Submitted: 6 April 2024
Accepted: 10 December 2025
Published online: 1 April, TAPS 2025, 10(2), 57-64
https://doi.org/10.29060/TAPS.2025-10-2/OA3332

Chatchai Kreepala¹, Srunwas Thongsombat², Krittanont Wattanavaekin³, Taechasit Danjittrong⁴, Nattawut Keeratibharat⁵ & Thitikorn Juntararuangtong¹

¹School of Internal Medicine, Institute of Medicine, Suranaree University of Technology, Thailand; ²Department of Orthopedics, Faculty of Medicine, Prince of Songkla University, Thailand; ³Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Thailand; ⁴Department of Anesthesiology, Chulabhorn Hospital, Thailand; ⁵School of Surgery, Institute of Medicine, Suranaree University of Technology, Thailand

Abstract

Introduction: Factors affecting decision-making duration in MCQs can enhance assessment effectiveness, ensuring they accurately measure the intended objectives and address issues related to incomplete exams due to time constraints. The authors aimed to explore the aspects of medical student’s perspective regarding the factors influencing their decision making on MCQ assessments.

Methods: A mixed-methods explanatory sequential design was utilised. Initial surveys were conducted using percentages, mean and non-parametric analysis obtained via online questionnaires from the sample group: all 2^nd – 5^th year medical students from SUT, Thailand. The validity of the questionnaires was verified by three independent reviewers (IOC=0.89). This was followed by semi-structured group interviews to explore student’s perspective on the factors affecting their decision. Qualitative analysis was conducted to explore detailed information until data saturation was achieved.

Results: Data from the quantitative analysis identified four factors that students believe affect the duration of the exam: the total word count of each question, test difficulty, and images in tests. Meanwhile, the qualitative analysis provided additional insights on factors such as the examination atmosphere affecting their decisions.

Conclusion: This report indicated that data acquired from a comprehensive reading question should be distinguished from those requiring decisive reading. Apart from text length, question taxonomy-such as recall or application- and questions with given images and tables should be considered as factors determining time allocation for an MCQ. Future research based on these results should aim to develop a mathematical formula to calculate exam duration, accounting for question difficulty and length.

Keywords:           MCQ, Medical Assessment, Medical Education, Testing Time Estimation, Qualitative Research, Students’ Perspective

Practice Highlights

• The multiple-choice question (MCQ) stands as one of the objective assessment methods, widely regarded as the most utilised form of assessment.
• The word-length effect has been proposed to determine the length of each examination.
• Educational theories on decision-making have posited that decision-making is a dynamic process stemming from prior experiences.
• The authors were interested in exploring the aspects of the medical student’s perspective about the factors affecting their decision on MCQs answering.

I. INTRODUCTION

The multiple-choice question (MCQ) stands as one of the available objective assessment methods, widely regarded as the most utilised form of assessment, particularly within the fields of medical sciences and technology. Evidence suggests that the recall of short words often surpasses that of longer words (Tehan & Tolan, 2007). This observation is frequently analysed within the framework of a working memory model and the role of the phonological loop in immediate recall. However, the word-length effect has also been observed in delayed tests and in lists that surpass the memory span, thereby challenging the working memory interpretation of the phenomenon. Three alternative interpretations of the word-length effect have been proposed to explain how an exam length should be determined (Arif & Stuerzlinger, 2009; Kumar et al., 2021).

Educational theories on decision-making have posited that decision-making is a dynamic process stemming from prior experiences (Phillips et al., 2004) and meaningful learning (Foley, 2019). As a result, the ability to comprehend text while reading does not automatically equate to reading for decision-making or answering questions. From the literature, the context of factors influencing medical students’ decisions on MCQs includes 1) Length or number of words: The time students need to read to gather information before making a decision on an answer (Arif & Stuerzlinger, 2009). 2) Difficulty of the questions: analytical thinking, especially calculations are involved, may increase decision-making time. This depends on the students’ prior learning experiences before the exam (González et al., 2008). 3) Language comprehension: since exams in medical schools are often in English, non-native speakers may take longer to read and understand the questions (Schenck, 2020). 4) Visuals and tables: these serve as symbols that help students retrieve information from their prior learning experiences more easily (Ziefle, 1998). It is certain that teachers want academic assessment tests, such as MCQs, to be used to distinguish between high-performing and low-performing students and to assess the knowledge and understanding they have acquired. However, these objectives may be undermined by issues such as students running out of time and resorting to guessing. This inevitably reduces the reliability of the test.

The authors were interested in exploring medical student’s aspect regarding factors affecting their decision on MCQs answering. Previous studies focused on duration required for question comprehension and understanding but not for analysis. These were also mostly done in native Englisher speakers. This study builds upon previous studies but with an emphasis on factors affecting non-native English speakers’ decision making after analysis of the provided questions to answer MCQs in English. This research should be approached from the perspective of the student to obtain appropriate data. Semi-structured qualitative interviews were analysed in conjunction with quantitative data to identify and clarify the reasons and factors that students believe influence their performance on exams.

II. METHODS

A. Study Population

The research participants were second to fifth-year Thai medical students who had taken MCQ tests during their preclinical and clinical years between the academic years 2021-2022. Questionnaires were sent to all students without sampling.

To minimise data artifacts caused by recall bias, the online questionnaires were distributed the first week after each MCQ test before the study to the students who completed the exams. All examinations in this study were computer-based, closed book, single best answer MCQs written in English. The participants were non-native English speakers of Thai nationality (as detailed in Definition of Terms). An online survey or questionnaire-based study was used to collect information from participants in this study. If the data was unsaturated, triangulated data from a group of interviews consisting of students from different rotations was included to receive as much information from students’ perspectives as possible.

B. Study Design and Data Collection

The authors employed a mixed method study comprising a quantitative approach and a sequential, explanatory approach. The literature review unveiled several factors influencing MCQ test duration, including the number of questions, question types (recall or comprehension), subject matter difficulty, calculation items, and picture identification, as outlined in the questionnaire (O’Dwyer, 2012). 

An online survey or questionnaire-based study was used to collect information from participants with minimal disruption to their learning activities. The quantitative research section was managed by CK, NK and TJ.  Students completed the questionnaire once, based on their experiences in medical school. This, therefore, necessitates the researcher to summarise the responses and, if required, categorise interviews into groups according to their year of study. Open-ended questions were included in the last section of the questionnaire. The open-ended questions about the factors that, in the student’s opinions, were helpful information about the other factors affecting MCQ time (Lertwilaiwittaya et al., 2019). Survey research was employed as a quantitative method, while semi-structured group interviews were utilised in qualitative data collection to gather insights from medical students’ perspectives. The interview questions were designed to investigate whether students possessed any additional insights regarding the factors influencing MCQ test duration (Carnegie Mellon University, 2019; Schenck, 2020; Wang, 2019).

There were three sections in the questionnaire. Part I consisted of the instruction and informed consent. Part II consisted of general information of the participants, including sex, age, and academic year. Part III consisted of the questionnaires covering all four constructive domains previously mentioned (the domains affecting MCQ time from the literature included: 1) the number and total word count, 2) English language questions, 3) calculation questions, 4) the analytical thinking questions and open-ended questions about the factors that, in the students’ opinions, were helpful information about the other factors affecting MCQ time. After the questions in Part One were completed, they would be taken away so that the researchers would not be able to identify whose students have answered Part II and Part III.

To prevent neutral opinions from students, each questionnaire item featured a four-point Likert scale corresponding to levels of agreement: ‘Strongly disagree,’ ‘Disagree,’ ‘Agree,’ and ‘Strongly agree.’ The researcher wanted clear opinion whether the students were trending towards which side, hence the four-point Likert scale to prevent neutral opinion which may complicate statistical analysis. Validity of the questionnaires were verified by three independent reviewers with an Index of Item-Objective Congruence (IOC) value of 0.89.

Semi-structured group interviews were adopted into this study as insufficient flexibility is provided by a structured interview, whereas unstructured interviews would be too flexible. Semi-structured group interviews were the combination of formal and informal interviews focusing on personal experience; this often leads to unexpected results, enhancing the quality of data collected.

These interviews would take place after class by independent interviewers without any conflict of interest. Two facilitators were present in each session, CK facilitated the conversation and NK contributed ideas. The two facilitators were known by the student participants as faculty members, but they were not actively engaged in their academic learning.  Audio and written recording would be coded then decoded by the researchers (SK, KW and TD).

The interview would take around 30-45 minutes per group, with each group consisting of five to eight people. Analysis would be done after the first three groups using relevant domain analysis and further analysis done after new interviews until data saturation was achieved.  Coding, theme identification, and triangulation would be undertaken following the analysis and evaluation of the quantitative and qualitative data of which the analysis could be extrapolated to form a conclusion of the study. In this study, the open-end question would be analysed, and the semi-structured interview would be done.

Triangulation helped to provide meaning and helped to gain broader and more precise understanding. It could help increase validity. Triangulation was undertaken following the analysis and evaluation of the quantitative and qualitative data of which the analysis was extrapolated to form a conclusion of the study.

C. Definition of Terms

1) Multiple choice question (MCQ): This paper exclusively focused on the Single Best Answer (SBA) Multiple Choice Questions (MCQs), which were structured as questions followed by 4 or 5 potential answers, with only one correct response per question (Coughlin & Featherstone, 2017).

2) Taxonomy MCQ: MCQs were formulated based on two assumptions: that they could be categorised into higher or lower orders according to Bloom’s taxonomy (Stringer et al., 2021). This study sought to comprehend students’ approaches to questions by examining variances in their perceptions of the Bloom’s level of MCQs regarding their knowledge and confidence. The authors employed Bloom’s taxonomy in this study, classifying questions as “recall,” “comprehension,” and “application” (Stringer et al., 2021).

3) Non-native English speakers: The term non-native English speakers was defined as those students who spoke a language other than English domestically. Non-native English speakers were inclusive of both competent bi-literate and limited English proficiency students. In addition, it is also defined as students who learn the language as older children or adults (Cassels & Johnstone, 1984).

D. Statistical Analysis

Statistical analyses were performed for quantitative analysis with SPSS Statistics for Windows, Version 18.0 (SPSS Inc., Chicago, Illinois, USA). Information in the quantitative section was elaborated and displayed in and counts percentage. The qualitative data was analysed by code grouping of text fragments based on content. Subsequently, the codes were reorganised and grouped, main themes and subthemes were identified, and illustrative quotations were selected. The authors assigned other three medical teachers to undertake independent coding of the transcripts for each interview. The final coding and discussions continued until the frameworks were agreed upon and new themes were derived (CK, SK, KW and TD).

III. RESULTS

A. Demographic Information

The questionnaire was done online by the participants from second to fifth-year medical students in the academic year 2021-2022. There were 93 second-year medical students, 92 third-year medical students, 92 fourth-year medical students, and 93 fifth-year medical students, respectively, with 370 participants in total. It was found that there were 298 respondents (a return rate of 81%). 73 second-year medical students (78% response rate) answered the questions, while 70 third year (76%), 75 fourth year (81%), and 80 fifth year medical students (86%) answered the questions respectively as shown in Table 1.

