A Path Less Taken: Reshaping the Future of Medical Education with a Community Focus in Pakistan

A Path Less Taken: Reshaping the Future of Medical Education with a Community Focus in Pakistan | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A Path Less Taken: Reshaping the Future of Medical Education with a Community Focus in Pakistan Irum Gilani, Azhar Rashid, Rahila Yasmeen, Ziyad Afzal Kayani This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6504864/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Community-based medical education (CBME) enhances social accountability by incorporating medical training into community settings. As part of the ongoing reform of undergraduate medical education, the Pakistan Medical and Dental Council (PM&DC) is committed to cultivating the attribute of "Community Health Promoter" within the framework of "Seven-Star Doctors" in Pakistan. Methods A qualitative exploratory study was conducted using focus group interviews at four medical colleges in Rawalpindi and Islamabad to explore the implementation gaps in community-oriented and community-based medical education (COME and CBME) at the undergraduate level in Pakistan. Results Except for one deviant case, fourteen participants in this research reported that their only exposure to community-based activities occurred during field visits throughout their undergraduate studies and faculty experiences. Despite being an outlier in experiences, the insights provided by the deviant case reinforced the thematic analysis of this study, highlighting the urgent need for clear regulatory guidance to bridge hospital-based medical education and community-oriented primary health care (PHC). Conclusion The experiences articulated by the outlier participant underscored a self-imposed social accountability mechanism embraced by a few medical colleges in Pakistan. This qualitative study pointed out the urgent need for regulatory standards across the country, aiming to integrate clinical, preclinical, interdisciplinary, and interprofessional medical education for advancing universal health coverage (UHC) in Pakistan. COME CBME PHC UHC Pakistan Figures Figure 1 Figure 2 1. Background The delivery of medical education has evolved to better address the healthcare needs of local communities. Future doctors must understand the social determinants of health to be socially responsible [ 1 ]. The community-oriented approach to medical education, rooted in the "Health for All" vision of the 1978 Alma Ata Conference, includes Harden's SPICES model for Community-Based Medical Education (CBME) [ 2 ]. The transfer of medical education to the community is complex. Different Community-Oriented Medical Education (COME) models are implemented globally [ 3 ]. The Pakistan Medical & Dental Council (PM&DC) is reforming to produce "Seven-Star Doctors," with "Community Health Promoters" as one attribute. However, most Pakistani medical colleges lack a structured framework for Community-Based Activities (CBAs) and assessment [ 4 ]. The Aga Khan University (AKU) in Karachi, Pakistan, has successfully implemented the COME curriculum since 1985 [ 5 ], but its introduction in the public sector faced a setback in 2004 [ 6 ]. This research aimed to explore practices regarding CBAs of the medical colleges in Pakistan's twin cities (Rawalpindi & Islamabad) for formulating recommendations to integrate CBME into undergraduate medical education in Pakistan. 2. Methods This exploratory qualitative study employed the focus group interview (FGI) technique, drawing insights from fifteen participants across four medical colleges in Rawalpindi and Islamabad. All participants provided written informed consent before enrollment in this Institutional Review Committee-approved study. The COREQ (COnsolidated criteria for REporting Qualitative research) checklist was utilized to ensure the quality assurance. The following procedure was adopted to conduct four focus group interviews (FGIs): - 2.1) Before an FGI The medical college's website was checked for the mission statement, curriculum details, student selection criteria, regarding diversity and equity in recruiting from underserved or underrepresented backgrounds and local health workforce needs. 2.2) Approaching Research Participants before an FGI The eligible (implementing outcome–based integrated curriculum) medical colleges were visited to meet with the principals and deans. A brief that included the research introduction, objectives, inclusion criteria, interview guide, and consent form was presented. Multiple visits were made to gain confirmation for the Focus Group Interviews (FGIs). 2.3) Approaching Research Participants during an FGI On the day of a Focus Group Interview (FGI), the researchers typically arrived at the designated venue about 45 minutes before the scheduled start time. This allowed for the setup of the PowerPoint presentation and the organization of folders containing pens, extra paper, and cover sheets for demographics and consent. "Name Cards" holders were arranged with plain paper and markers for participants to write down their names and designation. In the introductory slides aimed at building rapport, the researchers explained the purpose of the "Name Cards" — to facilitate the calling out of names for transcription — and the use of audio recording for transcription of the FGI. Each FGI was audio-recorded and stored on password-protected and encrypted drives accessible only to the research team. Observations and non-verbal cues were also noted in an FGI notebook. The participants were briefed about the importance of their "Name Cards" in audio–recording. The process of transcription with the help of audio recording was described to the participants. Before starting the FGI, written consent was obtained from the participants, including consent to the audio–recording and publication of results. Participants were assured de-identification of their responses before publishing the study findings. Additional "publication consent" is "not applicable" to this manuscript because no personal identifiers, images, or details of participants have been included that could compromise their anonymity and confidentiality. 2.4) Steps Taken Before Data Analysis The institutions and participants were assigned codes to facilitate data analysis. The introductory session and the prompts/questions for the focus group interviews (FGIs) were conducted in English, as outlined in Table 1 . However, discussions in the participants' native language ( Urdu - the official language of Pakistan) were encouraged to capture their views and opinions effectively. During transcription, the researchers translated the sections of Urdu dialogue into English. The NVivo version 10, a computer-assisted qualitative data analysis software (CAQDAS), was used. An inductive thematic analysis resulted in the "tree coding structure," comprising the initial fifty codes/nodes (Fig. 1 ) that stored references with their sources within the transcripts of the four FGIs. Table 1 Six Triggers Aligned with Research Questions Research Question 1: What community-based activities are part of the undergraduate outcome–based integrated curriculum in medical colleges in Pakistan's twin cities (Rawalpindi–Islamabad)? Theme recognized from the Literature Review Cues and Prompts Triggers for the First Research Question Community–based activities/practices ● Outcome–based curriculum ● Integrated curriculum 1. How do you reflect on your learning of community–related concepts as an undergraduate student? What are your views on the effectiveness of what lectures taught (back then) compared to teaching through community–based activities? 2. How do you perceive a "community setting" for community–based activities in undergraduate medical education? Research Question 2 : What community-based activities are part of the undergraduate outcome–based integrated curriculum in medical colleges in Pakistan's twin cities (Rawalpindi–Islamabad)? Themes recognized from Literature Review Prompt Triggers for the Second Research Question Community–based activities/practices Implementation of the COME (Community-Oriented Medical Education) and CBME (Community-Based Medical Education) by training the faculty, including a focus on interprofessional education, engagement of local GPs (General Practitioners), and the community. 3. What is Your opinion on the role of GPs (General Practitioners)/Family Physicians, interprofessional education, and community engagement in community–based activities? How can multidisciplinary teamwork be coordinated? 