To prepare and implement the intended changes in the medical schools’ curricula, the following are the actions taken and the outcomes achieved (Fig. 1):
Assessment of the existing situation
To assess the necessity and scope of the change, the RUMP conducted a comprehensive context evaluation, from October to December 2016, to explore the challenges of the traditional program from the stakeholders’ viewpoint. A survey was conducted to explore students’ opinions about the current situation of medical education and how to improve it (Additional file 1). The survey was prepared by the RUMP committee members and distributed to all medical schools’ students as a link on Google doc through the schools’ deans and medical student of EFMSA (Egypt Federation of Medical Students Associations). The link was available for 8 weeks. The data were saved as excel sheet then transformed to SPSS file. Revising and filtration of data were done to guard against any bias or missing data. Out of around 50,000 medical students in Egypt in 2016, 2,154 students from all academic years (one to six) participated in this initial survey. Analysis of the survey results showed that 66.6% of the students were dissatisfied with the traditional way of teaching by lectures and with the assessment methods. Additionally, knowledge recall without testing of higher levels of thinking and unfairness were the main disadvantages mentioned by the students. They also reported that they were required to resort to private tutoring in several subjects. Additionally, 70% found that their schools’ websites were not useful. These data were presented to the SCU.
A group discussion was also conducted with the academic leaders (Deans and Vice Deans of Education of medical schools) in several sessions conducted during the regular medical sector committee and attended by representatives of the RUMP committee members to get their feedback regarding the needed improvements in the existing medical curriculum. Incorporating newer teaching elements in the under-graduation course namely introduction of a foundation course after admission to prepare a student to study medicine effectively; facilitation of horizontal and vertical integration between different disciplines; advocating early clinical exposure right from the first year (viz. case scenarios for classroom discussion/case-based learning); addition of elective courses and methods to enhance self-directed learning, critical thinking and research abilities were the main responses of the academic leaders.
Proposed changes by RUMP committee
To respond to the assessment of the existing situation results, several meetings were conducted by RUMP committee in year 2016 where different international medical curricula were reviewed in order to agree on the proposed curriculum changes. The committee reached a consensus to formulate and adopt a competency based medical education national framework. The committee also recommended effective monitoring of the compliance of medical schools in implementing horizontal and vertical integration, self-directed learning, early clinical exposure, more emphasis on clinical practice and implementation of credit hour/point system.
Awareness campaign for all medical schools
To orient the medical schools about the intended changes in the medical program, an awareness campaign started in December 2016 and ended in January 2017. All governmental and private medical schools all over Egypt at that time were visited. There were 28 medical schools at that time, the public schools constituting the majority. Each visit was conducted by 2–3 RUMP members. The awareness package included information about the rationale for the change to competency-based medical education (CBME), the relevance to NARS-Medicine 2017, the definition, importance, types and levels of integration. Different models of curricula from UK, Europe and Arab countries were discussed as well.
The awareness package was delivered to the stakeholders in each school including students, recent graduates, academic leaders and faculty members. At least 40% of students and 30% of faculty members attended each awareness campaigns.
Preparing the framework for reform and getting higher authorities’ approvals
A series of meetings and focus group discussions were made between the coordinator of the RUMP, the head of the Medical Sector Committee (MSC) and the secretary general of the Supreme Council of Universities (SCU) and the relevant ministers in the period from June to September 2017 to propose the framework of reform and the required changes in the laws and bylaws. The required changes were approved by the Ministries’ Council on the 4th of October/2017 including modification of the bylaws clause 154, so that the period of undergraduate studies for the medical school in Egypt will be 5 years competency- based integrated program using a credit system followed by two years of internship and a licensing exam before practice. The SCU approved that the new program should be implemented by all medical schools starting from the academic year 2018/2019.
Preparing curriculum maps and bylaws by all medical schools
After getting the higher authorities’ approvals, two documents stating a framework for preparing the bylaws and curriculum maps were prepared by the RUMP committee and issued to all schools from the SCU to follow in preparing their curricular maps and new bylaws. Continuous communication occurred between RUMP members and the curriculum committees in each medical school during its work on bylaws and map to be ready for the approval of the new reform. In April to June 2018, RUMP members revised each medical school curriculum map and bylaws according to a pre-set standard checklist to ensure that each program fulfils the updated NARS-Medicine, 2017 requirements and the items stated in a document issued from SCU concerning the framework of the bylaws. RUMP members feedback was given to the schools and modifications were done accordingly. Before the start of the academic year 2018/2019 the bylaws of all medical schools were approved by the SCU which is the higher authority.
