Submitted: 11 March 2022
Accepted: 28 June 2022
Published online: 4 April, TAPS 2023, 8(2), 14-35
https://doi.org/10.29060/TAPS.2023-8-2/OA2762

Sayaka Oikawa¹, Ruri Ashida² & Satoshi Takeda³

¹Center for Medical Education and Career Development, Fukushima Medical University, Fukushima, Japan; ²Center for International Education and Research, Tokyo Medical University, Tokyo, Japan; ³Department of Emergency Medicine, The Jikei University School of Medicine, Tokyo, Japan

Abstract

Introduction: There are various difficulties in treating foreign patients; however, the existing educational programs are still insufficient for addressing this issue. The purpose of this study is to investigate what difficulties are encountered in the treatment of foreigners in emergency departments, and to create scenarios for simulation-based education using real-life cases.

Methods: A cross-sectional anonymous survey to 457 emergency departments was conducted in 2018. Additionally, we conducted a survey of 46 foreign residents who had visited hospitals for treatment in Japan. The data was analysed quantitatively, and the narrative responses were thematically analysed.

Results: Of the 141 hospitals that responded (response rate: 30.9%), 136 (96.5%) answered that they had treated foreign patients. There were 51 and 66 cases with cultural and linguistic difficulties, respectively. In the qualitative analysis, different ideas/beliefs towards treatments or examinations (51.0%) and communication with non-English speaking patients (65.2%) were most common categories in the cases with cultural and linguistic difficulties, respectively. The survey of 46 foreign residents on the surprising aspects of Japanese healthcare showed, 14% mentioned difference in treatment plans between own country and Japan, 12% each mentioned a lack of explanation by medical staff, and a lack of privacy in the examination room. Based on the survey results, we created 2 scenarios of simulation.

Conclusions: Scenarios of simulation-based education using real-life cases may be effective materials for cultivating cultural awareness of medical staff.

Keywords:           Cultural Awareness, Cultural Humility, Emergency Department, Foreign Patients, Simulation-based Education

Based on the survey results, we decided the main topic of the scenarios based on the contents overlapped in multiple cases. “Gender restriction of doctors who treated patients” and “communication difficulty in languages other than Japanese or English” were the most frequent topics in cultural and linguistic difficulties respectively. Following the selection of topics, we synthesised the similar responses to create a scenario that could occur in any size of ED setting. We developed the settings including patient age, sex, language, and backgrounds, regarding that the patient characteristics can be demonstrated by simulated patients. As a result, we developed two scenarios: a scenario of abdominal pain in a Muslim female patient and a scenario of forearm fracture in a Chinese male patient (Appendices 5 and 6).  In the abdominal pain scenario, no female doctor was available, and a learner, a male doctor, had to examine and treat a simulated patient who refused to be seen by a male doctor. In the forearm fracture scenario, no interpreter was available, and a learner had to communicate with a simulated patient who spoke Chinese only. The learning objective for the learners was to communicate appropriately with patients with different cultural and linguistic backgrounds. Based on the results of the survey for foreign residents, we indicated the importance of listening to the patient’s concerns carefully as a teaching point. Also, we reflected the survey results of how each hospital handled the cases on the information for instructors and teaching points.

IV. DISCUSSION

At the time of writing this paper, 96.5% of the EDs had accepted foreign patients; and 82.3% had English-speaking staff. However, only 32.6% of the EDs had multilingual signs for patients, which is listed as actions to be taken in the manual for treating foreign patients (Japan Ministry of Health, Labour and Welfare, 2021).

In the present study, most of the EDs used translation tools when treating foreign patients. Various types of translation methods were found to be used in the EDs, the use of which is consistent with the manual for treating foreign patients (Japan Ministry of Health, Labour and Welfare, 2021). However, we found that the EDs still encountered a significant number of cases with linguistic difficulties. This suggests that even though the EDs own the translation tools, medical staff are not able to utilise them in communicating with foreign patients. According to our survey result, it was revealed that more than half of the cases with linguistic difficulties were of non-English speaking patients. To overcome the linguistic difficulties, medical staff need to be capable of using them enough to communicate with patients of various native languages. In addition to the use of translation tools, multilingual medical explanation/consent forms or signs in hospitals may be effectively used in the aim of communication with foreign patients.

Regarding culturally difficult cases, our survey showed the various issues caused by differences of religious background, lifestyles, and ideas and beliefs on treatment and testing between medical staff and patients. This result is consistent with the reports which elaborated difficulties in treating foreign patients in Japan (Tatsumi et al., 2016). Our study showed that different ideas/beliefs towards treatments or examinations was most common theme in the cases with cultural difficulties in EDs. Knowing beliefs of other culture is one of individual’s capabilities to manage effectively in culturally diverse settings (Ang et al., 2007), and a report on psychiatric hospitals showed that medical staff adapted to hospitalised foreign patients’ culture and religion as they built the relationships with the patients over a long period of time (Kobayashi et al., 2014). Whereas, it is difficult to build relationships with foreign patients in the acute ED setting. Thus, we realised that practical training of communication with foreign patients provide knowledge about their cultures and religions in limited time and is critically important for medical staff in EDs.

SBE is an effective educational format which makes learners’ unconscious incompetence to conscious incompetence (Morell et al., 2002), in other words, medical staff may be able to recognise their unconscious biases towards foreign patients by participating in SBE. As consistent with the previous survey by the MHLW (2021), the culturally difficult cases included complicated issues that require the cooperation of administrative staff and full-time English interpreters in the hospital. In the present study, we created the two scenarios targeting medical staff as learners based on the real-life cases with the many responses in the survey. However, we need to create more varieties of scenarios that can involve other professions than health care professionals. Furthermore, the acquisition and retention of learners’ skills in a single training session of SBE is limited (Legoux et al., 2021). SBE aimed at cultivating cultural awareness cannot be completed in a single session but in continuous sessions with multiple scenarios.

The results of our survey of foreign residents showed that they had been surprised at the differences in treatment plans between their country and Japan, a lack of explanation by medical staff, and a lack of privacy in the examination room. We found that it is important to investigate the opinions of those who receive medical care in a country different from their home because their perspectives allow us to recognise the things taken for granted among medical staff.  Medical staff’s unconscious biases about patients of different cultural backgrounds or national origins influence their decision-making (Tervalon & Murray-Garcia, 1998), and implicit bias can contribute to miscommunication (Bartlett et al., 2019). Therefore, listening to the concerns of foreign patients is important in order to avoid providing treatment based solely on medical staff’s biases. Furthermore, in creating scenarios, referring to the survey results of multiple stakeholders made the contents more multi-dimensional and relevant. This study was conducted in the contexts of EDs in Japan, however, scenarios created with perspectives of both medical staff and patients who have various cultural backgrounds may effectively address to the real-life problems triggered by unconscious biases, even in other contexts. 

In Emergency situations, we often focus on the patients’ cultural backgrounds, national origins, languages, and religious background in order to provide effective treatments. However, recognising our own bias is not achieved by only focusing on the patients’ culture. Self-reflection is necessary to recognise one’s own cultural biases. The process of self-reflection of our own culture is important for cultivating cultural awareness. Furthermore, the importance of cultural humility – discovering one’s own values toward other cultures through continuous self-reflection and becoming aware of one’s own relationship to the world – has been recently noted in medical education (Chang et al., 2012). As a further research, the development of scenarios that include the study guide which ensure the learners’ self-reflection is required for SBE in emergency settings.

There are several limitations in this study. The response rate of a survey for EDs was 30.9%, which is unable to deny sampling bias. We conducted a survey for EDs with a focus on English, however, it is necessary to conduct surveys on languages other than English. In addition, the survey was only for the EDs of training hospitals in the top 10 prefectures with the most foreign tourists. We may consider expanding the number of hospitals to collect more information about difficulties they encounter in treating foreign patients. For the sub study, the snowball sampling had a methodological limitation in calculating total number the survey sent. As a further research, impacts of SBE using these scenarios on the treatment of foreign patients is less clear. To assess whether foreign patients’ satisfaction of medical care will change, and whether unconscious bias towards foreign patients among medical staff will decrease by conducting these scenarios are necessary.

V. CONCLUSION

In the current study, we were able to clarify linguistic and cultural difficulties in treating foreign patients in the EDs. We developed the scenarios for SBE using the real-life difficult cases of foreign patients with linguistic or cultural differences in medical care in Japan. The simulation training using these scenarios may be useful for promoting cultural awareness of medical staff in EDs. In future, more varieties of scenarios of SBE need to be created and shared in order to treat foreign patients safely and adequately.

Notes on Contributors

SO contributed to the design of the study and conducted data collection and analysis. RA devised the project, the main conceptual ideas, and conducted data collection and analysis. ST contributed to the design of the study and the interpretation of the data.

Ethical Approval

This study was approved by the Institutional Review Board of The Jikei University School of Medicine Japan (Approval No. 28-211(8454), 28-276(8519)). An informed consent was obtained from all the participants responded to the survey.

Data Availability

The data that support the findings of this study are not openly available due to privacy. The materials are available from the corresponding author on reasonable request.

Acknowledgement

The authors would like to acknowledge the respondents at the EDs of training hospitals, the foreigners living in Japan, and the young clinicians at The Jikei University School of Medicine for their cooperation in the study. 

Funding

This work has been supported by JSPS KAKENHI, grant number 16K08883.

Declaration of Interest

The authors report no conflicts of interest. The authors alone are responsible for the content of the article.