4. What community–based activities must be conducted by your university? Could you please share your experience (as faculty) with issues in implementing community–based activities in your institution, at present and in the past? Research Question 3 : What are the gaps and recommendations for implementing community–oriented and community–based medical education (COME & CBME) at the undergraduate level in Pakistan? Themes recognized from Literature Review Cues and Prompts Triggers for the Third Research Question ● Gaps in the implementation of COME and CBME ● Recommendations for the implementation of COME and CBME ● Interprofessional ● Issues related to funds, logistics, local GPs, community, and interprofessional ● Positive outcomes may include social responsiveness of the institution in terms of improved accessibility of the vulnerable population to basic health care, interprofessional education, enhanced linkages between the health system and medical education, intersectoral collaboration for social determinants of health, and community participation. ● Negative unintended outcomes may include the discontinuation of community–based rotations because of lack of funds, administrative, logistic, and security problems, or failure in the implementation of a CBME model due to conflict with the Department of Health, local representatives, including religious, political, Community, GPs, NGOs. 5. Considering cultural, social, and religious factors, including logistic and security concerns, what is your opinion on community–based activities to be included at the undergraduate level? Is there any activity that should be excluded? 6. "Community Health Promoter" is one of the PM&DC's (Pakistan Medical and Dental Council) competencies of a "Seven–star" medical graduate. Furthermore, PM&DC considers an integrated medical curriculum adequate when it is community–based. However, the PM&DC's skill training focuses on hospital-based activities. Considering this scenario, what are your thoughts on how community–based activities may be initiated and sustained in undergraduate medical education in Pakistan? 2.5) Summary of Data Analysis The researchers first listened to the audio recordings and reviewed the transcripts before proceeding with coding. The transcripts were open-coded to generate fifty codes using NVivo, incorporating both “in vivo” and descriptive codes without relying on a predetermined list. After analyzing the initial fifty codes, the researchers identified connections between concepts and reorganized them into ten sub-categories based on their relationships. These ten sub-categories were then merged into eight sub-themes. The sub-themes were further refined and consolidated into three main themes that directly addressed the research questions, complemented by participant quotations. 2.6) Quality Assurance Strategies 2.6.1) Credibility/Trustworthiness Cognitive interviews were conducted with five faculty members to prepare interview guide for data collection. Member checking was done via a WhatsApp group and a journal was maintained to record participants' expressions and non-verbal cues. 2.6.2) Transferability Research was conducted in participants' real-life settings, selected by institutional authorities based on detailed study introductions and inclusion criteria. One medical college belonging to the public and private sectors was chosen from each city to ensure that the study obtains a broader perspective. 2.6.3) Dependability The researchers kept a reflective journal to ensure that research findings were based on objective analysis rather than personal biases or preconceptions. 2.6.4) Confirmability Comprehensive documentation of data analysis, including triangulation, was maintained. The study incorporated the perspective of a single deviant case found in this research to ensure the findings accurately reflect the participants' views, minimizing the influence of researcher biases. 2.6.5) Reflexivity The research included personal, inter-personal, methodological, and contextual reflexivity [ 7 ]: 2.6.5.1) Personal Reflexivity Insights were gained during focus group interviews by enhancing participant engagement and identifying areas for improvement. 2.6.5.2) Inter–personal Reflexivity The researcher's role did not affect the data, and no power dynamics influenced her interactions, as participants were selected by their institutional heads. 2.6.5.3) Methodological Reflexivity Employing interpretivist and complexity theory, the researchers used a socio-material framework to analyze how various components interact in medical education, emphasizing continuous curriculum evaluation. 2.6.5.4) Contextual Reflexivity Focus group interviews were conducted in participants' workplaces to minimize bias and foster trust, allowing for candid discussions about community-based practices and recommendations for curriculum enhancement. 2.7) Theoretical Framework Three learning theories were utilized in this research’s theoretical framework (Fig. 2 ). Complexity theory is among the Socio–Materiality learning theories that focus on complex adaptive systems like Community-Oriented Medical Education (COME). Hence, this theory was used to analyze learning by Community–Based Activities (CBAs) that require interaction between students, faculty, community, healthcare system, healthcare professionals (e.g., nurses, lady health workers), and the material elements of the medical education system. Learning through COME is characterized by a dynamic, non–linear, unpredictable, and emergent web of social and material interplay [ 8 ]. More broadly, the government is also a part of this complex system in guiding through laws, funding, and other political strategies [ 9 ]. Socio–Cultural Situated learning theory of Lave & Wenger is relevant to the COME curriculum, where learning occurs in community settings [ 10 ]. In this way, the COME curriculum enables medical undergraduates to understand the health needs of their communities and the social determinants of health [ 11 ]. In medical education, the concept of social accountability necessitates a focus on engaging with the community. COME aims to cultivate social accountability in addition to inter-professional and inter-sectoral collaboration [ 12 ]. The implementation of the COME curriculum also utilizes Vygotsky's Socio-Constructivist Learning Theory [ 13 ]. COME is not just a way for students to learn; it is a whole strategy where students, faculty, local health authorities, health professionals, and people from the community are learning how to collaborate and participate in the improvement of the community and individual health. 3. Results Except for one deviant case, fourteen participants reported that field visits were their only exposure to community-based activities (CBAs), lacking defined learning outcomes and assessment strategies [ 14 ]. The deviant case, whether in the role of faculty or student, reported experiences significantly diverged from those described by other participants over the past fifteen years. Despite being an outlier, the deviant case’s experiences reinforced the broader participant recommendations, highlighting the urgent need for clear regulatory guidance to bridge hospital-based and community-oriented primary health care (PHC) models. 3.1) Divergent Experiences as an Undergraduate Medical Student The community-based activities (CBAs) in the deviant case's medical college were scheduled from the first year of the MBBS (medical graduation) program. The deviant case's departure from convention in undergraduate (UG) experience was noted when field visits emerged as the only CBA during the thematic analysis. Under the sub-themes, it was discussed that the regulatory authority had not specified the department responsible for the CBAs or field visits. The only CBA was conducted without learning objectives (LOs) or assessment under the Community Medicine (Com–Med) department in the fourth year of MBBS. Conversely, the deviant case's medical college had "Community Health Centers" set up in different city squatters. There was a "family ties program" where students would connect with at least two families in the community and follow their health problems for the next 2–3 years. Students would visit their assigned families in small groups of 2 to 3, accompanied by the facilitators. One day was reserved for community-based medical education (CBME); students would leave for the field/community visits after morning lectures. There would be an evening session where students reflect and discuss the day's activities in small groups, supervised by the facilitators. The deviant case's divergence from conventional norms was highlighted because safety and supervision concerns for traditional field/community visits emerged as serious concerns in this study. Additionally, the participants expressed a need for specifications regarding the number of visits, hours, or settings to be visited for the field visits. Participants suggested that the PM&DC's goal of cultivating the "Community Health Promoters" attribute in "Seven-Star Doctors" during undergraduate medical education cannot be achieved solely through traditional field visits. 