D. The Number Tests and Total Word Count

The exam questions, according to some students, were challenging and time-consuming, and the answer options were likewise lengthy. It was shown that not only the number of tests, but the length of each test item also affected the testing time.

Quote: Student B1F*; “The questions were too long. I can’t complete them in time.”

Quote: Student A2M*; “If there are too many questions in the exam, I wouldn’t be able to finish it”

* student’s code

English Language Questions and Examiners (Native Versus Non-Native English Speakers): The respondents, who were not native English speakers, believed that the English-language test took longer to finish than the Thai-language test. Accordingly, they decided to guess or answer each question slowly since they could not understand the questions. They believed that the English-language tests took longer to finish than the Thai-language tests. Accordingly, they decided to guess or answer each question slowly since they could not fully understand the English questions.

Quote: Student D1F*; “I’m not good at reading English. Sometimes I just have to guess on the exam.”

Quote: Student C1M*; “The language in the test is too hard to understand.”

* student’s code

E. Test Difficulty Determining Time Allocation

For the analysis of coding, grouping, and generating themes, the author found that the medical students paid attention to the difficulty level of the questions which affected the decision to answer the questions.

1) The Calculation and Analytical Thinking: The calculation and analytical thinking tests took students longer to read. Additionally, students believed that examinations they had never taken before or exams that required knowledge application took longer to complete, such as exams that included questions requiring the students to diagnose patients by themselves which occasionally left them unsure of how to respond.

Quote: Student C2M*; “Calculation tests take a long time to get the answers.”

* student’s code

2) Recall Question Leads to Quick Answers: Students commented that recall-type questions, including tests from previous academic years, contained duplicated sentences, pictures, or messages from textbooks that students remembered. This led to students being able to complete the test in a short thinking time.

Quote: Student K1M*; “If the teacher copied the exact words from the course sheet, I would remember and answer questions quickly.”

Quote: Student L1M*; “If the questions are the same as in the sheet provided, I can answer them.”

*student’ code

This information indicated that the taxonomy of the test (recall -compression-application) had a large effect on decision time. Applied questions, not direct or calculated questions, required more attention and time for decision-making when compared to comprehensive questions (questions about knowledge understanding). In contrast, recall questions required the least decision-making time.

F. The Visual Image and Atmosphere of the Examination: the New Derived Domains Recognised by Qualitative Analysis

1) Questions with images, graphs, or tables serve as key guides for decision-making: The students thought that the exams that consisted of graphs and tables helped them understand the questions and were better than the questions that only had descriptions. That would lead to less time consumed.

Quote: Student L2M*; “If the test got the exact same summary table from the book, I could remember and get the answers right away.”

* student’s code

2) The Atmosphere of the Examination: The environment and atmosphere of the exam were also mentioned. The student’s response time was slowed down by the distractions during the exam. The environment such as brightness, temperature, and examination devices affected the concentration of the students.

Quote: Student H1F*; “The atmosphere in the exam venue, noise, and the air quality in the room affect the exam results.”

*student’s code

IV. DISCUSSION

The results revealed that students perceived lengthy exam content or a large number of questions as time-consuming, particularly when exams were conducted in English. Studies indicated that English speakers could read up to 150 words per minute (Trauzettel-Klosinski et al., 2012). However, for non-native English speakers, the expected reading time for exams was longer. Hence, using the English reading rate as a basis for determining exam duration was deemed unsuitable for Thai students, given that English was not their primary language of communication. When compared with a previous study (Trauzettel-Klosinski et al., 2012), the increased duration may result from decision making, thus this implicates reading for decision making requires more time than reading for the context which is cumulatively longer for non-English native speakers.

Qualitative findings indicated that irrespective of the exam duration set by the administering professor, students generally completed exams within the allotted time frame. This often entailed guessing answers towards the end of the exam period, as students might not have adequate time to complete the exam thoroughly. It was observed that students tended to resort to guessing exam questions approximately five minutes before the exam conclusion, thereby minimising threats to validity posed by guessing due to time constraints during exam (Foley, 2019).

There may be limitations if the exam questions contain lengthy content that cannot be comprehended and decided upon within one minute. Furthermore, the difficulty level of the exam questions is often established as a passing criterion, prioritising validity considerations in terms of content format and achieving the intended objectives. Moreover, students naturally desire to obtain the highest possible score on the exam, regardless of the level of difficulty or length of the exam. Therefore, it is important for students to manage their time effectively to ensure they can complete all the exam questions within the given timeframe.

The qualitative results indicated that regardless of the exam duration set by the administering professor, students ultimately would complete the exam within the allotted time frame. Additionally, students agreed that application and calculation questions on the exam require more time to read and decide upon, as opposed to questions with figures and tables that aided in faster decision making. Based on these findings, it could be concluded that comprehensive reading rates may not be a reliable indicator of decision-making reading rates, particularly in the context of medical school exams. Therefore, studying decision-making reading rates within the context of medical school exams was crucial.

The researcher, therefore, examined the domain and specific factors on the characteristics of the MCQ test. Additionally, the study scope was limited to English tests administered to non-native English speakers and onsite computer-based tests, thereby eliminating unrelated factors that could impact exam duration. The analysis yielded the following results: Firstly, factors positively correlated with exam duration (negatively correlated with decision-making) included the number of questions, total word count, calculation questions, and analytical thinking questions. Secondly, factors negatively correlated with exam duration (positively correlated with decision-making) were recall questions, questions with provided images, and tables.

A factor contributing to longer reading times for decision-making purposes was when the exam contained a higher proportion of application or calculation questions, comprising over 33% of the exam questions, as evidenced by qualitative data from students. Therefore, analysing exam completion time based on reading comprehension data for decision-making purposes is not recommended. Moreover, it should be noted that these factors present internal threats to validity, but they can be managed to ensure that examination tools are effectively used and aligned with intended objectives. Incorporating data from research can lead to the identification of new themes related to factors influencing examination time.

Five constructive domains were identified: 1) the number and total word count, 2) positive difficulty factors (application/calculation questions), 3) negative difficulty factors (recall questions), 4) examiners (non-native English speakers or not), and 5) pictures/symbols in tests.

A distinctive aspect of this study was its targeted focus on Thai medical students who were non–native English speakers. While many studies have examined MCQ performance across broad and diverse populations, this research concentrated on a specific demographic, enabling a more in-depth exploration of how cultural and linguistic factors influence test-taking behaviour. The study uniquely combined quantitative survey data with qualitative insights from semi-structured group interviews. While some research utilised either quantitative or qualitative methods, this study’s integration of both provided a more holistic understanding of student perspectives and experiences (Lertwilaiwittaya et al., 2019). This methodological triangulation strengthened the validity of the findings by cross-verifying quantitative data with qualitative insights. In contrast to many existing studies that focused predominantly on performance metrics (such as scores or pass rates), this research examined the cognitive processes and decision-making strategies students employed while answering MCQs. It investigated how elements like question difficulty, language comprehension, and prior experiences shaped students’ approaches to test questions—a dimension less frequently explored in previous literature.

In conjunction with examination-related factors, students also recognised the importance of considering the test environment within the examination room which was a new finding found using qualitative analysis from this research. This was crucial for promoting student concentration and facilitating accurate response selection in line with assessment tool objectives. It aligned with existing literature, which suggested that the test environment poses a construct irrelevant threat to the validity of educational measurement. The findings from this study may have led to future research on developing a mathematical formula to tailor the exam duration for different sets of questions. This would have involved analysing factors such as the number of words, length, difficulty, and the presence of images and tables in the exam. Additionally, the impact of language proficiency on reading and decision-making time should have been considered, as there may have been differences between native and non-native speakers. The study suggested that the future research direction should include diverse populations of non-native English speakers from different countries and educational contexts. This could help identify whether the findings are consistent across various cultural backgrounds and educational systems. Moreover, conducted longitudinal studies should be used to track students’ performance and decision-making processes over time. This approach could provide insights into how experiences and familiarity with MCQs influence their strategies and confidence levels throughout their medical education.

A major limitation of this research was the variation in learning experiences, exam-taking skills, and analytical thinking among medical students at different year levels, which might lead to differing opinions. Therefore, the researcher needed to conduct qualitative analysis to examine the reasons behind these differences. However, the diversity of experiences might also introduce bias due to varying familiarity with different types of exams. The online format restricted the depth of responses, as students often did not fully articulate their thoughts without immediate follow-up questions, which limited the richness of the qualitative data. Additionally, the focus on Thai medical students constrained the applicability of the findings to other populations or contexts, thereby limiting broader conclusions about non-native English speakers in different educational settings.

V. CONCLUSION

Based on the student’s perspective, data showed questions with lengthy content required more time whilst those with tables or diagrams required less time. This report indicated that the data acquired from a comprehensive reading examination should be distinguished from a decisive reading examination.

In addition to the number of questions and the length of text, factors that should be positively correlated with the duration of the exam include the number of questions, word count, calculation-based questions, and analytical thinking questions. These factors should be considered for additional time allocation beyond the regular exam duration, particularly when the proportion of analytical thinking questions exceeds one-third of the total question set. On the other hand, recall questions, as well as questions accompanied by images and tables, should be taken into account to ensure a balanced distribution of exam time, as they can be answered more easily and quickly in terms of decision-making compared to general questions.

Notes on Contributors

CK conceived of the presented idea, developed the theory, and performed the computations and discussed the results and contributed to the final manuscript. ST, KW, and TD. discussed the results and wrote the manuscript with support from CK, NK, and TJ, designed the model and the computational framework and analysed the data.

Ethical Approval

All participants voluntarily signed a consent form prior to participating in the study. The participation protocol was approved by the Human Research Ethics Committee, Suranaree University of Technology (Issue # EC-64-102).

Data Availability

Institutional ethical clearance was given to maintain the data in the secure storage of the principal investigator of the study. The data to this study may be provided upon reasonable request to the corresponding author. A preprint of our manuscript, which is not peer-reviewed, is available at https://www.researchsquare.com/article/rs-3019852/v1

Acknowledgement

The authors would like to thank the participants of this study, the medical students in the Institute of Medicine, Suranaree University of Technology. Without their passionate participation and input, the validation survey could not have been successfully conducted.

Funding

This work was supported by the Grant of Suranaree University of Technology (contract number SUT-602-64-12-08(NEW)).

Declaration of Interest

The authors have no conflicts of interest to disclose.

References

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*Assoc. Prof. Chatchai Kreepala, M.D.
Institute of Medicine
Suranaree University of Technology
Thailand
+66(93)3874665
Email: chatchaikree@gmail.com

Submitted: 17 April 2024
Accepted: 18 December 2025
Published online: 1 April, TAPS 2025, 10(2), 65-70
https://doi.org/10.29060/TAPS.2025-10-2/OA3336

Rachael Tufui Masilomani¹, Sophaganie Jepsen¹, Maria Lourdes Villaruel¹, Aying Wang¹, Alena Kotoiwasawasa¹, Lusiana Naikawakawavesi¹, Norman Bartolome¹, Claudia Paterson², Andrew Hill² & Maria Concepcion Bartolome¹

¹Basic Clinical Medicine, Fiji National University, Fiji; ²Department of Surgery, Middlemore Hospital, University of Auckland, New Zealand

Abstract

Introduction: The MBBS programme at Fiji National University reduced its teaching weeks from 18 to 14 weeks in 2018. The purpose of this study was to assess student perceptions of learning and teachers following the reduction in the number of teaching weeks from 18 to 14 weeks.

