Submitted: 19 February 2025
Accepted: 14 May 2025
Published online: 7 October, TAPS 2025, 10(4), 73-76
https://doi.org/10.29060/TAPS.2025-10-4/SC3672

Astrid Pratidina Susilo¹, Lucia Pudyastuti Retnaningtyas¹, Lisa Aditama² & Karunia Wijayanti³

¹Faculty of Medicine, Universitas Surabaya, Indonesia; ²Faculty of Pharmacy, Universitas Surabaya, Indonesia; ³Faculty of Medicine, Universitas Negeri Surabaya, Indonesia

Abstract

Introduction: Healthcare professionals need to advocate for mothers and understand breastfeeding challenges, especially in a community-based culture. We developed a breastfeeding management course for healthcare professionals and students in health-related majors on an online platform at our university. This study aimed to explore what participants learned from an experiential learning assignment to interview mothers regarding their breastfeeding challenges, and write a reflection on it.

Methods: In this qualitative study, we analysed the written reflections of 56 participants after they interviewed mothers regarding their breastfeeding challenges. Thematic analysis and triangulation among the researchers were conducted to obtain themes.

Results: Four themes were identified: (1) differences in knowledge and beliefs about breastfeeding among mothers and their families, (2) breastfeeding challenges that can be a threat to breastfeeding, (3) healthcare professionals’ central role in providing education and advocating for breastfeeding, and (4) involvement of the family and community in breastfeeding education.

Conclusion: This interview and reflective writing assignment strengthened the participants’ awareness of how to advocate for breastfeeding mothers, including considering the influence of the community context.

Keywords:           Breastfeeding, Communal Culture, Experiential Learning, Reflective Writing

I. INTRODUCTION

Breastfeeding is a natural method of providing the best nutritional intake for babies’ growth and development, and strengthening the emotional bond between the mother and the baby. The low rate of breastfeeding is a global problem because only less than half of babies under six months of age are exclusively breastfed (Balogun et al., 2015).

Several factors influence breastfeeding, including stigma and support from people closest to the mother. These factors are prominent in communal cultures where the influence of family and community is strong (Susilo et al., 2019). Healthcare professionals can encourage the success of breastfeeding programs by providing education to mothers and their families. Therefore, they need to learn about breastfeeding management and strategies to increase public knowledge. Apropos this, mother-centred advocacy tailored to mothers’ needs can be offered by healthcare professional (Mulcahy et al., 2022).

We developed a breastfeeding management training program for healthcare professionals and students through an online course platform. One of the assignments in this course was to interview breastfeeding mothers and write reflections on their experiences. According to Kolb’s Experiential Learning Theory, this learning activity can help learners conceptualise the essential principles they must master (Yardley et al., 2012). Such a learning activity is innovative and scarcely reported in the existing literature. Additionally, this assignment is novel in the field of breastfeeding-related education. A systematic review of breastfeeding training reported that only one breastfeeding training program used reflective writing (Mulcahy et al., 2022). This study aimed to explore what participants learned from an experiential learning assignment of interviewing mothers on their breastfeeding challenges and writing reflections afterwards.

II. METHODS

This qualitative study used an interpretive descriptive approach to identify themes and patterns among subjective perspectives based on the reflections of breastfeeding management training participants. The training was conducted online through our university’s open online course platform Ubaya Global Academy (UGA). This online course consisted of six sessions and targeted healthcare professionals and students from different domains (medicine, pharmacy, and midwifery). The six sessions were basic science of breastfeeding, common challenges in breastfeeding for healthy mothers (part 1), common challenges in breastfeeding for healthy mothers (part 2), supporting breastfeeding in mothers with specific health issues (non-communicable disease), supporting breastfeeding in mothers with specific health issues (communicable disease), and essential principles in breastfeeding (wrap up and reflection). Students should have completed their first year of education to have basic exposure to health sciences. We invited all participants who had attended the training to participate in this study. At the beginning of the second session, each participant interviewed a mother who had breastfeeding experience, following which, they wrote a reflective writing of 200-500 words.

Submitted: 24 October 2024
Accepted: 5 July 2025
Published online: 7 October, TAPS 2025, 10(4), 26-34
https://doi.org/10.29060/TAPS.2025-10-4/OA3552

Shoko Horita^1,2, Masashi Izumiya², Satoshi Kondo^2,3,4, Junki Mizumoto^2,5,6, Hiroko Mori^6,7 & Masato Eto²

¹Department of Medical Education, School of Medicine, Teikyo University, Itabashi-ku, Tokyo, Japan; ²Department of Medical Education Studies, International Research Centre for Medical Education, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan; ³Department of Medical Education, Graduate School of Medicine, University of Toyama, Toyama, Japan; ⁴Center for Medical Education and Career Development, Graduate School of Medicine, University of Toyama, Toyama, Japan; ⁵Department of Family Practice, Ehime Seikyo Hospital, Matsuyama, Ehime, Japan; ⁶Center for General Medicine Education, School of Medicine, Keio University, Shinjuku, Tokyo, Japan; ⁷Professional Development Centre, The University of Tokyo Hospital, Bunkyo-ku, Tokyo, Japan

Abstract

Introduction: Conventionally, face-to-face education has been prevalent in medical education because it can help medical students learn interpersonal skills, including medical interviews and physical examination. However, because of the coronavirus disease 2019 pandemic, face-to-face education was suspended to prevent the spread of the infection. As face-to-face classes in Japan were discontinued when the pandemic began in the spring of 2020, we developed an online education program to develop medical interview skills. We were interested in determining the educational outcomes between face-to-face and online medical interview classes. Therefore, we compared them before and after the pandemic.

Methods: Fourth-year students of the University of Tokyo Medical School took medical interview classes. Under consent, the score of the medical interview area of the preclinical clerkship, Objective Structured Clinical Examination (OSCE), as a high-stakes examination, which falls at the top level of the Kirkpatrick’s model, was compared by year or before and after the pandemic.

Results: The online group showed higher item-wise scores of the medical interview of the preclinical clerkship OSCE than the face-to-face group. In terms of the global score, no significant difference was observed. In the computer-based test (CBT), the online group had higher scores compared with the face-to-face group.

Conclusion: The educational outcomes of online medical interview classes were not inferior to those of conventional face-to-face classes, as revealed by high-stakes examination preclinical clerkship OSCE. Similar to face-to-face education, online education is a viable option for developing interpersonal skills.

Keywords:          COVID-19 Pandemic, Medical Interview, OSCE, Educational Outcome, Online Education, Interpersonal Skills, Communication Skills

Practice Highlights

• Due to the COVID-19 pandemic, we shifted medical interview classes from face-to-face to online.
• The online group had interview global OSCE scores non-inferior to those of the face-to-face group.
• The online group had higher interview elementary OSCE scores than the face-to-face group.

I. INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic severely restricted face-to-face teaching and affected almost all levels and fields of education, including undergraduate preclinical medical education (Bastos et al., 2022; Crawford et al., 2020). Moreover, it resulted in drastic changes in medical education. Globally, face-to-face learning was forcibly discontinued as part of infection control. Thus, to continue medical education, online or remote learning was rapidly introduced (Daniel et al., 2021; Gordon et al., 2020). Various instrumental trans communication devices, including video conferencing tools, simulation, virtual reality, and augmented reality, were used to facilitate online learning. However, this rather hasty shift from face-to-face to online learning brought some confusion into the field of medical education. In the UK, Dost et al. (2020) reported that medical students were unsatisfied with online classes compared with face-to-face classes.

Globally, tele-education is increasingly being encouraged around the world (American Medical Association, 2016). In the field of medical interview (Budakoğlu et al., 2021; Hammersley et al., 2019; Zaccariah et al., 2022), telemedicine is gradually becoming common, showing favourable results. However, because of technical problems, tele-education did not spread smoothly (Zaccariah et al., 2022). Additionally, the educational outcomes of both strategies have not been satisfactorily studied (Khamees et al., 2022). Recently, some reports showing that the educational outcome of online classes are equal or more effective than traditional face-to-face education, however, they are restricted mainly in knowledge-based education (Alshaibani et al., 2023; Basuodan, 2024; Saad et al., 2023). Furthermore, few studies have compared high-stakes examination, including the Objective Structured Clinical Examination (OSCE), and no study has compared the educational results between face-to-face classes and tele-education (online) using the top level of Kirkpatrick’s model (Kirkpatrick, 1996).

The OSCE (Harden et al., 1975) has been widely accepted as a form to assess clinical performance in medical education. Currently, OSCEs are used worldwide to appraise medical students’ communication and clinical skills. Various educational methods have been evaluated using OSCE as one of the indicators of educational outcomes (Guetterman et al., 2019). In Japan, passing the preclinical clerkship (pre-CC) OSCE has become legally obligatory as one of the elements for promotion to the CC course since the spring of 2023. In 2023, the pre-CC OSCE in Japan is conducted in at least eight areas, which are medical interview, “Basic Clinical Procedure”, “Basic Life Support”, and physical examinations of “head and neck”, “chest”, “vital signs”, “abdomen”, and “neurological examinations”.

In the present study, we aimed to determine the educational outcomes between face-to-face and online medical interview classes. We provided medical interview classes to fourth-year medical students before taking the pre-CC OSCE, face-to-face classes before 2019, and tele-education (online) after 2020. We decided to conduct research in medical interview, other than the other areas of the pre-CC OSCE, because of the importance of the medical interview as the basis of medical practice. Moreover, it was inevitable that the medical interview classes had to be implemented as online classes to protect the simulated patients form the risk of infection, which was another main reason for selecting medical interview for this research. In another point of view, medical interview classes were able to implement via online. As mentioned above, no prior studies have compared face-to-face and online medical interview training using both high-stakes OSCE score and Kirkpatrick’s top-level outcomes, our study would have significant importance.

II. METHOD

A. Participants

This study was approved in 2021 by the ethics committee of the University of Tokyo (UTokyo) Faculty of Medicine (Approval No. 2021005NI). All methods were performed in accordance with the relevant guidelines and regulations. Moreover, the data of students who provided consent for the secondary use of their data (Approval No. 11763) in another research approved in 2017 were included.

B. Sample Population

Students in the UTokyo Faculty of Medicine were asked if they were willing to participate in “A Study of the Educational Effectiveness of Online “Medical interviewing Practice” in the post-class reflection questionnaire of the “Online medical interview classes or the waiting period after the pre-CC OSCE. Out of 229 students (2021 and 2022), 87 students participated in this study. A summary of the annual participants is shown in Appendix 1. In early 2020 almost all the classes in UTokyo were stopped due to the COVID-19 pandemic, which made it difficult to contact students face-to-face and to obtain participants in the previous research (Approval No. 11763); and as this research started in 2021, it was practically difficult to obtain consent to participate in this study in 2020. In 2020 the online medical interview classes have just been launched, which significantly improved in 2021. Hence, we thought that it would be better to exclude the small participants of 2020 from the analysis to keep the validity of this study.

C. Details of Medical Interview Classes

Before 2019, the medical interview classes were performed as follows: Early in their fourth year, students joined classes introducing the outline of medical interview. A few days before the class, students watched an instructional video of a medical interview performed by the Common Achievement Tests Organization (CATO) (2005) in Japan. Afterward, students in a group of eight to nine faced the simulated patient in a classroom in the UTokyo and performed a medical interview roleplay. Thereafter, feedback about the technical factor of the medical interview as well as rapport status and nonverbal communications such as faces and gesture was provided by the students themselves, other students, simulated patients, and teachers. Since 2020, most face-to-face classrooms, including those in the present study, were closed because of the COVID-19 pandemic and were replaced with online classes. The present face-to-face class was also held online with the simulated patients and teachers using Zoom(R). Using the “Close-Up” function of Zoom(R), the simulated patient and student were faced with each other, whereas other participants (e.g., other students, other simulated patients, and the teacher) were not on the television (Appendix 2). After the roleplay was over, all students and the teacher came back on the television and provided feedback to the student, similar to face-to-face classes. Moreover, the class was recorded using the function of Zoom(R) and provided to students exclusively for review. After the class students reflected on the reflection sheet (until 2019) or the Learning Management System (from 2020) which was reviewed and commented on by teachers. The contents of the reflections were used for this study to investigate the impressions of the students.