The framework of the new bylaws covered all the points that should be included in the bylaw such as: information about the College and University, graduate attributes, vision, mission, strategic objectives, educational strategies, departments and committees, admission process, the duration of study, the program structure, credit hours or credit points data and many other important instructions regarding complaints, withdrawal, transfer, etc. The bylaw also defined certain important items that should be emphasized in the curricula which are: 1) description of the integrated modules including types of integration and its level in addition to the used teaching methods that can achieve this integration. 2) the presence of a preparatory period for the students to be oriented with the new program and the presence of a study guide. 3) Self-directed learning and ways of maximizing it. 4) Early clinical exposure. 5) Communication and professionalism and other skills that are mandated in the NARS competencies. 6) Electives 7) Research methodology and research skills to be included in the early years of the program. 8) Including formative and summative assessment in addition to using new objective methods of student assessment that measures higher cognitive domain and practical and professional skills. 9) implementing quality assurance measures on the program.
The main curricula changes done by the medical schools in their new curricula were introducing different levels of integration according to the schools’ infrastructures and personal competencies, but all were exceeding level 5 according to Harden ladder . Modern teaching and learning methods were used, mostly interactive and self-directed. Almost all the schools added early clinical teaching mainly by using clinical skills labs and early experience with patients in different clinical settings. Most of the schools introduced an introductory module, in year one, preparing students for further undergraduate studies. All schools added elective module(s). Research methodology was introduced into all curricula. Assessment policies witnessed a dramatic change, getting away from knowledge recall and using objective, structured methods.
In preparation for implementation, a faculty development program under the title of teaching excellence in medical education was conducted by the Egyptian Knowledge Bank (EKB) in collaboration with the Medical Military Academy (Additional files 2 and 3). Throughout the years 2017—2020, the EKB organized 48 workshops of 430 h in total. The workshops were facilitated by 13 expert educational leaders from the United States of America, United Kingdom, Australia and Canada and were attended by around 300 participants. The main areas of training were excellence in curriculum design, teaching & learning and assessment. This faculty development program started in 2017, before the actual implementation of the new curriculum, with eight workshops and continued in 2018, after implementation, with ten workshops, one special service workshop for deans and one seminar conference. In 2019, 22 workshops and one seminar were conducted. In 2020, five workshops were done. In parallel, the EKB also provided free access to digital training resources, such as Incision Academy and Virtual Patient Learning to the medical students at all medical schools. All medical schools benefited from EKB services and 81,086 students logged in to the Incision Academy portal. The conducted workshops were considered a training of trainers (TOT) for continuing training of all involved faculty in all schools. In addition to this TOT, each medical school started its own faculty capacity building with the support of RUMP members. The evaluation conducted by EKB for the faculty development program in 2019 revealed that the responses of participants were as following: 97% stated that the courses met their expectations, 87% affirmed that they would recommend the courses to their colleagues, 87% said that they believe their professional work will improve as a result of the courses and 88% rated the course leader’s knowledge as above average/outstanding. The evaluation conducted by the EKB for the year 2021’s courses showed that the total satisfaction rate of the participants was 96%. The responses were: we gained valuable new ideas or insights from the attended workshops (97.5%), we gained practical knowledge after attending these workshops (95%) and we will share what we learned during these workshops with our colleagues (98%).
The new curriculum model implementation started on September 2018, for the first year students. This included horizontal and vertical integration of content, introduction of an orientation module, stronger clinical orientation starting already in the first semester, more elective components and integrated examinations. The curriculum included the modular line components (mostly organ/function modules lasting 3–6 weeks) supplemented with semester-vertical courses. Each medical school selected the coordinators for all modules of the new curriculum after an application process. These coordinators had the responsibility of choosing an interdisciplinary planning team of at least six members, including faculty members from non-clinical as well as clinical subjects. These planning teams were charged with selecting the content which would be covered in their module as well as the appropriate learning methods.
Monitoring (audit) visits
The RUMP members designed a comprehensive, multicomponent and program-wide monitoring system. The framework expects the quality of the program as comprising four main aspects: curriculum and resources; staff and teaching; student experience; and management support. Key principles of the adopted audit included feedback form students and staff, auditing of teaching, learning and assessments methods. An emphasis on corrective actions following evaluation was included (closing the loop), which was undertaken by teachers, course coordinators, and administrators. An external auditing checklist was prepared by the RUMP committee to be filled by the assigned auditors. The checklist included readiness of the bylaws, program specifications, course specifications, the curriculum matrix, the action plan, teaching and learning methods (interactive sessions, problem-based learning (PBL), self-directed learning (SDL), simulations, field visits and practical/clinical training), as well as details of the assessment process (strategy, blueprint, formative assessment documents and summative assessment tools).
