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CHAPTER 1 INTRODUCTION 1.1 Rationale and justification of the study Oral diseases, such as dental caries and periodontal diseases are most common chronic infectious diseases. Most caries and periodontal diseases are preventable, as recommended by resolution WHA 53.17 of the Fiftythird World Health Assembly in 2000 (1). However, the consequences of oral diseases are not only affected to oral cavity, but also to other systemic diseases such as diabetes, cardiovascular diseases, or respiratory diseases, preterm and low birth weight (2). There are several bacterial strains in normal flora of the oral cavity. Most of them are pathogens. Bacteria exist mainly inside the dental plaque and dental calculus and on the surface of soft tissue. Dental plaque was formed from mixture of food, saliva and other organic compounds inside oral cavity and it is the main cause of oral
MOVING THE MOUNTAIN: RENOVATING MEDICAL EDUCATION IN A CHANGING VIETNAM Luu Ngoc Hoat MOVING THE MOUNTAIN: RENOVATING MEDICAL EDUCATION IN A CHANGING VIETNAM Luu Ngoc Hoat ISBN: 978-604-66-0001-5 Front cover illustration: Photograph of the main building of Hanoi Medical University, the institution that led the process of change in medical education in Vietnam, with the support of the Ministry of Health, Ministry of Education and Training and the Netherlands-financed project The building was completed in 2002 but in the style of the original university established 100 years earlier VRIJE UNIVERSITEIT MOVING THE MOUNTAIN: RENOVATING MEDICAL EDUCATION IN A CHANGING VIETNAM ACADEMISCH PROEFSCHRIFT ter verkrijging van de graad Doctor aan de Vrije Universiteit Amsterdam, op gezag van de rector magnificus prof.dr L.M Bouter, in het openbaar te verdedigen ten overstaan van de promotiecommissie van de faculteit der Aard- en Levenswetenschappen op dinsdag 25 november 2008 om 10.45 uur in de aula van de universiteit, De Boelelaan 1105 door Luu Ngoc Hoat geboren te Nam Dinh, Vietnam promotoren: copromotoren: prof.dr E.J Ruitenberg prof.dr G.J van der Wilt dr E.P Wright dr J.E.W Broerse “Nếu kế hoạch tâm phải mười biện pháp phải hai mươi.” “If the plan is one, the determination must be ten and the measure must be twenty.” Ho Chi Minh The first President of Vietnam Members of the Thesis Committee: • Prof.dr J.C.C Borleffs, University Medical Centre Groningen • Prof.dr J.F.G Bunders, VU University Amsterdam • Prof.dr F Scheele, VU University Amsterdam • Prof.dr Truong Viet Dzung, Hanoi Medical University TABLE OF CONTENT Chapter 1: Introduction 1.1 Aim and purpose of the thesis 1.2 Theoretical Background 1.2.1 Medical education development 1.2.2 Management of change 1.3 Research design 17 1.3.1 Main objectives and research questions .18 1.3.2 Brief case description 19 1.3.3 Research methods 21 1.3.4 Research validity 25 1.3.5 Research team 27 1.4 Outline of the book 27 Chapter 2: The context for development of medical education in Vietnam 37 2.1 Health system in Vietnam 37 2.2 Human resources in the health system 40 2.3 Health indicators and changing disease patterns 44 2.3.1 Health indicators 44 2.3.2 Changes in disease patterns 46 2.4 Development of medical education in Vietnam and need for intervention 47 2.4.1 Colonial occupation by France (1886 – 1945) .48 2.4.2 Wars with France and America (1945 - 1975) .49 2.4.3 After the wars but before innovation (“Doi moi”) (1975 – 1985) 50 2.4.4 After innovation but before the intervention of a Dutch project for medical education (1986 – 1994) 50 Chapter 3: Medical education changes with support from an international project 55 3.1 Situation analysis at the beginning of the project 55 3.2 Main objectives, strategies and activities of the first phase of the project 59 3.3 Main objectives, strategies and activities of the second phase in comparison with the first phase of the project 67 3.4 Changes along the way: revision of plans on the basis of experience during implementation 74 3.5 Limitations of the project in medical education development and efforts to overcome them 76 Chapter 4: Constraints, challenges and lessons learned of the first phase of the project 85 4.1 Obstacles to the introduction of change in the medical schools 85 4.1.1.Isolation of Vietnam and its medical schools until recent years .85 4.1.2 Lack of standards for medical doctors as end-points for medical training 86 4.1.3.Low status of public health in medical schools .86 4.1.4.Time