Fasa University Medical School: a novel experience in medical education

In early 1970`s A combination of a shortage andmisdistribution of health services and growingpublic dissatisfaction about the health care available,along with increasing expectations, has put greatstrain on the mind of the staff of the Department ofMedicine Shiraz University School of Medicine, themedical school was known as a center of excellence forphysician training. The school also got its reputationfor its well-trained faculty, a fulltime system. Englishwas the media of instruction and facilities were up todate. The Government of Iran, relatively prosperouswith the sudden increase of oil price embarked onmassive importation of foreign doctors, which didnot, eased the aforementioned problem (1, 2).The Fasa Medical School was conceived, to addresshealth needs of majority of population residingin rural and small communities, by training bothmedical doctor and other health personnel, based onthe philosophy of community orientation, problembasedlearning and student-based curriculum,combined with innovations in staff and studentselection and training (3).The purpose of this report is to give an account ofwhat was originally planned and what has happenedsince the start of Fasa Medical School in April 1978.The health manpower situation in Iran in early 70sIn late 1960’s and early 70’s, Iran’s population wasapproximately 34 million and total numbers ofphysicians were about 14,000 a ratio of 0.41 physiciansper 1000 population (4). At the time, two majorproblems were facing our country. The first was grossmal-distribution of these healthcare facilities, whichwere mostly concentrated in Tehran and big citiesof Iran (1), and the second problem was continuousexodus of Iranian Medical graduates to the Westerncountries (5, 6).The study that was done in 1974 indicated apermanent loss of 1624 Iranian Medical Graduates(IMG) to the United States alone 5-6. Since over %60of Iranian population were residing in about 50,000small villages of 100-1000 population it was suggestedthat physician coverage to these scattered populationwould be close to impossible. Shiraz UniversityMedical School embarked and implemented thisprogram to cover health and sanitary measure ofrural population with astonishing results (1).The idea of Village Health Worker (VHW) wasbased on bare foot doctors of China, and for the firsttime was implemented in non- socialized marketEconomy Country (2). The name of VHW was“Behdar Roustaee,” and within 5 years, providedhealth coverage of approximately 1.5 Million of ruralpopulation of Southern Iran. Similar program waslater initiated in West Azerbaijan under Auspices ofTehran University School of Public Health and WHO(7, 8). In Lorestan and Tehran also similar programswere implemented.Main feature of Fasa Medical School programThe main idea of creating Fasa Medical School wasto create a system in which primary care in smallvillages are provided by VHW with the middle levelhealth workers of “Behdar Roustaee” to be supportedby local physicians who reside in small towns. Thelast step would be connecting the whole network totertiary care system.1. RecruitsHigh school graduate with minimum C average fromsmall towns of Fars province could apply. Severalfaculty members selecting those who would be mostsuitable for this program would interview applicants.During that same period, other medical schools inIran selected high school graduate from test results ofa national examination. This usually meant the top10% of entire nation were recruited.2. FacultyThere were 2 groups of faculty. One was the Shirazfaculty, who designed the program and wrote thecase studies. The other was local faculty including 4who were residents in community medicine and alsoreceived intensive medical education training. These4 were the preceptors for the case studies, hospitalpatients and village programs. There were alsophysicians in the hospital, which would review anddiscuss patients.3. FacilitiesA-Library- included 1500 books, mostly EnglishTexts along with subscription to 10 top InternationalMedical Journal. One US graduated informationscience, graduate of Brat Institute of N. Y., and 2librarians to manage the medical library.B-Labs-30 Microscope with bacteriology facilitiesand equipment along with some pathology labfacilities with part time pathology resident fromShiraz were utilized in Fasa program.C-Classroom-A general conference room withcapacity of 150 along with 15 different classes,equipped with projector and other audiovisualfacilities were provided.D- Audiovisual aids- Fasa was equipped with stateof art recording facilities and indeed with very closeco-operation with the Department. of Medicine andCommunity Medicine different professors discussedcurrent cases, which was presented to student andwere shown in group discussion.E- Hospital- A 50 bed red lion and sun (Equivalentto Red cross)- Hospital was already in operation andFasa got the privilege to have student practice therelater a 500 bed hospital was made adjust-to MedicalSchool, which considered University hospital.4. Curriculum:The first 3 years out of 6, were planned and included3 tracts:The first tract was case studies, one per weeks thatwere designed in a 3-year period to cover all majorproblems. Students were divided in groups of 4 or 5.They were given the patient case and had a preceptorthey had one week to study, discuss, look up and beready to discuss at the end of one week with theirother classmates, who had the same case. These patientstudies were designed in such a way as to permitdiscussion of basic science and pathophysiology ofdisease. The case studies started simple and becamemore complex. But always the emphasis was onproblem solving and self-learning.The second tract was clinical work in the hospital.Again in groups of 4 to 5, they were given a patient.Initially they took history and similar to the casestudies studied and discussed the patient withpreceptor. Gradually, physical exam was added.The third tract was “village health”. Each4- 5 studentswere given a village and simply told that in 3 years,we expected improvement of that village’s health.Defining and solving the problem was left to thestudents… again, they had preceptors and discussionperiods.Two classes of students, each with 18 studentswere selected prior to the Revolution and CulturalRevolution. Of the 36 students admitted to 2 classes 26were transferred to Shiraz University and graduatedwith Shiraz classmates. (The remaining 10 were eitherexpelled or dropped from the from the program)All 26 graduates from this program are presently(August 2013) practicing in Iran and 69% of them inFars province. Unfortunately the curriculum of Fasawas not continued but the concept of local schoolsin smaller cities has been established with a largerphysician output.ConclusionFasa School of Medicine was established to meet theneeds of the underserved and smaller communities,for Shiraz University it emphasized the importanceof relevance of medical education. For Fasa MedicalSchool, education was emphasized on communitybased, student centered, and problem based medicaleducation located in the community and based onteamwork and cooperation. Though its program wasinterrupted, it did show that medical students don’thave to be selected from the top grades and basicscience taught in the classic method is not essential.