Submitted: 5 March 2023
Accepted: 2 August 2023
Published online: 2 January, TAPS 2024, 9(1), 49-53
https://doi.org/10.29060/TAPS.2024-9-1/SC3016

Thamudi D Sundarapperuma^1, Eranthi Weeratunga¹, Prabhavi Wijesiriwardhana², Eranga Silva², Shanika Karunanayaka³, & Kithmini Yasarathne³

¹Department of Nursing, Faculty of Allied Health Sciences, University of Ruhuna, Sri Lanka; ²Department of Medical Laboratory Science, Faculty of Allied Health Sciences, University of Ruhuna, Sri Lanka; ³Department of Pharmacy, Faculty of Allied Health Sciences, University of Ruhuna, Sri Lanka

Abstract

Introduction: Several nations around the world had to close schools, colleges, universities, and other educational institutions as they were badly affected by the spread of COVID-19. The purpose of this study was to measure the effectiveness of online vs physical teaching during the COVID-19 pandemic, at the Faculty of Allied Health Sciences (FAHS), University of Ruhuna (UoR) Sri Lanka.

Method: A cross-sectional study was conducted among 200 undergraduates. The data were collected through displayed/approved results sheets of the students of selected batches in the Department of Nursing, Department of Pharmacy, and Medical Laboratory Science (MLS). Paired sample T-test was used to compare the results of undergraduates.

Results: The examination results of 47-54 undergraduates in nursing, 28 in pharmacy, and 22 in MLS were analysed. Significant differences in Psychiatry in Nursing and Nursing Clinical Attachment were identified in the Department of Nursing (p=0.001). In the Department of Pharmacy, only Pharmaceutical Chemistry I (p=0.012) reported a significant difference. The undergraduates of MLS who underwent online theory sessions had scored more in Microbiology and Immunology (p=0.022) and Basic Genetics and Molecular Biology (p=0.000) whereas in Research Methodology and Epidemiology, the undergraduates who participated in physical lectures had scored more marks (p=0.001).

Conclusion: Practical/interactive session-based course units and clinical appointments had a higher impact on the mode of teaching than many theoretical course units. The results might serve as a primer for the creation of an action plan to support the academics and clinical/practical components of undergraduates.

Keywords:           Undergraduates, Online Teaching, Physical Teaching, Examination Results, COVID-19

I. INTRODUCTION

The provisional closure of educational institutions during the coronavirus disease-19 (COVID-19) pandemic has unexpectedly transformed the Sri Lankan education landscape in favour of distance learning or online learning. As a result of this, drastic changes in digital platforms and applications i.e., digital learning management systems became common among universities (Ariyananda et al., 2022). These universities used existing modular object-oriented dynamic learning environment-based learning management systems (Moodle) and the Lanka Education and Research Network (LEARN) was connected to university web servers and used for online education to mitigate the effects of disrupted learning (Hayashi et al., 2020).

Online teaching was a novel experience for university lecturers and undergraduates, and it was a huge challenge for both parties. In the beginning, both parties had to face several issues due to the unfamiliarity of these novel methods, the unavailability of basic facilities, and insufficient network coverage in Sri Lanka. Though it would be an effective alternative to conduct Zoom lectures again as physical lectures once the university reopened, we were unable to conduct lectures due to limited time during the semester. Therefore, the need emerged to identify a more effective mode to deliver lectures to undergraduates. This study aims to address the effectiveness of online vs. physical teaching during the COVID-19 pandemic, by analysing the examination results at the Faculty of Allied Health Sciences (FAHS), University of Ruhuna (UoR).

II. METHODS

A cross-sectional study was conducted to measure the effectiveness of online teaching vs. traditional/physical teaching and its impact on the performance of undergraduates. The data were collected through displayed/approved results sheets of the students of selected batches in the Department of Nursing, Pharmacy, MLS, FAHS, UoR. Nursing, though considered as a separate discipline from other para-medical disciplines in other countries, is considered under the Faculties of Allied Health Science in Sri Lanka.  The examination results of two batches of undergraduates in a similar semester but who had learned in a different mode (in this group one batch has completely learned online while another batch has learned physically) were purposefully selected from each department. All lectures done via Zoom were recorded and distributed among students. Both groups underwent the same types of examination, mainly multiple-choice questions (MCQs) and short structured questions (SEQ) for theoretical knowledge. Practical and clinical skills were assessed using practical-based examination and patient-based clinical examination respectively. These examinations had been conducted in 2021 and 2022 and results were released in 2022. The analysis of results was conducted in January and February 2023.

Data from approximately 208 proper undergraduates (who sat for the first time) were analysed. The population was composed of nursing (n=108), pharmacy (n=56), and MLS (n=44) students. However, the results of repeat undergraduates were excluded. Six subjects were considered under the Department of Nursing. The number of candidates for the subjects was not equal. To analyse the effectiveness, a comparative analysis of the results of the end-semester examinations was performed by three departments separately. Mainly, in the Department of Nursing and Pharmacy the end semester examination results (two examinations/academic year) were evaluated while in the Department of MLS, the final term results were evaluated (three examinations /academic year).

Statistical Package for Social Science (SPSS) 26 software was used to analyse data. The mean and standard deviation (SD) values of the results sheets were analysed using descriptive statistics. After considering the distribution of the data set, paired sample T-test was used to compare the means of two batches. All results were regarded as statically significant at p < 0.05.

Ethical approval was obtained to analyse the published data from the Ethics Review Committee, Faculty of Allied Health Sciences, University of Ruhuna, Sri Lanka (Ref. no. 200.01.2023). Consent was obtained from all relevant authorities before taking results from the notice board.

III. RESULTS

Two batches were selected in the nursing department and each batch consisted of 54 undergraduates.  An equal number of candidates had not participated in every subject and therefore results were analysed based on students’ attendance for the different subjects.  Under the nursing department, there were six subjects for students. Four subjects out of these six subjects consisted only of theory components. One subject had both theory and clinical components and the other subject had only clinical-based examination.

All the subjects had only a theory component in the selected semester in the pharmacy department. Under the department of MLS, all subjects consisted of theory and practical components.

Submitted: 24 January 2023
Accepted: 2 August 2023
Published online: 2 January, TAPS 2024, 9(1), 42-48
https://doi.org/10.29060/TAPS.2024-9-1/SC2997

Rahizan Zainuldin¹ & Heidi Siew Khoon Tan^1,2

¹Health and Social Sciences Cluster, Singapore Institute of Technology, Singapore; ²Pre-Professional Education Office, Tan Tock Seng Hospital, Singapore

Abstract

Introduction: Singapore Institute of Technology’s undergraduate (UG) occupational therapy (OT) and physiotherapy (PT) programs are one of the first implementors of Entrustable Professional Activities (EPAs) in the respective allied health professions training. The aim of the paper is to report the outcomes of the first year of EPAs implementation in clinical practice education (CPE) and share next steps refining implementation.

Methods: A quality improvement (QI) study using the Plan-Do-Check-Act (PDCA) cycle was conducted. UG OT Year 2 and Year 3 students, UG PT Year 3 students and their clinical educators (CEs) who experienced the use of EPAs for the first time were surveyed at the end of the clinical block.

Results: There was generally high agreement (>70% agreed or strongly agreed) among all groups in using EPAs to better understand the learning objectives of CPE and practice expectations as future entry-level practitioners at conditional-registration. More than 70% of OT respondents but less than 50% PT respondents found the EPA assessment forms easy to use. Less than 60% of both program CEs did not include colleagues for EPA assessments. 55% of both OT and PT CEs found the EPA training and resources adequate. Overall, PT respondents showed lower agreement than OT respondents in five survey items.

Conclusion: The first implementation cycle of EPA in the undergraduate OT and PT CPE had mixed acceptability to the EPA assessment tools. Three strategic changes were made for the second implementation cycle., i.e., redesign of EPA-based assessment forms, training focus and ‘just-in-time’ training with streamlined resources.

