Submitted: 14 July 2020
Accepted: 16 September 2020
Published online: 13 July, TAPS 2021, 6(3), 99-103
https://doi.org/10.29060/TAPS.2021-6-3/PV2343

Colleen Cheek^1,2, Richard Hays³ & Janie Smith²

¹Education and Research, Tasmania Health Service North West, Australia; ²Faculty of Health Sciences and Medicine, Bond University, Australia; ³Centre for Rural & Remote Health, James Cook University, Australia

I. INTRODUCTION

Research ability is considered important in preparing medical graduates for their future work roles, providing openness to critical inquiry and astute information management (Frenk et al., 2010). The role of knowledge integrator, facilitator, and advisor, incorporating finely-tuned judgement, reasoning and decision-making, are important in achieving the leadership expected of the profession (Frenk et al., 2010). Engaging medical students in research training has historically proven challenging, and there is variable understanding of the level expected in primary medical training.

Most medical schools in Australia have now adopted a Master’s Level ‘Medical Doctorate’ (MD) for primary medical training. Both the Australian Qualifications Framework (2013) requirements (pertaining to the level of qualification) and the Australian Medical Council (AMC) standards (pertaining to the profession) expect graduates of an MD to have understanding of research principles, process and methods, and to be able to apply these to professional practice (Australian Medical Council Limited, 2012). Many schools have interpreted this as a requirement for more intensive research training. While research knowledge and skills are integrated throughout curricula, there is substantial variation in the way these are taught, and little evidence of effective learning exists.  

Varying approaches to align courses internationally may have muddied the situation further. For example, in the UK, primary medical training is considered to meet the requirements of a UK Level 7 Master’s Degree, although most programmes have retained historical titles of Bachelor of Medicine, Bachelor of Surgery, abbreviated as BM BS or MBChB. In Canada, graduates of primary medical training are awarded the degree of Doctor of Medicine (MD) but are considered to have achieved academic outcomes at Bachelor level. In the US, graduates of primary medical training are awarded the degree of Doctor of Medicine (MD) and widely assumed to achieve Master’s level learning outcomes. European medical schools, through conformance with the Bologna Declaration, are tending toward a 2nd cycle, or Master’s degree. In the Asia-Pacific region, Singapore retains a Bachelor of Medicine, Bachelor of Surgery (MBBS), as do Malaysia (a Level 6 Bachelor degree), Japan and New Zealand. In Australia, there are some Bachelor (Level 7) programmes but most medical schools have adopted a Master’s Degree (Extended) (Level 9E) for primary medical training, conferring a ‘Medical Doctorate’ (MD). In these examples there is little correlation between learning outcome levels and programme duration, which ranges from four to six years. 

 A. Defining Learning Outcomes and the Level of Understanding Required

The most recent standards of the World Federation for Medical Education promote ‘constructively aligned’ medical education. That is, teaching activities and assessment aligned with student-centred learning outcomes where the type of knowledge, whether declarative (book knowledge) or functional (professional know-how required in the workplace), and the level of understanding required are clear. 

The level of understanding can be mapped from taxonomies of action verbs. The Structure of Observed Learning Outcomes (SOLO) is one taxonomy (Biggs & Collis, 2014). It consists of five levels of understanding that reflect increasing learning complexity. The first is pre-structural (no understanding); through uni-structural and multi-structural (representing two stages of qualitative comprehension) to relational and extended abstract. The verbs ‘order’ and ‘compute’ might describe learning action at uni- and multi-structural stages, whereas ‘construct’ and ‘extrapolate’ describe learning action at relational and extended abstract stages. Once learning outcomes are explicit, decisions about teaching activities that will allow the student to achieve the learning outcomes can be made. For example, functional knowledge verbs e.g. ‘assess’ or ‘reflect’, reflects activity performed in the workplace (ideally), or an authentic simulated environment.   

Here we provide a perspective of the research knowledge and skills required of graduates of an Australian MD to promote shared understanding of the level of learning and the key elements for orientating teaching to medical practice.

II. METHODS

To define the Individual Learning Outcomes (ILO)  relating to research competency in Australia, the Level 9E Australian Qualifications Framework (AQF) criteria and descriptors (Australian Qualifications Framework, 2013) and the AMC standards and graduate outcomes (Australian Medical Council Limited, 2012) that pertained to research knowledge and skills were collated (Appendix 1). Using the SOLO taxonomy (Biggs & Collis, 2014), the types of knowledge and the required level of understanding was determined (Appendix 2).

III. RESULTS

Three issues emerged. The first was that the highest levels of understanding required (extended abstract), pertain to functional knowledge such as critically analysing information, reflecting on and applying theory. Graduates are expected to have ‘expert’ knowledge and abilities in this area based on ‘research, experience or occupation’. This may imply that achieving the higher-level learning outcomes requires a substantial research experience, such as a completed project that engages students in all aspects of planning, conducting, and reporting research. This reflects what happens during the AQF Level 10 (doctoral level) research training and may be difficult to achieve during a Level 9E programme.    

The second was that a high level of functional knowledge (relational) is required to plan and execute project work, reflecting the more traditional, Master’s (Research) programme. This should be achievable during Master’s (extended) programmes if the learning takes place over time and provides ‘reasonable’ experience in aspects of research. For this to fit in with the clinical immersion learning experience, such projects should engage students with healthcare delivery.   

The third was that a fairly high, but lower level of declarative knowledge (multi-structural and relational) is required pertaining to scientific methods, ethical and privacy principles, and these should be heavily grounded in application to the profession. This is consistent with the inclusion of research training modules in coursework, but without a requirement to complete a research project.

IV. DISCUSSION

Medical curricula should constantly evolve to meet the perceived needs of the changing population and health systems. Cooke et al. (2010) tell us that the virtues of being curious, of being open to further learning, taking time to consider different perspectives and weigh up the options are metacognitive skills that should be developed early in medical training to cultivate lifelong learning and drive for continuing improvement in health systems. The emphasis in current medical education commentary is to provide options and electives for flexible, student-led approaches to learning.

The AMC graduate outcomes (Australian Medical Council Limited, 2012) affirm that a critical component of developing competency as a doctor is the opportunity to hone generic skills such as communication and teamwork and apply developing knowledge through authentic experience in the clinical setting. Functional knowledge is demonstrated through project work conducted (ideally) in real work settings. This experience provides opportunities to learn to adapt to unforeseen medical problems and to learn interactive and reflective skills important in achieving both specialist professional performance and life-long learning. Fostering knowledge and skills in seeking information, considering alternatives, collaborating, making decisions, planning and executing the plan may better prepare medical professionals for leadership roles that are required of responsive health systems where emerging technology and global forces are likely to drive adaptation and reform. Facets of critical inquiry, such as recognising a knowledge gap, seeking information, seeing multiple perspectives, taking time to consider alternatives and then make a judgement, are also qualities of an adaptive leader. Achieving all of this through a completed research project during primary medical education is challenging. Performing one component well may be enough if it is known how the component fits as part of the whole.

Specific requirements for knowledge and skills in research and their application are still inherent in both AQF and AMC standards. Expertise in defining a searchable question and finding and assessing the evidence are realistic and useful goals for primary medical training and are professionally relevant to the work of doctors in the 21st century. Conducting literature reviews about topics that matter to the local community can be achieved in primary training. There are models of collaboration within healthcare settings where medical students are supported in a community of practice with more senior doctors overseeing local quality improvement projects. Quality improvement projects in Primary Care offer further opportunity.

There may be other ways of achieving Master’s level learning outcomes that do not require research experience, as some students are not ready for this. Examples include project work in professional and capstone settings, where students performed skills associated with developing leadership and management competency in a range of different contexts.

V. CONCLUSION

Achieving higher-order thinking by the end of primary medical education is emerging as crucial to graduating doctors who are better prepared for managing the future challenges of healthcare. Integration of research thinking with work-based experience may be the critical attribute to foster this and may also be achieved through professional and capstone projects. There is a case for providing stronger guidance on just what is intended and achievable within the constraints of contemporary medical education. It is unlikely that the move to Master’s level programmes in Australia will on its own result in more research capable graduates; more important may be how students are introduced to research knowledge and practical experiences. However, adopting Master’s level outcomes as the endpoint may improve consistency in achievement of higher-level thinking and the inferred ability to find solutions to challenges as healthcare evolves. 

Notes on Contributors

Colleen Cheek developed the methodological framework for the study, performed data collection and data analysis as part her PhD research project, and wrote the manuscript, collated edits and approved the final manuscript.

Richard Hays reviewed the study design and interpretation and developed the manuscript, read and approved the final manuscript.

Janie Smith reviewed the design of the study and gave critical feedback to the writing of the manuscript, read and approved the final manuscript.

Funding

No funding source was required.

Declaration of Interest

We have no conflict of interest to declare.

References

Australian Medical Council Limited. (2012). Standards for assessment and accreditation of primary medical programs by the Australian Medical Council. https://www.amc.org.au/wp-content/uploads/2019/10/Standards-for-Assessment-and-Accreditation-of-Primary-Medical-Programs-by-the-Australian-Medical-Council-2012.pdf

Australian Qualifications Framework. (2013). Australian Qualifications Framework (2^nd ed.). https://www.aqf.edu.au/sites/aqf/files/aqf-2nd-edition-january-2013.pdf.

Biggs, J. B., & Collis, K. F. (2014). Evaluating the quality of learning: The SOLO taxonomy (Structure of the observed learning outcome). Academic Press.    

Cooke, M., Irby, D. M., & O’Brien, B. C. (2010). Educating physicians: A call for reform of medical school and residency (Vol. 16). John Wiley & Sons.

Frenk, J., Chen, L., Bhutta, Z. A., Cohen, J., Crisp, N., Evans, T., Fineberg, H., Garcia, P., Ke, Y., Kelley, P., Kistnasamy, B., Meleis, A., Naylor, D., Pablos-Mendez, A., Reddy, S., Scrimshaw, S., Sepulveda, J., Serwadda, D., & Zurayk, H. (2010). Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. The Lancet, 376(9756), 1923-1958. https://doi.org/10.1016/S0140-6736(10)61854-5

*Colleen Cheek
ADON Education and Research,
Tasmania Health Service North West
PO Box 258, Burnie 7320
Email: Colleen.Cheek@ths.tas.gov.au

Submitted: 17 August 2020
Accepted: 30 September 2020
Published online: 13 July, TAPS 2021, 6(3), 111-113
https://doi.org/10.29060/TAPS.2021-6-3/PV2375

Nicholas Beng Hui Ng¹, Terri Chiong¹, Perry Yew Weng Lau¹ & Marion M Aw^1,2

¹Khoo Teck Puat – National University Children’s Medical Institute, National University Health System, National University Hospital, Singapore; ²Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

I. INTRODUCTION

The Coronavirus Disease (COVID-19) pandemic caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) virus has led to significant disruptions globally with alarming mortality rates and increasing economic burden. For the medical community, aside from massive changes in workflow, healthcare worker fatigue and direct risk of infection, COVID-19 has also resulted in significant disruptions to medical training. During a pandemic, it is not surprising that manpower, financial resources and time are allocated fully to contain the disease. We believe however, that structured teaching activities amidst this crisis play an important, if not pivotal role, in keeping the medical community united and informed of the rapidly changing evidence surrounding this disease. Our department instituted measures to ensure that disruptions to post-graduate training were minimised amidst the clinical workflow changes. In this article, we share our experience of how teaching activities were sustained through implementing various strategies. We also discuss the benefits derived from ongoing teaching during this pandemic.

II. EXECUTION AND EXPERIENCE

When Singapore first announced the escalation of the Disease Outbreak Response System Condition (DORSCON) alert level from yellow to orange in response to increasing community spread of COVID-19, all healthcare institutions immediately put in place protocols and workflow to cope with the demands of COVID-19 (A Singapore Government Agency Website, 2020). Our department, a paediatric department in a university hospital, followed suit with plans for team segregation and clinical workflow protocols for children with respiratory illnesses. At the same time, all face-to-face teaching activities and meetings were suspended, in an attempt to minimise gatherings of clinicians.

The Residency Programme Director quickly formed a dedicated Education Task Force (ETF) to look into adapting the post-graduate teaching activities to take into account clinical service needs, as well as team segregation. Prior to the pandemic, our post-graduate teaching (in additional to clinical learning on the job) were largely based on face-to-face large group sessions, as well as small group clinical bedside teaching.  As the department adjusted to the new COVID-19 clinical workflow, the ETF effectively morphed the delivery of post-graduate education to cater to the education needs of residents and faculty.

Our teaching sessions have been transformed from in-person to on-line delivery via the Zoom video-conferencing platform. This has allowed residents (interns, medical officers, senior residents) from different clinical locations, who are not allowed to meet physically, to attend. An added benefit is that residents off-site may also choose to attend these teaching activities. In addition, faculty members who would previously not attend resident teaching have also been able to attend these sessions and collectively contribute to the teaching and learning process. We have been able to conduct almost all our continued medical education (CME) programmes via video-conferencing; journal clubs, mortality rounds, radiology rounds, topic reviews, history taking sessions, case-based discussions and importantly, COVID-19 clinical workflow updates.

The ETF outlined ground rules for the on-line teaching sessions at the outset: participants have to sign in with appropriate identification, unmute microphones only when speaking and respect the confidentiality of teaching materials without taking pictures or recordings unless explicit permission is obtained. In order to ensure the security of these video-conferencing sessions, each session is managed by a host, with controlled admission of participants.

A. Modified Clinical Teaching

During this pandemic, we have been able to continue clinical history-taking teaching sessions for residents with real patients via video-conferencing. In this format, one resident in the “hot-seat” takes the history from the patient remotely, while other participants observe the encounter via a live video stream from different locations. This “live” history-taking session is followed by a discussion between the resident and faculty on the patient’s clinical history as well as management. Other residents are also able to participate in the discussion. We have been extremely encouraged by the responses from patients and their families who have readily consented to these video-streaming teaching sessions. Our experience has reinforced the notion that patients are willing to participate in medical education as a means to give back to the medical community (Stacy & Spencer, 1999; Thomas et al., 1999). In a time of crisis like this, where the medical community has to quickly learn and rapidly adapt to new discoveries of COVID-19, the role of patient involvement in teaching and research cannot be better overstated.

B. Specific Mock Code Training

Aside from core teaching sessions for residents, the department quickly recognized the importance for on-the-go pandemic-preparedness training for the residents. Faculty from the critical care division has developed COVID-19 relevant mock code scenarios for residents using high fidelity simulation equipment. These sessions are conducted during designated time slots and adhere to the team segregation plans. The scenarios involve the use of powered air-purifying respirator (PAPR) equipment and personal protective equipment (PPE). Residents are given the opportunity to perform the initial clinical assessment, cardio-pulmonary resuscitation and intubation, as well as communicate with the rest of the clinical team whilst dealing with mock patient emergencies in negative-pressure isolation facilities. Many of the junior doctors as well as nurses quickly realized the added challenge of performing seemingly standard resuscitation in isolation facilities whilst in full PPE. Routine tasks such as communication between team members, preparation of drugs, use of resuscitation drug charts and even mobile phones while wearing PAPR and PPE can be extremely difficult. These simulation sessions highlighted to us that good planning, coordination and communication between healthcare workers are all the more crucial while resuscitating in a COVID-19 setting.

C. Increase Trainee Participation

An initial unanticipated benefit of this style of teaching and learning was increased trainee participation in these sessions. We noticed that a proportion of residents who would otherwise have remained silent in an open group teaching encounter were now more willing to ask and answer questions, either through their voice audio or using the chat function of the Zoom platform. What is most interesting is that when we compared our teaching attendance rates for residents at these video-conferencing CME compared to the usual face-to-face teaching, there was an increase from an average of 32% (pre-COVID-19) to 68% (during COVID-19) in daily attendance rates. This increase attendance was seen for both COVID-19 and non-COVID-19 related teaching sessions, suggesting that it was not only the COVID-19 updates that drew participation for these sessions. Contributing factors could include the ease of access afforded by learning from various (remote) locations, particularly for residents posted off-site who are unable to travel back. In addition, the Zoom video-conferencing tool is readily available on a variety of platforms, including laptops, tablets and mobile phones.

D. Limitations and Challenges

The main issue raised had been that of internet connectivity in certain areas around the hospital, but this has been rectified with specific locations allocated as “teaching hubs”.