D. Pre-CC OSCE and Computer-Based Test (CBT)

In Japan, medical students usually take the pre-CC OSCE in the fourth year, prior to the two-year CC course. Before 2022, the minimum assessment factors were medical interview, physical examinations (including head and neck, chest, abdomen, neurological examinations), basic clinical procedure, and basic life support. The examinations were administered by CATO. The evaluation criteria are not publicly available because of CATO policy. Two scores are used in the evaluation: global score (GS) which means the evaluation as a total performance and item-wise score (IS) which means scores by checklist. Before 2023, the borderline was set by each institute. At least one certified evaluator per area was responsible, and each evaluator was a faculty member. Moreover, CATO sent at least one external evaluator per area and an external supervisor. After each performance, each examinee was evaluated by two or three evaluators per room. The pre-CC OSCE is one of the examinations that students must pass to proceed to the CC course.

Aside from the pre-CC OSCE, students must also pass the CBT. The CBT corresponds to the assessment of medical knowledge prior to the CC (Horita et al., 2021). In 2023, the pre-CC OSCE and CBT have been made official, and students must pass both examinations before they can take the national board examination in Japan.

E. Data Analysis

The pre-CC OSCE scores were analysed using R, Rstudio, JMP version17.0 (SAS Institute, N.C., USA) and Microsoft Excel (Microsoft Corporation, W.A., USA). Non-paired T test, Mann-Whitney U test, and Steel-Dwass test were used respectively, for parametric or non-parametric comparisons.

III. RESULTS

A. Year-to-Year Comparison of the Pre-CC OSCE Results in the Medical Interview area and CBT Results

First, we compared the year-to-year results of the pre-CC OSCE in the medical interview area. Table 1 and Figure 1 shows a statistical summary of the pre-CC OSCE scores in 2022, 2021, 2019, and 2018. The results of non-parametric tests revealed that the p-values in the IS between 2022 and 2019, 2022 and 2018, and 2021 and 2018 were below 0.05, whereas no significant difference was observed in the GS.

Submitted: 30 December 2024
Accepted: 5 July 2025
Published online: 7 October, TAPS 2025, 10(4), 63-72
https://doi.org/10.29060/TAPS.2025-10-4/OA3777

Chollada Sorasak¹, Worayuth Nak-Ai², Choosak Yuennan³ & Mansuang Wongsapai¹

¹Intercountry Centre for Oral Health, Department of Health, Thailand; ²Sirindhorn College of Public Health Chonburi, Praboromarajchanok Institute, Thailand; ³Boromarajonani College of Nursing Chiang Mai, Praboromarajchanok Institute, Thailand

Abstract

Introduction: Nutrition literacy represents a critical determinant of oral health outcomes. Guided by Social Cognitive Theory and the Nutrition Literacy Skills Framework, this study evaluated the implementation and effectiveness of a nutrition literacy programme for oral health promotion among village health volunteers (VHVs), key implementers in Thailand’s healthcare system, during January to December 2024.

Methods: A convergent parallel mixed-methods design was employed to address existing methodological gaps in nutrition literacy research. The quantitative component comprised a cross-sectional survey (N=60 VHVs trained in January 2024) and clinical outcome monitoring via electronic health records. The qualitative strand involved a multi-case study approach with purposive sampling (n=20) through in-depth interviews. Data collection occurred at 6-month post-implementation (July 2024), with clinical monitoring through December 2024. Analysis integrated descriptive and inferential statistics with thematic analysis.

Results: Post-implementation analysis revealed significantly enhanced nutrition literacy skills (M=4.14, SD=0.414), with notable improvements in communication (M=4.74, SD=0.511) and implementation (M=4.21, SD=0.440). All six nutrition literacy domains showed strong correlations (r=0.712-0.868, p<.01), supporting the framework’s interconnected nature. Clinical outcomes improved significantly: oral health check-up rates increased from 1.41% to 2.61% (p<.05), and functional teeth retention rose from 87.36% to 92.72% (p<.01). Qualitative findings revealed adaptive knowledge transfer methods and context-specific implementation strategies influenced by community readiness.

Conclusion: Through comprehensive mixed-methods evaluation, the 12-month implementation data demonstrated significant improvements in both VHVs’ nutrition literacy skills and clinical oral health outcomes. Success factors included theoretically-grounded implementation strategies and stakeholder engagement in resource-limited settings.

Keywords:         Convergent Parallel, Health Literacy, Mixed Methods, Nutrition, Oral Health, Thailand, Village Health Volunteer

Practice Highlights

• Nutrition literacy among VHVs significantly improved across all six key domains.
• Oral health check-up rates increased from 41% to 2.61% post-programme implementation.
• Functional teeth retention rose from 36% to 92.72% over the 12-month period.
• VHVs used context-specific strategies for community-based nutrition education.

I. INTRODUCTION

Oral health is fundamentally linked to nutrition and dietary behaviours, yet nutritional factors affecting oral health remain a significant public health challenge worldwide, particularly in low- and middle-income countries (Peres et al., 2019; Watt et al., 2019). In Thailand, the high prevalence of dental caries and periodontal diseases related to dietary habits (Chaianant et al., 2022), underscores the urgent need for effective nutrition education strategies for oral health promotion.

Understanding the relationship between nutrition literacy and oral health behaviours requires consideration of multiple theoretical perspectives. Social Cognitive Theory (Bandura, 2004) highlights how personal factors, dietary patterns, and environments interact to shape oral health behaviours, particularly relevant in Thailand’s family-based eating culture. The nutrition literacy skills Framework (Squiers et al., 2012) outlines how individuals develop and apply nutrition literacy competencies through interactions between dietary knowledge and social environments. Additionally, Ecological Systems Theory (Bronfenbrenner, 1979) demonstrates how family and societal systems influence health behaviours and programme implementation.

Within this theoretical context, nutrition literacy for oral health emerges as a critical determinant of oral health outcomes. While health literacy encompasses capacities for accessing and using health information (Sørensen et al., 2012), nutrition literacy for oral health specifically focuses on these competencies in oral healthcare. Evidence consistently shows that individuals with low nutrition literacy tend to exhibit poor oral health behaviours and outcomes (Berkman et al., 2011; Kickbusch et al., 2013). This relationship is particularly significant in reducing oral health disparities (Horowitz & Kleinman, 2012), with higher nutrition literacy correlating with improved oral hygiene practices and health outcomes (Baskaradoss, 2018).

Recent advances in nutrition literacy programmes for oral health promotion have revealed that culturally tailored, context-specific interventions can significantly enhance service accessibility and oral healthcare engagement (Macek et al., 2016). Various programme modalities have emerged, encompassing educational initiatives, community-based activities, and digital media interventions (Dickson-Swift et al., 2014). These approaches align well with Thailand’s dental public health policy, which emphasises proactive oral health promotion and community participation.  Systematic review (Firmino et al., 2017) identified several critical gaps in existing research: the absence of mixed-methods studies examining both programme effectiveness and change processes, limited analysis of community-level behavioural change mechanisms, and insufficient research in resource-constrained developing countries where success factors may differ substantially from developed nations.

To address these research gaps, this study aims to evaluate the effectiveness of a nutrition literacy programme for oral health promotion in Thailand’s context. Of particular interest is the role of VHVs as key implementation agents, given their established position in community health promotion (Kowitt et al., 2015). While previous research has demonstrated VHVs’ capacity to utilise technology for expanding health service coverage (Jandee et al., 2015), empirical evidence regarding their role in promoting nutrition literacy for oral health remains limited.

Guided by our theoretical framework, we employed a Convergent Parallel Mixed Methods design (Creswell & Plano Clark, 2017), enabling comprehensive assessment of both quantitative programme effectiveness and qualitative change mechanisms. This approach examines how social modelling, nutrition literacy skill development related to oral health, and environmental factors interact to influence programme outcomes. Ultimately, this study’s findings will contribute to developing contextually appropriate nutrition literacy strategies for oral health promotion in developing countries while aligning with Thailand’s dental public health policies.

II. METHODS

A. Study Design

This study employed a convergent parallel mixed methods design (Creswell & Plano Clark, 2017) to comprehensively evaluate the implementation and effectiveness of a nutrition literacy programme for oral health promotion. The design integrated quantitative outcomes with qualitative insights to achieve deeper understanding than single-method approaches. The quantitative component utilised a cross-sectional survey to assess nutrition literacy skills and clinical outcomes, while the qualitative component employed a multi-case study approach (Yin, 2018) to explore implementation experiences and contextual factors.

B. Population and Sampling

The quantitative phase included all VHVs who completed nutrition literacy training (N=60) in January 2024, with data collection occurring in July 2024. For the qualitative component, 20 VHVs were purposively selected using intensity sampling (Miles et al., 2013) based on four criteria: programme implementation experience exceeding six months, strong communication abilities, representation from varied performance areas, and voluntary informed consent. This sample size achieved theoretical saturation (Creswell, 2013; Guest et al., 2006). Gender distribution differed between samples (quantitative: 98.3% female; qualitative: 70% female) due to purposive sampling for diverse leadership perspectives. Sensitivity analysis confirmed no significant gender-based differences in primary outcomes (p > .05). The six-month assessment period aligned with established behaviour change evaluation timeframes (Glasgow et al., 2019), while monitoring through December 2024 captured seasonal variations and sustainability data.

C. Research Instruments

Two complementary instruments were developed and validated through pilot testing with 30 VHVs sharing similar characteristics with the target population, but excluded from the final sample. The questionnaire was designed according to Nutbeam’s health literacy framework (Nutbeam, 2000), operationalizing three literacy levels into six nutrition literacy components relevant to oral health promotion. Items utilised a five-point Likert scale (1 = “not confident at all” to 5 = “very confident”) for self-assessment of perceived competencies. A panel of five experts including community dentistry, nutrition, public health, health literacy, and health communication specialists assessed content validity, achieving a high IOC index of 0.96, while internal consistency demonstrated excellent reliability (Cronbach’s alpha = 0.929).

The structured interview guide explored knowledge application, teaching methods, implementation challenges, outcomes, and recommendations following established qualitative research principles (Jacob & Furgerson, 2012). Qualitative trustworthiness was ensured through member checking at two stages: during interviews for immediate verification and after preliminary analysis with eight selected participants for validation and refinement.

D. Data Collection

Baseline data was collected prior to programme implementation in January 2024, establishing pre-intervention metrics through public health service records. Following six-month implementation, parallel quantitative and qualitative assessments were conducted in July 2024. Self-assessment questionnaires were administered to all VHVs, followed by in-depth interviews (45-60 minutes) with 20 purposively selected participants until data saturation was achieved (Guest et al., 2006). In accordance with Consolidated Criteria for Reporting Qualitative Studies (COREQ) guidelines (Zachariah et al., 2024), participant confidentiality was maintained throughout the study, with written informed consent obtained after comprehensive briefing on study objectives and participant rights. Monthly data extraction from the Health Data Centre continued through December 2024 to capture sustained programme effects, with systematic collection on the 5^th of each month ensuring complete and timely data acquisition.

