Submitted: 28 July 2022
Accepted: 12 October 2022
Published online: 3 January, TAPS 2023, 8(1), 25-32
https://doi.org/10.29060/TAPS.2023-8-1/OA2850

Choon Peng Jeremy Wee¹, Mingwei Ng¹ & Pim W. Teunissen²

¹Department of Emergency Medicine, Singapore General Hospital, Singapore; ²School of Health Professions Education (SHE), Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands

Abstract

Introduction: This study was performed to understand how fixed clinical teams affected informal learning in Emergency Medicine Residents. Better understanding the effects of team dynamics on informal learning may help to optimise learning and improve performance.

Methods: From 8^th February 2020 till 27^th September 2020, the Singapore General Hospital Emergency Department adopted a fixed team system. Zoom interviews were carried out amongst Emergency Medicine Residents who worked in the fixed team system using a semi-structured iterative interview guide. A qualitative content analysis was used for this exploratory study. The interviews were transcribed verbatim, anonymised and coding via template analysis performed. Data collection and analysis were performed until data sufficiency.

Results: The themes identified centred around relationship dynamics, team composition and motivation for learning. The first was how improved relationships led to improved trust, communications and camaraderie among team members. This improved peer learning and clinical supervision and provided a more personalised learning experience. A balanced team composition allowed learners to be exposed to experts in various subspecialties. Finally, there was an initial increase in motivation, followed by a decrease with time.

Conclusion: In postgraduate medical education, working in a fixed team system with balanced members had positive effects on informal learning by strengthening relationships and communications.

Keywords:           Informal Learning, Workplace Learning, Fixed Teams, Medical Education, Postgraduate

Practice Highlights

• Fixed teams can strengthen relationships between members through better trust, familiarity and communication.
• A balanced fixed team with members having different areas of expertise allows a variety of perspectives.
• Rotation of team members may achieve a balance between the stronger relationship and familiarity of the members of fixed teams and the greater variance in perspectives from a non-fixed team system.

I. INTRODUCTION

Fixed teams (FT) and non-fixed teams (NFT) exist in medicine because of differing service requirements and manpower resources. Examples of FTs can exist in ward round teams and operating surgical teams (Eddy et al., 2016; Stepaniak et al., 2012) where personnel stay within the same work team for long periods. In other areas of healthcare like the Emergency Departments (ED), a NFT system is usually employed where teams are formed according to the personnel rostered to work on that shift and team members change every shift. This allows a more flexible system for the team members as they can request off days and leave according to their personal schedule and yet allows for 24-hour coverage in the ED. 

High levels of performance are required of medical teams, both fixed and non-fixed, to achieve good patient outcomes. Therefore, team members should learn how to work effectively together to deliver the best patient care. There are studies, both within healthcare and other industries, which showed mixed results when FT were compared with NFT with regards to team performance. A systematic review on minimal invasive surgical teams found that the FTs had better teamwork and had reduced rates of technical mistakes compared to NFTs (Gjeraa et al., 2016). However, an aviation study showed that FTs made more minor errors compared to NFTs due to FT members being too familiar with each other and overlooking errors (Barker et al., 1996). Although it is unclear how transferable specific research findings from non-healthcare domains are, what is clear is that FTs and NFTs are different in the way teams were formed and the amount of time team members spend working together. There is a lack of understanding if and how these differences affect the way learning takes place in FT and NFTs; which could translate to the performance of the team and its members. 

Workplace learning occurs through informal learning by experiencing work challenges and via interpersonal relationships. Informal learning can be supported through learner engagement by encouraging active participation in work activities and aligning learners’ interests with that of the organisation’s objectives towards improving the individuals’ and organisation’s capabilities (Billett, 2007). Informal learning is now widely accepted as a form of workplace learning that occurs out of a formal planned teaching program. It usually occurs during work activities which are not primarily aimed towards education, with learning objectives not planned beforehand (Callanan et al., 2011; Rogoff et al., 2016; Watkins et al., 2018). Although informal learning had been studied, there are very few studies looking at how being in FTs affects informal learning. A review on the involvement of employees in workplace learning (Kyndt & Baert, 2013) revealed that there was a paucity of literature on whether any team system improves the involvement of employees in informal learning. Thus, it remains to be studied what effects working in a FT system has on informal learning especially of the more junior team members. 

An integrative literature review on informal learning found that some of the important components of informal learning within members of a team and between teams included interpersonal relationships, feedback, networking and leadership (Jeong et al., 2018). Therefore, there may be differences in interpersonal relationships and feedback between the different team systems. It is known that good interpersonal relationships include good supervisor and peer support and both affect whether what is learnt is applied at the workplace (Burke & Hutchins, 2016), there was little published data on whether supervisor and peer support or even the supervisory relationship were affected by the amount of time spent together. Within some healthcare systems both FTs and NFTs consists of members with varying levels of experience, differing expertise and roles. In a FT, the learners are only supervised by supervisors within that team; therefore, each learner’s supervised time is divided within a small group of supervisors as compared to a NFT system where each learner’s supervised time is spread amongst a larger number of supervisors. Thus, despite this increased time spent together in a FT, it is not clear if working in a FT impacts supervisory or interpersonal relationship. 

Having a good trusted learner-supervisor relationship can result in the establishment of an “Educational Alliance” (Telio et al., 2015). This is because feedback from a credible trusted source was more readily accepted and feedback is another important component of effective informal learning within a team (Jeong et al., 2018).

Furthermore, a study among social work students and their supervisors in a rotational placement model, found that the longer the amount of time they spent with each other the greater the trust between them (Vassos et al., 2017). On the other hand, being in a FT could restrict networking and socialisation to a smaller group of people as contact with other teams’ members could be reduced however it is not known how this could affect informal learning. 

Understanding how informal learning takes place within FT and NFT may allow optimisation of learning within each and perhaps even configure teams to enhance learning and thus ultimately improve performance. Our study aimed to fill this gap in the literature by exploring how fixed clinical teams affected the experience of informal learning for Emergency Medicine (EM) Residents. By doing so we hope to understand how informal learning can be supported via the appropriate implementation of team systems especially where high performance is expected from the teams.

II. METHODS

To study how being in fixed clinical teams affected the experience of informal learning for EM Residents we conducted an exploratory qualitative study based on a constructivism research paradigm using content analysis of individual interviews. This is because informal learning could not be quantified with specific learning outcomes.

A. Setting

EDs teams manage a large number of critically ill patients who may need time sensitive interventions. These teams would comprise of experienced Emergency Physicians (EPs) and more junior Medical Officers (MOs) and Residents. The Residents are postgraduate doctors who are training to graduate as EPs; therefore, informal workplace learning is a crucial part of their training. Hence the residents would be good study subjects to investigate the effect of team systems on informal learning. 

The Singapore General Hospital (SGH) ED functioned via NFTs where the composition and number of members in the team differed with each 8 hour shifts accordingly to the anticipated patient load. The COVID-19 pandemic provided a naturalistic setting where the effect of a FT system can be compared to a NFT system which had existed before hand. After COVID-19 was declared a pandemic by the World Health Organisation (WHO) on the 11^th March 2020 (World Health Organisation, 2020). There was an emphasis on infection control to contain the pandemic. Many countries had instituted social distancing measures which included curfew-like measures and travel restrictions (Lake, 2020). Similarly, the Singapore government had instituted legislative measures to limit face-to-face interactions. In the ED of SGH, measures were put in place to limit the spread of COVID-19.

Thus, from 8^th February till 27^th September 2020, as part of infection control measures, doctors were organised into 5 FTs, each having between 5-7 Consultants, 3-5 EM Senior Residents, 2-3 EM Junior Residents and 7-9 non-EM Medical Officers (MO) (Liu et al., 2020; Quah et al., 2020). The Senior Emergency Physicians (SEPs) consisted of certified specialists in EM (Associate Consultants, Consultants and Senior Consultants); they played supervisory and educational roles to the junior doctors (JD) which included MOs, Junior Residents and Senior Residents. Each FT worked 12-hour shifts. Interactions between teams were kept to a minimum and members from different teams were not allowed to mingle. Thus, the residents were only supervised by their team’s SEPs. Informal learning would now occur within these FTs. 

Formal learning was converted to a remote online platform because of infection control measures. Lectures and tutorials were held and recorded using software which enabled online asynchronous access e.g. Zoom (Zoom, 2016) as not all residents could be given protected learning time together. Sessions which could not be transferred onto an online platform (e.g. hands on simulation and procedure skills training) were cancelled. Formal summative examinations were also cancelled.

B. Interviews

Interviews were conducted and recorded via Zoom (Zoom, 2016) to maintain social distancing. The primary investigator performed 11 interviews and a coinvestigator performed the remaining 4 out of a total of 15 interviews. A semi-structured iterative interview guide was developed based on Eraut’s typology on informal learning which included team activities, tasks and enabling/disabling factors (Eraut, 2010) was used, and the interviews were audio-recorded and transcribed verbatim and anonymised. The interviews allowed positive and negative aspects to be explored and being semi structured the questions asked varied according to the interviewees’ responses. This helped to focus the interviewees to what informal learning was with examples when it could occur within team activities. The guide was iteratively amended with each interview to enhance clarity which helped to obtain more in-depth data in later interviews. 

C. Participants

Twenty-four ED residents were working in the FT system in the ED of SGH during COVID-19. Fifteen were Junior Residents and 9 were Senior Residents. Purposive sampling was carried out with at least two Residents from each team being sampled. This is to ensure that there was good representation for all of the fixed clinical teams. All 24 residents were invited to participate via email and WhatsApp messaging platform with written consent being obtained. Fifteen individual interviews were conducted before data sufficiency was achieved where no new data would change the outcome of the study, thus no further interviews were conducted beyond data sufficiency (Varpio et al., 2017). Eleven interviewees were Junior Residents (4 females and 7 males) and 4 were Senior Residents (3 females and 1 male).

D. Data Analysis

Data analysis was performed via template analysis by the primary and coinvestigator independently (Brooks et al., 2015). Eraut’s typology developed from his research on informal learning was used as a priori themes in the initial coding template (Eraut, 2010). Coding template modifications were made as the analysis of the transcripts continued. Themes were categorised into hierarchical clusters and relationships between them were studied and defined. After final modifications, the coding template was applied to the entire data set. Coding themes were compared and discussed between the primary investigator and the coinvestigator until consensus was reached. 

E. Ethics

Waiver for approval was granted by the Singhealth Institutional Ethics Board. The primary investigator was a core faculty within the Singhealth Emergency Medicine Residency Program and although the interview was conducted among EM residents the primary investigator did not conduct the interviews when the interviewees were from the same team as the primary investigator. These were conducted by the coinvestigator. The coinvestigator was an EM Senior Resident who was not involved in the FT system. A reflexivity diary was kept, and peer debrief was done.

III. RESULTS

Three main themes emerged on how working in FTs affected informal learning amongst our participants (Figure 1). These included changes in relationship dynamics between members, effect of FT composition on informal learning of the participants and influence on motivation.

Figure 1. Themes and sub-themes

Theme 1: Changes in Relationship Dynamics between FT Members

From the interviews, the participants felt that the FT system resulted in more familiarity, trust, teamwork and improved communications between team members including SEPs, Residents and MOs. Interviewees felt that this strengthened the relationship dynamics between FT members as compared to a NFT. This meant that FT members were able to coordinate and exchange information better. It led to an increase in familiarity in knowing each member’s style of practice and way of thinking. The team members could understand each other better and how they reasoned.

The strengthened relationship between residents and SEPs changed with dynamics. Having a “closer rapport” and “deeper bond” allowed the residents to “tag along” with SEPs “more often” and gave the residents more insight as to why the SEPs behaved in a certain way as to “how they had practiced medicine” and the rationale behind each step was “more easily communicated to the residents who were tagging along” (Resident A), resulting in residents having a deeper understanding of why things were done in addition to how things were done. This strengthened relationship was also present between the residents and their peers. Therefore, peer learning improved within the FTs as junior residents reported feeling less reservation in asking each other questions. 

Resident D felt that peer learning was better within FTs because of the improved relationship, there were less reservations which had prevented him from asking his peers questions in a NFT setting. 

He elaborated:

“Fixed team [was] definitely better for peer learning. For the same reasons, because you know each other better, you’re more familiar. We don’t only talk to each other about work… after a while, when you go for meals together… or rather like resting together and no cases around you sit and talk. So there’s a lot more familiarity with the person you’re working with, and… you’re just more comfortable with asking questions… you don’t feel like this is somebody who’s going to judge you if [you] asked a stupid question”

This was not just amongst the residents but also with SEPs. Resident G felt that it was easier for the residents to speak to the SEPs because of familiarity and resulted in less workplace stress:

“Over the time as we knew each other better … the workplace stress was much lower… so I could… work with less stress at workplace… Because if you didn’t really know the consultant you tend to be afraid to talk to them; then of course your stress levels will be higher. But if you know that consultant and you know what kind of person, he or she is then you could be more comfortable to talk to them…”

“…It is more comfortable to… approach the senior because you know every day… we have a fixed team so naturally we feel that our relationship is closer…”

“… so, I won’t be too afraid to speak out or to talk to them to discuss with them.”

Contributing to additional ways of informal learning, communication within FTs even during work took on a more “friendly [and] social” form with greater congeniality and via more “communication platforms” (WhatsApp and Tiger Text) which continued even “outside of work” (Resident H). These platforms were also used as learning tools to facilitate case discussions, share learning points and experiences. This was not previously present in the NFTs. The residents felt that learning was more customised because of the change in relationship dynamics. In FTs, there was closer supervision of residents by SEPs. The residents “spent more time” with the same group of supervisors, thus the supervisors were able to better “assess both strengths, weaknesses and address any particular loopholes” of the residents (Resident A). 

However, there were some adverse effects of this change in relationship dynamics. Some residents felt that with a closer relationship between team members, supervisors sometimes were more tolerant of the learners’ shortcomings and be less likely to point it out because of not wanting to affect the relationship. This closer relationship could result in residents taking “shortcuts” and “flying under the radar” because they knew the SEPs could tolerate or would not scrutinise the learners closely once “trust” was established (Resident L). Resident H gave an example of how familiarity could lead to less critical thinking by the learner:

“If… the senior always does like… [Rapid Sequence Intubation] … even though I question the first time I saw him do that… subsequently … every time I work with him I will do [it] this way. I won’t really think does the patient really need this way [of management] or will the patient benefit in a different way… if you are working with different bosses then every case you need to restart your thinking…”

Theme 2: Effect of Composition of the FT

All interviewees felt that the composition of the FT had affected informal learning, and that having a balanced team in terms of a wide range of years of practice amongst both the SEPs as well as the JDs would help improve informal learning. Having a team where the JDs were of differing seniorities of practice could help with peer learning because the senior ones could help the junior ones more. This also applied to the SEPs as that provided a wider perspective to clinical issues due to having different clinical experience and expertise in different subspecialties. Furthermore, if the JDs in a FT were of a similar level of practice, Resident C expressed that they could be “competing with each other for cases and procedures” which adversely affected informal learning with fewer opportunities to perform procedures. In a NFT the members would be constantly changing and it would be unlikely its JD would be always of the same level of practice.

The interviewees expressed concern that within a FT system that, although residents had close contact with a fixed group of supervisors, they lacked contact with the other teams’ SEPs. Many residents felt that this had adversely impacted informal learning because the SEPs were experts in different subspecialties (e.g., Trauma, Toxicology, Ultrasound, etc). By not interacting with many SEPs, residents were unable to learn from them. Furthermore, different supervisors had different perspectives and approaches to patients which the residents may not be exposed to if they were not in the same team as these seniors. However, this was mitigated by having a team with a balanced variation in the areas of specialty of the seniors. Resident F summarised this:

“…a team with… people from different seniorities are essential… (even) juniors can teach seniors… the way that my team was composed… it was a good mix… there are people from different… specialties… from different seniorities even within the juniors … like first posting to… [senior post graduate years]… offers different perspectives, learning of different things… people from different [subspecialties] can offer insight into the systems-based learning or component from other parts of the institution…”

Theme 3: Influence of a FT System on Motivation

Many residents felt that having FTs increased their motivation to learn. This resulted from their supervisors being able to inspire them and follow up with their learning progress more closely. Resident M was motivated to learn because his “friends (FT members) were very motivating” and “enthusiastic”; this encouraged him to learn more. Furthermore, resident C felt more motivated to learn in a FT because he “always sees the same senior” and this more frequent contact results in him being “more likely to take their feedback and opinion more seriously and work harder”

However, “after some time everyone is comfortable with each other” and some participants feared that their motivation “might go down” (Resident N). This was because there was a feeling of complacency as time went on within a FT, hence the motivation to learn started to dwindle after an initial increase.

Other reasons for this decline were related to COVID-19, the focus was more on facing the threat rather than learning and the priority to learn was secondary. The motivation to learn “was a bit less” as “the mood was more to survive than to learn”; Resident L was “less driven to learn” because there was a “general bleakness in the whole situation of [COVID-19] which made his “inner desire to learn… wane a bit”

IV. DISCUSSION

This study explored how working in fixed clinical teams affected informal learning for EM Residents. There are many pros and cons to fixed team rostering however the focus of this study is on informal learning. The findings highlighted the importance of having a balanced team composition where team members were able to establish trust and a strong bidirectional relationship because of the longer time spent working together. Motivation to learn increased initially; however after some time, some felt a decrease. This was consistent with prior work which highlighted team dynamics and commitment and that feedback which was given often and in a socially interactive environment were factors which helped to enable effective work-based learning (Attenborough et al., 2019; Jeong et al., 2018; Kyndt et al., 2016). Unlike in Attenborough’s work where team leadership was one of the factors identified; our respondents did not mention the effect of team leadership on informal learning. Their focus was more on the relationships between the different team members. From this study the predominant factors which positively affected informal learning included teamwork, collaborative task performance, where good communication was needed between different people, and personal development especially in building interpersonal relationships and group decision making.

