Number of Citations: 0

Submitted: 13 June 2024
Accepted: 4 February 2025
Published online: 1 July, TAPS 2025, 10(3), 26-36
https://doi.org/10.29060/TAPS.2025-10-3/OA3439

Humairah Zainal¹, Xin Xiaohui¹, Julian Thumboo^1,2,3 & Fong Kok Yong^2,3

¹Health Services Research Unit, Singapore General Hospital, Singapore; ²Department of Rheumatology and Immunology, Singapore General Hospital, Singapore, ³Duke-NUS Medical School, National University of Singapore, Singapore

Abstract

Introduction: As healthcare becomes increasingly digital, undergraduate medical students receive limited formal training in digital healthcare technologies (DHTs). Additionally, stakeholders’ perspectives on essential digital health competencies (DHCs) across generations remain underexplored. This comparative study aims to identify knowledge gaps, inform evolving expectations, and promote continuous learning by comparing medical students’ and senior clinicians’ views on essential DHCs in Singapore.

Methods: Individual semi-structured interviews were conducted with medical students, clinical educators, and clinical teachers. Clinical-year medical students from all three local medical schools were recruited using convenience and snowball sampling, while purposive sampling ensured diverse representation of clinicians across Singapore’s public healthcare organisations, focusing on those engaged in education-related activities. Data were collected from September 2020 to February 2023 until thematic saturation was achieved, and analysed using qualitative thematic analysis.

Results: Sixty-three participants took part, including 30 medical students, 12 clinical educators and 21 clinical teachers. All clinicians had more than 10 years of clinical experience and came from 24 different disciplines and 12 healthcare institutions. The findings showed unanimous support for integrating electronic health records in patient communication, and training in DHTs like telemedicine and point-of-care ultrasound. Discrepancies emerged; clinicians prioritised physical examination, while students viewed it as potentially replaceable by DHTs. Furthermore, while students valued healthcare-related smartphone applications in patient care, few clinicians shared this view, citing privacy and security concerns.

Conclusion: Evaluating stakeholders’ perspectives highlights evolving clinical skills and essential DHCs for medical students, potentially informing global DHC training programmes.

Keywords:           Technology, Medical Education, Curriculum, Clinical Competence, Digital Competence, Qualitative, Singapore

Practice Highlights

• An inter-generational perspective in medical education leverages the strengths of both medical students and senior clinicians, ensuring a balanced approach that keeps pace with technological advancements while maintaining the core principles of patient care.
• The digital health competencies deemed essential for future clinical practice are consistent across all stakeholders.
• The study highlights the emerging need for additional competencies among medical trainees so as to meet the evolving demands of healthcare delivery.
• Regularly comparing the perspectives of various stakeholders in the healthcare system enables educational institutions to adapt and refine their curricula continuously.

I. INTRODUCTION

Digital healthcare, which leverages advanced technologies to enhance, complement, or replace traditional healthcare services, is becoming increasingly common in clinical practice (Alkire (née Nasr) et al., 2020). Digital healthcare technologies (DHTs) such as electronic health records (EHR), telemedicine, and Artificial Intelligence (AI) have significantly improved data management, diagnostics, and patient care (Clay-Williams et al., 2023; Food and Drug Administration, 2019; Welcher et al., 2018;). However, many studies and reviews have highlighted a global lack of formal and systematic training in DHTs for undergraduate medical students (Aungst & Patel, 2020; Edirippulige et al., 2018; Tudor Car et al., 2021). While recommendations for integrating digital health education (DHE) exist, they often propose standalone courses focused on specific DHTs rather than embedding DHE into the core medical curriculum (Tudor Car et al., 2021; Zainal et al., 2023a; Zainal et al., 2023b).  Barriers to consistently incorporating DHE into medical curricula, as reported in countries such as Canada, Germany, the United Kingdom (U.K.), and the United States (U.S.) include limited faculty expertise, curriculum overload and fragmented implementation efforts (Gillissen et al., 2022; Hurley et al., 2011; Machleid et al., 2020; Sit el al., 2020; Sorg et al., 2022).