E. Data Analysis

The analytical approach integrated multiple complementary methods for comprehensive understanding. Quantitative analysis included descriptive statistics (frequencies, percentages, means, standard deviations) with Shapiro-Wilk normality testing. Inferential analyses comprised paired t-tests for pre-post comparisons (α = 0.05), chi-square tests for categorical outcomes, and Pearson’s correlation coefficients examining relationships between nutrition literacy domains. Effect sizes were reported using Cohen’s d with bootstrap confidence intervals (1,000 resamples). Statistical analyses utilised IBM’s Statistical Package for the Social Sciences (SPSS) Statistics software. Missing data patterns were examined using Little’s Missing Completely at Random (MCAR) test, with multiple imputation (5 datasets) addressing missing values following Rubin’s guidelines (2004). Sensitivity analyses compared complete-case and imputed datasets (van Buuren, 2018).

Qualitative data underwent thematic analysis following established frameworks (Braun & Clarke, 2006), involving verbatim transcription, independent coding by two researchers, and iterative thematic framework development through consensus meetings. ATLAS.ti software facilitated systematic organisation and analysis. Quality assurance included investigator triangulation, member checking with eight participants, audit trail documentation, and researcher reflexivity journals.

F. Data Integration

A comprehensive integration strategy synthesised quantitative and qualitative findings through three interconnected phases (Cano & Lomibao, 2023). Joint displays facilitated systematic comparison of results, enabling identification of convergent and divergent patterns. Meta-inferences were constructed through iterative cross-method analysis, with attention to complementary insights. Pattern matching techniques examined alignments between quantitative outcomes and qualitative themes, developing integrated theoretical understandings. Conflicting findings were reconciled by contextualising quantitative results with qualitative explanations, while complementary data enriched overall interpretation, enhancing study rigor and validity.

III. RESULTS

All participants (N=60) completed quantitative assessments at baseline and a 6-month follow-up, with 20 VHVs participating in qualitative interviews. Clinical outcomes were monitored through December 2024 using complete Health Data Centre monthly data. Following convergent parallel design, quantitative and qualitative data streams were systematically merged to achieve comprehensive understanding of programme implementation and outcomes. The integrated analysis revealed that communication skills improvements were explained through qualitative evidence of adaptive teaching strategies, while regional outcome variations were illuminated by implementation challenges identified through qualitative inquiry. This systematic data merging approach provided richer insights than either quantitative or qualitative methods could offer independently.

A. Baseline Characteristics

1. Qualitative Sample (n = 20)

The qualitative sample achieved a full response rate (100%). Participants were predominantly female (70%), with males comprising 30%. The age distribution showed that 70% were between 50–60 years, while 15% each were aged 30–39 and 40–49 years. No participants were over 60. In terms of role, 65% served as Village Health Volunteers (VHVs), and 35% were Caregivers. None held dual roles.

2. Quantitative Sample (n = 60)

The quantitative sample also achieved a 100% response rate. Females constituted the vast majority (98.3%), with only one male respondent (1.7%). Most participants (70%) were aged 50–60 years, with smaller proportions aged 30–39 (11.7%), 40–49 (16.7%), and over 60 (1.7%). Regarding position, 85% were VHVs, 13.3% were Caregivers, and 1.7% held both roles.

The intervention (Table 1) demonstrated significant improvements across all six nutrition literacy domains (p< 0.001) with large effect sizes. Communication skills showed the greatest improvement (d = 1.64, mean difference: 0.84 points, 95% CI: 0.66-1.02), followed by Decision Making (d = 0.90), Critical Inquiry (d = 0.88), Understanding (d = 0.85), Application (d = 0.77), and Access (d = 0.74). Other domains improved by 0.36-0.41 points.

C. Clinical Outcomes and Programme Effectiveness

Clinical outcomes significantly improved. Dental check-up rates increased from 1.41% to 2.61% (difference: 1.20 percentage points, 95% CI: 0.90-1.50, p=0.032). Participants with ≥20 functional teeth rose from 87.36% to 92.72% (difference: 5.36 percentage points, 95% CI: 3.38-7.34, p< 0.001), indicating substantial improvements in both knowledge and oral health behaviour.

Submitted: 9 October 2024
Accepted: 25 July 2025
Published online: 7 October, TAPS 2025, 10(4), 90-93
https://doi.org/10.29060/TAPS.2025-10-4/II3539

Shigeki Matsubara

Department of Obstetrics and Gynaecology, Jichi Medical University, Japan; Department of Obstetrics and Gynaecology, Koga Red Cross Hospital, Japan; Medical Examination Centre, Ibaraki Western Medical Centre, Japan

I. INTRODUCTION

The concept of “gamification” has been introduced to medical education: game elements employed for education enhance learning outcomes by making the educational process more interactive and engaging (Lee et al., 2025). Various games have been introduced—serious games, escape rooms, simulation games, and others. Although the theoretical underpinnings of why “gamification” improves educational outcomes are not yet fully clarified, incorporating game mechanics into medical education appears to enhance learner motivation, engagement, and performance, particularly in teaching clinical reasoning and collaborative decision-making (Lee et al., 2025).

In this manuscript, I wish to introduce the application of “gamification” to medical meetings, especially from the viewpoint of the audience. More accurately, I have been practicing it for 30 years—long before the term “gamification” became widely recognised. Here, “gamification” does not refer to a systematic process involving meeting stakeholders, but rather to the individual audience member’s attitude toward how to attend. I believe that “gamification” activates attendees and benefits them: it helps them remain well informed in the face of ever-expanding knowledge.

Medical meetings consist of the audience, presenter, chairperson, and organizers. While some publications focus on how to deliver an effective presentation (Nundy et al., 2022), it is crucial to recognize that the top priority should be the audience (Matsubara & Matsubara, 2024a). A previous report suggested that presenters and chairpersons could activate audience-friendly meetings (Matsubara & Matsubara, 2024a). However, practical suggestions for the audience remain relatively scarce. Some literature merely advises: “Be an active learner; ask questions” (Fisher & Trautner, 2022). To my knowledge, there is limited evidence on whether “active learning and active asking” are truly lacking in real-world settings, and if so, what barriers may underlie this. If the absence of “gamification” factors partly contributes to these barriers, then the present proposal may become more reasonable and persuasive. That said, this proposal is not primarily based on such reasoning. But indeed, publications on active learning and active asking from the viewpoint of “gamification” are lacking, and senior staff are less likely to provide practical advice. Thus, audience members, especially younger generations, may receive little guidance on how to participate effectively in scientific meetings.

I propose a new way of how audiences actively participate in medical meetings. Based on my decade-long experience, I focus on two elements: “listening” and “asking”. These two actions are, I believe, the essence of audience participation. My proposal is to incorporate the concept of “gamification” into personal “listening and asking” activity.

II. “LISTENING”: EFFECTIVE KNOWLEDGE ACQUISITION AT MEDICAL MEETINGS

When I was younger, I took notes on everything and tried to memorise the data presented. For example, I wrote down, “Methotrexate 50 mg cured ectopic pregnancy”. While this approach might work for some, I found that for me, this classroom-like method was neither effective nor reliable. It exhausted my physical and mental energy, sometimes leading to the retention of inaccurate information.

Around 30 years ago, I changed my style. I began to approach meetings as if they were a “game”, the concept now acknowledged as “gamification”. The night before the scientific or medical meetings, I quickly glanced through the program listing titles of the presentations (and abstracts, if available) to form a rough idea of the topics, ignoring details. Before the session starts, I read the presentation titles, for example, “Methotrexate for ectopic pregnancy,” and came up with some likely scenarios (A, B, or C) that the presenter might discuss, akin to forming a hypothesis. If the presenter confirmed scenario A, I thought, “Got it!”. After the presentation, I created a one-line conclusion based on my interpretation, which might align with or differ from the presenter’s. Importantly, this conclusion should always be in my own words (Tip 1 and Additional Notes in the Appendix).

I always did this and made it a routine for medical or scientific meetings. It was useful to skim the titles or abstracts beforehand to become familiar with the field. This enabled me to predict what the presenter might say. Afterwards, I summarised the presentation in my own words. This process mirrors manuscript writing, where I gather general knowledge, form a hypothesis, and craft a key message—essential steps for completing a successful paper (Matsubara & Matsubara, 2024b). Thus, listening to presentations served as practice for writing manuscripts. This procedure changed my attitude toward scientific meetings, and even improved my paper productivity. I began to look forward to the next meeting, anticipating the new ideas I might encounter. I became an active audience member. The one-line conclusion made me continue contemplating whether my interpretation was correct. Even after the meetings, I repeatedly glanced at it, and sometimes a new idea or concept emerged from that single line, which triggered me to write some papers. Thus, this “gamification” concept in listening was effective not only during the scientific meeting but also afterwards. As described, “gamification” has now been widely discussed as an effective measure in medical education (Lee et al., 2025). Here, I propose that involving the concept of “gamification” at a personal level may enhance active participation in scientific meetings, and thereby support life-long learning.

Why not view medical meetings as a “game” rather than a mere duty? This perspective helped me stay relaxed and engaged throughout the session. It renewed my knowledge base and offered a chance for manuscript-writing practice.

III. VALUABLE QUESTIONS AND COMMENTS TO ACTIVATE MEETINGS

Asking questions not only deepens one’s understanding, but also helps activate the meeting itself. The following suggestions may be particularly useful for senior attendants, including meeting leaders, but they are equally relevant to the general audience, including the younger generation.

Valuable questions can:

1. help clarify knowledge for the audience and enhance their understanding,
2. increase the significance of the study being discussed. Here, “questions” can also refer to general remarks about the presentation.
   
   

Some studies present an incorrect message regarding treatment recommendations, which less-experienced doctors may apply without question. Ask questions to clarify. Some presenters may refrain from stating a clear conclusion. Ask for a tentative conclusion. These kinds of questions may also be considered, in a broader sense, a form of “gamification”: such questions can open further discussion and, in that sense, the questioner could act as a “game changer”.

Questions often increase the significance of a study. For example, ask if there’s another relevant interpretation of the data, if similar studies exist that the presenter might not be aware of, or if there are historical perspectives on the issue. Cross-disciplinary perspectives are often useful. For example, perspectives from fields like neurosurgery, gastroenterology, or urology can activate discussions in psychiatry, endoscopy, or nephrology meetings, respectively. Please focus on asking questions that relate to the study’s significance, rather than those solely of personal interest. This approach is akin to how a chairperson should handle the question-answer sessions (Matsubara & Matsubara, 2024a) (Tip 2 and Additional Notes in the Appendix).

Questions can complement presentations much like correspondences enrich published articles by offering additional perspectives. Good questions prompt the presenter and audience to recognise further significance in the presentation. This benefits everyone—the questioner, the presenter, and the general audience. This situation mirrors how good correspondence enriches all parties involved in the academic discussion.

IV. CONCLUSION: PASSING ON THE EXPERIENCE TO THE NEXT GENERATION

I propose a change in perspective: learning at scientific meetings should be viewed as a game.  “Listening” and “asking” share similarities with writing a paper. Having a bird’s-eye view, crafting a hypothesis, and forming a key message are essential for both “effective attendance to meetings” and paper writing (Matsubara & Matsubara, 2024b). A good question is like a brief, insightful correspondence. Thus, making an effort to be a good audience also nurtures good researchers and writers.

Finally, I would like to add that, medical meetings provide opportunities not only to gain knowledge, but also to engage in face-to-face communication. Making acquaintances there may broaden future research opportunities, which is especially important for younger physicians. A positive meeting atmosphere encourages such communication. I believe that good “listening” and thoughtful “asking” contribute to this. Active listening and well-considered questions benefit all participants in three ways: deepening understanding for those who ask, helping everyone grasp the presentation’s significance, and fostering a welcoming atmosphere.

