Use of epidemiological data as the basis for developing a medical curriculum

ABSTRACT CONTEXT AND OBJECTIVE: Epidemiology may help educators to face the challenge of establishing content guidelines for the curricula in medical schools. The aim was to develop learning objectives for a medical curriculum from an epidemiology database. DESIGN AND SETTING: Descriptive study assessing morbidity and mortality data, conducted in a private university in São Paulo. METHODS: An epidemiology database was used, with mortality and morbidity recorded as summaries of deaths and the World Health Organization’s Disability-Adjusted Life Year (DALY). The scoring took into consideration probabilities for mortality and morbidity. RESULTS: The scoring presented a classification of health conditions to be used by a curriculum design committee, taking into consideration its highest and lowest quartiles, which corresponded respectively to the highest and lowest impact on morbidity and mortality. Data from three countries were used for international comparison and showed distinct results. The resulting scores indicated topics to be developed through educational taxonomy. CONCLUSION: The frequencies of the health conditions and their statistical treatment made it possible to identify topics that should be fully developed within medical education. The classification also suggested limits between topics that should be developed in depth, including knowledge and development of skills and attitudes, regarding topics that can be concisely presented at the level of knowledge.


INTRODUCTION
Recent reports have identified overall challenges and the need for innovations in the structure and process of medical education at all levels.These documents suggest that doctors need to be prepared for a more demanding society, and be ready to cope with the explosion of scientific knowledge and technology.][3][4] It is interesting to note that active learning principles would need to be considered as early as possible during medical school in order to provide the benefits of teamwork in areas like primary care. 5Nonetheless, a systematic review has suggested that active learning, like the problem-based learning approach, does not have an impact on knowledge acquisition in undergraduate medical education, even though appropriate outcome measurements need to be considered. 6A generalist education that could provide skills, knowledge and attitudes that make it possible to understand patients' expectations, address wellness rather than illness alone, assimilate concepts of clinical epidemiology, develop interpersonal communication and strive to control costs would require shifts in attitude and behavior throughout the academic medical community. 7 Brazil, despite the large number of medical schools, just a few adopt active learning principles, and yet some reports also suggest that the traditional curriculum leaves students poorly educated about the underlying principles of the national health system. 8,9neral medical education guidelines usually have clear statements about content and skills, but there are no priorities defining central themes.The core curriculum with special study modules was considered to be a reliable response to content overload, but there is still no suggestion about how to choose a central theme. 10

OBJECTIVE
The aim of this paper was to present a methodological proposal that could help curriculum managers to address this challenge, taking local and regional morbidity and mortality into consideration.We constructed an epidemiological score that can be used by specialists to develop learning objectives or even international requirements. 11

Data relating to mortality (OBT) and morbidity (MRB) were
taken respectively from summaries of deaths and the Disability-Adjusted Life Year (DALY) measurement of the World Health Organization (WHO) for the year of 2004. 12These data were chosen to present an international perspective for educational taxonomy directed by mathematical treatment.
The reported numbers of registered deaths and diseases were distributed into columns and rows according to the list provided in the WHO database.No ages or genders were identified.The probabilities were reached by means of R syntax, to reach a cumulative distribution function (CDF) for any value x.R is a language and an environment for statistical computing and graphics that is available as free software under the terms of the Free Software Foundation's GNU General Public License, in source code form (http://www.r-project.org/).
The final score took into account the square root for the product of morbidity P(MRB) and mortality P(OBT) probabilities.Briefly, the frequencies were tested using the Shapiro-Wilk normality test or after Log10 transformation for both morbidity and mortality.Then, the Z numbers for both morbidity Z(MRB) and mortality Z(OBT) were obtained in order to use the definite integral, from which the results are the probability for each of the diseases from the WHO DALY and death summary lists (see Appendix for equations).In order to obtain a normal distribution, it is advisable to use a large database.
The 75 th percentile (quartile) from the score was used to indicate the subjects to be considered for educational taxonomy.

RESULTS
Three countries were selected for comparison: United Kingdom (UK), Brazil (BR) and Rwanda (RW).They were representative of higher to lower-accuracy database registering, according to the WHO DALY methodology.There were 71 conditions for UK, 82 for Brazil and 87 for Rwanda that reached a score higher than zero (Table 1).
The score allowed separation of the results into quartiles.
The highest quartile showed 24 health conditions for the UK, 27 for Brazil and 26 for Rwanda.Among the highest 10 health conditions for the UK, five also appeared in the Brazilian list but only one for Rwanda.On the other hand, among the 10 Brazilian health conditions, three were present in the Rwandan list (Table 2).

