Medical education in Jordan

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ISSN: 0142-159X (Print) 1466-187X (Online) Journal homepage: http://www.tandfonline.com/loi/imte20

Medical education in Jordan Ahmad Faleh Tamimi & Faleh Tamimi To cite this article: Ahmad Faleh Tamimi & Faleh Tamimi (2010) Medical education in Jordan, Medical Teacher, 32:1, 36-40 To link to this article: http://dx.doi.org/10.3109/01421590903196953

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Date: 10 October 2015, At: 21:55

2010; 32: 36–40

AROUND THE WORLD

Medical education in Jordan AHMAD FALEH TAMIMI1 & FALEH TAMIMI2 1

Jordan University, Jordan, 2McGill University, Canada

Abstract

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Jordan is an Arabic, Middle Eastern country that has recently experienced great development in healthcare and education. This development has happened in a short space of time, in a system suffering from limited infrastructure, insufficient faculty and limited research opportunity. The aim of this article is to give an overview on the history of Jordanian medical education and its current status. In this article, we discuss the infrastructures, admission system, curricula and academia of Jordanian medical schools, as well as recommending some ways forward.

Introduction

Practice points

Jordan is an Arabic, Middle Eastern country with a population of 6 million that gained its full independence from Britain in 1946. Jordan’s first university was built in the capital, Amman in 1962, under the name of ‘The Jordanian University’ ( JU). Today, there are 25 universities in the country (12 public and 13 private) (Department of Statistics of the Hashemite Kingdom of Jordan 2005). Undergraduate medical education in Jordan started in 1972 with the establishment of the first medical school in JU. The increasing demand for undergraduate medical studies created a motivation for additional medical schools, and a second medical school was established in Al-Yarmouk University at the northern city of Irbid in 1984; the university then branched out into Jordan University of Science and Technology ( JUST) in 1986. A third medical school was founded in 2001 in Mutah University (MU), situated in the southern city of Karak. Finally, in 2006, a fourth medical school was established in the central region of the country at Zarka city within the Hashemite University (HU) (Table 1). All of the medical schools, to date, have been established in public universities; there are no existing private medical schools. Graduates from Jordanian medical schools currently play an important role in the development of the country’s healthcare system. Moreover, the Jordanian medical education system is one of the most highly regarded in the Middle East and therefore many students from the region come to Jordan to study medicine. However, due to the economic situation often found in developing countries, for many years academic salaries were low, and the universities struggled in recruiting and maintaining their teaching staff. A series of measures were carried out in 1997 in order to improve the financial situation of the faculties, but this only led to an overloading of the faculties with an overwhelming numbers of students.

. Jordanian medical schools have witnessed a significant increase in the number of students during recent years. . There has not been a concomitant increase in the number of appropriately trained faculty to effectively teach these students. . Postgraduate research programmes need to be established in all the medical schools in order to provide the universities with the needed medical teaching staff. . There has been no development of national or institutional guidelines to increase the quantity and quality of the research carried out in Jordanian medical schools. . Continuing medical education programmes are poorly organised and often without purpose and relationship with continuing professional development.

Undergraduate medical education Admission to medical school As in most Arab countries, the sole admission criterion in Jordanian medical schools is the achievement of a satisfactory mark in the national exam for high school students, the ‘Tawjihi’. This form of admission system is supported by the majority of the society, who sees in it a mean of guaranteeing equal chances of accessing medical education for all. Medical schools’ admissions are further regulated by two different systems: (1) (2)

the general competition (applied in 1972); the parallel system (in operation since 1997).

Students with the highest marks in the national high school exams gain admission through the general competition system. The extremely low percentage of accepted applications, only 6%, is indicative of the high level of competition in

Correspondence: Ahmad Faleh Tamimi, Medical School, Jordan University, PO Box 13349, 11942 Amman, Jordan. Tel: 962 79 5548580; fax: þ962 6 5353388; email: [email protected]

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ISSN 0142–159X print/ISSN 1466–187X online/10/010036–5 ß 2010 Informa Healthcare Ltd. DOI: 10.3109/01421590903196953