Methods: A questionnaire was created using a modified Dundee Ready Education Environment Measure (mDREEM) tool (23 items). This was comprised of two subscales; Students Perception of Learning (SPL – 12 items) and Students Perception of Teachers (SPT – 11 items). This was circulated to Year 5 MBBS students through an online survey in 2020.

Results: The response rate was 96%. The students regarded their educational environment as positive in both length of teaching weeks, with an overall mDREEM mean score of 63.29 in 18 weeks and 62.03 in 14 weeks. No statistically significant differences were found between 18 week and 14 week scores across mDREEM scores, SPL scores or SPT scores. The highest scoring item over both was ‘teachers are knowledgeable’.

Conclusion: A positive perception was noted for both lengths of teaching weeks. Reducing the teaching weeks from 18 to 14 did not statistically significantly reduce students’ perception of their educational environment. Items identified with low scores will give a window of opportunity for lecturers and to improve these areas. Future studies may explore the use of the five subscales of the DREEM tool and this study can be integrated into further evaluations of educational environment at Fiji National University.

Keywords:           Medical Students, Educational Learning Environment, DREEM Tool, Fiji National University, Teaching, Medical Education

Practice Highlights

• mDREEM scores did not significantly differ between 18 weeks and 14 weeks of teaching.
• The highest scoring item over both weeks was ‘teachers are knowledgeable’.

I. INTRODUCTION

The Fiji National University (FNU) was founded in 2010 by the merging of six academic institutions in the Fiji Islands, including the Fiji School of Medicine (FSM). FNU has continued the FSM’s tradition of educating and training a diverse population of students from Fiji and neighbouring Pacific Island nations.  The Bachelor of Medicine and Bachelor of Surgery (MBBS) programme is a six-year course at FNU. As part of the academic year, each pre-clinical year group have a teaching week block course. During this time, students receive 2-4 hours of scheduled lectures, 2-hour tutorials twice weekly, as well as 2 hours of clinical skills and 2 hours of anatomy, 2 hours of laboratory sessions and a health centre attachment 4 hours a week.

In 2018, FNU reduced the teaching week block course in the MBBS programme from 18 weeks to 14 weeks. The teaching weeks were shortened due to the decision to move specialty courses such as Psychiatry and Public Health to their respective clinical blocks from Years 4 to 6. This adaptation was challenging for the lecturers, who had to reformat their teaching sessions, in addition to providing resources onto an online Moodle platform. It is well established that the educational environment plays an important role in determining the academic success of medical students (Prosser et al., 1999; Ramsden 2003). Therefore, it is important to evaluate the impact of any major changes to the educational environment, such as a reduction in teaching weeks from 18 weeks to 14 weeks.

Previous research has demonstrated that the duration of clinical rotations has been able to be decreased without adversely affecting the academic success of medical students. For example, one group demonstrated that a shortened four-week clinical rotation in Obstetrics and Gynaecology provided enough opportunity for final year medical students to undertake a quality improvement project in the curriculum (Kool et al., 2017).

The Dundee Ready Education Environment Measure (DREEM) is a quantitative tool used to evaluate students’ perceptions of the educational environment in medical schools. The DREEM tool consists of 50 items, each rated on a scale from 0 to 4. It has five domains, allowing for a maximum score of 200. Higher scores indicate a positive perception of the learning environment (Roff et al., 1997).

A systematic review published in 2012 analysed 40 studies reporting DREEM scores from 20 countries. This review demonstrated that DREEM had been used internationally for various purposes, including diagnostic assessments and comparative studies across different groups (Miles et al., 2012). Five studies focused on investigating the impact of a changed curriculum, which was our area of interest (Demirören et al., 2008, Edgren et al., 2010, O’Brien et al., 2008, Riquelme et al., 2009, Till et al., 2004). We identified three key themes: 1) the DREEM tool was able to highlight areas of concern and/or remediation among students (Riquelme et al., 2009 Till et al., 2004), 2) DREEM scores were different in different phases of medical education, with year 3 students having the highest scores, and year 5 students having the lowest scores (Demirören et al., 2008, Riquelme et al., 2009), and 3) the DREEM tool identified clusters of students based on how positively they perceived the curriculum (O’Brien et al., 2008).

The aim of this research was to compare students’ perception of learning and teachers between 18 weeks and 14 weeks, using a modified DREEM (mDREEM) tool which utilises two of the five domains from the original DREEM tool. The authors’ hypothesis was that students’ perception of learning and teaching would be reduced in with a decrease in teaching weeks to 14 weeks compared to 18 weeks.

II. METHODS

A. Participants

An online survey was developed by the authors. This was distributed via email to eligible participants using Google Forms from 12^th December to 17^th December 2020. Eligible participants included the Year 5 MBBS cohort of 2021, as this cohort was exposed to both 18 week and 14 week teaching programmes. Participation in the survey was optional and results were anonymous. Submission of a completed survey was taken as providing informed consent to participate in this research. Full ethics approval was provided through FNU’s College Human Health Ethics Committee (ID: 292.20). Facility approval was granted to conduct the research.

B. mDREEM Tool

The authors selected two of the five domains of the DREEM tool to be included in the survey. The selected two domains included students’ perceptions of learning (SPL) and students’ perceptions of teachers (SPT). The rationale for using only these two domains was that they were the two domains of interest for the teachers, and it was thought that a survey with less questions would be more likely to be filled to completion by more of the students. Using a Likert scale, each item was scored from 0 to 4, with 4 = strongly agree, 3 = agree, 2 = not sure, 1 = disagree and 0 = strongly disagree. Six of the 23 statements in the mDREEM tool were negative statements: 1) the teaching over-emphasised factual learning; 2) the teaching is too teacher-centred; 3) teachers ridicule the students; 4) the teachers are authoritarian; 5) teachers get angry in class and 6) the students irritate the teachers. These were scored in a reverse manner.

The mDREEM tool had a maximum score of 92. The SPL domain included 12 items, with a maximum score of 48. The SPT domain included 11 items, with a maximum score of 44. This research used the following guide to interpret the overall scores:

• 0–23 = Very poor environment
• 24 – 46 = A large number of problems in the environment
• 47–69 = More positive than negative environment
• 70–92 = Excellent

C. Statistical Analysis

Analysis of the collected data was by using R version 4.3.1. Mean scores were reported with standard deviations. Paired t-tests were performed to compare aspects of the mDREEM scores over 18 weeks and 14 weeks, with a statistical significance threshold of p<0.05. Reliability analysis of the mDREEM tool was assessed using Cronbach’s Alpha test, where >0.7 was deemed acceptable internal consistency.

III. RESULTS

Seventy-eight out of eighty-one (96%) MBSS Year 5 students participated in the online survey. Fifty-one (65%) were females and 51% of participants were aged between 23 and 25 years old. Fijian of Indian descent students made up the majority of the responders (67%) followed by other ethnicities (18%) and i-Taueki students (15%). The majority of students resided at the FNU Hostel (69%) while 28% lived within Suva and only 3% lived outside Suva.

Table 1 illustrates the 23 individual mDREEM items with mean scores across 18 weeks and 14 weeks. The item ‘the teaching overemphasised factual learning’ scored the lowest for both 18 and 14 weeks. The item ‘teachers are knowledgeable’ scored the highest for both 18 and 14 weeks.

Items	mDREEM item	Code	18 weeks		14 weeks
			Mean	SD	Mean	SD
1	I am encouraged to participate in class	SPL	3.13	0.91	2.78	1.03
2	The teaching is often stimulating	SPL	2.79	1.02	2.65	0.94
3	The teaching is student-centred	SPL	2.97	0.95	2.79	0.92
4	The teaching helps to develop my competence	SPL	3.06	0.82	2.63	0.92
5	The teaching is well focused	SPL	2.67	1.00	2.55	1.03
6	The teaching helps to develop my confidence	SPL	2.88	1.01	2.79	0.94
7	The teaching time is put to good use	SPL	2.81	1.12	2.60	1.00
8	The teaching over-emphasised factual learning	SPL	1.85	0.92	1.91	0.79
9	I am clear about the learning objectives of the course	SPL	2.77	1.02	2.78	0.98
10	The teaching encourages me to be an active learner	SPL	2.86	1.16	2.97	0.88
11	Long term learning is emphasised over short term learning	SPL	2.59	1.13	2.56	0.98
12	The teaching is too teacher-centred	SPL	2.85	0.80	2.74	0.78
13	The teachers are knowledgeable	SPT	3.18	0.83	3.13	0.80
14	The teachers are patient	SPT	3.01	0.73	2.74	0.89
15	The teachers ridicule the students	SPT	2.49	0.97	2.56	0.97
16	The teachers are authoritarian	SPT	2.49	0.96	2.58	0.91
17	The teachers have good communication skills	SPT	3.04	0.90	2.99	0.71
18	The teachers are good at providing feedback to students	SPT	2.54	1.15	2.86	0.96
19	The teachers provide constructive criticisms	SPT	2.85	0.90	2.92	0.84
20	The teachers give clear examples during class	SPT	2.78	0.91	2.79	0.84
21	The teachers get angry in class	SPT	2.63	1.01	2.63	0.85
22	The teachers are well prepared for their classes	SPT	2.87	0.90	2.92	0.81
23	The students irritate the teachers	SPT	2.23	0.95	2.23	0.83

The mean SPL scores over 18 weeks and 14 weeks were 33.23 (SD 7.38) and 31.74 (SD 7.52), respectively, out of a maximum of 48 (SPL 18 weeks: 69.33%; SPL 14 weeks: 66.13%). The mean SPT scores over 18 weeks and 14 weeks were 30.06 (SD 6.34) and 30.28 (SD 5.74), respectively, out of a maximum of 44 (SPT 18 weeks: 68.32%; SPT 14 weeks: 68.82%). The mean mDREEM scores over 18 weeks and 14 weeks were 63.29 (SD 12.58) and 62.03 (SD 12.01), respectively, out of a maximum of 92 (mDREEM 18 weeks: 68.80%; mDREEM 14 weeks: 67.42%). These results are presented in Table 2.

	SPL 18	SPL 14	SPT 18	SPT 14	mDREEM 18	mDREEM 14
Mean	33.23	31.74	30.06	30.28	63.29	62.03
SD	7.38	7.52	6.34	5.74	12.58	12.01

Table 2. Descriptive summary statistics for 18 and 14 teaching weeks

The mean difference in SPL scores between 18 weeks and 14 weeks was 1.48. This difference was not statistically significant (t (77) = 1.61, p = 0.11). The mean difference in SPT scores between 18 weeks and 14 weeks was -0.22, and this was also not statistically significant (t (77) = -0.43, p = 0.67). The mean difference in overall mDREEM scores between 18 weeks and 14 weeks was 1.27, which was also not statistically significant (t (77) = 1.04, p = 0.30).

The reliability analysis for both 18 and 14 teaching weeks found a Cronbach’s Alpha Test of 0.58 for SPL, which was less than the threshold of 0.7 and 0.84 for SPT, which was greater than the threshold of 0.7. For mDREEM, the Cronbach’s Alpha Test was 0.77, which was greater than the threshold of 0.7 and confirmed acceptable internal consistency for the mDREEM tool.

