Submitted: 1 June 2021
Accepted: 21 June 2021
Published online: 5 October, TAPS 2021, 6(4), 148-149
https://doi.org/10.29060/TAPS.2021-6-4/LE2545

Wai Jia Tam, Divya Hemavathi & Tikki Pang

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

Dear Editor,

Engaging medical students in frontline efforts during the COVID-19 pandemic has varied greatly worldwide (Kachra & Brown, 2020). This paper illustrates policy challenges in student volunteerism, focusing on Singapore. Although Asia often seeks policy guidance from the West, it possesses a unique culture, political climate, regional solidarity, evolution of the disease, and learnings from prior pandemic responses to SARS and MERS, which warrants distinctive guidelines.

Following the spread of COVID-19 in early 2020, many countries, including Singapore, rapidly suspended student involvement in direct patient care activities and converted clinical training to online modes (Kachra & Brown, 2020). However, others like the United Kingdom and University of Toronto provided detailed guidelines and activated processes set-up during past pandemics for interested medical students to volunteer (Kachra & Brown, 2020; Medical Schools Council, 2020).

In Singapore, by June 2020, 95% of the COVID-19 cases were from migrant worker facilities. Medical students were offered reimbursements for help with contact tracing by Ministry of Health. Manpower strains existed, especially when lockdown ended, as healthcare workers returned to their usual duties. This presented an opportunity for medical students to continue with risk communication and community engagement (RCCE) efforts. However, direct medical student involvement was disallowed, until community transmission rates stabilized in April 2021. Even then, students were barred again before volunteer recruitment began, as community cases rose in May 2021.

Scepticism of the value of RCCE, ethical concerns about the safety and uncoerced, voluntary participation of students, political concerns to manage public fear of community spread through medical students, and educational and practical barriers to coordinating medical training with on-ground efforts contributed to the impediment of the mobilization of medical students in frontline efforts at the start of the pandemic.

Clear, evidence-based guidelines may be articulated to overcome these challenges and enable safe and effective deployment of students to provide thoughtfully matched and risk-mitigated help in context during evolving pandemic situations, even in the immediate aftermath of an outbreak. This exposure to global, social and equity dimensions of pandemic impacts helps foster future public health leaders. Given Singapore’s position in the intersection between the East and the West, it can lead such education policy reform in Asia, providing valuable input for policy development regionally and internationally.

Medical education policy is affected by governments, public opinion, international issues, and health policies. Comparative evaluation of medical education policies in Asia, may reveal their influence on health outcomes.

Note on Contributor

Dr. Wai Jia Tam conducted the literature search, conceptualised and drafted the manuscript. Prof. Tikki Pang and Divya Hemavathi critically revised the manuscript for intellectual content. All authors read and approved the final manuscript.

Funding

No funds, grants or other support was received.

Declaration of Interest

The authors have no conflicts of interest to declare that are relevant to the content of the article.

References

Kachra, R., & Brown, A. (2020). The new normal: Medical education during and beyond the COVID-19 pandemic. Canadian Medical Education Journal, 11(6), 167-169. https://dx.doi.org/10.36834%2Fcmej.70317

Medical Schools Council. (2020, March 25). Statement of expectation: Medical student volunteers in the NHS. https://www.medschools.ac.uk/news/msc-issues-statement-of-expectation-for-medical-student-volunteers-in-the-nhs

*Tam Wai Jia
Dean’s Office, Yong Loo Lin School of Medicine,
National University of Singapore,
Level 11, NUHS Tower Block,
1E Kent Ridge Road,
Singapore 119228, Singapore
Tel: +65 9627 3580
Email: waijia@nus.edu.sg

Submitted: 22 December 2020
Accepted: 8 February 2021
Published online: 5 October, TAPS 2021, 6(4), 146-147
https://doi.org/10.29060/TAPS.2021-6-4/PV2453

Simon Tso

Jephson Dermatology Centre, South Warwickshire NHS Foundation Trust, United Kingdom

Continuing professional development (CPD) is a professional obligation of clinicians aiming to ‘improve the safety and quality of care provided for patients and the public’ and ‘covers the development of your knowledge, skills, attitudes and behaviours across all areas of your professional practice’ (General Medical Council UK, 2020). The professional practice of clinicians is highly variable and may include clinical practice, management, education, academia and research, media and public engagement, advisory to charities and pharmaceutical companies, politics, and working for the government. Despite the varied role of clinicians, literature suggested that clinicians undertake the majority of their CPD in their specialist areas, although many clinicians are also interested in undertaking CPD in areas outside their specialty (Maher et al., 2017).

The year of 2020 was a challenging and sobering year for clinicians across the world with redeployment of clinicians from many specialities to undertake activities they were less familiar with (Seah, 2020). The phrase ‘CPD’ took on a new personal meaning through the change of my role as a consultant dermatologist during the COVID-19 pandemic and an unsuccessful application for a National Institute for Health Research (UK) advanced research fellowship so that I can establish myself as an independent researcher.

I volunteered to help with COVID-19 research at my employing hospital, but unexpectedly found myself becoming a site principal investigator for the UK nationally prioritised Randomised Evaluation of COVID-19 Therapy (RECOVERY Trial) that led to the discovery of dexamethasone as a treatment for COVID-19 hospitalised patients requiring oxygen therapy or ventilation support (RECOVERY Collaborative Group et al., 2021). It was a baptism of fire learning to manage and deliver the clinical trial while frantically trying to familiarise myself with the literature on pharmacology of trial medicinal products, human physiology and COVID-19 literature. I sought the counsel from my hospital’s senior research nurses, and research manager to jointly govern and deliver the trial at my hospital; and I also talked to colleagues and doctors in training to learn about the practicalities of managing COVID-19 patients in clinical settings. I kept records of my CPD related to COVID-19, reflected upon these experiences in my learning portfolio and discussed these experiences in my annual appraisal. These records also serve as evidence to justify my practices outside my area of specialism. Although I may possess relevant transferable skills and experience that facilitates me to lead and undertake work outside my speciality during the unprecedented time of the pandemic, it is important to maintain insight about our own limitations; learn from different resources; seek and accept help from others in a position of knowledge and experience whoever they may be, as this is crucial for delivering a safe service.

Despite my portfolio of varied research experience and higher research degree, I once held the wishful thinking that I could directly transition into an independent researcher due to my clinical role as a consultant. The feedback I received from the unsuccessful advanced research fellowship application has encouraged much needed reflexivity into my own strengths and limitations, and successfully challenged the naïve viewpoint that I once held. A consultant transitioning into an independent researcher is not an automatic process, but requires the progressive development of experience and credentials to justify the award of an advanced fellowship and it is ok to start from the beginning.

The literature described three broad categories of career paths: progressive, by chance and enthusiasts (Tuononen et al., 2018). CPD was crucial to my progressive career development into a consultant dermatologist and help me keep abreast with the latest evidence based clinical practices. Just-in-time CPD was important for me to discharge my leadership role as a site principal investigator in the RECOVERY Trial that I took on by chance as it was important for me to become knowledgeable about the topic and take responsibility about every aspect of the trial delivered at my site. I am enthusiastic about research and CPD is one of the many tools that can help me build the skills necessary to pursue clinical academia.

In conclusion, CPD is not just a professional obligation to keep ourselves up to date about evidence based practices in our specialty to deliver safe and high quality patient care, it is also a valuable tool to help us maintain our generalist knowledge outside our specialty (which we may rely upon if we get redeployed) and prepare us to reconfigure our career path.

Note on Contributor

Dr Simon Tso is a consultant dermatologist at the South Warwickshire NHS Foundation Trust, United Kingdom. He was responsible for conception and design of the work reported in the manuscript, reviewed the literature, drafted the manuscript and approved the final version of the manuscript submitted.

Acknowledgement

The author would like to thank his clinical and research work colleagues for their support throughout the pandemic.

Funding

There is no funding source required for this study. 

Declaration of Interest

The author report no conflict of interest. The author is responsible for the content and writing of the article.

References

General Medical Council. (2020, December 11). Continuing professional development. General Medical Council United Kingdom. https://www.gmc-uk.org/education/standards-guidance-and-curricula/guidance/continuing-professional-development

Maher, B., Faruqui, A., Horgan, M., Bergin, C., Tuathaigh, C. O., & Bennett, D. (2017). Continuing professional development and Irish hospital doctors: A survey of current use and future needs. Clinical Medicine (London), 17(4), 307-315. https://doi.org/ 10.7861/clinmedicine.17-4-307

RECOVERY Collaborative Group., Horby, P., Lim, W. S., Emberson, J. R., Mafham, M., Bell, J. L., Linsell, L., Staplin, N., Brightling, C., Ustianowski, A., Elmahi, E., Prudon, B., Green, C., Felton, T., Chadwick, D., Rege, K., Fegan, C., Chappell, L. C., Faust, S. N., … Landray, M. J. (2021). Dexamethasone in Hospitalized Patients with Covid-19. The New England Journal of Medicine, 384(8), 693–704. https://doi.org/10.1056/NEJMoa2021436

Seah, K. M. (2020). Redeployment in COVID-19: Old dogs and new tricks. Emergency Medicine Journal, 37(7), 456. https://doi.org/ 10.1136/emermed-2020-210052

Tuononen, T. A., Suominen, A. L., & Lammintakanen, J. (2018). Career path from a dentist to a leader. Leadership in Health Services (Bradford England), 31(4), 384-397. https://doi.org/ 10.1108/LHS-08-2017-0051

*Simon Tso
Jephson Dermatology Centre,
South Warwickshire NHS Foundation Trust,
Warwick,
CV34 5BW, United Kingdom.
Tel: 01926495321 Ext 4569
Email: simontso@doctors.org.uk

Submitted: 15 January 2021
Accepted: 12 April 2021
Published online: 5 October, TAPS 2021, 6(4), 142-145
https://doi.org/10.29060/TAPS.2021-6-4/SC2489

Anne Thushara Matthias¹, Gam Aacharige Navoda Dharani¹, Gayasha Kavindi Somathilake² & Saman B Gunatilake¹

¹Faculty of Medical Sciences, University of Sri Jayewardenepura, Gangodawila, Sri Lanka; ² National Centre for Primary Care and Allergy Research, University of Sri Jayewardenepura, Sri Lanka

Abstract

Introduction: Multiple factors influence doctor-patient communication. A good consultation starts with an introduction of him or herself by the doctor to the patient. The next step is to address patients in a manner they prefer. There is a paucity of data about how best to address patients in an Asian country. This study investigates how patients prefer to be addressed by doctors.

Methods: This is a cross-sectional study conducted from July 1^st to August 31^st, 2020 at a single Centre: Colombo South Teaching Hospital in Sri Lanka.

Results: Of 1200 patients, 63.25% reported that doctors never introduced themselves and 97.91% of patients reported, doctors never inquired how to address them. 49.9% preferred to be addressed informally (as mother, father, sister) than by the name (first name, last name, title). The older female patients, married patients, patients of lower education, and lower monthly income preferred to be addressed informally.

Conclusion: Most doctors did not introduce themselves to patients during medical consultations and did not inquire how patients wish to be addressed.

Keywords:            Doctor-Patient Relationship, Medical Consultation, Professionalism, Introduction, Doctor’s Name Badge, South Asian, Sri Lanka

Table 1. Difference between how patients wish to be addressed and vice versa

B. How Doctors Addressed Patients

Of the 1200 patients, 1175 (97.91%) reported that doctors never inquired how to address them at the beginning of the consultation (Matthias, 2021). A large proportion, 1124 (93.66%) reported that doctors have addressed them informally and 599 (49.9%) preferred being addressed informally, 427 (35.58%) preferred to be addressed by their first name, and 77 (6.41%) by their last name. Only 18, preferred to be addressed by their title (Dr/Rev).

More females preferred to be addressed informally when compared to the males (451/868 (51.96%) vs 148/332 (44.58%) (Pearson Chi-Square = 4.345, p = 0.037). Married patients preferred to be addressed informally when compared to the unmarried/divorced/separated (578/1089 (53.1%) vs 21/111 (18.9%), Pearson Chi-Square = 54.339, p < 0.001). The ethnicity of the patients and the area they are from (Urban/Rural) had no significant impact on how they desired to be addressed.