Keywords:           Clinical Training, Entrustable Professional Activities, Occupational Therapy, Physiotherapy, Undergraduate, Workplace-based Assessment

I. INTRODUCTION

In 2021, the occupational therapy (OT) and physiotherapy (PT) undergraduate programs at Singapore Institute of Technology (SIT) added a novel assessment, Entrustable Professional Activities (EPAs), to the extant competency-based assessment tools in clinical practice education (CPE). EPAs are units of professional activities entrusted to a learner determined by five levels of supervision, once the learner has demonstrated the required competence (ten Cate & Taylor, 2020). OT EPAs and PT EPAs (Zainuldin & Tan, 2021) were developed and introduced to SIT CPE as part of the Ministry of Health’s review of healthcare professions’ training standards. EPA-based assessments are relevant in CPE where students perform professional activities at workplace, supervised by onsite clinical educators (CEs). Previous CPEs assessed only OT and PT student competencies using the validated Student Practice Evaluation Form-Revised Edition (SPEF-R) (Turpin et al., 2011) and the Clinical Competency and Reasoning Assessment (CCRA), respectively. Conceptually, the pairing of EPAs with SPEF-R or CCRA potentially offer CEs an opportunity to empower students through graduated levels of entrustment supported by appropriate proficiency levels. Operationally, EPA assessment does not add new activities. OT and PT CEs can utilise routine observations of students’ tasks, case discussions and case-notes documentation as sources to inform entrustment levels in EPAs.

No EPA implementation in any OT and PT curricula has been documented. At SIT, EPA implementation in CPE needs evaluation. Recognising that implementing process changes requires an iterative approach, SIT embarked on a quality improvement study using the Plan-Do-Check-Act (PDCA) cycle. This paper reports the results of operationalising EPAs for the first time in OT and PT CPE, including the use of EPA-based assessment forms. The Methods section describes the Plan and Do, followed by the Results section reporting outcomes of the Check and the Discussion section highlighting the Act to improve implementation.

II. METHODS

A. CPE Structure

OT CPE consists of four blocks of seven weeks each and interspersed between academic modules in Years 2, 3 and 4. PT CPE consists of five consequent blocks (four core and one elective) of six weeks each, begins only after all academic modules are completed in Year 3 and continues to Year 4. OT and PT students complete different clinical settings for each CPE block.

B. Participants and Study Design

OT Year 2 and Year 3 students, PT Year 3 students and their CEs who experienced EPA use for the first time were surveyed at the end of a clinical block. An online EPA survey is incorporated with routine post placement feedback for both students and CEs, therefore no consent was required. The QI study was exempt from ethics review (SIT Institutional Review Board, No. 2022122). Survey results were extracted from February to December 2021.

C. PDCA Cycle: Plan-Do

OT and PT have five core EPAs each. EPA-based assessment activities are short practice observations, entrustment-based discussions and case-notes evaluations. These activities serve as sources of information (SOIs), or workplace-based assessments (WBAs) in OT CPE, to inform entrustment decision-making. OT CE assesses EPAs by documenting in a single patient case form with all three WBAs per EPA. PT CE assesses EPAs for every patient case anchored by three different SOI forms with written justifications. OT and PT CEs and students were trained on nuts and bolts of EPAs and on using WBA/SOI forms in CE training workshops and student pre-CPE briefing, respectively.

Each OT EPA requires a total of six patient cases entrusted to students at Level 3 entrustment (indirect supervision) across four CPE blocks. Each PT EPA requires six cases at Level 3 entrustment at each core clinical block, which totals 24 cases by end of the program. Appendix 1 and 2 provides visualisation of EPA implementation across multiple CPE blocks.

The EPA survey has ten items. The first eight items are scored on a 4-point Likert-scale (strongly disagree-strongly agree). The final two questions seek qualitative feedback on benefits and challenges and suggestions for improvements. Unless indicated, items are phrased in the same manner in both student and CE surveys.

D. Data Collection and Analysis

Data were counted as proportions of respondents who agreed (pooled response from ‘agree’ and ‘strongly agree’) and proportions disagreed (pooled from ‘disagree’ and ‘strongly disagree’). The authors grouped the qualitative narrative into benefits and challenges.

III. RESULTS

A. PDCA Cycle: Check

There were 99.0% response rate from OT Year 2 students (105/106), 97.7% from Year 3 OT students (85/87), 93.2% from PT Year 3 students (137/147), 98.5% from OT CEs (199/202) and 92.5% from PT CEs (247/267). Proportion of respondents who agreed with each item statement is shown in Table 1. Data on item scores for each student and CE are available at online repository, http://doi.org/10.6084/m9.figshare.21941288

Submitted: 5 April 2023
Accepted: 17 August 2023
Published online: 2 January, TAPS 2024, 9(1), 28-35
https://doi.org/10.29060/TAPS.2024-9-1/OA3035

Aminda Faizura Omar, Tun Yasmin Iffah Mohd Suria Affandi, Mohd Isyrafuddin Ismail, Mas Suryalis Ahmad & Ilham Wan Mokhtar

Comprehensive Care Centre of Studies, Faculty of Dentistry, Universiti Teknologi MARA, Malaysia

Abstract

Introduction: This study was undertaken to investigate students’ perceptions of innovation-integrated learning, adopted as an alternative approach for special care dentistry (SCD) training.

Methods: Ninety final-year dental students from the 2021 cohort were divided into eight groups to complete an innovation project dedicated to eight categories of patients with special health care needs. Discussion and final presentations, involving related experts were conducted remotely via an online platform. Then, students were invited to answer a validated online feedback survey on their perceptions of the learning approach.

Results: The response rate for the feedback survey was 91.1% (n=82). Most students agreed that the activity was interesting, improved their knowledge and understanding of SCD, allowed engagement between peers, supported sharing of ideas and experiences, encouraged student–lecturer interactions, and enhanced knowledge integration and application. Students also expressed that the activity enhanced creativity and innovation, instilled an interest and positive attitude toward learning SCD, and encouraged teamwork. However, a few students noted facing some limitations in completing their projects (i.e., technological challenges and reduced physical access to purchase materials). Around half felt neutral about having an increased workload from this activity. Moreover, perceptions differed regarding time and financial commitments, as well as supervisors’ and patients’ involvement during the project development process.

Conclusion: Students perceived that the innovation-oriented learning activity, was beneficial in multiple aspects of SCD training.

Keywords:           Innovation, Learning, Dental Students, Perception

Practice Highlights

• We have developed a new integrated teaching method via the utilisation of innovation development for special needs groups.
• Students’ perceptions of this learning method were explored using both quantitative and qualitative methods via an online feedback questionnaire.
• Overall, students positively responded to the teaching method when it came to improving their knowledge and understanding of SCD, engagement between peers, sharing of ideas and experiences, student–lecturer interactions, and knowledge integration and application.
• This novel teaching method achieves the highest level of Bloom’s Taxonomy which is to create something new.

I. INTRODUCTION

Special care dentistry (SCD) involves managing patients with special health care needs, such as those with physical, intellectual, psychological impairments as well as complex medical conditions (Royal Australasian College of Dental Surgeons, 2021). At the undergraduate level, many teaching and learning activities have been conducted to provide students with learning experience in this area of patient care. These activities include lectures, community-based learning, simulation exercises and clinical training (Ahmad, Mokhtar, et al., 2020; Mohamed Rohani & Mohd Nor, 2021). Students who received training in SCD were found to have demonstrated better comfort and attitudes in managing patients with special health care needs (Mohamed Rohani et al., 2021).

However, these learning activities may be compromised by situations that limit face-to-face interactions, either among students, between teacher and learners, as well as with the patients. Such situations may happen due to disease (such as the recent COVID-19 pandemic), geographical barriers and accessibility issues (Amir et al., 2020). It was found that limitations of dental training that requires physical contact may compromise students’ learning experience, thus affecting their competency, knowledge and confidence in patient care (Chang et al., 2021).