IV. DISCUSSION

This study has demonstrated that a reduction in teaching from 18 to 14 weeks did not result in a significant decrease in mDREEM, SPL or SPT scores among Year 5 MBBS students at FNU in 2020. This finding refuted the authors’ hypothesis of a reduction in teaching weeks leading to student dissatisfaction of the educational environment.

Both 18 weeks and 14 weeks scored within the range of 47 to 69 out of 92, indicating a ‘more positive than negative environment’ based on predefined thresholds outlined in the methods section. The ‘excellent’ threshold of 70+ out of 92 was not obtained, indicating room for improvement. In particular, the item ‘teachers are knowledgeable’ scored the highest for both 18 and 14 weeks indicating that students perceived their teachers to have high levels of knowledge despite the reduction in teaching weeks. In contrast, ‘the teaching overemphasised factual learning’ was identified as the most significant negative statement and provides an area of focus for the lecturers.

One group used the DREEM tool to assess curriculum changes in an Irish medical school and that found that the new curriculum was associated with students reporting higher mean DREEM scores (Finn et al., 2014). While FNU’s curriculum change did not result in higher mDREEM scores, the maintenance of mDREEM scores is encouraging and provides a framework for ongoing work towards improving students’ perception of their educational environment.

This finding was similar to a previous study reviewing shortened medical education rotations previously discussed in the introduction section of this paper (Kool et al., 2017). Given the concordance with other similar research findings, the authors are of the belief that the results from this study are largely generalisable to MBBS students and lecturers worldwide, despite only being a single-centre study.

A major strength of this study was the high response rate of 96%. This ensures that data collected as part of this research is representative of the population of interest as compared to several studies with lower response rates (Al-Ansari et al., 2015; Ali et al., 2012; Hyde et al., 2018). Moreover, the results are comparable to the high response rates of other DREEM studies conducted internationally (Alraawi et al., 2020; Stormon et al., 2019; Till et al., 2004).

One limitation of this study was using only two domains of the DREEM tool, neglecting the three domains of Students’ Academic Self-Perception (SAP), Students’ Perception of Atmosphere (SPA) and Students’ Social Self-Perception (SSP). The authors selected SPT and SPL as the two key domains for this research, and thought that by selecting the two most relevant domains, that this would shorten the questionnaire and improve completion of the questionnaire amongst participants. Future research at FNU should trial the use of all five domains of the DREEM tool to assess whether this provides further insights into how teaching weeks can be improved for MBBS students. It will be of interest to see whether response rates are reduced with the use of the full DREEM tool in a questionnaire. Furthermore, future surveys should investigate perspectives of MBBS students over a range of year groups, given previous research suggesting that Year 3 MBBS students have higher DREEM scores than Year 5 MBBS students. A second limitation of this study was that the alpha value for SPL failed to achieve the threshold of >0.7, making it concerning that this domain was unable to achieve acceptable internal consistency. However, the authors note that SPT and mDREEM both achieved acceptable internal consistency. A final limitation of this study was the fully quantitative nature of the survey – the authors did not provide an option for students to add comments to this survey. Future surveys should provide an option for students to add comments, in order to provide more insights into the perspectives of MBBS students.

V. CONCLUSION

In conclusion, the students rated FNU’s MBBS programme educational environment positively. A reduction in teaching weeks from 18 to 14 did not result in a statistically significant decrease in SPL, SPT or mDREEM scores. This study identified valuable information for the authors regarding the improvement of educational environment for medical students. Utilisation of these results to guide educational development in these areas needing improvement will be of help in shaping the delivery of quality education to medical students. In addition, this research may open a door for further studies to investigate challenges faced by tutors and link it to the perceptions of medical students in their educational environment. Likewise, this study is important for future studies in evaluating the educational climate for FNU and other local and international universities.

Notes on Contributors

Dr Maria Bartolome is the corresponding author for this research. She is a PBL (problem based learning) lecturer at the School of Medicine, Fiji National University. She was involved in conceptualisation, methodology, investigation, formal analysis, and writing the original draft.

Dr Norman Bartolome is a PBL lecturer at the School of Medicine,  Fiji National University. He was involved in conceptualisation, methodology, investigation, and writing the original draft.

Dr Alena Kotoiwasawa is a PBL lecturer at the School of Medicine,  Fiji National University, and was involved in  conceptualisation, methodology, and investigation.

Dr Rachael Masilomani is a former PBL lecturer at the School of Medicine,  Fiji National University. She was involved in conceptualisation, methodology, investigation, and formal analysis.

Dr Lusiana Naikawakawavesi is a PBL lecturer at the School of Medicine,  Fiji National University, and was involved in conceptualisation, methodology, and investigation.

Dr Maria Villareul is a PBL lecturer at the School of Medicine, Fiji National University. She was involved in conceptualisation, methodology, and investigation.

Dr Sophaganie Jepson is a PBL lecturer at Fiji National University. She was involved in conceptualisation, methodology, investigation.

Dr Aying Wang is a former PBL Lecturer at Fiji National University. He was involved in conceptualisation, methodology, investigation.

Dr Claudia Paterson is a research fellow at The University of Auckland, New Zealand. She was involved in formal analysis, reviewing and editing.

Professor Andrew Hill is a colorectal surgeon and Professor of Surgery at Middlemore Hospital, Auckland, New Zealand. He was involved in supervision, reviewing and editing.

Ethical Approval

Ethical approval was provided through FNU’s College Human Health Ethics Committee (CHHREC) – reference ID: 292.20.

Data Availability

The corresponding author is able to provide researchers access to our anonymised dataset, on reasonable request.

Acknowledgements

The authors acknowledge the efforts of the students in participating in this study.

Funding

No funding was used for this study.

Declaration of Interest

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

References

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*Dr Maria Concepcion Bartolome
Basic Clinical Medicine Department
School of Medical Sciences (SMS)
College of Medicine, Nursing and Health Sciences (CMNHS),
Fiji National University
Hoodless House, Brown St. Suva, Fiji Islands
+679 3311700
Email: maria.bartolome@fnu.ac.fj

Submitted: 5 June 2024
Accepted: 30 October 2024
Published online: 1 April, TAPS 2025, 10(2), 71-81
https://doi.org/10.29060/TAPS.2025-10-2/OA3424

Mary Xiaorong Chen¹, Meredith Tsz Ling Yeung¹, Nur Khairuddin Bin Aron², Joachim Wen Jie Lee³ & Taylor Yutong Liu⁴

¹Health and Social Sciences Cluster, Singapore Institute of Technology, Singapore; ²Rehabilitation Department, Jurong Community Hospital, Singapore; ³Rehabilitation Medicine, Singapore General Hospital, Singapore; ⁴Clinical Support Services Department, National University Hospital, Singapore

Abstract

Introduction: Transitioning from a novice physiotherapist (NPT) to an independent practitioner presents significant challenges. Burnout becomes a risk if NPTs lack adequate support for learning and coping. Despite the importance of this transition, few studies have explored NPTs’ experiences in Singapore. This study aims to investigate the transitional journey of NPTs within this context.

Methods: Conducted as a descriptive phenomenological study, researchers collected data through semi-structured online interviews with eight NPTs from six acute hospitals across Singapore. Simultaneous data analysis during collection allowed for a reflexive approach, enabling the researchers to explore new facets until data saturation. Thematic analysis was employed and complemented by member triangulation.

Results: The challenges NPTs encountered include seeking guidance from supervisors, managing fast-paced work and patients with complex conditions. Additionally, NPTs grappled with fear of failure, making mistakes and self-doubt. They adopted strategies such as assuming responsibility for learning, developing patient-focused approaches, and emotional resilience. However, a concerning trend emerged with the growing emotional apathy and doubts about their professional choice.

Conclusion: This study provides a nuanced understanding of the challenges faced by NPTs during their transition. The workplace should be viewed as a learning community, where members form mutual relationships and support authentic learning. Recommendations include augmenting learning along work activities, fostering relationships, ensuring psychological safety, and allowing “safe” mistakes for comprehensive learning.

Keywords:           Novice Physiotherapist Transition in Practice, Clinical Learning and Supervision, Mentoring, Emotional Resilience and Support, Safe Learning Environment

Practice Highlights

• Gradual assumption of responsibilities helps Novice Physiotherapists (NPTs) build competence.
• Learning should be augmented along with work activities.
• It is important to support NPTs to overcome the fear of failure and self-doubt.
• NPTs’ ability to negotiate learning and emotional resilience are essential.
• Trusting relationships and a safe learning environment are essential to NPTs’ learning.

I. INTRODUCTION

Novice Physiotherapists (NPTs) are physical therapy graduates with two years or less of clinical practice, and during this transition to independent practitioners in clinical settings, they face significant challenges (Martin et al., 2020; Wright et al., 2018). Despite the expectation  of competence, concerns persist regarding NPTs’ abilities in various aspects of their practice.

It was reported that the persistent challenges faced by NPTs include managing workload, handling patients with complex conditions, seeking adequate guidance, and navigating relationship dynamics (Latzke et al., 2021; Mulcahy et al., 2010). One critical issue is the oversight of NPTs’ “new” status, leading to their assignment of patient loads comparable to experienced practitioners. Consequently, NPTs find themselves under tremendous stress in managing patients with complex conditions and diverse sociocultural backgrounds beyond their abilities (Stoikov et al., 2021; Wells et al., 2021). Workloads and time constraints hinder the development of meaningful connections between NPTs and supervisors, affecting teaching and coping abilities (Rothwell et al., 2021). In the busy clinical environment, NPTs cannot solely rely on their assigned supervisors, the support from senior colleagues around them along their developmental journey is necessary. Unfortunately, studies suggest that inadequate support and guidance from senior colleagues exacerbate these challenges (Forbes et al., 2021; Jones et al., 2021; Phan et al., 2022; Stoikov et al., 2020; Te et al., 2022).

Additionally, as NPTs are inexperienced, communicating with patients, their families, and other healthcare professionals present a significant hurdle in clinical decision-making (Atkinson & McElroy, 2016). The pressure to make informed clinical decisions, drawing upon extensive knowledge and experience, contributes to job-related stress and feelings of inadequacy among NPTs (Adam et al., 2013).

Job stress-related symptoms, including exhaustion, self-doubt, and depression, further impact NPTs’ well-being. These symptoms, akin to burnout, result from a mismatch between the worker’s performance and job expectations (Brooke et al., 2020; Pustułka-Piwnik et al., 2014). Studies reveal that burnout affects approximately 65% of physiotherapists in Spain (Carmona-Barrientos et al., 2020). This is a concern as burnout was found to be correlated positively with intentions to leave the profession (Cantu et al., 2022), leading to low morale, and compromised patient service quality (Evans et al., 2022; Lau et al., 2016).

Studies suggest that ill-prepared PTs may feel inadequate and lack confidence in making decisions which can negatively influence their clinical management and support for patients’ needs. For example, PTs who lack the ability to adopt a person focused approach might not be able to manage patients with chronic lower back pain effectively (Gardner et al., 2017). Furthermore, such impacts are subtle, difficult to pinpoint, and can result in poor care quality, low patient satisfaction and staff morale (Gardner et al., 2017; Holopainen et al., 2020; Marks et al., 2017).