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*Sayaka Oikawa
Center for Medical Education and Career Development,
Fukushima Medical University,
1 Hikarigaoka, Fukushima, 960-1295, Japan
Email: sayaka9@fmu.ac.jp

Submitted: 11 February 2022
Accepted: 21 July 2022
Published online: 4 April, TAPS 2023, 8(2), 4-13
https://doi.org/10.29060/TAPS.2023-8-2/OA2755

Tri Nur Kristina¹, Fatikhu Yatuni Asmara², Sudaryanto Sudaryanto¹, Nuryanto Nuryanto³ & Saekhol Bakri¹

¹Department of Medicine, Faculty of Medicine, Universitas Diponegoro, Indonesia; ²Department of Nursing, Faculty of Medicine, Universitas Diponegoro, Indonesia; ³Department of Nutrition, Faculty of Medicine, Universitas Diponegoro, Indonesia

Abstract

Introduction: This study aimed to examine the usefulness of Community Based-Education (CBE) and Interprofessional Education (IPE) to community health outcomes.

Methods: The design was a mixed-method study. Each small group worked together to identify family health problems, implement interventions, and evaluate the results. The Readiness for Interprofessional Learning Scale (RIPLS) questionnaire was applied to compare students’ perceptions before and after the implementation. In addition, qualitative data were acquired from students’ comments on the questionnaire, interviews with community representatives, and FGDs with instructors at the end of the program.

Results: Three hundred and sixty-seven out of 465 students returned the completed paired questionnaire (78.9 % response rate). Paired t-test showed that student perception of responsibility slightly increased, whereas teamwork and collaboration, negative and positive professional identity decreased somewhat. However, most pre-post students’ responses already trended to the positive side (scales 4 and 5). Moreover, the Chi-square test showed that pre-post students’ confidence levels significantly increased. Most small groups of students successfully empowered the community to solve health problems. Students, instructors, and representatives of community members appreciated the program. However, several students felt their instructors were not motivated to mentor their tasks, and sometimes they had difficulty conducting home visits together. 

Conclusion: This study showed that the combination of CBE-IPE contributes to more favourable community health outcomes. However, it was challenging in several aspects of preparation, including highly motivated instructors. Nevertheless, pre and post-implementation students’ attitudes are still positive.

Keywords:           Interprofessional Education (IPE), Community Based Education (CBE), Health Profession Students, Readiness

Published online: 4 April, TAPS 2023, 8(2), 1-3
https://doi.org/10.29060/TAPS.2023-8-2/EV8N2

Shuh Shing Lee¹ & John Norcini²

¹Centre for Medical Education, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; ²Foundation for Advancement of International Medical Education and Research, United States of America

It has been almost three decades since Boyer (1990) introduced the concept of the Scholarship of Teaching and Learning (SoTL). In their own disciplines, faculty members are required to stay abreast of emerging knowledge and to contribute to the literature so that they advance their field through well-informed inquiry and disseminated work. Although they also have educational responsibilities, faculty are neither similarly motivated nor are they incentivised to participate in educational scholarship. Consequently, their efforts in this regard are often based on personal belief and opinion rather evidence and scientific inquiry. This problem persists despite a growing body of evidence that adopting sound instructional practices and pursuing scholarly work related to teaching, will increase the quality of the institution’s educational processes. In turn, this will enhance student learning and ultimately lead to better patient care. To achieve this end, teaching and learning must be scrutinised in terms of theory, methods, evidence, and outcomes. And faculty members who engage in teaching need to be rewarded for their participation in educational scholarship just as they are for efforts in their own disciplines.

In supporting educators’ SoTL journey and enhancing the quality of their teaching, this special issue “Celebrating Excellence in Scholarship of Teaching and Learning” aims to demonstrate how educators adopt a scholarly approach and how they collect and present rigorous evidence of their effectiveness. It encompasses much of current health professions education, touching on topics such as interprofessional education, the globalisation of healthcare, the impact of COVID-19, vaccine hesitancy, and digital badges.

Educators from Indonesia shared their strategy for enhancing interprofessional education through community-based education (Kristina et al., 2023). Teams of students developed solutions to family health issues together. The authors found implementation challenges when applying this model, especially in terms of scheduling home visits. However, through this experience the students learned the value of teamwork and the roles of each of the representatives.

As a result of globalisation, there is a significant increase in the number of patients being admitted to hospitals outside of their home countries. The Emergency Department is often the first point of contact for these foreign patients and cultural differences naturally pose challenges. To address this issue and to help patients with different backgrounds obtain high quality care, some hospitals in Japan have initiated cultural awareness training for their doctors. While this is a positive step, doctors in the Emergency Department in Japan still face difficulties in this area. To address these challenges going forward, educators from Japan would like to identify the difficulties still encountered and eventually design scenarios, based on real life cases, for use in simulations (Oikawa et al., 2023).

COVID-19 has changed the way teaching has occurred and it has accelerated the use of technology in all phases of education. This special edition contains two Case Studies related to this issue. The report by Kushare et al. (2023) takes on the use of blended learning that occurred synchronously at different campuses in Malaysia. The report by Lim et al. (2023) focuses on student perspectives on the prohibition of direct patient contact during pandemic. It will be important to follow future developments in these areas as restrictions are lifted.

COVID-19 has not only affected teaching, but it has also had a profound influence on the practice of medicine. Vaccine hesitancy among patients is a growing phenomenon for which not all health care providers are prepared. Physicians may have misconceptions about what drives patient behaviour leading to the less effective provision of information and counselling. To better understand this issue and design a relevant curriculum to create awareness, Jenkins et al. (2023) explored medical students’ reactions to vaccine hesitancy and their reflections on their own biases in patient interactions. The qualitative analysis of students’ reflections offered by the authors is a useful basis for working with students around this issue. 

In recent years, digital badges have increasingly become a part of the educational landscape. They constitute an innovative instructional strategy combing the teaching and credentialing of competencies to provide evidence for achievement. However, research in this area is scare. Truskowska et al. (2023) introduced a pilot project regarding the use of digital badges in a Psychiatry module offered as part of a continuous assessment programme. They evaluated the effectiveness of the digital badges based on students’ perspectives of their utility, their level of engagement with the module, and their motivation to study. Students found the badges rewarding but noted that their value was unclear which would eventually lead to a loss of motivation.

Assessment has been a main topic of discussion in SoTL because it shapes how student learn and informs teachers about the effectiveness of their own work. Dayanidhi et al. (2023) present information about a radical curriculum and assessment reform that has been taken place in India. Forensic Medicine and Toxicology, a major competence, is often underrepresented in assessment. The authors established this through an analysis and comparison of the distribution of content tested, domain of learning and construct of the questions derived from undergraduate summative examination question papers on the topic from six universities across India. Also focused on assessment, Lim and Lim (2023) share an innovative assessment method – oral interactive assessment– which they have implemented among the occupational therapy students. Instead of multiple-choice questions or short written answers, each student was assessed with a standardised actor who simulate concerned parents, asking questions about their children’s development. While students are more anxious with this format, an interactive oral assessment has real world relevance.

There are several articles discussing initiatives that were conducted for faculty members in this special issue. For example, Lim et al. (2023) described a coaching programme aimed at providing educators a framework that helps students make discoveries and work towards their goals and training them how to question students. Field et al. (2023) offered a study in training their faculty members to teach and assess students’ clinical thinking skills using a model. Goh and Schlegal (2023) examined the journey of scholarship in health professions education and suggested tangible small steps to start, sustain, and succeed along the SoTL journey.

Felten (2013) in his paper “Principles of Good Practice in SoTL” mentioned that good scholarship should be grounded in context because it takes place in a particular classroom, institution, organisation, and education system where the culture is bounded. Tan et al. (2023) elaborated this aspect in his article using Bronfenbrenner’s Ecological Systems theory (EST). Grant (2023), similarly, highlighted the notion that the practice of teaching is socially bound and highly dependent on the culture, content and context. She further described the relationship between medical educationalists and teachers in the entire SoTL journey.

Good teaching is multidimensional, challenging, and contextual as demonstrated by all the authors in this special issue. However, this is an excellent place to start and it encourages all of us to apply the same thoughts processes to our teaching as we do in our discipline-specific research. Teaching is a process of reflection on our practice and if we follow this dictum, more scholarly teaching will result in higher quality in learning among our students. 

 

Shuh Shing Lee & John Norcini
Guest Editors 
The Asia Pacific Scholar (TAPS) 

 

Boyer, E. L. (1990). Scholarship revisited: Priorities of the professionals. Carnegie Foundation for the Advancement of Teaching.