Furthermore, there is limited research exploring the perspectives of both medical students and senior clinicians on the relevant digital health competencies (DHCs) required for clinical care. DHCs encompass the knowledge, skills, and attitudes essential for assessing, diagnosing, and treating patients in the digital age. An inter-generational comparison of these perspectives is crucial for identifying gaps in the existing curricula and ensuring medical education aligns with the rapidly evolving healthcare landscape. Medical students can offer fresh insights into emerging tools and platforms while senior clinicians can contribute perspectives on clinical skills given their wealth of clinical experience.

Despite Singapore’s advanced digitalisation, challenges remain in standardising DHE across its three medical schools: Yong Loo Lin School of Medicine at National University of Singapore (NUS), Lee Kong Chian School of Medicine at Nanyang Technological University (NTU) and Duke-NUS Medical School (Duke-NUS) (Zainal et al., 2023a). Although these institutions boast state-of-the-art facilities, a disconnect persists between medical training and clinical practice due to various institutional and structural barriers (Zainal et al., 2023a). While efforts to integrate DHE, such as virtual reality courses, have been initiated, there are variations in content and duration across institutions, underscoring the lack of a standardised approach (Zainal et al., 2023a).

This study uses Singapore as a case study to explore the perceptions of medical students, clinical educators, and teachers regarding DHCs, with the aim of improving DHE integration into undergraduate medical curricula. Specifically, it compares the views of these stakeholders in identifying any digital competencies that may be relevant for clinical practice in an increasingly digital healthcare landscape. By focusing on Singapore, this study not only sheds light on gaps in the local curricula but also provides insights that can inform global efforts to strengthen DHE integration in medical education.

II. METHODS

A. Setting and Sample

A qualitative study was conducted using individual semi-structured interviews with medical students, clinical educators, and clinical teachers. Participants were identified by Principal Investigator (P.I.) FKY, based on their year of study and clinical roles respectively, ensuring relevant knowledge and experience.

The study employed a combination of convenience sampling and snowballing technique to recruit students from all three local medical schools. Clinical-year students (third to fifth years) were included due to their potential exposure to DHTs during clinical rotations, while pre-clinical students were excluded. Convenience sampling was initially used for ease of access, and snowballing technique was subsequently employed to expand participation and capture diverse perspectives.

To ensure diverse representation among clinicians, purposive sampling was applied across Singapore’s three public healthcare organisations. Clinical educators dedicating over 20 per cent of their time to education-related activities (e.g., teaching, curriculum planning, research, and administration) and clinical teachers contributing less than 20 per cent of their time to such roles were included. Clinicians not involved in educational roles were excluded from the study.

This study was classified as a quality improvement (QI) project on medical education curricula by the SingHealth Research Integrity, Compliance, and Ethics (RICE) committee. As such, it did not meet the criteria for human subject research and was granted an ethical waiver by SingHealth Institutional Review Board (Reference Number: 2020/2880). Nonetheless, this research adhered strictly to the ethical principles of the Declaration of Helsinki and institutional guidelines.

Data collection occurred from September 2020 to February 2023. Participants were invited by the P.I. via email detailing the study’s purpose, procedures, potential risks, and benefits, with consent obtained before the interviews. To address potential biases due to the P.I.’s professional relationships, interviews were conducted by a research fellow without prior connections to participants. Verbal consent was recorded at the start of each Zoom session, and participants were reminded of their right to withdraw, with pre-withdrawal data retained for comprehensive analysis.

To ensure anonymity, participants were assigned coded identifiers (‘MS’ for medical students, ‘CL’ for clinicians). Identifying information and audio recordings were securely stored and separated from the main dataset. Results were reported with care to avoid identifying individuals, and the data was exclusively used for curriculum development.

