Medical education departments: a study of four medical schools in Sub-Saharan Africa

Interviews conducted with lead faculty from the four medical education departments
provide insight into the establishment and development, their mission as well as challenges
they faced.

Motivators for the establishment of medical education departments

The motivation to establish each of the four departments was quite different. At the
University of Zambia, the Medical Education Department was created in 2000 (making
it the oldest of the four studied) as an efficient solution to replace two complementary
teaching departments (the Medical Illustration Department and the Teaching Development
Department). The lead for the Department developed a concept paper, enlisted support
from senior medical school leadership, and then secured external funding for advanced
training in medical education. The Department was then formed and staffed with doctoral
students interested in medical education. At Stellenbosch University, the motivation
was different. The main University campus had a well-functioning teaching and learning
unit, but the medical school was located on a different campus. The growing need for
support in teaching and learning served as a catalyst for medical school faculty to
start their own department. At the University of Zimbabwe, the establishment of the
department was driven by a need to provide institutional support to ongoing curriculum
reform. In Nigeria, the University of Ibadan first established their medical education
department in 2012 to induct and train new faculty. In all cases, the director or
head was the catalyst for the departments serving as a champion for education, and
these individuals’ efforts were supported by the availability of funding and the prevailing
momentum for innovation in medical education. Interviewees described the process as
lengthy and complex, noting that establishment was often preceded by a period of negotiation
and planning.

Setting up a medical education department – leadership and staffing

The medical education departments at the four schools have different names (three
called Departments, and one called a Center), often reflecting the position of the
department in the institution 4], 15]. In all cases, a single person serves as a director or a coordinator for the departments.
All departments are positioned within a medical school and ultimately report to a
dean or head of the school. Staff numbers and appointments differ considerably across
the departments (Table 1). The more established departments have a cadre of academic and non-academic staff,
working either full or part-time. Across the institutions, the academic staff have
a variety of academic backgrounds, including PhDs in HPE or Education, experience
as clinician educators, and other educational qualifications. It is, however, important
to note that often many of the staff members have been employed with external funding.
Given the small staff complements, reporting structures are horizontal with academic
staff often being responsible for a particular role. For example, at Stellenbosch,
staff responsibilities include ‘student support,’ ‘faculty development,’ and ‘medical
education research’.

The mission and activities of medical education departments

All four schools use their departments to build capacity for their faculty in HPE,
to foster scholarship in teaching and learning, and to support the process of curriculum
review and renewal. Interviewees described the over-arching role of the department
as enhancing student learning and improving faculty skills as medical educators. As
one interviewee stated, “The mission of HPE is to promote professionalism and excellence
in health professions education”. The departments are driven by a desire to promote
social accountability (i.e. placing priority on the health needs of citizens and societies)
and introduce innovative teaching strategies such as community-based education, problem-based
learning, workplace-based learning and inter-professional education. To achieve these
aims, the departments offered a wide range of activities (Table 2).

Table 2. Summary of the activities of the four medical education departments canvassed in this
study

Challenges to establishing medical education departments

Interviewees reported that establishing a medical education department presented numerous
challenges. One of the main issues identified was establishing and maintaining the
legitimacy of the department within faculty and university leadership. As a discipline,
medical education was reported to be philosophically different from other medical
school disciplines. While most medical disciplines draw on a biomedical science model
and predominantly engage with research in a positivist paradigm, education draws its
philosophical roots from psychology and sociology. Medical education, therefore, requires
working across disciplines both within and outside health. One respondent, in describing
this tension and also emphasized the importance of engaging in activities such as
international collaboration to enhance faculty and leadership perceptions of the department:

The biggest challenge was that at inception the concept of medical education was new
to most members of staff who had a good 20–25 years [experience] and had not heard
about the medical education services the department is providing. As a result, [there
was] suspicion and resistance and uncertainty to where it was going but with more
exposure to international communities and training in other universities, the acceptance
uptake has been very high because they have seen that this is happening elsewhere.

