Submitted: 2 May 2025
Accepted: 8 September 2025
Published online: 7 April, TAPS 2026, 11(2), 89-101
https://doi.org/10.29060/TAPS.2025-11-2/OA3735

Ardo Sanjaya^1,2, Ray Sebastian³, Kevin Gunawan³, Christian Edwin⁴, Nathanael Andry Mianto¹ & Cindra Paskaria⁵

¹Department of Anatomy, Faculty of Medicine, Maranatha Christian University, Indonesia; ²Maranatha Biomedical Research Laboratory, Faculty of Medicine, Maranatha Christian University, Indonesia; ³Undergraduate Program in Medicine, Faculty of Medicine, Maranatha Christian University, Indonesia; ⁴Medical Education Unit, Faculty of Medicine, Maranatha Christian University, Indonesia; ⁵Department of Public Health, Faculty of Medicine, Maranatha Christian University, Indonesia

Abstract

Introduction: Medical students often face psychological distress affecting their academic performance and well-being. While coping and resilience may buffer this stress, their roles in academic outcomes across different training stages are poorly understood. This study explored how distress, coping, resilience, and learning perception relate to academic performance across semesters.

Methods: A cross-sectional study of 677 pre-clinical medical students was conducted in 2024 across Semesters 1, 3, 5, and 7. Standardised instruments measured psychological distress, burnout, resilience, coping, and perceptions of the learning environment. Data were analysed using ANCOVA to compare constructs across semesters. Principal Component Analysis (PCA) and Structural Equation Modeling (SEM) assessed the direct and indirect pathways linking distress to Grade Point Average (GPA).

Results: Psychological distress and burnout increased during mid-training while resilience traits such as perseverance and help-seeking consistently decreased. Coping styles remained stable. PCA identified three latent constructs: distress, coping, and resilience. SEM revealed that distress negatively predicted GPA both directly (β = –0.186, p < .001) and indirectly via resilience (β = 0.052, p = .003). Coping was positively associated with resilience (β = 0.412, p < .001), but its effect on GPA was marginal. A multi-group SEM confirmed a consistent relationship across academic semesters.

Conclusion: Although the effects were small, psychological distress significantly influenced academic performance, partially mediated by resilience. While coping remained stable, resilience declined and did not recover, highlighting the need for support. Interventions to enhance coping may bolster resilience and improve academic outcomes.

Keywords:           Medical Students, Resilience, Coping Strategies, Academic Performance, Psychological Distress

Practice Highlights

• Distress and resilience vary by semester, supporting tailored interventions in medical training.
• Psychological factors weakly predict GPA; wellness should target broader student outcomes.
• Adaptive coping links to greater resilience, underscoring its role in early medical training.
• Early-semester students report more distress, marking a window for mental health support.
• Structural modeling reveals psychological pathways for targeted interventions in education.

I. INTRODUCTION

The medical profession demands lifelong learning and commitment to high standards of care, requiring academic proficiency and a strong foundation of psychological well-being, resilience, and work-life balance (Braquehais & Vargas-Cáceres, 2023; Fares et al., 2016). However, increasing pressures within medical education have led to a mismatch between academic and clinical expectations with available personal resources, placing these students at risk for stress and burnout (Shanafelt, 2021; Siddiqui & Malik, 2019). These challenges are compounded by an often competitive and high-pressure environment that lacks adequate support (Almansour et al., 2024; Kassab et al., 2024; Wasson et al., 2016). Research has shown that the early years are often marked by adjustment difficulties, which heighten stress levels. Reports indicate that the prevalence of stress in medical students ranges from 20.9% to 90%, with burnout affecting up to 75% (Fares et al., 2016). Some students cope through constructive mechanisms like time management, help-seeking, and emotional regulation (van der Merwe et al., 2020), while others turn to avoidance, denial, or emotional withdrawal (Neufeld & Malin, 2021).

Stress and burnout are two related constructs that originated from distinct sources. Stress arises from outside demands exceeding personal resources, while burnout is typically defined as a prolonged response to chronic stress, manifesting as emotional exhaustion and depersonalisation (Bayram Deger, 2024; Dyrbye et al., 2008). Both are influenced by external factors such as academic load, social expectations, and institutional support, as well as internal factors like coping styles and resilience (Dyrbye et al., 2009; Findyartini et al., 2021). According to Lazarus and Folkman’s transactional stress model, individuals experience stress when their perceived demands outweigh their coping resources (Ben-Zur, 2019; Folkman, 2013). Coping mechanisms are broadly categorised into problem-focused, emotion-focused, and avoidant coping. Adaptive coping using problem-focused and emotion-focused strategies is associated with better academic and mental health outcomes (O. Ogoma, 2020; Simons et al., 1999), while avoidant or maladaptive forms of emotion-focused coping are linked to increased distress, poorer performance, and higher dropout risk (Abreu Alves et al., 2022; Ding et al., 2021; Holahan et al., 2005). Resilience, the capacity to recover from adversity, is a protective buffer against stress and burnout. It encompasses traits like perseverance, optimism, and help-seeking behavior (Lin et al., 2019). Resilience is dynamic, and changes are made in response to stressors and interventions (Wang et al., 2022). Programmes that incorporate cognitive, behavioral, and mindfulness strategies have demonstrated success in bolstering resilience and adaptive coping in medical students (Liu & Cao, 2022; Nguyen et al., 2023).

Although stress, coping, and resilience have been widely studied among medical students, most research has focused on these constructs independently and within a single academic stage. Few have examined how these psychological factors evolve across different phases of training or how they interact to influence academic performance. To address this gap, the present study compares levels of psychological distress, coping styles, resilience, and learning perceptions across semesters. Additionally, it integrates these constructs into a structural framework to explore their direct and indirect effects on academic performance, aiming to identify periods and mechanisms for intervention.

II. METHODS

This was a cross-sectional, single-center study involving medical students enrolled in four academic semesters (1, 3, 5, and 7), representing the pre-clinical years, conducted in 2024. The target population comprised 1,012 students, all invited to participate in an on-site survey administered via the SurveyMonkey platform using their electronic devices. 862 students responded, yielding an 85.2% response rate, with 726 students completing the survey. Students who had retaken any semesters were excluded from subsequent analyses to minimise potential confounding effects. Following these exclusions, the final sample consisted of 677 participants.

A. Instruments & GPA Calculations

This study initially gathered data using a set of standardised, validated instruments translated into Indonesian. The full details regarding the instruments and GPA calculations can be found in Appendix 1.

B. Demographics

Descriptive statistics were used to summarise the demographic and contextual characteristics of the participants across the four academic levels. Continuous variables were assessed for normality and were described using either means and standard deviations or medians with interquartile ranges. Categorical variables were reported as frequencies and percentages.

C. Analysis of Covariance

A series of ANCOVA models were conducted to examine differences in psychological and academic variables across semesters, using validated instrument scores as dependent variables (Appendix 1). Assumptions were checked prior to analysis. Minor non-normality was accepted, but models with robust standard errors were used when heteroscedasticity was detected.

Bivariate analyses identified significant demographic and lifestyle covariates, which were included in the models. For significant ANCOVA results, pairwise comparisons with Holm’s correction were performed. Analyses and visualisations were conducted in Python (v3.10.15) using seaborn (v0.13.2) and statsmodels (v0.14.4).

D. Structural Equation Modeling Analysis

A two-step approach was used to develop the Structural Equation Model (SEM). First, Principal Component Analysis (PCA) was performed on nine normalised psychological variables to address conceptual overlap and identify latent components. Variables were grouped, and composite scores were calculated by averaging items within each component for use in the SEM as observed variables.

The SEM tested the hypothesised relationships between psychological stress, coping, resilience, and learning environment perception, with GPA as the primary outcome. The model was guided by theories suggesting that stress negatively impacts academic outcomes (Almarzouki, 2024) and that this effect may be buffered through adaptive responses and psychological resources (Masten, 2001). The models were estimated using maximum likelihood (ML) estimation with bootstrapping (1,000 draws) and evaluated using multiple fit indices. A multi-group SEM was also conducted by semester to assess whether these relationships varied across academic stages. Constrained and unconstrained models were compared using a chi-square difference test. Analyses were conducted in R (v4.4.2) using the lavaan package (v0.6-19) for SEM and psych (v2.4.6.26) for PCA.

III. RESULTS

677 medical students were included in the final analysis. The demographic characteristics of the sample are summarised in Table 1. The majority of the participants are females (71.2%), and a considerable proportion (15.95%) reported having received formal mental health diagnoses. Daily routines such as average sleep duration and social media usage remained relatively stable across groups. However, some variability was observed in study-related behaviors. Similarly, involvement in extracurricular activities was more common among students in semesters 3 and 5, with participation rates exceeding 47% and 50%, respectively, reflecting higher engagement. A series of ANCOVAs were conducted to examine the influence of semester progression, and the full results are available on Figshare.

Table 1. Demographic Characteristics of the Research Participants

A. Psychological Distress and Burnout are Affected by Academic Progression

Semester progression had a significant effect on DASS-21 scores (F [3, 663] = 8.35, p < .001, η² = .036). Post-hoc comparisons (Figure 1) revealed that students in Semester 1 reported significantly lower distress compared to those in Semester 3 (adjusted mean difference = –0.27, 95% CI [–0.43, –0.11], p = .006) and Semester 5 ( –0.26, 95% CI [–0.42, –0.09], p = .010), suggesting a rise in psychological burden as students progressed. However, distress levels declined by Semester 7, possibly reflecting increased adaptation and adjustment over time. Mental health diagnosis was an even stronger predictor (p < .001, η² = .057), followed by gender (p < .001, η² = .043) and average sleep and social media time. The full post hoc results are available on Figshare.

Figure 1. Adjusted Mean Scores of Measured Variables Across Academic Semesters

Barplot displays adjusted means from ANCOVA analyses across four academic stages (Semesters 1, 3, 5, and 7) after adjustment for relevant covariates. Variables include psychological distress (DASS-21), school burnout (SBI), educational environment perception (DREEM), resilience traits (ARS-24), and coping strategies (Brief-COPE). Note that students in Semester 1 showed the most favorable characteristics, with lower distress and burnout and higher DREEM and positive resilience traits. In the middle of their training (particularly Semester 3), students were characterised by high distress, burnout, and low positive resilience traits. Error bars denote the 95% confidence intervals.

Student progression also influenced School Burnout Inventory scores (F [3, 663] = 5.33, p = .001, η² = .024). Post-hoc comparisons revealed that Semester 3 students reported the highest levels of burnout, with greater scores than those in Semester 7 (0.60, 95% CI [0.24, 0.96], p = .006) and a marginally significant difference than those in Semester 5 (0.40, 95% CI [0.08, 0.72], p = .075). These findings suggest a pattern of increased stress during the early-to-mid stages of medical training, which appears to taper off in later semesters. Like DASS-21, students with a mental health diagnosis and more time on social media reported higher burnout (p = .009, η² = .010 and p < .001, η² = .024, respectively).
B. Academic Progression and Lifestyle Factors Influenced Students’ Perception of the Learning Environment
DREEM scores differed significantly by semester (F [3, 663] = 14.53, p < .001, η² = .062) and represent one of the strongest effects observed in this study. These suggest that students’ perceptions are influenced by their stage of training. Post-hoc comparisons revealed that students in Semester 1 reported significantly higher DREEM scores compared to those in Semester 3 (0.31, 95% CI [0.20, 0.43]), Semester 5 (0.30, 95% CI [0.18, 0.42]), and Semester 7 (0.38, 95% CI [0.25, 0.51]). All pairwise comparisons were statistically significant at p < .001. These consistent declines in the perceived learning environment across semesters may reflect growing academic pressures and a gradual expectation shift, although we did not explore these potential causes. DREEM scores were also significantly influenced by chronic illness, sleep duration, daily social media use, and time spent studying (p < .05 for all), suggesting that these factors influence students’ perceptions of the learning environment.

C. Resilience Evolves with Academic Progression, while Coping Styles Remain Stable

Perseverance and Adaptive Help-Seeking differed significantly across semesters (F [3, 663] = 6.09, p < .001, η² = .027 and F [3, 663] = 6.92, p < .001, η² = .030, respectively). Post-hoc analysis revealed a consistent decline from Semester 1 compared to Semester 3 (0.20, 95% CI [0.07, 0.33], p = .013), Semester 5 (0.19, 95% CI [0.06, 0.31], p = .013), and Semester 7 (0.30, 95% CI [0.17, 0.44], p < .001). A similar pattern was observed for Adaptive Help-Seeking, with statistically significant declines in Semester 3 (0.27, 95% CI [0.13, 0.41], p = .002) and Semester 7 (0.22, 95% CI [0.07, 0.37], p = .023), and a marginally significant decline in Semester 5 (0.17, 95% CI [0.03, 0.32], p = .069). These findings suggest that these two resilience traits diminish as students progress through medical school, potentially due to academic fatigue or limited support. Both traits were associated with longer average study time (p < .001, η² = .025 and p < .001, η² = .022, respectively), reflecting a bi-directional relationship between them. In contrast, Negative Affect and Emotional Response did not differ significantly by semester (F [3, 663] = 2.21, p = .086, η² = .010). However, it was strongly associated with a history of mental health diagnosis (p < .001) and greater social media use (p < .001, η² = .026). These findings suggest that positive resilience traits like perseverance and help-seeking change dynamically with academic progression and reflect greater study effort. In contrast, negative emotional responses may reflect underlying mental health challenges and lifestyle factors.

Problem-focused, emotion-focused, and avoidant coping demonstrated non-significant effects during the semester. However, avoidant coping was significantly more prevalent among students with a history of mental health diagnosis (p < .001, η² = .038). The influence may be bidirectional as avoidant coping may exacerbate psychological distress, and vice versa. (Holahan et al., 2005) Additional factors such as chronic illness (p = .018), alcohol consumption (p = .004), and gender (p = .001) also showed small but statistically significant associations with avoidant coping. These findings suggest that coping styles are likely shaped more by individual characteristics and previous experiences than by semester progression.

D. Principal Component Analysis (PCA) Identified Distress, Coping, and Resilience as Latent Constructs

A PCA was conducted on the nine standardised variables to address conceptual overlap among psychological variables and improve model stability. Several prerequisites were tested, indicating that the data were suitable for subsequent PCA (Kaiser-Meyer-Olkin test = 0.77; Bartlett’s test of sphericity = p < .001). As shown in Figure 2A, the scree plot supports a three-component solution, which explains approximately 74.3% of the total variance. The component matrix (Figure 2B) showed the pattern of loadings. We interpret component 1 (RC1) as Distress with strong loadings from DASS-21, SBI, avoidant coping, and negative affect. Component 2 (RC2) was interpreted as Coping, haracterized by loadings from problem-focused and emotion-focused coping strategies. Lastly, Component 3 (RC3) was interpreted as Resilience with loadings from perseverance, adaptive help-seeking, and DREEM. Model fit was adequate, with a root mean square residual (RMSR) of 0.065 and an off-diagonal values fit of 0.969.

A. Scree plot showing eigenvalues from principal component analysis across component numbers. Note that the inflection point supports a three-component solution.

B. Heatmap of loadings for the three retained principal components. Component 1 (RC1) has strong loadings from DASS-21, SBI, avoidant coping, and negative affect. Component 2 (RC2) has loadings from emotion- and problem-focused coping. Component 3 (RC3) includes loading from perseverance, adaptive help-seeking resilience traits, and DREEM. Loadings below 0.5 are not shown

Figure 2. Dimensional Reduction Using Principal Component Analysis for the Measured Variables

E. Direct and Indirect Pathways Linked Distress to Academic Performance

A structural equation model (SEM) was tested to examine distress’s direct and indirect effects on GPA, with coping and resilience mediating variables (Table 2). The model was just-identified, and global fit indices indicated perfect fit (CFI = 1.000, TLI = 1.000, RMSEA = 0.000). Our interpretation centers on the theoretical basis and the significance of the individual path estimates. Figure 3 shows that distress significantly negatively affected resilience (β = –0.34, p < .001) and weakly positively affected coping (β = 0.08, p = .045). Coping was positively associated with resilience (β = 0.41, p < .001), suggesting that students using more adaptive coping reported higher resilience. Distress also negatively predicted GPA (β = –0.19, p < .001), while resilience (β = –0.15, p = .002) and coping (β = 0.18, p < .001) were also associated with GPA. Mediation analysis revealed a significant indirect effect of distress on GPA via resilience (β = 0.05, p = .003), while the path through coping was not significant (β = 0.02, p = .069). The total indirect effect was significant (β = 0.06, p < .001), supporting the role of coping and resilience as partial mediators. Note that indirect paths are not shown in Figure 3.

*Ardo Sanjaya
Maranatha Biomedical Research Laboratory,
Faculty of Medicine,
Maranatha Christian University
Jl. Surya Sumantri No. 65
Bandung, Indonesia, 40164
+62 859 1066 09851
ardo.sanjaya@med.maranatha.edu

Submitted: 8 April 2025
Accepted: 27 August 2025
Published online: 7 April, TAPS 2026, 11(2), 81-88
https://doi.org/10.29060/TAPS.2026-11-2/OA3714

Vy Van Thao Ngan Nguyen & Nguyen Bao Phuc Diep

School of Nursing and Medical Technology, The University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam

Abstract

Introduction: Self-efficacy significantly impacts academic performance and clinical competence in healthcare education. Students need to develop confidence and adaptability to handle unpredictable situations in high-pressure fields like anaesthesia nursing. While global studies emphasise self-efficacy’s role in clinical training, research on Vietnamese nursing students is limited. This study aimed to evaluate the clinical self-efficacy beliefs of anaesthesia nursing students to understand their confidence levels and identify factors influencing this.

Methods: A cross-sectional descriptive study was conducted from February to June 2024, with Stratified sampling of 205 third- and fourth-year anaesthesia nursing students at the University of Medicine and Pharmacy in Ho Chi Minh City. The Self-Efficacy in Clinical Performance (SECP) scale was used to evaluate students’ self-efficacy, and the Critical Thinking Disposition Inventory for Medical College Students (CTDI-M) measured critical thinking disposition.

Results: The overall clinical self-efficacy score for students was 105.4±12.87. A statistically significant positive correlation was found between self-efficacy and critical thinking disposition among students (r_s = 0.37, p < 0.001). Furthermore, a significant linear regression analysis indicated that critical thinking disposition (coefficient = 8.6, p < 0.001), attitudes regarding the characteristics of anaesthesia nursing students (coefficient = 0.9, p < 0.001), and academic year (coefficient = 6.1, p < 0.001) are significant predictors of clinical self-efficacy.

Conclusion: Integrating the promotion of critical thinking, addressing specific attitudes, and considering students’ academic progression into clinical training programmes is essential. This has important implications for developing training programmes that enhance essential skills and better prepare students for their professional careers.

Keywords:           Anaesthesia Nursing Students, Clinical Self-Efficacy, Critical Thinking Disposition, Clinical Practice

Practice Highlights

• Anaesthesia nursing students demonstrated a moderate level of self-efficacy in clinical practice, highlighting the need for targeted interventions to enhance their confidence and competency.
• A significant positive correlation was identified between self-efficacy and critical thinking disposition (p = 0.001), suggesting that students with stronger critical thinking skills tend to have higher confidence in clinical settings.
• Strengthening critical thinking skills and positive attitudes concerning professional characteristics may serve as a key strategy to enhance clinical self-efficacy among anaesthesia nursing students, improving their readiness for professional practice.

I. INTRODUCTION

In nursing education, the concepts of self-efficacy and critical thinking are essential for developing competent practitioners who can make sound clinical decisions.

