SUDANESE JOURNAL OF PAEDIATRICS

2021; Vol 21, Issue No. 2

REVIEW ARTICLE

Progress, challenges and partnerships of teaching medical professionalism in medical schools in Sudan: the success story of Sudan Medical Council

Osama Hafiz Elshazali (1), Hala Abdullahi (2), Zain A. Karrar (1),(3)

(1) Department of Paediatrics and Child Health, University of Khartoum, Khartoum, Sudan

(2) Department of Obstetrics and Gynaecology, Sidra Medical Centre, Doha, Qatar

(3) Ex-President of Sudan Medical Council, Sudan

Correspondence to:

Osama Hafiz Elshazali

Department of Paediatrics and Child Health, University of Khartoum, Khartoum, Sudan

Email: o.elshazali [at] uofk.edu

Received: 3 June 2021 | Accepted: 19 September 2021

How to cite this article:

Elshazali OH, Abdullahi H, Karrar ZA. Progress, challenges and partnerships of teaching medical professionalism in medical schools in Sudan: the Success story of Sudan Medical Council. Sudan J Paediatr. 2021;21(2): 110–115.

https://doi.org/10.24911/SJP.106-1622725530

ABSTRACT

This paper highlights the historical perspective of medical education in Sudan and the context within which initiatives for teaching medical professionalism were implemented. It reflects upon the present-day situation of teaching professionalism in Sudan and identifies the challenges of teaching professionalism in the medical schools in the country. The cultural and social adaptation and professional implementation challenges within a poorly resourced health system will be discussed. The successful experience of the Sudan Medical Council in conducting the accreditation for medical schools and in commencing and maintaining partnerships with major concerned partners is shared.

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KEYWORDS

Sudan; Medical education; Medical professionalism; Sudan Medical Council; Accreditation for medical schools.

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INTRODUCTION

Medical education in Sudan started in 1924 with the establishment of the Gordon School of Medicine, currently known as Faculty of Medicine at the University of Khartoum. In the late 1970s, two other medical schools were established. All of these schools were public schools. The number of intake of students per year to the three medical schools was 250 students. This small scale and well-balanced education within the available resources ensured that the graduates were well-trained and learning at a good and high standard.

Explosion in the number of medical schools and the challenge of resources

In 1991, the government announced the so called ‘Revolution in Higher Education’. This led to opening of new public and private medical schools for the first time. As a result, we now have 72 medical schools in the country [1,2], and the intake per year is more than 5,000 students.

This increased number of medical schools and the increased intake was not accompanied by a parallel increase in the number of training facilities and trained trainers. This has resulted in teaching large numbers of students without having the adequate resources for support, and not having enough well-trained mentors. This has in turn affected the amount of hand on training the students are receiving [1-3].

Currently, medical schools are facing great challenges in maintaining the quality of medical education and fulfilling the Sudan Medical Council (SMC) standards for accreditation for medical schools [4]. In spite of these challenges, Sudanese medical graduates are maintaining reasonable regional and international competitiveness both academically and professionally, as evident by their achievements in international professional examinations in UK, Ireland, USA and the Gulf region.

Situation of teaching professionalism in medical schools in Sudan

The professionalism curriculum of the medical schools in Sudan was reviewed by Galil [5]. His review had showed little evidence of teaching and training in this area and the few courses that existed were mainly theoretical courses, with no practical training to encourage the development of the desired skills, with no objective assessment of professionalism skills.

SMC conducted a number of advocacy activities addressing the importance of teaching professionalism and its positive impact on the medical practice of graduates. The outcome of these activities was publication of the guideline on teaching professionalism in medical schools in 2009 [3], and this was later updated in 2011 [6].

A study by Imam and Kheir [7] looked into undergraduate medical students knowledge, attitude and practice regarding professionalism. The study involved 504 students from two universities in Khartoum, Sudan. The study showed that 30% of the students had high knowledge, 56% had fair knowledge and 14% had poor knowledge. Thirty four percent of the students were found to have good professional attitude, 57% had fair attitude and 9% had poor attitude towards the concept of medical professionalism and its regulations. Twenty seven percent of students showed good practice in professionalism (i.e., professional behaviour), 40% showed fair practice and 33% showed poor practice.

The study by Husain et al. [8] included 675 final year medical students from six different medical schools. Of them, 666 (98.8%) acknowledged that medical professionalism and ethics were taught in their schools, only 60.3% of the respondents perceived that the course contents are enough. The study concluded that the professional knowledge, attitude and behaviour of Sudanese medical students are satisfactory.