Dayanidhi, V. K., Datta, A., Hegde, S. P., & Tiwari, P. (2023). Evaluating the content validity of the undergraduate summative exam question papers of Forensic Medicine & Toxicology from 6 medical universities in India. The Asia Pacific Scholar, 8(2), 57-65. https://doi.org/10.29060/TAPS.2023-8-2/OA2778

Felten, P. (2013). Principles of Good Practice in SoTL. Teaching & Learning Inquiry: The ISSOTL Journal, 1(1), 121-125. https://doi.org/10.2979/teachlearninqu.1.1.121

Field, S., Croskerry, P., Love, S., & Alexiadis Brown, P. (2023). An online programme in teaching and assessing critical thinking for medical faculty. The Asia Pacific Scholar, 8(2), 66-69. https://doi.org/10.29060/TAPS.2023-8-2/SC2894

Goh, P. S., & Schlegal, E. F. M. (2023). Small, sustainable, steps to success as a scholar in Health Professions Education – Micro (macro and meta) matters. The Asia Pacific Scholar, 8(2), 76-79. https://doi.org/10.29060/TAPS.2023-8-2/SC2861

Grant, J. (2023). The Scholarship of teaching: Who is the truth teller? The Asia Pacific Scholar, 8(2), 83-85. https://doi.org/10.29060/TAPS.2023-8-2/PV2874

Jenkins, M. C., Paul, C. R., Chheda, S., & Hanson, J. L. (2023). Qualitative analysis of reflective writing examines medical student learning about vaccine hesitancy. The Asia Pacific Scholar, 8(2), 36-46. https://doi.org/10.29060/TAPS.2023-8-2/OA2855

Kristina, T. N., Asmara, F. Y., Sudaryanto, S., Nuryanto, N., & Bakri, S. (2023). Increasing the value of Community-Based Education through Interprofessional Education. The Asia Pacific Scholar, 8(2), 4-13. https://doi.org/10.29060/TAPS.2023-8-2/OA2755

Kushare, V., MK., B., Pamidi, N., Selvaratnam, L., Sen, A., & Dominic, N. A. (2023).  Vertical integration of anatomy and women’s health: Cross campus blended learning. The Asia Pacific Scholar, 8(2), 89-92. https://doi.org/10.29060/TAPS.2023-8-2/CS2806

Lim, M. J., Wee, J. C. P., Han, D. X. T., & Wong, E. (2023). Perspectives of medical students towards the prohibition of direct patient contact during a pandemic. The Asia Pacific Scholar, 8(2), 93-96. https://doi.org/10.29060/TAPS.2023-8-2/CS2849

Lim, S. M., & Lim, C. Y. (2023). Use of interactive oral assessment to increase workplace readiness of occupational therapy students. The Asia Pacific Scholar, 8(2), 86-88. https://doi.org/10.29060/TAPS.2023-8-2/SC2804

Lim, S. M., Shahdadpuri, R., & Pua, C. Y. (2023). Coaching as an educator: Critical elements in a faculty development program. The Asia Pacific Scholar, 8(2), 70-75. https://doi.org/10.29060/TAPS.2023-8-2/SC2802

Oikawa, S., Ashida, R., & Takeda, S. (2023). Increasing cultural awareness in emergency departments with simulation scenarios created through a survey. The Asia Pacific Scholar, 8(2), 14-35. https://doi.org/10.29060/TAPS.2023-8-2/OA2762

Tan, K., Foo, Y. Y., & Tan, N. C. K. (2023). Refocusing SoTL – Myopia, context lenses and ecological systems theory. The Asia Pacific Scholar, 8(2), 80-82. https://doi.org/10.29060/TAPS.2023-8-2/PV2842

Truskowska, E., Emmett, Y., & Guerandel, A. (2023). Digital badges: An evaluation of their use in a Psychiatry module. The Asia Pacific Scholar, 8(2), 47-56. https://doi.org/10.29060/TAPS.2023-8-2/OA2869

Published online: 3 January, TAPS 2023, 8(1), 1-2
https://doi.org/10.29060/TAPS.2023-8-1/EV8N1

COVID pandemic created worldwide disruptions to all services and had profound impact on training of health professionals, posing serious challenges to maintaining essential healthcare services. During the height of the pandemic, most of the undergraduate learners were prevented from clinical training sites, restricted intra, inter-institutional and overseas learning opportunities and in many institutions, there were termination of onsite learner-educator engagements (Ng et al., 2021; Renaud et al., 2021; Samarasekera et al., 2020). Less face to face, peer and faculty interactions and restricted mobility of learners led to some of them facing poor mental wellbeing and health issues.  The learning activities were mostly restricted to online platforms during the pandemic for students following health professional programs. During the latter part of the pandemic, however, there were changes when better preventive measures and immunisation were developed. The students were also allowed to provide limited care services to assist the practitioners who were providing critical services (Lau et al., 2021).

The silver lining, however, was that several new curricular designs, teaching-learning and assessment modalities were developed due to the sheer necessity. The faculty members and students were forced to adapt and adopt these new measures, mostly online systems and processes, to continue the training and provide that much needed support to the healthcare services (Shorey et al., 2022). This became critical when it was apparent that the pandemic would continue for several years. There are some such innovations in teaching-learning highlighting not only the innovation and their impact but also the challenges faced by students and faculty members. Most of these changes to student learning environment were done hurriedly and, unfortunately, without the proper grounding in best evidence practices or taking a systematic approach to incorporate changes to a curriculum. Another reason was the lack of knowledge and support of educators to develop impactful curricula and learning environments leveraging on technology (Popa, 2022).

We are now emerging from the pandemic and many lessons have been learnt from this experience. We now have an opportunity to leapfrog from these experiences. The key to creating an impactful and sustainable post-pandemic learning environment lies with the faculty members. There are several important areas we need to focus on if we want to sustain and further improve the education based on our past experience.

As part of faculty development, it is necessary to engage our faculty members to share best practices and assist them to co-create with their learners teaching-learning activities. For faculty leadership, it is critical to create that safe practice environment for all stakeholders to reflect on and improve what they have developed. Through these collaborative activities, not only the faculty members learn about what works and what to avoid, but also build trust with other stakeholders including the students. Furthermore, it supports them to critically analyse the learning and assessment activities with regard to their relevance in one’s context. Providing a structured and timely faculty support with the necessary resources will augment the building of trust (Connolly et al., 2022).

Another important area we learnt especially during the pandemic and as we currently emerge from the pandemic is the necessity to modify the existing policies and guidelines. These should support systematic and rapid development of learning environments. What worked in the past may not be appropriate now, and even hinder the development of innovative strategies. We need to relook at how we evaluate an educator’s performance and the learning impact from traditional matrixes in place at present in health professional training institutions. Aligned to the performance evaluations, there needs to be supportive schemes to incentivise and reward faculty members who contributed to enhance the learning environment for students and residents.

Medical education is very much context-based and situation-focused. What worked in one setting may not be appropriate in another learning context. The leadership, planners, and educators must be aware of this and carefully design and incorporate innovations and new approaches to learning that have worked in another setting to one’s own. This is especially true when one is incorporating technology-enhanced learning activities such as simulation based or remote distance online learning formats. Finally, the quality improvement and quality assurance processes in health professions education must be aligned to the local context needs. These standards, however, should be benchmarked to internationally accepted best practices, but situated very much on the local needs and promoting impactful changes to student learning environments (Samarasekera & Gwee, 2021).

A quick literature search at present will demonstrate large number of innovations and changes that were incorporated to medical and health professional training curricula over the pandemic period (Ng et al., 2021). It is an opportune time now to focus on developing these changes, based on best evidence practices., The impact of these changes need to be subsequently evaluated to further enhance student learning. At the end of it all, what is most vital is to provide quality care to our patients by competent, caring, and empathetic health professionals.

 

Dujeepa D. Samarasekera 
Centre for Medical Education (CenMED), NUS Yong Loo Lin School of Medicine,
National University Health System, Singapore

 

 

 

Connolly, K. K., Olson, H. L., & Buenconsejo-Lum, L. E. (2022). Medical school faculty development post-pandemic – Opportunities in the digital shift. Hawai’I Journal of Health & Social Welfare, 81(11), 316-318.

Lau, T. C., Chong, Y. S., Loo, B. K. G., Ganapathy, S., Ho, J. M. D., Lee, S. S., Yeo, J., Samarasekera, D. D., & Goh, D. L. M. (2021). Adapting undergraduate paediatric medical education to the challenges of COVID-19 pandemic: Perspective of NUS medicine. Singapore Medical Journal, 62(1 Supp), S39-S42. https://doi.org/10.11622/smedj.2021075

Ng, N. B. H., Chiong, T., Lau, P. Y. W., & Aw, M. A. (2021). Delivering medical education amidst COVID-19: Responding to change during a time of crisis. The Asia Pacific Scholar, 6(3), 111-113. https://doi.org/10.29060/TAPS.2021-6-3/PV2375

Popa, S. (2022). Taking stock: Impacts of the Covid-19 pandemic on curriculum, education, and learning. PROSPECTS, 51, 541-546. https://doi.org/10.1007/s11125-022-09616-7

Renaud, C. J., Chen, Z. X., Yuen, H.-W., Tan, L. L., Pan, T. L. T., & Samarasekera, D. D. (2021). Impact of COVID-19 on health profession education in Singapore: Adoption of innovative strategies and contingencies across the educational continuum. The Asia Pacific Scholar, 6(3), 14-23. https://doi.org/10.29060/TAPS.2021-6-3/RA2346

Samarasekera, D. D., Goh, D. L. M., & Lau, T. C. (2020). Medical school approach to manage the current COVID-19 crisis. Academic Medicine, 95(8), 1126-1127. https://doi.org/10.1097/ACM.0000000000003425

Samarasekera, D. D., & Gwee, M. C. E. (Eds.). (2021). Educate, train and transform: Toolkit on medical and health professions education. World Scientific.

Shorey, S., Pereira, T. L.-B., Teo, W. Z., Ang, E., Lau, T. C., & Samarasekera, D. D. (2022). Navigating nursing curriculum change during COVID-19 pandemic: A systematic review and meta-synthesis. Nurse Education in Practice. 65, Article 103483. https://doi.org/10.1016/j.nepr.2022.103483

Submitted: 28 June 2022
Accepted: 16 August 2022
Published online: 3 January, TAPS 2023, 8(1), 54-56
https://doi.org/10.29060/TAPS.2023-8-1/CS2833

Ying Ying Koh^* & Caitlin Alsandria O’Hara^*

Yong Loo Lin School of Medicine, National University of Singapore, Singapore

*Both authors contributed equally as first authors.