Having participated in numerous meetings, I’ve developed this perspective. It’s unclear whether some hierarchical or systemic influences hinder “natural” listening and asking, especially among younger generations. If so, how best to address them should be studied. Regardless, we, as meeting participants, should cultivate the sensitivity to recognise a question that sparks a game-changing moment. I believe the present description offers a way to fully engage in medical and scientific meetings by viewing them as a “game”. This approach has helped me grow as a researcher-physician, contributing to the publication of over 600 PubMed-indexed papers. Thus, for me, this method is time-tested. I believe seasoned doctors like myself have a responsibility to pass on their experiences to the next generation. I invite you to try my perspective, and hope that it serves as a platform for further discussion.

Notes on Contributors

Shigeki Matsubara reviewed the literature, made the concept, wrote and edited the manuscript.

Acknowledgement

I thank Professor Shinya Ito (University of Toronto, Canada), Professor Yasushi Matsuyama (Jichi Medical Univeristy, Japan), and Teppei Matsubara (Harvard Medical School, USA), for their critical reading of this manuscript.

Funding

There are no funding sources for this paper.

Declaration of Interest

Shigeki Matsubara has no conflict of interest to declare.

References

Fisher, J.W. & Trautner, B.W. (2022). Maximizing the academic conference experience: Tips for your career toolkit. Journal of Graduate Medical Education, 14(2), 144-148. https://doi.org/10.4300/jgme-d-21-00943.1

Lee, C.Y., Lee, C.H., Lai, H.Y., Chen, P.J., Chen, M.M., & Yau, S.Y. (2025). Emerging trends in gamification for clinical reasoning education: A scoping review. BMC Medical Education, 25(1), 435. https://doi.org/10.1186/s12909-025-07044-7

Matsubara, S., & Matsubara, D. (2024a). An audience-friendly medical meeting: A good presentation and chairpersonship. JMA journal, 7(3), 406-409. https://doi.org/10.31662/jmaj.2023-0219  

Matsubara, S., & Matsubara, D. (2024b). A checklist confirming whether a manuscript for submission adheres to the fundamentals of academic writing: A proposal. JMA journal, 7(2), 276-278. https://doi.org/10.31662/jmaj.2023-0201

Nundy, S., Kakar, A., & Bhutta, Z.A. (2022). How to give an oral presentation? In Nundy S., Kakar A., & Bhutta Z.A. (Eds.), How to practice academic medicine and publish from developing countries?: A practical guide (pp. 357-366). Springer Nature.  https://doi.org/10.1007/978-981-16-5248-6

*Shigeki Matsubara
Department of Obstetrics and Gynaecology,
Jichi Medical University
3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan
Email: matsushi@jichi.ac.jp

Submitted: 28 October 2024
Accepted: 16 June 2025
Published online: 7 October, TAPS 2025, 10(4), 35-43
https://doi.org/10.29060/TAPS.2025-10-4/OA3559

Reshma Mohamed Ansari^1,2, Chan Choong Foong³, Hidayah Mohd Fadzil⁴ & Mohamad Nabil Mohd Noor³

¹Institute for Advanced Studies, Universiti Malaya, Malaysia; ²Department of Medical Education, International Medical School, Management and Science University, Malaysia; ³Medical Education and Research Development Unit (MERDU), Faculty of Medicine, Universiti Malaya, Malaysia; ⁴Department of Mathematics and Science Education, Faculty of Education, Universiti Malaya, Malaysia

Abstract

Introduction: Self-care agency, a core concept that helps alleviate the stressors of medical training, is postulated to be practiced by medical students who exhibit a growth mindset. Hence, this pilot study was designed to measure, compare, and correlate the self-care agency and mindsets of undergraduate medical students to assess the potential for scaling to a national survey.

Methods: This cross-sectional study was conducted at one public and one private medical university using a revised version of the Appraisal of Self-Care Agency Scale to measure self-care agency and the Implicit Theories of Intelligence Scale to measure participants’ mindset. Data was analysed using IBM SPSS.

Results: In total, 329 complete responses were obtained. Among the self-care domains, a higher capacity for self-care and a developing capacity for self-care, with a lower ability to indulge in self-care, were reported. Self-care agency showed a significant difference between pre-clinical and clinical students (p = .027; Cohen’s d = .2). Mindset measurements revealed a higher growth than a fixed mindset. The Pearson correlation coefficient showed a weak positive correlation, (r = 0.19) between the means of self-care agency and a growth mindset. Clinical students showed a higher tendency toward self-care than their pre-clinical counterparts in an independent-samples t-test, with no differences between genders and universities.

Conclusion: This pilot study found a positive correlation between self-care agency and growth mindset among undergraduate medical students. Although limited by two prototype universities and response bias, this study provides a solid foundation for future nationwide or cross-country studies.

Keywords:            Self-care Agency, Growth Mindset, Fixed Mindset, Medical Education, Undergraduate Medical Students, Pilot Study

Practice Highlights

• Undergraduate medical students acknowledge importance of self-care agency and growth mindset.
• Growth mindset correlates with self-care agency necessitating inculcation of both.
• Growth mindset combats the stressors of medical training by indulging in proactive self-care.

I. INTRODUCTION

Orem et al. (1995, p. 19) defined self-care as the “practice of activities that individuals start and perform for their benefit, for the maintenance of life, health, and well-being”. Self-care agency, a component of the self-care deficit nursing theory, is “the acquired, complex capacity to meet the requirements to take care of oneself, regulating life processes, maintaining or promoting integrity, structure, and functioning, as well as one’s development and promotion of well-being” (Oliveira et al., 2022, p. 20; Orem et al., 1995). Research has elucidated that the stressors of medical training, which can cause high rates of burnout, anxiety, depression and poor physical health in students (Ayala et al., 2017; Bostock et al., 2018), could be alleviated through self-care (Ayala et al., 2018).

However, during medical training, students find little to no time to engage in self-care; factors such as increased pressure, poor time management, and a negative environment often acting as barriers (Ayala et al., 2017; Ayala et al., 2018). Guldner et al. (2020) suggested that mindset is a predictor of depression and burnout among medical residents, highlighting the relationship between mindset and poor psychological well-being, alleviated by self-care practices (Carter et al., 2025).

Carol Dweck coined the terms “growth mindset” and “fixed mindset” as part of the implicit theories of intelligence, in which individuals could view intelligence as fixed (entity theory) or as a dimension that can be improved with effort (incremental theory) (Cook et al., 2018; Dweck, 2013). The mindset theory, when applied to the medical education context, suggests that a growth mindset views effort as a means to develop abilities (Theard et al., 2021). In contrast, a fixed mindset could lead to poorer outcomes in a high-pressure educational environment (Bostock et al., 2018) and resultant poor psychological well-being (Root Kustritz, 2017).

Studies have measured participants’ mindsets and correlated them with scales measuring anxiety or overall well-being (Guldner et al., 2020; Root Kustritz, 2017; Wolcott et al., 2021). One of the reasons for a growth mindset to aid students’ well-being is by allowing them to place greater value on health and fitness and exhibit health-seeking behaviours (Orvidas et al., 2018; Thomas et al., 2019).

Adding on, identification of stressors, the burnout caused by them, mental health issues, active self-care seeking behaviours including coping strategies are associated with a growth mindset (Burnette et al., 2020). Nursing students who were exposed to structured activities fostering a growth mindset, reported indulging in student-preferred strategies such as viewing obstacles from a newer perspective, working for competency, and indulging in self-care practices, thus directly relating a growth mindset to better self-care agency (Carter et al., 2025).

Medical students in Malaysia, akin to their global counterparts have reported increased levels of stress and psychological distress (Masilamani et al., 2020), due to stringent admission processes, higher cognitive load, and an assessment-based curriculum (Yusoff et al., 2013). Studies across four public medical schools in Malaysia have shown that students tend to alleviate stress through religious activities, active coping strategies, positive reinterpretation, acceptance, and planning (Yusoff et al., 2011), which could be viewed as a subtle expression of a growth mindset. Despite the postulation that a growth mindset accentuates self-care agency, there is a dearth of studies on the self-care agency of Malaysian medical students and its correlation with mindset.

Hence, this pilot study was conducted with the objective of measuring, comparing, and correlating self-care agency and the mindsets of Malaysian undergraduate medical students to gauge the feasibility of a nationwide survey (Lowe, 2019).

II. METHODS

This cross-sectional pilot study was conducted at a public and a private medical university in Malaysia. which were accessible to researchers. The selected public university is a prototype of Malaysian public universities characterised by highly qualified students with excellent examination results paying subsidised fees, as the operation of the university is funded by the government (Wan, 2007). The selected private university is representative of Malaysian private universities, which primarily provide an alternate pathway for the high school students who are not placed in public universities. Being self-funded, the fees are relatively higher, and the students are typically of paying capacity (Wan, 2007).

Permission to conduct this study was obtained from the ethics committees of both the public and private universities (UM.TNC2/UMREC_2872 and RMC/SEP/2023/EC02, respectively). Generally, although every medical school in Malaysia is homegrown and has variations in its curriculum, both the universities chosen for this study had a similar integrated curriculum spanning over five years for the Bachelor of Medicine, Bachelor of Surgery (MBBS) program, with two years of pre-clinical and three years of clinical studies.

The study instrument consisted of three sections. Data collection was anonymous, and the first section recorded the details of the participants’ age, gender, institution of study, and year of study. Section two included the revised version of the Appraisal of Self-care Agency Scale (ASAS-R), used to measure self-care agency (Oliveira et al., 2022). The ASAS is a 24-item scale developed by Evers et al. in 1986 (Evers, 1989) and modified by Sousa et al. (2010) into a 15-item scale that can be applied to adults aged over 18 years.

The three domains of ASAS-R holistically measure the three types of personal trait components that characterise the concept of self-care agency (Oliveira et al., 2022). The responses were ranked on a 5-point Likert scale (1 = totally disagree; 5 = totally agree). The total scores ranged from 15 to 75, with higher scores indicating greater self-care agency (Oliveira et al., 2022).

Sousa et al. (2010) divided the items into the following domains: Domain I: having the capacity for self-care (items 1, 2, 3, 5, 6, and 10; maximum domain score = 30); Domain II: developing the capacity to self-care (items 7, 8, 9, 12, and 13; maximum domain score = 25); and Domain III: inability to self-care (items 4, 11, 14, and 15; maximum domain score = 20), with acceptable Cronbach’s alpha values of 0.86, 0.83, and 0.79, respectively. The instrument has been validated among the general population in countries such as China, Spain, and Brazil, and among medical students in Portugal (Alhambra-Borrás et al., 2017; Guo et al., 2017; Oliveira et al., 2022; Yuan et al., 2021).  

Section three consisted of the Implicit Theories of Intelligence Scale (ITIS), adopted from the published version of the ITIS by Cook et al. (2017), to measure the mindset of medical students. The ITIS is an eight-item instrument with four items related to incremental beliefs (1, 2, 3, and 4) and four items related to entity beliefs (5, 6, 7, and 8) regarding intelligence and ability. Responses were based on a 6-point Likert scale (1 = strongly disagree; 6 = strongly agree) (Cook et al., 2017). For each domain, the scores ranged from 4 to 24.

A confirmatory factor analysis of the ITIS scores demonstrated an overall acceptable model fit; an exploratory factor analysis confirmed a two-factor structure (Cook et al., 2017), with the Cronbach’s alpha ≥ 0.77 for each domain (Cook et al., 2018).

The sample size of the study was calculated using Raosoft online software (http://www.raosoft.com/samplesize.html).

With an approximate total population of 1300 (public university = approximately 900; private university = approximately 400), based on a confidence level of 95%, a response distribution of 50%, and a margin of error of 5%, the sample size was determined to be 297. A quota sampling technique was applied to ensure adequate sample representation for each university: 204 from the public university and 93 from the private university.

The questionnaire items were entered into a Google Form, and the link was distributed to all the students of both the universities where they were asked to answer the questionnaire after reading the participant information sheet and providing informed consent.