Mohamed and Karrar [9] looked into the situation of teaching professionalism in Sudanese medical schools using SMC guidelines [3,6] as a benchmark. The study included 39 medical schools. They found that 7 medical schools (17.9%) had no formal teaching; 14 medical schools (35.8%) taught professionalism and allocated adequate time for teaching as recommended by the SMC guides, but only three medical schools (7.7%) addressed all objectives and concepts of professionalism.

Mohamed and Karrar [10] had published another study in 2019 exploring the students and teaching staffs’ perception regarding the teaching of professionalism and the challenges of its application. They found that the overall perception of medical ethics, good professional practice and communication skills is positive for both students and teaching staff alike. They identified some areas that needed to be addressed to improve the quality of the course.

The identified weak areas were that unprofessional behaviours were not well addressed, the learning environment was not suitable to promote professionalism, insufficient number of trained teaching staff, not having enough time allocated to the course, the lack of resources and the difficulty in integrating the course within the curriculum. Notably, 71.4% of the teaching staff had felt that the teachers did not always offer a good example of role modelling [10].

We can see that generally professionalism teaching in Sudan is satisfactory; however, there is still room for improvement and some challenges that need to be addressed.

Challenges facing enhancement of professionalism

Cultural and social challenges

Scholars continue to emphasize that professionalism is context-dependent and is a social construct. This social construct is defined within a sociocultural context at a particular time. Some sociologists are concerned that medical professionalism literature is dominated by influential scholars, groups and organizations based in North America and Europe, while there is a scarcity of literature on the universal applicability of this framework in the other parts of the world [10,11].

Professionalism perspectives in the Arabian [12,13] and Islamic [14] cultures and the challenges in adaptation have been acknowledged. The main principles of professionalism, the concept of the social contract, and the ten commitments of the physicians as set in the Physicians Charter [15] are consistent with the Islamic values that are based on respect to human values and sanctity of human life.

Sudan, like in any other country, has to adapt teaching of professionalism to the social and cultural context, especially as Sudanese culture is a diverse multi-ethnic society with a plethora of unique cultures, heritages, religions and beliefs. A number of resources published by scholars in the local Arabic language have provided excellent resources for concepts of professionalism and communication skills in the local setting [16-20].

Professional challenges: training environment and role models (hidden curriculum)

Studies from Sudan had shown the detrimental effect of the poorly resourced health care system on the training environment. This is compounded by weak clinical governance and accountability, the lack of policies ensuring the patients’ safety and rights, poor leadership and the declining number of trainers. All of these factors in unison are responsible for undermining professionalism and its enhancement [8-10].

Hafferty [21] reflected on teaching and training of medical professionalism, arguing that a great deal of learning occurs within the hidden curriculum. Since then, educational research had confirmed the power of the ‘hidden curriculum’ in shaping the values and behaviours of learners during their clinical training. Discordance between the teaching in the formal and the informal (hidden) curriculum faced in the reality of clinical practice is confusing to the students, and can have a negative impact on the acquired professionalism competencies [22].

The medical students and trainees’ perception should be assessed and used as tools for identifying any gaps and lapses, to allow remedial actions for improvements of the learning and training environments [11,23].

The significant impact of role models on the professional development of medical students, residents and medical team members, was addressed by many studies both locally and globally [10,12,24-26].

Role of the SMC

The SMC is an independent, autonomous body that was established in 1968. The purpose of the SMC is to protect, promote and maintain the health and safety of the public by ensuring proper standards in the practice of medicine, dentistry and pharmacy, by laying down a sound code of conduct and disciplinary measures.

The mission of the SMC is to help raise standards in medical education and practice by developing our standards and our guidance. This is done by focusing on ethical practice, professionalism and patient safety, to maintain the confidence of the public and the medical field in the Council’s processes. The SMC has developed training courses in professionalism for postgraduate as well as training courses for mentors, in order to promote and ensure the sustainability of the program. Working closely with other partners to improve standards of medical practice, the SMC has developed mutually beneficial partnerships with medical regulatory and accreditation authorities nationally, regionally and internationally.

Accreditation of medical schools

The curricula of medical schools in Sudan are diverse and are based on different educational philosophies and teaching strategies; to sustain the high professional standards of the medical graduates.