Limited studies were done on how FTs affect informal learning. Our study found that FTs resulted in more (informal) communication channels (e.g. WhatsApp) being formed which was not present in NFTs, resulting in more learning activities including sharing ideas, resources and experiences. These sharing activities were some of the major forms of informal learning activities identified in the literature (Lohman, 2006). FTs resulted in open communication and quality feedback which was well received, and were found to be beneficial towards informal learning (Jeong et al., 2018). Our study showed that working in a FTs led to more customised learning. Findings of improved communications and strengthened relationships in a bidirectional manner involving teacher and learner alike, supports a shift from a predominantly teacher to learner type of dynamics to a team learning dynamics where all team members can learn with and from one another. This is important because informal learning takes place effectively when learning from past mistakes and feedback exchange occurs, involving both cognitive and social interactions (Jeong et al., 2018).

FTs had negative effects on informal learning as well. Familiarity resulted in supervisors being more tolerant of shortcomings and FTs limited learners’ contact with other teams’ supervisors and adversely affected informal learning. This was because informal learning also takes place when there is sharing of ideas, expertise and experience (Lohman, 2006) and limiting the number of supervisors limits the variance of shared viewpoints.

Our study has limitations. Firstly, interviewee recall bias was possible because 6 months had passed after the FT system was stopped before the interviews. Therefore, some details may not have been accurately recalled given this period which could affect the trustworthiness of results. Secondly, the participants were likely to be comparing their experiences in the FT system during COVID-19 to a NFT system without a pandemic. Thus, some of the experienced changes may be because of the pandemic rather than purely due to the FT system. Thirdly, there are many pros and cons to FTs however the focus of this study is on informal learning thus other factors not investigated with this study may affect the feasibility of FT.  Lastly there could be power differential effects between the interviewers and the interviewees because the interviewers performed supervisory and roles to the residents. However, to mitigate this, a reflexivity diary was kept, and peer debrief between the two interviewers was performed. Furthermore, the interviewers did not interview members who had been in the same team as them.

V. CONCLUSION

In conclusion, FTs impact informal learning by building strong relationships with improved team communications and adding a social dimension for learning. A balance of team members as well as rotating the residents across different FTs may be beneficial for improving informal learning for EM Residents.

Notes on Contributors

Dr Wee Choon Peng Jeremy submitted the CIRB application, (with the help of the last author) conceptualised the study and its design. He performed the literature review, recruited and interviewed the participants, collected and transcribed the data, performed the thematic analysis of the data and wrote the manuscript. 

Dr Ng Mingwei helped to recruit and interview some of the participants, transcribed and collected the data. Dr Ng helped perform the thematic analysis of the data and helped edit the manuscript.  

Prof. Dr. Pim Teunissen was central to the conceptualisation of the study, advised on the design of the study and gave critical feedback to the writing of the manuscript and edited the manuscript extensively

All the authors have read and approved the final manuscript. 

Ethical Approval

We have included the letter for waiver of CIRB via email. Ethics approval for waiver of written informed consent was obtained from the Singhealth Institutional Review Board (CIRB Ref: 2020/3114).

Data Availability

As the data set is qualitative in nature, we are not able to upload that in any public repository.

Funding

There is no funding for this paper/study.

Declaration of Interest

The authors report there are no competing interests to declare. 

References

Attenborough, J., Abbott, S., Brook, J., & Knight, R. A. (2019). Everywhere and nowhere: Work-based learning in healthcare education. Nurse Education in Practice, 36, 132-138. https://doi.org/10.1016/j.nepr.2019.03.004

Barker, J. M., Clothier, C. C., Woody, J. R., McKinney, E. H., Jr., & Brown, J. L. (1996). Crew resource management: A simulator study comparing fixed versus formed aircrews. Aviation, Space, and Environmental Medicine, 67(1), 3-7.

Billett, S. (2007). Constituting the workplace curriculum. Journal of Curriculum Studies, 38(1), 31-48. https://doi.org/10.1080/00220270500153781

Brooks, J., McCluskey, S., Turley, E., & King, N. (2015). The utility of template analysis in qualitative psychology research. Qualitative Research in Psychology, 12(2), 202-222. https://doi.org/10.1080/14780887.2014.955224

Burke, L. A., & Hutchins, H. M. (2016). Training transfer: An integrative literature review. Human Resource Development Review, 6(3), 263-296. https://doi.org/10.1177/1534484307303035

Callanan, M., Cervantes, C., & Loomis, M. (2011). Informal learning. Wiley Interdisciplinary Reviews Cognitive Science, 2(6), 646-655. https://doi.org/10.1002/wcs.143

Eddy, K., Jordan, Z., & Stephenson, M. (2016). Health professionals’ experience of teamwork education in acute hospital settings: a systematic review of qualitative literature. JBI Database of Systematic Reviews Implementation Reports, 14(4), 96-137. https://doi.org/10.11124/JBISRIR-2016-1843

Eraut, M. (2010). Informal learning in the workplace. Studies in continuing education, 26(2), 247-273. https://doi.org/10.1080/158037042000225245

Gjeraa, K., Spanager, L., Konge, L., Petersen, R. H., & Ostergaard, D. (2016). Non-technical skills in minimally invasive surgery teams: A systematic review, Surgical Endoscopy, 30(12), 5185-5199. https://doi.org/10.1007/s00464-016-4890-1

Jeong, S., Han, S. J., Lee, J., Sunalai, S., & Yoon, S. W. (2018). Integrative literature review on informal learning: Antecedents, conceptualizations, and future directions. Human Resource Development Review, 17(2), 128-152. https://doi.org/10.1177/1534484318772242

Kyndt, E., & Baert, H. (2013). Antecedents of employees’ involvement in work-related learning. Review of Educational Research, 83(2), 273-313. https://doi.org/10.3102/0034654313478021

Kyndt, E., Vermeire, E., & Cabus, S. (2016). Informal workplace learning among nurses. Journal of Workplace Learning, 28(7), 435-450. https://doi.org/10.1108/JWL-06-2015-0052

Lake, M. A. (2020). What we know so far: COVID-19 current clinical knowledge and research. Clinical Medicine, 20(2), 124-127. https://doi.org/10.7861/clinmed.2019-coron

Liu, Z., Teo, T. L., Lim, M. J., Nadarajan, G. D., Segaram, S. S. C., Thangarajoo, S., Wee, L. E., Wee, J. C. P., & Tan, K. B. K. (2020). Dynamic emergency department response to the evolving COVID-19 pandemic: The experience of a tertiary hospital in Singapore. Journal of the American College of Emergency Physicians Open, 1(6),1395-1403. https://doi.org/10.1002/emp2.12264

Lohman, M. C. (2006). Factors influencing teachers’ engagement in informal learning activities. Journal of Workplace Learning, 18(3), 141-156. https://doi.org/10.1108/13665620610654577

Quah, L. J. J., Tan, B. K. K., Fua, T. P., Wee, C. P. J., Lim, C. S., Nadarajan, G., Zakaria, N. D., Chan, S. J., Wan, P. W., Teo, L. T., Chua, Y. Y., Wong, E., & Venkataraman, A. (2020). Reorganising the emergency department to manage the COVID-19 outbreak. International Journal of Emergency Medicine, 13(1), Article 32. https://doi.org/10.1186/s12245-020-00294-w

Rogoff, B., Callanan, M., Gutiérrez, K. D., & Erickson, F. (2016). The organization of informal learning. Review of Research in Education, 40(1), 356-401. https://doi.org/10.3102/0091732×16680994

Stepaniak, P. S., Heij, C., Buise, M. P., Mannaerts, G. H., Smulders, J. F., & Nienhuijs, S. W. (2012). Bariatric surgery with operating room teams that stayed fixed during the day: A multicenter study analyzing the effects on patient outcomes, teamwork and safety climate, and procedure duration. Anesthesia and Analgesia, 115(6), 1384-1392. https://doi.org/10.1213/ANE.0b013e31826c7fa6

Telio, S., Ajjawi, R., & Regehr, G. (2015). The “Educational Alliance” as a framework for reconceptualizing feedback in medical education. Academic Medicine, 90(5), 609-614. https://doi.org/10.1097/ACM.0000000000000560

Varpio, L., Ajjawi, R., Monrouxe, L. V., O’Brien, B. C., & Rees, C. E. (2017). Shedding the cobra effect: Problematising thematic emergence, triangulation, saturation and member checking. Medical Education, 51(1), 40-50. https://doi.org/10.1111/medu.13124

Vassos, S., Harms, L., & Rose, D. (2017). Supervision and social work students: Relationships in a team-based rotation placement model. Social Work Education, 37(3), 328-341. https://doi.org/10.1080/02615479.2017.1406466

Watkins, K. E., Marsick, V. J., Wofford, M. G., & Ellinger, A. D. (2018). The evolving Marsick and Watkins (1990) theory of informal and incidental learning. New Directions for Adult and Continuing Education, 2018(159), 21-36. https://doi.org/10.1002/ace.20285

World Health Organisation. (2020). World Health Organisation emergencies press conference on coronavirus disease outbreak – 11 March 2020. https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19—11-march-2020

Zoom. (2016). Security guide. Zoom Video Communications Inc.

*Wee Choon Peng Jeremy
Outram Road,
Singapore 169608
Email: jeremy.wee.c.p@singhealth.com.sg

Submitted: 26 November 2021
Accepted: 21 July 2022
Published online: 3 January, TAPS 2023, 8(1), 33-42
https://doi.org/10.29060/TAPS.2023-8-1/OA2712

Jaime Maria Tan¹, Junaidah Binte Badron¹ & Sashikumar Ganapathy^1,2

¹Department of Emergency Medicine, KK Women’s & Children’s Hospital, Singapore; ²Duke-NUS Medical School, Singapore

Abstract

Introduction: Perceptions towards the working and learning environment as well as coping mechanisms have been studied across different healthcare sectors. They have shown to reduce stress and burnout. However, perceptions of the work environment in the Emergency Department (ED) setting have not been studied in depth. The literature surrounding coping mechanisms also mostly focuses on their impacts rather than the mechanisms utilised. In addition, these were often investigated using surveys. This study aimed to use a phenomenological approach to explore the perceptions and coping strategies of junior doctors working in a paediatric ED.

Methods: Sixteen junior doctors working in the Paediatric ED were recruited. Semi-structured interviews were conducted after conducting literature reviews. Data was collected until saturation point. All interviews were recorded and transcribed verbatim manually and subsequently analysed.

Results: The greatest fears of junior doctors starting their paediatric emergency posting were lack of knowledge due to inexperience in the subspecialty; fear of the work environment due to unfamiliarity as well as workload and the intrinsic high-stress environment. The main coping strategies were ensuring clinical safety, obtaining psychosocial support from loved ones and colleagues, and placing focus on spirituality and wellbeing.

Conclusion: In this study, the perceptions and coping strategies of the junior doctors in the Paediatric ED were explored. The findings from this study will help to structure and improve the support given to future junior doctors who rotate to the department as well as better orientate them to allay their pre-conceived notions.

 Keywords:          Coping Behaviours, Perceptions, Paediatric Emergency Department, Stressors, Interviews

Practice Highlights

• Participants worried about knowledge, workload and responsibilities prior to starting their posting.
• Perceptions were mostly of an anticipatory nature, influenced by seniors’ past experiences.
• In work, support from senior staff was helpful in allaying their fears and increasing patient safety.
• Participants felt psychosocial support, spirituality and wellness were useful coping strategies.
• Maladpative coping strategies did not come up as a main theme in our study.

I. INTRODUCTION

Perceptions toward the work and learning environment can strongly impact experiences and even lead to large amounts of stress (Chan et al., 2016). A poorer perception of the learning environment is also associated with greater levels of burnout (Chew et al., 2019; Sum et al., 2019). Conversely, a positive perception of the work environment helps to alleviate stress (Abraham et al., 2018). Workers’ perception of their work environment contributes significantly to their overall experiences.

Main factors contributing to stress in the ED include heavy workload and critically ill patients. Workplace violence, trauma, abuse and morbidity also add to the stress and burnout experienced (Burbeck et al., 2002; Copeland & Henry, 2018; Healy & Tyrrell, 2011; Xu et al., 2019). In the paediatric setting, added stressors include dealing with sexual abuse and non-accidental injury as well as death and the inability to provide optimal care for children (Alomari et al., 2021; Basu et al., 2016; Durand et al., 2019; Greenslade et al., 2019; Shanafelt et al., 2012; Watson et al., 2019).

Given these significant stressors, individuals utilise different coping mechanisms to mediate these experiences (Howlett et al., 2015).

Some coping strategies discussed in previous studies include socialising with friends and family (Gribben et al., 2019). Focusing on physical wellbeing, clinical variety, reflectivity, and organizational activities were also helpful in alleviating burnout in other areas of healthcare (Barham et al., 2019; Koh et al., 2015).

Several studies also found that the use of maladaptive coping mechanisms, such as alcohol use and self-blame increased with the frequency of burnout (Jackson et al., 2016; Oreskovich et al., 2015; Ryali et al., 2018; Talih et al., 2018).

While many studies studied stressors and the effectiveness of the coping mechanisms used, the actual components of coping mechanisms were not well studied. In studies that did look at coping mechanisms and their effectiveness, these studies were also often done via the survey method and were only evaluated on the surface.

Most studies looked at healthcare workers in general. Few studies looked solely at the doctor population. This makes conclusively evaluating the doctor component of coping mechanisms and their effects difficult.

While other studies looked at an adult emergency perspective, there were also few studies looking at the paediatric ED. It has been reported that dealing with paediatric emergencies causes more stress compared to their adult equivalents. Some of the contributing factors are related to the nature of working with children. These, in itself, are unmodifiable (Guise et al., 2017). Therefore, it is important to study how the paediatric context can affect the experiences of the doctors who care for them.

In our study, we studied the perceptions of junior doctors at the beginning of their posting. We subsequently explored their coping mechanisms in the Singaporean context.

The element of stress in the ED among junior doctors is significant as the ED is often part of many specialist training pathways (Mason et al., 2015). During the time of training, the doctors are still learning and developing. Hence, many doctors experience sharp learning curves during their postings. This brings about more stress (McPherson et al., 2003). In some cases, the stress can even lead to doctors thinking about leaving clinical practice altogether (Degen et al., 2014).

In the Singaporean context, paediatric emergency postings are part and parcel of speciality training for junior doctors (especially for those in emergency medicine and family medicine training). Because of this, junior doctors spend the majority of their paediatric postings in the paediatric emergency. As such, a Singapore-specific context would give light on the challenges of this sizable group.

The nature of the healthcare system in Singapore is unique. Up to 60% of the consultations in the paediatric ED were for nonurgent conditions due to the overall perception of the severity of symptoms and parental preference towards paediatric specialist facilities (Ganapathy et al., 2015). This would lead to an increased workload for the paediatric ED. The distribution in workload may also differ compared to a global perspective, with the load of severe paediatric trauma in Singapore being low (Pek et al., 2019).

These subtleties in the paediatric ED in Singapore can influence the experiences of junior doctors differently. With these key differences in mind, we aimed to investigate the perceptions of junior doctors towards their paediatric ED posting in Singapore and how they subsequently coped with the challenges faced.

II. METHODS

A. Design

In this study, we examined the experiences of doctors in their paediatric ED rotation and how their thoughts and actions influenced their stress during their rotation. We deemed the phenomenological approach to be the most appropriate for this study. Phenomenology is defined as the study of how individuals see and experience a phenomenon and what this means to the individuals in their own experience (Neubauer et al., 2019; Smith, 2021).

The approach we chose was that of an interpretive phenomenological analysis in which we aimed to investigate the experience through the participants’ own experiences and perceptions. With the help of the various participants’ accounts, themes and ideas bound by their experiences were explored (Tuffour, 2017).

B. Methods

The members of the study performed a preliminary literature review on the topic and explored plausible methods of data collection. The study team decided on semi-structured interviews as it promotes sharing and would allow for sufficient privacy.

The team members included a senior consultant, a staff physician and a medical officer. Together, after discussions about concepts that the team was keen to explore, an interview guide was drawn up.

Subsequently, a proposal was submitted to the Hospital Centralised Institutional Review Board for approval.

One-on-one interviews were conducted with the participants by investigator A, a medical officer who was rotating within the department at the time of the study. This was done to reduce the power differential. Interviews were conducted at a location and time convenient to the participant.

Prior to the interviews, consent was sought and all interviews were recorded and subsequently transcribed verbatim. The interviews were conducted over a 1-month period in December 2019.

Questions were open-ended and allowed participants to share ideas that they were keen to raise with no restrictions to the topics brought up. Interview questions were tweaked alongside subsequent interviews so that they were easier to understand and would encourage sharing. Additional questioning in subsequent interviews was adopted to improve clarity. For example, one of the questions that featured early in the interviews was ‘What are some of the coping mechanisms you use?’ During subsequent interviews we noticed some participants utilised coping mechanisms before work to prepare themselves, some used other strategies during work to cope with the stress, while others dealt with their stressors after getting off work. We tweaked the question to include ‘during the shift or outside of the shift’ to help participants widen their perspective about certain coping methods they may have used but were not immediately conscious of when answering the questions. No new questions referring to particular themes were inserted although interviewers were aware of the themes that had been highlighted in previous interviews. This was done in addition to the initial interview guide and ensured the broad nature of questioning was not compromised and the breadth of interviews was maintained.

Themes were identified from the interviews until data saturation was reached. Data saturation was noted at the 12th interview. The team continued to learn from subsequent interviews, with interviews contributing additional depth to the issues explored. Further interviews were conducted to confirm that no new theme was being identified.

The interviews were then transcribed and de-identified. They were subsequently reviewed by 2 reviewers (Investigator A and Investigator B). Data was analysed using a step-by-step thematic analysis method (Braun & Clarke, 2006). Investigators A and B independently analysed the transcripts, identified themes and later reported the  common themes. These themes were discussed for concurrence. When any differences in opinion arose, these would be reviewed by investigator C to resolve any disagreement.

C. Setting

The research was conducted within the Paediatric ED in KK Women’s and Children’s Hospital, a tertiary paediatric hospital.

The Children’s Emergency of KK Women’s and Children’s Hospital is the largest paediatric emergency unit in Singapore. During the time of the interviews, the department treated over 400 patients daily. The Children’s Emergency sees all children under the age of 18 years for all medical complaints.

The department is staffed by over 60 junior doctors at a single time. These junior doctors come from various backgrounds and pass through the department for varying amounts of time. Thus, their experience can be very heterogeneous.

