Introduction
It has been more than 100 years since the revolutionary changes in medical education
made by Abraham Flexner and William Osler.[[1]],[[2]] Throughout the century, both undergraduate and postgraduate medical education systems
went through many updates, additions, and innovations. Yet, the most significant change
in medical education has just begun. This change is an attempt to transform the medical
education system to an outcome-based system or what is now known as competency-based
medical education (CBME).[[3]] One of the fundamental new additions that played an integral part of this new change
is the introduction of the concept of Entrustable Professional Activity by ten Cate,
which replaced the well-known goals and objectives or intended learning outcomes.[[4]] Despite the good reputation of the North American and British medical education,
both have decided to change their existing systems based on many evidence-based red
flags that showed the ineffectiveness and incompetence of the current systems. These
red flags include a high percentage of nonconfident new graduates,[[5]] medical errors as the third cause of mortality in the United States,[[6]] most disciplinary claims against physicians are related to professionalism,[[7]] inability of the current systems to solve the issue of “failure to fail,”[[8]] nonpracticality of some of the current systems,[[9]] and lack of objectivity and trust in teaching and assessment.[[10]] These changes are also made to meet the new societal needs and scientific advancements.
Most developing countries follow one of two main medical education systems; British
or North American; however, the quality of medical education has always been lower
in developing countries compared to the original systems. This gap in quality will
become increasingly larger with the new revolutionary changes and hence sending an
emergency alert to all developing countries, including Libya.
Furthermore, the 2015 revision of the WFME Global Standards for Quality Improvement:
Basic Medical Education requires that all medical schools meet the new accreditation
standards by 2023.[[11]] This is based on the World Health Organization (WHO) recommendation to have all
countries establish accreditation mechanisms for health training institutions by 2020.[[12]]
The Libyan medical education system has not seen any major update since the first
medical school was established in Benghazi in 1970. The system has aged and faced
many challenges over the years, which has led to a system that does not meet the international
standards and more importantly, societal needs.
Challenges to the Current Libyan Medical Education System
The best way to approach this complex subject is to discuss it systematically according
to stakeholders and resources that form the final structure of any learning environment.
Despite the excellent attempts to improve the medical education system in Libya, it
is obvious that we lack fundamental and integral components to create an ideal learning
environment that fosters competency, independency, creativity, innovation, professionalism,
scholarly activities, and health advocacy.
Governance of the medical education system in Libya
Clearly, there is a disconnection between the different governing bodies, and the
recent 2018 Ministry of Health (MOH) survey has showed an alarming disconnection between
the MOH and Ministry of Education (MOE).[[13]] This, in return, led to independent and randomized decisions over the years resulting
in unwanted outcomes. During their early years, both Benghazi and Tripoli medical
schools enjoyed good international reputations and their graduates succeeded in many
international postgraduate training programs. This most likely lasted up to the late
90s when the number of medical schools suddenly increased from 3 to 18,[[13]],[[14]] and an alarmingly large number of new students began to be accepted to medical
schools. We must realize that all advanced health-care systems are struggling with
providing the needed number of “competent” physicians. Nevertheless, they always kept
quality ahead of quantity. In this regard, I would like to remind the reader with
two similar historical issues that occurred in the USA and the UK. In 1910, Abraham
Flexner and his team reviewed the quality of medical schools in the USA and Canada,
and despite the shortage of physicians, his work resulted in closing approximately
50% of the 168 medical schools he visited.[[15]] Whereas in the UK, the Medical Act of 1858 resulted in closing medical schools
with poor quality.[[16]] Combining random decisions with the lack of accountability and quality assurance,
we can understand how sometimes higher government decisions can negatively affect
the medical education system. In Libya, such decisions have created an uncontrolled
number of independent medical schools, different unique systems of education in the
same country, uncontrolled admissions to medical schools, and most importantly, a
lack of government support to those medical schools.[[13]],[[17]]
Students
They are the focus of the medical education environment, and the quality of graduated
students is reflective of the quality of their medical education. There are many direct
learner-related factors that have contributed to the declining of medical education
in Libya. These include: (i) a high influx of students without increasing the learning
environment resources, (ii) low levels of secondary school education, (iii) lack of
the main teaching language, (iv) lack of accountability, (v) an unclear and ineffective
student selection process, (vi) lack of student-active roles in the learning environment,
(vii) poor nontechnical skills, and (viii) the effect of external psychosocial factors
that might result in stress and fatigue. Students should be protected by the system
and this will require clear policies to guide them in cases related to harassments,
abuse, safety, wellness, and mental health. Medical students, especially in their
clinical stages, should be treated as “adult learners” where they can have more proactive
roles and enhance their teaching and clinical skills, recognize professional boundaries,
provide feedback to their seniors, and participate in quality improvement projects,
while at the same time, acquire some accountability to their actions.[[18]] A lack of trust between the different stakeholders within the learning environment
has led to many known and unwanted complications in medical education that can either
directly or indirectly impact the quality of education.[[10]] This lack of trust has resulted in students seeking help from other private institutions
and specific teachers.
