Submitted: 13 February 2024
Accepted: 28 April 2025
Published online: 1 July, TAPS 2025, 10(3), 75-79
https://doi.org/10.29060/TAPS.2025-10-3/SC3235

Tayzar Hein¹ & Susan Somerville²

¹Department of Medical Education, Defence Services Medical Academy, Myanmar; ²University of Dundee, Scotland

Abstract

Introduction: Case-Based Learning (CBL) is increasingly used in modern medical schools to improve students’ critical thinking and problem-solving skills. While CBL is established in Western Resource-Structured (WRS) educational settings, its use in Asian-Pacific regions like Myanmar is under explored. This research studied the integration of CBL at the Defence Services Medical Academy (DSMA) in Myanmar, focusing on the perspectives of both students and faculty involved in curriculum reforms.

Methods: This study used constructivist grounded theory to gather data from 24 DSMA participants through four focus group discussions. Twelve students and twelve faculty members, were invited a subgroup of six, and after providing informed consent discussed their experiences of CBL, aiming to assess its effectiveness and relevance in their specific educational and cultural context.

Result: Analysis shows that students valued CBL for enhancing group discussions, reflecting upon real-world situations, and building critical thinking abilities. Faculty members also appreciated CBL for its capacity to create realistic applications and its support for student-centered learning and interpersonal skills development. Both groups acknowledged CBL as an effective method for simulating the complexities of medical practice.

Conclusion: This study found that CBL is well-regarded at DSMA for preparing students competence and confidence for clinical encounters. However, faculty indicated that the extensive time required in preparation of this teaching modality was a significant challenge for the wider adoption of CBL. These insights highlight the adaptability and potential challenges of implementing CBL in non-Western educational settings and suggest possible areas for development for its broader application in the Asia-Pacific region.

Keywords:           Medical Education, Case-based Learning, Perceptions, Grounded Theory, Focus Group Discussion

I. INTRODUCTION

In 2017, Defence Services Medical Academy (DSMA) in Yangon, Myanmar, introduced an outcome-based integrated curriculum incorporating Case-Based Learning (CBL) as a key pedagogical approach. This shift from teacher-centered to student-centered learning was aimed at encouraging students to take greater responsibility for their education. However, CBL’s widespread adoption across all subjects at DSMA remains uncertain, highlighting the need for further research. CBL has been established in Western Resource-Structured (WRS) medical education, where it fosters critical thinking, active learning, and problem-solving skills (Thistlethwaite et al., 2012). However, its adoption in the Asian-Pacific context, including Myanmar, has been limited. Cultural and institutional challenges such as insufficient faculty training, resource constraints, and resistance to pedagogical change present unique barriers (McLean, 2016; Yoo & Park, 2015). These challenges underline the importance of research to adapt CBL to resource-constrained settings.

At DSMA, CBL is relatively new, and while the institution can be considered an early adopter within the local context, faculty have faced challenges transitioning from traditional teaching methods due to inadequate training and support (Thistlethwaite et al., 2012). This study aimed to explore how students and faculty perceive the implementation of CBL and to assess the opportunities and challenges of CBL in a resource-constrained, Asian-Pacific context. By addressing gaps in the CBL literature, this research contributes valuable insights for adapting pedagogical practices to diverse cultural and educational settings.

This study aimed to explore:

1. How students and faculty at DSMA perceive the implementation of CBL.
2. The opportunities and challenges associated with implementing CBL in a resource-constrained, Asian-Pacific context.

 

By addressing gaps in the CBL literature, particularly in non-WRS settings, this research contributes to a better understanding of how pedagogical practices can be adapted to diverse cultural and educational contexts, offering insights for both early and late adopters within similar settings.

II. METHODS

This qualitative study used a constructivist grounded theory approach, focusing on the experiences and meanings constructed by participants engaged with CBL in the DSMA integrated curriculum.

A. Sampling and Focus Group Composition

Purposive sampling (Patton, 2014) was used to select participants with direct involvement in CBL activities, either as facilitators or active learners. The study included 24 participants, evenly split between 12 students and 12 faculty members. Four focus groups, each containing six participants, were conducted. To reduce power dynamics, the focus groups were divided by role, with separate groups for students and faculty.

B. Participant Demographics

Table 1 below shows the demographic breakdown of participants is for understanding the responses and receptivity to CBL.

Table 1. Participant demographic

C. Theoretical Framework

The constructivist grounded theory approach guided both data collection and analysis. This approach emphasises the co-construction of knowledge, meaning participants not only shared their experiences but actively engaged in interpreting them. The analysis followed a constant comparative method (Patton, 2014), allowing key themes to emerge from the data.

D. Data Analysis

Data were analysed using MAXQDA software, and the constant comparative method was applied to identify recurring themes and refine categories as new insights developed.

E. Ethical Considerations

Ethical approval was granted by the DSMA Ethical Review Board. Informed consent was obtained from all participants, ensuring they were aware of the study’s aims and their rights. Confidentiality and anonymity were maintained throughout the study, and all focus group discussions were audio-recorded with consent.

III. RESULTS

The core category identified in the study was that CBL is a student-centered approach that develops critical thinking, simulates discussion about real-world scenarios, and enhances interpersonal skills, making it a key facet of modern medical education. These findings emphasise the role of CBL in bridging theoretical knowledge with practical application and supporting the development of essential skills for clinical encounters. Both students and faculty members offered different but aligned perspectives, providing valuable insights into the opportunities and challenges associated with CBL.

A. Students’ Perceptions of CBL

1) Theme 1: CBL as group discussion: Students welcomed the collaborative nature of CBL, emphasising the shared learning experience it offers. One student stated, “It’s like a team effort where we learn from each other while solving problems.” This highlights the significance of peer interaction in CBL, which is consistent with research indicating that collaborative learning enhances problem-solving skills.

2) Theme 2: Real-World Relevance: Students appreciated the practical aspects of CBL, particularly its similarity to real-life clinical scenarios. A participant remarked, “It feels like we are preparing for actual hospital situations.” This theme aligns with studies showing how CBL effectively bridges the gap between theoretical knowledge and clinical practice, preparing students for real-world medical challenges.

3) Theme 3: Fostering Critical Thinking: Students frequently mentioned the role of CBL in promoting deeper analytical skills. One student shared, “CBL makes us analyse why things happen instead of just memorising.” This observation reflects the literature that highlights critical thinking as a fundamental outcome of CBL, encouraging students to engage more deeply with the material.

B. Faculty Perceptions of CBL

1) Theme 1: Preparation for Clinical Practice: Faculty members emphasised the effectiveness of CBL in preparing students for real-world medical contexts. One faculty member noted, “CBL allows students to apply their knowledge in realistic medical contexts.” This highlights the need for carefully designed scenarios that accurately mimic clinical challenges, supporting students in applying theoretical knowledge.

2) Theme 2: The Role of Facilitator: Faculty highlighted the critical role of facilitators in guiding effective CBL sessions. A faculty member stated, “Guiding discussions and asking the right questions is key to effective CBL sessions.” This underscores the importance of facilitator training, as their competence significantly impacts the success of CBL in achieving its objectives.

3) Theme 3: Development of Personal Skills: Faculty also emphasised the role of CBL in cultivating essential personal skills for medical practice, such as communication and empathy. One faculty member remarked, “CBL is instrumental in teaching students how to communicate effectively and empathise with patients, which are essential skills in medicine.” This theme reflects a structured focus on skill development, complementing students’ emphasis on the experiential aspects of learning.

IV. DISCUSSION

This study identified both the opportunities and challenges of adopting CBL in a resource-constrained, Asian-Pacific context. Students recognised CBL’s role in fostering teamwork and critical thinking, consistent with previous research (Ferguson & Lee, 2012; Thistlethwaite et al., 2012). Faculty highlighted its effectiveness in preparing students for clinical practice and developing essential interpersonal skills. However, both groups noted challenges, such as the time-intensive nature of CBL and the varying levels of facilitator preparedness.

A. Student Perspectives

Students appreciated the collaborative nature of CBL, noting that it enhanced communication and problem-solving skills. They also valued its practical relevance, which bridged the gap between theory and clinical practice. However, challenges related to the time commitment and inconsistent preparation for case studies were identified.

B. Faculty Perspectives

Faculty acknowledged the value of CBL in preparing students for real-world challenges but emphasised the importance of facilitator training. Inconsistent facilitation was cited as a barrier to effective implementation, suggesting the need for structured training programs focusing on communication and group management skills.

C. Adapting CBL for the Asian-Pacific Context

Cultural dynamics at DSMA, including hierarchical relationships, were seen as barriers to open dialogue and peer-led activities. Strategies such as peer-led activities and anonymous feedback could help mitigate these issues, creating a more inclusive and collaborative environment. Although hierarchical relationships are common across educational settings, these challenges may be viewed as institutional factors rather than unique cultural issues. Thus, the solutions proposed peer-led activities and feedback are relevant for various contexts beyond Asian-Pacific.

D. Core Category and Future Directions

The findings underscore the need for ongoing research to explore facilitation models and cultural adaptations that can optimise CBL in diverse settings. Future studies should examine how CBL can be further refined to address institutional factors like hierarchical relationships, and how these adaptations can be applied in resource-limited settings.

V. CONCLUSION

This study highlights both the strengths and challenges of implementing CBL at DSMA. Students valued CBL for its relevance to clinical scenarios and its emphasis on clinical reasoning, while faculty recognised its potential in fostering interpersonal skills. However, challenges such as inconsistent facilitation, insufficient faculty training, and the lack of localised case studies were identified. Moving forward, DSMA should focus on enhancing faculty development, particularly in facilitation skills, and integrate case studies that reflect local clinical realities. Additionally, leveraging technology to support CBL in resource-limited settings could improve access and engagement.

For the broader health education community, this study underscores the importance of adapting CBL to local contexts, considering cultural dynamics and institutional constraints. Successful implementation of CBL in resource-constrained settings requires flexibility in adapting global pedagogical methods to meet the needs of local learners and educators. Expanding CBL at DSMA, with a focus on faculty training, case study development, and the use of technology, will better prepare students for the challenges of medical practice. This study contributes to the growing body of literature on CBL and provides actionable recommendations for institutions in similar settings.

Notes on Contributors

Dr. Tayzar Hein contributed significantly to the manuscript’s conception, design, and writing, leveraging his expertise to shape its content.

Dr. Susan Somerville provided essential support during the research process, particularly in data collection and analysis, contributing to the manuscript’s presentation.

Ethical Approval

Ethics approval was granted by the Ethical Review Committee of the DSMA, Ethical Review Board (2/ ERB/ 2022).

Data Availability

The data that support the findings of this study are openly available in https://doi.org/10.6084/m9.figshare.26550262.v1.

Acknowledgement

The author would like to express sincere gratitude to their supervisor, Dr Susan Somerville, for her thoughtful guidance throughout the research project. Dr Susan Somerville provided invaluable suggestions, constant encouragement, and generously dedicated her time during video chats, despite being on the other side of the world. The support of the Ethical Review Committee at DSMA is also deeply appreciated. Their rigorous adherence to ethical standards ensured that the study met the highest research ethics guidelines, which is essential to both advancing medical knowledge and protecting human subjects.

Special thanks are extended to the Phase II medical students and faculty members who participated in interviews and provided honest, insightful discussions that significantly contributed to the research. Phase II students, typically in the years of medical education, engage in more clinical-based learning and were crucial in offering perspectives on applying Case-Based Learning (CBL) to real-world medical scenarios. Faculty members from both basic science and clinical practice domains also played an integral role in facilitating these discussions. The assistance of the Medical Education Department faculty in facilitating these interviews was also instrumental, and their support is gratefully acknowledged.

Finally, the author wishes to express heartfelt thanks to his wife and son for their unwavering support and encouragement throughout the academic journey. Without their constant love and understanding, this research project would not have been possible.

Funding

This research is entirely self-funded, as there is currently no external financial support available for the project, necessitating the coverage of all expenses independently.

Declaration of Interest

The author conducted original research and wrote this dissertation, which was not previously submitted for a degree. The author has the copyright to the dissertation according to UK Copyright Acts and University of Dundee’s rules. Any use of material from this thesis should be acknowledged.

References

Ferguson, A., & Lee, E. (2012). Desperately seeking… relevant assessment? A case study on the potential for using online simulated group based learning to create sustainable assessment practices. Legal Education Review, 22(1), Article 6. https:/​/​doi.org/​10.53300/​001c.6258

McLean, S. F. (2016). Case-based learning and its application in medical and health-care fields: A review of worldwide literature. Journal of Medical Education and Curricular Development, 3, S20377. 

Patton, M. Q. (2014). Qualitative research & evaluation methods: Integrating theory and practice (4^th ed.). SAGE Publications.

Thistlethwaite, J. E., Davies, D., Ekeocha, S., Kidd, J. M., MacDougall, C., Matthews, P., Purkis, J., & Clay, D. J. (2012). The effectiveness of case-based learning in health professional education. A BEME systematic review: BEME Guide No. 23. Medical Teacher, 34(6), e421-e444. https://doi.org/10.3109/0142159X.2012.680939

Yoo, M. S., & Park, H. R. (2015). Effects of case‐based learning on communication skills, problem‐solving ability, and learning motivation in nursing students. Nursing & Health Sciences, 17(2), 166-172. https://doi.org/10.1111/nhs.12151

*Tayzar Hein
Defence Services Medical Academy,
Pyay Road, Mingalardon Township,
Yangon, Myanmar
+9595188093
Email: dr.tayzarhein@gmail.com

https://doi.org/10.29060/TAPS.2025-10-3/TT003

Gominda Ponnamperuma

MBBS, MMEd, PhD
Professor in Medical Education
Faculty of Medicine, University of Colombo, Sri Lanka

Standard setting is the process of deciding the boundary or standard that separates the candidates into two (e.g. pass and fail) or more groups, based on their ability shown at an assessment. Standard setting methods can be broadly grouped into four clusters (see table below).

When to use which method, though a crucial decision for any Board of Examiners, is inadequately explored in the literature. The following brief guide attempts to bridge this literature gap.

Cluster of methods	Key features	Issues	When to use
Arbitrary standards and norm-referenced standards	Arbitrary standards produce a fixed pass mark, e.g., candidates scoring 50% or more pass. Norm-referenced standards produce a fixed pass rate, e.g., 40% of top-scoring candidates pass.	The pass mark is unrelated to the difficulty of assessment items.	Arbitrary standards: not indicated for high-stakes assessment. Norm-referencing: used for selection purposes.
Test-centred methods	A group of experts (judges) estimate the probability of a hypothetical borderline (a candidate who has a 50% probability of passing or failing) or a just-passing candidate passing the test items, e.g. Angoff (1971), Ebel (1972), Nedelsky (1954), Bookmark (Karantonis & Sireci, 2006), Jaeger (1982). The judges’ estimates are collated through an averaging process. An expert (judge) is a subject-matter specialist, with considerable experience as a teacher and an assessor, well versed with the educational basis behind standard setting.	Although the pass mark is directly related to the difficulty of test items, human judgement is not infallible: The pass mark can vary from one panel of judges to another, even for the same test. finding a sizeable group of experts (at least 8) satisfying all requirements is difficult. it is difficult for judges to visualise a hypothetical borderline candidate. the process is time-consuming. Due to the above difficulties, the pass mark can be unrealistic.	When an adequate number of properly trained and experienced expert judges who can devote quality time to the standard setting process is available. When modifications such as the Modified Angoff method can be used to overcome unrealistic standards by allowing judges to be informed by actual results of previous similar exams.
Partially results-based methods-I: Examinee-centred methods	Based on actual candidate performance, judges group candidates into two or more groups, e.g. Borderline group (Smee & Blackmore, 2001), Borderline regression (Kramer et al., 2003), Contrasting groups (p.35) (Livingston & Zieky, 1982) and Up-down (p.43) (Livingston & Zieky, 1982) methods. The pass mark is calculated using the actual candidate scores.	Although judgements are realistic, the introduction of actual test results tends to make the standard cohort-dependent, i.e., norm-referencing features influence the standard.	When there is a sufficiently large number of candidates. When a global score or a global pass/fail decision is available, in addition to the usual itemized score. When the judges are well-trained in making a global decision independent of the itemised scores.
Partially results-based methods-II: Compromise methods	Judges make judgements by looking at test items, and those judgements are superimposed on actual candidate scores to derive the pass mark, e.g., Hofstee method (Hofstee, 1973).	Expert judgements and actual results may not match each other. The standard can be cohort-dependent due to the norm-referencing features of actual candidate scores.	When trained judges, actual results of a sizable cohort of candidates and expertise in handling both judges’ judgements and results are available. Mostly used as a backup method to verify standards generated by other methods.
Results-based methods	Judges are not needed for standard setting. The pass mark is generated by statistically manipulating the actual marks, e.g. Cohen (Cohen- Schotanus & van der Vleuten, 2010) and Wijnen (1971) methods.	Due to the norm-referencing influence, the pass mark could be high and defensibility would be an issue.	These methods should be used in high-stakes assessment only when an adequate evidence base is built by conducting them parallelly with another more established method.

