Submitted: 9 February 2023
Accepted: 22 March 2023
Published online: 3 October, TAPS 2023, 8(4), 36-39
https://doi.org/10.29060/TAPS.2023-8-4/SC3000

Komson Wannasai¹, Wisanu Rottuntikarn¹, Atiporn Sae-ung², Kwankamol Limsopatham², Wiyada Dankai¹

¹Department of Pathology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand; ²Department of Parasitology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand

Abstract

Introduction: Global medical and healthcare education systems are increasingly adopting team-based learning (TBL). TBL is an interactive teaching programme for improving the performance, clinical knowledge, and communication skills of students. The aim of this study is to report the learning experience and satisfaction of participants with the TBL programme in the preclinical years of the Faculty of Medicine, Chiang Mai University.

Methods: Following the implementation of TBL in the academic year 2022, we asked 387 preclinical medical students, consisting of 222 Year 2 and 165 Year 3 medical students who attended the TBL class to voluntarily complete a self-assessment survey.

Results: Overall, 95.35% of the students were satisfied with the structure of the TBL course and agreed to attend the next TBL class. The overall satisfaction score was also high (4.44 ± 0.627). In addition, the students strongly agreed that the TBL programme improved their communication skills (4.50 ± 0.796), learning improvement (4.41 ± 0.781), and enthusiasm for learning (4.46 ± 0.795).

Conclusion: The survey findings indicated that students valued TBL-based learning since it enabled them to collaborate and embrace learning while perhaps enhancing their study abilities. However, since this is a pilot study, further investigations are warranted.

Keywords:           Team-based Learning, Small Group Interaction, Medical Education, Implementation

IV. DISCUSSION

TBL changes how students learn by encouraging them to become more accountable by preparing for the team assurance test and application exercise (Burgess et al., 2020a). Teacher-directed pre-class preparation for advanced tasks may involve reading textbooks, reference articles, or instructor-created material while the readiness assurance test enhances students’ enthusiasm for TBL (Parmelee et al., 2012). However, students may resist TBL or active learning because it varies from passive lecture-based learning. Teachers must be aware of this and advocate TBL-style learning to improve ability and encourage students to be more prepared. This research examines the attitudes of medical students towards the two courses post-TBL and provides valuable input on TBL strategies, regardless of the course schedule.

Student feedback can improve teaching and student satisfaction. Students agreed that TBL can improve communication, learning, and passion. Second-year medical students were less motivated than third-year (p = 0.023), implying they need to focus on the core content of the preclinical module rather than TBL preparation, while third years have more time management experience for pre-class self-study. Students liked the teaching material because, in addition to textbooks, the instructors prepared PowerPoint presentations, recorded VDOs, and documentation, allowing those with different learning styles to make the appropriate choice.

Interestingly, both classes found the TBL structure and location less satisfying, possibly because first-time students could not comprehend group activities. Students can further grasp the TBL framework and enjoy the structured process with a revamped instructional layout and additional classes. As for the classroom, the seat layout may prevent suitable group conversations, with a small-group or smart classroom being more appropriate for TBL.

The preparation time satisfaction results are significantly difference, with Year 2 students being considerably less satisfied than Year 3 (p = 0.012). Most second-year medical students spent one to two days planning, and third years one to four (p = 0.005), primarily because the third-year course was longer. Second-year medical students attended a two-week course on human skin and the connective tissue system with a TBL class in the second week, whereas third years took a five-week haematological system course with a TBL class in the fourth week. Both classes received course material on Mondays, while the TBL was on Fridays in the same week. Second-year medical students may need to study the basic science aspects and be unable to independently assess the pre-class material, whereas third-year students had more time. Accordingly, a TBL course should last at least three to four weeks to allow medical students to understand the basic TBL instructional material and independently assess it.

This study has limitations. The questionnaire was expert-evaluated without instructor facilitation. In addition, our study focused on students’ satisfaction with TBL, hence we didn’t include academic outcomes to prove the value of TBL.

V. CONCLUSION

The survey showed that students appreciated TBL-based learning since it helped them to work together and embrace learning, while potentially improving their study skills. A diversity of pre-class material allows students to choose learning tactics depending on their individual abilities. Students found the activity venue inadequate and classroom improvements would boost their satisfaction level.

Notes on Contributors

KW reviewed the literature, designed the study, analysed data, co-wrote the manuscript, critically reviewed and edited the manuscript, and then read it through prior to final approval.

WD reviewed the literature, analysed the data, co-wrote the manuscript, and critically reviewed and edited the manuscript.

WR gave critical feedback on the writing of the manuscript.

AS and KL provided scientific insight and advice, and critically reviewed and edited the manuscript.

Ethical Approval

This research was approved by the institutional ethics committee of the Faculty of Medicine at Chiang Mai University (Study code: PAT-2565-09243).

Data Availability

On reasonable request, the corresponding author will provide data to support the conclusions of this study. Due to privacy and ethical considerations, the data cannot be made public.

Acknowledgement

The authors wish to express their sincere appreciation to Ms. Naorn Sriwangdang for assisting with the preparation of the research proposal.

Funding

This study was supported by the Faculty of Medicine, Chiang Mai University, grant no. 062-2566.

Declaration of Interest

The authors confirm they have no potential conflicts of interest.

References

Burgess, A., Bleasel, J., Hickson, J., Guler, C., Kalman, E., & Haq, I. (2020a). Team-based learning replaces problem-based learning at a large medical school. BMC Medical Education, 20, Article 492. https://doi.org/10.1186/s12909-020-02362-4

Burgess, A., van Diggele, C., Roberts, C., & Mellis, C. (2020b). Team-based learning: Design, facilitation and participation. BMC Medical Education, 20(Suppl 2), Article 461. https://doi.org/10.1186/s12909-020-02287-y

Burgess, A. W., McGregor, D. M., & Mellis, C. M. (2014). Apply­ing established guidelines to team-based learning programs in med­ical schools: A systematic review. Academic Medicine, 89(4), 678–688. https://doi.org/10.1097/ACM.0000000000000162

Michaelsen, L. K., & Sweet, M. (2008). The essential elements of team-based learning. New Directions for Teaching and Learning, 2008(116), 7–27. https://doi.org/10.1002/tl.330

Parmelee, D., Michaelsen, L. K., Cook, S., & Hudes, P. D. (2012). Team-based learning: A practical guide: AMEE Guide No. 65. Medical Teacher, 34(5), e275–e287. https://doi.org/10.3109/0142159X.2012.651179

*Komson Wannasai
Department of Pathology,
Faculty of Medicine,
Chiang Mai University,
110 Inthavaroros road, Sriphume
Meaung, Chiang Mai, 50200
+6653935442
Email: komson.wanna@gmail.com

Submitted: 9 February 2023
Accepted: 15 May 2023
Published online: 3 October, TAPS 2023, 8(4), 23-35
https://doi.org/10.29060/TAPS.2023-8-4/OA3006

Sethapong Lertsakulbunlue¹, Kaophiphat Thammasoon², Kanlaya Jongcherdchootrakul³, Boonsub Sakboonyarat³ & Anupong Kantiwong¹

¹Department of Pharmacology, Phramongkutklao College of Medicine, Thailand; ²Department of Personnel Administration Division, Phramongkutklao College of Medicine, Thailand; ³Department of Military and Community Medicine, Phramongkutklao College of Medicine, Thailand

Abstract

Introduction: Although medical research (MR) is constantly promoted, a global deficit of medical researchers has been noted. We aimed to explore the relationship among practice, perceptions, attitudes, barriers and motivation toward MR and its impacts on MR publication.

Methods: A cross-sectional study included 262 senior medical students and interns. An electronic, standardised Likert scale questionnaire was used to collect the data. Binary logistic regression was used to determine the odds ratio between characteristics and MR publication. Confirmatory factor analysis was used to confirm the loading factor of each question, and structural equation modeling (SEM) was used to investigate the relationship between latent variables and MR publication.

Results: Cronbach’s alpha revealed a good internal reliability of 0.93. The accumulated grade point average did not differ between those who had published and those who had not. MR presentations were strongly associated with MR publication. SEM showed that attitudes (0.71, p<0.001) and perceptions (0.27, p<0.001) had a direct effect on practices. Practices (0.49, p<0.001) and attitudes (0.30, p<0.001) had a direct effect on motivation, while motivation had a total effect = 0.36, p<0.001 on MR publication through MR presentation as a mediator.

Conclusion: Positive attitudes and perceptions might lead to positivity in the intention to practice MR, which would lead to motivation and finally increase the odds of MR publication. Different approaches to promote excitement and perceptions in MR learning should be encouraged by teachers and faculty members.

Keywords:           Medical Research, Students, Perceptions, Attitudes, Barriers, Motivation

Practice Highlights

• Enjoyment and excitement should be promoted while learning medical research.
• Medical research experiences enhanced publication, particularly medical research presentations.
• Extracurricular medical research activities should be routinely promoted.
• Facilitators in medical research might be tailor-made for each individual.
• Regular meetings regarding medical research with mentors or role models should be held.