In Singapore, the healthcare system is bifurcated into public and private sectors. Public hospitals, which fall under government ownership (Ministry of Health, 2023), are pivotal in delivering healthcare services. These hospitals are organised into three distinct clusters, each serving specific regions within the country. Table 1 for a comprehensive list of public hospitals categorised by their respective clusters.

Submitted: 30 April 2024
Accepted: 25 September 2024
Published online: 1 April, TAPS 2025, 10(2), 82-85
https://doi.org/10.29060/TAPS.2025-10-2/SC3345

Sethapong Lertsakulbunlue & Anupong Kantiwong

Department of Pharmacology, Phramongkutklao College of Medicine, Thailand

Abstract

Introduction: Very Short Answer Questions (VSAQs) minimise cueing and simulate actual clinical practice more accurately than Single Best Answer Questions, as multiple-choice options might not be realistic. Phramongkutklao College of Medicine has developed a Self-Marked VSAQ (SM-VSAQ) for formative assessments. This study determines the validity and reliability of the SM-VSAQs.

Methods: Ninety-four third-year pre-clinical students took two occasions of 10-question SM-VSAQ exams regarding cardiovascular drugs. Each question consisted of two steps: (1) clinical vignettes with questions and (2) expected answers with scores, self-marking, and feedback comprehension. Scores ranged from 0.00 to 1.00 in 0.25 increments, though not every increment was applied to all questions. A distribution of the rating agreement between students’ and teacher’s ratings was presented to determine criterion-related validity and inter-rater reliability.

Results: Criterion-related validity revealed 90.64% and 93.19% of the ratings demonstrated exact agreement between students’ and teachers’ ratings, with an inter-rater reliability of 0.972 and 0.977 for the first and second occasions, respectively (p=0.001). The exact agreement was relatively lower on the first occasion for questions with more diverse expected answers (85.11%, r=0.867, p=0.001) and drugs requiring their specific full names for a perfect mark (74.47%, r=0.849, p=0.001). While questions with specific guides do not require complex answers, they received a higher exact agreement.

Conclusion: The SM-VSAQ format effectively combines guided answers with the VSAQ model. The agreement with teacher-rated is excellent. Marking discrepancies rooted in misconceptions underscores the importance of teacher feedback in improving self-grading in formative assessments. Regular self-assessment practice is recommended to enhance grading accuracy.

Keywords:           Very Short Answer Question, Self-assessment, Medical Education, Undergraduate, Pharmacology

I. INTRODUCTION

Very Short Answer Questions (VSAQs) emerge as a relatively novel assessment format, addressing the constraints of traditional examination methods like Single Best Answer Questions (SBAQs), Constructed Response Questions (CRQs), and Modified Essay Questions (MEQs) (Sam et al., 2018). Although SBAQs are widely adopted in medical education globally, they are prone to cueing effects, leading examinees to depend on contextual clues, promoting a recognition-based learning approach (Sam et al., 2018). Moreover, the absence of multiple-choice options in real-life scenarios diminishes the relevance of SBAQs to medical practice.

Conversely, while CRQs and MEQs better mimic real-life situations, they suffer from rater dependency and significant evaluation time. Whereas VSAQs, free-response questions with 1–5 word answers, lessen rater dependency and evaluation time. Evidence indicates that VSAQs outperform SBAQs in discrimination, validity, and reliability in undergraduate assessments. Their open-ended nature prevents recognition-based learning and cueing. Additionally, VSAQs adeptly pinpoint common errors, often missed by SBAQs, and offer valuable feedback opportunities for educators (van Wijk et al., 2023).

Feedback is crucial for supporting and enhancing learning. Despite its longstanding importance in medical education, effective feedback is frequently deemed insufficient (Kuhlmann Lüdeke & Guillén Olaya, 2020). Self-assessment, enabled by formative exams, allows learners to identify their learning needs (Gedye, 2010). To improve feedback in formative assessments, Phramongkutklao College of Medicine (PCM) developed the Self-marked VSAQ (SM-VSAQ) format, which pairs a VSAQ with possible answers and a marking guide. Students may assess their understanding and pinpoint study areas through SM-VSAQ, enhancing feedback. Although VSAQs offer several benefits, challenges remain in grading the tests, as they may require a longer time. The self-graded format could address this issue in low-stakes examinations. This study assesses whether the SM-VSAQ with partial credit format, utilizing the marking guide, would achieve valid and reliable ratings compared with the teachers.

II. METHODS

Ninety-four third-year pre-clinical students participated in two 10-item SM-VSAQ during a cardiovascular pharmacology course. The exams covered antihypertensive, antiarrhythmic, antianginal, antithrombotic drugs, heart failure drugs, rational drug use, dyslipidaemia treatments, and drugs for atherosclerotic cardiovascular disease (ASCVD). The second SM-VSAQ sessions vary by changing the clinical vignette, the question, or both while maintaining the same underlying blueprint as the first session. Difficulty levels align with the Thai Medical Competency Assessment Criteria. Students had attended lectures on these drug groups before the exams. The VSAQ was content-validated by three professors for relevance, difficulty, feasibility, and simplicity using the Item Objective Congruence method with all over 0.67 of 1.00, indicating acceptable content validity. This approach ensured comparable difficulty.

The formative test was administered through Google Forms under examination conditions within a one-hour timeframe. Ethical approval was obtained from the Institutional Review Board, Royal Thai Army, and the waiver of the requirement for participant consent was deemed unnecessary following national regulations. An information sheet was provided on the first page of the Google Form. This initial test was conducted a day after they completed all lectures. After receiving teacher-led feedback and having time to review, students took a second parallel formative test ten days before the summative exam.

The SM-VSAQs featured four components for each question: clinical vignettes and questions on the first page, answers with scoring guidelines on the next page after they’ve answered, and a self-scoring option with feedback on answer comprehension. Scores ranged from 0.00 to 1.00 in 0.25 increments, though not every increment was applied to all questions. After the students completed the exam, they provided open-ended feedback on the pros and cons of the format. Examples of the format are shown in supplementary figures 1 and 2.

The self-rated, according to the marking guide, were exported into a Microsoft Excel spreadsheet to facilitate teacher ratings of the VSAQ answers. Using the ‘filter’ function in Microsoft Excel, the range of answers for each question was examined, and marks were awarded (Sam et al., 2018). Minor misspellings or alternative correct spellings were considered correct. Three pharmacology professors, who assigned scores, reviewed student answers that fell outside the guide. Consensus-determined scores require agreement from at least two of the three professors.

The data analyses were performed using StataCorp, 2021, Stata Statistical Software: Release 17. College Station, TX: StataCorp LLC. Consistency reliability was analysed using Cronbach’s alpha. Criterion-related validity was demonstrated by the distribution of the rating agreement between student and teacher ratings, presented as frequency and percentages. Inter-rater reliability was calculated using Pearson’s correlation.

III. RESULTS

Cronbach’s alpha for the SM-VSAQ was 0.741 and 0.721 on the first and second occasions, respectively. The teacher-rated alpha was 0.766 initially and 0.735 on the second. Criterion-related validity was assessed through agreement analysis (Supplementary Tables 1 and 2). Table 1 summarises the results of the agreement analysis. 90.6% and 93.19% of the ratings showed exact agreement between the students’ and teachers’ ratings, with an inter-rater reliability of 0.972 and 0.977 for the first and second occasions, respectively. The exact agreement is relatively low on the first occasion of Drugs used in heart failure (85.11%) and Anti-angina drugs (74.47%). Conversely, antithrombotics and drugs used in ASCVD received a high exact agreement of 96.81%. Example of questions with high and low agreement is demonstrated in supplementary figures 1 and 2. Additionally, content analysis of student’s feedback revealed that they perceived that the format helps identify knowledge gaps, encourages review of missed topics, and aids in recognizing their current knowledge level (Supplementary Table 3).

Submitted: 30 April 2024
Accepted: 25 September 2024
Published online: 1 April, TAPS 2025, 10(2), 86-90
https://doi.org/10.29060/TAPS.2025-10-2/SC3551

Ozlem Tanriover¹, Sukran Peker², Seyhan Hidiroglu², Dilek Kitapcioglu³ & M. Ali Gülpınar¹

¹Department of Medical Education, School of Medicine, Marmara University, Türkiye; ²Department of Public Health, School of Medicine, Marmara University, Türkiye; ³Department of Medical Education, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Türkiye

Abstract

Introduction: This study aimed to identify the emotions experienced by medical students during the quarantine period, explore their coping strategies, and determine whether the pandemic affected their learning behaviours.

Methods: In this descriptive study, data were collected through an online questionnaire. The study included quarantined medical students enrolled in a distance education program at a medical school during the pandemic. The Positive and Negative Affect Scale was used to assess the emotional spectrum of the participants.

Results: The majority of medical students in the sample experienced predominantly negative emotions. Students with higher negative affect scores struggled with stress management and were less able to employ emotional regulation strategies, which adversely affected their learning behaviours.

Conclusion: Emotions should be explicitly addressed in medical education, and students should be supported in managing their emotions as part of their professional development and well-being.

Keywords:           Coping, Emotions, Emotion Regulation, Medical Student, Pandemic, Stress

I. INTRODUCTION

Medical education has long been a significant source of stress for students. The COVID-19 pandemic introduced additional challenges with social distancing, home confinement, and online learning, further intensifying this burden (Fegert et al., 2020). In Turkey, the Council of Higher Education suspended face-to-face education on March 26, 2020, shifting all theoretical and some practical medical courses online. This move removed students from campuses and hospital settings to protect public health. As a result, medical students from all years, including those close to graduation, were quarantined and separated from their academic routines.

Quarantine, a measure to prevent disease spread, often leads to frustration, boredom, and heightened distress (Brooks et al., 2020). Medical education is already emotionally taxing, and the pandemic amplified these challenges. While many studies have explored the emotions of healthcare workers and students on the front lines, little is known about how medical students in Turkey, confined at home, experienced and coped with this period. This study aims to explore their emotional experiences, coping mechanisms, and changes in learning behaviours during quarantine.

II. METHODS

This descriptive study utilised an online questionnaire sent via Microsoft Forms to medical students from a university in Istanbul. Participants included both preclinical and clinical students, all engaged in distance learning due to the pandemic. The survey was distributed in June 2020, with participation being voluntary and anonymous. The study ran from mid-June to the end of July 2020.

A. Ethical Approval

The study was approved by the School of Medicine Ethical Committee (No. 09.2020.657). Consent was obtained from all participants before data collection.

B. Data Collection

The questionnaire gathered sociodemographic data and inquired about online education experiences. The Positive and Negative Affect Scale (PANAS), developed by Watson et al. (1988) and adapted to Turkish by Gençöz (2000), was used to assess emotions. The PANAS contains 20 adjectives rated on a five-point Likert scale, with scores ranging from 10 to 50 for both positive and negative emotions. High positive scores reflect engagement and energy, while high negative scores indicate distress.