B. Data Collection

The interview guide followed Kallio et al.’s (2016) framework, including pre-requisites for semi-structured interviews, literature review, expert consultation, preliminary guide development, pilot testing with five participants, and finalisation. Questions addressed clinical competencies, their relevance to digital healthcare, and ways medical schools can better prepare students for digitalisation (Tables 1 and 2). Interviews included medical students and clinicians across specialties to ensure diverse perspectives.

The study involved 63 participants, with sample size guided by theoretical and practical considerations. Data collection continued until thematic saturation was reached, ensuring all relevant perspectives were captured. Practical constraints like time and resources influenced the participant number, but the focus remained on data richness and diversity for a comprehensive exploration of the research questions.

Sixty interviews were conducted via Zoom due to COVID-19 restrictions, with three in-person interviews held under local health guidelines. Each session lasted about 40 minutes and was audio-recorded. Transcriptions were generated using Otter AI and reviewed for accuracy by the P.I. and research fellow.

Table 2. Interview questions for clinical educators and teachers

C. Data Analysis

Thematic analysis followed Braun and Clarke’s six-step framework to explore curricular gaps (Braun & Clarke, 2006). Two researchers independently coded the data, resolving discrepancies through discussion to refine the codebook and ensure consistency. Credibility was enhanced by triangulating findings across participants from various medical schools and healthcare clusters, capturing diverse perspectives and minimising bias.

To contextualise the findings, comparisons were made with studies from other high-income countries undergoing similar healthcare digitalisation. Additionally, recent data from stakeholders, including medical school leaders, were analysed to understand the digital competencies needed for future clinical practice. Reporting adhered to the Standards for Reporting Qualitative Research (O’Brien et al. 2014).

III. RESULTS

Sixty-three participants took part in our study. Thirty of them were medical students who were undergoing clinical rotations in various disciplines, with 10 coming from each school. Twelve were clinical educators and 21 were clinical teachers. The clinicians were aged between 44 and 70 years. All had more than 10 years of clinical experience and came from 24 different disciplines and 12 healthcare institutions. A summary of their demographics is reported in Table 3 and illustrative excerpts are found in Table 4.

Table 3. Demographics of participants

Four major themes were derived from the data.

A. Limited and Inconsistent Exposure to DHTs

Students reported limited exposure to DHTs in core medical curricula, with training mainly through electives, select programmes, and student-driven initiatives. Exposure to health informatics and telemedicine was brief, with telemedicine training primarily prompted by the COVID-19 pandemic. Other DHTs like robotic surgery, virtual reality, and POCUS were inconsistently incorporated across medical schools. Some clinicians also reiterated the need for DHT exposure in public healthcare institutions, as doing so could inspire medical students to engage in innovation, research, and development in cutting-edge fields like robotics.

B. Unified Views among Clinicians and Students on Essential Competencies

Clinicians and students shared unified perspectives on incorporating key DHCs like EHR, telemedicine, and POCUS into medical curricula. These competencies are viewed as crucial for preparing students for contemporary clinical practice.

Participants emphasised the need to balance EHR use with effective patient interaction. M25, a third-year student, highlighted the importance of maintaining empathy and humanistic values, while CL27, a rheumatologist, stressed integrating EHR data into patient discussions to improve engagement and understanding of health conditions.

All groups also agreed on the importance of telemedicine training. Students expressed interest in learning how to identify conditions suitable for virtual consultations, build patient rapport, and conduct comprehensive assessments via tele-platforms. MS5 noted the challenges of teleconsultation, such as interpreting body language and addressing legal responsibilities. Clinicians like CL14 underscored the need to teach students how to select patients for teleconsultation and identify red flags effectively.

Additionally, both clinicians and students strongly supported incorporating POCUS into the curriculum. Students acknowledged its utility in bedside diagnostics, while clinicians like CL9 and CL18 highlighted its value in resource-limited settings and its role in enhancing diagnostic accuracy. They advocated for routine training in ultrasound, considering its increasing use in general practice and as a critical tool in diverse healthcare settings. These unified views suggest the need to prioritise these DHCs in medical education to meet the evolving demands of healthcare delivery.