Submitted: 2 December 2022
Accepted: 24 July 2023
Published online: 3 October, TAPS 2023, 8(4), 13-22
https://doi.org/10.29060/TAPS.2023-8-4/OA3093

Julie Yun Chen^1,2, Tai Pong Lam¹, Ivan Fan Ngai Hung³, Albert Chi Yan Chan⁴, Weng-Yee Chin¹, Christopher See⁵ & Joyce Pui Yan Tsang¹

¹Department of Family Medicine and Primary Care, University of Hong Kong, Hong Kong; ²Bau Institute of Medical and Health Sciences Education, University of Hong Kong, Hong Kong; ³Department of Medicine, University of Hong Kong, Hong Kong; ⁴Department of Surgery, University of Hong Kong, Hong Kong; ⁵School of Biomedical Sciences, The Chinese University of Hong Kong, Hong Kong

Abstract

Introduction: Medical students have long provided informal, structured academic support for their peers in parallel with the institution’s formal curriculum, demonstrating a high degree of motivation and engagement for peer teaching. This qualitative descriptive study aimed to examine the perspectives of participants in a pilot peer teaching programme on the effectiveness and feasibility of adapting existing student-initiated peer bedside teaching into formal bedside teaching.

Methods: Study participants were senior medical students who were already providing self-initiated peer-led bedside clinical teaching, clinicians who co-taught bedside clinical skills teaching sessions with the peer teachers and junior students allocated to the bedside teaching sessions led by peer teachers.  Qualitative data were gathered via evaluation form, peer teacher and clinician interviews, as well as the observational field notes made by the research assistant who attended the teaching sessions as an independent observer.  Additionally, a single Likert-scale question on the evaluation form was used to rate teaching effectiveness.

Results: All three peer teachers, three clinicians and 12 students completed the interviews and/or questionnaires. The main themes identified were teaching effectiveness, teaching competency and feasibility. Teaching effectiveness related to the creation of a positive learning environment and a tailored approach. Teaching competency reflected confidence or doubts about peer-teaching, and feasibility subthemes comprised barriers and facilitators.

Conclusion: Students perceived peer teaching effectiveness to be comparable to clinicians’ teaching. Clinical peer teaching in the formal curriculum may be most feasible in a hybrid curriculum that includes both peer teaching and clinician-led teaching with structured training and coordinated timetabling.

Keywords:           Peer Teaching, Undergraduate Medical Education, Bedside Teaching, Medical Students

Practice Highlights

• Peer-led teaching environment facilitates questions and answers from learners to strengthen learning.
• Training on specific skills and pre-case preparation can help improve peer teacher effectiveness.
• Clear understanding of the logistics and expectations is necessary to optimise the process.
• Formal peer teacher training may help quality assurance and encourage more participation.

I. INTRODUCTION

In accordance with the longstanding apprenticeship model of medical training, senior doctors and trainees have been responsible for teaching their junior colleagues across the continuum of medical education. Despite this accepted practice, peer teaching has not become widely formalised in undergraduate medical curricula.

Peer teaching has been shown to be beneficial at multiple levels. For students who are being taught by peers, learning is enabled by social and cognitive congruence because of the near-peer demographic which allows for a more comfortable learning environment for free flow of discussion and better understanding of the learner’s challenges including awareness of the primacy for exam success (Benè & Bergus, 2014; Rees et al., 2016). The peer teacher develops and hones teaching skills that will be useful in internship (Haber et al., 2006) and through teaching, develops higher motivation and deeper understanding of concepts and perhaps also improve their own exam performance (Burgess et al., 2014). The institution derives some practical benefit from the supplementary manpower (Tayler et al., 2015) due to the comparable effectiveness of peer teachers in teaching in certain areas such as physical examination and communication skills (Rees et al., 2016) but perhaps most importantly, it benefits from building a collaborative relationship with students in their learning process. Though the benefits of peer teaching have been noted, students remain an untapped resource as training provided for students to serve as teachers is inconsistent (Soriano et al., 2010).

Undergraduate medical curricula aim to provide a foundation for future training and the framework for such curricula are guided by the recognition that medical students must achieve certain outcomes, including being able to teach, to be prepared for future practice. Well-accepted frameworks such as the ‘Outcomes for Graduates’, from the UK General Medical Council (2015) and the ‘CanMEDS Framework’ from the Royal College of Physicians and Surgeons of Canada (2015) expect medical graduate to teach others. In Hong Kong, similar guidance is provided in the document ‘Hong Kong Doctors’ published by the Medical Council of Hong Kong, which states that undergraduate medical education must prepare graduates to fulfil the roles of ‘medical practitioner, communicator, educator…’ (Medical Council of Hong Kong, 2017).

It is common in medical schools to have informal peer teaching, where senior students coach junior students on an ad hoc basis or organise revision sessions before exams. Zhang et al. (2011) revealed that a majority of medical students believed that informal learning approaches, including the use of past student notes, and participation in self-organised study groups and peer-led tutorials, helped them pass examinations and be a good doctor. Similarly, in our institution, these kinds of informal peer teaching are popular among students and include sharing sessions on study and exam tips, bedside sessions, and sharing of organised study notes. These activities are not subject to any formal oversight.

With the documented benefits of peer teaching, the availability of enthusiastic senior students who are willing to coach their junior peers, and the demand from junior students to learn from their seniors, there is an opportunity to harness the potential peer teaching that is already taking place. This pilot project is important as it aimed to adapt existing student-initiated peer bedside teaching into the formal bedside teaching curriculum and to examine the perspectives of participants on the effectiveness and feasibility of this initiative. It will be helpful to understand the benefits and drawbacks of formal peer bedside teaching in order to further develop this pedagogical approach in medical education.

II. METHODS

This was a descriptive qualitative study of participants in a pilot peer-teaching initiative for bedside teaching implemented in the first clinical year of study for medical students.

A. Setting

1) Small group bedside teaching for Year 4 medical students in the Clinical Foundation Block: The 11-week Clinical Foundation Block (CFB) of the MBBS Year 4 curriculum at The University of Hong Kong runs from August to October and is the first block of the first clinical year of study. It serves to prepare students for the ward- and clinic-based teaching to follow in the clinical clerkships (Figure 1). Year 4 medical students were selected for the study because it is the first clinical year of study when clinical bedside teaching begins. In addition, as the most junior clinical students, they would benefit most from learning from their senior peers. During the CFB, all Year 4 students learn basic history taking, physical examination and clinical skills as well as common clinical problems of 10 key specialty disciplines. In internal medicine, students attend whole class sessions in which the proper clinical examination of each body system is demonstrated followed by seven small group sessions at the bedside for hands-on practice led by a clinician. 

Figure 1. Teaching activities under Medicine within the Clinical Foundation Block in the medical curriculum

Each small group bedside teaching session is comprised of six to eight CFB students who follow the same clinical teacher to examine 3 pre-selected ward patients over a two-hour period. In this pilot study, a peer teacher joined the clinical teacher for the bedside teaching with the first patient case taught by the clinician, the second case taught by the peer teacher under the supervision of the clinician and the final case taught by the peer teacher alone.

2) Peer teaching recruitment and training: Over the years, medical students have been organising bedside peer-teaching on their own and we identified these peer-teaching leaders to help recruit peer teachers for this initiative. Peer teachers recruited in July 2018 and comprised Year 5 students in Senior Clerkship, who were enthusiastic in teaching, and were available to join the training tutorial and take up a subsequent Year 4 CFB bedside teaching session. During the 2.5-hour tutorial, the CFB Coordinator explained the project, and three clinicians then provided a briefing on cardiovascular, neurological, respiratory and abdominal physical examination, common pitfalls, and how to give feedback. There was also time for students to raise questions both on the project and bedside teaching techniques.

B. Participants

The target participants included the three peer teachers who were recruited for this study, together with the three clinician partners and the 24 CFB students in the corresponding three bedside teaching groups. Written informed consent was obtained from all participants before data collection.

C. Data Collection

The qualitative data were collected using a dual subjective (peer teachers, clinicians and students) and objective (independent observer) approach was taken to provide a more holistic perspective of the peer teaching experience. A research assistant not involved in the teaching followed one (of the three) peer teachers as the independent observer. All peer teachers and clinicians were interviewed in-person, by phone or by email, using an interview guide (Appendix 1) by the research assistant after the session where field notes were taken and transcribed. CFB students were invited to complete an evaluation form comprised of open-ended questions and a single Likert-scale question (Appendix 2) immediately after the bedside session, to rate effectiveness and to give general feedback about the peer teaching session.

D. Data Analysis

The qualitative data comprising interview field notes, interview transcripts, email transcripts and open-ended questions from the evaluation form collected from CFB students were analysed thematically by the authors JC and JPYT. The Likert-scale question from the evaluation form was analysed using descriptive statistics. All data were anonymised.

III. RESULTS

All three peer teachers and three clinicians who participated in the pilot peer teaching sessions were interviewed. Eighteen out of 24 CFB students consented to participate and 12 completed questionnaires were collected. Three main themes were identified with two corresponding subthemes for each.

A. Teaching Effectiveness

Peer teachers were rated favourably in terms of their teaching effectiveness. From the evaluation form completed by CFB students, the mean peer teaching effectiveness rating was 4.5/5. While a few students felt the teaching effectiveness of clinicians and peer teachers was comparable, many of them felt less intimidated being taught by the peer teachers. Students also appreciated that the peer teachers understood their current level of understanding and therefore were able to make the teaching more effective by tailoring it to their needs. Students found the experience-sharing by the peer teachers an added-value as shown in Table 1 (Item 1-4). All clinicians agreed that the CFB students appeared more relaxed while the peer teachers were teaching, and the peer teachers met their standard of professionalism as shown in Table 1 (Item 3).