I. INTRODUCTION

Increasing attention has been given to the role of medical humanities in both clinical care as well as in medical education. Medical humanities is defined as an “interdisciplinary perspective that draws on both creative and intellectual methodological aspects of disciplines such as anthropology, art, bioethics, drama and film, history, literature, music, philosophy, psychology, and sociology” (Hoang et al., 2022). 

While 80% of health outcomes are related to the social determinants of health (Magnan, 2017), traditional medical education has largely focused on clinical knowledge and skills. Only in recent years have medical schools recognised the importance of medical humanities (Smydra et al., 2021). The strength of medical humanities is the ability to foster a more humanistic clinical practice and build professional social accountability (Pfeiffer et al., 2016). 

In Singapore, the Office of Medical Humanities was set up in the SingHealth Duke-NUS Academic Medical Centre to encourage the growth of the medical humanities in the local medical field (Ong & Anantham, 2019). This highlights the growing interest in medical humanities in Singapore. 

This paper aims to highlight an innovative approach for medical humanities education through student-led discussion groups, called ‘MedTalks’, conducted in the Yong Loo Lin School of Medicine, Singapore. 

II. A GROUND-UP APPROACH TO THE MEDICAL HUMANITIES

MedTalks was started as a student-led platform for medical students to gain exposure to the medical humanities social issues relating to healthcare. Through Socratic seminar-style discussion among students across all three medical schools in Singapore, MedTalks provides a safe space to learn from each others’ thoughts, and crystallise their own ideas and values. In the long term, MedTalks hopes to empower students to take actionable steps towards addressing the social determinants of health in their future clinical practice.

The initiative was inspired by a yearlong liberal arts non-degree programme in a liberal arts university in the United States which the two student-founders of MedTalks had experienced. This yearlong exposure to the liberal arts–particularly medical anthropology, medical history and political science–also informed the approach and development of the content of sessions. For specific sessions, experts or persons with lived experience were invited to be guest co-facilitators. While the liberal arts exposure provided a foundation, the facilitators themselves have made clear during sessions that  they are not subject matter experts, but students who are learning from fellow students through discussion.

III. FORMAT OF SESSIONS

MedTalks runs as a series of discussion sessions, which have three key features. Firstly, they are centred around a theme with accompanying pre-session reading materials for participants. These materials consist of excerpts from book abstracts, journal articles, and multimedia sources (e.g speeches, news sites or videos); these act as a primer on the topic and promote questions or ideas which can be raised in the discussions. Preliminary discussion questions are provided for students to ponder and reflect on prior to the session. Secondly, sessions are facilitated by the student-organisers of the programme. These student-organisers also curate the session themes and pre-reading materials prior to the session. Curation of session themes and materials is done based on themes encountered during clinical rotations, national current affairs, and suggestions from student-participants.  Thirdly, participants are not required to speak up during the session; they can choose to simply sit in for the discussion. The fact that sessions are student-led and verbal participation is non-obligatory facilitates a more comfortable environment for students in the discussion and allows them to participate in a way that suits their learning.

MedTalks discussions are varied in scope, with several broad subtypes as follows in Table 1:

Submitted: 12 April 2022
Accepted: 19 August 2022
Published online: 3 January, TAPS 2023, 8(1), 57-60
https://doi.org/10.29060/TAPS.2023-8-1/CS2791

Caitlin Hsuen Ng, Siaw May Leong, Arumugam Rajesh Kannan & Deborah Khoo

Department of Anaesthesia, National University Hospital (NUH), Singapore

I. INTRODUCTION

Airway management is critical for any anaesthetist. The Coronavirus Disease 2019 (COVID-19) pandemic has brought such skills to the forefront over the last three years. Yet, the outbreak has also disrupted traditional methods of airway skills training and limited the chances of in-person workshops and conferences due to social distancing requirements and demanding manpower needs. To lower the incidence of airway-related morbidity (Joffe et al., 2019), regular and effective instructional methods are needed to maintain airway providers’ skills.

Our Department of Anaesthesia at the National University Hospital (NUH) of Singapore shares our experience conducting small-group refresher sessions, and how that has changed during a pandemic.

II. ASSESSMENT OF CURRENT LEARNING PROGRAMME AND TRAINING NEEDS

Since 2013, our department has been conducting quarter-yearly intra-departmental mini-workshops for airway training. This was to address the airway component of our patient safety strategy, and the unmet need to maintain and upskill airway management techniques for as many anaesthesia providers as possible, who come with an uneven range of seniority and experience with difficult airways. We were challenged to achieve this goal, yet without overly impacting manpower and daily operations. Each session was led by in-house faculty and was open to anaesthesia providers of every level. On occasion, external faculty were invited if they had specific expertise in certain aspects. The syllabus aligned with Difficult Airway Guidelines (Rosenblatt & Yanez, 2022) and was done in a sequential, repeating manner.

III. INTERVENTION: REFRESHER WORKSHOPS IN THE PANDEMIC

As the COVID pandemic came to Singapore around early 2020, our department training was disrupted in many ways. Nationwide social-distancing measures meant that in-person teachings and elective operations were suspended. The increased patient load from the pandemic also meant more manpower redeployed to the frontlines and Intensive Care Units, with an increased focus on infection control and personal protection. In the event airway intervention was required for a patient, the procedure carried significant risks from the aerosol-generating procedures of intubation and mechanical ventilation to both staff and patients. As a result, clinical exposure for airway providers-in-training was severely hampered.

Hence, alterations were made to our existing regular airway training regime. The didactic segment was smoothly transitioned to the videoconferencing platform, Zoom. This had the added benefit of widening the audience to providers who would otherwise have not been able to physically attend. We continued with the hands-on component of the session, but limited participants in the room at any one time in accordance with the room size, ensuring at least one meter between personnel. Strict personal protection was adhered to, requiring all participants to wear N95 masks and perform hand hygiene before and after each station. Participants also assisted in maintaining the cleanliness of the equipment by using Isopropyl Alcohol 70% wipes to decontaminate all surfaces after use. Given the restricted participant size, a call-back system was used when participants had to be turned away. Attendance was tracked using a manual sign-in system. There were no incidences of transmission of COVID-19 because of these workshops.

We focused on airway management while wearing Personal Protective Equipment to better simulate clinical scenarios, bearing in mind the extra physical and cognitive load that airway providers bear in such circumstances (Foong et al., 2020). Specific skills such as how to safely transfer an intubated patient from one ventilator to another were also practiced and video laryngoscope intubation with a limited field of vision. Figure 1 outlines the suggested format, syllabus, and rationale of our mini-workshops, with the intent that it can be modified as needed and replicated in institution-specific settings.

Figure 1. Suggested template and syllabus of in-house refresher workshops

*added from 2020 onwards

IV. EVALUATION OF INTERVENTION DURING THE PANDEMIC

After almost 10 years, we review our airway training refresher sessions, including its adaptation to the COVID pandemic.

Firstly, the sessions were logistically manageable, using pre-existing equipment and a realistic number of faculty. The intimate number of participants not only complied with safe distancing measures but also encouraged more detailed guidance and supervision of practical skills tailored to the participant’s skill level. Flexibility in attendance allowed for continued participation without significantly affecting manpower during the ongoing pandemic.

Simulation-based mini-workshops allowed for continued honing of skills when authentic clinical scenarios were limited. While simulation is unable to replace the actual experience, it has a positive impact on healthcare systems and their patients during times of a pandemic (Santos et al., 2021). The equipment and techniques covered kept abreast of the latest developments and content was curated to help cope with the pandemic by facilitating familiarity and identification of otherwise unexpected problems in managing a COVID airway, prior to real-life encounters and emergent patient care situations. These measures ensure that such high-risk airways are handled in a safe, accurate, and swift manner, maximising first-pass success, and minimising risks to patients and airway providers in the actual situations (Cook et al., 2020).

The workshops were also able to touch on the softer skills required in airway management. The sessions catered to a mix of staff to build teamwork and coordination in a multidisciplinary airway crisis team. Having a shared plan and proper forms of communication are critical in crisis airway situations, even more so with the additional barrier of PPE. Our in-house training has received positive feedback in increasing staff confidence and preparedness for facing airway crises during times of the pandemic.

V. CONCLUSION

As with any skill, practice is essential. During these times of a public health crisis, we need to be adaptable in our instructional methods of continuing training. We believe that our hands-on refresher sessions have been beneficial in enhancing the accessibility of airway management practice even during a pandemic and suggest a syllabus and method that can be replicated and modified to suit the needs and resources of various settings.

Notes on Contributors

Caitlin Ng took lead in drafting and revising of the manuscript, along with aiding in data collection and analysis.

Leong Siaw May contributed to the conceptualisation of the study and revision of the manuscript and was faculty at some of these workshops.

Arumugam Rajesh Kannan contributed to the conceptualisation of the study and revision of the manuscript and was faculty at some of these workshops.

Deborah Khoo conceptualised of study, led the data collection, was faculty at some of these workshops, and contributed to the revision of the manuscript.

Acknowledgement

Our team would like to thank the department of Anaesthesia, NUH, for the provision of equipment, participation, and facilitation of the faculty in the workshops. We were fortunate to have the equipment and facilities at our disposal to conduct such workshops at our convenience. We understand that this privilege may not be generalisable elsewhere.

Funding

There was no funding received for this project, beyond that of the department’s resources.