Over 65% of the patients (44/67) with a lower level of education preferred being addressed in an informal way whereas only 36.7% (54/147) of the graduates/post graduates preferred the informal way (Pearson Chi-Square = 23.264, p < 0.001). Monthly family income was a statistically significant variable and patients with a higher family income (Over LKR 100,000) preferred to be addressed more formally when compared to patients with an income below LKR 20,000 (40/61 = 65.57% Vs 54/157 = 34.39%, Pearson Chi-Square = 23.928, p < 0.001). The occupations of the patients are also a significant factor which affected their preference in the way being addressed with 57.4% of the patients with unskilled occupations (UN) and 43.2% of the ones with skilled occupations preferring the informal way (339/591 = 57.36% vs 251/581 = 43.20%, Pearson Chi-Square = 34.771, p < 0.001). Older patients (40 and above) preferred to be addressed informally when compared to others. (346/536 = 64.6% Vs 253/664 = 38.1%, p < 0.001).

Of 1059 patients, 495 (46.7%) preferred being addressed the informal way as they felt it made the doctor-patient relationship more personal and 627 (59.2%) patients felt the doctor treated them as their relative. Of the Doctors, 759 (63.25%) did not introduce themselves to the patients and 865 patients (72.08%) prefer doctors to wear a name badge.  718(59.8%) wanted doctors to introduce themselves with the title, doctor’s designation and specialty. 246(20.5%) wanted doctors to tell their title and first name. Only 4(0.3%) didn’t want doctors to introduce themselves.

IV. DISCUSSION

One important finding from our study was that doctors did not introduce themselves to patients. In most state sector hospitals in Sri Lanka, doctors do not wear a white coat or a name badge at present. A study done in the UK showed that 59.1% of patients and in our study 72% felt that doctors should wear name badges as a form of identification (Van Der Merwe et al., 2016). In our study, 98% of patients reported that doctors never inquired how to address them at the beginning of the consultation. To improve this aspect, these areas should be included in the objectives of the medical curriculum and continuous medical education programs of young doctors. The “Personal and professional development stream” which is taught in the medical faculty at Sri Jayewardenepura in Sri Lanka is an avenue that can be used for this purpose.

Social, cultural, ethnic, and other demographic factors can influence preferred modes of address. In our study, 50% prefer to be addressed in the informal way.  There are several possible reasons for this. Sri Lankan people have long-standing cultural and religious beliefs. Sri Lankan traditions revolve around two dominant religions Buddhism & Hinduism. Filial piety, respect for one’s parents and elders, is a concept that is present in Asian countries. Addressing a person as a mother, father, son, etc. is considered as showing respect. The patients feel the doctors treat them as their own family or relative when they are addressed this way.

In studies done in most western countries, patients wish to be addressed by their first name. The higher the income and higher the education level of the patient, the lower is their preference for being addressed the informal way as they might perceive it as less professional.  To solve the dilemma of whether to call the patient formally or informally and to make sure the patient is addressed according to their preference, the best approach would be to question the patient about their preferred name during their initial consultation and to record that in the patient’s records.

A. Strengths and Limitations

The large number of participants and recruiting from different wards; medical, surgical, paediatric, gynecology, and obstetrics to cover patients who were in the hospital for different illnesses are strengths. Not only did the study examine the patients’ preferred method of address, it examined the reasons behind the preference.

V. CONCLUSION

Our findings support a patient preference for informal greetings from their doctors in half the study population. It is not safe to assume that the patient can be addressed anyway the doctor deems right and it is good practice to ask patients how they prefer to be called at the beginning of the consultation. Doctors should introduce themselves clearly to patients and the current rates of introduction are inadequate. Majority of the patients prefer doctors to wear a name badge. In order to address patients in a culturally appropriate and patient preferred method it is always useful to ask the patient how they wish to be addressed.

Notes on Contributors

Anne Thushara Matthias was involved in conceptualisation, Methodology, Validation, Writing – Review & Editing, Supervision, Gam Aacharige Navoda Dharani was involved in investigation and data Curation, Gayasha Kavindi Somathilake was involved in formal analysis and Saman B Gunatilake was involved in writing final draft and review.

Ethical Approval

Ethical approval was from the Ethics Review Committee of the Colombo South Teaching Hospital(ERC 873/2020). There were no ethical issues. Informed consent was taken from the participants. 

Data Availability

The datasets used during the current study are available from the corresponding author on reasonable request https://figshare.com/s/e6db9a7246f9ef08474a10.6084/m9.figshare.13633949 (Matthias, 2021).

Funding

No funding sources are associated with this paper.

Declaration of Interest

The authors declare that they have no competing interests.

References

Blank, L., Kimball, H., McDonald, W., & Merino, J. (2003). Medical professionalism in the new millennium: A physician charter 15 months later. Annals of Internal Medicine, 138(10), 839–841. https://doi.org/10.7326/0003-4819-138-10-200305200-00012

Egener, B. E., Mason, D. J., McDonald, W. J., Okun, S., Gaines, M. E., Fleming, D. A., Rosof, B. M., Gullen, D., & Andresen, M. L. (2017). The charter on professionalism for health care organizations. Academic Medicine, 92(8), 1091–1099. https://doi.org/10.1097/ACM.0000000000001561

Gillen, P., Sharifuddin, S. F., O’Sullivan, M., Gordon, A., & Doherty, E. M. (2018). How good are doctors at introducing themselves? #hellomynameis. Postgraduate Medical Journal, 94(1110), 204–206. https://doi.org/10.1136/postgradmedj-2017-135402

Matthias, T. (2021). Patient preferences of how they wish to be addressed in a medical consultation – Study from Sri Lanka. https://figshare.com/s/e6db9a7246f9ef08474a

Van Der Merwe, J. W., Rugunanan, M., Ras, J., Röscher, E. M., Henderson, B. D., & Joubert, G. (2016). Patient preferences regarding the dress code, conduct and resources used by doctors during consultations in the public healthcare sector in Bloemfontein, free state. South African Family Practice, 58(3), 94–99. https://doi.org/10.1080/20786190.2016.1187865

*Anne Thushara Matthias
Faculty of Medical Sciences,
University of Sri Jayewardenepura
Email: thushara.matthias@sjp.ac.lk

Submitted: 21 January 2021
Accepted: 16 April 2021
Published online: 5 October, TAPS 2021, 6(4), 135-141
https://doi.org/10.29060/TAPS.2021-6-4/SC2484

Caroline Choo Phaik Ong^1,2, Candy Suet Cheng Choo¹, Nigel Choon Kiat Tan^2,3 & Lin Yin Ong^1,2

¹Department of Paediatric Surgery, KK Women’s and Children’s Hospital, SingHealth, Singapore; ²SingHealth Duke-NUS Academic Medical Centre, Singapore; ³Department of Neurology, National Neuroscience Institute, SingHealth, Singapore

Abstract

Introduction: The COVID-19 pandemic accelerated use of technology like videoconferencing (VC) in healthcare settings to maintain clinical teaching and continuous professional development (CPD) activities. Sociomaterial theory highlights the relationship of humans with sociomaterial forces, including technology. We used sociomaterial framing to review effect on CPD learning outcomes of morbidity and mortality meetings (M&M) when changed from face-to-face (FTF) to VC.

Methods: All surgical department staff were invited to participate in a survey about their experience of VC M&M compared to FTF M&M. Survey questions focused on technological impact of the learning environment and CPD outcomes. Respondents used 5-point Likert scale and free text for qualitative responses. De-identified data was analysed using Chi-squared comparative analysis with p<0.05 significance, and qualitative responses categorised.

Results: Of 42 invited, 30 (71.4%) responded. There was no significant difference in self-reported perception of CPD learning outcomes between FTF and VC M&M. Participants reported that VC offered more convenient meeting access, improved ease of presentation and viewing but reduced engagement. VC technology allowed alternative communication channels that improved understanding and increased junior participation. Participants requested more technological support, better connectivity and guidance on VC etiquette.

Conclusion: VC technology had predictable effects of improved access, learning curve problems and reduced interpersonal connection. Sociomaterial perspective revealed additional unexpected VC behaviours of chat box use that augmented CPD learning. Recognising the sociocultural and emotional impact of technology improves planning and learner support when converting FTF to VC M&M.

Keywords:            Teleconferencing, Morbidity and Mortality Meeting, Continuous Professional Development, Sociomaterial Theory

Table 1. Results of the survey

Table 1 shows the collated responses to survey questions comparing experience of FTF and VC M&M (Q1-11) and questions specific to VC technology (Q12-14). There were six participants who either had zero experience of FTF M&M or had experienced FTF M&M only in other departments, not ours. We carried out subgroup analysis excluding these 6 persons to remove possible influence of other M&M styles, since the study focus was on impact of VC technology. 

In general, self-reported perceptions of CPD outcomes were similar for both FTF and VC M&M. Participants appreciated that VC allowed us to continue M&M practice during the pandemic while acknowledging both positive and negative technological influences on process. Two questions (Q1 and Q9) had minor differences that were significant on whole group analysis but not significant on subgroup analysis. There was a trend towards decreased engagement for VC M&M compared to FTF M&M (Q8) that was not statistically significant.

When using VC (Table 1: Q12-14; Appendix B qualitative responses), more participants preferred to ask questions or comment by typing in the chat box than speaking on microphone. The most common reason given was to avoid interrupting meeting flow; some highlighted that the chat box facilitated junior staff participation. A few felt that keeping ‘video-on’ for all participants improved engagement but the rest preferred to have own ‘video-off’ with presenter ‘video-on’ to reduce distraction. Participants felt that while technology offered easier meeting access and simplified scheduling, it sometimes reduced engagement and interfered with community-building. Participants preferred more technological support, clearer guidance on expected VC behaviours, better infrastructure and connectivity.

A copy of the informed consent, survey questions and anonymised database are available at https://doi.org/10.6084/m9.figshare.13611611.v1.

IV. DISCUSSION

Sociomaterial perspectives offer new ways to conceptualise health professions education beyond individual cognitive and sociocultural educational lenses (Fenwick, 2014). Underpinned by diverse theories like cultural-historical activity theory, actor-network theory, and complexity theory, it recognises that “objects and humans act upon one another in ways that mutually transform their characteristics and activity” (Fenwick, 2014). Therefore, sociomaterial perspectives illuminate how technology (VC) and related infrastructure (devices and internet connectivity) interact with humans to modify the VC CPD learning environment.

In our context, widespread device penetration and free hospital Wi-Fi access aided rapid adoption of technology. Institution policy mandates internet separation from patient electronic health records, so staff use personal devices instead of hospital computers for meeting access, but it was otherwise straightforward to convert to VC M&M. Nevertheless, some unanticipated issues and VC behaviours manifested.

Introducing new technology is commonly associated with distress with learning how to use it. We chose Zoom as the most user-friendly VC platform because majority had no prior experience with VC. Unfortunately, early issues like ‘Zoom-bombing’ induced the company to make frequent user-interface changes that confused some users. A few participants (both younger and older) felt inadequately supported during their learning curve. We had provided a simple guidance document with link to online Zoom technical support but most preferred trial and error and asking for help during meetings.

Technical support alone is insufficient to address discomfort caused by social aspects of changed processes. We anticipated that uncertainty about protocols or inappropriate participant behaviours could lead to disengagement with poor CPD outcomes. We preempted these risks by following the same CPD framework as FTF M&M (e.g. moderator controls discussion, presentation template, focus on peer review learning without blame) and instituted additional VC safeguards for patient confidentiality by limiting patient identifiers, preventing recording and confirmation of attendee identity for meeting admission. We naturally evolved VC etiquette of queueing using the ‘raise-hand’ button while the moderator invites discussants by name and manages their order.

An ethnographic study of distributed VC in undergraduate medical education found that unintended ‘technologies of exposure’ – visual, curricular and auditory, discomforted the faculty and students (MacLeod et al., 2019). Similarly, many in our study disliked having their ‘video-on’. Although ‘video-on’ could improve interpersonal trust, visual exposure discomfort may interfere with aims of improved engagement and relationship-building. Originally, our department encouraged but did not mandate universal ‘video-on’. Gradually, it became the norm for all to have ‘video-off’ except the host and presenter. Despite ‘video-off’, we can maintain honest conversations necessary for M&M because of trust built through years of training and working together. Prolonged loss of FTF contact may erode trust, hence we created a departmental WhatsApp chat group to enhance social connection.