Another shortcoming of the on-line teaching programme is that bedside teaching for clinical skills has not been possible, in the interest of staff and patient safety. The ETF has since explored other innovative approaches; using video clips of clinical signs, as well as preparing pre-taped clinical examination signs with patient and caregiver consent.

III. THE RECIPE TO SUCCESS

The feedback received from residents for this on-line delivered teaching has been extremely positive, with 42 of 46 residents rating it positively on a feedback survey. Many of our residents look forward to attending these sessions, not only as a means to learn, but also as an opportunity to connect with fellow colleagues.

We believe that our success in maintaining a relevant teaching programme during the COVID-19 pandemic is attributed also to the following factors:

• Strong teaching culture with a mission of ensuring that residents are appropriately trained.
• Faculty realising the importance of pandemic-preparedness training for residents.
• The ability to innovate and the flexibility to adjust the delivery of medical education to meet the needs of the current pandemic situation.
• The availability of reliable resources and use of latest educational technology such as the Zoom Video-Conferencing to allow delivery of web-based teaching.

IV. CONCLUSION

As our health workers continue to brave the frontline battling against COVID-19, we are frequently reminded of the importance that flexibility and adaptability is crucial during this pandemic. While we continue to deliver the best possible patient-centred care and ensure the safety of our healthcare workers amidst this COVID-19 pandemic, structured teaching in our department continues to be an important part of our daily routine. We experienced first-hand the benefits of web-based learning and would retain some of these sessions post-pandemic. The deliberate strategies taken by our department to ensure that teaching activities continue has allowed learning to persist in a structured and relevant way. Importantly, on-the-go training for pandemic-preparedness for residents is a highly valuable skill to teach during this time. We are very proud to be able to continue to learn and keep abreast the latest developments on COVID-19 as a department. As former United States First Lady, Abigail Adams so eloquently said, “Learning is not attained by chance, it must be sought for with ardour and attended to with diligence”.

Notes on Contributors

Ng Nicholas Beng Hui contributed in design, analysis and interpretation of data, drafting the article, and final approval of the version to be published. Chiong Terri contributed in analysis and interpretation of data, revising it critically for important intellectual content, and final approval of the version to be published. Lau Perry Yew Weng contributed in conception and design, and interpretation of data, revising it critically for important intellectual content, and final approval of the version to be published. Aw Marion M contributed in conception and design, and interpretation of data, revising it critically for important intellectual content, and final approval of the version to be published.

Acknowledgement

We thank Dr Dimple Rajgor for helping with in editing, formatting and in submission of the manuscript for publication.

Funding

No funding is required for this paper.

Declaration of Interest

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

References

A Singapore Government Agency Website. (2020). Additional measures introduced with DORSCON Orange Singapore. Retrieved March 10, 2020, from https://www.gov.sg/article/additional-measures-introduced-with-dorscon-orange

Stacy, R., & Spencer, J. (1999). Patients as teachers: A qualitative study of patients’ views on their role in a community‐based undergraduate project. Medical Education, 33(9), 688-694.

Thomas, E. J., Hafler, J. P., & Woo, B. (1999). The patient’s experience of being interviewed by first-year medical students. Medical Teacher, 21(3), 311-314. https://doi.org/10.1080/01421599979608

*Ng Nicholas Beng Hui
Khoo Teck Puat-National University
Children’s Medical Institute,
National University Health System,
1E Kent Ridge Road,
NUHS Tower Block Level 12,
Singapore 119228
Email: nicholas_bh_ng@nuhs.edu.sg

Submitted: 19 July  2020
Accepted: 7 October 2020
Published online: 13 July, TAPS 2021, 6(3), 67-74
https://doi.org/10.29060/TAPS.2021-6-3/OA2347

Tess Lin Teo, Jia Hao Lim, Choon Peng Jeremy Wee & Evelyn Wong

Department of Emergency Medicine, Singapore General Hospital, Singapore

Abstract

Introduction: Singapore experienced the COVID-19 outbreak from January 2020 and Emergency Departments (ED) were at the forefront of healthcare activity during this time. Medical students who were attached to the EDs had their clinical training affected.

Methods: We surveyed teaching faculty in a tertiary teaching hospital in Singapore to assess if they would consider delivering clinical teaching to medical students during the outbreak and conducted a thematic analysis of their responses.

Results: 53.6% felt that medical students should not undergo clinical teaching in the ED and 60.7% did not wish to teach medical students during the outbreak. Three themes arose during the analysis of the data – Cognitive Overload of Clinical Teachers, Prioritisation of Clinical Staff Welfare versus Medical Students, and Risk of Viral Exposure versus Clinical Education.

Conclusion: During a pandemic, a balance needs to be sought between clinical service and education, and faculty attitudes towards teaching in high-risk environments can shift their priorities in favour of providing the former over the latter.

Keywords:           Disease Outbreak, Pandemic, Faculty, Medical Students, Attitudes, Clinical Teaching, Emergency Medicine

Practice Highlights

• In a pandemic, a balance needs to be sought between clinical education and risking learner exposure to the virus.
• A crisis situation can affect educators’ priorities and attitudes towards the provision of clinical education, in favour of providing crucial clinical services.

Since the first reported cases of COVID-19 infections in Wuhan, in December 2019, the month of January 2020 saw Singapore’s Ministry of Health (MOH) issue guidelines and implement a series of calibrated defensive measures to reduce the risk of imported cases and community transmission (Lin et al., 2020; WHO, 2020). Singapore has a Disease Outbreak Response System Condition (DORSCON) framework, which guides the nation’s response to various emerging infectious diseases outbreaks. The four-level colour-coded system of Green, Yellow, Orange and Red, describes the increasing severity of the outbreak in the community  (Quah et al., 2020).

The Department of Emergency Medicine (DEM) of Singapore General Hospital saw 130 000 visits in 2019 (SGH, 2019). It hosted 158 medical students (MS) through the year. Aside from some elective students, the majority were in their second year of clinical postings. Formal clerkships consisted of four weeks of clinical exposure in which they were expected to clerk and present cases to teaching faculty and perform minor procedures such as intravenous cannulation and insertion of bladder catheters etc., with about nine hours of classroom tutorials.

In early January 2020, DORSCON yellow was declared, indicating either a severe outbreak outside Singapore or that the disease was contained locally with no significant community spread (Quah et al., 2020). All DEM staff were required to wear personal protective equipment (PPE). Hospital elective surgeries were postponed. Other outbreak measures included setting up new isolation areas for patients. DEM staff had their leave embargoed to ensure that there was adequate manpower to staff these areas in anticipation of a gradually worsening outbreak (Chua et al., 2020).

On 7 February 2020, the outbreak alert rose to DORSCON Orange (DO) as there were cases of community transmissions (Quah et al., 2020). Based on previous experience managing the Severe Acute Respiratory Syndrome (SARS) outbreak 17 years prior, the DEM transitioned to an Outbreak Response Roster, where physicians and nurses of the DEM were split into teams that worked 12 hour shifts, with no overlapping shifts, hence limiting staff contact to only those within their teams (Chua et al., 2020). With DO in effect, the department needed to come to a rapid decision about whether or not to accept MS in the ED. A group of 12 MS that the DEM was supposed to host this April already had their clerkship cancelled due to concerns of breaching infection control and safe distancing measures. There have been no studies to date on faculty attitudes towards clinical teaching of MS during a pandemic, although papers have been published about students’ attitudes towards clinical training during disease outbreaks. The Clerkship Director conducted a short and focused survey amongst the faculty between the 27th-29th of March, amidst rising public concerns that the country might soon be locked down, to explore their attitudes on having MS clerkships during the COVID-19 pandemic. The results of this survey allowed the Director to quickly understand the sentiments of the faculty and thus decided that an entirely remote, online teaching program would be created instead. 9 days after the survey, on the 7th of April, the Singapore government officially announced the implementation of a lockdown, known locally as a ‘circuit breaker’ (Quah et al., 2020).

II. METHODS

Clinical teachers of the DEM were issued an anonymous survey over a period of three days via an online survey tool, SurveyMonkey (www.surveymonkey.com). Participants were informed prior to completing the survey that it was anonymous, and by proceeding with the survey they consented to the results being used for research purposes. The data collected included their professional appointments in the department and two yes/no questions: “Do you think medical students should be performing their EM clerkship during DO?” and “Are you keen on teaching MS clinically during DO?”. Participants answering “No” to the latter were asked to elaborate. All participants were asked to write about any concerns they had about having MS in the emergency department (ED) during DO. No other personal identifying information was sought. The survey was deliberately kept short and easy to answer to promote staff participation within the short timeframe the DEM had to make the decision about accepting students. Informed consent was waived as per the Institutional Review Board (IRB).

A simple descriptive quantitative analysis of responses to the 1^st two yes-no questions identified the overarching sentiment of the department towards hosting MS during DO and was followed by a thematic analysis of the free-text answers to the last two open-ended questions (Braun & Clarke, 2006).

As many participants used the last question (‘any other comments?’) to emphasise or elaborate on the preceding question (‘why aren’t you keen to teach?’), the majority of the qualitative data gathered pertains to the issues of having MS in the department during DO. There was a paucity of data detailing why participants were in favour of teaching MS, as the survey did not specifically ask this. Hence, the authors chose to focus on analysing the responses of participants who were not keen to teach during this time. This analysis yielded three different themes. However, a small number of respondents supportive of MS felt strongly about teaching and volunteered their reasons in response to the last question. While this data is insufficient to support a robust thematic analysis, a small section is included at the end in order to present as complete a discussion as possible.

III. RESULTS

A. Participant Background

Participants consisted of Emergency Medicine (EM) specialists, permanent registrars or middle grade staff and EM senior residents. These groups were chosen because they each hold significant roles, such as being named supervisors or clinical instructors of MS, and have considerably more contact time with MS in the DEM as opposed to nursing staff or junior doctors.

B. Quantitative Results

A total of 28 out of 45 (62.3%) responses were recorded. Except for two individuals, all other respondents in favour of hosting MS in the ED during DO (46.4%) were also keen to teach them. About two-thirds of the participants (60.7%) were not keen to teach MS during DO. However, of this latter group, 23.5% of respondents offered (without prompting) a compromise – where they proposed teaching only during the relatively less busy night shifts, in their response to ‘Any other comments?’  Table 1 shows the breakdown of responses.

C. Qualitative Results – Reasons Against

Each of the three themes presented here begins with a short paragraph that describes the situational context in which this survey took place, followed by a series of selected statements, and ends with a general summary and discussion of the responses within the respective theme. In order to maintain the authenticity of the data, each response is reproduced verbatim, sometimes in Singlish, the local colloquial variety of Standard Singaporean English (Bokhorst-Heng, 2005). Any edits to the text for clarification purposes have been clearly identified.

1) First theme: Cognitive overload of clinical teachers– There is only so much one can handle: Emergency physicians are no strangers to high stress environments, and are aware that as frontline workers they will be at the forefront in dealing with any emerging infectious disease. The move into DO represented the shifting of the local virus epidemiology from predominantly imported cases that could be easily identified and isolated, into the community-at-large. With this shift came changes to existing workflows and the re-arrangement of department space to form isolation areas for treating potential infectious cases. The implementation of a strict team-based roster described earlier meant that almost half the entire department would not physically meet the other half, and a surge in manpower requirements saw many junior doctors from other departments being rotated into the ED to help tackle the increased clinical load. Being new to the DEM, these new doctors required more supervision and assistance in adapting to the unfamiliar work environment. Responses that supported this theme include:

“High clinical load, long hours. Already cognitively overloaded. Not conducive for teaching. New [junior doctors] need to be taught also.”

Participant #6, Specialist

“Focus on daily evolving challenge first.” and in response to the last question “Please no.”

  Participant #2, Senior Resident 

“During DORSCON ORANGE we are in stress, if clinical teaching sessions start then other [doctors’] stress and workload level will increase.”

Participant #25, Staff registrar

“May be more a hassle if we have to look after the new [junior doctors] rotating and students [as well].”

Participant #4, Specialist

“We are also in a 12-hour outbreak roster which is physically, emotionally and mentally draining. Teaching students in this environment is far from ideal” and in response to the last question “Am fairly strongly against this idea”.

Participant #8, Specialist

“Day shifts no bandwidth to teach […] also can’t pay attention to [medical students] during day shifts, too tiring and too busy […] but I feel I can’t do [medical students] justice because I can’t debrief after a shift either, too tired.”

Participant #17, Specialist

Many of these responses conveyed a sense of exhaustion, reflecting the toll that constant workflow changes, longer work hours and relative social isolation was taking on the faculty. Teaching and supervising MS appeared to be viewed as a “hassle” or “extra work”, an additional drain to a clinical faculty’s energy during a busy and stressful shift.

This brought the department to a discussion on the provision of clinical services versus clinical education – whether teaching the next generation of future doctors was as important as treating the patient in front of us. One school of thought held that as clinician educators, physicians should – as the name implies – be clinicians first before educators. However, the interplay between these two roles is likely dependent on the faculty’s attitudes towards learners, as will be described later. Being cognitively overloaded naturally results in a shuffling of One’s priorities, which is seen next.

2) Second theme: Prioritisation of staff welfare – whose welfare is more important, staff or students? : It is well known that mental health can be adversely affected in crisis situations, and as the COVID-19 situation unfolded, boosting morale and maintaining the welfare of all staff became an important consideration (Matsuishi et al., 2012; McAlonan et al., 2007). At the forefront of this effort was the need to provide the staff with a supply of good quality personal protective equipment (PPE) so the staff would feel safe and confident in existing infection control measures. Although Singapore had yet to experience a shortage of PPE, there was still a concerted effort made by all hospitals to conserve these resources. Staff wellness was a theme seen in several responses:

“[I] can’t do the [junior doctors] justice because having a [medical student] attached to them is another stressor in an already stressful shift.”

Participant #17, Specialist

“Having to keep our doctors and nurses safe takes up a lot of energy. Students are young and naïve and will require even more time and resources to ensure they are safe.”

Participant #22, Specialist

“Furthermore, they will need to use PPE and again this should be conserved during the period of the outbreak.”

Participant #27, Specialist

“Medical students are important for future but I feel staff currently working in the department should be look after well.”

 Participant #25, Staff registrar

“Waste PPE.”

Participant #20, Specialist

The importance of conserving PPE during a pandemic is undisputed and the concern that MS would use them up is valid. It was interesting to note in these responses hints of an “us-versus-them” mentality, where MS were seen as competition for the limited resources of PPE, time, and energy. Students were not viewed as part of the DEM team and perceived more as “stressors”, who required attention because they were “young and naïve”, and their use of PPE was viewed as a “waste”. This identification of an “in-group” of staff and an “out-group” of students led to a prioritisation or favouring of the former over the latter. This behaviour can be explained by the Social Identity Theory (SIT), which states that part of an individual’s self-image or self-concept is derived from the social groups to which they perceive themselves to belong to (Hogg & Reid, 2006; Tajfel & Turner, 1979). Thus, in order to maintain a positive self-image, there is a tendency for people to favour the in-group and discriminate against the out-group. This phenomenon was famously demonstrated by Tajfel et al in their Minimal Group Paradigm studies, which essentially showed that the mere perception of belonging to one of two distinct groups was enough to trigger social discrimination between the groups (Tajfel et al., 1971). Behaviour like this is indicative that a significant number of the department hold the belief that there is a distinct divide between students and staff, rather than seeing MS as belonging to the wider group of the medical fraternity. Creating such a divide between staff and student is problematic because it hinders effective teaching, especially because MS will eventually transition from the “out-group” of students to the “in-group” of staff upon graduation, and clinician educators are responsible for providing a safe environment for them to learn in. However, beyond this discussion of intergroup competition, there were concerns amongst the faculty with regards to the appropriateness of siting clinical learning in the high-risk, front-line location of the ED in a pandemic, as discussed in the next theme.

3) Third Theme: Risk of viral exposure vs clinical education – What is the price to pay and who pays it?: During the initial period of DO, medical schools pulled MS out of the clinical environment and moved to online learning, with the aim of protecting them from unnecessary exposure to the virus and for safe distancing. However, when they proposed that students be allowed back into the hospitals after undergoing PPE training, this risk of exposure had not changed, as the number of positive cases was rising daily still. Responses that reflected this theme included:

“Don’t think it’s appropriate to have students around in a high-risk environment.”