The data were collected over four weeks, starting on November 1 – November 30, 2023, which was two months from the start of the new semester (September 2023) in both universities which gives ample time for the students to experience the learning environment and respond to the questionnaire. A reminder was provided two weeks after the start of data collection, and data collection ended two weeks after the reminder. The students were informed of the closure of data collection.

The data were analysed using the IBM Statistical Package for Social Sciences (SPSS) v.26 via descriptive and inferential tests. The normality of the data distribution was screened. Pearson’s product-moment correlation was used to analyse the relationship between self-care agency and mindset, whereas independent-samples t-tests were used for comparative analyses between gender and years of study.

III. RESULTS

A. Participants’ Characteristics

A total of 329 valid responses were received. The participants’ demographic characteristics are presented in Table 1.

The distribution of the participants according to their year of study followed the same pattern in both universities, with more female than male respondents and more pre-clinical than clinical students, implying that the sample was representative of the population.

Submitted: 24 September 2024
Accepted: 14 May 2025
Published online: 7 October, TAPS 2025, 10(4), 84-89
https://doi.org/10.29060/TAPS.2025-10-4/II3528

Seema Tanaji Methre¹, Ramya Jayakumar¹, Sugata Sunil Jadhav¹, Chhaya Anil Saraf ², Rajkumar Sansarchand Sood¹ & Ashwini Namdeorao Patil³

¹Department of Physiology, Dr. D. Y. Patil Medical College, Hospital & Research Centre, India; ²Department of Physiology, Vydehi Institute of Medical Sciences and Research Centre, India; ³Department of Physiology, Symbiosis Medical College for Women, Symbiosis (International) (Deemed University), India

I. INTRODUCTION

Soft skills help a person to boost his or her own performance. They are necessary for professional development. Effective communication and decision making are an integral part of good clinical care. Introduction to soft skills during undergraduate training helps students to appreciate and learn effective interpersonal communication with patients and their families. Soft skills training was not a part of academic curriculum in formal traditional medical training. (Sancho-Cantus et al., 2023).

However, since 2019, AETCOM module was added in medical profession in India, in which students need to learn attitude, ethics and communication (Medical Council of India [MCI], 2018). In addition to verbal communication, non-verbal communication including body language, eye contact, facial expression, touch and gestures are equally important in building trust in doctor-patient relationships. In order to inculcate these soft skills in their future profession, students need to practice these skills again and again.

Various professional bodies and medical students have revealed the need for soft skills training in the curriculum (Modi et al., 2016). Integrating these soft skills with clinical skills training is a big challenge. The concept of role play has been widely used to introduce soft skills in medical profession. Role play promotes active learning among the students and motivates them to work as a team. In contrast to lectures, students get completely involved while performing the act during the role play. This enables them to retain and remember the concepts for longer duration. Role play helps the students to have an in-depth understanding of the topic at hand as they are made to think, script and act out the complete scenario on their own. (Goothy et al., 2019). Role play promotes better understanding and leaves an impact not only amongst the participating students but also in peers who are observing them (Rønning & Bjørkly, 2019). The current study aimed to evaluate effectiveness of role play in nourishing various soft skills in the first-year medical students.

II. METHODS

An interventional study was conducted at a teaching medical institute in Western Maharashtra, India. Ethics clearance from the Institutional Ethical Committee was taken before the commencement of the study (Reference Code: I.E.S.C./159/2022). Selection of participants was purely on a voluntary basis.

A. Pre-Role-Play Self-Assessment of Skills

Topics for role play were given 15 days prior to role play. Five students gave verbal consent for this study. The study procedure was explained to the participants. Topics were given as shown in Appendix 2. They wrote their own script for the role play. Pre-test was conducted through Google form which included following types of questions related to various skills like communication, interpersonal, intellectual, self-management and learning. Pre-validated questionnaire was adapted from the website of College of Physiotherapists of Ontario which was modified and rectified by senior faculties as per the need of our study.

This questionnaire allows students to self-assess their own skills so that they know where they may need to improve. Each question has 3 columns as A, B & C. Each column should be filled per the instructions given below as shown in supplementary table (Appendix 1).

1. Column A

How important is the skill for the participant that he/she thinks should possess/acquire? Need to write the number as per the scale given below:

6 – very important
5 – important
4 – slightly important
3 – slightly unimportant
2 – unimportant
1 – very unimportant

2. Column B

Where does participant see himself/herself in already possessing the following skills (i.e., his/her self-assessment of present skill level)? Need to write the number as per scale given below:

6 – Expert, no need for further training
5 – Expert, needs self-training
4 – Good, needs occasional training from experts
3 – Average, needs frequent training
2 – Poor, needs regular training
1 – Bad, needs handholding and training

3. Column C

Participants need to subtract column B number from column A number (column A – column B). The highest number in this column C shows a major disparity between what he/she thinks about the importance of a particular skill and its current expertise level. These are the skills where participants need to improve whenever she gets opportunity in future.

B. Role Play Enactment Sessions (Intervention)

A total of 3 role plays were enacted by the participants focusing on-bad followed by good 1) attitude, 2) behavior and 3) communication of doctor with patients as per topics given to them (Appendix 2).

C. Post-Role-Play Self-Assessment of Skills

Post-test was conducted for participants using the same questionnaire.

1. Statistical Analysis

Scores of pre-test and post-test were copied into excel sheet and data was analysed by paired t -test using Primer of Biostatistics software, version 7.0.

III. RESULTS

Present study showed self-assessed improvement in communication skills, interpersonal skills and self–management skills due to role play in the participants which was highly significant. Intellectual skills and learning skills also improved significantly in this study. Role play promotes active learning. Participants write scripts on their own, think about the characters, plan for acting and do rehearsal also. Role play helps to build leadership qualities and teamwork amongst participants (Goothy et al., 2019). In order to provide good quality health care, soft skills training is necessary to strengthen these skills in professional training. Improvement in soft skills like communication, interpersonal, intellectual, self-management & learning skills enhances academic performance as well as overall professional development of the student (Sancho-Cantus et al., 2023). Cognitive and psychomotor skills are also enhanced through such activities (Goothy et al., 2019). Such soft skill training also improves coping abilities during disturbances as seen in COVID 19 pandemic and also reduces the incidence of anxiety and depression (Sancho-Cantus et al., 2023).

Only five students volunteered to participate in this study. Improvement in these skills was based on self-assessment. Due to small sample size, social desirability bias and self-report bias, statistical significance may vary and might affect the generalisation of the findings. But this pilot study can be extended with large sample size for getting more appropriate results. Focus group discussions, direct observations and reflective essays might give more in-depth information in future studies.

V. CONCLUSION

Soft skills like communication skills, interpersonal skills and self–management skill may be improved along with Intellectual skills and learning skills by the role play in students of medical profession. Role play can be used as an effective tool to enhance soft skills in the students. Such studies should be facilitated in larger population.

Notes on Contributors

Seema Tanaji Methre was involved in conceptualisation, methodology, project administration and supervision, data analysis and writing (original draft and editing).

Ramya Jayakumar was involved in conceptualisation, methodology, project administration and supervision, data analysis and writing (editing).

Sugata Sunil Jadhav was involved in methodology, project administration and supervision, data analysis and writing (editing).

Chhaya Anil Saraf was involved in project administration and supervision.

Rajkumar Sansarchand Sood was involved in conceptualisation, methodology and writing (editing).

Ashwini Namdeorao Patil was involved in conceptualisation, methodology, data analysis and writing (editing).

Ethical Approval

This study was reviewed by the Institutional Ethics Sub-Committee Committee from the Dr. D. Y. Patil Vidyapeeth, Pune (Deemed to be University), Dr. D. Y. Patil Medical College, Hospital & Research Centre, Pimpri, Pune with an exemption from IRB review and the approval to conduct research at institute (Reference Code: I.E.S.C./159/2022).

Acknowledgement

We would like to acknowledge our participants whose efforts were truly appreciable in this study.

Funding

This study was self-funded.

Declaration of Interest

The authors declare no conflicts of interest.

References

Submitted: 19 August 2025
Accepted: 30 September 2025
Published online: 7 October, TAPS 2025, 10(4), 1-4
https://doi.org/10.29060/TAPS.2025-10-4/GP3858

Dujeepa D. Samarasekera¹, Gominda Ponnamperuma², Lee Shuh Shing¹ & Han Ting Jillian Yeo¹

¹Centre for Medical Education (CenMED), Yong Loo Lin School of Medicine, National University of Singapore, Singapore; ²Faculty of Medicine, University of Colombo, Sri Lanka

Abstract

Introduction: Medical education aims to produce healthcare professionals who are not only competent, but also able to perform effectively in clinical practice settings. Assessment systems are critical to achieving this by guiding learning, ensuring competence, and certifying readiness for independent practice. This article proposes a staged assessment approach that integrates both competence and performance to ensure safe and empathetic healthcare practice.

Methods: First, we analysed the strengths and limitations of the existing assessment methods and their roles in medical education. Then, we explored strategies to integrate diverse assessment tools into a cohesive assessment system capable of effectively and reliably evaluating the competencies required for developing holistic practitioners.

Results: Competence is assessed via structured assessment tools such as written assessments. Clinical performance in real-world settings relies on Supervised in-practice assessments (SuPs), including tools like Direct Observation of Procedural Skills (DOPS) and Mini-Clinical Evaluation Exercises (mini-CEXs). Assessment tools used to evaluate performance rely on expert judgement, which, although subjective, is essential for evaluating non-cognitive skills such as empathy and professionalism.

Conclusion: This article outlines the design of a progressive assessment system, transitioning from objective assessment methods such as Multiple-Choice Questions (MCQs) to performance-focused methods, anchored by Entrustable Professional Activities (EPAs), using Workplace-Based Assessment tools and portfolios. The progression from early objective assessment tools to those which leverage expert judgement and situational specificity are highlighted as essential for preparing safe, effective, and empathetic healthcare practitioners.

Practice Highlights

• Modern assessment systems focus on both competence in non-practice settings and performance in authentic clinical practice settings.
• A combination of tools is required to assess from “knows” to “is” level of clinical performance.
• Expert evaluations provide qualitative insights into candidate performance.

I. INTRODUCTION

Traditionally, assessments in clinical education strived for standardisation, structuredness and objectivity. A single quantitative method, such as paper-based Multiple-Choice Questions (MCQs), was often used to assess a student’s competence in knowledge. Similarly, the Objective Structured Clinical Examinations (OSCEs) or long/short clinical cases were used for assessing psychomotor and affective domains related to clinical skills. To deliver healthcare effectively and empathetically, a broad range of skills must be cultivated. Over the years, there has been a gradual yet noteworthy transition from exclusively focusing on the development and assessment of one’s competence in clinical skills to placing greater emphasis on enhancing clinical performance within specific clinical contexts (Hays et al,2024).

Miller’s Pyramid (1990) of Clinical Competence illustrates this progression: from “knows” to “knows how”, “shows how”, and finally “is” as proposed by Cruess et al. (2016). At present, medical and health professional training programs judiciously select a combination of assessment methods to ensure learners are task-ready, empathetic, and safe for clinical practice. This article proposes and elaborates on the use of a staged assessment approach in health professional training, progressing from the development of competence to the refinement of clinical performance within specific practice contexts. The core idea is that competence alone does not ensure effective clinical practice. Both competence and performance must be developed to ensure safe and compassionate care.

Figure 1: The diagram adapted from Cruess et al (2016) article on “Amending Miller’s Pyramid to Include Professional Identity Formation”, to illustrate a shift in focus as trainees progress to the later stages of training from assessment of competence to assessment of performance.

II. COMPETENCE AND ITS ASSESSMENT

As illustrated in Figure 1, competence or “Readiness to Practice” refers to an individual’s “ability”, encompassing knowledge, psychomotor or clinical skills, and attitudes, which together form the foundation of medical practice. Knowledge-based skills include problem-solving and clinical reasoning, psychomotor skills involve physical examinations and procedural techniques, while affective skills pertain to empathetic communication. Historically, our assessments have primarily focused on evaluating competence, employing a range of assessment tools as the following.