VC technology afforded unexpected learning contributions. The chat box promotes participation of reticent staff, both senior and junior, especially those preferring written expression; it augments understanding of audio discussion and allows sharing of links to supporting literature. The ease of participation empowers juniors and shifts focus from the vocal few who dominated FTF M&M. While the VC constraint of turn-taking for speakers slows down discussions, it improves interprofessional respect and meeting discipline when host can ‘mute’ the recalcitrant interrupter.

V. CONCLUSION

Sociomaterial perspectives highlight how VC technology changes the CPD learning environment of the M&M. VC provides improved access for participation and alternative communication channels but potentially reduces engagement. Recognising constraints and trade-offs of technology-driven enhancements allows better planning and learner support in VC CPD.

Note on Contributor

Caroline Choo Phaik Ong reviewed the literature, designed the study, analysed de-identified data and wrote the manuscript. Candy Suet Chong Choo performed data collection and de-identification, analysed the data and gave critical feedback to the writing of the manuscript. Nigel Choon Kiat Tan reviewed the literature, advised the design of the study and gave critical feedback to the writing of the manuscript. Lin Yin Ong advised design of the study and gave critical feedback to the writing of the manuscript. All the authors have read and approve the final manuscript.

Ethical Approval

This study received institutional research board ethics waiver (CIRB Ref: 2020/2697).

Acknowledgement

The authors would like to acknowledge the participants of the survey for sharing their responses freely.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of Interest

All the authors have no declarations of conflicts of interest.

Data availability

A copy of the informed consent, survey questions and anonymised database are available at http://doi.org/10.6084/m9.figshare.13611611.v1 under CC0 licence.

References

Chipps, J., Brysiewicz, P., & Mars, M. (2012). A systematic review of the effectiveness of videoconference-based tele-education for medical and nursing education. Worldviews on Evidence-Based Nursing, 9(2), 78-87. https://doi.org/10.1111/j.1741-6787.2012.00241.x 

Cleland, J., Tan, E. C. P., Tham, K. Y., & Low-Beer, N. (2020). How COVID-19 opened up questions of sociomateriality in healthcare education. Advances in Health Sciences Education, 25(2), 479-482. https://doi.org/10.1007/s10459-020-09968-9 

de Feijter, J. M., de Grave, W. S., Koopmans, R. P., & Scherpbier, A. J. J. A. (2013). Informal learning from error in hospitals: what do we learn, how do we learn and how can informal learning be enhanced? A narrative review. Advances in Health Sciences Education, 18(4), 787-805. https://doi.org/10.1007/s10459-012-9400-1     

Fenwick, T. (2014). Sociomateriality in medical practice and learning: Attuning to what matters. Medical Education, 48(1), 44-52. https://doi.org/10.1111/medu.12295

MacLeod, A., Cameron, P., Kits, O., & Tummons, J. (2019). Technologies of exposure: Videoconferenced distributed medical education as a sociomaterial practice. Academic Medicine, 94(3), 412-418. https://doi.org/10.1097/ACM.0000000000002536 

*Caroline CP Ong
KK Women’s and Children’s Hospital,
100 Bukit Timah Road,
Singapore 229899
Tel: +65 63941113
Fax: +65 62910161
Email: Caroline.ong.c.p@singhealth.com.sg

Submitted: 27 January 2021
Accepted: 1 April 2021
Published online: 5 October, TAPS 2021, 6(4), 131-134
https://doi.org/10.29060/TAPS.2021-6-4/SC2478

Lean Heong Foo & Marianne Meng Ann Ong

Department of Restorative Dentistry, National Dental Centre Singapore, Singapore

Abstract

Introduction: The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused the COVID-19 pandemic which started in 2020. This resulted in a disruption to educational activities across the globe. Dental education, in particular, was affected because of its vocational nature where learners come into close contact with patients when performing dental procedures.

Methods: This is a narrative review with no research data analysis involved.

Results: Social distancing measures introduced to curb the spread of the infection revolutionised the advancement of online education as the virtual environment is a safer place to conduct teaching compared to face-to-face teaching. In this article, we share our experience at the National Dental Centre Singapore (NDCS) in ensuring the safety of our faculty and learners when conducting didactic and clinical education during the pandemic. Didactic lectures were conducted in the virtual environment via synchronous and non-synchronous teaching. Essential clinical education was conducted in small groups with safe management measures in place. In addition, we provide guidelines to highlight the importance of meticulous planning, thorough preparation, and seamless delivery in conducting effective synchronous teaching.

Conclusion: Safe management measures put in place to ensure the well-being of our faculty and learners can ensure dental education continuity during the pandemic.

Keywords:            Dental Education, Education Continuity, COVID-19

I. INTRODUCTION

The COVID-19 pandemic is severely affecting dental professionals since the Department of Labor Occupational and Health Administration United States of America (USA) published guidelines associating aerosol-generating procedures (AGP) in dentistry with SARS-CoV-2 virus spread. Many dental schools in the USA and Asia Pacific have desisted clinical practice and simulation sessions, causing severe disruption in dental training (Chang et al., 2021). Innovative guidelines were developed to conduct dental education during the pandemic (Hong et al., 2021). Singapore has undergone five phases during the pandemic: Pre-pandemic, Circuit Breaker (CB), Phase 1, Phase 2, and Phase 3 (current). We share our experience in continuing dental education for oral healthcare team learners (residents, dental technicians trainees, dental assistant trainees) in NDCS during the pandemic.

II. CLINICAL ADJUSTMENTS

After the Ministry of Health Singapore (MOH) raised the Diseases Outbreak Response System Condition (DORSCON) level from yellow to orange on 7^th February 2020 (Pre-pandemic), NDCS senior management immediately adopted team segregation by establishing three self-contained teams comprising clinicians, dental surgery assistants, lab technicians, patient service associate executives, and health attendants (Tay et al., 2020). Learners at NDCS were also assigned to teams. All staff and learners were briefed on safe management measures to observe during clinical sessions. They were required to wear a surgical mask at all times except during meals, perform hand hygiene with an alcohol-based hand sanitiser, and report their temperature twice daily online. Triage and risk assessment of patients were carried out (Hong et al., 2021; Tay et al., 2020) and dental procedures were limited to emergency procedures to relieve pain, ongoing dental treatment, and dental clearance before medical procedures during CB. Use of personal protective equipment (PPE) comprising an eye shield, N95 mask or respirator, surgical gown, and gloves were indicated for all AGP while the use of an eye shield, surgical mask, and surgical gown was indicated for non-AGP following a risk-based assessment (Tay et al., 2020). Patients with suspected COVID-19 or who had close contact with a confirmed case were treated in a negative pressure room with proper PPE. All patients were required to rinse with cetylpyridinium chloride mouth rinse before their procedure. A 15-minute window in between patients was implemented to disinfect the operatory until Phase 3.

III. EDUCATION PROGRAMME ADJUSTMENTS

We conduct three structured education programmes in NDCS–National Institute of Technical Education (NITEC) Dental Assisting (DA), NITEC Dental Technology (DT), and National University of Singapore Master of Dental Surgery Residency Training Programme (RTP) for six dental specialties. In addition, Singapore Institute of Technology (SIT) Diagnostic Radiography (DR) students have observation attachments at NDCS. During CB, Phase 1, and Phase 2, we postponed the new intake of learners for DA due to logistic issues with our collaborators. The posting of DR learners to our centre was also halted. All existing DA and DT learners were allocated to the same clinical team and completed their programme during the pandemic. Residents in the RTP were divided into two groups; one group was based in NDCS and the other in National University Centre for Oral Health Singapore during the 7-week CB. From Phase 1 onwards, the two groups of residents started weekly alternating rotations for their clinical sessions between the two institutions.

NDCS education activities are classified into didactics and clinical sessions. We conducted didactics using synchronous and non-synchronous formats while clinical sessions gradually resumed from Phase 1 to 3 following prevailing MOH and institutional policies. Synchronous teaching and seminars were carried out using Zoom and WebEx online platforms. Voice annotated presentations and e-learning modules were launched in the SingHealth e-learning platform, Wizlearn, for non-synchronous teaching. Clinical sessions were conducted with a small clinical supervisor-learner ratio (1:5), triage of patients, use of complete PPE with an N95 mask, hand hygiene, and high suction evacuator for AGP (Tay et al., 2020). Face-to-face sessions for essential hands-on clinical skills building were organised in Phase 2 and 3 with safe management measures in place such as small instructor-learner ratio, safe distances between learners and instructors, segregation of learners and instructors in groups, donning of surgical masks, meticulous hand hygiene, and proper disinfection after equipment use (Tay et al., 2020).

IV. GUIDELINES FOR ONLINE SYNCHRONOUS TEACHING

Mayer’s theory of multimedia learning (Mayer, 2002) describes the learning process in online education by highlighting the dual channels (auditory and visual) and three stages of memory (sensory, working, and long-term) for processing information. The learner’s eyes and ears capture diagrams and text in the multimedia presentation with sensory memory input. These are converted into a pictorial and verbal mode respectively in the working memory and integrated with prior knowledge from the long-term memory. Educators should prevent cognitive overload in content planning, as learners have limited capacity to hold the pictorial and verbal mode in working memory. A three-phase guide highlighting salient information for conducting effective online synchronous teaching is provided.

A. Meticulous Planning

To understand learners, faculty can adopt a 5W and 1 H concept [(who (the learners), where (location of teaching), why (learning objectives), what (lesson content), when (duration), and how (online platform in this context)] when planning a teaching module. Besides, faculty can construct the learning objectives and teaching activities using Bloom’s taxonomy based on learning outcomes. Bloom’s taxonomy covers six cognitive domains in the following order: knowledge, comprehension, application, analysis, synthesis, and evaluation, where a higher-order is more complicated for the learners to master and demonstrate.

B. Thorough Preparation

Apart from teaching material, a faculty guide is recommended. It should contain the schedule and details of the teaching session, teaching activities, and probing questions and answers for reference; to ensure all the teaching tasks are completed within the planned schedule. Handouts are used to reduce cognitive overload and as a backup when the connection is down. Generally, a good camera, laptop or smartphone, internet connection, a simple background with light, and a quiet room are sufficient for online teaching.

C. Seamless Delivery

Good online synchronous teaching platforms include Zoom, WebEx, Microsoft Teams, Google Meet, Mikogo, and Slack with breakout rooms and annotation board features that are included in the premium subscription of these platforms. A dry run is recommended to familiarise oneself with the functions on the various platforms. Setting the learning climate during the session by preparing learners to respond at appropriate times is crucial. The faculty should look at the camera frequently to keep eye contact with learners. Backup plans that include standby internet access and soft copy handouts are useful when connection is down. Increased feedback and communication between faculty and learners is crucial in online teaching and can be achieved by:

i) Using a learning management system such as GoSoapBox to allow learners to input text individually, particularly useful for clinical case discussion.

ii) Using Slido or Poll Everywhere to conduct needs analysis or summative or formative assessment between teaching.

iii) Utilising the question and answer segment to assess learners’ responses and check progress.

iv) Using the chatbox to allow learners to post questions and comments.

Teleconferencing has limited non-verbal cues coupled with milliseconds delay in observation by other participants that can subconsciously force our brain to restore the synchrony present in face-to-face contact. This overworking can lead to tiredness and discomfort from virtual teleconferencing tools, termed as ‘Zoom fatigue’. Recommendations to reduce Zoom fatigue include taking a rest in between brief lessons and turning off the camera when muted to reduce stimulus and mental fatigue. Netiquette, a blend of ‘internet etiquette’, refers to a code of good behaviour for both educators and learners (Table 1) that should be practised in an online environment (Lateef, 2020) to promote courteous communication between learners and educators for a pleasant learning experience. Evaluation of online education can be conducted during the session by performing formative and summative assessment; assessing quality and completion rate of learners’ assignment; analysing learners feedback from the post-session questionnaire as well as learners’ grade during module assessment and performance in the clinic.