Participant #4, Specialist

“Having medical students around not only will expose them to infection it will also compromise the rest of the staff in the event of a breach in infection [protocols]. Also, them just hanging around & not allowed to have hands-on [participation] in the procedures, clerking, [patient] contact etc will not be of any benefit [to them] at this time.”

Participant #7, Senior Resident

“Student safety issue. No minder to ensure students’ adherence to strict PPE as Doctors and Nurses will be busy with clinical service.”

Participant #11, Specialist

“I think medical students are not providing clinical care to patients and having them in the ED increases risk to patients (without the attendant benefits) and increases risk to themselves (without the moral obligation to do so as doctors) and their family.”

Participant #27, Specialist

“Can students be [held] responsible for their own health? Or the school or the department? As doctors, we know it as our duty and occupational hazard. But as students – their duty is to learn (best done in a safe environment), not put their health at risk.”

 Participant #6, Specialist

Responses that addressed the risk of virus exposure in the ED could be divided into two groups –those that were predominantly concerned about the students themselves catching the virus, and those that were more concerned about the consequences of such an event. The risk of catching the virus was seen as too high a cost – one that was borne not only by the individual student but by the patients and the staff as well. The benefits of clinical bedside instruction were called into question, as students’ movements would be restricted to low or medium-risk areas only. More than one participant raised the potential issue of students breaching infection control protocol or needing supervision in donning their PPE, despite reassurances given that schools would send MS for PPE training. This reflected a lack of trust in MS – themselves adult learners – who could be reasonably expected to understand the importance of infection control protocols. It begs the question of how big a role the educator plays in the personal safety of a MS and that of the patients and staff they interact with.

D. Qualitative Results – Reasons For

The survey design did not specifically ask responders about their reasons for supporting teaching MS during this pandemic. However, some participants felt strongly enough about this to advocate for clinical postings. Their reasons are shared below.

1) Theme: For the sake of tomorrow – In defence of teaching amidst a crisis:

“I feel we can still provide a meaningful learning experience for these students. We just need to lay out clear instructions and precautions for them to follow. It is a good opportunity to show to students how emergency medicine is adaptive, versatile, and for them to appreciate how quickly workflows can change, or how triage works in a disaster setting.”

Participant # 15, Specialist

“The way it is done has to be different […] the traditional method of teaching, where the students look to the seniors and may expect some form of spoon feeding […] Only when this mind-set is removed, will the tutors […] look at them as part of the team and incorporate them […], and will students see […] themselves as Drs to be [sic], practice safe habits from the very start and protect themselves as the patient’s doctor. This sense of ownership, accountability, professionalism can be started from that stage as a medical student. This is the perfect opportunity to state that this is what is expected and groom them likewise.”

Participant #19, Specialist 

“I feel that the teaching should as much as possible be a simulation of working life and that working in high-risk areas such as these gives a semblance of pressure which cultivates good habits such as mindfulness of hand hygiene, donning of PPE etc.”

Participant #26, Senior Resident

The responses share a commonality of seeing the pandemic as an opportunity for modelling positive attitudes that would benefit the student in the future. This point of view advocates for the acknowledgement of the realities of being a doctor and assumes that students are already part of the “in-group” of the medical team rather than the “out-group” as seen in the earlier discussion.

IV. DISCUSSION

A. Limitations

This study has its limitations, chiefly being the lack of qualitative data representing the opinions of those who were keen to teach MS as the initial survey was conducted with the purpose of gauging whether or not the department would be open to receiving MS during DO. This lack of data meant that this study is at best a one-sided representation of the department’s opinion.

Additionally, all four of the authors have a keen interest in the education of MS and two of the authors are actively involved in faculty development. They were all both participants in the study as well as its evaluators. Prior to evaluation of results, the authors themselves suspected that majority of the faculty would be too overwhelmed with the changes the pandemic wrought to want to teach students, which may have contributed to confirmation bias in the analysis of the data. However, throughout the analysis, every attempt was made to ensure that the themes uncovered remained true to the data, and much of the original data was reproduced here faithfully to maintain transparency, such that the reader may draw their own conclusions.  

Another limitation of the study was that the survey was unable to measure shifts in the attitudes of faculty as the pandemic evolved, which would have allowed us to understand the amplitude of the effect of the pandemic itself more clearly.

B. New Insights

It was worth noting that nearly two-thirds of the department did not want to teach MS during DO, despite each participant having taught MS routinely prior to this pandemic. Initial analysis of the reasons given for this refusal revealed three distinct themes of Cognitive Overload of Teachers, the need to Prioritise Staff Welfare and the Risk of Viral Exposure to Students – themes that are transferrable to many departments involved in pandemic response, regardless of locality.

Expounding further on this topic, it can be seen in some of the responses detailed under the themes of Cognitive Overload and Prioritising Staff Welfare, that there was a perceived increase in the need to supervise the new junior doctors rotating into the department on short notice (as opposed to the junior doctors who were already in the middle of their rotation and thus more familiar with the department’s protocols). This supervision is an important component of the continuing clinical education of junior doctors, which in itself is part of a larger debate surrounding the competing aims of clinical service versus clinical education that has been ongoing for many years (Woods, 1980). It is often the case in EM that when overwhelmed with patients, clinical education is sacrificed for clinical service without much short-term complications. Indeed, even amongst EM residents, more research is needed to define the optimal balance between service and education (Quinn & Brunett, 2009). However, a pandemic presents a rather unique situation in that most junior doctors will not have worked in a pandemic before. Thus, the need to educate junior doctors on both pandemic response and the importance of personal safety – with its direct impact on patient safety – now cannot be sacrificed without directly affecting the provision of clinical service.

It is beyond the scope of this paper to comment on whether educating MS on pandemics through clinical immersion programs during a pandemic better prepares them for future outbreaks, or in the broader sense, whether the clinical education of today’s MS by immersive learning can bolster the clinical service of tomorrow’s junior doctors. In fact, it seems almost premature to consider this question given the paternalistic attitude many of our faculty appeared to have towards students, perceiving them as learners to be looked after – to the extent that they could not even be trusted with their own safety and that of the patients and staff they interact with. Interestingly, this view seems to be shared by MS themselves – an electronic survey conducted at one of Singapore’s medical schools showed that a third of currently enrolled MS were concerned that they might introduce possible risks to the patient should they return to the clinical setting (Compton et al., 2020). These findings are indicative of a more deeply rooted mindset in which the social hierarchy draws a clear line between Teacher and Student. This becomes clearer when one considers that in Confucian Heritage Cultures such as Singapore (Biggs, 1998), the teacher holds great authority and students brought up in such cultures tend to defer to such authority as a matter of course (Ho, 2020). Given the multiple factors that contribute to this debate, it is unlikely that we will be able to arrive at a clear answer without further research, but what is certain is that medical students are not essential workers and, in a pandemic, medical schools need to balance their educational needs and ethical obligations to keep students safe (Menon et al., 2020).

Within our paper, it is heartening that many participants who were not keen to teach still tried to offer a compromise of teaching during the relatively less busy night shifts instead, and that 46% of our department were willing to accept MS during this period. COVID-19 allowed us to uncover some of the underlying attitudes towards MS and to consider them in the context of Singapore’s cultural heritage. These attitudes are important for us to address if we are to improve the delivery of medical education in the ED and we would like to invite the reader to consider whether the same uncovering has occurred in their respective departments.

V. CONCLUSION

The balance between clinical service and clinical education is a precarious one that appears to shift quickly in favour of the former in the high-risk environment of an evolving pandemic, which presents significant challenges even for experienced educators to overcome. As seen in our paper, cognitive overload of educators and the need to prioritise the welfare of junior staff inexperienced in pandemic response takes clear precedence over the education of MS. The paternalistic view that majority of our faculty hold leads to doubts about the ability of MS to keep themselves and their patients safe from virus exposure, doubts that are surprisingly shared by MS as well, and is indicative of the social hierarchy deeply ingrained in Confucian Heritage Cultures such as Singapore and surrounding countries in the region, where students tend to defer to authority as a matter of course. In order to improve as medical educators, we must place further effort into uncovering the underlying attitudes of both faculty and MS and address them in ways specific to our cultural heritage.

Notes on Contributors

Author Teo TL analysed the transcripts, conducted the primary thematic analysis and wrote the manuscript. Author Lim JH co-wrote the manuscript. Author Wee JCP conducted the literature review and developed the manuscript. Author Wong E designed and conducted the study, performed the data collection and developed the manuscript. All the authors have read and approved the final manuscript.

Ethical Approval

IRB approval for this study was obtained (SingHealth CRIB reference number 2020/2134).

Acknowledgement

The authors would like to acknowledge all participants of the survey.

Funding

No funding sources are associated with this study. 

Declaration of Interest

All authors work in SGH DEM and answered the survey as participants.

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*Evelyn Wong
Department of Emergency Medicine,
Singapore General Hospital
Outram Road
Singapore 169608
Email: evelyn.wong@singhealth.com.sg

Submitted: 30 August 2020
Accepted: 9 December 2020
Published online: 13 July, TAPS 2021, 6(3), 56-66
https://doi.org/10.29060/TAPS.2021-6-3/OA2440

Gayathri Devi Nadarajan¹, Kirsty J Freeman², Paul Weng Wan¹, Jia Hao Lim¹, Abegail Resus Fernandez² & Evelyn Wong¹

¹Department of Emergency Medicine, Singapore General Hospital, Singapore; ²Office of Education, Duke-NUS Medical School, Singapore

Abstract

Introduction: COVID-19 challenged a graduate medical student Emergency Medicine Clinical Clerkship to transform a 160-hour face-to-face clinical syllabus to a remotely delivered e-learning programme comprising of live streamed lectures, case-based discussions, and telesimulation experiences. This paper outlines the evaluation of the telesimulation component of a programme that was designed as a solution to COVID-19 restriction.

Methods: A mixed methods approach was used to evaluate the telesimulation educational activities. Via a post-course online survey student were asked to rate the pre-simulation preparation, level of engagement, confidence in recognising and responding to the four clinical presentations and to evaluate telesimulation as a tool to prepare for working in the clinical environment. Students responded to open-ended questions describing their experience in greater depth.

Results: Forty-two (72.4%) out of 58 students responded. 97.62% agreed that participating in the simulation was interesting and useful and 90.48% felt that this will provide a good grounding prior to clinical work. Four key themes were identified: Fidelity, Realism, Engagement and Knowledge, Skills and Attitudes Outcomes. Limitations of telesimulation included the inability to examine patients, perform procedures and experience non-verbal cues of team members and patients; but this emphasised importance of non-verbal cues and close looped communication. Additionally, designing the telesimulation according to defined objectives and scheduling it after the theory teaching contributed to successful execution.

Conclusion: Telesimulation is an effective alternative when in-person teaching is not possible and if used correctly, can sharpen non-tactile aspects of clinical care such as history taking, executing treatment algorithms and team communication.  

Keywords:           Telesimulation, COVID-19, Emergency Medicine, Programme Evaluation

Practice Highlights

• Telesimulation doesn’t replace but can be an effective alternative when in-person teaching is not possible.
• When implemented correctly, it can sharpen non-tactile aspects of clinical care.
• It is possible to achieve a level of fidelity and realism in a telesimulation environment.
• Simulation faculty needs to be skilled in debriefing techniques that enable the learner to reflect.
• Limitations of telesimulation can be reframed as learning opportunities.

I. INTRODUCTION

COVID-19 brought about unexpected challenges to medical education, especially to student clinical clerkships where medical students would spend time within a clinical discipline, interacting with clinicians and learning from patients. Healthcare institutions restricted student movement within clinical environments and barred students from entering the high-risk frontline areas to reduce exposure risk.

Prior to COVID-19, students undertaking an Emergency Medicine (EM) Clinical Clerkship, would have the opportunity to manage and deliver care to high acuity patients, with bedside teaching, small group tutorials, problem-based learning and simulation modalities. With COVID-19, students were not permitted into the Emergency Department (ED) and face-to-face teaching activities were halted. Hence this clerkship had to be conducted remotely. The EM clerkship was transformed from a 160-hour clinical programme to a remotely administered programme comprising 40 hours of e-learning, 40 hours of interactive live online session and 15 hours of telesimulation. As part of this programme, we decided to utilise telesimulation to help students achieve some of the objectives of a clinical clerkship.

Telesimulation is defined as the “Process by which telecommunication and simulation resources are utilised to provide education, training and/or assessment to learners at an off-site location” (McCoy et al., 2017). By allowing simulation to be conducted through devices such as the computer and phone, it mitigates the problem of physical proximity. Though telesimulation has existed for about a decade, its utilisation appears limited to the rural settings and studies mainly describe its usage for learning skills (Mikrogianakis et al., 2011; Naik et al., 2020; Okrainec et al., 2010) rather than for emergency management of patients. With the need to adapt teaching to remote experiences, telesimulation is gaining popularity (Sa-Couto & Nicolau, 2020).

A. Programme Overview

This remote learning programme was developed in a tertiary ED in Singapore which receives both undergraduate and postgraduate medical students for their EM clerkship. There were 58 postgraduate medical students undertaking their 4-week EM clerkship in June 2020. The EM core clinical training curriculum was taught by EM faculty via online modules and interactive classroom sessions delivered via the video conferencing platform, Zoom. The learners spent the mornings in interactive online sessions with faculty, and afternoons in self-study as part of a flipped classroom learning, using provided learning materials. The telesimulation session was scheduled in the last week, over five days. The students were split into ten groups each comprising of five to six students, where two groups participated in one telesimulation session each day.

Our objectives for this telesimulation programme was to ensure that the students could take a focused clinical history from the simulated patients, communicate with them, construct a list of differentials and manage them  accordingly in the emergency setting. The secondary objectives were to train them to prioritise the investigations and management of critically ill patients and to communicate and work effectively within a team. Using Kern’s six step approach, the team of simulation and clinical educators’ planned and implemented the telesimulation activity to achieve these outcomes (Harden et al., 1999; Smith & Dollase, 1999) during their EM clerkship.

As medical students, the learners are at a novice stage according to The Dreyfus Model of Skill Acquisition (Benner, 2004; Dreyfuss & Dreyfus, 1980). Hence, the deliberate attempt not to assess skills such as intubation or defibrillation through telesimulation as it may create unnecessary anxiety and feelings of incompetence (Papanagnou, 2017). Furthermore, it was deemed challenging to conduct procedural skill teaching through this modality. Instead, the focus was on clinical reasoning and patient management. The clinical students fall under the category of “show how” within the Miller’s pyramid, with regards to history taking, clinical reasoning and management. As adult learners, a problem centred (Knowles, 1990), experiential learning approach (Kolb, 1984) would be more valuable. Hence telesimulation was an appropriate modality. 

Each telesimulation session was conducted by two simulation and one physician faculty. There was a total of four scenarios for each session, where one group, consisting of five to six students, will participate in the scenario, while the other group observes, before switching. This allowed each group of students to participate in two clinical scenarios. The topics chosen for telesimulation were Anaphylaxis, Cardiac Arrest, Meningitis, and Syncope where the theory was covered in the core topics in the preceding weeks. Each of these scenarios began with the students taking a history from the simulated patient, before the patient progressively deteriorated and required resuscitation. Figure 1 shows a summary of the scenarios. The scenarios were selected as they did not require much procedure-based interventions (e.g. chest tube insertion in a poly trauma victim) which would be difficult to assess via Zoom.

Figure 1. Brief case description of simulation scenarios and visual presentation of the flow of the telesimulation experience

The sessions commenced with a briefing where the students were orientated to the online environment, including the use of video and microphones. As depicted in Figure 1, using the share screen feature, the simulation technician switched between different views. The briefing included a photo of the patient as a visual cue, along with the text of the presenting case. One of the simulation faculty played the circulating nurse, providing prompts to aid students’ engagement and asking participants to clarify their statements or orders as the scenario progressed. Using existing mannequin software and ensuring sharing of screen sounds, real-time patient monitoring was provided to the learners when requested. Upon request, additional visual cues of investigation results would be displayed, reverting back to either a picture of the patient or the patient monitoring. With their video off, the clinical faculty voiced the patient. At the conclusion of the scenario, all participants and faculty turned their video and microphones back on to participate in the large group debrief before proceeding on to the next scenario. 