The job scope and responsibilities of all the junior doctors are primarily the same despite the different levels of experience. They are expected to treat the patients that present to the ED. These doctors can seek advice from the senior doctors who are on the ground. However, for the majority of the time, they would be tasked to treat patients on their own.

D. Participants

Participants were recruited through an email that was circulated to all junior doctors in the department. Participation in the study was voluntary and participants were not remunerated.

A total of 16 junior doctors were recruited and interviewed over a 1-month period. Due to the busyness of the ED and the limited time frame in which the interviews were conducted, only 16 interviews were conducted. Convenience sampling was chosen for the sampling method. The first 16 volunteers who had volunteered were interviewed. However, it was noted that saturation point was reached prior to the conclusion of the interview process.

The variety within the ED was well represented. The details of participant breakdown are elaborated on in Table 1.

Submitted: 19 May 2022
Accepted: 21 September 2022
Published online: 3 January, TAPS 2023, 8(1), 3-12
https://doi.org/10.29060/TAPS.2023-8-1/OA2817

Junji Haruta^1,2, Ayumi Takayashiki², Ryohei Goto², Takami Maeno², Sachiko Ozone² & Tetsuhiro Maeno²

¹Medical Education Center, School of Medicine, Keio University, Japan; ²Department of Primary Care and Medical Education, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan

Abstract

Introduction: The pandemic caused by the novel coronavirus (COVID-19) has produced dramatic changes in the learning environment for clinical practice in medical education, and the impact on medical students has been significant. However, few program evaluation studies involving professional identity, now emphasised in medical education, have compared current with pre-COVID-19 programs. Here, we compared the professional identity recognised by medical students in the years before and during COVID-19.

Methods: Medical students who participated in clinical practice were evaluated using the Japanese version of the Professional Self-Identity Questionnaire (PSIQ), a 9-item inventory rated using 7-point Likert scales. They answered on the first day of a 4-week clinical practice module within a community-based medical education (CBME) program and at graduation in 2018-2019 (pre-COVID-19 pandemic) and in 2019-2020 (during-COVID-19 pandemic). We compared the mean difference in total PSIQ score of the 2019-2020 students to those of the 2018-2019 students as a historical cohort using an unpaired t-test.

Results: Participants were 104 medical students in the 2018-2019 academic year and 92 in the 2019-2020 academic year. PSIQ was increased at graduation. Mean difference in total PSIQ score was statistically higher for the 2019-2020 students (13.5 ± 9.4) than for the 2018-2019 students (10.3 ± 8.1) (t =2.6, df =195, p = 0.01).

Conclusion: Although clinical practice was restricted by COVID-19, this had some positive impact on the strengthening of professional identity recognised by medical students. This finding may have been influenced by the imprinting of professional norms and changes in society.

Keywords:           Novel Coronavirus Infection, Professional Identity, Clinical Practice, Questionnaire Survey, Program Evaluation

Practice Highlights

• Professional identity recognised by medical students in Japan was assessed by questionnaire.
• Changes during clinical practice were compared between two grades using a historical cohort.
• Medical students’ recognised professional identity scores improved after one year in both cohorts.
• Medical students experienced the COVID-19 pandemic showed some positive impact on professional identity.
• Medical students internalised their role as healthcare professionals owing to COVID-19 pandemic.

I. INTRODUCTION

The pandemic caused by the novel coronavirus (COVID-19) has caused unprecedented disruption to medical education systems around the world (Kaul et al., 2021; Khasawneh et al., 2020; Lucey & Johnston, 2020; Papapanou et al., 2021). In particular, the pandemic has made it difficult to continue medical educational programs, including regular lectures, and face-to-face lectures, experiments, and clinical practice involving patients (Al Samaraee, 2020; Emanuel, 2020; Shankar & Wilson, 2020). The Association of American Medical Colleges took the unprecedented decision to suspend clinical practice and issued guidance instructing medical students to avoid clinical practice involving direct patient contact (Association of American Medical Colleges, 2020). The many university hospitals in the U.S. have made it a priority to utilise students in controlling the spread of COVID-19 infection. Other countries followed this precedent. Medical students accordingly lost the opportunity to learn through patients in clinical practice. In Japan also, clinical practice was suspended at many universities.

Commonly implemented alternative teaching methods were online interactive discussions and video lectures (Chiodini, 2020; Mian & Khan, 2020). To prevent the spread of COVID-19 from medical students in clinical practice (Alsoghair et al., 2021), students were required to socially distance not only from patients but also from healthcare providers and faculty members. However, implementing the requisite changes to curricula, such as interrupting or drastically postponing clinical practice, was difficult, forcing faculties to develop curricula that provided students with opportunities to supplement their ongoing clinical practice as early as possible, while making use of online devices (Ross, 2020). These changes in the learning environment affected medical students’ learning. For example, a survey of 2nd-6th grade students at the University of Geneva found that 2/3 of the medical students experienced decreased motivation and concentration in distracting learning environments such as home, whereas some medical students who were exposed to clinical practice during the COVID-19 pandemic showed an increased sense of belonging to the profession (Wurth et al., 2022). A change in perception with remote learning in response to the COVID-19 pandemic among Canadian undergraduate students also revealed a significant decrease in students’ achievement goals, engagement, and perceptions of success, and an increase in perceptions of cheating (Daniels et al., 2021). Perceptions of learning due to changes in the curriculum due to COVID-19 have been investigated and controversially reported, but few reports have investigated professional identity as a foundation for becoming a physician.

To be effective clinicians, it is important that medical students acquire not only knowledge and skills but also professional identity formation (Cruess et al., 2014; Hafferty & Franks, 1994). Professional identity is defined as “attitudes, values, knowledge, beliefs, and skills shared with others in a professional group” (Crossley & Vivekananda-Schmidt, 2009). Professional identity formation is noted as an ongoing process influenced by several factors, including practice experience and professional socialisation (Adams et al., 2006). In this study, we adopted a theoretical framework which is based on a concept that illustrates the interplay of professional identity formation and socialisation through a complex conscious and unconscious process centered on role models, mentors, and the accumulation of individual experiences (Cruess et al., 2015). Because clinical practice is a period in which medical students meet role models and mentors and gain their first experiences as a healthcare provider, clinical practice is major contributor to the development of professional identity in medical students (Haruta et al., 2020).

Although studies have reported that medical education programs altered by the COVID-19 pandemic have affected medical students’ perceptions of the role of the physician and their learning strategies (Findyartini et al., 2020; Wurth et al., 2022), little is known about the influence of curricula changes on medical students with regard to their professional identity formation as physicians affected by role models, mentors, and individual experience (Stetson et al., 2020).

Here, we aimed to compare professional identity as a physician as perceived by medical students in clinical practice before and during COVID-19 using the Professional Self Identity Questionnaire (PSIQ).                                                                                                     

II. METHODS

A. Setting

Japan first faced the challenge of the COVID-19 pandemic in January 2020, and a state of emergency was declared for all regions of Japan on April 16, 2020 (Prime Minister’s Office of Japan, 2020). During that time, some medical universities suspended clinical training and implemented online education instead. The COVID-19 Outline of Measures for COVID-19 formulated by the Japanese Ministry of Education, Culture, Sports, Science and Technology was sent to all higher education institutions, including medical schools, on June 5, 2020 (Hayashi et al., 2022), with the main advice that universities should operate in a resilient manner for experiential educational practices such as clinical practice. Under these circumstances, leaders of Japanese medical schools were asked to consult various stakeholders and make decisions on whether or not to continue clinical practice, often leaving detailed instructions to local operations managers in each field (Hayashi et al., 2022).  In contrast, primary care physicians were forced to adapt to local conditions (Haruta et al., 2021).

Students enter medical school in Japan after graduating from high school, and the curriculum is six years long. Clinical training usually takes place in the fourth to sixth years. This schedule is also implemented at the University of Tsukuba in Japan: clinical training is divided into a first half from October of the fourth year to September of the fifth year and a second half from October of the fifth year to June of the sixth year, for a total of 78 weeks. After clinical training, medical students spend time studying for graduation and national exams, in addition to attending lectures.

The first phase of this clinical practice consists of a four-week rotation in basic departments such as internal medicine, surgery, obstetrics and gynecology, pediatrics, and emergency medicine, mainly at affiliated hospitals. The second phase incorporates some elective subjects and includes 4 weeks’ mandatory clinical practice in a CBME curriculum and a further 4 weeks’ clinical practice in a department of interest. Typically, 15 to 17 students rotate every 4 weeks through clinical practice in the CBME curriculum. This clinical training was conducted before the pandemic, but was discontinued in response to it at the end of March 2020. In March, medical students continued clinical training while all elementary and junior high schools were closed. All clinical training was then cancelled in April 2020 and replaced with report assignments only. These were replaced in May and June with online training and on-demand assignments. Sixth-year students in the class of 2020, and subsequently also in 2021 and 2022, were required to adhere to health observation recording and infection prevention behaviors in accordance with the University of Tsukuba Hospital staff behavior guidelines, which had not been previously followed. Similarly, they were also restricted from participating in training hospital tours and extracurricular activities, which were usually a part of their training.

B. Study Design

Training in clinical practice at the University of Tsukuba consists of a first phase for 4th and 5th year students and a second phase for 5th and 6th year students. CBME is included in the latter phase. Data from 5th-year medical students who participated in clinical practice in a 4-week community-based medical education (CBME) program from October 2019 to March 2020 and who graduated in March 2021 were compared to those of the previous year’s students (2018-2019) as a historical cohort. This cohort included 6th-year medical students who graduated in March 2020 and who had participated in a similar clinical practice program the previous year, from October 2018 to May 2019. As in the 2018-2019 academic year, a questionnaire was administered using the PSIQ in the 2019-2020 academic year. The PSIQ, conducted as part of program evaluation of the CBME program, was administered on the first day of the 4-week clinical practice of the program and at graduation. Study participants included 118 fifth- and sixth-year medical students who participated in clinical practice in the CBME program from October 2018 to May 2019 (pre-COVID-19 pandemic) and 100 fifth- and sixth-year medical students who participated from October 2019 to March 2020 (during-COVID-19 pandemic). The 35 participants from April-May 2020, when the 4-week clinical practice in the CBME program was switched to online practice due to COVID-19, were excluded because they could not be pre-evaluated.

C. Instrument: Japanese Version of the Professional Self Identity Questionnaire (PSIQ)

The Professional Self-Identity Questionnaire (PSIQ) is a 9-item inventory which is rated using 7-point Likert scales (Crossley & Vivekananda-Schmidt, 2009). This instrument measures the sense of students in identifying their current position on a continuum between ‘first-day student’ and ‘qualified doctor’ when engaged in each of nine domains of professional activity. These nine domains include “Teamwork,” “Communication,” “Conducting assessment,” “Cultural awareness,” “Ethical awareness,” “Using records,” “Dealing with emergencies,” “Reflection,” and “Teaching”. Each item is rated on a 7-point Likert scale. For this research, we set 1 point as “equivalent to the first day of clinical practice” and 7 points as “equivalent to the first day of initial residency”. The PSIQ is an assessment sheet form originally designed in English. The original study was validated in a sample of 496 medical students across multiple phases of education, and the overall internal reliability (Cronbach’s alpha) was reported to be 0.93 (Crossley & Vivekananda-Schmidt, 2009). Previously, we developed a Japanese version of the PSIQ and operationally defined PSIQ scores as professional identity as a physician as perceived by medical students. Cronbach’s alpha of the Japanese PSIQ was reported to be 0.93 (Haruta et al., 2021), which allows students to measure changes in their own professional identity by tracking each of the nine professional activities over time. We set the total score on this scale as the main outcome of this study. The study showed that this was a reliable and valid tool for program evaluation during clinical practice (Haruta et al., 2021).

D. Participants and Data Collection

In 2018-2019 (pre-COVID-19 pandemic) and 2019-2020 (during-COVID-19 pandemic), we assessed the professional identity of medical students from October of their fifth year to May of the sixth year using PSIQ. The survey was administered on the first day of clinical practice in the CBME program as PSIQ 1 (September 2018 to May 2019 and September 2019 to March 2020) and at graduation as PSIQ 2 (2020 January, and January 2021) (Figure 1).

Figure 1. Timing in clinical practice and the PSIQ in 2018-2019 and 2019-2020

	2018-2019 (pre-COVID-19 pandemic) (n=104)	2019-2020 (during-COVID-19 pandemic) (n=92)
Age, mean ± standard deviation	20.6±1.5	21.2±3.4
Gender, number of persons (%)
Male	66 (63.5)	51 (55.4)
Female	33 (31.7)	33 (35.9)
Unknown	5 (4.8)	8 (8.7)

Table 1. Characteristics of medical students included in the analysis

Table 2 shows that the means of total PSIQ scores and each PSIQ item for 2018-2019 and 2019-2020 were increased at graduation. A comparison of the mean for the difference using the unpaired t-test in total PSIQ score for 2018-2019 and 2019-2020 revealed that it was statistically higher for the 2019-2020 students (13.5 ± 9.4) than for the 2018-2019 students (10.3 ± 8.1) (t =2.6, df =195, p = 0.01). However, there were no statistically significant differences using the unpaired t-test with Bonferronni correction at a 0.005 level of significance in mean scores for 9 items of the PSIQ, namely “Teamwork”  (t=0.96 df=195, p=0.341),  “Communication” (t=1.84, df=195, p=0.068),  “Conducting assessment” (t=2.31, df=195, p=0.24) “Cultural awareness” (t=1.41, df=195, p=0.022),  “Ethical awareness” (t=2.25, df=195, p=0.161), “Using records”  (t=2.67, df=195, p=0.026),  “Dealing with emergencies”  (t=2.33, df=195, p=0.008),  “Reflection” (t=2.32, df=195, p=0.021) and “Teaching” (t=2.19, df=195, p=0.030).  The effect size (Cohen’s d) for total PSIQ scores from the first day of clinical practice in the CBME program to graduation was Δ1.3 in 2018-2019 and Δ1.4 in 2019-2020. The effect size (Cohen’s d) for each item of the PSIQ was Δ1.4 in 2018-2019. Range for items was Δ0.8-1.1 in 2018-2019 and Δ0.9-1.2 in 2019-2020.

	Fiscal year (usually April 1 to March 31)	First day of the CBME program (1)	At graduation　(2)	Mean difference in PSIQ　(2)-(1)	t score	Df	p-value	Cohen’s d
Total score 　(Main outcome)	2018-2019 (pre-COVID-19 pandemic)	28.5±7.6	38.8±8.5	10.3±8.1	2.60	195	0.01	1.3
	2019-2020 (during-COVID-19 pandemic)	28.0±6.6	41.6±9.2	13.5±9.4				1.4
Sub-analysis
Teamwork	2018-2019	3.0±1.2	4.4±1.0	1.4±1.2	0.96	195	0.341	1.1
	2019-2020	3.0±1.1	4.6±1.1	1.6±1.3				1.2
Communication	2018-2019	3.7±1.1	4.7±1.1	1.0±1.2	1.84	195	0.068	0.8
	2019-2020	3.5±1.1	4.9±1.1	1.4±1.3				1
Conducting assessment	2018-2019	3.2±1.0	4.4±1.1	1.2±1.2	2.27	195	0.024	1
	2019-2020	3.1±1.0	4.7±1.1	1.6±1.3				1.2
Cultural awareness	2018-2019	2.9±1.1	4.2±1.3	1.3±1.3	2.31	195	0.022	1
	2019-2020	2.8±1.1	4.5±1.3	1.8±1.5				1.2
Ethics awareness	2018-2019	3.4±1.2	4.5±1.1	1.1±1.3	1.41	195	0.161	0.9
	2019-2020	3.5±1.2	4.9±1.1	1.4±1.4				1
Using record entries	2018-2019	3.4±1.0	4.5±1.1	1.0±1.1	2.25	195	0.026	0.9
	2019-2020	3.4±0.9	4.8±1.1	1.4±1.3				1.1
Dealing with emergencies	2018-2019	2.5±1.1	3.8±1.3	1.3±1.2	2.67	195	0.008	1.1
	2019-2020	2.3±1.2	4.1±1.4	1.9±1.7				1.1
Reflection	2018-2019	3.3±1.1	4.3±1.1	1.0±1.3	2.32	195	0.021	0.8
	2019-2020	3.2±0.9	4.6±1.3	1.4±1.5				1
Teaching	2018-2019	3.1±0.9	4.1±1.1	0.9±1.1	2.19	195	0. 030	0.8
	2019-2020	3.2±1.0	4.5±1.2	1.3±1.4				1

IV. DISCUSSION

We found that the means of total and each PSIQ score of medical students who graduated during the COVID-19 pandemic were statistically increased compared to those of students graduating before the pre-COVID-19 pandemic. These findings indicate that, compared with students in the preceding year, the COVID-19 pandemic had a certain positive impact on professional identity formation in medical students with regard to clinical practice.

Considering the framework we used, in which the interaction and reflection of role models, mentors, and individual experiences are key, we believe that all participants were influenced by COVID-19. In addition, professional identity formation is reported to be strongly influenced by environment, context, and other personal variables. (Jarvis-Selinger et al., 2012) The increase in total PSIQ score from the previous year’s medical students may have been due not only to changes in clinical practice, but also to changes in what is expected of medical students by the university hospital and society. In light of these factors, medical students had fewer opportunities to acquire the knowledge and skills required of physicians in the clinical setting directly from role models and mentors, but may nevertheless have been affected by compliance with COVID-19 control measures conducted by the university hospital, and thereby followed the norms of medical professionals communicated through intentional and unintentional messaging. In addition, with the all-engrossing impact of the COVID-19 pandemic throughout society, we speculate that at least some of the students in the COVID-19 group were consulted by family and social contacts as experts and authorities on a daily or more frequent basis, and that such constant reinforcement might also have encouraged PIF. That is, medical students under the COVID-19 pandemic may have internalised the values and norms of the medical professional (Kinnear et al., 2021). Since professional identity formation involves social and relational factors, it is possible that the students’ life and social changes due to COVID-19 reinforced their recognised professional identity (Goldie, 2012).