Written assessments, such as MCQs and Modified Essay Questions (MEQs), are designed to evaluate the “knows” and “knows how” levels of Miller’s Pyramid. These assessments primarily focus on theoretical knowledge, including understanding disease pathophysiology, as well as the procedural steps involved in performing clinical skills and managing medical conditions.

In contrast, practical and competence-based assessments, such as OSCEs, evaluate psychomotor and affective competencies, including procedural skills, diagnostic reasoning, patient interaction and communication in a controlled environment. Long and short cases, on the other hand, assess the same abilities within semi-controlled environments. These assessment formats target the “shows” level of Miller’s Pyramid, emphasising the development and demonstration of clinical skills in structured, controlled testing settings.

The feature of “shows” assessment methods is that they promote standardisation and assessment based on a rubric. Hence, they are “objective” and fairly reliable for assessing specific aspects of competence.

III. PERFORMANCE AND THE ROLE OF SUPERVISED IN-PRACTICE ASSESSMENTS (SuPs)

As illustrated in Figure 1, as learners progressed from early stages to later or final stages of learning, the focus shifts from assessment of competence to assessment of performance. While the assessment of knowledge continues to play an important role, the focus increasingly shifts towards ensuring that graduates are ready for clinical practice. Performance or “Quality in Practice” requires learners to apply their competence in dynamic, high-pressure clinical settings. These situations are both context-specific and situation-specific. In modern medical education, Entrustable Professional Activities (EPAs) anchor these authentic clinical tasks. EPAs focus on specific professional responsibilities, such as managing acute care or conducting patient handovers. These tasks are assessed by an “expert” using professional judgement. Entrustment decisions are based on evaluations from multiple experts (Cate & Schumacher, 2022).

Common tools used during SuPs include Direct Observation of Procedural Skills (DOPS), Case-Based Discussions (CBDs), multi-rater or 360 assessments, and Mini-Clinical Evaluation Exercises (mini-CEXs). These tools provide real-time feedback on a student’s or resident’s clinical performance in specific contexts. Collectively, they are also known as Workplace-Based Assessment tools (WBAs).

As students’ progress through clinical rotations or clerkships, these SuPs are compiled into an assessment portfolio. This portfolio includes case logs, feedback from supervisors and learner reflections. Together, these elements document the student’s longitudinal development. At certain time points, the portfolio is assessed by a Committee of Experts (CoE), and an Entrustment Decision is given. SuP assessments immerse learners in authentic clinical environments, enabling them to demonstrate how they apply competence gained in clinical practice. Final judgement of a student or a trainee’s performance and fitness for clinical practice then should be based on the CoE’s value judgement based on the portfolio.

IV. ADVOCATING FOR EXPERT JUDGEMENT: HOLISTIC EVALUATION OF A LEARNER

Expert judgement by assessors when conducting SuP assessments is commonly perceived to be subjective and bias-laden as it shifts away from quantitative to qualitative measures. However, we offer a different insight on how SuP assessments can triangulate with other more “objective” assessment tools to formulate a complete evaluation of a learner.

Expert judgement made by assessors can synthesise multiple facets of performance of a task such as that involving clinical reasoning, empathy and professionalism, in a specific context, into an interconnected evaluation, something that an objective assessment is unable to measure authentically. Multiple ‘subjective’ evaluations by many experts often provide richer, more personalised feedback that helps learners understand their strengths and areas for improvement, promoting deeper learning and growth. At the same time, in WBA, if multiple cases (i.e., patients with varying disease conditions) in many situations/contexts are assessed by multiple expert assessors, both validity and reliability of such assessment are not compromised.

Expert judgement is essential for performance assessments. While often viewed as subjective, expert judgement is vital for evaluating attributes like clinical reasoning, empathy, and professionalism. For example, in EPA-based assessments, experts determine whether learners can perform specific tasks independently, considering not just technical skills but also communication, prioritisation, and adaptability (Cate & Regehr, 2018). To ensure consistency, assessors require thorough calibration through training. Standardised tools, rating scales, and regular discussions among assessors enhance reliability and minimise bias.

Non-cognitive skills such as empathy and professionalism are essential for safe practice but challenging to assess. Portfolios which incorporate Multi-Source Feedback (MSF) provide avenues to evaluate these qualities, incorporating input from patients, peers, and supervisors. Reflective exercises encourage learners to explore biases, communication styles, and values, fostering self-awareness and empathy, and continued learning.

V. PRACTICAL CONSIDERATIONS

A. Balancing Objectivity and Subjectivity

The challenge lies in balancing “objective” assessments with “subjective” evaluations of performance. While MCQs and OSCEs provide standardised measures, expert judgement is crucial for situational assessments. Safeguards need to be in place to maximise the value of subjectivity while ensuring fairness and reliability. These include developing a structured rating scale, calibrating assessors on the scale through vocalising their thought process, discussion on biases, and using judgements from many assessors and contexts before an assessment decision is made.

B. Resource Allocations

SuP assessments demand significant resources, including trained assessors, robust documentation systems, and protected time for feedback as well as the transience of the judgement. Institutions must prioritise these investments to sustain an effective assessment system.

C. Prioritising Transparency

Ensuring transparency of expectations and standards for all assessment tools for educators and learners is important. This involves clearly defining and effectively communicating the criteria for both “objective and subjective” components of the assessment process. Judgements should be documented and explained, with a clear linkage to observable behaviours or outcomes, to foster understanding and trust in the assessment process.

VI. COMPETENCE AND ITS ASSESSMENT

Designing an assessment system to develop a safe, effective, and empathetic practitioners requires a staged, integrated approach. Competency-based assessments build foundational skills, while SuP assessments evaluate task-specific performance through expert judgement. The gradual shift from competence to performance ensures learners are prepared for the complexities of clinical practice. By incorporating EPAs, expert feedback and portfolios, the system prepares graduates to deliver patient-centred, professional, and safe care.

Future innovations like simulation-based assessments, AI-driven capture of assessor comments and feedback systems hold promise for further improving the credibility, transferability, dependability and confirmability of assessments processes for health professional programmes. The ultimate goal is to prepare practitioners for high-quality, empathetic care in an evolving healthcare landscape.

Notes on Contributors

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

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

Gominda Ponnamperuma contributed to reviewing the manuscript.

Funding

This study has not received any funding.

Declaration of Interest

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

References

Cate, O. T., & Regehr, G. (2018). The power of subjectivity in the assessment of medical trainees. Academic Medicine, 94(3), 333–337. https://doi.org/10.1097/ACM.0000000000002495

Cate, O. T., & Schumacher, D. J. (2022). Entrustable professional activities versus competencies and skills: Exploring why different concepts are often conflated. Advances in Health Sciences Education, 27(2), 491–499. https://doi.org/10.1007/s10459-022-10098-7

Cruess, R. L., Cruess, S. R., & Steinert, Y. (2016). Amending Miller’s Pyramid to Include Professional Identity Formation. Academic medicine: Journal of the Association of American Medical Colleges, 91(2), 180–185. https://doi.org/10.1097/ACM.0000000000000913

Hays, R.B., Wilkinson, T., Green-Thompson, L., McCrorie, P., Bollela, V., Nadarajah, V.D., Anderson, M.B., Norcini, J., Samarasekera, D.D., Boursicot, K. and Malau-Aduli, B.S. (2024). Managing assessment during curriculum change: Ottawa consensus statement. Medical Teacher, 1-11. https://doi.org/10.1080/0142159X.2024.2350522

Miller, G. E. (1990). The assessment of clinical skills/competence/performance. Academic Medicine, 65(9), S63-7. https://doi.org/10.1097/00001888-199009000-00045

*Dujeepa D. Samarasekera
Yong Loo Lin School of Medicine,
National University of Singapore,
Block MD 11, #01-11,
Clinical Research Centre 10 Medical Drive,
Singapore 117597
Email: dujeepa@nus.edu.sg

Submitted: 1 January 2025
Accepted: 12 August 2025
Published online: 7 October, TAPS 2025, 10(4), 44-54
https://doi.org/10.29060/TAPS.2025-10-4/OA3613

Dinushee Atapattu-Bakmeewewa¹, Bhagya Devagiri¹, Gayanthi Kodituwakku¹ & Madawa Chandratilake²

¹Department of Disability Studies, Faculty of Medicine, University of Kelaniya, Sri Lanka;  ²Department of Medical Education, Faculty of Medicine, University of Kelaniya, Sri Lanka

Abstract

Introduction: Tele-clinical training is an effective approach, increasingly adopted post-pandemic and in resource-limited settings. However, it requires systematic development. This study details the first-time implementation of a tele-clinical training in an undergraduate Speech and Hearing Sciences programme, exploring student experiences and validating a novel evaluation tool, specifically designed for tele-clinical training programmes.

Methods: The study used a mixed-method approach. Quantitative data were gathered from 128 students using the developed 23-item Kelaniya Tele-Clinical Evaluation Tool (KeTCET), which covers three broad areas: Learning Environment, Supervisory Attributes, and Telehealth Teaching Practices. Qualitative insights from 13 participants were thematically analysed. The tool was validated for reliability and psychometric robustness using expert feedback and statistical evidence.

Results: Quantitative analysis showed high domain scores: Learning Environment 80.64%, Supervisory Attributes 81.67%, and Telehealth Teaching Practices 80.31%. Strong positive correlations between domains (r > 0.86, p < 0.001) indicated interconnectedness. The 23-item evaluation tool demonstrated high internal consistency (Cronbach Alpha = 0.98) and a single-factor structure (Eigenvalue = 17.12, 74.44% variance explained). Qualitative data highlighted strengths in supervisor interaction and resource availability, also noting challenges such as issues in connectivity and limited peer learning. Students appreciated structured feedback and supervisor presence during tele-clinical sessions.

Conclusions: The successful development of a tele-clinical programme requires consideration of multiple elements broadly categorised as pedagogical environment, supervisory characteristics, and virtual teaching practices. Well-structured programmes can effectively meet training needs in resource-limited settings, although strengths and challenges may vary across learning environments. The validated 23-item KeTCET offers a reliable framework for evaluating and improving tele-clinical programmes.

Keywords:           Tele-clinical Programmes, Tele-clinical Supervision, Speech and Language Therapy, Audiology, Tele-clinical Evaluation, Tool Development, Undergraduate Clinical Training, KeTCET

Practice Highlights

• Tele-Practice based clinical programmes can be delivered successfully even in countries with limited resources.
• Robust planning is required to ensure that tele-clinical programmes address specific training needs and satisfy student expectations.
• Incorporating virtual clinical training modules into the regular curriculum can effectively address some of the barriers students have identified in tele-clinical learning.
• The unique features of tele-clinical training should guide the formulation of tailored guidelines and supervisory models for the virtual format.
• The evaluation of tele-clinical programmes is most effective when customised tools are developed to incorporate elements of the virtual format of training.

I. INTRODUCTION

The COVID-19 pandemic necessitated a global shift to online platforms in healthcare and education. Higher education institutions implemented online teaching methods, including webinars and interactive sessions (Hameed et al., 2020), while healthcare education adopted tele-medicine as a platform to continue clinical training, ensuring graduate preparedness for professional practice. Speech and language therapy and audiology professionals swiftly utilised tele-therapy, a method previously endorsed by the American Speech-Language-Hearing Association (ASHA, n.d.). This model of service delivery employs synchronous, asynchronous, and hybrid methods, tailored to patient needs and available resources. Beyond the pandemic, tele-medicine programmes offer enduring benefits, including improved access to care for remote and underserved populations, enhanced patient satisfaction and cost-effectiveness (Car et al., 2020). The World Health Organization emphasises the role of tele-medicine in broadening healthcare access, especially for people in remote areas and underserved communities (WHO, 2022).