Meanwhile, it has become incumbent on dental education providers to prepare future graduates with essential skills that are deemed beneficial for practicing health care professionals. These skills include innovation, leadership, critical thinking and enterpreneurial abilities (Malaysian Dental Council, 2021). Acquisition of these abilities have been associated with many aspects of personal and professional development including emotional intelligence and practice management (Saleem et al., 2019; Wang et al., 2020).

In view of the various challenges and demands of the current (and future) educational environment and healthcare needs, an innovation-integrated educational approach was developed and adopted as an alternative teaching and learning method to teach SCD. This approach, undertaken mostly remotely using an online learning platform, involved the integration of students’ cognitive function, psychomotor ability, and affective skills through the development of innovative products to address oral health issues experienced by the different categories of patients with special health care needs. As a novel educational approach, assessment of its effectiveness is therefore essential. This study was undertaken to investigate students’ perceptions of the innovation-integrated learning, conducted remotely via an online platform, developed during the COVID-19 pandemic, as an alternative approach for SCD training.

II. METHODS

A. Study design

This was a descriptive, cross-sectional, quantitative and qualitative study, using a validated online feedback questionnaire involving the final-year undergraduate students of the Bachelor of Dental Surgery program of the Faculty of Dentistry, Universiti Teknologi MARA.

B. Study Population

Because this module is a compulsory component of the final-year undergraduate dental curriculum (Faculty of Dentistry, 2022), all students were required to be involved with the group innovation project. However, participation in the online feedback survey was voluntary. At the beginning of the semester, the students were made aware of the study and that their participation in the innovation program and the research were treated separately.

All students who agreed to participate in the online feedback survey provided informed consent, attached to the information sheet supplied to all potential participants via their official university email. To avoid coercion, students were provided with an explanation in the information sheet that their participation was entirely voluntary and anonymous. Those who wished not to participate in the online feedback survey would not be penalised, and they could withdraw their participation at any point without having to provide a justification.

C. Study Instrument

The questionnaire used for the online feedback survey was adopted from the study by Rowe and Wood (2008). It was content-validated by a panel of 2 experts in dental education before its use in the main survey. From the item-level content validatiy index (I-CVI) for each item as well as a summation of the I-CVI divided by the number of average (S-CVI/Ave), a  score of 1 was obtained for both indices as the  panelists rated all items with a score of 3 or 4. The questionnaire consisted of nine items about the perception of students towards this teaching method, measured using a 5-point Likert scale (strongly disagree, disagree, neutral, agree, and strongly agree). Open-ended questions were included at the end of the questionnaire to further explore students’ perceptions of the learning activities.

D. Study Conduct

For the group innovation project, all final-year students (n=90) were divided into eight groups, based on their assigned clinical groupings. Each group was assigned to an academic or clinical specialist in SCD, who acted as a supervisor. Eight categories of patients with special health care needs were identified and randomly allocated to the different groups. The categories of patients were 1) hearing disability, 2) speech disability, 3) visual disability, 4) geriatric, 5) Down syndrome, 6) autism, 7) cerebral palsy, and 8) dementia.

Students were given three months to develop innovative products. They were expected to engage with their supervisors during the whole development process, which involved 1) identification of health complications related to the condition and its impact on oral health, 2) understanding of issues related to patients’ oral health care; 3) creation of a prototype to address the related oral health–related complications. Because all students were at the time subjected to restrictions in having physical classes due to COVID-19 (Samat et al., 2020), large-group discussions and final presentations were undertaken remotely online.

At the end of this group activity, an online presentation, judged by experts in related fields, was conducted as a form of assessment, as well as constructive feedback on improvements and the marketability of the product. Students were then invited to participate in the online feedback questionnaire, which was distributed via their official university email. An English language questionnaire was used as the respondents were undergraduate dental students with a good command and understanding of the language. A reminder email was sent a week later, with another reminder sent the following week.

E. Data Analysis

To maximise the outcome, quantitative data were simplified into a 3-point Likert scale (agree, neutral, and disagree). Using SPSS version 27, the frequency of the data was analysed to compare students’ responses for each item. For analysis of the benefits, the nine items of the questionnaire were further categorised into different themes: Theme 1—Acceptance of the teaching method concept (Item 1), Theme 2—Effectiveness of teaching method (Items 2, 3, 6, and 7), Theme 3—Important role of supervisors (Items 4, 5, and 8), and Theme 4—Impact on students’ workload (Item 9).

For the qualitative component, data were analysed via thematic analysis involving open and closed coding. Emerging themes were then identified based on these codes, which were then validated through comparisons amongst researchers.

F. Ethical Approval

Ethics approval was obtained from the Research Ethics Committee (REC) Universiti Teknologi MARA, Malaysia, in accordance with the Declaration of Helsinki (REC12/2021 [MR 1004]).

III. RESULTS

A total of 82 out of 90 students returned the questionnaire, giving a response rate of 91.1%. The frequency of responses for each question or item, categorised into the different themes, is shown in Table 1.

Submitted: 30 January 2023
Accepted: 2 August 2023
Published online: 2 January, TAPS 2024, 9(1), 20-27
https://doi.org/10.29060/TAPS.2024-9-1/OA2999

Mitsumi Masuda, Naomi Kimura & Akemi Nakagaki

Graduate School of Nursing, Nagoya City University, Japan

Abstract

Introduction: The level of BLS achievement at the end of basic education is not clear, so to develop a BLS training program using QCPR Learner^Ⓡ and to verify its effectiveness.

Methods: A quantitative descriptive study design was used. The developed BLS program was implemented for 81 fourth-year students at the school of nursing. The program consisted of 2 minutes of training per student and real-time feedback by QCPR Learner^Ⓡ as well as feedback among students and from faculty members and was conducted twice for each student. Evaluation was conducted from three aspects: learner response and program evaluation both using questionnaires, learning achievement of QCPR score.

Results: The mean values of learners’ responses before and after the program were: attention, 4.32 before and 4.59 after; relevance, 4.48 before and 4.75 after; confidence, 2.32 before and 3.78 after; and satisfaction, 2.12 before and 3.41 after, which increased significantly after the program. The QCPR Learner^Ⓡ scores increased significantly from 74.08 for the first time to 86.76 for the second time. In the free response, some respondents stated that “visualisation of the procedure by the application improved my skills.”

Conclusion: The results of the evaluation from three aspects showed that this program was effective in improving students’ motivation to learn and skills.

Keywords:           Basic Life Support, Real-Time Feedback, Basic Nursing Education, Simulation Training, QCPR Learner

Practice Highlights

• Real-time feedback application was effective in increasing motivation to learn and BLS skills.
• QCPR Learner^Ⓡ can be easily installed on the learner’s device, making it suitable for self-learning.

I. INTRODUCTION

Submitted: 10 April 2023
Accepted: 15 May 2023
Published online: 3 October, TAPS 2023, 8(4), 59-60
https://doi.org/10.29060/TAPS.2023-8-4/LE3036

Siti Suriani Abd Razak, Bhavani Veasuvalingam, Pathiyil Ravi Shankar & Norul Hidayah Mamat

IMU Centre for Education, International Medical University, Malaysia

Dear Editor,

We read the article titled ‘Involving stakeholders in re-imagining a medical curriculum’ (Foster, 2022) with great interest. We would like to share our experiences and extend the importance of stakeholder involvement in postgraduate health professions education programmes (PGHPE). These programmes are utilised by educators for skills development, career progressions and advancement of health professions education across various health professions. Our institution started accredited PGHPE programmes in 2018 to equip health professional educators within and outside our institution with competencies to deliver evidence-based education and impact graduate outcomes positively. Our curriculum review conducted in early 2023, began with a stakeholder engagement meeting involving students, facilitators, alumni, employers, and ‘institutional partners’ (national and international HPE experts). Focus group discussions were held on four areas: (1) HPE ‘Industry’ institutional Needs and Graduate Competencies, (2) Student Experience, (3) Scholarship in HPE, and (4) Inter-Institutional Partnership and Collaboration.

