THE NEED FOR INNOVATIVE CURRICULUM IN IRAQI MEDICAL AND NURSING COLLEGES (REALITY AND ASPIRATION)

	Dr. Thamer Kadum Yousif Al Hilfy MBChB/DCM/FICMS/MsC MHPE/Medical Education Master Degree. Head of community and familly medicine deaprtment Assistant Professor / Alkindy College Of Medicine/Baghdad Director of Health for all center(NGO) Consultant in medical education/Director of CME unit
	Home Phone: 7721963 Mobile: 07901734108 E-mail: thamer_center2005@yahoo.com

INTRODUCTION AND CURRICULUM OUTLINE

Despite the fact that the curriculum is the heart of the educational process, yet, to find the answer to the question: What is a curriculum? might require hours and days of literature search without getting a definite answer or a universal agreement. As stated by Posner (2004), this is something inherent in the field of curriculum, and something inescapable about education. Although Posner added that we have to deal with the lack of absolute certainty in a field like education, and to accept the fact that the experts in our field are in fundamental disagreement, he suggested choosing the option of reflective eclecticism.

If we follow this reasonable suggestion, then, the most reasonable definition of curriculum among the seven famous alternatives is; The Planned Experience, which in a broad sense means that the curriculum comprises the totality of the learning experiences planned by the schools for the students to pass through during a given period of time. It includes a written document that describes the intended learning outcomes, the content, instructional strategies to achieve these outcomes, the ways the students will be assessed and the system of the evaluation of the curriculum, besides the actual process of implementation.

Innovative curriculum is essentially needed in Iraqi medical colleges for the sake of responding to public agreement towards strengthening health care providers clinical reasoning skills, providing them with basic clinical competencies that enable them to provide primary health care services in the community safely and efficiently, and developing their professional and communication skills that allow them to assume their leadership role in the promotion of community healthy habits and prevention of major community health problems..

The needs assessment indicated clearly that there is a gap between what graduates of Faculty of medicines learn, and the competencies they need to provide the health care services required in their primary employment sites.

Enhancing medical and nursing education was one of the priorities in the educational reform plan of action.

Among the many changes that have evolved in the world with the process of globalization, educational reform became a priority in many countries, both in the developed and developing world. However, the challenges and risks are much more intensified in developing countries.

Experts have realized the intense need for higher educational reform since the beginning of the new millennium. CURRICULUM OUTLINE

The reason for choosing core curriculum in pediatrics (the curriculum is similar in almost all Iraqi medical colleges) is because it is intended as a guide for the departments of pediatrics in the Iraqi Faculties of Medicine to help them develop their complete curriculum to meet their departmental, faculty, local and or regional needs.

The educational program in most of the Iraqi Faculties of medicine is discipline-based. This course curriculum is intended for the teaching learning process of the subject of Pediatrics for the undergraduate students in the 4th and 5th grade of medical schools. The number of students studying this course ranges from 80-150 students.

The curriculum needs to be started with an introduction that highlights the mission and vision of undergraduate medical education in Iraq, with emphasis on the importance of applying quality national and international academic standards. The introduction should include also, the rationale and background of the curriculum which is based on the philosophy that child health care is a basic requirement for achieving community health standards and welfare. The curriculum needs to clearly identify the major health problems that cause the great burden of infants and childhood morbidity and mortality with its adverse effects on the community health and national economy and to give approaches to the solution of these problems through a curriculum that should aim mainly toward providing the students with the necessary knowledge skills and attitudes to recognize, prevent, and manage these problems in primary health care.
Therefore the statements of intent including the goals and intended learning outcomes, need to be clearly described in the curriculum which should also be preceded by a list of the foundation skills the students must acquire before joining the course of Pediatrics. The contents are to be outlined as a topics list with a distribution of the time allocated for teaching/learning of each topic, as both theoretical and practical clinical classes. Few have mentioned that the curriculum allocates only 80% of the total time of the course, leaving for each department the freedom to allocate the remaining 20% of time according to the learning needs.

The curriculum needs to describe clearly the intended teaching strategies and outline of the students' assessment methods besides listing the methods to monitor teaching and the basis to evaluate and upgrade the curriculum.
All these points are not clearly stated in the current curriculum. DOCUMENTATION AND ORIGIN OF CURRICULUM

As described fully in the introduction, the current curriculum will be analyzed based on documents that provide information about scope, learning objectives, the rationale behind objectives, teaching strategies, and evaluation.

• As defined, the scope lists intended learning outcomes (ILOs) in each level, and are listed in sequence. ILOs are grouped according to topic or theme.
• Each category should have its own ILOs to cover the 3 domains of learning, cognitive, psychomotor and attitudes. To explore in more detail the rationale why these objectives are important for each topic, the ILO's should emphasize the importance of building knowledge on previously acquired parts, and starting from simple understanding to more complex intellectual skills, with the emphasis on helping the students to develop knowledge networks and clinical reasoning and problem solving skills.
• According to ILOs, contents need to be outlined clearly and key points to be listed to help teachers prepare for their teaching sessions in accordance with the overall aim of the curriculum.
• As for teaching strategies, the curriculum does not state in detail the instructional strategy in relation to each group of ILO's and the corresponding contents nor provide a guide for the instructional strategies recommended to be adapted by the departments for each instructional unit according to the objectives It also need to provide one sample of a course syllabus for a topic (instructional unit) that includes teaching methods, learning materials, and students assessment.
• Student assessment and curriculum evaluation; formative and summative students' assessment tests are recommended in the curriculum for both knowledge and skills. Objective student assessment in written and clinical/practical exams is to be emphasized and suggestions on different methods are encouraged.