Table 1. Netiquette for online education

Note: Adapted from “Computer-based simulation and online teaching netiquette in the time of COVID 19,” by F. Lateef, 2020, EC Emergency Medicine and Critical Care, 4(8), 84-91.

V. MOVING FORWARD

It may take years to return to pre-COVID-19 normalcy, where physical interaction and large gatherings were social norms. Moving forward, we can consider a hybrid or blended learning module alongside limited face-to-face sessions confined to essential skill-based training. However, the effectiveness of online learning compared to traditional modes of clinical teaching has not been elucidated. Dentistry is a practical vocation that requires developing surgical and psychomotor skills to perform specific tasks. Online learning addresses the delivery of didactics but translating theory into practice which involves hands-on skills, teamwork and communication are challenging in the virtual setting. Virtual and augmented reality programmes such as Spatial, coupled with simulation video demonstration, may be suitable for skill-based training in dental education in the virtual environment. Psychological support for faculty and learners and forming a digital technology community of practice among educators can help to improve resilience and coping mechanisms during this challenging period. With safe management measures in place to ensure the well-being of our faculty and learners, we can adapt and continue education activities while looking for innovative ways to deliver clinical teaching effectively in dentistry amidst this pandemic.

Notes on Contributors

Dr Lean Heong Foo is a Consultant Periodontist in the Department of Restorative Dentistry and Head to the Dental Surgery Assistant Certification Programme. FLH reviewed the literature, contributed to the conception, data acquisition, drafted and critically revised the manuscript.

Dr Marianne Meng Ann Ong is a Senior Consultant Periodontist & Director of Education in National Dental Centre Singapore. MO contributed to the conception, data acquisition and critically revised the manuscript. All authors gave their final approval and agree to be accountable for all aspects of the work.

Ethical Approval

This is a narrative review related to dental education continuity during the COVID-19 pandemic and no ethical approval is required.

Data availability

This paper is a narrative review with no data analysis.

Acknowledgement

The authors would like to thank Ms Safiyya Mohamed Ali for providing editorial support.

Funding

There is no funding involved in the preparation of the manuscript.

Declaration of Interest

The authors declare no conflict of interest.

References

Chang, T., Hong, G., Paganelli, C., Phantumvanit, P., Chang, W., Shieh, Y., & Hsu, M. (2021). Innovation of dental education during COVID-19 pandemic. Journal of Dental Sciences, 16(1), 15-20. https://doi.org/10.1016/j.jds.2020.07.011

Hong, G., Chang, T., Terry, A., Chuenjitwongsa, S., Park, Y., Tsoi, J. K., Kusdhany, M. F. L. S., Egusa, H., Yamada, S., Kwon, J., Seow, L., Garcia, M. C. A. G., Wong, M. L., Ayuchai, P., & Hsu, M. (2021). Guidelines for innovation in dental education during the coronavirus disease 2019 pandemic. Journal of Oral Science, 63(1), 107-110. https://doi.org/10.2334/josnusd.20-0399

Lateef, F. (2020). Computer-based simulation and online teaching netiquette in the time of COVID 19. EC Emergency Medicine and Critical Care, 4(8), 84-91.

Mayer, R. E. (2002). Multimedia learning. Psychology of Learning and Motivation, 41, 85-139.

Tay, J. R. H., Ng, E., Ong, M. M. A., Sim, C., Tan, K., & Seneviratne, C. J. (2020). A risk-based approach to the COVID-19 pandemic: The experience in National Dental Centre Singapore. Frontiers in Medicine, 7. https://doi.org/10.3389/fmed.2020.562728

*Foo Lean Heong
National Dental Centre Singapore
5, Second Hospital Avenue,
168938 Singapore
Email: foo.lean.heong@singhealth.com.sg

Submitted: 31 August 2020
Accepted: 8 February 2021
Published online: 5 October, TAPS 2021, 6(4), 118-130
https://doi.org/10.29060/TAPS.2021-6-4/OA2481

Isabella E. Supnet, Jose Alvin P. Mojica, Sharon D. Ignacio & Carl Froilan D. Leochico

Department of Rehabilitation Medicine, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Philippines

Abstract

Introduction: In the Philippines, telerehabilitation has been at the forefront of integrating telemedicine into the medical curriculum. However, the course evaluation tool used for traditional classroom-based courses is not appropriate in evaluating the unique teaching-learning tool that is telerehabilitation. This study aimed to develop a questionnaire that will aid in addressing this gap.

Method: A mixed methods study was devised to gather information from medical students exposed to telerehabilitation from the College of Medicine, University of the Philippines Manila as well as the residents from the Department of Rehabilitation Medicine, Philippine General Hospital from October to November 2019. The investigators obtained informed consent from all participants as well as their demographics before undergoing interviews. Themes were identified to create questions under the previously identified constructs, along with items derived from other course evaluation tools and opinions gathered from experts in telerehabilitation.

Results: In total, 26 individuals participated in the study. Most of the respondents had experience or ownership of various communication technologies and were well-versed in communication strategies through these technologies. There were 52 questions formulated from the interviews and review of previous tools.

Conclusion: This study is the first step in providing more research in the student evaluation of telerehabilitation and telemedicine. To match the needs of changing times evaluation of new standards and methods should follow. More research must be done to standardise teaching evaluation tools to validate the data gathered, and allow courses, such as telerehabilitation, an opportunity to adapt and promote further learning.

Keywords:           Assessment, Educational, Education, Medical, Telemedicine, Medical Informatics, Physical and Rehabilitation Medicine

Practice Highlights

• Telemedicine has been used as a tool to educate students on rehabilitation medicine.
• Almost all students at this time have had experience in the usage of information and communication technologies.
• Evaluation tools must be more specific to the method of instruction used.
• Clarity, congruence, and relevance are the most sought-after characteristics in telerehab courses.
• The recipient of the evaluation must account for the effect of the teacher or logistical concerns.

I. INTRODUCTION

A. Background

Telemedicine is defined as the use of advanced telecommunications technologies to exchange health information and provide health care services across geographic, temporal, social and cultural barriers (Myers, 2003). It has been widely used in the treatment and care of patients as we go through the COVID-19 pandemic and has also been vital in improving medical education in the age of online classes and social distancing. Through telemedicine, students are exposed to a variety of specialties, and gain experience in their observation of the management of diseases, such as in the case of telesurgery, or hone their skills in communication and counselling, such as through telerehabilitation (Jumreornvong et al., 2020).

Now more than ever, due to the capacity of students to interact and adapt with digital infrastructure (Pathipati et al., 2016), integration of telemedicine into the medical curriculum is increasingly important and evaluations of telemedicine curricula are necessary to ensure quality and to detect areas for growth and improvement. Previous studies have used general evaluation forms to evaluate their telemedicine programmes or created general surveys from their course objectives, which have yielded some valuable insights (Brockes et al., 2017; Bulik & Shokar, 2010). However, due to the nature of instruction of telemedicine, specialised and validated tools are necessary to provide a comprehensive assessment.

In the Philippines, telerehabilitation has been at the forefront of integrating telemedicine into the curriculum, particularly in the University of the Philippines. Because it has been four years since the start of the initiative, and one year since its implementation, it is important to evaluate the previous courses in order to improve them for the next generation.

Through this research, a preliminary evaluation questionnaire for telerehabilitation as a teaching-learning tool was developed. From this questionnaire, perceptions of students regarding telerehabilitation courses will be more efficiently gathered and evaluated, which will serve to further improve the telerehabilitation curriculum and possibly bring forth interventions to improve medical education in general.

B. Literature Review

1) Teaching programmes in telemedicine: In the process of conducting telemedical evaluations in order to aid patients, clinical training may also be received. Telemedicine has had good acceptance in training institutions abroad, with Neurology trainees agreeing that it should be part of their curriculum and supporting a formalised telemedicine rotation within their residency. Dermatology programmes in particular observed that telemedicine supported rather than detracted from the core competencies required from them (Lee & Nambudiri, 2019). No significant differences were seen between clinical outcomes of patients who underwent surgery through telementoring versus the traditional method, and case supervision using e-mails and voice-over applications afforded similar psychiatry education as compared to rotations in mental health clinics (O′Shea et al., 2015).

The methods through which telemedicine education is given also vary considerably per institution (Waseh & Dicker, 2019). Some schools have telemedicine included primarily as didactic sessions. Others allow their students to take part in patient encounters and interprofessional training. Some institutions also allow scholarly projects to be done in telemedicine.

Because telemedicine in medical education has yet to be explored formally, no evaluation tools have been developed to assess its application. Other institutions used generalised forms and made their own questionnaires (Brockes et al., 2017; Bulik & Shokar, 2010). Literature review for formally developed evaluation materials showed the presence of a Telehealth Usability Questionnaire, with items and domains encompassing many telehealth assessment tools (Parmanto et al., 2016). It was made for use with various types of telehealth systems, including computer-based systems, videoconferencing programmes, and adaptable for progressive innovations, particularly for mobile telemedicine applications. However, this was primarily utilised as an assessment tool between clinicians and patients and does not assess instruction on the usage of the programme or the organisation of the implementation.

2) Teaching programmes in telerehabilitation: In 2015, the Department of Rehabilitation Medicine, College of Medicine and Philippine General Hospital, University of the Philippines Manila (PGH DRM) has initiated education on this aspect of telemedicine, with telerehabilitation used as a teaching-learning tool for medical students in full implementation in the 2018 curriculum. The programme has expanded from its origins since then; from students engaging in telerehabilitation to actual telerehabilitation consultations and teletherapy services with the rural health unit of Alfonso, Cavite, as part of the University of the Philippines Community Health and Development Programme (UP CHDP).

Telerehabilitation as a teaching-learning tool was formally included as part of the curriculum for rehabilitation medicine in 2018 (Philippine General Hospital Department of Rehabilitation Medicine, 2018). The students start their engagement during their third year of medical school (known as Learning Unit 5), their first year of clinical exposure, with the concepts and theories behind telerehabilitation, and do observations of an actual telerehabilitation session. A year later, during Learning Unit 6, they then get to do a simulated telerehabilitation encounter, with guidance and techniques on how to present a rehabilitation case through telemedicine. During their final year of medical education (Learning Unit 7), the student is then evaluated on the presentation, evaluation and management given during an actual patient encounter. All students from the UP College of Medicine receive two sessions of telerehabilitation instruction per year.  On the other hand, Post-Graduate Interns (PGIs), who are students who have received their first four years of medical education in other medical schools and have chosen to spend their last year of medical school in the Philippine General Hospital, receive only one compressed session. Overall, the participants reported the experience to be excellent, and should be explored further (Leochico & Mojica, 2017).

Telerehabilitation was also included in January 2019 as a formal service for training residents in the Department of Rehabilitation Medicine, featuring the same concepts in a more compressed manner, and highlighting the hybridisation of standard rehabilitation practice with telemedicine.

The initiative is currently being evaluated by the students in part through the Course Evaluation by Students (CEBS) given by the University of the Philippines College of Medicine (UPCM) (University of the Philippines Manila College of Medicine, 2005), and through a Devised Telerehabilitation Feedback Form for Students (Philippine General Hospital Department of Rehabilitation Medicine, n.d.), which does not distinguish usability attributes of the telerehabilitation system from the telerehabilitation curriculum itself.

3) The usage of student evaluations: Student evaluation forms are a commonly used tool in determining teacher and course effectiveness in many areas of higher education. These evaluations commonly serve three purposes: to improve teaching quality, to support faculty decisions, and to provide evidence for institutional accountability. Many evaluation measures have been constructed and performed with students as the main and sometimes sole indicator of education quality; however, the implementation, reliability and validity of these methods and instruments have been a source of concern within academic circles (Soto-Estrada et al., 2018). Due to this, student evaluation remains a field of active study.

Although helpful, some caution must be undertaken in interpreting results of student evaluations. A recent meta-analysis by Uttl et al. (2017) argues that studies looking into student evaluations of teaching (SETs) were scant in terms of data to support the equivalence of high student evaluation ratings to student performance, and positive correlations between the two were primarily due to small study size effects. However, it is unfair to assume that SETs have no value whatsoever. Responses to the meta-analysis have been published as well, and aside from critiquing the method Uttl used to form his study, they support the view that, while it is poor practice to use student ratings of instruction alone in evaluating teaching, it remains to be necessary (Ryalls et al., n.d.).