C. Statistics

Statistical analysis was conducted using SPSS 20.0. Normality was tested with Kolmogorov-Smirnov and Shapiro-Wilk tests. Descriptive statistics were presented as medians (IQR) for non-normal data and frequencies for categorical data. The Mann-Whitney U test was used for two-group comparisons, and the Kruskal-Wallis test for comparisons across more than two groups. A p-value < 0.05 was considered statistically significant.

III. RESULTS

A total of 145 students participated in the survey, with a slight female majority (57%, n=83). The participants’ ages ranged from 20 to 27 years (mean=21.4, SD=1.99), and most (93%, n=135) lived at home with their families. Students attended an average of 4-6 hours of online lectures per day during quarantine. Emotions such as “interested,” “alert,” and “enthusiastic” had low scores, while 63.4% reported feeling distressed, followed by 40.7% upset and 39.3% irritable.

The PANAS total score comparison showed that students aged 22-25 scored significantly higher than those aged 18-21 (51.7 vs 48.1, p=0.028). Similarly, positive affect (PA) scores were higher in older students (p<0.001). Students living alone had higher total PANAS scores (59 vs 49, p=0.008) and PA scores (31.7 vs 23.6, p<0.001) than those living with their families.

A. Coping Strategies

Most students (65.5%) coped with stress using distraction activities like watching TV, while 8.3% sought emotional support. A minority engaged in substance use or denial (4.9%), and 8.3% reported being unable to cope. Those who made an effort to cope had higher PA scores (24.6 vs 21.2, p=0.036) and lower negative affect (NA) scores (25.3 vs 29.5, p=0.01).

B. Changes in Learning Behaviour

About 74.5% of students reported changes in their study methods during the pandemic, though no significant differences in PANAS scores were observed. When asked about adapting to online learning, 33.7% of students reported difficulty adjusting, while 17.3% used self-motivation, and 11.5% created study programs with peers.

C. Emotion Regulation

Cognitive reappraisal was the most common strategy used by 65.5% of students to manage emotions, while 8.3% used expressive suppression. Nearly 25% reported no effective emotion regulation strategy, and 1.4% felt they didn’t need one. Those who used emotion regulation strategies had significantly lower NA scores (p=0.017).

Submitted: 14 March 2024
Accepted: 13 November 2024
Published online: 1 April, TAPS 2025, 10(2), 91-93
https://doi.org/10.29060/TAPS.2025-10-2/II3264

Han Ting Jillian Yeo & Dujeepa D. Samarasekera

Centre for Medical Education (CenMED), Yong Loo Lin School of Medicine, National University of Singapore, Singapore

I. INTRODUCTION

Assessment is an important component of training in ensuring that graduating students are competent to provide safe and effective medical care to patients. Typically, the passing score is set as a fixed mark, but this approach does not account for the varying difficulty of exams. As a result, students who have achieved the required level of competence might fail if the exam items are particularly challenging (false negative), while students who have not attained the necessary competence might pass if the items are unusually easy (false positive). Hence, deciding on the right pass mark is important for each assessment. To mitigate this issue, criterion referenced standard setting was adopted in medical education (Norcini, 2003). It determines the minimum competence level expected of a candidate and whether a candidate would pass or fail the assessments (Norcini, 2003). The Angoff method is one of the more commonly used standard setting techniques. It is an examinee centred method and requires a panel of judges to estimate the probability that a borderline candidate would get the item correct.

Literature have questioned the reliability of the Angoff method. Variations in pass mark have been reported when the different panels of judges were engaged (Tavakol & Dennick, 2017; Taylor et al., 2017). Judges reportedly faced challenges in visualising and defining the knowledge and skills required of borderline students and hence have difficulty estimating the probability that a borderline student would answer an item correctly (Tavakol & Dennick, 2017). A study by Yeates et al. (2019) also reported the complexity judges faced in the standard setting process due to interaction between the environment, individual judgments, and interaction between the judges. Such variations in pass marks might lead to unfairness to students who were meant to pass but did not due to a higher pass mark. It is of a greater concern to patient safety if students who were meant to fail passed the examination due to a lowered pass mark.  To assist the judges, a guide was developed to set standards for medical and health professions examinations using a probability estimate.

II. DEVELOPING A GUIDE

Judges were to rate each item based on three criteria: relevance, frequency, and difficulty. The guide focused on these areas to assist the judges in their evaluations. The relevance of an item was rated on a 5-point scale ranging from “1 – not knowing will not harm a patient” to “5 – not knowing will cause possible death to the patient”. A highly relevant item was one which assessed a foundational knowledge or a core skill. A less relevant item assessed on knowledge or skill which was good to know or acquire but not required for progression to the next level of education. The difficulty of an item was rated on a 5-point scale ranging from “1 – very easy” to “5 – very difficult”. The difficulty of the item was dependent on the ease of understanding the item construction or the difficulty of the disease condition assessed. For instance, the inclusion of multiple comorbidities in the item stem, as opposed to one comorbidity, required the student to synthesise information before responding. The difficulty of the item was also associated with the level of learning that was assessed. Hence, an item which was assessed on application would be more challenging to the student compared to an item assessing recall. The frequency of an item was rated on a 4-point scale from “1 – very rarely seen in practice of a basic doctor” to “4 – seen very often in practice of a basic doctor”. For example, in the local context, influenza is a clinical condition commonly seen in clinical practice while tetanus is a rarer clinical condition.

Judge’s ratings of each criterion were converted into a probability estimate that a borderline candidate would get the item correct ranging from 0 to 100 percent for each item. An item with a low relevance and frequency but a high difficulty would be assigned a probability estimate between 0 to 30 percent suggesting that a borderline candidate was less likely to get the item correct. An item with a high relevance and frequency but a low difficulty would be assigned a probability estimate between 70 to 100 percent suggesting that there was a high probability a borderline candidate would get this item correct. Judges were given the freedom to assign an estimate from the range provided in the guide or to assign a probability estimate based on their own judgement or expertise.

III. IMPLEMENTATION

To date, the guide was shared with judges during the Angoff standard setting sessions for the medical undergraduate assessments. The guide was given at the start of the session when calibrating judges to a similar mental model on what a borderline candidate was. Judges were free to use the guide in the decision-making process when providing a probability estimate for each item. During the calibration phase and discussion phase of the Angoff standard setting session, we observed that judges provided justifications for their probability estimates by referring to the three criteria. This was more prevalent among judges who were new to the Angoff method.  We believed that the well-defined and objective criteria provided in the guide served as a useful framework for judges to develop a mental model on what a borderline candidate was.

IV. LIMITATIONS AND FUTURE DIRECTIONS

Several limitations have been identified. While we have attempted to implement the guide, judge’s ratings remained influenced by their own criteria set by their personal experiences and beliefs which were often deeprooted and independent of the three identified criteria. This is especially so for judges who had prior experience in standard setting with Angoff method and had formed their own set of criteria. We see greater value in the use of the guide for training judges who were participating in Angoff standard setting for the first time.

The guide was developed within a specific medical school in Southeast Asia with its own unique curriculum and learning objectives. Its applicability and effectiveness may be limited in different educational contexts with varying curricula and assessment methods. These limitations highlighted the need for ongoing evaluation and adaptation of the guide and standard-setting methods to ensure they meet the needs of diverse educational settings and provide reliable assessment outcomes. The team is working on validating the use of the guide in our own local context. This would be conducted by quantifying the level of agreement between judges’ ratings, correlating with other standard setting methods and soliciting feedback from judges on the utility of the guide.

V. CONCLUSION

As more medical schools begin to adopt criterion referenced standard setting methods to set a defensible pass mark for assessments and given the complex process judges face when rating items, there is value in the provision of a guide to judges with defined criteria to facilitate the process of rating items.

By focusing on criteria such as relevance, frequency, and difficulty, the guide aimed to provide a structured framework for judges to make more consistent and objective probability estimates of a borderline candidate’s performance. Preliminary observations suggested that the guide has been useful in standardising judges’ evaluations and aligning them with the intended competence levels of a borderline candidate. However, variability in judges’ personal criteria and context-specific development posed potential issues. Pilot testing, inter-rater reliability studies, and expert reviews were essential in evaluating the guide’s impact on the pass marks. Ultimately, a well-validated guide has the potential to improve the fairness and reliability of assessments in medical and health professions education, ensuring that graduating students are competently prepared to provide safe and effective patient care.

Notes on Contributors

Han Ting Jillian Yeo contributed to writing and editing the manuscript.

Dujeepa Samarasekera contributed to the concept and development of the manuscript.

Ethical Approval

No ethical approval was required for this study as no data were collected.

Funding

No funding sources are associated with this paper.

Declaration of Interest

There are no conflicts of interests related to the content presented in the paper.

References

Norcini J. J. (2003). Setting standards on educational tests. Medical Education, 37(5), 464–469. https://doi.org/10.1046/j.1365-2923. 2003.01495.x

Tavakol, M., & Dennick, R. (2017). The foundations of measurement and assessment in medical education. Medical Teacher, 39(10), 1010–1015. https://doi.org/10.1080/0142159X. 2017.1359521

Taylor, C. A., Gurnell, M., Melville, C. R., Kluth, D. C., Johnson, N., & Wass, V. (2017). Variation in passing standards for graduation-level knowledge items at UK medical schools. Medical Education, 51(6), 612–620. https://doi.org/10.1111/medu.13240

Yeates, P., Cope, N., Luksaite, E., Hassell, A., & Dikomitis, L. (2019). Exploring differences in individual and group judgements in standard setting. Medical Education, 53(9), 941–952. https://doi.org/10.1111/medu.13915

*Han Ting Jillian Yeo
10 Medical Drive
Singapore 117597
Email: jillyeo@nus.edu.sg

Submitted: 27 June 2024
Accepted: 14 October 2024
Published online: 1 April, TAPS 2025, 10(2), 94-96
https://doi.org/10.29060/TAPS.2025-10-2/II3451

Sulthan Al Rashid

Department of Pharmacology, Saveetha Medical College and Hospital, Saveetha Institute of Medical and Technical Sciences (SIMATS), India

I. INTRODUCTION

In response to the evolving landscape of medical education, this personal view article explores the integration of advanced digital tools into the curriculum for medical students. As the field of medicine continues to advance rapidly, leveraging technologies such as Google Lens, WhatsApp, Microsoft Word (MS Word), Coggle mapping software, and artificial intelligence (AI)-driven assistants like Chat Generative Pre-Trained Transformer (ChatGPT) can significantly enhance the learning experience. This article outlines strategies for creating impactful PowerPoint presentations, developing comprehensive concept maps, and extending class hours to foster active engagement and a deeper understanding of medical concepts. The integration of these digital tools is increasingly recognised as essential in contemporary medical education. Digital tools can offer interactive and personalised learning experiences, providing medical students with innovative ways to grasp complex concepts and apply them in clinical scenarios. For instance, Google Lens can facilitate quick access to medical references and visual aids, while WhatsApp can enable real-time communication and collaboration among students and educators. MS Word is a versatile tool for drafting and organising written content, and Coggle mapping software can assist in visualising and connecting intricate medical concepts. Meanwhile, AI-driven assistants like ChatGPT offer opportunities for interactive learning and immediate support. Contemporary medical education must continuously evolve to effectively harness these technological advancements. Extending class hours and incorporating digital tools can provide students with more opportunities for engagement and learning, thus enhancing their preparedness for modern healthcare challenges. As medical education adapts to incorporate personalised learning and evidence-based practices, it is crucial to integrate these digital tools to navigate complex clinical scenarios effectively (Park et al., 2021). The subsequent sections of this manuscript will delve into the specific ways in which these digital tools can be utilised to improve medical education, ensuring a consistent and impactful learning experience for students.