The objective of this paper is to describe the students’ experience of telesimulation as part of an online clerkship programme and how such techniques can be used to meet learning outcomes (Harden et al., 1999) in various settings. At the time of writing, there is no literature describing evaluation of the use of a telesimulation programme within the ED for medical student education, with this paper aiming to address this gap.

 II. METHODS

A mixed methods approach was used to evaluate the introduction of telesimulation to the EM online clerkship, and to gain students’ perspective on learning through telesimulation. Programme evaluation research aligns with a mixed methods approach as the collection of both quantitative and qualitative data provide a deeper understanding of the student experience (Cohen et al., 2011).

A. Participants, Data Collection and Analysis

58 final year medical students who participated in the EM Online Clerkship programme were invited to participate in a post-telesimulation activity evaluation survey. Using a 5-point Likert scale, students were asked to indicate their agreement on 11 items addressing pre-simulation preparation, their level of engagement, confidence in recognising and responding to the four clinical presentations and telesimulation as a tool to prepare for working in the clinical environment. Seven open-ended questions were asked to enable the students to describe their experience in greater depth. 24hrs after completing the telesimulation session, students received an email with a link to the survey. Qualtrics online survey software was used to build, distribute and collect the survey responses. Voluntary consent was assumed by participation in the anonymised online evaluation. A statement outlining the purpose of the survey was included at the start of the survey and require an agreement before the survey could be commenced. Completion of the survey therefore implied consent.  The survey took between three and five minutes to complete, all responses were anonymous, with no identifiable data collected.

Descriptive statistics was used to analyse the responses to the Likert scale questions, with thematic analysis of the open-ended survey questions. Author one (GN) and author two (KF) reviewed the transcripts separately, making note of key phrases, outline possible categories or themes. Both authors then jointly rearranged and renamed the codes, developing higher order themes. NVivo 12™ was used to store, code and manage the qualitative data.

III. RESULTS

Of the 58 students who were invited to participate in the survey, 42 complete responses were received, a response rate of 72.4%. As seen in table 2, the results demonstrated that 97.62% of respondents agreed/strongly agreed that participating in the telesimulation session was interesting and useful to their learning. In relation to the use of visual and auditory cues, 93% of respondents felt that these helped them engage in the simulation. In relation to their level of preparedness to participate in the telesimulation experience, nearly 17% of respondents reported that the pre-session handout did not adequately preparing them for what to expect in the session.

Table 1. Results of the student responses to the Likert scale items

When asked to rate if they felt more confident recognising and responding to the four clinical presentations (anaphylaxis, cardiac arrest, meningitis, and syncope), between 90% and 93% agreed/strongly agreed that participating in the telesimulation sessions resulted in them feeling more confident in recognising and responding to the specific clinical presentations (Figure 2).

Figure 2. Student rating to the question “I feel more confident in recognising and responding to a patient with …”

Four key themes were identified following the data analysis of the open-ended survey questions, describing around the telesimulation experience of the respondents: 1) Fidelity; 2) Realism; 3) Engagement; and 4) Outcomes. As demonstrated in Figure 3, the themes do not exist in isolation, but intersect as they describe the telesimulation experience that the students had. The students feedback reflected the benefits and limitations which fall under these main themes.

Figure 3. Themes reflecting the students experience with telesimulation

A. Fidelity – Physical, Psychological and Conceptual

The theme Fidelity reflects how closely the telesimulation mimics or reproduces, reality.  Subthemes of conceptual, physical and psychological fidelity were also reflected. The students’ feedback reflected limitations in physical fidelity while conceptual and psychological fidelity was present mostly.

They reported that the auditory and visual stimulus from the dynamic display of investigations and real-time vital signs monitoring, provided a high level of physical fidelity.        

“Auditory and visual information on patients’ vitals and results were really helpful in generating the differential list.”

Student 37 

“The noise and sights is a good proxy for real life cases in a virtual environment.”

Student 4 

“Seeing the vitals of the patient in real-time allows us to experience the importance of time in managing critically ill patients”

Student 20 

However, aspects of physical fidelity, particularly related to the patient assessment, were reported as challenging via telesimulation. With the patient represented as a static picture, voiced by the clinical faculty, students shared how the lack of non-verbal and visual cues from the patient impacted their ability to perform a physical assessment of their patient.

“….we don’t get to observe the body language of the patient as much as we would like”  

Student 12 

“More difficult than in real life. Seeing and hearing a real patient gives much information”

 Student 15 

“I think what is lacking is being able to visually evaluate the patient”

Student 21

In terms of the level of psychological fidelity, the auditory cues from the ‘patient’ and the real-time vital signs monitoring simulated the ED resuscitation room, which appears to have instilled a similar sense the stress and the need to think under pressure, as reflected by the students’ feedback.

“Have to work around the distractions of beeping monitors, seizing patient, teammates asking questions/suggestions.”

Student 33

“It’s dynamic and gives us the opportunity to think under pressure.” 

Student 13 

“Stressful but probably close to reality?” 

Student 35

The students’ statements reflected the subtheme of conceptual fidelity, where they felt the context and sequence was similar to what they would encounter in the ED, where they are required to deliver timely and lifesaving treatment. This was possibly because the faculty made deliberate attempts to ensure that events during the simulation would unfold as it usually would in the ED room, based on the learners’ actions. 

“It simulates a clinical environment with real time updates of vitals and test results in addition to the history and communications.”

Student 5 

What the students did report struggling with however, was the limitations of the platform in terms of multiple actions occurring simultaneously. Unlike in real life, multiple tasks could not be performed at the same time over the online platform, and this impeded the conceptual fidelity.

“In reality, multiple interventions would be carried out in tandem.”

Student 35 

“More challenging to perform tasks concurrently over Zoom.”

Student 36 

“…many things cannot occur concurrently.”

Student 2

B. Realism

The theme Realism captures the degree to which the experience represented details or situations in a way that is accurate or true to life. Students reported that aspects of the telesimulation experience represented what they thought an actual ED encounter would be like.

“I think the process is similar to the actual clinical environment, it is difficult, especially when the patient is deteriorating in front of you, and your team are waiting for you to make the decisions.”

Student 41

“The pictures/videos and the beeping of the monitor, they make it more real”.

                                                                           Student 42 

“It was realistic as getting the differentials was time sensitive”.

Student 13

The students also acknowledged the limitations in achieving realism presented by telesimulation as the various team members could not perform tasks simultaneously and take in cues from the patient to assess the outcome of their actions. 

“Harder to communicate with my teammates compared to real life because only one person could speak at a time while in real life, multiple conversations could be occurring”

                                                                           Student 3 

“More difficult than taking a history in real life – more technical issues (can’t hear properly), Can’t see the patient”

Student 8 

C. Engagement

The theme Engagement relates to the level of interest, attention and involvement in the learning experience. The level of fidelity and realism impacts the level of engagement of the learners. Most students were able to immerse themselves and fully engage in the scenarios, possibly because aspects of fidelity and realism were deliberately given close attention during the preparation phase.

“I actually forgot that the patient was being voiced by the clinical tutor”

Student 41

“My heart was racing doing the simulation – what will I be like when I am there for real?”

                                                                           Student 41

However, on the downside, without being together in the same place, some felt that the scenario was too “messy” and “chaotic” and found it difficult to follow.

“It was a little hectic with the many other ongoing tasks in the background”

                                                                           Student 6 

“Easier to detach oneself from the patient (less affected by patient’s appearance, tone of voice, blood, gore, suffering etc.)” 

Student 28

 

At the same time, some students faced technical difficulties, such as small or flickering screen, poor internet connection or poor audio, which were barriers to their engagement.

“…there were some issues hearing the faculty clearly which may affect the quality of learning.”

                                                                           Student 6 

By addressing the concepts of realism and fidelity, the students reported increased levels of engagement, although it appears that technical barriers unique to telesimulation provide challenges for some students achieving a greater level of engagement.

D. Outcomes- Knowledge, Skills and Attitudes

The theme Outcomes encompasses what students feel they learnt from the experience that could be useful in future clinical encounters. Under outcomes, there were sub-themes of knowledge, skills and attitudes. From a knowledge perspective, students reported that the telesimulation reinforced their clinical reasoning to arrive at a differential list.

“It was very useful and helped with our clinical reasoning. It was also useful in learning how to generate differential diagnoses as a team and going down the path of a working differential diagnosis while keeping others in mind.”

Student 32 

Whilst the lack of hands-on practice was acknowledged, the telesimulation environment required them to practice the skills of prioritisation, leadership, teamwork and effective, close loop communication to manage the patient and this accounted for their skills gained.

“I will be able to apply the concept of teamwork, thinking on my feet, thinking broad, and constant reassessment of the unstable patient in my clinical training over the next few months”

                                                                           Student 6 

“Stay calm, go back to first principles, have the approach at your fingertips, make an effort to remember drug doses and administration route”

Student 2

IV. DISCUSSION

In relation to Kirkpatrick’s model for evaluating educational outcomes, the results of this study (table 1) demonstrate achievement of both level one (reactions) and level two (learning) outcomes (Kirkpatrick & Kirkpatrick, 2009). Whilst these findings may not determine the effectiveness of telesimulation, it does however provide insight into the learners’ experience that have highlighted the strengths and limitations of telesimulation, which the authors of this paper believe provides a foundation upon which others can build. 

It is well documented in the simulation literature that fidelity and realism are important concepts that need to be considered when planning simulation-based education (Oliver, 2002). And this was an initial concern by the educators. The lack of a physical ‘patient’ on which to carry out procedures and physical examination could limit the effectiveness of the telesimulation experience. To address this limitation, faculty briefed the learners about the limitations and the strategies, such as the use of a ‘nurse confederate’ to provide clinical information, as well as having visual cues such as pictures and videos to trigger their actions. Interestingly, the feedback suggests that the lack of a physical ‘patient’ to examine, resulted in more emphasis being placed on the audio and visual cues during the session. This allowed the learners to proactively compensate for the lack of tactile cues with audio and visual ones, reinforcing the importance of clinical alerts and alarms. The inability to perform a physical examination provided an opportunity for the debriefer to emphasise the importance of the skill in clinical care.

There was a deliberate attempt to create scenarios that were commonly seen in the ED in as much details as possible to achieve realism in the virtual space. This limited the scenarios that could be used as we had to use ensure procedures were not required for the patient management to progress (for example, trauma was deemed inappropriate). The faculty feel that the typical, non-complex ED scenarios compounded with the sequence of events as it would occur in real life possibly contributed to the student’s perception of realism during the telesimulation.

Instructional scaffolding was key to student engagement.  The faculty configured the telesimulation session to be held after three weeks of interactive and didactic sessions on Zoom. This allows the learners to acquire essential knowledge which they can then apply during the telesimulation session. With the background baseline knowledge, the telesimulation setup and audio and visual prompts of a real ED environment, the faculty felt that they were able to immerse the students within the scenario rather than conducting it as an online Problem-Based-Learning session. This may have contributed to their engagement.

Communication skills were a common thread reported by the students, both positively and negatively in many of their statements. They described the shortcomings of communication over Zoom and felt that the session highlighted how non-verbal cues and the physical presence influences the way one communicates. At the same time, the absence of visual and tactile stimuli forced them to practice good communication to get their points across when managing the patients.

Interestingly, though many students scored high on the Likert scale about feeling confident in managing emergencies, with the open-ended questions, they reflected feelings of nervousness, fear and a lack of confidence to working in the ED, showing that perhaps this cannot replace patient contact.

Cognisant of the limitations of telesimulation, most of the learners enjoyed the session. This may have been due to the novelty of it and ED room mimics such as the beeping of the monitors and the realistic scenarios. Faculty also realise that the limitations of telesimulation and used them as discussion points to highlight elements that one may take for granted during their patient encounters, such as the non-verbal cues and the tactile stimuli.

Key to this successful telesimulation session was establishing realistic and focused objectives (Harden et al., 1999). Failing to recognise that telesimulation differs from conventional simulation and therefore emphasising on tactile skills such as procedures and physical examination will minimise the effectiveness of the session. Knowing the inherent limitations helped faculty to prepare holistically for the session. Learning objectives focused on non-tactile aspects, such as history taking and executing treatment algorithms. In addition, as tactile cues are limited in the telesimulation setting, all other cues such as visual and audio were optimised.

Debriefing during the telesimulation sessions has an even more vital role in student learning compared to conventional simulation sessions (Fanning & Gaba, 2007). The debriefer not only has to highlight salient clinical points regarding the case, but also probe learners to think about limitations of the telesimulation modality. Therein, understanding the importance of highlighting tactile and visual feedback. For example, one learner recognised that he was “unable to visually observe and direct the teammate”; another came to the conclusion that “being able to see the patient and physical expression of fellow doctors/nurses is crucial”. This allows the educator to discuss the importance of situational awareness and non-verbal cues in enhancing team dynamics. However, if the debriefer fails to address this limitation, the learners may leave the session feeling dissatisfied or inadequate with their performance at the session. The uniqueness of telesimulation adds another facet to debriefing where the debriefer needs to be able to address the limitations of telesimulation and relate it back to clinical relevance. Therefore, there might be a need to provide additional training for educators in debriefing telesimulation sessions.

Simulation-based training is an effective modality to teach procedural skills, put into practice treatment algorithms and hone soft-skill relevant to team dynamics. (Lateef, 2010; Sirimanna & Aggarwal, 2014). As demonstrated through this innovative programme, it has an important role to play in medical education during such a pandemic where it might be used to mitigate the negative educational impact of no patient contact, team-based training and protocol development and testing  (Chaplin et al., 2020; Dieckmann et al., 2020). All this is done within a psychologically and physically safe environment.

Based on the feedback collected, a conceptual framework below (Figure 4) was drawn, showing the relationship between the concepts of fidelity and realism in the telesimulation experience to the level of engagement and therefore outcomes perceived by the learners. This is supported by the objectives, experiential learning and a safe learning environment.

Figure 4. Conceptual framework

V. CONCLUSION

The role of face-to-face interactions with patients and immersing oneself in the acute care environment in bridging the theory to practice gap experienced by all healthcare students is essential to their clinical training.  The restrictions encountered due to COVID-19 have required clinical educators to be agile and innovative in their approach the clinical clerkships. The EM clerkship telesimulation programme set out to provide an avenue for medical students to hone their clinical skills (history taking) and clinical reasoning (deriving differential diagnosis) in a safe environment. The evaluation of this programme has highlighted key areas of telesimulation which educators need to consider when planning to use it. The feedback from the students is promising and it highlights certain teaching points which may not be reflected upon during in-person simulation. Educators who wish to implement a telesimulation programme should pay particular attention to the learning objectives and debriefing methods. Whilst this paper has outlined how telesimulation can be implemented during a pandemic, it is envisaged that educators from other healthcare disciplines could use these findings to support the adoption of telesimulation in a variety of educational contexts. Telesimulation is a good alternative in settings such as this pandemic or during distance training programmes and may be a convenient way to hone history taking, clinical reasoning and communication skills without the use of an expensive simulation laboratory. The modality needs to meet the learning objectives and the debriefing should be adopted for telesimulation. However, the authors/faculty feel it cannot replace the full benefits of in-person simulation or learning from direct patient contact.

Notes on Contributors

Gayathri Devi Nadarajan and Kirsty J Freeman conceptualised the article, undertook the thematic analysis, contributed to article sections, and reviewed and revised manuscript based on suggestions from the other authors.

Lim Jia Hao, Wan Paul Weng and WONG Evelyn contributed to the conceptualisation of the paper, contributed to the article sections, reviewed and revised drafts.

Abegail Resus Fernandez undertook the quantitative analysis, and reviewed drafts.

All authors were involved in the development and delivery of the EM Clerkship Telesimulation Programme. All the authors have read and approved the final manuscript.

Ethical Approval

The SingHealth Centralised Institutional Review Board (CIRB) granted an exemption, CIRB Ref. No.: 2020/2719, as this study was assessed as a quality improvement project.

Data Availability

All relevant data are within the manuscript.

Acknowledgement

We would like to thanks the students who participated in this unit and their willingness to adapt to the online platform with grace and enthusiasm. 

Funding

This work has not received any external funding. 

Declaration of Interest

All authors declare that there are no conflicts of interest.