Self-efficacy, as defined by Bandura, refers to an individual’s belief in their ability to perform the behaviours required to achieve specific outcomes (Bandura, 1991). Higher self-efficacy in nursing correlates with improved clinical performance, motivation, job satisfaction, and patient care outcomes (Köseoglu, 2015; Shorey & Lopez, 2021). Nursing students, especially those in the Anaesthesia specialisation, face unique clinical challenges, including high-pressure hospital environments, which necessitate strong self-efficacy to manage professional responsibilities and emergencies (Albooghobeish et al., 2023). Additionally, errors in this field can lead to serious consequences for both patients and practitioners, including legal issues and psychological trauma.

Critical thinking is equally vital, as it involves the objective analysis of information necessary for effective clinical decision-making (Nederland, 2010; Yildirim et al., 2012). This is particularly important for nurse anaesthesia students, who must cultivate strong critical thinking skills to navigate the complexities of anaesthesia care. They need to make quick and accurate decisions in unpredictable situations during operations (Burns et al., 2013; Scott Imus et al., 2017).

Moreover, transitioning from classroom learning to clinical practice presents significant challenges for students. Numerous studies have highlighted the connection between critical thinking skills and confidence in clinical practice. Students who possess strong critical thinking abilities are more likely to demonstrate greater confidence in making clinical decisions and performing nursing tasks (Albooghobeish et al., 2023; Dehghani et al., 2011; İşeri et al., 2023; Sahebi & Barkhordari-Sharifabad, 2023; Salimi et al., 2017). This connection not only enhances students’ clinical experiences but also creates a bridge between theory and practice.

Some Research indicates that educational interventions, such as simulation-based learning and case-based learning platforms, can enhance essential competencies in nursing education, especially having positively impacted nursing students’ self-efficacy and clinical performance (Azizi et al., 2022).

Despite the recognised importance of self-efficacy and critical thinking in nursing education, there is a notable lack of research specifically focused on anaesthesia nursing students, particularly in Vietnam. Understanding the relationship between these constructs is crucial for developing targeted educational strategies that enhance clinical competence. Therefore, the research question focuses on whether there is a relationship between students’ clinical self-efficacy and their critical thinking disposition, as well as the factors that influence this relationship.

The University of Medicine and Pharmacy in Ho Chi Minh City (UMP HCMC) is a leading institution for training anaesthesia nursing professionals in southern Vietnam, emphasising the importance of assessing and enhancing students’ self-efficacy and critical thinking skills.

This study aims to evaluate the levels of self-efficacy and critical thinking disposition among third- and fourth-year anaesthesia nursing students at UMP HCMC. Additionally, it seeks to examine the relationship between these variables and their combined impact on clinical performance. The findings are expected to inform curriculum development and instructional methodologies, ultimately improving the preparedness of anaesthesia nursing students for clinical practice. This, in turn, will contribute to enhancing the quality of training and support the comprehensive development of students, ensuring they meet the demands of the profession in the near future.

II. METHODS

A. Design and Setting

This cross-sectional research employed an exploratory, descriptive, and quantitative study design that utilised a structured questionnaire to gain insights into nursing students’ perspectives. It was conducted at the School of Nursing and Medical Technology at the University of Medicine and Pharmacy in Ho Chi Minh City from February 2024 to June 2024.

B. Sample

This study involved 205 students enrolled in the anaesthesia nursing degree programme at the University of Medicine and Pharmacy in Ho Chi Minh City, Vietnam. The sample size was determined through a two-step process: first, an initial sample size for the mean was calculated, and then Cochran’s formula for finite populations was applied to make the necessary correction. A stratified random sampling method was employed, based on the academic year, to ensure proportional representation. Since the curriculum for this four-year programme requires students to begin clinical practice related to their major in their third year, we stratified the population of eligible students into two groups: third-year students and fourth-year students. Simple random sampling was then applied within each stratum to select participants until the required sample size for that stratum was reached. This process resulted in 53% of the participants (110 students) being in their third year, accurately reflecting their proportion within the total student population. Only students who provided informed consent were included in the study.

C. Instruments

This study evaluated the self-efficacy of nursing students in the clinical practice environment using the Self-Efficacy for Clinical Performance (SECP) scale (Cheraghi et al., 2009). The translation and back-translation technique was used to convert the English version to Vietnamese, and four experts assessed the content validity with a CVI (content validity index) of 1. The SECP scale includes 37 questions divided into four subcategories: Assessment (12 items), Diagnosis and Planning (9 items), Implementation (10 items), and Evaluation (6 items). Each item on the questionnaire is rated on a Likert scale ranging from 1 (not relevant) to 5 (very relevant). The total score is calculated by summing the ratings for all questions, with possible scores ranging from a minimum of 37 to a maximum of 148. A higher score reflects greater self-efficacy. The questionnaire demonstrated a high Cronbach’s alpha coefficient of 0.96 in a pilot test, indicating strong reliability.

This study also utilised the Critical Thinking Disposition Inventory for Medical College Students (CTDI-M) to assess critical thinking skills. Developed by Wang et al. in 2019 (Wang et al., 2019), the inventory consists of 18 items categorised into three factors: open-mindedness, systematic/analytical thinking, and truth-seeking. To adapt the instrument for the Vietnamese context, a translation and back-translation methodology was employed. The content validity of the translated instrument was then independently assessed by four experts, who collectively assigned a Content Validity Index (CVI) of 0.9. Participants respond using a Likert scale that ranges from 1 (strongly disagree) to 5 (strongly agree). The overall score for each factor is calculated by averaging the scores of the relevant questions. The questionnaire achieved a Cronbach’s alpha of 0.85, indicating good reliability.

To evaluate the internal reliability of the questionnaire, a pilot study was conducted with 25 students from the anaesthesia nursing programme at the University of Medicine and Pharmacy in Ho Chi Minh City. We employed a stratified simple random sampling method to select participants, ensuring the sample was representative of the different academic years (third and fourth year) engaged in clinically relevant practice. The study included only students who provided informed consent and did not participate in the main study.

D. Data Analysis

The study data were processed using Stata 15.0, a statistical software. The first step involved analysing background variables through descriptive statistics, which included calculating the mean, standard deviation, percentiles, and ranges for all parameters. To examine the relationship between sociodemographic characteristics and nursing students’ self-efficacy and critical thinking, we used one-way analysis with the Kruskal-Wallis test and the Mann-Whitney U test. Spearman’s correlation was employed to identify the relationship among the main variables. We set the threshold for statistical significance at p < 0.05. Finally, we used multivariate linear regression to predict self-efficacy in clinical practice based on several independent variables.

III. RESULTS

A. Participant Characteristics

In the study, 74.1% of the participants were women. The youngest student was 21 years old, while the oldest was 30, with an average age of 21.69 years (± 1.01 years). The majority of the students (95.1%) identified as belonging to the Kinh ethnic group, which is the predominant ethnic group in Vietnam. Additionally, more than half of the participants (65.9%) did not identify with any specific religious affiliation. Third-year students made up the largest proportion of participants at 53.7%, while fourth-year students accounted for 46.3%. Moreover, the average score of students’ attitudes towards the professional characteristics of anaesthesia nursing students in clinical practice was 27.50 ± 3.80, with a minimum score of 16 and a maximum score of 33.

Table 2. Descriptive Analysis of Critical Thinking Disposition and Self-Efficacy for Clinical Practice of Nursing Students (N = 205)

Regarding critical thinking disposition, the students exhibited relatively strong critical thinking skills, demonstrated by an average score of 3.7 ± 0.47. Among the various categories of critical thinking dispositions, “open-mindedness” received the highest average score of 3.8, with an interquartile range (IQR) of 3.4 to 4.0. In terms of self-efficacy, the total score was 105.4 ± 12.87. The highest score was obtained in the area of “Assessment” (mean = 34.7, IQR = 31-37), while the lowest score was in “Evaluation” (mean = 16.5, IQR = 14-18).

Table 3. The Correlation Between Self-Efficacy for Clinical Practice and Critical Thinking Disposition (N=205)

The results presented in Table 3 show a significant positive correlation between nursing students’ self-efficacy in clinical practice and their disposition toward critical thinking (rs = 0.37, p < 0.0001). There are also notable relationships with factors associated with critical thinking (p < 0.001). The highest score was recorded in the area of “Systematicity” (rs = 0.40, p < 0.001), while the lowest score was noted in “Open-mindedness” (rs = 0.24, p < 0.001). Additionally, the strongest correlation was found between the “Systematicity” aspect of critical thinking disposition and self-efficacy in “Evaluation” (rs = 0.43, p < 0.001). Conversely, the weakest scores were observed for the “Open-mindedness” disposition concerning the “Evaluation” skill (rs = 0.20, p < 0.001), as well as the “Diagnosis and Planning” skill of self-efficacy (rs = 0.20, p < 0.001).

This study employed linear regression analyses to investigate the impact of several factors on students’ self-efficacy in clinical practice. The model satisfied the assumptions of multicollinearity and homoscedasticity, ensuring the reliability of the regression estimates. Table 4 presents the confidence intervals for the predictors of self-efficacy.

Karahan Okuroğlu, G. (2022). Hemşirelik Öğrencilerinin Klinik Performanslarına İlişkin Öz Yeterliklerinin Akademik Öz Yeterlikleri ve Akademik Başarıları ile İlişkisi: Tanımlayıcı Araştırma [The relationship between Nursing students’ self-efficacy regarding clinical performance and their academic self-efficacy and academic success: A descriptive study]. Turkish Clinics Journal of Nursing Sciences / Turkiye Klinikleri Journal of Nursing Sciences, 14(1), 125-31. https://doi.org/10.5336/nurses.2021-83326

Submitted: 26 March 2025
Accepted: 5 November 2025
Published online: 7 April, TAPS 2026, 11(2), 73-80
https://doi.org/10.29060/TAPS.2026-11-2/OA3702

Maheen Zulfiqar, Muhammad Khalil ur Rahman, Behram Khayyam, Naeem Sarwar, Ashbil Malik, Ayesha Mazhar Khan & Hassan Saleem

Department of Surgery, Arif Memorial Teaching Hospital/Rashid Latif Medical College, Lahore, Pakistan

Abstract

Introduction: Absenteeism during clinical rotations among medical students is on the rise, adversely affecting both patient care and the development of essential clinical skills. Factors such as inadequate learning resources, exhaustion, and disengagement contribute to this trend, which must be addressed to safeguard the quality of medical training and future healthcare quality. This study aimed to identify the underlying causes of absenteeism among undergraduate medical students and to propose strategies to improve attendance and learning outcomes.

Methods: A cross-sectional study was conducted on third, fourth, and final-year students of primary medical qualification at Rashid Latif Medical College, Lahore, Punjab, Pakistan, from June 2024 to July 2024. A validated, self-structured questionnaire was distributed during clinical rotations. Data were analysed using SPSS version 25. Frequencies and percentages were calculated to summarise attendance patterns and perceived barriers. Pearson’s correlation was used to examine associations between absenteeism factors—personal health, family obligations, academic workload, perceived relevance of rotations and academic year, with statistical significance set at p ≤ 0.05.

Results: Out of 450 surveys, 270 students responded: 31% third year, 27% fourth year, and 43% final year students. Faculty-related barriers included poor feedback (3.2), ineffective communication (3.2), lack of preparation (3.3), and unprofessional attitude (3.3). Personal obstacles included personal health (3.2), lack of learning resources (3.4), and family obligations (3.3). Additionally, 41% of the students believed that non-exam-specific rotations were irrelevant.

Conclusion: Faculty dissatisfaction, peer pressure and downplaying non-exam specific rotations cause clinical rotation absenteeism. Systemic reforms and enhanced faculty engagement are essential to improve students’ professional development and clinical engagement.

Keywords:           Medical Education, Absenteeism, Faculty, Clinical Rotations

Practice Highlights

• Many students do not find non-exam-specific rotations valuable due to the heavy workload.
• Students often feel demotivated to attend rotations because of uncooperative and unprofessional behaviour from faculty members.
• It is recommended that institutions implement policies to manage student workload, uphold professional conduct, and create a more motivating environment for clinical rotations.

I. INTRODUCTION

Absenteeism refers to the habitual absence from classes/ clinical rotations without a valid or justifiable reason (Qureshi & Ahmad, 2019). Student absenteeism is a common issue observed globally across all academic fields, and medicine is no exception (Gul et al., 2016). However, in the field of medicine, absenteeism has several negative consequences. It impacts students not only academically but also in terms of their professional development (Shenawi et al., 2021). Absenteeism, especially during clinical rotations, hinders both academic learning and patient care as well (Qureshi &
Ahmad, 2019).

Despite strict policies regarding attendance at clinical rotations and lectures, absenteeism remains prevalent among students (Sharmin & Azim, 2017). In Pakistan, there is a growing trend where medical students primarily attend clinical rotations for subjects that carry weight in their current year of study. According to student feedback and informal discussions, many students tend to skip ward rounds, following the example of their seniors, who claim that the material will be thoroughly covered the following year when the subject becomes compulsory. Even those who wish to attend non-compulsory wards often feel pressured by their peers to do otherwise. Additionally, a lack of professionalism among some faculty members and the overall ward environment can diminish students’ morale and motivation (Khan et al., 2019; Mitra et al., 2022).

Despite being a widespread issue, there is no valid justification for the absence of undergraduate medical students from their clinical rotations. To date, no study has been published that thoroughly investigates the key factors contributing to student absenteeism from clinical rotations, particularly at Rashid Latif Medical College and Arif Memorial Teaching Hospital in Lahore. Therefore, this study was undertaken to explore the primary reasons for low attendance among third year, fourth year and final year students of primary medical qualification (PMQ) at Rashid Latif Medical College and to identify initiatives that could improve their participation in clinical rotations.

II. METHODS

This cross-sectional study was conducted from June 2024 to July 2024 on 450 students after taking approval from the Institutional Review Board (RLMC/IRB/2024/153). The aim was to explore the factors influencing attendance in clinical rotations among undergraduate medical students. A self-designed, validated questionnaire was used. The study targeted 3rd, 4th and final year students of primary medical qualification (PMQ) at Rashid Latif Medical College, Lahore, Punjab, Pakistan.

Non-probability purposive sampling was used to recruit students. A total of 450 students were approached during their ward rotations. Out of those, 270 completed the survey, yielding a response rate of 60%. The inclusion criteria were students who were currently enrolled in the clinical years and attending rotations during the study period. Students in pre-clinical years (namely first and second year), those on academic leave or suspension, or those who declined participation were excluded. While purposive sampling allows access to students in relevant clinical settings, it does, however, carry the inherent limitation of selection bias, potentially over-representing students with better attendance or stronger academic engagement.

Data were collected using a self-designed, validated questionnaire. A thorough analysis of the body of research on medical school absenteeism and suggestions from three senior medical education specialists guided the development process. The questionnaire underwent content validation by the expert panel to assess clarity, relevance, and alignment with study objectives. There were both closed-ended and open-ended questions on the finished form.

Closed-ended questions included demographic variables, frequency of clinical attendance, and 5-point Likert scale items evaluating perceived faculty behaviours, personal and academic barriers, and attitudes toward clinical teaching. Preliminary reliability testing using pilot data yielded a Cronbach’s alpha of 0.779, indicating moderate internal consistency. Factor analysis revealed that the questionnaire could be sub-grouped into eight distinct domains, collectively accounting for 97% of the variance in responses.

Participation was entirely voluntary, and informed consent was implied through the completion and return of the questionnaire. Anonymity and confidentiality were ensured to encourage honest and uninfluenced responses. Questionnaires were distributed in printed form during each academic year’s scheduled ward rotations, with responses collected immediately to minimise non-response and preserve the context of clinical learning environments. Data were entered and analysed using IBM SPSS version 25.

Quantitative variables were presented as mean ± standard deviation (SD). For qualitative variables, mean scores were used to assess correlations between causes of absenteeism among third, fourth, and final year MBBS students. Frequencies and percentages were calculated to summarise attendance patterns, causes of absenteeism, and deficiencies in clinical faculty impacting attendance. Pearson’s correlation was employed to assess the relationships between absenteeism factors (such as personal health, family responsibilities, workload, perceived relevance of rotations) and academic year, with significance set at p ≤ 0.05.

III. RESULTS

This study explores the factors influencing attendance in clinical rotations among medical students. The data supporting the finding is available at Figshare (https://doi.org/10.6084/m9.figshare.28602041.v1) (Mazhar Khan, 2025).

Evaluating responses from 450 students we found that 270 students participated in the survey, representing diverse academic years: 31% from the third year, 27%

from the fourth year, and 43% from the fifth year. Notably, gender distribution among respondents included 133 males (49.1%) and 137 females (50.9%).

A. Regularity of Attendance

The attendance at clinical rotations was recorded as follows: 29% of third-year students, 40% of fourth-year students, and 36% of final-year students reported attending all required rotations in their third and fourth academic years (Figure 1).

Figure 1. Regularity of Attendance in Clinical Wards

Among these students, a significant proportion missed their clinical wards sometimes (3–4 times per month; 24%) and often (5–6 times per month; 20%), respectively (Table 1). Further analysis of exam-specific and non-exam-specific rotations showed that only 18.5% of students attended both rotations equally, whereas 40.7% reported attending exam-specific rotations more frequently. The most important reasons for attending exam specific rotation were because it was required for their course completion (63%) and was directly related to their assessments and exam (56%).

Academic Year	All (100%)	Most (75–99%)	Some (50–74%)	Few (25–49%)	None (0–24%)
Third Year	25 (29.4%)	20 (23.5%)	15 (17.6%)	15 (17.6%)	10 (11.8%)
Fourth Year	28 (40.0%)	18 (25.7%)	15 (21.4%)	5 (7.1%)	4 (5.7%)
Final Year	35 (30.4%)	40 (34.8%)	20 (17.4%)	15 (13.0%)	5 (4.3%)
Total	88 (33%)	78 (29%)	50 (19%)	35 (13%)	19 (7%)

Table 1. Regularity of Attendance in Current Clinical Rotations (Third to Final Year)

B. Causes of Absenteeism

Furthermore, students expressed that discouragement from attending clinical rotations stemmed primarily from faculty behaviours. The mean scores for these factors were as follows: unprofessional behaviour (3.3), lack of preparation for teaching sessions (3.2), inadequate feedback on performance (3.2), ineffective communication (3.2), overemphasis on rote learning over critical thinking (3.1), and lack of enthusiasm in teaching (3.1) (Table 2). Specifically, Barriers to attending non-examination-specific rotations were identified, with 41% of students citing a lack of perceived value, 30% referring to heavy workloads as a limiting factor.

Submitted: 10 February 2025
Accepted: 17 October 2025
Published online: 7 April, TAPS 2026, 11(2), 64-72
https://doi.org/10.29060/TAPS.2026-11-2/OA3666

Sameera Anuruddha Gunawardena, Rovindu Sandul Hettige, Yap Hui Nee & Tai Suyee Sophia

School of Medicine, IMU University, Kuala Lumpur, Malaysia

Abstract

Introduction: English is the main medium of medical education in many institutions worldwide. However, several terms in the medical lexicon carry colonial, cultural, or linguistic origins that may be outdated or confusing for students from non-English-speaking backgrounds. This study explores culturally exclusive and outdated metaphorical terms in medicine and debates their continued usage.

Methods: A two-stage protocol was followed. First, textbooks and teaching material from the pre-clinical phase of the medical curriculum at the authors’ institution were screened for metaphorical medical terms with outdated concepts or Anglo-European cultural elements. Next, the definitions and origins of each term were explored using open-source etymological resources and peer-reviewed literature from PubMed and Google Scholar. Terms were then thematically grouped and narratively analysed.

Results: Twenty Anglo-European references were identified and categorised into sub-themes: Western food (e.g., “port-wine stain,” “maple syrup urine disease”), fiction (e.g., “Alice-in-Wonderland syndrome”), religion (e.g., “Hand of Benediction”), and foreign languages (e.g., “café-au-lait spots,” “tache noire”). These may be unrelatable to students from diverse cultural or religious backgrounds. In addition, ten obsolete societal references were noted (e.g., “Washerwoman’s hands,” “rugger jersey spine,” “Indian file pattern”), which are no longer part of common knowledge.