Submitted: 28 September 2022
Accepted: 2 March 2023
Published online: 3 October, TAPS 2023, 8(4), 5-12
https://doi.org/10.29060/TAPS.2023-8-4/OA2883

Soumia Merrou¹, Abdellah Idrissi Jouicha², Abdelmounaim Baslam³, Zakaria Ouhaz³ & Ahmed Rhassane El Adib¹

¹Health Sciences Research Centre (HSRC), Faculty of Medicine and Pharmacy of Marrakech, Cadi Ayyad University, Morocco; ²Health Sciences Research Centre (HSRC), Faculty of Science Semlalia, Cadi Ayyad University, Morocco; ³Pharmacology, neurobiology and behaviour Lab, Faculty of Science Semlalia, Cadi Ayyad University, Morocco

Abstract

Introduction: A deep understanding of physiology, physiopathology, pharmacology, and the management of pain is crucial for nurse anaesthetists to ensure the well-being of their patients. Thus, the teaching strategies should enhance the transition from acquiring the fundamental pain phenomena, to developing translational and critical thinking. The aim of the study is to determine if the flipped classroom that is considered an active learning approach is most effective compared to the traditional method in teaching pain management and if it improves students’ academic performance.

Methods: This study was quasi experimental, at a higher institute of nursing professions, among third-year anaesthesia resuscitation nursing students. participants were randomly allocated into either: the flipped classroom group where PBL was used (FG, n = 19), or the traditional lecture-based classroom group (TG, n = 19). The results and impact of the above approach were appreciated via the analysis of the summative assessment of the class group and from the questionnaire submitted to students.

Results: The present study revealed that in the midterm exam, the mean score of the flipped classroom group (14.0) which is significantly higher (p<0.01) than the traditional lecture group (11.9). Moreover, the standard deviation of this latter is slightly higher (2.41) which indicates scores far from the average. Also, a significant difference between the averages of the two approaches in favor of flipped classroom Group was revealed (p<0.01).

Conclusion: The assessment of student’s grades and their appreciation of both teaching approaches showed a preference for the PBL.

Keywords:           Flipped Classroom, Nursing Education, Pain Management, Problem-Based Learning

Practice Highlights

• Flipped classroom showed advantageous results on nursing students’ grades.
• Flipped classroom endorsed positive results on course comprehension by nursing students.
• Flipped classroom has shown to effectively support content learning.

I. INTRODUCTION

Flipped classroom is a pedagogical approach defined as: “What was previously completed as homework is now finished in class, and what was previously completed in class is now completed at home” (Dong, 2016). Using this approach, traditional classroom time is spent on active learning strategies such as problem-based learning, games, or practice questions to allow teachers to guide students in developing strategies. critical thinking (Dong, 2016). Flipped classrooms are used as the main teaching method in the courses of health professions such as nursing theory, statistics and pharmacology (Hanson, 2016; Immekus, 2019; Peisachovich et al., 2016). In fact, there is evidence that students’ academic performance improved in midterm exams while using flipped classroom approach (Geist et al., 2015).

Despite feeling that this method increased their knowledge, nursing students said they preferred traditional lectures to the use of a flipped classroom (Hanson, 2016). It is not uncommon for students to prefer lectures to the flipped classroom method, which may be related to how much work they feel they have to do or insecurity of exam preparation or both of them (Dong, 2016; Tune et al., 2013). The use of the flipped classroom in nursing was supported by evidence that showed lecturers were enthusiastic about this method. The most effective method for implementing and assessing this strategy in nursing education, though, is not consistently supported by the available data (Barranquero-Herbosa et al., 2022; Dong, 2016; Njie-Carr et al., 2017).

Contextual learning can encourage the growth of critical reasoning, which enables students to pick out the top nursing concerns for patients from a long list of problems, ultimately fostering the development of problem-based nursing analysis in line with Benner’s model (Dong, 2016). Problem-based learning (PBL) uses problem scenarios to develop knowledge and understanding learning objectives (Wood, 2003). Among the strategies used in a flipped classroom, the PBL has been used in nursing education, in courses such as pharmacology, mental health nursing and critical care nursing (Alton, 2016; Gholami et al., 2016). Any teaching strategy that involves students in the learning process is considered to be an active learning strategy, which includes PBL (Peisachovich et al., 2016).

Despite the introduction of pain management in health professions education, pain is still undertreated. It affects 80%-90% of patients in medicine, surgery, and cancer units (Gerbershagen et al., 2009; Gianni et al., 2010). Previous research also highlighted that 43% to 51% of patients received inadequate or insufficient analgesic treatment and only 14% of patients who received analgesia benefit from reassessment (Deandrea et al., 2008; Manias et al., 2005). To effectively manage pain, nurses are crucial. Therefore, it is crucial that they receive effective training to ensure better pain management (Teike Lüthi et al., 2015).

In this direction, in order to encourage students’ acquisition strategies, nursing science professors must implement effective teaching techniques. Training typically aims to increase knowledge, which is insufficient in this case; as a result, skills development is a top priority (Kerner et al., 2013). While prior research emphasised the value of nurse-patient interactions in pain management, it undervalued the impact of nurses’ scientific knowledge of pain mechanisms and pharmacology. It is interesting to note that a recent study highlighted the significance of the classroom setting and instructional methods in approaching pain management in a novel manner (Teike Lüthi et al., 2015).

However, a need for a rigorous evaluation of learning strategies is crucial for best practices in nursing education (Barranquero-Herbosa et al., 2022; Njie-Carr et al., 2017). The present study provides an assessment of PBL as a model of applied learning in a flipped classroom of anesthesia nursing students in the context of a pain management course.

The main purpose of the study was to determine if the flipped classroom is more effective than traditional learning in teaching pain management by assessing students’ academic performance and determine their perceptions about the flipped classroom approach. In that capacity, the research questions of the study are:

1. Is there a significant difference in students’ academic performance between the traditional and flipped classroom approaches on declarative knowledge?
2. Is there a significant difference in students’ academic performance between the traditional and flipped classroom approaches on conditional knowledge?
3. What are anesthesia and resuscitation nursing students’ perceptions of PBL impact on the acquisition and application of pain management knowledge?
4. What are anesthesia and resuscitation nursing students’ perceptions of PBL as a model for learning in pain management?

II. METHODS

A. Research Design and Samples

This study is quasi experimental, and was conducted from September at a higher institute of nursing professions. The participants are third-year anaesthesia resuscitation nursing students. Participation in the study was voluntary and anonymous. Oral consent of all participants was obtained. These participants were randomly allocated into either: The flipped classroom group where PBL was used (FG, n = 19), or the traditional lecture-based classroom group (TG, n = 19). Both classroom groups had the same professor.

B. Curriculum Description

The “pain management” course (50h) is taught during the third year of nursing studies in the institute. It is composed of three parts: the pathophysiology of pain; the evaluation of pain, and the pain management.

C. Problem Based Learning on Flipped Classroom Approach

The problem-based template was designed by the professor who teaches the course, by using small groups of 5 to 6 students. The students were the facilitators of the discussion; they meet in group work to discuss a case for an hour. The objective is to identify the type of pain or to choose the best pain assessment tool for the case. The group must then suggest a drug treatment protocol and design appropriate nursing interventions. The role of the professor was to provide immediate and specific feedback during the discussion.

All cases were written by the professor. The objectives were the acquisition of knowledge and the development of clinical reasoning. Each case contained 300 words and included key patient data. Each of these cases included information that could be analysed to provide priority elements to the discussed case.

D. Data Collection and Statistical Analyses

The results and impact of the above approach were extracted via an analysis of the summative assessment of the class group and from the questionnaire submitted to students.

1) Summative assessment (exam):

Students in both groups went through two exams: midterm exam (ME) which took place in the middle of the course in the 6^th week in order to assess the students’ declarative knowledge, and a final exam (FE) which took place at the end of the course, to assess conditional knowledge. The tests were graded from zero to twenty. The final score (FS) was obtained by the following equation:

FS=(ME+FE)/2

2) Questionnaire:

At the end of the course, the FG students were asked to fill out an anonymous questionnaire divided into two sections. The questions were developed in the first section of the questionnaire to determine students’ perceptions of knowledge acquisition. Elements evoked in the questionnaire were created with a language that demonstrates perceived ability and related to self-efficacy (Tune et al., 2013). The second set of items was created to determine students’ perceptions of the cases used in the course. The statements began, for example, with “Participating in the group discussions made me more confident for…”. Likert scale was used to measure the responses. The scale is presented as follows:

1 = Strongly disagree, 2 = Disagree, 3 = Neither agree nor disagree, 4 = Agree, and 5 = Strongly agree.

3) Statistical analyses:

Data analysis was performed using MS Excel (21), background variables of the study participants were calculated, and the results are presented as frequency distribution, percentages, mean, and standard deviation, statistical significance when p <0.05.

III. RESULTS

The data that support the findings of this RCT study are openly available at https://doi.org/10.6084/m9.figshare.22639279  (Merrou et al., 2023).

A. Demographics

The number of participants in the study was 38 students, 19 per group. Female students represented 79% of the study participants, whereas 21% were male.

B. Students’ Grades

Based on the data obtained, statistical analysis was done to analyse the influence of the teaching approach and the type of examination on learners’ results. The obtained findings have been presented in Tables 1 and 2. They indicate the average performance of learners in both exams: midterm (ME) and final exam (FE) where conditional knowledge is measured for both teaching approaches.

 

Type of exam	Teaching approach	M	Sd	Inf born	Sup born	P value
ME	TG	11.9	2.41	7.38	16.1	<0.01
	FG	14.0	1.94	9.0	16.5
FE	TG	11.9	3.28	6.09	16	<0.01
	FG	14.1	1.96	10	16

Table 1. Descriptive statistics by exam type for each teaching approach.