constraints 87 4.2.Constraints and obstacles in project implementation 88 4.2.1.The understanding between the four medical schools and KIT .88 4.2.2.Misunderstandings after Workshop on curriculum .90 4.2.3.Conceptual differences .91 4.2.4.Identification of indicators for project monitoring 91 4.2.5.Sustainability .93 4.3.Lessons learned 93 4.3.1.Language 94 4.3.2.Balance between motivation and sustainability 94 4.3.3.Time 95 4.3.4.Strengths and weaknesses of the schools 95 4.3.5.Future developments 96 Chapter 5: Participatory identification of learning objectives in eight medical schools in Vietnam 99 5.1 Introduction 99 5.2 Project aim 101 5.3 Methods to identify learning objectives (needed KAS) 101 5.4 Results of the steps in the process 102 5.4.1 Step 1: Inter-school workshop on KAS process 102 5.4.2 Step 2: Policy documents 103 5.4.3 Step 3: Formulation and selection of KAS topics 103 5.4.4 Step 4: Teaching staff contributions 105 5.4.5 Step 5: Achieving consensus .106 5.4.6 Step 6: Skills levels 106 5.4.7 Step 7: KAS survey 107 5.4.8 Step 8: Final KAS book 107 5.5 Difficulties with key concepts 107 5.5.1 Distinguishing among knowledge, attitudes and skills 107 5.5.2 Selecting the problems and issues for KAS lists 108 5.6 Coordination system 108 5.7 Discussion 109 5.8 Conclusion 111 Chapter 6: Practicing doctors’ perceptions on new learning objectives for Vietnamese medical schools 115 6.1 Background 115 6.2 Methods 117 6.2.1 Study design 117 6.2.2 Study participants 117 6.2.3 Data collection tools 117 6.2.4 Qualitative data 119 6.2.5 Data analysis 119 6.3 Results 119 6.3.1 Key characteristics of the study population .119 6.3.2 Relevance of skill levels set by teachers and perception of the practicing doctors .120 6.3.3 Frequency of using selected skills according to discipline 122 6.3.4 Appropriateness of skill levels set by teachers compared to frequency of use by practicing doctors 123 6.3.5 Priority of the selected skills as perceived by practicing doctors 125 6.3.6 Discrepancies between skill levels set by teachers and priority rating by practicing doctors 125 6.3.7 Focus group discussions 127 6.4 Discussion 129 6.5 Conclusions 131 Chapter 7: Perceptions of graduating students from eight medical schools in Vietnam on acquisition of key skills identified by teachers 135 7.1 Background 136 7.2 Methods 137 SAMENVATTING ondersteuning, waardoor het proces sneller verliep en technisch van een kwalitatief hoger niveau was De participatieve benadering, waarbij rekening werd gehouden met de meningen en ervaringen van vele belanghebbenden, resulteerde in een gevoel van eigendom en een bereidheid om het veranderingsproces ook na beëindiging van het project voort te zetten Hierdoor werden duurzame resultaten behaald Het feit dat er niet alleen ervaren docenten, maar ook beginnende stafleden, studenten, afgestudeerden en een scala aan mensen uit de samenleving werden betrokken, maakte het voor iedereen makkelijker om de verandering te accepteren Dit proces opende tevens de deur voor veel andere projecten, die sindsdien op de fundamenten van het eerste project zijn voortgebouwd Dit heeft geleid tot een effect dat geen deel uitmaakte van het oorspronkelijke plan, maar effectief bijdraagt aan de duurzaamheid ervan Het veranderingsproces in de acht medische opleidingsinstituten loopt nog steeds Zolang er blijvende aandacht is voor de geïdentificeerde factoren en voor de voortdurende ontwikkeling van het onderwijs in de medische opleidingsinstituten, zullen de afgestudeerden van deze opleidingsinstituten in toenemende mate in staat zijn de voortdurende veranderingen in de behoeften en eisen van de gezondheidszorg in Vietnam het hoofd te bieden 228 TĨM TẮT Mục đích giáo dục chuẩn bị đầy đủ kiến thức cho sinh viên để trường họ thực tốt vai trị với xã hội Hệ thống giáo dục muốn có hiệu phải đáp ứng nhu cầu xã hội có thay đổi phát triển kinh tế sách Cũng vậy, giáo dục y học cần phải đáp ứng thay đổi nhu cầu chăm sóc sức khỏe người dân Kể từ có sách mở cửa vào năm 1986, việc áp dụng chế thị trường Nhà nước cho phép loại hình kinh tế tư nhân phát triển dịch vụ chăm sóc sức khỏe Việt Nam có nhiều thay đổi Những sách tạo tiền đề cho việc đời nhiều sách khác chúng tạo nên động lực để tạo thay đổi lớn lao kinh tế, văn hóa xã hội cho quốc gia, thay đổi ảnh hưởng rõ rệt lên mơ hình bệnh tật nhu cầu yêu cầu chăm sóc sức khỏe người dân Cũng giai đoạn này, đời phát triển bảo hiểm y tế, viện phí phát triển dịch