 

References

Angoff, W. H. (1971). Scales, norms, and equivalent scores. In R. L. Thorndike (Ed.), Educational measurement (2^nd ed., pp. 508-600). American Council on Education.

Ebel, R. L. (1972). Essentials of educational measurement. Prentice Hall.

Nedelsky, L. (1954). Absolute grading standards for objective tests. Educational and Psychological Measurement, 14(1), 3-19. https://doi.org/10.1177/001316445401400101

Karantonis, A., & Sireci, S. G. (2006). The bookmark standard-setting method: A literature review. Educational Measurement Issues and Practice, 25(1), 4-12. https://doi.org/10.1111/j.1745-3992.2006.00047.x

Jaeger, R. M. (1982). An iterative structured judgment process for establishing standards on competency test: Theory and application. Educational Evaluation and Policy Analysis, 4(4), 461-476. https://doi.org/10.3102/01623737004004461

Smee, S. M., & Blackmore, D. E. (2001). Setting standards for an Objective Structured Clinical Examination: The borderline group method gains ground on Angoff. Medical Education, 35(11), 1009-1010. https://doi.org/10.1111/j.1365-2923.2001.01047.x

Kramer, A., Muijtjens, A., Jansen, K., Dusman, H., Tan, L., & van der Vleuten, C. (2003) Comparison of a rational and an empirical standard setting procedure for an OSCE. Medical Education, 37(2), 132-139. https://doi.org/10.1046/j.1365-2923.2003.01429.x

Livingston, S. A., & Zieky, M. J. (1982). Passing scores: A manual for setting standards of performance on educational and occupational tests. Educational Testing Service.

Hofstee, W. K. B. (1973). Een alternatief voor normhandhaving bij toetsen. Nederlands Tijdschrift voor de Psychologie, 28, 215-227.

Cohen-Schotanus, J., & van der Vleuten, C. P. M. (2010). A standard setting method with the best performing students as point of reference: Practical and affordable. Medical Teacher, 32(2), 154-160. https://doi.org/10.3109/01421590903196979

Wijnen, W. H. F. W. (1971). Onder of boven de maat. Amsterdam: Swets & Zeitlinger.

Submitted: 30 October 2024
Accepted: 8 April 2025
Published online: 1 July, TAPS 2025, 10(3), 89-92
https://doi.org/10.29060/TAPS.2025-10-3/SC3562

Shanya Shanmugam¹, Rajeswari Kathirvel^1,2, Kayda Soh² & Xinyi Li^1,2

¹Lee Kong Chian School of Medicine, Singapore; ²Division of Obstetrics and Gynaecology, KK Women’s and Children’s Hospital, Singapore

Abstract

Introduction: The Objective Structured Clinical Examination (OSCE) is a popular method for assessing medical students’ clinical proficiency. Mock OSCEs are often incorporated into medical curricula to help students familiarise themselves with the examination format. While the impact of mock OSCEs on academic performance has been studied, their perceived utility remains less explored. This study aimed to assess the effectiveness of a mock OSCE in preparing medical students for their final examinations.

Methods: A prospective study was conducted at a tertiary hospital in Singapore, involving medical students undergoing their Obstetrics and Gynaecology posting. The mock OSCE consisted of five stations and included immediate feedback from examiners. Students completed three questionnaires: pre-mock OSCE, post-mock OSCE and post final examinations, rating the utility of the session and their confidence levels.

Results:  Of the cohort of 147 students, 121 responded to the pre-mock OSCE survey, 132 responded to the post-mock OSCE survey, and 105 to the survey after their final examinations. The percentage of students who found the mock OSCE useful/very useful increased significantly from 97.5% before to 98.5% after the session, and significantly decreased to 96.2% after the examinations. Confidence levels rose significantly from a mean score of 2.34/5 pre-mock to 3.89/5 post-mock, to 4.67/5 post-exam. Qualitative feedback was positive, highlighting the benefit of familiarisation with examination mark schemes.

Conclusion: The mock OSCE was well-received by students and perceived as a valuable tool in preparation for examinations. Despite the limited sample size, these findings support the implementation of mock OSCEs to enhance students’ learning and exam preparedness.

Keywords:           OSCE, Undergraduate, Medical Education, Medicine, Students’ Perception

I. INTRODUCTION

The Objective Structured Clinical Examination (OSCE) is a well-established, widely utilised method for assessing the clinical proficiency of medical students. This format comprises multiple stations where students perform clinical tasks, including history taking, physical examination, and discussing clinical management. Despite being a crucial assessment tool, OSCEs can be a daunting experience for medical students. Educational institutions often incorporate mock OSCEs into curricula to alleviate this stress, allowing students to familiarise themselves with the format and receive feedback. These sessions aim to mimic the actual OSCE, allowing students to familiarise themselves with the format and requirements, and offer an opportunity to receive feedback. 

The correlation between mock OSCE practice and performance in the actual OSCE has yielded mixed results in literature. Studies on medical students (Townsend et al., 2001), and residents from internal medicine (Pugh et al., 2016), paediatrics (Hilliard et al., 1998), and emergency medicine (Lee et al., 2021) have established positive correlations between mock OSCE scores and final examination scores. Conversely, a study on second-year medical students concluded that while the mock OSCE led to improved performance in individual stations, it did not cause a significant change in the pass rate of the final examinations (Chisnall et al., 2015).

While the impact of mock OSCEs on students’ academic performance has been examined, the perception of their utility among participants has not been extensively analysed. As OSCE is viewed as a stressful component of medical assessments, the introduction of mock OSCE sessions is thought to mitigate this stress by fostering confidence and familiarity among students (Chisnall et al., 2015).

We performed a study to determine the perceived effectiveness of a mock OSCE in preparing its participants for their final examinations. More specifically, the study aimed to assess whether participation in the mock OSCEs improved students’ understanding of the domain-based exam scoring system employed by markers, enhanced their time management skills, delivered valuable content, helped them develop effective approaches to OSCE stations, and boosted their confidence levels.

II. METHODS

This prospective study evaluated students’ perceptions of the mock OSCE’s utility. This was conducted at KK Women’s and Children’s Hospital (KKH), which is a tertiary hospital in Singapore. KKH caters to students from the three different medical schools in Singapore including Lee Kong Chian School of Medicine (LKC), Yong Loo Lin School of Medicine and Duke-NUS Medical school.

A mock OSCE programme was organised by the Obstetrics and Gynaecology (O&G) department for the fourth-year medical students from LKC during their O&G posting from 2022-2023. The mock OSCE was conducted three times as the students attended in three streams. This is the first of such a programme in the O&G curriculum and was introduced as this cohort had reduced clinical exposure due to COVID-19 restrictions during their clinical years.

The mock OSCE included five 10-minute stations covering history taking, physical examination, and clinical management in O&G. Students were evaluated according to the domain-based scoring system used by LKC for their final examinations. The assessment was designed to be formative in nature and the students received immediate feedback at the conclusion of each station. 

The students were asked to complete anonymous questionnaires before and after participating in the mock OSCE, and after completing their final year examinations. A 4-point Likert scale was used to gauge the usefulness of the mock OSCE session, with 1 being “not useful at all” and 4 being “very useful” and a 5-point Likert scale was used to gauge confidence for final examinations, where 1 represented “not confident” and 5 represented “very confident”. The responses collected before and after the mock OSCE session were compared. The study also examined the impact of the mock OSCE on insight into exam scoring system, time management, and content relevance through Likert scale questions. Qualitative feedback was obtained through open-text responses. The data obtained through the Likert scales were combined into nominal categories. Statistical significance was determined by performing Chi-square tests, with p<0.05 being considered significant.  Informed consent was implied through the voluntary participation of individuals in the questionnaires.

The study was approved and given exempt status by the Nanyang Technological University Institutional Review Board for research (IRB 2023-677).

III. RESULTS

There were 147 fourth-year medical students for the academic year 2022–2023. 121 students responded to the questionnaire prior to the mock OSCE (82.3%), 122 (83.0%) after the mock OSCE, and 105 (71.4%) after their final examinations.

Before the mock OSCE, 97 (80.8%) students believed that it would be very useful for their exam preparation, while 20 (16.7%) believed it would be useful, and 3 (2.5%) were unsure. After the mock OSCE, 120 (91.6%) students thought it was very useful for their exam preparation, with 9 (6.9%) believing it was useful, 1 (0.8%) being unsure, and 1 (0.8%) believing it was not useful. After the final examinations, 77 (74.8%) students found it to be very useful for their exam preparation, 22 (21.4%) found it was useful, 3 (2.9%) were unsure, and 1 (1.0%) found it was not useful (Figure 1). Overall, the percentage of students who found the mock OSCE useful/very useful increased from 97.5% before to 98.5% after the session and decreased to 96.2% after the examinations. The difference in perceived utility of the mock OSCE, as determined by the combining “very useful” and “useful” into one category and “unsure” and “not useful” into another, from before the OSCE, after the OSCE, and after the examinations, was statistically significant at p<0.05, with a p-value of 0.0147.

Figure 1. Comparison of perceived utility of mock OSCE

When asked to rate their confidence regarding their final examinations, the overall score improved from 2.34/5 before the mock OSCE to 3.89/5 after, to 4.67/5 after the examinations. This rise in confidence levels was statistically significant, with a p-value of <0.00001. 

We asked the students to rate the domain that they found the mock OSCE helped them with the most, including improved insight into domain-based exam scoring system, improved time management, useful content, prepare an approach for OSCE stations, and improved confidence. Almost a third (n = 32, 30.5%) of the students found that the mock OSCE helped them to prepare an approach for OSCE stations the most. This was followed by improved confidence (28, 26.7%), improved insight into exam scoring system (21, 20.0%), useful content (15, 14.3%), and lastly, time management (9, 8.6%). Furthermore, a majority of students (n=70, 66.7%) felt that the O&G mock OSCE was helpful not only for the O&G component, but for the entire OSCE examination.

Qualitative feedback obtained from the students was largely positive. The common theme that surfaced was how the mock OSCE allowed students to familiarise themselves with what to expect from the final examination. Examples include:

“Helped to give us a broader understanding of how 1) clinician thinks and how 2) an examiner grades.”

“It was a great opportunity for medical students to learn about history taking and physical examination in a controlled environment.”

IV. DISCUSSION

Overall, the mock OSCE was well-received by students as a useful tool in preparation for final examinations. The differences in the perceived utility of the mock OSCE from before the OSCE, after the OSCE, and after their final examinations was statistically significant. This supports the value of the mock OSCE programme, given the students’ lack of exposure to clinical scenarios and examination structure as previously outlined. Interestingly, the proportion of students who found the mock OSCE programme useful/very useful decreased from 98.5% after the OSCE to 96.2% after final examinations. This drop can be explained by the qualitative feedback obtained, which cites the examination’s increased complexity and variations in content.

Most students felt that the mock OSCE helped them prepare their approach to OSCE stations, consistent with previous studies showing that mock OSCEs help students familiarise themselves with the format. (Lee et al., 2021, Chisnall et al., 2015) These sentiments are echoed in the qualitative feedback obtained. Furthermore, the difference in confidence levels before and after the mock OSCE was statistically significant.

This study is limited by its small sample size, ranging from 105 to 132 students. As participation was voluntary and the questions were not compulsory, some students did not complete the survey, leading to discrepancies in response rates. Furthermore, due to the anonymous nature of the surveys, we are unable to monitor for survey drop-offs. Using Likert scales to assess the utility of the mock OSCE may not fully capture participants’ opinions. Students may have interpreted the scales differently, as utility is subjective to the individuals’ standards for themselves. This could have resulted in less reliable data due to the diversity in how participants understood the scales.

V. CONCLUSION

The results of this study indicate that a mock OSCE is perceived to be an important part of examination preparation for medical students. Despite being a single-specialty mock OSCE, most students felt it was useful for preparing for their entire final exam.

These findings suggest that there is great potential in using mock OSCEs as a revision tool for medical students and support the implementation of such programmes to guide students in their learning and examination preparation.

Notes on Contributors

Shanya Shanmugam is a medical student at Lee Kong Chian School of Medicine, who is interested in medical education. She reviewed the literature, analysed data and wrote the manuscript.

Dr Rajeswari Kathirvel is a senior consultant at KK Women’s and Children’s Hospital and the principal lead for Obstetrics and Gynaecology at Lee Kong Chian School of Medicine. She, alongside with Dr Li Xinyi, designed the study, developed the questionnaire, and developed the manuscript.

Kayda Soh is an executive in KK Women’s and Children’s Hospital OBGYN Academic Clinical Programme. She was involved in administering the questionnaires and collating the data.

Dr Li Xinyi is a consultant at KK Women’s and Children’s Hospital and the posting lead for Obstetrics and Gynaecology at Lee Kong Chian School of Medicine. She, alongside with Dr Rajeswari Kathirvel, designed the study, developed the questionnaire, and developed the manuscript.

Ethical Approval

The study was approved and given exempt status by the Nanyang Technological University Institutional Review Board for research (IRB 2023-677).

Data Availability

The data that support the findings of this study are openly available in the Figshare repository, at https://doi.org/10.6084/m9.figshare.25903786.

Acknowledgement

We would like to thank the students at Lee Kong Chian School of Medicine who participated in this study.

Funding

The authors report that there is no funding associated with the work featured in this article.

Declaration of Interest

The authors report there are no competing interests to declare.

References

Chisnall, B., Vince, T., Hall, S., & Tribe, R. (2015). Evaluation of outcomes of a formative objective structured clinical examination for second-year UK medical students. International Journal of Medical Education, 6, 76–83. https://doi.org/10.5116/ijme.5572.a534

Hilliard, R. I., & Tallett, S. E. (1998). The use of an objective structured clinical examination with postgraduate residents in Pediatrics. Archives of Pediatrics & Adolescent Medicine, 152(1). https://doi.org/10.1001/archpedi.152.1.74

Lee, M. H., Phua, D. H., & Heng, K. W. (2021). The use of a formative OSCE to prepare emergency medicine residents for summative OSCE: A mixed-methods cohort study. Research Square. https://doi.org/10.21203/rs.3.rs-495003/v1

Pugh, D., Bhanji, F., Cole, G., Dupre, J., Hatala, R., Humphrey-Murto, S., Touchie, C., & Wood, T. J. (2016). Do OSCE progress test scores predict performance in a national high-stakes examination? Medical Education, 50(3), 351–358. https://doi.org/10.1111/medu.12942

Townsend, A. H., Mcllvenny, S., Miller, C. J., & Dunn, E. V. (2001). The use of an objective structured clinical examination (OSCE) for formative and summative assessment in a general practice clinical attachment and its relationship to final medical school examination performance. Medical Education, 35(9), 841–846. https://doi.org/10.1046/j.1365-2923.2001.00957.x

*Shanya Shanmugam
Lee Kong Chian School of Medicine,
11 Mandalay Road,
Singapore
Email: shanya001@e.ntu.edu.sg

Submitted: 19 October 2024
Accepted: 28 April 2025
Published online: 1 July, TAPS 2025, 10(3), 84-88
https://doi.org/10.29060/TAPS.2025-10-3/SC3547

Eranthi Weeratunga, Shashika Karunanayaka, Pramudika Kariyawasam & Bimba Wickramarachchi

Department of Nursing, Faculty of Allied Health Sciences, University of Ruhuna, Sri Lanka

Abstract

Introduction: Palliative care nursing (PCN) supports individuals with life-threatening illnesses, aiming to improve the quality of life (QoL) for patients and families. The objective was to assess the necessity of establishing an Advanced Certificate Course in PCN at University of Ruhuna, Sri Lanka.

Methods: A descriptive cross-sectional study was conducted among 220 registered nurses (RNs) using purposive sampling, working at National Hospital Galle. A pre-tested, interviewer-administered questionnaire was used, including questions on prior education or training experiences on palliative care (PC), and its principles, services, and management. Descriptive statistics and the chi-square test were used to analyse.

Results: The majority of the RNs were aged 31-40 years (45.2%), females (86.0%), and married (55.7%). A higher proportion of RNs were nursing diploma holders (67.4%), with 55.7% having less than ten years of nursing experience. Only 11.3% of the RNs had formal additional training on PC, such as workshops and a few training hours. Most RNs correctly identified PC aims: improving survival (59.7%), improving QoL of patients and their families (91.4%), providing relief and pain (93.7%), understanding PC (80.1%), etc. The majority (84.6%) had a good attitude toward palliative caregiving, though only 20.4% had average knowledge of PC. Formal PCN training was significantly associated with PC knowledge (p=0.004).

Conclusion: Limited educational exposure, average knowledge levels, and good attitudes toward PC suggest the need for a PCN course for nurses. Providing a special education programme reduces the current gaps in PC by equipping RNs with the respective knowledge, skills, and attitudes to deliver complex management for patients requiring PC.