3.2) Divergent Experiences as a Faculty As the Head of the Community Medicine (Com–Med) department, the deviant case initiated exposure to the students through a community–based clinic. However, this endeavor could not succeed due to the pre-clinical versus clinical dilemma. The deviant case faced resistance because of the Com-Med faculty's argument that their postgraduate qualification did not train them for patients' clinical care. Therefore, they could not attend to the patients. Thus, the deviant case's community–based clinic was moved from pre-clinical to clinical year. The rotations to the clinic and assessments were relocated from the Community Medicine (Com–Med) to the Family Medicine (Fam-Med) department in the final year of the MBBS program. According to the deviant case (participant P12 M4), I have interacted with many Com–Med faculty, but they were unwilling to go to the community. They didn't think of themselves as clinicians. They said they do research and don't have training for attending to patients, although they were all MBBS! We started recruiting family physicians at that time. Seeing patients in the community is not glamorous at all. It is not easy to travel and go to the streets. Unlike the deviant case, none of the other participants tried to establish a community–based clinic; however, the need for a “hybrid model for pre–clinical & clinical CBME" emerged as one of the important sub-themes in the thematic analysis. Based on the discussions of the research participants, there needed to be more clarity on the departments responsible for the clinical and pre-clinical aspects of the community-based activities (CBAs). There was a consensus among participants that Community Medicine (Com–Med) faculty had been content in perceiving them as pre-clinical faculty who do not attend to the patients. The participants believed the Com-Med faculty lacked motivation and visibility in decision–making, which was traditionally occupied by clinicians. Therefore, the emphasis has always been on hospital-based medical education, not the community-based medical education (CBME). Participant P7 M2 suggested, Leadership is critical. We must start integrating all this from the first year of MBBS to bring our students into the community. Let's look at the behavioral science syllabus. It doesn't connect behavior with community–based activities (CBAs). It can only be done if the PM&DC dictates what needs to be done and how many hours will be spent in the community because dispensing primary care at the patient's doorstep is community–based medical education (CBME). The basic health unit (BHU) is the first setting to which students should be exposed. Currently, we teach everything to the students in the technically rich tertiary care hospitals and expect them to perform at the BHU after graduation as socially responsive doctors! 4. Discussion Despite being an outlier in experiences, the insights provided by the deviant case reinforced the thematic analysis of this study [ 14 ], highlighting the urgent need for regulatory standards across the country, aiming to integrate clinical, preclinical, interdisciplinary, and interprofessional medical education for advancing universal health coverage (UHC) in Pakistan 4.1) Provision of Universal Health Coverage through CBME The deviant case was exposed to community–based medical education (CBME) during their time as undergraduate medical students, while none of the other participants had experience with CBME at the undergraduate or faculty levels. Nonetheless, all research participants acknowledged the need for the Pakistan Medical and Dental Council (PM&DC) to establish clear guidelines for the departments responsible for CBME. These guidelines should include the hours allocated for community-based activities (CBAs) and specify when CBME should commence within undergraduate medical education. It was suggested that improvements to CBME are necessary for future generations of students to ensure social accountability in medical education and to promote universal health coverage (UHC) for underprivileged communities in our country. The World Health Organization (WHO) strongly advises overhauling curricula to broaden the future health professionals’ perspectives on health. The organization recognizes that individuals are products of the societies in which they reside [ 15 ]. Evidence suggests that the time devoted to CBME can range from 20–35%, depending on the institution [ 16 ]. Reforming how we teach and learn CBAs is complex because of insufficient good leadership, teachers' lack of motivation, inadequate incentives and training, and the need for more resources [ 17 ]. The research participants suggested that the PM&DC should frame and enforce standards that link medical education to the country's healthcare system. The global effort that started at the 1978 Alma Ata Conference on Primary Health Care (PHC) is still going on, aiming for Universal Health Coverage (UHC) as described in Sustainable Development Goal 3 (SDG 3.8.1). Despite adhering to international agreements, Pakistan's healthcare system still needs improvement to ensure fairness for everyone [ 18 ]. The COME (Community-Oriented Medical Education) resembles the PHC (Primary Healthcare) approach to the healthcare system. It can improve health outcomes for all [ 19 ]. Community-Based Medical Education (CBME) is a priority for nations endeavoring to bolster PHC and achieve UHC. To this end, the undergraduate CBME curriculum should encompass contextual learning within primary healthcare settings at macro, meso, and micro levels [ 20 ]. 4.2) Hybrid Model for Pre–Clinical & Clinical CBME As the Head of the Community Medicine (Com–Med) department, the deviant case introduced CBME for students through a community–based clinic. Faced with the challenge of balancing pre-clinical versus clinical aspects, the deviant case took the role of a family physician for the community-based clinic because the Com–Med faculty was reluctant to address the clinical aspect of the clinic. She organized the clinic by involving family physicians in the process. Lived experiences of the inspirational deviant case found in this research validate the ongoing age–old debate between clinical/disease–oriented and community/people–oriented approaches to health. The pre-clinical versus clinical dilemma emerged as one of the sub-categories in the thematic analysis of this study. The research participants recommended that the regulatory authority establish and implement a hybrid faculty model to address this issue. This model should integrate clinical, pre-clinical, interdisciplinary, and interprofessional aspects of Community-Based Medical Education (CBME) in a standardized manner across all medical colleges in Pakistan. Family Medicine (Fam–Med) doctors in Pakistan are known as General Practitioners. Undergraduate medical education in Pakistan does not mandate exposure to Fam–Med/General Practice (GP). Research participants recommended that the PM&DC enforce the implementation of CBME, specifically focusing on providing systematic exposure to Family Medicine/General Practice. Although public Health/Community Medicine and Family Medicine/General Practice have different focuses, they complement each other. While Family Medicine/General Practice provides ongoing healthcare for individuals and families, Public Health/Community Medicine concentrates on population health through activities such as vaccination and education [ 21 ]. General practice data in numerous countries offers valuable insights into population health, making it possible to prevent chronic diseases and epidemics [ 22 ]. Different health systems integrate Fam–Med /GP and Public Health/Com–Med in varying ways, from complete overlap to total segregation. The WHO (World Health Organization) advocates for increased Fam–Med /GP training to enhance Primary Health Care (PHC), the first point of contact between an individual and the healthcare system [ 23 ]. 