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Medical education in Jordan

order to gain access to the medical schools. Students admitted through this general competition pathway are rewarded with partially subsidised, inexpensive tuition fees. Currently, 52% of students’ admissions are in this category (Table 2). Non-resident foreigners and Jordanian students with lower high school marks can still gain access to medical education by paying more expensive international tuition fees (the parallel system). The minimum requirement for these students is a high school mark of at least 85%. The parallel admission system was established as an answer to the increasingly poor financial situation within the medical schools. However, this step has led to a rapid increase in the number of students, which stretch the schools’ infrastructures and academia to their limits. Most of the medical schools in Europe give admission to less than 200 students per year (53.4%) (Patricio 1999), while in the USA the average number of admissions per school is of 132 in public universities and 127 in private ones (Barzansky & Etzel 2005). In Jordan, three out of the four medical schools give admission to less than 200 students per year; these numbers resemble those of some universities in industrialised countries. During the academic year of 2006–2007, there were 4095 medical students registered in all Jordanian medical schools, many of them from foreign countries of 29 different nationalities, all of which credit Jordanian medical education within their own country. The number of female students (35.1%) is slightly lower than in most Western countries.

The curricula The 6-year medical education programme in Jordanian universities is divided into an initial 3-year pre-clinical stage followed by a period of clinical training lasting a further 3 years. All of the medical schools in the country have adopted semi-integrated curricula, which involve integrated Table 1. Jordan universities and medical schools. Name of the institution JU JUST MU HU

Year of institution establishment

Year of medical school establishment

1962 1986 1981 1995

1972 1984a 2001 2006

Note: aMedical school started at Yarmouk University in 1984 and transferred to JUST in 1986.

(contextual) teaching during the pre-clinical stage and traditional teaching during the clinical stage. Even though the overall curricula of Jordanian medical schools are similar to those in European universities (Dusek & Bates 2003), there are modifications and differences between the four schools rendering it difficult for students to change faculty during their studies.

The pre-clinical stage The courses at this stage are divided into basic sciences, basic medical sciences and university requirement courses (free choice credits lectured in non-medical departments). The integrated system pre-clinical phase requires that the students are assessed at the end of each course by a series of multiple choice examinations. This integrated system has only been operational for the last 8 years, and its success has only been partially assessed, (Bani-Hani et al. 2003), and needs to be subject of a more thorough and comprehensive evaluation in the future. Accordingly, the Jordanian Ministry of Higher Education has established a National Committee for standards and accreditation to carry out this quality assessment.

The clinical stage Clerkship rotations start at the beginning of the fourth academic year and continue throughout the final 3 years. During this stage, rotations take place in different clinical units, with mandatory rotations in certain departments. The length of these rotations ranges between 2 and 12 weeks. During these rotations, students work under the supervision of a senior physician, and are responsible for interviewing and examining patients at admission, and following them during hospitalisation. Students are expected to learn the techniques of history taking and physical examination. At the end of each rotation, they are assessed by the supervisors, taking into account both behavioural criteria (attendance and relationship with staff and patient) and the quality of their clinical work. In all Jordanian medical schools, assessments at this stage consist of multiple choice questions (MCQ), patient management problems and oral examination. Three years ago, in addition to the other forms of assessment, objective structured clinical examinations (OSCEs) were introduced at JU. At the end of the 6th year, students are assessed by a comprehensive theoretical assessment of mainly written examinations, and a clinical assessment conducted by

Table 2. Medical students’ data for the academic year 2006/2007. New applications

Students registered in Jordanian medical schools Citizenship

Total number 9195

Gender

Registration system

Accepted application (competitive system)

Jordanian

Non-Jordanian

Male

Female

Competitive

Parallel

Total number

6.0%

65.0%

35.0%

64.9%

35.1%

48.6%

51.4%

4095

Source: Department of Statistics of the Hashemite Kingdom of Jordan 2005.

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A. F. Tamimi & F. Tamimi

committees composed of faculty teaching staff, national external examiners from different Jordanian medical schools, and external examiners from Arab and western universities. The National Bachelor’s degree in Medicine and Surgery is awarded to the students who pass both assessments. This degree is equivalent to those awarded by schools in both US and UK medical schools. The credibility of the Jordanian medical degrees is confirmed by the success rate of its graduates in the United States medical licensure examination (USMLE) for specialty access to the USA (Unpublished data provided by the FAIMER, 2007). Between 2002 and 2006, 92.52% of the Jordanian graduates presenting to the USMLE step 1 (basic medical sciences) passed the exam on their first attempt and 93.62% the step 2 (clinical sciences). However, one of the problems with the present training system is the lack of research opportunity; research oriented learning and self-directed learning, which has a strong negative effect on continuing professional development.

rendering research a rather weak point. This is a serious problem for the sustainability of the medical education system and healthcare in general; a problem that needs urgent remediation. This could, in part, be rectified by increased cooperation and collaboration with international institutions.