Conclusion: While such terms aided understanding for Anglo-European learners, they may now burden today’s diverse student population. Medical educators should reassess their continued use to ensure clarity and equity in global medical education. This review, based on single institutional findings, provides a foundation for broader, multi-institutional studies to explore the prevalence and impact of these terms across curricula.

Keywords:           Medical Terminology, Equity in Medical Education, Colonialism in Medicine, Obsolete Medical Terms, Global Medical Education

Practice Highlights

• Several medical metaphors are based on culturally exclusive and outdated references.
• Many metaphorical terms require knowledge of Anglo-European history, culture, or religion.
• Some metaphors refer to societal elements or occurrences that are no longer common knowledge.
• Such metaphors would be meaningless to students who do not understand their relevance.
• Learning these outdated terms intended to simplify medicine would now be an additional burden.

I. INTRODUCTION

Medicine is an extremely challenging and complex program of study (Davis & Harden, 2003; Ogden et al, 2023; Woodruff, 2019) and many medical undergraduates face numerous difficulties in mastering the program, especially during the early years of the course (Kirtchuk et al, 2022; Malau-Aduli BS et al, 2020). Amidst the countless hours of study, clinical rotations, and immersive learning experiences, medical students are also expected to acquire a robust vocabulary of medical terms that enables them to comprehend, communicate, and apply complex medical concepts. Language has been identified as one of the main challenges in medical education programs. (Tayem et al, 2020) Since most institutions deliver their medical programs in English, there is a high expectation of English language proficiency among medical entrants (Chan et al, 2022; Hayes & Farnill, 1993; McLean et al, 2013). English has been considered as a barrier for understanding basic medical disciplines among non-native English-speaking students (Bendriss & Bendriss, 2015; Lucas et al., 1997) and interviews with trainers have found that the deficiencies in the figurative and colloquial language affected the performance of international students even at the graduate level (Henderson et al., 2017). Although studies like Jain & Krieger (2010) and Byrne et al. (2019) highlight the linguistic and cultural adaptation struggles among medical students, they do not specifically address the difficulties in comprehending medical language.

Medical lingo is as complex as the science itself and is rife with idiosyncrasies and irregularities that can confound even native English speakers. Modern English has evolved through the influence of Greco-Roman, French, and Germanic languages. (Van der Auwera & Genee, 2002) Many medical terms, therefore, have etymological roots in Latin, Greek or French (Banay, 1948; Faure, 2018). Some terms are often shaped by scientific advancements and technological innovations, and quite a number of them are eponymous references to a person or persons who described a particular phenomenon. (Thomas, 2016; Whitworth, 2007) Similarly, some terms originate from specific cultural and linguistic nuances to English folklore, literature, and society while some others have an archaic origin or are metaphors representing a phenomenon that is non-existent or inapplicable in today’s context. Many clinicians and lecturers continue to use these terms in medical education and in the authors’ experience, students from non-English speaking backgrounds, tend to learn these terms without truly understanding their relevance. Although there have been concerns raised over the authenticity and appropriateness of use of eponyms in medical literature (Strous & Edelman, 2007; Whitworth, 2007; Woywodt & Matteson, 2007), however, there is very little attention given to the propriety of culturally specific and obsolete metaphorical terms in the medical lexicon. This study explores culturally exclusive or outdated metaphorical medical terms and traces their meanings and etymological origins with the aim of stimulating dialogue on whether their continued use in contemporary medical education is justifiable. Except for a few articles (Cohen et al., 2013; Gheewala et al., 2022; Torrey, 2023), no published study has systematically undertaken an exploration of the historical and cultural context of these terms.

II. METHODOLOGY

We followed a two-stage qualitative approach that combined a document analysis with an exploratory targeted search to identify and contextualise terms that were metaphors, figurative labels, or colloquial descriptions of a medical condition. This approach followed previously published strategies for mapping and contextualising terminology from medical documents (Bearman et al., 2021; Bowen, 2009; Dalglish et al., 2020).

A. Stage 1: Document Analysis

During the period from November 2023 to November 2024, all four authors screened the teaching-learning material and textbooks within the pre-clinical medical program at the authors’ university. The pre-clinical curriculum is distributed within 12 modules over four semesters and delivered in the form of synchronous and asynchronous lectures, practical’s, team-based learning, problem-based learning, case-based learning, and self-directed learning. Teaching-learning material for all lessons are uploaded and accessible via the university’s e-learning portal, either in document form, voice-over narrations, microlearning videos, or interactive SCORM packages. We also identified the most frequently borrowed textbook within each of the six main pre-clinical disciplines through the institutional library resource utilisation data. The indices of the textbooks in anatomy (Agur et al., 2019), pathology (Rubin & Reisner, 2019), and pharmacology (Whalen, 2019) were screened by the first and second authors while physiology (Widmaier et al., 2019), biochemistry (Abali et al., 2022), and microbiology (Bauman, 2015) were screened by the other two authors.

The terms were eligible for inclusion if they met at least one of the two following criteria: 1) Anglo-European connotations – terms including Latin and French words and terms requiring knowledge of Western culture, literature or history. 2) Outdated terms – references to phenomena or practices that used to be common knowledge during previous times but are no longer present or rarely encountered in modern-day living. We did not collect data on the frequency of the use of the terms. We also did not screen any formative or summative assessment documents.

B. Stage 2: Contextualisation of Identified Terms

We then conducted an exploratory targeted search of the definitions, etymological origins and medical relevance of each term. We did not intend to conduct an exhaustive review based on any systematic protocol but instead focused on gathering sufficient contextual information using the term itself as a key word, or where necessary, combining them with words such as ‘origin’, ‘history’ or ‘etymology’. Our sources included online open-source etymological databases, such as the online etymology dictionary (https://www.etymonline.com), Oxford reference (https://www.oxfordreference.com), the Oxford concise medical dictionary and peer reviewed publications indexed in PubMed and Google Scholar.

Terms were grouped into subcategories, and each term was then charted according to definition, medical usage, historical or etymological context and justification for inclusion. Any disagreements on the meaning of the terms or the justification for their inclusion in this study were resolved through mutual consensus among the authors.

III. RESULTS AND DISCUSSION

We identified 20 terms as Anglo-European references and 10 terms as obsolete phenomena. A summary of the terms and their medical context is given in Table 1 and is discussed in more detail below.

Submitted: 8 January 2025
Accepted: 25 August 2025
Published online: 7 April, TAPS 2026, 11(2), 54-63
https://doi.org/10.29060/TAPS.20256-11-2/OA3622

Zaw Phyo, Ye Phyo Aung, Tun Tun Naing & Tayzar Hein

Department of Medical Education, Defence Services Medical Academy, Myanmar

Abstract

Introduction: This study evaluates military medicine education at the Defence Services Medical Academy (DSMA) in Myanmar, focusing on curriculum structure, practical training quality, and alignment with evolving military and civilian healthcare needs. Despite a comprehensive approach, identified gaps in practical training (e.g., trauma care, CBRN management) and curriculum continuity hinder student preparedness for modern military medicine.

Methods: This qualitative study used Focused Group Discussions (FGDs) with 24 participants (12 students, 12 faculty) to explore themes like time constraints, practical training, curriculum integration, and modern technology integration. Data were analysed using MAXQDA 24 to identify key themes related to the curriculum’s content and effectiveness.

Results: Findings indicate that while the military medicine module of DSMA covers a broad range of topics, practical training remains inadequate, especially in critical areas such as trauma care, CBRN management, and digital health technologies. Furthermore, curriculum continuity issues, marked by disconnected annual topics, impede clear progression. The study recommends revising the module to include modern warfare medicine, expanding hands-on training, and incorporating mobile learning platforms. It also suggests increasing simulation-based training, restructuring the module to enhance its practical application, and establishing a dedicated military medicine department.

Conclusion: The study identifies critical gaps in DSMA’s curriculum, particularly in practical training (e.g., trauma, CBRN) and coherence. These must be addressed to better prepare students for the challenges of modern military and civilian healthcare. Proposed improvements will ensure DSMA graduates are equipped to handle contemporary healthcare demands, reinforcing the academy’s role as a leader in military medical education.

Keywords:           Military Medicine, Curriculum Development, Practical Training, Outcome-Based Education, Tactical Combat Casualty Care, Qualitative Analysis

Practice Highlights

• Extending the duration of military medicine training will provide more hands-on practice, ensuring students are better equipped to handle high-pressure medical situations.
• Making “THAMAR ZARNI” field exercises mandatory and increasing their frequency will offer students the essential real-world medical experience necessary for operational readiness.
• Updating the curriculum to incorporate modern medical technologies and advanced trauma care will prepare students to effectively address the challenges posed by modern warfare.
• Improving resource allocation, including the integration of mobile learning platforms and high-fidelity simulations, will enhance the overall training experience and increase student engagement.
• Establishing a dedicated military medicine department at DSMA will centralise education, improve curriculum coherence, and provide students with a focused space for more in-depth learning.

I. INTRODUCTION

Military medicine is a vital branch of healthcare that ensures the operational readiness of armed forces personnel in high-stakes environments such as combat zones, disaster areas, and peacekeeping missions (van der Wal et al., 2024). Unlike traditional civilian healthcare, military medicine integrates clinical expertise with operational skills, including trauma care, medical logistics, crisis management, and adaptability under resource-constrained conditions (Woolley et al., 2017). Given the complexity and high-pressure nature of military operations, it is essential that healthcare professionals are trained to handle rapidly evolving situations (McGraw, 2023).

As global security landscapes evolve, with rapid advancements in warfare technologies and the rise of hybrid threats, military medicine has adapted to meet new challenges. Training programs worldwide now integrate contemporary medical practices to address the shifting dynamics of military operations. For example, the Tactical Combat Casualty Care (TCCC) guidelines have significantly reduced battlefield fatalities, demonstrating how modern medical education can improve outcomes (Butler Jr et al., 2007). Additionally, NATO’s initiatives to standardise medical practices across member states have emphasised the importance of interoperability in multinational military operations (Onderková et al., 2024). While studies like Butler Jr et al. (2007) and Kollek et al. (2009) establish best practices in TCCC and CBRN training, few explore their integration into OBE curricula in resource-constrained regions like Southeast Asia, where there are significant gaps in practical training.

Military medicine programs in NATO aligned countries and U.S. based institutions also face similar gaps in training, particularly in areas such as trauma care and the management of chemical, biological, radiological, and nuclear (CBRN) incidents. However, what sets the Defence Services Medical Academy (DSMA) in Myanmar apart is the unique context within Southeast Asia, where resource constraints are more pronounced, necessitating tailored strategies for integrating modern military medical practices. This underscores the challenges DSMA faces compared to other institutions and highlights the need for resource-sensitive solutions in military medical education.

DSMA in Myanmar has played a significant role in shaping military medicine education in Southeast Asia since 1992. The academy’s curriculum combines traditional medical education with specialised military training, equipping graduates with skills in combat casualty care, medical logistics, disease prevention, and trauma management (Naing et al., 2022). Since 2017, DSMA has implemented an Outcome-Based Education (OBE) curriculum, which aligns with global standards set by the World Federation for Medical Education. This approach focuses on measurable outcomes and competency-based learning, marking a shift from traditional teacher-centred methods to student-centred learning. Despite these advances, integrating a comprehensive military medicine module remains a challenge due to the need for specialised skills and faculty development (Garg et al., 2017).

DSMA employs innovative teaching strategies, such as case-based learning (CBL), problem-based learning, and simulation exercises to equip students with high-pressure competencies. However, the academy continues to face significant gaps in practical training, particularly in trauma care, CBRN incident management, and the application of digital health technologies. These gaps indicate a misalignment between the academy’s training programs and the evolving demands of modern military medicine. While CBRN preparedness and digital health solutions are critical for addressing military and civilian crises, these areas remain underdeveloped within military medicine module of DSMA’s curriculum (Kollek et al., 2009).

This study aims to assess how military medicine is integrated into DSMA’s OBE curriculum, focusing on aligning it with essential military medical competencies. By evaluating the effectiveness of current teaching methods and identifying areas for improvement, this research seeks actionable insights to enhance military medicine module of DSMA’s curriculum and offer a model for other countries with similar resource constraints. The ultimate goal is to ensure DSMA graduates are prepared to meet the multifaceted demands of both military and civilian healthcare sectors, particularly in the context of modern warfare and global health challenges. Furthermore, this research will highlight how countries facing resource limitations can adapt military medical education strategies to overcome gaps and improve operational readiness.

II. METHODS

A. Research Design

This study utilised a qualitative research design to examine the military medicine module of DSMA’s curriculum and identify areas for improvement. A qualitative approach was chosen to capture participants’ perspectives, particularly on practical training, integration of modern warfare knowledge, and the curriculum’s effectiveness in preparing students for both military and civilian medical roles. Data were primarily collected through Focused Group Discussions (FGDs) to gain in-depth insights into participants’ experiences and perceptions.

B. Interview Guide Development

The interview guide for military medicine education was developed through a review of literature and consultations with the DSMA curriculum committee. It focused on key aspects such as practical training, curriculum continuity, modern warfare strategies, and simulation effectiveness. The guide began with broad open-ended questions and gradually moved to specific ones. Pilot testing provided feedback that helped refine the guide before the main study.

C. Validity and Reliability

To ensure the validity and reliability of the data collection instruments, the interview guide was reviewed by three expert researchers in the field of military medicine education. These experts provided feedback on the relevance and comprehensiveness of the questions, which enhanced the study’s overall rigor. Additionally, all FGDs and interviews were conducted in a controlled environment to minimise external influences and ensure consistency across data collection sessions.

D. Participant Selection and Data Saturation

Data collection for this study was conducted over a three-month period. A total of 24 participants, comprising 12 students and 12 teachers, were organised into two main groups. These groups were further divided into four FGDs, with six participants in each. Participants were selected using a purposeful sampling method to ensure a representative mix of perspectives from both students and faculty across various academic years.

Each session was led by the principal investigator, who ensured a conducive environment for open dialogue, encouraging active participation and ensuring all voices were heard. Data collection continued until thematic saturation was achieved, meaning no new themes or significant insights emerged from the discussions.

E. Data Analysis

The data were transcribed and analysed using MAXQDA 24. A codebook was created to guide the analysis, and themes were identified both deductively (based on research objectives) and inductively (emerging from the data). To ensure consistency, intercoder agreement was checked by comparing codes with a second researcher. While MAXQDA was used for systematic analysis, manual coding could have been sufficient given the small dataset.

F. Informed Consent

Prior to participation, informed verbal consent was obtained from all respondents, ensuring that they understood their autonomy in deciding whether to participate in the study. Participants were also made aware that they could withdraw from the study at any time without consequence.

G. Ethical Considerations

Ethics approval was obtained from DSMA ethical Committee, and participant confidentiality and anonymity were ensured by assigning unique identifiers and securely storing personal data, accessible only to the research team. The Principal Investigator (PI), a lecturer at the Defence Services Medical Academy, conducted the FGDs. To mitigate the potential power imbalance and encourage open dialogue, several measures were implemented.

Participants were assured of complete anonymity and confidentiality, and informed consent was obtained with the explicit understanding that they could withdraw at any time without consequence. The PI began each session by emphasising that the research’s sole purpose was to improve the curriculum, fostering a non-judgmental environment where all feedback was valued, regardless of its critical nature. These steps were crucial to ensure participants felt safe to speak their minds freely.

III. RESULTS

This qualitative study explores the military medicine module at DSMA, focusing on the perspectives of both students and faculty. By examining their experiences, perceptions, and suggestions, the study identifies critical gaps and areas for improvement in the integration of military and civilian medical education. The findings reveal that the current military medicine module struggles to meet the practical and theoretical needs of students preparing for both military and civilian medical roles.

The results are categorised into two primary areas of focus:

• Table 1: Challenges and Relevance of Military Medicine Education – Summarises concerns regarding insufficient training time, lack of curriculum cohesion, and the relevance of military medicine education.
• Table 2: Curriculum Structure, Practical Training, and Improvement Strategies – Proposes strategies for improving curriculum integration, expanding practical training, and enhancing resource availability.

These findings underscore the urgent need for strategic reforms to improve DSMA’s curriculum, better preparing students for the multifaceted challenges of both military and civilian healthcare.

A. Challenges and Relevance of Military Medicine Education

The following table presents the challenges and relevance of military medicine education, as viewed by both students and teachers. It outlines key concerns regarding time constraints, curriculum integration, and the importance of military medicine across different sectors, particularly in response to real-world scenarios such as national disasters.

	Theme	Sub-Theme	Student Perspectives	Teacher Perspectives
1.	Challenges in Military Medicine	Time Constraints and Practical Exposure	“We only spend one to two weeks per year learning about military medicine, insufficient for crisis management.” (Student 5)   “Field training, like ‘THAMAR ZARNI,’ should be extended to a minimum of two weeks during the internship.” (Student 12)	“The military medicine module lasts around 150 hours from Year 1 to internship, with a need for more time during internships to develop essential skills for future military doctor duties.” (Teacher 10)
		Curriculum Integration	“Annual topics aren’t connected, making it feel like starting from scratch.” (Student 1)	“Curriculum needs real time, relevant topics with more hands-on training.” (Teacher 4)
2.	Relevance of Military Medicine	Importance Across Sectors	“Military medicine is important not just for military doctors, but also for civilian doctors, especially given the current situation in our country, Myanmar.” (Student 3)	“Essential knowledge for all medical students, regardless of future sectors.” (Teacher 3)   “Given the current situation in our country, military medicine is crucial for supporting both military personnel and civilians during times of crisis.” (Teacher 8)
		Real World Application	“Crucial for work in the military and responding to national disasters.” (Student 2)   “Military medicine is essential for both military operations and providing critical healthcare during national disasters, ensuring support for civilians in times of crisis.” (Student 11)	“In recent years, our country has faced numerous crises, including the COVID-19 pandemic, natural disasters, and ongoing conflicts. Military doctors have played a crucial role in responding to these challenges, providing essential healthcare not only to military personnel but also to civilians in need.” (Teacher 9)

Table 1. Challenges and Relevance of Military Medicine Education

The study found that the limited time for military medicine training at DSMA—only two to three weeks each year—impedes students’ crisis management development. The academic year structure, with time allocated to commemoration parade training and national holidays, further reduces training opportunities. The study recommends restructuring the military medicine module of the curriculum to allocate more time for military medicine.

The study also highlighted a need for more practical training. Despite the introduction of OBE, faculty resistance limits its impact. Increasing field exercises and internships, such as “THAMAR ZARNI”, would better prepare students for real-world military medical challenges.

B. Curriculum Structure, Practical Training, and Improvement Strategies

This table highlights student and teacher views on military medicine education, emphasising the need for a more focused curriculum, modern warfare updates, and increased practical training. Both groups called for better resource allocation, use of technology, and consistent assessments, with students suggesting mobile platforms and teachers recommending a dedicated department.