Keywords:           Palliative Care Nursing, Sri Lanka, Educational Needs, Registered Nurse

I. INTRODUCTION

Palliative care (PC) is an approach that aims to improve the quality of life (QoL) of patients and their families facing the physical, psychosocial, and spiritual problems associated with life-threatening illnesses (World Health Organization [WHO], 2022). About forty million people need a PC every year in the world, but the majority are from lower-middle-income countries (LMICs) (WHO, 2022). PC is offered by a range of professionals comprising physicians, nurses, support workers, etc., who are equally important, in addition to family members (WHO, 2022).

The major obstacle to improving PC among healthcare professionals (HCPs) and policymakers in LMICs is a lack of education/training (WHO, 2022) and a need for knowledge on PC for nursing professionals, which emphasised in previous findings in Sri Lanka (Meegoda et al., 2018) in addition to less PC content in the undergraduate curriculum (Pesut & Greig, 2018).  Further, less awareness of PC, cultural/social barriers, and misconceptions was found among HCPs; PC education improved nurses’ knowledge, confidence, attitudes, and communication abilities (WHO, 2022).  In Sri Lanka, there is a growing number of non-communicable diseases (NCDs), such as cancers, end-stage renal disease, HIV/AIDS, motor neuron disease, etc., that require comprehensive PC at every stage of the disease process in addition to the rapidly aging population.

PC services in Sri Lanka remain limited due to a shortage of trained HCPs. In response to the rising burden of NCDs, the Ministry of Health has emphasised the need to strengthen PC across all levels of the healthcare system. However, gaps in knowledge, skills, and attitudes among HCPs hinder effective implementation. While universities have introduced theoretical PC education, nursing undergraduates receive minimal practical exposure. Although a one-year post-basic diploma in palliative care nursing (PCN) has been launched for registered nurses (RNs), it is insufficient to meet the growing national demand. The initiation of a new course is of paramount importance, as specialisation in PCN has become an urgent necessity both nationally and internationally. The rising number of patients requiring PC, driven by demographic transitions, underscores this need. In developed countries such as Japan and Australia, the demand for PCN is expected to increase due to aging populations. Nationwide studies in Japan estimated that PC needs will continue to rise. Evidence suggests a growing demand for PC services in Australia, in particular, as the number of Australians aged over 85 continues to increase, the need for PC services has also surged. As a result, the demand for Sri Lankan RNs specialising in PC is expected to rise in these developed countries.

To address the existing gaps in PC knowledge and skills among RNs, we sought to quantify RN’s readiness for specialisation in PCN. The key objective was to assess the necessity of establishing an Advanced Certificate Course in PCN at the Department of Nursing, Faculty of Allied Health Sciences (FAHS), University of Ruhuna (UoR), Sri Lanka, to enhance professional competency and meet the growing demand for PC services.

II. METHODS

This descriptive cross-sectional study was conducted at the National Hospital Galle (NGH), Sri Lanka. The study participants were 220 RNs purposively selected based on having at least one year of experience, surveyed from June to December 2023. Data were collected using a content-validated and pre-tested questionnaire, which had been previously utilised in a Sri Lankan study (Fernando & Prathapan, 2019). The questionnaire comprised sections designed to assess socio-demographic characteristics and knowledge of four distinct domains: basic principles, service organisation, clinical management, and ethical considerations. Additionally, participants’ attitudes were evaluated after obtaining written informed consent. Statistical Package for Social Science (SPSS) 26 software was used; the descriptive statistics, frequencies, and percentages were checked. Further, a chi-square test was used. All results were regarded as statistically significant at p < 0.05.

III. RESULTS

The majority of the RNs were aged 31-40 years (45.2%). The mean±SD age was 36.61 ± 7.47 years. The majority were female (86.0%) and married (55.7%). Of the RNs, 35.7% had a monthly income between Sri Lankan Rupees 50,000 and 74,999. A higher proportion of RNs were nursing diploma holders (67.4%), with 55.7% having less than ten years of nursing experience. Emergency trauma care was the special training received by the RNs (4.5%). Only 11.3% of the RNs had formal additional training on PCN, such as workshops and a few training hours. Most RNs correctly identified PC aims (Table. 1). However, the majority gave incorrect answers regarding general knowledge/concepts of PC principles, such as increasing the life expectancy of terminally ill patients (59.7%) and consultants as ideal coordinators for PC (87.8%). Most RNs agreed that PC offers hope to patients (47.1%) and considered it a basic human right (79.6%). The majority (84.6%) had a good attitude toward PC, though only 20.4% had average knowledge of PC. Knowledge of PC was significantly associated with formal PCN training (p=0.004).

Table 1. General principles of PC among RNs, service organisation, drug management aspects, and ethical concerns

IV. DISCUSSION

This study assessed PC knowledge, management, ethical concerns, and attitudes among RNs in the NHG, Sri Lanka. RNs reported average knowledge and satisfactory attitudes, with age and prior PC training significantly influencing knowledge levels. Compared to the current study, Fernando and Prathapan (2019) reported higher satisfactory scores.

Sri Lankan medical graduates showed limited PC knowledge (37.23%), lower than RNs (20.4%), likely due to curriculum gaps (Fernando & Prathapan, 2019; Prem et al., 2012). While young medical graduates had adequate knowledge of general principles (63%), ethics was the weakest area (19.55%), mirroring findings among RNs.

PC is a relatively new discipline in Sri Lanka, contributing to limited ethical awareness. Cultural norms favor “hiding bitter truths” over transparency rather than “telling the truth,” which is a fundamental principle in Western healthcare practices, influencing attitudes and ethical concerns (Fernando & Prathapan, 2019).

The medical graduates studied by Fernando and Prathapan (2019) were younger than the RNs in this study. Despite some PC exposure, RNs had fewer opportunities for specialised training, impacting knowledge levels. Nevertheless, their positive attitudes likely stem from empathy-based patient care within the Asian context.

A previous study highlighted insufficient PC preparedness among nurses, attributing it to curriculum deficiencies and inadequate training in pain management (Prem et al., 2012). Female RNs performed better than males, but knowledge gaps remain a global issue. Student nurses and new RNs often feel inadequately prepared to discuss end-of-life issues, death, and other ethical concerns.

Meegoda et al. (2018) emphasised the need for adequate PC knowledge among nurses, as limited PC services worsen cancer care challenges. Heavy workloads and time constraints hinder learning, and 96% of RNs had not attended PC training. In-service programmes were considered beneficial, but specialised training is mainly available in Colombo, restricting accessibility. Distance learning could bridge this gap.

Nurses are vital in PC across various healthcare settings. Skilled PCNs provide essential support to patients and families. WHO (2022) stresses PC’s role in alleviating suffering and advocates its integration into national healthcare. However, LMICs face educational and awareness barriers.

Although Sri Lankan nurses have access to higher education, PC specialisation remains limited, especially in remote areas. With rising NCDs and aging populations, introducing PCN courses is crucial. Establishing a PCN programme aligned with national priorities would enhance patient care and improve career opportunities, particularly for nurses seeking employment abroad. A PCN course at FAHS, UoR, outside Colombo, could improve access to PC education.

A. Limitations

This study highlights the need for PC training, but it has limitations. Sampling bias may affect validity, and self-reported data could introduce response bias.

V. CONCLUSION

Limited educational exposure, average knowledge, and positive attitudes toward PC indicate a need for PCN courses to address existing gaps. RNs at NHG support an Advanced Certificate Course in PCN, emphasising the necessity for specialised training. Expanding PC education will enhance patient care and create new professional opportunities. Future research should assess the impact of PC training on HCP competencies and patient outcomes. Collaboration between the University of Ruhuna and the Ministry of Health is essential for establishing a sustainable PCN course.

Notes on Contributors

EW was involved in conceptual development, data collection/entry/analysis, manuscript drafting, editing, and final correction. SK was incorporated into conceptual development, data collection/entry/analysis, and editing. Data entry/analysis, editing, and final correction were done by PK, and BW was involved in manuscript draft editing.

Ethical Approval

Ethical approval (Ref. No. 83.11.2021) and institutional approval were obtained from the Ethics Review Committee of the FAHS, UoR, and the relevant institutions/authorities.  

Data Availability

Data analysed during the current study will be available from the corresponding author upon reasonable request.

Acknowledgment

The authors are grateful to the Dean, FAHS, UoR, Galle, Sri Lanka, and the Head, Department of Nursing, FAHS, UoR, Galle, Sri Lanka. The Director, Chief Grade Nursing Officer, and all in-charge nursing sisters of the National Hospital Galle are acknowledged for their permission. Ms. Nimesha and Mr. Dilan (11th batch/nursing graduates) are appreciated for their enormous contribution while collecting data despite their busy schedules. All consented RNs were further acknowledged for giving their true opinions and great support to uplift nursing education in the PCN field. 

Funding

The authors received no funding for this study.

Declaration of Interest

The authors declare that they have no competing interests.

References

Fernando, G. V. M. C., & Prathapan, S. (2019). What do young doctors know of palliative care; How do they expect the concept to work? BMC Research Notes, 12(1), 1–6. https://doi.org/10.1186/s13104-019-4462-2

Meegoda, D. L., Fernando, D. M. S., Atulomah, N., Sivayogan, S., & Marasinghe, R. B. (2018). Improvement of nurses’ skills following a hybrid model educational intervention on cancer palliative care. International Journal of Health Sciences & Research, 8(5), 196–203. http://www.ijhsr.org/IJHSR_Vol.8_Issue.5_May2018/IJHSR_Abstract.031.html

Pesut, B., & Greig, M. (2018). Resources for educating, training, and mentoring nurses and unregulated nursing care providers in palliative care: A review and expert consultation. Journal of Palliative Medicine, 21(S1), S50–S56. https://doi.org/10.1089/jpm.2017.0395

Prem, V., Karvannan, H., Kumar, S. P., Karthikbabu, S., Syed, N., Sisodia, V., & Jaykumar, S. (2012). Study of nurses’ knowledge about palliative care: A quantitative cross-sectional survey. Indian Journal of Palliative Care, 18(2), 122–127. https://doi.org/10.4103/0973-1075.100832

World Health Organization. (2022). Palliative care. https://www.who.int/news-room/fact-sheets/detail/palliative-care

*Eranthi Weeratunga
Department of Nursing,
Faculty of Allied Health Sciences,
University of Ruhuna
Galle, 80 000, Sri Lanka
+94 71 440 2662, +94 77 225 8519
Email: eranthiw@ahs.ruh.ac.lk,
eranthiweeratunga@yahoo.com

Submitted: 22 July 2024
Accepted: 4 February 2025
Published online: 1 July, TAPS 2025, 10(3), 80-83
https://doi.org/10.29060/TAPS.2025-10-3/SC3470

Zaitunnatakhin Zamli¹, Rohaini Ramli², Hidayah Sulaiman², Mohd Zulfaezal Che Azemin³, Wan Muhamad Salahudin Wan Salleh⁴, Nurul Asyiqin Yusof⁵, Imran Mahalil² & Azmi Mohd. Yusof²

¹Department of Biomedical Science, Kulliyyah of Allied Health Sciences, International Islamic University Malaysia, Malaysia; ²Department of Informatics, College of Computing & Informatics, Universiti Tenaga Nasional, Malaysia; ³Department of Optometry and Visual Sciences, Kulliyyah of Allied Health Sciences, International Islamic University Malaysia, Malaysia; ⁴Department of Basic Medical Sciences, Kulliyyah of Medicine, International Islamic University Malaysia, Malaysia; ⁵Department of Basic Medical Sciences, Kulliyyah of Pharmacy, International Islamic University Malaysia, Malaysia

Abstract

Introduction: Virtual reality (VR) has been widely used in medical and health sciences education since the late twentieth century. VR complements the conventional teaching and learning (T&L) approach by providing an engaging and immersive 3D spatial learning environment, especially for understanding the orientation of anatomical structures. Despite these advantages, the usability and student preference of highly immersive head-mounted display-based (HMD) and less immersive desktop-based (DB) VR in human anatomy courses have yet to be determined.

Methods: In a cross-sectional study, 49 Year-2 medical students were recruited through a convenient sampling. The participants were asked to identify 15 skeletal system components using the HMD and DB platform with human anatomy VR application. Both applications’ System Usability Scale (SUS) and preference scores were obtained via a self-administered questionnaire. The data were expressed as median [IQR] and statistically analysed using MATLAB R2022b.

Results: Most participants preferred the HMD over the DB platform (p=0.04), especially the male participants (p=0.01). There was no significant difference in overall SUS scores between both platforms (p=0.14). However, when compared within and between genders, females scored significantly higher in the DB than HMD (p=0.02) and higher than males’ DB SUS scores (p=0.03).

Conclusion: The overall usability of HMD was comparable with the DB platform for learning human anatomy. Although most participants prefer to use the HMD, further exploration of why females prefer the DB is needed. Subsequently, VR application developers must consider gender-related adaptions to promote the equitability and inclusivity of the technology for all users.

Keywords:           Human Anatomy, Virtual Reality, Head-mounted Display, Desktop-based Application, Usability, Preference

I. INTRODUCTION

Virtual reality (VR) is a simulated three-dimensional (3D) environment that enables users to explore and interact with virtual surroundings, perceiving them through their senses as if they were in the real world. It has been widely used in various fields, including education, to provide users with immersive, engaging, and experiential learning experiences.

In medical education, VR allows students to manipulate anatomical structures into different planes, sections and orientations in a simulated environment, benefiting learners with low-spatial ability. VR also helps students better grasp the relative size differences of organs and allows students to relate the location and position of the organs with their surroundings, resulting in better memorisation and learning outcomes, with VR groups outperforming control groups in post-test assessments (Kurul et al., 2020). As the current generation is more digitally savvy, most students are easily adapted to VR simulation, which enables them to grasp knowledge from a new perspective. For instance, students can dissect a muscle from the human body, gaining insight into the interaction and innervation of individual muscles during exercise.

However, despite the high acceptability of use in anatomy courses among students, some participants reported simulator sickness symptoms like headaches, dizziness, and blurred vision. These symptoms are more pronounced in females, who tend to experience discomfort in a VR environment (Stanney et al., 2020), potentially due to differences in spatial awareness, sensitivity to sensory stimuli, or physiological responses. In addition, regardless of gender, the mismatch between visual motion and the body’s sensory feedback in VR environments can lead to sensory conflict and an increased likelihood of discomfort.

While VR modalities show great potential in anatomy education, research comparing highly immersive head-mounted display-based (HMD) with less immersive desktop-based (DB) VR platforms, particularly regarding gender differences in usability and preferences, remains limited. In addition, considering the high cost of VR applications for HMD, addressing this knowledge gap before its development is crucial to ensuring optimal and cost-effective learning outcomes for a diverse student population. Therefore, this study aimed to compare the usability and preferences between DB and HMD platforms in exploring the VR anatomy applications, within and between genders, among medical students.

II. METHODS

Upon their written consent, forty-nine undergraduate medical students (23 males and 26 females, aged 19-21 years) were recruited through a convenience sampling. They were second-year medical students and participated in this study in two sessions. The participants were asked to identify 15 skeletal components (i.e. skull, vertebrae, hyoid bone, sternum, ribs, scapula, clavicle, humerus, radius, ulna, hip bone, femur, patella, tibia, and fibula) using two platforms: a head-mounted display-based (HMD) virtual reality system with the human anatomy VR application (BodyMap v3.2, https://www.mai.ai/bodymap), and a desktop-based (DB) application (Zygote Body, https://www.zygotebody.com/). BodyMap v3.2 is a VR application for exploring the human body in 3D using the Oculus Quest 2 headset, which provides an immersive and interactive experience for anatomy education. Meanwhile, Zygote Body is a web-based platform that offers detailed 3D anatomical models for desktop or laptop exploration.

Each platform was given a time limit of 15 minutes for the participants to complete the task. After completing the task, the participants completed the System Usability Scale (SUS), a 10-item questionnaire designed to measure the perceived usability of both platforms. The SUS score ranges from 0 (very poor usability) to 100 (perfect usability). In addition, the participants were also asked to rate their preference for using each platform on a scale from 1 (do not prefer at all) to 10 (most preferred). The data were expressed as median (interquartile range, IQR), which best represents the central tendency for non-normally distributed data. Normality was assessed using the Kolmogorov-Smirnov test, and the Wilcoxon signed-rank tests were used to compare the median scores of SUS / Preferences within and between genders. All statistical analyses were performed using MATLAB R2022b, with a p-value < 0.05 considered statistically significant.

III. RESULTS

A. Demographic Data

Forty-nine Year-2 IIUM medical students participated in this study. Most of the students were female (n=26, 53%), with a mean age of 20.10 ± 0.37 years old. 

B. Comparison of SUS and Preference Scores between the HMD and DB

There was no significant difference between the median SUS scores between the HMD and DB applications (p=0.14). However, most students preferred the HMD (90, IQR 80.0-100.0) rather than the DB (80, IQR 75.0-90.0) applications (p=0.04).