Tele-clinical programmes, that is, clinical training conducted using tele-therapy have proven to be an effective method in clinical teaching and skills training. Considerable evidence demonstrates the tele-clinical programmes can be successfully used for clinical training, not limiting it to practical skills (Anderson et. al., 2023) but also addressing attitudinal changes (Wearne et. al., 2015) and clinical soft skills (Bramstedt et. al., 2014; Liu et. al., 2022).

Clinical supervision, distinct from classroom teaching, involves case-based learning, critical thinking, and professional behaviour modelling (Council of Academic Programmes in Communication Sciences and Disorders (CAPCSD), 2013). Traditionally conducted face-to-face clinical supervision shifted to tele-clinical supervision during the pandemic, utilizing a variety of strategies (Shawwa, 2023). However, much of the available literature on tele-supervision does not clearly state whether important aspects of clinical teaching, such as supervisor–student relationships and feedback (Kilminster & Jolly, 2000), were considered during programme design.

Evidence suggests that the effectiveness of tele-supervision depends significantly on the qualities of both the supervisor and the supervisee (Martin et al., 2017). Positive supervisory relationships, characterised by structure and support (Martin et al., 2014) are achievable in both virtual and face-to-face formats (Reese et al., 2009). Effective tele-supervision also depends on communication strategies, supervisor availability, and feedback models (Gibson et al., 2007; Snowdon et. al., 2019). Technological barriers, such as poor connectivity and equipment issues, can hinder outcomes, necessitating proactive solutions (Martin et al., 2017; Reese et al., 2009; Tarlow et al., 2020).

Systematic evaluation of student experiences in tele-clinical programmes is essential to understand their effectiveness. Most studies that report on tele-clinical programmes in allied health sciences (e.g., Bacon et al., 2023; Snowdon et al., 2019) and medicine (e.g,. Pit et al., 2021; Wearne et al., 2015) rely primarily on qualitative interview data. Ideally, such qualitative data should be supplemented with the use of a validated and reliable tools specifically designed to evaluate a virtual model of clinical training. This ensures that tele-clinical learning meets the professional standards and training requirements of audiology and speech and language therapy. The objectives of this study were to evaluate student experiences in an undergraduate Speech and Hearing Sciences tele-clinical training programme, and to validate a feedback tool to evaluate similar tele-clinical programmes.

II. METHODS

A. Context and Setting

The BSc (Hons) Speech and Hearing Sciences is a full-time, four-year undergraduate programme. The qualification allows graduates to practice as speech and language therapists or audiologists following registration at the national medical regulatory body. The programme consists of theoretical classroom-based sessions, synchronous to intensive supervised clinical training offered across the four years of study. Speech and Language Therapy (SLT) undergraduates are trained to work with communication and swallowing disorders while audiology undergraduates train in the detection and management of hearing loss, across the life span.

The data gathered in this study reflects experiences from the pandemic period, when clinic and hospital-based teaching was significantly limited. For almost two and a half years since the commencement of the pandemic, SLT and audiology service provision shifted fully into a tele-therapy programme. Simultaneously, students were enrolled in a tele-clinical programme, offered two to three times per week, where they worked with the patient under the supervision of an academic or qualified clinician. All sessions took place using the Zoom platform, which was made freely available to students by the university. Tele-therapy for adult patients requiring SLT services was delivered primarily using a synchronous method and for paediatric clients using an asynchronous or a mixed method. Audiology clinical services were primarily synchronous. The tele-clinical training was designed to align with the method of tele-therapy (Table 1).

Format	Synchronous Method	Asynchronous Method	Hybrid Method
Tele-therapy	Conducted in real time using audio or video interactive sessions.	Clinical management through stored images and captured data.	Combines both synchronous and asynchronous methods.
Tele-clinical Supervision	Students conduct session. Supervisor joins in. Feedback is provided simultaneously and after session.	Students join session. Supervisor shares recorded videos and relevant clinical information/documentation. Students are given time to reflect.	Students conduct session. Supervisor joins in. Following a short real-time session, a recorded video is watched together. A discussion follows.

Table 1. Modes of Tele-therapy and tele-supervision delivery

The general arrangement of a synchronous session was that the patient, student and supervisor joined the session at a mutually agreed time, but from three separate locations. Material for the therapy session, if required, was developed and shared on the screen by the student. For paediatric clients, parents arranged the toys needed. In audiology, students gathered patient data through interviews and questionnaires with limited use of conventional hearing tests. Auditory verbal training  (AVT sessions) in audiology followed a similar format to SLT synchronous sessions. The supervisor remained a silent observer unless intervention was required. In all sessions, supervision concluded with an interactive patient discussion, facilitated by the supervisor using Zoom features such as whiteboard, break out rooms etc.

The evaluation of the tele-clinic programme was conducted using mixed methods by collecting students’ perceptions quantitatively (Phase I) and qualitatively (Phase II).

B. Phase 1- Development of Evaluation Tool and Quantitative Feedback

The quantitative evaluation of the tele-clinical programme was conducted with the aim of developing and validating a standardised tool for evaluating similar programmes.

1. Tool Development

As there are no existing tools available to evaluate SLT or audiology clinical programmes, whether face-to-face or virtual, a new evaluation tool was developed based on the Clinical Learning Environment, Supervision and Nurse Teacher evaluation scale (CLES +T ) (Mikkonen et al., 2017) and the Nursing Clinical Facilitator Questionnaire (NCFQ) (Espeland & Indrehus, 2003). The resulting 23-item tool, named the Kelaniya Tele-Clinical Evaluation Tool (KeTCET), was designed to map onto three primary domains: pedagogical/learning environment (LE; 9 items), supervisory relationship (SA; 6 items), and telehealth teaching practices (TTP; 8 items). The stem question used here was, how often did you experience this aspect in the online clinical learning sessions provided for the SHS programme during university closure? (Table 2). Participants rated each item on a 5-point Likert scale (0 – never, 1 – rarely, 2 – sometimes, 3 – often and 4 – always).

To enhance face and content validity, a panel of 10 experts in speech and language therapy and/or audiology  rated the tool items on a five-point scale for [a] content appropriateness, [b] relevance, and [c] technical accuracy (1 = Very Low, 5 = Very High). Experts could also provide comments to refine the items. The panel scored the items high across all three aspects (mean[a]=4.8; mean[b]= 4.8; mean[c]=4.7). A measure of item relevance, I-CVI (Item- Content validity Index) scores for all items (n=23) were > 0.9. Minor language adjustments suggested were incorporated. The tool was then translated into Sinhala and Tamil and pre-tested with five students (three Sinhala speakers and two Tamil speakers) to confirm clarity and translation accuracy.

2. Study Participants

All 155 SLT undergraduate students in the SLT and audiology programmes who had attended at least 80% of the tele-clinical training sessions were considered eligible for participation in phase I. All eligible students were invited to participate in the study. At the time of data collection, these students were in their second, third, and fourth years of study. The minimum sample size required was calculated based on the recommended item-to-response ratio of 1:5 for factor analysis (Bujang et al., 2012; Gorsuch, 1983), requiring at least 115 responses. A total of 128 students responded (82.6%) to phase I.

https://doi.org/10.29060/TAPS.2025-10-4/TT004

Lambert Schuwirth

Professor of Medical Education
NewMedSchool, Australia

We are currently living in a time in which different assessment paradigms co-exist. There are contexts in which assessment is purely seen as a measurement, for instance national licensing. There are contexts in which assessment is predominantly judgement, such as in VIVAs and there are contexts in which these are combined to form an integral programmatic assessment for learning program.

Although a programmatic assessment for learning aims to combine both measurements and judgements, the manner in which all assessment data is synthesised and fed back to the learner is always through judgement and narratives. That is inevitable because numerical outcomes without added narratives are as meaningless as a scientific paper without an introduction, methods and discussion section and only the tables of the results. Numerical outcomes can only drive learning purely by punishment and reward and cannot provide the learner agency or support with meaningful self-regulation of their learning. Modern professionals, however, need capabilities to self-regulate their learning.

Assessment for learning therefore always needs to be programmatic – as opposed to formative assessment which can simply be a test that does not count.

But are narratives defensible? This is a common concern as we tend to trust quantitative outcomes more than qualitative. I find this odd. We trust healthcare as a system, even though the history, physical examination results, pathology and imaging reports and even contextualised lab values are all narratives, as are the diagnosis and management plan.

In an educational context, I would therefore plea that assessment should be more like a diagnostic and therapeutic relationship with the medical student. Assessment should guide them to become the best doctor they can be, and with our intake of the brightest and most hard-working young people the vast majority are. But what about the minority? Yes, they need to be identified as well but focusing an entire system on an issue with a low prevalence (the irremediable student) creates a huge NNT problem and is a waste of money and resources.

But assessment needs to be credible and fair. That is where programmatic assessment differs from a testing approach. Testing defines fairness as equality – everybody receives the same standardised test. Programmatic assessment defines fairness as equity – everybody receives the same quality of assessment. Just like we don’t push all patients through the same template in healthcare, but offer bespoke and high-quality diagnostic and therapeutic care, we should do the same with assessment.

Submitted: 10 March 2025
Accepted: 5 July 2025
Published online: 7 October, TAPS 2025, 10(4), 55-62
https://doi.org/10.29060/TAPS.2025-10-4/OA3690

Aaron Tigor Sihombing^1,2, Antonia Kartika^3,4 & Anglita Yantisetiasti^2,5

¹Department of Surgery, Division of Urology, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; ²Hasan Sadikin General Hospital, Bandung, Indonesia; ³National Eye Center-Cicendo Eye Hospital, Bandung, Indonesia; ⁴Department of Ophthalmology, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; ⁵Department of Anatomical Pathology, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia

Abstract

Introduction: Music preferences have been linked to personality traits, which in turn may influence career choices. This study explores the potential relationship between music genre preferences and medical specialty selections among residents at Padjadjaran University, Indonesia.

Methods: A cross-sectional survey was conducted among all residents trained in urology, ophthalmology, and anatomic pathology. Data collected included demographic characteristics, music genre preferences, and work habits related to music. Independent t-tests are used when data are normally distributed, whereas Kruskal-Wallis tests are used when data are not normally distributed.

Results: The study included 125 residents (19 pathology anatomy, 33 urology, 73 ophthalmology). Pop was the most preferred music genre across all specialties (48% in urology, 61% in ophthalmology, 52% in pathology anatomy). However, secondary preferences varied: rock (21%) was the second most popular among urology residents, jazz (10.9%) and indie (10.9%) among ophthalmology residents, and classical music (26%) among pathology anatomy residents. Demographic differences were noted, with pathology anatomy residents being older and urology residents having a higher proportion of males. Ethnic distribution was relatively consistent across specialties, primarily mixed ethnicity, Sundanese, and Javanese.

Conclusion: While pop music was the predominant preference across all specialties, secondary music preferences varied, potentially reflecting different personality traits associated with each specialty. The study’s findings are limited by its single-institution sample and cross-sectional design, necessitating further research with larger, more diverse populations to explore the underlying mechanisms linking music preferences to medical specialisation choices.

Keywords:           Music Preferences, Medical Specialty Selection, Personality Traits

Practice Highlights

• Personality traits could predict specialty preferences among medical students.
• Music genre preferences are associated with personality traits, thus are drawn to particular type of music.
• Residents in different specialties distributed music genres differently.