vụ y tế tư nhân công tác chăm sóc sức khỏe dần thay loại hình chăm sóc sức khỏe có bao cấp Nhà nước trước Ngồi ra, sách địi hỏi bác sỹ phải đào tạo theo hướng cộng đồng thay cho cách đào tạo hướng bệnh viện trước Chính tính cấp thiết nhằm đáp ứng với địi hỏi sách xã hội nên giáo dục y học Việt Nam cần phải có bước chuyển biến thích hợp Nhận thức thách thức này, Trường Đại học Y Việt Nam đề nghị Chính phủ Hà Lan hỗ trợ cho dự án (cả tài kỹ thuật) để thực q trình đổi giáo dục y học Công việc năm 1994 tiếp tục qua hai giai đoạn Dự án đầu năm 2006, Dự án lại tiếp tục thực giai đoạn năm 2012 Chính hỗ trợ mà tám Trường Đại học Y Việt Nam có hội tốt tạo thay đổi để đáp ứng tốt yêu cầu sách xã hội Trong Luận án này, học kinh nghiệm có từ q trình thay đổi nêu mơ tả phân tích Chúng tơi chia sẻ kinh nghiệm học thu trình đổi giáo dục y học theo xu hướng cộng đồng, bối cảnh cộng đồng đổi suốt 12 năm qua tác động phát triển kinh tế sách Chúng hy vọng trường đại học y khác nước học tập từ học, kinh nghiệm mà thu Câu hỏi nghiên cứu trọng tâm luận án là: 229 TÓM TẮT Các điều kiện, đầu vào hoạt động cần thiết mà Dự án cần có để tạo đóng góp bền vững cho việc đổi giáo dục y học ngữ cảnh thay đổi nhanh chóng kinh tế xã hội Việt Nam? Nghiên cứu bắt đầu với việc phân tích thực trạng việc lập kế hoạch cho nhiều can thiệp dựa số tiêu chí với mức độ ưu tiên khác Quá trình đổi giáo dục y học đóng góp Dự án cho q trình phân tích thơng qua phương pháp tiếp cận đánh giá nghiên cứu trường hợp (Case study evaluation approach) Một loạt phương pháp thu thập số liệu sử dụng thời điểm khác suốt trình đổi giáo dục y học 12 năm qua Các phương pháp bao gồm việc tham khảo tài liệu quốc tế nước, điều tra, thăm dò đối tác liên quan khác nhau, sử dụng câu hỏi tự điền, vấn, thảo luận nhóm quan sát Một số học thuyết mơ hình lĩnh vực giáo dục y học, kinh doanh, quản lý sử dụng để phân tích q trình thay đổi Đặc biệt tham gia bên liên quan, phương pháp động viên, thúc đẩy, thay đổi hành vi trì tham gia đối tác Nghiên cứu đề cập đến câu hỏi chi tiết sau Các yếu tố liên quan đến thay đổi tổ chức Dự án cân nhắc thay đổi giáo dục y học Việt Nam? Mơ hình Tổ chức Lồng ghép (Integrated Organizational Model -IOM) áp dụng để phân tích thực trạng phân tích tổ chức mơ hình cung cấp khung lý thuyết giúp cho việc cân nhắc đồng thời nhiều yếu tố chủ thể bên bên tổ chức Trong nghiên cứu này, yếu tố môi trường bên Trường Đại học Y đề cập bao gồm yếu tố kinh tế, sách, văn hóa xã hội chủ thể bên ngồi bao gồm nhóm đích, nhóm hưởng lợi, nhà cung cấp, nhà tài trợ, đối tác cạnh tranh Các yếu tố bên Trường Y bao gồm cấu trúc tổ chức, hệ thống, chiến lược, phong cách quản lý, văn hóa tổ chức phương pháp khuyến khích, động viên nhân viên Phương pháp rà sốt mơi trường (environmental scan) phương pháp phân tích điểm mạnh, yếu, hội thách thức tổ chức (SWOT analysis) sử dụng với khung IOM để nghiên cứu môi trường ngữ cảnh mà trình thay đổi diễn Một số lý thuyết mơ hình khác sử dụng nghiên cứu mơ hình Khuếch tán Đổi (Diffusion of Innovation), Cửa sổ Johari (Johari Window), Lý thuyết Động viên Herzberg (Herzberg’s Motivation Theory) để phân tích đánh giá can thiệp tác động Dự án trình đổi giáo dục y học nào? Cho bên liên quan? Có phù hợp hay khơng? Tại lại phù hợp không phù hợp? Kết phân tích cho thấy lý thuyết mơ hình quản lý nêu thích hợp phân tích bối cảnh thay đổi giáo dục y học Việt Nam hữu ích khơng cho hiểu biết mà giúp cho việc hướng dẫn trình thay đổi 230 TĨM TẮT Kết cho thấy hỗ trợ Dự án, Trường Đại học Y cân nhắc kỹ yếu tố bên bên ngoài, điểm mạnh, điểm yếu Trường giai đoạn để lựa chọn chấp nhận can thiệp thích hợp, khả thi có hội thành cơng cao Các Trường gặp phải khơng khó khăn, thách thức trình đổi Các học kinh nghiệm, đặc biệt việc áp dụng mơ hình nhận thức thay đổi góc nhìn khác nhau, mơ hình thu hút động viên bên liên quan có ích việc dẫn dắt, điều tiết trình thay đổi Tiếp cận theo cách có tham gia nhà trường-cộng đồng ứng dụng mức độ để phát triển mục tiêu học tập thích hợp cho sinh viên Trường Y Việt Nam, để làm sở cho việc phát triển chương trình, tài liệu/phương pháp dạy học công cụ đánh giá? Ở Việt Nam trước đây, việc điều chỉnh, xây dựng chương trình đào tạo y khoa mức chương trình khung thường nhóm nhỏ chuyên gia với lãnh đạo Trường Đại học Y Phòng Đào tạo thực thông qua việc sử dụng kinh nghiệm họ với việc cân nhắc chương trình cũ sách có liên quan Chính phủ Đây lần q trình đổi giáo dục y học có nhiều bên liên quan tham gia Bước trình thống