Kamien M (1993) has analyzed the situation in many of the "old" medical schools. He stated that if these schools were to implement educational reform they will continue to graduate doctors who are on the whole, largely adequate but who could be so much more, as these medical schools were facing many problems and suffocations related to many factors, among which, related to educational issues, are teacher-centered schools,the fact that the student is passive and completely dependant on lectures given without any positive interaction, busy schedules (lectures mainly),absence of creation and research that student should require. Paying less attention to skills and attitude aspects, these curricula are not properly organized to meet intended outcomes, focusing in examination on knowledge aspects mainly and ignoring the community health needs.(5)

The current curriculum is suffering from the same points mentioned above, besides there are many general and local changes occurring which make the need for change mandatory. Among these is the change in the concept of health after the WHO declaration in AL Maata, which stated health for all as a target and adopting the concept of PHC services. Also the Adenbara announcement in August 1988 which was held by the international union of medical college's. This was supposed to encourage the development of new curricula that would suit and cover the health needs of the communities.

Additionally there were local causes where the higher authorities and experts in this field tried to realize and follow the importance of revising and recreating the learning processes in order to be relevant and capable of participating in the progress and revolution in information in other parts of the world; but the end results were not very encouraging.

The objectives which are statements that describe what the students will know and be able to do after completing the study, i.e. what knowledge, skills and attitudes should students acquire, or in other words the students cognitive learning, the psychomotor learning domain and the affective learning domain, should be considered in the curriculum very clearly and in details.

These objectives should be included:
To support acquisition of basic knowledge of normal and abnormal growth and development (physical, physiological and psychological) all clinical application from birth through to adolescence, to enable students to provide basic health care for individuals in the pediatric age group (neonate, children and adolescents), to provide students with appropriate background covering important and common pediatric emergencies and diseases and to enable the development and application of professional attitudes, communication and problem solving skills.

The students are to acquire the necessary knowledge, attitude and skills regarding pediatric medicine to become competent primary care physician. Students will have the opportunity to participate in the clinical activities of pediatric services putting into consideration that the services are focused on basic issues and common illnesses important for the education of primary care physician.

The knowledge objectives in this curriculum should emphasise (listing, identifying and assessing, interpreting, analyzing etc…) the skills objectives (performing, inserting and demonstrating), while attitudinal objectives should cover (demonstrating, counseling and obtaining) relevant and comprehensive information about topics mentioned in the curriculum.

The rational and educational philosophy behind the curriculum should be stated, mainly as regards the vision and goals in which to produce a graduate able to function competently and thoughtfully according to the accepted national and international standards in primary health care considering community health needs, researchers and teachers capable of applying national and international standards of medical care and follows its ethics, besides promoting outstanding programs of medical care to serve thesociety and promote environmental development in an atmosphere of cooperation, peer relation and mutual respect.

The curriculum should cover successfully the content issues regarding skills (professional, clinical and therapeutic), also the content to be mentioned and sequenced in logical order.

Each schedule has to define hours for teaching which is supposed to be outlined in the curriculum clearly. A sample course syllabus is to be included as a guide to the use of the topics teaching outline given in the curriculum. This includes topics title and description, intended outcomes, description of the teaching methods and learning materials (lectures with discussion, brainstorming, case studies, clinical simulation and drills, demonstrations and role play).

Guidelines for evaluation of students to be considered and includes: assessment of knowledge (objective written examination, objective structured oral exam. case studies and project report)
The common skill assessment, which included (structured clinical exam (OSCE), direct observation with check list, structured feedback reports, portfolio and structured practical examinations).
Monitoring of teaching (what teachers need to know and be able to do and be committed to do) is to be described in this curriculum beside the resources required both to conduct monitoring activities and to implement necessary changes in teaching in addition to the methods used for collecting in formations about teaching process, résumé student evaluation and feedback from faculty members will guarantee the curriculum dynamics.

Financial constraints must be addressed clearly in this curriculum according to our understanding; also the relationship to other parts of the curriculum and how it will relate to other subjects, should be addressed.

The current curriculum should stress on the means end reasoning. Also, the ILO's are to be classified clearly into those that help the development of knowledge and understanding, those that foster the development of clinical reasoning and problem solving, and ILO's to enhance the development of clinical competencies, and professional attitudes. The curriculum should stress also on the importance of providing the students enough chances to master the clinical competencies required for them to provide health care services. This will ensure that the curriculum has both behavioral and constructive perspectives at least in its statement of intents.

Still we think that this curriculum needs to represent in one aspect the structure of the disciplines perspective as it will deal with the gap between school subject matter and the scholarly disciplines from which they derive i.e. view teaching as the induction of novices into community of scholars(1). Part of thinking in this way is the need for professor's involvement in this creation of curriculum that is mainly in the academic disciplines. BASIC CONCEPT

We need to identify the meanings of terms commonly used in describing the curriculum components with as much certainty as possible.

The very first step in analyzing the purpose of the curriculum is to identify aspects of the curriculum that are intended for training and what are those intended for education. Learning contexts are either defined as training or education. When we can predict with some confidence the situations in which people will use what they learn, then this is termed "Training" (1). In other words, when students use the knowledge they learned in their learning experience in the form and context that closely resembles the situation in which they learned it, then they are replicating and applying the knowledge (2). This means that this learning experience is training. Meanwhile, when the situations in which learners will use what they learn cannot be predicted with any degree of specificity or certainty, this learning experience is termed "Education".(1) Again, according to Broudy et al, this is equivalent to situations when the learner uses the knowledge he learned associatively and interpretatively(2) . It is to be noted that this distinction does not mean that one of the 2 contexts is inherently more valuable than the other, but curricula should provide both training and educational contexts of variable proportions.

The core curriculum of Pediatrics should contain aspects for both training and education. The emphasis is generally to be laid on training when the part of the curriculum deals with clinical and management skills..

On the other hand, educational aspects are emphasized when the context is to learn fundamental principles and concepts as well as to solve problems. An example is when the students are learning the principles of nutrition of infants and children, the nutritional disorders that result from various nutritional deficiencies and their effects on body functions, as well as how to apply this, and the related knowledge to solve patients' problems. In this context, the students need to use this knowledge associatively and interpretatively, and we cannot predict with certainty in which situations they are going to use this knowledge.

Curriculum Purposes; Aims, Goals and Objectives:
The levels of educational purposes should take into consideration; societal goals, administrative goals, educational aims, educational goals, and learning objectives.