5. Conclusion The experiences articulated by the outlier participant underscored a self-imposed social accountability mechanism embraced by a few medical colleges in Pakistan. This qualitative study pointed out the urgent need for regulatory standards across the country, aiming to integrate clinical, preclinical, interdisciplinary, and interprofessional medical education for advancing universal health coverage (UHC) in Pakistan. Pakistan’s regulatory authority’s aspiration to cultivate the attribute of "Community Health Promoters" in "Seven-Star Doctors" within undergraduate medical education cannot be achieved solely through field visits. Abbreviations COME Community–oriented medical education CBME Community–based medical education PHC Primary health care UHC Universal health coverage PM&DC Pakistan Medical and Dental Council CBA Community–based activity UG Undergraduate Declarations Acknowledgements We express our sincere thanks to all the participants and institutions involved in this study. Author contributions IG and ARconceptualized and designed the study. RY and ZAK developed the FGI guide. IG, RY, and ZAK led the data collection and analysis. AR supervised the study. All authors read and approved the final manuscript. Funding The authors received no financial support for this manuscript's research, authorship, or publication. Clinical trial number : Not Applicable Data availability Transcripts of the four FGIs are available on Mendeley (DOI:10.17632/pw7kcfhh4y.1). Except for the experiences of one deviant case in this manuscript, the thematic analysis of fourteen participants can be found at: https://www.iiste.org/Journals/index.php/JEP/article/view/62397. Human Ethics and Consent to Participate The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki (1964) and its subsequent amendments. The Institutional Review Committee of Islamic International Medical College (IIMC), 274-Peshawar Road, Rawalpindi, Pakistan (approval no. Riphah/IRC/23/3043) granted approval to the study. All participants provided written informed consent prior to enrollment in the study . 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Career destinations of graduates from a medical school with an 18-week longitudinal integrated clerkship in general practice: a survey of alumni 6 to 8 years after graduation. Ir J Med Sci (1971-). 2021;190:185–91. Tran M, et al. Transitions in general practice training: quantifying epidemiological variation in trainees’ experiences and clinical behaviours. BMC Med Educ. 2022;22(1):124. Shaikh BT, Ali N. Universal health coverage in Pakistan: is the health system geared up to take on the challenge? Globalization Health. 2023;19(1):4. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6504864","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":478797375,"identity":"b8df50e5-f26a-4768-ac7a-e94abebece50","order_by":0,"name":"Irum Gilani","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6UlEQVRIie2PMQrCMBSGEwLpkrarBcErVJwExatYXKsnUCkU6lKdFRFvkdkS0KV6gYyuChUXEQdftKu2o2C+4f8f4X2Eh5BG84tscKCKWWrOIKhRVqEQyVwppFDJWymEqalIsaSIrqY/qlJjn4jWndcsgnB28T8rzsELlybfMcoGXdGfyXpEEHEW/LPipjgkJt/CLb4r+rHEoFB4KaPYJ1c0Y9kpqwwZrcAv6Ca9QsUBBa/4BpSTm0wD2YsIDr/eYqXGEZ35uGPbfiO7PWR7PQmT7PJFyRHvwtErg8J9YJz3o8yyRqPR/BtPHqJOYaCP3rsAAAAASUVORK5CYII=","orcid":"","institution":"AJK Medical College, Muzaffarabad, Pakistan","correspondingAuthor":true,"prefix":"","firstName":"Irum","middleName":"","lastName":"Gilani","suffix":""},{"id":478797376,"identity":"ecba7889-9aa6-455e-9a55-b38f9d9435f5","order_by":1,"name":"Azhar Rashid","email":"","orcid":"","institution":"Riphah International University Islamabad, Pakistan","correspondingAuthor":false,"prefix":"","firstName":"Azhar","middleName":"","lastName":"Rashid","suffix":""},{"id":478797381,"identity":"2b179670-3655-4ef9-90e5-2eb2676cff4b","order_by":2,"name":"Rahila Yasmeen","email":"","orcid":"","institution":"Riphah International University Islamabad, Pakistan","correspondingAuthor":false,"prefix":"","firstName":"Rahila","middleName":"","lastName":"Yasmeen","suffix":""},{"id":478797383,"identity":"15585645-f427-494c-a83b-13bc1147f326","order_by":3,"name":"Ziyad Afzal Kayani","email":"","orcid":"","institution":"AJK Medical College, Muzaffarabad, Pakistan","correspondingAuthor":false,"prefix":"","firstName":"Ziyad","middleName":"Afzal","lastName":"Kayani","suffix":""}],"badges":[],"createdAt":"2025-04-22 13:38:28","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6504864/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6504864/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85992223,"identity":"ee11a753-7a32-4215-b62e-5af8d7a8eab7","added_by":"auto","created_at":"2025-07-04 05:33:03","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1066880,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eInitial Fifty Open Codes by NVivo 10\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6504864/v1/e042426e7587518c45b03cb2.jpeg"},{"id":85992224,"identity":"561bf2d8-1c83-42b3-8629-8fe143989815","added_by":"auto","created_at":"2025-07-04 05:33:03","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":604825,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTheoretical framework of the study\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6504864/v1/3a250a9df5a21814823a8c7c.jpeg"},{"id":88109358,"identity":"365a0b7d-8846-49f8-8844-07b517968562","added_by":"auto","created_at":"2025-08-01 13:09:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3172574,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6504864/v1/02965b85-721c-4121-a275-d87fc8139da9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Path Less Taken: Reshaping the Future of Medical Education with a Community Focus in Pakistan","fulltext":[{"header":"1. Background","content":"\u003cp\u003eThe delivery of medical education has evolved to better address the healthcare needs of local communities. Future doctors must understand the social determinants of health to be socially responsible [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The community-oriented approach to medical education, rooted in the \"Health for All\" vision of the 1978 Alma Ata Conference, includes Harden's SPICES model for Community-Based Medical Education (CBME) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The transfer of medical education to the community is complex. Different Community-Oriented Medical Education (COME) models are implemented globally [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Pakistan Medical \u0026amp; Dental Council (PM\u0026amp;DC) is reforming to produce \"Seven-Star Doctors,\" with \"Community Health Promoters\" as one attribute. However, most Pakistani medical colleges lack a structured framework for Community-Based Activities (CBAs) and assessment [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The Aga Khan University (AKU) in Karachi, Pakistan, has successfully implemented the COME curriculum since 1985 [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], but its introduction in the public sector faced a setback in 2004 [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis research aimed to explore practices regarding CBAs of the medical colleges in Pakistan's twin cities (Rawalpindi \u0026amp; Islamabad) for formulating recommendations to integrate CBME into undergraduate medical education in Pakistan.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003e This exploratory qualitative study employed the focus group interview (FGI) technique, drawing insights from fifteen participants across four medical colleges in Rawalpindi and Islamabad. All participants provided written informed consent before enrollment in this Institutional Review Committee-approved study. The COREQ (COnsolidated criteria for REporting Qualitative research) checklist was utilized to ensure the quality assurance. The following procedure was adopted to conduct four focus group interviews (FGIs): -\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1) Before an FGI\u003c/h2\u003e \u003cp\u003eThe medical college's website was checked for the mission statement, curriculum details, student selection criteria, regarding diversity and equity in recruiting from underserved or underrepresented backgrounds and local health workforce needs.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2) Approaching Research Participants before an FGI\u003c/h2\u003e \u003cp\u003eThe eligible (implementing outcome\u0026ndash;based integrated curriculum) medical colleges were visited to meet with the principals and deans. A brief that included the research introduction, objectives, inclusion criteria, interview guide, and consent form was presented. Multiple visits were made to gain confirmation for the Focus Group Interviews (FGIs).