No.	Theme	Sub-Theme	Student Perspectives	Teacher Perspectives
1.	Curriculum Structure and Integration	Overlap and Redundancy	“I suggest reviewing and reorganising these areas to eliminate overlap, making the curriculum more focused and efficient for better learning outcomes” (Student 6)	“Beneficial to remove overlapping topics to focus on practical aspects.” (Teacher 2)
		Modern Warfare Updates	“As a medical student, I suggest incorporating updates on modern warfare into the curriculum, focusing on new medical technologies, advanced trauma care, and the evolving challenges of treating injuries in current conflicts.” (Student 8)	“Need updates to include relevant modern warfare information.” (Teacher 5)   “It is important to update our curriculum to reflect on the current national and global situations.” (Teacher 7)
2.	Practical Training and Hands-On Learning	Increased Field Exercises	“Annual field training like ‘THAMAR ZARNI’ should be mandatory.” (Student 4)	“Strong need for more practical learning opportunities.” (Teacher 6)
		Hands-on Experience during Internship	“Opportunities like ‘THAMAR ZARNI’ are crucial for practicing essential skills.” (Student 2)	“Hands-on experience is vital for building competence for real world situations.” (Teacher 4)
3.	Improvement and Evaluation	Use of Technology in Learning	” If there are no limitations on using mobile devices, we can learn more effectively, not just in military medicine but across all modules” (Student 10)	“While the Learning Management System (LMS) is currently running, it is not fully activated.” (Teacher 6)
		Need for Resources	“There is a significant limitation of resources for military medicine training.” (Student 4)	“Limited resources means students can only see, not use, items like first aid kits and other essential tools during internships.” (Teacher 5)
		Curriculum Assessments	“It’s important to assess these topics across all years, not just in Year 4, to ensure consistent learning and engagement throughout the program.” (Student 5)	“We conduct formative assessments in Years 1, 2, 3, 5, and during internships, with a summative assessment in Year 4.” (Teacher 1)
		Establish a Dedicated Department	“If a military medicine department is established, we would have a dedicated space to learn more and ask questions about any unclear concepts, ensuring a deeper understanding of the field.” (Student 12)	“No dedicated department at our university; coordinators come from other departments specialising in relevant fields.” (Teacher 4) “The plan to establish a military medicine department is still ongoing, but once it’s in place, it will provide students with a dedicated space to deepen their knowledge and address any uncertainties in the field.” (Teacher 8)

Table 2. Curriculum Structure, Practical Training, and Improvement Strategies

This table highlighted key insights from both students and teachers regarding the DSMA military medical curriculum. Both groups agreed on the need to eliminate military medicine module of the DSMA’s curriculum overlap and incorporate updates on modern warfare, such as new medical technologies and advanced trauma care to keep pace with global needs.

Regarding practical training, both students and teachers emphasised the importance of increasing field exercises, particularly “THAMAR ZARNI”, and providing more hands-on experience during internships to improve real-world competence. Both groups also noted resource limitations, including a lack of access to essential tools like first aid kits. Lastly, the creation of a dedicated military medicine department was supported to facilitate deeper learning and address any gaps in knowledge.

IV. DISCUSSION

The research analyses DSMA’s military medical curriculum, focusing on its strengths and areas for improvement. This study emphasises the importance of specialised training, the quality of practical training, curriculum continuity, the relevance of military medical education to civilian healthcare, and the need for updates reflecting modern technologies. The study concludes with evidence-based recommendations to improve DSMA’s military medical education and better prepare students for real-world healthcare challenges.

A. Time Constraints in Military Medicine Education

A significant limitation identified in the study is the insufficient time allocated to military medicine within the DSMA curriculum. The time spent on military medicine—no more than two or three weeks per academic year—is inadequate for developing the necessary skills for effective crisis management. Furthermore, the academic structure of DSMA consists of a ten-month academic year, in addition to approximately 30 national holidays within that year. Each year, students undergo one month of commemoration parade training, followed by an additional month off. This schedule is consistently followed each calendar year as part of the academic calendar. These time constraints exacerbate the gap in students’ preparedness for real-world military medical challenges. This aligns with findings from Ellington and Farrukh (2020), who argue that time constraints are a major obstacle in military medicine education. To address this, this study suggests a restructuring of the curriculum to emphasise military medicine. Extending the duration of military medicine training would provide students with the necessary time to gain hands-on experience and develop critical competencies for high-pressure situations, ultimately enhancing their operational readiness and ability to respond effectively to emergencies (Watson et al., 2025).

B. Enhancement of Practical Training

The study finds consensus among both students and faculty on the need to enhance the practical training components of the DSMA curriculum. While the OBE curriculum introduced in 2017 aims to foster better learning outcomes, faculty resistance remains due to their familiarity with previous teaching methods. Increasing hands-on experiences, such as field exercises and internships, is crucial for developing the competencies required for real-world medical challenges. This finding is consistent with Vogel and Harendza (2016), who emphasise that practical training directly impacts clinical competence, especially in military environments.

The study also highlights the importance of mandatory field exercises like “THAMAR ZARNI”, which are essential for preparing students for emergency situations. Increasing the frequency and intensity of such training will significantly enhance the competence and confidence of DSMA graduates, aligning with Dieck-Assad et al. (2021)’s recommendation for more frequent high-stakes training to improve real-world emergency response skills.

C. Curriculum Disjointedness and Continuity

The study reveals a critical issue in the lack of continuity and integration within the military medicine of DSMA’s curriculum. The curriculum does not progressively build upon itself from year to year, leading to fragmentation in the educational experience. This finding mirrors the research by Brauer and Ferguson (2015), who argue that fragmented curricula hinder the development of cohesive medical knowledge.

The study contributes to the growing body of literature by identifying this issue as not unique to DSMA but prevalent in military medical education programs worldwide. Vertical integration of the curriculum is proposed as a solution to this problem. By ensuring that content from earlier years builds upon that of subsequent years, students will be able to better understand military medicine as a cohesive discipline and apply their theoretical knowledge in practice. A unified curriculum will improve both learning outcomes and operational readiness, enabling students to apply what they have learned in real-world scenarios (O’Connell et al., 2021).

While both students and faculty acknowledged the disjointedness, their perspectives on its impact differed. Students, such as Student 1, described it as “starting from scratch” annually, highlighting the learning burden and lack of a foundational understanding. In contrast, faculty members, like Teacher 4, focused more on the need for “real-time, relevant topics,” which suggests a priority on content relevance over the structural flow of the curriculum. This nuanced finding is a significant contribution to the literature, showing that even with a shared concern, the specific priorities of stakeholders can vary significantly. This requires a dual approach that not only updates the content but also ensures its logical progression throughout the academic years. The current structure, which dedicates a few weeks each year to isolated topics, prevents students from developing a deep and cumulative understanding of military medicine as a cohesive discipline.

Vertical integration of the curriculum is proposed as a solution to this problem. By ensuring that content from earlier years builds upon that of subsequent years, students will be able to better understand military medicine as a cohesive discipline and apply their theoretical knowledge in practice.

A unified curriculum will improve both learning outcomes and operational readiness, enabling students to apply what they have learned in real-world scenarios (O’Connell et al., 2021).

Furthermore, the study highlighted a subtle but important divergence in views on resource limitations. Both groups agreed on the lack of resources, but their specific concerns differed. Students focused on the lack of hands-on access to essential tools like first aid kits, which directly impacts their ability to practice skills. In contrast, teachers’ concerns centred more on the overall resource allocation, including the need for a dedicated department and functional digital platforms, which they see as necessary for institutional-level improvement. This highlights the need for a two-pronged strategy: addressing the immediate, practical needs of students while simultaneously working towards the long-term, structural improvements advocated by the faculty.

D. Relevance to Civilian Roles

Another key finding of the study is the relevance of military medicine training to civilian healthcare. Both students and faculty agree that skills acquired in military medicine, such as triage, emergency response, and disaster management, are increasingly relevant in civilian healthcare systems. The integration of military medical knowledge into civilian contexts is beneficial not only for DSMA graduates but also as a model for global healthcare systems, where military and civilian medical teams often collaborate during disasters and public health crises.

The study suggests that DSMA should incorporate more dual-use military medical knowledge, such as trauma treatment and public health strategies, into its curriculum. These additions would better prepare students for both military and civilian healthcare roles, improving the overall military medicine module of DSMA’s curriculum and ensuring that DSMA graduates can transition seamlessly between the two sectors (Cole et al., 2024; Michaud et al., 2019).

E. Curricular Updates for Modern Warfare

The study also identifies the need for curricular updates to include modern military and medical technologies. DSMA’s current module of the curriculum fails to adequately cover emerging topics such as drones, cyber warfare, and modern medical technologies used in combat situations. As Lewis et al. (2024) note, outdated curricula do not prepare students for the evolving complexities of modern medical practice in conflict zones.

To address this, the study recommends that DSMA regularly update its curriculum to include the latest advancements in battlefield medicine. For example, training on medical drone operations could enhance the ability of military medical teams to deliver supplies to remote areas under combat conditions. Furthermore, training in cyber warfare would ensure that students understand how to protect military medical infrastructure from digital threats. Incorporating such cutting-edge technologies would ensure that DSMA graduates are prepared to handle the future challenges of military medicine (Fuentes, 2021).

F. Practical Training and Hands-On Learning

As noted earlier, field exercises and internships are essential for bridging the gap between theoretical knowledge and real-world application. However, the limited frequency and scope of these opportunities hinder effective training. While the “THAMAR ZARNI” exercise is a valuable learning tool, its infrequency limits students’ exposure to real-world complexities (McGraw, 2023).

To improve this, the study suggests expanding opportunities for hands-on learning through more frequent and diverse field exercises. Kolb’s Experiential Learning Theory suggests that learners best acquire skills through reflection on experience. The lack of hands-on training at DSMA limits opportunities for reflective learning, which may hinder students’ development in real-world medical scenarios (Kolb et al., 2014). Additionally, the integration of virtual simulations and augmented reality (AR) platforms could create simulated combat medical environments, allowing students to practice trauma care and disaster response in a controlled, virtual setting, thus overcoming logistical constraints of traditional field exercises.

G. Improvement and Evaluation

The study highlights the underuse of the Learning Management System (LMS) at DSMA, which remains a missed opportunity for self-directed learning. Mobile platforms and real-time feedback through LMS could significantly enhance the training experience, creating a more dynamic and responsive learning environment. This challenge is mirrored in other military medical institutions worldwide, where underutilisation of technology limits students’ ability to engage with learning materials outside of the classroom.

The study also suggests that increasing the frequency of formative assessments could help reinforce key concepts and improve knowledge retention over time. By providing more consistent feedback, DSMA could better prepare students for military medical practice. Furthermore, the lack of a dedicated department for military medicine education results in a fragmented approach to military medicine module delivery. A specialised department would ensure better curriculum coherence and oversight, ultimately improving the quality of military medical education.

V. CONCLUSION

This research identifies key areas for improvement in the DSMA military medical curriculum, focusing on time management, practical training, curriculum integration, and content modernisation. Findings show that limited training time, insufficient practical opportunities, and a lack of curriculum continuity hinder students’ preparedness for real-world military medical challenges. Recommendations include extending training durations, increasing hands-on experiences like field exercises, and reorganising the military medicine module for better integration.

The study also stresses the need for military medicine module updates to include emerging medical technologies and dual-use knowledge relevant to both military and civilian healthcare. Enhancing technology use and improving assessment structures are also proposed to create a more dynamic learning environment. Implementing these changes will better prepare students to meet the evolving demands of military and civilian healthcare.

These recommendations have global relevance, offering valuable insights for institutions in resource-constrained regions to bridge the gap between military medicine and civilian healthcare. By adopting new technologies and integrating dual-use knowledge, military medical education can better equip students for modern warfare and global health challenges.

A clear action plan for restructuring the module of the DSMA’s curriculum includes extending practical training time, integrating simulation-based learning, and establishing a dedicated military medicine department. However, barriers such as budget constraints and faculty resistance to new teaching methods must be addressed for successful implementation.

To address the identified gaps, a phased implementation strategy is recommended, acknowledging the budget constraints and potential faculty resistance.

Phase 1 (Immediate & Low-Cost): Focus on quick, resource-efficient changes. This includes making “THAMAR ZARNI” field exercises mandatory and increasing their frequency to provide more hands-on practice, as noted by both students and teachers. Additionally, the underutilised Learning Management System (LMS) can be fully activated to support mobile learning and self-directed study, a cost-effective solution to improve access to materials. These measures can be implemented quickly with minimal budget impact and will show immediate benefits.
Phase 2 (Mid-Term & Moderate-Cost): This phase involves curriculum restructuring and targeted faculty development. The curriculum should be reorganised to eliminate overlapping topics and vertically integrate content from year to year, a key recommendation from both students and faculty to improve learning continuity. Investment in faculty training is also crucial to ensure they adopt the Outcome-Based Education (OBE) model effectively and embrace modern teaching methods like simulation. This phase requires a moderate investment but will build the necessary institutional capacity for long-term change.

Phase 3 (Long-Term & High-Cost): The final and most impactful change is the establishment of a dedicated military medicine department at DSMA. While this requires significant budget allocation, it is essential for centralising education, ensuring curriculum coherence, and providing a focused space for in-depth learning and expertise development. This step should be pursued after the foundational improvements from the first two phases are successfully implemented, demonstrating the academy’s commitment to prioritising military medical education and justifying the necessary financial investment.

By adopting this strategic, phased approach, DSMA can systematically address its curriculum’s shortcomings while managing resource constraints and garnering buy-in from all stakeholders. This plan offers a clear path forward, ensuring that DSMA graduates are not only prepared for the challenges of modern warfare but also equipped to serve as leaders in both military and civilian healthcare contexts.

Notes on Contributors

Dr Zaw Phyo is the Principal Investigator. As a lecturer at Myanmar’s Defence Services Medical Academy, he played a significant role in the development of the manuscript. His contributions included a thorough review of the existing literature, identification of research gaps, and clarification of the study’s objectives and questions. Additionally, he was involved in drafting and revising the manuscript, ensuring that the content was both relevant and of significant value to the field of medical education.

Dr Ye Phyo Aung, serving as a mentor, played a crucial role during the methodology phase of the study. He endorsed the chosen research design, sampling strategies, and data collection techniques, providing valuable insights that greatly enhanced the research execution.

Dr Tayzar Hein contributed by assisting in the meticulous proofreading of the article, ensuring that it met clarity, coherence, and strict academic standards.

Dr Tun Tun Naing was instrumental in analysing the collected data. He applied statistical techniques to ensure the research findings were robust and reliable, further enriching the manuscript’s quality and academic integrity.

Ethical Approval

The Ethical Review Committee of the Defence Services Medical Academy, Yangon, Myanmar, granted ethical approval (2/Ethics/2024).

Data Availability

The data that support the findings of this study are openly available in Figshare repository, https://doi.org/10.6084/m9.figshare.28245230.v1.

Acknowledgement

The author would like to thank his supervisor, the head of the medical education department (DSMA), and his colleagues. Without their help, the author would not have been able to conduct the research. The author is grateful to all the curriculum committee members and students from DSMA, Myanmar, who helped to complete the survey and provide valuable opinions and experiences.

Funding

No financing is associated with this publication; it is produced for personal and professional advancement.

Declaration of Interest

There is no conflict of interest in the current research.

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*Dr Zaw Phyo
Department of Medical Education,
Defence Services Medical Academy (DSMA),
Yangon, Myanmar
No. 94, Pyay Road, Mingaladon Township,
Yangon, Myanmar Postal code – 1102
+95 92032754
Email: dr.zawphyoo@gmail.com

Submitted: 16 March 2025
Accepted: 11 September 2025
Published online: 7 April, TAPS 2026, 11(2), 49-53
https://doi.org/10.29060/TAPS.2026-11-2/OA3593

Clarisse Chu¹, Rehena Sultana², Neville Wei Yang Teo¹ & Abhilash Balakrishnan¹

¹Department of Otorhinolaryngology – Head and Neck Surgery, Singapore General Hospital, Singapore; ²Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore

Abstract

Introduction: The ACGME-I Singapore Otorhinolaryngology residency programme started in 2011. Our first Exit MCQ Examinations were held at the start of the fifth year of residency, in 2015. Its questions are developed by the American Boards and modified by Singapore’s regulatory bodies to ensure relevance to local clinical practice. In contrast, Otorhinolaryngology residents in both Singapore and the USA take the same Otorhinolaryngology Training Examination (OTE) annually. Otorhinolaryngology residents in Singapore sit for the OTE in their first to fourth years of the five-year residency programme.

Multiple specialities have described a positive association between in-training examination and final board MCQ examination pass rates. Our study aims to demonstrate that that OTE scores may serve as predictors of performance in our local Exit MCQ Examination.

Methods: A retrospective review was performed of all 24 Otorhinolaryngology residents who entered and took the Exit MCQ Examination at a single institution’s residency programme between 2016 to 2023.

Results: 75% (18/24) passed the Exit MCQ Examination in their first sitting. Univariate logistic regression analyses showed lower OTE stanines in the fourth year of residency was significantly associated with failing the Exit MCQ Examination. Youden’s index showed attaining an OTE stanine <4 in the fourth year of residency training was most associated with failing the Exit MCQ Examination.

Conclusion: OTE scores may be a better predictor of Exit MCQ performance in the fourth year of residency. Optimal OTE score targets for each year of residency were established.

Keywords:           Health Profession Education, Board Examinations, Assessments, Otorhinolaryngology, Residency, ACGME

Practice Highlights

• The OTE serves as an important goalpost for resident learning as they work towards specialist accreditation.
• Our findings will facilitate the identification of residents at risk of performing poorly in the final Exit MCQ Examination, such that remediation measures can be instituted early.

I. INTRODUCTION

Medical education is important for doctors in training throughout their years in residency and beyond. A key tenet of medical education is the use of regular examinations and assessments. They serve multiple functions such as evaluating the retention of medical knowledge, the clinical competencies, and tracking of residents’ progress. Multiple specialities such as Anaesthesia, General Surgery, and Internal Medicine have established a positive correlation between in-training examination performance and pass rates amongst their residents in the final board examinations (McDonald et al., 2020; Patzkowski et al., 2023; Stain et al., 2021).

The Accreditation Council for Graduate Medical Education – International (ACGME-I) Singapore Otorhinolaryngology residency programme was started in 2011 to provide a comprehensive and holistic training programme for prospective Otorhinolaryngologists in Singapore. Our first Exit Multiple-Choice-Question (MCQ) examinations were held at the start of the fifth year of residency, in 2015 (Ministry of Health Singapore, 2023).

There are two summative assessments in Singapore’s five-year Otorhinolaryngology residency programme, namely the Master of Medicine (Otorhinolaryngology) (MMed(ORL)) Examination and the Exit Examinations (Figure 1). Residents usually take the MMed(ORL) Examination in their second year. This is set by the Division of Graduate Medical Studies (DGMS), part of the National University of Singapore. It currently comprises an Objective Structured Clinical Examination (OSCE) and Oral Examination (Division of Graduate Medical Studies, Yong Loo Lin School of Medicine, 2024). Residents have to pass the MMed(ORL) Examination by the fourth year of residency in order to sit for the Exit Examinations.

Figure 1. Background of Assessments in Singapore’s Otorhinolaryngology Residency Programme (ABOHNS: American Board of Otorhinolaryngology – Head and Neck Surgery; ACGME: Accreditation Council for Graduate Medical Education; DGMS: Division of Graduate Medical Studies; NUS: National University of Singapore; ABMS: American Board of Medical Specialities; MOH: Ministry of Health)

The Exit MCQ Examination is the first of the two-part Exit Examination comprising both the MCQ and Oral Examinations. Residents take the Exit MCQ Examination at the start of the fifth year of residency. Candidates are required to pass the MCQ in order to be eligible for the Oral Examination at the end of the same year of residency. It is colloquially known as the Exit Examination because it is a regulatory requirement before a resident can complete (and therefore “exit”) specialist training and subsequently obtain specialist accreditation in Singapore. The Exit MCQ Examination is developed by the American Board of Otorhinolaryngology – Head and Neck Surgery (ABOHNS), ACGME-I and Ministry of Health (MOH) Singapore. Its questions are based on the established blueprint used by the three regulatory bodies, and modified to ensure relevance to local clinical practice (ACGME International, 2024).

On the other hand, Otorhinolaryngology residents in the United States of America (USA) take the Board Examinations developed by ABOHNS following completion of specialty training in an ACGME accredited residency programme (Cantrell & Goldstein, 1999; Miller, 2007).

The Otorhinolaryngology Training Examination (OTE) is an MCQ assessment developed by the ABOHNS. It is a formative assessment, and is conducted on an annual basis, to assess Otorhinolaryngology residents’ clinical knowledge. Unlike the Exit MCQ Examination, residents in both Singapore and the USA take the same OTE with the same set of questions. Otorhinolaryngology residents in Singapore sit for the OTE in their first to fourth years, while those in the USA sit for the OTE in their second to fifth years of the five-year residency programme (Puscas, 2019).