According to Table 1, it is noted that in the midterm exam (ME), the mean score is significantly higher (p<0.01) in the FG (14.0) compared to the TG (11.9), also, with this latter, there is a slightly high standard deviation of 2.41 which indicates scores far from the average. FG, on the other hand, dressed a lower standard deviation (1.94) which indicates that the scores are more grouped around the mean (14.0). The application of the PBL on flipped classroom approach has, as it appears, improved the grades and reduced the gap between them.

For the final exam, with the traditional approach, the dispersion increased (Sd=3.28). On the other hand, PBL approach has improved student outcomes and widened the gap between them compared to TG (p<0.01). Figure 1 highlights the dispersion of the continuous and final control data (before for the traditional approach and after for PBL).

Figure 1. Students’ performance during the midterm exam (ME) and final exam (FE)

The ME grades were improved using PBL. As the number of compared participants is limited, a nonparametric test was carried out (Paired Mann-Whitney test) which revealed that the average grade of MEs is significantly different (p <0.01), between the traditional approach and the PBL. Similarly, an improvement in FE grades is observed when using the PBL approach. This approach allowed an improvement in the means as well as the dispersion. This leads us to state that the teaching approach based on case studies in the context of a flipped classroom (PBL), may improve both declarative and conditional knowledge on students’ outcomes.

Teaching approach	N	M	Standard deviation	Δ mean	p
TG	19	11.9	3.30	2.21	0.01
FG	19	14.1	1.95

Table 2: Descriptive statistics by teaching approach for the different types of controls.

From Table 2, there is a difference between the averages of the two approaches in favor of FG (p<0.01). This means that students who have taken the PBL approach had increased grades compared to those who have taken the traditional approach. To check if these differences are significant, a Paired Mann-Whitney test was used. This one demonstrated that the average rank of the grades is significantly different between the two studied approaches (p = 0.01).

The mean score and the standard deviation for each question in the questionnaire was determined. Average responses to the 12 items that referred to acquisition and application of knowledge related to the pain management ranged from 3.8 to 4.5 (See Table 3).

Submitted: 6 September 2022
Accepted: 1 March 2023
Published online: 3 October, TAPS 2023, 8(4), 1-4
https://doi.org/10.29060/TAPS.2023-8-4/GP2878

Saroj Jayasinghe¹, Santhushya Fernando²

¹Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Sri Lanka; ²Department of Medical Humanities, Faculty of Medicine, University of Colombo, Sri Lanka

Abstract

Introduction: Medical Humanities is the interface of health sciences and humanities and an emerging field of interest. Several papers have outlined the status of this field in the Asian region where a diversity of teaching and learning approaches have been used. We share developments initiated in a Sri Lankan medical school and discuss its relevance to the southern Asian region, especially in using arts in medical humanities.

Methods: Historical records, narratives, grey literature, and published resources were collated to describe the initiative in the Faculty of Medicine, University of Colombo.  The data was collected, synthesized and described especially in the context of the region.

Results: We observe a structured development of medical humanities in the curriculum. The novelty of the curriculum is that it evolving to include wider experiences from the visual and performance arts, in order to achieve the goal of promoting humaneness. The contents were locally developed, based on needs with an indigenous cultural bias giving rise to a unique southern Asian perspective of medical humanities.

Conclusion: There are diverse experiences and initiatives in medical humanities in Asian, and some are not captured in published literature. It is challenging to follow these diverse trends in different locations, share experiences and learn from each other, and place medical humanities in the regional and global maps of health professional education.

Practice Highlights

• Asia has seen several developments in the field of medical humanities.
• Sri Lanka has made significant progress and introduced it to medical education.
• One key innovation is the integration of arts to its teaching-learning.
• Southern Asia has rich and diverse religious, cultural and artistic traditions.
• The region could give a unique perspective to medical humanities.

I. INTRODUCTION

A recent scoping review traced the history of developments in the teaching / learning of humane care and recognition of its importance in medical training (Zhu et al., 2021). This paper also outlined the need to develop culturally relevant, effective, and integrative curricula that would promote humanistic attitudes and behaviours among medical students and physicians in Asia. There were developments of this field in Nepal that were shared in a subsequent correspondence (Shankar, 2022).  These papers and several other publications have highlighted the developments in the field with a diversity of experiences.

We share a few developments from Sri Lanka that demonstrate a widening interest in the field in southern Asia and opportunities to use its unique heritage to move forward.

II. SCOPE AND BACKGROUND INFORMATION

The Faculty of Medicine, University of Colombo is one of the oldest continuously functioning medical schools in Asia (from 1870). It has the distinction of pioneering an integrated curriculum in the country in 1995 and establishing the first Department of Medical Humanities in 2016.

For decades, the curriculum was based on Flexner’s structures and was a conventional discipline-based curriculum with little inputs from the humanities. The reforms in 1995 led to a more integrated modular system with a longitudinal input from Behavioural Sciences (BS). The BS program had modules that focused on teaching / learning in topics related to personal development, communication skills, medical ethics, health management and professionalism (Jayasinghe, 2017).  It was organized by appointing a group of academics to a Behavioural Science Stream (BSS) to coordinate the teaching / learning programs through the 5-year MBBS course.

However, inputs from the arts were minimal though it flourished outside the formal curriculum in the form of concerts, art festivals, photography exhibitions and musical events organized by the student body. These activities were heavily influenced by the urbanized Western culture and activities such as ball-room dancing, predominantly British literature, and Western models of theatre played a predominant role.

A qualitative change in the range of activities was observed around 1974 with the establishment of an Arts Circle in the Faculty of Medicine that promoted infusion of local culture. Interestingly, this coincided with changes in the admission criteria to universities that resulted in student intakes from diverse of social groups and a significant increase in entry from a wider range of districts and more rural schools.

In 2011, the BSS began to organize internal workshops to review its curriculum and propose future developments. During these discussions, participants expressed the need to promote more humaneness, empathy and compassion among students (Jayasinghe, 2017). This led to discussions on the potential role of the arts to meet these needs. The first lecture on “Illness from the perspective of humanities” was introduced in 2012. Soon a consensus view emerged to establish a Department of Medical Humanities in order to deliver a heavier educational input from humanities and thereby promote humane values in students. In August 2016, the Faculty of Medicine, University of Colombo, formally established the first Department of Medical Humanities in the country. In 2020 the BSS was renamed Humanities, Society and Professionalism Stream (HSPS) to reflect the introduction of new content to the curriculum.

III. EDUCATIONAL STRATEGIES

In order to identify contents for its new curriculum, the Department organized a series of invited lectures and discussions targeting the academic staff. It was titled “Exploring the Role of Humanities in Health”.  The resource persons were experts on medical humanities and a diverse range of topics included “Role of Arts in Medicine”; “Approaches to teaching humanities to medical students”; “Medical narratives”; “Using poetry to inculcate attitudes”; and “Humanities in medicine: The Ruhuna Experiment”.  Other opportunities, such as invitations to deliver guest lectures in conferences, were used by the authors to stimulate discussions on the potential role of the arts in health professional education (Jayasinghe, 2018).

The series of lectures culminated in the First International Conference on Medical Humanities held in 2018, on the theme “Learning to be more humane: The role of Medical Humanities” (Colombo Medical Humanities News, 2019). It included a half-day workshop on “Arts in Health Professional Education”. There was wide participation by experts in the field and the conference and workshop were used to refine the curriculum on medical humanities, especially on how to effectively introduce the arts to health professional education. This issue was further debated and discussed during seminars on Medical Humanities at the Colombo Medical Congress (in 2020) and orations dedicated to Medical Humanities (from 2021).

The knowledge gained from the above activities, were used to design an innovative curriculum that included a wider infusion from the arts and narrative-based learning. The main goals of the latter were to promote humaneness, encourage learners to develop a person-centred approach to clinical practice, and appreciate patient perspectives of illness. A range of educational strategies were used: assignment on appreciation of the arts and its relevance to empathy in care; student seminar to reflect on personal experiences of kind and unkind health professional behaviours, obtaining narratives from patients to highlight the humane and person-centered issues of illness; large-group lectures on topics such as “The Arts in Health and Illness” and “Empathy and Compassion”. The latter focused on research evidence from neurophysiology to demonstrate links between art appreciation and traits such as compassion and empathy.

In 2021, during the COVID pandemic, the HSPS and the Department of Medical Humanities introduced an innovative programme aimed at the students. A series of interactive multi-disciplinary webinars termed Humanitas were organied to explore contemporary issues connected to health and have continued as part of the teaching-learning programme. They have been held approximately at bi-monthly intervals and addressed a wide range of issues: life-experiences amidst environmental disasters, linguicism and decolonizing tertiary education, the world of animal welfare, lives of workers in the apparel industry, social and psychological issues faced by those with different sexual identities and orientations, and the emotional journey of a parent who lost her child to cancer.

Interviews from affected groups of people, artists, academics and intellectuals were creatively juxtaposed with short films, extracts from movies, selected musical scores. Examples of the latter included songs of peace sung during non-violent protests organised by Mahatma Gandhi and Martin Luther King Sr., and extracts of poetry and literature that drew attention to contemporary issues such as the plight of garment factory workers. Contributions were predominantly from Sri Lankan commentators reflecting our own historical and cultural context and local experiences.