C. Divergent Opinions on Traditional Clinical Skills

Discrepancies in opinions emerged regarding traditional clinical skills, particularly physical examination. Students often viewed diagnostic imaging and tests as superior to these skills, perceiving physical exams as less critical. For instance, M11, a Year 4 student, argued that ultrasonography provides more precise diagnoses, making physical examination less relevant.

Clinicians, however, emphasised preserving traditional skills like history-taking and physical examination, especially for resource-limited settings. CL3, an ophthalmologist, expressed concern that reliance on diagnostic tools has led to the erosion of these essential skills.

D. Emerging Technologies and Concerns

The perceived competencies for medical education varied between students and senior clinicians. Students valued wearables and healthcare apps for patient empowerment, personalised care, and strengthening doctor-patient trust. For instance, MS30, a fourth-year student, suggested that wearable data could help create personalised care plans and enhance clinical practice.

Clinicians, however, expressed concerns about the privacy and security of patient data in these apps. They emphasised the responsibility to protect patient information and were cautious about using apps that did not meet security standards. These differing opinions highlight the need for a DHE curriculum that addresses both student interests and clinician concerns.

In our sample selection, we included both clinical educators and clinical teachers to capture a range of perspectives on the integration of DHCs into medical education. However, our analysis did not reveal significant differences in the views expressed by these two groups. Both shared similar opinions on the importance of teaching DHCs such as EHR, telemedicine and POCUS. This alignment may be attributed to their shared roles in preparing medical students for clinical practice, regardless of their specific titles or responsibilities. As such, the findings reflect a unified perspective among clinicians involved in medical education, despite the initial distinction made in the sample selection.

Table 4. Illustrative quotes from interviews with participants

IV. DISCUSSION

This study contributes to the literature by comparing the views of medical students, clinical educators, and clinical teachers on essential competencies for medical school curricula. It highlights a consensus on the need for training in EHR, telemedicine, and POCUS, while also identifying emerging needs like interpreting data from healthcare devices and engaging patients with this data. Unlike previous studies that focused on either clinicians or students (Blacketer et al., 2021; Foadi et al., 2021; Gillissen et al., 2022; Hersh et al., 2017; Liu et al., 2022; Machleid et al., 2020; Pontefract & Wilson, 2019), this research explores inter-generational differences, revealing that younger trainees prioritise patient-centred care and digital health literacy. This emphasis on inclusivity and data literacy is crucial given the global challenge of inadequate health literacy, particularly among older populations (Sørensen et al., 2021; Wittink & Oosterhaven, 2018). Integrating these competencies into curricula can foster ongoing improvement in medical education.

In comparing the views of medical students and senior clinicians regarding DHCs, it is important to acknowledge that the latter group represents a diverse range of roles within the clinical environment. While this study focused specifically on clinicians involved in medical education, senior clinicians may also take on roles as clinical researchers, administrators, or leaders in healthcare innovation. These differing responsibilities could shape their perspectives on the DHCs that should be emphasised in medical curricula. The results of this study should be interpreted within the context of the clinical educators’ primary role in teaching medical students, which may prioritise practical and immediate clinical skills over broader administrative or research-based digital competencies.

The integration of EHR systems into medical education has been recognised as essential. Successful models in the U.S. and U.K. have embedded EHR systems into training, such as allowing students to write notes at primary clinical sites or use de-identified patient data for practice (Pereira et al., 2018; Pontefract & Wilson, 2019; Welcher et al., 2018). These approaches ensure hands-on learning and prepare students for modern healthcare environments. For broader applicability, partnerships with local healthcare institutions and technology providers can enable the development of localised EHR modules tailored to different healthcare contexts. However, over-reliance on EHR systems may reduce critical thinking or direct patient interaction. Mitigation strategies include embedding reflective practices into training and balancing EHR use with patient engagement activities. When successfully implemented, EHR training enhances data management skills and promotes patient interaction.