The more uncertain and ambiguous the period, the more important reflection becomes in PIF. To cope with such uncertainties as the transition from the classroom curriculum to online platforms, rapid changes in the clinical practice environment, and the isolation caused by social distancing, medical students need a well-formed professional identity and socialisation practices (Costello, 2005).  Poor PIF is reported to manifest in burnout (Abedini et al., 2018), and depression and anxiety disorders have increased in COVID-19 (Daniels et al., 2021). Since a core component of PIF is the acceptance of uncertainty and ambiguity, medical educators may have provided reflection opportunities for medical students to consciously consider the social factors manifested in COVID-19, such as individual and professional duties, resource priorities, and health disparities, all of which have a positive impact on PIF and socialisation (Stetson et al., 2020). Alternatively, emotion-focused coping strategies (e.g., arts engagement) and problem-solving strategies (e.g., volunteering) to reduce medical students’ anxiety, fear, and stress may be effective (Moula et al., 2022). Students require time and space to reflect on their emergent identity as professionals in these crisis situations (Moula et al., 2022). The extended time for independent learning may have allowed the students to subconsciously reflect on their professional identity, taking seriously the changes in society caused by COVID-19. PIF scores may have accordingly increased in this study.  

In general, medical teachers should have made efforts to promote medical students’ professional identity formation even during the COVID-19 pandemic (Goldhamer et al., 2020). Professional identity formation is not a process that should be left to chance; it should be explicitly supported through systematic support and curriculum initiatives (Cruess et al., 2015; Schumacher et al., 2012). In reality, it is necessary to require rapid changes in clinical practice to prevent infection caused by COVID-19, and it has been difficult to promote systematic support for professional identity formation for medical students. However, COVID-19 might not have negatively affected the professional identity recognised by medical students who were in clinical practice immediately after the pandemic. The efforts of Japanese medical educators to implement online and other types of learning to replace clinical practice, and the well-considered efforts of faculty to make clinical practice as feasible as possible may have served as role models or mentors, and influenced medical students’ professional identity formation.

This study has three limitations. First, because there was a difference of 8-17 months between the first day of clinical practice in the CBME program and graduation, given that more clinical practice experience may strengthen the professional identity recognised by medical students, it is possible that differences in clinical practice experience may have affected PSIQ scores. Second, extrapolation from this study should be done with care, since it is a comparison of a one-year questionnaire survey at a single university. Third, a degree of response bias may be present due to the self-reporting design, with inclusion of student ID number. Fourth, evaluation at three or more points may allow a more precise comparison of changes, given that professional identity formation is a dynamic process. Even allowing for these limitations, our findings provide meaningful feedback to medical students and faculty, particularly given the paucity of studies evaluating and comparing changes in professional identity formation – which consists of multiple factors – before and during the COVID-19 pandemic. For the future of medical education, it is imperative to track the professional identity recognised by physicians whose student experience in clinical practice was restricted under the COVID-19 pandemic, and was accordingly significantly changed compared with other years.

V. CONCLUSION

Comparison of the professional identity recognised by medical students whose experience of clinical practice was affected by the COVID-19 pandemic to that of students in the previous year showed some positive impact on professional identity. This lack of negative difference in recognised professional identity even under restricted clinical practice may have been influenced by the imprinting of professional norms and changes in society.

Notes on Contributors

JH, AT, SO, TaM and TeM were involved in the conception and design of this study. JH, AT, and TaM collected the data. JH and RG conducted data analysis. JH mainly wrote the paper. AT, SO, TaM and TeM gave critical feedback on the manuscript. All authors have read and approved the final manuscript.

Ethical Approval

This study was approved by the Ethics Committee of the University of Tsukuba’s Faculty of Medicine and Medical Sciences (No. 1329). All participants have given written consent for their data to be used in the research and for publication.

Data Availability

It is not possible to share data since we did not obtain consent from participants to share all data collected.

Acknowledgement

We thank the faculty staff members Shoji Yokoya, Hisashi Yoshimoto, Shogen Suzuki, Naoto Sakamoto, Yu Yamamoto, Yoshihiro Kataoka, Shoichi Masumoto, Haruka Kuno, Takashi Inaba, Shuhei Hamada, Shogo Kawada, and Sayaka Nin of the Department of Primary Care and Medical Education, Faculty of Medicine, University of Tsukuba. Additionally, we thank the healthcare staff who taught the medical students at the CBME program sites in clinical practice.

Funding

This study was funded by the education/research fund of Department of Primary Care and Medical Education, Faculty of Medicine, University of Tsukuba.

Declaration of Interest

There are no companies or other entities with which the authors have conflict of interest relationships that should be disclosed in relation to the content of the paper.

References

Abedini, N. C., Stack, S. W., Goodman, J. L., & Steinberg, K. P. (2018). “It’s not just time off”: A framework for understanding factors promoting recovery from burnout among internal medicine residents. Journal of Graduate Medical Education, 10(1), 26–32. https://doi.org/10.4300/JGME-D-17-00440.1

Adams, K., Hean, S., Sturgis, P., & Clark, J. M. (2006). Investigating the factors influencing professional identity of first-year health and social care students. Learning in Health and Social Care, 5(2), 55–68. https://doi.org/10.1111/j.1473-6861.2006.00119.x

Al Samaraee, A. (2020). The impact of the COVID-19 pandemic on medical education. British Journal of Hospital Medicine, 81(7), 1-4. https://doi.org/10.12968/HMED.2020.0191

Alsoghair, M., Almazyad, M., Alburaykan, T., Alsultan, A., Alnughaymishi, A., Almazyad, S., Alharbi, M., Alkassas, W., Almadud, A., & Alsuhaibani, M. (2021). Medical Students and COVID-19: Knowledge, preventive behaviors, and risk perception. International Journal of Environmental Research and Public Health, 18(2), 842. https://doi.org/10.3390/ijerph18020842

Association of American Medical Colleges. (2020). Guidance on medical students’ participation in direct in-person patient contact activities. https://www.aamc.org/system/files/2020-08/meded-August-14-Guidance-on-Medical-Students-on-Clinical-Rotations.pdf

Chiodini, J. (2020). Online learning in the time of COVID-19. Travel Medicine and Infectious Disease, 34, Article 101669. https://doi.org/10.1016/j.tmaid.2020.101669

Costello, C. Y. (2005). Professional identity crisis: Race, class, gender, and success at professional schools. Vanderbilt University Press.

Crossley, J., & Vivekananda-Schmidt, P. (2009). The development and evaluation of a professional self identity questionnaire to measure evolving professional self-identity in health and social care students. Medical Teacher, 3(12), e603–e607. https://doi.org/10.3109/01421590903193547

Cruess, R. L., Cruess, S. R., Boudreau, J. D., Snell, L., & Steinert, Y. (2014). Reframing medical education to support professional identity formation. Academic Medicine, 89(11), 1446–1451. https://doi.org/10.1097/ACM.0000000000000427

Cruess, R. L., Cruess, S. R., Boudreau, J. D., Snell, L., & Steinert, Y. (2015). A schematic representation of the professional identity formation and socialization of medical students and residents: A guide for medical educators. Academic Medicine, 90(6), 718–725. https://doi.org/10.1097/ACM.0000000000000700

Emanuel, E. J. (2020). The inevitable reimagining of medical education. JAMA, 323(12), 1127–1128. https://doi.org/10.1001/jama.2020.1227

Findyartini, A., Anggraeni, D., Mikhael Husin, J., & Greviana, N. (2020). Exploring medical students’ professional identity formation through written reflections during the COVID-19 pandemic. Journal of Public Health Research, 9(s1), 1918. https://doi.org/10.4081/jphr.2020.1918

Goldhamer, M. E. J., Pusic, M. V., Co, J. P. T., & Weinstein, D. F. (2020). Can covid catalyze an educational transformation? Competency-based advancement in a crisis. New England Journal of Medicine, 383(11), 1003–1005. https://doi.org/10.1056/NEJMP2018570

Goldie, J. (2012). The formation of professional identity in medical students: Considerations for educators. Medical Teacher, 34(9), e641–e648. https://doi.org/10.3109/0142159X.2012.687476

Hafferty, F. W., & Franks, R. (1994). The hidden curriculum, ethics teaching, and the structure of medical education. Academic Medicine, 69(11), 861–871. https://doi.org/10.1097/00001888-199411000-00001

Haruta, J., Maeno, T., Takayashiki, A., Goto, R., Ozone, S., & Maeno, T. (2021). Validation of the professional self-identity questionnaire for medical students during clinical practice in Japan. International Journal of Medical Education, 12, 160–165. https://doi.org/10.5116/ijme.610d.104b

Haruta, J., Ozone, S., & Hamano, J. (2020). Doctors’ professional identity and socialisation from medical students to staff doctors in Japan: Narrative analysis in qualitative research from a family physician perspective. BMJ Open, 10(7), e035300. https://doi.org/10.1136/bmjopen-2019-035300

Hayashi, M., Saiki, T., Kanter, S. L., & Ho, M. J. (2022). Leaders’ perspectives and actions to manage challenges in medical education presented by the COVID-19 pandemic: A nationwide survey of Japanese medical colleges. BMC Medical Education, 22(1), 144. https://doi.org/10.1186/s12909-022-03193-1

Jarvis-Selinger, S., Pratt, D. D., & Regehr, G. (2012). Competency is not enough: Integrating identity formation into the medical education discourse. Academic Medicine, 87(9), 1185–1190. https://doi.org/10.1097/ACM.0b013e3182604968

Kaul, V., Gallo de Moraes, A., Khateeb, D., Greenstein, Y., Winter, G., Chae, J. M., Stewart, N. H., Qadir, N., & Dangayach, N. S. (2021). Medical education during the COVID-19 pandemic. CHEST, 159(5), 1949–1960. https://doi.org/10.1016/j.chest.2020.12.026

Khasawneh, A. I., Humeidan, A. A., Alsulaiman, J. W., Bloukh, S., Ramadan, M., Al-Shatanawi, T. N., Awad, H. H., Hijazi, W. Y., Al-Kammash, K. R., Obeidat, N., Saleh, T., & Kheirallah, K. A. (2020). Medical students and COVID-19: Knowledge, attitudes, and precautionary measures. A descriptive study from Jordan. Frontiers in Public Health, 8, 253. https://doi.org/10.3389/fpubh.2020.00253

Kinnear, B., Zhou, C., Kinnear, B., Carraccio, C., & Schumacher, D. J. (2021). Professional identity formation during the COVID-19 pandemic. Journal of Hospital Medicine, 16(1), 44–46. https://doi.org/10.12788/jhm.3540

Lee, S., & Lee, D. K. (2018). What is the proper way to apply the multiple comparison test? Korean Journal of Anesthesiology, 71(5), 353-360. https://doi.org/10.4097/KJA.D.18.00242

Lucey, C. R., & Johnston, S. C. (2020). The transformational effects of COVID-19 on medical education. JAMA, 324(11), 1033–1034. https://doi.org/10.1001/jama.2020.14136

Mian, A., & Khan, S. (2020). Medical education during pandemics: A UK perspective. BMC Medicine, 18(1), 100. https://doi.org/10.1186/s12916-020-01577-y

Moula, Z., Horsburgh, J., Scott, K., Rozier-Hope, T., & Kumar, S. (2022). The impact of COVID-19 on professional identity formation: An international qualitative study of medical students’ reflective entries in a global creative competition. BMC Medical Education, 22(1), 545. https://doi.org/10.1186/s12909-022-03595-1

Papapanou, M., Routsi, E., Tsamakis, K., Fotis, L., Marinos, G., Lidoriki, I., Karamanou, M., Papaioannou, T. G., Tsiptsios, D., Smyrnis, N., Rizos, E., & Schizas, D. (2021). Medical education challenges and innovations during COVID-19 pandemic. Postgraduate Medical Journal, 98, 321-327. https://doi.org/10.1136/postgradmedj-2021-140032

Prime Minister’s Office of Japan. (2020). [COVID-19] Declaration of a state of emergency in response to the Novel Coronavirus Disease. https://japan.kantei.go.jp/ongoingtopics/_00020.html

Ross, D. A., & the members of National Neuroscience Curriculum Initiative “Quarantine Curriculum” Committee (2020). Creating a “Quarantine Curriculum” to enhance teaching and learning during the COVID-19 pandemic. Academic Medicine, 95(8), 1125–1126. https://doi.org/10.1097/ACM.0000000000003424

Schumacher, D. J., Slovin, S. R., Riebschleger, M. P., Englander, R., Hicks, P. J., & Carraccio, C. (2012). Perspective: Beyond counting hours: The importance of supervision, professionalism, transitions of care, and workload in residency training. Academic Medicine, 87(7), 883–888. https://doi.org/10.1097/ACM.0b013e318257d57d

Shankar, P. R., & Wilson, I. G. (2020). The COVID-19 pandemic and undergraduate medical student teaching-learning and assessment. Canadian Medical Education Journal, 12(1), e190–e191. https://doi.org/10.36834/cmej.70800

Stetson, G. V., Kryzhanovskaya, I. V., Lomen-Hoerth, C., & Hauer, K. E. (2020). Professional identity formation in disorienting times. Medical Education, 54(8), 765–766. http://doi.org/10.1111/medu.14202

Wurth, S., Sader, J., Cerutti, B., Broers, B., Nadia Bajwa, M., Carballo, S., Escher, M., Galetto-Lacour, A., Grosgurin, O., Lavallard, V., Savoldelli, G., Serratrice, J., Nendaz, M., & Audétat-Voiro, M. C. (2022). Correction to: Medical students’ perceptions and coping strategies during the first wave of the COVID-19 pandemic: Studies, clinical implication, and professional identity. BMC Medical Education, 22(1), Article 232. https://doi.org/10.1186/s12909-022-03307-9

*Junji Haruta
35 Shinanomachi Shinjukuku Tokyo
160-8582, Japan
Email: junharujp@keio.jp

Submitted: 12 May 2022
Accepted: 3 August 2022
Published online: 3 January, TAPS 2023, 8(1), 13-24
https://doi.org/10.29060/TAPS.2023-8-1/OA2810

Audrey Lim¹, Vicki Xafis² & Clare Delany³

¹Health and Social Sciences Cluster, Singapore Institute of Technology (SIT), Singapore; ²Graduate School of Humanities and Social Sciences, University of Melbourne, Melbourne, Australia; ³Department of Medical Education, School of Medicine, University of Melbourne, Melbourne, Australia

Abstract

Introduction: Workplace contexts, including political and sociocultural systems influence health professions’ perception and experience of ethical issues. Although established health ethics principles are relevant guiding values, they may be experienced and interpreted differently within different health contexts. How should ethics education account for this? This paper presents ethical dilemmas and concerns encountered by physiotherapists practicing in Singapore and discusses the implications for ethics education.

Methods: Qualitative methods informed by interpretivism and phenomenology were employed. In-depth interviews with 42 physiotherapists from different workplace settings in Singapore were conducted. Participants described everyday ethical challenges they encountered. Inductive content analysis was used to analyse the interview transcript data.

Results: Ethical issues occurred within and across three spheres of ethics:  micro, meso and macro. Ethical issues at the micro sphere centered around physiotherapist-patient relationships, interactions with colleagues, and therapists’ feelings of moral distress. In the meso sphere, ethical challenges related to influences arising from the organizational resources or systems. In the macro sphere, ethical challenges developed or were influenced by sociocultural, religious, economic, and political factors.

Conclusion: The findings reflect current literature indicating that context can influence ethical situations, as experienced and perceived by physiotherapists in their unique settings. Such empirical data might inform the development of ethics curricula to ensure that universal ethical principles are situated within the realities of clinical practice. Locally relevant and realistic ethical case studies will better enable students to recognise and address these situations.

Keywords:           Ethics, Physiotherapy, Health Professions Education, Ethics Education, Asian Context, Singapore, Healthcare Principles, Health Ethics Principles

Practice Highlights

• Context can influence the ethical situations experienced and interpreted by healthcare professionals.
• Contextualised cases studies need to be developed to make ethics real and relevant to students.
• Ethics education should incorporate local context and not focus only on ethics epistemic knowledge.
• Ethics education should incorporate the dynamic influence of macro, meso and micro factors.

I. INTRODUCTION

The established health ethics principles articulated by Beauchamp and Childress (2001): autonomy, beneficence, non-maleficence, and justice guide healthcare practice, including physiotherapy (Carpenter & Richardson, 2008; Edwards, Delany, et al., 2011). Although these principles were originally proposed as universally relevant and foundational to health ethics, health professionals interpret them differently, depending on their professional and personal background, their values, and the culture of the community and settings in which they work (Fuscaldo et al., 2013). In physiotherapy ethics scholarship, there is growing recognition that the universal nature of principlism as a supporting ethical decision-making framework, may not be a sufficient guide for physiotherapists in their ethical decision-making, because of the  plurality of values and diverse contexts of healthcare practice (Carpenter, 2010; Carpenter & Richardson, 2008; Edwards, Wickford, et al., 2011; Fryer et al., 2021; Greenfield, 2006; Hudon et al., 2019; Oyeyemi, 2011; Souri et al., 2020; Sturm et al., 2022). Consequently, there is increasing pedagogical interest in using case studies drawn from everyday practice to bring authenticity and contextual relevance to ethics education (Aguilar-Rodríguez et al., 2019; Fuscaldo et al., 2013).

In physiotherapy, empirical studies have shown that different work contexts, political and sociocultural systems have a direct influence on physiotherapists’ perception and experience of ethical issues (Delany et al., 2018; Fryer et al., 2021; Sturm et al., 2022). A recent example is the study of ethical issues physiotherapists experienced by Sturm et al. (2022). The authors reported physiotherapists working in specific countries described having to compromise their professional integrity due to overt threats and intimidation by suppressive professional organisations or leaders. They were directed to follow the societal or organisational hierarchies or risk jeopardizing their careers. Studies of ethical experiences of physiotherapists practicing in the African nations (Aderibigbe & Chima, 2019; Chigbo et al., 2015; Nyante et al., 2020; Oppong, 2019; Oyeyemi, 2011) and the Greater Middle East region (Edwards, Wickford, et al., 2011; Qamar et al., 2014; Souri et al., 2020) similarly discussed how cultural influences, such as religion or spirituality can directly affect ethical practice and decision-making. Despite increasing empirical evidence globally, the influence of cultural and societal contexts on ethical decision-making and therapists’ interpretation of health values  has not been examined in the East and Southeast Asian regions. There has also been little exploration of how societal and cultural context in which physiotherapy is practiced might be used to inform and shape curricula for ethics education.