I. INTRODUCTION

The notion that music genres reflect and influence personality traits is a topic of much debate and interest. Research has shown a correlation between musical preferences and personality traits, with certain genres being associated with specific characteristics (Andrews et al., 2022; Wang et al., 2024). For example, music in slow tempo and music in minor keys were significantly predicted by emotional stability and optimism, whereas music in fast tempo and music in major keys was significantly predicted by openness to experiences, introversion, and gender (Dobrota & Reić, 2014; Upadhyay et al., 2017). Some evidence suggests that individuals drawn to certain music genres may exhibit personality profiles that align with specific career paths. For instance, individuals who prefer classical music tend to score higher in openness and introversion—traits associated with analytical or solitary professions—while those who enjoy rock or pop may display extraversion and sensation-seeking behaviors, often linked to high-energy or interactive professions (Rentfrow & Gosling, 2003; Schäfer & Mehlhorn, 2017). Moreover, individuals with high levels of achievement tend to prefer music that reflects their professional identity, indicating a potential association between occupational roles and musical preferences (Knox & McDonald, 2017).

Similarly, in the field of medicine, there is a growing interest in understanding how personality traits may influence medical residency preferences. Studies suggest that certain personality types may be drawn to specific medical specialties, and this alignment could impact their satisfaction and performance within that field. This intersection of music, personality, and medical career choices highlights the complex ways in which our preferences and personalities shape and reflect our identities and professional paths.

Culture and environment have a profound effect on a person’s personality (Smaldino et al., 2019; Triandis & Suh, 2002). Culture provides a framework within which individuals develop beliefs, values, and behaviours that are in harmony with their societal norms. It shapes personality through language, customs, and social norms, which guide an individual’s actions and interactions. Environment, encompassing family dynamics, social relationships, and educational experiences, also plays a pivotal role in molding personality traits. As individuals navigate through different environmental contexts, their personalities adapt and evolve, reflecting the dynamic interplay between their innate dispositions and external influences. This complex interconnection suggests that personality is not a static entity but a fluid construct that changes over time, influenced by the cultural and environmental landscapes we inhabit.

Indonesia’s rich of cultures is indeed a testament to its diversity, with over 300 ethnic groups calling it home. This multicultural environment offers a unique blend of traditions, languages, and beliefs, which can significantly shape an individual’s personality. Exposure to diverse cultural practices and values can foster open-mindedness, adaptability, and a complex worldview. Research suggests that multicultural experiences can enhance creativity, reduce stereotypes, and provide a broader perspective on life. Moreover, individuals who navigate multiple cultures may develop a multicultural identity, integrating different cultural influences into their personal identity, which can contribute to their overall well-being and social harmony.

The exploration of a potential correlation between musical preferences and medical specialty choice in Indonesia is indeed a fascinating subject. Since music has been noted to affect personality, which in turn influences the choice of medical specialisation, Indonesia is a multicultural country, and this correlation is intriguing. As a result, this study aims to determine if there is a distribution difference between music genre preferences and healthcare specialisations in Indonesia.

II. METHODS

This research employed a cross-sectional study design, with total sampling of all Padjadjaran University resident utilising a comprehensive survey administered to all residents. The study population comprised residents specialising in three distinct medical disciplines: urology, ophthalmology, and anatomic pathology. All residents in urology, ophthalmology, and anatomic pathology were eligible to be included. Exclusion criteria included incomplete responses or refusal to provide consent. This selection allowed for a comparative analysis across specialties with varying degrees of procedural and cognitive demands. In this study we utilised total sampling, all eligible residents during the study period were invited to participate. The survey instrument was designed to collect a range of demographic and preference-based data. Participants were asked to provide information regarding their age, current year of residency training, and their preferred music genres. Crucially, the survey also explored the residents’ work habits related to music, specifically inquiring whether they typically worked with or without background music and their preferred music genre. The survey also collected information on spouse employment status, which was divided into two groups: physicians and non-physicians.

Statistical analysis was performed to assess the difference between groups within the collected data. The independent t-test was employed to analyse continuous data that demonstrated a normal distribution. For continuous data that did not meet the assumptions of normality, the non-parametric Kruskal-Wallis test was utilised. In all statistical analyses, a significance level (p-value) of 0.05 was established as the threshold for statistical significance, indicating a 5% risk of concluding a relationship exists when it does not. All participants have given informed consent before any data were collected.

III. RESULTS

A total of 125 residents participated in this study. Nineteen pathology anatomy residents, 33 urology resident and 73 ophthalmology residents were included. The descriptive statistic of age and sex are presented in Table 1. Marital status and ethnicity are presented in Appendix 1.

		Pathology Anatomy (n = 19)	Urology (n = 33)	Ophthalmology (n = 73)	p-value
Age
	Mean ± SD	33.16 ± 3.11	30.09 ± 2.11	30.51 ± 2.55	0.002*
	Median (Range)	34.00 (29-39)	30.00 (27-37)	30.00 (26-36)
Sex
	Male	4 (21.1%)	26 (79.8%)	22 (30.1%)	<0.01
	Female	15 (78.9%)	7 (21.2%)	51 (69.9%)

*Kruskal Wallis Test

Table 1. Age, sex, ethnicity and marital status of the residents

In male resident population, distribution between married and not married is quite equal between specialty (Figure 1). In urology, married male residents is 58%, while it is 68% and 50% in ophthalmology and pathology, respectively. There is sharp difference in female urology resident compared to other specialties. There are only 14% female urology residents who is married, while in ophthalmology and pathology is 63% and 67%, respectively.

Figure 1. Marital status proportion in male (A) and female (B) residents

Figure 2. Proportion of married residents with physician spouse

In urology, 81% of residents also married to physicians, while it is only 55% in ophthalmology and 42% in pathology (Figure 2).

Most residents in urology (69.70%) and pathology (73.68%) reported that they were listening to musical background while working (Figure 3). While only 38.36% in ophthalmology that worked with musical background.

Figure 3. Comparison between residents working with musical background and those without

Figure 4. Residents’ music genre preference (in percentage)

IV. DISCUSSION

This study explored the relationship between music genre preferences and medical specialty selections among residents at Padjadjaran University. There is a higher median age among pathology anatomy residents than among urology and ophthalmology residents, and there is a greater proportion of males in the urology department (Table 1). In spite of this, all residents from the three departments belong to the same generation (Juekiewicz, 2023). As residents in the same generation (generation Y), they are influenced by similar external influences, values, and ethical principles which influence their music genre preferences (Juekiewicz, 2023; Krumhansl, 2017).

Given that Indonesia is composed of multiple ethnic groups, and ethnicity could influence music genre preference, we found that the top three ethnic groups that reside in the three departments are somewhat similar, namely mixed ethnicity, Sundanese, and Javanese (Table 1). This percentage ranking differs from that of the Badan Pusat Statistik (BPS), which indicates that the top three groups by population are Java (40.22%), Sundanese (15.5%), and Batak (3.58%) (Badan Pusat Statistik [BPS], 2010).

Since music serves as a connection function between people, we evaluate the marital status of the residents (Bamford et al., 2024). In urology, 52% of residents are married, while in pathology and anatomy, 37% and 36% are married, respectively (Table 1). While females comprise only 21% of urology residents, the majority of them are unmarried (86%), which is compared to only 33% and 37% of female pathology anatomy and ophthalmology residents who are unmarried, respectively (Figure 1).

Eighty-one percent of urology residents are married to a physician compared to 55% of ophthalmology residents and 42% of pathology anatomy residents (Figure 2). Study by Dutta RR, et all showed that only 26.1% of physician married with physician (Dutta et al., 2024). However, the study did not compare the percentage of physicians who are married to other physicians in each specialty.

Compared with urology residents (69.7%) and pathology anatomy residents (73.68%), only 38.36% of ophthalmology residents listen to music while working (Figure 3).

Pop genre is the most preferred genre among three groups of residents, comprising 48% of residents in the urology and 61% of residents in the ophthalmology groups, as well as 52% of residents in the pathology anatomy groups (Figure 4). This finding is similar to a study by Krumhansl that the pop genre is the most preferred genre for individuals born between 1940 and 1999 (Krumhansl, 2017). However, the second most preferred genre among urology residents is rock (21%), while jazz (10.9%) and indie (10.9%) are the second most preferred genres in ophthalmology, and classical music (26%) is the second most preferred genre in pathology anatomy. The difference in genre music preference can also be observed in the third to last rank on the list (Figure 4).

The variation in secondary music genre preferences among specialties may be partially explained by psychological theories of personality, particularly the Five-Factor Model (FFM), which posits five broad domains of personality: openness, conscientiousness, extraversion, agreeableness, and neuroticism. Prior research has shown that individuals who prefer classical music tend to score high in openness and introversion—traits often linked to reflective and analytical disciplines such as pathology. In contrast, rock and pop fans tend to exhibit higher levels of extraversion and openness to experience, traits more commonly observed in high-intensity, procedurally driven fields like urology (Rentfrow & Gosling, 2003; Schäfer & Mehlhorn, 2017). However, in our study, most residents prefer pop music.

From a sociological perspective, medical specialties may be seen as “occupational subcultures” (Becker, 1963), each with distinct values, stress profiles, and interaction patterns. These subcultures attract individuals whose identities align with the implicit norms of the field (Light, 1979), potentially explaining the alignment between music preference and specialty. For example, the high-paced, team-intensive nature of urology might attract residents who identify with more energetic and expressive music like rock. Conversely, fields like pathology, which involve solitary analysis, may appeal to those who appreciate structured and introspective genres like classical music.

This study has several limitations that affect generalisability of the findings. While the study used a total sample of residents from three departments, the number of residents from each specialty varies, with 19 respondents from pathology anatomy, 33 respondents from urology, and 73 respondents from ophthalmology. In addition, the study’s sample was drawn exclusively from residents of one university.

Despite its limitations, this study presents several strengths that contribute to its value. The study explores a unique and interesting relationship between music genre preferences and medical specialty selection, particularly within the Indonesian cultural context. This area is relatively understudied and by focusing on medical residents, a specific population facing unique career pressures, the research addresses a relevant and understudied group. Furthermore, we acknowledgment of Indonesia’s diverse cultural influences, highlighting the potential impact of environment on both musical tastes and professional choices. We hope that this study will open avenues for further research and raising awareness about the potential influence of external factors like music on medical professionals.

V. CONCLUSION

This cross-sectional study explored the relationship between music genre preferences and medical specialty selections among residents at Padjadjaran University in Indonesia. While the study revealed variations in music preferences distribution across different specialties, pop being the most favored genre and different preference in second to last rank.

We found that there are differences in demographic distributions, particularly age and gender, among the resident groups, it is important to acknowledge the limitations of the study’s design. The use of a single-institution sample and the cross-sectional methodology limit the generalisability of the findings and preclude the establishment of causal relationships. Nevertheless, the study offers a preliminary investigation into the potential interplay between musical tastes and career choices within the medical field, raising intriguing questions for future research.

Further studies with larger and more diverse samples, are needed to expand upon these findings, and to explore the underlying mechanisms that might link music preferences to medical specialisation.

Notes on Contributors

ATS contributed to the conceptualisation, data curation, methodology, formal analysis, project administration, validation, investigation, funding acquisition, resources, visualisation, software, supervision, writing of the original draft, review and editing.

AK contributed to the methodology, formal analysis, resources, visualisation, software, supervision, writing of the original draft, review and editing.

AY contributed to the investigation, visualisation, software, supervision, writing of the original draft, review and editing.

Ethical Approval

This study was performed under the ethical approval from Hasan Sadikin Hospital Ethical Committee (Approval Number: DP.04.03/D.XXIV.16/14527/2024). This study is in line with the 1964 Declaration of Helsinki and existing ethical standards.

Data Availability

The data supporting this study are available upon reasonable request to Corresponding Author.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Interest

The authors declare no relevant financial or non-financial competing interest from any party.

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*Aaron Tigor Sihombing
Jl. Raya Jatinangor, Cikeruh, Kec. Jatinangor,
Kabupaten Sumedang, Jawa Barat 45363
+62 813-2132-9126
Email: aarontigor@gmail.com