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3) Approaching Research Participants during an FGI\u003c/h2\u003e \u003cp\u003eOn the day of a Focus Group Interview (FGI), the researchers typically arrived at the designated venue about 45 minutes before the scheduled start time. This allowed for the setup of the PowerPoint presentation and the organization of folders containing pens, extra paper, and cover sheets for demographics and consent.\u003c/p\u003e \u003cp\u003e\"Name Cards\" holders were arranged with plain paper and markers for participants to write down their names and designation. In the introductory slides aimed at building rapport, the researchers explained the purpose of the \"Name Cards\" \u0026mdash; to facilitate the calling out of names for transcription \u0026mdash; and the use of audio recording for transcription of the FGI. Each FGI was audio-recorded and stored on password-protected and encrypted drives accessible only to the research team. Observations and non-verbal cues were also noted in an FGI notebook.\u003c/p\u003e \u003cp\u003eThe participants were briefed about the importance of their \"Name Cards\" in audio\u0026ndash;recording. The process of transcription with the help of audio recording was described to the participants.\u003c/p\u003e \u003cp\u003e Before starting the FGI, written consent was obtained from the participants, including consent to the audio\u0026ndash;recording and publication of results. Participants were assured de-identification of their responses before publishing the study findings. Additional \"publication consent\" is \"not applicable\" to this manuscript because no personal identifiers, images, or details of participants have been included that could compromise their anonymity and confidentiality.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4) Steps Taken Before Data Analysis\u003c/h2\u003e \u003cp\u003eThe institutions and participants were assigned codes to facilitate data analysis. The introductory session and the prompts/questions for the focus group interviews (FGIs) were conducted in English, as outlined in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. However, discussions in the participants' native language (\u003cem\u003eUrdu\u003c/em\u003e - the official language of Pakistan) were encouraged to capture their views and opinions effectively. During transcription, the researchers translated the sections of \u003cem\u003eUrdu\u003c/em\u003e dialogue into English. The NVivo version 10, a computer-assisted qualitative data analysis software (CAQDAS), was used. An inductive thematic analysis resulted in the \"tree coding structure,\" comprising the initial fifty codes/nodes (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) that stored references with their sources within the transcripts of the four FGIs.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSix Triggers Aligned with Research Questions\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eResearch Question 1: What community-based activities are part of the undergraduate outcome\u0026ndash;based integrated curriculum in medical colleges in Pakistan's twin cities (Rawalpindi\u0026ndash;Islamabad)?\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTheme recognized from the Literature Review\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eCues and Prompts\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eTriggers for the First Research Question\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCommunity\u0026ndash;based activities/practices\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e● Outcome\u0026ndash;based curriculum\u003c/p\u003e \u003cp\u003e● Integrated curriculum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1. How do you reflect on your learning of community\u0026ndash;related concepts as an undergraduate student? What are your views on the effectiveness of what lectures taught (back then) compared to teaching through community\u0026ndash;based activities?\u003c/p\u003e \u003cp\u003e2. How do you perceive a \"community setting\" for community\u0026ndash;based activities in undergraduate medical education?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResearch Question 2\u003c/b\u003e: What \u003cb\u003ecommunity-based activities\u003c/b\u003e are part of the undergraduate outcome\u0026ndash;based integrated curriculum in medical colleges in Pakistan's twin cities (Rawalpindi\u0026ndash;Islamabad)?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eThemes recognized from Literature Review\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ePrompt\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eTriggers for the Second Research Question\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCommunity\u0026ndash;based activities/practices\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImplementation of the COME (Community-Oriented Medical Education) and CBME (Community-Based Medical Education) by training the faculty, including a focus on interprofessional education, engagement of local GPs (General Practitioners), and the community.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3. What is Your opinion on the role of GPs (General Practitioners)/Family Physicians, interprofessional education, and community engagement in community\u0026ndash;based activities? How can multidisciplinary teamwork be coordinated?\u003c/p\u003e \u003cp\u003e4. What community\u0026ndash;based activities must be conducted by your university? Could you please share your experience (as faculty) with issues in implementing community\u0026ndash;based activities in your institution, at present and in the past?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResearch Question 3\u003c/b\u003e: What are the \u003cb\u003egaps\u003c/b\u003e and \u003cb\u003erecommendations\u003c/b\u003e for implementing community\u0026ndash;oriented and community\u0026ndash;based medical education (COME \u0026amp; CBME) at the undergraduate level in Pakistan?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eThemes recognized from Literature Review\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eCues and Prompts\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eTriggers for the Third Research Question\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e● Gaps in the implementation of COME and CBME\u003c/p\u003e \u003cp\u003e● Recommendations for the implementation of COME and CBME\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e● Interprofessional\u003c/p\u003e \u003cp\u003e● Issues related to funds, logistics, local GPs, community, and interprofessional\u003c/p\u003e \u003cp\u003e● Positive outcomes may include social responsiveness of the institution in terms of improved accessibility of the vulnerable population to basic health care, interprofessional education, enhanced linkages between the health system and medical education, intersectoral collaboration for social determinants of health, and community participation.\u003c/p\u003e \u003cp\u003e● Negative unintended outcomes may include the discontinuation of community\u0026ndash;based rotations because of lack of funds, administrative, logistic, and security problems, or failure in the implementation of a CBME model due to conflict with the Department of Health, local representatives, including religious, political, Community, GPs, NGOs.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5. Considering cultural, social, and religious factors, including logistic and security concerns, what is your opinion on community\u0026ndash;based activities to be included at the undergraduate level? Is there any activity that should be excluded?\u003c/p\u003e \u003cp\u003e6. \"Community Health Promoter\" is one of the PM\u0026amp;DC's (Pakistan Medical and Dental Council) competencies of a \"Seven\u0026ndash;star\" medical graduate. Furthermore, PM\u0026amp;DC considers an integrated medical curriculum adequate when it is community\u0026ndash;based. However, the PM\u0026amp;DC's skill training focuses on hospital-based activities. Considering this scenario, what are your thoughts on how community\u0026ndash;based activities may be initiated and sustained in undergraduate medical education in Pakistan?