C. Objectives

1) General objective:

• To develop a questionnaire that will evaluate telerehabilitation as a teaching-learning tool for medical students.

2) Specific objectives:

• To determine themes regarding the evaluation of telerehabilitation as a teaching-learning tool from residents of the PGH Department of Rehabilitation Medicine, as well from the medical students who have undergone the telemedicine courses.
• To formulate questionnaire items for the telerehabilitation course evaluation tool.

II. METHODS

A mixed methods study was devised to gather information from medical students exposed to telerehabilitation from the Philippine General Hospital and the College of Medicine, University of the Philippines Manila (with exposures corresponding to Learning Units 5, 6, and 7) as well as the residents from the PGH DRM from October to November 2019 (Figure 1). All participants were greater than 18 years old.

Figure 1. Flowchart of study methodology

Submitted: 18 January 2021
Accepted: 19 May 2021
Published online: 5 October, TAPS 2021, 6(4), 107-117
https://doi.org/10.29060/TAPS.2021-6-4/OA2470

Sarah Brown & Justin L C Bilszta

Department of Medical Education, Melbourne Medical School, University of Melbourne, Australia

Abstract

Introduction: Use of complementary and alternative medicine (CAM) is popular in the general population and medical practitioners may not be fully equipped in their knowledge of CAM to advise patients appropriately. The aim of this paper was to perform a scoping review of current literature describing undergraduate medical student use, attitudes, and knowledge of CAM as a means of better understanding the educational needs of these students.

Methods: A systematic search of Medline, PubMed and the Education Resources Information Center (ERIC) databases with keywords related to “complementary and alternative medicine” and “undergraduate medical students” for relevant articles published until August 2020.  

Results: Of 131 papers identified, 38 underwent full review. It was found 13-80% of medical students use CAM, and overall have a positive attitude towards CAM therapies.  Female medical students and those with religiosity had more positive attitudes towards CAM than their male colleagues and those without a religion. Knowledge of CAM is lacking with approximately only half of students feeling they were knowledgeable about CAM therapies. Popular information resources are the Internet and social media, but students expressed they want more teaching of CAM in the undergraduate medical curriculum.

Conclusion: Evidence suggests high usage of CAM amongst undergraduate medical students, and positive attitudes towards CAM therapies; however, knowledge of CAM is poor, and students want more CAM teaching to upskill them in counselling patients interested in CAM therapies. Further areas for research include a better understanding of resources medical students use for their knowledge and how gender and religiosity influence attitudes towards CAM.  

Keywords:           Undergraduate Medical Student, Complementary and Alternative Medicine, CAM, Attitude, Knowledge, Use

Practice Highlights

• Medical student’s personal use of CAM is significant, with the most popular therapies being massage, meditation and herbal medicine.
• Medical students have a positive attitude towards CAM but potential differences between attitudes of preclinical and clinical student populations exist.
• Medical student’s knowledge of CAM is lacking, and this impacts their ability to advise patients appropriately.
• Medical students want more CAM teaching integrated into their UGME curriculum, and believe conventional western medicine could benefit from CAM methods and ideas.
• Better integration of the principles of EBM rather than teaching related to specific CAM therapies can provide medical students with the skills to critique claims of CAM efficacy.

Complementary and alternative medicine (CAM) encompasses a range of health practices including, but not limited to, acupuncture, naturopathy, chiropractic traditional Chinese medicine (TCM), herbal, vitamin & homeopathic therapies (Zollman & Vickers, 1999). Complementary refers to the practice of something alongside conventional Western medicine, whilst alternative refers to the practice of something instead of conventional Western medicine (Zollman & Vickers, 1999).

In comparison to conventional Western medicine, the eclectic range of CAM is often cited as having a poor-quality evidence-base regarding its efficacy (Australian Medical Association, 2018), yet it remains popular with the general public (Frass et al., 2012). With surveys suggesting 10–76% of the public has used CAM (Ernst, 2000; Harris et al., 2012) the demand for CAM is evident. How knowledgeable medical practitioners are, and their attitudes towards CAM, can influence the advice they might provide to patients who seek information about CAM therapies or want to use CAM in lieu of conventional Western medicine. Janamian et al. (2011) have reported general practitioners feel they do not have the education to appropriately advise patients on CAM (Janamian et al., 2011). This may deter patients from seeking guidance from their healthcare provider and result in a breakdown of communication and lack of congruence over health goals (Xue et al., 2007).

Medical students’ insights into their prevailing attitudes and knowledge of CAM can help determine if CAM teaching within undergraduate medical education (UGME) should be expanded to better meet the needs of growing public demand. The last significant review of medical students’ attitudes and knowledge of CAM was published in 2016 (Joyce et al., 2016), and reported overall medical students believed they lacked knowledge of CAM but were generally positive towards CAM education and thought CAM teaching should be incorporated into UGME. What this review did not explore was the rates of CAM use by medical students, and whether this influenced attitudes towards CAM. Importantly, since the publication of Joyce et al’s review, not only have there been additional studies exploring medical students’ use, attitudes and knowledge of CAM, but the increasing use of the Internet and social media as a source of information means it is timely to re-evaluate the findings of this earlier study and determine whether the results presented remain relevant.

We conducted this scoping review of primary studies to evaluate undergraduate medical student use, attitudes, and knowledge of CAM as a means of better understanding the educational needs of these students. The specific research questions were: 1) what is the usage and knowledge of CAM among medical students?; 2) what are medical students’ attitudes towards CAM?; 3) what factors influence medical students’ attitudes towards CAM, and where do they seek information about CAM? and; 4) what are medical students’ views on the current teaching they receive in UGME about CAM?

II. METHODS

This study adopted the “Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews” (PRISMA-ScR) protocol (Tricco et al., 2018).

A. Search Strategy

Electronic databases Medline (Ovid), PubMed and ERIC were searched for full text articles describing undergraduate medical students use, attitudes, and knowledge of CAM (see Appendix 1). Additional papers were found through a hand search of reference lists of articles identified through the database search. There was no limit on publication date.

B. Selection of Sources

Papers were included if published in English and reported on undergraduate medical students. Papers were excluded if they were not published in English; opinion pieces or review articles; reported on non-undergraduate medical students or; reported on osteopathic medical students. This group was excluded due to the potential bias these students may have due to their medical training including specific CAM teaching.

C. Key Words and Boolean Operators

The search strategy (see Appendix 1) included Boolean operators (AND, NOT, OR), Medical Subject Headings (MeSH) and specific key words.

D. Data Extraction and Charting

Data extraction was performed using a predetermined checklist, and included

• Article details: first author and publication year
• Research aim: purpose of the study
• Method: methods of data collection
• Sample size: number of students invited to participate and the number who responded
• Student CAM use: number of students using CAM, including use of specific therapies and timeframe of use
• Student attitudes/perceptions to CAM: student attitudes to CAM including desire to undertake further education about CAM, beliefs about CAM efficacy, role of CAM in conventional Western medicine and, sources of CAM information
• Influencing factors: factors reported to influence student’s attitudes/perceptions to CAM
• Limitations: identified study limitations

E. Synthesis of Results

Included studies were described by author, publication year, and characteristics described above. Thematic analysis was conducted to identify commonality between included studies. No inferences were made about students’ use, attitudes, or knowledge of CAM if this was not explicitly stated.

Literature searching, title and abstract screening, full text review & data extraction, and charting were undertaken by the 1st author (SB). Where there was uncertainty regarding the aforementioned, these articles were reviewed independently by the 2nd author (JB) and discussed until consensus was reached. The 2nd author also independently reviewed the data extraction and charting results once this process was completed by the 1st author.

III. RESULTS

From the initial search strategy, 131 articles were obtained for screening based on title and abstract. Following screening, 17 duplicate citations were excluded, leaving 114 papers. Abstract and title screening excluded papers focused on pharmacy or nursing students, and those that did not centre on the research questions. Following this, 58 articles underwent full review. Of these, 21 were excluded as they were not in English, did not provide enough detail regarding medical students specifically or focused heavily on medical curricula. The total number of articles included is 38 (see Figure 1); a full version of the outcome harvesting data can be found at https://doi.org/10.6084/m9.figshare.14471250 (Brown & Bilszta, 2021).

Figure 1: PRISMA Diagram

A. CAM usage

Twenty-two studies assessed CAM usage in medical students (Baugniet et al., 2000; Chaterji et al., 2007; Chez et al., 2001; Ditte et al., 2011; Donald et al., 2010; Flaherty et al., 2015; Frye et al., 2006; Greenfield et al., 2000, 2002; Hegde et al., 2018; Hopper & Cohen, 1998; James et al., 2016; Lie & Boker, 2004, 2006; Nicolao et al., 2010; Oberbaum et al., 2003; Rees et al., 2009; Sadeghi et al., 2016; Samara et al., 2019; Shani-Gershoni et al., 2008; Wong et al., 2006; Yildirim et al., 2010). Rates of usage ranged from 13% to 80% (Chez et al., 2001; Wong et al., 2006). The most common CAM therapy used by medical students was difficult to evaluate due to inconsistent methods of collecting this information with studies either asking students to nominate usage from a predefined list of therapies (Baugniet et al., 2000; Chaterji et al., 2007; Frye et al., 2006; Hegde et al., 2018; James et al., 2016; Lie & Boker, 2004, 2006; Nicolao et al., 2010; Sadeghi et al., 2016; Samara et al., 2019; Shani-Gershoni et al., 2008; Wong et al., 2006; Yildirim et al., 2010); self-report the therapies they had engaged with (Donald et al., 2010; Greenfield et al., 2000, 2002) or; indicating CAM usage without nominating a specific therapy (Chez et al., 2001; Ditte et al., 2011; Flaherty et al., 2015; Hopper & Cohen, 1998; Oberbaum et al., 2003; Rees et al., 2009). The challenge in evaluated CAM usage is highlighted by two separate studies (Lie & Boker, 2004, 2006) which reported a range of practices to be popular including massage, meditation and yoga compared to vitamins, meditation and spirituality, respectively (Lie & Boker, 2004, 2006).

B. CAM perception/attitudes

Overall, the general attitude of medical students towards CAM is positive (Ahmed et al., 2017; Akan et al., 2012; Chaterji et al., 2007; Chez et al., 2001; Ditte et al., 2011; Flaherty et al., 2015; Frye et al., 2006; Furnham & McGill, 2003; Godin et al., 2007; Greenfield et al., 2002, 2006; Hegde et al., 2018; Hopper & Cohen, 1998; James et al., 2016; Lie & Boker, 2004, 2006; Loh et al., 2013; Nicolao et al., 2010; Oberbaum et al., 2003; Perkin et al., 1994; Rees et al., 2009; Sadeghi et al., 2016; Samara et al., 2019; Templeman et al., 2015; Torkelson et al., 2006; Wong et al., 2006; Xie et al., 2020; Yeo et al., 2005) with positive attitudes ranging from 49% to 60% (Ditte et al., 2011; Perkin et al., 1994; Sadeghi et al., 2016). Different methods were used to collect this data including validated measures (for example: (Flaherty et al., 2015; Frye et al., 2006; Rees et al., 2009)), rating scales with various stages of validation (for example: (Ahmed et al., 2017; Oberbaum et al., 2003; Sadeghi et al., 2016; Samara et al., 2019)) or qualitative interviews (for example: (Templeman et al., 2015)).

Differences in the attitude of preclinical and clinical cohorts varied between studies. Akan et al., Furnham & McGill and Syverstad et al. reported preclinical students had a more positive attitude compared to clinical students (Akan et al., 2012; Furnham & McGill, 2003; Syverstad et al., 1999), however others found clinical students were more positive, perhaps due to them receiving more CAM education (Chaterji et al., 2007; Xie et al., 2020). However, multiple studies found no difference between preclinical and clinical cohorts (Ditte et al., 2011; Flaherty et al., 2015; Hopper & Cohen, 1998; Rees et al., 2009). Additionally, all studies bar one (Hübner et al., 2012) asked students to consider attitudes and perceptions in relation to ‘…their clinical practice…’ rather than associated with a specific clinical context or medical condition.