In this paper, we present data about the ethical situations physiotherapists in Singapore encounter in their everyday clinical practice. Singapore is multi-racial, multi-religious and multi-cultural. The values of Singaporean people are very much rooted in their Asian heritage, with Confucianism as the prevailing social model (Ong, 2020; Tan, 1989; Yang et al., 2006). This research aims to contribute to knowledge about  the influence of context on clinical ethical issues and decision-making, as interpreted by physiotherapists in Singapore. The empirical data will then be used to inform subsequent ethics curricula. Identifying and analysing the factors influencing ethical issues, as they are experienced and interpreted by physiotherapists in the Singaporean context, is an important pedagogical strategy to inform the development of health ethics curricula.

II. METHODS

We used a qualitative methodology drawing on the research paradigm of phenomenology and conducted in-depth interviews. We recruited physiotherapy clinicians using purposive (Palys, 2008) and snowball sampling (Holloway & Galvin, 2016). Written and verbal consent was obtained. Semi-structured interviews were conducted by AL and ranged from 44 to 123 minutes. Audio recordings were professionally transcribed verbatim and were reviewed by AL. Content analysis was used to analyse the transcribed data, with interviewer’s written field notes as supporting reference. Data was systematically coded and categorised with the aim of identifying themes, their frequency, and relationships, through both description and interpretation (Elo & Kyngäs, 2008; Hsieh & Shannon, 2005; Lindgren et al., 2020; Vaismoradi et al., 2013). Assisted by QSR NVivo 12 Software, the data analysis was organised into five steps (Figure 1). Although illustrated as a linear, chronological sequence, analysis occurred in a non-linear, iterative manner till there was clarity and meaning in the themes that were identified.

Figure 1. Sequence of data analysis

III. RESULTS

A total of 42 physiotherapists from four settings: acute, community, specialised institutions, and private practice participated (Table 1). All participants have been practicing physiotherapists in Singapore for the past three years, with 33.3 % in geriatrics and neuro rehabilitation, 45.3% in musculoskeletal and sports, and 21.4% in cardiopulmonary and other niche specialties. Thirty-six participants are Singaporeans and six are from Malaysia, Philippines, Hong Kong, New Zealand, and the UK. Ages ranged from 27 to 54 years old.

Submitted: 26 May 2022
Accepted: 10 June 2022
Published online: 4 October, TAPS 2022, 7(4), 86-87
https://doi.org/10.29060/TAPS.2022-7-4/LE2816

Tomoko Miyoshi¹, Fumiko Okazaki², Jun Yoshino³, Satoru Yoshida⁴, Hiraku Funakoshi⁵, Takayuki Oto⁶ & Takuya Saiki⁷

¹Department of General Medicine, Kurashiki Educational Division, Graduate School of Medicine Dentistry and Pharmaceutical Sciences, Okayama University, Japan; ²Center for Medical Education, The Jikei University School of Medicine, Japan; ³Department of Physical Therapy, Faculty of Health and Medical Science, Teikyo Heisei University, Japan; ⁴Emergency and Critical Care Medical Center, Niigata City General Hospital, Japan; ⁵Department of Emergency and Critical Care Medicine Tokyobay Urayasu Ichikawa Medical Center, Japan; ⁶Department of General Dental Practices, Kagoshima University Hospital, Japan; ⁷Medical Education Development Center, Gifu University, Japan

Dear Editor,

We are delighted to report that the Japanese translated version of R2C2 (relationship, reaction, content, coaching) was published in the Journal of Medical Education in Japan, under kind permission of the author and Journal of Academic Medicine. The R2C2 model, developed by Sargeant et al. (2015), promotes behavior change through reflection and feedback, while incorporating coaching. The effectiveness and influencing factors have been demonstrated in supervisor–resident pairs in various residency programs (family medicine, psychiatry, internal medicine, surgery, and anesthesiology) in the U.S., Canada, and the Netherlands. The R2C2 model is fascinating since it emphasises the relationship and dialogue between the resident and the supervisor, and provides insights into the residents’ in-depth learning.

While we are interested in factors that influence feedback, common across different specialties and contexts, we hypothesise that national culture and health profession disciplines may affect the dialogue and impact of the R2C2 model, especially in bridging the gap between self-assessment and supervisor’s assessment.

Reports of such cultural differences demonstrate the Japanese learning more from their failures, while Westerners learning more from their successes, as well as differences in learners’ self-evaluation. In addition, Hofstede reports that the relationship between learners and teachers in East Asia, including Japan is hierarchical, and feedback is therefore likely to be one-sided. Regarding mentoring/coaching, we have revealed that Japanese physician–scientist relationships are dependent on trust in mentors, and the cultural influence of acceptance of paternalistic mentoring (Obara et al., 2021) suggests the need for building trusting relationships. Furthermore, we as multidisciplinary author teams are keen to explore how different health profession disciplines shape the different perspectives on effective feedback and supervisor–learner relationship. We expect this topic to become more apparent as modern health services are becoming more multi-professional and the discourse may develop in a multi-professional relationship.

The Japanese version has been cautiously translated and published to overcome any issue involving translation. Although we had successfully conducted the nationwide workshop on R2C2 in Gifu, Japan in 2021 to disseminate its philosophy, we realised variety of factors should affect when we conduct R2C2 in our context. Our future goal is to examine the utility of R2C2 model in cross-cultural settings as well as cross-disciplinary situations in order to generate findings that will contribute to the glocalisation of medical education and multi-disciplinary education.

Notes on Contributors

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

F Okazaki conceptualised cultural difference of R2C2 and revised and approved the manuscript.

H Funakoshi conceptualised cultural difference of R2C2 and revised and approved the manuscript.

T Oto conceptualised different health profession disciplines of R2C2 and approved the manuscript.

J Yoshino conceptualised different health profession disciplines of R2C2 and approved the manuscript.

S Yoshida conceptualised different health profession disciplines of R2C2 and approved the manuscript.

Prof T Saiki supervised and edited the manuscript.

Acknowledgement

We would like to acknowledge Rintaro Imafuku, Kaho Hayakawa, Chihiro Kawakami in Gifu University Medical Education Development Center, for writing and editing the Japanese translated version of R2C2 collaboratively.

Funding

There is no funding provided.

Declaration of Interest

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

References

Obara H, Saiki T, Imafuku R, Fujisaki K, & Suzuki Y. (2021). Influence of national culture on mentoring relationship: a qualitative study of Japanese physician-scientists. BMC Medical Education, 21, 300. https://doi.org/10.1186/s12909-021-02744-2

Sargeant J, Lockyer J, Mann K, Holmboe E, Silver I, Armson H, Driessen E, MacLeod T, Yen W, Ross K, & Power M. (2015). Facilitated Reflective Performance Feedback: Developing an Evidence- and Theory-Based Model That Builds Relationship, Explores Reactions and Content, and Coaches for Performance Change (R2C2). Academic Medicine, 90(12), 1698-1706. https://doi.org/10.1097/ ACM.0000000000000809

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

Submitted: 9 May 2022
Accepted: 3 August 2022
Published online: 4 October, TAPS 2022, 7(4), 83-85
https://doi.org/10.29060/TAPS.2022-7-4/CS2808

Chi Sum Chong¹ & Woei Yun Siow²

¹Yong Loo Lin School of Medicine, National University of Singapore, Singapore, ²Raffles Hospital, Singapore

I. INTRODUCTION

The AO foundation aims to improve patient outcomes in the surgical treatment of trauma and musculoskeletal disorders and promote education and research. Yearly, approximately 30,000 Orthopaedics surgeons worldwide attend AO foundation courses. To ensure that the planned curriculum is delivered, the AO foundation requires its surgeon-faculty to attend the Faculty Education Program (FEP) before teaching at regional and international courses.

FEP participants are AO member-surgeons who are actively teaching within their own countries. They are selected by their local AO committees and invited to attend. Every participant is encouraged to teach at regional and international courses thereafter.

II. METHODS

Course structure:

• Five weeks of online learning

This includes a self-assessment. Thereafter, participants learn through reading assignments, case studies and peer discussion at their own pace. These provide a problem-based and collaborative approach to learning. Most participants experience the same planned curriculum. Participants from locations with poor internet signals require a modified delivery of the curriculum e.g. email and hard copies.

• One-and-a-half days of live event

This begins with a group discussion to derive the core principles of effective learning from one’s learning experiences. This is followed by an “introduction to the Pendleton method of giving and receiving feedback”. Thereafter, each participant presents a lecture, conducts a small group discussion and demonstrates teaching of a practical session through role playing. For each activity, each participant receives feedback from the other participants and the faculty (Benton & Young, 2018). The event concludes with feedback to evaluate the course. Face-to-face learning activities are contextual and allow for learning of knowledge and skills of teaching strategies in a collaborative fashion. The online and face-to-face curriculum follow the SPICES model and align with the learning outcomes (Harden et al., 1984).

• One week of online follow-up with a post-course self-assessment.

The learning outcomes are:

• Prepare and present a lecture
• Moderate a small group discussion
• Instruct in practical exercises
• Receive and give feedback
• Evaluate one’s own teaching
• Work with outcomes in teaching strategies
• Set expectations of a teaching or learning activity
• Use information about learners e.g. learners’ needs and cultural context in the educational process
• Motivate learners
• Encourage interaction among learners

The outcomes encompass knowledge and skills in teaching and awareness of best practice guidelines in teaching strategies i.e. attitudinal domain. They are specific, relevant and timely for the participants who are young surgeons interested in teaching (Harden et al., 1999).

Some outcomes are easily measurable e.g. prepare and present a lecture, moderate a small group discussion, instruct in practical exercises and receive and give feedback. Participant performance is measured against a set of guidelines (Kogan et al., 2009). Some outcomes are embedded within the learning activities e.g. set outcomes and expectations in learning activities, motivate learners and encourage interaction among learners and evaluate one’s own performance.  Some outcomes are not easily measurable e.g. using learner information to plan learning activities. Overall, Kirkpatrick’s level three achievement is met in most outcomes.

For outcomes that cannot be easily measured during the course, longitudinal assessment of the participants will allow these outcomes to be measured i.e. when they teach at future AO courses after the FEP. Thus, entrustable professional activities from the FEP are aligned with the course outcomes (Shorey et al., 2019).

Feedback was gathered from participants attending the FEP courses where the author Siow was one of the faculty. All participants verbally consented to give feedback. A total of 103 participants attended six FEP courses between 2016 to 2019. The response rate was 100%. Achievement of course outcomes was measured using three categories ranging from “not achieved” to “fully achieved”. Faculty effectiveness, content relevance and overall course impact were assessed using five categories ranging from “not at all effective” to “very effective”.

According to the Canton Zurich Ethical commission, this study does not require an authorisation from the ethics committee (BASEC-Nr. Req-2022-00536).

III. RESULTS

Eighty percent or more of graduates agreed that the following outcomes were fully achieved: prepare and present a lecture, moderate a small group discussion, instruct in practical exercise, encourage interaction, work with outcomes in teaching strategies, set expectations and evaluate one’s own teaching.

Seventy-five to seventy-eight percent of graduates agreed that the following outcomes were fully achieved: motivate learners, receive and give feedback and manage time and logistics.

Sixty-six percent of graduates agreed that the following outcome was fully achieved: using learner’s information in the educational process.

Ninety-five to ninety-eight percent of graduates agreed that the faculty, the course content and the overall course impact were very effective.

IV. DISCUSSION

A large majority of the participants were able to fully achieve these outcomes: prepare and present a lecture, moderate a small group discussion, instruct in practical exercise, encourage interaction, work with outcomes in teaching strategies, set expectations and evaluate one’s own teaching. This is likely because these outcomes are more familiar to the participants.

Seventy-five to seventy-eight percent of graduates agreed that the following outcomes were fully achieved: motivate learners, receive and give feedback and manage time and logistics. The achievement rate for this group of outcomes is slightly lower than the previous group of outcomes possibly because these outcomes are less familiar to the participants. Furthermore, the AO method of giving and receiving feedback presents a new concept and practice to many participants.

Sixty-six percent of graduates agreed that the following outcome was fully achieved: using learner’s information in the educational process. One reason for this lower score may be because the application of this outcome was not specifically highlighted and explained to the participants. This outcome was strictly adhered to and applied in the planning and the execution of the very FEP course attended by the participants, but the manner in which participant’s information was used to do so was not clearly explained to the participants themselves.

V. CONCLUSION

The FEP is a rare opportunity for surgeon-educators to learn about scholarly teaching. Feedback from the courses support the continuation of these courses to help faculty improve their teaching skills.

Notes on Contributors

Chi Sum Chong reviewed the literature, performed data analysis and developed the manuscript. Woei Yun Siow reviewed the literature, designed the study, performed the data collection and wrote the manuscript. All authors read and approved the final manuscript.

Funding

This work has not received any external funding.

Declaration of Interest

All authors declare that there are no conflicts of interest.

References

Benton, S. L., & Young, S. (2018). Best practices in the evaluation of teaching. IDEA paper No. 69.

Harden, R. M., Crosby, J. R., & Davis, M. H. (1999). AMEE Guide No. 14: Outcome-based education: Part 1-An introduction to outcome-based education. Medical Teacher, 21(1), 7-14. https://doi.org/10.1080/01421599979969

Harden, R. M., Sowden, S., & Dunn, W. R. (1984). Educational strategies in curriculum development: The SPICES model. Medical Education, 18(4), 284-297.

Kogan, J. R., Holmboe, E. S., & Hauer, K. E. (2009). Tools for direct observation and assessment of clinical skills of medical trainees. A systematic review. Journal of the American Medical Association, 302(12), 1316-1326.

Shorey, S., Lau, T. C., Lau, S. T., & Ang, E. (2019). Entrustable professional activities in health care education: A scoping review. Medical Education, 53(8), 766-777.

*Woei Yun Siow
Raffles Hospital,
585 North Bridge Road,
Singapore 188770
Email: siowwoeiyun@gmail.com

Submitted: 14 April 2022
Accepted: 3 August 2022
Published online: 4 October, TAPS 2022, 7(4), 76-82
https://doi.org/10.29060/TAPS.2022-7-4/CS2780

Eusni RM Tohit¹, Fauzah A Ghani¹, Hizmawati Madzin³, Intan N Samsudin¹, Subashini C Thambiah¹, Siti Z Zakariah² & Zainina Seman¹

¹Department of Pathology, Faculty of Medicine & Health Sciences, Universiti Putra Malaysia, Malaysia; ²Department of Medical Microbiology, Faculty of Medicine & Health Sciences, Universiti Putra Malaysia, Malaysia; ³Department of Multimedia, Faculty of Computer Science & Information Technology, Universiti Putra Malaysia, Malaysia

I. INTRODUCTION

Twenty first century learning requires analytical thinking and problem solving; hence, medical educators must design suitable model to prepare learners for challenges in future. Medical teaching and learning are moving towards this direction and use of technology in education is embedded in the process. The role of laboratory testing in patients care is recognised as a critical component of modern medical care (Smith et al., 2010). Ability of practicing physicians to appropriately order and interpret laboratory tests is declining and little attention was given to appropriate medical student education in pathology (Smith et al., 2010).

Clinical Pathology (CP) is a module recently introduced in our medical programme. In depth learning of pathology requires learners to identify appropriate tests and specimen containers, interpret patients’ results with consideration of other factors that may influence them.

Design thinking skills (DTS) is a guided process of thinking where learners’ work in a team and work through to identify problems (patient case), analyse through collaborative learning, provide justification for investigation, interpretation of results, and outline relevant effective management. Experiential learning emphasises the central role of the learners in the educational process by allowing the learner to draw own conclusions and ruminate on meaning of the learned material (Clem et al., 2014). Blending DTS and experiential learning creates a holistic approach to the learning of CP.

II. METHODS

A pilot study was executed amongst year 3 medical students in the Faculty of Medicine and Health Sciences, University Putra Malaysia, Serdang, Selangor, Malaysia. The study was approved by Ethics Committee for Research Involving Human Subjects, Universiti Putra Malaysia, (JKEUPM-2019-387). It was conducted over a span of two months outside students’ formal teaching and learning. Inclusion criteria include students who in clinical years and never been expose to Clinical Pathology module. Students were divided into small groups of either 4 or 5 students, and all were equipped with the CP app (Appendix 1) in Android smartphone together with DTS task book. Each group had a clinical pathologist facilitating the four hybrid sessions (physical and online) due to the global pandemic. In brief, phases involved introduction to CP (empathy), case findings (define), laboratory workup (ideation), results interpretation (solution), case approach (prototype), critical analysis (reflection and post-mortem). [Details in Appendix 2]. These were then presented in the final phase of DTS in a simulated grand ward round. Learners went through pre and post-test in CP and were asked to evaluate their experiences using a modified 28 items questionnaire (Appendix 3) using Likert scale score; adapted from a validated experiential learning questionnaire (Clem et al., 2014).

III. RESULTS

Twenty students from Medicine and Surgery posting participated in this pilot study, conducted from 27^th April 2021 to 26^th June 2021. In general, students were very satisfied with the experiential learning project. Responses of experiential learning and score marks were tabulated in Table 1. The 28 items were divided into 4 subheadings; as for the type of environment used, 66% agreed to the hybrid approach used in running of the project. Seventy-five percent agreed on the active participation in different phases of DTS. Eighty-six percent agreed with the relevance of the content of CP in their teaching and learning towards being a medical professional. Over two third of respondents agreed on utility of the CP learning experience be adapted in their future learning. As per for students’ performance (n=20) in pre and post-test OSCE in pathology, students scored significantly higher mark in all items evaluated as seen in Table 1.

Encouraging responses were recorded from some of the respondents as stated below:

“I enjoyed it very much. I received a lot of clarity on how important clinical pathology is after the session. Even after all these sessions, I even read again and again the clinical pathology notes that I have. I feel I can slowly relate my prior knowledge when it comes to clinical.”