References

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Fanning, R. M., & Gaba, D. M. (2007). The role of debriefing in simulation-based learning. Simulation in Healthcare, 2(2), 115–125. https://doi.org/10.1097/SIH.0b013e3180315539

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*Gayathri Devi Nadarajan
Department of Emergency Medicine
Singapore General Hospital
1 Outram Road, Singapore 169608
Tel: +65 96804724
Email: gayathri.devi.nadarajan@singhealth.com.sg

Submitted: 28 July 2020
Accepted: 23 December 2020
Published online: 13 July, TAPS 2021, 6(3), 104-107
https://doi.org/10.29060/TAPS.2021-6-3/PV2363

Tushar Hari¹, Dennis Hathey¹, Sonia Kumar², Ilona Blee², Rachel Browne³ & Simon Tso³

¹Buckingham Medical School, United Kingdom; ²South Warwickshire National Health Service Foundation Trust, United Kingdom; ³Jephson Dermatology Centre, South Warwickshire National Health Service Foundation Trust, United Kingdom

I. INTRODUCTION

We live in unprecedented times with the COVID-19 pandemic disrupting our normal way of life. First identified in December 2019, the novel SARS-CoV-2 strain has brought about vast devastation. According to the World Health Organisation (WHO), as of 21st November 2020, there are 56.9 million confirmed cases and 1.3 million deaths worldwide. The government approach to control the spread of COVID-19 in the United Kingdom (UK) is underpinned by social distancing measures; to limit the spread and prevent the inundation of National Health Service (NHS).

Social distancing impacts society on both an individual and population level. Across the country, virtual learning has become the new normal. It is our experience at Buckingham Medical School that students saw their clinical placements suspended. Educational resources were shared via online platforms and final year examinations done remotely to fast-track the transition to newly qualified doctors with an interim registration with the UK General Medical Council (GMC).

In this opinion piece, a diverse panel of two medical students, two doctors-in-training and two educators, including individuals with international student status, learning and sensory difficulties, chronic diseases, and dependents, discussed the impact on undergraduate medical education for individuals who may risk being left behind if efforts towards widening participation are not considered amidst this crisis and its aftermath. The focus group was held as an online asynchronous unstructured discussion through emails over a three-month period, moderated by a consultant, who regularly posted questions for the groups to discuss. This was supplemented by face-to-face discussion between the participants to summarise key outcomes and then circulated the conclusions to the panel before manuscript inclusion. Verbal consent was obtained from participants.

II. OVERVIEW: THE CHANGING LANDSCAPE OF UNDERGRADUATE MEDICAL TRAINING IN THE UK

What was once a curriculum encompassing face-to-face clinical teaching to deliver a degree in medicine, has now become reliant on the virtual learning environment (VLE).

In the UK, medical teaching methods vary between institutions. Under such unprecedented times, these long-established methods of education have required immediate reform, with VLE taking over and clinical teaching being significantly reduced or temporarily paused (Taha et al., 2020).

The use of VLE in UK medical schools has increased within the last decade. Many already utilise VLE for lecture recording, uploading learning materials, or online assessments. Challenges with virtual teaching existed before COVID-19, particularly the lack of time for educators to become familiar with and implement online learning. Some educators view virtual teaching negatively and thus engage poorly with these platforms (O’Doherty et al., 2018). These learning platforms may also be perceived as expensive. However, need is a big driver for change. With the COVID-19 pandemic forcing the need for socially distant learning, many institutions have become more receptive to this change and many students are benefitting from the flexibility of engaging with the material remotely.

Since the start of the pandemic, medical schools have begun to disseminate pre-recorded or live lectures using online platforms such as Microsoft Teams or Zoom. Simulations of the clinical setting are being recreated to accommodate for the loss of practical experience and provide medical students in the early stages an introduction to the clinical environment. Reduced opportunity for workplace-based clinical learning, suspension of rotational training and medical electives could also potentially impact on career choices due to a lack of exposure.

Student pastoral care is vital during this pandemic, with new anxieties and stresses arising daily. This can be continued on these virtual platforms, either as one-to-one sessions or in tutorial groups. However, members of our focus group expressed how they found video conferencing less personal, and difficulty with internet connections can make it hard to discuss personal problems.

III. INCLUSIVITY AND WIDENING PARTICIPATION CONSIDERATIONS

The GMC states that: “a diverse population is better served by a diverse workforce” (General Medical Council, 2018). Much effort has gone into widening access to medicine and focusing on inclusivity and diversity within medicine. This work must not be forgotten amidst this crisis.

A. Our International Community of Medical Students in the UK

An international UK medical student from our focus group explained that governments are advising their citizens abroad to return home. COVID-19 has impacted countries to varying degrees and many students have been recalled to help with national efforts such as volunteer work and contact tracing. With medical school teaching resuming via VLE in the UK, the challenge of now balancing voluntary commitments at home, family life and university work is made more difficult by differing time zones. Educators in the UK should bear in mind that these factors could impact on students’ level of engagement and learner satisfaction with online synchronous learning opportunities. Furthermore, access to certain learning resources such as the electronic British National Formulary and NICE (National Institute for Health & Care Excellence) guidelines is restricted outside the UK, causing difficulties with revision for some. Many have expressed concern regarding the future of their degrees; with questions around when respective governments will change travel advice so that they can return to the UK, and implications of the pandemic on their visas and degree duration. This uncertainty and stress are impacting some international students’ focus on their degrees. International students have also found positives to the new methods of teaching. Many students shared that online learning is more engaging compared to live classes and easier to access, ensuring standardised availability of resources for all, regardless of location. Also, many are content to be home with family support during a time of international crisis.

B. Students with Sensory Disability, Learning Differences and Chronic Diseases

In 2016/2017 the proportion of students with a declared disability was 9.3%, rising to 10.4% in 2017/2018 (General Medical Council, 2021). In the time of COVID-19, having a disability or chronic disease presents an additional barrier to effective workplace-based learning. Specific learning differences could impact on students’ ability to assist on ward round activities such as documentation. Documentation in medical notes at our institution is now performed away from patients’ bedside following completion of daily ward rounds due to infection control considerations. This presents student scribers with difficulties in working memory or other specific learning differences, the additional challenge of recalling large volumes of complex information after an event. In our real-life example, the clinician supported and debriefed the student after the ward round, and ensured the student had adequate time to document the plan in the patient notes, demonstrating a positive example of inclusivity.

Medical students with hearing impairment require lip-reading as a communication adjunct. Unfortunately, implementation of using face masks in the clinical setting limits this and there is a lack of availability of medical grade transparent face masks. Therefore, considerations on using appropriate debriefing and non-verbal communication skills such as hand gestures and written forms of expression can be vital in delivering a complete learning experience for students.

Many vulnerable students are concerned about their risks of contracting COVID-19 and thus their ability to complete their degree in the original timeframe. High-risk individuals have been advised to avoid clinical areas or even isolate at home. Students must fulfil time-based and performance-based criteria to be awarded a GMC-recognised medical degree, but the loss of time and clinical experience in a compact degree programme could put into question their ability to complete on time.

C. Students with Dependents

Students with dependents and those balancing part-time work with medicine to ease the financial burden of their degree could also require additional support. Universities and Colleges Admissions Service (UCAS) guidelines state, a student who holds responsibility for a child aged 17 or younger, should have access to additional support with studies (Universities and Colleges Admissions Service [UCAS], 2021). Students with dependents face many challenges during their degree due to personal obligations. The VLE offers students with dependents an opportunity to maintain their learning at a time when access to schools and care facilities are restricted during the lockdown, but this also presents the challenge of learning and completing coursework while simultaneously caring for their dependents. For some, a distinction between the place of study and the home environment was key to maintaining an effective work-life balance. The availability of care facilities, financial health of students and access to university hardship grants and support systems, would be key to maintaining this group of students’ participation in studying medicine.

IV. CONCLUSION

From our experience, the COVID-19 pandemic has changed the delivery of undergraduate medical education at the current time – whether these changes persist remains to be seen. Educators should be considerate about student support in this new way of working, to benefit all students. This applies especially to those with undeclared or undiagnosed learning difficulties, disability, chronic disease, and those with dependents, to encourage their full participation in all available workplace and online-based learning activities and integrate them into the clinical team. It is also important to implement the perceived advantages of VLE in future medical curricula. Further literature is required to see if these changes have truly made a positive impact on learning. Such inclusion is crucial to not deter students from continuing medicine. Neglecting the demands for these groups can hinder our previous efforts at widening participation within the NHS.

Notes on Contributors

Tushar Hari was involved mainly with creating the first draft of the paper and leading the focus group. He contributed some of his experiences as an international student. He participated in revising the paper prior to submission.

Dennis Hathey was involved with initially drafting the paper and helped organise the focus group. He was involved with designing the focus group questions and gathering various perspectives. He took part in final approval of the published version as did all the other authors.

Dr Sonia Kumar contributed to shaping the paper in the later stages and added input on all aspects of the paper. She helped with data collection and critical appraisal of the final draft of the submitted paper.

Dr Ilona Blee added input into the needs of disabled students and overall shaped the paper to its final draft. She played an important role in approving the final copy and contributed to data analysis and interpretation.

Dr Rachel Browne contributed to final changes made to the draft and made final approval of the paper along with the other authors.

Dr Simon Tso contributed to the final approval of the paper and helped supervise the conception and progression of the paper and focus group.

In summary, all authors fulfill the four criteria stated for authorship.

Acknowledgement

We would like to express our gratitude to our focus group participants for their contributions.

Funding

No funds were required for this paper.

Declaration of Interest

We have no conflicts of interest to disclose.

References

General Medical Council. (2018). Medical school reports. https://www.gmc-uk.org/education/reports-and-reviews/medical-school-reports.

General Medical Council. (2021). Who is a disabled person. https://www.gmc-uk.org/education/standards-guidance-and-curricula/guidance/welcomed-and-valued/health-and-disability-in-medicine/who-is-a-disabled-person.

O’Doherty, D., Dromey, M., Lougheed, J., Hannigan, A., Last, J., & McGrath, D. (2018). Barriers and solutions to online learning in medical education – An integrative review. BMC Medical Education, 18(1), 130. https://doi.org/10.1186/s12909-018-1240-0

Taha, M., Abdalla, M., Wadi, M., & Khalafalla, H. (2020). Curriculum delivery in Medical Education during an emergency: A guide based on the responses to the COVID-19 pandemic. MedEdPublish, 9(1), 69. https://doi.org/10.15694/mep.2020.000069.1

Universities and Colleges Admissions Service. (2021). Students with parenting responsibilities. https://www.ucas.com/undergraduate/applying-university/individual-needs/students-parenting-responsibilities

*Tushar Hari
Buckingham Medical School
Yeomanry House, Hunter Street,
University of Buckingham
Buckinghamshire, UK, MK181EG
Email: 1606656@buckingham.ac.uk

Submitted: 14 August 2020
Accepted: 6 November 2020
Published online: 13 July, TAPS 2021, 6(3), 45-55
https://doi.org/10.29060/TAPS.2021-6-3/OA2377

Nathalie Khoueiry Zgheib¹, Ahmed Ali² & Ramzi Sabra¹

¹Department of Pharmacology and Toxicology, American University of Beirut Faculty of Medicine, Beirut, Lebanon; ²Medical Education Unit, American University of Beirut Faculty of Medicine, Beirut, Lebanon

Abstract

Introduction: The forced transition to online learning due to the COVID-19 pandemic has impacted medical education significantly.

Methods: In this paper, the authors compare the performance of Year 1 and 2 classes of medical students who took the same courses either online (2019-2020) or face-to-face (2018-2019), and compare their evaluation of these courses. The authors also present results of three survey questions delivered to current Year 1 medical students on the perceived advantages and disadvantages of online learning and suggestions for improvement.

Results: Performance and evaluation scores of Year 1 and 2 classes was similar irrespective of the mode of delivery of the course in question. 30 current (2019-2020) Year 1 students responded to the survey questions with a response rate of 25.4%. Some of the cited disadvantages had to do with technical, infrastructural and faculty know-how and support. But the more challenging limitations had to do with the process of learning and what facilitates it, the students’ ability to self-regulate and to motivate themselves, the negative impact of isolation, loss of socialisation and interaction with peers and faculty, and the almost total lack of hands-on experiences.

Conclusion: Rapid transition to online learning did not affect student knowledge acquisition negatively. As such, the sudden shift to online education might not be a totally negative development and can be harnessed to drive a more progressive medical education agenda. These results are particularly important considering the several disadvantages that the students cited in relation to the online delivery of the courses. 

Keywords:           Online Learning, COVID-19 Pandemic, Medical Students

Practice Highlights

• The authors report on the forced transition to online learning due to the COVID-19 pandemic.
• The performance and evaluation scores were similar in online delivery vs face-to face. 
• The sudden shift to online education might not be a totally negative development despite the several disadvantages that students cited.

Survey question	Theme	Quote
Advantages of online teaching and learning in comparison to face to face teaching and learning	Time flexibility with asynchronous learning	“Better scheduling that allows us to sleep and rest at night in order to wake up better prepared to ace those PowerPoints” (S9) “Easier to manage our time” (S18)
	Control of learning pace with VOP	“Being able to speed through slides/concepts we already understood and pausing and replaying concepts that we have trouble with makes the whole learning process a lot more efficient and focused” (S27)
	More wellbeing	“Less time to commute which allows more time to rest and take care of oneself” (S9) “Having a very healthy diet with my family in the village” (S12) “The [exam] performance is better and stress in minimal” (S23)
Disadvantages of online teaching and learning in comparison to face to face teaching and learning	Potential for procrastination and loss of motivation	“Less motivation, harder to follow the schedule, requires strong time management skills” (S5) “Face to face teaching helps me organize my day better” (S4) “Being at university with other students around studying during the day motivated me” (S26)
	Bad internet connection	“Internet connection in our country is not stable to hold a class or an exam, so we are resorting to 3g/4g. This leads to a lot of extra expense” (S3) “Time consuming” (S2) and “Sessions would run for more than their original allocated time” (S3) “Longer exams might coincide with the times of the electricity shut offs. This would automatically freeze Respondus and the student will have to restart their computer and so on. Although we are given extra time this adds a lot of stress to an already stressful situation” (S19)  “Asking questions are much more difficult and needs much more time” (S7) “WebEx needed a stronger Wi-Fi in some sessions which leads to a harder way to grasp the information” (S18) “The internet connection everywhere in Lebanon is not the best, sometimes we have trouble listening. Sometimes it also gets really crowded when everyone wants to talk at the at the same” (S21)
	Home environment less conducive to learning	“Not everybody has the privilege of adjusting their environments to their liking, whether that be because of their dog barking or their family members not respecting their study time” (S28) “This experience helped my appreciate how much I concentrate better in the library” (S9)
	Loss of interaction with teachers	“No direct interaction, harder to communicate directly with professors” (S2) “Face to face interaction was lost: no clues to non-verbal clues, no gestures seen” (S17)  “It is true that we can always email the doctors for any additional questions but that does not compare to in person interactions” (S19)
	Loss of interaction with students	“not being able to interact with my friends” (S12) “Students lose their social skills as they interact less with each other-more into introversion” (S17) “You feel there is a barrier between you and the students” (S17)
	Lack of immediate feedback	“One problem is during exams not being able to see my mistakes” (S15) “Not correcting our exam and not seeing our mistakes was a huge disadvantage for the online learning” (S18) “Restricting questions to only emails” (S11) and “some professors don’t respond to emails” (S16) and “the response may be delayed” (S29)
	Loss of hands on experiences	“No hands-on experience for courses like clinical skills” (S3) “Mainly missing out on clinical skills” (S22)
	Faculty’s lack of IT knowhow or experience	“Professors have different abilities and effectiveness in knowing how to do a VOP/online lecture” (S11) “Most Drs. don’t know how to use zoom or WebEx” (S6) “Many instructors are not technically inclined or are outright aversive to it” (S13) “So much time is wasted on technical issues” (S19) “Professors sometimes don’t see the raised hands and sometimes it doesn’t even work. In some lectures we had to wait for the professor to give us access, so we spent time waiting while they didn’t see that some people are trying to access the lecture” (S21) “One of the disadvantages is using the live WebEx sessions. Some professors are losing their recordings, others have a poor connection” (S23)
	Effect on faculty’s teaching skills	“Some professors …just read instead of teaching” (S7) “Many professors are not exactly cooperative in terms of explaining mainly because they read their PowerPoints” (S23) “Can’t explain a topic and be passionate about it if talking to a screen or microphone” (S23)
Suggestions to improve the current online teaching	Technical support and knowhow	“Train the staff on the proper way of utilising the platforms” (S2) “Make IT staff more readily available to help instructors” (S16) “Agree on one way to give the lecture via WebEx as some professors used WebEx team, where we had to ask permission for access, and it was kind of chaotic. It would also be better if the professor agreed on one way to have the questions asked to avoid interruptions and multiple people talking at the same time” (S21)
	More VOPs and less WebEx for lectures	“I think VOP is a much safer option and a less tiring one” (S23) “Revert from live WebEx sessions to VOP” (S3)
	More interaction and immediate feedback	“Open forums for discussion” (S3)  “Adding analytical questions in PowerPoints” (S9) “See exams and mistakes” (S15) “If the professors want to use WebEx … then they should allow questions at all times and not only at the end of the session” (S11) “Include small assessment questions (clicker like questions) at the end of each major concept so that the students can assess their understanding” (S19) “Recording voice over PowerPoint for lectures, with every group of lectures followed by a WebEx session where the professor answers questions” (S24) “Review/Q&A session once a week” (S25)

Table 1. Themes Generated from the Three Survey Questions with Selected Representative Quotes

VOP: Voice Over PowerPoint

As shown in Tables 2 and 3, there were no statistically significant differences in the MCAT scores between any two classes that were compared. The performance of the Year 1 students on the CMM course during the current academic year (online) was higher than that of students during the previous year (face-to-face); however, the passing grade for the two courses was slightly different.  When the passing grades were equalised, there was no longer a difference between the two classes. Similarly, there was no difference in the performance of the Year 2 students on either the CMM course they took in Year 1, or on The Kidney and Urinary System course between the current class and the previous year’s class (all face-to-face).