Since the pandemic ended, Humanitas will be conducted in-person. The first for 2023 was titled ‘Dance and Life’, featuring live Indian and traditional Sri Lankan dance recitals by professional dancers. These performances were accompanied by commentaries by dancers on the emotions they felt while dancing, and the mechanisms of evoking feelings in the audience described by medical experts. These emotions and feelings were in turn linked to the ability of certain dances to generate compassion and empathy. The session ended with an expert dancer performing and describing how certain traditional dances of the Sinhalese (e.g. ‘Thovil’) were used as therapy for a diversity of illnesses.

The second recent innovation relates to activities on medical humanities organized for the 3^rd Colombo Medical Congress in November 2022, an annual event in the University calendar and open to students. We organised a symposium exploring the neurophysiological correlates of music, poetry, and dance and complemented the academic program with a series of activities throughout the conference: free exhibitions of art, sculptures and photography, open-air musical events by students, and live sculpture and portrait sessions by professional artists. The latter live sessions enabled students and attendees to experience and interact with the process of artistic creations. 

IV. DISCUSSION

Medical Humanities is an emerging field of interest in the interface of health sciences and humanities. The diversity of experiences in the Asian region has led to several initiatives. The initiative in Colombo used contemporary topics with contributions mainly from Sri Lankan commentators reflecting on our own historical and cultural contexts. We believe this enriched a field that is dominated by an allopathic or modern medical system that are predominantly Eurocentric and based on ‘Western’ values and culture.

We hope our experiences would diffuse in the Asian region.  Southern Asia has a rich, historical and cultural heritage based predominantly from the Indian religions and include Hinduism, Sikhism, Jainism, Buddhism, and Islam that came from the Middle East and spread to the Indian sub-continent. The philosophical, cultural and religious foundations of this region give us a unique opportunity to give a novel perspective to the field. This will require a process of decolonizing our values and beliefs, and reconnecting to our own cultures and heritages. We also need to follow these trends in different locations, share experiences and learn from each other, often a difficult task because these initiatives may fail to reach mainstream journals or remain unpublished.

V. CONCLUSION

The paper highlights the need to have more collaborations within the southern Asian region and share knowledge that would be mutually beneficial. Southern Asia has a rich historical and cultural heritage. These roots could help develop a unique southern Asian version of Medical Humanities and place our version of medical humanities in the global maps of health professional education.

Notes on Contributors

Saroj Jayasinghe conceptualised and wrote the initial draft.

It was revised and expanded by Santhushya Fernando.

Both authors read and approved the manuscript.

Funding

The study was funded by personal funds.

Declaration of Interest

The authors have no conflicts of interest, including financial, consultant, institutional and other relationships that might lead to bias.

References

Our beginnings. (2019). Colombo Medical Humanities News, 1(1). https://med.cmb.ac.lk/medical-humanities/

Jayasinghe, S. (2017). Of course! We must look at the Arts… in its widest sense! Journal of the Ruhunu Clinical Society, 22(1), 4-5. http://doi.org/10.4038/jrcs.v22i1.26

Jayasinghe, S. (2018). Can the arts promote more humane health professionals? Exploring evidence from the neurosciences. Ceylon Journal of Medical Science, 55(1), 1-2. http://doi.org/10.4038/cjms.v55i1.4938

Shankar, P. R. (2022). Learning humanistic values in Nepal. The Asia Pacific Scholar, 7(3), 63-64. https://doi.org/10.29060/TAPS.2022-7-3/LE2777

Zhu, C. S., Yap, R. K. F., Lim, S. Y. S., Toh, Y. P., & Loh, V. W. K. (2021). Humanism in Asian medical education – A scoping review. The Asia Pacific Scholar, 7(1), 9-20. https://doi.org/10.29060/TAPS.2022-7-1/RA2460

*Saroj Jayasinghe
Faculty of Medicine,
University of Colombo,
No 25, Kinsey Road,
Colombo 8, Sri Lanka
+94718619331
Email: saroj@clinmed.cmb.ac.lk

Submitted: 19 August 2022
Accepted: 1 February 2023
Published online: 4 July, TAPS 2023, 8(3), 72
https://doi.org/10.29060/TAPS.2023-8-3/MA1603

Christopher See¹*, Cynthia Sin Nga Lam²* & Yalsin Yik Sum Li²

¹School of Biomedical Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong; ²Hospital Authority, Hong Kong

*Authors contributed equally

References

Chang, C. Y., Hwang, G. J., & Gau, M. L. (2022). Promoting students’ learning achievement and self‐efficacy: A mobile chatbot approach for nursing training. British Journal of Educational Technology, 53(1), 171-188. https://doi.org/10.1111/bjet.13158

Huang, W., Hew, K. F., & Gonda, D. E. (2019). Designing and evaluating three chatbot-enhanced activities for a flipped graduate course. International Journal of Mechanical Engineering and Robotics Research, 8(5), 813-818. https://doi.org/10.18178/ijmerr.8.5.813-818

Inkster, B., Sarda, S., & Subramanian, V. (2018). An empathy-driven, conversational artificial intelligence agent (Wysa) for digital mental well-being: Real-world data evaluation mixed-methods study. JMIR mHealth and uHealth, 6(11), e12106. http://doi.org/10.2196/12106

Lam, C. S. N., Li, Y. S., Chan, L. K., & See, C. (2019, November 11). Can the A.I.natomy chatbot teach anatomy? [Poster presentation]. 2nd Korea University International Medical Student Conference, Korea University, Seoul, Korea.

Li, C., Zhang, X., Chrysostomou, D., & Yang, H. (2022). ToD4IR: A humanised task-oriented dialogue system for industrial robots. IEEE Access, 10, 91631-91649. https://doi.org/10.1109/ACCESS.2022.3202554

Schlögl, S., Doherty, G., & Luz, S. (2015). Wizard of Oz experimentation for language technology applications: Challenges and tools. Interacting with Computers, 27(6), 592-615. https://doi.org/10.1093/iwc/iwu016

See, C., Lam, C. S. N., Li, Y. S., & Chan, L. K. (2019, May 31). Methods for training an AI for Higher Education [Poster presentation]. Centre for Information Technology in Education Research Symposium 2019, Faculty of Education, the University of Hong Kong, Hong Kong.

Suleman, R. M., Mizoguchi, R., & Ikeda, M. (2016). A new perspective of negotiation-based dialog to enhance metacognitive skills in the context of open learner models. International Journal of Artificial Intelligence in Education, 26, 1069-1115. https://doi.org/10.1007/s40593-016-0118-8

Kron, F. W., Fetters, M. D., Scerbo, M. W., White, C. B., Lypson, M. L., Padilla, M. A., Gliva-McConvey, G. A., Belfore II, L. A., West, T., Wallace, A.M., Guetterman, T. C., Schleicher, L. S., Kennedy, R. A., Mangrulkar, R. S., Cleary, J. F., Marsella, S. C., Becker, D. M. (2017). Using a computer simulation for teaching communication skills: A blinded multisite mixed methods randomized controlled trial. Patient Education and Counseling, 100(4), 748-759. https://doi.org/10.1016/j.pec.2016.10.024

Ward, T., Falconer, L., Frutos-Perez, M., Williams, B., Johns, J., & Harold, S. (2016). Using virtual online simulations in Second Life® to engage undergraduate psychology students with employability issues. British Journal of Educational Technology, 47(5), 918-931. https://doi.org/10.1111/bjet.12307

Weizenbaum, J. (1966). ELIZA – A computer program for the study of natural language communication between man and machine. Communications of the ACM, 9(1), 36-45.

*Christopher See
Rm 610S, 6/F, Choh-Ming Li Basic Medical Sciences Building,
The Chinese University of Hong Kong, Shatin, New Territories,
Hong Kong Special Administrative Region, China
+852 3943 0465
Email: christophersee@cuhk.edu.hk

Submitted: 16 December 2022
Accepted: 3 January 2023
Published online: 4 July, TAPS 2023, 8(3), 68-69
https://doi.org/10.29060/TAPS.2023-8-3/LE2930

David Mathew

Department of Anaesthesia, Khoo Teck Puat Hospital, Singapore

Dear Editor,

I read with great interest the article entitled “The associates of Emotional Intelligence in medical students: A systematic review” (Edussuriya et al., 2022) in your journal published in October 2022. The association of Emotional Intelligence (EI) with wellbeing cannot be underestimated, especially with the plethora of positive effects it has on mental health and academic performance. In fact, I think this can be extended beyond students, to all healthcare professionals.

In my opinion, humanities in medicine provide a potentially novel way of improving emotional intelligence. The writer of a piece acknowledges the scientific experience that has moved him/her, and subsequently reflects on the entire experience through the arts and writing. The process of writing can be cathartic as it presents an avenue for the writer to release emotions that might have been pent-up or hidden as we provide a brave front to our patients. Once written, the piece can be shared, and reach out to other healthcare professionals who might have encountered similar experiences. Some may find comfort in reading such pieces, as they realise they are not alone in experiencing the roller-coaster of emotions in their daily lives.

I have appended a piece I wrote regarding my experience with an obstetrics patient and how sometimes the lesser said, the more it means. The process of writing and sharing this piece helped me better understand and appreciate what I went through and I hope it can do the same for fellow readers.

Cry

The day I saw her cry

was when her baby’s heart

slowed.

She needed the Caesarean

quickly.

 

Her eyes conceived tears

crawling down her cheeks

shaping into an anxious cry.

I counted the tears

and spoke more words

comforting, reassuring.