Respondent 1

 

“In my opinion, I think this research project has given me a lot of benefits such as I can know how to correctly fill in the form to order the lab investigation, understand how to choose the correct tube for each lab investigation. I like this project very much as it can help me in this medical field”

Respondent 2

 

“I am grateful for being part of this research since I learnt a lot from the sessions. I have learnt about the type of lab investigations and blood tube, the sequence of taking blood as well as the phlebotomy techniques from the sessions which may help me in my future medical career.”

Respondent 3

Subheading I	Agree (%)	Neutral (%)		Disagree (%)
On the environment of Clinical Pathology used in the experiential learning	66	15		19
On the active participation and learning of Clinical Pathology	75	14		11
On the relevance of the content of Clinical Pathology module	86	3		11
On the utility of Clinical Pathology experience in future learning	68	3		29
Subheading II	Pre-test (/5)		Post-test (/5)
Correct selection of specimen container	0.6		3.5
Correct order of blood draw	2.5		4.0
Correct preanalytical variables identified	0.3		3.0
Relevant information in the laboratory form	2.3		4.0
Interpretation of laboratory tests	3.5		4.5

Table 1. Responses to the questionnaire, pre and post-test score for OSCE in Clinical Pathology

IV. DISCUSSION

The pilot study conducted has shown to be beneficial for the clinical students who participated in the research.

Using Kirkpatrick model (Kirkpatrick & Kirkpatrick, 2021), students in this pilot study achieved level 2 of the model outcome. As Clinical Pathology is a new subject in the amended curriculum, ‘sensitising’ the students to the importance of Clinical Pathology (CP) is achieved.

Small group teaching practised in this pilot study is in line with other schools who used small group teaching which resulted in close relationship between students & facilitator (Smith et al., 2010). The CP app provided self-directed learning on information about laboratory tests which able to improve students’ performance (Smith et al., 2010). When students worked through their own clinical case, this create inquisitive learners as they were able to do clinical correlation with the laboratory findings of their patients.

Disagreement showed by some of the students’ implied the need to improve implementation and running of the project. Students’ learning preferences varies from visual, aural, reading, and kinaesthetic (VARK) and a suitable approach need to be designed to suit spectrum of students.

Post-test OSCE scores showed improvement in common pathology knowledge required from students. This general knowledge will assist them in other clinical postings in future. CP app provided earlier will be useful as self-directed learning. However, there’s still challenges in developing a standardised approach to assessing students’ knowledge and skills in this area (Smith et al., 2010) which is an avenue for future research.

V. CONCLUSION

Students developed more confidence in CP which is useful for future learning experience in other disciplines and future career.

Notes on Contributors

ERT designed the research, developed the CP app storyboard, created the DTS task book, analysed the results, wrote the manuscript. HM developed the CP application, edited the manuscript. FAG, INS, SCT, SZZ, ZS revised the protocol, CP app story board, DTS task book, facilitated the project, edited the manuscript.

Acknowledgement

The authors would like to acknowledge Sufi Firdaus and Rubhan AL Chandran on technical help in assisting the development of CP application and DTS task book.

Funding

This work was supported by Geran Inovasi Pengajaran Pembelajaran2018 /Universiti Putra Malaysia/ Centre of Academic Development (800-2/2/15).

Declaration of Interest

All authors declared there is no conflict of interest, including financial, consultant, institutional and other relationships that might lead to bias or a conflict of interest.

References

Clem, J. M., Mennicke, A. M., & Beasley, C. (2014). Development and validation of the experiential learning survey. Journal of Social Work Education, 50, 490-506. https://doi.org/10.1080/1043 7797.2014.917900

Kirkpatrick, J., & Kirkpatrick, W. K. (2021). Introduction to the New World Kirkpatrick model. Kirkpatrick Partners. Retrieved June 7, 2022, from https://www.kirkpatrickpartners.com/wp-content/uploads/2021/11/Introduction-to-the-Kirkpatrick-New-World-Model.pdf

Smith, B. R., Aguero-Rosenfeld, M., Anastasi, J., Baron, B., Berg, A., Bock, J. L., Campbell, S., Crookston, K. P., Fitzgerald, R., Fung, M., Haspel, R., Howe, J. G., Jhang, J., Kamoun, M., Koethe, S., Krasowski, M. D., Landry, M. L., Marques, M. B., Rinder, H. M., . . . Wu, Y. (2010). Educating medical students in laboratory medicine: A proposed curriculum. American Journal of Clinical Pathology, 133(4), 533–542. https://doi.org/10.1309/AJCPQCT9 4S FERLNI

*Eusni Rahayu binti Mohd.Tohit
Department of Pathology,
Faculty of Medicine & Health Sciences,
University Putra Malaysia,
43400 Serdang, Selangor
+60397692379
Email: eusni@upm.edu.my

Submitted: 11 March 2022
Accepted: 10 June 2022
Published online: 4 October, TAPS 2022, 7(4), 73-75
https://doi.org/10.29060/TAPS.2022-7-4/CS2783

Kiyotaka Yasui, Maham Stanyon, Yoko Moroi, Shuntaro Aoki, Megumi Yasuda, Koji Otani & Yayoi Shikama

Centre for Medical Education and Career Development, Fukushima Medical University, Fukushima, Japan

I. INTRODUCTION

Educational strategies that are effective in one culture may not elicit the expected response when transferred across cultures. For instance, discussion-based learning methods such as problem-based learning, which were developed in Western contexts to foster self-directed lifelong learning (Franbach et al., 2019), are not easy for Asian students to adapt to. The quietness of Asian students, noted in multi-national contexts, is not always due to linguistic or cultural literacy barriers (Remedios et al., 2008) and requires contextual deconstruction to enable effective solution generation. In a Japanese context, we have observed how quietness manifests through insufficient question generation and a lack of spontaneous opinion expression in class. Such attitudes may be interpreted by western standards as lacking initiative and critical thinking (Tavakol & Dennick, 2010) but are in line with Japanese social norms and traditional views of learning. Because effective learning through discussion requires cognitive conflict to facilitate conceptual transformation (De Grave et al., 1996), it is necessary to ease the psychological burden experienced by our students when deviating from inherited cultural habits so that they can comfortably express opinions to embrace such conflicts. In this case study we share how we created a supportive environment to enable Japanese medical students to embrace this behavioural change.

Through our understanding of Japanese cultural norms, we hypothesised that student quietness could be attributed to the following: 1) belief that their question is insignificant and a desire not to impose on the time of others; 2) reluctance to express different opinions which might cause conflict; and 3) risk aversion to making incorrect statements. Reasons 1) and 2) reflect Japanese social norms requiring people to always act with consideration for others, while 3) is related to a Confucian-affected traditional view of learning that values humility for one’s imperfection as a driving force to self-cultivation which potentially reinforces embarrassment when giving incorrect statements. We aimed to address the above points by introducing environmental changes to boost student confidence in the significance of their questions and minimise the psychological burden of expressing their opinions during a class on ethical dilemmas.

II. METHODS

The class was undertaken by 256 first-year medical students at Fukushima Medical University in 2018 and 2019, as shown in Figure 1.

Figure 1. Flow diagram explaining the class: The closed circles represent the presenting group members and their interaction with the rest of the class (open circles) during the discussion and plenary session

A. Building Student Confidence

To minimise the risk aversion and associated anxiety of voicing incorrect opinions, we tasked students to reflect on ethical dilemmas with no clear answer, that they encountered during a 3-day placement in local nursing homes which was presented in groups of 5-6 to the rest of the class. Through removing the expectation of a right answer from the start, we created an atmosphere where students felt comfortable in generating multiple questions rather than being focused on reaching a single ‘correct’ answer.

B. A Conducive Environment for Cognitive Conflict

To break down the barriers of students seeking conformity and agreement during their presentations, we refocused the objective of the session onto the reasoning process of how they considered their ethical dilemma. This reframing supported students to embrace conflicting perspectives without worrying about achieving a consensus.

C. Nurturing a Diversity of Opinions

To facilitate the voicing of minority opinions, we harnessed a positive psychological trait in Japanese culture where pleasure is felt in acting as a collective. Therefore, when opinions were presented to the class, the entire group embraced ownership of the discussion, allowing the individuals who raised the points to remain anonymous. This reduced the potential for personal conflict and allowed diverse opinions to be aired without a loss of face.

At the end of the class, students were asked to evaluate the class using a 4-point Likert scale (good, fairly good, not so good, not good) and to write a reflection on the experience in one to two lines.

III. RESULTS

Out of the 245 students who submitted ratings, 89.9% evaluated the course as “good” or “fairly good”. About half mentioned their surprise at the diversity of opinions and their satisfaction with hearing them, acknowledging that hearing the different perspectives deepened their thoughts, broadened their perspectives, and created new ideas. Satisfaction with being able to express one’s thoughts was stated by a small number of students. Some of the students who chose “not so good” or “not good” pointed out that discussion was tough and required getting used to.

IV. DISCUSSION

When adopting a teaching method developed in a different culture, it should be delivered in the context of one’s own culture to optimise student learning. Once given a supportive environment, Japanese students, previously more content to listen than to actively contribute to discussions, exchanged their ideas and positively encountered cognitive conflict, rather than suffer from low confidence and an aversion to personal conflict. This demonstrates their potential to assimilate different perspectives and advance their thinking, akin to undergoing conceptual transformation. Through this work, we show that the standardisation of teaching methods does not equate to the globalisation of education, but how teaching must be adapted with clear implementation strategies and outcome definition, grounded in the culture to which the learners belong.

V. CONCLUSION

Generalising our adaptations outside of a Japanese context is limited, because of the cultural diversity within Asian countries that brings different challenges to discussion-based learning methods. However, vast numbers of students migrate across cultures in higher education and healthcare training. For universities and clinical training institutions with international students, understanding the barriers and supporting ‘quiet’ students to learn effectively through discussion alongside inherited cultural norms is a priority. This study aids in this understanding by providing an example from a Japanese medical undergraduate context.

Notes on Contributors

Kiyotaka Yasui designed and conducted the course, analysed the student reflections and wrote the manuscript.

Maham Stanyon analysed student reflctions and wrote the manuscript.

Yoko Mori conducted the course facilitation and supported the contextualisation of the results and discussion.

Shuntaro Aoki conducted the course facilitation and supported the contextualisation of the results and discussion.

Megumi Yasuda conducted the course facilitation and supported the contextualisation of the results and discussion.

Koji Otani conducted the course facilitation and supported the contextualisation of the results and discussion.

Yayoi Shikama planned and conducted the course as a course supervisor, analysed the student course ratings and reflections, and wrote the manuscript.

Acknowledgement

The authors would like to thank Dr. Rintaro Imafuku (Gifu University, Gifu, Japan) for constructive advice given during the medical education and research mentoring program sponsored by the Japan Society of Medical Education and Oliver Stanyon for editing a draft of this manuscript.

Funding

This study did not receive any funding.

Declaration of Interest

The authors have no conflict of interest to declare.

References

De Grave, W. S., Boshuizen, H. P. A., & Schmidt, H. G. (1996). Problem based learning: Cognitive and metacognitive processes during problem analysis. Instructional Science, 24, 321-341. http://doi.org/10.1007/BF00118111

Franbach, J. M., Talaat, W., Wasenitz, S., & Martimianakis, M. A. (2019). The case for plural PBL: An analysis dominant and marginalized perspectives in the globalization of problem-based learning. Advances in Health Sciences Education, 24, 931-942. http://doi.org/10.1007/s10459-019-09930-4

Remedios, L., Clarke, D., & Hawthorne, L. (2008). The silent participant in small group collaborative learning contexts. Active Learning in Higher Education 9(3), 201-216. http://doi.org/10.1177/1469787408095846

Tavakol, M., & Dennick, R. (2010). Are Asian international medical students just rote learners? Advances in Health Sciences Education, 15, 369-377. http://doi.org/10.1007/s10459-009-9203-1

*Kiotaka Yasui
1 Hikarigaoka,
Fukushima 960-1295,
Japan
Email: taka-y@fmu.ac.jp

Submitted: 23 November 2021
Accepted: 10 May 2022
Published online: 4 October, TAPS 2022, 7(4), 59-70
https://doi.org/10.29060/TAPS.2022-7-4/OA2714

Deepthi Edussuriya¹, Sriyani Perera², Kosala Marambe³, Yomal Wijesiriwardena¹ & Kasun Ekanayake¹

¹Department of Forensic Medicine, Faculty of Medicine, University of Peradeniya, Sri Lanka; ²Medical Library, University of Peradeniya, Sri Lanka; ³Department of Medical Education, Faculty of Medicine, University of Peradeniya, Sri Lanka

Abstract

Introduction: Emotional Intelligence (EI) is especially important for medical undergraduates due to the long undergraduate period and relatively high demands of the medical course. Determining associates of EI would not only enable identification of those who are most suited for the discipline of medicine but would also help in designing training strategies to target specific groups. However, there is diversity of opinion regarding the associates of EI in medical students. Aim of the study was to determine associates of EI in medical students.

Methods: The databases MEDLINE, CENTRAL, Scopus, EbscoHost, LILAC, IMSEAR and three others were searched. It was followed by hand-searching, cited/citing references and searching through PQDT. All studies on the phenomenon of EI and/or its associates with medical students as participants were retrieved. Studies from all continents of the world, published in English were selected. They were assessed for quality using Q-SSP checklist followed by narrative synthesis on selected studies.

Results: Seven hundred and ninety-two articles were identified of which 29 met inclusion criteria. One article was excluded as its full text was not available. Seven articles found an association between ‘EI and academic performance’, 11 identified an association between ‘EI and mental health’, 11 found an association between ‘EI and Gender’, 6 identified an association between ‘EI and Empathy’ while two have found an association with the learning environment.

Conclusion: Higher EI is associated with better academic performance, better mental health, happiness, learning environment, good sleep quality and less fatigue, female gender and greater empathy.

Keywords:           Emotional Intelligence, Associates of Emotional Intelligence, Medical Students, Mental Wellbeing, Empathy

Practice Highlights

• Higher emotional intelligence is associated with better academic performance.
• Higher emotional intelligence is associated with better mental health.
• Higher emotional intelligence is associated with female gender.
• Higher emotional intelligence is associated with greater empathy.

I. INTRODUCTION

Emotional intelligence (EI) is defined as “the ability to perceive emotions accurately, appraise, and express emotion; the ability to assess and/or generate feelings when they facilitate thought; ability to understand emotions and emotional knowledge, and to regulate emotions to promote emotional and intellectual growth” (Mayer & Salovey, 1997). Studies have found that there is a positive effect between EI and academic as well as professional success (Suleman et al., 2019).  It has been reported that people and college students with good EI show better social functioning and interpersonal relationship and peers have identified them as less antagonistic and conflictual (Petrovici & Dobrescu, 2014).

Several tests and instruments that have been used to assess the Emotional intelligence of medical students were identified through the literature. These include standard EI tests, modified versions of standard EI tests, and authors’ assessment methods of their own. Schutte self-report EI test, TEIQue questionnaire and Bar-on’s emotional intelligence questionnaire ((EQ-i) 2.0) have been used frequently. Each of these instruments has different advantages and disadvantages of their own.

The Emotional Quotient Inventory (EQ-i) 2.0 is a revision of the EQ-I (Bar-On, 2004). The Emotional Quotient Inventory (EQ-I) 2.0 measures the interaction between an individual and their environment. Since the EQ-i 2.0 is a revision of the original Emotional Quotient Inventory (EQ-I) the standard platform of the EQ-i validation remains intact.

The Schutte Self-Report Emotional Intelligence Test (SSEIT) is a method of measuring general Emotional Intelligence (EI), using four sub-scales: emotion perception, utilising emotions, managing self- relevant emotions, and managing others’ emotions (Schutte et al., 1998). The SSEIT model is closely associated with the EQ-I model of Emotional Intelligence. It has a reliability rating of 0.90. The EI score, overall, is fairly reliable for adults and adolescents. However, the utilising emotions sub-scale has shown poor reliability (Ciarrochi et al., 2001).  Also, they report a mediocre correlation of the SSREI with self-estimated EI, the Big Five EI scale, and life satisfaction (Petrides & Furnham, 2000).  However, SSREI correlated poorly with well-being and EI criteria.

The Trait Emotional Intelligence Questionnaire (TEIQue), is an openly accessible instrument developed to measure global trait emotional intelligence. Based on the Trait Emotional Intelligence Theory, a significant number of research has been conducted regarding emotional intelligence (EI) (Mikolajczak et al., 2007). The TEIQue is available in long form and short forms. Internal consistency and test-retest both indicated scale reliabilities of 0.71 and 0.76. High correlations between the TEIQue with Shrink’s Emotional Intelligence Scale showed validity in measuring emotional intelligence and the “Big Five” Personality Traits.

Apart from those assessment methods, Genos Emotional Intelligence Assessment, Mayer-Salovey-Caruso Emotional Intelligence Test, TMMS-24 data and DASS-21 scale, Bradbury-Graves’s Emotional Intelligence and Siberia Schering’s Emotional Intelligence Questionnaire have also been used by the authors to assess the EI.

A comprehensive survey in medicine states that EI had a positive contribution in doctor-patient relationship, increased empathy, teamwork, communication skills, stress management, organisational commitment and leadership (Arora et al., 2010). EI is invariably important to medical professionals as it is associated with self-monitoring which would not only ensure adapting to clinical situations appropriately and having desirable interpersonal relations but also result in a favorable outcome for the patient and the wellbeing of the practitioner.

Few studies suggest that EI training can help medical students to build their leadership and empathy skills, as they enter the clinical years (Austin et al., 2005; Dolev et al., 2019). Literature surveys on emotional intelligence and medicine, and physician leadership qualities concludes that EI correlates with many of the competencies that modern medical curricula seek to deliver including leadership (Mintz & Stoller, 2014; Reshetnikov et al., 2020). Other studies indicate that age and gender are associated with emotional intelligence. However, some studies showed that EI at medical school admission could not reliably predict academic success in later years (Reshetnikov et al., 2020). These studies have all looked at the associates in an isolated sense. However, it would also be interesting to reflect on the concept of EI in a broader sense as it is inevitable that there would be an interaction of factors.