Four key outcomes emerged from the engagement. The four outcomes were increased educators’ competency, digitalisation in health profession education, supporting scholarly work and publication and widening the scope of learning with global engagement.

The first theme of increased educators’ competency is related to the value of our PGHPE programmes. Our alumni strongly felt their teaching and learning competencies were enhanced and they were more confident in accepting leadership roles. Greater emphasis on contextualisation was requested for example local and regional accreditation frameworks. Stakeholders jointly highlighted the increasing use of artificial intelligence (AI) in HPE and emphasised that both awareness of and being able to work with digital tools is important. The use of AI in curriculum design, review and assessment may need greater emphasis. Greater HPE student engagement with online learning tools and assessments to promote deep learning was firmly echoed by our stakeholders.

The need for greater support to facilitate educational research and the possible formation of research consortiums was widely agreed upon by participants. The team has identified and initiated Health Professional Educational Research Clusters to facilitate HPE students achieve this goal. The final theme focused on widening engagement and collaboration. The centre’s strong international collaboration provides opportunities for HPE students to share ideas and thoughts and enhances networking and collaboration.

As a postgraduate programme, the number of alumni is more limited, and are educators with work experience, hence stakeholder involvement becomes more valuable to programme developers. Importantly, postgraduate programmes provider can utilise stakeholder engagement and feedback during different stages in a developmental manner.

Notes on Contributors

Siti Suriani Abd Razak organised and conducted the stakeholders’ engagement meeting, conceptualised and wrote the manuscript and approved the final version.

Bhavani Veasuvalingam organised and conducted the stakeholders’ engagement meeting, conceptualised, revised the manuscript and approved the final version.

Pathiyil Ravi Shankar organised and conducted the stakeholders’ engagement meeting, conceptualised, revised the manuscript and approved the final version

Norul Hidayah Mamat organised and conducted the stakeholders’ engagement meeting, revised the manuscript and approved the final version.

Acknowledgement

We would like to thank Professor Vishna Devi Nadarajah and Professor Er Hui Meng for their support and feedback in the process of conducting the stakeholders engagement meeting and writing this letter.  

Funding

No funds, grants, or other support were received. 

Declaration of Interest

No conflicts of interest are associated with this paper.

References

Foster, K. (2023). Involving stakeholders in re-imagining a medical curriculum. The Asia Pacific Scholar, 8(1), 43-46. https://doi.org/10.29060/TAPS.2023-8-1/SC2807

*Siti Suriani binti Abd Razak
No 126, Jalan Jalil Perkasa 19
Bukit Jalil, 47000
Kuala Lumpur, Malaysia
+6019-4429985
Email: sitisuriani@imu.edu.my

Submitted: 14 March 2023
Accepted: 31 March 2023
Published online: 3 October, TAPS 2023, 8(4), 57-58
https://doi.org/10.29060/TAPS.2023-8-4/LE3021

Tomoko Miyoshi¹, Mikiko Iwatani² & Fumio Otsuka¹

¹Department of General Medicine, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Japan; ²Department of Nursing, Okayama University Hospital, Japan

It was found that the excess mortality rate for U.S. physicians was considerably lower during the COVID-19 pandemic than in the general population, but more physicians died than expected when compared to pre-pandemic levels. These results suggest that appropriate infection control measures can reduce mortality; however, additional measures are needed.

During the COVID-19 pandemic, there have been many reports of burnout among healthcare professionals (HCPs). Although no causal relationship has been established, it is acknowledged that it would be difficult to pay attention to mental health issues and the creation of a healthy work environment during a pandemic.

Globally, the COVID-19 pandemic has subsided, but what have we learned from this COVID-19 pandemic?

We conducted six online significant event analyses (SEAs) in collaboration with facilities providing administrative support, nursing care, and medical care for COVID-19-infected individuals in March 2022. The participants were limited to HCPs and healthcare students. The presentations were based on actual cases of COVID-19-infected patients, focusing on the struggles of their positions and efforts to overcome them. Seventy-three people participated, and 38 responded to the post-event survey (52.1% response rate). Twenty respondents (52.6%) were satisfied, and 16 (42.1%) were very satisfied with this initiative, with gratitude for having the reflection.

SEA, a method of reflection, is a learning process in which recognition of one’s feelings is important (Henderson et al., 2002). HCPs are always considered to be engaged in reflective practices. However, during the COVID-19 pandemic, there were issues that were insufficient to transfer previous experiences. However, in the case of the COVID-19 pandemic, “reflection in action” was not sufficient to overcome the challenges, and the SEA may have served as a place for “reflection on action” to prepare for the next stage of the COVID-19 pandemic.

Furthermore, this SEA provided an opportunity to recognise the existence of “common humanity,” which is one of the three elements of self-compassion (the ability to understand that people other than oneself are also suffering). It is believed that, through the SEA, the HCPs were able to become aware of the feelings of other HCPs. It has been reported that increased self-compassion increases compassion for others (Neff & Germer, 2013), and the increased self-compassion of HCPs may increase their compassion for other HCPs and patients.

In the COVID-19 pandemic, reflection among healthcare providers beyond the facility may enhance self-compassion and compassion for others in preparation for the next pandemic, which may lead to HCPs’ well-being.

Notes on Contributors

T Miyoshi conceptualised and wrote the manuscript and approved the final version.

M Iwatani conceptualised and approved the manuscript.

F Otsuka supervised and edited the manuscript.

Funding

There is no funding provided.

Declaration of Interest

There is no conflict of interest, including financial, consultant, institutional or otherwise for the author.

References

Henderson, E., Berlin, A., Freeman, G., & Fuller, J. (2002). Twelve tips for promoting significant event analysis to enhance reflection in undergraduate medical students. Medical Teacher, 24(2),121–124. https://doi.org/10.1080/01421590220125240 

Neff, K. D., & Germer, C. K. (2013). A pilot study and randomized controlled trial of the mindful self-compassion program. Journal of Clinical Psychology. 69(1), 28–44. https://doi.org/10.1002/jclp.21923

*Tomoko Miyoshi
2-5-1 Shikata-cho, Kita-ku
Okayama, 700-8558, Japan
+81-86-235-7342
Email: tmiyoshi@md.okayama-u.ac.jp

Submitted: 4 February 2023
Accepted: 19 April 2023
Published online: 3 October, TAPS 2023, 8(4), 53-56
https://doi.org/10.29060/TAPS.2023-8-4/CS3003

Maximilian Andreas Storz¹ & Rintaro Imafuku²

¹Department of Internal Medicine II, Center for Complementary Medicine, Faculty of Medicine, Freiburg University Hospital, University of Freiburg, Germany; ²Medical Education Development Center, Gifu University, Japan

I. INTRODUCTION

International medical electives are a central component of the academic curriculum in many medical schools and universities worldwide (Storz, 2022). As short-term clinical immersion experiences, abroad electives are essential in connecting medical faculties and academic hospitals around the globe. They foster cross-cultural exchange, medical skill training, as well as professional identity formation (Imafuku et al., 2021; Storz, 2022). From a global health perspective, abroad electives provide medical students with an opportunity to gain a better understanding of healthcare and medical education in an international context.

Historically, some countries cultivate close relationships in this regard. One example is the bilateral relation between Japan and Germany, which is characterised by a strong economic cooperation and close political dialogue (Hook et al., 2011). As pluralistic democracies, both share fundamental values and are closely tied in many socioeconomic aspects. Traditionally, there has also been a strong partnership in medical sciences between both countries (Horowski, 2018).