II. INTEGRATION OF AI TOOLS IN MEDICAL EDUCATION

AI tools like Google Lens and ChatGPT are transforming how students retrieve, process, and present information in medical education. Google Lens allows students to extract information from textbooks and clinical images, aiding in the understanding of disease pathogenesis. For instance, it can scan textbooks to pull relevant content for study notes or presentations. PowerPoint is effective for delivering concise information (Seth et al., 2010), and its impact can be further enhanced by using AI tools to automate content extraction.” The author’s recommendation of using bold 40-point Calibri font for single-sentence slides is suggested to further improve student engagement and focus during lectures. In addition to ChatGPT, tools like Quizlet and Cortana support personalised learning. Quizlet helps create tailored flashcards based on individual learning needs, while Cortana can assist in scheduling study sessions. IBM Watson for Health further revolutionises education by aiding in the interpretation of clinical data, providing real-time analysis and treatment recommendations. AI-driven tools, such as chatbots and intelligent tutoring systems (ITS), play a crucial role in modernising medical education. Chatbots offer instant support, while ITS create customised learning paths, enhancing outcomes through adaptive learning experiences. Gamification and virtual reality (VR) further boost student engagement by making learning interactive and immersive, allowing for realistic practice in clinical scenarios (Narayanan et al., 2023).

III. ENHANCING MEDICAL EDUCATION THROUGH DIGITAL COMMUNICATION AND WORD PROCESSING TOOLS

Additionally, WhatsApp groups can promote Digital communication platforms like WhatsApp and word processing tools like MS Word have become integral to modern medical education, significantly enhancing content distribution and student engagement.

A. WhatsApp in Medical Education

WhatsApp facilitates structured communication within medical education. For instance, medical schools can create dedicated groups for subjects or cohorts, enabling the exchange of vital information. Faculty can share updates on guidelines, fostering discussions about implications and applications. WhatsApp’s voice messaging and video call capabilities allow for immediate feedback and consultations, enhancing student support awareness of current medical issues. During disease outbreaks, for example, specialised groups can disseminate updates and discuss clinical strategies. Educational challenges, such as a “case of the week,” encourage peer interaction and collaborative analysis, reinforcing learning.

B. MS Word in Medical Education

MS Word is widely used for organised note-taking, which aids students in systematically recording lecture content. For instance, during pharmacology lectures, students can create structured notes with headings for different topics and use bullet points for key concepts. The software also allows for annotating texts and research documents, enabling students to clarify and deepen their understanding.

Furthermore, MS Word supports detailed exploration of medical concepts through documentation and conceptual mapping. Students can create outlines or concept maps, integrating diagrams and linking to additional resources. Custom templates for clinical reports ensure consistency and enhance the overall learning experience.

IV CONCEPT MAPPING

Concept mapping is a powerful tool for visualising relationships between medical topics, facilitating deeper understanding and retention (Baliga et al., 2021). Coggle software is an example of a tool that helps illustrate the connections between risk factors and disease outcomes.

A. Expanding on AI-driven Tools for Concept Mapping

While Coggle is useful, several AI-driven tools offer enhanced features for concept mapping. ChatGPT can generate textual descriptions for relationships, which can then be visualised using software like Coggle. Other platforms, such as MindMeister, Lucidchart, and Xmind, provide advanced functionalities for creating dynamic and interactive concept maps, including collaborative features and automated suggestions.

Detailed examples of concept maps can demonstrate their application in medical education. For instance, a map showing the relationship between lifestyle factors and chronic diseases can visually represent how different elements influence disease progression. Incorporating concept maps at the end of sessions can reinforce key points, aiding retention and comprehension.

V. EXTENDED CLASS HOURS FOR ACTIVE ENGAGEMENT

Extending class hours offers opportunities for immersive learning experiences and practical application of medical knowledge. By increasing lecture durations, students can engage more deeply with content through interactive methods such as case-based discussions and clinical simulations. For example, additional time may be allocated for simulating patient consultations, enhancing both practical skills and theoretical knowledge. Research supports the benefits of extended instruction time, particularly when coupled with a high-quality learning environment, fostering individualised learning essential for mastering complex medical concepts (Rivkin & Schiman, 2015).

VI. IMPLEMENTATION CONSIDERATIONS

Successful integration of digital tools and extended class hours requires meticulous planning and consideration. Ensuring equitable access to digital tools among students and faculty, providing technology through university-provided devices, and offering professional development to enhance faculty digital literacy and instructional effectiveness are crucial. Implementing effective assessment methods to evaluate learning outcomes and measure the impact of digital tools on educational efficacy, such as online quizzes using AI-generated questions simulating clinical decision-making scenarios, is essential.

VII. FUTURE DIRECTIONS & CONCLUSION

Summarising the transformative potential of integrating digital tools and extended class hours in medical education, this section highlights the benefits for medical students in terms of enhanced learning, preparation for modern healthcare challenges, and future career readiness. Equipping medical graduates with skills in digital tool utilisation prepares them for evidence-based practice and lifelong learning in clinical settings. Recommendations for future research focus on advancing AI technologies, conducting longitudinal studies on educational outcomes, and expanding digital integration across medical disciplines. Proposing avenues for further research and development in digital-enhanced medical education, this section explores advancements in AI tools to personalise learning experiences and improve adaptive educational technologies. It discusses potential applications of AI-driven learning modules across medical specialties to enhance interdisciplinary collaboration in patient care and research. Curriculum development should continually evolve to integrate digital tools and extend class hours, framed by ongoing research into their efficacy and impact on medical education.

Notes on Contributors

Sulthan Al Rashid contributed to the concept, scientific content, data collection, and manuscript preparation. 

Acknowledgement

ChatGPT has been employed for manuscript preparation, encompassing tasks such as preparing, drafting, or editing text, without receiving authorship credit.

Ethical Approval

No ethical approval was required for this study as no data were collected.

Funding

The author did not receive any financial support for this study.

Declaration of Interest

The author asserts that he has no conflict of interest.

References

Baliga, S. S., Walvekar, P. R., & Mahantshetti, G. J. (2021). Concept map as a teaching and learning tool for medical students. Journal of Education and Health Promotion, 10, 35. https://doi.org/10.4103/jehp.jehp_146_20

Narayanan, S., Ramakrishnan, R., Durairaj, E., & Das, A. (2023). Artificial intelligence revolutionizing the field of medical education. Cureus, 15(11), e49604. https://doi.org/10.7759/cureus.49604

Park, J. C., Kwon, H. E., & Chung, C. W. (2021). Innovative digital tools for new trends in teaching and assessment methods in medical and dental education. Journal of Educational Evaluation for Health Professions, 18, 13. https://doi.org/10.3352/jeehp.2021.18.13

Rivkin, S. G., & Schiman, J. C. (2015). Instruction time, classroom quality, and academic achievement. The Economic Journal, 125(588), F425–F448. https://doi.org/10.1111/ecoj.12315

Seth, V., Upadhyaya, P., Ahmad, M., & Moghe, V. (2010). PowerPoint or chalk and talk: Perceptions of medical students versus dental students in a medical college in India. Advances in Medical Education and Practice, 1, 11-16. https://doi.org/10.2147/AMEP.S12154

*Sulthan Al Rashid
Department of Pharmacology
Saveetha Medical College and Hospital,
Saveetha Institute of Medical & Technical Sciences (SIMATS),
Chennai, Tamil Nadu, India
+919629696523
Email: sulthanalrashid@gmail.com

Submitted: 21 May 2024
Accepted: 4 February 2025
Published online: 1 April, TAPS 2025, 10(2), 97-100
https://doi.org/10.29060/TAPS.2025-10-2/II3367

Prabanjini Rajkumar & Lucy Victoria Everett Wilding

Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore

I. INTRODUCTION

The transition from pre-university education to medical school marks the first significant change medical professionals face in the medical education continuum, and is deemed as a remarkable stressor (Sá et al., 2021). This paper seeks to explore the experiences of incoming students in further detail, noting that current literature focuses predominantly on the transition from pre-clinical to clinical years instead. These findings may offer valuable insight for medical educators to incite change in the current medical curriculum that would foster a smoother transition.

II. METHODS

This study employed a qualitative approach in obtaining data to capture expressive information. Individual semi-structured interviews were conducted  (Appendix 1) with 11 first-year medical students with voluntary sampling. Informed consent was obtained from all participants to gather information surrounding predetermined questions while also allowing for exploration of new topics, in an individual setting that would allow participants to express themselves freely. Thematic analysis was then used to analyse the transcribed data deductively with the Westerman framework. Other frameworks considered include Tinto’s Model of Student Integration and Mezirow’s Transformative Learning Theory, but these were ultimately not chosen due to their dated nature and lack of direct applicability to the medical context. Furthermore, the Westerman framework uniquely provides clear guidelines on how to incite future change. Westerman’s conceptual framework describes how “novel disruptive elements (first theme) due to the transition from pre-university to undergraduate medical school are perceived and acted on (second theme), and how this directs new medical students’ personal development (third theme)” (Westerman et al., 2010).

III. RESULTS

The themes that surfaced from the data are presented in alignment with the transitional context and the related tasks students encountered (Table 1).

Submitted: 16 August 2024
Accepted: 12 September 2025
Published online: 1 April, TAPS 2025, 10(2), 104-105
https://doi.org/10.29060/TAPS.2025-10-2/LE3494

Thazin Han¹, Tun Tun Win², Zaw Phyo¹ & Zin Min Htike¹

¹Department of Medical Education, Defence Services Medical Academy, Myanmar; ²Department of Preventive & Social Medicine, Defence Services Medical Academy, Myanmar

Dear Editor,

The Department of Radiology, Defence Services Medical Academy reports the results on the impact of a 2-week radiology program on year 4 medical students’ perception of radiology. Advances in imaging modalities has led to almost every patient getting a scan prior to any planned management making it essential for medical students to understand the importance of radiology’s role in clinical practice. Limited exposure to radiology can perpetuate negative stereotypes by perceiving radiology as providing no significant contribution to patient care (Grimm et al., 2021). In the academic year of 2020/2021, we piloted a 2-week radiology program for 4^th year medical students and conducted a qualitative, experiential, and phenomenological study design using Focus Group Interviews (FGIs) from January to July 2022 after obtaining ethical approval to find out the effectiveness of exposure to radiology impacts on 4^th year medical students’ opinions and views on radiology. Eighteen out of 20 4^th year medical students volunteered to participate. FGIs can be used to gather rich data through participant exchange of ideas or comments on each other’s views (Stalmeijer et al., 2014). We found that students who were hesitant to express their views individually were willing to do so in small groups.