With regard to The Blood course, the grade on the final examination was significantly lower for current students (online) relative to their predecessors (face-to-face); however, the passing grades on these examinations were different, with the current year’s examination having a lower passing grade than last year’s. When the passing grades were equalised, there was no longer a difference in the performance on the final examination.

The performance of the students in the Human Development and Psychopathology course’s final examination was almost identical in the online group compared with their predecessors (all face-to-face). Interestingly, the passing grade on this year’s examination was lower than that on last year’s examination, such that when the passing scores were equalized, the current class had better performance on the final examination than last year’s class.

IV. DISCUSSION

Medical education scholars have been increasingly disseminating opinions about sudden transitioning to online education to COVID-19 and the adaptations that are being implemented. Few studies have documented the actual institutional experiences, the perspectives of students, and the lessons learned in different medical courses or curricula such as TBL (Gaber et al., 2020), anatomy (Srinivasan, 2020) and continuing medical education in obstetrics and gynaecology (Kanneganti et al., 2020). Only one report from Wuhan, China, evaluated nursing interns’ outcomes on emergency medicine theoretical and practical examination scores (Zhou et al., 2020). The current paper is the first to examine the impact of this abrupt transition to online learning, which occurred in numerous countries worldwide, on the performance of our medical students in knowledge-based examinations. It reveals that the sudden shift to full online learning that our medical school had to adopt did not have a negative influence on the students’ knowledge acquisition as judged by their performance on final examinations. It also did not affect their overall reception and evaluation of the courses. These results are particularly interesting and important considering the many disadvantages that the students cited in relation to the online delivery of the courses. 

Many of the limitations and disadvantages of online education cited by students had to do with technical and infrastructural matters and with faculty know-how and IT support. These are problems that can, theoretically, be easily remedied. The more challenging, however, limitations had to do with the process of learning, what facilitates or hampers it, the students’ ability to self-regulate and to motivate themselves, the negative impact of isolation, loss of socialisation and interaction with peers and faculty, and the almost total lack of hands-on experiences. 

These limitations did not affect the students’ ability to achieve learning, at least in the domain of knowledge acquisition and application. It is clear that students in the three classes that were examined had, at baseline, a similar level of achievement meaning that any differences in student performance in the courses that were given online this year cannot be ascribed to differences in the academic performance or ability of the students. Therefore, the lack of difference in performance between classes taking the course online versus those taking it face-to-face suggests a consistency in performance that was not affected adversely by the sudden transition to online learning.

One reason for this lack of difference in performance between online and face-to-face delivery of the courses may be that the outcomes that were being sought and assessed were essentially knowledge acquisition and knowledge application. This agrees with the overall results of multiple studies that compared online vs offline learning in medical school, and which, in fact, tended to favour online learning (Pei & Wu, 2019). Indeed, even before our sudden shift to total online education, many of our students had adopted their own approaches to achieve the knowledge learning outcomes. Even though lectures were not available online, attendance at face-to-face lectures (which was not mandatory) was never complete, and for the majority of students, the rate of attendance ranged between 25% and 75% (unpublished data). In fact, the students indicated that they depended instead on notes and voice recordings made during the lecture that were shared by their classmates or predecessors, and that they used several Web-based resources. In contrast, attendance at TBL exercises and other interactive and small group sessions is mandatory at our school, and students uniformly participated in them, as they did in the online Zoom-based sessions. Thus, our students were probably well prepared for this sudden shift. In line with this view, Ferrel and Ryan (2020), in a recent editorial on the impact of COVID-19 on medical education, predicted that many medical students in their didactic years may perceive little change in their study schedule, since many of them already use outside resources and watch school lectures after they have been presented.

The lack of significant differences in scores and attitudes may also attest to our – and indeed all – medical students’ resilience and adaptability to difficult situations, for they are high-achieving and resourceful students who have been selected from among an exceedingly competitive group of applicants, and likely have the cognitive powers and non-cognitive qualities to meet such challenges.  Ferrel and Ryan (2020) also emphasised the need for medical students to adapt and be innovative during the pandemic, and to devise ways by which they can exhibit their skills, work ethics and teamwork. In fact, one of the advantages of the online shift that our students cited was the flexibility this approach afforded them in managing their time, setting their schedules, controlling their pace of learning and achieving better self-care. Nevertheless, some of them found it challenging to do so, and to regulate their environment and motivate themselves; rather, they seemed to require external cues or assistance to get into a learning mode, and found difficulty in establishing boundaries between work and home, as suggested recently by Rose (2020). In this context, it is noteworthy that our students preferred asynchronous to synchronous learning, and this is consistent with Daniel’s recommendation to use this approach because it gives teachers “flexibility in preparing learning materials and enables students to juggle the demands of home and study” (Daniel, 2020).

Our findings also raise questions about certain assumptions regarding student learning and the optimal teaching approaches for knowledge-based objectives, such as the value and benefits of face-to-face interactions among students and with faculty in a didactic context. Our results suggest that students can achieve these knowledge objectives without the personal interaction and contact with faculty. This, of course, does not address the non-cognitive learning outcomes that might be negatively affected by pure online learning. As summarised by Fawn et al. (2020), while content may be covered well in such abrupt transitions to online learning, we cannot be sure that the valuable non-cognitive learning that happens as a result of the “social activity, the relationship-building, the problem-solving, the dialogue and generation of ideas and the students’ own discovery of other content that has not been pre-defined by the teacher” has been achieved.

We cannot make definite, long-term conclusions from this single account that is restricted to 2 courses in the preclinical years, a brief period of time, and one institution, and a low response rate for the survey questions, but the results are encouraging, and may have implications for educational practice. The lack of decline in cognitive performance may suggest that the sudden shift to online education might not be a totally negative development. If our findings are reproduced or generalised, one can use them to validate what progressive medical educators have been advocating for years, that: online educational technology must change the way we educate our students; didactic lecturing should give way to flipped classrooms; and valuable teacher time must be expended to help students apply knowledge rather than to simply transfer information in scheduled lectures. Quoting Ezekiel Emanuel (2020), who in a recent article stated that the reconfiguration of medical education, fuelled by online educational technology, seemed inevitable, Wolanskyj-Spinner (2020) suggested that the coronavirus epidemic appears to be an inflection point that is forcing a disruption in how we teach medicine. At AUBFM, we have long pressed the faculty who teach medical students to record their lectures and use the scheduled class time thus saved to implement flipped classrooms, employing small-group-based, problem-solving and interactive sessions. While many responded, many also hesitated, objected, and even resisted. The following two additional comments provided by two students illustrate their frustration with the resistance of faculty and their hopes to move in that direction: 

“I really hope we can make online learning standard coming out of this phase … There was an attempt a few years ago but many instructors refused to be recorded or to fiddle with computers; we must seize the opportunity now.”

“Please never stop recording lectures, regardless of the status of live classes!”

Ahmed et al. (2020) recently reported that during the 2003 SARS epidemic in China, novel online problem-based learning techniques had to be implemented in one medical school that proved to be so popular that they were applied as part of the regular curriculum in later years. We believe that medical educators can harness the current disruption in how we teach medical students, and make use of to implement novel and sound educational practices and adopt a wide variety of valid approaches and tools that, otherwise, might have been resisted by unwilling individuals with entrenched ideas.

V. CONCLUSION

In conclusion, rapid transition to online learning did not affect student knowledge acquisition negatively. As such, the sudden shift to online education might not be a totally negative development and can be harnessed to drive a more progressive medical education agenda. These results are particularly important considering the several disadvantages that the students cited in relation to the online delivery of the courses. 

Notes on Contributors

Nathalie Zgheib developed the concept, collected and analysed data, and wrote the first draft of the manuscript. Ahmed Ali also developed the concept, performed the literature review, and revised the manuscript write-up. Ramzi Sabra also developed the concept, collected and analysed data, and revised the manuscript write-up. The three authors read and approved the final version of the manuscript.

Data Availability

The data that support the findings of this manuscript are available from the corresponding author upon reasonable request.

Ethical Approval

This is a report of experience with educational practices. It was confirmed by our Institutional Review Board (IRB) that the activities described in this article do not constitute human subject research.

Acknowledgments

 The authors wish to thank AUBFM faculty and medical students for their support, diligence and flexibility during the COVID-19 pandemic.

Funding

This study did not receive any funding.

Declaration of interest

The authors do not have any conflict of interest to declare.

References

Ahmed, H., Allaf, M., & Elghazaly, H. (2020). COVID-19 and medical education. The Lancet Infectious Diseases, 20(7), 777-778. https://doi.org/10.1016/S1473-3099(20)30226-7

Ashcroft, J., Byrne, M. H. V., Brennan, P. A., & Davies, R. J. (2020). Preparing medical students for a pandemic: A systematic review of student disaster training programmes. Postgraduate Medical Journal, Advance online publication. https://doi.org/10.1136/postgradmedj-2020-137906

Daniel, S. J. (2020). Education and the COVID-19 pandemic. Prospects, 49, 91-96. https://doi.org/10.1007/s11125-020-09464-3  

Emanuel, E. J. (2020). The inevitable reimagining of medical education. Journal of the American Medical Association, 323(12), 1127-1128. https://doi.org/10.1001/jama.2020.1227

Fawn, T., Jones, D., & Aitken, G. (2020). Challenging assumptions about “moving online” in response to COVID-19, and some practical advice. MedEdPublish, 9(1), 83. https://doi.org/10.15694/mep.2020.000083.1

Ferrel, M. N., & Ryan, J. J. (2020). The impact of COVID-19 on medical education. Cureus, 12(3), e7492. https://doi.org/10.7759/cureus.7492

Frehywot, S., Vovides, Y., Talib, Z., Mikhail, N., Ross, H., Wohltjen, H., Koumare, A. K., & Scott, J. (2013). E-learning in medical education in resource constrained low- and middle-income countries. Human Resources for Health, 4(11), 4. https://doi.org/10.1186/1478-4491-11-4

Gaber, D. A., Shehata, M. H., & Amin, H. A. A. (2020). Online team-based learning sessions as interactive methodologies during the pandemic. Medical Education, 54(7), 666-667. https://doi.org/10.1111/medu.14198

Kanneganti, A., Lim, K. M. X., Chan, G. M. F., Choo, S. N., Choolani, M., Ismail-Pratt, I., & Logan, S. J. S. (2020). Pedagogy in a pandemic – COVID-19 and virtual continuing medical education (vCME) in obstetrics and gynecology. Acta Obstetetricia et Gynecologica Scandinavica, 99(6), 692-695. https://doi.org/10.1111/aogs.13885 

Liang, Z. C., Ooi, S. B. S., & Wang, W. (2020). Pandemics and their impact on medical training: Lessons from Singapore. Academic Medicine, 95(9), 1359-1361. https://doi.org/10.1097/ACM.0000000000003441

Lim, E. C., Oh, V. M., Koh, D. R., & Seet, R. C. (2009). The challenges of “continuing medical education” in a pandemic era. Annals of Academic Medicine Singapore, 38(8), 724-726.

McKimm, J., Mclean, M., Gibbs, T., & Pawlowicz, E. (2019). Sharing stories about medical education in difficult circumstances: Conceptualizing issues, strategies, and solutions. Medical Teacher, 41(1), 83-90. https://doi.org/10.1080/0142159X.2018.1442566

Patil, N. G., Chan, Y., & Yan, H. (2003). SARS and its effect on medical education in Hong Kong. Medical Education, 37(12), 1127-1128. https://doi.org/10.1046/j.1365-2923.2003.01723.x

Pei, L., & Wu, H. (2019). Does online learning work better than offline learning in undergraduate medical education? A systematic review and meta-analysis. Medical Education Online, 24(1), 1666538. https://doi.org/10.1080/10872981.2019.1666538

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

Ross, D. (2020). Creating a “quarantine curriculum” to enhance teaching and learning during the COVID-19 pandemic. Academic Medicine, 95(8), 1125-1126.

Sandars, J., Correia, R., Dankbaar, M., de Jong, P., Sun Goh, P., Hege, I., Oh, S., Patel, R., Premkumar, K., Webb, A., & Pusic, M. (2020). Twelve tips for rapidly migrating to online learning during the COVID-19 pandemic. MedEdPublish, 9(1), 82. https://doi.org/10.15694/mep.2020.000082.1

Srinivasan, D. K. (2020). Medical students’ perceptions and an Anatomy teacher’s personal experience using an e-learning platform for tutorials during the Covid-19 crisis. Anatomical Sciences Education, 13(3), 318-319. https://doi.org/10.1002/ase.1970

Wolanskyj-Spinner, A. (2020). COVID-19: The global disrupter of medical education. ASH Clinical News, https://www.ashclinicalnews.org/viewpoints/editors-corner/covid-19-global-disrupter-medical-education/

Woodward, A., & McLernon-Billows, D. (2018). Undergraduate medical education in Sierra Leone: A qualitative study of the student experience. BMC Medical Education, 18(1), 298. https://doi.org/10.1186/s12909-018-1397-6

Zhou, T., Huang, S., Cheng, J., & Xiao, Y. (2020). The distance teaching practice of combined mode of massive open online course micro-video for interns in emergency department during the COVID-19 epidemic period. Telemedicine Journal and E-Health, 26(5), 584-588. https://doi.org/10.1089/tmj.2020.0079

*Ramzi Sabra
Department of Pharmacology and Toxicology,
Faculty of Medicine,
American University of Beirut,
PO. Box 11-0236, Riad El Solh,
Beirut, Lebanon
Tel: +961-1-350000 Ext: 4848
Email: rsabra@aub.edu.lb

Submitted: 20 July 2020
Accepted: 30 September 2020
Published online: 13 July, TAPS 2021, 6(3), 108-110
https://doi.org/10.29060/TAPS.2021-6-3/PV2369

Kimberly Hires¹ & Colleen Davis²

¹Lewis College of Nursing and Health Professions, Georgia State University, United States of America; ²Leadership Development, Vuselela Davis, South Africa

I. INTRODUCTION

Historically, health professional education has focused on the development of clinical expertise over leadership skills that enable practitioners to lead dynamic teams who can adapt and pivot rapidly in a crisis. Clinical acumen and the ability to lead effectively are not mutually exclusive within healthcare systems. Leadership development is vital for health professionals as it allows them to lead patients and health systems, adapt to rapidly changing healthcare environments, and elicit optimal performance from their teams—all of which lead to improved health outcomes. The COVID-19 crisis highlights an opportunity to innovate health professional education to create practitioners who can treat and lead with excellence.