The medical course extends over a period of five years as opposed to most undergraduate degrees which are shorter. Medical training involves close interactions with different categories of people including patients, doctors of different grades and the paramedical staff. Training includes long hours of work in stressful environments where some situations could be emotionally challenging. This long undergraduate period and relatively high demands of the medical course would require medical students to possess a high degree of EI. As findings of different studies on EI are sometimes diverse in opinion, it would be useful to conduct a systematic review to identify the associates of EI in order to design training strategies which target specific groups.

Even though EI is considered a trainable trait, the extent of trainability depends on many personal and institutional factors (Mattingly & Kraiger, 2019). Völker (2020) expresses that trainability in emotional intelligence is subjected to acquired knowledge which is situational and may depend on accumulating relevant experience.

In the Sri Lankan context, the sole criteria for selection of students to a medical course is the academic excellence at the Advanced level examination, which alone may not reflect their suitability to follow a profession like medicine (University Grants Commission, 2022).

However, since EI is an essential trait especially for medical practice many universities worldwide use different tools to assess EI in their applicants. Furthermore, different universities adopt varying techniques to develop EI of their students throughout the course. It is envisaged that this review would not only help determine what additional factors could be considered in the selection of applicants for a medical course but would also help teachers design training strategies to target specific groups of students and also ensure a more enjoyable and productive learning experience for the students as a whole. There is no doubt that these selection and intervention programs would produce doctors with more favourable qualities which would not only produce greater benefits to the patient but would prevent burn out among doctors.

A. Objective

The objective of this study is to find out, the associates of Emotional Intelligence in Medical students based on available literature in English from 2015 to 2020.

II. MATERIALS AND METHODS

The research question was defined based on the PICOS (Population, Intervention, Comparison, Outcomes and Setting) format. The review protocol was developed according to PRISMA-P 2015 (Preferred reporting items for systematic review and meta-analysis protocols) statement (Moher et al. 2015) by all three authors DE, KM and SP and was registered in the PROSPERO Registry (CRD42021227877). The methodology for the systematic review (SR) followed the guidelines and standards of IOM (Institute of Medicine) (Eden et al., 2011) and PRISMA-2015 for reporting.

A. Search Strategy

A Systematic and comprehensive search was conducted by SP in April 2020 and references were managed using the software Mendeley. The search explicitly aimed to identify all published and unpublished relevant studies in order to limit bias in the searching process.  The key search terms were identified with the aid of a search-term-harvesting table by KM and DE. A combination of relevant medical subject headings and search terms tagged with other appropriate search fields were used in the literature search. The following databases were searched:

CDSR (Cochrane Database of Systematic Reviews), DARE (The Database of Abstracts of Reviews of Effects), MEDLINE (1950- 2020) via Pubmed (See supplemental Appendix 1 for search strategy), CENTRAL (The Cochrane Central Register of Controlled Trials, 1948 – 2020), Scopus, EbscoHost, LILAC, IMSEAR (Index Medicus for South East Asian region) and WHO International Clinical Trials Registry Platform (ICTRP). In addition to electronic searches, two key journals (2015-2020) were hand-searched, and cited & citing references of all included studies were screened for further relevant articles. Searches were limited to studies published between the years 2015-2020. Searching other resources included grey literature such as PQDT (ProQuest Dissertations and Thesis database) and Global health (via WHO).

B. Selection Criteria

After removal of duplicates from the retrieved articles, the remaining articles with abstracts were uploaded to the Web application, Rayyan (Quzzani et al., 2016) for the purpose of screening. The criteria for selection of articles were based on the PICOS elements. The studies were from all continents of the world and limited to those published in English. All studies focusing on the phenomenon of EI and/or its associates with medical students as participants were considered for inclusion in the review.

The authors DE, KM, SP and KE independently screened the uploaded articles in Rayyan, using the above eligibility criteria. In the first phase, title and abstract of each article were reviewed by any of the two authors independently for its candidacy.  Following this initial evaluation, the full text of all those selected articles were retrieved and further examined by KM and DE independently (second phase), for the final verification before inclusion in the review. Any disagreements regarding eligibility of studies were resolved by consulting a third author (SP). Reviews, systematic reviews, editorials, letters and comments were removed.  Articles which met the eligibility criteria were selected for inclusion in the review. Excluded studies were marked with the ‘reason’ in Rayyan.

C. Data Extraction and Quality Assessment

Data from all included studies were extracted by the review authors YW and KM using a data extraction table developed for the purpose of this review (Appendix 2). Data extracted were cross-checked by SP for any errors. Information recorded included: study details (author, year, country of origin), participants (number of participants, gender, level of undergrad program, etc.), methods (study aim, design, total study duration, tools used), study type (phenomenon /context studied) and outcomes (all relevant findings related to primary and secondary outcomes).

SP and YW independently assessed the quality of those selected studies using Quality Assessment Checklist for Survey Studies in Psychology (Q-SSP) (Protogerou & Hagger, 2020) Results of the quality assessments were compared (Appendix 3); any disagreements were resolved by consensus. Articles which met the required quality criteria were selected for inclusion in the review.

D. Strategy for Data Synthesis

Due to the heterogeneity between the included studies, a quantitative synthesis was not considered. A narrative synthesis of the findings from individual included studies was carried out by DE, based on the characteristics of the targeted populations and the type of outcome such as association/correlation of EI with academic performance, professional success, social functioning, interpersonal relationship, empathy, teamwork spirit, communication skills, stress management, organizational commitment, leadership quality, self-monitoring, mental health and emotional well-being.

III. RESULTS

A total of 792 articles were retrieved during the literature search. After removing the duplicates, 752 articles were considered for screening using the eligibility criteria. Initial evaluation of articles through title and abstract resulted in only 29 articles meeting the selection criteria. During the full-text evaluation, one article (Parijitham, 2018) was removed, as its full-text article could not be found even after contacting the author. The data that support the findings of this study are openly available at https://doi.org/10.6084/m9.figshare.15564210 (Edussuriya et al., 2021). Twenty-eight articles were finally selected for quality assessment. Flow diagram of the selection of studies is shown in Figure 1.

Figure 1. Flow diagram illustrating included and excluded studies in the systematic review

The study design of the selected studies comprised of 26 cross sectional (majority), one longitudinal and one quasi-experimental. However, all studies used standard validated survey questionnaires to collect data. Therefore, to assess the quality of selected studies, Quality Assessment Checklist for Survey Studies in Psychology (Q-SSP) was selected as the best, ‘applicable to all’ tool in this review, considering its relevance also to the trait emotional intelligence since emotions, thoughts and mental processes are aspects of psychology. The quality of the studies was determined by the extent to which the items on above checklist were met by each of the articles. There were 20 checklist items in the tool out of which one item (item-19 – Debriefing participants at the end of data collection) could be justifiably waived; one reason being none of the included studies used it in the methodology. Thus 19 items were considered to be applicable in this review (Appendix 4).

Table 1. Characteristics of included studies

Table 2. Categorisation of findings of the studies

A. Findings of Studies and Data Analysis

1) EI and academic performance: According to studies, a positive correlation was identified between EI and academic performance (Aithal, et al., 2016, Ibrahim et al. 2017; Moslehi et al., 2015, Wijekoon et al., 2017) while (Ranasinghe et al., 2017; Unnikrishnan et al., 2015) also found a significant association between EI and academic performance. These studies indicated that students with higher EI intend to perform better in their academic work. A cross-sectional study done by Chew et al. (2015) showed that medical students with less emotional intelligence were largely unaware of their anxiety, which was associated with lower academic performance. According to studies done by Holman et al., 2016, Gupta et al., 2017 and Vasefi et al., 2018 there was no correlation of EI with academic performance. A study by Othman et al., 2020 revealed that EI showed a significant positive effect on intuitive decision-making style and a negative effect on avoidant and dependent decision-making styles which may explain better academic performance of medical students with high EI.

2) EI and mental health (emotional wellbeing): A direct relationship between EI and academic satisfaction was found in studies done by Rouhani et al., 2015, Unnikrishnan et al., 2015 and Carvalho et al., 2018. Further, Carvalho et al., 2018 reported that a positive relationship was observed between EI and academic-related well-being which accounts for both academic performance and mental health. It was seen that medical students with less emotional intelligence were largely unaware of their anxiety (Chew et al., 2015) and those with higher emotional intelligence perceived lesser stress (Gupta et al., 2017 and Ranasinghe et al., 2017). Shi and Du (2020) found that EI was strongly and negatively associated with Personal Distress. Heidari Gorji et al. (2018) identified a direct relationship between emotional intelligence and mental health while a study done by Mahaur et al. (2017) did not find a significant relationship between the two. Ghahramani et al. (2019) identified a significant positive relationship of EI with happiness while Abdali et al. (2019) showed a positive correlation with sleep quality and a negative correlation with general fatigue.

3) EI and demographic characters: Higher EI in females compared to males was found (Aithal et al., 2016, Bertram et al., 2015, Ibrahim et al., 2017, Khan et al., 2016, Raut & Gupta, 2019 Sundararajan and Gopichandran, 2018, Tyszkiewicz-Bandur et al., 2017, Unnikrishnan et al., 2015 and Wijekoon et al., 2017). Irfan et al. (2019) suggests that female medical students had significantly higher empathic behavior and emotional intelligence than male students. However, Skokou et al. (2019) did not find any difference in EI in males and females. Vasefi et al. (2018) and Abe et al. (2018) too did not find a significant relationship between EI and gender. However, Abe et al. (2018) revealed that females showed significantly higher Neuroticism, Agreeableness and Empathy scores than males. According to Ibrahim et al. (2017) increasing age resulted in higher EI. However, Yee et al. (2018) did not find a significant association of EI with age. According to Yee et al. (2018) there was no significant association of EI with ethnicity.

4) EI and empathy: Significant correlation between EI and Empathy was identified (Bertram et al., 2015, Irfan et al., 2019 Khan et al., 2016; Sundararajan & Gopichandran, 2018). Shi and Du (2020) suggests that EI helps medical professionals to establish a better association with the patient.

5) Learning environment: Relationship between EI and academic background was identified by both Irfan et al. (2019) and Sundararajan and Gopichandran (2018). According to Sundararajan and Gopichandran (2018), students who attended government schools for high school education had greater emotional intelligence than students from private schools. But Irfan et al. (2019) suggests that medical students of private medical schools showed higher level of empathy as compared to public medical schools. Dolev et al. (2019) reveals that there are no differences in EI levels between first-year and sixth-year medical students.

IV. DISCUSSION

The review included studies conducted in South and Southeast Asian, European, Arabian, North American and South American countries.  Majority of studies on Asian students revealed a high association between EI and academic performance. However, two studies on Asian students and one on US students failed to observe such associations. The impact of EI on academic performance may be explained by the fact that being aware of one’s anxiety relieved stress and those with high EI experienced greater mental wellbeing and satisfaction with their programs; which may contribute to better academic performance. Furthermore, the fact that EI showed a positive correlation with better mental health/wellbeing, less perceived stress/distress, happiness, good sleep quality and less fatigue may account for the better academic performance of students with high EI.

Empathy is an important aspect in the delivery of high-quality healthcare. Several researchers from different regions of the world reported strong association between empathy and high EI scores. Therefore, assessment of EI may be useful in admitting students for medical degrees. However, since EI is considered as a “trainable trait”, the role that EI plays in admitting students to medical schools is debatable. Therefore, all efforts must be taken by medical schools to include activities that enhance EI, during the medical course, irrespective of the EI levels of students on admission.   The fact that EI did not improve with seniority does not purely support the fact that EI is not trainable but it maybe those students were not exposed to and not sensitised to activities which enhance EI.

 Evidence indicated a positive association between high EI scores and female gender. It maybe postulated that the “nurturing and caring” role assigned by society to the females influence their upbringing. Thereby improving their emotional intelligence.

In conclusion it must be stated that since a majority of studies revealed that higher EI is associated with better academic performance, better mental health and greater empathy and since EI is considered a trainable trait, curricular need to be developed with a view to improving EI.

In order to develop EI, curricular should contain programs on general leadership development, self-care/ wellness and burn-out prevention (Monroe & English, 2013). Small-group experiential learning activities and meeting with trained mentors throughout the years would be helpful. Debriefing sessions and maintaining a journal are some other techniques that need to be considered. It may be helpful to discuss change management and quality improvement with students (Audra et al., 2020). Exposure of students to skills of self-awareness and self-management through discussion, exposure to theories of conflict management, mindfulness practice, leadership training, discussions on learning styles, discussions on power and influence, identification of team dynamics, exposure to high-functioning inter-professional teams, peer coaching, health care leader interview and shadowing of experienced clinicians are some techniques that could be adopted in attempting to develop EI among students (Kozlowski & Ilgen, 2006). It would be beneficial to evaluate acquisition based on completion of an EI inventory, feedback from peers and staff, project presentations, reflective writing, measurement of achievement of professional and personal development benchmarks and milestones, performance on simulated scenarios and small-group exercises (Pan & Allison, 2010).

During the study it was observed that there is paucity of longitudinal studies on Associates of EI. Therefor it would be beneficial to conduct longitudinal studies which may help identify some aspects with regard to the trainability of EI in medical students.

V. CONCLUSION

Through this review it was revealed that higher EI is associated with

• better academic performance,
• better mental health including less perception of stress and distress, happiness, good sleep quality and less fatigue,
• female gender, and
• greater empathy.

No significant association was found between age, ethnicity, and seniority in the medical course, and emotional intelligence. No conclusions could be made about the association between the nature of the educational institute (private or state) and emotional intelligence.

A. Limitations

In this review, it was found that authors of included studies which used several different tools to assess the EI of medical students. Each of these tools have their own advantages and disadvantages which cause comparison difficult. It could not be assumed that, each and every one of these methods provide results in the same level.

B. Recommendation

Since high EI has shown a positive correlation with academic performance and better mental wellbeing of students and since it has been identified as a “trainable trait” all efforts should be made to enhance EI of medical students during their undergraduate training.

Notes on Contributors

Edussuriya D.H (DE) was the Principal Investigator of the study. Protocol drafting, study selection, analysis and interpretation of data, synthesis of findings of individual studies and the drafting of manuscript was done by the author.

Perera S. (SP) facilitated the methodology, involved in drafting the protocol and retrieved selected articles, since the author has previous experience in conducting systematic reviews. Reference management in Mendeley and Rayyan, cross-checking the extracted data, assessed quality of selected studies and final review of draft was also done by the author.

Marambe K.N (KM) was involved in drafting the protocol, involved in article selection and extracted data from the selected articles.

Wijesiriwardena W.M.S.Y (YW) extracted data from selected articles, assessed the quality of selected articles and finalised the manuscript.

Ekanayake E.M.K.B (KE) has screened the uploaded articles in Rayyan.

Ethical Approval

The review is registered in PROSPERO – The International Prospective Register of Systematic Reviews under the registration number CRD42021227877 for the systematic review.

Data Availability

Data set that support the findings of this study are openly available in Figshare repository https://doi.org/10.6084/ m9.figshare.15564210

Acknowledgement

The authors acknowledge Information Officers of National Science Library and Resources Center, National Science Foundation, Sri Lanka for support in Scopus searches and staff of Medical Library of Faculty of Medicine, University of Peradeniya for the assistance in finding full text articles of the included studies in the review.

Funding

No funding sources are associated with this study.

Declaration of Interest

No conflicts of interest are associated with this paper.

References

Abdali, N., Nobahar, M., & Ghorbani, R. (2019). Evaluation of emotional intelligence, sleep quality, and fatigue among Iranian medical, nursing, and paramedical students: A cross-sectional study. Qatar Medical Journal, 2019(3), 15. https://doi.org/10.5339/qmj.2019.15

Abe, K., Niwa, M., Fujisaki, K., & Suzuki, Y. (2018). Associations between emotional intelligence, empathy and personality in Japanese medical students. BMC Medical Education, 18, Article 47. https://doi.org/10.1186/s12909-018-1165-7

Aithal, A. P., Kumar, N., Gunasegeran, P., Sundaram, S. M., Rong, L. Z., & Prabhu, S. P. (2016). A survey-based study of emotional intelligence as it relates to gender and academic performance of medical students. Education for Health, 29(3), 255–258.

Arora, S., Ashrafian, H., Davis, R., Athanasiou, T., Darzi, A., & Sevdalis, N. (2010). Emotional intelligence in medicine: A systematic review through the context of the ACGME competencies. Medical education, 44(8), 749–764. https://doi.org/10.1111/j.1365-2923.2010.03709.x

Audra, V. W., O’Brien, T. C., Varvayanis, S., Alder, J., Greenier, J., Layton, R. L., Stayart,C. A., Wefes, I., & Brady, A. E. (2020). Applying experiential learning to career development training for biomedical graduate students and postdocs: Perspectives on program development and design. CBE—Life Sciences Education, 19(3), 1-12. https://doi.org/10.1187/cbe.19-12-0270

Austin, E. J., Evans, P., Goldwater, R., & Potter, V. (2005). A preliminary study of emotional intelligence, empathy and exam performance in first year medical students. Personality and Individual Differences, 39(8), 1395-1405. https://doi.org/10.1016/j.paid.2005.04.014

Bar-On, R. (2004). The Bar-On Emotional Quotient Inventory (EQ-i): Rationale, description and summary of psychometric properties. In G. Geher (Ed.), Measuring Emotional Intelligence: Common Ground and Controversy (pp. 115–145). Nova Science Publishers.

Bertram, K., Randazzo, J., Alabi, N., Levenson, J., Doucette, J. T., & Barbosa, P. (2016). Strong correlations between empathy, emotional intelligence, and personality traits among podiatric medical students: A cross-sectional study. Education for Health (Abingdon), 29(3), 186–194.

Carvalho, V. S., Guerrero, E., & Chambel, M. J. (2018). Emotional intelligence and health students’ well-being: A two-wave study with students of medicine, physiotherapy and nursing. Nurse Education Today, 63, 35–42. https://doi.org/10.1016/j.nedt.2018.01.010

Chew, B. H., Hassan, F., & Zain, A. M. (2015). Medical students with higher emotional intelligence were more aware of self-anxiety and scored higher in continuous assessment: A cross-sectional study. Medical Science Educator, 25(4), 421-430. https://doi.org/10.1007/s40670-015-0168-9

Ciarrochi, J., Chan, A. Y., & Bajgar, J. (2001). Measuring emotional intelligence in adolescents. Personality and Individual Differences, 31(7), 1105-1119. https://doi.org/10.1016/S0191-8869(00)00207-5.

