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

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

IMU Centre for Education, International Medical University, Malaysia

Dear Editor,

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

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

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

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

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

Notes on Contributors

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

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

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

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

Acknowledgement

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

Funding

No funds, grants, or other support were received. 

Declaration of Interest

No conflicts of interest are associated with this paper.

References

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

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

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

Tomoko Miyoshi¹, Mikiko Iwatani² & Fumio Otsuka¹

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

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

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

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

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

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

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

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

Notes on Contributors

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

M Iwatani conceptualised and approved the manuscript.

F Otsuka supervised and edited the manuscript.

Funding

There is no funding provided.

Declaration of Interest

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

References

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

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

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

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

Maximilian Andreas Storz¹ & Rintaro Imafuku²

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

I. INTRODUCTION

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

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

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

II. METHODS

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

III. RESULTS

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

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

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

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

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

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

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

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

IV. DISCUSSION

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

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

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

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

V. CONCLUSION

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

Notes on Contributors

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

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

Funding

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

Declaration of Interest

The authors declare that they have no competing interests.

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Notes on Contributors

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

WANVL drafted the initial version of the mauscript.

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

Funding

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

Declaration of Interest

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

References

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

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

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

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

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

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

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

Dhivya Subramanian

School of Medicine, University of Dundee, United Kingdom

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

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

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

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

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

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

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

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

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

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

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

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

Notes on Contributors

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

Acknowledgement

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

Funding

No funding has been received for this article.

Declaration of Interest

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

References

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

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

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

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

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

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

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

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

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

Abstract

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

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

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

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

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

I. INTRODUCTION

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

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

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

II. METHODS

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

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

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

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

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

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

III. RESULTS

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

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

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

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

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).