mục tiêu học tập dựa tài liệu đóng góp từ giảng viên Mục tiêu học tập xây dựng thơng qua q trình có tham gia gần 1000 giảng viên từ tám Trường, thông qua hội thảo, tập huấn, seminar môn liên môn Trường khác Sản phẩm trình thảo sách xanh mang tên “Kiến thức, Thái độ, Kỹ cần đạt tốt nghiệp bác sỹ y khoa” Các kỹ mà giảng viên xác định sách sau kiểm định lại đóng góp hai nhóm bên liên quan chủ chốt khác 1,100 sinh viên năm thứ sáu tốt nghiệp tám Trường Y gần 800 sinh viên tốt nghiệp công tác sở y tế tuyến khác Kết từ nguồn đối chiếu với tập hợp để có cuối sách xanh Đây q trình phức tạp có tham gia nhiều bên liên quan diện rộng, thời gian năm tạo sản phẩm có giá trị ủng hộ chấp nhận lãnh đạo, giảng viên tám Trường Y Bộ Y tế phê duyệt Các bên liên quan tham gia mức độ việc làm cho giáo dục y học thích hợp với nhiệm vụ bác sỹ trường nhu cầu xã hội? Do lần ngàn giảng viên tham gia vào trình xác định mục tiêu, phát triển khung chương trình giảng dạy nên họ cảm thấy đánh giá cao, cảm thấy có quyền sở hữu sản phẩm 231 TĨM TẮT chuẩn bị để áp dụng sản phẩm vào q trình giảng dạy Khơng giảng viên hữu Trường mà giảng viên kiêm nhiệm bệnh viện, viện giảng viên hướng dẫn giảng dạy thực địa sở y tế nơng thơn có hội để đóng góp ý kiến nội dung sinh viên cần học Thơng qua việc tham gia vào q trình thay đổi tham gia giảng dạy sinh viên họ có dịp bổ sung kiến thức, nâng cao lực Đây lần đầu tiên, nhà quản lý y tế cán địa phương, thành viên cộng đồng hỏi ý kiến điều tra lớn tỉnh nằm khu vực đào tạo trường Đại học Y Các thành viên cộng đồng hỏi ý kiến mục tiêu giảng dạy thực địa, phương pháp chương trình mà sinh viên mang đến cộng đồng họ Các sinh viên hỏi số vấn đề trình đổi mới, từ giảng dạy thực địa đến kỹ cần phải đạt môi trường học tập Cách tiếp cận có tham gia rộng rãi mở cửa cho nhiều bên liên quan tạo điều kiện thu nhận đóng góp từ bên liên quan khác nhau, với quan điểm khác kết giáo dục y học nước nhà đổi đáp ứng tốt nhu cầu thay đổi xã hội Các điểm Dự án đóng góp cho thành cơng bền vững trình thay đổi giáo dục y học? Đánh giá cuối thành công Dự án thực sinh viên học xong chương trình giáo dục y học đổi công tác khoảng thời gian định xem họ cung cấp dịch vụ chăm sóc sức khỏe tốt hay khơng Thậm trí thời gian đủ cho triển khai đánh giá, yếu tố sai số nhiễu làm cho ta khó đánh giá thành cơng tính bền vững một tập hợp can thiệp Dự án Tuy nhiên, khuôn khổ Dự án, điều tra, đánh giá bên trong, bên thông tin thu thập từ nhà lãnh đạo, giảng viên sinh viên cho chứng chứng tỏ có nhiều thay đổi xảy việc giảng dạy có nhiều tiến Các lý dẫn đến thành cơng tìm thấy qua việc nhu cầu bên liên quan quan tâm, ý suốt trình thay đổi Điều đặc biệt quan trọng để khuyến khích động viên giảng viên, giảng viên hữu kiêm nhiệm bên ngồi nhà trường, đóng góp vào thay đổi cần thiết Ngay từ bắt đầu, Dự án xác định rõ quan điểm Dự án hỗ trợ cho Trường Bộ thực nhiệm vụ mà họ phải thực hiện, có nghĩa họ làm cho Dự án mà làm cho họ Dự án có hỗ trợ kỹ thuật tài để làm cho trình thay đổi diễn nhanh với chất lượng kỹ thuật cao Cách tiếp cận có tham gia, có cân nhắc đến quan điểm kinh nghiệm nhiều bên liên quan, kích thích vào quyền sở hữu, tính chủ động trách nhiệm bên liên quan, tạo cho họ hứng thú sẵn sàng tiếp tục với trình thay đổi sau Dự án 232 TÓM TẮT kết thúc Đó lý đáng ý việc tạo kết bền vững can thiệp Khơng giảng viên có kinh nghiệm mà cán trẻ, sinh viên, bác sỹ trường nhiều bên liên quan cộng đồng tham gia vào trình chuyển đổi Điều giúp người chấp nhận thay đổi cách dễ dàng Quá trình mở cánh cửa cho nhiều dự án khác xây dựng triển khai, điều khơng tạo động lực lớn cho thay đổi giáo dục y học mà cịn có hiệu đóng góp cho bền vững Quá trình thay đổi tiếp tục diễn tám Trường Đại học Y Nếu Trường tiếp tục quan tâm tới yếu tố tiếp tục phát triển theo hướng Dự án can thiệp, bác sỹ tốt nghiệp trường đáp ứng tốt với thay đổi liên tục nhu cầu yêu cầu chăm sóc sức khỏe người dân Việt Nam 233 ACKNOWLEDGEMENTS It was June 2004 when I applied to be a part-time PhD student at the VU University, Amsterdam (VUA), in the Netherlands One year later, in June 2005, I was promoted to be Vice-Rector of Hanoi Medical University (HMU), besides my daily work in the school as Head of the Department of Biostatistics, Vice Head of International Cooperation Department and member of the management boards of several units, divisions and projects, later including the University Hospital At that time, it was very hard for me to believe that I would be able to manage