Our study aims to demonstrate a similar relationship amongst Otorhinolaryngology residents in Singapore’s largest healthcare cluster, that OTE scores can be used to predict performance in our local Exit MCQ Examination. This enables medical educators to identify residents who are at risk of failing the Exit MCQ Examination and institute remediation programmes early.

II. METHODS

A retrospective review was performed of the examination results of all 24 Otorhinolaryngology residents from our healthcare cluster who entered and took the Exit MCQ Examination between 2016 and 2023. Approval from the SingHealth Institutional Review Board (IRB) was obtained for a waiver of informed consent (IRB reference number 2024-3953). All data was de-identified to ensure anonymity.

Each individual resident’s performance in the OTEs from year one to four of residency and the subsequent Exit MCQ Examination was included in the analysis. The profile and educational background of the individual residents were also obtained. These include their age, gender, primary medical education and the numbers of years spent as a practising medical doctor.

The OTE performance across the first to fourth years of residency is reported in terms of stanines, where raw test scores are converted to a 9-point standard scale across a bell curved distribution of all residents across the same residency training year. An OTE stanine of 9 is the highest, while a stanine of 1 was the lowest – i.e., best and poorest performance respectively. The results of the Exit MCQ Examination are binary, either pass or fail.

Frequencies (proportions) were used to summarise variables. The effects of various factors on Exit MCQ Examination performance was evaluated using logistic regression analyses and association from logistic regression analyses were expressed as odds ratio with 95% confidence interval (CI). Receiver operating characteristic (ROC) curves were also calculated to predict the OTE stanines most associated with a pass result in the Exit MCQ Examination. SPSS for Windows version 25 was used in the analyses.

III. RESULTS

Between 2016 to 2023, 24 Otorhinolaryngology residents in our healthcare cluster entered and took the Exit MCQ Examination. 45.8% (11/24) were male and 54.2% (13/24) were female. 95.8% (23/24) underwent their undergraduate medical training in Singapore, while 4.2% (1/24) studied overseas. The mean post-graduate year at exits was 8.7 ± 2.3 years. 75% (18/24) passed the Exit MCQ Examination in their first sitting (Table 1).

*A/Prof Abhilash Balakrishnan
31 Third Hospital Ave
Singapore General Hospital
Singapore 168753
Email: balakrishnan@singhealth.com.sg

Submitted: 16 July 2024
Accepted: 27 August 2025
Published online: 7 April, TAPS 2026, 11(2), 40-48
https://doi.org/10.29060/TAPS.2026-11-2/OA3458

Siti Suhailah Zahari¹, Roshan Peiris^1,3,4, Ruhaya Hasan², Nik Aloesnisa Nik Mohd Alwi¹ & Nurhafizah Ghani¹

¹Medical & Basic Dental Sciences Unit, School of Dental Sciences, Universiti Sains Malaysia, Malaysia; ²Dental Public Health Unit, School of Dental Sciences, Universiti Sains Malaysia, Malaysia; ³Department of Basic Sciences, Faculty of Dental Sciences, University of Peradeniya, Sri Lanka; ⁴College of Health Sciences, VinUniversity, Vietnam

Abstract

Introduction: The growing use of social media among students offers educators in dental education enhanced opportunities for student-teacher interaction and improved access to learning materials. This study aims to examine the patterns of social media usage for learning purposes among undergraduate dental students at Universiti Sains Malaysia.

Methods: A cross-sectional questionnaire-based study was conducted involving 222 undergraduate dental students from all academic years, excluding those without social media accounts or who declined participation. A validated questionnaire was distributed online via Google Forms and WhatsApp, collecting data on socio-demographics, smartphone ownership and internet access, preferred social media platforms, and the use of social media for academic purposes.

Results: All 222 respondents completed the survey. The majority (65.8%) were iPhone users, and 95.0% reported access to internet data via Wi-Fi or 4G networks. Almost all participants used social media to connect with friends (99.1%), while 10.4% used it for business. Instagram (99.1%), WhatsApp (97.7%), and YouTube (91.9%) were the most commonly used platforms, with WhatsApp being the most frequently used (86.0%). Gender showed a significant association with academic use, particularly for inquiries and consultations, with female students engaging more than males. No significant differences were found across academic years. Google (91.0%) and YouTube (84.2%) were the preferred platforms for academic content.

Conclusion: Social media presents valuable opportunities to support dental education by enhancing learning engagement and communication. However, as the study focuses on a single institution, broader research involving multiple dental schools is recommended to achieve more generalisable findings.

Keywords:           Dental Education, Dental Undergraduate, Learning, Malaysia, Social Media

Practice Highlights

• Widespread social media usage indicates the extensive integration of social media into their daily lives.
• Gender was significantly associated with the use of social media for academic purposes.
• Google and YouTube platforms are key resources for dental education.

I. INTRODUCTION

The world is in a state of perpetual evolution, particularly in relation to the internet and its various impacts, both positive and negative (Al-Dayyeni, 2021). Acquiring information has never been easier, with social media playing a crucial role in communication and information retrieval (Uma et al., 2021). According to Uma et al. (2021), professional and personal lives have become intertwined as a result of numerous interactions they have with each other on various issues. They elaborated those social media platforms facilitate users in generating and distributing information or engaging in social networking. This includes social networking platforms such as Facebook, YouTube and Instagram (Uma et al., 2021). According to Giroux and Moreau (2022), social media platforms serve both formal and informal learning purposes in health professions education (HPE). Formal learning pertains to structured educational activities like classes or assignments, while informal learning involves knowledge gained from other extracurricular activities.

Social media has become widespread in society and significantly impacts personal and professional aspects, including dentistry (Uma et al., 2021). Social media has been crucial for communication and education throughout the COVID-19 pandemic (Giroux & Moreau, 2022). Amid the pandemic, medical and dentistry education relied on digital tools and social media platforms for information retrieval, sharing learning resources, and conducting virtual meetings. Students and lecturers frequently used these technologies for academic and non-academic activities (Uma et al., 2021).

Currently, more dentists are using social media to share and acquire knowledge, advertise their professional practice, and offer online consultations (Ghandhi et al., 2022). Affendi et al. (2020) investigated the utilisation of social media for advertising by dentists in Malaysia and found that most respondents believe that social media marketing could gain popularity in the field of dentistry, despite its current primary use for personal reasons (Affendi et al., 2020). Meanwhile, Rani et al. (2020) detailed how Malaysian dental undergraduates are educated to utilise social media to advocate for oral health in the community. Social media also plays roles in dental education outcomes. Platforms such as YouTube and Instagram are increasingly used by dental students to access clinical demonstrations, case discussions, and peer-shared learning resources, which can enhance clinical reasoning and practical understanding (Acosta et al., 2025; Khanagar et al., 2022). This growing use of social media shows its expanding role in dentistry, not only for professional promotion and health education, but also as a helpful tool for dental students to support their own learning.

Undergraduate dental students in Malaysia, typically aged 20–27, belong to Generation Z (born 1997–2012), the largest generational group in the country, comprising 27% of the population (DOSM, 2024). Gen Z is known for being digitally connected, well-educated, entrepreneurial, and empowered (Tjiptono et al., 2020). They rely heavily on technology, using the internet and smartphones for communication, news, education, and social interactions (Slepian et al., 2024). Education integrated with social media enhances learning for Gen Z, promoting engagement, collaboration, and the development of critical skills for the digital era. This tech-savvy nature shapes their learning preferences and readiness for modern professional challenges.

Incorporating social media into education has been shown to enhance learning and promote positive behavioral changes in health profession students (Hamid & Jaafar, 2021). Undergraduate dental students reported enjoying online learning more than conventional lectures (Jayasinghe et al., 2021). However, excessive social media use may cause distractions and unethical online behavior (Nieminen et al., 2022). Students with poor social skills and internet usage exceeding 40 hours weekly are at greater risk of internet addiction (Radeef & Faisal, 2019). Thus, while social media offers educational benefits, its overuse poses potential challenges to student well-being and professionalism.

Numerous social media platforms have proven to be effective for educational reasons (Spallek et al., 2015). With reference to the COVID-19 epidemic, technological advancements have radically revolutionised teaching and learning activities. Previous studies had identified social media has been seen as a mean for connection and a substitute for information distribution (Hamid & Jaafar, 2021; Jayasinghe et al., 2021; Nieminen et al., 2022). In Malaysia’s educational context, there has been a strong national push toward digital learning and technology integration across universities, including in dental education (Kathirveloo, 2024). Given these global trends, understanding social media’s role in Malaysian dental education is critical.

Despite these developments, the use of social media for academic purposes among dental undergraduates in Malaysia has not been firmly established.

Therefore, this study intends to investigate the utilisation of social media platforms for educational purposes in Malaysia. The current study aims to establish the prevalence and characteristics of social media usage for educational purposes among dental undergraduates and to identify the association between the type of social media platforms and its educational purposes. Furthermore, this study could offer essential foundational data for further studies on the advantages of integrating social media into education and this data will help educators to determine which platform and engagement strategies will be most effective with the current generation of learners.

II. METHODS

A. Study Design

A questionnaire-based online cross-sectional survey was conducted from April to October 2023 with participation of all dental undergraduates from Year 1 – Year 5 academic session 2022/2023 in Universiti Sains Malaysia (USM). The validated google form questionnaire used was adapted from a previous similar study (Alshuaibi et al., 2015). The questionnaire developed by Alshuaibi et al. (2015) was designed for a similar sample group which are undergraduate students in Malaysia. This justifies its suitability for the current study. This study was approved by the Human Research Ethics Committee USM (HREC) (Ref. No.: USM/JEPeM/KK/23040324). Data were collected via a Google Form link shared through WhatsApp and email to student representatives, who forwarded it to peers. Participation was voluntary, with informed consent obtained by ticking an agreement box. The questionnaire contained no sensitive information, ensuring anonymity, and all responses were kept strictly confidential.

B. Questionnaire Form

The questionnaire, adapted from Alshuaibi et al. (2015) with permission, had a content and face validity index > 0.80 (Hamid & Jaafar, 2021), indicating strong expert agreement on its content and clarity. It comprised four sections: (1) Socio-Demographic Factors: age, gender, year of study, and other relevant details to contextualise findings; (2) Smartphone Ownership and Connection: smartphone usage, features, and preferred internet connection; (3) Social Media Applications: frequently used platforms and purposes; (4) Social Media for Academic Purposes: use of social media for learning, including information exchange, consultations, and educational queries.

A five-point Likert-type frequency scale was used to assess the respondents’ frequency of behaviour, with response options ranging from “Never” to “Almost always”: Never, Seldom, Sometimes, Often, and Almost always. This scale was employed for all questionnaire items, with response options ranging from Never (1) to Almost Always (5). Items were organised into specific domains. To generate a domain score for each respondent, individual item responses within the same domain were numerically coded and then averaged. This method ensured standardisation across domains.

This structured approach provides a holistic understanding of students’ interaction with technology and social media, particularly in academic settings, while ensuring the findings are relevant and actionable for improving educational practices.

C. Sample Size Determination

The outcome variable selected for estimating sample sizes was the use of social media for academic purposes. Finite population correction formula was utilised to estimate the minimum sample sizes at Universiti Sains Malaysia:

Where n= required minimum sample size, P= 95.1% which is proportion of the outcome variable (Hamid & Jaafar, 2021), p(1−p) = variance of the outcome variable, Z= 1.96 for 95% confidence limit with absolute precision (Δ)= ± 5%. For anticipated 10% of non-response rate, the minimum number of participants required is 80.

For the gender variable, a priori power analysis was performed with G*Power version 3.1.9.7 to establish the required sample size for testing the study hypothesis. The study found that a sample size of N=128 is needed to have an 80% power of detecting a medium effect size with a significance level of α=0.05 when comparing two independent means (male and female). The overall sample size of N=128 was sufficient to test the study hypothesis.

For the years of study variable, a priori power analysis is performed with G*Power version 3.1.9.7 to establish the appropriate sample size for testing the study hypothesis. It was found that a sample size of N=200 was needed to have an 80% power of detecting a medium effect in a one-way ANOVA test at a significance level of α=0.05. Therefore, the sample size of N=200 was sufficient to test the study hypothesis. Since the calculated sample size for the difference in social media use among dental undergraduates between years of study was the highest (200), this number was used for the study.

D. Data Analysis

IBM SPSS Statistics for Windows, Version 26.0 (IBM Corp., Armonk, NY, USA) was used for data entry and analysis. Data was presented using tables and graphs. Descriptive analysis included frequencies and percentages for categorical variables and mean with standard deviation or median with interquartile range for continuous variables, depending on normality. An independent t-test assessed differences in social media use between male and female dental undergraduates at Universiti Sains Malaysia.

A one-way ANOVA test was utilised to assess the use of social media for learning in different undergraduate years of study and to differentiate the type of internet access. A multiple logistic regression analysis was also applied to provide insight into how various factors impact learning outcomes. The independent variables are influencing factors (ResearchGate, Google, YouTube, Skype, LinkedIn, WhatsApp, Instagram, Twitter, Facebook, and TikTok). These platforms were selected based on their popularity among the target population, relevance to academic and social communication. Multicollinearity among the independent variables was assessed using Variance Inflation Factor (VIF) and Pearson correlation coefficients. The dependent variable is the outcome (Never, Seldom, Sometimes, Often, and Almost always). The outcome tested in the study significance level was set at p ≤ 0.05. at 95% confidence intervals.

III. RESULTS

A. Demographic Characteristics

There were 222 dental undergraduates who participated in the study. The mean age of the participants was 22.1 ± 1.50 years. The vast majority of the participants were female, accounting for 79.7% of the total sample (n = 177). 20.7% (n = 46) in the first year, 19.4% (n = 43) in the second year, 23.0% (n = 51) in the third year, 14.0% (n = 31) in the fourth year, and 23.0% (n = 51) in the fifth year. While all academic years were represented, the distribution was not exactly even, with slightly lower participation from fourth-year students and slightly higher representation from third- and fifth-year students. This variation reflects natural variation in voluntary participation across cohorts.

B. Smartphone Ownership and Connection

The majority of dental undergraduates were iPhone users (65.8%) while the other respondents were android smartphone users. Particularly, 95.0% (n = 211) of the participants were able to connect to the internet through a fourth generation (4G) mobile carrier and Wi-Fi.

C. Social Media Application

Most participants utilised social media for connecting with friends (99.1%), communicating with family members (92.8%), and acquiring new skills or information (85.1%). About 74.8% of individuals engage with their lecturers through these communication channels. About 67.1% of participants use these tools to build professional or social connections and only 10.4% of respondents focus on promoting their business through these platforms. Most participants had accounts on Instagram (99.1%), WhatsApp (97.7%), and YouTube (91.9%). The most frequently used platforms were WhatsApp (86.0%), Instagram (81.1%), and YouTube (61.7%) (Figure 1).

Figure 1. Social media membership accounts and the most frequently utilised social media accounts by the respondents (n=222)

D. Social Media for Academic Purposes

The social media apps that assist respondents in their education are shown in Figure 2. Participants chose Google (91.0%), YouTube (84.2%), WhatsApp (53.2%), ResearchGate (48.6%), and Instagram (25.2%) as their top five social networking applications. Google was the most popular application.

Figure 2. Social media applications that assist the respondents in the course of their studies

Table 1 displays the respondents’ utilisation of social media for academic purposes. Most respondents selected “often” for the exchange of information, consulting, and queries domains. About 46.4% of respondents prefer to stay updated on a subject/course “almost always,” while 33.3% chose to consult teachers “sometimes” to clarify challenging subjects. The domain of exchange of information, consultation, and queries had a grand mean score of 2.94 (SD = 0.67), 2.81 (SD = 0.75), and 3.09 (SD = 0.74), respectively.

Submitted: 21 June 2024
Accepted: 18 November 2025
Published online: 7 April, TAPS 2026, 11(2), 32-39
https://doi.org/10.29060/TAPS.2026-11-2/OA3446

Prabodha De Silva¹, Kavishan De Silva¹, Supun Deshapriya¹, Sachini Dewagiri¹, Uthpali Dhammadinna¹, Kasun Bandara Ekanayake² & Amal Nishantha Vadysinghe²

¹Faculty of Medicine, University of Peradeniya, Sri Lanka; ²Department of Forensic Medicine, Faculty of Medicine, University of Peradeniya, Sri Lanka

Abstract

Introduction: University students may be influenced by intimate relationships (IR) and extracurricular activities (EA), which can impact academic performance (AP). This study assessed the effects of IR and EA on the AP of medical undergraduates.

Methods: A cross-sectional study was conducted among 253 medical undergraduates at the University of Peradeniya, Sri Lanka. Data was collected using an online self-administered questionnaire. AP was evaluated using the cumulative grade point average (cGPA) from the previous semester.

Results: Of the 253 participants, 110 (43.5%) were involved in IR and 143 (56.5%) were single; 56.9% were female. Among participants in relationships, 44.5% had partners within the same faculty. There was no significant association between involving in an IR and AP (p=0.651), regardless of the other variables of IR. Most participants (51.8%) believed EA had no impact on AP, and analysis showed no significant association between EA and AP (p=0.394). Economic status of participants was positively associated with their AP (p=0.015). The prevalence of IPV in IR was 18.2% (7.9% of the total sample), with psychological type being the most prominent. Out of those in relationships, 18.2% reported experiencing IPV, of whom 75.0% were male and 25.0% were female, possibly due to underreporting by females. However, there was no significant association between experiencing IPV and AP (p=0.534).

Conclusions: Although involvement in IR and EA did not significantly affect AP, the presence of IPV highlights the need for targeted interventions. Males were more likely to report IPV than females, emphasising the importance of support programs.

Keywords:           Academic Performance, Demographic Data, Intimate Relationships, Extracurricular Activities, Medical Education, Medical Undergraduates

Practice Highlights

• There was no significant association between academic performances and intimate relationships.
• Extracurricular activities didn’t show any impact on academic performances.
• No significant association was observed between intimate partner violence and academic performance.
• Males were more likely to experience intimate partner violence than females.

I. INTRODUCTION

Intimate relationships (IR) include, but are not limited to, heterosexual/homosexual romantic relationships. IR can have a significant impact on the university life of medical students. Medical undergraduates represent a unique population because their training requires them to fulfil high academic demands. Unlike many other undergraduate groups, medical students have limited time for leisure or personal life. These challenges make them particularly vulnerable to stressors arising from balancing IR with academic commitments.

Studies have shown that medical students in IR often experience higher levels of stress, anxiety, and depression than their single counterparts (Dyrbye et al., 2006). This is likely due to the demanding nature of medical school and the pressure to balance academic and personal responsibilities. Additionally, medical students in IR may have a harder time maintaining boundaries and achieving work-life balance. They may also have difficulty finding time for their relationship due to the demands of medical school and clinical rotations.

However, some studies suggest that healthy IRs shown to have a positive impact on students in healthcare professions (Avci et al., 2022). Being in a relationship can provide emotional support, which can be beneficial for coping with the stress of medical education. Additionally, having a partner can provide a sense of social support, which can help medical students feel less isolated and lonely. Despite the potential challenges, many medical students can successfully navigate IR while in medical school. Even so, to prevent the potential harmful impact of IRs, medical schools need to provide support and resources for students in relationships, such as counselling services and relationship awareness programs.

A Sri Lankan study found that 52% of the participants who were university students were engaged in romantic relationships (Gunawardena et al., 2012). Therefore, it’s crucial to understand how these relationships impact their university experience. The majority of studies regarding IRs were focused on violence towards intimate partners, and there was an overall lack of relevant literature when it came to the effects of IRs as general on academic performances (AP). Previous studies have identified vulnerabilities among university students, particularly young women, who are at increased risk of experiencing unwanted sexual attention (Forke et al., 2008) and unhealthy or stressful IRs (Hayden et al., 2016). These findings highlight the importance of further research into how such relational factors may influence AP. A study from the United States involving over 6800 female undergraduates revealed that there is an indirect link between physical and psychological intimate partner violence (IPV) and academic disengagement via depression symptoms (Schrag et al., 2020). Furthermore, American studies involving over 84,000 subjects found that undergraduates experiencing IPV were more likely to have increased academic difficulties (N. Brewer et al., 2018) as well as health impairments (N. Q. Brewer & Thomas, 2019).