Societal goals are broad goals that express what citizens and policy makers want their political, economic, social and educational institutions to accomplish. Thus, the outcomes of these goals are not only the result of education, but education contributes to its accomplishment with influence on other societal organizations.

Administrative goals intention is to maximize the utilization of the available departments and faculty recourses to meet the educational goals without increasing the financial expenditure in face of the economic constraints of the country. Or, alternatively, to find out other sources of financial support to the university in addition to the limited budget available from the government. These goals in our opinion are essential in determining the ways schools will implement the curriculum in view of the limited available recourses.

Thus, the absence of explicit or implicit societal and administrative goals in the current curriculum can be considered as blind spots of the curriculum.

Educational aims are again broad aims that express what citizens and policy makers want the educational institutions to accomplish, described in terms of the desired characteristics of a graduate who has been well educated. These aims are influenced by many factors, one of them is the educational process itself.

Educational aims are classified into 4 related categories:

• Personal development: includes self-cultivation or self-actualization.
  
• Socialization, includes citizenship and interpersonal relationship
  
• Economic productivity
  
• Further learning including the acquisition of basic skills and other requirement for continuous and independent learning.

The personal development aspect should be presented at least in the aim: as to develop an outstanding and honorable clinician, practitioner, researcher and teacher capable of applying national and international standards of medical care and following medical ethics. This aim will involve both educational and training contexts since it describes the individual after learning in specific situations, where he/she is going to use what they have learned. Meanwhile, applying standards of medical care indicates that the learner has also to use the knowledge they learnt associatively and interpretatively (i.e. education) to be able to solve patients' problems as an honorable clinician and practitioner.

The same will be with respect to the socialization aspect, which should be stated; as to promote outstanding educational programs of medical care to serve the society and promote environmental development in an atmosphere of cooperation, peer relation and mutual respect. This aim emphasizes the importance of serving the society, as individuals, as well as in cooperation with other members (peer relation and mutual respect). We believe that this aim will also include training: (communication and teamwork skills), and education (principles of community health care services, preventive aspects of common health problems etc.) These 2 aims implicitly involve an economical aspect, which is to increase job opportunity for graduates by equipping them with the competencies that enable them to perform up to the national and international standards. Thus they will be able to get better jobs on the national and international level.

Educational goals: are the educational institute's translations of the educational aims into accomplishments. They are formulated as characteristics that the learner will acquire over the period of learning in the educational program (or course).

In order to implement the aims of basic medical education, the core curriculum in pediatrics has to put forward 4 broad goals that describe the characteristics of the graduates after learning the course. These goals emphasize;

• The acquisition of knowledge of normal and abnormal growth through infancy, childhood, and adolescence as a basic concept unique to pediatrics, its implications on health and disease of these particular age groups.
  
• The ability to provide basic health care needs for the pediatric age groups.
  
• The ability to recognize and perform initial management of common pediatric emergencies.
  
• The development and application of appropriate professional attitudes, communication and problem solving skills.

The current curriculum does not take into consideration all these educational aims. LEARNING OBJECTIVES

Learning objectives are defined by Posner (2004) as the intended educational consequences of course or unit of study. (1)

Objectives are also described as SMART; Specific, Measurable, Achievable, Relevant, Time-bound. (3) Though published as early as 1956, Blooms taxonomy stands till now as one of the popular and widely acceptable classification of learning objectives. This Taxonomy classifies learning objectives according to the three domains of learning into; Cognitive, Psychomotor, and Affective. Bloom further classified the cognitive objectives into 6 major classes (5). Although Bloom and his colleagues gave a similar classification for the affective objectives, they did not publish a similar classification for the psychomotor objectives. Harrow A (1972) had given an acceptable classification of the psychomotor objectives. Blooms' taxonomy of cognitive objectives received some critics that argued mainly on 2 points. One is that it is not hierarchical, since one can learn a higher level of cognition without learning the corresponding lower level. The 2nd point of criticism is about trivializing the concept of knowledge to mere "recall of facts".

Nevertheless, Blooms' Taxonomy had a great impact on education since it had drawn attention to the fact that most of the education systems are aimed at low level objectives.

Other classifications of objectives include; Gagne (1977) five classes: Cognitive, intellectual, verbal information, motor skills, and attitudes, Ryle (1949), Knowledge classification: Knowing whatand knowing how, and Broudy (1977) who added the "know with" category of knowledge.

Regardless of the classification of objectives the curriculum designers use, the important issue is that the curriculum should state its objectives in a clear and comprehensive way that is intended to demonstrate the outcomes the students will achieve through the designed learning experiences.

The general objectives of the core curriculum of Pediatrics should be classified into 3 categories: Knowledge and understanding, Clinical skills and Intellectual skills.

This classification if used by the curriculum designers will help in guiding the teachers to plan their instructional strategies and learning environments appropriately to facilitate achievement of the learning outcomes. Again, they will reflect the specific outcomes that will result in the accomplishment of the educational aim and goals. The community care aspect should be clear in objectives such as: Demonstrate an understanding of the impact of congenital and inherited diseases on children and their families, and Describe appropriate measures for health promotion as well as prevention of diseases and injury in children.

The above point, as well as the lack of a clear distinction of objectives that are specific for affective domain or attitudes might be considered as a blind spot in the current curriculum, because one of the major defects we are suffering from in our medical education curricula is the lack of training or education to develop positive and professional attitudes.

Contents are considered by some people as the 'heart of the curriculum". Posner (2004) decided to treat contents as a curriculum topic separate from the objectives. He based his decision on the fact that; the same contents could be taught for different purposes, and any objective could be pursued , by a range of different contents. (1) Although this point of view sounds logical with the given justifications, yet, many other educationists prefer to use the objectives as the core of the curriculum and base all other curriculum components on them. (3)

We also believe that this approach to the curriculum contents, particularly in disciplines that contain large amounts of knowledge and requires the learners' acquisition of a lot of basic fundamental motor skills like medicine, to guide the choice and presentation of the contents by the clear objectives. This helps to determine with certainty the emphasis that must be given to each part of the contents. In other words, it serves as the determinant of the conception of subject matter, which is one corner of focus in the pedagogical view of the contents expressed by Posner. CURRICULUM STANDARDS

After this comprehensive discussion on the purpose and contents of the curriculum, one must think carefully of how we can assess the curriculum alignment with the national and international standards of the discipline. Standards are broadly defined as: the facts, skills and processes the students are expected to learn. (1) In medical education, the standards are defined as: A model design or formulation related to various aspects of medical education and presented in a manner that enables the assessment of graduates' performance in compliance with generally accepted professional requirements. They are set up by consent of experts or by decision of educational authority.(7) Generally the standards place a great priority on higher level thinking, and in the case of medical education, emphasis is also placed on competencies the graduates must exhibit to be able to practice their profession. Standards address all the four categories of the educational
Aims.