Japan is traditionally a popular destination for German-speaking medical students (Storz et al., 2021), and the most frequently reported elective destination in Asia. Nevertheless, little is known about student’s elective experiences in Japan. To address this gap, we reviewed four German open-access online-databases cataloguing elective testimonies and extrapolated key elective characteristics that may allow for a better understanding of abroad elective experience in Japan.

II. METHODS

The employed analysis method with its strengths and drawbacks has been described elsewhere (Storz et al., 2021). In brief, we analysed the 4 largest German open-access clinical elective reports databases called “Famulatur-Ranking” (www.famulaturranking.de), “PJ-Ranking” (www.pj-ranking.de), “ViaMedici” (https:// www.thieme. de/viamedici/medizin-im-ausland-ausland saufenthalt-allgemein-1627.htm), and “Medizinernach-wuchs” (www.medizinernachwuchs.de). Databases allow students to anonymously rate medical electives and to share their experience by uploading reports on a voluntary basis. Key information necessary to upload a report include the precise elective destination (e.g. country, city, hospital name), the elective year, the elective discipline and duration, a subjective elective rating (ranging from 1 to 6, whereby 1 is the best and 6 is the worst grade), and a short comment allowing a brief narrative summary of the elective experience. Generally, elective ratings refer exclusively to a subjective “overall elective experience”, and are not based on a clear rubric to guide students in their rating process. The databases’ search function was used to filter Japan-specific electives. For this particular analysis, all electives from 2005 onwards were considered. Databases were reviewed in September 2022 and data pertaining to any kind of clinical elective experience in Japan was then extrapolated to a Microsoft Excel-File.

III. RESULTS

We extrapolated n=36 Japan elective reports uploaded until 2020. Tokyo was the most frequently reported elective destination, accounting for 47% of reports (n=17), followed by Kyoto (11%, n=4). The remaining elective destinations are shown in Figure 1, which displays regions (coloured) and prefectures of Japan.

Figure 1. Elective destinations in Japan: An overview. Modified from TUBS (https://commons.wikimedia.org/wiki/File:Regions_and_Prefectures_of_Japan_no_labels.svg), based on a license under the Creative Commons Attribution-Share Alike 4.0 International license.

General surgery was the most frequently reported discipline (30.56%, n=11), followed by internal medicine (22.22%, n=8). Surgical disciplines accounted for 45% of reported electives (n=16), whereas internal medicine (including subspecialties) accounted for 1/3 of reports (n=12). The following disciplines accounted for n=3 reports each: Gastroenterology, Gynaecology, Neurology and Radiology.

Thirty-three students shared organisational details of their electives. More than 60% of electives were self-organised (n=20). Thirty-nine percent of electives (n=13) were organised through a bilateral international elective exchange program where a Japanese university partnered with a German university based on a signed memorandum of understanding.

Eight students possessed Japanese language skills to a varying degree (22.22%). Three students reported learning Japanese for one year, while one student learned Japanese for more than two years. The remaining four students did not share any information about their level of Japanese language skills. Despite the rather low percentage of students speaking Japanese, the vast majority of students rated their overall experience in Japan as excellent (grade: A, n=26). Of 28 students, two students rated their elective with the grade B.

Students reported a diverse set of gratifying elective experiences. The large majority of reports (n=33, 97.22%) highly appreciated the Japanese hospitality and the high level of social manners. More than half of students (n=19, 52.78%) reported the impression that students were generally highly respected in Japan. Frequent high-quality teaching and a thorough elective organisation were frequently mentioned (n=27 and n=29 mentions, respectively). Students also valued that they received clear instructions on the first elective day, often receiving in the form of a timetable or schedule, detailing their assignments, classes and teaching opportunities. Fourteen reports explicitly mentioned that a contact person at the international office was always available for questions, and reported their elective to be first-class in terms of organisation and structure.

Many students were surprised that students are denied hands-on experience in Japan by law prior to graduation, although this is usually explicitly mentioned on the elective program homepages. Almost 42% of students (n=15) valued that their hosting institution organised social and cultural events, including get-togethers and language courses. Eating-out after work with other hospital staff was considered an important and highly appreciated team-building strategy.

One third of students (n=12) stated that they received enough free time to explore the Japanese culture. Finally, n=5 students (13.89%) expressed their appreciation for the high technical standard in Japanese hospitals, particularly in terms of medical equipment and workflow.

IV. DISCUSSION

Our descriptive analysis allows for various helpful insights into German medical students’ destinations and experiences during their Japan elective. Students reported gratifying experiences and emphasised the very good organisation of electives in Japan.

Such information may be of paramount importance for host institutions because incoming students may be a double-edged sword. Hosting elective students is time-consuming and requires human resources. In some cases, international elective students may negatively impact the local community in terms of patient care and resource allocation (Storz et al., 2021), Then again, well-structured electives may also increase the reputation of hosting institutions and help foster bidirectional and transnational academic exchange.

As in most cases, benefits and downsides of electives are context-specific, and depend on local elective program structures. Here, students valued their electives and reported a substantial amount of gratifying experiences. Several students explicitly mentioned that their Japan elective was the “best elective during [their] entire time at medical school”. Understanding incoming students’ perspectives is vital for host institutions, and may benefit them in multiple dimensions, e.g. when tailoring elective programs. This may apply in particular to the post-COVID-19 era, where an increase in international student mobility is expected (Storz, 2022). In this context, it is worthy to mention that the majority of electives in our sample was self-organised. Host institutions should be prepared for receiving an increasing amount of elective applications in the post-pandemic years, where the elective landscape will likely be characterised by a more competitive seat-to-applicant ratio.

The reservation must be made that our analysis builds on a small convenience sample (n=36) that is not representative of German medical students in general (Storz et al., 2021). Additional interesting aspects, for example as to whether clinical experiences in Japan affected students’ career or future goals, were not ascertainable from our data. In addition, we were unable to measure whether Japan electives strengthened student’s clinical skills. Our data predominately suggested an increase in cultural competences but due to the cross-sectional nature of our data no reliable statementa can be made. For this, an interview-based approach utilising focused interviews with returnee students would have been more suitable. Regrettably, such an approach was hardly realisable during the past pandemic years.

V. CONCLUSION

Our results enable hosts to understand why foreign students seek electives at their institutions. Said information might be of paramount importance for elective organisers, since well-structured electives may increase the reputation of hosting institutions and help fostering transnational academic exchange.

Notes on Contributors

Maximilian Andreas Storz conceputalised the study, collected the data, performed the formal analysis, wrote the first draft of the manuscript, and approved the final version submitted.

Rintaro Imafuku contributed to the project administratition, supported the visualisation and criticially revised the manuscript for important intellectual content and approved the the final version submitted.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Interest

The authors declare that they have no competing interests.

References

Hook, G. D., Gilson, J., Hughes, C. W., & Dobson, H. (2011). Japan’s International Relations: Politics, economics and security (3rd ed.). Routledge. https://doi.org/10.4324/9780203804056

Horowski, R. (2018). Japanese medicine and Berlin: A very special and successful relationship. Journal of Neural Transmission, 125(1), 3–7. https://doi.org/10.1007/s00702-017-1800-1

Imafuku, R., Saiki, T., Hayakawa, K., Sakashita, K., & Suzuki, Y. (2021). Rewarding journeys: Exploring medical students’ learning experiences in international electives. Medical Education Online, 26(1), Article 1913784. https://doi.org/10.1080/10872981.2021.1913784

Storz, M. A., Lederer, A.-K., & Heymann, E. P. (2021). German-speaking medical students on international electives: An analysis of popular elective destinations and disciplines. Globalization and Health, 17(1), Article 90. https://doi.org/10.1186/s12992-021-00742-z

Storz, M. A. (2022). International medical electives during and after the COVID-19 pandemic – current state and future scenarios: A narrative review. Globalization and Health, 18(1), Article 44. https://doi.org/10.1186/s12992-022-00838-0

*Maximilian Andreas Storz
Hugstetter Str. 55
79106 Freiburg im Breisgau, Germany
+49 15754543852
Email: maximilian.storz@uniklinik-freiburg.de

Submitted: 19 February 2023
Accepted: 10 July 2023
Published online: 3 October, TAPS 2023, 8(4), 50-52
https://doi.org/10.29060/TAPS.2023-8-4/PV3007

Nathasha Luke¹, Reshma Taneja¹, Kenneth Ban², Dujeepa Samarasekera³ & Celestial T Yap¹

¹Department of Physiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; ²Department of Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; ³Centre for Medical Education, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

Health Professional Education has considerably evolved over the years. Traditional classroom teaching has shifted to blended learning modalities, and clinical teaching has embraced virtual reality and simulation-based learning.