C. Comparison of SUS and Preference Scores of the HMD and DB within and between Gender

The SUS and preference scores of the HMD and DB applications within and between genders are shown in Figure 1, and individual scores are accessible at https://doi.org/10.6084/m9.figshare.26711965. Based on gender, significantly higher median SUS scores were observed for the DB (85, IQR 77.5-95.0) than the HMD application (75, IQR 59.4-85.6) among the female students (p=0.02). In contrast, the male students had a significantly higher preference score for the HMD (100, IQR 85.0-100.0) than the DB application (80, IQR 70.0-90.0) (p=0.01). A significant difference between gender was only observed in the SUS score, in which the female students scored 85 (IQR, 77.5 – 95.0), and the male students scored 75 (IQR, 58.1 – 86.9; p=0.03) for the DB application.

 

Figure 1. Comparison of SUS and Preference median scores of the HMD and DB application within (A-B) and between genders (C-D). A significant difference of p≤0.05 is denoted as *.

IV. DISCUSSION

This study found that the overall usability scores of the head-mounted display-based (HMD) and the desktop-based (DB) in human anatomy VR applications are comparable. However, a significant gender-related difference was observed in the reported usability scores of the HMD. Female participants reported significantly better usability with the DB than the HMD, likely due to their unfamiliarity with the HMD modality and disadvantage in the 3D spatial ability than males in visualising and manipulating objects in the navigating space. While traditional explanations link these gender differences to brain lateralisation, Bartlett and Camba (2023) challenge this view, suggesting societal expectations and gender roles may shape spatial skills.

Despite this, the study also found that most participants, especially males, prefer the HMD over the DB. This preference might be due to males’ active engagement and early adaptation to the technology, particularly in online gaming, making it more intuitive. This aligns with Deisinger et al. (1997), who found that inexperienced users favoured screen-based projection due to their familiarity with the conventional technology over the HMD. Interestingly, although females perceived DB as more usable, this did not significantly affect their preference for HMD. Many females acknowledged needing more technical help with the HMD but believed they would quickly adapt and prefer it over time. The study’s findings resonate with prior research in medical education, where HMDs are favoured for their immersive experience, enhancing spatial or physical presence and interaction as compared to DB (Yamazaki et al., 2021). However, the effectiveness of HMDs in improving learning outcomes compared to traditional methods remains inconclusive.

Given HMDs’ potential to enhance anatomy education, further research is crucial, especially in complex topics like embryology and neuroanatomy. Developers must focus on high content quality, intuitive user interfaces, and user comfort to ensure a positive learning experience. Gender-related adaptations can promote inclusivity, ensuring that the educational benefits of HMDs are accessible to all users.

Three main limitations of the present study also warrant mention. First, we used the available human anatomy VR applications from two developers, which may have different image quality of VR. However, both VR applications are comparable in terms of content quality. Second, we have not explored their reasons for high preference for utilising HMD when exploring human anatomy VR, potentially limiting our understanding of the user experience (e.g. comfort, immersion, satisfaction, and overall interaction) related to HMD usage. Third, participants’ previous experience using HMD in other platforms, such as gaming, virtual tours, etc, was not determined. Future studies should consider these limitations to understand user experiences with the HMD platform better and identify factors influencing user preferences.

V. CONCLUSION

In summary, this study concluded that the usability of both HMD and DB in exploring the human anatomy VR application is almost similar. As seen in other studies, students tend to favour HMD over DB because of its immersive, interactive, and engaging features. However, at an individual level, gender may influence their perception of its usability and preference. Therefore, it is essential to take gender-related adaptations into account when developing VR applications. 

Notes on Contributors

Zaitunnatakhin Zamli reviewed the literature, designed the study, performed data collection and analysis, and developed the manuscript. The author has read, given critical feedback and approved the final manuscript.

Nurul Asyiqin Yusof reviewed the literature, designed the study, performed data collection and analysis, and developed the manuscript. The author has read, given critical feedback and approved the final manuscript.

Azmi Mohd Yusof reviewed the literature, designed the study, performed data collection and analysis, and developed the manuscript. The author has read, given critical feedback and approved the final manuscript.

Wan Muhamad Salahudin Wan Salleh designed the study and performed data collection, analysis and interpretation. The author has read, given critical feedback and approved the final manuscript.

Mohd Zulfaezal Che Azemin designed the study and performed data collection, analysis and interpretation. The author has read, given critical feedback and approved the final manuscript.

Rohaini Ramli advised on study design and data interpretation. The author has read, given critical feedback and approved the final manuscript.

Hidayah Sulaiman advised on study design and data interpretation. The author has read, given critical feedback and approved the final manuscript.

Imran Mahalil facilitated the data collection process. The author has read, given critical feedback and approved the final manuscript.

Ethical Approval

Ethical approval of this study was granted by the Kulliyyah Postgraduate and Research Committee (IIUM/305/20/4/1/7) and IIUM Research Ethics Committee (IREC) (IIUM/504/14/11/2/IREC2022-194). All participants involved in the study had given their written consent, and their participation was voluntary.

Data Availability

The data of this study data are available at a Figshare repository, https://doi.org/10.6084/m9.figshare.26711965

Acknowledgement

The authors would like to thank the Department of Informatics, College of Computing & Informatics, Universiti Tenaga Nasional, Selangor, Malaysia, for providing equipment, software and logistics support. 

Funding

This study did not receive any funding or financial support.

Declaration of Interest

The authors declare that there are no conflicts of interest regarding the publication of this paper.

References

Bartlett, K. A., & Camba, J. D. (2023). Gender differences in spatial ability: A critical review. Educational Psychology Review, 35(1), Article 8. https://doi.org/10.1007/s10648-023-09728-2

Deisinger, J., Cruz-Neira, C., Riedel, O., & Symanzik, J. (1997). The effect of different viewing devices for the sense of presence of immersion in virtual environments: A comparison of stereoprojections based on monitors, HMDs and screens. Proceedings of the Seventh International Conference on Human-Interaction Computer, (2), 881-884. https://www.usu.edu/math/symanzik/papers/1997_HCI_Int.html

Kurul, R., Ögün, M. N., Narin, A. N., Avci, Ş., & Yazgan, B. (2020). An alternative method for anatomy training: Immersive virtual reality. Anatomical Sciences Education, 13(5), 648-656. https://doi.org/10.1002/ase.1959

Stanney, K., Fidopiastis, C., & Foster, L. (2020). Virtual reality is sexist: But it does not have to be. Frontiers in Robotics and AI, 7, 476417 https://doi.org/10.3389/frobt.2020.00004

Yamazaki, A., Ito, T., Sugimoto, M., Yoshida, S., Honda, K., Kawashima, Y., Fujikawa, T., Fujii, Y., & Tsutsumi, T. (2021). Patient-specific virtual and mixed reality for immersive, experiential anatomy education and for surgical planning in temporal bone surgery. Auris Nasus Larynx, 48(6), 1081-1091. https://doi.org/10.1016/j.anl.2021.03.009

*Azmi Mohd. Yusof
Jalan IKRAM-UNITEN,
43000 Kajang,
Selangor, Malaysia
Email: azmiy@uniten.edu.my

Submitted: 17 February 2024
Accepted: 25 March 2025
Published online: 1 July, TAPS 2025, 10(3), 65-74
https://doi.org/10.29060/TAPS.2025-10-3/SC3251

Dani R Firman^1,2, Friedo W Dekker^2,3, Eriska Riyanti¹, Sunardhi Widyaputra¹ & Peter GM de Jong²

¹Faculty of Dentistry, Universitas Padjadjaran, Indonesia; ²Center for Innovation in Medical Education, Leiden University Medical Center, the Netherlands; ³Department of Clinical Epidemiology, Leiden University Medical Center, the Netherlands

Abstract

Introduction: To explore the current situation regarding teaching evidence-based practice (EBP) in Indonesian dental schools as a low-middle-income country (LMIC) setting.

Methods: Two nation-wide surveys were administered to all Indonesian dental schools (N=32) to capture the perceived value of the deans about EBP skills and teaching with its resource-related situation, as well as the actual teaching implementation and its challenges by their curriculum teams. The analysis was performed descriptively as national aggregate data.

Results: The response rates were 96.9% and 90.6%, respectively. The deans considered EBP skills to be very important (61.3%) or important (38.7%). However, only 16.1% of deans reported that the implementation of teaching EBP met their expectations. Most schools (75.9%) considered providing training for teachers as the priority plan. Most schools (62.1%) had an independent EBP course in their curriculum, while 86.2% incorporated EBP teaching (also) into other courses. All dental schools employed a lecture strategy for teaching EBP topics, but also used other strategies such as interactive strategies with a wide range of percentages being utilised (10.3 – 89.7%). EBP-specific topics were generally taught with a level of implementation varying from 34.5% to 96.6% in the pre-clinical and from 10.3% to 62.1% in the clinical programme.

Conclusion: The used approach can be considered an effective strategy to provide opportunities for schools to reflect their EBP teaching. This study confirmed the necessity for improvement, especially the need to support faculty development. The deans and their curriculum teams highly value collaborative improvement plans.

Keywords:           National Survey, Evidence-based Practice, Faculty Perception, Low-middle-income Country

I. INTRODUCTION

Evidence-based practice (EBP) is emerging as the standard in clinical dentistry. It integrates the best research evidence with patients’ values, preferences, and clinical experiences (Young et al., 2014). The EBP process involves five key steps in sequence (ask, acquire, appraise, apply, and evaluate). The appraise or critical appraisal skill as part of the steps is related to research capacity still considered as crucial gaps in the LMIC setting compared to high-income country (HIC) setting, and known to hinder EBP development and implementation (Gill et al., 2021). Furthermore, the suboptimal practice of EBP among dental professionals in lower and middle-income countries (LMIC) was suspected due to limited access of web-based subscription database and scarcity of experts as mentor (Minja & Lwoga, 2021).

Potentially, dental schools can play a significant role in promoting EBP implementation in dentistry of such setting by providing the access to evidence, supporting professional development and integrate the EBP teaching and learning in the curriculum. However, institutionalising EBP requires consistent policy and strong administrative support. To understand the current situation of EBP teaching in Indonesian dental schools, we conducted a study exploring the deans’ perceptions about its importance and the need for improvement. We also determined the actual level of implementation as reported by their curriculum teams. The study’s outcomes could inform future interventions to enhance EBP teaching in Indonesian dental schools.

II. METHODS

At the time of the study, in September 2022, there were 32 dental schools in Indonesia, all of which ran a bachelor’s programme (year 1-4) and a clinical programme (year 5-6). A descriptive survey study was conducted online using two sets of Indonesian-language questionnaires in sequence.

The first survey was launched during an in-person national meeting in Surabaya. Only the principal investigator himself participated via Zoom. This first survey aimed to gauge deans’ perceived importance of EBP skills and teaching, along with necessary resource improvements. The questionnaire included demographic items, five-point of Likert-scale questions on EBP teaching value, resources-related, an open-ended item on EBP teaching challenges, and a section for additional comments. Most deans completed the first online survey during that meeting, while those who did not attend the meeting were received the survey’s link via email.

Upon completion for each school by the deans, a second survey was sent to vice dean for academic affairs as corresponding contact using the email address provided by the deans in the previous survey. In the introduction letter, we specifically requested the involvement of their curriculum team of the bachelor and clinical programme as a group response for each school. This second survey gathered data on EBP teaching implementation and challenges more in details. It was translated and adapted from a previous survey used by Gorgon et al. (2013) which was considered relevant to all health professions, including dentistry. The adaptation included a pilot test beforehand to ensure its relevance and clarity.

The study protocol was approved by the Educational Research Review Board of the LUMC (Registry number: OEC/ERRB/20220913/1). Participants electronically consented to both surveys after reviewing the provided information. Respondents with missing or unclear data were contacted for clarification. Five-point Likert scale items, checklist items, and multiple-choice items were analysed descriptively. The open-ended item responses and additional comments were analysed thematically.

III. RESULTS

The first survey’s responses were received from 31 dental schools across Indonesia (96.9%). The schools were located on Java (18), Sumatera (6), Sulawesi (3), and Kalimantan and Bali (2 each). For the second survey, which targeted the curriculum team for each school, the responses were received from 29 schools (90.6%).

A. The Perceived Value of EBP Teaching (The 1^st Survey, n=31)

The deans perceived EBP skills as very important/essential (61.3%) or important (38.7%) for students. Incorporating EBP in the curriculum was seen as very important/essential (51.6%) or important (48.4%). Improving teachers’ EBP teaching expertise was deemed very necessary (54.8%) or necessary (38.7%). Five deans (16.1%) felt their schools met faculty expectations for EBP teaching, while others observed room for improvement (64.5% necessary, 19.4% very necessary). Resources like database access and librarian expertise varied in satisfaction. Most respondents (71%) valued collaboration with other schools on EBP training and implementation (See Appendix 1).

B. The Implementation of EBP Teaching (The 2^nd Survey, n=29)

Over half (62.1%) of participated schools have a standalone EBP course, and 86.2% incorporate EBP in other courses. Lecture-based teaching is the most common EBP strategy, followed by thesis discussions, journal readings, colloquiums, and seminars. Small group discussions and problem-based tutorials are also used. “Critically appraised topics” (CATs) are least used, with only three schools employing this active learning method. Both summative and formative assessments are used. Most schools use a blended approach for EBP courses, with one school offering a fully online course (See Appendix 2.a).

C. Available Resources for EBP Teaching (The 1^st and 2^nd Survey, n=31 and n=29)

Of the participating institutions, only 8 out of 29 dental schools have teachers formally-trained in EBP. Most schools have access to scientific databases, with ScienceDirect being the most accessible (58.6%). Other databases include Web of Science, Cochrane Library, EBSCO Host, CINAHL, and UpToDate, with some schools also subscribing to Springer Link, Wiley, Emerald, and SAGE (See Appendix 2.b). Database access is mostly provided by the university (80.6%), with some funded by faculty budgets (29%) or government institutions (9.7%). Only one school lack subscribed database access (See Appendix 3.a).

D. The EBP Specific Topics Coverage (The 2^nd Survey, n=29)

The five EBP steps (ask, acquire, appraise, apply, evaluate) are taught in Indonesian dental schools, with varying implementation levels from 34.5% to 96.6% in pre-clinic programmes and 10.3% to 62.1% in clinic programmes. The ‘apply’ and ‘evaluate’ steps are least taught in pre-clinic programmes. Interpreting forest plots in systematic reviews is the least covered topic, with only 10 out of 29 schools teaching it in pre-clinic levels, 3 in clinical levels, and 19 not covering it at all. Over a third of the schools (37.9%) do not teach critical appraisal of a systematic review. See Table 1 below for details.

	Pre-clinic		Clinic		Not taught in both programme**
EBP steps and its specific topics coverage (n=29)	Taught*	Not taught*	Taught*	Not taught*
I. Asking clinical question
(1) Formulating clinically questions using the PICO format	22 (75.9)	7 (24.1)	12 (41.4)	17 (58.6)	5 (17.2)
(2) Guided literature search by the clinical questions	20 (69.0)	9 (31.0)	18 (62.1)	11 (37.9)	5 (17.2)
II. Search the evidence
(3) Constructing a focused search with Boolean operator in a database	23 (79.3)	6 (20.7)	7 (24.1)	22 (75.9)	6 (20.7)
(4) Locating clinical evidence using electronic databases	26 (89.7)	3 (10.3)	8 (27.6)	21 (72.4)	3 (10.3)
(5) Utilising a reference manager software	25 (86.2)	4 (13.8)	9 (31.0)	20 (69.0)	4 (13.8)
III. Critically appraising evidence
(6) Study designs and their major strength and limitations	27 (93.1)	2 (6.9)	7 (24.1)	22 (75.9)	2 (6.9)
(7) Assessing the relevance of study design to the question asked	22 (75.9)	7 (24.1)	5 (17.2)	24 (82.8)	7 (24.1)
(8) Hierarchy or levels of evidence	23 (79.3)	6 (20.7)	6 (20.7)	23 (79.3)	5 (17.2)
(9) Difference between narrative, systematic review, and meta-analysis	21 (72.4)	8 (27.6)	4 (13.8)	25 (86.2)	7 (24.1)
(10) Difference between clinical and statistical significance	22 (75.9)	7 (24.1)	9 (31.0)	20 (69.0)	6 (20.7)
(11) Interpreting t tests, chi-square tests	28 (96.6)	1 (3.4)	6 (20.7)	23 (79.3)	1 (3.4)
(12) Interpreting p-value, confidence interval	28 (96.6)	1 (3.4)	6 (20.7)	23 (79.3)	1 (3.4)
(13) Understanding sensitivity and specificity, number needed to treat, odds ratio	28 (96.6)	1 (3.4)	6 (20.7)	23 (79.3)	1 (3.4)
(14) Understanding intention to treat analysis and power calculation	20 (69.0)	9 (31.0)	3 (10.3)	26 (89.7)	9 (31.0)
(15) Use of appraisal tool(s) to assess validity	22 (75.9)	7 (24.1)	7 (24.1)	22 (75.9)	7 (24.1)
(16) Ways in which study validity can be threatened	25 (86.2)	4 (13.8)	5 (17.2)	24 (82.8)	4 (13.8)
(17) Difference between internal and external validity	21 (72.4)	8 (27.6)	3 (10.3)	26 (89.7)	8 (27.6)
(18) Critical appraisal of systematic reviews	18 (62.1)	11 (37.9)	6 (20.7)	23 (79.3)	11 (37.9)
(19) Interpreting forest plots in systematic reviews	10 (34.5)	19 (65.5)	3 (10.3)	26 (89.7)	19 (65.5)
(20) Critical appraisal of studies about intervention (RCTs and clinical trials)	18 (62.1)	11 (37.9)	7 (24.1)	22 (75.9)	9 (31.0)
(21) Critical appraisal of studies about diagnosis (cohort, case-control studies)	21 (72.4)	8 (27.6)	5 (17.2)	24 (82.8)	7 (24.1)
(22) Critical appraisal of studies about prognosis (longitudinal studies)	18 (62.1)	11 (37.9)	5 (17.2)	24 (82.8)	10 (34.5)
IV. Implementation and communication
(23) Communicating the recommendation from EBP process to the patient	14 (48.3)	15 (51.7)	9 (31.0)	20 (69.0)	12 (41.4)
(24) Deciding the clinical decision considering the patient’s value	12 (41.4)	17 (58.6)	11 (37.9)	18 (62.1)	11 (37.9)
V. Evaluation
(25) Evaluation of the EBP implementation (The patient’s outcome and student’s performance through self-reflection)	13 (44.8)	16 (55.2)	9 (31.0)	20 (69.0)	13 (44.8)

Table 1. EBP steps and its specific topics coverage for each programme level (n=29)^b

* n (%)

** n (%) Overlap calculation with the number of not taught on each programme

^b From the 2^nd survey to the curriculum teams

E. Challenges (The 1^st Survey, n=31 and The 2^nd Survey, n=29)

The top three challenges in Indonesian dental schools, as reported by curriculum teams, are a lack of EBP experts (72.4%), insufficient accessible EBP courses for faculty (69%), and students’ inadequate knowledge of statistics and research methodology (65.5%) (See appendix 4). In the open-ended item section, most of the deans expressed the challenges of EBP teaching. Teachers-related factors were considered the most challenging, such as limitation in knowledge and skills, and an overloaded work situation.