Teachers
Our medical education system lacks the numbers and qualifications needed to make the
system sustainable and productive.[[13]] Many factors have contributed to the decline in teachers' productivity. These are
(i) the increase in the number of medical schools which added more work to faculty
members, (ii) the exceptionally large number of students that made teachers unable
to provide high-quality lectures and perform fair and effective assessments, (iii)
the lack of accountability, which created nonhealthy work relations within the educational
institutes, (iv) the socioeconomic status of the country resulting in many faculty
members spending more time in the private clinical and/or educational sectors, (v)
the lack of strict promotion criteria that resulted in a large number of professors,
which could confuse the system and disrupt the iconic professorship rank and its image,
(vi) the lack of experts in medical education who are needed to monitor, design, and
update the system, and (vii) the ineffective continuous professional development programs.
These factors have led to deterioration in teachers' competency, interest, and productivity.
This has also led to low-quality research that is either published in low impact journals
or deemed nonpublishable.[[19]] The focus on research as the main drive for faculty promotion had a negative impact
on education and quality improvement. Basic science teachers should be supported and
promoted based on their research, education, and quality improvement achievements,
whereas clinical excellency and leadership should be added to the promotion requirements
of clinical teachers. Many advanced medical education systems have very strict promotion
criteria that require the faculty member to be recognized nationally to be promoted
to the Associate Professor rank and internationally to qualify for the full professorship.[[20]]
Resources
The typical medical education system is expected to support its two main pillars,
namely, students and teachers, by providing them with an environment that supports,
protects, and promotes learning. We lack many mandatory requirements such as physical
space, financial support, effective assessment systems, effective faculty promotion
systems, sufficient library resources, adequate laboratory equipment, student protective
policies, and resources to acquire nontechnical skills, such as simulation centers.
Despite the clear lack of major supportive services, the system continues to open
new medical schools, create new postgraduate programs, and accept large numbers of
medical students.
Curriculums
The current curriculums are now almost 50 years old and have not seen any major update
nor do they meet the new accreditation requirements.[[13]] Curriculums are mainly delivered as large group sessions, except for the Libyan
International Medical University who had already updated their curriculum and adopted
many new teaching techniques. The current curriculum delivery system lacks most of
the relatively new innovations, such as problem-based learning,[[21]] flipped classrooms,[[22]] and portfolios.[[23]] The weak English language has affected all aspects of curriculum delivery and assessments.
Therefore, it is critical for medical schools to focus on improving the main language
of instruction. Over the years, and with the deterioration of infrastructures, medical
students became more focused on taking classes and curriculum outside of medical school.
