Designing the Curriculum of General Medicine with Military Approach

INTRODUCTION:

In today’s world, disputes and conflicts among states have caused numerous and widespread wars. Meanwhile, the campaign and greed of arrogant powers against other countries may lead to human losses and damages during the defense of the raided countries. However, the use of weapons by invading countries has become various and widespread. The existence of these conditions has made the formation, development and qualifying of military medicine foundations in military forces inevitable as well as necessary, especially in training professional human resources to protect the health and combat power of military forces. In this regard, Leone (2005) wrote: Considering the current military clashes around the world and the high number of victims, the need to prepare more military medical personnel is more obvious than ever and the role of medical services to victims has become important (1).

Since, military medicine is traditionally thought in non-military medical colleges in most countries, today teaching and training military personnel and making them ready through the military medial academies and training programs have been considered more seriously.    

Jackson (2010) on the need of the military medicine for professional physicians wrote: "In undergraduate degree, there is no much difference between military medical training and non-military medical training, but in graduate schools that the special military skills are addressed, a resident chooses a special type of military Medicine profession to study (2). Shapir (2011), in relation to the kinds of expertise needed in the army, stated: after the completion of the training period or internship, a medical student receives the Medical degree (MD) and then enters to the military medical courses, which include: Mobile medicine in peacetime, advanced trauma of nuclear, chemical and biological war, military physiology, aviation medicine, space medicine, economy in military medicine, military epidemiology and military psychology (3).

Department of Military Medicine (2009) has introduced the professional issues and topics required in military medical training program as follows:

Military medicine before and after transferring of troops are: soldiers' medicine, medicine before transferring army and mobility-moral in military medicine, rehabilitation medicine, work health in the army forces, military medicine in operations, the treatment and care of the wounded, care for victims of war and tactics, trauma management of war, surgery in war emergencies, military dermatology, military psychology, environmental medicine, heat stroke, frostbite, forest frost, mountain sickness, seasickness, naval medicine, air medicine, military medicine related to chemical, biological and nuclear agents, crisis medicine, and military preventive medicine (4).

In countries where military medicine does not exist, their civilian medicine is usually used in addressing the needs of the injured and victims, as well as the events of war. According to the researcher and considering the experiences of the early years of Iran-Iraq war, non-military physicians, despite their plenty contribution in treatment of the war wounded, had weakness in military clinics for responding different therapeutic needs of war victims, especially in relation to injuries caused by modern weapons because of differences between military medicine and non-military medicine. Obviously, this weakness was due to lack of enough knowledge, attitude, and skills in relation to military medicine for non-military physicians.

Regarding the similarities and differences between military and non-military medicine, military department (2009) wrote: Many subjects of military medicine have interdisciplinary overlapping with civilian medicine. Many military physicians first are trained in non-military medicine and then trained in various subjects of military medicine (4).

According to the researcher, because of some differences in military medicine and non-military medicine, the military systems need physicians educating in military medicine. In this regard, Holcombe (2007) stated: Military and non-military traumas are different in four aspects including the following:

1. Difference in the causes of trauma,

2. Difference in the setting of occurred trauma,

3. Difference in people who take care of the wounded (expressing the need to military physician to take care of the wounded),

4. Difference in the time of the evacuation and transferring the wounded that usually takes longer time (5).

In relation to the difference between the military and civil traumas and their requirements Troit et al (2011) wrote: Comparison of these two types of trauma has been shown that there is much difference between the two in terms of mechanism and distribution of trauma. So it is necessary for the care and management of trauma to provide the necessary preparations for training surgeon (6). Also Kashen (2011; quoted from Rahman, 2013) stated that: Training of military specialist physicians in America to acquire the knowledge, attitudes, skills and qualifications is beyond traditional civilian training. The mission of military specialist medicine is to train physicians with high quality an official certification to serve in the military environments (7,8). Kohl (2013) also stated that military medicine curriculum is very different from civilian medicine, because the conditions and applications of military medicine are different from those of civilian medicine (9).