my time, energy and work to fulfill the requirements to complete a PhD within four years, while implementing the heavy workload in the University Therefore, several times I doubted whether I should continue doing this international PhD or should come back to a PhD in Vietnam Now, finally, my thesis is finished and I find myself at the point of writing thanks to the people who encouraged and supported me to this PhD and to those who shared my daily duties so that I could periodically focus on my study For me, the acknowledgement is the most difficult part of the thesis to write, because I cannot find enough words to express my gratitude to those who have supported me to come this far Therefore, I want to start by saying, from my heart, that I extend my sincere thanks to all of those who have contributed, directly and indirectly, to the success of my PhD study And I must say that without your support and encouragement I would never have finished it I must apologize if someone who has contributed does not find his or her name mentioned here, or if my thanks are not satisfactory to them Please forgive me This part should not be too long, and my language is not rich enough to express the many thanks that could satisfy all of you For my first words, I would like to express my deep gratitude to Prof Dr E.J Ruitenberg, the first promoter, who accepted and guided me as a PhD student and made a bridge for me to learn and work with other people at VUA The combination of his expertise, patience and kindness encouraged me to overcome difficulties that I have coped with during four years of studying The most challenging for me is how to write enough thanks to Dr Pamela Wright, since her contribution is not only for my PhD study but also for whole my life since I met her thirteen years ago For my PhD, she was the one who suggested that I apply to my PhD in the Netherlands when my study in Vietnam on the effects of leaded gasoline on children was no longer appropriate due to the change in policy of Vietnam She also introduced me to Prof E.J Ruitenberg and advised me to apply at the VUA And most importantly, she encouraged and supported me to continue with this PhD study when I felt depressed about the burden of the PhD on top of my heavy daily workload in Vietnam I realize that it is impossible to express enough thanks to her, so it may be wiser for me just to write that Dr Pamela Wright is my teacher, my adviser, my PhD co-promoter, my colleague, my friend and my sister and she has had excellent roles in all of these positions I must say that without her support, I could not have completed my study My thankfulness to Dr Pamela Wright, of course, cannot be separated from my thanks to Prof Peter Mason, her husband, who has extensive experience in writing and editing international scientific publications and gave comments and advice on my draft articles 234 ACKNOWLEDGEMENTS before we submitted them to the journals Besides that, he and Pamela have been very good “landlords” when I stayed in their house in Amsterdam during study periods there Their hospitality and especially the varied and delicious meals that I was served made me feel that my life was very luxurious, not the same as other PhD students abroad Another person that I find very difficult to thank enough is Prof Dr Nguyen Lan Viet, Rector of Hanoi Medical University When he asked me to be Vice Rector of the University, I said I was afraid that I could not accept, because the burden of my PhD study would affect the quality of my work as a Vice Rector He reassured me by saying “Don’t worry, when you have to go to the Netherlands for your PhD study, I will your work or assign it to other rector board members.” He kept his promise and I was able to go to the Netherlands six times for all together more than five months during my three years as Vice-Rector I must say that without that support, I could not have continued with my PhD study in Amsterdam From my heart, I consider Prof Nguyen Lan Viet not only an excellent boss, but also my very good colleague, my very faithful friend and my gracious brother I would like to address my sincere thanks also to Prof J.F.G Bunders, who is not my promoter but has played an important role to coordinate among the promoters and copromoters to support my study As the Head of the Biology and Society Department and Director of the Athena Institute for Research on Communication and Innovation in Health and Life Sciences, VUA, she