F. Action Plans (The 2^nd Survey, n=29)

Most respondents (75.9%) highly valued teacher training. They also preferred incorporating EBP skills into the curriculum (48.3%) and holding faculty meetings to discuss EBP programme development (44.8%) (See appendix 3.b).

IV. DISCUSSION

To our knowledge, this is the first nation-wide survey with very high response rate to report insights of EBP teaching in the South-east Asia region, more specifically in Indonesian dental education setting. Targeting both deans and curriculum teams yielded rich data and stakeholder involvement, potentially fostering acceptance of future EBP improvements at institutional or national levels.

There is a slight gap between the perceived importance of EBP skills for students and the importance of incorporating such skills into the curriculum, which may be related to limited resources. The deans considering room for improvement, especially in teacher expertise. This is echoed by curriculum teams, as less than a third of Indonesian dental schools’ teachers have formal training experience, i.e. training from a well-known academic-based institution or recognised training organisation. This lack of EBP teachers is a top challenge identified by respondents. Deans and curriculum teams agree on the need for improved teacher skills.

The majority of Indonesian dental schools are teaching EBP topics in stand-alone EBP courses as well as incorporated in other regular courses using both face-to-face and online delivery. Lecture-based is the most used teaching strategy among the schools. Our findings suggest that there is room for enhancing the teaching strategy of EBP in Indonesian dental schools towards a more multi-facet, interactive and more authentic setting in the clinical environment as suggested by Howard et al. (2022).

Regarding critical appraisal topics based on the study design (See Table 1, item 18, 19-21), there were very few schools implementing a Critically Appraised Topics (CATs) teaching strategy (See Appendix 2.a). CATs, one-page summaries of evidence on a clinical question, offer active, authentic learning and being recommended in the literature to provide both a critique of the research and a statement of the clinical relevance of its findings. It is crucial to teach critical appraisal skills using the teaching strategy that is supported by the evidence to ensure sufficient development of EBP skills. Many Indonesian dental educators may not be familiar with this CATs teaching method.

The survey reveals that the ‘apply’ and ‘evaluate’ steps of EBP are less addressed than the ‘ask’, ‘acquire’, and ‘appraise’ steps. These five-steps, identical to those in Evidence-Based Medicine (EBM), form the basis of clinical practice and teaching. Key EBM developments like shared-decision making skills, part of the ‘apply’ step, are often overlooked. Hence, it’s vital to teach all EBP steps, ideally in a more authentic clinical setting.

The need for more EBP-trained faculty in most schools highlights the importance of a faculty development programme supported by national collaboration. As a lower-resource country, Indonesia faces challenges in dental education, including limited access to databases and librarian expertise, primarily due to financial constraints, inadequate institutional support, and the absence of national policies prioritising scientific resources. These limitations hinder faculty and students from fully implementing evidence-based practices, widening disparities with high-income countries. To address these issues, a policy brief should be directed to high-level stakeholders, advocating for essential infrastructure, more funding and resource investments for both private and government-funded schools.

This study has limitations. Due to the five-point Likert scale in the first questionnaire were not constructed on the same concept, the reliability test was not feasible. This is also applied for the second questionnaire, which adapted from a previous study, was mostly factual and checklist-based. The value of EBP teaching, reported by deans and curriculum teams, might be socially desirable. However, the results underscore the importance of EBP teaching and the need for improvement. It is worth noting that after the data collection was completed, Indonesia formally transitioned from a lower-middle-income to an upper-middle-income country as of July 2023. This transition suggests a more promising future, with potential improvements in the financial capacity, but it will require the national policy support to be fully implemented.

V. CONCLUSION

This first national survey reveals the state of EBP teaching in Indonesian dental schools, representing Southeast Asian countries. It highlights the need for faculty development and more active, authentic learning experiences but further analysis is required to adopt and adapt these interventions for lower-resource settings. The deans and their curriculum teams highly value collaborative improvement plans. This supports EBP’s vision of using current research to improve Indonesian oral healthcare.

Notes on Contributors

DF is the principal investigator. He designed, analysed, prepared and wrote the manuscript collaboratively with co-authors.

SW and ER made substantial contributions to preparation of the instruments, data collection and editing the final manuscript.

FD and PJ made substantial contribution to the design, analysis, preparation and editing the final manuscript.

All authors read and approved the final version.

Ethical Approval

The study protocol was approved by the Educational Research Review Board of the LUMC (Registry number: OEC/ERRB/20220913/1).

Data Availability

Due to confidentiality of the responses and commitments made with the study participants, also considering the small size data set with its unique data for some variables that might still be traceable to the respondent. Data are available on reasonable request by email to the corresponding author.

Acknowledgement

The authors express gratitude to all participants and schools involved in this study, AFDOKGI and its members for their support and data access, the Research group at the OEC LUMC for their constructive feedback, Universitas Padjadjaran for sponsoring the first author’s PhD scholarship, and Edward Gorgon for permitting the modification and use of the questionnaire.

Funding

This research is part of the first author’s (DF) PhD study, funded by a scholarship from Universitas Padjadjaran, Indonesia (Registry number 3781/UN.6.WR2/KP.10/2021).

Declaration of Interest

The first author (DF), an assistant professor at the Faculty of Dentistry, Universitas Padjadjaran, which participated in this study. DF also had ties until 2020 with AFDOKGI, the association of Indonesian dental schools, as a dental education consultant. 

References

Gill, P. J., Ali, S. M., Elsobky, Y., Okechukwu, R. C., Ribeiro, T. B., Soares dos Santos Junior, A. C., Umpierre, D., & Richards, G. C. (2021). Building capacity in evidence-based medicine in low-income and middle-income countries: Problems and potential solutions. BMJ Evidence-Based Medicine, 26(3), 82–84. https://doi.org/10.1136/bmjebm-2019-111272

Gorgon, E. J. R., Basco, M. D. S., & Manuel, A. T. (2013). Teaching evidence-based practice in physical therapy in a developing country: A national survey of Philippine schools. BMC Medical Education, 13(1), Article 154. https://doi.org/10.1186/1472-6920-13-154

Howard, B., Diug, B., & Ilic, D. (2022). Methods of teaching evidence-based practice: A systematic review. BMC Medical Education, 22(1), Article 742. https://doi.org/10.1186/s12909-022-03812-x

Minja, I. K., & Lwoga, E. T. (2021). Evidence based dentistry among dentists in low- and middle-income countries: A systematic review. The East African Health Research Journal, 5(2), 129–136. https://doi.org/10.24248/eahrj.v5i2.662

Young, T., Rohwer, A., Volmink, J., & Clarke, M. (2014). What are the effects of teaching evidence-based health care (EBHC)? Overview of systematic reviews. PLOS ONE, 9(1), e86706. https://doi.org/10.1371/journal.pone.0086706

*Dani R Firman
Jalan Sekeloa Selatan I,
Kota Bandung, Jawa Barat 40132,
Indonesia
+62222534985
Email: dani.firman@unpad.ac.id / d.r.firman@lumc.nl

Submitted: 6 November 2024
Accepted: 11 April 2025
Published online: 1 July, TAPS 2025, 10(3), 58-64
https://doi.org/10.29060/TAPS.2025-10-3/OA3567

Nathania Nishida Tan¹, Daniel Ardian Soeselo^2,3, Natalia Puspadewi², V. Dwi Jani Juliawati² & Gisella Anastasia²

¹Faculty of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, Indonesia;  ²Medical Education Unit and ³Department of Surgery, Faculty of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, Indonesia

Abstract

Introduction: Career selection is a critical decision influenced by various factors, including media exposure. As a popular genre among adolescents, medical dramas may shape perceptions of the medical profession. This study explores the impact of medical dramas on medical students’ motivation to pursue a career in medicine.

Methods: This study was conducted at the School of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, between February and March 2024, using a mixed-method approach. Quantitative data were gathered through a questionnaire, followed by qualitative insights from in-depth interviews. A two-stage sampling strategy was employed, initially identifying first-year students influenced by medical dramas through screening, followed by purposive sampling to select participants for in-depth interviews.

Results: Analysis identified six key motivational aspects through which medical dramas influence students’ decision to pursue medicine. These include the detailed portrayal of doctors’ roles, their daily lives, and the reinforcement of a positive perception of the profession. Notably, emotional engagement- such as inspiring doctor characters- and the realistic depiction of challenges, including the dedication and hardships of becoming a doctor, emerged as significant factors.

Conclusion: Medical dramas play a significant role in shaping students’ motivation and perception of the medical profession. This study highlights six key motivational aspects influencing career decisions, offering new insights into media-driven career choices and their potential implications for medical education.

Keywords:           Medical Dramas, Medical Education, Medical Students, Student Motivation, Career Choice

Practice Highlights

• Medical dramas serve as informal educational tools through entertainment for the public.
• Television influences adolescents’ career aspirations by shaping their interests.
• Medical dramas shape public perceptions of the medical profession and may inspire viewers.

I. INTRODUCTION

Medical dramas have remained a widely popular television genre since their emergence in the 1960s, continuously evolving to portray healthcare professionals’ professional and personal lives within hospital settings (14^th Media Mutations International Conference, 2023; Sonego & Rocchi, 2024).

Communication theorist Marshall McLuhan had predicted the success of medical dramas as early as 1964 in his book Understanding Media: The Extensions of Man, attributing their appeal to the immersive experience viewers have when witnessing medical procedures, which fosters an “obsession with bodily well-being” (Aboud, 2012; Levine & McLuhan, 1964).

Beyond entertainment, medical dramas serve as informal educational tools illustrating medical practices, bioethical dilemmas, and professional conduct (Cambra-Badii et al., 2021; Zago et al., 2024). Research suggests that these dramas reinforce key principles of medical ethics and professionalism, including communication skills, patient confidentiality, and empathetic bedside manner (Aboud, 2012). By portraying both the challenges and rewards of medical practice, these narratives may also shape viewers’ perceptions of the profession, inspiring people to pursue careers in healthcare (Alahmari, 2023).

Research indicates a correlation between specific television programs and career aspirations, suggesting that the content adolescents consume can shape vocational interests and goals (Gehrau et al., 2016). As an accessible informal educational resource, television provides insight into professional responsibilities and challenges (Mendick & Williams, 2022). Within this context, medical dramas may play a significant role in shaping students’ motivation to enter the medical field. Unlike prior studies that broadly examine media influence over career perceptions, this study focuses on first-year medical students, analysing their motivational drive. By integrating quantitative and qualitative data, this study provides deeper insight into how medical dramas influence medical students’ motivation to pursue a career in medicine.  

II. METHODS

This study was conducted at the School of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, from February to March 2024, using a mixed-method approach. A two-stage sampling method was employed, beginning with a questionnaire to identify eligible participants, followed by purposive sampling to select individuals for in-depth interviews. The target population consisted of first-year medical students enrolled in the 2023 academic year who acknowledged that medical dramas had influenced their motivation to pursue a medical degree.

A. Participant Selection

Out of 210 first-year students, 114 reported watching medical dramas. These students completed a demographic questionnaire, which gathered information on gender, parents’ profession, and their viewing habits related to medical dramas. Additionally, they completed the Strength of Motivation for Medical School Revised (SMMS-R) Questionnaire, a validated self-report instrument consisting of 15 items rated on a 5-point Likert scale (ranging from “strongly disagree” to “strongly agree”), with possible scores ranging from 15 to 75, indicating the strength of motivation for medical school.

B. Qualitative Phase Sampling

Purposive sampling was used to ensure an accurate representation of the study population based on key demographic factors, specifically the profession of participants’ parents. The selection process identified respondents from diverse parental backgrounds in the medical field: those with both parents as physicians, those with one parent in medicine, and those with no parental medical background. To ensure gender diversity, one male and one female were selected from each category, all of whom had high motivation scores based on their SMMS-R results. Six participants were selected to achieve thematic saturation, as preliminary analysis showed no new themes emerging beyond this point. Although not statistically representative, this sample captures diverse perspectives on medical career motivation based on different childhood backgrounds.

C. Data Collection

The in-depth interviews, conducted by the researcher (NNT), explored participants’ perceptions of how medical dramas influenced their motivation to pursue a career in medicine. The interview guide addressed various aspects of this influence on their decision-making process. One key question asked was “How have medical dramas influenced your decision to pursue medicine?” All participants provided written informed consent, including permission for audio recording. The interviews were then transcribed verbatim for further analysis.

D. Data Analysis

The transcribed interviews were analysed using thematic analysis with an inductive coding approach, facilitated by Atlas.Ti software. Initial coding was conducted by NNT, who identified key patterns and concepts. These were then systematically categorised into themes and subthemes to capture broader meanings and insights emerging from the interviews. To ensure coding reliability, DAS and NP reviewed the preliminary codes and analysis results. Through thorough discussions and iterative revisions, the team resolved discrepancies and achieved near-total agreement on the coding structure. To maintain participant confidentiality, each transcript was assigned a unique identification code. 

III. RESULTS

A total of 114 respondents participated in this study, consisting of 26 males and 88 females, reflecting a possible gender disparity in medical drama viewership. Among them, 93 students (81.6%) reported that medical dramas significantly impacted their decision to pursue a medical career, while 21 students indicated no such impact.

Characteristic		Respondents (n)	Percentage (%)
Parental Background
	Both parents are doctors	8	7.0
	Only one parent is a doctor	18	15.8
	Neither parent is a doctor	88	77.2
Reports Motivation to Enter Medical Field Due to Medical Dramas
	Yes	93	81.6
	No	21	18.4
	Total Respondents	114	100.0

Table 1. Distribution of Respondent Demographic Characteristics

A. Various Dimensions of the Impact of Medical Dramas on Motivation

The following table presents the themes and subthemes derived from the in-depth interview analysis, which has been discussed and approved by each inter-rater.

No.	Theme	Subtheme
1.	Medical dramas provide an in-depth portrayal of the roles and responsibilities of doctors.	Medical dramas shape public perceptions of the medical profession and doctors’ roles.
		Medical dramas depict the challenges and rewards of doctors’ daily work.
		Medical dramas highlight doctors’ lives beyond their profession.
2.	Medical dramas depict both the professional and personal aspects of doctors’ lives.	Medical dramas reveal lesser-known aspects of doctors’ personal experiences.
		Medical dramas provide an authentic portrayal of doctors’ daily lives.
		Medical dramas depict ethical dilemmas, emphasising doctors’ professional integrity.
3.	Medical dramas contribute to a positive public perception of the medical profession.	Medical dramas portray impressive doctors, evoking admiration, and inspiration in viewers.
		Doctors’ life-saving actions in medical dramas evoke deep emotions and motivation.
		Medical dramas illustrate doctors’ perseverance and resilience in their profession.
		Medical dramas spark curiosity about medical procedures and treatments.
4.	Medical dramas evoke emotional responses that may inspire viewers to pursue a medical career.	Medical dramas evoke empathy by portraying patients in distress.
5.	Medical dramas showcase inspiring doctor characters, motivating viewers to follow in their footsteps.
6.	Medical dramas illustrate the challenges and dedication required to become a doctor.