 

I saw her cry

one week later,

this time her littlest bundle

the greatest joy.

 

Tears of happiness

dancing muted screams of relief

I counted the tears

but spoke nothing

comforting, reassuring.

 

Tears

instead of words,

won wars of emotions.

And staying silent

might be the most reassuring cry

of comfort.

Note on Contributor

DM came up with the concept of the manuscript, and wrote the entirety of its contents.

Funding

There was no funding for this paper.

Declaration of Interest

There is no conflict of interest declared.

References

Edussuriya, D., Perera, S., Marambe, K., Wijesiriwardena, Y., & Ekanayake, K. (2022). The associates of Emotional Intelligence in medical students: A systematic review. The Asia Pacific Scholar, 7(4), 59–70. https://doi.org/10.29060/taps.2022-7-4/oa2714

*David Mathew
Khoo Teck Puat Hospital,
90 Yishun Central, Singapore
Email: davidmathew3142@gmail.com

Submitted: 20 October 2022
Accepted: 3 January 2023
Published online: 4 July, TAPS 2023, 8(3), 65-67
https://doi.org/10.29060/TAPS.2023-8-3/CS2906

Hiroshi Kawahira¹, Yoshitaka Maeda¹, Yoshihiko Suzuki¹, Yuji Kaneda¹, Yoshikazu Asada², Yasushi Matsuyama², Alan Kawarai Lefor³ & Naohiro Sata³

¹Medical Simulation Center, Jichi Medical University, Japan; ²Medical Education Center, Jichi Medical University, Japan; ³Department of Surgery, Jichi Medical University, Japan

I. INTRODUCTION

The ongoing COVID-19 pandemic has a significant impact on medical education, forcing changes in the curriculum　(Rose, 2020). Since the COVID-19 pandemic began, governments and authorities in many countries have imposed online learning on medical students and in many institutions, medical students were not permitted to participate in in-person clinical clerkships or other practical training at university hospitals (Mian & Khan, 2020). Although the surgical clerkship is an important contributing factor to nurture student interest in a surgical career (Khan & Mian, 2020), medical students were excluded from the operating room due to lack of personal protective equipment, and participation in ward duties and training facilities were restricted (Calhoun, et al., 2020).

The purpose of this study is to analyse how the lack of in-person surgical experience and ward duties (online clerkship), among the most important components of a surgical clerkship, affected student interest in a career in surgery. The impact on student perceptions of surgery comparing online learning and onsite clinical clerkship (typical in-person clerkship) was assessed by comparing student satisfaction with the surgical clerkship, changes in interest in a career in surgery, and changes in the image of surgery at the beginning and end of rotations for online and onsite training groups.

II. METHODS

This study was reviewed by the Ethical Review Committee of Jichi Medical University, and no ethical review was required (Reference No. 20-186).  A total of 133 fifth-year medical students, all in the same academic year, participated in surgery clerkships from April 2020 to February 2021. All 133 medical students completed clerkships in internal medicine during the previous academic year. The 133 students were divided into eight groups, with 16 or 17 students per group, rotating in surgery every three weeks. The first five groups of that academic year had online lectures only and the last three groups had onsite practice (typical clerkship experience).

Of the 133 students, 124 who provided consent were included in this study. Of these, 79 received online training from April through September 2020, and 45 received onsite clerkship training from October 2020 through February 2021. Moodle, an online learning management system, was used as the platform for online learning, and designed content to be studied on demand. An orientation and lecture with a comprehensive explanation of each aspect of surgical training were synchronous, and online communication with individual students was also conducted. Faculty also communicated online with individual students using Moodle, and individual questions were answered via email as appropriate.

Questionnaires for students in the clerkship were administered using the Moodle platform regardless of whether the clerkship was onsite or online. Questionnaire items addressed: 1. anxiety about surgery, 2. Opinion about difficulty of surgery compared to internal medicine, and 3. interest in surgery. Responses were given as a single choice and were scored using a four-point scale: 1: disagree, 2: somewhat disagree, 3: somewhat agree, and 4: agree.

Comparisons between responses at the beginning and end of the three-week clerkship for all participants were made with the Wilcoxon signed rank test. After calculating differences between the beginning and end of the clerkship, the online and onsite groups were compared using the Mann-Whitney U test. A p < 0.05 was considered statistically significant. Cohen’s d was used as an index of effect size, with 0.2 as a small effect size, 0.5 as a medium effect size, and 0.8 as a large effect size. The statistical software used was R 3.6.1 with GUI 1.70 (The R Project for Statistical Computing, Vienna).

III. RESULTS

The results for the 124 students enrolled in this study showed that after three weeks of practice compared to the beginning of the study, they were less anxious about surgery (p<0.00001, effect size 0.43), less likely to find surgery difficult compared to study in other departments (p<0.00001, effect size 0.57), and were more interested in surgery as a career (p<0.0001 and effect size 0.38) (See Table 1).

The onsite clinical clerkship resulted in less anxiety about surgery (p = 0.017, effect size 0.41) compared with the online clerkship. There was no significant difference in change of the image of surgery as hard compared to other departments (p = 0.293, effect size 0.21) or change of interest in surgery (p = 0.407, effect size 0.09) in comparing the onsite and the online groups, and the effect size on change of image and interest were also small (See Table 1).

Table 1. Changes in the results of responses at the beginning and end of online and onsite clerkships

p*: Wilcoxon signed rank test, p^#: Mann-Whitney U test

IV. DISCUSSION

During the COVID-19 pandemic, medical schools have established integrating digital technology and novel pedagogy (Tan, et al., 2022). Regardless of the clerkship format, three weeks of surgical clinical clerkship resulted in less anxiety about surgery than initially felt, a less daunting image of surgery in comparison to other departments, and significantly higher interest in surgery. However, the effect sizes were moderate (0.43, 0.57, and 0.38), suggesting a positive change in the image of surgery, especially in comparison with other departments. The onsite clinical clerkship group showed a greater decrease in change in anxiety about surgery than the online clinical clerkship at the end of the surgical clinical clerkship (effect size 0.41). The effect size was moderate, suggesting the effectiveness of the onsite clinical clerkship. This study also shows that there were no statistical differences in the feeling of difficulty or interest in a surgical career between the onsite and the online groups. We believe that online content via Moodle was attractive for medical students. Also, medical students could feel the realism of the surgical workplace using Moodle.

V. CONCLUSION

Face-to-face communications with senior physicians are essential to foster an image of the role of physicians to medical students. It is desirable to develop a hybrid type of clinical clerkship that takes advantage of the advantages of the realism of surgery provided by an onsite clinical clerkship and the easy accessibility of educational content of an online clinical clerkship.

Notes on Contributors

Kawahira, Maeda and Suzuki designed the study. Asada and Kawahira constructed the Moodle platform. Kaneda, Lefor and Sata conducted surgical clinical practice. Kawahira and Maeda analyzed data. Kawahira and Lefor wrote the manuscript.

Acknowledgement

The authors would like to acknowledge Ms. Yasuko Saikai who did the administrative contact for the students, and all the staffs and surgeons of the Department of Surgery for instructing the students on the clinical clerkship.

Funding

This research was funded by the education and research expenses from Jichi Medical University.

Declaration of Interest

The authors declare that they have no competing interests.

References

Rose, S. (2020). Medical student education in the time of COVID-19. JAMA, 323(21), 2131-2132. https://doi.org/10.1001/jama.2020.5227

Mian, A., & Khan, S. (2020). Medical education during pandemics: a UK perspective. BMC Medicine, 18, Article 100. https://doi.org/10.1186/s12916-020-01577-y

Khan, S., & Mian, A. (2020). Medical education: COVID-19 and surgery. British Journal of Surgery, 107(8), Article e269. https://doi.org/10.1002/bjs.11740

Calhoun, K. E., Yale, L. A., Whipple, M. E., Allen, S. M., Wood, D. E., & Tatum, R. P. (2020). The impact of COVID-19 on medical student surgical education: Implementing extreme pandemic response measures in a widely distributed surgical clerkship experience. American Journal of Surgery, 220(1), 44-47. https://doi.org/10.1016/j.amjsurg.2020.04.024 

Tan, C. J., Cai, C., Ithnin, F., & Eileen, L. (2022). Challenges and innovations in undergraduate medical education during the COVID-19 pandemic – A systematic review. The Asia Pacific Scholar, 7(3), 1-9. https://doi.org/10.29060/TAPS.2022-7-3/OA2722

*Hiroshi Kawahira
Medical Simulation Center
Jichi Medical University
3311-1 Yakushiji, Shimotsuke, Tochigi
Japan 329-0498
Email: kawahira@jichi.ac.jp

Submitted: 14 December 2022
Accepted: 22 March 2023
Published online: 4 July, TAPS 2023, 8(3), 62-64
https://doi.org/10.29060/TAPS.2023-8-3/PV2926

Sachiko Kasamo, Satoshi Ozeki, Hiroyasu Inoue & Seiji Matsumoto

Institutional Research Office, Asahikawa Medical University, Japan

I. INTRODUCTION

There is growing interest in social responsibility around the world in order to accomplish a sustainable society. Indeed, modern universities cannot be ivory towers unrelated to society. It would not be an overstatement to say that without interaction and contribution to society, the university’s survival and development are unlikely.