has considered me a colleague more than a PhD student We have discussed at length how to develop further collaboration between VUA and HMU and other institutions in Vietnam I am happy to say that my PhD study has opened the door for the collaboration between VU and HMU My sincere thanks are devoted to the second promoter, Prof G J van der Wilt, who was always available and responded quickly when I needed his help He guided me in detail how to improve my articles and the thesis and I always found it encouraging to learn from him The second co-promoter, Dr Jacqueline Broerse, became formally involved in guiding my PhD only recently, but in fact she helped me from the beginning by advising me as I developed the outline and theoretical framework of my thesis Her comments and suggestions were always quick, detailed and critical, encouraging me to improve my thesis I learned a lot from her expertise and want to express my appreciation for all the time she spent to help me complete the thesis This whole project was only possible because of the excellent cooperation with the Royal Netherlands Embassy in Hanoi through all these years We worked with First Secretaries, Ms Marieke Boot, Ms Els Klinkert, Ms Maaike van Vliet and Dr Ger Steenbergen, who all supported the project not only financially but also with their ideas and their flexibility to allow the project to evolve as the needs in the schools evolved Throughout the whole period, the Program Officer Ms Nguyen Nu Hoai Van was also supportive and encouraging to all of us in the project We are grateful that all of these people and their colleagues in The Hague recognized that such change processes take a long time and were willing to support the medical schools for several years They can be as proud as we are of the results When I was studying at the VUA, I also received support in different ways from other staff there, such as Balram Bissumbhar, Prof Tj De Cock Buning, Frea Haker and Kees Swaans, 235 ACKNOWLEDGEMENTS as well as the secretarial staff I would like to thank all of them for their contribution to my success Apart from VUA staff, I enjoyed enormous support, both physical and spiritual, from other friends and colleagues in the Netherlands when I studied there On this occasion, I would like to express my gratitude to those at the Royal Tropical Institute (KIT) who were involved in the project during the first phase (Dr Herman Folmer, Dr Dee Burck, Dr Prisca Zwanikken, Ms Jenny Postema, Mr Jean Biezen) Among them, I would like express my special thanks to Dr Prisca Zwanikken, KIT’s Area Leader for education, and Ms Marjolein Dieleman, for their continuing support for medical education in Vietnam They also offered me opportunities to improve my capacity and to work as a trainer and consultant in the Netherlands in combination with my PhD study My special thanks go to Ms Jenny Postema and her family; their support to my whole family and their attention to interesting activities for my free time helped to reduce the stress of the study and to make me feel as though I had a family in Holland too I was also lucky to have another home in Amsterdam, at the office of Medical Committee Netherlands-Vietnam (MCNV) on the Weteringschans My special gratitude is addressed to the staff there, Willie, Ab, Karin, Carlijn, Veronique, and Ron, for their very warm welcome and support whenever I was there In Vietnam, staff in the MCNV offices in Vietnam also treated me like a member of the family, and encouraged me in my study My thanks go to Thuy Huong, Hong Ha, Loan, Nga, Ha Viet, Hieu, Quang, Ha Lan, Lan Ha and all the others, too many to list all of their names here Not only friends in the Netherlands but also in Australia provided ideas for this work; Assoc Prof Anna Whelan, University of New South Wales, carried out the external evaluation and used that opportunity to share her experience and views on changing medical education, which taught me a lot I realize that my PhD study could not have been completed within four years if I had not received so much support and sharing from the other Rector Board members of HMU Therefore, I would like to express my sincere thanks to other Vice Rectors: Assoc Prof Pham Nhat An, Assoc Prof Dao Van Long and Assoc Prof Do Doan Loi, who always encouraged me and shared my duties when I was on study leave After taking on the position of Vice-Director of the University Hospital in early 2007, I had to leave my