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5) Summary of Data Analysis\u003c/h2\u003e \u003cp\u003e The researchers first listened to the audio recordings and reviewed the transcripts before proceeding with coding. The transcripts were open-coded to generate fifty codes using NVivo, incorporating both \u0026ldquo;in vivo\u0026rdquo; and descriptive codes without relying on a predetermined list. After analyzing the initial fifty codes, the researchers identified connections between concepts and reorganized them into ten sub-categories based on their relationships. These ten sub-categories were then merged into eight sub-themes. The sub-themes were further refined and consolidated into three main themes that directly addressed the research questions, complemented by participant quotations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.6) Quality Assurance Strategies\u003c/h2\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003e2.6.1) Credibility/Trustworthiness\u003c/h2\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eCognitive interviews were conducted with five faculty members to prepare interview guide for data collection. Member checking was done via a WhatsApp group and a journal was maintained to record participants' expressions and non-verbal cues.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003e2.6.2) Transferability\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eResearch was conducted in participants' real-life settings, selected by institutional authorities based on detailed study introductions and inclusion criteria. One medical college belonging to the public and private sectors was chosen from each city to ensure that the study obtains a broader perspective.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003e2.6.3) Dependability\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe researchers kept a reflective journal to ensure that research findings were based on objective analysis rather than personal biases or preconceptions.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003e2.6.4) Confirmability\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eComprehensive documentation of data analysis, including triangulation, was maintained. The study incorporated the perspective of a single deviant case found in this research to ensure the findings accurately reflect the participants' views, minimizing the influence of researcher biases.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003e2.6.5) Reflexivity\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe research included personal, inter-personal, methodological, and contextual reflexivity [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]:\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section4\"\u003e \u003ch2\u003e2.6.5.1) Personal Reflexivity\u003c/h2\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e Insights were gained during focus group interviews by enhancing participant engagement and identifying areas for improvement.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section4\"\u003e \u003ch2\u003e2.6.5.2) Inter\u0026ndash;personal Reflexivity\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe researcher's role did not affect the data, and no power dynamics influenced her interactions, as participants were selected by their institutional heads.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section4\"\u003e \u003ch2\u003e2.6.5.3) Methodological Reflexivity\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eEmploying interpretivist and complexity theory, the researchers used a socio-material framework to analyze how various components interact in medical education, emphasizing continuous curriculum evaluation.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section4\"\u003e \u003ch2\u003e2.6.5.4) Contextual Reflexivity\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eFocus group interviews were conducted in participants' workplaces to minimize bias and foster trust, allowing for candid discussions about community-based practices and recommendations for curriculum enhancement.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e2.7) Theoretical Framework\u003c/h2\u003e \u003cp\u003eThree learning theories were utilized in this research\u0026rsquo;s theoretical framework (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Complexity theory is among the Socio\u0026ndash;Materiality learning theories that focus on complex adaptive systems like Community-Oriented Medical Education (COME). Hence, this theory was used to analyze learning by Community\u0026ndash;Based Activities (CBAs) that require interaction between students, faculty, community, healthcare system, healthcare professionals (e.g., nurses, lady health workers), and the material elements of the medical education system. Learning through COME is characterized by a dynamic, non\u0026ndash;linear, unpredictable, and emergent web of social and material interplay [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. More broadly, the government is also a part of this complex system in guiding through laws, funding, and other political strategies [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eSocio\u0026ndash;Cultural Situated learning theory of Lave \u0026amp; Wenger is relevant to the COME curriculum, where learning occurs in community settings [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In this way, the COME curriculum enables medical undergraduates to understand the health needs of their communities and the social determinants of health [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In medical education, the concept of social accountability necessitates a focus on engaging with the community. COME aims to cultivate social accountability in addition to inter-professional and inter-sectoral collaboration [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe implementation of the COME curriculum also utilizes Vygotsky's Socio-Constructivist Learning Theory [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. COME is not just a way for students to learn; it is a whole strategy where students, faculty, local health authorities, health professionals, and people from the community are learning how to collaborate and participate in the improvement of the community and individual health.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eExcept for one deviant case, fourteen participants reported that field visits were their only exposure to community-based activities (CBAs), lacking defined learning outcomes and assessment strategies [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The deviant case, whether in the role of faculty or student, reported experiences significantly diverged from those described by other participants over the past fifteen years. Despite being an outlier, the deviant case\u0026rsquo;s experiences reinforced the broader participant recommendations, highlighting the urgent need for clear regulatory guidance to bridge hospital-based and community-oriented primary health care (PHC) models.\u003c/p\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e3.1) Divergent Experiences as an Undergraduate Medical Student\u003c/h2\u003e \u003cp\u003eThe community-based activities (CBAs) in the deviant case's medical college were scheduled from the first year of the MBBS (medical graduation) program. The deviant case's departure from convention in undergraduate (UG) experience was noted when field visits emerged as the only CBA during the thematic analysis. Under the sub-themes, it was discussed that the regulatory authority had not specified the department responsible for the CBAs or field visits. The only CBA was conducted without learning objectives (LOs) or assessment under the Community Medicine (Com\u0026ndash;Med) department in the fourth year of MBBS.\u003c/p\u003e \u003cp\u003eConversely, the deviant case's medical college had \"Community Health Centers\" set up in different city squatters. There was a \"family ties program\" where students would connect with at least two families in the community and follow their health problems for the next 2\u0026ndash;3 years. Students would visit their assigned families in small groups of 2 to 3, accompanied by the facilitators. One day was reserved for community-based medical education (CBME); students would leave for the field/community visits after morning lectures. There would be an evening session where students reflect and discuss the day's activities in small groups, supervised by the facilitators.\u003c/p\u003e \u003cp\u003eThe deviant case's divergence from conventional norms was highlighted because safety and supervision concerns for traditional field/community visits emerged as serious concerns in this study. Additionally, the participants expressed a need for specifications regarding the number of visits, hours, or settings to be visited for the field visits. Participants suggested that the PM\u0026amp;DC's goal of cultivating the \"Community Health Promoters\" attribute in \"Seven-Star Doctors\" during undergraduate medical education cannot be achieved solely through traditional field visits.