In 2008, the SMC started the accreditation and external evaluation process of the medical schools [4]. The standards of accreditation introduced were based on the adaptation of the World Federation for Medical Education (WFME) and the national standards of the medical colleges issued by the Ministry of Higher Education and Scientific Research (MOHE & SR).

The latest update of the standards included satisfying the requirement of teaching and training courses of professionalism as mandatory requirement [27]. The SMC issued guidelines on teaching professionalism in medical schools in 2009 [3] which were updated in 2011 [6].

Accreditation of the SMC by the WFME

The SMC eventually obtained international recognition as the national accrediting body by the WFME in June 2018, becoming one of the first 10 regulatory authorities to obtain this recognition internationally and the first in the region [28].

These advances have improved the quality of medical education in Sudan through the use of oversight and regular monitoring of the SMC and its partners; enhancing the different professional teaching and training areas including professionalism [6,29].

Teaching and training of professionalism is a focus of scrutiny during the accreditation process. This accreditation process has given the SMC the power and authority to improve teaching and training of professionalism within medical schools [3,6,29].

As the result of these changes, the medical schools in Sudan have made alterations and improvements to their curriculum, teaching and the learning environment, in order to meet SMC accreditation standards.

Partnerships

The vision of the SMC would have been unattainable without the commitment and dedicated support of its partners and stake holders. The main partners are the MOHE & SR, the Ministry of Health (MOH), medical schools, the Sudan Medical Specialisation Board and the medical professional associations of the World Health Organization (WHO), and WFME. The partners’ input was mainly in planning and implementing training courses, training of trainers’ activities, support for teaching and training at all levels and ensuring its sustainability through legislations and bylaws.

Role of the partners

The MOHE & SR is the regulatory body that is responsible for all the higher education in the country, including medical education. It is the licensing body and it grants new medical schools the permission required to start. It is also a monitoring and oversight authority, through its legislation and bylaws on all the colleges and universities in the country.

The MOH: The Ministry runs the hospitals in the country and employs all grades of doctors. The training of undergraduate and postgraduate doctors occurs within this, and it is responsible for improving the training environment. The SMC and MOH run professionalism courses for both trainees and trainers regularly.

The medical schools: These are responsible for teaching and training the undergraduate students within the college.

The Medical Specialisation Board: This independent body is responsible for the postgraduate education of doctors in all the specialities.

Medical Professional Associations: These are associations for different specialities within the field, e.g., for physicians, surgeons, cardiologists. They work in tandem with the SMC and Medical Specialisation Board to oversee the training in their respective speciality.

Medical Students Associations: They represent the students and make sure that the students voices are heard by the administration.

Regional and international collaborations with the WHO, WFME and international experts in medical education have provided the much needed professional and technical support.

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CONCLUSION

Implementing a national program for teaching professionalism to undergraduate students is a challenge; collaboration of many agencies would be required to promote professionalism and good medical practice teaching and training at all levels. The accreditation program for medical schools will ensure quality and sustainability. Partnerships are essential for creating a common vision and mission and ensure the quality of medical education in a low resources country.

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CONFLICT OF INTEREST

The authors declare that they have no conflict of interest.

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FUNDING

None.

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ETHICAL APPROVAL

No ethical approval was required.