These findings suggest that IPV and its consequences may be particularly relevant for medical students, who already face high academic stress. Therefore, exploring not only the general influence of IRs but also the potential academic impact of IPV is essential in understanding the relationship between students’ personal and academic lives. The University of Peradeniya, being one of the largest public universities in Sri Lanka, attracts students from diverse regions and socioeconomic backgrounds. Its academically rigorous environment provides a suitable context to study how interpersonal and extracurricular factors relate to AP. The objective of this study was to examine the association between involvement in IR, AP and extracurricular activities (EA) among the medical undergraduates of the University of Peradeniya, Sri Lanka.

II. METHODS

A descriptive cross-sectional study with an analytical component was conducted with the participation of 2018/19 (3rd year), 2019/20 (2nd year) and 2020/21 (2nd year) batches enrolled at the Faculty of Medicine, University of Peradeniya, Sri Lanka. The senior-most batches were excluded because they were engaged in clinical rotations at external hospitals, making it logistically difficult to ensure their participation. The sample size was calculated based on a total population of 707 students from the 2018/19, 2019/20, and 2020/21 batches. Using a conservative proportion (p=0.5), a 95% confidence level (z=1.96), and a 5% margin of error (e=0.05), the minimum required sample size was 249.

A self-administered questionnaire was newly developed to assess the study objectives. It included sections on demographic factors (age, gender, economic status), IR status, partner characteristics, AP, and EA. Items related to IPV assessed physical, psychological, and combined abuse using Yes/No questions. The questionnaire was pilot tested to ensure clarity and reliability. Economic status was self-reported by participants and categorised as less than 50,000 LKR (1 USD = 323 LKR at the time of data collection in August 2023), between 50,000–100,000 LKR and above 100,000 LKR. IR included romantic relationships, heterosexual or homosexual, in the duration of the last semester’s work. IPV types were specified as physical, mental or both. EA were defined as participation in university clubs, sports, arts or other organised student activities.

Data collected using the questionnaire, via Google Forms, was entered into a Microsoft Excel spreadsheet and analysed using IBM SPSS Statistics 26. Normality of the data collected was assessed, and non-parametric tests (Chi-square tests) were used accordingly. Microsoft Excel was used to calculate a cumulative Grade Point Average (cGPA) value for examination results up to the last semester, based on the university’s 0.000 to 4.000 grading scale. Before administering the questionnaire, written informed consent was obtained from each participant. The ethical approval for the study was obtained from the Ethics Review Committee (2023/EC/SP/38) of the Faculty of Medicine, University of Peradeniya, Sri Lanka.

III. RESULTS

Data was collected from 253 medical undergraduates enrolled in 2018/19, 2019/20 and 2020/21 batches of the Faculty of Medicine, University of Peradeniya, Sri Lanka.

A. Socio-Demographic Profile

The age of the sample ranged from 19 to 26 years, with a mean age of 23.2 years. The sample included 144 females (56.9%) while males accounted for 43.1% (n=109) respondents. Among the 3 batches considered, the 2018/19 batch had the highest number of responses, which amounted to 33.9% (n=86). Respondents from the 2020/21 batch amounted to 33.2% (n=84) while the 2019/20 batch had 32.8% (n=83) respondents. When considering the economic background of the family, 58 subjects (22.9%) represented the group earning less than 50,000 LKR per month, followed by 90 subjects (35.6%) earning 50,000-100,000 LKR per month and 105 subjects (41.5%) earning more than 100,000 LKR per month.

Out of 253 respondents, 110 respondents (43.5%) claimed that they were involved in IR during the last semester. Out of the females in the sample, 58 subjects (40.3%) were involved in an IR during the last semester. Among the 110 subjects who were involved in IR, 67 respondents (60.1%) had their partners in the same university, and 49 of them (44.5%) in the same medical faculty as the subjects. Only 43 (39.0%) claimed to have partners outside the university, including in other universities (34, 30.9%), another residential area (8, 7.2%) and in the health training sector (1, 0.9%).

B. Academic Performance

When the Shapiro-Wilk test was applied to the total sample of 253, the distribution of cGPA significantly deviated from a normal distribution (p<0.001). Therefore, the median (3.200) of the cGPA of respondents was used as a cut-point for assessing AP, differentiating between high-performing and low-performing, instead of the mean (3.065). More than half of the samples (58.1%) had a cGPA of 3.000 or more, while only 7.9% had a cGPA of less than 1.500.

Of the 110 respondents involved in IR, 57 (51.8%) scored lower than a cGPA of 3.200, while 73 (51.0%) of the respondents who were not involved in any IRs scored at or above a cGPA of 3.200 (Table 1). However, this finding was not statistically significant (p=0.651, OR=1.12, 95% CI: 0.68–1.84). The mean cGPA for respondents involved/not involved in IRs was calculated, and respondents who were in an IR had a mean cGPA of 3.05, in contrast to a mean cGPA of 3.08 of the respondents with no involvement in IRs.

Submitted: 22 February 2025
Accepted: 6 October 2025
Published online: 7 April, TAPS 2026, 11(2), 9-21
https://doi.org/10.29060/TAPS.2026-11-2/RA3677

Jyoti M. Benni & Anupama M. Gudadappanavar

Department of Pharmacology, Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research (KAHER), Deemed-to-be-University, Belagavi, India

Abstract

Introduction: Medical education is continuously adapting to new challenges. Cinemeducation, the use of films in teaching, provides contextualised learning experiences, yet its role in pharmacology has not been systematically reviewed. This systematic review synthesises the reported applications and outcomes of cinemeducation in pharmacology education.  

Methods: A systematic review (PROSPERO ID: CRD42024568417) was conducted following PRISMA 2020 guidelines. PubMed, Scopus, and Google Scholar were searched for studies published up to June 2024. Eligible studies included healthcare undergraduates where films were used as teaching interventions in pharmacology. Methodological quality was assessed using the QuADS (Quality Assessment with Diverse Studies) tool. Data extracted included study characteristics, teaching approaches, and reported educational outcomes (e.g., test performance, reflections, feedback, and student perceptions).

Results: A total of 77 records were identified; 22 full texts were assessed, and 9 studies met inclusion criteria. Most involved medical undergraduates, using qualitative, longitudinal, or cross-sectional designs. Key details are summarized in Table 1. Reported outcomes included improved post-test scores, better knowledge retention, enhanced engagement, and deeper understanding of pharmacological concepts, ethics, and palliative care. Students also reported greater motivation and confidence in decision-making.

Conclusion: Cinemeducation is an engaging adjunct to conventional pharmacology teaching, supporting cognitive, affective, and ethical learning. However, the lack of control groups and heterogeneous methodologies limit the strength of conclusions. Short, thematically relevant film clips integrated into lectures are recommended to enhance comprehension and engagement.

Keywords:           Cinemeducation, Movies, Pharmacology, Medical Education, Systematic Review

Practice Highlights

• Medical education continues to evolve to address changing needs and expectations.
• Cinemeducation refers to the use of movies or video clips as a tool for teaching medical education.
• Movies can bring dry concepts to life, make them more comprehensible, and support diverse types of learning.
• Cinemeducation is an effective approach for teaching pharmacology, as it makes classes more interactive, improves learning, supports knowledge retention, and adds enjoyment to the process.

I. INTRODUCTION

Pharmacology, the study of drugs, is a crucial component of the medical curriculum. It serves as the cornerstone of medical science and lays the groundwork for clinical practice among physicians. The applied aspects of pharmacology strengthen rational therapeutic approaches in clinical settings. However, teaching pharmacology presents challenges. The principal objective is to prepare undergraduate medical students to make informed therapeutic decisions in clinical contexts (Parimala et al., 2013). Given the vast scope of the pharmacology syllabus, students often struggle to remember and recall concepts and drug names. This challenge can be addressed by making pharmacology education more engaging and relevant.

Traditional didactic lectures, utilising either “chalk and board” or PowerPoint presentations, have long been the predominant teaching methods in pharmacology (Agarwal & Sankdia, 2016; Sahu & Supe, 2000). The integration of audio-visual aids enhances the appeal and effectiveness of these lectures (Priyadarshini et al., 2012; Roy & Saha, 2015). In recent years, pharmacology education for undergraduates has undergone significant transformation with the adoption of innovative teaching approaches such as computer-assisted learning, advanced audio-visual tools, mannequins, role-playing, and clinical pharmacology practices (Seth et al., 2010). Additionally, clinical pharmacology and problem-based learning (PBL) methods are now employed in many universities (Burrows & Tamlyn, 1989; Sim, 2004). As pharmacology remains a dynamic and ever-evolving discipline, its complexity and need for contextual learning it’s essential for educators to regularly review and adapt their teaching and evaluation strategies to meet contemporary educational needs (Jayakaran et al., 2010; Padmanabha et al., 2016).

Medical education continues to evolve to address changing needs and expectations. In modern society, television and movies have become deeply ingrained in daily life, presenting diverse life situations and addressing a variety of issues. This versatility makes movies a valuable tool in medical education. The first recorded usage of videos in medical education was at a 1979 psychiatry session (Fritz & Poe, 1979). Cinema, through its combination of sight and sound, engages viewers by encouraging interaction with audio-visual media. It stimulates the affective domain, connects learning with real-life experiences, enhances observational learning, fosters reflection, and boosts motivation. In 1994, Matthew Alexander introduced the term “Cinemeducation” to describe the integration of movies into medical education (Alexander et al., 1994).

The concept of “Cinema + Medicine + Education” refers to the use of movies or video clips as a tool for teaching medical education (Lumlertgul et al., 2009). Recent studies in medical literature highlight videos as an effective and innovative teaching method (Alexander, 2002). Movies offer several advantages: they can bring abstract and dry concepts to life, make them more comprehensible, and support diverse types of learning. They can also explore the emotional, social, and ethical dimensions of diseases, such as suffering, emotions, conflicts, and dilemmas. Films have been utilised as teaching aids in various fields, including clinical research, medical ethics, pharmacology, microbiology, doctor–patient relationships, professionalism, mental health, and psychosocial topics like breaking bad news or dealing with terminal illnesses (Blasco et al., 2016; Farre et al., 2004; Saab et al., 2005; Bhaskara & Shelley, 2016). The profound emotional impact of movies can be leveraged to teach vital qualities such as empathy, self-reflection, compassion, and altruism, and medical professionalism – areas often overlooked in traditional medical training (Shankar, 2019).

Cinemeducation is a globally adaptable teaching approach, capable of exceeding verbal and cultural boundaries. Films, whether local or international, offer universally relatable themes such as ethical dilemmas, patient care, and human behavior, making them effective across diverse educational and cultural settings. This global relevance justifies the inclusion of studies from diverse regions, providing a broader perspective on the application of cinemeducation in pharmacology education. The Medical Council of India, in its 2019 curriculum revision for “Competency-Based Medical Education,” recommended incorporating short films and videos as teaching tools (Medical Council of India, 2019). Published data indicate that cinemeducation is increasingly being used to train healthcare professionals across undergraduate, postgraduate, and continuing medical education programs in diverse clinical settings (Swanwick, 2018). To our knowledge, no prior systematic reviews have focused exclusively on the application of cinemeducation in the teaching of pharmacology. Therefore, this review aims to evaluate the use of cinemeducation in pharmacology education, examining its applications and reported outcomes. Furthermore, it will explore the perceptions of educators and students regarding the integration of cinemeducation into pharmacology teaching.

II. METHODS

A. Search Strategy

Our review was conducted and reported in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines, which are widely recognised for systematic review reporting (Page et al., 2021). With registration number CRD42024568417, the study protocol was pre-registered in PROSPERO: International Prospective Register of Systematic Reviews. A comprehensive literature search on the use of movies in pharmacology education was independently carried out by both authors, covering publications from inception up to June 2024. The primary databases used for the search were PubMed and SCOPUS. In order to find further pertinent research, Google Scholar was also used, and the reference lists of the publications that were retrieved were reviewed.

B. Search Terms

The search utilised the following keywords:
(“Cinemeducation”[All Fields] OR “Cinemedicine”[All Fields] OR “movies”[MeSH] OR “films”[MeSH] OR “motion pictures”[MeSH] OR “audiovisual aids”[MeSH] OR “TV series”[All Fields]) AND (“Pharmacology/education”[MeSH] OR “Pharmacology/ethics”[MeSH] OR “Pharmacology/methods”[MeSH] OR “Pharmacology/research”[MeSH] OR “Pharmacology/clinical trials”[MeSH]). Free-text terms were searched in the title, abstract, and keywords, while MeSH terms were used to capture indexed articles. Database full search strategy details are provided in Appendix 1.

C. Selection Criteria

The articles that were included in this review were chosen because they satisfied the following selection criteria, and those that did not were excluded.

D. Inclusion Criteria

1. Peer-reviewed scholarly research articles were taken into consideration.
2. Articles that addressed the use of motion pictures, television shows, and cinema as teaching resources in pharmacology.
3. Studies describing teaching experiences in pharmacology within medical, dental, pharmacy, or nursing degree programs were eligible.
4. Only articles published in English were included.
5. All types of articles, from randomised controlled trials to letters, were considered, with no restrictions on publication date.

E. Exclusion Criteria

1. Articles that weren’t entirely available in the selected databases.
2. Research that is not fully translated into English.
3. Book reviews, review articles and editorials were not included.

F. Study Selection

The search strategy (PRISMA flow chart) is illustrated in Figure 1. The reviewers independently screened all article titles. Once the findings were retrieved from the chosen databases, irrelevant research and duplicates, including conference papers and publications written in languages other than English, were eliminated. We evaluated the remaining papers’ abstracts for initial eligibility. Full articles that were deemed eligible were examined to make sure they satisfied the requirements for inclusion. All articles were assessed by both authors, who discussed and resolved any disagreements to improve the validity and reliability of the selection process.

G. Data Extraction, Quality Assessment (Risk of Bias) and Data Synthesis

This study aims to explore the role of cinema and motion pictures in medical education. The research team reviewed and collected data aligned with the keywords in the research questions, results, and discussions of the selected publications. Quality Assessment of Diverse Studies (QuADS) technique, both authors independently assessed every study that was involved (Albert et al., 2024; Harrison, et al., 2021). This tool provides a straightforward scoring system for assessing study quality in systematic reviews. It consists of 13 items, with each study receiving a score between 0 and 3, where ‘0’ indicates no mention, ‘1’ signifies minimal detail, ‘2’ represents moderate detail, and ‘3’ denotes complete information, resulting in a maximum possible score of 39. For the purpose of this review, studies were grouped descriptively into three categories of methodological quality: low (≤17), moderate (18–28), and high (≥29). These categorisations were used solely for summarising study quality and not for excluding any studies from the review. All studies that met the inclusion criteria were retained, and the quality appraisal results were used to inform the interpretation of the findings rather than as an exclusion criterion.

A standardised data extraction form was designed to collect predefined data points from each study. Extracted data included study authors, year, country, participant characteristics, study design, intervention details (e.g., film used, duration, pre/post-tests, group discussion, reflection writing), and results. In order to ensure a comprehensive and uniform assessment, disagreements during the review were settled through a consensus meeting. When analysing results and drawing conclusions, the significance of the findings was taken into account rather than the quality scores of the studies. In order to improve the validity and reliability of the review findings, the research team also addressed any difficulties or ambiguities that arose during the selection and data extraction procedure.

III. RESULTS

The search process is depicted in the PRISMA flow diagram (Figure 1). A total of 77 publications were found through the search method. After removing duplicates and irrelevant studies, 22 publications were selected for preliminary eligibility screening. Of these, 13 were excluded for studies not pertaining to pharmacology teaching, or absence of a cinema-based intervention, and review articles or editorials. Finally, 09 publications were included in the study after they fully satisfied the selection criteria. Every member of the study team developed a consensus to address any possible ambiguities in meeting the inclusion criteria.

A. Study Characteristics

Table 1 provides a detailed summary of the study characteristics, which were published between 2000 and 2024 and conducted in Spain, India, Brazil, Iran, Netherlands, Slovenia, and Thailand. Most studies employed qualitative approaches, while a few used longitudinal or cross-sectional quantitative designs. Importantly, none of the studies included a control group for comparison.

B. Study Participants

Most of the research involved medical undergraduate students and were carried out in academic institutions such medical colleges and universities (Cambra-Badii, 2020; Kadivar et al., 2018; Kersnik & Klemenc-Ketiš, 2011; Lumlertgul et al., 2009; Patel et al., 2022; Picanço et al., 2019; Shankar et al., 2016). One study focused on pharmacy undergraduate students in a pharmacy college (Desai & Kakodkar, 2022). An alternative study included students from medical, human biology and pharmaceutical and biotechnological industry (Cambra-Badii, 2020). Another study was carried out in a hospital setting to assess patient safety in the hospital environment (Cambra-Badii, 2024). Of the included studies, six used films or movies (Cambra-Badii, 2020; Kadivar et al., 2018; Kersnik & Klemenc-Ketiš, 2011; Lumlertgul et al., 2009; Patel et al., 2022; Picanço et al., 2019; Shankar et al., 2016), one employed TV series (Cambra-Badii, 2024), and two studies incorporated both films and TV series in their methodology (Desai & Kakodkar, 2022; Lumlertgul et al., 2009).

C. Cognitive Outcomes

Three studies employed pre- and post-intervention questionnaires to assess baseline knowledge and subsequent changes after the intervention (Cambra-Badii, 2020; Cambra-Badii, 2024; Patel et al., 2022). Knowledge was typically measured using multiple-choice or open-ended questions, and all three reported improved post-test scores, indicating enhanced understanding of pharmacology concepts.

D. Affective Outcomes

Most studies used post-intervention questionnaires to evaluate students’ perceptions and attitudes toward cinemeducation (Cambra-Badii, 2020; Desai & Kakodkar, 2022; Kadivar et al., 2018; Lumlertgul et al., 2009; Picanço et al., 2019; ShaJnkar et al., 2016). Students consistently reported that incorporating movies or TV shows increased their motivation, attention, and concentration, while adding entertainment value to learning. They also felt that they understood more compared to conventional lecture-based teaching.

E. Ethical Understanding

Several studies addressed the role of cinema-based learning in enhancing awareness of ethical and professional issues such as informed consent (Patel et al., 2022), clinical trial enrolment (Shankar et al., 2016), adverse drug reactions (Cambra-Badii, 2020), error management (Lumlertgul et al., 2009), and ethical considerations in medical and palliative care (Kadivar et al., 2018; Kersnik & Klemenc-Ketiš, 2011). Student reflections indicated that cinematic narratives helped them better appreciate the complexity and importance of these issues in real-world clinical practice.

F. Quality Appraisal of Studies

The QuADS scores for the included studies are shown in Table 2. Scores ranged from 24 to 34 out of a maximum of 39. Four studies were rated as high quality, and five received a moderate quality rating; none were classified as low quality. The studies performed well in clearly stating aims and objectives, describing the research setting and target population, outlining data collection procedures, selecting appropriate study designs, and using analytical methods that matched the research aims. However, there were limitations in explaining conceptual or theoretical frameworks and justifying the chosen analytical methods. Most studies scored zero for involving research stakeholders in the planning or conduct of the study. This underscores the importance of enhancing stakeholder engagement and participant collaboration in the co-creation of research.