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003e3.2) Divergent Experiences as a Faculty\u003c/h2\u003e \u003cp\u003eAs the Head of the Community Medicine (Com\u0026ndash;Med) department, the deviant case initiated exposure to the students through a community\u0026ndash;based clinic. However, this endeavor could not succeed due to the pre-clinical versus clinical dilemma. The deviant case faced resistance because of the Com-Med faculty's argument that their postgraduate qualification did not train them for patients' clinical care. Therefore, they could not attend to the patients. Thus, the deviant case's community\u0026ndash;based clinic was moved from pre-clinical to clinical year. The rotations to the clinic and assessments were relocated from the Community Medicine (Com\u0026ndash;Med) to the Family Medicine (Fam-Med) department in the final year of the MBBS program. According to the deviant case (participant P12 M4),\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cb\u003eI have interacted with many Com\u0026ndash;Med faculty, but they were unwilling to go to the community. They didn't think of themselves as clinicians. They said they do research and don't have training for attending to patients, although they were all MBBS! We started recruiting family physicians at that time. Seeing patients in the community is not glamorous at all. It is not easy to travel and go to the streets.\u003c/b\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eUnlike the deviant case, none of the other participants tried to establish a community\u0026ndash;based clinic; however, the need for a \u0026ldquo;hybrid model for pre\u0026ndash;clinical \u0026amp; clinical CBME\" emerged as one of the important sub-themes in the thematic analysis. Based on the discussions of the research participants, there needed to be more clarity on the departments responsible for the clinical and pre-clinical aspects of the community-based activities (CBAs). There was a consensus among participants that Community Medicine (Com\u0026ndash;Med) faculty had been content in perceiving them as pre-clinical faculty who do not attend to the patients. The participants believed the Com-Med faculty lacked motivation and visibility in decision\u0026ndash;making, which was traditionally occupied by clinicians. Therefore, the emphasis has always been on hospital-based medical education, not the community-based medical education (CBME).\u003c/p\u003e \u003cp\u003eParticipant P7 M2 suggested,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cb\u003eLeadership is critical. We must start integrating all this from the first year of MBBS to bring our students into the community. Let's look at the behavioral science syllabus. It doesn't connect behavior with community\u0026ndash;based activities (CBAs). It can only be done if the PM\u0026amp;DC dictates what needs to be done and how many hours will be spent in the community because dispensing primary care at the patient's doorstep is community\u0026ndash;based medical education (CBME). The basic health unit (BHU) is the first setting to which students should be exposed. Currently, we teach everything to the students in the technically rich tertiary care hospitals and expect them to perform at the BHU after graduation as socially responsive doctors!\u003c/b\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eDespite being an outlier in experiences, the insights provided by the deviant case reinforced the thematic analysis of this study [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], highlighting the urgent need for regulatory standards across the country, aiming to integrate clinical, preclinical, interdisciplinary, and interprofessional medical education for advancing universal health coverage (UHC) in Pakistan\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003e4.1) Provision of Universal Health Coverage through CBME\u003c/h2\u003e \u003cp\u003eThe deviant case was exposed to community\u0026ndash;based medical education (CBME) during their time as undergraduate medical students, while none of the other participants had experience with CBME at the undergraduate or faculty levels. Nonetheless, all research participants acknowledged the need for the Pakistan Medical and Dental Council (PM\u0026amp;DC) to establish clear guidelines for the departments responsible for CBME. These guidelines should include the hours allocated for community-based activities (CBAs) and specify when CBME should commence within undergraduate medical education. It was suggested that improvements to CBME are necessary for future generations of students to ensure social accountability in medical education and to promote universal health coverage (UHC) for underprivileged communities in our country.\u003c/p\u003e \u003cp\u003eThe World Health Organization (WHO) strongly advises overhauling curricula to broaden the future health professionals\u0026rsquo; perspectives on health. The organization recognizes that individuals are products of the societies in which they reside [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Evidence suggests that the time devoted to CBME can range from 20\u0026ndash;35%, depending on the institution [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Reforming how we teach and learn CBAs is complex because of insufficient good leadership, teachers' lack of motivation, inadequate incentives and training, and the need for more resources [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe research participants suggested that the PM\u0026amp;DC should frame and enforce standards that link medical education to the country's healthcare system. The global effort that started at the 1978 Alma Ata Conference on Primary Health Care (PHC) is still going on, aiming for Universal Health Coverage (UHC) as described in Sustainable Development Goal 3 (SDG 3.8.1). Despite adhering to international agreements, Pakistan's healthcare system still needs improvement to ensure fairness for everyone [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The COME (Community-Oriented Medical Education) resembles the PHC (Primary Healthcare) approach to the healthcare system. It can improve health outcomes for all [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Community-Based Medical Education (CBME) is a priority for nations endeavoring to bolster PHC and achieve UHC. To this end, the undergraduate CBME curriculum should encompass contextual learning within primary healthcare settings at macro, meso, and micro levels [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003e4.2) Hybrid Model for Pre\u0026ndash;Clinical \u0026amp; Clinical CBME\u003c/h2\u003e \u003cp\u003eAs the Head of the Community Medicine (Com\u0026ndash;Med) department, the deviant case introduced CBME for students through a community\u0026ndash;based clinic. Faced with the challenge of balancing pre-clinical versus clinical aspects, the deviant case took the role of a family physician for the community-based clinic because the Com\u0026ndash;Med faculty was reluctant to address the clinical aspect of the clinic. She organized the clinic by involving family physicians in the process.\u003c/p\u003e \u003cp\u003eLived experiences of the inspirational deviant case found in this research validate the ongoing age\u0026ndash;old debate between clinical/disease\u0026ndash;oriented and community/people\u0026ndash;oriented approaches to health. The pre-clinical versus clinical dilemma emerged as one of the sub-categories in the thematic analysis of this study. The research participants recommended that the regulatory authority establish and implement a hybrid faculty model to address this issue. This model should integrate clinical, pre-clinical, interdisciplinary, and interprofessional aspects of Community-Based Medical Education (CBME) in a standardized manner across all medical colleges in Pakistan.