management tasks to the Hospital Director, Assoc Prof Dao Van Long and another ViceDirector, Dr Bui Van Lenh, when I went out for my PhD study I would like to take this opportunity to express my thanks to all of them Of course, the leaders and staff of departments and divisions of HMU and the University Hospital in my management area had to work harder and more independently when I was not available in Vietnam My thanks and appreciation are directed at all of those who have been working in these departments and divisions and keeping things going in my absence Among them, I would like to express especial thanks to Mr Tran Anh Tuan, Vice Director of Printing Center of HMU where I have been Director since 2006 and all of staff there (The, Dung, Diep, Linh, Hue, Thu, Son…) for their supports and sharing works of the Center when I was away and especially for their effort to prepare procedures and to print this book as it is expected both in terms of quality and timing 236 ACKNOWLEDGEMENTS This thesis is based mainly on articles published in international journals For these publications, I used data, reports, documents and results from surveys, researches and exchange visits from the Vietnam-the Netherlands project on strengthening of teaching in medical schools in Vietnam The main financial support for my study periods in Amsterdam came from this project My sincere thanks are therefore due to the Directors of the project (Assoc Prof Ton That Bach and Prof Nguyen Lan Viet), the Project Coordinators before and after my time in that position (Assoc Prof Nguyen Tran Hien and Dr Nguyen Thi Bach Yen), Senior Technical Advisers and Coordinators from the Dutch side (Dr Herman Folmer and Dr Pamela Wright) Thanks also to the members of the Project Steering Committee, representatives of the Ministry of Health and Ministry of Education and Training, experts of the project and the project team leaders in the eight medical schools in the different project phases (Nguyen Van Hien, Ho Hieu, Nguyen Do Nguyen, Truong Ba Nhan, Hac Van Vinh, Nguyen Ngoc Sang, Tran Quoc Kham, Vo Van Thang, Do Van Dung, Pham Thi Tam, Hoang Xuan Thao, Vuong Minh Ngoc) Also thanks to the project accountant Ms Le Thi Tuyet, the project secretaries and all the project team members We all benefited from the inputs from the thousands of teaching staff who participated in the project activities, the thousands of students, health staff and other stakeholders involved in medical education change with the support of this project Without their active participation the process of medical education change in Vietnam could not have reached the success it did, and consequently I could not have done a PhD on this topic The contribution for my study came not only from the project, but also from the Community Health Training and Consulting Network (CHTCN) in the medical schools, one concrete outcome of the project Many members of CHTCN participated in the projects and studies that provided data for my thesis, such as the pilot project on field teaching in Melinh and the study to get feedback from sixth year students on KAS Let me express my thanks to those who participated in these essential activities, including as Pham Ngan Giang, Hoang Van Minh, Le Thi Thanh Xuan, Ha Thu Huong, Le Thi Hoan, Kim Bao Giang, Nguyen Thuy Hanh, Le Van Hoi, Quỳnh Anh, Hoang Hai Van, Do Thanh Toan and others, too many to mention all their names here Especially Carlijn van Aalst helped me a lot with the international literature reviews, Pham Ngan Giang helped with the Vietnamese literature reviews and data analysis when we were drafting the articles and the thesis Their expertise in Internet searches save me a lot of time My thanks are due also to the leaders, teachers and staff of the Faculty of Public Health, Hanoi Medical University, where I have been working since I graduated from medical school in 1980 I am especially grateful to my colleagues in the Department of Biostatistics and Medical Informatics and Department of Demography (Prof Dao Ngoc Phong, Le Van Hoi, Nguyen Thi Thuy Hanh, Hoang Hai Van, Do Thanh Toan, Pham Ngan Giang, Lam Van Chien…) Without their support, encouragement and sharing of my duties, how could I have finished my study in just four years? I am also grateful to my colleagues at the Department of International Cooperation of HMU, where I was the Vice Head of Department from when I started to be a PhD student until early 2007, when I moved to be