Attitudes towards specific CAM therapies demonstrated acupuncture received consistent positive perceptions ranging from 77% to above 90% (Loh et al., 2013; Torkelson et al., 2006; Yeo et al., 2005). Other therapies with consistent positive perceptions include massage and meditation, with more than 70% of medical students feeling positively towards these practices (Furnham & McGill, 2003; Loh et al., 2013; Torkelson et al., 2006). Conversely, Greenfield et al. and Loh et al. both found homeopathy had the most negative perception from students (Greenfield et al., 2006; Loh et al., 2013). Interestingly, studies indicate ambivalence towards chiropractic practice, with some reporting positive attitudes whilst others reported negative attitudes (Greenfield et al., 2006; Loh et al., 2013). When asked about the integration of CAM with conventional Western medicine, there was overwhelming belief from medical students that benefits may come from applying these practices together. Ahmed et al. and Chez et al. reported a large percentage of their cohorts believed conventional Western medicine could benefit from CAM methods and ideas (67% and 89%, respectively) (Ahmed et al., 2017; Chez et al., 2001). Similar findings have been reported by others, with the percentage of students wanting the integration of CAM and conventional Western medicine ranging from 71% to 92% (Chez et al., 2001; Hopper & Cohen, 1998; Lie & Boker, 2004; Loh et al., 2013; Nicolao et al., 2010; Torkelson et al., 2006; Xie et al., 2020; Yeo et al., 2005).

An important question to consider when evaluating medical student knowledge and attitudes towards CAM is whether they believe CAM works. This question arose frequently in the reviewed literature, with investigators trying to determine if there was congruence between having a positive perception of CAM and belief in its efficacy. When asked if participants found the results of CAM were mainly due to the placebo effect, there were mixed findings with 39-59% of medical students agreeing the CAM efficacy was mainly due to the placebo effect (Baugniet et al., 2000; Nicolao et al., 2010; Yeo et al., 2005; Yildirim et al., 2010). Interestingly, recent studies by Xie et al. and Samara et al. reported only 10% and 35%, respectively, believed CAM efficacy was due to the placebo effect (Samara et al., 2019; Xie et al., 2020). Whether this is simply a cohort effect or a reflection that over time students may be becoming less sceptical of CAM, is unable to be confirmed.

Factors that influence attitudes towards CAM should be considered as they may alter how medical students perceive CAM therapies. The most frequent influence reported was gender, with female medical students overall tending to have a more positive attitude than male colleagues (Akan et al., 2012; Chaterji et al., 2007; Ditte et al., 2011; Donald et al., 2010; Flaherty et al., 2015; Frye et al., 2006; Furnham & McGill, 2003; Godin et al., 2007; Greenfield et al., 2002, 2006; Hübner et al., 2012; Oberbaum et al., 2003; Rees et al., 2009; Schmidt et al., 2005; Xie et al., 2020). Interestingly, Ditte et al. found male medical students feared the social stigma of using CAM more than female students (45% vs 36%) and Donald et al. reported male students were more likely to be more sceptical of CAM than female students (50% vs 44%) (Ditte et al., 2011; Donald et al., 2010).

Religion may also influence attitudes to CAM. Yeo et al. reported nearly two thirds of their cohort believed spiritual/religious beliefs influenced attitudes towards CAM (Yeo et al., 2005). Furnham & McGill reported similar findings as female students and students that rated themselves higher religiously, were more eager for CAM to be on the curriculum compared to males and those who were less religious (Furnham & McGill, 2003). In contrast, Loh et al. reported students with no religion tended to be less interested in CAM (Loh et al., 2013).

C. CAM knowledge

The included studies suggest approximately only half of medical students felt knowledgeable about CAM (Hopper & Cohen, 1998; James et al., 2016; Sadeghi et al., 2016; Shani-Gershoni et al., 2008) and the most common individual therapies students were subjectively knowledgeable in were massage (Baugniet et al., 2000; Chez et al., 2001; Frye et al., 2006; Furnham & McGill, 2003), acupuncture (Akan et al., 2012; Nicolao et al., 2010; Sadeghi et al., 2016; Yeo et al., 2005), chiropractic (Baugniet et al., 2000; Chez et al., 2001; Frye et al., 2006) and herbal medicine (Akan et al., 2012; Baugniet et al., 2000; Chez et al., 2001). It is clear, however, medical students still perceive significant gaps in their knowledge of CAM. Nicolao et al. reported although students indicated acupuncture and homeopathy as their most knowledgeable areas, this was only for a minority of the cohort (34% and 43%, respectively) and the majority of students felt their level of knowledge, and therefore ability to appropriately advise patients, was poor (Nicolao et al., 2010). In one Australian study, investigators found out of ten common CAM therapies (acupuncture, chiropractic, herbal medicine, homeopathy, hypnosis, massage, meditation, naturopathy, reflexology and spiritual healing) 56% of their cohort had no knowledge of any of these therapies (Hopper & Cohen, 1998).

The Internet appears to be a popular avenue for finding CAM information with Lie and Boker reporting 81% of their cohort used online resources as their main information source (Lie & Boker, 2004). Although the specific online resources used were not described, journals, books and health databases were used less frequently in comparison (41%, 38% and 28%, respectively) (Lie & Boker, 2004). A study of Chinese medical students with CAM teaching integrated into their UGME, found their cohort’s main source of information was from teachers, making up 91% with only 2% using the Internet (Xie et al., 2020). Samara et al. reported 73% of their cohort used social media as their main source of information (Samara et al., 2019).

It is clear medical students want more teaching about CAM in their UGME. Flaherty et al. reported just over two thirds of students across all year levels had a desire to study CAM, however, there was a positive correlation between those students who wanted more teaching and a positive attitude towards CAM (Flaherty et al., 2015). Similar findings were reported by Perkins et al. and Frye et al. with approximately 85% of clinical and preclinical students believing they should learn about CAM in UGME (Frye et al., 2006; Perkin et al., 1994). In terms of this would look like in the curriculum, Greenfield et al. reported 67% wanted to study the theory, with Greiner et al. and Yeo et al. finding 72% and 86%, respectively, wanted clinical exposure (Greenfield et al., 2006; Greiner et al., 2000; Yeo et al., 2005). In semi-structured qualitative interviews of Australian medical students, CAM education was considered important regardless of specialisation and CAM literacy was an ethical responsibility (Templeman et al., 2015).  

IV. DISCUSSION

In this Discussion, we provide commentary on our findings, consider how these might be applied to the design of UGME curriculum, and suggest areas of further research.

In the current study, we found a significant number of medical students use CAM, however reported rates varied considerably, and our analysis suggests inconsistency in approaches used to assess CAM use may explain the observed differences. As highlighted, data collection was split between those studies that provided a predefined list of specific CAM therapies, with a limited number of response options, and the exact therapies between papers incongruent; those that allowed students to self-report usage and; those indicating CAM usage without nominating a specific therapy (see Table 1). Cultural differences may also explain usage variation; for example, the high use of yoga in Indian medical students (Hegde et al., 2018), TCM in Chinese medical students (Wong et al., 2006) and, traditional Iranian medicine in Iranian medical students (Sadeghi et al., 2016).

Table 1. Example of the differing methods used to collect student CAM usage data. Data collection of medical student CAM usage was split between those studies that provided a predefined list of specific CAM therapies; those that allowed students to self-report usage and; those indicating CAM usage without nominating a specific therapy. The above examples highlight the inconsistent approaches to collecting this information.

Although medical students believe conventional Western medicine could benefit from CAM methods and ideas, an important caveat to this finding is it does not consider how they feel about specific CAM therapies. For example, would medical students think conventional Western medicine could benefit from integrating herbal medicine or homeopathy approaches, compared to osteopathy or acupuncture? Given the diversity of CAM, it is arguably unfeasible (Wetzel et al., 1998) to teach students about each individual therapy, so an EBM teaching model equipping students with skills needed to critically appraise evidence presents a potential solution, and several medical schools have designed curricular in this way (Bailey et al., 2015; Forjuoh et al., 2003; Hassed, 2004; Jeffries, 2001; Mahapatra et al., 2017; Owen & Lewith, 2001; Perlman & Stagnaro-Green, 2010). This addresses a thematically overwhelming and resource intensive area of medical education where learned knowledge and skills can be adapted for differing CAM therapies.

Only three studies (Lie & Boker, 2004; Samara et al., 2019; Xie et al., 2020) specifically explored how medical students use digital resources to supplement formal CAM teaching, so this is a clear direction for further research. It is important medical students have access to high quality evidence-based information and the skills to determine the validity of evidence presented on digital platforms. Whilst there is evidence to demonstrate resources such as blogs, social networking sites and online support groups are useful platforms for health education, social connection and experience sharing, they are at significant risk of misinformation and mischaracterisation of CAM (Delgado-López & Corrales-García, 2018; Molassiotis & Xu, 2004). Sharma et al. (2016) have underscored the challenges in developing approaches for identifying the reliability of CAM-related information on the Internet, which may not be supported by a reliable evidence-base (Sharma et al., 2016). This means medical students require skills to critique claims related to CAM efficacy for their own education needs, but also so they can appropriately counsel patients. As advocated, an EBM teaching model would provide students with the skills to critique claims of CAM efficacy as well as empower patients to make informed decisions relevant to their health needs.

V. LIMITATIONS OF THE STUDY

As we did not conduct a systematic review of the literature, we are unable to draw any conclusions about the quality of the included studies. We excluded non-English studies, and this potentially creates a gap in the literature and may have altered the findings as CAM use, attitudes and knowledge may be different in non-English speaking countries (for example, the high use of acupuncture or Traditional Chinese medicine in Asian countries). The lack of consistency in data related to medical student use, attitudes and knowledge of CAM therapies is reflected in its heterogeneity. This makes generalisations related to ‘medical students’, even within the same medical school or UGME curriculum, difficult. Despite this significant limitation, the diversity of reported outcomes reflects important contextual differences in medical programs, and medical student cohorts, across the globe.

VI. CONCLUSION

Overall, medical students have a positive attitude towards CAM, with significant influencing factors being gender and religion, and potential differences between preclinical and clinical cohorts. The included literature indicates medical students’ personal use of CAM is significant, with therapies such as massage, meditation and herbal medicine being more popular than others. It is clear medical students’ CAM knowledge is lacking and integration of the principles of EBM may be beneficial in addressing this, ultimately leading to better educated doctors who have better relationships with their patients.

Notes on Contributors

JB: conceptualised the review; JB, SB: designed the search strategy; SB: conducted the search and screened the literature; JB, SB: reviewed the included studies; SB: analysed the data; JB: drafted the manuscript; JB, SB: critically revised the manuscript. All authors had full access to all study data, read and approved the final version of the manuscript.

Ethical Approval

As all the data were retrieved from public databases, this study did not require institutional review board approval.

Data Availability

The data that support the findings of this study are openly available in Figshare repository, https://doi.org/10.6084/m9.figshare.14471250. The data extraction sheet used during the current study is available from the corresponding author on request. All data is based on published studies.

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Declaration of Interest

None of the listed authors have financial and personal relationships with organisations or people that could inappropriately influence their work.

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*Justin Bilszta
Department of Medical Education,
Melbourne Medical School,
University of Melbourne, Australia
Parkville, Australia 3052
Tel: +61 3 8344 7826
Fax: +6567775702
Email: jbilszta@unimelb.edu.au

Submitted: 6 November 2020
Accepted: 27 January 2021
Published online: 5 October, TAPS 2021, 6(4), 92-106
https://doi.org/10.29060/TAPS.2021-6-4/OA2459

Ardi Findyartini^1,2, Natalia Widiasih Raharjanti³, Nadia Greviana^1,2, Gregorius Ben Prajogi⁴ & Daniar Setyorini²

¹Department of Medical Education, Faculty of Medicine Universitas Indonesia, Indonesia; ²Medical Education Center, Indonesian Medical Education and Research Institute (IMERI), Faculty of Medicine, Universitas Indonesia, Indonesia; ³Department of Psychiatry, Faculty of Medicine, Universitas Indonesia, Indonesia; ⁴Department of Oncology Radiation, Faculty of Medicine, Universitas Indonesia, Indonesia

Abstract

Introduction: E-portfolio may facilitate the entrustment process from supervisors to residents in postgraduate medical education. The present study was aimed at identifying necessary features of an e-portfolio application and to conduct pilot study in a teaching hospital.