Dolev, N., Goldental, N., Reuven-Lelong, A., & Tadmor, T. (2019). The evaluation of emotional intelligence among medical students and its links with non-cognitive acceptance measures to medical school. Rambam Maimonides Medical Journal, 10(2), e0010. https://doi.org/10.5041/RMMJ.10365

Eden, J., Levit, L., Berg, A., & Morton. S. (2011). Finding what works in health care: Standards for systematic reviews. National Academies Press. https://doi.org/10.17226/13059

Edussuriya, D., Perera, S., Marambe, K., Wijesiriwardena, Y., & Ekanayake, K. (2021). Emotional intelligence systematic review (Version 3) [Data Set]. Figshare. https://doi.org/10.6084/m9.figshare.15564210.v3

Ghahramani, S., Jahromi, A. T., Khoshsoroor, D., Seifooripour, R., & Sepehrpoor, M. (2019). The relationship between emotional intelligence and happiness in medical students. Korean Journal of Medical Education, 31(1), 29–38. https://doi.org/10.3946/kjme.2019.116

Gupta, R., Singh, N., & Kumar, R. (2017). Longitudinal predictive validity of emotional intelligence on first year medical students perceived stress. BMC Medical Education, 17(1), 139. https://doi.org/10.1186/s12909-017-0979-z

Heidari Gorji, A. M., Shafizad, M., Soleimani, A., Darabinia, M., Goudarzian, A. H. (2018) Path analysis of self-efficacy, critical thinking skills and emotional intelligence for mental health of medical students. Iranian Journal of Psychiatry and Behavioral Sciences. 12(4), e59487. https://doi.org/10.5812/ijpbs.59487

Holman, M. A., Porter, S. G., Pawlina, W., Juskewitch, J. E., & Lachman, N. (2016). Does emotional intelligence change during medical school gross anatomy course? Correlations with students’ performance and team cohesion. Anatomical Sciences Education, 9(2), 143–149. https://doi.org/10.1002/ase.1541

Ibrahim, N. K., Algethmi, W. A., Binshihon, S. M., Almahyawi, R. A., Alahmadi, R. F., & Baabdullah, M. Y. (2017). Predictors and correlations of emotional intelligence among medical students at King Abdulaziz University, Jeddah. Pakistan Journal of Medical Sciences, 33(5), 1080–1085. https://doi.org/10.12669/pjms.335.13157

Irfan, M., Saleem, U., Sethi, M. R., & Abdullah, A. S. (2019). Do we need to care: emotional intelligence and empathy of medical and dental students. Journal of Ayub Medical College, Abbottabad: JAMC, 31(1), 76–81.

Khan, M. A., Niazi, I. M., & Rashdi, A. (2016). Emotional intelligence predictor of empathy in medical students. Rawal Medical Journal, 41(1), 121-124.

Kozlowski, SWJ., & Ilgen. D.R. (2006). Enhancing the effectiveness of work groups and teams. Psychological Science in the Public Interest, 7(3), 77-124. https://doi.org/10.1111/j.1529-1006.2006.00030.x

Mahaur, R., Jain, P., & Jain, A. K. (2017). Association of mental health to emotional intelligence in medical undergraduate students: Are there gender differences? Indian Journal of Physiology and Pharmacology, 61(4), 383-391.

Mattingly, V., & Kraiger, K. (2019). Can emotional intelligence be trained? A meta-analytical investigation. Human Resource Management Review, 29(2), 140-155. https://doi.org/10.1016/j.hrmr.2018.03.002

Mayer, J. D., & Salovey, P. (1997). What is emotional intelligence? Emotional development and emotional intelligence: Educational implications (pp. 3-31). Basic Books.

Mikolajczak, M., Luminet, O., Leroy, C., & Roy, E. (2007). Psychometric properties of the Trait Emotional Intelligence Questionnaire: Factor structure, reliability, construct, and incremental validity in a French-speaking population. Journal of Personality Assessment, 88(3), 338–353. https://doi.org/10.1080/00223890701333431

Mintz, L. J., & Stoller, J. K. (2014). A systematic review of physician leadership and emotional intelligence. Journal of Graduate Medical Education, 6(1), 21–31. https://doi.org/10.4300/JGME-D-13-00012.1

Moher, D., Shamseer, L., Clarke, M., Ghersi, D., Liberati, A., Petticrew, M., Shekelle, P., Stewart, L. A., & PRISMA-P Group (2015). Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Systematic Reviews, 4(1), Article 1. https://doi.org/10.1186/2046-4053-4-1

Monroe, A. D., & English, A. (2013). Fostering emotional intelligence in medical training: The SELECT program. AMA Journal of Ethics, 13(6), 509-513. https://doi.org/10.1001/virtualmentor.2013.15.6.medu1-1306

Moslehi, M., Samouei, R., Tayebani, T., & Kolahduz, S. (2015). A study of the academic performance of medical students in the comprehensive examination of the basic sciences according to the indices of emotional intelligence and educational status. Journal of Education and Health Promotion, 4, 66. https://doi.org/10.4103/2277-9531.162387

Noughani, F., Bayat, R. M., Ghorbani, Z., & Ramim, T. (2015). Correlation between emotional intelligence and educational consent of students of Tehran University of Medical Students. Tehran University Medical Journal, 73(2), 110-116.

Othman, R., El Othman, R., Hallit, R., Obeid, S., & Hallit, S. (2020). Personality traits, emotional intelligence and decision-making styles in Lebanese universities medical students. BMC Psychology, 8(1), Article 46. https://doi.org/10.1186/s40359-020-00406-4

Ouzzani, M., Hammady, H., Fedorowicz, Z., & Elmagarmid, A. (2016). Rayyan- A web and mobile app for systematic reviews. Systematic Reviews, 5(1), Article 210. https://doi.org/10.1186/s13643-016-0384-4

Petrides, K., & Furnham, A. (2000). On the dimensional structure of emotional intelligence. Personality and Individual Differences, 29(2), 313-320. https://doi.org/10.1016/S0191-8869(99)00195-6 

Petrovici, A., & Dobrescu, T. (2014). The role of emotional intelligence in building interpersonal communication skills. Procedia-Social and Behavioral Sciences, 116, 1405-1410. https://doi.org/10.1016/j.sbspro.2014.01.406

Protogerou, C., & Hagger, M. S. (2020). A checklist to assess the quality of survey studies in psychology. Methods in Psychology, 3, 100031. https://doi.org/10.31234/osf.io/uqak8

Ranasinghe, P., Wathurapatha, W. S., Mathangasinghe, Y., & Ponnamperuma, G. (2017). Emotional intelligence, perceived stress and academic performance of Sri Lankan medical undergraduates. BMC Medical Education, 17(1), Article 41. https://doi.org/10.1186/s12909-017-0884-5

Raut, A. V., & Gupta, S. S. (2019). Reflection and peer feedback for augmenting emotional intelligence among undergraduate students: A quasi-experimental study from a rural medical college in central India. Education for Health (Abingdon, England), 32(1), 3–10. https://doi.org/10.4103/efh.EfH_31_17

Reshetnikov, V. A., Tvorogova, N. D., Hersonskiy, I. I., Sokolov, N. A., Petrunin, A. D., & Drobyshev, D. A. (2020). Leadership and emotional intelligence: current trends in public health professionals training. Frontiers in Public Health, 7, 413. https://doi.org/10.3389/fpubh.2019.00413

Schutte, N. S., Malouff, J. M., Hall, L. E., Haggerty, D. J., Cooper, J. T., Golden, C. J., & Dornheim, L. (1998). Development and validation of a measure of emotional intelligence. Personality and Individual Differences, 25(2), 167–177. https://doi.org/10.1016/S0191-8869(98)00001-4

Shi, M., & Du, T. (2020). Associations of emotional intelligence and gratitude with empathy in medical students. BMC Medical Education, 20(1), Article 116. https://doi.org/10.1186/s12909-020-02041-4 

Skokou, M., Sakellaropoulos, G., Zairi, N. A., Gourzis, P., & Andreopoulou, O. (2019). An exploratory study of trait emotional intelligence and mental health in freshmen Greek medical students. Current Psychology, 40, 6057–6066. https://doi.org/10.1007/s12144-019-00535-z

Suleman, Q., Hussain, I., Syed, M. A., Parveen, R., Lodhi, I. S., & Mahmood, Z. (2019). Association between emotional intelligence and academic success among undergraduates: A cross-sectional study in KUST, Pakistan. PloS one, 14(7), e0219468. https://doi.org/10.1371/journal.pone.0219468

Sundararajan, S., & Gopichandran, V. (2018). Emotional intelligence among medical students: A mixed methods study from Chennai, India. BMC Medical Education, 18(1), Article 97. https://doi.org/10.1186/s12909-018-1213-3

Tyszkiewicz-Bandur M., Walkiewicz M, Tartas M, Bankiewicz-Nakielska J. (2017). Emotional intelligence, attachment styles and medical education. Family Medicine & Primary Care Review, 19(4), 404–407. https://doi.org/10.5114/fmpcr.2017.70127

University Grants Commission, Sri Lanka. (2022). University Admissions. Retrieved April 21, 2022, from https://www.ugc.ac.lk/index.php?option=com_content&view=article&id=25&Itemid=11&lang=en

Unnikrishnan, B., Darshan, B., Kulkarni, V., Thapar, R., Mithra, P., Kumar, N., Holla, R., Kumar, A., Sriram, R., Nair, N., Juanna, Rai, S., & Najiza, H. (2015). Association of emotional intelligence with academic performance among medical students in South India. Asian Journal of Pharmaceutical and Clinical Research, 8(2), 300-302.

Vasefi, A., Dehghani, M., & Mirzaaghapoor, M. (2018). Emotional intelligence of medical students of Shiraz University of Medical Sciences cross sectional study. Annals of Medicine and Surgery, 32, 26–31. https://doi.org/10.1016/j.amsu.2018.07.005

Völker, J. (2020). An examination of ability emotional intelligence and its relationships with fluid and crystallized abilities in a student sample. Journal of Intelligence, 8(2), 18. https://doi.org/10.3390/jintelligence8020018

Wei, P., & Joseph, A. (2011). Implementing and evaluating the integration of critical thinking into problem based learning in environmental building. Journal for Education in the Built Environment, 6(2), 93-115. https://doi.org/10.11120/jebe.2011.06020093

Wijekoon, C. N., Amaratunge, H., de Silva, Y., Senanayake, S., Jayawardane, P., & Senarath, U. (2017). Emotional intelligence and academic performance of medical undergraduates: A cross-sectional study in a selected university in Sri Lanka. BMC Medical Education, 17(1), Article 176. https://doi.org/10.1186/s12909-017-1018-9

Yee, K. T., Yi, M. S., Aung, K. C., Lwin, M. M., & Myint, W. W. (2018). Emotional intelligence level of year one and two medical students of University Malaysia Sarawak: Association with demographic data. Malaysian Applied Biology, 47(1), 203-208.

*Edussuriya D.H
Department of Forensic Medicine, Faculty of Medicine,
University of Peradeniya, Sri Lanka, 20400
+94711698916
Email: deepthi.edussuriya@med.pdn.ac.lk

Submitted: 27 May 2022
Accepted: 10 June 2022
Published online: 4 October, TAPS 2022, 7(4), 71-72
https://doi.org/10.29060/TAPS.2022-7-4/PV2819

Bhuvan KC^1,2 & P Ravi Shankar³

¹Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia; ²College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Australia; ³IMU Centre for Education, International Medical University, Kuala Lumpur, Malaysia

I. INTRODUCTION

Healthcare systems and medicines operate in a complex landscape and constantly interact with individuals, the environment, and society. In such a complex healthcare delivery system, nonlinearity always exists, and treatments, different healthcare services, and medicines cannot be delivered without factoring in the uncertainty brought about by human, behavioural, system, and societal factors.

A medical doctor prescribes medication/s to treat diseases or healthcare problems following certain treatment protocols and guidelines. However, in the community, several factors affect the adherence and outcomes, such as adverse effects, lifestyle factors, socioeconomic aspects, attitudes, and belief systems, so it is difficult to entirely predict the success of a regimen. These factors that can influence the outcomes of therapy have not received adequate attention. Furthermore, the complexity of healthcare delivery is starker in the treatment of ageing populations or those with chronic diseases.

Our world is becoming increasingly complex. Many uncertainties affect the delivery of healthcare services today. There are inherent challenges within the healthcare system such as lack of adequate funding, ageing population, rising burden of chronic diseases, and overstretched health workforce. In addition, newer challenges such as the impact of climate change on health delivery, the use of digital health technologies, the emergence of new epidemics, and questions regarding sustainability make healthcare delivery complex and uncertain. Healthcare systems operate through a network of subsystems such as hospitals and health systems, clinics, primary healthcare networks, rehabilitation centres, pharmacies, hospices, care homes, families, and patients. They interact with each other in a complex way sometimes producing unintended consequences such as adverse reactions, medication errors, unintended hospitalisations, and hospital-acquired infections. Thus, if we view the health system as a complex entity we can appreciate its dynamic behaviour helping us in delivering health services in a self-organized way (Lipsitz, 2012).

There is an urgent need to teach complexity science to undergraduate and postgraduate health sciences students as it better prepares them to deliver healthcare services and medicines to a dynamic and complex society. The healthcare systems we work for and the communities and societies we deliver healthcare services and medicines are complex. Healthcare delivery is disrupted by access to funding and resources, information and communication technology (ICT) applications, healthcare professionals who keep moving in and out of the system, and the increasing burden of chronic diseases and elderly populations needing several healthcare services and medicines. It is difficult to predict the outcome of the healthcare services and medicines that are delivered via both primary and secondary healthcare systems. Furthermore, it is difficult to predict the impact of healthcare services and medicines on patients. A patient may develop an adverse drug reaction to a medication, patient may have different genetic polymorphisms affecting the metabolism of medication or factors such as socioeconomic conditions, education level, support system might affect the way they receive and use healthcare services and medicines. There has been a growing recognition of such complex needs and the biological, psychological, social, and cultural aspects of medicine in the healthcare sciences curriculum (Quintero, 2014). There is also a greater appreciation for the collaborative care and practice model that brings together medical doctors, pharmacists, nurses, and other healthcare professionals together for patient care (Blount et al., 2006). The collaborative care model attempts to implement change in small and manageable cycles, appreciating the complexity involved. We must introduce complexity in medicine and pharmacy teaching and learning by introducing concepts, terminology, and lexicons regarding complexity and uncertainty. Students’ engagement and appreciation of the complexity of healthcare systems and delivery can be assessed through reflective practice, clinical reasoning, and evidence-based practice.

Complexity recognises that relationships may be nonlinear and emphasises the relations and interconnections between different components. Flow, interdependence and the emergence of structures and patterns are emphasised. An acceptance of the non-linear cause and effect relationship is stressed. Evidence-based medicine is based on statistics derived from large populations. Applying the results to an individual patient requires caution. Diagnosis and treatment outcomes are probabilistically determined. With the advent of large data sets the probabilistic nature of medicine is becoming apparent. A particular set of signs and symptoms provides a set of differential diagnosis in either increasing or decreasing order of probability. A variety of social, emotional, and political factors can influence treatment decisions, access to care, and treatment outcomes.

Universities have begun to realise the importance of teaching complexity science to medicine and health sciences students. A study by Jorm et al. (2016) had shown how complexity theory can be used to guide interprofessional learning. It showed how complexity theory can be used to design cases, formats, and assessments and how it enabled students to achieve complex interprofessional learning outcomes (Jorm et al., 2016). Another study by Jorm and Roberts (2018) reported the use of complexity theory to design evaluations with a new focus on developing medical students as future change agents for the transformation of the health system and patients’ lives (Jorm & Roberts, 2018). Several institutions like the Santa Fe Institute (New Mexico, United States) have already begun training programs on complexity in medicine and health care systems. Such programs and training need to be developed and evaluated globally so that medicine and pharmacy students can better tackle the complexity of health systems and the uncertainty around delivering medicines and healthcare in a complex environment. Training students for complexity today can ensure they are better prepared for both current and future challenges. 

Notes on Contributors

BKC contributed to the conceptualisation of the manuscript, wrote the first draft, revised the subsequent draft, and contributed to the final draft. PRS contributed to the conceptualisation of the manuscript and critically revised the first draft. The author contributed to the subsequent revision and finalisation of the manuscript.

Funding

No funding has been received for this article.

Declaration of Interest

The authors state that they do not have any conflicts of interest, including financial, consultant, institutional, and other relationships that might lead to bias or a conflict of interest.

References

Blount, A., DeGirolamo, S., & Mariani, K. (2006). Training the collaborative care practitioners of the future. Families, Systems, & Health, 24(1), 111-119. https://doi.org/10.1037/1091-7527.24.1.111

Jorm, C., Nisbet, G., Roberts, C., Gordon, C., Gentilcore, S., & Chen, T. F. (2016). Using complexity theory to develop a student-directed interprofessional learning activity for 1220 healthcare students. BMC Medical Education, 16(1), Article 199.  https://doi.org/10.1186/s12909-016-0717-y

Jorm, C., & Roberts, C. (2018). Using complexity theory to guide medical school evaluations. Academic Medicine, 93(3), 399-405. https://doi.org/10.1097/ACM.0000000000001828

Lipsitz, L. A. (2012). Understanding health care as a complex system: The foundation for unintended consequences. JAMA, 308(3), 243-244. https://doi.org/10.1001/jama.2012.7551

Quintero, G. A. (2014). Medical education and the healthcare system-why does the curriculum need to be reformed? BMC Medicine, 12(1), Article 213. https://doi.org/10.1186/s12916-014-0213-3

*P Ravi Shankar
IMU Centre for Education
International Medical University+94711698916
126, Jln Jalil Perkasa 19, Bukit Jalil,
57000 Kuala Lumpur, Malaysia
Email: ravi.dr.shankar@gmail.co