Declaration of Interest

The authors report no conflict of interest.

References

Cook, T. M., El-Boghdadly, K., McGuire, B., McNarry, A. F., Patel, A., & Higgs, A. (2020). Consensus guidelines for managing the airway in patients with COVID-19: Guidelines from the Difficult Airway Society, the Association of Anaesthetists the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetists. Anaesthesia, 75(6), 785-799. https://doi.org/10.1111/anae.15054

Foong, T. W., Hui Ng, E. S., Wee Khoo, C. Y., Ashokka, B., Khoo, D., & Agrawal, R. (2020). Rapid training of healthcare staff for protected cardiopulmonary resuscitation in the COVID-19 pandemic. British Journal of Anaesthesia, 125(2), e257-e259. https://doi.org/10.1016/j.bja.2020.04.081

Joffe, A. M., Aziz, M. F., Posner, K. L., Duggan, L. V., Mincer, S. L., & Domino, K. B. (2019). Management of difficult tracheal intubation: A closed claims analysis. Anesthesiology, 131(4), 818-829. https://doi.org/10.1097/aln.0000000000002815

Rosenblatt, W. H., & Yanez, N. D. (2022). A decision tree approach to airway management pathways in the 2022 Difficult Airway Algorithm of the American Society of Anesthesiologists. Anesthesia & Analgesia, 134(5), 910-915. https://doi.org/10.1213/ane.0000000000005930

Santos, T. M., Pedrosa, R. B. S., Carvalho, D. R. S., Franco, M. H., Silva, J. L. G., Franci, D., Jorge, B., Munhoz, D., Calderan, T., Grangeia, T. A. G., & Cecilio-Fernandes, D. (2021). Implementing healthcare professionals’ training during COVID-19: A pre and post-test design for simulation training. Sao Paulo Medical Journal, 139(5), 514-519. https://doi.org/10.1590/1516-3180.2021.0190.R1.27052021

*Caitlin Ng
5 Lower Kent Ridge Road,
Singapore 119074
Email: caitlin_ng97@hotmail.com

Submitted: 27 July 2022
Accepted: 21 September 2022
Published online: 3 January, TAPS 2023, 8(1), 61-63
https://doi.org/10.29060/TAPS.2023-8-1/CS2852

Janaka Eranda¹, Hewapathirana Roshan² & Karunathilake Indika³

¹Ministry of Health, Sri Lanka; ²Department of Anatomy, Genetics and Biomedical Informatics, Faculty of Medicine, University of Colombo, Sri Lanka; ³Department of Medical Education, Faculty of Medicine, University of Colombo, Sri Lanka

I. INTRODUCTION

Anatomy is considered as one of the key components of undergraduate medical education. Hence, it is important to have a sound knowledge in anatomy to proceed into clinical medicine. Didactic lectures, textbooks, prosected specimens, and cadaveric dissection are the most frequently used anatomy teaching methods. However, with the emergence of COVID-19 pandemic, conventional teaching and learning were challenged. Technology integration for medical education has been increased during COVID-19 in many countries. With the integration of new technologies to the anatomy teaching, the traditional ‘directed self-learning’ started to move towards ‘self-directed learning’. This transformation however, was not without various challenges, especially in low-resource settings such as Sri Lanka (Karunathilake et al., 2020). Augmented reality (AR), Virtual reality (VR), and principles of gamification play an important role in motivation and engagement in medical teaching and learning by enhancing interactivity (Moro et al., 2021). Such technologies also found to have positive impact on students’ spatial understanding and 3D comprehension of anatomical structures.

The objectives of this case study were to identify the context-specific factors in designing AR/VR-based anatomy instructional materials and to assess the student motivation and engagement to use gamification in their studies. The instructional systems design model ADDIE (Molenda, 2003), which is an acronym for Analyze, Design, Develop, Implement, and Evaluate, was used to develop the instructional materials in this study since it found to ensure the appropriateness of the materials used in an optimal manner to bring the maximum educational outcome.

II. METHODS

During the study, mixed-method tradition was followed in a Sri Lankan medical faculty from September 2020 to February 2021. Ethics approval was obtained from the Ethics Review Committee of the Postgraduate Institute of Medicine, University of Colombo where the study was exempted from the review process. Purposive sampling was the method adhered recruiting 92 undergraduate medical students and 20 lecturers with the informed consent of the participants. The methodology was phased out according to the ADDIE model.

A. Analysis

A qualitative study was conducted using semi-structured interviews with the lecturers. The interviews were informed by the six dimensions of the Hexagonal E-Learning Assessment Model – HELAM (Ozkan & Koseler, 2009) which consists of students’ attitudes, teachers’ attitudes, technology-enhanced learning, content quality, service quality and supportive factors in designing effective E-learning materials. This phase revealed lecturers’ suggestions to develop AR/VR contents in terms of graphical user interfaces, modes of navigation, interactivity, and strategies in incorporating modes of gamification into learning materials.

B. Design

The results of the analysis phase were used to develop a blueprint of the instructional materials integrating the modes of gamification. These were instrumentalised to enhance the motivation and engagement in developed learning materials.

C. Development

An AR/VR application was developed using Unity game engine using 3D anatomy models to project 3D anatomy models over 2D reference images to be used with smart phones and generic VR boxes.

D. Evaluation

This phase consisted of a quantitative study offered to undergraduate students. The self-administered questionnaire with 40 questions of the type 5-point Likert-scale was used to assess participants’ self-reported perceptions of motivation and engagement in self-directed learning. The questionnaire assessed the gamification approach, teaching materials, user interfaces, practicability, physical discomfort, student attitudes on PC-based games, AR/VR apps. The developed apps were used by the students prior to complete the survey.

III. RESULTS

A. Qualitative Study

Lecturers expressed their interest in AR/VR technology with gamification and suggested to link the new AR/VR contents to the existing Learning Management System as the students already have a good engagement with it. They highlighted different modes of gamification such as interactive quizzes, animated interactive 3D anatomy models, teleport targets for VR navigation and video clips to enhance interactivity. Furthermore, they emphasized the importance of the quality of the content, reliability of the information technology services and course administration related factors to improve the overall quality of the learning experience and the sustainability of the new approach.

B. Quantitative Study

The results were organized along the dimensions, gamification, teaching materials, user interfaces, practicability, students’ attitudes toward the technology-enhanced learning and AR/VR apps. The gamification dimension indicated the overall acceptance for the AR/VR techniques and tools and adapting the technology-enhanced learning in formal medical curricula. The highest mean value (4.20 out of the scale ranging from 1 to 5) was observed for the use of the augmented reality app indicating that medical students participated were satisfied with the offered interactivity in the AR/VR apps. The average satisfaction score for gamification, practicability, physical discomfort, teaching materials, user interfaces, student attitudes on the technology-enhanced game and AR/VR app were above satisfactory level (score ≥ 4). The student’s satisfaction on the physical discomfort showed the lowest average score compared to the rest of the dimensions. Further to this, the students had lesser variation in the satisfaction score about the dimension attitudes on the technology-enhanced learning (SD 0.41) compared to the other dimensions. The questionnaire included six questions to measure the level of motivation and engagement. On average, 88% of the students have expressed their willingness to engage with the AR/VR learning style and confirmed that the technology-enhanced learning is a beneficial learning style.

IV. DISCUSSION

The study was conducted to identify the measures to improve motivation and engagement in learning anatomy when integrating technology-enhanced interactive learning contents into the undergraduate medical curriculum. The importance of having a systematic approach is necessary when designing instructional content to obtain a better outcome. The use of principles of gamification improved motivation and engagement which is in line with previous studies (Moro et al., 2022). Sustainability of the technology-enhanced learning was a key concern among the lecturers.

V. CONCLUSION

This research attempted to identify the student motivation and engagement towards the gamified anatomy learning with AR/VR technology. The study provided the insight into context-specific factors in designing interactive learning contents and methods. The ability to deliver an immersive experience in AR/VR methods helps the student to study anatomy in self-directed learning even in situations, such as COVID-19 pandemic and mandatory social distancing, which demands strict remote teaching.

Notes on Contributors

Dr G.K.M.E. Janaka, MBBS, MSc, MD was involved in reviewing the literature, formulating the methodological framework, designed the gamified AR and VR learning tools and and writing the original draft.

Dr Roshan Hewapathirana, MBBS, MSc, PhD, MIEE was involved in the study by developing the methodological framework, data curation, formal analysis, and editing the original draft.

Professor Karunathailke Indika, MBBS(Col), CTHE (Col), DMedEd (Dundee), MMedEd (Dundee), FHEA (UK), FCGP( SL), FRCP (Edin.), FCME (SL) was involved in the study by conceptualizing the idea, developing the methodological framework, creviewing the manuscript and supervising the overall study.

Acknowledgement

The authors would like to acknowledge the Head of the Department and the lecturers of the Department of Anatomy, Genetics and Biomedical Informatics, Faculty of Medicine, University of Colombo who supported giving valuable comments and all the students who had volunteered in participating in the study.

Funding

There are no funding sources to declare.

Declaration of Interest

The authors declare that they have no competing interests.

References

Karunathilake, I. M., Dissanayake, V. H. W., Yasawardena, S., Abegunawardena, A., Raviraj, S., Wijesinghe, P. S., Anthony, A. A., Wijesinghe, R. A. N. K., Bowatte, S., Wickramaratne, N., Pathirana, K. D., Pilapitiya, S., Edirisinghe, S., Hettiarachchi, D., Kohombange, C., & Olipeliyawa, A. (2020). The new normal of medical education – Challenges and opportunities. South-East Asian Journal of Medical Education, 14(1), 2. https://doi.org/10.4038/seajme.v14i1.241

Molenda, M. (2003). In Search of the Elusive ADDIE Model. Performance Improvement, 42(5), 34–37.