DISCUSSION
This investigation used statistical data on morbidity and mortality collected by official government agencies to list and rank themes to be adopted by an undergraduate curriculum.This framework was proposed in order to manage educational taxonomic levels such as knowledge, skills and attitudes, for those in the highest quartile as well as to ensure knowledge for those in the lowest quartile.
An undergraduate curriculum should be based on and related to the needs of learners and society. 13However, it is not an easy task to define what a need is.Needs have a social origin and they may correspond to habits that are gradually created and also legitimized by references to ideals. 14Careful analysis could point out and identify needs for individuals, groups, institutions and societies.This investigation used statistical frequencies of registered health conditions as a way to identify conditions that might constitute such needs in medical education.
The taxonomy of objectives in education is a framework used to classify statements of what students are expected to learn.The domains of learning are considered to be related to cognitive, affective/attitude and psychomotor/skills.The revised Bloom taxonomy presents six major categories that differ in their complexity,  such that the basic level "remember" is considered to be less complex than "understand".From this point on, higher levels are supposed to be reached: apply, analyze, evaluate and create. 15Many educators have proposed that the educational process should proceed from the lowest levels to the highest levels, and also that the main goal should be the highest levels.Although the taxonomy does not propose any priority regarding the three domains (cognition, skills and attitudes), it is useful for developing educational objectives.However, one difficulty educators may have is making decisions to identify objectives between adjacent categories.Educators ought to carefully reflect on their objectives.In this regard, the taxonomies are valuable tools for defining such objectives. 16 the medical educational field, there are curriculum proposals spanning from single themes to entire competencies. 10,17,18ch discussions have also been reviewed from the point of view of whether to consider that healthcare providers should have an expanded role relating to entire communities or whether the tradition of one patient's doctor should be maintained, with regard to arranging educational priorities. 19However, discussion addressing the priorities for the composition of knowledge topics and skills in studying health-related issues seems to be new.
The method proposed in this study identified health conditions that could be used for construction of a medical curriculum, no matter what approach is chosen, i.e. involving either medical care providers or individual doctors, as well as in relation to any instructional design.These results established the morbidity and mortality data as reasonable sources of information for defining curriculum priorities.
Ranking of diseases according to their locally defined morbidity and mortality may suggest that some topics could be classified as presenting lower complexity in the educational taxonomy.However, this action does not eliminate the theme; rather, it instructs the learner that such knowledge could be worth remembering rather than studied up to the creative level, as would be the case for designing research proposals (higher educational taxonomic level).A recent survey of some medical schools in the United States found out that the curricula were compressed, with a large quantity of subjects, and there was no emphasis on any core competencies. 20The present method developed here could direct the efforts of medical educators towards how to prioritize such subjects, since there would be information to feed their reflections on the objectives.

An initiative in the United States, Undergraduate Medical
Education for the 21 st Century (UME-21), has sponsored curricular changes focusing on core primary care clinical clerkships and outpatient settings, with an emphasis on learning objectives and competencies that would supposedly be at the center of the future healthcare system. 21However, the content was not taken into consideration.On the other hand, a recent study describing the process used for curriculum development stated that the disciplines chosen to run through the course were retrieved from associations of medical specialists. 22The results presented in this work give prominence to an epidemiological database, ensure that educational expertise from medical societies remains relevant and have the capacity to reveal the reality of local conditions.
This study has some limitations.The score was constructed using a database made available from a WHO inventory (DALY), taken from compulsory notification of diseases.Given that the data originated from government officials and agencies, some diseases with high incidence that would be considered to be public health priorities, but with low lethality and low hospital admission rates, would not be totally represented by the proposed score if they were not in the morbidity database.Proper measurement would rely more on systematic sources derived from outpatient and primary care services.Such reports would capture the spontaneous needs for healthcare, in order to constitute the proposed score.The National Ambulatory Medical Care Surveys (NAMCS) and National Hospital Ambulatory Medical Care Surveys (NHAMCS) produce annual estimates of outpatient care in the United States that show these primary diagnoses. 23The issue of why it would not simply be better to use prevalence to choose which diseases should be taught in undergraduate medical courses would imply accepting unreal equivalence between morbidity and mortality data.This proposed method respects both types of data, but does not emphasize either of them and allows the related database to point out their relative importance in time.

CONCLUSIONS
In conclusion, the registered health conditions, their statistical treatment and careful analysis made it possible to identify themes that may constitute needs in medical education that have to be mastered.They also suggested that there are limits between topics that should be considered in depth at higher levels of knowledge, skills and attitudes, among those that should be worked on at lower levels of taxonomic educational complexity.

Table 1 .
List of conditions and scores derived from World Health Organization Disability-Adjusted Life Year (WHO DALY) database.Scores are divided by10 5 *Lower limit of highest quartile for the country's score

Table 2 .
List of 10 highest scores derived from World Health Organization Disability-Adjusted Life Year (WHO DALY) database Underline: conditions present in both Brazil and Rwanda.Italics: conditions present in UK, Brazil and Rwanda.