Continuing medical education Several national and regional medical associations organise meetings on a regular basis within Jordan. However, the reliance upon pharmaceutical companies to arrange and support these means that many are of a promotional nature; the events being scientifically weak and often biased. The continuing medical education programmes at national institutions are scarce and poorly organised, with little objective in mind. As a result, continuing medical education can be seen as poor and unstructured in Jordan.

Teaching faculty Postgraduate medical education Postgraduate medical education in Jordan is orientated towards the attainment of specialty degrees in all the major clinical specialties and follows a similar system to those in Europe and North America. The quality of these degrees is well recognised, both in the region and internationally, which has a subsequent negative effect of the retention of trained staff within Jordan. Initially, only partial training programmes (2–3 years only) were established in 1968 at the Royal Medical Service (Military Health Care System) and some hospitals of the Ministry of Health. This resulted in residents having to be sent abroad to complete their training and obtain their specialty degree from other countries. In 1982, the Jordan Medical Council ( JMC) was created to control the practice of medical specialties in the country, and the first complete residency programme was established at the University Hospital of JU. This was followed by new programmes at hospitals of the Ministry of Health, the Royal Medical Services, JUST University Hospital, and more recently, in some private hospitals. Access to postgraduate medical and surgical training programmes is through an entrance examination, performed at specific training centres, accredited by the JMC. The training duration varies among the specialties, ranging between 3–6 years, and the trainees are evaluated on a yearly basis. In order to qualify as specialists, the trainees must pass the JMC competency assessment at the end of the programme. This assessment is supervised by a select committee of senior qualified specialists and is divided in two parts: (i) an MCQ on basic medical and clinical sciences related to the specialty; (ii) a final comprehensive assessment that includes a speciality-specific MCQ, an oral assessment and a clinical examination. After passing these final exams, the residents are qualified to practice as specialists throughout the country. Specialists trained in other countries have to pass these exams as well in order to be eligible to practice in Jordan. At the present time, postgraduate research education, such as a PhD programme, is absent in Jordanian medical schools 38

Due to the increasing number of students, the staff/student ratio is rapidly decreasing and is already very low compared to other countries (Tables 3 and 4), and at the present time are considered to be below a critical mass level for effective teaching and learning. A reduction in the number of medical students would have a negative effect on the country’s health in the future; in a system that is already suffering from a limited number of physicians per capita. This could be rectified by the training institutions of the country modifying their financial and institutional system to allow the recruitment of additional academic members. There are currently 557 academic members in the country distributed in the medical schools and teaching healthcare centres (Table 3). Unlike North America and European schools, the teaching load in Jordan medical schools lays on full time academia; the number of part time teaching staff is very low (Patricio 1999; Barzansky & Etzel 2005). To assure the quality of the programmes, a PhD degree is mandatory for any academic position in basic medical sciences, whilst clinical teachers are required to have a degree within their clinical specialty and at least 2 years of postgraduate training in a well-recognised foreign medical institution. Research or academic backgrounds are not mandatory for the recruitment of clinical teaching members at the moment. Once appointed, the academic members are enrolled in the activities of the University Centre for Staff Table 3. Teaching staff distribution in Jordanian medical schools.

Teaching staff Full time Full professors Associate professors Assistant professors Honorific professors Lecturers Total number: 308 Total number: 557

Part time 77 74 143 7 7 Total number: 249

Clinical professor Clinical trainers

4 245

Full time/Part time: 1.23 Student/Teacher: 7.35

Medical education in Jordan

Table 4. Comparison of the Jordanian medical teaching institutions, with those of other industrialised countries.

Country Jordan France Japan United States Spain

Accepted applications (%)

Female students (%)

First year students

Student/ teacher

Hospital bed/ Clinical student

Population (millions)

Number of medical schools

Physician per capita/10,000

6.0 8.7 10.0 49.4 47.6

35.27 61 32.8 47.9 75.0

552 1292 7742 17,118 4471

6.9 NA NA 0.84 3.02

4.88 NA NA NA 4.49

5.7 58.1 127.9 302.8 43.9

4 45 79 141 27

24.0 34.0 21.0 26.0 33.0

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Source: Segouin et al. 2007; Kozu 2006; Barzansky & Etzel 2005; Bombi 2005; complemented with data from WHO annual report 2007.