Moro, C., Birt, J., Stromberga, Z., Phelps, C., Clark, J., Glasziou, P., & Scott, A. M. (2021). Virtual and augmented reality enhancements to medical and science student physiology and anatomy test performance: A systematic review and meta analysis. Anatomical Sciences Education, 14(3), 368–376. https://doi.org/10.1002/ase.2049

Moro, C., Phelps, C., & Birt, J. (2022). Improving serious games by crowdsourcing feedback from the STEAM online gaming community. The Internet and Higher Education, 55, Article 100874. https://doi.org/10.1016/j.iheduc.2022.100874

Ozkan, S., & Koseler, R. (2009). Multi-dimensional students’ evaluation of e-learning systems in the higher education context: An empirical investigation. Computers & Education, 53(4), 1285–1296. https://doi.org/10.1016/j.compedu.2009.06.011

*Janaka Eranda
Ministry of Health,
Sri Lanka
+94714747309
Email: erandajanaka1979@gmail.com

Submitted: 24 May 2022
Accepted: 16 August 2022
Published online: 3 January, TAPS 2023, 8(1), 51-53
https://doi.org/10.29060/TAPS.2023-8-1/CS2818

Teresa Diana B. Bongala

Department of Obstetrics and Gynaecology, Faculty of the College of Medicine, University of the East Ramon Magsaysay Memorial Medical Centre, Philippines

I. INTRODUCTION

The world will never be the same after the COVID-19 pandemic. Education has had to evolve. Evaluation of cognitive skills is still achieved by written examinations administered through learning management systems. However, an integral part of evaluation, the Objective Structured Clinical Examination (OSCE), which assesses the students’ ability to obtain, communicate information, perform physical examination, diagnose, and solve problems, could not be given due to COVID-19 restrictions.

Simulation during teaching and assessments like the OSCE have been done worldwide, (Nguyen et al., 2015) and have been utilised in our university for more than twenty years.  Because of lockdowns due to Covid-19, the OSCE was given online in medical schools worldwide, however the number of students were limited (Boyle et al., 2020; Lara et al., 2020).  In the Philippines, by December 2020, immunisation against Covid-19 had not started, and travel was still restrictive, hence face-to-face classes were still limited. (Department of Education, 2020). Hence, the Department of Obstetrics and Gynaecology of our university planned and conducted the first large-scale summative virtual OSCE (VOSCE) for Level III medical students. 

II. METHODS

The summative VOSCE was conducted using a Zoom licensed Education account, with features called “Breakout Rooms” and “Screen Share” and the Canvas learning management system. There were 17 faculty, 10 residents, 15 post-graduate interns, 10 Level IV and 440 Level III students who participated. The Level III students had synchronous and asynchronous lectures for four-and-a-half months in Obstetrics, and nine weeks of small group discussions (SGD).

The table of specifications was based on the learning outcomes in Obstetrics and skills taught during SGDs. Six sets of examinations with four stations, were prepared.  The first two stations were given in Canvas, while the last two “performance” stations, namely history taking, and Physical Examination (PE) were given over Zoom. The evaluation in OSCE was modified to fit tasks for VOSCE. It underwent an MPL setting by three members of the faculty using the Angoff method. (Livingston & Zieky, 1982)

All participants underwent orientation. The students were informed of the materials they needed: a computer, for Canvas and for zoom in stations 3 and 4; a mobile device, for proctoring, communication and to demonstrate performance /PE in Station 4; and other materials needed for Station 4.  The faculty were instructed to Screen Share tasks via Zoom in the “performance” stations and oriented on student evaluation and result submission.

Three days before the VOSCE, a simulation involving clinical clerks, post-graduate interns and residents was conducted. Clarity of video, audio and internet speed were checked.  Timing and transfer of examinees between breakout rooms was also rehearsed. The tasks for Stations 3 and 4, and evaluation forms, were sent to the faculty the 12 hours before the VOSCE. 

Thirty minutes before the VOSCE, the students underwent identity verification, their gadgets and positions checked.  Concurrently, the post-graduate interns, who acted as patients, were given the script.

The examinees, in stations 1 and 2, givenclinical vignette and images of speculum examination, had to diagnose and write a prescription.  After Canvas stations, in another breakout room, the students were informed of materials needed for Station 4.  In Station 3, they elicited the history from a simulated patient, and in Station 4, they performed PE with annotation.

Communication with students was through Telegram and Zoom, while Viber was used between faculty and residents.

III. RESULTS

Four hundred and forty students took part in the VOSCE. Post-VOSCE survey with 397 respondents showed that 382 (96.2%) students took it in the Philippines, and 15 (0.38%) students were out of the country. 

Forty-three (10.8%) had internet speed <10mbps. Thirty (9.0%) had connection problems/unable to view images in stations 1 and/or 2. Thirty students were given another examination, three hours post-VOSCE. Table 1 shows the location and the internet connection of the students, their perception of the VOSCE and the problems they encountered during the examination.

Submitted: 22 February 2022
Accepted: 3 August 2022
Published online: 3 January, TAPS 2023, 8(1), 47-50
https://doi.org/10.29060/TAPS.2023-8-1/SC2764

Kye Mon Min Swe¹ & Amit Bhardwaj²

¹Department of Population Medicine, University Tunku Abdul Rahman, Malaysia; ²Department of Orthopaedics, Sengkang General Hospital, Singapore

Abstract

Introduction: During the era of COVID-19 pandemic, online learning has become more prevalent as it was the most available option for higher education training which has been a challenging experience for the students and the lecturers especially in the medical and health sciences training.  The study was conducted to determine the perceptions of clinical year medical students on online learning environments during the COVID-19 pandemic.

Methods: A cross sectional study was conducted to clinical year medical students at University Tunku Abdul Rahman. The validated Online Learning Environment Survey (OLES) was used as a tool to conduct the study.

Results: Total 84 clinical year students participated in the study. Among four domains of OLES questionnaire, the domain; “Support of online learning” had the highest mean perception scores, 4.15 (0.55), followed by “Usability of online learning tools” 3.89 (0.82), and “Quality of Learning; 3.80 (0.68) and the domain “Enjoyment” was the lowest mean perception scores 3.48 (1.08). Most of the students (52.4%) rated the overall satisfaction of online teaching experiences “Very good” while (13.1) % rated “Excellent”.

Conclusion: In conclusion, the perceptions of clinical year medical students on online learning environments during the COVID-19 pandemic were satisfactory although there were challenging online learning experiences during the pandemic. It was recommended to include qualitative method in future studies to provide more useful in-depth information regarding online learning environment.

Keywords:            Online Learning Environment, Perceptions, Medical Students, Malaysia, COVID-19

I. INTRODUCTION

Online learning is defined as learning via web-based technology and students interact with their peers and educators through web-based communication tools (Bonk & Reynolds, 1997). The usability of the web-based learning system is important as are its applications such as interactive video, forums, chat rooms, email, and document sharing systems (Klein et al., 2006).

Online learning is regarded nowadays as a new way of interaction in the educational process and online learning facilities offer various opportunities to get new knowledge and develop students’ skills through engagement and interaction in new learning environments. (Samoylenko et al., 2022)

Due to the novel coronavirus pandemic, all the higher education training has converted to online teaching and assessments including medical programs. To fulfil the student physical learning time requirement, the academic year of MBBS clinical year programmes (Year 3 to Year 5) has been divided into Phase 1; purely online teaching as medical students were not allowed to be posted to hospitals followed by Phase 2; face to face physical clinical training at the hospital. Phase 1 teaching for clinical years include, online task-based learning, online lectures and online case-based discussion, online clinical skill, and procedures. This research study was conducted to evaluate the online learning environment of clinical year students and to find out differences in students’ perceptions between the academic years.

II. METHODS

A cross sectional study was conducted to (total=135) Year 3 to Year 5 clinical year medical students. 43 students were in Year 3, 49 students were in Year 4 and 43 students were in Year 5 at University Tunku Abdul Rahman (UTAR), Selangor, Malaysia. All the clinical year students were invited to participate in the study by sending electronic invitations emails, informed consent was taken. Data was collected via google form and the information was anonymised.

A validated Online Learning Environment Survey (OLES) (Pearson & Trinidad, 2005) was used to evaluate the online learning environment of medical students of UTAR during Phase 1 of purely online teaching. The questionnaire consists of two sessions. Section (I) general demographic information, Section (II) contains 50 items of OLES questionnaires developed by Pearson and Trinidad (2005). The validity of the tool was recorded as Cronbach’s Alpha Coefficient value of 0.79 to 0.90.  The OLES consists of nine scales: Computer Usage (CU); Teacher Support (TS); Student Interaction & Collaboration (SIC); Personal Relevance (PR); Authentic Learning (AL); Student Autonomy (SA); Equity (EQ); Enjoyment (EN); and A-synchronicity (AS) which can further classified into four domains: (1) Support for learning; (2) Quality of learning; (3) Usability of online learning tools; and (4) Enjoyment. Responses were recorded against a five-point scale with the following representations: 1- Never; 2- Seldom; 3- Sometimes; 4- Often; and 5- Almost Always. (Pearson & Trinidad, 2005)

Data were analysed by using SPSS (Statistical Package for Social Science) for Windows, version 26.0. The categorical variables were described by frequency and percentage. Student t-test and Analysis of variance (Anova) test was used to compare means between the groups of different academic years. Ethical approval was acquired from the Scientific Ethical Review Committee of the UTAR.