In order to analyze the curriculum in terms of its provision with the standards, we must look to the curriculum objective and find out whether it translates the standards into measurable behavioral outcomes of the process of learning. We also need to find out how the curriculum will assess whether the students have achieved these standards at the end of the course.

Although the Iraqi national standards of medical education are supposed to be set before, the current curriculum should have a set of well-defined core competencies the students must demonstrate their ability to perform by the end of the course in pediatrics. These competencies are to address many of the domains as the acceptable standards for undergraduate programs of medical schools. However, no focusing on the area of professional values and attitudes as well as no information management are noted. This deficiency can also be seen all through the contents of the curriculum, and has been highlighted partly in the previous discussion.

The curriculum must also demonstrate how the assessment of students will be adjusted to verify that they have achieved the standard outcomes. In other words, it must clearly define the methods of assessment that will be used to confirm that the students demonstrate each of the required competencies. In the core curriculum of pediatrics, no general outline of the assessment of students is given. Detailed description of student assessment that should be used to carefully assess students' performance according to the standards must be shown in the sample course syllabus of the unit,
which is supposed to include both formative and summative; class room and final examinations, in addition to Tests that include written and clinical examinations.

Success in clinical test is considered if the student performs the clinical skill up to the standard. However, it is not indicated in the curriculum what are the criteria for performing the skill successfully. It should have been mentioned clearly that this must be done through the use of standardized clinical check lists. It is clear that the success criterion needs to be modified to ensure the alignment of the assessment with the standards.

Although there are five perspectives that shape the curriculum purposes and contents, two are in common use by educational psychologists and are still receiving a lot of debate between their proponents. These are the behavioral and the constructivist perspectives. Both agree that the purpose of education is to promote learning. However, they differ in their views about what learning is, how it takes place, how the teacher facilitates learning, how to formulate objectives that express the intentions for learning outcomes, and how the curriculum will be planned according to these objectives.

The basic concept in the Behavioral perspective is that; "learning is a change in behavior". According to Socket S (1976), the principles of the curriculum that follows this perspective are:

• A curriculum that consists of a set of stated objectives that are expressed in specific, observable and measurable terminal behaviors.
  
• The purpose of the instruction is to change the behavior. The change is from the entry behavior to the terminal one.
  
• Both the content taught and the methods used are means to the terminal behavior.
  On the other hand, the constructive perspective focuses on the internal mental structures and processes, sometimes called schemata or cognitive operation.

The perspective proponents are interested in thinking, reasoning, decision-making and perception rather than behavior and performance. The constructivists believe that objectives must describe the changes in the students that are not directly observable. These changes are described using schematic diagrams that are called concept maps, or a list of cognitive operations or concepts. In the latter, the objectives are also described as statements that start by an action verb, which describes levels of cognitive functions. Two models for the teaching learning process are derived from constructive perspective; conceptual change approach and cognitive apprenticeship. Both approaches focus attention on helping the students to think more effectively, and make sense of the world.

When we look carefully at the two perspectives; behavioral and constructive, one does not find fundamental discrepancy. The behavioral perspective is required for subject areas that deal with psychomotor skills. Here training becomes the main context of the curriculum; objectives must be strictly behavioral, instructions must focus on modeling, with opportunities for students to practice under supervision and receive constructive feed back until the teacher is confident that they can practice independently without making major mistakes. On the other hand, the constructive perspective dominates when the required competencies/ outcomes are concerned with development of cognitive abilities including problem solving, critical thinking and reasoning. In medicine, the graduate must master a lot of essential psychomotor skills as well as be able to build a network of illness patterns (scripts), analyze the patient's problem and identify its similarity to the scripts, synthesize, the diagnosis and plan the patient management. Obviously any curriculum in medical disciplines must consist of both behavioral and constructive aspects and the objectives must describe the both types of outcomes.

The pediatric curriculum should take into consideration the assumption that effective education offers a balance of theoretical and practical experiences that will allow students to develop the competencies necessary to enter a health care profession and to continue their professional development throughout their careers. The curriculum outlines the cognitive abilities that students will acquire and the practical skills that students will be able to perform after studying the designed course in a balanced way. Looking to the ILO's of the current curriculum, one can see clearly that there is an overlap between behavioral and constructivist perspectives as the objectives were categorized into 3 main subdivisions; knowledge and understanding; clinical skills and intellectual skills & attitudes.

The cognitive apprenticeship model described by Resnick and Klopfer (1989) is important and needed for the following reasons:

• Students need to be confronted with real tasks (real patients or simulated ones), challenged with case problems to solve and, are requested to interpret radio-imaging and laboratory results.
  
• Students need to be offered opportunity to observe instructors or tutors demonstrating clinical skills they are expected to perform, and get feedback on their performance (be praised or corrected).
  
• Meanwhile, the students are expected to perform certain clinical and therapeutic skills properly according to check lists and to receive structured feedback from their teachers. which is the part of the behavioral perspective of the curriculum.

Lessons that a hidden curriculum teaches include lessons about sex roles, importance of being neat, orderly, and on time, the distinction between work and play, who has the right to make decisions for whom, and what kinds of knowledge are considered legitimate (Posner, 2000). Examples of such hidden curriculum in medical schools are connected to what students perceive during their faculty study from the common attitudes and behaviors of the professors and teaching staff. Believing that doctors know everything about human body functions and diseases, while people do not know, thus doctors give orders and people must obey; similarly, doctors education is higher and superior than the education of other members of the medical team, are among the lessons students commonly learn through the hidden curriculum in medical schools. Again, social inequity represents an important lesson students sometimes learn after passing through oral exams that depend largely on the opinion of the examiner and are influenced to a great deal, by personal relationships of the examiners with the students and their families.