Four meetings were held with the auditors who include the RUMP committee members in addition to a selected group of faculty members from different universities who have qualifications and experience in medical education. One meeting was held at the beginning of the academic year 2018/2019 to standardize the auditing process and discuss the items of the external auditing checklist with the auditors. The other meetings were held before each cycle of monitoring visits. Three in-person monitoring visits were conducted: two in the first year of implementation (once per semester) and the third one in the first term of the academic year 2020/2021. The third visit occurred during the evolving COVID-19 pandemic. Because of the COVID-19 lockdown, auditing in the academic year 2020/2021 was paused. In each auditing visit, two assigned RUMP members visited each school. The auditing visits in 2021 were mostly done online.
The filled checklists were included in a final report. Generally, the auditors found that the program specifications were prepared in almost all the faculties by the 2020 audit. Conversely, the alignment matrix between the 2017 NARS-Medicine and program intended learning outcomes (ILOs) were completed in about three-quarters of the faculties visited. The reform action plans that were formulated by the faculties to address the comments of the audit reviewers were implemented in 71% of faculties in the first audit and 80% in the second round of the audit.
Students’ and faculty feedback after implementation
To assess the students’ and faculty’s points of view after implementation, questionnaires, designed by RUMP committee, was distributed to all medical schools through a survey monkey application. The first student survey (Additional file 4), conducted in 2019, received 9,044 responses. Students reported that the preparatory period and study guides were beneficial (70%), the interactive teaching methods were interesting (50%), the teachers spent efforts on their training (50%) and they used the schools’ websites (40%). The second student survey (Additional file 5), conducted in the year 2020, received a total of 18,655 responses. The students’ main responses were that the learning outcomes were well explained (60%); the websites were useful (60%); they received training in research and clinical skills (40%); they had courses in communication and ethics (50%); and electives were applied (40%). Fifty percent of the students were satisfied by small-group teaching, clinical teaching and formative and continuous assessment (50%). Additionally, 40% of the students expressed their satisfaction regarding E-learning and the received feedback.
Regarding feedback of the faculty members, their implementation survey (Additional file 6) elicited 1,911 responses. About 95% stated that a team exists for implementation of the integrated medical program in their faculties. Half of the respondents indicated their involvement in the implementation of the program. About 70% of the respondents received training either through the EKB or in their faculty about the concept of integration, its design and implementation. Only 60% received online training for teaching and assessment and 70% of the respondents stated that their students received teaching in small groups.
Coping with the pandemic
In order to manage the teaching and learning activities during the COVID-19 pandemic, all the faculties adopted a blended learning approach of online and on-campus activities. In the auditing visits, auditors noticed that most of the faculties used the Microsoft Teams platform as well as the EKB resources. The utilized EKB resources included the Incision Academy and Virtual Patient Learning. Although free access to the EKB learning management system was provided, some faculties implemented the open-source learning platform MOODLE (Moodle Pty Ltd, West Perth, WA, Australia) and continued to utilize its options during the pandemic.
Conversely, variable approaches occurred for the assessment process during the pandemic. Most faculties used online formative assessments to motivate the students learning. Regarding final written tests, some faculties used online assessments, while other faculties requested that students submit review articles that were uploaded online. Considering the practical skills, they were assessed by objective structured practical exam (OSPE) on campus with the application of all COVID-19 prophylactic procedures.
Challenges of implementation reported by auditors
During the implementation of the new medical curriculum, RUMP explored the challenges by questioning the auditors who met representatives of faculty, students and leaders of medical schools during the monitoring visits. Their answers can be summarized in the following points:
Skepticism and resistance were found from some faculty members who felt that such young students would be unable to adopt self-directed learning. Faculty members of certain disciplines expressed concerns that the new scoring system in the integrated curriculum, which assigned scores to learning outcomes rather than disciplines, would encourage some students to ignore subjects that contributed a small share in some modules. Because the integrated modules followed a common sequence, some faculty members argued that this order was the most suitable one for their disciplines. Some believed that moving the students into the modular system would not provide a good base of the required knowledge in all disciplines. Others saw that the integrated system required that instructors must change the way of teaching, which they had been adopting for a long time. Collaboration with colleagues from other departments would also be needed to plan classes. In other words, they would be required to make an extra effort that they used to do in the original curriculum.
Many students complained of marked overload in the content of some modules, apparently because some departments did not do enough effort to tailor the content to the shortened time of their disciplines.
Early clinical exposure could not be satisfactorily achieved in some medical schools because of the large number of students and logistic difficulties in securing the required training places.
Some RUMP reviewers reported that in some medical schools, the level of horizontal integration was limited to synchronization without actual exchange of material and educational plans to ensure proper sequencing of educational activities.
In some schools, examinations, especially in the first year, largely addressed recall with a small percentage of questions devoted to testing higher cognitive levels.
Lastly, the COVID-19 pandemic presented an extra burden during the implementation.