III. RESULTS

A total of 84 clinical year medical students participated from Year 3 to Year 5. There were 27 out of 43 Year 3 students (62.79%), 26 out of 49 Year 4 students (53.06%), 31 out of 43 Year 5 students (72.09%) who completed the questionnaire. Approximately 82 (97.6%) students were aged between 21 to 25 years and (63.1%) were female students.

The online learning environment survey (OLES) tool consists of four domains to evaluate student online learning environments such as “Support of Online learning”, “Usability of online learning tools”, “Quality of Learning” and “Enjoyment”. Among four domains of OLES tool, the domain; “Support of online learning” had the highest mean perception scores 4.15 (0.55), followed by “Usability of online learning tools” 3.89 (0.82), and “Quality of Learning; 3.80 (0.68) and the domain “Enjoyment” was the lowest mean perception scores 3.48 (1.08).

Domains of perceptions of online learning environment	Subscales of perceptions of online learning environment	Mean (SD)	Mean (SD)
Support for learning	Computer Usage	4.24 (0.64)	4.15 (0.55)
	Teacher Support	4.09 (0.78)
	Student Interaction and Collaboration	4.02 (0.78)
	Equity	4.25 (0.82)
Quality of learning	Personal Relevance	3.60 (0.87)	3.80 (0.68)
	Authentic Learning	3.66 (0.82)
	Student Autonomy	4.16 (0.76)
Usability of online learning tools	A-synchronicity	3.89 (0.81)	3.89 (0.82)
Enjoyment	Enjoyment	3.48 (1.08)	3.48 (1.08)

Table 1: The mean perception scores of domains and subscales of online learning environment

Regarding the relation between academic year and student perception on different domains of the online environment, Year 5 students 3.89 (1.01) enjoyed the online learning as compared to Year 3 3.25(0.95) and Year 4 students 3.22 (1.18) respectively and the difference was statistically significant (P<0.027). Year 4 students perceived more positive on domains support of learning (P=0.658) and quality of learning (P=.396) and Year 5 students perceived online learning tools were useful (P=0.681).

The students were asked to rate their online learning experience via 5 points scale, poor to excellent and (52.4%) of the students found online learning experiences very good followed by (29.4%) good and (13.4%) rated excellent. The data for this research can be accessed at http://doi.org/10.6084/m9.figshare.19322297

IV. DISCUSSION

During COVID-19 pandemic era, medical clinical teaching via online was a challenging experience for both clinical lecturers and clinical year students and this study was to determine the perceptions of clinical year medical students on online learning environments during the COVID-19 pandemic.

A. Evaluating Online Learning Environment

In the literature, there were quite several tools which have been developed to specifically evaluate online learning environments such as Constructivist On-Line Learning Environment Survey (COLLES), Web-Based Learning Environment Inventory (WEBLEI), Technology-Rich Outcomes-Focused Learning Environment Inventory (TROFLEI), and Online Learning Environment Survey (OLES). The OLES instruments have been used to evaluate the university’s online learning environment and found to be a useful tool to evaluate online learning environments as the questionnaires were applicable to our local setting of online teaching. The OLES tool consists of four domains to evaluate student online learning environments such as Support of Online learning, Usability of online learning tools, Quality of Learning and Enjoyment. (Chew, 2015) The scores on scales which received specific attention for online educators to monitor the online learning environment provided for students.

1) Support of online learning: This domain includes four sub scales and it is the most important part for the students to be able to cope with the online learning environment. Regarding support for computer usage, the findings indicate the students received good support from the university regarding online learning such as the providing internet package for students, laptops, online learning tools and platforms such as Microsoft team. The support from lecturers and peers were also important in regarding clinical case discussion and group works. But in some cases, the students need to go and use internet at their relative’s house. On the “Lecturer Support Scale” and “Equity scale”, that the students got support and equivalent chances to contribute in class discussion. (Chew, 2015)

2) Usability of online learning tools: This domain includes asynchronicity subscale. Asynchronicity allows students to learn on their own schedule, within a certain timeframe. In this study, there were high mean scores for the “Asynchronicity” scale which indicates that the students found it easier to communicate online. But the result was contrary to a study by Chew (2015), found out that the students found it challenging to communicate online depends on the availability of internet and usage of social media.

3) Quality of learning: This domain includes three subscales: Personal Relevance, Student Autonomy, and Authenticity learning. The findings indicate that the students were able to manage and play significant roles in their learning in the online learning climates.

4) Enjoyment: The Enjoyment scale was used to evaluate the extent of enjoyment of learning in an online learning environment. Among all four domains, the enjoyment was the least mean perception score which indicated that although the students received support from university and lecturers, they enjoyed less with the online classes as the classes were entirely online. The result was similar to a study by Chew (2015), stated that the students had limited enjoyment in online learning environments due to lack of motivation and technical problems.

B. Limitations of the study

The study was conducted in a private medical university and quantitative approach. A mixed methods approach with larger sample was recommended for future investigations. Validation of the survey recommends carrying out for local setting.

C. Implication of the study

The present study evaluates the online learning environment experienced by clinical year medical students which found to be useful by giving them different learning opportunities and this can be used to implicate future clinical teaching as hybrid mode to create an effective and safe learning environment. The information from this study about the students’ perceptions on online learning, provided significant implications in the field such as implementation of hybrid learning, telemedicine in medical curriculum.

V. CONCLUSION

In conclusion, the perceptions of clinical year medical students on online learning environments during the COVID-19 pandemic were satisfactory although there were challenging online learning experience during the pandemic. It was recommended to include qualitative method in future studies to provide more useful in-depth information regarding online learning environment.

Notes on Contributors

Dr Kye is the corresponding author for this paper. She designed the study, analysed the data, prepared the manuscript working together with the co-author.

Dr Amit Bhardwaj made substantial contributions to the design, editing and preparation of the final manuscript.

Ethical Approval

The research study was approved by Universiti Tunku Abdul Rahman Scientific and Ethical Review committee on 20th July 2020 (Approval number: U/SERC/92/2020). 

Data Availability

The data that support the findings of the study are openly available at http://doi.org/10.6084/m9.figshare.19322297

Acknowledgement

We would like to acknowledge the clinical medical students of UTAR (Academic Year 2020/2021) for voluntary participation in this study.

Funding

There was no funding for this research study.

Declaration of Interest

The authors declare that there are no conflicts of interest, including financial, consultant, institutional and other relationships.

References

Bonk, C. J., & Reynolds, T. H. (1997). Learner-centred web instruction for higher order thinking, teamwork, and apprenticeship. In B. H. Khan (Ed.), Web-based instruction (pp.167-178). Englewood Cliffs.

Chew, R. (2015). Perceptions of online learning in an Australian University: Malaysian students’ perspective – Support for Learning. International Journal of Information and Education Technology, 5(8), 587-592. https://doi.org/10.7763/ijiet.2015.v5.573

Klein, H.  J., Noe, R. A., & Wang, C. W. (2006). Motivation to learn and course outcomes: The impact of delivery mode, learning goal orientation, and perceived barriers and enablers. Personnel Psychology, 59(3), 665–702. http://doi.org/10.1111/j.1744-6570.2006.00050.x  

Samoylenko, N., Zharko, L., & Glotova, A. (2022). Designing online learning environment: ICT tools and teaching strategies. Athens Journal of Education, 9(1), 49-62. https://www.athensjournals.gr/education/2022-9-1-4-Samoylenko.pdf

Pearson, J., & Trinidad, S. (2005). OLES: An instrument for refining the design of e-learning environments. Journal of Computer Assisted Learning, 21(6), 396- 404. https://doi.org/10.1111/j.1365-2729.2005.00146.x   

*Kye Mon Min Swe
Jalan Sungai Long, Bandar Sungai Long,
43000 Kajang, Selangor
+601115133799
Email: drkyemonfms@gmail.com

Submitted: 29 May 2022
Accepted: 16 August 2022
Published online: 3 January, TAPS 2023, 8(1), 43-46
https://doi.org/10.29060/TAPS.2023-8-1/SC2807

Kirsty Foster

Academy for Medical Education, Medical School, University of Queensland, Brisbane, Australia

Abstract

Introduction: A series of workshops was held early in our MD curriculum redesign with two aims: gaining stakeholder input to curriculum direction and design; engaging colleagues in the curriculum development process.

Methods: Workshops format included rationale for change and small-group discussions on three questions: (1) Future challenges in healthcare? (2) our current strengths? (3) Future graduate attributes? Small-group discussions were audio-recorded, transcribed and fieldnotes kept and thematically analysed. We conducted a literature review looking at best practice and exemplar medical programs globally.

Results: Forty-seven workshops were held across 17 sites with more than 1000 people participating and 100 written submissions received. Analysis showed alignment between data from workshops, written submissions and the literature review.

The commitment of our medical community to the education of future doctors and to healthcare was universally evident.

Six roles of a well-rounded doctor emerged from the data: (1) Safe and effective clinicians – clinically capable, person-centered with sound clinical judgement; (2) Critical thinkers, scientists and scholars with a thorough understanding of the social and scientific basis of medicine, to support clinical decision making; (3) Kind and compassionate professionals – sensitive, responsive, communicate clearly and act with integrity; (4) Partners and team players who collaborate effectively and show leadership in clinical care, education and research; (5) Dynamic learners and educators – adaptable and committed to lifelong learning; and (6) Advocates for health improvement – able to positively and responsibly impact the health of individuals, communities and populations

Conclusion: Deliberate stakeholder engagement implemented from the start of a major medical curriculum renewal is helpful in facilitating change management.