The current curriculum cannot show such aspects as this requires also active observation of the teaching process and knowledge about the rules of the school/department implementing the curriculum.

Critical theorists consider that one of the main disadvantages of the technical discussions about objectives, is that it diverts the attention away from the hegemonic effects likely to be exerted through the curriculum purposes. When curriculum objectives represent the educational intent of the institution board of administration that is planned for the group of students, then it might become an indirect means for controlling, at least, their study. This effect becomes a direct hegemonic role for the curriculum, if the dominating group (Institution board) is from a different social class, ethnic group, race or gender than the dominated group (students), enforced also by the authority of student assessment that the institution teachers have. However, this direct hegemonic role of the objectives will be clear if the objectives include racial, social or ethnic directives that might serve the interests of those in power.

The objectives of the curriculum of Pediatrics do not embody any of these directives. On the other hand, the objectives should stress more than the importance of serving the community as a whole, but, for better recognizing and effectively managing the prevailing health problems among rural as well as urban parts of the country equally. Diseases such as acute diarrhea, respiratory infections, and malnutrition, which are more prevalent in lower socio economic classes, are given more weight in the curriculum contents, more time for teaching, and greater percentage of assessment questions.
Organization means: to bring together separate elements into a whole that consists of interdependent and coordinated parts. If we apply this general definition to the curriculum, then curriculum organization would reflect the process of bringing together the elements of the curriculum (programs, levels, courses and subjects) into an integrated coordinated structure.

Curriculum organization includes 2 levels: macro and micro, and 2 dimensions; horizontal & vertical.
In its very specific meaning, curriculum organization at the micro level refers to the organization of a course or a unit, while at the macro level one refers to organization of courses to form a program. On the other hand, dimensional organization refers to the organization of the curriculum elements along a time line. This includes organization of curriculum contents that are studied concurrently i.e. within a semester or an academic year, (horizontal organization), and the organization of contents taught following each other i.e. sequence of contents, (vertical organization). The levels and dimensions of organization are independent and thus we can organize the elements in either dimensions at a macro, or micro level.

If we examine the "core curriculum" of pediatrics from the organizational aspect, we must re-emphasize that this is a course curriculum of a discipline that is taught to 4th and 5th grade undergraduate medical students who must have studied in the previous years all basic biomedical sciences.

The curriculum should identify course prerequisites and list it under the title of: Foundation skills, which include clinical and therapeutic skills as well as professional conduct and attitudes that the students must master before they study the course of Pediatrics. The student is expected to acquire such skills from his/her previous courses in the preclinical and clinical phase. The current course curriculum does not even specify the type or titles of the courses the student must have before he/she starts the course of pediatrics.

Identification of the prerequisite courses is a form of vertical organization of the curriculum.
It is difficult to describe the horizontal organization of the pediatrics curriculum at a macro level as it is not mentioned within its document its relation to the courses concomitantly taught. However, in all of the Faculties of medicine, the pediatrics curriculum is taught concurrently with the junior level medicine curriculum. Yet, the organization of the concomitant topics in both course curricula - medicine and pediatrics, so that they complement each other e.g. concomitant teaching of nutritional disorders, cardiovascular diseases, infectious diseases etc., is lacking so far in most of these faculties' programs.

Depending upon the degree of horizontal and vertical organization and the configuration of the curriculum contents, we can recognize 4 types:

• Discrete: where all the courses/ topics within the course are independent; the student can begin his study at any segment and does not require any pre or co- requisite.
  
• Linear (Vertical): each single concept and skill of the content must be mastered by the students before the next concept or skill is introduced. The students' practice the concept/ skill repeatedly with the subsequent one until all are mastered by the end of the course. This approach is based on the mastery-learning concept of Bloom (1971).
  
• Hierarchical: Multiple concepts and skills are taught together and all are necessary for learning the subsequent concepts and skills.
  
• Spiral: This organization is based on the cognitive developmental assumption that learners internalize concepts they learn in different modes (ways) at different ages and learning levels.

Thus, important concepts and skills must be taught to learners repeatedly with increasing level of sophistication and abstraction, and not only once but forever.

Media structure refers to the organization of the instructional strategies (materials and methods of teaching) in relation to the other elements of the curriculum.

Parallel media organization implies the use of selected media for facilitating the learning of specific ILO's e.g.: Clinical practice in a simulated and real environment for development of clinical skills of history taking, physical examination etc.

Convergent organization entails the use of a variety of methods to help students acquire limited ILO's as students differ in their ability to learn from one medium. Thus, the acquisition of knowledge and conceptual skills is facilitated through a variety of methods including lectures, group discussions, case studies, assignments and students self-earning activities through essays and projects, as well as during clinical training with a real patient encountered.

Organizational principles state why the curriculum is organized in a particular way. These principles apply to both vertical and horizontal dimensions.

Organizational principles can be categorized into 4 common places (Schwab): the subject matter, the learners and the learning process, the teachers and teaching process and the milieu of education. Most of the curricula are organized at the macro and even the micro level around the subject matter. One must always bear in mind that the process of curriculum organization at both macro and micro levels is a difficult one and that trial to organize according to more than one of the common places is much more difficult.

1. Subject Matter: Organization of the curriculum on the basis of the subject matter entails sequencing the curriculum according to the way the subject matter is organized. This follows one of 3 principles: world related, concept related and inquiry related principles. The world related principle arranges the curriculum according to the way the subject exists in the real world.
   
2. Learners and learning: Here, curriculum organization depends on the learners' interests, needs, abilities, previous experiences and developmental or conceptual level. These characteristics may be used as point of start of the curricular activities, a focus around which the curricular elements are organized or a basis of content order. An extreme form of learner based curriculum organization is the program curriculum in which the entire curriculum is centered on the students' needs and interests. This is planned cooperatively between the students and teachers. The subject matter is used as a means to solve the problems which were identified as the students needs rather than being the end by itself (goal).
   