\u003c/p\u003e \u003cp\u003eFamily Medicine (Fam\u0026ndash;Med) doctors in Pakistan are known as General Practitioners. Undergraduate medical education in Pakistan does not mandate exposure to Fam\u0026ndash;Med/General Practice (GP). Research participants recommended that the PM\u0026amp;DC enforce the implementation of CBME, specifically focusing on providing systematic exposure to Family Medicine/General Practice. Although public Health/Community Medicine and Family Medicine/General Practice have different focuses, they complement each other. While Family Medicine/General Practice provides ongoing healthcare for individuals and families, Public Health/Community Medicine concentrates on population health through activities such as vaccination and education [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. General practice data in numerous countries offers valuable insights into population health, making it possible to prevent chronic diseases and epidemics [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Different health systems integrate Fam\u0026ndash;Med /GP and Public Health/Com\u0026ndash;Med in varying ways, from complete overlap to total segregation. The WHO (World Health Organization) advocates for increased Fam\u0026ndash;Med /GP training to enhance Primary Health Care (PHC), the first point of contact between an individual and the healthcare system [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThe experiences articulated by the outlier participant underscored a self-imposed social accountability mechanism embraced by a few medical colleges in Pakistan. This qualitative study pointed out the urgent need for regulatory standards across the country, aiming to integrate clinical, preclinical, interdisciplinary, and interprofessional medical education for advancing universal health coverage (UHC) in Pakistan. Pakistan\u0026rsquo;s regulatory authority\u0026rsquo;s aspiration to cultivate the attribute of \"Community Health Promoters\" in \"Seven-Star Doctors\" within undergraduate medical education cannot be achieved solely through field visits.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCOME\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Community–oriented medical education\u003c/p\u003e\n\u003cp\u003eCBME\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Community–based medical education\u003c/p\u003e\n\u003cp\u003ePHC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Primary health care\u003c/p\u003e\n\u003cp\u003eUHC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Universal health coverage\u003c/p\u003e\n\u003cp\u003ePM\u0026amp;DC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Pakistan Medical and Dental Council\u003c/p\u003e\n\u003cp\u003eCBA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Community–based activity\u003c/p\u003e\n\u003cp\u003eUG \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Undergraduate\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe express our sincere thanks to all the participants and institutions involved in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIG and ARconceptualized and designed the study. RY and ZAK developed the FGI guide. IG, RY, and ZAK led the data collection and analysis. AR supervised the study. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no financial support for this manuscript\u0026apos;s research, authorship, or publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e: Not Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTranscripts of the four FGIs are available on Mendeley (DOI:10.17632/pw7kcfhh4y.1). Except for the experiences of one deviant case in this manuscript, the thematic analysis of fourteen participants can be found at: https://www.iiste.org/Journals/index.php/JEP/article/view/62397.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki (1964) and its subsequent amendments. The Institutional Review Committee of Islamic International Medical College (IIMC), 274-Peshawar Road, Rawalpindi, Pakistan (approval no. Riphah/IRC/23/3043) granted approval to the study. All participants provided written informed consent prior to enrollment in the study\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed written consent from the participants, included consent to the publication of results. Additional \u0026quot;publication consent\u0026quot; is \u0026quot;not applicable\u0026quot; to this manuscript because no personal identifiers, images, or details of participants have been included that could compromise their anonymity and confidentiality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKhan N, et al. Social justice in undergraduate medical education: a meta-synthesis of learners\u0026rsquo; perspectives. 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Roadblocks to Integration; Faculty\u0026rsquo;s perspective on transition from Traditional to Integrated Medical Curriculum. Pakistan J Med Sci. 2021;37(3):788.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNundy S et al. Academic medicine and the social determinants of health. How to Practice Academic Medicine and Publish from Developing Countries? A Practical Guide, 2022: pp. 3\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChangiz T, Alizadeh M. A comparative study of community medicine and public health curriculum at medical schools in Iran and North America. Res Dev Med Educ. 2021;10(1):19\u0026ndash;19.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBourn D, Soysal N. Transformative learning and pedagogical approaches in education for sustainable development: Are initial teacher education programmes in England and Turkey ready for creating agents of change for sustainability? Sustainability. 2021;13(16):8973.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGlynn LG, et al. Career destinations of graduates from a medical school with an 18-week longitudinal integrated clerkship in general practice: a survey of alumni 6 to 8 years after graduation. Ir J Med Sci (1971-). 2021;190:185\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTran M, et al. Transitions in general practice training: quantifying epidemiological variation in trainees\u0026rsquo; experiences and clinical behaviours. BMC Med Educ. 2022;22(1):124.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShaikh BT, Ali N. Universal health coverage in Pakistan: is the health system geared up to take on the challenge? Globalization Health. 2023;19(1):4.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"COME, CBME, PHC, UHC, Pakistan","lastPublishedDoi":"10.21203/rs.3.rs-6504864/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6504864/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eCommunity-based medical education (CBME) enhances social accountability by incorporating medical training into community settings. As part of the ongoing reform of undergraduate medical education, the Pakistan Medical and Dental Council (PM\u0026amp;DC) is committed to cultivating the attribute of \"Community Health Promoter\" within the framework of \"Seven-Star Doctors\" in Pakistan.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA qualitative exploratory study was conducted using focus group interviews at four medical colleges in Rawalpindi and Islamabad to explore the implementation gaps in community-oriented and community-based medical education (COME and CBME) at the undergraduate level in Pakistan.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eExcept for one deviant case, fourteen participants in this research reported that their only exposure to community-based activities occurred during field visits throughout their undergraduate studies and faculty experiences. Despite being an outlier in experiences, the insights provided by the deviant case reinforced the thematic analysis of this study, highlighting the urgent need for clear regulatory guidance to bridge hospital-based medical education and community-oriented primary health care (PHC).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe experiences articulated by the outlier participant underscored a self-imposed social accountability mechanism embraced by a few medical colleges in Pakistan. This qualitative study pointed out the urgent need for regulatory standards across the country, aiming to integrate clinical, preclinical, interdisciplinary, and interprofessional medical education for advancing universal health coverage (UHC) in Pakistan.\u003c/p\u003e","manuscriptTitle":"A Path Less Taken: Reshaping the Future of Medical Education with a Community Focus in Pakistan","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-04 05:32:58","doi":"10.21203/rs.3.rs-6504864/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"48e70fc8-9d35-4d64-bd49-bd72ffc7b7a8","owner":[],"postedDate":"July 4th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-01T13:08:49+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-04 05:32:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6504864","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6504864","identity":"rs-6504864","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}