Table 2. Table of Themes and Subthemes

B. Medical Dramas Provide an In-Depth Portrayal of the Roles and Responsibilities of Doctors

Medical dramas frequently portray various medical scenarios using specialised terminology, offering viewers insight into the daily responsibilities of doctors. As medical settings are generally inaccessible to the public, these dramas provide a unique perspective on the profession. Among the key influences explored in this study, this aspect resonated most with respondents, with four out of six students emphasising its significance.

One participant explained how watching medical dramas sparked their interest in the field, as they previously had limited information about medicine.

“Grey’s Anatomy offered me insight into the medical field and sparked my interest, as reliable information is not easily accessible to those outside the profession” (V1_H3_B19)

Another respondent shared how their perception of doctors shifted from fear to admiration after watching medical dramas, recognising the profession’s vital role in society:

“As a child, I perceived doctors as intimidating due to painful medical visits, such as dental appointments. However, after watching Grey’s Anatomy, I realised that medicine extends beyond that and saw how doctors can positively impact many lives.” (V1_H2_B27)

Beyond hospital settings, medical dramas also depict the role of doctors in broader societal contexts. Through diverse narratives, these dramas offer multiple perspectives on the medical profession. For example, Doc Martin illustrates the role of a doctor in a rural community, showcasing their involvement in local issues, such as water problems and education (V2_H4_B21). This highlights how doctors contribute beyond clinical practice, reinforcing their role in public health and community development.

Additionally, medical dramas influence students’ motivation to pursue medicine by portraying the realities of medical work, including complex procedures and life-saving interventions. More than half of the respondents identified this as a significant factor in their decision to study medicine. As one participant stated:

“The scenes depicting doctors helping others, particularly during surgeries, inspired me to study medicine. I wanted to experience performing surgeries and learn how to help others.” (V4_H7_B19)

These findings suggest that medical dramas not only enhance public understanding of the profession but also play a role in inspiring future medical students.

C. Medical Dramas Depict Both the Professional and Personal Aspects of Doctors’ Lives

Medical dramas depict not only medical procedures but also the personal lives of doctors, including their relationships, friendships, and personal struggles. By presenting doctors as multidimensional individuals beyond their professional roles, these narratives contribute to a more relatable and humanised portrayal of the profession. Notably, four out of six highlighted the importance of this aspect in shaping their motivation. One respondent noted that their interest in medical dramas stemmed primarily from the blend of romantic elements, rather than the medical content alone (V3_H6_B1).

The public often has limited insight into the personal experiences of doctors, making it difficult to relate to them. However, medical dramas help bridge this gap by shedding light on aspects of doctors’ lives that are not commonly shared. This increased visibility fosters a sense of closeness and enhances a deeper understanding of the profession, which may, in turn, inspire career interest. As one participant expressed:

“Medical dramas reveal stories that doctors seldom share, providing an effective way to convey these experiences to the general public.” (V5_H11_B4)

By offering a representation of doctors’ daily lives, medical dramas provide viewers with a deeper understanding of what a career in medicine entails. This additional perspective can be a key factor in the decision-making process for those considering entering the field (V2_H4_B28).

D. Medical Dramas Contribute to a Positive Public Perception of the Medical Profession

Three out of six respondents emphasised that medical dramas portray the ethical dilemmas faced by doctors, reinforcing professional values that shape viewers’ perceptions of the medical field. One respondent noted that the depiction of doctors’ strong work ethic in these dramas increased their interest in pursuing a career in medicine (V3_H6_B4).

Additionally, medical dramas present compelling and admirable doctor characters, which can serve as a source of inspiration for viewers. As one respondent shared:

“The dramatised portrayal made it inspiring for my younger self, leading me to think, ‘Doctors are cool.’” (V5_H11_B2)

The depiction of medical procedures, particularly surgeries, also left a strong impression on some respondents, reinforcing their motivation to enter the medical field. One participant stated:

“Medical dramas provide insight into a doctor’s work, including various surgeries, highlighting the fascinating ability to help many people.”  (V4_H7_B33)

Furthermore, the portrayal of doctors saving lives in medical dramas can evoke strong emotional responses, fostering admiration and a desire to pursue medicine. One respondent expressed how these scenes encouraged them to consider a career in medicine (V5_H11_B2). Medical dramas also emphasise the perseverance and resilience of doctors in the face of various pressures and stress, further reinforcing the appeal of the profession for aspiring medical students (V5_H9_B11).

E. Medical Dramas Evoke Emotional Responses that may Inspire Viewers to Pursue a Medical Career

Medical dramas can spark viewers’ curiosity about medical procedures, motivating them to explore the medical field further and increase their interest in the profession. One respondent noted that medical dramas played a role in their initial motivation for pursuing medicine, as the cases depicted often align with real-world medical scenarios, piquing their interest to learn more:

“I believe the medical procedures shown in Grey’s Anatomy exist in real life and are up to date. For example, an episode featured an abdominal wall transplant, which piqued my curiosity. After researching it, I discovered that the procedure had only recently been developed, showing how the show connects to world medicine.” (V1_H2_B14)

Beyond fostering curiosity, medical dramas also evoke strong emotional responses, such as sadness and empathy, particularly when portraying patients in need of medical care. One respondent shared that such portrayals heightened their awareness of the number of people requiring medical assistance. The emotions they experienced, combined with this awareness, ultimately served as an inspiration to pursue medicine (V1_H2_B31).

F. Medical Dramas Showcase Inspiring Doctor Characters, Motivating Viewers to Follow in their Footsteps

Medical dramas can inspire viewers through uplifting scenes and compelling portrayals of doctor characters. These representations serve as role models, fostering admiration and desire to follow in their footsteps. Notably, three out of six respondents indicated that such portrayals influenced their decision to pursue a medical career. As one participant shared:

“In ‘New Amsterdam’, there is a doctor who stands out from others – someone who wants to create change and has a unique vision. I found him quite inspiring.” (V3_H6_B5)

G. Medical Dramas Illustrate the Challenges and Dedication Required to Become a Doctor

Medical dramas not only portray the professional responsibilities of doctors but also illustrate the journey of becoming one, highlighting the challenges and obstacles along the way. Two out of six students emphasised the significance of this theme, noting that the depiction of medical interns’ experience in these dramas played a crucial role in their motivation to pursue medicine. As one participant shared:

“Medical dramas often depict doctors under immense stress, highlighting the challenges of the profession. However, rather than discouraging me, witnessing their struggles made the career even more appealing.” (V5_H10_B28)

IV. DISCUSSION

The in-depth interviews revealed that medical students felt more mentally prepared and motivated to pursue medicine after watching medical dramas. These shows provided insight into both the professional and personal lives of doctors, reinforcing previous studies on their educational influence in shaping viewers’ perceptions of the medical field. This aligns with the Media Effect Theory, introduced by Gerbner in 1960, which suggests that television shapes individuals’ perceptions of reality, particularly among frequent viewers (Stacks et al., 2015). Hoffman and colleagues further applied this theory to medical dramas, highlighting their role in influencing viewers’ perception of the medical profession (Arias, 2018).

Beyond depicting technical medical procedures, medical dramas also emphasise ethical principles and professional values, contributing to a favourable image of the profession. Research indicates that medical and nursing students often use these shows as supplementary learning tools for bioethics and professionalism (Cambra-Badii et al., 2021). Similarly, these portrayals may inspire high school students to consider careers in medicine by offering an engaging introduction to the field.

Emotional engagement is another key factor in the influence of medical dramas. Strong emotional responses- such as curiosity, empathy, and excitement- can enhance motivation, as emotions play a crucial role in learning, achievement, and psychological well-being, particularly in adolescents (Pekrun, 2017). Positive emotions make tasks more appealing, fostering inner motivation that arises after the initial external excitement provided by medical dramas (Legault, 2016).

Furthermore, medical dramas often depict the challenges of medical training, including long working hours and emotional strain, providing a more nuanced perspective on the profession. While these portrayals may initially present an idealised view of medicine, they also serve as a reality check, reinforcing the dedication required to pursue a medical career. This dual representation may deter less committed individuals while strengthening the resolve of those deeply passionate about the field (Tedeschi, 2024).

However, the potential for misinformation in medical dramas must also be considered. The oversimplifications or dramatisation of medical practice may create discrepancies between fictional portrayals and real-world medicine, leading to misconceptions among viewers (Alismail et al., 2018).  One notable bias is the tendency to depict doctors as infallible heroes performing miraculous saves amidst dramatic emergencies, often intertwined with personal achievements and romantic subplots. This portrayal fosters unrealistic expectations, potentially leading to disillusionment when aspiring medical students encounter the demanding and less glamorous realities of medical education and practice (Tedeschi, 2024).

These findings highlight the complex role of medical dramas in shaping career motivation, offering both inspiration and potential misconceptions. Their influence appears particularly significant for students without a familial background in medicine, as most respondents came from non-medical families. This trend may suggest that medical dramas serve as an accessible source of insight into the profession for those without direct exposure. However, the possibility of sampling bias should be considered, as students already interested in medicine may be more likely to engage in medical dramas. While these dramas may serve as informal educational tools, their impact should be critically assessed to ensure they provide a balanced and realistic portrayal of the medical profession.

V. CONCLUSION

Medical dramas play a significant role in shaping students’ motivation to pursue a medical career by providing an engaging portrayal of the profession. These shows offer insight into the roles and responsibilities of doctors, their daily challenges, and the emotional rewards of the profession. Additionally, they influence public perceptions of medicine and evoke strong emotional responses through inspiring characters and narratives. By depicting both the struggles and triumphs of medical training, medical dramas contribute to students’ understanding of the dedication required to become a doctor. This study highlights six key aspects through which medical dramas impact students’ decision to pursue medical education, highlighting their role as both an informational and motivational tool.

Notes on Contributors

Nathania Nishida Tan participated in data collection, data analysis, review, the writing of the paper, and the formatting for publication.

dr. Daniel Ardian Soeselo, Sp.B, MSi.Med. participated in the data analysis, review, and direction of the paper.

dr. Natalia Puspadewi, M.Med.Ed, Ph.D participated in the data analysis, review, and direction of the paper.

dr. Gisella Anastasia, MHPE participated in the review of the paper.

dr. V. Dwi Jani Juliawati, M.PD, Sp.KKLP participated in the review of the paper.

Ethical Approval

This study received ethical clearance from the Research Ethics Commission of the Faculty of Medicine and Health Sciences Atma Jaya Catholic University of Indonesia under the ethical approval code 13/02/KEP-FKIKUAJ/2024. To ensure confidentiality and data security, all interview transcripts were anonymised and securely stored in password-protected files, accessible only to the research team.

Data Availability

The data of this qualitative study are not publicly available due to confidentiality agreements with the participants.

Acknowledgement

The authors would like to thank all the students who participated in this study.

Funding

There was no funding for this article.

Declaration of Interest

The authors have no conflicts of interest in connection with this article.

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Alismail, A., Meyer, N. C., Almutairi, W., & Daher, N. S. (2018). CPR in medical TV shows: Non-health care student perspective. Advances in Medical Education and Practice, 9, 85–91. https://doi.org/10.2147/AMEP.S146149

Arias, E. (2018). How does media influence social norms? Experimental evidence on the role of common knowledge. Political Science Research and Methods, 7(3), 561–578. https://doi.org/10.1017/psrm.2018.1

Cambra-Badii, I., Moyano, E., Ortega, I., Baños, J., & Sentí, M. (2021). TV medical dramas: Health sciences students’ viewing habits and potential for teaching issues related to bioethics and professionalism. BMC Medical Education, 21, Article 509. https://doi.org/10.1186/s12909-021-02947-7

Gehrau, V., Brüggemann, T., & Handrup, J. (2016). Media and occupational aspirations: The effect of television on career aspirations of adolescents. Journal of Broadcasting & Electronic Media, 60(3), 465–483. https://doi.org/10.1080/08838151.2016.1203319

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Tedeschi, R. (2024). The paradox of medical dramas: Global aspirations versus realities. BJPsych Advances, 31(1), 62–64. https://doi.org/10.1192/bja.2024.56

Zago, D., Cautero, P., Scarpis, E., Pompili, E., Voglino, G., Siliquini, R., Brusaferro, S., & Brunelli, L. (2024). TV medical dramas: Assessing the portrayal of public health in primetime. Frontiers in Public Health, 12. https://doi.org/10.3389/fpubh.2024.1432528

*Daniel Ardian Soeselo
Medical Education Unit and Department of Surgery,
Faculty of Medicine and Health Sciences,
Atma Jaya Catholic University of Indonesia
Jl. Pluit Raya No.2 21, RT.21/RW.8,
Penjaringan, Kec. Penjaringan, Jakarta Utara,
Daerah Khusus Ibukota Jakarta, Indonesia 14440
Email: daniel.ardian@atmajaya.ac.id

Submitted: 16 August 2024
Accepted: 23 December 2024
Published online: 1 July, TAPS 2025, 10(3), 49-57
https://doi.org/10.29060/TAPS.2025-10-3/OA3495

Shuh Shing Lee¹, Shefaly Shorey², Tang Ching Lau³ & Dujeepa D. Samarasekera¹

¹Centre for Medical Education, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; ²Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; ³Dean’s Office, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

Abstract

Introduction: Numerous studies have been conducted on COVID-19, with the majority focusing on interventions involving students and teachers. However, limited research has delved into the pandemic’s impact on the wellness of various stakeholders and how they have adapted to the challenges it presented. This study aims to fill this gap by exploring these neglected areas.

Methods: This study employs a sequential mixed-method approach to study these areas. The quantitative data collection was carried out using a combination of validated surveys (ranging between 63-88 items) for students, faculty and administrators.  Subsequently, qualitative data collection was gathered via semi-structured interview using a convenient sampling method.

Results: Seventeen faculty, 18 administrators and 369 students responded to the survey. The quantitative data indicated faculty (teachers) exhibited the lowest stress levels and the highest resilience during the pandemic. In comparison, administrators and students experienced moderate levels of stress, with students scoring slightly higher on the stress level. The themes that emerged from the qualitative data were personal endurance, emotional reaction, cognitive-behavioural reaction and social support.

Conclusion: Our study highlighted that, apart from personal endurance, the tension arises from emotional and cognitive-behavioural responses of students, teachers, and administrators can be mitigated based on the presence or absence of support mechanisms.

Keywords:           Wellbeing, Change, Stakeholders, Educational Environment, Culture

Practice Highlights

• Students experienced the highest stress levels compared to administrators and teachers.
• However, students and administrators demonstrated resilience, bouncing back quickly after challenging times.
• Students and administrators tolerated for uncertainty and displayed cognitive flexibility to enable them to adapt and seek opportunities.
• Teachers and administrators initially experienced negative emotions, but their emotional resilience facilitated quick recovery.
• Coming from a culture emphasising collectivism, the sense of belonging and social connection served as a protective factor against psychological distress.

Table 1. Sections of the Surveys for Administrators, Teachers and Students

The survey was validated by 10 medical educators from various departments (Paediatrics, Surgery, Centre for Medical Education, Nursing). After the validation, the survey was administered to medical (Year 1 – 5) and nursing (Year 1 – 4) students, administrators and faculty members in Yong Loo Lin School of Medicine and Alice Lee Centre for Nursing Studies using convenient sampling. It took about 20-30 minutes to complete the survey and the data was collected between Jan – June 2021.

B. Phase II Qualitative Data Collection

The qualitative data collection was gathered via semi-structured interview. The interview was conducted for about 60-90 minutes among the medical/nursing students, administrators and faculty members (teachers). Followed up from the data collected from the quantitative data, the questions were revolved around teaching and learning, content, assessment, policies, guidelines, communication, environment (safety)/support and wellness.

From July 2021 – Nov 2022, we used convenient sampling method to recruit of students, administrators and faculty members. The interviews were carried out by 2 trained interviewers with no power relationship with the interviewees. Interviews were carried out after getting consent from the volunteer interviewees. All digital audio recordings made during the interviews were transcribed and member-checked with the interviewees to ensure transparency and trustworthiness of the data.

Data collection ceased when the data reached saturation stage.

C. Data Analysis

The quantitative data was analysed using descriptive statistics (such as mean, frequency and percentage) using Microsoft Excel for the data collected from students, administrators and teachers.

The interviews were thematically analysed by 2 researchers in the team. The two researchers coded the transcripts independently and came together to resolve any discrepancy or disagreement on the coding.  Subsequently, they continued to code and form categories and eventually themes. There were multiple discussions that took place among the researchers and the team before the themes were crystalised.

III. RESULTS

A. Phase I Quantitative Data

The demographic information was illustrated in Table 2. Majority of the participants were not quarantined during the pandemic and more than 80% of them did not have a family member tested positive for COVID when this study was conducted. The teachers from the school of medicine were mainly from Family Medicine, Paediatrics, Physiology, Pathology, Public Health, Medicine, Anatomy and Anaesthesia departments. They are educators for postgraduate and undergraduate students. As for administrators, their roles in the departments are educational related such as instructional design, learning analytics, planning and execution of education, managing project and training.