3. Teachers and teaching: Although it might not be stated explicitly in the curriculum, many of the organizational decisions might be based on the teacher's characteristics and the tasks the teacher faces. Teacher's characteristics can influence the starting point, the focus or the emphasis of the course (curriculum). Meanwhile, teachers who are teaching large numbers of students against their will and in crowded places have to accomplish predefined tasks. In order to achieve the organizational goals, the teachers will apply pragmatic organizational principles that enable them to achieve the tasks within the constraints described.
   
4. Milieu: Can affect curriculum organization through 5 factors: social, economical, political, organizational and physical. Probably the most relevant of these factors in determining the pediatrics core curriculum organization are the organizational and the physical factors.

• The influence of the institutional organization here will be the effect of the department structure on organizing the curriculum elements. If the department organizes topics following the department organization into subspecialties, thus, teaching of each unit goes separately, this leads to compartmentalization of knowledge, and a discrete type of curriculum ensues.

• One of the important milieu of factors that influence organization is the physical facilities. This is probably the main factor that governs a lot of organizational activities in our situation. Owing to the limited physical facilities and with the large student numbers, the clinical training sites cannot accommodate the number of students. Instead of organizing the clerking activities and clinical training exclusively with real patients, some of these activities are substituted by theoretical teaching.
• Again, sequencing of clinical training in correlation with the relevant knowledge learned in lectures and group activities sometimes become difficult because of the effect of seasonal variation on disease incidence.

These are 2 concepts that describe the social organization of Knowledge. Stratification means the degree of the social value that is differentially given to the subject. According to the degree of stratification, selection and exclusion of curricular contents will be done. Stratification also defines the degree of distinction between the teacher on one hand and the parents and students on the other. According to this stratification, the subjects will be accorded different levels of status. Status will determine whether or not academic credit is assigned to the subject, whether the subject is a major or an elective one, and the time allocated for its study. One can see such type of organization in discipline based undergraduate medical programs in the stratification of basic biomedical sciences on one hand and clinical disciplines on the other hand. The latter are stratified higher than the former. Accordingly, Professors of clinical sciences are much more difficult to be approached by the students and sometimes even by the faculty administration than the basic sciences' professors. Again, within the clinical sciences, medicine and surgery have long been stratified at a higher level than pediatrics, and community medicine. However, in the last decade, this stratification has been modified, based on the increasing social and political importance of the latter 2 subjects being the basis of community based medicine together with obstetrics and gynecology

Tracking: In multicultural communities, tracking in education means the provision of different types of curricula to learners of different ethnic or socio-economic background. The rationale is to direct minority and less privileged students to the low ability education with less academic and more vocational types of curricula.

The program offered in undergraduate medical education is one and the same for all students who are admitted to the faculties of medicine according to their degrees in the final high school examination, regardless of their ethnic or socio-economic status.

Curriculum Organization Perspectives; Epistemological and Psychological assumptions:
It is time to begin to unpack assumptions underlying pediatric curriculum's organization by examining 3 contrasting patterns, termed the "top-down", the "bottom-up", and the "project" approaches.

The top-down Approach: Simply stated, a top-down view is based on the assumption that the curriculum is organized around fundamental themes, concepts or principles, and from understanding of these concepts or themes, students can derive particular facts and applications. In other words this perspective is also termed the hypothetical deductive approach.

This epistemological basis of the approach was laid by Karl Popper (1959) and further modified by Schwab (1962, 1964), who identified 2 structures that form the body of knowledge of any discipline; the substantive and the syntactical. The substantive structures are formed by basic concepts or themes that from which more specific facts in the discipline can be deduced. The syntactical structure of a discipline is what counts as evidence for a claim or the way scholars establish truth and validity.

The psychological principle of this approach assumes that when learners understand the fundamental concepts of the disciplines they can, at any age or level of learning, deduce other facts and concepts of the discipline through a process of inquiry similar to that adopted by the scholars of the discipline and following the same rules. Accordingly, the process of curriculum development must be dominated by the subject experts (scholars).

The content of the curriculum must be organized in a spiral configuration where the knowledge is studied by the students at increasing level of sophistication and abstraction with advancement of the students in the levels of education. Students play the major role in learning the applications of the discipline through the process of inquiry. While in the Bottom-up approach and in contrast with the hypothetical deductive assumptions, this approach is supported by the epistemological assumptions of David Hume (1975, 1976) and Gagne (1965, 1970), who believed that knowledge originates in experience, and that complex learning, even problem solving, is achieved by successively linking together previously learned simple behaviors. Educational psychologists assumptions are based on the way learners learn rather than the way knowledge is organized in the discipline (Gagne, Esumbul, and Bloom).

According to their assumptions, learning occurs through a hierarchy that starts with the most basic, simple skills which must be mastered, before the learning of the related higher order skills. Curriculum development requires the construction of carefully sequenced objectives where each objective builds on the prerequisite one.

This curriculum is called a behavioral one only if the objectives are carefully designed to describe a specific behavior, and the whole curriculum is organized around these objectives. Curriculum development requires the active participation of behavioral psychologists.

The project approach; encourages students to bring their interests, psychological needs, and previous experience to active study i.e. student-directed experience. It is also called an experiential approach. The curriculum is organized around student's activities that are planned cooperatively between students and teachers and are based upon experiences in the real world particularly the social life of the community. The educational activities are thus interdisciplinary, since the projects approach social problems as wholes using information and skills from different disciplines. The epistemological foundations of this approach are laid out by Dewy (1916) including his elaboration of the scientific method and elevation of the social knowledge. Dewey elaborated the scientific method as a cycle of thought-action and reflection. The interdisciplinary project approach allows students to gain knowledge, skills and attitudes necessary to participate in a democratic society. It also enforces group and team-work and interaction between group members. The curriculum does not follow certain sequencing principles. Most important is the developmental organizing principle, in which the students are given increased responsibilities in their projects with progress in their activities. The contents are organized to allow such student growth through experiential activities by following a general guidance which entails the progression through increasingly complex type of knowledge, skills and attitudes as the students progress in their projects; a spiral type of configuration. The best example of project based (experiential) approach in medical education is seen in problem-based curricula.