Islamic Republic of Iran has always been threatened by different enemies in the military areas. Considering these facts that today’s changes, new weapons and their deployment complexities, complications and their emerged effects, as well as the armed forces that are routinely confronted to specific work issues of their military ranks such as artillery, missiles, armor, etc. and also because our country is one of the accident-prone places in terms of natural disasters such as floods and earthquakes, it is necessary for military medical universities to adopt the necessary measures to develop training and education of military medicine physicians.

Since we are at the early stages of developing military medicine by considering the primary needs of war and disaster accidents to medical emergencies and also according to the theory of new orientations of military medicine in military missions, it seems that the establishment of the specialized course of military medicine has a priority and can provide the need of armed forces to carry out their missions successfully.

Given the deficiency of graduated military physician in Iran in current conditions and the necessity of the presence of armed forces in the war fields and unpredicted events, this study was done to design a curriculum of military medicine in Army Medical University in Islamic Republic of Iran by investigating the global experiences in this field and considering the opinion of experts for the first time in Iran. In fact, researcher sought to answer the main question that "what are the characteristics of military medicine's clinical expertise curriculum in Iran based on international experience and experts' opinions?"

Research questions

What are the special courses of Military Medicine in doctoral degree at major universities?

What are the general medicine curriculum goals with military medicine approach?

What are the special courses of Military Medicine in doctoral degree of general medicine in Iran?

 METHODS:

The present research was done using mixed method research of continuous exploratory design. In this study, among the qualitative research methods, the qualitative content analysis method was used. In the quantitative aspect, after developing the framework of qualitative methods, the Delphi descriptive method was used to collect data.

Statistical population

The statistical population of the research consists of all universities and training centers implementing military medicine curricula, all physicians and military faculty members of Army University of Medical Sciences of the Islamic Republic of Iran, and some experts of other Iranian Medical Sciences and nurses of military faculty members.      

Sample and sampling method

The purposive sampling method was used in the present study. Also, sampling method using Delphi and snow ball techniques were used to select a sample of military physicians of Army University of Medical Sciences of the Islamic Republic of Iran and medical professors of other Iranian Universities of Medical Sciences with military medical experiences.

Collecting information through the study of literature

In documental research, the researcher collects the needed information through the study of literature. One of the important steps in this type of study is note-taking. In other words, data collection from sources and documents is one of the important steps in the research called note-taking in the library studies.

In the second phase of this research, the opinion poll of experts, in relation to the curriculum of military medicine, was used through the two researcher-made questionnaires as follows:

A) The first phase questionnaire: This questionnaire was designed for need assessment of military medicine course and the study of the features of its curriculum as a semi-structured one with open-ended questions and multiple questions in five-point Likert scale for survey on the needs for this discipline, goals, and other key factors.

B) The second phase questionnaire: this questionnaire was designed as a structured questionnaire after collecting information in the first phase and applying the experts’ opinions. It consisted of four sections including objectives, content, methods of teaching-learning, and evaluation according to specialists.

The procedures and processes of doing research

This study was done according to the following diagram by studying documents, resources and global experience in military medicine by doing a comparative study and a survey of experts through Delphi method.

The validity and reliability of questionnaires

The first stage questionnaire (basic curriculum of Military Medicine): This questionnaire was designed based on a global survey of military medicine curriculum that its validity was reviewed, modified and approved through content validity method and experts' opinions. The reliability of the questionnaire was obtained equal to 0.88 by Cronbach's alpha coefficient. With preparation of the questionnaire, collecting data from experts was performed by Delphi method in three stages as follows:

The first stage: At this stage, the groups of experts were selected by purposive sampling. The pre-prepared questionnaires were delivered to and collected from these experts through direct and non-direct (e-mail) methods. The questionnaire in this stage was unstructured. It collected the opinions of experts about the need assessment of military medicine curriculum, content, teaching-learning methods, and evaluation.

The second stage: in this stage, the data derived from the questionnaires were analyzed. According to the results of the first stage, especially about the need assessment of military medicine discipline in Iran and considering the common opinions of the experts, a structured questionnaire was designed including four sections of objectives, content, teaching-learning method, and evaluation. The new questionnaire was distributed to the experts of the previous stage. The results of this phase were analyzed. The elements of the curriculum which had obtained over than 75% of the experts' favor votes were selected.

The third stage: At this stage, the designed and developed military medicine curriculum was studied by the expert group in an expert panel and ultimately it was approved.