Development in order to develop their teaching skills. Each year, this centre organises a special course on teaching and communication skills for medical school faculty. A major problem with finding adequate numbers of effective teaching staff is the lack of academic postgraduate education in Jordan. Currently, there is not a single PhD programme in any of the Jordanian medical schools, and graduate students have to be sent abroad to continue their academic development. This carries a great financial cost to the local institutions and limits the number of available teaching staff. Moreover, the income of the pre-clinical academic members is low compared to many neighbouring and industrialised countries, leading to the newly formed professors leaving Jordan for better posts in abroad. Most of the clinical teaching staff is obliged to work exclusively in university hospitals, preventing them from any, more profitable, private practice. Consequently, many clinical professors leave the universities for better ones in the Jordanian private health sector. PhD and master programmes should be established in Jordanian medical schools in order to increase the number of students with academic postgraduate education, needed to run the pre-clinical teaching stages. The number of clinical academic members could be improved by allowing the recruitment of more part time professors coming from the private health system.

Teaching methodology In all of the four medical schools, courses are given through traditional lectures, together with small group student-centred discussions. In addition, the students are taught and encouraged to be self-directed learners using the available learning resources, which are mainly libraries. More recently, there has been an increased use of e-learning and teleconferencing for very limited topics at JU, JUST and MU.

Healthcare facilities Jordanian hospitals have a total number of 10,141 beds (Statistical yearbook of Jordan, 2005), 6136 of which are available for medical schools’ teaching purposes. However, the number of teaching beds varies dramatically between schools (between 300 and 3451). The ratio of teaching beds per clinical student varies between schools, leaving some schools with a ratio as low as 1.9 while others enjoy a ratio of 8.6. However, the average ratio is an acceptable 3.88, similar to

many industrialised countries (Table 4), which indicates the great achievement of the relatively young Jordanian health system in providing the infrastructures needed for training these new physicians.

Challenges for the future The total number of physicians affiliated to the Jordanian Medical Association ( JMA) is quite high (12,050). However, due to the well-recognised qualification of Jordanian medical graduates many have been hired outside the country ( Jordan Medical Association 2006). Currently 4059 of these physicians work abroad (34%), and therefore there are only 7991 medical doctors working in Jordan at the moment. This means that the real ratio of physicians per capita/10,000 is a dramatic 12.9, instead of the 24.0 reported by the World Health Organization (2008). This value is extremely low, and therefore the Jordanian institutions are in great need for new physicians. Despite the relative success of their education system, Jordanian medical schools still need to change to provide the society with the needed healthcare professionals. In order to maintain and improve the quality of the programmes, special attention should be paid to staff recruitment and programmes in appropriate staff development, together with the necessary academic and financial support.

Conclusions Undergraduate medical education in Jordanian universities is very similar to that found in programmes established in many other countries. However, there are many weak points in the programmes and their organisation that need to be addressed: . The admission system must be updated, to take into consideration the students’ biomedical and personal skills rather than depending solely on the secondary education marks. . The curricula should be revised and evaluated at a national level in order to improve the quality of the programmes. . Medical and research ethics need to be addressed more thoroughly in the different programmes. . E-learning needs to be increased and utilised in students’ assessment. . The low number medical teaching staff must be a reflection of the needs of the medical schools and accompanied by a positive drive in recruitment.

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A. F. Tamimi & F. Tamimi

. Establish national and institutional guidelines to increase the quantity and quality of the research carried out in the Jordanian medical schools. . New medical schools should be established to address the increased need of doctors, especially general practitioners. . PhD and postgraduate research programmes must be implemented in the medical schools in order to provide the institutions with the necessary, qualified academic staff.

Acknowledgements

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The author would like to thank the Deans of the following medical schools in Jordan for their help and support in this study: M. Mhelan (University of Jordan), A. Hader ( Jordan University of Science and Technology), M. Rawashdeh (Hashemite University) and Assistant Dean M. Ahram (Mutah University). This work was sponsored by a sabbatical grant from Jordan University (A. F. Tamimi) and FECYT (F. Tamimi). Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.

Notes on contributors A.F. TAMIMI, MD, PhD, carried out the gathering of institutional information and participated in writing the manuscript.

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F. TAMIMI, DDS, PhD, carried out the bibliography review and participated in writing the manuscript.

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