An official curriculum is meaningless unless it is translated by teachers into an operational curriculum. To put life into it, the teacher must take many factors into account; physical, cultural, temporal, economic, organizational, political-legal, and personal. These factors either make or break a curriculum.

Implementation of curriculum in teaching must take realities into consideration. These realities of teaching include coping with five tasks; coverage, mastery, management, positive affect, and evaluation.

Teachers must cover certain topics, contents, skills, and objectives. The students must learn the material at least at some minimal level of mastery or depth. These two tasks present a dilemma facing every teacher, the coverage/mastery dilemma. The teacher has to manage the classroom; to maintain some semblance of order in a crowded room full of very different students. To accomplish the latter task, teachers must develop at least a minimal degree of positive feeling on part of students toward the subject matter, the teacher, or the class. The teacher is also responsible for evaluating students to decide what aspects of curriculum are to count and to hold students accountable for.

Frame factors function as limitations or constraints on teaching, and thus on curriculum implementation. Meanwhile, the same frame factors might function as the resources that make teaching possible. Proximal frame factors act directly on interactions between teachers, subject matter and students, for example availability of textbooks and content knowledge of teachers, time availability, space and equipments. Distal or higher -order frames include those factors like budget size, laws and regulations, and demands for accountability. Those factors function as boundary conditions for proximal factors.

Regarding temporal requirements, Time is the most precious resource of teacher. Quantity and difficulty of content, and the audience expected to master it, all affect time necessary to teach curriculum. Time is the most influential factor in the content/mastery dilemma, a competition between coverage of topics (breadth) and going into the depth of the contents. In addition, temporal factors include time needed by teachers to prepare for teaching, to support, and to provide feedback to students (1).

There are no special scheduling requirements mentioned in the curriculum under analysis.
The physical space (built environment of classroom; lighting, aeration, class layout) in which teachers teach and the stuff (materials provided for teaching as mannequins, instruments, apparatuses, instructional materials) with which they teach, are the most obvious and tangible commodities. Skills laboratories that are required to coach students while practicing and enough number of classes that accommodate large number of students are physical constraints to implement the pediatrics curriculum. In some faculties, there are initiatives to construct pediatrics skills labs with the help of some national projects. However, this is not achieved yet in all faculties that will or will be implementing the curriculum; a physical constraint that is hindering the implementation of an essential component of the curriculum. The increase in the number of students per clerkship rotation that was mandated by the extension of the time allotted to each rotation, is posing another physical constraint due to the relative inadequacy of class rooms and lecture halls that can accommodate this number. However, these physical constraints can be managed through departmental efforts to collect budget for the required physical extensions.

Regarding the political-legal requirements, correspondence with national tests, licensing and standards requirements, the range of possible classroom events is always circumscribed by prior decisions at higher governmental levels.

Since the faculties that will or will be implementing the core curriculum in pediatrics are governmental, the implementation of the curriculum is largely governed by the hierarchical system of administrative decisions and the relative lack of faculties and departmental autonomy in this system. Standards have much to say about the nature of the curriculum and work of teachers. As we need standards that lay emphasis on practical competencies and clinical reasoning skills the graduates must exhibit the ability to practice their profession. The curriculum should be in congruence with these standards, thus, its implementation would help the faculties to achieve the accreditation standards. However, the faculties are facing the challenge of limited economic resources in face of the physical requirements that are necessary to achieve these competencies, a constraint to the proper implementation of the curriculum. Unless faculties could find a source for funding them, the implementation of the curriculum according to the required standards might be impeded.

At the same time, the departments need to modify the student assessment methods they use, to be able to objectively evaluate the students' degree of achievement of these standards using objective standardized tools. This requires sincere efforts from the department staff to revise and adjust the assessment methods according to the standards. The expected resistance to change from some of the faculty staff must be dealt with in a judicious, planned way.

Regarding organisational requirements and regardless of the previously mentioned political/authoritarian factors, it is the organizational unit which, in practice, significantly determines the extent to which a new curriculum will flourish or wither. As a subject (course) curriculum, the organizational unit for implementing the pediatrics core curriculum is the Faculties' Pediatrics Departments. Whether a factor is proximal (class size, ability groupings) or distal (school size) does not necessarily determine its impact as a constraint or resource for curriculum change. The main influence is exerted by the organizational unit itself (the departments and their members and administration) who can make the implementation possible through maximizing the use of the available resources, or on the other hand, create obstacles to prevent proper implementation of the curriculum through magnifying the deficiencies and preventing trials of adjustments. Accordingly, the relative inadequacy of physical places for teaching and training due to the larger number of students can be managed by the departments' members and administration through extending the time for teaching along the day if the staff are willing to do so. On the other hand, this inadequacy might become a big problem that prevents the proper implementation of the curriculum if the departments' staff and administration decide not to try to manage the situation with alternative solutions.

The costs and benefits change cannot be expressed only at the bottom line expenditure and income generated or saved, but it must extend to include such factors as: staff and student morale, student learning; time and effort needed for teaching, learning and administration, community and parent relations, and the "ripple effect" of the change. A change in staff or student morale might be considered as a cost if morale appears to get worse or as a benefit if it appears to improve.
The teachers play a highly significant role in determining the success and direction of curriculum change. Although in the analysed curriculum, teachers do not need much more knowledge compared to what they had before; some of their teaching and training skills however, may still need to be changed and developed.

These development programs can greatly help to increase teachers' skills and knowledge, but are less likely to alter their attitudes fundamentally. Teachers attitude, in our belief, is a cornerstone of successful implementation of the curriculum, especially their willingness to change. Unless the process of change is preceded by, and accompanied with efforts to motivate the faculty staff to participate actively and positively in implementing the curriculum, there will be great difficulty towards achievement of curricular goals. Students are the second cornerstone on which successful implementation of the curriculum depends. The extent to which students possess academic skills, computer skills, interpersonal skills and the prerequisite skills and knowledge, together with motivation are essential for successful implementation of the curriculum.