RESULTS

What are the goals of designing the curriculum of military medicine at the universities of the world?

The objectives of military medicine in Russia

1. Maintaining and strengthening the health of military personnel, enhancing the level of preparedness and quality of medical assistance in all possible cases specified by laws of the Defense Ministry, 2. Modernizing and updating the knowledge and equipment in the public health centers, convalescent homes, hospitals and health centers of military epidemiology, 3. Participation in federal health programs, 4. Participation ad coalescence in national health researches through enhancing the level of the health of the personnel and their families as the members of the society, 5. Planning for teaching and managing the necessary surgical and non-surgical treatments when confronting with a large number of the wounded of the war and paying due attention to development of the concept of war-field or surgeries of the war-field, 6. Professional research and development on issues of military medicine that the army is confronted when mobilizing the army forces and operations, such as infectious diseases, vaccines, medicine, environmental health, water and food, and systems of evacuating the wounded and military epidemiology, 7. Military psychology and psychiatric for mentally selecting individuals appropriate for various military jobs, creating and developing modern psychological methods for preparing personnel to do presented missions and treating the resulted psychological damages in the war-field, 8. Rehabilitation of the victims of war 9. Attempting to train and prepare completely the military physicians in all specialties required and related paramedics (cited from 7&8).

Objectives and competencies required in training military doctors with expertise in environmental and workplace medicine at American University of USUHS

1. Training military physicians working in occupational and environmental medicine and using their knowledge, skills and abilities in a full range of occupational and environmental medicine at public health level and individual diseases, 2. The residents are trained with unique conditions in the military career in a military environment, 3. The residents acquire medical and public health qualifications and work as the chief physicians in the high ranks of Department of Defense, 4. Acquiring knowledge, attitudes and skills in epidemiology, infection control, and tropical diseases in war, 5. Paying attention to occupational and environmental health in military divisions, 6. Medical responsibility against nuclear, biological, and chemical events, 7. Paying attention to special health cases in basic trainings such as acute respiratory infections and designing barracks, 8. Considering the aspects of health in the quick replacement of forces and assessment of medical threats and their security, 9. Organizing the activities of physicians of military medicine and professional medicine in the barracks within the established military forces, 10. Paying attention to legal requirements and regulations in the region and the states that have military personnel and posts, 11. Medical cares from workers exposed to nuclear, biological, and chemical substances (4).

What are the specialized courses of Military Medicine at doctoral degree in world's leading universities?

Table1. The courses of the American USUHS University are presented in the following table.

The courses of General Military Medicine in Slovakia that have been cited (10) as the following (Table2).

Table2. The courses of General Military Medicine in Slovakia

What are curriculum design objectives of the general physician with military approach in Iran?

It is expected for the specialists of general military medicine to have the following abilities (knowledge, attitude and experience) (Table 3)

Table3. Abilities (knowledge, attitude and experience)

The above table shows that the objectives determined for general military medicine were approved by experts and elites of military medicine. All determined objectives were agreed by more than 70 percent and some important goals such as nutrition affairs, research in military medicine, care for the injured and patients, the treatment of the injured and trauma patients, and preventive medicine was agreed by experts with more than 90%, because the objectives have determined from the results of need assessment and the intended needs have been specified by these experts.

What are the specialized courses of Military Medicine at doctoral degree in Iran?

In your opinion, how much the proposed content is appropriate for the determined objectives?

Table 4. Specialized courses of Military Medicine in Iran

Table 4 shows that the experts agreed more than 70 percent with designed lessons for intended objectives except the Radiography Interpretation that received an agreement of 61 percent to be incorporated in the curriculum of the general military medicine. According to this table, the key courses such as medical ethics, care and treatment of the sick and wounded, military health, crisis (disaster) medicine, etc., received an agreement of more than 90 percent.

Table 5. Courses of Military Medicine

Table 5 shows the new courses of general medicine curriculum in doctoral degree. For each course, in addition to the current curriculum, the following military courses have been presented.

The learning-teaching methods and evaluation  

According to the type and content of new courses and also the characteristics of learners in new curriculum the teaching methods of lecture, question and answer, goal and scenario-based learning, discussion in small groups, cooperative learning, problem solving, field trips in military environments, film screenings and also the evaluation methods of the internship report or practical project, portfolio, participation in discussions, conferences in the classroom, translation (article or book), the written assessments (continued and final) will be used more.