Methods: Six programs participated. Eight interviews with education directors and six focus group discussions with residents and supervisors were completed for the needs analysis stage. The application was developed based on the thematic analysis of the needs analysis stage. The mobile-app e-portfolio pilot was conducted for four weeks and a modified version of the System Usability Scale (SUS) was distributed to participants following the pilot program.

Results: Key features of the e-portfolio were identified. A total of 45 supervisors and 66 residents participated in the pilot study. The residents utilised the application according to the clinical activities and supervision level, and the information was fed to the supervisors as per the application design. Challenges during the pilot study in terms of feedback provision and residents’ workload which influence the e-portfolio use for entrustment decisions are discussed.

Conclusion: Current e-portfolio features were created for supervision and are potential to facilitate the entrustment process in Entrustable Professional Activities (EPA) implementation. The pilot study highlighted challenges of the implementation which should be considered for future improvement.

Keywords:           Postgraduate Medical Education, E-Portfolio, Entrustable Professional Activities, Supervision, Needs Analysis, Pilot Study

Practice Highlights

• Development of assessment application, including e-portfolio, should consider input from the stakeholders.
• The e-portfolio should further be defined to emphasise the documentation, reflection, and feedback processes.
• Consideration of adequate evidence for EPA should be determined based on the aim of the e-portfolio.
• A robust e-portfolio implementation will potentially support the implementation of EPA.
• Challenges in e-portfolio implementation should be aware of and tackled for future improvement.

I. INTRODUCTION

Supervision is a critical component of postgraduate medical education as it allows residents to have a gradual achievement of competencies while still fulfilling patient safety standards. Patient care conducted by residents under adequate supervision can have results comparable to the care provided by more experienced medical doctors (Farnan et al., 2012). To entrust the resident, a supervisor considers several factors, including incidents experienced during supervision, the resident’s characteristics, the results of assessments, and encountered situations (Cianciolo & Kegg, 2013).

Ten Cate et al. (2015) introduced the Entrustable Professional Activities (EPA) concept to facilitate the implementation of a competency-based curriculum in the workplace (Ten Cate et al., 2015). EPAs are observable and measurable units of work that can correspond to competency milestones, allowing for safe and effective performance (Carraccio et al., 2017).  Easily accessible and interpreted information about a resident’s past performance using the EPA concept is, therefore, suggested to facilitate the entrustment process, both for ad-hoc and summative purposes (Hauer et al., 2013; Ten Cate et al., 2015).

Entrustment decision-making refers to a supervisor’s decision to trust a resident to carry outpatient care ‘without supervision’ (Crossley et al., 2011; Ten Cate, 2006; Weller et al., 2014). Given the need for assured patient safety, ‘without supervision’ refers to the reduction of educational supervision and the provision of ‘relational autonomy’, whereby interdependence between the resident, the supervisor, the healthcare team, and the healthcare system becomes critical (Holmboe et al., 2011). However, the amount of data accessible about a resident’s performance should be analysed comprehensively to enable ad-hoc entrustment (Sandhu, 2018).

Logbooks and portfolios have been considered as workplace-based assessment methods that would enable summarising a resident’s performance as well as maintaining assessment results during training (van Tartwijk & Driessen, 2009). Electronic portfolios, or e-portfolios, are believed to increase the accessibility of a portfolio in medical training provided that the purpose of the portfolio development is well defined, such as for learning, assessment, or continuing professional development (Deketelaere et al., 2009, Tepper et al, 2020; van Tartwijk & Driessen, 2009). Generally, an e-portfolio aims to monitor a resident’s competency development and to stimulate the capacity for self-reflection (Meeus et al., 2006).

An e-portfolio may consist of a list of a resident’s performance, the supporting evidence, and the resident’s self-reflection (van der Schaaf, et al., 2017). The content is specific according to the e-portfolio’s purpose and the required activities/competencies for the resident at each level (Mulder et al., 2010). The use of an e-portfolio with a mobile application and updated evidence of residents’ performance potentially enhance informed decision-making in the entrustment process, and hence, it can be embedded in the resident supervision system (Ten Cate et al., 2016). An exploratory study in Australia showed that an EPA-driven e-portfolio model assisted trainees and supervisors in agreeing upon expected trainees’ performance in order to obtain competence level (Bramley et al., 2020).

Implementation of e-portfolio as a supporting system for EPA should consider supporting and hindering factors specific to an institution. Implementation of best practices in this area can be accompanied by an exploration of the most suitable system according to the stakeholders’ needs. Therefore, the current study aimed to explore stakeholders’ needs and develop a mobile-app e-portfolio model in a teaching hospital with various postgraduate medical education programmes located in a resource-limited setting. The study also aims to identify challenges of e-portfolio implementation. The research questions of this study were: (1) What are mobile-app e-portfolio features needed to support EPA implementation in the current teaching hospital? (2) How do stakeholders perceive the use of the developed mobile-app e-portfolio during the pilot study? 

II. METHODS

A. Context

Cipto Mangunkusumo General Hospital (CMGH) is the main teaching hospital for the Faculty of Medicine Universitas Indonesia (FMUI) and is located in Jakarta, Indonesia. All 31 study programmes implement a competency-based medical curriculum and EPA approach. CMGH is obliged to have all study programmes participate in clinical activities, which are gradually entrusted to residents in accordance with the resident’s level. The EPA document in form of a matrix is then used to develop supervision system. Supervisors are trained to provide feedback through compulsory clinical teacher training conducted by the faculty. Assessment documentation has been conducted mostly manually in hardcopies for all study programs; consequently, tracking the residents’ performance to provide formative or summative EPA decisions has been challenging in the current setting.

B. Design

This study is participatory action research with a mixed -method approach. The exploration stage was aimed at exploring the needs and features expected from the mobile application. Following the exploration stage, the research team in collaboration with a professional vendor developed the mobile-app e-portfolio according to the results of the exploration stage. The pilot implementation phase aimed to implement and train residents and supervisors in the use of the application. A follow-up evaluation was conducted to assess users’ perception about the use of the e-portfolio application.

C. Respondents

Respondents of this study were education leaders from the medical school and the teaching hospital. Residents, clinical teachers, and administrators from six study programs representing medicine, surgery, and diagnostic: anaesthesiology and intensive care, obstetrics and gynaecology, psychiatry, oncology radiation, radiology, and internal medicine at CMGH/FMUI were recruited with maximum variety sampling method taking into account gender, age, and length of study (residents) or work (clinical teachers). Detailed information of the study was given to all participants who then provided written consents prior to the interviews and completion of the questionnaire.

D. Data Collection

The exploration stage involved interviews with: (1) residency programme directors; (2) education leaders from the medical school and the teaching hospital. Focus group discussions (FGDs) were also conducted with clinical teachers and residents from the six study programmes. The guiding questions of the interviews and FGDs were developed according to e-portfolio and EPA concepts used in medical education, and are shown in Table 1. The data obtained were used as a reference for further development of the application’s content and features. In addition, the EPA document from each study program was also analysed as baseline data for developing the platform.

Following the development of the application, a four-week-long pilot implementation was conducted in November 2018. After week four, the back-end system data were analysed. Supervisors’ and residents’ perceptions of the use of mobile-app e-portfolio for supporting EPA were collected using a modified questionnaire of System Usability Scale (SUS) (Brooke, 1986). Active commentaries were also added in the questionnaire to obtain users’ suggestions:

Table 1. Guiding questions of interviews and focus groups

E. Data Analysis

The transcripts of interviews and FGDs of the need analysis stage were analysed using thematic analysis. The agreed subthemes and themes and the results of the analysis of EPA documents from each study program were then translated into a computational framework to be developed as mobile application e-portfolio’s features, also considering the best practice and theoretical framework of e-portfolio development and EPA practice.

Back-end data of the activities, case variations, and supervisors’ feedback were descriptively analysed using SPSS IBM 22.0. The words submitted on the reflection-on-action section of each activity were counted along with the feedback recorded by the supervisors. Residents’ reflections were categorised into those with descriptions of difficulties (DD), lessons learned (LL), and action plans (AP). The feedback recorded was classified into descriptive (D), constructive (C), and neither descriptive nor constructive (N) categories.

The modified SUS questionnaires were descriptively analysed using chi-square/fisher exact analysis (SPSS 22.0) to compare residents’ and supervisors’ perceptions. The active commentaries in the questionnaire were also thematically analysed to identify areas of improvement in the e-portfolio development.

III. RESULTS

A. Exploration Stage

Eight in-depth interviews were conducted with each residency program director as well as with the leader of FMUI and with teaching hospital director representatives. Two FGDs were conducted, each with three study programmes faculty members. In addition, three FGDs were conducted, each with two study programmes resident representatives. The number and characteristics of the participants are described in Table 2.

Table 2. Characteristics of Focus Group Discussion (FGD) Participants in Exploration Stage

Four main themes and 22 subthemes were identified during the exploration stage. The main themes identified were (1) resident supervision; (2) current implementation of workplace-based assessments; (3) current implementation of portfolios and logbooks; and (4) development of the mobile application e-portfolio.

	Theme	Subtheme	# of Quotes	Quotations
1	Resident supervision	Constraints in supervision (faculty members, patient/clinical cases)	59	“For example, during the mid-level programme, residents were required to be fully supervised, but when they should be fully supervised was not specifically stated.” (W1, p. 1)
		Form of supervision	46	“…we should report to the supervisor when anything goes wrong to get feedback; otherwise, it will become our fault.” (FGD 2, [R5], p. 2)
		Determination of entrustment (written curriculum, residents and patients factor, workplace, agreement among faculty members)	42	“At some point, we might feel that the resident is eligible to perform the procedure after he/she has observed several times, and then we try to let him/her give it a try, but we are actually risking our trust…” (W7, p. 5)
		Background and determination of supervision (workplace, resident’s educational stage)	26	“Supervision was given hierarchically; the third-year residents attain duty as the chief, supervisor, and the highest form was division of weekly rounds.” (FGD 4, [R1], p. 2)
		Documentation of supervision level	10	“Our logbook contains a very clear explanation about supervision level, such as what cases should be achieved so that we can evaluate and reflect on our progress in one semester.” (FGD 3, [R6], p. 9)
2	The current implementation of workplace-based assessment	Scheduled WBA	17	“During each rotation, residents and consultants were scheduled with case-based discussions or miniCEX; while for surgical DOPS, [it] is not specifically scheduled because it depends on the availability of the case.” (W3, p. 1)
		WBA as stage step-up procedure	6	“In our programme, there are several cases we need to get done at each level, usually cases written in the logbook.” (FGD 2, [R7], p. 3)
		Based on the written curriculum	4	“In our programme, we arrange evaluation at every level. We evaluate every intern according to the required competency they should achieve.” (FGD 4, [R3], p. 7)
3	The current implementation of portfolio and logbook	Technical portfolio and logbook implementation (as monitoring, communication, and assessment instrument)	26	“On a routine basis, the form was filled in each afternoon, when the patient’s information, such as name, weight, and height, are recorded.” (FGD 2, [R7], p. 4)
		Constraints in portfolio and logbook implementation (lack of ownership, faculty member factor)	38	“Due to the enormous workload every day, such as examining patients, attending division rounds, filling out electronic health records, and receiving so many instructions, they couldn’t complete the logbook routinely. Besides, the supervisor might find it unnecessary to write down their supervision in the log book after discussions, rounds, or treatments.” (W2, p. 10)
		Understanding of portfolio and logbook for residents’ development (clinical, academic, non-academic)	24	“Portfolio consists of one’s creativity, innovation, and organisation experiences.” (W8, p. 1)
4	Development of the mobile application-based e-portfolio	Residents’ performance and experience (clinical and academic) tracking	20	“We evaluated one intern’s competency in ultrasound, and the result wasn’t quite satisfying. It turned out that this intern lacked of practice that could’ve been done every day since the cases were quite abundant.” (W6, p. 10)
		User-friendliness and real-time access	18	“The application may have to be ‘consultant-friendly,’ so they can finish it in a click.” (FGD 2, [R3], p. 7)
		Feedback documentation	13	“In my opinion, there has to be some immediate feedback.” (FGD 2, [R5], p. 7)
		Accessibility and confidentiality	11	“As they save the record of the treatment that has been checked by the doctor in charge, they can no longer change it because only the supervisor has the authority to change.”(FGD 4, [R4,] p. 19)
		Encompass achievement of competence and modules within the curriculum	7	“We want it to be comprehensive, so it can be evaluated. This is about clinical skills, but then the related academic skill is also important.” (W4, p. 9)
		Ensuring patients were treated by competent and authorised residents	4	“We need to ensure that the patient is treated by competent, authorised, and certified doctors.” (W7, p. 10)
		Reminder and consequences for undocumented activity	5	“There must be something to force the resident to write down his activity so the next day, he can keep up with the new tasks.” (W2, p. 10)
		Paperless attribute, but printable if needed	6	“The record and the format will be the students’ database as well as the supervisors’. Therefore, it needs to be printable for our benefit.” (FGD 2, [R3], p. 7)
		Integrated with service care system	3	“We have to write down the same thing repetitively in so many books and records.” (FGD 3, [R8], p. 12)
		Collect important evidence of accomplishments (cases and complications, image documentation)	4	“Compiling the number of cases is required, and reporting complications in cases is equally important. Let’s say they are in the third level, but complications occurred in most of the procedures they performed.” (W3, p. 7)