Education is poised for another major change with the development of artificial intelligence (AI) models that can emulate human-like intelligent behaviour, particularly in the field of large language models (LLM) that are capable of generating text in response to user input. There has been remarkable progress in the development of these models, with each iteration having an increasing ability to generate human-like responses to user input.

In November 2022, Open AI released ChatGPT. This marked a major milestone in the ability of LLMs. This leap in performance was driven in part by the training of the model on large text datasets from various sources such as books, articles, and websites. It was combined with supervised learning and reinforcement learning to fine-tune the model based on human feedback about the quality of the output. This was further augmented by the release of GPT-4, a further advanced version in early 2023.

A study demonstrated that ChatGPT was able to pass or preform at near parsing threshold in the United States Medical Licensing Examination (USMLE) (Kung et al., 2023). Also, ChatGPT passed a law entrance examination at a level equivalent to a C+ grade (Kelly, 2023). These studies highlight the potential of modern LLMs to impact education.

Despite its impressive performance, LLMs have limitations. These caveats notwithstanding, when educators and students are aware of the capabilities and limitations, LLM tools could provide opportunities to improve the way we teach and the way students learn. More evidence is needed to depict a specific model as if how this technology could be incorporated. This article particularly focuses on capabilities and limitations of LLMs in the context of medical education with suggestions on how this technology might be used. There is a huge scope for discussion on the impact of LLMs in various dimensions of medical education. However, we limit this discussion to commonest domains pertaining undergraduate medical education.

Being widely available and accessible to educators and students around the world including resource poor settings, LLMs promote equity in medical education.  Certain educational institutes have customised learning platforms to support student learning while such amenities are not accessible in resource poor settings.  On the contrary, the technology of LLMs could at least partially counterbalance such shortages promoting equity.

In addition, Universities in resource-poor settings often find inadequate number of educators as a barrier to implement new teaching strategies and curriculum reformation, particularly with the shifting paradigms to competency based medical education (Ramanathan et al., 2022). Effective incorporation of LLM tools could ease their workload to some extent, providing more time to explore new teaching pedagogies and scope for curricular reformations.  

LLM tools are being adopted in medical education, and assistive in both clinical and non-clinical settings, as discussed below. In non-clinical settings, the following are some areas where LLMs are helpful.

From an educator’s perspective, LLM tools are helpful in generating summaries, quizzes, and flashcards to make the learning interesting.

From learners’ perspective, LLM tools can generate customised information within a short span of time. For example, we may ask the LLM tool to answer a question ‘at a level of a medical student’ or ‘at the level of a resident’, to generate distinct responses. This will assist students in self-learning and understanding difficult concepts. LLM tools are also helpful in generating mnemonics, poems, and flashcards. Students who are not native English speakers will have the added advantage of AI tools being assistive in improving language skills. 

Additionally, LLMs are assistive tools in many stages of research including design and development, implementation, literature survey and data analysis.

There is emerging literature illustrating capabilities of LLMs as useful tools in medical practice (Lee et al., 2023). Though there aren’t many publications evaluating implications of current LLM technology in the domain of clinical education per -se, this technology is likely to be helpful in the development of skills such as history-taking and doctor-patient communication. Customized chatbots have been used by some medical schools to improve history-taking skills. Development of such tools are not affordable in resource-poor settings. LLM tools such as ChatGPT are not capable of ‘acting’ as a model patient to practice history taking. However, they can guide students to formulate relevant questions for effective history-taking in specific scenarios. Students should not be encouraged to use AI tools as the sole reference to guide the task, rather use it as an adjunct to ones’ thought process. For instance, if a student encounters a patient with palpitations, he or she should brainstorm based on theoretical knowledge to formulate relevant questions to be asked in history taking. An LLM tool can be an adjunct to ‘cross-check’ if all salient points were captured.

LLMs could potentially be assistive in improving patient communication skills among students and junior doctors.AI systems could aid in generating facts that are comprehensible to non-medical personnel. This ability is particularly helpful for students in generating content to practice patient communication skills. Accuracy and suitability of such information should be objectively assessed, before recommending LLM tool use for this purpose.

The LLM technology is a tool that can augment the process of multi- dimensional education, encompassing competency-based approaches to education, in addition to discipline-based education. This multidimensional approach comprises knowledge along with various other skills including professionalism, communication, practice-based learning, and patient care. This approach demands more commitment from students and educators and requires more learning resources. With the emergence of more sophisticated AI technologies, harnessing of LLM capabilities could be explored as future learning resources to be developed.

Unbundling and rebundling the curriculum is a concept that emphasizes revising the existing curricula by combining various educational resources including textbooks, lectures and web-based resources (Morris et al., 2018). This is pertinent to the multi-dimensional approach discussed above. The advances in current LLM tools have the potential to become an integral component of the curriculum bundle to meet the demands of reformations in modern medical education. 

Potential negative implications of LLM tools have caused anxiety among educators. Firstly, the content generated may not be accurate at all times. LLMs generate responses from language patterns learnt from the training data and not from a deeper understanding of a subject. This is also compounded by the inability of some LLMs to link to external resources to gauge the validity of the output. Another limitation of the current LLM technology is ‘hallucination’ to create non-existent or wrong information in a convincing manner. (Lee et al., 2023) Consequences of such information could cause huge impact particularly in patient safety in medical education.  

LLMs have potential negative implications on the evaluation of students’ learning. In modern-day multidimensional education, assessments have moved a long way from traditional examinations to include projects, assignments, and research. Certain assignments are designed to foster the development of critical thinking and analytical skills. AI tools may direct students to take an easier path in completing these tasks, impeding the accomplishment of intended learning outcomes.

There is no consensus on how this technology should be adopted in higher education. At the start, certain educational institutes banned the use of LLMs, and software was developed to detect work done by AI. These approaches are not sustainable in the long run.

Users should have a clear understanding on potentials and imitations of current LLM technology, in order to use LLMs effectively.

LLM technology is improving rapidly, and efficacious compared to many other sources of education. However they are not yet at a standpoint to be recommended as the primary source in education, rather, they could be adjuncts to standard resources like lectures, textbooks, peer-reviewed literature, and online materials. Students should know when and when not to use it, and the content should be critically and cautiously looked into.

Educators have a crucial role in guiding the students on using AI effectively. Navigating students to experience the limitations of LLMs through practical scenarios is a potential strategy. An example would be to assign students to critically analyse a draft answer generated through an LLM platform. This will allow both the students and tutors identify the capabilities and limitations of LLMs.

In the context of evolving LLMs educators have to re look into the existing assessment modalities and implement changes to ensure the potential objectives of the assessment are met. The policies regarding LLM use for the particular task should be clearly communicated to the students on contextual basis.

Impacts of LLMs on educational development is yet another area warranting discussion. This encompasses exploring the role of LLMS in instructor, instructional and organizational development. We didn’t include it within the scope of this write up.

In summary, generative AI could be harnessed to potentiate students’ learning, in knowledge acquisition as well as application. Even though LLM tools may pose challenges, we foresee a larger potential for the betterment of medical education, ultimately leading to the overall goal of better patient care. 

Notes on Contributors

WANVL, CTY, RT, DS and KB were involved in planning of the article.