DISCUSSION

Medical curriculum at military medical universities in the world is different based on their circumstances. In American University of USUHS, there is a special curriculum for military medical students. The content of this curriculum is 700 hours more than the curriculum of other universities. In this curriculum, the topics of military preventive medicine, medicine of military events, military emergency medicine, medical logistics, management and administration of the wounded on the battlefield, etc., are emphasized. By passing these courses of military medicine, students will receive the preparedness to recognize and treat diseases and combating and non-combating trauma injuries (10). The Czech and Slovakia military curriculum for military medical students includes about 54 theoretical and practical specific military medicine courses (11).

Thailand has a unique medical curriculum for medical officers in relation to military medicine. In terms of content, the curriculum includes the topics of prevention, assessment of threatening health issues, clinical care of illnesses and injuries caused by occupational exposure and evacuate the sick and injured. In other words, the curriculum includes military science, medical skills of war, military preventive medicine, applied military physiology and medicine of military job accidents (12). The Australian Quizland University has introduced a curriculum for military medicine aiming at training military physician officers to medical operations in military environments. The most important topics of this curriculum includes an introduction to health services in war (defense) for one week, medical inspection for two weeks, occupational and environmental health for 5 weeks, defense services in confronting chemical, biological and nuclear weapons for 6 weeks, aviation medicine for 7 weeks, medical air evacuation for 8 weeks, tropical medicine for 9 weeks, submarine medicine for 10 weeks, military epidemiology for 11 weeks, health care for soldiers for 12 weeks and practical ethics in military medicine for 13 weeks (7). In Jerusalem Hebrew University and Hadassah University in occupied Palestine, specific curriculum of military medicine includes marine medicine, air medicine, war medicine, internal medicine, emergency medicine, trauma and terror medicine, sport medicine, climate medicine (vulnerability due to weather and climate conditions) and management of mass casualties in war conditions and unexpected crises (13).

Baghiattollah (AJ) University of Medical Sciences has designed the discipline of military medicine in military emergency in doctoral degree. In this curriculum the teaching aspects of the curriculum includes objectives, content, teaching-learning strategies and evaluation, and the important courses such as principles of military medicine, health and preventive medicine in crisis and war, disaster medicine, medical ethics, forensic medicine, triage and transporting the wounded, emergency medicine, anesthesiology, emergency cyclic courses, environmental medicine, statistics and research methodology, surgery, internal medicine, clinical traumatology, orthopedics, aerospace medicine, familiarity with accidents, and occupational diseases in armed forces (7,8).

With more serious institutional need to military medicine and not allowance to continue this trend, that is, the training of physician with the same typical and national program, and also according to the importance of military medicine for the armed forces, reviewing the curriculum of the military medicine at the universities of Iran is a matter of urgency (7). So Iranian military medical universities must review their curricula according to the needs of the audiences of the curricula as what there were in the present study.

Military medicine curriculum designed with the military medicine approach in this study is a special program that includes materials of 30 theoretical-practical and training course related to military medicine. As well as some changes have been made in the rest of the existing courses, that is, the specific topics of military medicine in basic and clinical courses have been added to the existing curriculum consistent with present study. In fact, the curriculum and its content is an additional program to the general medicine curriculum in doctoral degree. In the present program, physicians can be trained to have enough knowledge, skills and attitudes to meet the needs of military medicine for health of military personnel.

Limitations of the present study include limited research sample of faculty members and experts in Baqiyatallah and AJA University of Medical Sciences. The lack of the available resources on military medicine in other countries, and the poor cooperation of some experts to participate are noted in the present study.

Ethical considerations 

Ethical issues (Including plagiarism, informed consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc.) have been completely observed by the authors.

ACKNOWLEDGEMENT

The authors would like to thank the deputy of research, experts and authorities who helped to conduct this study.

Financial Support:

This article was taken from a research project approved no 993422 by the deputy of research and technology at AJA University of Medical Sciences.

Conflict of Interest: we have no conflicts of interest. This manuscript has not been previously published or submitted