The thematic analysis of the coded transcripts produced 6 themes which are (1) Earlier exposure to radiology-; (2) Integration of radiology into the undergraduate curriculum-; (3) Collaborative learning and practice-; (4) Motivation to learn radiology-; (5) Genuine interest in radiology and (6) Importance of radiology in clinical practice. Students reflected during FGIs that the radiology program provided meaningful learning when correlating radiology images to clinical findings. Learning is a continuous process grounded in experience and the educator’s job is to dispose, modify or implant new ideas as propounded by Kolb. This study showed that the 2-week radiology program disposed of the idea that radiology did not have any significant role on clinical management and implanted new ideas concerning the importance and appropriate use of radiology. The study is evaluated up to Kirkpatrick’s level 3 whereby there is change of students’ behavior as they now appreciated the importance of the role of radiology in clinical practice as evidenced by theme 6.

In conclusion, the radiology program was impactful in changing 4^th year medical students’ perceptions regarding the role of radiology in clinical practice and provided justification to roll out the 2-week radiology program for consecutive academic years.

Notes on Contributors

Thazin Han developed the conceptual framework and piloted the radiology program. Tun Tun Win did data sampling, acquisition and analysis. Zaw Phyo recorded the FGIs. Zin Min Htike did member checking and data transcribing. All 4 took turns to conduct and moderate the FGIs and review the data.

Acknowledgement

We wish to express our gratitude and thanks to the Rector of the Defense Services Medical Academy for allowing us to conduct this research. We would like to express special thanks to the Head of the Medical Education Department for providing us with the logistic support. Finally, thanks to the study team members without whom this research would not have been achieved.  

Funding

No funding is involved for this research. The research was conducted based on situation analysis of the undergraduate curriculum regarding radiology.

Declaration of Interest

There is no conflict of interest for the current research.

References

Grimm, L. J., Fish, L. J., Carrico. C. WT., Martin, J. G., Nwankwo, V. C., Farley, S., Meltzer, C. C. & Maxfield, C. M. (2022). Radiology stereotypes, application barriers, hospital integration: A mixed methods study of medical student perceptions of radiology. Academic Radiology, 29(7), 1108-1115. https://doi.org/10.1016/j.acra.2021.08.020

Stalmeijer, R. E., Mcnaughton, N. & Van Mook, W. N. (2014). Using focus groups in medical education research: AMEE Guide No. 91. Medical Teacher, 36(11), 923-939. https://doi.org/10.3109/0142159X.2014.917165

*Thazin Han
No. 94, D-1, Pyay Road
Mingaladon Township
Yangon, Myanmar
Postal code – 11021
Email: thazinhn@gmail.com

Submitted: 30 May 2024
Accepted: 21 October 2025
Published online: 1 April, TAPS 2025, 10(2), 101-103
https://doi.org/10.29060/TAPS.2025-10-2/II3420

Nadhee Peries, Nadeeja Samarasekara, Inuka Gooneratne, Niroshan Lokunarangoda, Ushani Wariyapperuma, Senaka Pilapitiya, Mihara Silva & Nandalal Gunaratne

Faculty of Medicine, University of Moratuwa, Sri Lanka

I. THE EARLY CLINICAL EXPOSURE PROGRAM

According to a large body of research, early clinical exposure and simulation-based learning are beneficial for medical students in many ways, hence the University of Moratuwa has used these concepts together in the MBBS program (Peries et al, 2024). It allows students to develop their thinking, communication, clinical reasoning, and room for trial and error (Krajic, 2003). The faculty has developed a spirally integrated, simulation-based program named Early Clinical Exposure (ECE) for students from 1st year onwards to facilitate step-by-step, yet continuous mastering of concepts and skills of history-taking and examination.

5-year MBBS program of the university consists of three phases: Phase 1 (1^st / 2^nd years), Phase 2 (3^rd / 4^th years), Phase 3 (Final year). During phase 1, students learn basic sciences integrated into body system-based modules; in phase 2, students learn applied sciences integrated into clinical subjects in body system-based modules, simultaneously ward-based clinical training. Phase 3 consists of full-time clinical training. The article describes how the ECE program was designed and exposed students of phase 1 and the early stage of phase 2 to early clinical skill training via various methods, in which, simulation-based history taking, and examination were major components.

II. DESIGN OF THE PROGRAM

The ECE program was pre-tested to see the content, timing, necessity of resources, and efficacy of teaching tools. We identified the limited number of staff as a challenge at the time, and we trained demonstrators to couple with lecturers ensuring the program ran smoothly until more academics were available.  In phase 1, students learned history taking and examination concerning building a rapport and gathering information using communication skills while appreciating patient privacy and concerns. The scenarios were developed and integrated into relevant modules, to cover the applicability of basic sciences in clinical practice and the basics of the ‘clinical method’.

During phase 2 which spanned over 8 weeks, history-taking and examination sessions were revisited where learning outcomes were designed to reach higher skill levels. At this stage, the scenarios were designed to introduce concepts such as identifying problems, critical thinking, and clinical reasoning. Students were taught a holistic approach to medicine and to recognise patients as ‘whole human beings’ rather than health issues/disease entities. These scenarios were developed to ensure students follow a basic history-taking framework and stepwise method to system examination to gather relevant information on symptoms, aetiology, complications, systemic inquiry, compliance, family history, drug history, allergies, co-morbidities, patient concerns, impact on life and fears, etc.

III. DELIVERY OF THE PROGRAM

The program was delivered via small group role-playing between students and lecturers as a series of blended learning activities. The sessions were sequenced just after the relevant basic sciences teaching session to help students understand the relevance and applicability of the knowledge into practice as early as possible. Every student was given adequate time to practice with constructive feedback from teachers and observers.

Furthermore, students were encouraged to relate the most applicable components of the history concerning the patient and his/her presentation appreciating they have different concerns, either related to or not related to the main complaint that needs to be considered. As an example, a scenario developed in the respiratory module on ‘tuberculosis’, allowed students to be involved in a comprehensive information gathering and examination. Further, it also allowed students to evaluate the associated stigma affecting mental status, compliance with drugs, family support, effects on occupation, income, social interaction etc.

At the end of each examination session, videos of body system examinations were posted on Moodle followed by a small discussion forum on common abnormal signs.

IV. DISCUSSION

The ECE program allowed the students to engage in the basics of the ‘clinical method’ at the early stage of their training. It is well noted that early clinical exposure is widely used across Europe (80% of medical schools) (Basak et al., 2009). Even though the medical faculty of the University of Moratuwa is newly developed in a developing country, this program has assisted in targeting high standards in the quality of medical education. 

ECE program also aligned with the MBBS program learning outcomes by teaching; clinical skills, patient management, communication skills, information management, critical thinking, professional values, and attitudes. This is similar to the suggestions given by Ottenheijm et al. (2008), that ECE activities should be well-planned with clear learning goals. Many ECE programs in Europe are unstructured, using real patients in ward settings and observation as the main teaching tool (Basak et al., 2009). In contrast, this program uses simulation patients, blended learning methods, hands-on experience, and direct feedback.

Even though the objectives were achieved, the program is currently in the middle of an evaluation. Therefore, the exact evidence is lacking to claim that this program has achieved the intended learning outcomes. On the other hand, a study done in Iran in 2016 shows, that early clinical exposure has allowed medical students to understand the value and the integration of the subjects they learn during their early years and also has provided an opportunity to get motivated regarding their role as future doctors (Mafinejad et al., 2016). It should be noted that the program needs feedback from students and resource persons to improve it further. Additionally, data should be collected from the students after they have completed the ECE program to investigate whether the program has contributed to achieving program learning outcomes.

V. CONCLUSION

Simulation is used in the Faculty of Medicine, University of Moratuwa to teach skills needed for students to take a proper history and to examine a patient before commencing ward-based learning. This spirally-integrated early clinical exposure with specially selected important case scenarios incorporated into body system-based modules in basic and applied sciences improves student preparedness for ward-based clinical training. It also provides an opportunity to improve soft skills, which contributes to achieving program learning outcomes of the degree. We plan to review and then expand and develop the program in the future with proper feedback taken at different levels.

Notes on Contributors

Nadhee Peries has planned this curriculum component, developed the program, and contributed to executing it. As the first author, she has drafted, edited, and finalised the paper. Nadeeja Samarasekara, Inuka Gooneratne, Niroshan Lokunarangoda, Ushani Wariyapperuma, and Senaka Pilapitiya contributed to developing the program to improve it further with relates to the content. They were involved in planning the program, writing the simulation scenarios, and conducting sessions. They also reviewed and improved the drafted paper. Mihara Silva contributed to arranging logistics at the planning stage and provided inputs on delivery methods. She also supported writing the paper by formatting and proofreading. Nandalal Guneratne was involved as a supervisor who conceptualised the idea of simulation-based learning in our MBBS program and guided the execution of the lessons in several steps: writing up the lesson plan, developing learning outcomes, and executing the teaching-learning method. All the authors have read and approved the drafted paper.

Ethical Approval

Specific ethical approval was not applicable as this was a part of the routine curriculum development process of the MBBS program which was approved and expected to be executed by the faculty. There is no data collection involved.

Acknowledgement

We would like to acknowledge the Faculty Board, Curriculum Development Committee, and the Medical Education Department for the guidance, support, approval, and recognition of the developed activity.

Funding

The project is funded neither by any person nor institute.

Declaration of Interest

There are no conflicts of interest, specially regarding financial, consultant, institutional, and other relationships that might lead to bias or a conflict of interest.

References

Başak, O., Yaphe, J., Spiegel, W., Wilm, S., Carelli, F., & Metsemakers, J.F.M. (2009). Early clinical exposure in medical curricula across Europe: An overview. European Journal of General Practice, 15(1), 4–10. https://doi.org/10.1080/13814780 902745930

Krajic, K. E. (2003). Observation during early clinical exposure – An effective instructional tool or a bore. Medical Education, 37(2), 88–89. https://doi.org/10.1046/j.1365-2923.2003.01421.x

Mafinejad, K. M., Mirazazadeh, A., Peiman, S., Hazaveh, M. M., Khajavirad, N., Edalatifars, M., Allameh, S., Naderi, N., Forounmandi, M., Afshari, A., & Asghari, F. (2016). Medical students’ attitudes towards early clinical exposure in Iran. International Journal of Medical Education, 7, 195–199. https://doi.org/10.5116/ijme.5749.78af

Ottenheijm, R. P., Zwietering, P. J., Scherpbier, A. J., & Metsemakers, J. F.  (2008). Early student-patient contacts in general practice: An approach based on educational principles. Medical Teacher, 30(8), 802–808. https://doi.org/10.1080/01421 590802047265

Peries, N., Samarasekara, N., Gooneratne, I., Lokunarangoda, N., Wariyapperuma, U., Pilapitiya, S., Silva, M., & Gunaratne, N. (2024, January 15-21). Simulated History Taking and Examination as a Part of Early Clinical Exposure in Undergraduate Medical Education of Faculty of Medicine, University of Moratuwa [Conference presentation abstract]. Asia Pacific Medical Education Conference 2024, Colombo, Sri Lanka.

*Nadhee Peries
Department of Medical Education
Faculty of Medicine, University of Moratuwa,
Bandaranayake Mawatha, Moratuwa,
Sri Lanka, 10400
0094772003061
Email: nnperies@gmail.com, nadheep@uom.lk