In December 2019, the Wuhan Municipal Health Commission reported four cases of pneumonia of an unknown origin. The cluster of cases were the first sign of COVID-19. COVID-19 is caused by a novel coronavirus that can spread from person to person. Within six months, the virus spread to 231 countries and infected over 13 million people worldwide. In attempts to slow the spread of the virus, countries issued emergency shutdowns, schools were closed, global travel was prohibited, and every industry was affected. One industry most affected by COVID-19 is the healthcare industry. Healthcare infrastructures are facing unprecedented challenges to meet the demands for care related to COVID-19. Providers are battling burnout, insufficient supply of personal protective equipment, depression, anxiety, job dissatisfaction and in some cases increased rates of suicide (Greenberg et al., 2020). To identify the contributing factors to challenges faced by health professionals during COVID-19, leaders must go to the root: health professional education.

Current health professional education competencies prioritize the development of hard skills that focus on clinical performance or evidence-based practice over the development of soft skills that facilitate building healthy interpersonal relationships, self-awareness, communication, leadership skills and effective coping (Albarqouni et al., 2018). Health professions encompass art and science. Current health professional education rewards the science of healthcare but starves the art of leadership. The COVID-19 pandemic, has created a collective trauma within the global community for which current leaders are not equipped to respond (Greenberg et al., 2020). The evidence for COVID-19 is constantly changing and leaders do not have the confidence and care algorithms to which they have grown accustomed. Due to COVID-19, health care workers worldwide have experienced an increase in depression, anxiety, and other forms of psychological distress. Health professionals already experience higher levels of burnout and job dissatisfaction than other professions; COVID-19 has amplified existing challenges for healthcare leaders who were struggling with employee recruitment and retention prior to the global pandemic.

As COVID-19 becomes a critical component of the world’s new normal, this is the optimal time for health professional education to innovate and prepare graduates who can lead in the midst of the new normal. This paper draws on experience of the two authors and their work with students enrolled in health professional programmes at the initial level and the specialist level, as well as the post-academic level in the United States and South Africa. This paper aims to introduce a new model of leadership development informed by over three decades of observations from combined experiences in health professional education, hospital learning and development, and leadership coaching.

II. DISCUSSION

Top down, traditional styles of leadership with an emphasis on self-sacrifice do not have a future in 21st century healthcare leadership. Leaders who are highly aware, connected, and genuinely compassionate experience success in productivity, high performing teams, cost effectiveness, strategy, innovation and employee retention. Just as health professional education relies on evidence-based practice, the Human-based leader (HBL) Model was developed to explain how effective leadership skills are developed. The HBL model utilizes an ecological framework. Ecological systems theory was developed by Urie Bronfenbrenner and posits that development is guided by interactions between an individual and the surrounding environment; this interaction populates a system (Bronfenbrenner, 1979). Bronfenbrenner’s original system is comprised of four systems represented as four concentric circles: the individual/microsystem (the core), mesosystem (second sphere), exosystem (third sphere), and macrosystem (fourth sphere) (Bronfenbrenner, 1995).

The HBL is comprised of three concentric circles. At the core is phase I. The goal of phase I is the development of self-awareness. The microsystem (the individual/leader) is housed within this sphere. The next sphere is phase II which houses the mesosystem (relationships with others such as family, friends, team members, peers) and the exosphere (additional factors related to the organization including patients and the community). In phase II leaders develop an awareness of others. The third sphere, phase III, houses the macrosystem (factors related to the profession, population, values, and cultural customs). Development of this phase allows the health professional leader to contribute to the building of a global community. The HBL makes the following assumptions: (1) Leadership development is a dynamic process that is influenced by exchanges between the individual (the leader) and the environment. (2) Leadership development is a continuous process. (3) Leadership success is not limited to job related competencies. Success includes healthy organizational culture, employee job satisfaction, recruitment, retention, customer/client satisfaction, and work-life balance as well as profit and loss.

Historically, health professional education focuses on team development and neglects teaching students how to understand their own experiences and worldview. Engaging in reflective practices are vital for professional identity development, however, current practices limit the reflection to clinical experiences (Wald, 2015). This approach ignores the very rich and varying life experiences students bring with them into a health professional programme. These life experiences follow students well into practice. Healthcare leaders with decades of experience are often surprised to find how influential their worldview is on patient care and working within teams. In this phase, it is vital for the individual to be able to answer, “Who am I?” beyond the professional identity. As individuals reflect on who they are, they can identify triggers, motivators and fears. Seeing the Self and helping a leader understand the Why behind behaviour is fundamental to healing and growth for the leader and the organization. Leaders who are self-aware in a crisis, such as a pandemic, can move dynamically as the environmental norms shift.

Current practices in health professional education emphasizes teamwork, however, by ignoring phase I, health professional educators make a fallible assumption that self-awareness is not vital to working effectively in teams. If individuals are unable to see the humanness in themselves (self-awareness) to value their own stories, challenges, and uniqueness, then they will fail to see it in others (peers, staff). In this phase, leaders gain a clear understanding of how to connect with and motivate each member of the team for optimal performance and retention. Failure to successfully achieve this phase results in poor performance, increased risk for medical errors, and high turnover.

Once leaders have an awareness of self and an appreciation for others, then they can graduate to the macrosystem or global sphere. The COVID-19 pandemic has illustrated the power of globalization. Within six months, healthcare systems experienced a global rate of infection that needed a swift, fluid, innovative and agile response. It is imperative that health professional education helps students and future leaders develop a global paradigm that sees beyond local hospitals and communities. A healthy worldview facilitates an easier transition into a global macrosystem.

The HBL can be adapted and implemented at various levels of health professional education and practice. It can be incorporated as learning modules in existing courses at the initial level and as a formal coaching programme at the specialist and post-academic levels. At the initial level of health professional education, the HBL was implemented with students in their final semester of a health professional (baccalaureate) programme at a research institution in the United States. The model was integrated into a leadership and management course as learning modules, case-studies, and self-development activities to equip students with skills needed to successfully progress through phases I, II, and III. At the specialist level, health professional students in the United States benefited from a formal coaching programme comprised of individual and group coaching sessions delivered over 12 weeks. At the post-academic level, the HBL model was implemented with practitioners in the United States and South Africa. At the post-academic level, practitioners benefit from a formal, customised coaching programme comprised of individual coaching sessions or a combination of individual and group coaching sessions delivered over 12 to 16 weeks. The greatest challenge with implementing the HBL at the specialist and post-academic levels is facilitating the unlearning of maladaptive leadership behaviours that lead to unhealthy organizational culture.

III. CONCLUSION

As demands for quality health care increase, health professional education is charged with meeting the supply. COVID-19 has provided a unique disruption for global health professional education to pivot from a rigid, process-driven and task-oriented model towards a model of a self-aware, empathetic leader. The Asia Pacific health care market was significantly impacted by COVID-19. Building this model into health professional education curriculums now will result in increased resilience and retention among providers. The HBL model can be adapted to regional needs to provide guidance for health professional educators to help students embrace their unique worldview and experience, teach lifelong reflective processes, be effective members of teams, and significantly contribute to improving population health.

Notes on Contributors

Assistant Professor Kimberly Hires reviewed the literature, designed the manuscript, developed the conceptual framework, and wrote the manuscript. Colleen Davis developed the conceptual framework, developed the manuscript, gave critical feedback to the writing of the manuscript. All the authors have read and approved the final manuscript.

Acknowledgements

The authors thank all students, faculty, colleagues, and clients who have informed our model.

Funding

No funding was used for the development of this personal view.

Declaration of Interest

The authors declare no conflict of interest concerning any aspect of this research.

References

Albarqouni, L., Hoffmann, T., Straus, S., Olsen, N. R., Young, T., Dragan, I., Shaneyfelt, T., Haynes, R., Guyatt, G., & Glasziou, P. (2018). Core competencies in evidence-based practice for health professionals: Consensus statement based on a systematic review and Delphi Survey. Journal of the American Medical Association Network Open, 1(2), e180281. https://doi.org/10.1001/jamanetworkopen.2018.0281

Bronfenbrenner, U. (1979).  The ecology of human development: Experiments by nature and design.  Harvard university press.

Bronfenbrenner, U. (1995). Developmental ecology through space and time: A future perspective. In P. Moen, G. H. Elder, Jr., & K. Lüscher (Eds.), Examining lives in context: Perspectives on the ecology of human development. (pp. 619–647). American Psychological Association. https://doi.org/10.1037/10176-018

Greenberg, N., Docherty, M., Gnanapragasam, S., & Wesseley, S. (2020). Managing mental health challenges faced by healthcare workers during COVID-19 pandemic. British Medical Journal, 368, m1211. https://doi.org/10.1136/bmj.m1211

Wald, H. S. (2015). Professional identity (trans)formation in medical education: Reflection, relationship, resilience. Academic Medicine, 90(6), 701-706. https://doi.org/10.1097/ACM.0000000000000731

*Kimberly A. Hires
Georgia State University
Atlanta, GA 30302,
United States
Email: khires@gsu.edu

Submitted: 28 August 2020
Accepted: 3 March 2021
Published online: 13 July, TAPS 2021, 6(3), 32-44
https://doi.org/10.29060/TAPS.2021-6-3/OA2385

Judy McKimm¹, Subha Ramani² & Vishna Devi Nadarajah³

¹Swansea University Medical School, United Kingdom; ²Harvard Medical School, United States of America; ³International Medical University, Malaysia

Abstract

Introduction: The COVID-19 pandemic has caused huge change and uncertainty for universities, faculty, and students around the world. For many health professions’ education (HPE) leaders, the pandemic has caused unforeseen crises, such as closure of campuses, uncertainty over student numbers and finances and an almost overnight shift to online learning and assessment. 

Methods: In this article, we explore a range of leadership approaches, some of which are more applicable to times of crisis, and others which will be required to take forward a vision for an uncertain future. We focus on leadership and change, crisis and uncertainty, conceptualising ‘leadership’ as comprising the three interrelated elements of leadership, management and followership. These elements operate at various levels – intrapersonal, interpersonal, organisational and global systems levels. 

Results: Effective leaders are often seen as being able to thrive in times of crisis – the traditional ‘hero leader’ – however, leadership in rapidly changing, complex and uncertain situations needs to be much more nuanced, adaptive and flexible.

Conclusion: From the many leadership theories and approaches available, we suggest some specific approaches that leaders might choose in order to work with their teams and organisations through these rapidly changing and challenging times.

Keywords:            Leadership, Followership, Management, Health Professions Education, Change, Crisis, Uncertainty, Emotional Intelligence, COVID-19 Pandemic, Universities

Practice Highlights

• In rapid change and uncertainty, different leadership approaches are needed.
• Primal leadership and emotional intelligence are essential.
• Followers need to feel safe, physically and psychologically.
• Authentic and inclusive leadership draws from diverse views.
• Adaptive and regenerative leadership acknowledges interrelated systems.

I. INTRODUCTION

The COVID-19 pandemic has caused huge change and uncertainty for universities and their stakeholders around the world. For many health professions education (HPE) leaders, the pandemic has caused an unforeseen crisis, the ripples from which will probably be felt for years to come. Effective leaders are often seen as being able to thrive in times of crisis – the traditional ‘hero leader’ – however, leadership in rapidly changing, complex and uncertain situations need to be much more nuanced and flexible. In this article we explore leadership approaches, some of which are more applicable to times of crisis, and others which will be required to take forward a vision for the ‘new normal’ to ensure that we learn from our experiences during the pandemic. 

In this article we focus on leadership and change. We start with an overview of the leadership triad, a discussion of the educational challenges imposed by the COVID-19 pandemic, followed by detailed discussion of effective leadership styles and competencies during challenging situations, approaching these through three lenses: Intrapersonal, referring to characteristics that successful leaders possess; interpersonal, referring to leadership styles and approaches leaders can adopt when they interact with others; and system level, which refers to leadership attributes to effectively lead organisations during a crisis. We conceptualise ‘leadership’ as comprising three interrelated elements: leadership, management, and followership (see Figure 1), which we call the ‘leadership triad’ (McKimm & O’Sullivan, 2016).

Figure 1: The Leadership Triad

Note: From “When I say … leadership,” by J. McKimm, and H. O’Sullivan, 2016, Medical Education, 50(9), 896–897. https://doi.org/10.1111/medu.13119

Figure 2: Four levels of leadership for addressing challenges during a crisis

Note: Drawing from “ABC of clinical leadership,” by T. Swanwick and J. McKimm, 2017, John Wiley & Sons.

A. The Intrapersonal Level: Working with Emotional and Social Intelligence

Figure 3: Intrapersonal leadership attributes: Emotional and social intelligence competencies essential to lead and manage change during challenging circumstances.

Note: Adapted from “Competencies as a behavioral approach to emotional intelligence,” by R. E. Boyatzis, 2009, Journal of Management Development, 28(9), 749–770. https://doi.org/10.1108/02621710910987647

While the construct of EI and competencies can serve as a useful guide to leaders in leading and managing change, the actual behaviours that are most effective depend on the organisational culture and the societal culture within which an organisation is situated. Moreover, at institutions which feature diversity in the composition of its leaders, staff and learners, leaders should recognise that individuals on a team might have different emotional reactions even when working towards a common goal. All four domains of EI competencies are essential for leaders to manage the groups of people they lead (See Table 1).

Submitted: 14 August 2020
Accepted: 14 October 2020
Published online: 13 July, TAPS 2021, 6(3), 114-117
https://doi.org/10.29060/TAPS.2021-6-3/PV2376

Meredith T. Yeung¹, Melissa Y. Chan¹, Clement C. Yan^1,2 & Katherin S. Huang¹

¹Health and Social Sciences Cluster, Singapore Institute of Technology, Singapore; ²Department of Physiotherapy, Sengkang General Hospital, Singapore

I. INTRODUCTION

Coronavirus Disease 2019 (COVID-19), which requires no introduction, is transmitted through droplet transmission and is highly contagious (del Rio & Malani, 2020; Guan et al., 2020; Sohrabi et al., 2020). After it was declared a pandemic on 11 March 2020, the Singapore government implemented a “circuit breaker” period, or partial lockdown, on 7 April 2020 (Ministry of Health, 2020). In spite of numerous initiatives for faculty to embrace technology-enhanced learning over the past years, it was a steep take-off for most programmes at institutes of higher learning. This short personal view intends to share our experience from the sole entry-level physiotherapy programme in Singapore.

II. ONLINE LESSONS

During the preliminary stages of the pandemic, faculty proactively switched all face-to-face lectures and tutorials that involved 50 or more students to online lessons. As the academic timetable had already been established, there was little to no disruption to lesson scheduling. Synchronous methods of e-learning occurred via video-conferencing software, such as Zoom and Microsoft Teams, and was used for lectures and tutorials. The virtual classroom allowed live interaction, and was especially useful for small group case study discussions when students were allocated into breakout rooms. Asynchronous methods of e-learning took the form of pre-recorded lectures, predominantly via Microsoft PowerPoint or iSpring, or recordings of live lectures. This promoted ubiquitous learning where the learner could learn at a time and place of their convenience, and which garnered positive feedback of over 60% from an unofficial survey of students. One student commented that “the online lectures were very useful, especially those that are pre-recorded so [that we] won’t miss out on what the professor is saying”. 

While the move to online teaching was essential, it certainly had its challenges. Many of the faculty were not proficient with the advanced features of Zoom, resulting in initial hiccups in organising multiple lessons for over a hundred students. For example, being unfamiliar with the software, lack of stable Wi-Fi off-campus, and insufficient software accounts were some teething problems. Training workshops for the use of Zoom were initially planned prior to the pandemic, however these could not be realised due to sudden time constraints. Training and troubleshooting manuals were thus made available for all educators and students via an online portal, in addition to a phone helpdesk for further assistance. Furthermore, the other challenge we faced was the short amount of time available to produce and upload enough e-learning material, such as filming of teaching videos, organising self-directed packages, and modifying lecture material to suit live online or pre-recorded delivery. Students also faced challenges due to the multiple modules they were enrolled in during the academic term, having to keep track of up to five randomly-generated meeting identification numbers (ID) each day. The use of one meeting ID per module, set at a regular occurrence, was implemented to alleviate this burden. 