WANVL drafted the initial version of the mauscript.

WANVL, CTY, RT, DS and KB revised and edited the initial draft manuscript and approved the final version of the manuscript for submission.

Funding

The authors received no financial support for the authorship or publication of this article.

Declaration of Interest

The authors do not have any conflicts of interest to disclose.

References

Kelly, S. M. (2023, January 26). ChatGPT passes exams from law and business schools. CNN Business. https://edition.cnn.com/2023/01/26/tech/chatgpt-passes-exams/index.html

Kung, T. H., Cheatham, M., Medenilla, A., Sillos, C., De Leon, L., Elepaño, C., Madriaga, M., Aggabao, R., Diaz-Candido, G., Maningo, J., & Tseng, V. (2023). Performance of ChatGPT on USMLE: Potential for AI-assisted medical education using large language models. PLOS Digital Health, 2(2), Article e0000198. https://doi.org/10.1371/journal.pdig.0000198

Lee, P., Bubeck, S., & Petro, J. (2023). Benefits, Limits, and Risks of GPT-4 as an AI Chatbot for Medicine. The New England Journal of Medicine, 388(13), 1233–1239. https://doi.org/10.1056/NEJMsr2214184

Morris, N., Ivancheva, M., Swinnerton, B., Coop, T., & Czerniewicz, L. (2018, September 11-13). Critical perspectives on unbundling and rebundling higher education provision online [Research session]. [18-97]. ALT Annual Conference, Manchester, UK. https://www.youtube.com/watch?v=F2FS0n3Dr0k

Ramanathan, R., Shanmugam, J., Gopalakrishnan, S. M., Palanisamy, K. T., & Narayanan, S. (2022). Challenges in the Implementation of Competency-Based Medical Curriculum: Perspectives of Prospective Academicians. Cureus. https://doi.org/10.7759/cureus.32838

*Celestial T Yap
Department of Physiology
Yong Loo Lin School of Medicine
National University of Singapore
+6590560468
Email: phsyapc@nus.edu.sg

Submitted: 21 December 2023
Accepted: 3 July 2023
Published online: 3 October, TAPS 2023, 8(4), 46-49
https://doi.org/10.29060/TAPS.2023-8-4/PV2934

Dhivya Subramanian

School of Medicine, University of Dundee, United Kingdom

Portfolio has been used since the early 15^th century to showcase designs, and folders of work for architectural, artistic and financial purposes. Though the method of delivering a portfolio has shifted over the years from a “folder of loose papers” to “electronic portfolios” with the advent of technology; the crux of portfolios has remained the same. The purpose of portfolio to allow for a personalised approach for each individual to showcase their knowledge, professional values and skills has remained constant over the past hundreds of years. (Buckley et al., 2009) The usage of portfolio in medical education has been thought to give students more responsibilities for their own learning and development and aid in stimulating the reflective thought process (Driessen et al., 2003). Moreover, portfolio has been considered being a more holistic approach to assessing students in medicine, which allows a broader method in assessment rather than a ‘snap-shot’ examination (Van Tartwijk & Driessen, 2009).

Portfolio was first introduced in the University of Dundee in 1997 and the first portfolio assessment occurred in 1999. Portfolios are formatively assessed from 1^st to 4^th year and are a summative assessment in 5^th, the final year (Davis et al., 2009). As a final year Singaporean student from the University of Dundee, I was introduced to the new concept of portfolio during my medical course (MBChB) and its importance was emphasised from the very beginning in Year 1. Appendix 1 underlines the portfolio requirements for the respective years. These requirements are regularly updated in our portfolio section on Medblogs (medical school website for students and staff), allowing us to check deadlines and ensure we are up to date with tasks required.

The portfolio in the University of Dundee and all universities in the United Kingdom is based on the 3 Outcomes of Graduates 2018 set by the General Medical Council (Outcome 1–Professional values and behaviours, Outcome 2–Professional skills, Outcome 3–Professional knowledge) (Monrouxe et al., 2018). All portfolios are uploaded on to the system known as “NHS e-portfolios” which provides a platform for all students throughout the nation to upload their works.

Four years ago, as a 1st year medical student, I found it hard to understand the importance of portfolio. The medical school organised lectures to inform us about the purpose of portfolio and its significance to aid our professional development. However, it appeared more of an abstract concept. Since the school gave information on what we needed to submit and when, it seemed more of a checklist of things we needed to finish. It was difficult to appreciate the holistic picture of portfolio and its purpose in our development as a medical professional.

Growing up in Singapore, practicing reflections was not part of our culture. A more difficult task-oriented environment is what most of us are used to during our schooling and work life in Singapore. The concept of reflections was new and seemed redundant, however as years went by and when I entered the clinical years of medicine (year 4 and year 5), I began to understand why the emphasis on reflection was so strong.

The reflective essays we add in our portfolio can be chosen from a list provided to us but also can be done on topics we choose ourselves to reflect on. This gives us freedom to decide what we felt was impactful during our placements and does not constrain us to write about certain issues, thus avoiding the ‘checklist-like’ feeling that can often be felt during the initial stages of developing a portfolio. The University of Dundee encourages the use of either Gibb’s cycle, Rolfe et al, or John’s model as reflective writing models to aid the reflection process.

Often my peers including myself would debate that reflections are things we do regularly, such as thinking about how the day went before we sleep or reflecting on action such as recognising a patients’ emotions while speaking to them and reacting appropriately. However, I recognised the importance of writing down reflections as we can look back at it in the future and learn from the past.

During my paediatric placement in 4^th year, I had the opportunity to reflect on a case I found myself getting emotionally involved. A two-year old child was vigorously shaken by his parents which led to a hypoxic brain injury and consequently cerebral palsy. Seeing the patient every day on ward rounds was disheartening as I could witness the stark difference between the neglected, immobile child and another child playing happily in the next bed. Upon reflecting, I could appreciate that there will be circumstances in the future where I encounter similar situations, and the practice of reflecting and debriefing with colleagues can aid in alleviating the emotional weight we take back home. This served as a turning point in appreciating the value of reflections as a medical student.

Even though portfolio assessments are summative in final year, the process of developing the portfolio became more genuine nearing the end of the course. On reflection, I would think this is mainly due to the realisation that the reflective process required in building a portfolio helped me become a better medical professional; with not only arming myself with the right skills but also enabling the confidence to perform well once we set foot into the clinical world as a Foundation Doctor / House Officer.

It is important to emphasise that it is not only reflective questions that use the skill of reflection. Reflections for feedback given for case discussions and clerkings allow us to reflect on the process of writing the essays and how we could improve in the future. The reflection serves as a critical interrogation which creates meaning from an event and urges us to act. I realised that only if one identifies their limitations and develops an action plan, they can work towards a target in mind. Setting an action plan paves path to avidly look for opportunities in order to gain more practice in those areas. This made me realise that it is truly up to an individual’s initiative whether they want to gain something useful from building a portfolio.

If I had the opportunity to tell my year 1 self something, I would advise to regularly update her portfolio rather than leaving it to the very end and to approach it as something she does for herself rather than to impress a supervisor or faculty member. Even if one does not understand the purpose of portfolio at the initial stages, completing reflections and small pieces of work are valuable as the skill is slowly starting to develop. Ultimately “every expert was once a beginner”.

Looking back at my portfolio and seeing all my achievements collated in one area fills me with a sense of pride and fulfilment. After all, portfolio is something you develop throughout your life; from the first year you start working till the day you retire. So why not start early if you can!

Notes on Contributors

Dhivya Subramanian is a final year medical student at the University of Dundee, UK. The author based this personal view from past experiences in developing a portfolio during the period of undergratudate medical school.

Acknowledgement

Thanks to Dr. Shuh Shing Lee for her support and guidance.

Funding

No funding has been received for this article.