Figure 1. Study selection flow diagram (Prisma Flow diagram)

A quantitative synthesis of pre/post-test data was not undertaken due to substantial heterogeneity in outcome measures, assessment tools, scoring systems, and reporting formats. Only three studies (Cambra-Badii, 2020; Cambra-Badii, 2024; Patel et al., 2022) provided pre/post-intervention knowledge data, but variations in question types, item numbers, and scoring methods precluded meaningful pooling. The results are therefore narratively presented with an emphasis on ethical, affective, and cognitive outcomes. Most of the included studies had post-test, pre/post-test, or single-group designs without a control arm. The lack of comparator groups makes it challenging to attribute improvements to the intervention alone, even though these designs show that cinemeducation has positive effects. This is because confounding factors, such as related coursework, cannot be completely ruled out. The formats of the interventions also differed, ranging from short clips incorporated into lectures to full-length film screenings. Shorter clips were more focused on particular pharmacology or patient management concepts, whereas full films tended to offer richer narratives that encouraged ethical reflection and empathy. These variations probably affected the scope of learning objectives and added to limited quantitative synthesis.

Sl. No.	Authors, Year, Country	Study design / settings	Participants	Intervention	Result
1	Cambra-Badii 2024, Spain	Qualitative study, pre & post-test questionnaire	70 medical students, 2nd year	TV series ‘The Resident’ centred on patient safety, focused on adverse events during hospitalisation and error management.  Pre and post intervention scores, 10 questions on patient safety, single best answer. Also, 2 open ended questions were used.	Cinemeducation significantly improve learning on patient safety in complex situations.
2	Desai & Kakodkar, 2022, India	Qualitative study, pre & post-test questionnaire	111 students, from 3rd year Bachelor of Pharmacy	Movie/ web series were used.  Presentation of topics related to pharmacology of drugs like ephedrine, cocaine, alcohol, beta blockers, digitalis. Pedagogy notes to be written and Fill feedback google form, 8 closed ended questionnaire using Likert scale.	Movies are an effective academic method for learning pharmacology. It makes learning interesting, increases enthusiasm and motivation for learning, piques students’ curiosity, accelerates learning, helps them retain information, and aids in understanding the subject through visual imaging.
3	Patel et al., 2022, India	Qualitative study prospective, longitudinal, interventional study	139 second professional year medical students	Watch movie clips à divided into groups à presentation and Individual reflection writing done. Feedback was taken.  Pre & post-test questionnaire to test baseline & change in knowledge about the ethics (informed consent, clinical trial enrolment & details about, inform drugs) and right to choose treatment available.	The students said they would treat patients with respect, honour their choices of treatment, follow ethics and professionalism, respect co-workers.
4	Picanço et al., 2019, Brazil	An exploratory, cross-sectional, quantitative study was con­ducted	107 students, first- to sixth-year students from the Medicine course	Two Movies were screened. The psychometric scale (questionnaire) with Likert scale responses, included the primary health care, physician’s role and importance of research were utilised.	The preclinical series of the medical course uses films as an effective teaching tool to develop humanistic attitudes.
5	Kadivar et al., 2018, Iran	Quantitative and qualitative data analysis	270 medical students participated in this study	Student viewed 09 movies in different sessions, related to biopsychosocial topics like palliative care, managing terminal illness and ethics in medical care, palliative care and mental illness. Group discussion and post-test questionnaire with 11 questions with Likert scale and one open ended question about perception & attitude were used.	Through watching and analysing films, medical students can gain knowledge on psychosocial topics related to medicine through cinemedicine.
6	Shankar et al., 2016, Netherlands	Qualitative data analysis	60 basic science undergraduate medical students	Two Movies were screened and student presented on findings related to enrolling a patient in clinical trials, process of obtaining written informed consent, treatment modalities. Later student presentation and feedback was obtained through questionnaire.	The session received great reviews from the students. Movies help medical students learn about humanistic issues, improve their comprehension of death and dying, and promote professionalism.
7	Kersnik & Klemenc-Ketiš, 2011, Slovenia	Qualitative data analysis	Group of eleven fourth year medical students	Students watch movie, followed by discussion and reflection writing & presentations on the topics. Topics chosen were (doctor/patient communication, ethical issues and the role of doctor and nurse in palliative care).	Students understood that physicians should respect patients’ ability to select their own treatments and offer palliative care.
8	Lumlertgul et al., 2009, Thailand	Qualitative study	26 second-year (preclinical) medical students	Five movies were chosen for the project and ethical issues were depicted as main themes for group discussion, which included the doctor–patient relationship, informed consent and clinical trials in patients, management of genetic disorders, patient management, and brain death and organ transplantation. Movie screening followed by discussion. Questionnaire and reflection writing were used.	Movies have proven to be an effective and entertaining method of facilitating students with learning on professionalism.
9	Cambra-Badii, 2020, Spain	Exploratory comparative analysis	237 students participated in the study	Movie clips were used to study the pharmacovigilance processes and adverse drug effects. Also, the film shows about the importance of a signal alert, the studies needed to confirm/reject causality of an adverse drug event, and the roles of the pharmaceutical industry and public health agencies.  Pre & post-test questionnaire were used.	The teaching activity used in this study helped students learn about adverse drug reactions and the process of pharmacovigilance.

Table 1. Characteristics of the included studies in the review

Table 2. Quality assessment of reviewed studies using the Quality Assessment of Diverse Studies (QuADS) criteria

IV. DISCUSSION

This study aimed to explore the applications and reported outcomes of incorporating movies/films into pharmacology teaching and their impact on enhancing knowledge and skills among undergraduate students. A qualitative review of nine eligible studies revealed various cinemeducation strategies employed as teaching tool in undergraduate pharmacology education. These studies demonstrated that using movie clips are a promising tool for enhancing engagement and understanding in pharmacology. It makes classes more engaging, sparks student interest, enhances learning, aids knowledge retention, and makes the process enjoyable. Additionally, it fosters greater interest and motivation, helps students grasp concepts through visual representation, and improves understanding of empathy, research ethics, patient care, palliative care, error management in complex scenarios, and autonomy in treatment choices. The findings strongly support cinemeducation as a valuable tool for medical education, effectively enhancing both knowledge and skills.

Medical education is encountering new and evolving challenges. Over the past few decades, the field of pharmacology has significantly expanded its scope. Traditional teaching methods, such as lectures and practical sessions, are increasingly being replaced by innovative pedagogical approaches to enhance the conceptual understanding of pharmacology. A recent systematic review of these methods highlighted the positive impact of using movies in pharmacology education across various health disciplines (Baños et al., 2024). Films have been utilised to teach diverse topics, including pharmacology concepts, preclinical and clinical research, pharmacovigilance, medical ethics, the doctor-patient relationship, microbiology, mental health, drug addiction, palliative care, pain management, medical professionalism, and social conflicts in healthcare (Baños et al., 2024; Cambra-Badii, 2020; Darbyshire & Baker, 2012; Farre et al., 2004; Icart Isern, 2012). Historically, the movie Awakenings was among the first to be used in pharmacology education, with Koren employing it to teach principles of clinical pharmacology to medical students. This approach proved to be a valuable tool for improving pharmacology instruction (Koren, 1993).

Movies serve as an excellent tool to boost students’ motivation to grasp clinical pharmacology principles and can inspire a stronger desire to learn (Farre et al., 2004). A recent systematic review highlights several popular films that are particularly effective for teaching topics such as basic and clinical pharmacology, drug research, and bioethics. These include Awakenings, Lorenzo’s Oil, Miss Evers’ Boys, The Fugitive, Wit, The Constant Gardener, Side Effects, and Dallas Buyers Club (Baños et al., 2024). Additionally, various TV series, such as House MD, Emergency Room (ER), Grey’s Anatomy, The Resident, and New Amsterdam have been employed to teach concepts like pharmacovigilance, drug abuse, pharmacological classifications, and the doctor-patient relationship, which can influence therapeutic compliance (Baños et al., 2024; Cambra-Badii, 2024; Desai & Kakodkar, 2022; Williams et al., 2015). Notably, House MD episodes have proven effective for teaching clinical pharmacology (Wicclair, 2008). Another example of cinemeducation is the film Wit, which portrays pain management in a woman undergoing chemotherapy for late-stage ovarian cancer. This movie helped students understand approaches to pain management and the importance of professionalism in patient care (Carpenter et al., 2008). A study demonstrated that incorporating the TV series The Resident into teaching effectively enhanced students’ understanding of patient safety strategies in complex situations. Students reported gaining valuable insights into identifying, preventing, and managing adverse events, showcasing learning progression from Level 1 to Level 5 of Bloom’s Taxonomy (Cambra-Badii, 2024).

Movies have been utilised effectively to teach medical students ethics and professionalism in countries such as the USA, Brazil, Israel, and Korea (Shankar, 2019). Given that Indian Medical Graduates (IMGs) are frequently seen to be less competent in comprehending the moral implications of informed consent in clinical research, a study was carried out to use cinemeducation to teach second-year medical students about ethics (Patel et al., 2022). Most participants thought this approach was a good way to teach ethics and professionalism. The study revealed strong agreement among students on the importance of obtaining informed consent, thoroughly explaining clinical trials, and discussing potential adverse drug reactions with patients before their enrolment (Patel et al., 2022). Additionally, students emphasised the significance of informing patients about their treatment options. It was also discovered that using fictional audio-visual materials encouraged students to think critically and morally, pushing them to consider ethical issues outside of the scope of textbooks (Piqué-Buisan, Sorribes, & Cambra-Badii, 2024).

Palliative care, an evolving medical field, often highlights the limitations of modern medical technologies and is fraught with ethical dilemmas, communication challenges, and professional behaviour issues (Meier & Morrison, 2004). Through the movie Wit, students identified several key aspects of palliative medicine and began to understand their significance. They recognised that doctors should incorporate palliative care as a legitimate form of treatment, emphasising that managing symptoms is just as crucial as addressing pain and providing psychological support. Additionally, students believed that palliative care planning should be done in collaboration with patients, particularly regarding critical decisions such as resuscitation (Kersnik & Klemenc-Ketiš, 2011).

The articles reviewed indicate that most experiences with movies lead to increased knowledge and higher student satisfaction. In this review, some authors suggested that a traditional lecture prior to viewing these materials is essential to help students retain key theoretical concepts and terminology afterward. They provided a brief lecture about the process, to clear concepts and hands on training was conducted for the participants, which primarily helped them to develop their rational thinking and cognitive skills and aided to write reflections at the end of the project (Kersnik & Klemenc-Ketiš, 2011; Lumlertgul et al., 2009; Patel et al., 2022), Similar results were found with previous studies, where they suggested that using cinematic resources alone may not significantly augment students’ acquaintance and should be complemented with didactic classes to reinforce core concepts (Aboul-Fotouh & Asghar-Ali, 2010; Self, 1993). Thus, finding a balance between this creative approach and conventional teaching techniques might be the most effective way to promote learning.

In our review, some studies utilised entire movies (Kadivar et al., 2018; Lumlertgul et al., 2009; Picanço et al., 2019; Shankar et al., 2016) while others relied on selected video clips (Baños et al., 2024; Cambra-Badii, 2024; Lumlertgul et al., 2009). While authors acknowledged that watching an entire movie could be time-consuming, they noted it provided valuable context for each character and helped students better understand the complex and controversial issues presented. Similarly, earlier studies have recommended viewing the full movie (Masters, 2005; Silk & Weber, 2007) as part of the learning process, whereas others argue that a few carefully selected clips are sufficient to achieve the desired educational outcomes (Alexander, 2002; Blasco, 2006; Onsman & Ventura, 2009). Some authors recommended adding one to two-minute movie clips that referenced the topic being covered to power point presentations in pharmacology lectures. These clips received positive feedback because they allowed students to connect theory to simulated practice, encouraged them to attend lectures, and served as a sectioning break that kept them interested throughout the entire lecture (Onsman & Ventura, 2009). According to encouraging faculty input, students’ attention spans, retention of the material, and engagement were all enhanced by cinemeducation, which also helps to associate the films with real-life situations. Faculty pointed out that this approach has several shortcomings, including the possibility of pupils misinterpreting the situation, the need for extensive technical assistance, and the fact that it can only cover a limited number of topics (Patel et al., 2022).

To sum up, incorporating films alongside traditional teaching methods has received positive feedback from students, as it helps review and enhances the retention of theoretical concepts. These films promote lively debates on difficult pharmacology subjects, like the difficulties of organising and carrying out clinical trials on novel medications, the significance of following bioethical guidelines in human subjects’ research, Pharmacovigilance, and the psychological and social facets of medication treatment. Still, others contend that engaging with actual patients or taking part in bedside rounds can offer more worthwhile educational opportunities.

A significant disadvantage of using films is the time required for preparation and scheduling during the academic calendar. Furthermore, films may sometimes exaggerate medical or pharmacological information for dramatic effect. The main limitation of our systematic review is the selection of databases, which may have excluded publications in other languages. The primary drawback is the lack of a comparison group employing alternative teaching methods in the included studies. Furthermore, these studies focused only on immediate knowledge gains, without exploring long-term knowledge retention or evaluating the impact on the clinical application of that knowledge. Additional restrictions that could restrict the findings’ generalisability include the diversity of medical programs, English language bias, and the prevalence of cross-sectional studies. Although they draw attention to important gaps in the literature, the comparatively small number of studies on some fields may also limit interpretation. Lastly, publication bias may have influenced the findings of this review, as most included studies reported favorable outcomes. Negative or neutral findings may be underrepresented in the literature, thereby skewing the overall perception of cinemeducation’s usefulness.

Few practical recommendations for teachers include, educators can select films or clips that match the learning objectives, are relevant to the topic, and are of suitable length. Short clips (5–10 minutes) that clearly show key concepts work best. These can be combined with traditional teaching methods and followed by discussions or reflection activities to deepen understanding.

V. CONCLUSION

Cinemeducation emerges as a valuable adjunct in pharmacology education, with reported benefits in enhancing student engagement, contextual understanding, and reflective thinking. Integrating short, thematically relevant film clips – addressing issues such as drug use, side effects, ethical dilemmas, and informed consent – into lectures, followed by guided discussions or reflection activities, can enrich the learning experience. Current evidence primarily highlights short-term gains; further studies are needed to explore its influence on long-term knowledge retention, professional attitudes, and clinical practice. Beyond pharmacology, cinemeducation holds potential for wider application in fields such as public health, physiotherapy, and nursing, thereby extending its educational impact.

Notes on Contributors

Dr Jyoti M. benni contributed to conceptual development of the study, conducting the literature search, reviewing the literature retrieved, synthesising the data, data analysis, writing and reviewing the manuscript.

Dr Anupama M. Gudadappanavar contributed to conducting the literature search, reviewing the literature retrieved, synthesising the data and reviewing the manuscript.

Ethical Approval

As this study is a systematic review, ethical approval is not required. The review is registered in PROSPERO – The International Prospective Register of Systematic Reviews, with the registration number CRD42024568417.

Data Availability

All reviewed articles reported in this systematic review are listed in the References section for readers to access.

Funding

The study was not funded by any funding agencies.

Declaration of Interest

The author declares no conflict of interest.

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*Dr Jyoti M. Benni
Department of Pharmacology,
Jawaharlal Nehru Medical College,
KLE Academy of Higher Education and Research (KAHER),
Deemed-to-be-University, Belagavi-590010. Karnataka. India
Email: benni_jyoti@yahoo.co.in

Submitted: 11 February 2025
Accepted: 6 October 2025
Published online: 7 April, TAPS 2026, 11(2), 22-31
https://doi.org/10.29060/TAPS.2026-11-2/RA3871

Leonaldo Lukito Nagaria¹, Sri Linuwih Menaldi² & Diantha Soemantri¹

¹Department of Medical Education, ²Department of Dermatology and Venereology, Faculty of Medicine, University of Indonesia, Indonesia

Abstract

Introduction: The culture of respect is a crucial aspect of medical learning environments. It has many positive impacts on learning, inclusivity, healthcare collaboration, and healthcare quality. Since it has not been specifically described in previous studies, this review aimed to describe the nature of respect cultivation in medical education (including its definition, assessment, exemplary actions, actors, impacts, and barriers) and thus identify the potential gaps therein.

Methods: This scoping review adapted Arksey and O’Malley’s steps for scoping reviews. Five databases (PubMed, Medline, Science Direct, Google Scholar, and Wiley) were searched, using combinations of related keywords and Boolean operators. The publication year was limited to within the last 15 years. The data analysis was performed using descriptive charting and thematic analysis.

Results: Out of 3,900 articles searched, 169 were full text screened, and 23 were included for further analysis. Six discussed themes were (1) the definition of respect, (2) assessment methods of respect, (3) exemplary actions of respect, (4) contributing actors of respect, (5) the impacts of respect, and (6) barriers to cultivating respect.

Conclusion: The nature of respect in medical education was described diversely in the studies, which lacked specific assessment instruments. Barriers to cultivating respect were reported on multiple levels (personal, interpersonal, and institutional), thus requiring multilevel-based approaches. Further studies are required to explore the theoretical framework of respect in various medical educational settings and strategic approaches for cultivating respect in each context.

Keywords:           Respect, Professionalism, Learning Environment, Culture, Medical Education

Practice Highlights

• Practices of respect might vary according to the medical education sociocultural context.
• No valid instrument to assess the culture of respect in medical education yet exists.
• Respect could enhance professionalism, trust, healthcare collaboration, and patient safety.
• Cultivating respect is challenging and should incorporate multilevel-based approaches.

I. INTRODUCTION

The learning environment comprises a complex interplay between the psychosocial, personal, and organizational aspects surrounding the educational setting (Gruppen, 2014). A supportive learning environment creates a safe learning climate, enhances professional identity formation, and nurtures students’ academic achievement (Alotiby et al., 2021). Conversely, a negative learning environment has been associated with medical students’ burnout, psychological distress, and suboptimal learning outcomes. Of all aspects, educational norms and cultures play a significant role in constructing the medical environment (Karani, 2015).

Medical educational culture is still perceived as hierarchical, with a disequilibrium in the distribution of power. In such a culture, individuals with higher social status have a better chance of gaining respect and becoming more influential toward others (Claramita et al., 2022). From the medical education perspective, the hierarchical culture has tended to produce a disrespectful culture and behaviours from faculty toward students, perceived as the inferior group (Lim et al., 2021). For instance, 85% of surveyed Indonesian medical students had experienced disrespectful behaviours from faculty, senior peers, or other health professionals (Rozaliyani et al., 2019).

In extreme cases, disrespectful actions might lead to negative consequences regarding patient care delivery, commonly termed disruptive behaviours (Leape et al., 2012). Dabekaussen et al. (2023) reported that 63% of 388 healthcare workers had experienced disruptive behaviours, such as humiliation, shaming, angry outbursts, insensitive comments, threats, and uncooperative behaviours. These behaviours might result in burnout, moral distress, workflow disengagement, and loss of trust among health professionals. More specifically, the loss of trust and workflow disorganization could contribute to higher risks of miscommunication, false decision-making, and medical errors, which threaten patient safety (Leape et al., 2012).

To foster safety in healthcare settings, respect should be cultivated from the training stage. Medical students who feel respected by their colleagues will treat patients in the same manner (Leape et al., 2012). However, the nature of respect in medical education has been expressed variously across studies. For instance, Karnieli-Miller et al. (2010) described respect as an intrinsic value of being non-judgmental to students and patients. Subramani and Biller-Andorno (2022) broadened the concept to describe attitudes and behaviours that reflect physician bioethics codes. This lack of agreement regarding the nature of respect might prevent us from deeply understanding this topic and subsequently recommending a plausible approach to cultivating respect in medical contexts.

A standardized tool to assess respect in medical education has also not been formulated yet (Karnieli-Miller et al., 2010). Numerous previous studies have attempted to measure expressed respect from a patient perspective, using the Patient Dignity Inventory tool (Aboumatar et al., 2015). Another study by Karnieli-Miller et al. (2010) used qualitative assessment to describe the culture of respect. Considering the wide range of descriptions, this study focused on describing the nature of respect in medical education and identifying the potential gaps in cultivating it. The study findings should provide new insights for medical institutions on how to more appropriately cultivate respect.