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REFERENCES

1. Fahal AH. Medical education in the Sudan: its strengths and weaknesses. Med Teach. 2007;29(9):910–4. https://doi.org/10.1080/01421590701812991
2. Al Mahdi TA. The path of undergraduate medical education in Sudan. Sudan J Med Sci. 2019;14(4):188–201. https://doi.org/10.18502/sjms.v14i4.5899
3. Karrar Z. Professionalism and good medical practice: the role of Sudan Medical Council. Sudan Med J. 2009;45(2):1–4.
4. Sukkar M. Accreditation of medical schools in the Sudan. Khartoum Med J. 2008;1(1):49–50.
5. Galil M. Report on curricula of medical schools in Sudan. Khartoum, Sudan: WHO report; 1997.
6. Sudan Medical Council. Teaching and assessing professionalism- a guide to course development. Khartoum, Sudan: Sudan Medical Council; 2011.
7. Imam JA, El Kheir DYM. Assessment of the concepts of medical professionalism among medical students. Khartoum Med J. 2014;07(02):979–88.
8. Husain N, Elsheikh N, Elsheikh M, Mahmoud A, Sukkar M, Ibnouf M, et al. Final year medical students and professionalism: lessons from six Sudanese medical schools. J Public Health Emerg. 2018;2(27):1–7. https://doi.org/10.21037/jphe.2018.08.01
9. Mohamed IN, Karrar Z. Teaching methods and assessment of professionalism among undergraduate medical schools in Sudan. Khartoum Med J. 2018;11(01):1454–9.
10. Mohamed IN, Karrar Z. Perception of medical students and faculty on teaching of professionalism: challenges and suggestions for improvement. Khartoum Med J. 2019;12(2):1587–95.
11. Passi V, Doug M, Peile E, Thistlethwaite J, Johnson N. Developing medical professionalism in future doctors: a systematic review. Int J Med Educ. 2010;1:19–29. https://doi.org/10.5116/ijme.4bda.ca2a
12. Hays R, Hamlin G, Worthington R. Developing professionalism in health professional learners. Clin Teach. 2013;10(1):64–6. https://doi.org/10.1111/tct.12026
13. Al-Eraky M, Chandratilake M. How medical professionalism is conceptualised in Arabian context: a validation study. Med Teach. 2012;34(sup1):s90–5. https://doi.org/10.3109/0142159X.2012.656754
14. Kasule O. Medical professionalism and professional organizations. J Taib Univ Med Sci. 2013;8(3):137–41. https://doi.org/10.1016/j.jtumed.2013.09.003
15. Brennan T, Blank L, Cohen J, Kimballa H, Smelser N. Medical professionalism in the new millennium: a physician charter. Project of the ABIM Foundation, ACP-ASIM Foundation, and European Federation of Internal Medicine. Ann Intern Med. 2002;136(3):243–6. https://doi.org/10.7326/0003-4819-136-3-200202050-00012
16. Alsafi A. The doctor [الحكيم]. Khartoum, Sudan: Currency Printing Press; 2013.
17. Balla H. The way to be a distinguished doctor [كيف تكون طبيبا متميزا]. Riyadh, Saudia Arabia: Alobekan Publishing; 2018.
18. Sudan Medical Council. Ethics and professional duties of the Doctor [دليل أخلاقيات مهنة الطب]. Khartoum, Sudan: Sudan Medical Council; 2013 [cited 2021 May 25]. Available from: http://www.sudmc.org/images/books/Guidance-of-Medical-Professional-Ethics.pdf
19. Alsafi A. Speak to me in my language [كلمنى بى لغه افهما]. Khartoum, Sudan: Madarek Printing Press; 2016.
20. Aziz OA. Medical doctrine and ethics .[فقه الطبيب وأخلاقيات المهنة] n2nd ed. Khartoum, Sudan: Ribat National University Press; 2008.
21. Hafferty F. Confronting medicine’s hidden curriculum. Acad Med. 1998;73(4):403–7.
22. Quaintance J, Arnold L, Thompson G. What students learn about professionalism from faculty stories: an “appreciative inquiry” approach. Acad Med. 2010;5(1):118–23. https://doi.org/10.1097/ACM.0b013e3181c42acd
23. El Shazali OH, Abdullahi H, Osman HES. Assessment of quality of counselling for Down syndrome in Sudan. J Pediatr Neonat Care. 2019;8(5):232–4. https://doi.org/10.15406/jpnc.2018.08.00347
24. Mclean M. Clinical role models are important in the early years of a problem-based learning curriculum. Med Teach. 2006;28(1):64–9. https://doi.org/10.1080/01421590500441711
25. Ainsworth MA, Szauter KM. Medical student professionalism: are we measuring the right behaviors? A comparison of professional lapses by students and physicians. Acad Med. 2006;81(10):S83–6. https://doi.org/10.1097/00001888-200610001-00021
26. Arnold E, Blank L, Race K, Cipparrone N. Can professionalism be measured? The development of a scale for use in the medical environment. Acad Med. 1998;73(10):1119–21. https://doi.org/10.1097/00001888-199810000-00025
27. Karrar Z. Sudan Medical Council: updates and recent initiatives. Presented at migration of Sudanese doctors dynamics and opportunities. Galway, Ireland; 2012 [cited 2021 May 25]. Available from: https://www.youtube.com/watch?v=eHe7klzGKEM
28. World Federation for Medical Education. Accrediting Agencies; 2021. Available from: https://wfme.org/accreditation/accrediting-agencies-status/
29. Karrar Z. Global trends in quality assurance in medical education: implications and challenges to medical education in Sudan. Khartoum Med J. 2018;11(3):1518–23.