Table 2. Demographic Information of the Respondents

For each section, the summary was illustrated in Table 3. The mean for different sections was quite close for the 3 groups. Likewise, the items that were scored low and high were quite similar for all the sections. For example, Section B The psychological impact of COVID-19, The sleep quality and concentration in all three groups were not affected by the pandemic, but they are more worries about their family members contracted with COVID-19.

Table 3. Summary of the Mean for Different Sections for the 3 Groups

During the pandemic, students expressed significant concerns about the adequacy of their training, particularly due to reduced patient contact, raising apprehensions about their preparedness for exams. This concern will be elaborated upon in the qualitative data section, shedding light on the depth of their worries. All three groups shared the view that information originating from the government and hospitals was the most reliable, with friends and family scoring the lowest mean among all sources. Despite this, the participants unanimously agreed that the support from friends and family, in terms of both source and level of assistance, was the most substantial. Conversely, organisational support from entities such as the University Wellness Centre, Dean’s office, community, and social media was perceived as unreliable and lacking during the pandemic.

Furthermore, our observations revealed that teachers exhibited the lowest stress levels and the highest resilience during the pandemic, showcasing their ability to cope effectively. In comparison, administrators and students experienced moderate levels of stress, with students scoring slightly higher on the Perceived Stress Scale. Although students acknowledged challenges, as indicated by their agreement with statements such as “I have a hard time making it through stressful events” (mean: 2.93), they also exhibited resilience, agreeing with the statement “I tend to bounce back quickly after hard times” (mean: 3.76). Additionally, concerning self-efficacy towards technology integration, students reported the highest mean score, indicating confidence in their ability to navigate various Internet applications. While teachers felt competent in using technology for teaching and learning, their confidence wavered when it came to resolving technical issues, as reflected in their mean score of 3.47. This nuanced understanding underscores the complex interplay of stress, resilience, and technological proficiency among the different groups during the challenging circumstances of the pandemic.

B. Phase II Qualitative Data

As for the qualitative data collection, we have recruited 7 administrators, 17 teachers (12 from Yong Loo Lin School of Medicine and 5 from Alice Lee Centre for Nursing Studies) and 9 undergraduate students (6 from Yong Loo Lin School of Medicine and 3 from Alice Lee Centre for Nursing Studies). The themes and subthemes that emerged were depicted in the Figure 1.

Figure 1. Themes and Subthemes of the Qualitative Data

1) Theme 1: Personal Endurance

Personal endurance depends on perceived ability and tolerance to uncertainty. For administrators, they felt that it was quite stressful and frustrated during the pandemic as the situation was unclear. However, they were able to manage and there was a sense of relief after they had gone through the critical phase.

“It was very intense, stressful but looking back now, it is not that bad. We have gone through the worse” (Admin 5)

While administrators’ contribution to the education system is crucial, some of the administrators perceived their contribution was minor as compared to medical front liner.

“We are not front liner, our contribution is limited.” (Admin 3)

Although the situation was stressful in the beginning, we noticed a positive endurance among the teachers and perceived the pandemic as an opportunity instead of a threat.

“Overall, I think the predominant mood was of a challenge that needs to be overcome and that brought a certain amount of excitement.” (Teacher 7)

On the other hand, the students felt that they were being too protected and perceived themselves as having the ability to manage the situation themselves.

“I understood that they wanted to protect us but I felt that eventually, they can’t protect us anymore” (Student 3)

The students also perceived that the teachers lacked ability in using technology in teaching and learning especially in remote learning.

“A lot of professors are not familiar with the technology.” (Student 5)

2) Theme 2: Emotional Reaction

There were a lot of negative emotions illustrated by the students, administrators and teachers due to various reasons. Students were worried, frustrated and anxious that they may not learn since the contact with the patients was less during the pandemic. Too much protection from the school and the system put in place has heightened these negative emotions.

“We feel quite unconfident because we feel we have not seen enough patients”/ “..fear that we are not as good as the previous batch” (Students 1 & 2)

Administrators were frustrated mainly because they need to manage the family and work at the same time when working from home system was implemented. However, some of them shared that they are able to regulate and get used to the situation after a while.

“Everybody was under pressure at that time…while I have to juggling with work, my kids were at home because school close.” (Admin 4)

“I usually regulate my own emotion.” (Admin 7)

While there were some positive emotions state in Theme 1 for teachers, they did feel stressful in the early stage of the pandemic due to the change of the approaches in teaching and learning and they are unsure of the outcomes when the teaching was entirely online.

“…stressful in the beginning… I even have nightmares…dreaming students get lost in the virtual room.” (Teacher 17)

“It was a bit stressful in the beginning because you did not know how is going to turn out…” (Teacher 5)

3) Theme 3: Cognitive-Behavioural Reaction

Amidst the challenges posed by the pandemic, administrators, students, and teachers made concerted efforts to adapt their cognition and behavior in response to various initiatives, including social distancing measures, reduced patient contact, and a shift to virtual teaching environments. Throughout this period, interviewees shared both positive and negative reactions to these changes.

Administrators and teachers found themselves navigating the delicate balance between the need to innovate and the need to maintain productivity (ambidexterity). Administrators, in particular, faced the challenge of fostering creativity in coordinating and delivering the curriculum, which involved tasks such as timetabling, resource management, and providing IT support for online learning. These adjustments were made within a short timeframe, reflecting their resilience and adaptability. However, amid these innovative efforts, administrators were also keen on upholding the quality of their work, highlighting the complexity of their role in managing these rapid changes.

“We have to deliver in a short time but also the content has to be rigorous” (Administrator 3)

Similarly, teachers tried to be creative in an online teaching environment and ensure the student learned at the same time especially in small group teaching. However, they find it challenging.

“…there is an urgency to find a way around this small group teaching…we kind of lose the whole power of collaboration.”  (Teacher 5)

There is also a tension arose among the students for being too protected by the school and compromised with their learning as shared in the quotes below. This was repeatedly mentioned by the students, and they felt they have to face the situation eventually.

“I am not very interested in surgery, but this is like once in a lifetime and after I go out of medical school I won’t have the chance to see surgery” (Students 3)

“There’s a culture… in the society in general…protect my child from COVID. But once day we are going to deal with COVID” (Students 6)

Notwithstanding the aforementioned tensions, it’s worth noting that administrators, students, and teachers exhibited remarkable innovativeness and adaptability during the pandemic. All three groups demonstrated evidence of both Operational Capabilities, which encompass the efficient and effective use of resources, and Dynamic Capabilities, which involve the continuous development of competencies to align with the evolving environment.

With the predominant shift in communication from face-to-face to virtual platforms, administrators found themselves assuming the role of intermediaries responsible for conveying information to various stakeholders. In this new virtual setting, where body language cues were less apparent, administrators recognised the need to be more attuned and sensitive to subtle nuances in communication compared to traditional face-to-face interactions. This adaptation reflected their ability to pivot and operate effectively within the changing landscape of remote communication.

“We play the middleman role because we have to speak administrative language to certain people and be sensitive when communicate with faculty members” (Admin 3)

“We have to start thinking about (what kind of information needed) before the faculty member even ask those questions” (Admin 7)

Teachers utilised different resources to innovate in their teaching as well as learning from different others.

“I break it up my lectures into smaller bits and disperse it with PollEverywhere” (Teacher 5)

“We formed a group we called a brown bag meeting – basically we meet at lunchtime with technologically savvy administrators to introduce to the staff on how to make online learning more interactive.”  (Teacher 10)

Likewise, since there was less patient contact time, students tried to make use of their time for other learning sessions.

“Since there’s little time in the hospital, I had read up a lot” (Students 1)

“It allows us to have some processing time and have time to consolidate our knowledge” (Students 5)

4) Theme 4: Social Support Mechanism

Social support mechanism has been mentioned by the 3 groups as one of the prominent mechanisms in adapting the changes during pandemic. It includes transparent communication, team collaboration and support from various stakeholders. For example, administrators shared that they all came together and supported each other during the hard times.

“All different teams come together, I think that was very precious” (Administrator 2)

Students sought seniors’ help to provide additional sessions to compensate their learning.

“What my group would do is we call our seniors to give us extra tutorials” (Student 2)

However, there was also lack of support mechanism brought up by the teachers which led to negative emotion (such as frustration).

“Educational technology team are overworked…if the school would really want to be the best or world class, I think we need a very good support from the IT.” (Teacher 9)

IV. DISCUSSION

The impact of the COVID-19 pandemic on both our educational systems and personal lives has been profound. This unprecedented disruption has been keenly observed by various stakeholders, including administrators, teachers, many of whom were also frontline workers, and students in medical schools. Swift adaptation to the ever-changing situation became imperative, particularly in response to the government’s new guidelines. The abrupt alterations in social interactions and extracurricular activities routines compelled a shift towards a heightened emphasis on family life, accompanied by the necessity to work and learn from home due to lockdown measures. These changes had profound physical and psychological effects on our lives.

Our study revealed that students experienced the highest stress levels compared to administrators and teachers, a finding consistent with previous research indicating that medical students often have higher baseline anxiety than their peers studying other disciplines (Dyrbye et al., 2006; Lasheras et al., 2020). Qualitative data highlighted that students’ stress levels were primarily attributed to the lack of patient contact and inadequate training, potentially impacting their future practice. Additionally, students expressed feelings overly protected due to initiatives like stay-at-home learning. The altered learning environment, combined with a lack of guidance on learning strategies and interpersonal relationships, left students vulnerable to intense emotional fluctuations and strained family relationships (Zhang et al., 2020). Similarly, for administrators, the shift to remote work and social isolation policies posed challenges in balancing work and family responsibilities, as evident from their qualitative comments.

However, students and administrators demonstrated resilience, bouncing back quickly after challenging times. According to Del Carmen Pérez Fuentes et al.’s (2020) Adaptability to Change framework, a sense of control, tolerance for uncertainty, and cognitive flexibility are crucial in coping with adverse situations. Despite feeling anxious and frustrated due to the inability to control the study-from-home or working-from-home policy, student and administrator tolerated for uncertainty and display cognitive flexibility to enable them to adapt and seek opportunities. Emotional resilience, the ability to generate positive emotions and recover swiftly from negative emotional experiences, played a pivotal role in psychological resilience (Zhang et al., 2020). This emotional resilience led to diverse emotional responses, influencing the cognitive processing of emotional information. Teachers and administrators initially experienced negative emotions, but their emotional resilience facilitated quick recovery, evident from their transcripts.

Emotional and cognitive-behavioural responses were further shaped by social support mechanisms within peer groups, colleagues, organisational leaders, and the government. While studies have shown that social media can heighten anxiety due to misinformation and distressing news (Gao et al., 2020), our research indicated that students, teachers, and administrators placed significant trust in information provided by the government and institutions. This trust in government intentions and capabilities fosters adherence to health regulations, essential in crisis management (Siegrist & Zingg, 2014).

Coming from a culture emphasising collectivism, our society values interdependence and family connections highly. This sense of belonging and social connection served as a protective factor against psychological distress, aligning with previous research findings (Xiao, 2021; Yu et al., 2020) . Conversely, a lack of social support within a collectivist culture, as reported by teachers and students, contributed to psychological distress. Our qualitative and quantitative data in this study support this observation, emphasising the significance of social support structures in mitigating the adverse effects of challenging circumstances. The importance of fostering a supportive environment, both within institutions and at a societal level, cannot be overstated in times of crisis.

V. LIMITATIONS

This study has some potential limitations. The study was carried out in a single medical school; hence, the results can only be transferable to the same context. The number of respondents was quite small (especially for nursing respondents) despite multiple reminders sent to the various groups. Therefore, they may not be representative of the entire student, teachers and administrator’s population. Third, the survey was a self-reported survey and may have inherent biases while answering the questions. While rigor is more challenging to achieve in qualitative data collection and analysis, the researchers adhere to the trustworthiness principles as much as possible in analysing and presenting the results in this paper.

VI. CONCLUSION

In conclusion, achieving wellness during a pandemic is indeed possible, but it hinges not only on the resources that organisations and governments can marshal but also on individual resilience in navigating uncertainty, cultural factors, trust, and support systems. Our study highlights the importance of familial and peer connections within our cultural context, underscoring how these bonds facilitate adaptation and innovation amid the challenges posed by the pandemic. The emotional and cognitive-behavioural responses of students, teachers, and administrators are depending on their personal endurance. However, the tension that arises in these individuals can be mitigated or exacerbated based on the presence or absence of adequate support mechanisms. Sufficient support can act as a buffer, helping individuals cope effectively with the challenges they face. Conversely, insufficient support can exacerbate stress and strain, hindering their ability to adapt and respond positively to the situation at hand.

Therefore, fostering a strong support network, both within organisations and communities, is crucial. This support not only alleviates the immediate challenges faced by individuals but also empowers them to build emotional resilience, enabling them to navigate uncertainties and adversities with greater ease. In this way, the collective endurance of individuals, coupled with robust support systems, becomes the cornerstone of achieving wellness and fostering positive responses in the face of a pandemic.

Notes on Contributors

DDS developed the research idea and design with SSL, SR & LTC. The data collection was performed by SSL. The data were analysed by SSL & DDS. DDS, SSL, SR & LTC performed the data interpretation. DDS, SSL & SR wrote the article with revision by LTC. All the authors read and agreed with the final manuscript.

Ethical Approval

Ethics approval was sought from the National University of Singapore (NUS) Institutional Review Board (NUS-IRB-2020-216). Written informed consent was obtained from all participants.

Data Availability

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available as the participants of this study did not give written consent for their data to be shared publicly.

Acknowledgement

We would like to express our heartfelt gratitude to Jillian Yeo and Lilusha Kaludewa for helping in data collection and analysis.

Funding

No funding is available for this research.

Declaration of Interest

The authors report that there are no conflict of interests to declare.

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*Lee Shuh Shing
Centre for Medical Education,
Yong Loo Lin School of Medicine,
National University of Singapore, Singapore
10 Medical Dr, Singapore 117597
Email: medlss@nus.edu.sg

Submitted: 31 July 2024
Accepted: 24 February 2025
Published online: 1 July, TAPS 2025, 10(3), 37-48
https://doi.org/10.29060/TAPS.2025-10-3/OA3473

Kevin Xuan Hong Tang¹, Koon Kee Teo¹ & Kye Mon Min Swe²

¹Department of Medicine, Faculty of Medicine, Newcastle University Medicine Malaysia (NUMed), Malaysia; ²Department of Research, Faculty of Medicine, Newcastle University Medicine Malaysia (NUMed), Malaysia

Abstract

Introduction: Every medical graduate is expected to fulfil the teaching responsibilities stated by the General Medical Council (GMC). It is beneficial to nurture both teaching motivation and skills early in the undergraduate program. This study aims to evaluate the outcomes of final-year medical students as near-peer teachers in a student-led near-peer teaching program and their fulfilment of the educational responsibilities stated by the GMC.

Methods: A cross-sectional study was conducted among the year 5 medical students who participated in the Peer Teaching Program. A structured post-participation 6-point Likert scale questionnaire with written consent was distributed to the near-peer teachers to assess their perspectives on skills enhancement, motivation, and career direction. Additionally, the Peer Tutor Assessment Instrument questionnaires were distributed to the near-peer students to evaluate the performance of the near-peer teachers in five areas: responsibility and respect, information processing, communication, critical analysis, and self-awareness.

Results: There were 28 near-peer teachers, and 49 near-peer students participated in the study.  The near-peer teachers score the highest in skills (5.36 ± 0.53), followed by motivation (5.16 ± 0.60) and career direction (4.79 ± 0.82). Three quarters of the near-peer teachers considered teaching to be their future primary career path after experiencing this teaching experience (4.36 ±1.34). Generally, the near-peer teachers were highly evaluated by the near-peer students across all domains (5.06 ± 0.51).

Conclusion: Overall, the near-peer teaching programme likely improved the final-year medical students in fulfilling the “Doctors as Teachers” responsibilities outlined by the GMC.

Keywords:           Near-peer Teaching, Medical Students, Undergraduate Medical Education, General Medical Council, Doctors as Teachers

Practice Highlights

• Near-peer teachers are likely improved in skills enhancement, motivation and career direction.
• Sex and students’ background are not associated with the perceived outcomes of near-peer teachers.

I. INTRODUCTION

One of the aspects of Good Medical Practice outlined by the General Medical Council (GMC) for all medical professionals is to “be willing to offer professional support to colleagues, including students, through teaching” (General Medical Council, 2023). The role of doctors as teachers has been widely recognised as they need to teach and educate juniors, students and even patients (General Medical Council, 2011, 2015, 2023). On average, junior doctors spend around 80 minutes per day teaching medical students (Busari et al., 2002). This task is daunting for every new medical graduate who has just begun their UK foundation programme. They need to assume this responsibility with minimal formal training and preparations (Pierce et al., 2024; Qureshi et al., 2013).