Table 3. Themes and Subthemes Identified in Exploration Stage

Submitted: 19 October 2020
Accepted: 12 April 2021
Published online: 5 October, TAPS 2021, 6(4), 80-91
https://doi.org/10.29060/TAPS.2021-6-4/OA2456

Balakrishnan Ashokka^1,2, Tat Leang Lee¹ & Daniëlle M.L. Verstegen³

¹Department of Anaesthesia, National University Health System, National University Hospital, Singapore; ²Centre for Medical Education (CenMED), Yong Loo Lin School of Medicine, National University of Singapore, Singapore; ³Department of Educational Development and Research, Faculty of Health Medicine and Life Sciences, Maastricht University, Netherlands

Abstract

Introduction: There are certain factors in exam preparedness that are not well studied in the postgraduate medical education context. Non-academic predictors have been extensively researched but usually in isolation.

Methods: The study involved a sequential explanatory mixed methods research design. The study was conducted among anaesthesia postgraduates appearing for high-stake nation-wide primary examination. Data obtained by a questionnaire assessing pre-examination attributes were compared with the students’ reflections through focus group discussions (FGD) after the formal declaration of results. The examination had an overall pass rate of 42.9% (18 out of 42).

Results: The study showed that pre-examination questionnaire could identify attributes and study behaviours in the postgraduates who passed. Passers procrastinated three times lesser, pursuing a timetable-based study (conscientiousness); had higher metacognitive self-regulation (p value<0.05) applying concentrated self-directed learning & effective group study and higher self-efficacy compared to those who failed. The focus group discussions affirmed of these attributes in candidates who ‘breeze through exams’. Postgraduate success required better ‘work-study’ balance, self & cross regulation and peer and faculty support.        

Conclusion: Implementing a composite tool to assess ‘exam preparedness’, we propose, would help the learners and teachers to skim for non-academic factors (metacognitive self-regulation, self-efficacy, conscientiousness) that influence the chances of success. Understanding & predicting this would help educators to identify the ‘candidates with difficulty’ and delegate personalised faculty attention. This could guide the exam candidates to have a ‘reality check’ to plan and pace their effort with peer learning, consolidated study and goal orientation.

Keywords:           Postgraduate Exam Success, Non-Academic Predictors, Self-Regulation

Practice Highlights

• Non-academic attributes impact success in postgraduate examinations.
• Postgraduate exam success necessitates work-study & work-life balance.
• Time on task, self-regulation to task demands is needed when assessments are tougher and high stake.
• Exam preparedness: A collective attribute is proposed with a questionnaire to measure predictability of exam success.
• Shunning away from ‘shame of mock vivas’ spirals down to poor chance of passing.

Submitted: 16 January 2021
Accepted: 17 May 2021
Published online: 5 October, TAPS 2021, 6(4), 65-79
https://doi.org/10.29060/TAPS.2021-6-4/OA2447

Yee Cheun Chan¹, Chi Hsien Tan¹ & Jeroen Donkers²

¹Department of Medicine, National University Health System, Singapore; ²Department of Educational Development and Research, Faculty of Health, Medicine and Life Sciences, Maastricht University, Netherlands

Abstract

Introduction: Reflection is a critical component of learning and improvement. It remains unclear as to how it can be effectively developed. We studied the impact of reflective writing in promoting deep reflection in the context of learning Accreditation Council for Graduate Medical Education (ACGME) competencies among residents in an Internal Medicine Residency programme.

Methods: We used a convergent parallel mixed-methods design for this study in 2018. We analysed reflective writings for categories and frequencies of ACGME competencies covered and graded them for levels of reflection. We collected recently graduated residents’ perceptions of the value of reflective writings via individual semi-structured interviews.

Results: We interviewed nine (out of 27) (33%) participants and analysed 35 reflective writings. 30 (86%) of the writings showed a deep level (grade A or B) of reflection. Participants reflected on all six ACGME competencies, especially ‘patient care’. Participants were reluctant to write but found benefits of increased understanding, self-awareness and ability to deal with similar future situations, facilitation of self-evaluation and emotional regulation. Supervisors’ guidance and feedback were lacking.

Conclusion: We found that a reflective writing programme within an Internal Medicine Residency programme promoted deep reflection. Participants especially used self-reflection to enhance their skills in patient care. We recognised the important role of mentor guidance and feedback in enhancing reflective learning.

Keywords:           Reflective Writing, ACGME Competencies, Internal Medicine, Residency

Practice Highlights

• Reflection is a critical component of learning and improvement.
• Written reflections offer theoretical advantages over other forms of reflections in requiring more commitment and ownership of experience, promoting critical thinking and offering more opportunities for feedback.
• Written reflections can be a record for mentored reflection, included in a portfolio, used in ongoing self-assessment and longitudinal integration of learning.
• Practitioners reported benefits of increased understanding, self-awareness and ability to deal with similar future situations, facilitation of self-evaluation and emotional regulation.
• Supervisors’ guidance and feedback are important for enhancing reflective learning.

I. INTRODUCTION

Medical competencies are developed through experience and application, not just knowledge acquisition (Frank et al., 2010). Kolb (1984) conceptualises experiential learning in a four-stage cyclical process.  An experience triggers a reflection on that experience that leads to the formation of abstract concepts and generalisations. These are then tested in future situations, resulting in new experiences.  Reflection is an essential aspect of the learning experience. It remains unclear how it can be developed most effectively.

Reflection is a complex concept that has been defined in several ways. One definition describes it as the process of engaging self in attentive, critical, exploratory, and iterative interactions with one’s thoughts and actions, and their underlying conceptual frame, with a view on the change itself (Nguyen et al., 2014). Thus, reflection has an iterative dimension which describes a cyclic process with phases triggered by experience, which produces new understanding, and then an intention to act differently in future encounters of similar experience (Mann et al., 2009). There is also a vertical dimension correlating to the depth of reflection. The surface levels are more descriptive and less analytical than the deeper levels. For example, Boud et al. (1985) described iterative phases of returning to experience, attending to feelings, re-evaluation of experience and outcome/resolution. Mezirow (1991) described increasing depth of reflection as habitual action, thoughtful action/understanding, reflection, critical reflection. Evidence suggests that deeper levels of reflections are associated with deep approaches to learning (Leung & Kember, 2003).

Reflective writing is a commonly utilised method in developing reflective learning but evidence for its value remains limited. Theoretically, written reflections offer advantages over other types of reflections e.g. verbal discussions. Creating an artefact by writing involves a commitment to learning, ownership of experience, promotes critical thinking and offers more opportunities for feedback (Aronson, 2011). The writings can be a record for mentored reflection, included in a portfolio, used in ongoing self-assessment and longitudinal integration of learning. A systematic review (Winkel et al., 2017) looking at the impact of reflection in graduate medical education found only three studies (Epner & Baile, 2014; Levine et al., 2008; Winkel et al., 2010) that involved reflective writings. Levine et al. (2008) found that the process of narrative writings encouraged deepening of reflection leading to reconsideration of core values and priorities, improved self-awareness, provided an emotional outlet and motivation to improve. However, the study did not formally gauge the depth of reflections in the writings.

We aimed to further study the impact of reflective writing in promoting reflection and the learning of medical competencies. Better understanding this will guide the development of reflective learning skills in training programmes for medical trainees.

A. Research Question

Does reflective writing promote deep reflection in the context of learning core competencies defined by the Accreditation Council for Graduate Medical Education (ACGME) (Accreditation Council for Graduate Medical Education, 2013)?

II. METHODS

A. Research Paradigm and Design

Our study adopted a phenomenological approach. We used a convergent parallel mixed-methods design (Figure 1). Quantitative data included the tabulation of the categories of ACGME competencies and the frequency they were covered in the reflective writings. Quantitative scoring of levels of reflections in the reflective writings was done using two grading scales. Qualitative data included graduates’ perceptions of the value and effects of reflective writings on learning ACGME competencies. The quantitative and qualitative data were analysed, compared and related together to answer the research question.

Figure 1. Convergent parallel mixed-methods design to study the role of reflective writing in promoting reflective learning of ACGME competencies

B. Study Setting and Subjects

The study setting was the Internal Medicine Residency of a single tertiary university hospital in 2018. We have used reflective writing as a tool for developing reflective learning and practice in our Internal Medicine Residency. Our programme has a competency-based curriculum using the ACGME framework. Residents are encouraged to write their reflections on how an encounter or situation helped them develop one or more of the competencies. They are required to include at least two such reflective writings in their portfolio each year. The reflective writings are not graded but are read by the residents’ supervisors as part of their portfolio’s content during regular reviews and by the competency review committee during 6-monthly meetings. They provide insight into the residents’ competencies development.

We invited all past residents (27) who graduated from the programme one year earlier to participate. We used a convenience sampling method. We determined the final number of participants after data saturation was reached in the analysis of the collected qualitative data.

The study was approved by the National Healthcare Group Domain Specific Review Board (NHG DSRB) (Reference number: 2017/01219). We obtained informed consent from each participant.

C. Data Collection

We collected and analysed reflective writings from the participants’ three years of residency. We used individual semi-structured interviews to gather participants’ perceptions to avoid bias from others’ opinions. One researcher (YCC) conducted, recorded and transcribed the interviews. Box 1 shows the main questions that were asked. An interactive approach was used, and interviews conducted till thematic saturation was reached.

Box 1. Main questions asked during interviews

D. Data Analysis

Reflective writings from participants were analysed for the categories as well as frequencies of ACGME competencies covered. They were graded for levels of reflection using grading rubrics. To reduce possible interpretation bias or conflicts related to confidentiality and power relationships, grading was done by an ‘external’ co-researcher (CHT) who was a faculty member of the Neurology residency programme. Two grading scales were used. The first (Box 2) had a simple grading scale from A to F (Moon, 2004). The other grading rubric provided more categorical details and was based on that used by Tsingos et al. (2015) (Supplementary Table 1). The rubric graded the reflective writings on seven stages of reflection based on the model by Boud et al. (1985) and categories of non-reflector, reflector or critical reflector according to Mezirow’s model (Mezirow, 1991). The co-researcher read through each reflective writing and first determined if stages of ‘returning to experience’, ‘attending to feelings’, ‘association’, ‘integration’, ‘validation’, ‘appropriation’ and ‘outcomes of reflection’ were present. He then assessed if the written content related to these stages fit the descriptors for non-reflector, reflector or critical reflector as given in the rubric. Finally, he graded the reflective writing on the simple grading scale of A to F according to the descriptors given (Box 2).