One concern we had was over “Zoom fatigue” and general lack of engagement from students. One strategy we implemented was to insert stretching exercises and a rest period after each hour of lesson. Quiz apps, such as Kahoot and Socrative, was also used to poll content-specific questions, to promote student engagement and active participation. These strategies helped to sustain attention span and was deemed successful as reflected by near-100% participant responses and structured module feedback. One student commented that she was “quite happy that we can still continue lessons, although it is modified…and not have to worry about the uncertainty of lessons being cancelled”. 

III. BLENDED FORMAT FOR PRACTICAL LESSONS

Physiotherapy students are highly dependent on skills-based learning and hands-on practice, which equips them with competencies to treat real patients in the clinical setting. Conducting practical lessons was met with additional challenges due to the strict rules on safe distancing, restrictions on human movement, and limits on class size and frequency. We approached this using video-augmented practicum. A pre-recorded demonstration of physiotherapy skills was disseminated to students via the learning management system (LMS) before each hands-on lesson. This strategy was useful for teaching of skills which require physical space and simulation, such as performing auscultation, manual handling, patient positioning and transfers, airway suctioning, or walking tests. To illustrate, in the teaching of cardiopulmonary exercise testing (CPET), we divided the content into several components: an introductory video and stepwise guide on how to conduct the exercise test; a self-directed learning package on CPET results interpretation with self-evaluation; and a hands-on practical session of performing the full CPET with peers in the human performance laboratory on university campus. Faculty then utilised the face-to-face practical sessions to provide critical feedback and correct students’ techniques. Students were further able to consult with faculty and receive real-time feedback on their performance of skills via video-conferencing, if requested. 

IV. CONDUCTING ASSESSMENT DURING A PANDEMIC

Following the declaration of the pandemic, our programme converted all physical paper examinations to online examinations. Commercially available remote proctoring systems, such as Respondus® and Proctortrack by Verificient, allowed us to mitigate cheating in the virtual environment. The three-point identity check in these systems ensures that authentication is vigorous, while the manual or artificial intelligence proctoring technology enables remote invigilation. ‘Browser lock’ disables platform-sharing functions such as screen-sharing or remote desktop control that would otherwise allow a proxy to take the examination. 

V. ONLINE VIVA VOCE

To assess the “thinking” portion of patient management, we conducted online viva examinations in lieu of physical examinations. To prepare for the large volume of online assessments, we underwent several trials of Zoom, tinkering with features such as the waiting room and breakout rooms. These trials enabled us to familiarise ourselves with the logistic flow, as well as troubleshoot issues such as interruptions during entrance and exit, transfer of host rights, and audio-visual glitches. Administrative coordinators were designated to manually allocate students into the breakout rooms, which was preferred over pre-allocation in order to reduce errors. In anticipation of potential lapses, we used a separate chat messaging software for assessors and coordinators to flag and resolve technical issues. A spreadsheet was used to schedule detailed information about switchover times and room allocation for each candidate, ensuring smooth transition from main room to breakout rooms, as well as to resolve any scheduling conflict. Advance dissemination of the examination schedule and login details was crucial in minimising technical issues. Marking rubrics with clear descriptors were developed, with time set aside for pre- and post-viva calibration amongst assessors. Students had access to the marking rubrics, and a mock run was held to familiarise students with the logistic flow of the assessment. With these preparations in place, we were able to conduct online viva examinations for over a hundred students successfully and efficiently. 

VI. VIDEO SUBMISSION FOR SKILLS ASSESSMENT

To assess the “doing” portion of patient management, we utilised video-based assessment. The evidence for video-based assessment in healthcare education is at its infancy, with most evidence evolving around the idea of video-based peer feedback, assessment for communication skills, or the assessment of surgical skills. We tested this method in a final-year elective module that required learners to demonstrate manually-assisted cough—a skill that would traditionally be performed in front of an assessor and marked against a checklist. Casually dubbed the ‘open-book practical assessment’, faculty listed detailed requirements of the assessment, which gave students time to practise skills before recording and submission. The use of student-generated video assessment (mean marks 77.84 ± 4.59, class size of 30) to replace traditional skills assessment (mean marks 80 ± 3.88, class size of 25) was considered a success as there was no significant difference in the pass-fail ratio between the affected cohort and prior cohorts. In addition, we observed some unintentional benefits, such as the demonstration of digital capability and communication skills by the students, while aligned with the learning and assessment objectives – a finding consistent with the available literature (Walters et al., 2015).

The assessment of skills may also be performed real-time through video-conferencing. However, the logistics and time required to assess such a large number of students within a relatively short timeframe made it a task too immense for us to undertake. Nonetheless, with adequate manpower and resources, it could undoubtedly be feasible, perhaps even superior, as a form of video assessment.

VII. CONCLUSION

The unprecedented COVID-19 pandemic has forced us to refashion pedagogical approaches to our curriculum and to embrace positive changes for the future of physiotherapy education. Utilising aforementioned strategies, we were able to deliver our teaching effectively and almost entirely virtually, despite initial hiccups. Pragmatically, it would be ideal to formally evaluate the impact of a virtual curriculum on established learning outcomes, as well as the general acceptability of such a programme for both students and faculty. In the event of future similar state of emergencies, it may even be prudent to develop a blueprint of and stepwise approach to pedagogy escalating along the spectrum of face-to-face methods versus virtual technology. We hope that this short personal view will provide other educators with some solutions to coping with the challenges of teaching surrounding this exigent time. 

Notes on Contributors

Meredith T. Yeung is an Associate Professor at the Health and Social Sciences Cluster, Singapore Institute of Technology, Singapore. She contributed to the conception and revision of the manuscript critically for important intellectual content.

Melissa Y. Chan is an Associate Faculty at the Health and Social Sciences Cluster, Singapore Institute of Technology, Singapore. She contributed to the conception and revision of the manuscript critically for important intellectual content.

Clement C. Yan is an Associate Professor at the Health and Social Sciences Cluster, Singapore Institute of Technology, Singapore and Senior Principal Physiotherapist at the Department of Physiotherapy, Sengkang General Hospital, Singapore. He contributed to the conception and revision of the manuscript critically for important intellectual content.

Katherin S. Huang is an Associate Faculty at the Health and Social Sciences Cluster, Singapore Institute of Technology, Singapore. She contributed to the conception and revision of the manuscript critically for important intellectual content.

Acknowledgements

The authors wish to thank all students and staff members from the Singapore Institute of Technology and the physiotherapy programme for all the support during this challenging time of COVID-19. All comments and module feedback referred to in this article were willingly and voluntarily provided by students.

Funding

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

Declaration of Interest

The authors declare no form of possible conflicts of interest, including financial, consultant, institutional and other relationships that might lead to bias or a conflict of interest.

References

del Rio, C., & Malani, P. N. (2020). 2019 Novel coronavirus – Important information for clinicians. Journal of the American Medical Association, 323(11), 1039-1040. https://doi.org/10.1001/jama.2020.1490

Guan, W., Ni, Z., Hu, Y., Liang, W., Ou, C., He, J., Liu, L., Shan, H., Lei, C., Hui, D. S. C., Du, B., Li, L., Zeng, G., Yuen, K.-Y., Chen, R., Tang, C., Wang, T., Chen, P., Xiang, J., … Zhong, N. (2020). Clinical characteristics of Coronavirus Disease 2019 in China. New England Journal of Medicine, 382(18), 1708–1720. https://doi.org/10.1056/NEJMoa2002032

Ministry of Health (2020, April 7). Speech by Mr Gan Kim Yong, Minister for Health, at the second reading of COVID-19 (temporary measures) Bill, 7 April 2020 [Press release]. https://www.moh.gov.sg/news-highlights/details/speech-by-mr-gan-kim-yong-minister-for-health-at-the-second-reading-of-covid-19-(temporary-measures)-bill-7-april-2020

Sohrabi, C., Alsafi, Z., O’Neill, N., Khan, M., Kerwan, A., Al-Jabir, A., Iosifidis, C., & Agha, R. (2020). World Health Organization declares global emergency: A review of the 2019 novel coronavirus (COVID-19). International Journal of Surgery, 76, 71–76. https://doi.org/10.1016/j.ijsu.2020.02.034

Walters, S. R., Hallas, J., Phelps, S., & Ikeda, E. (2015). Enhancing the ability of students to engage with theoretical concepts through the creation of learner-generated video assessment. Sport Management Education Journal, 9(2), 102-112. https://doi.org/10.1123/smej.2014-0041

*Meredith T. Yeung
Singapore Institute of Technology,
10 Dover Drive,
Singapore 138683
Tel: +65 65928671
Email: Meredith.Yeung@SingaporeTech.edu.sg

Submitted: 16 July 2020
Accepted: 4 November 2020
Published online: 13 July, TAPS 2021, 6(3), 118-120
https://doi.org/10.29060/TAPS.2021-6-3/CS2392

Wai Keung Chui, Han Kiat Ho, Li Lin Christina Chai & Paul J. Gallagher

Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore

I. THE CHANGING LANDSCAPE IN PHARMACY PRACTICE

Pharmacy practice in Singapore is rapidly evolving with the advent of technological innovations and changes in patient demographics. For instance, the dispensing process in hospitals have been automated; telepharmacy has made access to pharmaceutical services more convenient in the community; an aging population has brought along complex co-morbidities, chronic diseases, polypharmacy and community-based pharmaceutical care services that will require clinical interventions by pharmacists. These examples have raised the question of the “relevance of pharmacists” in the evolving health system. To stay relevant, pharmacists must move from the traditional medication supply (product focus) role to curating the optimal use of medicines by patients (patient focus) in a technology and informatics driven health system. This paradigm shift can only be enabled if the education of pharmacists is suitably re-constructed with outcomes that will future-roof their capabilities in the new healthcare ecosystem. This prompted the Department of Pharmacy at the National University of Singapore (NUS) to make a commitment to review its present programme thereby turning the threats into opportunities for its future pharmacy graduates. This case study reports the approach taken by the Department to re-engineer its curriculum for modern pharmacy practice in the twenty-first century.

II. NEEDS ANALYSIS AND RECOMMENDATIONS

In late 2018, a needs analysis was conducted by the Department to inform the design strategies. This was done through structured interviews by informed consent of key opinion leaders, and focused group discussions with alumni and students. The data collected were coded and analysed thematically. Some main themes about the graduates that came through were the weakness in applying their knowledge, their lack of an understanding of the health system and their reluctance to take leadership role. Feedback on the present curriculum included a lack of connectivity between modules that were taught in silos and the structured experiential learning was scheduled too late in the curriculum. It was recommended that a competency-based and integrated curriculum (Husband et al., 2014; Pearson & Hubball, 2012) would help students achieve the necessary competence as a health professional and apply the multidisciplinary knowledge holistically to problem solve. An introduction of systems thinking, and a longitudinal experiential learning programme across the four years will help students understand their future work environment better.

III. PROGRAMME DESIGN

Based on these recommendations, the department had to deconstruct and re-organise the current traditional teaching approach where basic sciences are taught in separate modules in years 1 to 2 while topics in pharmacy practice and therapeutics are introduced from years 3 to 4; with work-place learning happening only after year three. A Curriculum Design Group (CDG) was established to dissect and develop the curriculum. The CDG adapted the key competencies listed in the Association of Faculties of Pharmacy in Canada Educational Outcomes for First Professional Degree Programs in Pharmacy (Association of Faculties of Pharmacy of Canada, 2017) as the basis for the competency-based curriculum. The students will learn to approach pharmacy practice by skilfully integrating sub-competencies of communicator, collaborator, leader-manager, scholar-innovator, health advocate and professional roles into an overarching care provider role. The scholar role is expanded to scholar-innovator role as innovation aligns well with the core value of NUS and is also a critical attribute to safeguard against future disruptions. The key competencies under each role are carefully mapped onto the learning outcomes of themed modules. The themed modules (based on physiological systems) are designed using a theoretical framework of integrating basic, clinical and systems sciences (Gonzalo et al., 2017) (Figure 1). To help students make sense of what they learn, experiential learning is incorporated longitudinally across the four years so that students can apply their theoretical studies at the workplace when they go on clinical placements (Figure 1). This 3-pillar educational framework has been successfully applied in medical education in the US to develop medical competencies and systems thinking among the physicians (Gonzalo et al., 2017); the CDG believed that the same framework would work for pharmacists in Singapore.

Pharmacy graduates must be prepared for a health system that is driven by informatics and technology. Joseph Aoun in his book “Robot-Proof: Higher Education in the Age of Artificial Intelligence” (Aoun, 2017) recommended undergraduate students to acquire technical, data and human literacies, which he collectively refers to as the “humanics”, for them to stay ahead of the technological revolution. Therefore, subjects such as medical sociology, computational thinking, health informatics are included to cultivate the humanics in the pharmacy students. It is envisaged that this approach can better prepare the graduates to work with patients, co-workers, data and technologies in providing quality care. Furthermore, instilling characteristics of a transformational leader and familiarising students to implementation science will take a step closer to grooming the student pharmacists into future leaders.

Figure 1: The theoretical framework of curricular integration. Adapted from Gonzalo et al. (2017) and Pearson and Hubball (2012).

In the new programme, students are made accountable of their own learning through pre-class preparations and interactive team-based learning (TBL) in the classroom. TBL sessions are facilitated by a scientist and a clinician who help students to use integrative thinking to solve the cases. In the laboratory, students will also work in teams to gather scientific data for inquiry-based learning. The impact of the new educational approach will be evaluated against all the four levels of the new world Kirkpatrick Model to determine the effectiveness of the curriculum.

IV. TRANSFORMING PHARMACY EDUCATION IN RESPONSE TO THREATS

The fourth industrial revolution has indeed caused disruptions to pharmacy practice. Pharmacists will have to step forward and be leaders of change when it comes to any matter related to medicines, be it optimising drug use, identifying drug-related problems or recommending cost-effective therapy. Therefore, it is the mission of NUS Department of Pharmacy to respond to the threats by transforming its professional pharmacy programme to one that can future proof its graduates who will be ready to seize new opportunities in a dynamic health system.

Notes on Contributors

Professor Christina Chai is the Head of the Pharmacy Department at NUS. She initiated the EduRx project by calling for the need to redesign the professional pharmacy degree curriculum to better prepare the graduates for the evolving healthcare landscape in Singapore.

Associate Professor Ho Han Kiat, in the capacity of the Deputy Head (Education), supported the curriculum design group in ensuring that the new pharmacy curriculum is closely aligned to both the NUS educational philosophy and the educational outcomes for pharmacy graduates.

Professor Paul Gallagher and Associate Professor Chui Wai Keung are co-leaders of the EduRx project who under their co-leadership worked with the curriculum design group to develop the competency-based and integrative pharmacy programme.

Acknowledgements

The authors would like to acknowledge the contributions made by the curriculum design group that comprises the following members: Chng Hui Ting, Fan Wenjie, Han Zhe, Priscilla How, Law Hwa Lin, Eugene Lim Zi Jie, Anson Lim Zong Neng, Tan Bee Jen, Matthias Gerhard Wacker, and Yeo Shao Jie.

Funding

There is no research funding source for the programme review project. 

Declaration of Interest

The authors declare no conflict of interest concerning any aspect of this case study.

References

Aoun, J. (2017). Robot-proof: Higher education in the age of artificial intelligence. The MIT Press.

Association of Faculties of Pharmacy of Canada. (2017). AFPC educational outcomes for first professional degree programs in pharmacy in Canada 2017. https://afpc.info/system/files/public/AFPC-Educational%20Outcomes%202017_final%20Jun2017.pdf 

Gonzalo, J. D., Haidet, P., Papp, K. K., Wolpaw, D. R., Moser, E., Wittenstein, R., & Wolpaw, T. (2017). Educating for the 21st-century healthcare system: An interdependent framework of basic, clinical and systems sciences. Academic Medicine, 92 (1), 35-39. https://doi.org/10.1097/ACM.0000000000000951

Husband, A. K., Todd, A., & Fulton, J. (2014). Integrating science and practice in pharmacy curricula. American Journal of Pharmaceutical Education, 78 (3), 63. https://doi.org/10.5688/ajpe78363

Pearson, M. L., & Hubball, H. T. (2012). Curricular Integration in Pharmacy Education. American Journal of Pharmaceutical Education, 76 (10), 204. https://doi.org/10.5688/ajpe7610204

*Wai Keung Chui
Department of Pharmacy,
Faculty of Science,
Block S4A, 18 Science Drive 4,
Singapore 117543.
Tel: +65 6516 2933
Email: phacwk@nus.edu.sg