Declaration of Interest

No conflicts of interest, including financial, consultant, institutional, and other relationships that might lead to bias or a conflict of interest.

References

Buckley, S., Coleman, J., Davison, I., Khan, K. S., Zamora, J., Malick, S., Morley, D., Pollard, D., Ashcroft, T., Popovic, C., & Sayers, J. (2009). The educational effects of portfolios on undergraduate student learning: A Best Evidence Medical Education (BEME) systematic review. BEME Guide No. 11. Medical Teacher, 31(4), 282–298. https://doi.org/10.1080/01421590902889897

Davis, M. H., Ponnamperuma, G. G., & Ker, J. S. (2009). Student perceptions of a portfolio assessment process. Medical Educa- tion, 43(1), 89–98. https://doi.org/10.1111/j.1365-2923.2008.03250.x

Driessen, E., Van Tartwijk, J., Vermunt, J., & van der Vleuten, C. (2003). Use of portfolios in early undergraduate medical training. Medical Teacher, 25(1), 18–23. https://doi.org/10.1080/0142159021000061378

Monrouxe, L. V., Bullock, A., Gormley, G., Kaufhold, K., Kelly, N., Roberts, C. C., Mattick, K., & Rees, C. E. (2018). New graduate doctors’ preparedness for practice: a multistakeholder, multicentre narrative study. BMJ Open, 8(8), 1–15. https://doi.org/10.1136/bmjopen-2018-023146

Van Tartwijk, J., & Driessen, E. W. (2009). Portfolios for assessment and learning: AMEE Guide no. 45. Medical Teacher, 31(9), 790–801. https://doi.org/10.1080/01421590903139201

*Dhivya Subramanian
University of Dundee, Nethergate,
Dundee DD1 4HN, United Kingdom
Email: sdhivya1509@gmail.com

Submitted: 18 February 2023
Accepted: 28 March 2023
Published online: 3 October, TAPS 2023, 8(4), 40-45
https://doi.org/10.29060/TAPS.2023-8-4/SC3010

Kit Mun Tan¹, Chan Choong Foong², Donnie Adams³, Wei Han Hong², Yew Kong Lee⁴ & Vinod Pallath²

¹Department of Medicine, Faculty of Medicine, Universiti Malaya, Malaysia; ²Medical Education and Research Development Unit (MERDU), Faculty of Medicine, Universiti Malaya, Malaysia; ³Department of Educational Management, Planning and Policy, Faculty of Education, Universiti Malaya, Malaysia; ⁴Department of Primary Care, Faculty of Medicine, Universiti Malaya, Malaysia

Abstract

Introduction: The global COVID-19 pandemic had greatly affected the delivery of medical education, where institutions had to convert to remote learning almost immediately. This study aimed to measure undergraduate medical students’ readiness and factors associated with readiness for remote learning.

Methods: A cross-sectional quantitative study was conducted amongst undergraduate medical students using the Blended Learning Readiness Engagement Questionnaire, during the pandemic where lessons had to be delivered fully online in 2020. 

Results: 329 students participated in the study. Mean scores for remote learning readiness were 3.61/4.00 (technology availability), 3.60 (technology skills), 3.50 (technology usage), 3.35 (computer and internet efficacy), and 3.03 (self-directed learning). Male students appeared more ready for remote learning than females, in the dimensions of self-directed learning and computer and internet efficacy. Students in the pre-clinical years showed a lower level of readiness in the technology availability domain compared to clinical students. The lowest score however was in the self-directed learning dimension regardless of the students’ year of studies.

Conclusion: The pandemic had created a paradigm shift in the delivery of the medical program which is likely to remain despite resumption of daily activities post-pandemic. Support for student readiness in transition from instructor-driven learning models to self-directed learning models is crucial and requires attention by institutions of higher learning. Exploring methods to improve self-directed learning and increase availability of technology and conducting sessions to improve computer and internet efficacy can be considered in the early stages of pre-clinical years to ensure equitable access for all students.

Keywords:            Remote Learning, Student’s Readiness, Medical Education

I. INTRODUCTION

The COVID-19 pandemic and global emergency from the end of January 2020 had greatly affected the education sector, with many institutions including undergraduate medical schools converting to remote learning within a short timeframe.

Previous studies have shown that e-learning methods were effective and acceptable among medical undergraduate students (Chen et al., 2020). Studies have also suggested that students may struggle in adapting to a self-directed learning process (Vaughan, 2007), prefer traditional face-to-face lectures and possibly lacking the technological skills and infrastructure for a satisfactory remote learning experience.

It is important to determine the remote learning readiness of undergraduate medical students to facilitate the adaptation of these practices to maximise student competencies. Therefore, the primary objective of this study was to determine the readiness for remote learning in undergraduate medical students in a South-East Asian university and the secondary objective was to identify factors associated with their remote learning readiness.

II. METHODS

This was a cross-sectional quantitative study to measure medical students’ readiness towards remote learning using the BLREQ questionnaire. This study was approved by the Research Ethics Committee (Reference UM.TNC2/UMREC-889) of the university.

In the Covid-19 enforced scenario at that time, the physical face-to-face teaching in our institution was moved to online almost immediately, requiring the students to adapt their learning approaches rapidly to suit the needs of a virtual learning environment.

The duration of the study was one month, from the 19th of June to the 19th of July 2020. Our country implemented a national lockdown (and emergency remote learning) due to COVID-19 on the 18th of March 2020. Thus, data collection occurred in the first few months of the remote learning situation and represented students’ experiences and readiness during the early phase of the change.

The students were from all five years of study in the medical undergraduate program. They were contacted via their online educational platform and WhatsApp group chats with details of the study, participant’s consent form, link to the online self-administered questionnaire and weekly reminders to encourage participation. Participation was voluntary and consent was obtained from the students. Data were anonymised and not traceable to a particular individual.

This study utilised Section A and B of the BLREQ questionnaire which is a validated questionnaire on the readiness and engagement of students in blended learning (Adams et al., 2018). Although ‘Blended Learning’ is defined as a combination of e-learning (online) and traditional education (face-to-face) approaches, the BLREQ is appropriate for this study as it primarily measures students’ readiness for remote learning. Section A contained basic demographic questions (i.e., age, gender, year of study). Section B had 37 items in five dimensions which addressed various aspects of students’ readiness for remote learning. A 4-point Likert-type scale ranging from strongly disagree (1) to strongly agree (4) was provided with only one response allowed per item.

The data was analysed using IBM SPSS version 25.  The data was non-normally distributed; hence the Mann-Whitney U test was used to test for significant difference in scores between gender and stages of study.

III. RESULTS

There were 329 complete responses out of 734 invited participants (44.8% response rate). Most respondents were aged between 20 to 24 years old (Mean=21.9; SD=1.8). Approximately 59% were female and 59% were clinical students.

The total dimension and individual item mean scores are reported in Table I with the highest and lowest scores of each dimension annotated. The dimensions of remote learning readiness arranged in descending order of total mean score are Technology Availability (3.61+50), Technology Skills (3.60+.43), Technology Usage (3.50+.44), Computer and Internet Efficacy (3.35+.49), and Self-directed Learning (3.03+.51) (Table 1). Research data of this study are available at https://doi.org/10.6084/m9.figshare.21443100

Analysed by gender, the mean scores of male students were significantly higher than female students in the dimensions of Self-directed Learning; 3.13 vs 2.96 (U=10354.5, z=-3.18, p=.001), and Computer and Internet Efficacy; 3.39 vs 3.32 (U=11332.5, z=-2.02, p=.044). Individual items in which male students scored significantly higher in each dimension were [SDL1], [SDL4], [CIE2] and [CIE3].

When comparing between stages of study, the mean score of clinical students was significantly higher than pre-clinical students only in the Technology Availability dimension; 3.65 vs 3.55 (U=11376.0, z=-2.13, p=.034) An individual item which clinical students scored significantly higher in Technology Availability dimension was [TA3].