It is frequently said that the university fulfils three different missions: education, research, and social contribution. J. A. Perkins, the eminent theoretician of higher education in the 1960s, proposed there are three aspects of knowledge that must be understood as they have their institutional reflections in the university’s three missions (Perkins, 2016). For knowledge itself to have significant power, there must be communication and interaction between the newly acquired knowledge, its transmission, and its application. The above concept began in the United States and has since been widely adopted as three major missions in many universities worldwide. Despite these three missions, however, depending on the university’s expertise and readiness, and the resources and support received from external organisations and individuals, the university may be more active on some missions and less active on others.

Some with a conventional conception of “social contribution” may wonder “why now?”, as the results of both “education and research” are ultimately returned to society. However, the major difference is that while the conventional efforts of the university were at the level of individual responses by faculty members and others, the current “social contribution” is positioned as the essential function of the university. Expectations for universities have changed significantly, and universities have changed in a variety of ways; universities are now required to use knowledge for society from various perspectives. The greater the need to contribute to society and the greater its role, the more we need to question the meaning of “social contribution” in relation to the traditional roles of “education and research” in the university.

II. GLOBAL CONCEPTS OF SOCIAL ACCOUNTABILITY IN MEDICAL SCHOOLS

The concept of social contribution is embedded in the social accountability of medical schools. The World Health Organization defined it as “the obligation to direct their education, research and service activities towards addressing the priority health concerns of the community, region, and/or nation they have a mandate to serve” (Boelen & Heck, 1995). Following this, the Global Consensus for Social Accountability of Medical Schools defined a socially accountable medical school as one that “responds to current and future health needs and challenges in society, re-orientates its education, research and service priorities accordingly, strengthens governance and partnerships with other stakeholders and use evaluation and accreditation to assess their performance and impact” (Global Consensus for Social Accountability of Medical Schools [GCSA], 2010). This document also emphasised the significance of enhancing medical schools’ ability to address the demands and difficulties of providing healthcare for citizens and society at large, in accordance with the fundamental principles of quality, equity, relevance, and effectiveness. In addition, the criteria for ASPIRE-to-Excellence Award for Social Accountability by Association for Medical Education in Europe provide a practical framework for medical schools to consider when examining their own social contribution. This award itself gives schools the opportunity to be acknowledged globally for their excellence in education, which also covers social accountability (Mori et al., 2022). These internationally accepted concepts should always be kept in mind when promoting social contribution activities in medical schools.

III. SOCIAL CONTRIBUTIONS IN JAPANESE MEDICAL SCHOOLS

Japan might be one of the unique countries to set clear objectives regarding the university’s social contribution in legislation. There are two revisions that have pushed the idea of social contribution forward as a fundamental function of the university (Hosono, 2014). First, the 2006 Revision of Basic Act on Education, Article 7 stated, “Universities, as the core of scholarly activities, are to contribute to the development of society by cultivating advanced knowledge and specialised skills, inquiring deeply into the truth to create new knowledge, and broadly offering the fruits of these endeavours to society.” Second, 2007 Revision of School Education Act, Article 83(2) stated, “Universities shall contribute to the development of society by conducting education and research to achieve their objectives and by providing the results widely to the society.” In light of these key statement revisions, the mission of the universities has changed along with the social trends, and more direct social contributions are being sought.

The importance of social contribution is also emphasised by Japanese medical schools. The recent study has analysed the Japan Accreditation Council for Medical Education accreditation documents of 45 medical schools against a global framework, and revealed that social contribution is identified to be one of the key components in the main category of “issues in society” for social accountability (Mori et al., 2022). As an essential aspect of social contribution, the need for an individual’s lifelong learning has increased by an accumulation of factors, such as disaster-related disruptions, pandemics, and the ageing population with longevity. Medical schools can certainly use their strengths as health experts to assist in health literacy and well-being for the members of communities. In addition, the government has long been prioritising, promoting, and advancing lifelong learning in Japan, in recognition of global challenges and social changes. Therefore, social contribution activities by medical schools can come into play to satisfy the need of individuals, society, and the country.

IV. SOCIAL CONTRIBUTION THROUGH COMMUNITY LECTURES: A CASE FROM A REGIONAL MEDICAL UNIVERSITY

Here, we share an example of ongoing direct social contribution activity at our university. The university positions social contribution as a significant role and mission in Educational Philosophy, and our “Community Lectures (haken kouza)” constitutes one of the essential elements in this role. This activity began in 2002 to meet the local community’s lifelong learning needs, and the university’s members have been giving lectures at the request of local public organisations. There are over 350 different topics offered to date. The lecture themes are not limited to medical and nursing topics, but also include educational and cultural topics. Between 2016 and 2019, we provided over 600 lectures to the local and regional communities. As the northernmost medical university in Japan, it is necessary to devise something unique to the region that makes the best use of the regional characteristics, and we firmly believe that there is a stage for the university to play an active role.

V. WHAT, THEN, IS THE SOCIAL CONTRIBUTION OF UNIVERSITIES

We acknowledge that the above Community Lecture is just one example, and in fact, social contribution can take many forms and shapes and be offered at various levels. The social contribution made by universities must not be merely the provision of free labour or lending facilities, but should fully utilise the characteristics of the university as the base for intellectual creative activities. In other words, the knowledge acquired and transmitted through the university’s education and research activities should be returned to the local community by the mechanism of social contribution with the aim of improving the lives and welfare of the local population. The ideal relationship between the university and the community should not be a one-way relationship but should be a reciprocal one; where the community benefits from the intellectual and human resources of the university through community cooperation, and the university makes effective use of the region as part of its education and research.

In addition, activities such as international collaboration, regional collaboration, industry-academia-government collaboration, and training programs are all solid initiatives aimed at giving back to society in a more direct way. The university faculty and staff have been independently engaged in these activities as experts in their respective fields. These include serving on committees of administrative agencies, supporting science education in schools, joint research with industries, and public lectures for non-students. They voluntarily carry out these social contribution activities (without even recognising them as such) alongside their busy daily clinical duties, teaching and research. However, these activities are often missed or not subject to systematic evaluation by the universities. In the future, these activities should be highlighted and evaluated as important activities that play a role in the functions of universities. We hope this article will stimulate interest in expanding social contribution in the university context. For future work, we plan to review other areas of social contribution activities conducted at the university.

Notes on Contributors

Sachiko Kasamo reviewed the literature, conceptualised and took the lead in writing and editing the manuscript.

Satoshi Ozeki contributed to the conception and revision of the manuscript critically.

Hiroyasu Inoue contributed to the conception and theoretical ideas of the manuscript.

Seiji Matsumoto supervised and gave critical feedback on the intellectual content of the manuscript.

All the authors have read and approved the final manuscript.

Acknowledgement

We sincerely thank Ms Misako Sato (Institutional Research Office’s administrative staff) and the Research Support Section of Asahikawa Medical University for their support.

Funding

There is no funding source required for this study.

Declaration of Interest

All authors have no conflicts of interest to disclose.

References

Boelen, C., & Heck, J. E. (1995). Defining and measuring the so­cial accountability of medical schools. Geneva: World Health Or­ganization.

Global Consensus for Social Accountability of Medical Schools (GCSA). (2010). Global census for social accountability of medi­cal schools. https://healthsocialaccountability.sites.olt.ubc.ca/files/2011/06/11-06-07-GCSA-English-pdf-style.pdf

Hosono, M. (2014). Kokuritsu daigaku niokeru syakaikoukenka­tsudouno genjyou to kadai. [Current Status and Issues of Social Contribution Activities at National Universities]. The Journal of Science Policy and Research Management, 29(1), 44-49. https://doi.org/10.20801/jsrpim.29.1_44

Mori, H., Izumiya, M., Hayashi, M., & Eto, M. (2022). Current perception of social accountability of medical schools in Japan: A qualitative content analysis. Medical Teacher, 1-8. https://doi.org/10.1080/0142159X.2022.2140033

Perkins, J. A. (2016). The university in transition. Princeton Uni­versity Press.

*Seiji Matsumoto
Institutional Research Office,
Asahikawa Medical University,
2-1-1-1, Midorigaoka-Higashi,
Asahikawa, Hokkaido,
078-8510, Japan
Email: matsums@asahikawa-med.ac.jp

Submitted: 11 September 2021
Accepted: 22 March 2023
Published online: 4 July, TAPS 2023, 8(3), 58-61
https://doi.org/10.29060/TAPS.2023-8-3/SC2694

Maria Isabel Atienza & Noel Atienza

San Beda University College of Medicine, Philippines

Abstract

Introduction: An evaluation of the online medical course was conducted to assess student readiness, engagement, and satisfaction at the San Beda University College of Medicine in Manila during the COVID-19 pandemic.

Methodology: A convergent mixed methods approach was done with a quantitative online survey and a qualitative thematic analysis of focus group discussions (FGD) with medical students. A total of 440 students participated in the survey while 20 students participated in the FGDs.

Results: The medical students were sufficiently equipped with computers and internet connections that allowed them to access the online medical course from their homes. The 5 themes identified during the study that were relevant to education were: Student readiness for online learning, Learning Management System (LMS) and internet connectivity, teaching and learning activities, the value of engagements, and teaching effectiveness of the faculty. The combined quantitative and qualitative analysis revealed vital issues that affect student learning. This included the need for students to interact with fellow students and to be engaged with their faculty. The issues that affect teaching included the need for continuing faculty training and management skills in delivering the full online course.

Conclusion: The success of online education rests heavily on the interactions of the students, the teachers, and the knowledge. Student interactions, managerial and skills training for the faculty, and providing students with a mix of synchronous and asynchronous activities are the most effective means to ensure the effective delivery of online medical courses.