The curriculum depends on two different sets of cultural factors; the culture within the school (faculty) and the culture of the community in which the faculty exists. A faculty itself represents a culture that is, a set of accepted beliefs and norms governing people's conduct. One of the potential problems which might face the implementation of the innovative core curriculum of pediatrics, is the large number of faculty professors who will implement it within each faculty. Inevitably, though coming from nearly one culture, some of their values concerning university undergraduate education are different, and are conflicting with the curriculum in some areas. The curriculum embodies the main task of offering primary health care services to the vast majority of children in the community aiming at decreasing the morbidity and mortality in this vulnerable group. To achieve this goal, the curriculum lays much less emphasis on covering the depth of other diseases that are prevalent in developed communities as well as ignoring descriptions of higher technological approaches to rare diseases. The concept is to equip the graduates with the fundamental knowledge and skills to serve their primary functions while allowing the graduate to upgrade his/her competencies with self learning and post graduate studies according to his/her personal directives.

The conflicting values come from the belief of some professors that the duty of academic schools include mainly uncovering the depth of the subject matter to the students and mandating them to learn the recent advances in the field.

On the other hand, and despite of the great efforts required to design and develop a curriculum, what determines the success of a curriculum is how it is implemented. The perspective that influences curriculum development extends to affect its way of implementation. Out of the five theoretical perspectives of the curriculum, two main perspectives appear to exert the greatest influence; the behavioral and the experiential. In the process of implementation, these two perspectives are seen as two approaches to curriculum change; the Research, Development and diffusion, (RD&D) and the Collaborative approach. The RD&D approach manifests behavioral assumptions and features. It is based on the assumptions that technologies like behavioral objectives, competency based teaching and programmed instructions together with educational research would improve teaching practices.

Accordingly, the process of curriculum change would go in a linear manner starting with; Research that establishes the principles of teaching and learning, Development which applies the results of the research in the production of materials to be used in the process of teaching & learning, Diffusion of these materials for use by teachers and learners, and adoption of the material by teachers in the actual process of curriculum implementation. According to the RD&D approach, the knowledge and skills necessary for implementing the curriculum are explicit tacit knowledge that can be developed in the teachers through training, demonstration by experts, and reading self learning manuals, all prepared by experts who are in this role, behavioral scientists. This is similar to the behavioral approach to curriculum content development, which depends on subject experts.

The focus of development efforts in the RD&D approach is the production of such material to be used by the teacher for his/her self-development as well as for use in teaching the curriculum to the students. The process of implementation is directed by the objectives that are strictly behavioral, thus the assessment of success depends upon psychometric tests that measure the behavioral outcomes of the curriculum implementation.

In contrast to the RD&D, the collaborative approach considers that teachers are active shapers of the curriculum change to meet the local needs, that, although some skills needed to be implemented the curriculum can be specified and learned, and much of skills and knowledge of good teaching is tacit knowledge of the teaching craft. The focus of development effort is the professional growth of the teacher through reading, observing other teachers and discussing ideas. The curriculum change is directed by teacher's beliefs. The process of curriculum evaluation depends on class room observations, semi structured interviews and examination of student class work; ethnographic methods.

Teaching in class rooms, as well as clinical training, did not follow any systematic schemes. Rather, it was dependant totally on professors' views. The number of students is increasing, however, the number of teaching staff is also large and consequently the views are diverse and a minimum degree of standardization is lacking. According to these and other relevant data, there emerged a great need to achieve an acceptable degree of standardization especially for training of students in essential clinical skills, as well as for their assessment during examination.

Although these activities represent one of the disadvantages of the behavioral approach; pushing teachers to adopt rather than adapt the curriculum, in our view, this is required to a certain degree. To balance this, we find in favour of the introduction of the curriculum document.

The core curriculum is supposed to comprise approximately 80% of the department's entire curriculum. Are self assessment, feed back from students, peer review, and analysis of student examination results undertaken. CONCLUSION

The current pediatrics core curriculum (Iraqi medical colleges in general), being a course curriculum, is organized at the micro level. The remaining 20% is to be designed and implemented by the departments themselves, including the allocation of more time to specific topics and/or the addition of new topics to the curriculum. The core curriculum is intended as a guide. Using it and adding to it, departments will develop their complete curriculum to meet their departmental, faculty, local, and /or regional needs. This statement clearly demonstrates that the previous national curriculum committee, though adopting minor rules of the behavioral perspective in designing the curriculum and of the characteristics of the RD&D approach in implementation, yet still, there are major disadvantages of this approach; differences between teachers and developers goals and expectations, and cultural blind spots. That is why we should try to ensure a reasonable degree of freedom and creativity for teachers during the process of implementation, and an approach that implies some of the characteristics of a collaborative one.

The core curriculum should consider monitoring of teaching as a process that is continual, cyclical, including collecting information about teaching, and reviewing this information to identify changes needed. The curriculum views that in order to be effective, there should be an open organizational culture that encourages a commitment to student learning, self-awareness, constructive feedback, reflection and professional development. In addition, monitoring requires a clear understanding of the course goals and objectives, and the responsibilities of different teachers and administrators. The common methods recommended by the innovative curriculum for monitoring as discrete units (horizontal dimension), the topics within each unit are organized in a hierarchical pattern (vertical dimension).

The instruction methods must be used both in parallel as well as convergent with the organization. The media use is not very clear in the document. Printed materials which were mentioned include only lecture notes, no video illustration and simulations, and there is no mention of computer software programs and internet web sites as learning resources. The curriculum contents are organized mostly according to the subject matter organization in the real world. The inadequacy of some physical facilities in the faculties, sometimes leads to a shift from organizing clinical training with real patients to theoretical teaching. The status of the subject at present is not high and the curriculum is not given enough time for teaching and reasonable weight in student assessment. There is no evidence of tracking in the curriculum. The curriculum organization from the epistemological and psychological views, follows the bottom-up (behavioral) approach, with more attention toward carefully designed objectives needed; still they are arranged in a hierarchical fashion. REFERENCES

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