In addition to establishing the credibility of the department, interviewees described
a number of other challenges in running their departments including transient funding
sources, the need to manage faculty expectations, and setting realistic goals while
working towards an ambitious vision. Funding streams tend to be grant-based rather
than institutional, placing the sustainability of the department at risk. Funding
was required for physical infrastructure (such as office space, equipment, and telephones)
as well as personnel. Department staff members are often appointed with ‘soft’ funding
from grants and other outside sources. Despite the challenges of working with grant
funding, there was acknowledgement of the value of external funding as it stimulated
interest, activity, and support for the department both from within and outside of
the institution. In this regard, the impact of MEPI was specifically noted as essential
to the establishment and maintenance of the departments, especially at Ibadan and
Zimbabwe. Some departments were able to expand their activities through MEPI funding,
particularly in the areas of e-learning and medical education research. One interviewee
described how the MEPI goals shaped the development of the medical education department:

We are going to work with the MEPI group so that we develop the department in line
with the demands of MEPI which are: capacity-building, improving quality of medical
education, retention and introduction of new methods of applying knowledge.

Key enablers in establishing a medical education department

The challenges of establishing and maintaining medical education departments were
mitigated through various strategies including engaging leadership and building key
relationships (Table 3). The University of Zambia interviewee indicated that support from management was
important because it facilitated “[jumping] through the different [bureaucratic] hoops”.
Engaging faculty from different disciplines and from different departments was also
seen as an enabler and critical to earning the sort of credibility that was described
earlier. The interviewee from Stellenbosch reported that, because the work and research
of the Center crossed disciplinary boundaries, the department had high visibility
within the school. At the University of Zambia, the staff members from the medical
education department collaborate with the library to support faculty in transferring
lecture material to the e-learning platform. Exposing faculty to the discourse of
medical education globally was seen as crucial to informing the work of the department
and raising the standards of teaching and learning, specifically with regard to curriculum
reform. Adequate funding for the department was also critically linked to recruiting
and retaining academic staff members who can provide leadership for teaching faculty.
Having a qualification in HPE or exposure to other advanced training in education
was seen as necessary for both the leads and the staff of a medical education department.
One interviewee explained, “I think it is an advantage, definitely an advantage to
have someone with preferably a formal qualification in teaching”.

Table 3. Challenges and perceived enabling factors as reported by the four medical education
departments in this study

Measures of success

Interviewees pointed to a number of measures of success. Departments at the Universities
of Stellenbosch, Ibadan, and Zimbabwe have evolved to become recognized academic departments
and thus established entities in their institutions. Other successes include the growth
in HPE postgraduate offerings, increased graduates from HPE programs, increased numbers
of grants secured that can support the work in medical education departments, and
the provision of support to other institutions on matters relating to medical education
activities. Building up capacity to offer postgraduate degrees in HPE was cited as
an important indicator of success.

The interviewee from the University of Zambia further explained the impact of the
medical education department in terms of its potential to act as a change agent:

With regard to education innovation, we know that [medical education department] has
been a prime player. For instance, the adoption of changing examination systems from
the traditional long case and short case for our clinical courses was championed by
the [department], for introduction of more objective and more varied assessment methods,
including the objective strategy for clinical medical education. The drive to try
and get the school do a self-evaluation against the World Federation of Medical Education
standards was driven by [medical education department staff]. Also, the initiative
to do a comprehensive curriculum review in the School of Medicine to begin to bring
awareness of innovative educational methods and to change the curriculum from a totally
traditional curriculum to start moving towards some innovative strategies was driven
by [departmental staff]. So with regard to being a change agent, I think [medical
education departments] plays a very key role.

The future and sustainability of medical education departments

All interviewees had clear objectives for the future of their departments and reported
seeing medical education as an area destined for expansion and increasing legitimacy.
One interviewee at the University of Zambia viewed the work being done currently as
a “pipeline issue” that would bear fruit in years to come. Developing and maintaining
a medical education research agenda was a priority for all interviewees. Having a
research output was considered critical to maintaining the credibility and significance
of the department as well as achieving international visibility. The interviewee from
Stellenbosch University felt it was important for the department to have a well-defined
research focus and to identify faculty who would conduct research in this area. Collaboration
around capacity-building initiatives, conferences, and more medical education journals
for Sub-Saharan Africa, were also seen as desirable goals.

All interviewees articulated a need for developing future staff, particularly staff
focused on medical education scholarship (e.g. PhD and Masters graduates). They also
planned to continue capacity-building by offering workshops to provide advanced training
in innovative teaching methods as well as mentoring for faculty members interested
to pursue careers in medical education. The interviewee from the University of Ibadan
reported plans to advocate for recognition of teaching excellence as a criterion for
promotion, while the interviewee from Zimbabwe shared the hope of establishing a College
of Health Professions Education to provide comprehensive postgraduate training. Finally,
interviewees intended to ensure legitimacy of their respective departments by conducting
rigorous evaluation of their activities.