Keywords:            Medical Education, Medical Curriculum, Stakeholder Engagement, Collaboration

I. INTRODUCTION

The quality of the medical education we provide to future doctors is directly related to the quality of care they will provide to their future patients (Torralba & Katz, 2020). It is the responsibility of those involved and of medical schools to promote the highest standards of medical education and medical student learning. At the University of Queensland, a major reimagining of the MD Program is underway to ensure that our already strong medical program remains informed by best practice in both medicine and in education. This is crucial to enabling our medical graduates to be optimally equipped for their internship, pre-vocational and specialist training. It is our responsibility to enable our graduates to be ready for the future medical needs of the people and communities they serve.

Medical programs are complex and involve many people. As well as University academic and professional staff, medical students are taught, supervised and supported by a wide variety of doctors and other health professionals during the four years of our postgraduate degree. At our university we have approximately 4,500 affiliates who may have a role in teaching, supervising or otherwise influencing one or more medical students at some point during their four-year MD program. Many of these are clinical teachers or supervisors who work for the health services with which UQ has a student placement agreement in place. Cognisant that major curricular review is challenging we implemented a deliberate strategy of engagement with as many of our stakeholders as possible from the start of the MD Design project in 2019. In the first stage we planned a series of engagement workshops with key stakeholders and this is the basis of the study.

The purpose of our study was twofold:

Firstly, to gain input from a wide range of stakeholders early in the process to futureproof our curriculum – that is, to inform the vision on what our graduates need to be able to know, do, and be, to succeed in internship and beyond.

Secondly, to involve our key stakeholders in the curriculum design process as a component of change management.

II. METHODS

A series of stakeholder workshops was held. The format of each workshop was to start with a brief outline of the drivers and rationale for curricular change, followed by small-group interactive discussions focusing on three questions:

1. What are the major future challenges in relation to healthcare?
2. What are our current strengths as a Medical Program, as a university and as a health community?
3. What are the important attributes for our future graduates to achieve to best prepare them for their careers?

Ethics approval for the study was granted by the University of Queensland Human Research Ethics Committee (Approval number 2019001725). At the start of each workshop attendees were provided with information about the study and given the opportunity to withdraw. Their participation in the workshop was regarded as consent. All small-group discussions were overseen by KF, audio-recorded and transcribed. KF and the administrative team kept field notes capturing any elements additional to the spoken word such as the general atmosphere of the workshop. KF and JH analysed the transcripts thematically identifying key elements in each focus area. In parallel a literature review was conducted looking at best practice medical education and exemplar medical programs across the globe were explored.

III. RESULTS

Over a period 15 months between July 2019 and January 2021 47 workshops were held across 17 sites with more than 1100 people participating. More than 100 written submissions were received and 5814 people and organisations contacted. Analysis demonstrated general agreement that major change was needed and there was good alignment between feedback received from stakeholder workshops, written submissions and the key findings from the current state analysis as outlined above. There were some stakeholders who felt that they needed to see more substantial evidence that the current curriculum needed refreshing. This group felt reluctant to embark on further change in view of modifications already made in recent years. They were also concerned that ‘change fatigue’ may be a challenge especially among our health service colleagues who contribute to the program.

A key finding was that the passion and commitment of our medical community to the education of future medical doctors and to make a positive contribution to healthcare was universally evident.

The resulting vision for our new MD program is:

To nurture and educate future medical graduates who are clinically capable, team players, kind and compassionate, serve responsibly and are dedicated to the continual improvement of the health of people and communities in Queensland, Australia and across the globe.

To enhance the capability of our graduates to meet the needs of their future patients a set of six roles of the all-round high-quality doctor was developed from the data. These roles map to the four domains that the Australian Medical Council require for primary medical degrees (Australian Medical Council (AMC), 2012), and have been adopted as the vertical themes of the new MD program. They are:

1. Critical thinkers, scientists and scholars who have a thorough knowledge and understanding of the social and scientific basis of medicine, and able to apply evidence and research to inform and support clinical decision making.
2. Dynamic learners and educators who continue to adapt, are curious, agile, motivated, self-directed, with the ability to honestly and humbly appraise their own learning needs, and have a commitment to lifelong learning.
3. Advocates for health improvement who stand with people and are able to positively and responsibly impact the health of individuals, communities and populations. Are able to apply an understanding of health inequalities to strive for health equity, and incorporates prevention and advocacy into clinical practice in all settings.
4. Partners and team players who collaborate effectively and show leadership when appropriate in the provision of clinical care and health-related education and research.
5. Kind and compassionate professionals who are sensitive, responsive, communicate clearly and act with integrity. Compassion and professionalism are linked not only to improved patient outcomes but to better practitioner outcomes including job satisfaction and to better institutional outcomes.
6. Safe and effective clinicians who are clinically capable, person-centred and demonstrate sound clinical judgement – and who can see that they cannot be safe and effective unless they are also capable in all other roles.

The new MD program is structured as five fully integrated courses, three year-long and two semester long courses in final year, with assessment focused on growth and development of knowledge skills and attitudes through active engagement in learning. Assessment for learning as well as of learning is fundamental in enabling all students to reach their full potential. The project has progressed through development of staged learning outcomes for each year of the program and now into detailed and appropriately sequenced learning activities.

Figure 1. The six roles of a well-rounded doctor

IV. DISCUSSION

Communication throughout a period of major change is challenging especially where there are many diverse stakeholders across a large and complex organisation like a medical school (Velthuis et al., 2018). Our strategy was a deliberate one to retain connection and involvement during a lengthy process. Our initial engagement work reported here gave us a good start by actively involving as many people as possible from the beginning of the project. As the project has progressed stakeholders have remained engaged and have been particularly keen on seeking the detail needed to assist in implementation of the new curriculum. This has, on occasion, been challenging when tension between some specialist discipline areas protecting their ‘patch’ and the needs of medical students at primary medical degree level emerge. We also found that education is not regarded as a specialist field by some of our experienced clinical teachers. A lack of understanding about the iterative process of outcomes-based curriculum development contributed to colleagues seeking answers about what is to be taught being frustrated at what they saw as a laborious process of careful scaffolding and integration. This contesting of curriculum is recognised within institutions where it can inhibit development of more effective curricula which promote learning and are more than simply identification of content to be taught (Prideaux, 2003). By engaging with stakeholders from the earliest stage of the curriculum development process we feel that we have minimised this effect.

V. CONCLUSION

Our experience demonstrates that a deliberate stakeholder engagement strategy implemented from the start of a major curriculum renewal is helpful in maintaining key stakeholder involvement. We found that facilitating a collective discussion about the direction and underpinning values of an innovative medical curriculum was a helpful strategy although some stakeholders felt that, since their wishes had not been adopted, they had not been involved. Despite this, we found that, in most cases, stakeholder involvement from the start led to ongoing collaboration in the change management of implementing a new medical program.

We must ensure that our graduates are optimally prepared to begin their careers as medical practitioners over the next 30 to 40 years, and are ready to meet the needs of the people of Queensland, Australia and globally. We are confident that our early engagement on MD Design will help to achieve that goal.

Notes on Contributors

KF conceptualised, led the workshops where data were collected, contributed to data analysis and wrote the manuscript.

Ethical Approval

Ethics Approval for the study was obtained from the University of Queensland Human Research Ethics Committee, Application number 2019001725 granted June 2019. Potential participants were provided with study information prior to the workshops and their active participation in the ensuing workshop was taken to indicate consent.

Data Availability

Data is not currently stored in the UQ Data repository because of its nature, as transcripts of meeting discussions where the partipants may be identified would breach the conditions of ethics approval. 

Acknowledgement

The curriculum design project described in this study is an endeavour involving a large number of people. The author would especially like to thank Professor Stuart Carney, Dean of the Medical School for his support in many of the engagement sessions, Dr Jane Hallos for her assistance with data collection, analysis and literature review, Ms Alexandra Longworth for assistance in data collection and all workshop participants for their input.

Funding

The study was funded as part of the MD Design project led by the Faculty of Medicine at the University of Queensland. There was no specific grant funding but the Mayne Bequest supported medical education research expenses.

Declaration of Interest

The author has no conflict of interest to declare.

References

Australian Medical Council (AMC). (2012). Standards for assessment and accreditation of primary medical programs by the Australian Medical Council 2012. Australian Medical Council Ltd.

Prideaux, D. (2003). ABC of teaching and learning in medicine: Curriculum design. BMJ, 326(7381), 268-270. https://doi.org/10.1136/bmj.326.7383.268

Torralba, K. M. D., & Katz, J. D. (2020). Quality of medical care begins with quality of medical education. Clinical Rheumatology, 39, 617-618. https://doi.org/10.1007/s10067-019-04902-w

Velthuis, F., Varpio, L., Helmich, E., Dekker, H., & Jaarsma, A. D. C. (2018). Navigating the complexities of undergraduate medical curriculum change: change leaders’ perspectives. Academic Medicine, 93(10), 1503-1510. https://doi.org/10.1097/ACM.0000000000002165

*Kirsty Foster OAM
Academy for Medical Education, Medical School,
Level 6, Oral Health Centre,
288 Herston Road
Herston QLD 4006 Australia
+61 7 3346 4676
Email: Kirsty.foster@uq.edu.au