outcomes
The main goal of medical education is to train physicians who are capable of delivering quality health care leading to improved patient outcomes (Moreau and Eady, 2015). The significance of exploring subject matter to be learned in terms of intended learning outcomes is established. Learning outcomes can be defined as broad statements of what is achieved and assessed at the end of the course of study (Harden, 2002). The learning outcomes of the Medical Ethics and Professionalism curriculum are presented in Table 2.

Table 2: Medical Ethics & Professionalism Curriculum Learning Outcomes
By the end of this course, students will be able to 1 Comprehend the basis of responsibilities especially relevant ethical principles that will enable you to make the right decisions. 2 Recognize the skills needed to act professionally after making the right choices. 3 Applying the knowledge and skills appropriately in a given situation.

Educational Strategies
After defining the curriculum goals and determining the learning outcomes of Medical Ethics and Professionalism curriculum, the 4 th step of curriculum development i.e. Educational Strategies will be discussed which ensures the achievements of curricular objectives. The specific material to be included in the curriculum called as content and the way by which that material is presented or delivered is known as a method, are components of educational strategies. Educational strategies are the heart of the curriculum and they provide the means by which curriculum objectives are achieved (Thomas et al., 2015).
To deliver this content, various educational strategies will be employed such as a combination of lectures, readings, small group discussions, large group discussions, submission of papers, problem-based learning, presentations, and audio-visual reviews aligned with the goals of the curriculum. This course will be delivered over five years. In the first two years of medical school, lectures will be delivered by the subject specialist and most general topics in Medical Ethics and Professionalism such as principles of ethics, informed consent, confidentiality, and research ethics will be presented in lectures. Students will be required to read selected readings from the selected journals and participate in discussions through Problem-based learning. In 3 rd and 4 th years, facilitation of openness, role-models, and reflective writing strategies will be used to equip the students with knowledge and skills required to anticipate an ethical dilemma, analyze, and present a solution to the problematic situation involving ethics or professionalism. In the fifth year, ethical questions raised by the cases will be addressed using demonstration by the experts and roleplay strategy for instance a student (acting as a physician) will demonstrate the skills of breaking the bad news to the fellow student (acting as the patient or the family of the patient) in the presence of a facilitator or a subject specialist and the performance will be recorded with the audio-visual equipment. The facilitator will then provide feedback to the student. Research papers and elective opportunities will be optional and available to those students who aspire to excel further in this field. The educational strategies aligned with the goals and learning outcomes are listed in Table  3. , and Does (Action). The first two levels are concerned with knowledge and it will be tested through multiple choice questions, short answer questions, modified essay questions, script concordance test, matching items, and true & false items. For third and fourth level performance, assessment methods such as Objective Structured Practical Examination (OSPE), direct observation and video reviews will be used (Downing and Yudkowsky, 2009). The assessment strategies appropriate for the learning experiences are listed in Table 4. Programmatic assessment will be applied. There will be nine assessments over the course of five years. One assessment will be conducted at the end of the first year, and two assessments every six months onwards. As all assessment methods have limitations and not a single method can assess a student's ability, therefore, each assessment moment will be considered as a single data point and at the end of five years, students will be declared pass or fail or awarded distinction based on their performances on all assessments. Feedback will be given at the end of each assessment to facilitate students in improving their knowledge and skills. The distinction, pass and fail criteria are listed in Table 5.

Conclusion
The Medical Ethics and Professionalism curriculum has been designed to be implemented at the undergraduate level of medical education. The logic model presented in Table 6 may act as a blueprint for educators developing a Medical Ethics and Professionalism course for teaching guiding principles of practice of medicine to prospective doctors. The logic model highlights the elements e.g. human, financial resources and PMDC's support, the impact of short terms and long-term outcomes for learners, educators, and patients that should be taken into account at every step of implementation.
The curriculum focuses to educate prospective doctors to understand why a physician should act in one way rather than another. It involves reasoning behind believing why one course of action is better than another. Physicians are expected to counsel, explain and give reasons for the choices they make as doctors to their patients, patients' families and to their colleagues. This curriculum empowers physicians to understand and respond to relevant medical issues.   The curriculum focuses to educate prospective doctors to understand why a physician should act in one way rather than another. It involves reasoning behind believing why one course of action is better than another. Physicians are expected to counsel, explain and give reasons for the choices they make as doctors to their patients, patients' families and to their colleagues. This curriculum empowers physicians to understand and respond to relevant medical issues.

Take Home Messages
Physicians are expected to counsel, explain and give reasons for the choices they make as doctors to their patients, patients' families and to their colleagues.

Notes On Contributors
Dr. Arslaan Javaeed wrote this paper as one of the assignments of the course "Curriculum Design for Health Professions Education", taken to fulfil the requirements of Masters in Health Profession Education (MHPE) from Faculty of Education, University of Ottawa, Canada.