II. METHODS

This study adapted the Arksey and O’Malley (2005) scoping review protocol as its methodological guidance. The study method is divided into five appropriate steps, consecutively described below.

A. Identifying Research Questions and Relevant Studies

This scoping review aimed to address the nature of the cultivation of respect in medical education. Through prior literature scanning, we agreed on six leading research questions:

1. What are the definitions of respect throughout studies?
2. What instruments were used to assess respect throughout studies?
3. Who are the contributing actors in cultivating respect throughout studies?
4. What are the exemplary actions of respect throughout studies?
5. What are the impacts of cultivating respect throughout studies?
6. What are the barriers to cultivating respect throughout studies?

The PCC (population, concept, and context) framework was used as guidance for the literature searching and screening. The descriptors were as follows:

• Population: Any individual involved in medical education
• Concept: The nature of respect culture (definitions, assessment instruments, actors, exemplary actions, impacts, and barriers)
• Context: Medical educational settings.

B. Identifying Relevant Studies

Five online databases were used for the literature search: PubMed, Medline, Science Direct, Google Scholar, and Wiley. The search used synonymous terms (such as “respect,” “respectful,” and “dignity”), along with Boolean operators (“AND” and “OR”). The detailed search terms are described in Table 1.

The inclusion criteria were (1) studies conducted in medical education settings, (2) published during 2009–2024, and (3) written in English. The timeframe limit was selected considering that studies specifically discussing “respect” were rarely retrieved before then. The exclusion criteria comprised (1) studies that were not full-text accessible, (2) secondary studies (including reviews, commentaries, and books), and (3) studies that did not empirically assess respect. The publication years were pre-determined using the journals’ automatic search filters.

Database(s)	Searching keywords	Hits
Medline	((respect[Title/Abstract] OR respectful[Title/Abstract] OR dignity [Title/Abstract]) AND (“medical student”[Title/Abstract] OR preclinical[Title/Abstract] OR “clinical education”[Title/Abstract] OR “medical school”[Title/Abstract] OR “resident”[Title/Abstract])) AND (“learning environment”[Title/Abstract] OR culture [Title/Abstract] OR interaction [Title/Abstract] OR relationship[Title/Abstract])	1001
Science Direct	(“medical education” OR “medical student” OR “medical school” OR “resident”) Year: 2004-2024 Title, abstract, keywords: (respect OR respectful OR dignity) AND (learning environment OR culture OR relationship OR interaction)	1254
Wiley	“respect OR respectful OR dignity” in Abstract AND “medical education OR medical student OR clinical education OR medical undergraduate OR resident” in Abstract AND “interaction OR culture OR relationship OR learning environment” anywhere	652
Google scholar	Allin title: (“medical student” OR medical training) AND (“respect” OR “respectful” OR “dignity”)	486
PubMed Central	(((respect[Abstract] OR respectful[Abstract] OR dignity[abstract])) AND (medical education[Abstract] OR medical student[Abstract] OR medical undergraduate[Abstract] OR residency[Abstract] OR learning environment [Abstract])) AND (interaction OR culture OR value OR relationship)	507

Table 1. Search Strategy and Keyword Combinations

C. Study Selection

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) diagram is shown in Figure 1. The initial search of the five databases extracted 3,900 articles. After excluding duplicate articles, 2,963 were screened based on their abstracts, and 169 full-text articles underwent full-text eligibility screening. Finally, 23 articles were included.

Figure 1. PRISMA-ScR Flow Chart

D. Charting the Data

The methodological characteristics of all the studies included were visualized. Several elements were recorded, such as the authors, publication year, study type, study setting, and study population. As needed, the data were visualized using tables and appropriate graphics.

E. Collecting, Summarising and Reporting

Data regarding the culture of respect in medical education were thematically analyzed into several themes in concordance with the research questions. Then, all studies’ findings were summarized using a narrative approach, manually performed by all authors (LLN, SLM, DS).

III. RESULTS

A. Study Charting Results

23 studies were considered eligible according to the study criteria. The dataset is available in Figshare (https://doi.org/10.6084/m9.figshare.28479062). Most were published in either 2021 or 2024 (three studies each). On average, fewer than three related articles were published annually during the last 15 years. Based on geographical distribution, 21 out of 23 studies were published in Western countries, of which 14 originated from the United States. Two studies originated from Eastern countries: Malaysia (Haque et al., 2016) and Iran (Hazrati et al., 2020). One study compared cultural perspectives in Canada and Thailand (Wong, 2011).

By methodology, most (nine) studies used a cross-sectional design with a self-made survey. The others comprised six mixed-methods studies, five qualitative studies, two retrospective cohort studies, and one interventional study. The interventional study evaluated pediatric residents’ skills after they underwent focused communication training (Howell et al., 2022). The study settings were either the pre-clinical (five studies) or clinical phase (18 studies). The study details are provided in Supplementary Table 1.

1. What are the definitions of “respect” throughout studies?

Five out of the 23 studies stated the definition of respect. Klinner et al. (2024) explained that respect is a multidimensional concept, projected as three distinct concepts: (1) individual intrinsic value, (2) interpersonal relationship, and (3) organizational culture or norms. Respect is a basic humanistic value, encouraging every person to treat others the way they want to be treated (Hazrati et al., 2020). Karnieli-Miller et al. (2010) believed that every individual is worthy of respect and dignity. Klinner et al. (2024) also highlighted the importance of dignity, the universal conscience implying that every person is worthy of respect.

From interpersonal perspectives, respect was defined as attitudes of upholding adversity (Weiss et al., 2021). Respectful relationships could be expressed through politeness and kindness toward others (Curry et al., 2011). Referring to the educational environment, medical staff should appropriately perceive students as individuals who are growing and hence deserving of respectful treatment during their learning (Klinner et al., 2024). One study referred to a “respectful culture” as a supportive educational environment that embraces diversity (Weiss et al, 2021).

2. What instruments were used to assess respect throughout studies?

All studies assessed respect using either questionnaires (15 studies) or qualitative interviews (eight studies). All surveys were self-made, consisting of various questions. For example, DiBrito et al. (2024) used three questions to assess the respectful behaviours of clinical mentors toward patients, learners, and other healthcare members. Haque et al. (2016) used six questions regarding self-respect. Jauregui et al. (2016) used two questions, addressing equal treatment and respect toward healthcare coworkers.

In other studies, respect was assessed as a part of other assessed aspects, such as humanism (Hazrati et al., 2020), professionalism (Gillespie et al., 2009; Haque et al., 2016; O’Flynn et al., 2014), learning environment (Gillespie et al., 2009), communication (Verhagen et al., 2024), or healthcare collaboration (Nagraj et al., 2018). No specific instruments were developed to assess the culture of respect in medical education settings.

3. Who are the contributing actors for cultivating the culture of respect?

Figure 2 conveys the contributing actors for cultivating a culture of respect in medical education. The relevant individuals consist of medical students (Curry et al., 2011), residents (Gonzalo et al., 2014), faculty (DiBrito et al., 2024; Marquardt et al., 2022), patients (Elfassy et al., 2020), senior / peers (Haque et al., 2016), and other health professionals such as nurses (Gillespie et al., 2009). Faculty, medical students, and patients were the most reported contributors to respectful actions. Three studies also showed that respectful interactions could be mutually given by students and faculty (Hazrati et al., 2020; Verhagen et al., 2024; Wong, 2011).

Figure 2. Respectful Relationships in Medical Education

4. What are exemplary actions of respect throughout studies?

Respect in medical education can be expressed by various actions. For instance, respect might be given to students by responding to questions properly (Marquardt et al., 2022), appreciating students’ work (Ekenze et al., 2013), and giving constructive feedback (Jung et al., 2021). On the other hand, respect toward residents was shown by providing autonomous clinical guidance (Wong, 2011) and acknowledging difficulties (Verhagen et al., 2024).

Several studies also described concrete forms of respect toward faculty staff, including polite communication and active engagement during teaching (Haque et al., 2016). The details are provided in Table 2. In medical education, respect could also be regulated by the faculty or institution in the form of targeted policies, such as workload restriction and mistreatment prevention policies. Institutions could also implement specific development programmes for students or faculty as needed (Ekenze et al., 2013).

5. What are the impacts of cultivating respect throughout studies?

Sociocultural impact was the most frequently mentioned effect of a culture of respect. Respect also enhanced trust among healthcare team members and minimized hierarchical gaps (Hazrati et al., 2020). For instance, respect could be portrayed by allowing discussion regarding medical errors and dilemmatic cases (Nagraj et al., 2018), which might foster interprofessional collaboration and improve patient care quality (Klinner et al., 2024).

A culture of respect also positively impacts psychological status. With the cultivation of respect in educational settings, students and residents might develop empathy, trust, inclusivity, and a sense of belonging in the learning process. They would be less afraid of making mistakes while learning and thus feel safer expressing their opinions in such environments (Howell et al., 2022; Karnieli-Miller et al., 2010; Klinner et al., 2024). Conversely, disrespectful culture might lead to psychological stress (Weiss et al., 2021), negativity (Karnieli-Miller et al., 2010), and moral distress (DiBrito et al., 2024).

A culture of respect might boost the academic outcomes of medical students and residents by providing more learning opportunities and clinical experiences (Gillespie et al., 2009; Klinner et al., 2024). Medical teachers also played significant roles as positive role models by giving constructive feedback to foster students’ confidence, motivation, and professionalism (Raikhel et al., 2024).

6. What are the barriers to cultivating respect throughout studies?

Extracting from 11 studies, challenges in cultivating respect involved several layers, including at the personal, interpersonal, and institutional levels. The most frequent challenge to cultivating respect was related to organizational aspects, particularly due to hierarchical cultures (Abedini et al., 2015; DiBrito et al., 2024; Klinner et al., 2024; Marquardt et al., 2022; Wong, 2011) and stressful workloads (Abedini et al., 2015; Elfassy et al., 2020; Marquardt et al., 2022; Verhagen et al., 2024).

From an interpersonal perspective, negative role models (Haque et al., 2016; Weiss et al., 2021), could also hinder the cultivation of respect because they tend to portray disrespectful behaviours toward others. In one study from Western countries, racial microaggressions also represented a barrier to health professionals’ respectful interaction.
Personal barriers derived from a lack of specific skills, namely cultural sensitivity (Weiss et al., 2021) and respectful communication. Some individuals could also perceive respect differently, seeing the same behaviours as mistreatment or disrespect. For instance, some faculty might unconsciously involve certain students less in clinical experience, for which these students might feel disrespected (Ekenze et al., 2013).

Orientation	Study Count	Exemplary Actions of Respect		References
Respect toward students and residents	7		Acknowledging student/residents’ concerns Accepting sociocultural diversity among students	(Ekenze et al., 2013; Gordon et al., 2012; Haque et al., 2016; Klinner et al., 2024; Marquardt et al., 2022; Raikhel et al., 2024; Weiss et al., 2021)
			Showing a respectful manner
			Rejecting any form of bullying
			Accepting questions from students/residents
			Involvement in real clinical experiences
			Appreciating students’ work and achievements
			Giving feedback with polite language
Respect toward faculty	4		Communicating politely	(Ekenze et al., 2013; Haque et al., 2016; O′Flynn et al., 2014; Wong, 2011)
			Active engagement in teaching sessions
			Greeting staff politely
Respect toward other health professionals	7		Collaborating with other health professionals	(Curry et al., 2011; Gillespie et al., 2009; Haque et al., 2016; Jauregui et al., 2016; Nagraj et al., 2018; Palvic et al., 2018; Verhagen et al., 2024)
			Giving clear briefings to healthcare teams
			Respectfully resolving interdisciplinary conflict
			Acknowledging other professionals’ contributions
			Considering suggestions regarding patient care
			Actively listening to other professionals’ concerns
			Being willing to help with patient care
			Showing gratitude for other professionals’ work
			Courageously apologizing if necessary
			Establishing rapport with healthcare teams
Respect toward patients	12		Upholding patient privacy and dignity	(Abedini et al., 2015; Curry et al., 2011; DiBrito et al., 2024; Elfassy et al., 2020; Gillespie et al., 2009; Haque et al., 2016; Howell et al., 2022; Jauregui et al., 2016; Jung et al., 2021; Karnieli-Miller et al., 2010; Klinner et al., 2024; Palvic et al., 2018)
			Treating patients equally
			Being considerate of patients’ decisions
			Respecting patients’ boundaries while teaching
			Acknowledging patients’ feelings sincerely
			Showing empathy
			Giving compassionate care
			Actively listening to patients’ stories
			Showing professionalism in patient care
			Taking history with appropriate questions
			Communicating politely
			Involving patients’ family members Respecting others’ time (being on time)
Respect for the learning environment	1		Setting clear expectations for learning	(Clay et al., 2022)
			Maintaining positivity for learning
			Reinforcing constructive feedback
			Respecting others’ time (being on time)

Table 2. Respectful Relationships in Medical Education

IV. DISCUSSION

Fundamentally, respect is a basic moral value that applies to all. Treating other people how we would like to be treated is a basic human obligation (Hazrati et al., 2020; Subramani & Biller-Andorno, 2022). According to Darwell, respect can be generated by valuing individuals’ merit (appraisal respect) or simply by human moral conscience (recognition respect) (Subramani & Biller-Andorno, 2022). Both concepts resonate well with the humanism concept in medical education, which depends on the “respect for others” principle (Karnieli-Miller et al., 2010). Nevertheless, the theoretical framework of respect in medical education settings is still lacking.

The unique sociocultural aspects of medical education might impact how respect should be conveyed (Subramani & Biller-Andorno, 2022). For instance, respect toward medical residents could be specifically demonstrated by giving autonomy to their clinical work (Wong, 2011), which might be irrelevant in other educational settings (Subramani & Biller-Andorno, 2022). Additionally, respect toward patients could be specifically portrayed by ensuring their confidentiality, involving their beliefs in decision-making, and delivering compassionate care (Elfassy et al., 2020; Hazrati et al., 2020; Karnieli-Miller et al., 2010). For students, respect could be portrayed by delivering constructive feedback (Jung et al., 2021) and involving them in relevant clinical work (Elfassy et al., 2020).

The authors believed that cultivating respect in medical education was important for several reasons. First, medical doctors treat patients with diverse conditions and sociocultural backgrounds (Subramani & Biller-Andorno, 2022). Internalizing respect could enhance their clinical skills, particularly in effective communication, active listening, empathy, and cultural awareness (Hazrati et al., 2020), which may benefit the quality of patient care. Second, medical doctors must collaborate with other health professionals, who have their own roles and perspectives in managing patients (Nagraj et al., 2018). In terms of mutual respect, health professionals must actively recognize others’ roles and capabilities, hence promoting mutual trust and interprofessional collaboration (Croker et al., 2016).

Generally, fostering respect could nurture students’ academic outcomes and professionalism, thus creating a supportive learning environment (Klinner et al., 2024; Raikhel et al., 2024). However, this review revealed multilevel barriers to cultivating respect in medical education. Consequently, due to hierarchical cultures, many of these disrespectful behaviours were skeptically reported or even misperceived as common culture in medical education (Claramita et al., 2022; DiBrito et al., 2024; Klinner et al., 2024). Work-related stress might also be associated with a high risk of moral distress and unprofessional behavior by fellow students or faculty. Moreover, Palvic et al. (2018) reported that some health professionals might be seen as negative role models, tending to feel superior to others, which might break the sense of teamwork and respectful interaction.

Another concerning issue was that, even with a presumably less hierarchical culture (Wong, 2011), disrespectful actions were still reported in Western medical education (DiBrito et al., 2024; Weiss et al., 2021). This might be due to individualism and a lack of social communalism in Western cultures, which leads to cynicism. Cynical people express much negativity and distrust towards others, which is the core of many disrespectful acts (Stavrova et al., 2020). Some also reported that residents from Western cultures tended to show professional arrogance, which might be another challenge to cultivating respect (Wong, 2011).

Concerning practical implications, the authors proposed that respect should be cultivated using multilevel interventional approaches. At the individual level, medical institutions should promote skills that enhance respect through various approaches, such as promoting cultural sensitivity (Weiss et al., 2021) and respectful communication skills (Elfassy et al., 2020). At the interpersonal level, the sense of interprofessional collaboration should be more emphasized, especially when encountering role conflicts. Medical faculty development programme is also warranted, particularly in developing positive role-modelling and respectful feedback delivery skills.

Lastly, at the institutional level, leaders should arrange a code of conduct for respectful interactions and promote policies of respect toward students and faculty (e.g., working hour restrictions, formal reporting system for disrespectful behaviours etc.). Concrete exemplary actions and commitments from educational leaders should be mandatory; otherwise, all codes and policies would work only on paper (Leape et al., 2012; Raikhel et al., 2024).

This scoping review also highlighted several research gaps that could be further explored. The current research lacked a theoretical framework for respect cultivation in medical education, which could be different from many perspectives. For instance, respect between faculty and medical students could be different from respect toward residents or other health professionals. Secondly, no valid instrument existed to properly assess respect culture in medical educational settings. Most studies used either self-made questionnaires or other constructs containing respect as one of their indicators (Ekenze et al., 2013; Gillespie et al., 2009). This could raise an issue regarding external validity. By comparison, other studies used more standardized assessment tools, such as the Perceived Workplace Civility Climate Scale and Nursing Civility Scale (Peng, 2023).

To the best of the authors’ knowledge, this is the first scoping review to summarize the nature of respect in the medical education context. Previous reviews have mentioned respect, but not as a single entity. Respect was more likely to be integrated with broader concepts such as professionalism (Desain et al., 2022) or cultural competence (Constantinou & Nikitara, 2023). By placing more attention on respect itself, we could further explore both the theoretical construct and practical aspects to cultivating respect in medical educational contexts. While the role of organizational-level leadership has been previously highlighted (Sokol-Hessner et al, 2021), this scoping review also emphasized the roles of personal, interpersonal, and sociocultural barriers to cultivating respect.

Several limitations are acknowledged in this study. First, the literature search and thematic analysis were performed manually by the authors, which might contribute to subjectivity. Second, studies written in non-English languages were excluded due to language barriers. Consequently, some studies discussing respect, especially from local Eastern journals, might be under-reported. Much room exists for further studies, particularly discussing the theoretical framework of respect in various medical education settings and developing specific approaches to cultivate respect in such contexts.

V. CONCLUSION

Respect in medical education is a multifaceted concept. Theoretical frameworks and specific instruments to assess the culture of respect in such settings were lacking. Therefore, medical education should focus on cultivating a culture of respect because it likely enhances academic outcomes, professional development, sense of trust, healthcare collaboration, and patient safety.

Notes on Contributors

Dr Leonaldo Lukito Nagaria developed ideas and methodology, conducted literature searching, synthesized the included data, wrote the initial draft, and finalized the manuscript.

Prof Dr Sri Linuwih Menaldi, Sp.D.V.E, Subsp.D.T, FINSDV, FAADV developed the ideas and methodology, synthesized the included data, and finalized the manuscript.

Prof Dr Diantha Soemantri, M.Med.Ed, Ph.D developed the ideas and methodology, synthesized the included data, and finalized the manuscript.

Ethical Approval

Ethical approval is not necessary as no human subjects or data were involved.

Data Availability

Extracted datasets are freely accessible at (https://doi.org/10.6084/m9.figshare.28479062).

Acknowledgement

We would like to thank all the staff from the Medical Education Department, Faculty of Medicine, University of Indonesia who also contributed to giving valuable feedback and support throughout the entire process.

Funding

This research received no specific funding or grant from any agencies in any sector.

Declaration of Interest

All authors confirmed no affiliation or conflict of interest with any related institutions regarding the study materials or issues.

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*Leonaldo Lukito Nagaria
Department of Medical Education
Faculty of Medicine, University of Indonesia
Jalan Salemba Raya No 6,
Jakarta 10430, Indonesia
Email: leonaldo.lukito@ui.ac.id