Vice Director of the University Hospital The colleagues always encouraged me and shared my work when I was absent for my study 237 ACKNOWLEDGEMENTS My sincere thanks also go to the many friends, colleagues and staff whose names are not mentioned above, for sharing with me the moments of happiness and sadness during my PhD I would love to give my most heartfelt thanks to my father and my mother Even though my mother died two years before I registered as a PhD student, her image has been with me always and has given me strength and encouragement, especially when I was depressed Spiritual support also came from my parents-in-law, and my adoptive mother, the late Leah Wright, in Canada; special thanks go to them and to all other members of my family, including the in-laws, for the support they have given to me through all the years from when I was a small child in a poor family in a village beside the Red River up to now, when I have some achievements in my study and career And last but not in any way the least, my words are addressed to my wife and my two sons, who have given me not only love, but also their priority and encouragement to enable me to concentrate on my study They share fully in my success in completing this PhD As everyone, knows, written words never can be sufficient to express strong feelings What I can say is only that I belong to them, I care for them and will always my best for them and all my family 238 MEDICAL PUBLISHING HOUSE MOVING THE MOUNTAIN: RENOVATING MEDICAL EDUCATION IN A CHANGING VIETNAM Responsible Publisher HOANG TRONG QUANG Edited by: Pamela Wright Book formatted by: Luu Ngoc Hoat Cover designed by: Luu Ngoc Dung Printed 500 copies, size 16 x 24 cm at Hanoi Medical University Printing Center, Hanoi, Vietnam Publishing permit No 929-2008/CXB/1-118/YH, Medical Publishing House Completed and registered in October 2008 Nearly 200 heads and vice-heads of line departments from the eight medical schools discuss actively about the details of the KAS lists at one of the two big inter-school workshops organized to finalize the learning objectives for general medical students in Vietnam 241 Changing medical curriculum and the teaching and learning in medical schools to respond to the changing needs of society is necessary, but medical schools have not always been quick to respond to that demand Changing a medical school is considered very hard work, according to a teacher in one Vietnamese school, even harder than “moving a mountain” With project support from the Netherlands Government, eight medical schools in Vietnam worked together for more than 12 years to change their training of general medical doctors The process was comprehensive, from formulating new and more communityoriented learning objectives through revising the curriculum, developing and applying new teaching and learning materials, to updating teaching methods and student assessment tools Using the case study evaluation method, the change process was dissected and analyzed and the achievements and limitations of the medical education changes made with the support of this project were assessed Experiences and lessons learned from this case can be shared with other medical schools that want to change their education A key product in the change process was a book presenting detailed learning objectives for general medical students The 350-page book presents the knowledge, attitudes and skills (KAS) that medical doctors are expected to have when they graduate from any medical school in Vietnam The KAS book, pictured below, has been approved by the Ministry of Health for use in all medical schools in Vietnam Luu Ngoc Hoat is currently Head of the Department of Biostatistics and Medical Informatics and Vice Rector of Hanoi Medical University, the lead school in the project to support medical education change in Vietnam ... methods and related materials used in the teaching The range includes the classical lecture approach as well as a variety of more active and interactive approaches, including problem- or scenario-based... related to organizational change, that need to be taken into account when changing medical education in Vietnam? To what extent can a participatory and community-university approach be applied to... What are the factors related to organizational change that need to be taken into account when changing medical education? , the main data collection methods were document analysis and literature