Telemedicine training varies globally, often focusing on rural healthcare placements, as seen in Australia and the U.K. (Rienits et al., 2016; Wootton, 1999). In Singapore, telemedicine exposure arose mainly during the COVID-19 pandemic’s social distancing requirements, highlighting its potential in urban healthcare. To ensure comprehensive telemedicine training, curricula should include simulated consultations, role-playing exercises, and coverage of diverse scenarios, such as breaking bad news over digital platforms. To address the challenge of interpreting body language, medical schools should incorporate modules that focus on interpreting non-verbal cues, such as facial expressions and gestures, which are essential for building rapport and understanding patients’ concerns. Courses that address the legal responsibilities in telemedicine, including patient confidentiality, informed consent, and documentation requirements, should also be integrated to ensure students are aware of the regulatory frameworks guiding virtual care. Case studies and real-life examples that discuss the legal implications of telemedicine can also help students navigate potential legal challenges. With regard to patient selection, it is crucial for professional bodies to develop frameworks that guide clinicians in determining when in-person care is more appropriate, especially for complex or high-risk cases. Additionally, the curricula should provide guidance on how to recognise red flags such as signs of mental health distress, urgent medical conditions, or patient non-compliance with digital tools, and escalate them appropriately. Providing continuing education opportunities for practising clinicians is also important to keep them updated on telemedicine advancements. The healthcare system can then pair students with experienced telemedicine practitioners who can provide the necessary mentorship and guidance.

POCUS has become an essential component of undergraduate medical education (Glass et al., 2021; Sheppard et al., 2023). However, its application is often limited to specific specialties, such as emergency medicine, obstetrics and gynaecology, and radiology (Glass et al., 2021). In contrast, our study advocates for a longitudinal POCUS curriculum spanning all years and specialties. Integrating POCUS training into medical curricula improves diagnostic accuracy, enhances bedside decision-making, and builds clinical confidence. A structured approach, such as Kern’s six-step model, provides a robust framework for designing and implementing a standardised curriculum with consistent competency assessments (Kern, 1998). Innovative teaching methods, including handheld devices and near-peer instruction, have been shown to improve ultrasound proficiency and student performance, as evidenced by successful implementations at the University of Connecticut School of Medicine (Boivin et al., 2022). While improper use of POCUS can result in diagnostic errors, these risks can be mitigated through routine competency evaluations and guided practice, ensuring students develop the necessary skills safely and effectively.

Addressing differing opinions regarding DHC priorities in schools requires collaboration among medical educators, technology developers, and healthcare providers. Medical curricula should include training on the responsible use of DHTs, and evaluating the reliability of apps. Developers should design apps that address clinicians’ data security concerns. Moreover, healthcare organisations should establish guidelines and protocols for healthcare-related app use to ensure patient safety and privacy. Integrating these competencies into medical curricula will better prepare future healthcare professionals for evolving demands of healthcare delivery.

Implementing DHC also requires consideration of diverse healthcare systems and resource availability. Local adaptations, coupled with ongoing evaluation and feedback, ensure curricula remain relevant and scalable. Training programmes must balance global standards with local needs, enabling students to navigate evolving healthcare landscapes effectively. By addressing the implementation strategies, risks, and benefits of DHTs, this study provides actionable insights for advancing DHE.

A. Strengths and Limitations

This qualitative study highlights the DHCs needed in the core medical curricula from the perspectives of students, clinical educators and teachers. The diverse sample of institutions and specialties enriched the data. Student feedback provided up-to-date information on curricula gaps, while senior clinicians’ experience enhanced credibility. Interviewing participants from different generations ensured medical education remains relevant to current and future healthcare needs.

A perceived limitation of this study is its small sample size, which may affect its generalisability, validity and reliability. With a small sample, the findings might not represent the broader population and could miss the population’s diversity (Sandelowski, 1995). Additionally, small sample sizes may not adequately capture the diversity within the population of interest (Sandelowski, 1995). Moreover, the unique socio-political, cultural and economic context of Singapore may limit the generalisability of our findings to other settings. Singapore’s relatively small population and centralised governance create conditions that may differ from other countries. Consequently, while the insights from our study provide valuable lessons, they should be interpreted with caution when applying them to contexts with different governance structures or cultural dynamics.