This resulted in low-class attendance at the main school, which could be part of a
“hidden curriculum” that resulted in an inherited learning behavior and attitude toward
medical school teachers, classes, and curriculums.[[24]] Most international medical schools transformed their traditional curriculums to
an “integrated” one, aiming to break down barriers between the basic and clinical
sciences currently in place because of traditional curricular structures. This should
also promote retention of knowledge and acquisition of skills through repetitive and
progressive development of concepts and their applications.[[25]] There is now a higher focus on teaching and assessing the nontechnical skills,
and there has been major developments and updates in this regard. In fact, this was
the first step made before the new Canadian competence by design project that transformed
the medical education structure in Canada as of July 2017.[[26]] They started by updating their Canadian Medical Education Directives for Specialists
roles, which are equivalent to the non-technical skills in other systems.[[27]] Furthermore, adding the non-technical skills is now a mandatory step according
to the new World Federation of Medical Education (WFME) international standards.[[11]] These non-technical skills should include professionalism, research, communication,
collaboration, and leadership skills. Recently, there has been a move toward including
quality improvement and patient safety to all medical school curriculums and assessments.[[28]]
Accreditation standards
The WFME Global Standards for Quality Improvement: Basic Medical Education comprises
106 basic standards and 90 quality development standards.[[11]] According to the recent review by the MOH,[[13]] only 22 (20%) of the WFME basic standards are achieved by Tripoli's medical school,
33 (31%) by Benghazi's medical school, and only 4 (3%) by Omar Mukhtar's Medical School.
The very few quality indicators achieved by all medical schools are quite alarming
and calls for a resilient process to make the appropriate changes and additions. At
present, in Libya, accreditation is the responsibility of the Center for Quality Assurance
and Accreditation, a division within the Ministry of Higher Education and Scientific
Research. Accreditation is a complex process, and advanced medical training programs
have one strong independent governing body that overlooks a robust accreditation process.
The same concern applies to the Libyan postgraduate medical education since the current
system has no clear process of accrediting centers for both Libyan and Arab board
programs.
Assessments
Assessments are now considered the backbone of medical education, and improving assessment
has a vast impact on the quality of learning.[[2]] There have been many advancements in assessments within medical education and it
will require a comprehensive plan to update these assessments and to provide the right
tools to achieve that. Examples of new techniques that are currently used in advanced
systems are O-Score,[[29]] 360/multisource feedback,[[30]] logbooks,[[31]] and portfolios.[[23]] Most of the recent changes in medical education surround assessment. In fact, there
is a move toward changing the word “assessment” to “observation,” which will mainly
focus on an objective direct observation of the student and enhance the relationship
between students and teachers.[[32]] The current system uses old assessment techniques of written and oral methods and
may be hard to update without working on the other contributing factors, such as the
large number of students and medical schools, shortage of teachers, lack of technical
support, and lack of physical spaces.
Postgraduate education
It seems that the control over the postgraduate training has been lost, and we have
noticed an increase in the number of postgraduate “clinical degrees,” making it almost
impossible for our current medical environment to support them all. At present, enrolled
physicians can obtain Libyan and Arab Board certificates in addition to clinical masters
and diploma degrees. This is mainly based on passing examinations and not fulfilling
strict training requirements. We all know that the current health-care system lacks
the ability to support one full training program and having multiple different postgraduate
medical training programs are unprecedented in the modern world. Most advanced training
systems adopt one main training (or board) system, as in the UK, USA, Australia, and
Canada. These countries have more resources than Libya, yet, they have not considered
adding a second similar and parallel specialization degree. Furthermore, these countries
limited their masters and PhD programs to research without any clinical component.
The ultimate goal should be “readiness to independent practice” and not just passing
board examinations. Therefore, the focus should be on improving the quality of training
and the implementation of a strong accreditation system to ensure that. In fact, the
new international revolutionary change in postgraduate medical education is to move
the final board examination from a certification examination to an in-training assessment
that is needed to be passed before graduation and certification.[[26]]
Low research productivity
The number of publications from Libyan medical schools has always been low compared
to international numbers and has deteriorated over the years.[[14]] In addition, most publications were produced by a very small cohort of researchers,
with two-thirds of them originating from one university and being published in low
impact journals.[[14]] This decline has occurred despite the dramatic increase in the number of medical
schools and the addition of a research project as an essential requirement to obtain
the Libyan Board and master's degrees. As of 2007, medical research output in Libya
was about twenty times less than other countries with similar backgrounds.[[33]] Factors that could have contributed to the poor research activities are (i) weak
faculty promotion criteria, (ii) lack of research courses at all levels of medical
education, (iii) lack of publication requirements for both Board and master's programs,
and (vi) no clear national program that supports and promotes research.