Keywords:       Medical Curricular Revision, Formative Evaluation, Student Engagement, Synchronous and Asynchronous Online Learning, Cognitive Overload

I. INTRODUCTION

The COVID-19 pandemic necessitated a shift to online teaching and a revision of the medical curriculum with synchronous and asynchronous online activities. Medical schools worldwide adapted teaching strategies utilising Video Conferencing and Learning Management Systems.

This program evaluation of the online medical course aimed to evaluate the effectiveness of instruction using the various components of online learning. The study centered on the perspectives of students using a mixed methods design (Fitzpatrick et al., 2011). The study focused on the interplay of digital capabilities, students’ perceptions and satisfaction with the interactions and engagements during the online course.

II. METHODS

The mixed methods research protocol was approved by the Institutional Ethics Board of San Beda University. The study utilised a convergent mixed method design with a quantitative online survey that was conducted on 440 respondent students representing each of the four-year levels of the medical school. Six focus group discussion (FGD) sessions were conducted on 20 students. All student participants provided a signed informed consent form to participate in the survey and in the FGDs. The 25-item online survey questionnaire included a 5-point Likert scale for items on readiness for the online course, overall satisfaction, and engagement. The online FGD sessions were conducted using an open-ended questionnaire guide on student capabilities for the online course, student satisfaction, and student engagement.

The FGD recordings were transcribed and subjected to thematic analysis to identify major themes. Quantitative and qualitative data were analysed simultaneously through a joint display of the two sets of results. A joint display using pillar integration was done to demonstrate the themes where the data corroborated or validated each other. The conceptual framework, data collection tools, the data results, and the pillar integration table are posted in a data repository file for this study can be accessed through a repository at: https://doi.org/10.6084/m9.figshare.16682569.v2 (Atienza & Atienza, 2021).

III. RESULTS

The survey revealed that students were adequately equipped with the necessary computers and smartphones needed to access the online course. Only 50% of the students were taking the online course from their homes within the same city as the medical school. While 72% encountered internet connectivity problems, 88% of students were successful in the use of the LMS and the videoconferencing platform to access the course and take online examinations.

Seventy-eight percent of students found online student-to-student and faculty-to-class interactions to be beneficial to student learning. Among the synchronous activities, 63% of students preferred live online lectures. Among the asynchronous activities, 52% of students preferred uploaded video lectures. Overall, around 52% of students experienced being overloaded with study requirements while 48% of students felt there was sufficient time for independent study.

The results of the survey and the thematic analysis of the FGDs were organised into themes and subthemes. These themes were generated from the integration of the quantitative and qualitative data. The schematic diagram (Figure 1) demonstrates how the themes are related to the effectiveness of learning based on the perspective of the students.

The first theme that surfaced from the results was Student Readiness to engage in online learning. Students found their readiness to be dependent on two subthemes:

1) Study environment at home: Students expressed that the sudden shift to studying from home required that they designate sufficient time and space for studying. Students recognised that responsibilities at home and to the family could be distractions if not managed properly.

2) Psychological preparedness: The students also expressed the value of psychological preparedness as essential in dealing with stress and fatigue resulting from the unexpected shift to the online learning mode.

B. LMS and Internet Connectivity

The second theme highlights the importance of having computers and a stable internet connection as major determinants of student satisfaction with the online course. The introduction of an LMS for the medical course required immediate training for both the students and the faculty. While 81% of the students had the necessary gadgets and a good internet signal, 17% experienced major connection problems that disrupted up to 50% of live lectures and offline recorded videos. Student satisfaction with online learning was dependent on how timely and how organised the learning materials were uploaded into the LMS.

C. Teaching and Learning Activities

The third theme refers to the blend of online and offline activities for the different courses. The major subthemes included cognitive overload, variability of teaching and learning activities across courses, and the lack of clinical exposure.

1) Cognitive overload: Students had a perception of being overloaded by the volume of information delivered through the online course. The introduction of new forms of assessments such as video assignments, group reports, and research outputs contributed to the perceived cognitive overload.

2) Variability of teaching and learning activities: The variability in the blend of online and offline activities across the different courses required varying degrees of adjustments from the students. The students expressed their preference for live or recorded lectures over small group discussions and live laboratory demonstrations.

3) Lack of clinical exposure: Students in the 3^rd and 4^th year levels were apprehensive about the lack of clinical exposure in the actual medical environment due to the restrictions brought about by the pandemic. They recognise that they may not have the necessary skills training needed for internship.

D. The Value of Engagements

Unexpectedly, the fourth theme that students found important in the shift to online learning was the value of engagements.

1) Student-to-student online interactions: Up to 78% of students found support through interactions with other students. These interactions were useful not only for sharing the academic workload but also for mental and emotional support highlighting the value of student camaraderie despite being limited to virtual interactions.

2) Faculty-to-class interactions: Up to 80% of students expressed appreciation for the efforts of the faculty to get student feedback, answer clarificatory questions, and provide explanations when necessary. The students also expressed greater satisfaction with courses delivered online. Both faculty interactions with the class and with individual students were recognised as faculty approachability.

E. Teaching Effectiveness of The Faculty

The fifth theme Teaching pertains to the ability of the faculty to manage the online platform for teaching.

1) Faculty management skills: Teaching effectiveness is facilitated by the ease by which the faculty manages virtual teaching.

2) Faculty peer communication: Students recommend that the faculty within and across different courses coordinate their activities so that students can more easily manage their time and learning.

IV. DISCUSSION

The experience of delivering the medical course online has been very limited in the past. The teaching and learning strategies for medical courses to be delivered fully online require extensive preparation of the three main points in the transaction of learning: the learners, the teachers, and the course content. Learner readiness entails a clear delineation of the study environment in terms of time and space for study. Proper orientation to the online learning environment and psychological support should be made available to the students before the course begins. An inventory of the students’ computers and internet connectivity should also be done to ensure readiness for the course.

Delivering the course online necessitates faculty training on teaching and learning strategies for synchronous and asynchronous delivery as well as the proper navigation of the LMS and its available features. The faculty must maximise the benefits of technology as well as pedagogy in the online learning environment.

This study showed that in the shift of medical education to an online mode during the pandemic, student learning relies heavily on interactions between the learners, the teachers, and the course content. In an online course that relies so much on technology as a means of course delivery and integration, teaching and learning success depends on how well the interactions are established among these three points (Ifinedo & Rikala, 2019).

The design of courses must facilitate student-to-student interactions while faculty-to-class interactions using both synchronous and asynchronous activities would provide a good learning experience for students (Rhim & Han, 2020; Seymour-Walsh et al., 2020).

V. CONCLUSION

To succeed in the delivery of the online medical course, sufficient time must be given for faculty-to-student interactions during synchronous sessions and after the online classes. The faculty must demonstrate approachability by being open to continuing interactions with students outside the synchronous sessions. The coordination of faculty members within and across different courses must be enhanced to reflect efficiency in delivering their respective courses.

This study was performed during the early phase after the shift to full online delivery of the medical course. While the study is based on the perceptions of the students, the results of this study may be valuable in planning for continuing the online delivery of the medical course. The results of this study may be more robust with the inclusion of faculty perceptions and indicators of student academic performance.

Notes on Contributors

Dr. Maria Isabel Atienza conceptualised, designed, and implemented this study. She conducted the focus group discussions, prepared the thematic analysis, and wrote the manuscript for this study.

Dr. Noel Atienza helped in the design and conduct of the online survey and was involved in the data processing and data analysis of the survey. He was also involved in the preparation and editing of the final manuscript.

Ethical Approval

The research protocol SBU-REB # 2020-028 for this study was reviewed and approved by the San Beda University Research Ethics Board on November 28, 2020.

Data Availability

Data collection tools and research data are available and can be accessed by any interested reader through a repository at: https://doi.org/10.6084/m9.figshare.16682569.v2. The data in the repository may not be copied or cited without written permission from the authors.

Acknowledgment

The authors would like to acknowledge the support provided by the Alumni of San Beda and their commitment to promoting faculty research activities.

Funding

This study was funded by the Jesus P. Francisco Distinguished Professorial Chair Research Grant from the San Beda College Alumni Foundation, Inc.

Declaration of Interest

There are no conflicts of interest in this study.

References

Atienza, M., & Atienza, N. (2021). An online medical course during the COVID-19 pandemic: A mixed methods analysis. [Data set]. Figshare. https://doi.org/10.6084/m9.figshare.16682569.v2

Fitzpatrick, J., Sanders, J., & Worthen, B. (2011). Program evaluation: Alternative approaches and practical guidelines 4^th Edition. Pearson Education, Inc.

Ifinedo, E., & Rikala, J. (2019). TPACK and educational interactions: Pillars of successful technology integration. World Conference on E-Learning. Association for the Advancement of Computing in Education, 295-305. https://www.learntechlib.org/primary/p/211094/

Rhim, H., & Han, H. (2020). Teaching online: Foundational concepts of online learning and practical guidelines. Korean Journal of Medical Education, 32(3), 175-183. https://doi.org/10.3946/kjme.2020.171

Seymour-Walsh, A., Bell, A., Weber, A., & Smith, T. (2020). Adapting to a new reality: COVID-19 coronavirus and online education in the health professions. Rural and Remote Health, 20, 6000. https://doi.org/10.22605/RRH6000

*Maria Isabel Maniego Atienza
San Beda University, Mendiola Street,
Barangay San Miguel,
City of Manila, Philippines
+639178668751
Email: mimatienza@yahoo.com