Therefore, it is beneficial to motivate medical graduates to teach and equip them with appropriate teaching skills as early as their undergraduate programme (General Medical Council, 2011; Knobloch et al., 2018). Near-peer teaching involves students one or more academic years ahead teaching their peers or junior students (De Menezes & Premnath, 2016; Ten Cate & Durning, 2007; Yu et al., 2011). This has long been thought of as a programme to be incorporated into the medical curriculum to optimise teaching qualities and to produce more competent and knowledgeable doctors in the future (Botelho et al., 2022; Burgess et al., 2014; Zheng & Wang, 2022). Generally, medical schools provide a safe space for medical students to practice, correct and improve their teaching and pedagogical skills (Hardie et al., 2022). Most medical students feel less daunted and more supported involved in teaching their near-peer students (Yu et al., 2011).

To address this gap of insufficient teaching opportunities, most medical schools provide near-peer teaching programmes for their medical student (Frearson & Gale, 2017). However, most of the near-peer teaching programmes are carried out formally with structured guidance and training (General Medical Council, 2011), be it in the form of the Peer Assisted Learning Scheme (PALS) student-selected components (SSC) (Furmedge et al., 2014; Hettle & Morgan, 2019; Ross & Cameron, 2007; Ten Cate & Durning, 2007) or Doctors as Teachers and Educators training course (Cook et al., 2010; General Medical Council, 2011). Little is known about the outcomes of the student-led, student-run, near-peer teaching (NPT) programme in medical schools.

In the academic year 2023/2024, the Newcastle University Medicine Malaysia (NUMed) final-year medical students were involved as near-pear teachers in an NPT programme. This study thus aims to evaluate the outcomes of participation of the final year medical students as near-peer teachers in the student-led near-peer teaching programme and to determine whether the soon-to-be medical graduates can fulfil the “Doctors as Teachers” responsibilities stated by the GMC.  

II. METHODS

The NPT Programme was a purely student-led, student-run 3-month teaching programme which provided additional focus on the learning outcomes of the third-year medical curriculum. This programme functioned as an adjunct to the formal curriculum and provided precious opportunities for final-year medical students to improve their teaching skills.

Before the academic year started, invitation email was sent out to recruit final-year medical students to participate voluntarily as the near-peer teachers and the year 3 medical students as the near-peer students. A total of 51 final-year medical students and 100 year 3 medical students signed up for this programme. The near-peer students were randomly assigned to groups of 5 to 6 each, and each group was guided by 3 near-peer teachers. Before the programme commenced, all near-peer teachers were required to attend a mandatory online training course conducted by the lecturers to enhance their presentation and teaching skills.

This programme comprised a total of twelve teaching sessions spanning twelve weeks, covering four sessions of Essential Clinical Placement teaching sessions, four sessions of Case-Based Discussion, one surgical teaching topic and case-based session, one Single Best Answer practice session, one Written Prescribing Exam (WRISKE) session and one Objective Structural Clinical Examination (OSCE) session. Most sessions were delivered virtually (Zoom) or physically, depending on students’ preferences, except for the OSCE session, which was always conducted physically. The teaching materials were prepared by the near-peer teachers beforehand and distributed to the students after each teaching session. The NPT programme coordinator supervised and provided necessary support to both near-peer teachers and near-peer students throughout the entire programme.

The near-peer teachers and near-peer students consented to participate in this study via written consent. A structured post-participation Likert 6-point scale “Peer Tutors Own Assessment” questionnaire with written consent, which was adopted from Liew et al. (2015), was sent to the near-peer teachers after this Near-Peer Teaching Programme via Google form to explore their perceived benefits in three components which are 1) Skills Enhancement, 2) Motivation and 3) Career Direction [Expectation]. This questionnaire (Appendix 1) contains 14 items, with responses scale from strongly disagree (1) to strongly agree (6). Cronbach’s alpha was 0.801, 0.714, and 0.814 for the domains of skills enhancement, motivation, and career direction.

Similarly, all the near-peer students who participated in this near-peer teaching programme were given the Peer Tutor Assessment questionnaire adopted from Liew et al. (2015), to fill in via Google form (Appendix 2). This questionnaire is to assess the acceptability of the teachings of the near-peer teachers. It contains 16 items that evaluate five domains: (1) Responsibility and Respect, (2) Information Processing, (3) Communication, (4) Critical Analysis, and (5) Self-Awareness. Subgroup analyses were conducted to evaluate whether sex and student background affect self-perceived outcomes of near-peer teachers using independent T-test. Each participant was given 3 weeks to complete the questionnaire. Several reminders were sent via email throughout these 3 weeks to each participant to encourage them to fill in the questionnaire. Both near-peer teachers and near-peer students’ data were checked for normality. The asymmetry fell between -1 and +1 and assumed relatively symmetrical and mesokurtic.

III. RESULTS

A total of 51 medical students in their final year signed up as near-peer teachers. Of these, 28 near-peer teachers completed the questionnaire (response rate 54.9%), while 49 out of 100 near-peer students who joined this NPT programme responded in this study (response rate 49.0%). Among those near-peer teachers who responded, there were 9 (32.1%) males and 19 (67.9%) females. More local students responded in this study than international students (75% vs 25%). The overall mean age ± SD of the near-peer teachers is 23.75 ±1.21 years old.  For the near-peer students, the overall mean age ± SD is 21.69 ± 0.74 years old. The number of international and local near-peer students who responded was similar. The data of the responses of both near-peer teachers and near-peer students that supports the findings of this study  is openly available at Figshare https://doi.org/10.6084/m9.figshare.26886517.v1 (Tang et al., 2024a) and https://doi.org/10.6084/m9.figshare.26886514.v1 (Tang et al., 2024b).

Table 1 showed peer review findings to ensure their voices were represented. To ensure the trustworthiness of the findings, actions were taken to address credibility, dependability, confirmability, transferability, and reflexitivity are outlined in Table 2. Figure 1 indicates the near-peer teachers view of the benefits of involving in the student-led near-peer teaching program.

Table 1. Demographic data of the near-peer teachers

Table 2. The mean score (± SD) for the self-evaluation of near-peer teachers in relation to (1) skills enhancement, (2) motivation and (3) career direction (expectation)

Figure 1. Near-peer teachers view of the benefits of involving in the student-led NPT program: Analysis of post-participation questions responses (n=28) in Likert 6-point scale in relation to (a) skills enhancement, (b) motivation and (c) career direction (expectation)

Based on the responses to the questionnaire, the near-pear teachers widely agreed that the NPT programme positively impacted them (5.11 ± 0.58), with the highest score in the domain of skills enhancement (5.36 ± 0.53), followed by motivation (5.16 ± 0.60) and career direction (4.79 ± 0.82). Most of the near-peer teachers considered this programme improved their skills in terms of teaching, organising, communicating and understanding educational principles (Table 2). 100% of them agreed that this NPT programme increased their confidence in speaking to groups and enhanced their planning and organising skills.  Furthermore, all 28 respondents (100%) reported being more motivated to revise their own clinical skills and focus more on their practical skills after teaching near-peer students to address the

knowledge gap. A significant proportion of near-peer teachers felt more encouraged to participate in more teaching programmes in the future (n=27, 96.43%) and more inclined to help fellow students next time (n=25, 89.28%).  It is noteworthy that 96.43% of near-peer teachers agreeing that this NPT programme helped in deciding their career direction and motivated them to undertake more trainings. Besides, three quarters of them would consider teaching as their major career pathway in the future, with a mean score of 4.36 ± 1.34. Lastly, all 28 respondents (100%) agreed that joining the NPT programme had enhanced their curriculum vitae (100%).

Table 3 shows the mean score of near-peer students’ evaluation of near-peer teachers in five domains after joining the near-peer teaching programme.

Table 3. The mean score (± SD) for the near-peer students’ evaluation of near-peer teachers after the NPT programme in relation to (1) responsibility and respect, (2) information processing, (3) communication, (4) critical analysis and (5) self-awareness

When asked to evaluate the teaching of their near-peer teachers, the near-peer students considered the near-peer teachers demonstrating positive outcomes in all five domains (5.06 ± 0.51). The near-peer teachers were thought to have a high degree of professionalism in terms of responsibility and respect (5.15 ± 0.57) and self-awareness (5.11 ± 0.62). The most outstanding attribute demonstrated was the ability to complete assigned tasks appropriately (5.27 ± 0.73). Besides, the near-peer teachers performed satisfactorily to process information (5.12± 0.66), communicate (5.01± 0.65) and analyse critically (4.93 ± 0.66). However, the near-peer teachers were identified to score slightly lower in making non-confusing comments and responses (4.92 ± 0.84) as well as giving a summary of the session (4.90 ± 0.82).

Variables	Independent T- test
	Mean difference (95% CI)	P-value
Sex (Male vs Female)
Skills	-0.101 (-0.549, 0.348)	0.649
Motivation	0.118 (-0.385, 0.621)	0.634
Career Direction (Expectation)	0.507 (-0.154, 1.169)	0.127
Students’ background (Local vs International)
Skills	-0.210 (-0.688, 0.268)	0.376
Motivation	-0.276 (-0.810, 0.258)	0.297
Career Direction (Expectation)	0.280 (-0.439, 1.034)	0.414

Table 4. Comparison of self-perceived outcomes of near-peer teachers between male and female, local and international students (Independent t-test)

The independent t-test were performed to find out the association between sex and perceived outcomes of the near-peer teachers. Our study revealed that it is statistically insignificant between male and female in the perceived benefits for skills (P = 0.649), motivation (P = 0.549) and career direction (P = 0.127).

Besides, there is no correlation between students’ background and the three measured outcomes. There is statistically insignificant between local and international students in term of skills (P = 0.376), motivation (P = 0.397) and career direction (P = 0.414).

IV. DISCUSSION

This study provides valuable insights into the background and characteristics of the final-year medical students who voluntarily participated in a student-led, student-run NPT programme. The outcomes of their participation concerning their perceived benefits in terms of skills, motivation, and expectations were investigated. Overall, the near-peer teachers reported that this NPT programme helped them tremendously to improve their skills in terms of learning and teaching, which might be driven by their primary motive for joining this programme. This finding was similar to previous studies, which showed skills enhancement in volunteer near-peer teachers (Buckley & Zamora, 2007; Liew et al., 2015). Our study further reaffirms the plausibility of a student-run NPT programme to enhance teaching and learning skills. However, due to the voluntary nature of participation in this near-peer teaching programme, the students who are likely most in need of skill enhancement may have been omitted from this programme, and they might be less equipped to teach after they graduate. Some studies recommended more incentives to be given to such students to encourage them to make use of the opportunities offered (Buckley & Zamora, 2007).

The motivation evaluated includes both self-actualising inner motivations to improve their clinical and practical skills and the external, tangible desire to help fellow students. The high motivation score suggests the reinforcement of a desirable attitude towards future educational and teaching responsibilities, which matches the GMC’s emphasis on the teaching role of doctors (General Medical Council, 2015). A couple of reasons may explain this: firstly, the near-peer teachers are final-year medical students, who will sit for their final examinations very soon and are desperately finding ways to improve their learning. The process of teaching, which requires extensive preparation, a comprehensive understanding of the content, dynamic synthesis, and anticipation of the questions that may be asked of them, forms an efficient learning strategy. Secondly, the near-peer teachers, inspired by the excellent teaching they once had, wish to impart good teaching to the near-peer students going through the same journey.

Although many near-peer teachers are more motivated to be involved in more teaching and even take up teaching training courses in the future, the influence is not apparent in the long-term career direction. This could be explained well by the brief intervention of this NPT programme that lasted 3 months. However, the lucrative income opportunities in other medical specialities and the limited exposure to medical education pathways in undergraduate medical schools are some factors that may sway them away from considering medical education as their primary career pathway (Puri et al., 2021; Sarikhani et al., 2021). Therefore, more effort should be directed to increase teaching opportunities and to raise awareness of medical education career options in the undergraduate medical school programme. This includes developing Student Selected Components focusing on medical education and giving opportunities to shadow clinical teaching staff (Liew et al., 2015; Wilson et al., 2008).

After participating in this study, the near-peer students evaluated the near-peer teachers highly in all the domains. This provides a strong indication of the recognition and acceptance of the teaching skills of the near-peer teachers. In addition, the ability of the near-peer teachers to demonstrate responsibility and respect throughout this programme shows their preparedness to work under the GMC with desirable attitudes and professionalism. Previous studies have also shown that near-peer teachers gain more subjectively and objectively than students (Liew et al., 2015; Ten Cate & Durning, 2007). This can be related to the underpinning of the psychological and social theories behind the dynamics between near-peer teachers and near-peer students (Loda et al., 2019). The theoretical model of cognitive and social congruence explains the positive evaluation of the near-peer teachers (Loda et al., 2019; Rollmann et al., 2023). The proximity of age between the near-peer teachers and the near-peer students enables them to share similar knowledge frameworks, language and social roles.  Besides, near-peer teachers are perceived to be more approachable and understanding of the needs and struggles of the near-peer students. This may be because the near-peer teachers have had similar experiences themselves. Therefore, near-peer teachers are better able to process difficult concepts and frameworks, emphasize the key points, and communicate the information using familiar and non-confusing language to ensure that near-peer students comprehend better (Loda et al., 2019; Loda et al., 2020). The perceived barrier to providing feedback to near-peer teachers is also lower compared to faculty-led staff, as the age difference between them is much smaller. This might suggest why near-peer teachers feel less offended by criticism and are more likely to accept and respond to criticism gracefully (Loda et al., 2019). Nevertheless, the near-peer students thought that some near-peer teachers experienced some difficulties in giving relevant input and summary of the sessions, thus necessitating more structured pedagogical training for near-peer teachers in this aspect. Mastering these teaching skills would allow the near-peer students to appreciate better the big picture and key takeaway points of each lesson (Khaw & Raw, 2016).

One of the focuses of this study is to analyse the sex-specific difference of the perceived outcomes of the near-peer teachers. Although there is an appropriate twice female near-peer teachers who responded to this study compared to male near-peer teachers, the results shows that the sex-specific difference in the perceived improvement in motivation, skills and career direction is not significant. There is no sex-specific difference in term of enthusiasm and motivation to involve in near-peer teaching (Messerer et al., 2021).  Throughout the whole process, they receive similar gender-equitable support and guidance without any discrimination.

V. LIMITATIONS AND RECOMMENDATIONS

As few studies have reported outcomes for a purely student-led student-run NPT programme, this study offers valuable insights concerning the perceived benefits for near-peer teachers. However, this study has several limitations. Firstly, given the relatively small sample size of the near-peer teachers and the subjective nature of the self-reported questionnaire, the results may benefit from further objective testing, such as correlation with examination results. Secondly, this study is only carried out in a single medical school, with a slight variation in the implementation of the NPT compared to other institutions. Verification of these results across various medical schools would strengthen these findings. This study thus calls for more structured student-led peer teaching programmes to be implemented in more medical schools and to be assessed longitudinally to evaluate the association between the student-led peer teaching programme and the outcomes of participation of the near-peer teachers. It may also be worthwhile to investigate and assess the perspective of near-pear teachers who demonstrated interest in medical education, as well as to evaluate the long-term outcomes in career direction for medical graduates who once participated in near-peer teaching programmes.

VI. CONCLUSION

In conclusion, this purely student-led, student-run near-peer teaching programme likely improved the final-year medical students in fulfilling the “Doctors as Teachers” responsibilities outlined by the GMC. Besides, the near-peer teachers also reported having positive outcomes in their skills and career direction.  Likewise, from the perspective of the near-peer students, the near-peer teachers demonstrated outstanding skills and professionalism in all five domains: responsibility and respect, information processing, communication, critical analysis and self-awareness. Possessing the skills and professionalism fulfils the expectations of GMC for healthcare professionals to provide the right care at the right time with the right skills for the good of patients.

Notes on Contributors

Kevin Xuan Hong Tang was a final year medical student who conceptualised and designed the study, reviwed the literature, conducted the data collection and analysis, prepared the figures and wrote the manuscript.

Koon Kee Teo was a final year medical student who reviewed the literature, collected and analysed the data, prepared the figures and helped in writing the manuscript.

Kye Mon Min Swe is an Associate Professor in Education Research in NUMed. She participated in conceptualising the study, performed statistical analysis and drafted, reviewed and edited the manuscript. All the authors have read and approved the final manusript.

Ethical Approval

 This study titled “Embracing Doctors as Teachers: Evaluating the Student-led Near-Peer Teaching at Transnational Campus” was approved by the Research Management Committee and the Newcastle University Ethics Committee (Approval number 45070/2023).

Data Availability

The data that support the findings of this study are openly available in Figshare repository, as below,

https://doi.org/10.6084/m9.figshare.26886517.v1 (Tang et al., 2024a) and

https://doi.org/10.6084/m9.figshare.26886514.v1 (Tang et al., 2024b).

Acknowledgement

The authors would like to thank the NUMed Medical Education Society for carrying out this programme. The authors are grateful for Professor Vishna Devi Nadarajah for her support and feedback in this research.

Funding

The authors declare that there is no funding received in this study.

Declaration of Interest

The authors declare that there is no conflict of interest.

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*Kye Mon Min Swe
1, Jalan Sarjana 1, Educity,
79200 Iskandar Puteri, Johor, Malaysia
Email: kye-mon.min-swe@newcastle.edu.my

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