Despite the limitations, this qualitative study provides a contextualised understanding of participants’ expectations and concerns through in-depth narrative analysis. While not entirely generalisable, the findings have significant implications for medical curricula in other developed countries. They highlight valued competencies, informing curriculum design, training programmes and continuing education initiatives.

Furthermore, this study focused on clinicians from public healthcare institutions, which may influence their perspectives on DHCs. Public sector clinicians often work within more structured systems that prioritise certain competencies differently than in the private sector. While this focus provides insights specific to public healthcare education, it is important to note that the views of private-sector clinicians, who may face different digital health challenges, were not captured in this study. Future work comparing clinicians across both sectors could provide a more comprehensive view. The perspectives of clinicians from the private healthcare sector may also differ due to the distinct operational and financial frameworks in which they practise. 

Moreover, future research could explore the perspectives of clinicians in various roles beyond medical education, such as clinical researchers, healthcare administrators, or those involved in clinical governance. By comparing these viewpoints with those of clinical educators, a more comprehensive understanding of the DHCs required across different professional pathways in healthcare can be developed. Such studies could further inform curriculum development to ensure that medical students are adequately prepared not only for clinical practice but also for the evolving demands of digital health in research, administration, and leadership.

V. CONCLUSION

In conclusion, an inter-generational perspective in medical education leverages the strengths of both medical students and senior clinicians, ensuring a balanced approach that keeps pace with technological advancements while maintaining the core principles of patient care. This collaborative model prepares future healthcare professionals to navigate the evolving landscape of healthcare technology effectively. As the findings have shown, despite their varying levels of experience and diverse medical backgrounds, the DHCs deemed essential for future clinical practice are consistent across all stakeholders. While all stakeholder groups considered most basic clinical skills important, medical students viewed physical examination as replaceable by DHTs. In contrast, the clinical educators and teachers thought otherwise. To address the needs and concerns of all groups, DHCs should complement instead of replace traditional clinical skills.

We acknowledge that the DHTs deemed important in other countries may vary from those reported in this study. However, the type of DHTs to be introduced should not distract us from the main goal of ensuring that the curricula of medical schools around the world remain updated and relevant to current and future healthcare needs. Regularly comparing the perspectives of various stakeholders in the healthcare system is crucial, as it enables educational institutions to adapt and refine their curricula continuously. This iterative process ensures that the curricula remain responsive to the dynamic nature of clinical work.

Notes on Contributors

Humairah Zainal collected and analysed the data, wrote the initial drafts, revised the manuscript for publication and approved the submitted copy of the manuscript.

Xin Xiaohui reviewed, edited, read and approved the submitted copy of the manuscript.

Julian Thumboo reviewed, edited, read and approved the submitted copy of the manuscript.

Fong Kok Yong was involved in the conception and design of the study, reviewed, edited, read and approved the submitted copy of the manuscript.

Ethical Approval

Waiver for ethical approval was granted by SingHealth Institutional Review Board (Reference Number: 2020/2880). 

Data Availability

The data that support the findings of this study are available from the first author upon reasonable request. The data cannot be uploaded to the repository as it contains some confidential views of participants.

Acknowledgements

The authors extend their gratitude to the reviewers for their insightful feedback on the manuscript drafts. Special thanks go to Anisa Muhammad for transcribing the interviews, as well as to Dr. Warren Fong Weng Seng and Dr. Ng Qin Xiang for their assistance in recruiting some of the medical students. The authors also deeply appreciate the invaluable contributions of the study participants.

Funding Statement

This study was supported by SingHealth Duke-NUS Medicine Academic Clinical Programme under Seah Cheng Siang Distinguished Professorship in Medicine.

Declaration of Interest

There are no relevant financial or non-financial competing interests to report.

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*Fong Kok Yong
10 Hospital Boulevard
Singapore 168582
+65 6908 8949
Email: fong.kok.yong@singhealth.com.sg